Blazing New Trails: Shifting the Focus on Alcohol and Drugs


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Presented at the National Academy for State Health Policy's 20th Annual State Health Policy Conference in Denver, Colorado. Authors: Barbara Cimaglio, Sally Fogerty, BSN, M.Ed., John C. Higgins-Biddle, Ph.D.

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  • Blazing New Trails: Shifting the Focus on Alcohol and Drugs

    1. 1. NASHP Annual Conference <ul><li>Blazing New Trails: </li></ul><ul><li>Shifting the Focus on Alcohol and Drugs </li></ul><ul><li>Barbara Cimaglio </li></ul><ul><li>Sally Fogerty, BSN, M.Ed. </li></ul><ul><li>John C. Higgins-Biddle, Ph.D. </li></ul><ul><li>October 15, 2007 </li></ul>
    2. 2. Main Topics <ul><li>What’s the Problem? </li></ul><ul><li>What is Screening, Brief Intervention, and Referral to Treatment? </li></ul><ul><li>What is the Federal Government Doing? </li></ul><ul><li>What States Can Do? </li></ul>
    3. 3. Alcohol and Drugs . . . <ul><li>Kill over 85,000 Americans per year; third leading cause of death </li></ul><ul><li>Cost over $250 billion in lost productivity, health costs, legal and justice issues </li></ul><ul><li>Are perceived to be moral problems, legal problems, social problems, a failure of individual responsibility </li></ul>
    4. 4. Alcohol and Drugs . . . <ul><li>Cause/exacerbate many medical, mental, social and family problems </li></ul><ul><li>Their use is often unidentified by doctors </li></ul><ul><li>Diagnose & treatment of many diseases & disorders often neglect their use </li></ul><ul><li>This applies to many levels of use besides alcoholism and drug dependence </li></ul><ul><li>Understanding requires new perspective </li></ul>
    5. 5. How we address other issues <ul><li>Are you a better driver than a typical 16 year-old male? </li></ul><ul><li>Have you had an auto crash? </li></ul><ul><li>Does your state require seatbelt use? </li></ul><ul><li>Who has more heart attacks: People diagnosed with heart disease; those without heart disease? </li></ul><ul><li>So what? </li></ul>
    6. 6. The Preventive Paradox <ul><li>Large group (LG) with small problems vs. small group (SG) with big problems </li></ul><ul><li>Good drivers (LG) have more accidents than high-risk drivers (SG)—hence seatbelts for all </li></ul><ul><li>Patients without a diagnosis of heart disease (LG) have more heart attacks than those with a diagnosis (SG) —hence screen all for cholesterol </li></ul>
    7. 7. Types of Alcohol/Drug Risk <ul><li>Dependence—a cluster of behavioral, cognitive, and physiological phenomena that may develop after repeated use </li></ul><ul><li>Harmful Use—consumption causing physical, mental, or social harm </li></ul><ul><li>Hazardous Use—consumption causing elevated risk without presence of physical or mental harm (yet ) </li></ul>
    8. 8. Who Causes the Harm? <ul><li>Small group with Dependence experience & cause the most harm </li></ul><ul><li>But there are far more Hazardous and Harmful users </li></ul><ul><li>So Hazardous & Harmful drinkers cause at least half of alcohol/drug harm </li></ul><ul><li>Two ways—high-level regular use and occasions of intoxication lead to work, health, social, legal problems </li></ul>
    9. 9. What we don’t see can hurt!
