Screening and brief intervention partnering with primary care   field
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  • 1. 2/1/2012 Craig Field, PhD, MPH Associate Professor Program Director Screening & Brief InterventionHealth Behavior Research       & Training Institute Trauma Department UT Austin University Medical Center at Brackenridge craig.field@austin.utexas.edu 2 Source: JAMA, 2004. Source: CASA Columbia University, 1994. 3 1
  • 2. 2/1/2012 Source: Closing the Addiction Treatment Gap, 2010. 4 Substance use services have been focused in two areas:  Primary Prevention – Delaying onset of substance use.  Tertiary Prevention (Treatment) – Providing time, cost,  and labor intensive services to patients who are acutely  or chronically ill. 5Substance Dependent No Problem 6 2
  • 3. 2/1/2012Substance Dependent Treatment No Problem No Intervention 7 U.S. Population 8 Dependent 9 3
  • 4. 2/1/2012 Excessive 10dependent 4% dependence symptoms harmful 25% hazardous low risk 71% current abstinence lifetime abstinence 11 6 1 12 4
  • 5. 2/1/2012 We could provide a 100% cure to every substance  dependent person in the United States we wouldn’t be  close to curing most of the substance related problems  in our country. 13 4% Dependent 25% Heavy Drinkers 71% Low or No Risk 14 The health care system routinely screens for potential  medical problems (cancer, diabetes, hypertension),  provides preventative services prior to the onset of  acute symptoms, and delays or precludes the  development of chronic conditions. 15 5
  • 6. 2/1/2012 Substance Use Is A Public Health Problem 16# Service Preventable  Cost  Burden Effectiveness1 Aspirin: Men 40+ Women 50+ 5 52 Childhood Immunizations 5 53 Smoking Cessation 5 54 Screening & Brief Intervention 4 55 Colorectal Cancer Screening 4 46 Hypertension Screening and  5 3 Treatment Source: Am J Prev Med 2006; 31 (1) 52-61 17 6
  • 7. 2/1/2012 Maximum Daily Limits Maximum Weekly LimitsWomen 3 7Men 4 14Men >65 3 7 Less is Better! Source: NIAAA, 2009 19 Our prime directive should no longer be limited to  identifying people who are dependent and need higher  levels of care. Our prime directive should also be to identify those  who are at moderate or high risk for psycho‐social or  health care problems related to their substance use  choices. 20  SBIRT uses a public health approach to universal  screening for substance use problems.  SBIRT provides:  Immediate rule out of non‐problem users;  Identification of levels of risk;  Identification of patients who would benefit from brief  intervention, and;  Identification of patients who would benefit from higher  levels of care. 21 7
  • 8. 2/1/2012 Brief  Brief  Out‐ Hospital‐ Screening Interven‐ ization Inpatient Therapy patient tion 22 Stepped‐Care Model  Try to intervene with the least complicated and/or  least costly intervention.    Proceed to the next level of intervention only if the  student fails to respond to the first.  Requires follow‐up to determine if the intervention  was effective. SBIRT is a primary, secondary,  and tertiary prevention and  treatment strategy designed to  intervene based on patient need  and prevent/treat substance use  problems at various levels. 24 8
  • 9. 2/1/2012  Pre‐screening (universal).  Full screening (for those with a positive pre‐ screen).  Brief Intervention (for those scoring over the cut  off point). 25 Brief Treatment (for those who have moderate risk,  high risk, abuse, or dependence, would benefit from  ongoing, targeted interventions, and are willing to  engage). Traditional Treatment (for those who are dependent  and are willing to engage). 26 Universal Brief Screen Positive Reinforcement Negative Low Risk: Positive Positive Reinforcement Moderate Risk: Brief Intervention Further Moderate – High Risk: Screening Referral to Brief Therapy High Risk: Referral to Treatment 27 9
  • 10. 2/1/2012 Severity of Alcohol ProblemsDependent drinking/Alcoholism SBIRTHarmful drinking/Abuse SBIRisky/Hazardous drinkingSafe drinking ScreenAbstinent  SBIRT is an evidenced based practice that is supported  by:  Center for Substance Abuse Treatment  The World Health Organization  The American Preventative Task Force  The American Trauma Nurses Association  The American Medical Association  The American College of Surgeons  The Office of National Drug Control Policy 29  DUI  Injury  Violence  Pregnancy  STD  Substance Dependence  Health Care Problems 30 10
