Brief intervention begins by informing the patient about the meaning of the screening results. This includes a very brief explanation of the total score in relation to the cutoff norms for problem use. This feedback should also reflect the patient’s subjective profile. As the patient learns about his or her screening score, the provider helps the patient appreciate why it has evoked concern.
Individual motivation has been shown to correspond to a theoretical model of change that identifies stages through which individuals pass in the process of modifying their behavior. The stages of change model has five different stages.Pre-contemplationContemplationPreparationActionAnd Maintenance
It is very important to meet the patient where they are, in other words speak at a level in which they can understand. The patient will be much more receptive when you; are a good listener, present in an open manner and show concern. Provide your feedback in a non judgmental manner. The following slides will provide tools which will enable you to accomplish this goal.
When providing a Brief Intervention it is helpful to take the Frames approach. In other words Provide Feedback about how the patient s alcohol or other drug use is affecting their current or future health status.Letting then know that the Responsibility is on the patient to change their behaviorYou may give Advice based on your medical concernsAnd also provide the patient with a Menu of options for changeAlways use EmpathyAnd reinforce the patients belief in their own ability to change (Self-efficacy)
The first step in delivering feedback or brief Intervention to a patient is to ask the patient for permission to share the results. Then proceed when given permission to inform the patient of the meaning of the screening results as you have interpreted them. In addition it may include a very brief explanation of their total score in relation to the cut off norms for problem use as listed in the drinkers pyramid. This feedback should also reflect the patients subjective profile. As a patient learns about his or her screening score, the provider helps the patient appreciate why it has evoked concern. This is an opportunity for the provider to frame the results in the context of a health assessment using the screening results in the same fashion as an elevated clinical laboratory value. As a provider offers this feed back care must be taken to avoid blame or the implication of scolding. State your conclusion and recommendation clearly.
Patients motivation is increased when their primary care physicians or healthcare provider relate how their alcohol or drug use is impacting their health. By recognizing their alcohol or drug use and relating it to their health the patient has a better chance of increasing their motivation to reduce or abstain from their current level of use. The follow are examples of integrating advice with health issues.Remember to relate your concerns to the patients concerns and medical conditions if present. Consider the potential interaction with medication that the patient is now using or you are going to prescribe. Another tool is the drinkers pyramid. It illustrates the distribution of persons who achieve various audit scores and where they fall on the drinkers pyramid. Sometimes incorporating the drinkers pyramid in a brief advice session can motivate a patient to consider reducing or abstaining from their current patterns of use.Giving advice provides the opportunity for the provider to frame the results in the context of a health assessment. Again as the provider offers this feedback, care must be taken to avoid blame or the implication of scolding. State your conclusion and recommendation clearly. By recognizing their alcohol and / or drug use and relating to their health, the patient has a better chance of increasing their motivation to reduce or abstain from their current level of use.
Another important component of providing a Brief Intervention is remembering that it is the patients responsibility to change. Your job is to merely plant the seed in order to help the patient consider change.
Giving advice without telling what to do . Always ask the patients permission to discuss their substance use before providing information about their use. Patients need to be active in discussing options, but the ultimate goal is that they make the decision. It is better to suggest than to tell people what to do. Offering advice with permission can be either in the form of making a suggestion or explaining educational information. It is important to note that educational information is factual data that is based on creditable information. Facts that relate specifically to the patients health, substance use or other information that is shared through the assessment should be presented in a non threatening way. Advice should be simple and matched to the patients level of understanding and readiness.
Perhaps one of the most challenging steps of the Frames approach is to express Empathy. Empathy entails reflective listening. In other words listening attentively to each statement and reflecting it back in different words so that the patient sees you understand what they are saying. To Be empathic is to convey warmth, respect, caring commitment and personal interest in the patient. The patient does most of the talking when a safe environment is created. Allow the process to flow which will permit the patient to move in a new direction. This does require patience particularly when a patient is resistant. It is imperative that they be allowed the opportunity to talk about their resistance to a non-judgmental person that does not react to their defenses.
