Seth Eisenberg, MD. Danielle Kirby, MPH. Illinois Department of Human Services Division of Alcohol and Substance Abuse

Transcription

1 Illinois Seth Eisenberg, MD And Danielle Kirby, MPH Illinois Department of Human Services Division of Alcohol and Substance Abuse This publication was made possible by Grant #TI from the United States Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment to the Illinois Department of Human Services, Division of Alcoholism and Substance Abuse. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Center for Substance Abuse Treatment or the Illinois Department of Human Services, Division of Alcoholism and Substance Abuse.

2 Danger: Acronyms Will Be Used

3 A Question to The Audience 1. How much do you know about SBIRT? 2. What do your patients know about SBIRT? 3. Who needs treatment for substance abuse? 4. How do you think patients will respond when asked about their use of drugs and alcohol? 5. How do you think they will feel about talking to their medical providers about it? ARE YOU READY FOR SBIRT??

4 No Use Experimental Ritual use Continuum of Use Intermittent use---occasional Use Social use Regular Use Binge use ( heavy drug use for days, or 5 drinks for a man, 4 for a woman in rapid succession) Abuse Substance Abuse DSM-IV-TR criteria Harmful, Hazardous drinking (use) Substance Dependence DSM-IV-TR criteria Severely and Persistently Chemically Dependent (numerous attempts to abstain; chronic relapse)

5 Meeting Goals and Objectives GET READY to implement SBIRT Learn definition of SBIRT Understand the benefits of SBIRT to health Understand the benefits of SBIRT to your organization Learn the potential for billing depending on your healthcare system and the populations you serve Consider the characteristics of an effective implementation Consider the characteristics of an effective implementation of SBIRT at your organization and leave with the knowledge to determine if SBIRT is appropriate for your organization

6 What is? creening: Identification of substance related problems rief Intervention: raises awareness of risks and motivates patient toward acknowledgement eferral to reatment: Referral of those patients with more serious addictions to Specialty treatment

7 A comprehensive, integrated, public health approach to the delivery of early intervention and treatment services for persons with substance use disorders, as well as those who are at risk of developing these disorders. (SAMHSA)

8 A proactive initiative for: - Identifying patients at ALL levels of alcohol and drug use through dependence. - Providing brief intervention to patients who are misusing alcohol and other drugs; - Assessing patients t who are experiencing i problems due to their use to determine appropriateness for treatment. - Referring patients who are in need of additional treatment to specialized treatment.

9 Reduces incidence and severity Intervenes earlier to mitigate negative/fatal consequences Focuses on primary healthcare settings Capitalizes on Primary Health Care (PHC) personnel s connection to the patient population Primary model for integrating substance abuse treatment with primary care

10 is Cost Effective Cost savings of $43,000 in future healthcare costs for every $10,000 invested in early intervention Patients receiving BI have fewer hospital days and fewer ED visits Unit of BI costs $205 and saves $712 in healthcare costs Ranks high among effective preventive services Source: TAP 33

11 Billing Payer Code Description Fee Schedule Alcohol and/or substance abuse structured CPT screening and brief intervention services; 15 to 30 $33.41 Commercial Insurance minutes Alcohol and/or substance abuse structured CPT screening and brief intervention services; greater $65.51 than 30 minutes Alcohol and/or substance abuse structured G0396 screening and brief intervention services; 15 to 30 $29.42 Medicare minutes Alcohol and/or substance abuse structured G0397 screening and brief intervention ti services; greater $57.69 than 30 minutes H0049 Alcohol and/or drug screening $24.00 Medicaid H0050 Alcohol and/or drug service, brief intervention, $48.00 per 15 minutes Medicaid codes for reporting are not billable in Illinois, except for pregnant women, but are available for reporting purposes. Source:

12 SBIRT in PHC - Most health risks and disease from substance abuse is suffered by ypeople p who are not addicted The Nation s number one health problem 23.3 million dependent d users (NSDUH, 2007) million non- dependent, high-risk users (NSDUH, 2007) SBIRT targets the majority of substance users who do not need treatment but who have or who are at risk for problems because of theirsubstance use.

