sbirt implementation clayton chau, md, phd medical director, behavioral health services
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SBIRT Implementation Clayton Chau, MD, PhD Medical Director, Behavioral Health Services [email protected]. Updated 04/21/2014. Goals. Definition Understanding the benefit The tool and the process The training requirements. Definition. - PowerPoint PPT PresentationTRANSCRIPT
SBIRT Implementation
Clayton Chau, MD, PhDMedical Director, Behavioral Health [email protected]
Updated 04/21/2014
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Goals
DefinitionUnderstanding the benefit The tool and the processThe training requirements
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Definition
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Screening, Brief Intervention& Referral to Treatment
(SBIRT)
SBIRT
Screening
Referral to
Treatment
Brief Interventi
on
An evidence-based method to intervene in unhealthy alcohol and drug use, but underemployed in medical settings.
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Key Terms
• Screening – A brief set of questions that identifies risks of substance use related problems
• Brief intervention – Brief counseling that raises awareness of risks and motivates client/patient toward acknowledgment of problem and initiates changes
• Referral – Procedures to help client/patient to access specialized care
Why implement SBIRT?
High prevalence of unhealthy alcohol and drug use
Significant morbidity, mortality, and cost
Screening instruments work
Brief interventions effective, inexpensive, and acceptable
VS.Routine and universal screening
Inconsistent and selective assessment
SBIRT Business as usual
Validated screening toolsNon‐systematized narrativequestions
Alcohol use seen as a continuum
Alcohol use seen as dichotomous
Evidence-based, patient-centered change talk
Ineffective, directive style of communication
Transition between primary care and treatment
Dis-coordinate/unclear referrals and follow up
NIAAA. Manwell, 1998
Unhealthy alcohol use among PC patients
Low risk or abstention:
78%
Low-risk limits
Drinks
per week
Drinksper day
Men 14 4
Women 7 3
All age >65 7 3
Unhealthy use: 22%
Stratified prevalence of alcohol
use among PC patients
Manwell, et. al, 1998
Low risk: 38%Abstain: 40%
5%8%9%
Dependent
HarmfulRisk
y
Risky zone
I
IIIIIIV
Risky
• Risky drinking likely leads to new health problems or makes existing ones worse
• This zone defined by quantity alone
• Any illicit drug use is risky
• Repeated negative consequences
• Failure to fulfill major obligations
• Use continues despite persistent problems
• Associated with “alcohol abuse”
The Harmful zone
I
IIIIIIV
Harmful
Donovan, et al. 2006
The Dependent zone
• Patient’s life orbits around use
• Distress or disability
• Tolerance and withdrawal
• Use in larger amounts or longer period than intended
• Persistent desire to quit (or failed efforts)
I
IIIIIIVDepende
nt
Donovan, et al. 2006
MMWR Weekly, 2004, Naimi, 2002
• Chronic liver disease & cirrhosis
• Eight specific cancers
• Heart disease• Pancreatitis• Stroke• Injuries• Pneumonia• Seizures
• Gastritis/PUD• Alcoholic
Cardiomyopathy• Interacts with many
medications • Exacerbates
numerous chronic medical conditions (HTN, DM, PUD, etc.)
Unhealthy alcohol use associated with:
Risks of unhealthy drinking, cont.
Disorder Odds
Anxiety Disorders 2.6xMood Disorders (especially Major
Depression) 4.1x
Personality Disorders 4.0x
Antisocial Personality Disorder 7.1x
Drug Dependence 36.9x
Nicotine Dependence 6.4x
Grant., et al, 2004
Alcohol: Psychiatric co-morbidity
Odds of co-occurrence of Current (12-month)
NY Times 2009:•Government spending related to
substance use reached $468 billion
in 2005.
•Most spending went toward direct health care costs or law enforcement,
including incarceration.
•Just over 2% of the total went to prevention, treatment and addiction
research.
Public spending on substance use
Evaluations of SBIRTMeta-analyses & reviews: More than 34 randomized
controlled trials Focused primarily on at-risk and
problem drinkers
Result: 13-34% reduction in alcohol consumption at 12 months
Moyer et al, 2002; Whitlock et al, 2004; Bertholet et al, 2005
USPSTF, 2004 and 2013
• For both alcohol screening and brief intervention
• Adults and pregnant women
• Insufficient evidence for adolescents
USPSTF on SBI
Class B
rating
Screening &
intervention cost per pt.:
$177
Cost savings per
patient
$1170
Benefit / cost ratio:6.6/1
SBIRT effectiveness
• Fewer hospitalizations & ER
visits
• Cost savings:
Fleming, et al, 2002
Washington state SBIRT ER
project• 2003-2008 study implementing
SBIRT in ER depts.
