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SBIRT: Behavioral
Health Screenings &
Patient-Centered Care
Presented By: Zoe O’Neill
July 24, 2013
Welcome!
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Patient-Centered Primary Care Institute History and Development
• Launched in 2012
• Public-private partnership
• Broad array of technical assistance for practices at all stages of transformation – Learning Collaboratives
– Website (www.pcpci.org)
– Webinars & Online Learning
• Ongoing mechanism to support practice transformation and quality improvement in Oregon
Oregon’s PCPCH Model is defined by six core attributes, each with specific standards and measures • Access to Care
– “Be there when we need you”
• Accountability – “Take responsibility for us to receive the best possible health care”
• Comprehensive Whole Person Care – “Provide/help us get the health care and information we need”
• Continuity – “Be our partner over time in caring for us”
• Coordination and Integration – “Help us navigate the system to get the care we need safely and timely
manner”
• Person and Family Centered Care – “Recognize we are the most important part of the care team, and we our
responsible for our overall health and wellness”
Read more: http://primarycarehome.oregon.gov
PCPCH Model of Care
Welcome!
– Introductions
• OPCA
• Zoe O’Neill
• SBIRT
– Presentation Objectives
• Overview of SBIRT
• Evidence of effectiveness!
• Example Workflows
• SBIRT billing
• Implementation best practices and available resources
Introduction to SBIRT
Screening
Brief
Intervention
Referral to
Treatment
Why Screen?
“SBIRT has been identified by SAMHSA as a comprehensive, integrated, public health
approach to the delivery of early intervention for individuals with risky alcohol and
drug use, and the timely referral to more intensive substance abuse treatment for those
with substance abuse disorders” ∞
The issue: • Tobacco use, risky drinking, drug use, and depression cost our
country $872 Billion a year in healthcare, productivity, and
societal costs
• Patients with chronic illness and untreated substance use or
mental health disorder are hospitalized 4.2-5.7 times more each
year than those with the chronic illness alone.
• In Oregon currently, only 0.42% of patients identified as having
an alcohol or drug disorder are treated. ⌂
∞SAMHSA’s National Registry for Evidence-Based Programs and Practices (2008). Brief alcohol screening and intervention. ⌂ Dr. Rich Brown, Wellsys, “Behavioral Screening and Intervention” 2013. http://www.samhsa.gov/data/NSDUH/2k11State/NSDUHsae2011/NSDUHsaeOR2011.pdf
Why Screen?
The outcomes following universal SBIRT
implementation:
– Significant reduction in 7-day alcohol use and frequency of
excessive drinking
– Fewer days of hospitalizations ∑
– $523 reduction in healthcare costs per risky drinking patient
– $4,392 reduction in total healthcare costs per dual-eligible patient
– 20% reduction in binge drinking
– 15% reduction in marijuana use
– 55% reduction in depression symptoms.
– Increased patient satisfaction! ∆
∑ Fleming MF, et all “Brief Physician Advice for problem drinkers: long term efficacy and benefit-cost analysis” 2002. ∆ Brown, Richard, University of Wisconsin and Wisconsin Medical Society, 2010.
Overview of Process
Annual Screen • AUDIT-3 • DAST • PHQ-2
Full Screen • AUDIT • DAST • PHQ-9
Brief Intervention
If patient answers
“yes” to any initial
screening
question, full
screening is
administered
If patient response
indicates risky or
harmful use, a
brief intervention
is performed
If patient response
indicates
dependence refer
to treatment
Referral to Treatment
Screening tools
Annual Patient Questionnaire
• PHQ-2
• 1-2 Questions on alcohol use
• 1-2 Questions on drug use
• Question on tobacco
How many times
in the past year
have you had 5 or
more drinks in a
day?
During the past
two weeks, have
you been
bothered by little
interest or
pleasure in doing
things?
Annual Screening Form Example
MEN: How many times in the past year have you had 5 or more drinks in a day?
WOMEN: How many times in the past year have you or more drinks in a day?
Alcohol: One drink =
12 oz. beer
5 oz. wine
1.5 oz. liquor (one shot)
None 1 or more
MEN: How many times in the past year have you had 5 or more drinks in a day?
WOMEN: How many times in the past year have you had 4 or more drinks in a day?
Annual Screening Results
Did the patient answer
“no” to all questions?
Did the patient answer
yes to any question?
Fantastic! Congratulate patient and
reinforce healthy behaviors. Patient
should be re-screened in 12 months
• If yes to mood questions,
administer PHQ-9
• If yes to alcohol questions,
administer AUDIT
• If yes to drug question(s),
administer DAST
Full Screen: DAST
1. Have you used drugs other than those required for medical reasons?
2. Do you abuse more than one drug at a time?
3. Are you unable to stop using drugs when you want to?
4. Have you ever had blackouts or flashbacks as a result of drug use?
5. Do you ever feel bad or guilty about your drug use?
6. Does your spouse (or parents) ever complain about your involvement with drugs?
7. Have you neglected your family because of your use of drugs?
8. Have you engaged in illegal activities in order to obtain drugs?
9. Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking
drugs?
10. Have you had medical problems as a result of your drug use (e.g. memory loss,
hepatitis, convulsions, bleeding)?
