Screening, Brief Intervention and Referral to Treatment (SBIRT)

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1 Screening, Brief Intervention and Referral to Treatment (SBIRT) (Part 1 of 2) Teresa Halliday National Council for Behavioral Health February 14, 2018

2 Learning Objectives 1. Define SBIRT and present evidentiary support for this framework 2. Discuss benefits of intervention on health outcomes and cost-savings 3. Identify operational and financial aspects to implementation, including workflow and sustainability issues.

3 Risky Use is Prevalent 20% of adolescents and adults engage in risky or harmful drinking or substance use One in eight adults consumes alcohol at an unhealthy level 30.2% of men and 16.0% of women 12 and older reported binge drinking (5+drinks on one occasion) in the last month 1 People are most likely to begin abusing substances during adolescence and young adulthood 2 By 12th grade, about 50% of adolescents have misused an illicit drug at least once 15.2% of individuals who start drinking alcohol by age 14 will develop dependence vs. 2.1% of those who wait until they are 21 1 National Institute on Drug Abuse. (2015). National Survey on Drug Use and Health. Retrieved from: 2 U.S. Department of Health & Human Services, Office of Adolescent Health. (2018). Substance Use and Adolescent Development. Retrieved from:

4 Substance Use Disorder (SUD) Substance Abuse and Mental Health Services Administration. (2017). Key substance use and mental health indicators in the United States: Results from the 2016 National Survey on Drug Use and Health (HHS Publication No. SMA , NSDUH Series H-52).Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. Retrieved from

5 SUD Treatment

Substance Use is Costly For the User People with SUD are disproportionately affected by chronic diseases Direct impact of use risk behaviors Restricted access to quality

6 Substance Use is Costly For the User People with SUD are disproportionately affected by chronic diseases Direct impact of use risk behaviors Restricted access to quality health care Tx adherence rates Risky users incur more negative consequences at population level Brown, et al., 2006; Substance Abuse and Mental Health Services Administration, 2007.

Substance Use is Costly Healthcare For Society Specialty Tx, prevention, medical consequences Crime & criminal justice Traffic accidents, fires Lost productivity: Death, illness, crime victims,

7 Substance Use is Costly Healthcare For Society Specialty Tx, prevention, medical consequences Crime & criminal justice Traffic accidents, fires Lost productivity: Death, illness, crime victims, incarceration Antisocial behavior Miller, T. and Hendrie, D. Substance Abuse Prevention Dollars and Cents: A Cost-Benefit Analysis, DHHS Pub. No. (SMA) Rockville, MD: Center for Substance Abuse Prevention, Substance Abuse and Mental Health Services Administration, 2008.

8 Cost of the Opioid Crisis The White House Council of Economic Advisers (CEA) estimates that in 2015, the economic cost of the opioid crisis was $504 billion The Underestimated Cost of the Opioid Crisis. November Retrieved from

9 Cost effectiveness of Screening SBIRT targets the large population of risky to harmful users before they become dependent Research shows that treated individuals have lower rates of emergency room use and hospitalization lower overall healthcare costs Impact of effective treatment on societal costs Lower criminal justice costs associated with addiction-related arrests and incarceration. Improved employability higher earnings for those who reduce or eliminate their substance abuse. Robin E. Clark, Ph.D., Elizabeth O Connell, M.S., and Mihail Samnaliev, Ph.D.; Substance Abuse and Healthcare Costs Knowledge Asset, Web site created by the Robert Wood Johnson Foundation's Substance Abuse Policy Research Program; March 2010.,

Impact of Screening for Substance Use S c r e e n i

SBIRT Target Population High Risk *percentages based

Treatment Brief Intervention Primary Prevention

10 Impact of Screening for Substance Use S c r e e n i n g 40% Abstinent/ Low risk 35% Moderate risk 20% SBIRT Target Population High Risk *percentages based on adult alcohol use 5% Moderate/Severe Referral Treatment Brief Intervention Primary Prevention Dawson, Alcohol Clin Exp Res 2004; Grant, Drug Alcohol Dep 2004

Referral to Treatment for access to specialized treatment services; coordinate care between systems for those with higher risk and/or dependence.

