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Screening for Behavioral Health

Martha Kurgans, L.C.S.W.Department of Behavioral Health and Developmental Services

January 30, 2015

Substance use, emotional problems and intimate partner violence threaten the health and safety of women and their newborns.

Women who experience one or more of these problems are often reluctant to acknowledge it.

These risks often co-occur - placing women at even greater risk.

The best way to identify who is “at risk” is to routinely screen all women at regular intervals.

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Identifying Women at Risk

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• Pregnant women are at greater risk to experience depression and/or domestic violence than non-pregnant women.

• Pregnant women who use drugs and alcohol place their unborn infant at risk.

• 2013 National Survey Drug Use and Health (NSDUH): Substance Use During Pregnancy Alcohol use: 9.4% (VA=9,575)* Tobacco use:15.4% (VA=15,687)* Illicit drug use: 5.4% (VA=5,501)*

Pregnancy Increases Risks

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During Pregnancy

2007 – 2008* Physical abuse: 4.8% Alcohol use: 8.6% Tobacco use:12.5% Reported depression: 26%

2010 -2011*Physical abuse: 3.4 % Alcohol use:11.5%Tobacco use: 8.3 %

Virginia’s PRAMS* Data

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• Sleep Related Infant Deaths in Virginia (2014), Child Fatality Review Team : • Reviewed 119 cases of sleep related infant deaths;

determined substance use was a major factor that contributed to these deaths.

• Maternal Mortality Review Team – will soon release their report on unintentional overdose Reviewed 397 cases of maternal deaths that occurred

between 1999-2007. Determined that substance use contributed to 96 of these deaths (24.4%).

41 of the 397 women overdosed (10%); 34 of these overdoses were unintentional.

Recent Virginia Reports

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Earlier identification of substance use and referral to treatment might have prevented these deaths.

Providers failed to implement Virginia laws which were designed to identify and refer pregnant and postpartum substance using women to needed treatment and services.

Similar Conclusions

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SBIRT : a public health model intended to identify individuals who may have or be at risk to develop a substance use disorder (S.U.D.)

SBIRT identifies those “at risk” of developing substance use disorders and provides brief intervention on the spot.

Screening, Brief Intervention, Referral to Treatment (SBIRT)

Draws on principles of motivational interviewing when conducting a brief intervention

Builds upon the idea that those with few problems or mild problems who are “at risk” may benefit from a brief intervention with a non-substance abuse specialist

Acknowledges that those with significant problems usually need specialty care, like addiction treatment services and encourages their referral to specialty care.

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What is SBIRT ?

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Model can also be used to identify and refer individuals who experience other behavioral health risks◦ Emotional problems, including perinatal depression◦ Intimate partner violence◦ Tobacco use

In Virginia, SBIRT has already been used in primary care, mental health, and community settings to intervene with women who may have co-occurring behavioral risks.

What is SBIRT?

Screening: Administer a brief screening tool that can identify if a woman may have a behavioral health problem.

Brief Intervention: If she screens as “at risk”, in 3-5 minutes, elicit the woman’s perspective on her problem and what risks she may experience if her situation continues and doesn’t change. The intervention is matched to her level of knowledge and motivation. Only bits of information are provided to supplement what she knows. No pushing or arguing is involved. Invite her to discuss again at next visit.

Referral to Treatment : If she screens as “ dependent/ having a problem” and is receptive to being referred, refer her for an assessment to determine appropriate treatment and services.

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SBIRT’s Core Components

Screening: ◦ A standardized set of questions you ask – not a

medical test, exam or history.◦ Indicates whether a thorough assessment is

needed.◦ Does not determine a diagnosis or what type of

treatment is needed◦ Can be completed by a variety of service

providers

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Screening Versus Assessment

◦A Substance Use or Mental Health

Assessment must be completed by a qualified service provider (QSP) in that field

◦ To determine an individual’s diagnosis and develop an initial treatment plan, the QSP obtains a comprehensive history of their

past and current functioning other related problems and risks social supports and motivation

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Screening versus Assessment

A brief instrument or set of questions that is intended to detect the possibility of a problem

Cannot diagnosis a problem but can indicate if further assessment is needed

Ideally, it should be: ◦ Brief and easy to use◦ Inexpensive◦ Non-intrusive◦ Tested (validated) on the population its to be used with◦ Within the expertise of a wide range of professionals

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“Screening Tool”

Screen all clients Screen for substance use, emotional

health and intimate partner violence Screen periodically Utilize a standard tool or protocol Ask questions in a health context – this

lessens the stigma Use everyday language; be honest and

direct Use a positive, non-judgmental and non-

confrontational approach

Screening Best Practices

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Substance use, mental health (including perinatal depression) and tobacco use: Virginia’s Behavioral Health Screening Tool

Substance Use : 4 P’s or 5 P’sMental Health: PHQ2 or PHQ9Perinatal Depression: Edinburgh Depression

Scale or Edinburgh 3Intimate Partner Violence : AAS or WEB/RAT

Suggested Screening Tools for Pregnant and Parenting Women

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Simple, effective way to screen women for high risk behaviors, tobacco use and perinatal depression all at one time.

Combines validated screening tools◦ The “5Ps” screens for substance use in women◦ The “Edinburgh 3” screens for perinatal depression◦ Questions on intimate partner violence (IPV).

◦ Can be provider or self administered. Available in 3 languages.