• Medicaid savings from pts receiving BI: $185-192 per member per month
• Due to less inpatient hospitalizations from ER admissions
Estee, et al, 2008
Missed opportunities in primary care
Prevalence of ever discussing alcohol use with a health professional:
• 16% of U.S. adults overall
• 17% of current drinkers
• 25% of binge drinkers
• 35% of those who reported binge drinking ≥10 times in the past month
CDC, 2011
Missed opportunities in primary care
Most patients (68-98%) with alcohol abuse or dependence are not detected by physicians
Physicians are less likely to detect alcohol problems:
• When screening tools are not used universally
• In patients who they do not expect to have alcohol problems: whites, women, higher SES
Friedman et al., 2000; Yersin et al., 1995; Wilson et al., 2002.
0
20
40
60
80
100
8%2%
Perc
en
tHypothetical patient: Top 5 physician diagnoses (Survey of 648 PCPs) Male vs Female
CASA, 2000
Clinician barriers to discussing alcohol with
patients57.7%Belief that patients lie
35.1%Time constraints29.5%Fear that it will question patient’s integrity25% Fear of frightening/angering patient15.7%Uncertainty about treatments12.6%Personally uncomfortable with subject11% May encourage patient to see other MD10.6%Insurance doesn’t reimburse PCP time
CASA: Missed Opportunity: National Survey of Primary Care Physicians and Patients on Substance Abuse, April 2000
Miller, et al. 2006
Agree/Strongly Agree
“If my doctor asked me how much I drink, I would give an honest answer.” 92%
“If my drinking is affecting my health, my doctor should advise me to cut down on alcohol.”
96%
“As part of my medical care, my doctor should feel free to ask me how much alcohol I drink.”
93%
Disagree/Strongly Disagree
“I would be annoyed if my doctor asked me how much alcohol I drink.” 86%
“I would be embarrassed if my doctor asked me how much alcohol I drink.” 78%
Survey on patient attitudes
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Understanding The Benefit
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The Policy
•In 2013, the USPSTF recommended that clinicians screen adults
age 18 years or older for alcohol misuse and provide persons engaged
in risky or hazardous drinking with brief behavioral counseling
interventions to reduce alcohol misuse
•Effective January 1, 2014, California offers Alcohol Screening, Brief
Intervention, and Referral to Treatment (SBIRT) benefit in primary care
settings to all Medi-Cal beneficiaries, 18 years and older
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Process
• Pre-screen
• (Expanded) Screening
• Brief intervention: One to three 15-minute sessions
• Referral to Treatment: the Department of Public Health/Substance Abuse Prevention & Control program
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Pre-Screen• A single alcohol screening question included in the Staying
Healthy Assessment (SHA) which must be conducted within 120 days of enrollment and every three years with annual reviews of the member’s answer
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Screen• Screen members 18 years of age and older who answer
“yes” to the alcohol question in the SHA or at any time the PCP identifies a potential alcohol misuse problem.
• Recommended screening tool – the Alcohol Use Disorders Identification Test (AUDIT) (or the Alcohol Use Disorder Identification Test—Consumption (AUDIT-C))
Developed by the World Health Organization (WHO) as a simple method of screening for excessive drinking and to assist in brief assessment
10 questions – multiple choices Accurate across many cultures/nations
Brief Intervention• Members screened positively for risky or hazardous alcohol
use or a potential alcohol use disorder (Zone III) shall be offered up to three 15-minute brief interventions (per member per year)
• Each intervention is limited to one (1) session per unit, 15 minutes per unit, per member
• Brief intervention services may be provided on the same date of service as the expanded screen, or on subsequent days
• Each intervention can be offered in-person or via telephone or telehealth modalities
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The Effects
•Brief interventions trigger change• A little counseling can lead to significant change, e.g., 5 min. has same impact as 20 min.
• SBI can reduce accidents, injuries, trauma, emergency department visits, depression, drug- related infections and infectious diseases• SBI for alcohol saves $2 - $4 for each $1.00 expended
• Research is less extensive for illicit drugs, but promising
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Behavior change
Awareness of problem
Motivation
Presenting problem
Screening results
Referral to Treatment
Members should be referred to the Department of Public Health/SAPC for Drug Medi-Cal SUD services if they:
Didn’t respond to the brief interventions; or Were screened positively for possible alcohol use
disorder (Zone IV); or Whose diagnosis is uncertain
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Referral to Treatment
• Approximately 5% of patients screened will require referral
to substance use evaluation and treatment
• A patient may be appropriate for referral when:• Assessment of the patient’s responses to the screening • reveals serious medical, social, legal, or interpersonal • consequences associated with their substance use
•These high risk patients will receive a brief intervention followed by referral
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Purpose: determine diagnosis and appropriate
level of care:
• Level I: Outpatient treatment
• Level II: Intensive outpatient treatment
• Level III: Residential/inpatient treatment
• Level IV: Medically managed intensive
inpatient treatment
Substance abuse treatment
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The Reimbursement•Screen, using a Medi-Cal approved screening instrument, and billed with HCPCS
code H0049, is limited to one unit per recipient per year, any provider. Note - the pre-
screen or brief screen is not reimbursable. Diagnostic code???