    10. 10. Biggest Drug Issue: Alcohol <ul><li>Despite publicity, illicit drugs are a small part of America’s problems </li></ul><ul><li>Alcohol misuse dwarfs the problems of illicit drugs </li></ul><ul><li>Misuse occurs in all age, racial, and social groups, and in both genders </li></ul><ul><li>But the biggest problem is not alcoholism </li></ul>
    11. 11. The Drinkers’ Pyramid Dependent Drinkers Harmful/Hazardous Drinkers Responsible Drinkers Abstainers
    12. 12. Treatment alone won’t work <ul><li>For 50 years USA has had the world’s best treatment system but always 5% dependent </li></ul><ul><li>87% of people who need TX don’t want it </li></ul><ul><li>We typically wait 20 years—until dependence-to help people who drink too much </li></ul><ul><li>For every dependent patient who quits or dies, a harmful user becomes dependent </li></ul><ul><li>Meanwhile harmful users produce ½ our harm while we could help many in 5 minutes </li></ul>
    13. 13. Summary of the Problem <ul><li>25% use too much at least once/year </li></ul><ul><li>5% are dependent; 20% are not </li></ul><ul><li>Reducing problems requires finding and helping both groups </li></ul><ul><li>So how can we find them and help the hazardous, harmful, and dependent—each of whom needs somewhat different kinds of help? </li></ul>
    14. 14. We need a new focus <ul><li>Alcohol & drug treatment are not provided where most people regularly go </li></ul><ul><li>To find a health problem among all Americans we must go to general medical settings </li></ul><ul><li>So to find people who misuse alcohol & drugs we must enlist medical services </li></ul><ul><li>This is requiring a new focus & approach </li></ul>
    15. 15. SBIRT Provides a Way <ul><li>S creening identifies degree of risk and likelihood of a condition </li></ul><ul><li>B rief I ntervention helps patients reduce hazardous and harmful use </li></ul><ul><li>R eferral sends dependent patients to specialized T reatment </li></ul>
    16. 16. Screening for Drugs/Alcohol <ul><li>25 years of research in medical sites </li></ul><ul><li>Where people go with health issues and expect to be asked questions </li></ul><ul><li>Self-report screening is quick, accurate, and inexpensive </li></ul><ul><li>Can be done via paper, oral, computer </li></ul><ul><li>Good screens distinguish risk levels </li></ul><ul><li>But do patients get upset? </li></ul>
    17. 17. Patient Comfort
    18. 18. Patient Sense of Importance
    19. 19. Goals of Screening <ul><li>Identify both hazardous/harmful use and those likely to be dependent </li></ul><ul><li>Create a professional, helping atmosphere </li></ul><ul><li>Gain the patient information needed for an appropriate intervention </li></ul><ul><li>Use as little patient/staff time as possible </li></ul>
    20. 20. Who and When to Screen? <ul><li>Not knowing who drinks or uses drugs, we must screen everyone who is able yearly </li></ul><ul><li>Rough estimates of excessive use by setting: </li></ul><ul><ul><li>Primary Care—10-25% </li></ul></ul><ul><ul><li>Ob-Gyn—10-20% </li></ul></ul><ul><ul><li>Emergency—20-40% </li></ul></ul><ul><ul><li>Trauma—40-60% </li></ul></ul><ul><li>Should become as common as blood pressure </li></ul><ul><li>Can be done by existing or special personnel </li></ul>
    21. 21. Brief Intervention <ul><li>Structured brief advice/counseling </li></ul><ul><li>Builds upon screening info </li></ul><ul><li>Non-judgmental, interactive, empathic </li></ul><ul><li>Aims: to reduce or stop use; or to refer patient to specialized treatment </li></ul><ul><li>Cognitive info and motivation to change </li></ul><ul><li>Differing protocols, similar results </li></ul>
    22. 22. Elements of an Intervention <ul><li>Feedback from screening on risks </li></ul><ul><li>Advice to reduce use & risk </li></ul><ul><li>Negotiation of patient acceptance of responsibility & choice of a goal </li></ul><ul><li>Information on limits and “how to” </li></ul><ul><li>Encouragement/Motivation </li></ul>
    23. 23. Referral To Treatment <ul><li>Screening can supply a likelihood of dependence </li></ul><ul><li>Those who are dependent may benefit from a brief intervention but probably need motivation for traditional treatment </li></ul><ul><li>Early identification may get more patients to treatment earlier; thus increasing effectiveness of therapy, decreasing costs </li></ul>
    24. 24. Research Findings <ul><li>Since 1980, 50+ different clinical trials—One 3-5 min. to multiple 15-30 min. sessions </li></ul><ul><li>Most studies show positive results of decreasing use among many (not all) patients </li></ul><ul><li>Effective with all ages, races, genders, ethnics </li></ul><ul><li>Some benefit from follow-up session; least effective with most severe cases </li></ul><ul><li>Low cost: One study--<$1 screen; <$4 doc BI </li></ul><ul><li>Supports a preventive public health service </li></ul>