13 90% of people with active substance use disorder are untreated 5% 10% 85% Did not feel need for treatment Felt need for treatment but did not receive Received specialized treatmentt t

14 Millions of visits to primary care providers each year offers the trusted medical environment for these issues There were 1.1 billion ambulatory care visits There were over 902 million visits to physicians offices Medical personnel are key to early detection and intervention and can reduce morbidity 82% of adults had contact with a healthcare professional 91% of children had contact with a healthcare professional Substance use is related to many presenting medical conditions Most health risks and disease from substance abuse is suffered by people who are not addicted Discussing substance use in the context of general health conditions can reduce stigma associated with substance use 7/25/2013 SBIRT at ACCESS 14

15 SBIRT in Primary Care Setting Unique opportunity for primary care providers to: Educate patients as to the link between their medical condition(s) and substance usage Identify and intervene with those not seeking substance treatment Link health care services and alcohol and drug treatment services Increase access to clinically appropriate care for non dependent as well as dependent persons in a general healthcare setting. 15

16 At-Risk Use At-Risk Alcohol Use (National Institute on Alcohol Abuse and Alcoholism (NIAAA) Guidelines) Men > 14 drinks per week, or > 4di drinks per occasion Women or age > 65 years > 7 drinks per week, or > 3 drinks per occasion At-Risk Drug Use Any illicit drug use in past 3 months 16

17 Increased Risks of Moderate Drinking (# drinks/day) Fetal harm (>0) Violent death (2-3) Infertility (<1) Breast cancer (1-2) Oral, esophageal, laryngeal, pharyngeal, liver cancers (1-2) Alcoholism (>2) Kidney failure (>2) Death (2-3) Cirrhosis (2-3) Hypertension (>3) Medical conditions worsening Depression Medication interactions

18 Alcohol Attributable Fractions (%) Esophageal cancer 75 Chronic pancreatitis 60 Cirrhosis & chronic hepatitis 50 Lip, oral cavity, pharynx, larynx cancer 45 Acute pancreatitis 42 Pulmonary tuberculosis 25 Hepatic cancer 15 Esophageal, stomach, duodenal diseases 10 Hypertension 8 Cerebrovascular disease 7 Diabetes 5 Pneumonia 5 Harwood et al. NIAAA 1998

19 Screening and Brief Intervention In opportunistic ti Settings Shorter, less expensive Rely less on theory, more on relationship Patient may not be motivated Focus is to deliver a message Highly structured Requires flexibility Be mindful of setting Confidentiality issues

20 SBIRT Reframing Addiction in a Chronic Disease Management Model No Disease Severe Disease Screening Addiction Treatment Brief Intervention Recovery Management Self-Management Care Delivery System Community Generalist Health Care Providers Substance Use Disorder Treatment Specialists Mental Health Specialists June 15, 2004

21 Introducing the Screening We ask everyone Confidentiality Tools We ask because it affects your health Time period=1 year By alcoholic beverages we mean By drugs we mean Acknowledge prohibition and encourage candor Standard drink definition

22 Importance of Universal Screening For identifying people p who use alcohol or drugs in a way that puts them at risk for problems or injuries related to their substance use. Part of primary prevention aimed at educating members about the health effects of using alcohol and other drugs. Universal screening reduces stigma by normalizing asking.

23 We Ask Everyone In a society that mistakes substance use disorders for moral failings, many people who develop these disorders stigmatize themselves as strongly as others stigmatize them. SBIRT is a non-stigmatizing approach to screening and intervention which recognizes substance disorders as chronic medical conditions.

24 PA : Uniform Screening Signed by the Governor August 24, 2012 Defines a uniform screening, and when warranted an assessment and referral, in three statutes: Public Aid Code (305 ILCS 5/5-5) (from Ch. 23. par. 5-5) Medical services The Alcoholism and Other Drug Abuse and Dependency Act (20 ILCS 301/10) The Community Services Act (405 ILCS 30/2) (from Ch. 91 1/2, par.902) Effective immediately.

25 PA : Uniform Screening Sec Medical services. The Illinois Department, by rule, shall determine the quantity and quality of and the rate of reimbursement for the medical assistance for which payment will be authorized, and the medical services to be provided, which may include all or part of the following... (13) other diagnostic, screening, preventive, and rehabilitative services, to ensure that the individual's need for intervention or treatment of mental disorders or substance use disorders or co-occurring mental health and substance use disorders is determined using a uniform screening, assessment, and evaluation process inclusive of criteria, for children and adults;

26 Screening: How Many Questions? Prescreen: Four questions: recommended prescreen Two questions: Two 1-question screens Screen: 10 AUDIT (alcohol) questions if prescreen is positive 10 DAST (drug) questions if pre-screen is positive

27 Two Single-Question Screens Alcohol How many times in the past year have you had X or more drinks in a day? (where X is 5 for men and 4 for women, and a response of 1 is considered positive). J Gen Intern Med 24(7):783 8 Other Drugs Have you used drugs other than those required for medical reasons? DAST

28 Four Question Pre-Screen

29 Image adopted from do it drink smarter/

30

31 Universal Screen: AUDIT The Alcohol Use Disorders Identification Test Used to identify persons with hazardous and harmful patterns of alcohol consumption. Developed by the World Health Organization (WHO) as a simple method of screening for excessive e drinking and to assist in brief assessment. Widespread use by both health workers and alcohol Widespread use by both health workers and alcohol researchers.