•Brief intervention services may be provided on the same date of services as the full
screen, or on subsequent days, using HCPCS code H0050. The brief intervention is
limited to three sessions per recipient per year, any provider
•For the Federally Qualified Health Centers (FQHCs) and the Rural Health Clinics
(RHC) providers, the costs of providing SBIRT services are included in the all-inclusive
prospective payment systems (PPS) rate. SBIRT services that meet the definition of an
FQHC/RHC visit, as defined in the Rural Health Clinics (RHCs) and Federally Qualified
Health Centers (FQHCs) section of the Part 2 – Medi-Cal Billing and Policy manual, are
billable
•Any claims reimbursed for more than the maximum units per year are subject
to recovery by the Department of Health Care Services (DHCS).
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The tool
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Standard Drink in the US• 1 standard drink = 14 grams of pure alcohol (about 0.6 fluid
ounces or 1.2 tablespoons)
• Standard drink equivalent: Beer: 12 oz = 1 22 oz = 2
16 oz = 1.3 40 oz = 3.3 Table wine: a 5 oz glass = 1
a standard 750 ml (25 oz) bottle = 5 Malt liquor: 12 oz = 1.5 22 oz = 2.5
16 oz = 2 40 oz = 4.5 Hard liquor or ‘80-proof spirits’:
a pint (16 oz) = 11
a fifth (25 oz) = 17
1.75 L (59 oz) = 39
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The AUDIT
Tool
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AUDIT Scores
*Continue monitoring with each intervention
Risk Level AUDIT Score Intervention
Zone I 0-7 Alcohol Education
Zone II 8-15 Simple Advice
Zone III 16-19 Brief Intervention
Zone IV 20-40 Referral to Treatment
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The Training Requirements
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Requirements• SBIRT services must be provided by a licensed health care
provider (PCP/PA/NP/Psychologist) or a non-licensed staff working under the supervision of the licensed health care provider
• Non-licensed staff must be trained in SBIRT services in order to provide services
• The supervising licensed provider and the non-licensed providers of SBIRT services must attest that they have obtained the required trainings on SBIRT within the first 12 months. The training is a one-time requirement
• The reporting and monitoring requirements will follow as per DHCS
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Training Requirements for Licensed Providers
At least one supervising licensed provider per clinic or practice must take 4 hours of
SBIRT training within 12 months after initiating SBIRT services
*Beyond the first 12 months of providing SBIRT services, at least one
supervising
licensed provider per clinic or practice must have completed training
At all times, rendering licensed providers are highly encouraged, but not required,
to take training in order to provide the services
A minimum of 4 hours of SBIRT training is highly encouraged for both supervising
and rendering licensed providers within the first 12 months; however, the rendering
licensed providers are not required to take the training in order to provide the services
For solo physician practices, the physician is highly encouraged, but not required,
to take the training within the first 12 months.
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Training Requirements for Non-licensed Providers
Trained non-licensed providers: Includes health educators, certified addiction
counselors,
health coaches, medical assistants, and non-licensed behavioral health assistants
Requirements:Be under the supervision of a licensed provider
Complete a minimum of 60 documented hours of professional experience such
as coursework, internship, practicum, education or professional work within their
respective field.
Should include 4 hours of training directly related to SBIRT services
such as Motivational Interviewing
Complete a minimum of 30 documented hours of face-to-face client contact
Within his or her respective field, in addition to the 60 hours of clinical professional
experience described above.
These contact hours may include internship, on-the-job
training, or professional experience and SBIRT services training.
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SBIRT Training•SAMHSA funded – Addiction Technology Transfer Center Network:
“Foundations of SBIRT” at http://www.attcelearn.org/
•NIAAA Clinician’s Guide Online Training “Video Cases: Helping Patients Who Drink Too Much” at http://www.niaaa.nih.gov/publications/clinical-guides-and-manuals/niaaa-clinicians-guide-online-training
•SBIRT Core Training Program: Screening, Brief Interventions, and Referral to Treatment at http://www.sbirttraining.com/sbirtcore
•NAADAC’s The Addiction Professional’s Mini-Guide to Screening, Brief Intervention and Referral to Treatment (SBIRT) at http://www.naadac.org/theaddictionprofessionalsminiguidetosbirt
•SBIRT Oregon Training Curriculum for Primary Care at http://sbirtoregon.org/training.php
•Institute for Research, Education & Training in Addictions – SBIRT in Action – Another Vital Sign at http://ireta.org/webinarlibrary
•New York State’s SBIRT Training Provider Certification at http://www.oasas.ny.gov/workforce/training/SBIRTCert.cfm
*Other trainings resources can be found on DHCS website at www.dhcs.ca.gov
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L.A. Care Behavioral Health Contacts
• Leilanie Mercurio, Health Services Coordinator, 213-694-1250 x4456, [email protected]
• Clayton Chau, Medical Director, [email protected]
• Suzie Matsuda, Director of Clinical Services, [email protected]
• Nicole Lehman, Director of Operations, [email protected]
• Anthony Perera, Administrative Manager, [email protected]
• Robert (RJ) Key, Program Manager, [email protected]
• Torhon Barnes, Care Coordination Manager, [email protected]
• Hieu Nguyen, Strategic Initiatives Manager, [email protected]
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