    25. 25. Policy Actions to Date <ul><li>USPSTF rates evidence for alcohol SBI with Cholesterol Screening and Flu Shots for Elderly </li></ul><ul><li>Most physician societies have endorsed it </li></ul><ul><li>Am. College of Surgeons Com. on Trauma requires it in Level I centers; other levels to follow </li></ul><ul><li>Federal govt. agencies now acting </li></ul>
    26. 26. How to pay for SBIRT <ul><li>CMS issued new Medicaid codes for SBIRT </li></ul><ul><ul><li>H0049 for Screening </li></ul></ul><ul><ul><li>H0050 for Brief Intervention </li></ul></ul><ul><li>Must be adopted within state plans </li></ul><ul><li>AMA will announce in November two CPT codes for SBIRT to be used for private insurance and Medicare beginning Jan. 08 </li></ul>
    27. 27. Federal Agency Actions <ul><li>NIAAA supported research; NIDA beginning </li></ul><ul><li>VA initiated program; IHS starting in trauma </li></ul><ul><li>NHTSA supporting dissemination; CDC supports emergency/trauma dissemination </li></ul><ul><li>White House ONDCP supporting budgets and implementation </li></ul><ul><li>SAMHSA providing large state & university grants; more on the way </li></ul>
    28. 28. SAMHSA SBIRT Initiative <ul><li>Largest Federal program </li></ul><ul><li>11 state/tribal coop. agreements ave. >$2 mil. per year for 5 years; </li></ul><ul><li>12 campus grants ave. $1.3 mil. over 3 years </li></ul><ul><li>Over 500,000 patients screened since 2004 </li></ul><ul><li>Programs in large urban hospitals to small rural clinics </li></ul><ul><li>More grants to come; plus residency training </li></ul><ul><li>Stay informed at: </li></ul>
    29. 29. Massachusetts Implementation of SBIRT into Primary Care Sally Fogerty, BSN, M.Ed. Director, Bureau of Family and Community Health
    30. 30. Four Models <ul><li>MASBIRT – Implementation in one large Boston medical center. Implementation on medical inpatient floors, in one ED and several outpatient clinics. </li></ul><ul><li>3 Mass colleges are completing the final year of their SAMHSA college SBIRT grants </li></ul><ul><li>Twelve Emergency Departments around the state </li></ul><ul><li>Community Health Centers – adolescents and women of child-bearing age integration into regular care </li></ul>
    31. 31. 4 Key Components All Models <ul><li>Screening </li></ul><ul><li>Brief Intervention </li></ul><ul><li>Referral to Assessment and/or </li></ul><ul><li>Treatment </li></ul>
    32. 32. MASBIRT <ul><li>Massachusetts is one of 10 states and one tribal council awarded this SAMHSA funded 5 year grant </li></ul><ul><li>Clinical service that utilizes specially trained Health Promotion Advocates to universally screen and help patients with risky or unhealthy tobacco, drug and alcohol use through brief intervention counseling and facilitated referrals to assessments and specialty addiction treatment. </li></ul><ul><li>Screening in hospital inpatient, emergency department, and rolling out to 4-5 outpatient clinics </li></ul>
    33. 33. MASBIRT <ul><li>3 CHCs will be added in FY08 </li></ul><ul><li>Staffing resources – </li></ul><ul><ul><li>Health Promotion Advocates work with hospital social workers, some clinical staff in clinics – medical assistants, nurses and physicians. </li></ul></ul><ul><li>Standardized questionnaire. Automated patient screening using TLC (telephonic linked care) and a web-based link from EMR to questionnaire and back being developed </li></ul><ul><li>New level of treatment – brief treatment </li></ul>
    34. 34. Massachusetts Colleges <ul><li>Purpose was to screen students and link with services </li></ul><ul><li>Wrapping up and evaluation just being completed </li></ul><ul><li>Three colleges involved: </li></ul><ul><ul><li>Northeastern University, Boston </li></ul></ul><ul><ul><li>University of Massachusetts, Amherst </li></ul></ul><ul><ul><li>Bristol Community College, Fall River </li></ul></ul><ul><li>Issue was campus vs. community services – how do you link and get students to utilize community services. </li></ul>
    35. 35. Emergency Room <ul><li>Specially trained Health Promotion Advocates are funded in emergency departments to screen for tobacco, drug and alcohol use, brief intervention counseling and facilitating referrals </li></ul><ul><li>12 emergency departments – at least one in each region of the state </li></ul><ul><li>800 people screened in August </li></ul>
    36. 36. CHC Integration Model <ul><li>Goal: integration into existing primary care services of on-going screening for </li></ul><ul><ul><li>Violence </li></ul></ul><ul><ul><li>Tobacco use </li></ul></ul><ul><ul><li>Substance use </li></ul></ul><ul><ul><li>Behavioral health issues </li></ul></ul><ul><li>Utilized a new procurement for services for women of reproductive age and adolescents which were previously funded as prenatal and adolescent health programs under MCH. </li></ul>