32 AUDIT Screen + brief assessment of alcohol use 10 items, 0-4 points each Can be self-administered by patient or by staff Use total score to predict risk level & triage patient to intensity of intervention Babor FT, WHO/MSD/MSB/01.6a, World Health Organization, 2001

33 AUDIT Services Indicated Based on Score

34 Universal Screen: DAST Drug Abuse Screening Test DAST-10 First question serves as a pre-screen If client responds No to the first question, stop the DAST, score is 0. If client responds Yes to the first question, ask all of the questions.

35 DAST Services Indicated Based on Score

36 Resources Full AUDIT Toolkit DAST

37 Effective BRIEF INTERVENTION? the evidence says it doesn't look like this 37

38 Brief Intervention Landmark ED Study, 1961 MGH emergency department Men w/ alcoholism (n=200) Brief advice from a psychiatrist vs. none 42% vs. 1% followed-up in an alcohol clinic i Chafetz ME. Q J Stud Alcohol 1961;22:325-8.

39 Brief Interventions for heavy alcohol use Meta-analysis of 12 RCTs, total 3,948 heavy or problem drinkers f/u 6-12 months compared to no intervention: 15-52% etoh use, sick days, GGT Wilk, JGIM 1997;12:

40 Bi Brief fintervention ti in ED with ithetoh+ older adolescents RCT patients years (N=94) At 6 month f/u intervention group reported: significant reduction in alcohol use (p<.001) Less driving after drinking ( p<0.05), less alcohol related injury (p<0.01) less alcohol-related problems (p<0.05) Monti et al. J Consulting & Clinical Psychology, 1999

41 Project ASSERT: Brief Intervention & Referral in ED Health Promotion Advocates SBI & referral 7,118 adult ED patients screened for alcohol & other drug problems 2,931 problem detected (41%) 1,096 enrolled 90 day follow-up (N=245, 22% of enrolled) 67% cocaine/crack use 56% alcohol use, 64% binge drinking > 50% f/u with treatment referral Bernstein et al. Ann Emerg Med, 1997.

42 Personal Change Think of a behavior of yours that you have tried to change in the past - either successfully or not - or a current behavior that you would like to change (smoking, unhealthy eating, unhealthy drinking, driving too fast). Time 1 = when you 1 st began exhibiting the behavior Time 2 = when you first made an earnest attempt to change the behavior How much time elapsed between Times 1 and 2?

43 Helpers Think of individuals who tried to help pyou change your behavior. Now focus only on those whose help you appreciated. List some adjectives that describe these individuals or their manner of helping:

44 Not Helpers Now focus on those individuals who tried to help in a way that you did not appreciate, or in a way that was not effective. List some adjectives that describe these individuals or their manner of helping.

45 Motivational Interviewing Definition: A directive, patient-centered counseling style that enhances motivation for change by helping patients clarify and resolve ambivalence about behavior change.

46 Motivation to Change Motivation is a key to change Motivation is multidimensional Motivation is a dynamic and fluctuating state Motivation is interactive Motivation can be modified Clinician s style influences patient motivation

47 Spirit it of Motivational Interviewing i Collaboration Working in Partnership Elicit Learning from the patient Autonomy Patient is responsible for change Empowerment Help patients take ownership over their own health management Respect

48 Stages of Change Precontemplation Contemplation Maintenance Action

49 MI--Five General Principles Develop Discrepancy Express Empathy Acknowledgeg Accomplishmentsp Roll with Resistance Support Self-Efficacy

50 BI Clinical Approach Relies on rapid assessment (screening) Requires quick and effective engagement Provide feedback Facilitates the change process Implement change strategies Provide information Establishes follow up Babor, Higgins-Biddle, 2001

51 BI Clinical Approach Be empathetic and non-judgmental Patients respond best to sincere concern Be an authority (not authoritative) Patients respond to supportive advice Tailor advice to the stage of change Deflect Denial Don t be confrontational or accusatory Encouragement to change Babor, Higgins-Biddle, 2001

52 Brief Intervention Goals Raise awareness Encourage patients t to talk, explore ambivalence about behavior Goal to develop a plan for change Goal to enhance engagement and follow through

53 Elements of BI 1. Screening and Engagement In the context of patient s health, healthcare 2. Personalized Feedback and Empowerment what you do with this information is up to you 3. Inquire about change Assess motivation, Explore ambivalence, Menu of options and setting goals 4. Summarize Action Plan for Change Support Self-efficacy Follow up