  • 11. 2/1/2012 New Referral Streams Evidence‐based Practices Improved Outcomes Enhanced Relationships with Health Care More Inclusive Continuum of Care Broader Patient Base Alternate Funding Streams Larger Role and Increased Credibility 31 • Healthcare reform provides an  opportunity for SBIRT • Emphasis on preventive care and wellness • Integration of primary and behavioral  health • SBI as essential health benefit 32 Screening is a broad term defined as a range of  evaluation procedures and techniques. A screening  instrument does not result in a clinical diagnosis, but  indicates the probability that the condition looked for is  present. A brief intervention is a short (10‐15 min) conversation  based on motivational interviewing that ends on good  terms and improves chances that the person that is  involved in risky alcohol consumption will alter their  behavior to reduce risk. 11
  • 12. 2/1/2012Dunn C. et al. Hazardous drinking by trauma patients during the year after injury. J Trauma. 2003;54:707–712. 12
  • 13. 2/1/2012 Precontemplation = Never Contemplation = Maybe Preparation = Soon Action = NowDunn C. et al. Hazardous drinking by trauma patients during the year after injury. J Trauma. 2003;54:707–712. 13
  • 14. 2/1/2012 14
  • 15. 2/1/2012 The absolute risk reduction implies that only nine patients  would need to receive a BI to prevent one DUI arrest.  Level I & II Trauma Hospitals  “The trauma center does not have a mechanism to identify  patients who are problem drinkers: Level I Trauma Hospitals  “ The trauma center does not have the capability to provide  intervention or referral for patients identified as problem  drinkers” ‐ COT Resources for Optimal Care of the Injured Patient 2006‐ 15
  • 16. 2/1/2012 Substance use screening, brief intervention, referral,  and treatment (SBIRT) is a systems change initiative requiring us to re‐conceptualize, how we  understand substance use problems,  re‐define how we identify substance use problems,  and re‐design how we treat substance use problems. 48 16
  • 17. 2/1/2012• Getting buy‐in at all levels • Administrators • Clinical • Business• Cost savings• Reimbursement is available• The Joint Commission• The American College of Surgeons• Committee on Trauma• SBIRT purpose and effectiveness • Evidence base The World Health Organization The American Preventative Task Force The Emergency Nurses Association The American Medical Association The American College of Surgeons/COT• Patient stories 17
  • 18. 2/1/2012 • Cost savings were $89 for each patient  screened and $330 for each patient provided  with a BI • Reduced health expenditures were $3.81 for  every $1.00 spent on SBI • If SBI was routinely offered to eligible injured  adult patients the potential net savings would  exceed $1.5 billion annually. Source:  Gentilello, Eble, Wickizer, et al., (2005). Alcohol Interventions for trauma patients treated in  emergency departments and hospitals: A cost benefit analysis. Annals of Surgery, 241(4):541‐550.  • Needs assessment • Inform, educate and train staff • Define your target population • Develop clear protocols • Establish relationships  • Develop a charting protocol • Develop a billing strategy • Develop a data collection and storage plan • Develop quality improvement initiatives • Establish referral networkConduct a facility needs assessment thatconsiders patient demographics, patientflow, time requirements, internal andexternal policy, staffing resources, fiscalresources, space, IRB requirements, andtechnology.  54 18
  • 19. 2/1/2012• Top down and bottom up support• Internal champion• Internal and external policy • Current screening protocols• Training needs• Space• Patient flow• Patient demographics• Technology  • Hospital Administration • Chief of Trauma Surgery • Trauma Nurse Coordinator • ER Nurse Manager • Behavioral Health Staff • Business office staff  • Medical Records • Legal department (HIPAA/42 CFR, Part 2). 56• Who is the population to be served? • Who will provide the service?• What tools will they use?• When/where will the service be  provided?• How will records be kept?• How will the services be billed? 19
  • 20. 2/1/2012 Who, how many, when, and where you screen will affect  the time requirements for interventions.  Typical patient service sequences and lengths of stay will  influence when interventions can be performed. The type and length of intervention you choose will affect  time availability.  How you will cover different shifts (if necessary) will affect how many interventionists you need.  Whether you have intervention personnel also perform  screening or have others do screening will affect time  required. 58 • Which patients will you screen? • Universal vs. targeted • Dependent users/Risky users • Adults/Adolescents (consent) • Which patients will you exclude from  screening? • What substances will you screen for • Will you screen for mental health • Who will conduct pre‐screen/screen • When and where will screening be conducted • How will results be documented • How will results be communicated 20