11 The SBIRT Model Screening to identify those at-risk for developing substance use disorders. Brief Intervention to raise awareness of risks and consequences, internal motivation for change, and help set healthy goals. Referral to Treatment for access to specialized treatment services; coordinate care between systems for those with higher risk and/or dependence. Wilk, J Gen Int Med, 1997; Bien, Addiction, 1993; Cuijpers, Addiction, 2004; Kahan, Canadian Med Assoc J, 1995; Madras, Drug and Alcohol Dep, 2009; Moyer, Addiction, 2004; Kaner, Cochrane Database, 2007; Whitlock, Ann Int Med, 2004; Bertholet, Arch Int Med, 2005; Vasilaki, Alcohol and Alcoholism,

12 SBIRT is Effective

13 Endorsed by Experts National Institutes of Health World Health Organization U.S. Surgeon General and U.S. Preventive Services Task Force American Public Health Association Society for Adolescent Health and Medicine Emergency Nurses Association Substance Abuse and Mental Health Services Administration White House Office of National Drug Control Policy American Medical Association American Academy of Family Physicians American College of Physicians American Psychiatric Association American College of Emergency Physicians American College of Surgeons Committee on Trauma American College of Obstetricians and Gynecologists American Society of Addiction Medicine The American Academy of Pediatrics (AAP) and National Institute on Alcohol Abuse and Alcoholism (NIAAA) explicitly endorse the use of SBIRT with young people.

14 Strategies to integrate SBIRT protocol into health services

15 SBIRT Implementation Identify a Champion and Form a Multidisciplinary Team Assess Barriers and Facilitators Process Mapping Ongoing Performance Monitoring CASA Columbia, An SBIRT Implementation and Process Change Manual for Practitioners

16 8 Key Implementation Questions Who needs to be at the table? What is the plan? What staff training is needed? How do we entrench SBIRT into our protocols? How do we track SBIRT and know it s working? How do we pay for it?

17 Who needs to be convinced and at the table? Leadership Clinical staff IT/ EHR staff Billing staff HR Training Office Staff How do you communicate with key stakeholders & speak to their priorities?

18 Identifying a Champion Leads efforts to implement SBIRT Should be a team player, knowledgeable about the health care setting, enthusiastic, and well-respected Helps to gain buy-in from staff!

19 Gain commitment from senior leadership Secure a commitment from CEO Identify and engage other key leaders Engage policymakers, as applicable

20 Form a Multidisciplinary Team ID key organizational units that will impact/be impacted by SBIRT ID leaders for each unit Convene SBIRT Team & Engage! Inform all staff

21 Common Barriers Provider Attitudes and Competence Workflow and Resources SBIRT Adaptability Organizational Support Client Characteristics and Background CASA Columbia An SBIRT Implementation and Process Change Manual for Practitioners

22 Implementation Questions: Who will conduct the screening? Screening What screening tools will be used? Which patients will be screened? Where and when will screening take place? How much time will it take to complete? How will information be documented and shared?

23 Implementation Questions: Brief Intervention (BI) Who will conduct the BI? Where will the BI be performed? What is needed to ensure that staff are properly trained? How will the BI be documented in the EHR? Who will set up protocols to bill for SBIRT? When will the BI be performed?