Virginia BehavioralHealth Risks Screening Tool

SBIRT :

Providing a Brief Intervention

The SBIRT model incorporates Motivational Interviewing (MI), a method to have a constructive conversation about change.

MI is based on the belief that

◦ people are ambivalent about change and continue harmful behaviors because of their ambivalence.

◦ MI helps people resolve their ambivalence and increase

their motivation to change.

◦ Motivation for change can be fostered by an accepting, empowering, and safe atmosphere

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Brief Intervention

Empathy (provide support) Develop Discrepancy (encourage individuals

to question their own behavior) “Roll with Resistance” (don’t argue) Support Self-efficacy (empower)

No matter whether you’re addressing substance use, intimate partner violence or a mental health concern, the same MI principles apply.

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Principles ofMotivational Interviewing (MI)

Most women want what is best for their baby

Sometimes, education alone can be sufficient to promote change

Even brief interventions can trigger change. Assess the problem, her motivation to make changes and adjust the intervention, Set appropriate goals with her.

If additional services are needed, a warm handoff will ensure a successful referral.

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Can a Brief Intervention Really Help?

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Providers should be familiar with

Treatment resources available in their community and how to access them.

Community support services that can help individuals overcome barriers they may experience related to transportation, child care and/or funding.

Federal confidentiality regulations as well as state legislation that may impact on their patients and be prepared to discuss them.

Before Making Referrals

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Community Service Boards: provide public mental health, substance use, and intellectual disabilities services • Required to provide gender specific outpatient substance

use treatment to pregnant & parenting women Pregnant substance using women receive treatment priority.

Must be seen within 48 hrs of their request for services.• Services for perinatal depression may be more difficult to

access

6 women’s residential substance abuse treatment programs in the Commonwealth accept pregnant women

Crisis stabilization units (CSU’s) will accept pregnant women

Treatment Resources

Explain the referral process, the importance of sharing information and their role coordinating the woman’s treatment with the new provider

Explore and address any questions or concerns their patient might have about the referral as well as how it will or won’t affect their work with her.

Discuss confidentiality. Have the woman sign a release so they can make the referral and share critical information. Encourage the woman to sign a release with the new provider as well so they will also be able to share information.

Assist the woman and help her make the appointment. Provide support and encouragement.

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When Making a Referral

Follow up to be sure she contacted the organization, received necessary services and was helped.

Continue to support the woman’s efforts, provide encouragement and support any positive efforts to change

Periodically, check back . Stressors and events in her life may change over time.

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After Making a Referral

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Training regarding SBIRT and implementing M.I. techniques is available through face to face and web based instruction.

The SBIRT process gets easier and quicker

with practice. The more often providers screen individuals the more comfortable they will become using this approach.

Screening is intended to stimulate open discussion between patient and providers

Developing SBIRT Skills

Recognize and support her accomplishments

Educate her regarding the importance of remaining “risk “ free. ◦ “Based on what you’ve said today, it seems like

you are not at high risk of substance use problems. This could change, and if it does, let me know if you want to talk about it.”

Let her know that help is available if something changes.

What If She Doesn’t Identify Any Risk Areas?

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• Screening is intended to encourage discussion between a woman and her provider

• These are very difficult issues to discuss. What’s most important is that women know their provider is familiar with these issues and is willing and able to talk about them.

• As women develop trust in their treatment provider, they may be more able to acknowledge their problems and share concerns.

What if She’s NotHonest or Denies her

Problem?

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What If She Doesn’tFollow Through With

Referrals? Continue to encourage her to follow through with

recommended referrals. Empathize with her struggle Convey a clear interest in her and her effort Help her set achievable goals Support any positive attempts to change Avoid arguments. The client should be the one

arguing for change. Acknowledge that now may not be the best time,

but invite her to talk further at another visit.

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Medicaid will reimburse for substance abuse screening and brief intervention services 3 times per year per provider

CPT99408 (>15 min) =$25.84CPT99409 (>30min) = $50.38

Client must be Medicaid eligible; Provider must be Medicaid approved.

Provider must use a DMAS approved substance use screening tool and document their intervention

SBI Medicaid Coverage

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Screening tools & guidance are available on the DBHDS website

http://www.dbhds.virginia.gov/individuals-and-families/substance-abuse/substance-abuse-screening/pregnant-women-childbearing-age

Virginia’s Home Visiting Consortium (HVC) provides a skill based series for home visitors on Screening and Brief Intervention◦ Why Screen? (web based)◦ Motivational Interviewing (1 day training)◦ SBIRT for Risky Health Behaviors (1 day training)

SBIRT Resources

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SBIRT/ Substance Abuse and Mental Health Services Administrationhttp://www.samhsa.gov/sbirt

SBIRT CORE Training Programhttp://www.sbirttraining.com

SAMSHA –HRSA Center for Integrated Health Solutionshttp://www.integration.samhsa.gov/clinical-practice/sbirt

The Big Hospital SBIRT Initiativehttp://hospitalsbirt.webs.com/webinars.htm

SBIRT Resources

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Behavioral health (substance use, tobacco use, emotional health, intimate partner violence) impacts on maternal and fetal outcomes.

Women are receptive to screening when done in a health context and presented in a nonjudgmental manner.

Use screening tools suited for pregnant women.

Screening enables providers to intervene before women experience more serious consequences.

Review