Feasibility of SBIRT at KPCO          Carmen R Martin, MPH           Jennifer Boggs, MSW                      HMORN Confer...
What is SBIRT? Screening, Brief Intervention and Referral to Treatment    – Broadly supported by SAMHSA; adapted into mul...
SBIRT Implementation at KPCO   Pilot 1: Implementation Planning   Pilot 2: Pilot Implementation   Pilot 3: Implementation ...
Design: SBIRT Pilot 1                            Members        English-Speaking                    Spanish-Speaking      ...
Member Focus Groups                    • Well visit in past 3 months     Participants   • 2 groups, various membership dur...
Behavioral Health    Behavioral              Chemical             Mental Health     Medicine              Dependency    Sp...
Primary Care - Nursing Nurses and Nurse managers  – Generally supportive  – To gain buy in, need to discuss SBIRT validit...
Primary Care - Physicians “Intellectually” support the idea Where to go for help? (BMS vs MH vs CD) Perceived patient r...
REFERRALS                                          REFERRALS                                                              ...
KPCO Systems Issues – Pilot 1 Appropriate timing – Depression Governance Council , Rx  Drug Abuse Pilot, KP’s “New Realit...
KPCO Pilot 2 Plan – Implementation at one clinic  – Literature review - Executive Summary for Clinic Staff  – Collaboratio...
KPCO Pilot 2 Plan Evaluation   – Members screened vs. members eligible, %BI, %RT   – Compare to matched non-implementatio...
KPCO Pilot 2 so far….. Clinic is in midst of new roles from the “New Reality” and  trying to introduce SBIRT.    “This i...
Pilot 1 recommendations vs. REALITYGain high level leadership        Hard to do with short timeinvolvement and support.   ...
Thank you to our study team: Alanna Kulchak Rahm, ArneBeck, David Price, James W Dearing, Thomas E Backer, LKendall Krause...
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Feasibility of Implementing Screening Brief Intervention and Referral to Treatment at Kaiser Permanente Colorado RAHM

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  • Overall – not knowledgable about SBIRT, Very positive as group about use in primary care to identify moderate risk individuals
  • Once we review key facilitators and barriers by each stakeholder group, we’ll need to incorporate this information into our implementation strategies, e.g., if RNs’ concern is liability, we’ll want to address this directly and show the limits of their liability, and who can back them up (for example BMS, BH, etc.)
  • Last Carmen slide, transition to Jenn. Competing demands (clinical priorities, initiatives)
  • Hard when you have a funding timeline that doesn’t line up with clinic timeline.
  • Defin SBIRT CO. A 3 month post-implementation follow-up period (months 10-12) will follow. Measures of the number of patients screened and numbers referred for brief intervention or treatment at the implementation clinic will be compared with those at a matched non-implementation clinic. Brief intervention utilization will be determined for the implementation and usual care clinics through chart review of all identified at-risk individuals for delivery of brief intervention elements. This chart review will also record type of provider delivering the brief intervention (e.g. physician, nurse, BMS). Qualitative measures of implementation will include exit interviews or focus groups with all implementation clinic staff related to satisfaction with care pathway, challenges and successes of implementation, unintended consequences, and intention to continue SBIRT as part of standard care. Similar interviews and focus groups will be conducted with BMSs, Chemical Dependency, and Mental Health providers.
  • A 3 month post-implementation follow-up period (months 10-12) will follow. Measures of the number of patients screened and numbers referred for brief intervention or treatment at the implementation clinic will be compared with those at a matched non-implementation clinic. Brief intervention utilization will be determined for the implementation and usual care clinics through chart review of all identified at-risk individuals for delivery of brief intervention elements. This chart review will also record type of provider delivering the brief intervention (e.g. physician, nurse, BMS). Qualitative measures of implementation will include exit interviews or focus groups with all implementation clinic staff related to satisfaction with care pathway, challenges and successes of implementation, unintended consequences, and intention to continue SBIRT as part of standard care. Similar interviews and focus groups will be conducted with BMSs, Chemical Dependency, and Mental Health providers.
  • Talk about helpful learnings from Pilot 1, such as…..Executive Summary of literature as being helpful in addressing evidence for SBIRT, confidentiality concerns for patient diagnostic data of alcohol and drug use, PCP will not want anything added to their HMV agenda, BMS instrumental for delivering MI and doing assessment for further treatment.
  • Feasibility of Implementing Screening Brief Intervention and Referral to Treatment at Kaiser Permanente Colorado RAHM