24 Implementation Questions: Referral to treatment What does your patient need? What current referral resources exist? Are the available resources appropriate for your patients? How will you connect and follow-up with providers/patients? Identify level of care Substance, severity, comorbidity Culturally, linguistically, and age appropriate Prepare patient for Tx Plan, reassure, support Identify provider list Co-occurring capacity Provider communication protocol Identify documentation Identify support staff Location/transport Insurance coverage Follow-up plan with patient Provider list and handouts on alcohol/drug limits and consequences

Guidelines for SBIRT Implementation Identifies policy for SBIRT: Target population for screening and intervention Screening frequency Purpose of intervention Defines screening instruments Defines

25 Guidelines for SBIRT Implementation Identifies policy for SBIRT: Target population for screening and intervention Screening frequency Purpose of intervention Defines screening instruments Defines appropriate clinical responses Incorporates SBIRT into EHR Identifies staff roles and responsibilities Identifies SBIRT billing rates Transcends transitions in leadership and staff written and approved regardless of changes

26 Data is your friend Maximize data collection and utilization strategy, including use of electronic medical records, to translate data into action and foster continuous quality improvement.

27 Why collect data? Evaluation Measures Can Be Used to: Identify processes that need improvement Assess and maintain staff competencies Provide data on cost effectiveness and program outcomes Demonstrate program success and sustainability Describe and quantify quality of care improvements

28 Process Measures Percent screened with risk tool. Data Collection Percent screened who received a brief intervention. Percent screened who received a brief intervention and a referral to treatment. Percent screened at high risk who received a brief intervention and a referral to treatment and attended first treatment appt. Outcome Measures Decreased risk tool score. Decreased self-reported quantity/frequency of use. Increased readiness to change as indicated by an increase in score on the Readiness Ruler at second brief intervention.

29 Financing SBIRT Identify and develop sustainable financing strategy to support SBIRT, including identification of relevant policy, reimbursement processes, and opportunities within existing service incentive programs. a. Calculate cost b. Identify potential SBIRT funding sources c. Investigate payment parameters d. Work with financing staff to investigate and understand: a. Requirements and limitations of: services, staff, documentation

30 Calculating Cost Operating costs Management, technology, finance, office, equipment, HR Staff Salary, benefits, training, supervision, time SBIRT specific implementation Planning/Sustainability

Potential Funding Sources Selected public sources HRSA Bureau of Primary Care, PHSA Section 330 Public Insurance Medicaid CHIP Other federal funding (e.g. SAPTBG) State/County/Local funding Private sources Explore your state s SBIRT financing Commercial Insurance environment: Combination http://my.

31 Potential Funding Sources Selected public sources HRSA Bureau of Primary Care, PHSA Section 330 Public Insurance Medicaid CHIP Other federal funding (e.g. SAPTBG) State/County/Local funding Private sources Explore your state s SBIRT financing Commercial Insurance environment: Combination Exchanges Foundations, bequests, other unencumbered funds

32 Commonly Used SBI Codes

33 Financial Literacy Identify SBIRT funding sources Work with financing staff to: Specify requirements and limitations of each source Number of screenings per year Identify billing rules and requirements Staff qualifications Codes for referral to treatment and follow-up Understand documentation and reporting requirements Case records, EHR

34 SBIRT Implementation Resources General and setting/substance/population-specific resources are available ( Standardized, nationally applicable guidelines for practice transformation in primary care under development Clear, specific, practical guidelines for operational and clinical elements of implementation Facilitating Change for Excellence in SBIRT (FaCES): Adolescent SBIRT in FQHCs with support from the Conrad N. Hilton Foundation (currently in pilot release 2020) Implementing Care for Alcohol & Other Drug Use in Medical Settings: An Extension of SBIRT made possible by SAMHSA (release 2018)

35 Questions? Thank You Teresa Halliday Senior Director, Practice Improvement

36 Looking Ahead Join us for Part 2 -Clinical Aspects of SBIRT February 23 rd, 2-3pm EST Location: Washington, D.C. NatCon18.TheNationalCouncil.org for more information

SBIRT in Mental Health Settings

SBIRT in Mental Health Settings Teresa Halliday, MA Director, Practice Improvement Pam Pietruszewski, MA Integrated Health Consultant Overview 1. Rationale for support 2. Continuum of use and risk 3. Overview