To succeed in changing patients must understand that they have the ability to change. This will require self-confidence or self-efficacy in their ability to succeed fully to take steps toward a goal. The steps need to be small. One of the most important roles that you will have is to foster hope and optimism by reinforcing their ability to be successful. Sometimes this means capitalizing on other changes that the patient has made before, reminding them of their previous success and drawing parallels to their substance use, assuring the patient that he or she can be successful and that you are there to help them.
Resistance is normal and should be expected. However, the provider should not revert into being the expert and telling the patient what to do. Rather, listen to what the patient is saying. They are providing you with very valuable information. Here are a few examples you may encounter and how to respond to these situations.
In order to gain some insight into how people change stop and think about your own behaviors. Pick a behavior that you are ambivalent about changing. Whether it be your diet, exercise or smoking. What stage would you say you fall into? What would it take for you to move into the next phase?
For more examples of Brief Intervention please click on the following link.
The goals of Intensive Intervention can be adapted to outcomes that correspond to each stage of change. Intervention programs often fail because of the mismatch between the individual’s readiness to make changes and the intervention program’s focus on action. When people are not ready to commit to a change in their behavior, they ordinarily react to being pressured or pushed into change by becoming resistant and defensive or they become even more ambivalent about change and view the message as irrelevant to their personal situation. Efforts to persuade individuals who may be contemplating changing their behavior but aren’t yet ready, are seldom as effective as efforts to assist them in resolving their ambivalence or strengthen their own motivation. In this slide the goals of Intensive Intervention in the Pennsylvania SBIRT Project are listed.
In Pennsylvania, each region approached the delivery of II differently. In Allegheny County, the II was delivered on-site by the Healthcare Educator that was employed by the site and properly trained and supervised in providing this level of service. In Bucks County, II was delivered as part of an intervention program within the community overseen by the Bucks County Council on Alcoholism & drug Dependence. In Philadelphia, a contracting provider agency worked with the Einstein Medical Health Care system to complete Brief Treatment with the patients that were referred by the medical provider to the providing agency.
In order to overcome some of the frustrations with regards to making referrals to specialized treatment providers. Pennsylvania recommends establishing a connection with a substance abuse treatment provider in your area and creating a referral system prior to implementing SBIRT into your daily routine.In Pennsylvania, each county has a Single County Authority that oversees the substance abuse treatment providers. Establishing this connection with the county was vital in accessing treatment services for patients with Medicaid, those that were under-insured, uninsured or did not have coverage for this specialized treatment. This allowed for easier access to treatment services.In addition the County can serve as a lead in:Making referrals to treatment providersResources County funding processesAct 106 informationAnd to help cultivating personal relationships between the providers both medical and specialized treatment
There is support building for screening and brief intervention. The American Medical Association developed codes 99408 and 99409 for screening and brief intervention in the medical community. In addition 10 states have activated the Center for Medicaid Service codes for screening and brief intervention. For more information on the subject we recommend you go to www.ensuringsolutions.org.
In addition to the AMA CMS codes there is continued support building for Screening and Brief Intervention amongst private insurers. Health plans who have committed to paying for Screening and Brief Intervention are listed In addition, JCAHO recently called for input into what role if any it might play in developing standards for Screening and Brief Intervention in various Medical Settings.
The following is a list of resources or online trainings that are available for implementing SBIRT.