54 FRAMES Feedback I am specifically concerned about your substance use because Responsibility What you do with your substance use is up to you. Advice In my medical opinion, you can best minimize your health risks by Menu What do you think would work for you if you decided to make a change? Empathy It is not easy to change. Self-Efficacy I can see that you are a strong person. 54

55 NIAAA Clinicians i i Guide Helping Patients Who Drink Too Much Ask Assess Advise and Assist

56 WHO BI Manual Draft, 2003

57 5StepBrief Intervention 1-5 for BI; 1-10 for BT (WHO) 1. Ask clients if they are interested 2. Provide personalized Feedback 3. Give Advice on how to reduce risk 4. Allow clients Responsibility for choices 5. Ask clients how Concerned are they

58 10 Step Brief Treatment 1 5 f BI 1 10 f BT (WHO) 1-5 for BI; 1-10 for BT (WHO) 6. Weigh the Good Things about using 7. Against the Less Good Things Decisional Balance-Health, Social, Legal, Financial, Occupational, Spiritual 8. Summarize and reflect Final emphasis on the less good things 9. Ask about Concern for less good things 10. Give Take-home Materials

59 Yale Brief Negotiated Interview 1. Raise the Subject Medical context, establish rapport, assess comfort 2. Provide Feedback Review patterns of use, consequences 3. Enhance Motivation Assess readiness, increase motivation 4. Negotiate and Advise Negotiate goal, give advice 5. Summarize Adapted from Yale SBIRT Training Manual, 2008

60 Brevity Feedback Explore readiness Clients reactions Resolve ambivalence Recommendations Empowerment Action plan Identify barriers Brief Intervention Components of BI Summarizes and Follow-up

61 Stay objective Interviewer Qualities for Effective BI Deliver relevant information Be empathetic and non-judgmental Don t argue Use open ended questions Show the patient you are listening Respect patient choices-patient is a partner

62 Motivational Interviewing Directive but non-authoritarian style Patient-centered, elicits patient s goals Responsibility for change is ultimately patient s Uses supportive strategies (reflective listening) Avoids judgmental & argumentative ti language Explores patient s ambivalence Moves towards change using patient s t own concerns & arguments

63 Why in healthcare settings? Morbidity from alcohol and drug use can be reduced by brief interventions in general health care settings Mainstream medical care should become a part of a continuum of early intervention and treatment for alcohol and drug problems Substance Dependence Disorders, like other chronic medical diseases,, should be identified in medical settings and referred for specialty care

64 Substance Abuse Referrals

65 Warm Referrals Linkage Get to know referral sources, work out what they need and consents Consents Consent may be required to engage g with the provider regarding the client/patient Introductory o Call Call the provider with the client and introduce them to each other Follow Up Call client/patient after the scheduled appointment to debrief and/or reschedule

66 Public Referral System Funded - By a combination of Block Grant, Medicaid and other State Funds Assessment Providers assess client finances and apply a sliding fee scale Changing g Medicaid, d, insurance exchange, private insurance with the Block Grant filling in what isn t covered for some patients Waiting Lists Exist for some services, particularly Outpatient Methadone Therapy and Residential

67 Implementing SBIRT

68 Administrative Considerations Organizational Readiness Target Population(s), Settings and Patient Flow Who will Screen and staffing in general Pre-screen and How Many Questions Implementation: Training, rollout Paper or electronic (or hybrid) Confidentiality and Privacy Considerations for what data will be collected Documentation 68

69 Staffing Models In-House Generalist Staff member trained to perform SBIRT functions in addition to regular job, i.e. triage nurse, physician In-House Specialist Staff member who conducts only SBIRT activities, thus freeing other staff from this role, i.e. health educator Contracted Specialist Outside provider conducts SBIRT services, i.e. co-location

70 Training Modules Administrative Overview Clinic Manager, other administrative staff per clinic, 1 hour Screening and Project Flow all clinic staff, (providers optional unless they are screening), 30 minutes Brief Intervention all clinic staff, including providers, 1 hour Referrals Case Managers or Case Coordinators, 15 Minutes Data Collection and Documentation 15 minutes 70

71 Next Steps Determine if SBIRT is appropriate p for your organization Request Technical Assistance Learn more about SBIRT Implementation Develop a Plan Build Collaborations Engage with Ongoing Support

72 Ongoing Support Free resources, including information and materials that are free to copy and use; Subsequent training available by scheduled interactive webinar and recorded webinar for your convenience. Free targeted ed training and technical ca assistance s a will be available upon request