    37. 37. Integration into CHC Primary Care <ul><li>Joint effort of two program areas: Bureau of Substance Abuse Services and Bureau of Family and Community Health </li></ul><ul><li>Paradigm shift from how care currently delivered for women of reproductive age with focus on pre and intra conception and prenatal period. </li></ul><ul><li>Train existing providers to do screening and brief intervention </li></ul><ul><li>32 programs funded – 17 both adolescents and Women of Reproductive Age; 5 adolescents only and 10 women only. </li></ul>
    38. 38. Process – CHC Integration Model <ul><li>Screening of all individuals at annual visit/prenatal care visit </li></ul><ul><ul><li>Adult screening tools utilized </li></ul></ul><ul><ul><li>CRAFFT for adolescents </li></ul></ul><ul><li>Early identification of individuals at risk for problems or addiction </li></ul><ul><ul><li>Brief intervention if high-risk </li></ul></ul><ul><li>If positive screen further assessment by professional, may or may not be on site, with additional training </li></ul><ul><li>Referral for treatment </li></ul>
    39. 39. Process – CHC Integration Model <ul><li>Primary care site will follow-up to ascertain individual goes for first appointment </li></ul><ul><li>Collaboration between Primary Care and Treatment providers. </li></ul>
    40. 40. Implementation CHC Integration Model <ul><li>Identifying an SBIRT champion </li></ul><ul><li>Regional trainings by substance abuse vendor </li></ul><ul><ul><li>Basic Overview </li></ul></ul><ul><ul><li>Interview skills </li></ul></ul><ul><ul><li>Referrals </li></ul></ul><ul><li>One-on-one at each site to develop plan to integrate into existing care </li></ul>
    41. 41. Where are we – 1 year later CHC Integration Model <ul><li>100% integrated tobacco </li></ul><ul><li>90+ integrated violence </li></ul><ul><li>Substance abuse/behavior health </li></ul><ul><ul><li>1/3 have integrated utilizing questionnaire </li></ul></ul><ul><ul><li>1/3 in process majority “tweaking” electronic medical record to incorporate questions </li></ul></ul><ul><ul><li>1/3 still at early stage of implementation </li></ul></ul>
    42. 42. CHC Integration Implementation Challenges <ul><li>Takes time – long learning curve </li></ul><ul><li>Need to change “pattern” of how care delivered – asking to do something new according to prescribed questions difficult </li></ul><ul><li>RFR spelled out expectations and requirements but needed to reinforce and reinforce. </li></ul><ul><li>If just setting up electronic medical record easier </li></ul>
    43. 43. What have we learned? <ul><li>Basic acceptance of Concept </li></ul><ul><li>Development of HCSPCS codes for CMS billing and CPT codes may promotes screening and brief intervention </li></ul><ul><li>Implementation in all sites requires change in process and is a challenge </li></ul><ul><li>Need to have a champion </li></ul><ul><li>If provide “trained advocate” easier to begin implementation and collect data but sustainability is questionable </li></ul>
    44. 44. What Have We Learned <ul><li>Need to have treatment/referral resources available and easy to access. </li></ul><ul><li>Need to have relationships between health care and substance abuse/behavioral health treatment providers. </li></ul>
    45. 45. What States Can Do <ul><li>Executive Organization </li></ul><ul><ul><li>Substance abuse agencies often do not relate to general medicine. Coordinate across many agencies & budgets to reposition the focus & linkages </li></ul></ul><ul><ul><li>A public health issue affecting economic development, health, safety, & more (see below) </li></ul></ul><ul><ul><li>Establish relations with Level I trauma centers now developing programs & link treatment programs </li></ul></ul><ul><ul><li>Work with state medical society to develop programs, provide training, and TA </li></ul></ul>
    46. 46. What States Can Do <ul><li>Economic Development/Labor </li></ul><ul><ul><li>Educate employers that hazardous/harmful users cause lower productivity and higher health costs </li></ul></ul><ul><ul><li>Encourage SBIRT coverage in all health plans </li></ul></ul><ul><li>Health/Insurance </li></ul><ul><ul><li>Assure insurance reimburses cost for intoxicated patients so health services can screen & get paid </li></ul></ul><ul><ul><li>Include new HCPCS codes in state Medicaid plan </li></ul></ul><ul><ul><li>Encourage state insurers/HMOs to cover new CPT codes </li></ul></ul><ul><ul><li>Get state-supported medical systems to include SBIRT </li></ul></ul>
    47. 47. What States Can Do <ul><li>Administrative Services—Include SBIRT services in health plans for state employees </li></ul><ul><li>Higher Education—Implement SBIRT in campus health services </li></ul><ul><li>Veterans Affairs—Implement SBIRT </li></ul><ul><li>Legislature —Require SBIRT inclusion in state plans & set measurable goals and timelines </li></ul><ul><li>Everywhere: Educate all in state leaders & legislators about the real problem & SBIRT </li></ul><ul><li>Stay informed at: </li></ul>