3 to 5 minutes<br />Provides education about current use and potential risks of current use pattern<br />Health education approach<br />Matches patient’s stage of <br /> change – no arguing,<br /> pushing, or dragging!<br />Basics of a Brief Intervention<br />
Stages of Change: Meeting Patients Where They Are<br />Stages of Change Model<br />Stages of Change and Corresponding Needs of Patients<br />Intensive Intervention and Motivational Levels/Stages of Change<br />
Stages of Change<br />Provides an Understanding and appreciation of Behavior Change<br />Cyclical in nature<br />Applicable in Lifestyle Behavior Changes<br />Disease prevention<br />Disease management<br />Anticipates relapse<br />Recognizes barriers to change<br />
Meeting Patients Where They Are<br />Take the Health Promotion Approach<br />Do you wear seat belts?<br />Are you safe in your current relationship?<br />Do you smoke?<br />Do you use non-prescription drugs?<br />Respect the patient’s autonomy, culture, and choices<br />Listen <br />Show concern<br />Provide feedback<br />Don’t shame, blame, preach, or stereotype <br />
“A client-centered, yet goal-directed counseling method to resolve ambivalence about health behavior change by building intrinsic motivation and strengthening commitment” <br />-Miller & Rollnick, 2002<br />Motivational Interviewing (MI)<br />
MI In Healthcare Settings<br />DirectingGuidingFollowing<br /> Acute “Tour Guide” Nothing can be done<br />
Identification of use, misuse, and problematic use; screen with simple direct methods<br />Connection of use/misuse to health related issues and feedback <br />Consumption reduction<br />Brief Intervention <br />Referral for formal assessment<br />Role of the Healthcare Professional in SBIRT<br />
Feedback: how their use may impact their current and future health<br />Responsibility: patient’s responsibility to change their behavior<br />Advice: based on medical concern<br />Menu: variety of options for change<br />Empathy: attitude<br />Self-efficacy: reinforce patient’s belief in their own ability to change<br />FRAMES<br />
Ask permission to share results<br />Screening results and interpretation <br />Score in relation to:<br />norms<br />low-risk limits<br />consequences that others with similar results often experience <br />Feedback<br />
Based on fact and medical concern…<br /> “I will be prescribing medication for your pain. However it has a negative interaction with alcohol. I am concerned that your alcohol use will interfere or lead to additional problems if you drink while on medication.”<br /> “ I appreciate your honesty in reporting your marijuana use. I am concerned about your asthma and how marijuana use in addition to your smoking may lead to further complications.” “I would like for us to meet with our Healthcare Specialist to work on a plan to reduce or abstain your marijuana use.” <br /> “You are having a hard time falling asleep at night, so you have 4 drinks to help. Let’s talk about other ways to help you sleep.” <br />Advice-Integrated with Health Issues <br />
Responsibility for change is on patient, not provider.<br />Patient’s task to articulate and resolve ambivalence about change.<br />Responsibility<br />
Giving Advice-Without Telling What to Do<br />Ask for permission:<br /> “There is something that <br /> concerns me. Would it be ok if I shared my concerns with you?”<br />Preface advice with permission to disagree: <br />“This may or may not be helpful to you…”<br />
Your patient has options that they can decide what works best for them. These include:<br />Cutting down on their use<br />Reducing harm associated with use<br />Quitting all use<br />Getting help<br />Absolutely nothing<br />You provide the options, let them make the choice<br />Patients have Options<br />
Open<br />Nonjudgmental<br />Reflective<br />Understand patient’s frame of reference<br />Acceptance and affirmation<br />No “authoritative/expert” tone <br />Express Empathy<br />
What positive changes has patient made before?<br />Remind patient of their previous successes<br />Draw parallels to substance use <br />Assure patient that he/she can be successful and that you will assist <br />Self-Efficacy<br />
Responding to Resistance <br />“Look, I don’t have an alcohol problem.”<br />“My dad was an alcoholic and I’m not like him.”<br />“I can quit anytime I want to.”<br />“This isn’t what I came for.”<br />“Everybody drinks during the Steelers game.”<br />“I’m not going to push you to change anything you don’t want to.”<br />“I’d like to give you information, what you do is up to you.”<br />“I’d like to hear your opinions about…”<br />“What are some things that bother you about your use?”<br />