    1. 1. Feasibility of SBIRT at KPCO Carmen R Martin, MPH Jennifer Boggs, MSW HMORN Conference May 2nd, 2012
    2. 2. What is SBIRT? Screening, Brief Intervention and Referral to Treatment – Broadly supported by SAMHSA; adapted into multiple sets of questions – Validated, now applied millions of times SBIRT is a universal screening protocol that requires little time of the patient, the provider, or the healthcare system Target : the 25% of Americans who are “risky’ drinkers/substance users (not the 4% with dependencies, nor the 70% of abstainers/low risk) One of a class of screener protocols for risks of various kinds (alcohol, drugs, inactivity, poor mental health, etc)
    3. 3. SBIRT Implementation at KPCO Pilot 1: Implementation Planning Pilot 2: Pilot Implementation Pilot 3: Implementation Planning Outside KPCO Dissemination Studies
    4. 4. Design: SBIRT Pilot 1 Members English-Speaking Spanish-Speaking Behavioral Health Behavioral Medicine Mental Health Chemical Specialists Dependency Primary Care Physicians Nurse Managers Front Line Nurses4
    5. 5. Member Focus Groups • Well visit in past 3 months Participants • 2 groups, various membership duration • Privacy concerns in medical recordEnglish-Speaking • Pre-screen…“ would help realize what ‘too much’ is” • Asked at every visit, including Rx useSpanish-Speaking • “Grateful” because doc is best person to help & direct to resources • Decision support in EMR for positive screening/Brief intervention useRecommendations • Normalize as standard care for all; avoid “profiling” 5
    6. 6. Behavioral Health Behavioral Chemical Mental Health Medicine Dependency Specialists • MDs, RNs, • Supervisors, psyc• Psychologists counselors hologists, counsel• Clinic-based • Moderate risk ors, therapists• All follow-up after should be • Brief Intervention PCP prescribes followed in impossible unless meds Primary Care done by BMS• Want to prove • Referral stigma to • Need workflow value to KPCO CD pre-defined• SBIRT good fit • “providers don’t
    7. 7. Primary Care - Nursing Nurses and Nurse managers – Generally supportive – To gain buy in, need to discuss SBIRT validity – Could be added to workflow of Health Maintenance Visit (already do PHQ9) – Workflow important: 6-8 min for rooming in a 20 min visit – MD or Behavioral Medicine Specialist for Brief Intervention and Referral to Treatment, not part of nursing role – Concern: liability
    8. 8. Primary Care - Physicians “Intellectually” support the idea Where to go for help? (BMS vs MH vs CD) Perceived patient resistance Fear of time sink Motivational interviewing skills Validity of SBIRT tool vs other quicker methodologies – Cost/benefit analysis – evidence that better then status quo Confidentiality of patient information for life insurance, or other releases of information.
    9. 9. REFERRALS REFERRALS “What relationship?” Need more MI training CD shuts down pt Prior CD Individual BMS Supervisor MH CD BMS DOverwhelmed with Crisis only setup Want closer oe snReferrals that Not open to relationship w/ CD ’tshould go to CD moderate risk Open to CD training kn ow ho w to ge tt o C D REFERRALS REFERRALS May be stigma associated w/ referral to CD Primary Care
    10. 10. KPCO Systems Issues – Pilot 1 Appropriate timing – Depression Governance Council , Rx Drug Abuse Pilot, KP’s “New Reality.” Recommendations – Higher level support needed – insert into already existing initiative that has leadership support (Physical Activity Vital Sign Group) – Clinic champions important – Stakeholders co-create workflow – Pilot in one clinic initially
    11. 11. KPCO Pilot 2 Plan – Implementation at one clinic – Literature review - Executive Summary for Clinic Staff – Collaboration with SBIRT – Colorado and NIAAA funded SBIRT KP Northern California region study. – Address stakeholder concerns determined in Pilot 1 – Convene stakeholder group to develop workflow – Identify one clinic to pilot for 4-6 months – PDSA Cycles for iterations of workflow – Provider training through SBIRT Colorado program
    12. 12. KPCO Pilot 2 Plan Evaluation – Members screened vs. members eligible, %BI, %RT – Compare to matched non-implementation clinic with BMS and one without BMS through chart review  Documentation: codes used, screening tools, alerts, after-visit summary with alcohol/drug advice, variables vs. text. – Pre-implementation survey on teamness and importance of alcohol and drug screening. – Key informant interviews from clinic leaders (Chief, Nurse Manager, other leaders). – “What Happened” Qualitative Tracking of Implementation
    13. 13. KPCO Pilot 2 so far….. Clinic is in midst of new roles from the “New Reality” and trying to introduce SBIRT.  “This is overwhelming” vs. “good to do all changes together.”– How is this different from what I already do?– Role of physician in SBIRT (if BMS going to do the Brief Intervention) – process of hand-off to BMS?– Scripting for introducing SBIRT and transitions between staff.
    14. 14. Pilot 1 recommendations vs. REALITYGain high level leadership Hard to do with short timeinvolvement and support. line, important to start small and gain clinic support.Recommendation to insert Px Vital Sign had high levelSBIRT into a new initiative (Px support, but lacked clinicVital Sign) that had high level support, ended up going grass rootssupport already. with clinics choosing to implement or not.Stakeholders should createworkflow In order to have Stakeholders wanted input on“ownership” of workflow. workflow, but wanted detailed draft to start with from research team.
    15. 15. Thank you to our study team: Alanna Kulchak Rahm, ArneBeck, David Price, James W Dearing, Thomas E Backer, LKendall Krause.Thank you to SBIRT Colorado for their collaboration andsupport of the project.Questions?

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