Screening, Brief Intervention and Referral to Treatment (SBIRT) (Part 2 of 2) Pam Pietruszewski National Council for Behavioral Health February 23, 2017
1. Understand the clinical components of SBIRT and best practices around this framework 2. Define Motivational Interviewing and its role in SBIRT 3. Provide examples of SBIRT implementation strategies in primary care practices
Blood Pressure Screening: Prevention & early intervention to reduce the risk of heart disease No one would refuse to screen for hypertension or diabetes out of fear it might upset a patient. - CDC, 2014
Preventive Services Rankings Based on Clinically Preventable Burden + Cost Effectiveness #1 Immunizations children Tobacco use screening, brief prev counseling youth & adults #2 Alcohol screening & brief intervention adults Aspirin daily low dose adults 50-59 at higher CVD risk Cervical cancer screening women 21-65 Colorectal cancer screening adults 50-75 #3 Chlamydia and gonorrhea screening sexually active women 24 and older women at increased risk for infection Cholesterol screening - adults Hypertension BP screening - adults Maciosek, M. et al. Ann Fam Med 2017;15:14-22
40% Abstinent/ Low risk The SBIRT View: Continuum of Alcohol Use 35% Moderate risk SBIRT Target Population 20% High Risk Brief Intervention 5% Abuse/Dep. Specialized Treatment Primary Prevention Dawson, Alcohol Clin Exp Res 2004; Grant, Drug Alcohol Dep 2004 5
A Paradigm Shift Not looking for addiction Looking for unhealthy substance use patterns Looking for opportunities for early intervention Meeting people where they are
Designed to provide: 1. Universal screening for substance use 2. Secondary prevention (detecting risky or hazardous substance use before the onset of a substance use disorder) 3. Early intervention SBIRT is a comprehensive, integrated public health model 4. Timely referral and treatment for people who have a substance use disorder SAMHSA, Technical Assistance Publication (TAP) Series 33. 2013
SBIRT Work Flow Screening No Use or Low Risk Use Moderate Risk Use High Risk Use Reinforce healthy choices Brief Intervention Referral to Treatment Follow-up
Screening A systematic way of identifying potential for problems using a standardized, reliable and valid tool
What s wrong with this screening?
Example Screening Tools AUDIT Alcohol Use Disorder Identification Test Alcohol Adults DAST Drug Abuse Screening Test Drugs Adults ASSIST Alcohol, Smoking, and Substance Abuse Involvement Screening Test Alcohol, Drugs, Tobacco Adults CRAFFT Car, Relax, Alone, Forget, Family or Friends, Trouble Alcohol & Drugs Adolescents http://www.integration.samhsa.gov/clinical-practice/sbirt/screening
AUDIT
Risk level AUDIT Results Low risk 0-7 Hazardous Use 8-15 Harmful Use 16-19 Possible dependence 20-40 Babor, 2016 IJADR
Adult Low Risk Drinking Guidelines NIAAA, 2010
CRAFFT
Risk level CRAFFT Results Low No use in past 12 mo and score = 0 Medium No use in past 12 mo and yes to Car question OR Use in past 12 mo and score < 2 High Use in past 12 mo and score 2 Knight, 2002 Arch Pediatr Adolesc Med
Single Occasion Weekly Over Time IMMEDIATE RISKS Motor vehicle crashes Pedestrian injuries Drowning Falls Intimate partner violence Depressed mood Homicide & suicide Unintended firearm injuries Alcohol poisoning Unprotected sex (leading to STI s & unintended pregnancy) Assaults Child abuse & neglect Property crimes Fires LONG-TERM RISKS Gastric distress Hypertension Cardiovascular disease Permanent liver damage Cancer Pancreatitis Diabetes Alcoholism Chronic depression Neurologic damage Fetal alcohol spectrum disorders (which include physical, behavioral, and learning disabilities) CDC, 2014
Screening in Context As part of our commitment to your overall health and well-being, we have a set of questions we give everyone. We use this information so we can align services with your needs and goals. 18
Brief Intervention To raise a person s awareness of risks associated with substance use, elicit internal motivation for change, and help set behavior change goals A 5-30 minute conversation depending on setting, procedure codes
BI Focus Based on Risk Low Risk/Abstinence Focus on affirming healthy choices, reinforcing person s reasons for non-use Moderate Risk High Risk Focus on reduced use and reduced risky behavior Focus on achieving commitment to return and accepting treatment
BI Models 1. FRAMES Feedback Responsibility Advice Menu of options Empathy Self-efficacy 2. Brief Negotiated Interview Raise the Subject Provide Feedback Enhance Motivation Develop a Plan 3. FLO Feedback Listen & understand Options explored
Stages of Change
Contemplation Stage: Explore Ambivalence What are the good things about? What are the not so good things about? Benefits Downsides
Increasing Change Talk What would need to happen for you to want to make a change? (Desire) How would you do it if you decided? (Ability) What s the best thing that could happen if you cut back? (Reason) What s most important to you? (Need)
Readiness Rulers On a scale of 0 to 10, how important is it for you to do something different? On a scale of 0 to 10, how confident are you that you can do something different?
Framing Success Reducing risk, quantity, frequency What would a shift in use look like? What might be your next step?
Referral to Treatment A process involving proactive and collaborative coordination between SBIRT providers and those providing substance use disorder treatment to ensure a person has access to and engages in an appropriate higher level of care regarding the consequences associated with their substance use. http://www.integration.samhsa.gov/sbirt/tap33.pdf
Help clients trust the process By being part of the process Steven over at the treatment center is really good at I d like to touch base to see how you re doing
RT Considerations Are staff prepared to discuss types of treatment, levels of intensity and duration and admission requirements? Is there a policy for internal vs external referrals? What is expected for documentation? Who does the warm hand off? Do you have workflows with accountability Who follows up on no-shows How is information shared Frequency of communication
What if the person does not want a referral? Make a Follow Up Plan Even one additional visit can significantly improve intervention effectiveness Collaborate on time frame, connect to other visits & services ( hook ) Opportunity to check-in and see how things are going with the plan
Implementation Tips Organizational support is critical. Expect workflows to evolve. Incorporate brief screens into other lifestyle questionnaires. Ensure that screening tools are being appropriately introduced and framed in order to prevent patients from feeling targeted. Strong BIs require ongoing training and practice. Referrals benefit from strong bidirectional relationships & warm hand offs. Make data a team member. Have a plan for keeping your board, payers, customers and community aware of this new service.
What Happens When SBIRT Sticks Improves clinical care Transforms culture Prepares your organization and workforce for health care changes Expands reach to new audiences Replaces less effective screening methods Views substance use on a continuum, with biological and behavioral factors
Resources National Council SBIRT Training & Consultation thenationalcouncil.org/sbirt National Institute on Alcohol Abuse and Alcoholism (NIAAA) niaaa.nih.gov/ Substance Abuse Mental Health Administration (SAMHSA) samhsa.gov/sbirt CDC Implementation Guide cdc.gov/ncbddd/fasd/documents/alcoholsbiimplementationguide.pdf Kognito Online SBIRT Training & Assessment go.kognito.com/health
Location: Gaylord National Resort & Convention Center, National Harbor, MD Pre-Conference Events the week prior (Hill Day Policy Institute, MHFA, MMA, WHAM) Pre-Conference University programs: April 22 Hill Day visits: April 25 th NatCon18.TheNationalCouncil.org
Thank You Pam Pietruszewski pamp@thenationalcouncil.org