Pick a behavior that you are ambivalent about changing (diet, exercise, smoking, etc). Practice with a partner. <br />It will help you better relate to patients who are ambivalent about changing their alcohol or other drug use!<br />
Brief Intervention Videos <br />Click below to view video examples from the NIAAA<br />http://www.niaaa.nih.gov/Publications/EducationTrainingMaterials/VideoCases.htm<br />Or Click Here to view the videos from The BNI-ART Institute<br />http://www.ed.bmc.org/sbirt/cases.php<br />
AUDIT 16-19<br />Positive DAST<br />Refuses referral to treatment<br />Remission for one substance but abuses another substance<br />Medications that may interact<br />Few social supports <br />Presence of co-occurring medical or mental health problem<br />Prior treatment or attempts at recovery<br />Waiting for treatment admission<br />Pregnant patients (previous or current use)<br />Criteria for Intensive Intervention (II) <br />CLINICAL JUDGMENT<br />
Make decision regarding changing current use<br />Develop plan of action to support decision<br />Increase internal motivation for recovery/treatment<br />Identify, address, and work through ambivalence<br />Reduce risk of harm<br />Increase awareness of problems <br />Assess how patient thinks and feels about self in relation to substance use<br />Educate patient<br />Set realistic goals that allow experience of success<br />Goals of II<br />
Who can do II?<br />Where should II be done?<br />What are some models for II?<br />Structure of II<br />
Referral to Treatment<br />About 2-5% need formal drug/alcohol treatment (not all will accept)<br />Physicians in focus groups frustrated with: <br />Facilitating access to treatment - related to decreased desire to screen at all<br />Lack of effective referral system<br />Waiting lists or denial by third party payers even when patient was eligible <br />Treatment enrollment rules and regulations <br />
How can the County serve as the Connector between healthcare and specialized substance abuse treatment?<br />Info and referral<br />Resource listings<br />County funding process <br />Act 106 information <br />Cultivate personal relationships <br />Making Connections<br />
Support Building for SBI<br />AMA Codes <br />99408 Alcohol and/or substance (other than tobacco) abuse structured screening (e.g., AUDIT, DAST), and brief intervention (SBI) services; 15 to 30 minutes and 99409 greater than 30 minutes. <br />CMS Codes<br />Medicare fee-for-service schedule (FFS) patients: G0396 Alcohol and/or substance (other than tobacco) abuse structured assessment (AUDIT, DAST), and brief intervention (SBI) services; 15 to 30 minutes and G0397 greater than 30 minutes.<br />SBI codes for Medicaid: H0049 Alcohol and/or drug screening and H0050 Alcohol and/or drug services, brief intervention, per 15 minutes. <br />
Support Building for SBI<br />JCAHO recently called for input into what role if any it might play in developing standards for SBI in various medical settings.<br />Health plans that have committed to paying for screening and brief intervention (SBI), when covered under particular plan documents, include: <br />AETNA (nationwide) <br />CIGNA (nationwide) <br />Anthem Blue Cross and Blue Shield (Colorado, Connecticut, Indiana, Kentucky, Ohio, Maine, Missouri, Nevada, New Hampshire, Virginia, and Wisconsin) <br />Blue Cross of California <br />Blue Cross Blue Shield of Georgia <br />Blue Cross Blue Shield of Minnesota <br />Empire Blue Cross Blue Shield of New York <br />Independence Blue Cross <br />HealthPlus (Michigan) <br />HealthPartners (Minnesota)<br />
Resources & Online Trainings<br />PA SBIRT site: www.ireta.org/sbirt<br />National SBIRT site: http://sbirt.samhsa.gov<br />MI: www.motivationalinterview.org<br />NIAAA Helping Patients Who Drink Too Much: A Clinician’s Guide and Related Professional Support Resources http://www.niaaa.nih.gov/Publications/EducationTrainingMaterials/guide.htm<br />American College of Emergency Physicians video training http://acepeducation.org/sbi<br />Boston University Alcohol Screening and BI Curriculum<br />http://www.bu.edu/act/mdalcoholtraining/<br />ACOG Drinking and Reproductive Health FASD Prevention Tool Kit<br />http://www.acog.org/departments/healthIssues/FASDToolKit.pdf<br />Web BI University of Vermont<br />http://dln.uvm.edu/webbi/index.html<br />Alcohol Screening and Brief Intervention for Trauma Patients Committee on Trauma Quick Guide<br />http://mayatech.com/cti/sbitrain07/include/SBIRT_COT_Guide.pdf<br />
Thank You <br />For additional information about implementing SBIRT, please contact IRETA at 412-258-8565 <br />