  • 21. 2/1/2012• Who will conduct the brief intervention• Which BI support materials will be used• Which patient handouts will be used• When and where will brief intervention be conducted• How will goals be documented• How will goal be communicated • Knowledge and experience• Interpersonal skills• Willingness to take on responsibility• Flexibility in work schedule• Where will chart note be kept • Main medical record • Locked files • Separate from the medical record• What information will be included  related to the screen and/or brief  intervention• Determine the flow of information,  paperwork, and data 21
  • 22. 2/1/2012Payer Code Description FeeCommercial CPT 99408 Alcohol and/or substance abuse structured $33.41 screening and brief intervention services; 15 to 30 minutes Alcohol and/or substance abuse structured CPT 99409 screening and brief intervention services; greater than 30 minutes $65.51Medicare G0396 Alcohol and/or substance abuse structured $29.42 screening and brief intervention services; 15 to 30 minutes Alcohol and/or substance abuse structured G0397 screening and brief intervention services; greater than 30 minutes $57.69Medicaid H0049 Alcohol and/or drug screening $24.00 Alcohol and/or drug service, brief intervention, H0050 per 15 minutes $48.00 64 • CMS authorized two new HCPCS codes to reimburse  for SBI. • States may choose not to activate these codes. • CMS has authorized the use of two new G codes to  reimburse for SBI. • These codes can be billed beginning January 08. • The AMA has authorized the use of two new CPT  codes to reimburse for SBI. • Insurance carriers may choose not to reimburse these codes. 65 • Who will monitor and report SBI productivity • Who is collecting your trauma data • What will be reported and to whom • % of all patients eligible  to be screened • % of all eligible for screening actually screened • % of all those screened who screened positive • % of all those positive screens who received a BI 66 22
  • 23. 2/1/2012 • What data do you collect • How do you collect data • Can you incorporate your SBI data into the  Trauma Registry • How do you ensure data security 67 Screening, Brief Intervention & Referral for Treatment for Trauma Patients Trauma Patients Meeting Criteria : 187 September 16 – October 15, 2011 Self Report/BAC/UDS Brief Interventions Provided Outcomes: Discharge Prior,  16 Discharge  Negative Interventions  Prior, 12 108 44 Positive Unable to  63 Participate, 6 Decline, 1Summary: Admission Order Set: UDS Collected• Patients screened 91.4% • Trauma 74.8%• Patients had UDS drawn 55.1% • Hospitalist 48.7%• Patients had BAC drawn 64.0% • Surgery 8.3%• Brief Interventions provided 77.2% Screening, Brief Intervention & Referral for Treatment for Trauma Patients Trauma Patients Meeting Criteria : 1825 December 15, 2010 – December 15, 2011 Self Brief Interventions Provided Report/BAC/UDS Discharge prior, 119  Outcomes: Negative, 941  Discharge  Interventions, prior, 89  Interventions, 38 533 Positive, Positive, 765  Unable to  67 participate , 92 Shift, 42 Decline, 9Summary:• Patients screened 93.2 %• Total Urine Drug Screen  52.0 %• Total BAC drawn 63.2%• Brief Interventions provided 84.5% 23
  • 24. 2/1/2012 Extrapolating from data presented in peer reviewed publications, program activities last year are estimated to have prevented 59 arrests for driving while intoxicated following discharge and 26 readmissions for treatment of a traumatic injury.  Given that the average cost of admission for a traumatic injury in a Level 1 Trauma Center is $14,567, $378,742 in healthcare cost will be avoided in the next three years as the result of reductions in rates of injury recidivism.  Given that the net cost savings of the intervention has been estimated at $89 per patient screened or $330 for each patient offered an intervention, total healthcare cost savings from the program are conservatively estimated at nearly $250,000.  In summary, screening and brief intervention for at risk drinking fills a gap in current services, the program has positively impacted the lives of patients and the surrounding community at no, or minimal costs to the organization. • What are your outcome measures • What are your training requirements • How do you monitor fidelity 71 24
  • 25. 2/1/2012RESOURCES 25
  • 26. 2/1/2012 Rethinking Your Drinking  RethinkingDrinking.niaaa.nih.gov  Physician’s Guide  niaaa.nih.gov Brief Intervention  who.int/substance_abuse  26
  • 27. 2/1/2012 Health Behavior Change a Guide for Practitioners  Rollnick, Mason & Butler Motivational Interveiewing in Health Care: Help  Patients Change Behavior  Arkowitz, Westra, Miller & Rollnick 1. One thing you liked. 2. One thing you liked less, thought was missing and/or  would’ve like to heard more about. 27