Do you inject drugs? _______
How often do you use drugs __________________________________________________
Full Screen: AUDIT
1. How often do you have a drink containing alcohol? Never Monthly or less 2 - 4
times a month
2 - 3 times a week
4 or more times a week
2. How many drinks containing alcohol do you have on a typical day when you are drinking?
0 - 2 3 or 4 5 or 6 7 - 9 10 or more
3. How often do you have six or more drinks on one occasion? Never Less than monthly
Monthly Weekly Daily or almost
daily
4. How often during the last year have you found that you were not able to stop drinking once you had started?
Never Less than monthly
Monthly Weekly Daily or almost
daily
5. How often during the last year have you failed to do what was normally expected of you because of drinking?
Never Less than monthly
Monthly Weekly Daily or almost
daily
6. How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?
Never Less than monthly
Monthly Weekly Daily or almost
daily
7. How often during the last year have you had a feeling of guilt or remorse after drinking?
Never Less than monthly
Monthly Weekly Daily or almost
daily
8. How often during the last year have you been unable to remember what happened the night before because of your drinking?
Never Less than monthly
Monthly Weekly Daily or almost
daily
9. Have you or someone else been injured because of your drinking? No Yes, but not in the last year
Yes, in the last
year
10. Has a relative, friend, doctor, or other health care worker been concerned about your drinking or suggested you cut down?
No Yes, but not in the last year
Yes, in the last
year
Full Screen: PHQ-9
I Low risk/Abstain
AUDIT: 0–7 DAST: 0
II Risky
AUDIT: 8–15 DAST: 1-2
III Harmful
AUDIT: 16-19 DAST: 3-5
IV Dependent
AUDIT: 20+ DAST: 6+
Drinks Per week
Drinks Per day
Men 14 4
Women 7 3 All age
>65 7 3
Categories of drinking
0cm 1 2 3 4 5 6 7 8 9 10
III IV
I
Low risk or Abstain: 78%
Dependent: 5%
II Harmful: 8%
Risky: 9%
www.sbirtoregon.org Primary Care Residency Initiative
Low-risk drinking limits
Very
Brief Interventions
Why Brief Intervention?
The goal of BI is to educate patients and
increase their motivation to reduce risky
behavior. BI is conducted with patients
who score into risky or harmful use
categories.
Example 1
Review Video: http://www.youtube.com/v/80XyNE89eCs
Example 2
Review Video: http://www.youtube.com/v/URiKA7CKtfc
Referring to Treatment
For patients who score into
“dependent” zones for alcohol or
drug use they will need to be
referred to more specialized
treatment.
Examples of referrals include:
• Medication Assisted Treatment
in Primary Care (Suboxone)
• Referral to
outpatient/inpatient/detox
facilities in your community
• Call the State Resource and
Crisis line: 1-800-923-4357
For patients who indicate suicidality or
severe depression, referrals include:
• Immediate suicide/crisis
management
• Medication
• Counseling
• Further diagnostic examinations by
mental health provider
SBIRT Workflow
OPCA’s pilot
project
Annual Screen
Full Screen (AUDIT,
DAST and/or PHQ-9)
Brief Intervention
Referral to Treatment
Reception
MA Scores Screen
Health Educator* Provider
* Commonly a non-clinically
trained, lay person
SBIRT Workflow
Annual Screen
Full Screen (AUDIT,
DAST and/or PHQ-9)
Brief Intervention
Referral to Treatment
Reception
MA Scores Screen
Provider
Another common clinical
workflow
SBIRT Billing
• Who can bill?
• Billing codes and the
CCO quality measures
• Code alignment in
Oregon!
SBIRT billing
Full screen +
brief intervention: 15–30
min > 30 min
Medicaid 99408 99409
Medicare G0396 G0397
Comm. CPT
99408 CPT
99408
Implementing SBIRT in YOUR primary care clinic!
Executive Sponsorship
Primary Care Provider leadership
Clinic/Mid-Manager supervision and leadership
Care-Team level engagement
Initial Screener involvement
Financial Viability discussion
Organizational alignment
Engage Staff in SBIRT project Initiate training for identified staff Identify target population for universal screening
Design initial workflow and task assignment Design approach to rapid cycle improvement of SBIRT work
Identify billing policies and procedures
Standardize EMR Documentation for: ∙When patient is due for screening
∙Results of screening
∙Interaction with Health Educator
∙Referral to Treatment
∙Measurement and Reporting
Motivational Interviewing training Collaborative Care Model overview
Screening tool proficiency
Billing for SBIRT
EMR/Documentation/Reporting
Workflow planning and referral mapping
Ongoing and Continuous Improvement
% of total target population screened % of positive screens that receive a brief intervention/total positive screens % of positive screens indicating need for treatment that receive referral/total screens needing referral % of patients with reduction in risky behavior at re-screen
Engagement Training Implementation
Measurement
Available Resources
Addiction Technology Transfer Care Network (ATTC) The Northwest Addiction Technology Transfer Center (NWATTC) provides SBIRT training and technical assistance to primary care clinics, behavioral health organizations; as well as county and state systems. Located at OHSU in the Public Health & Preventative Medicine department, our workforce development training and consulting services enhance knowledge, skill and service delivery. Denna Vandersloot, M.Ed, the NWATTC Director at [email protected] (503)494-2767 or Traci Rieckman, Ph.D., NWATTC PI, at [email protected] (503) 494-6739. www.attcnetwork.org
Oregon Primary Care Association (OPCA) OPCA is a membership organization that provides technical assistance, policy support and advocacy for Oregon's 31 Federally Qualified Community Health Centers. With a mission of achieving health equity for all, OPCA has partnered with the Oregon Community Foundation to allow for SBIRT engagement, implementation, training, and measurement support to our FQHC sites. www.orpca.org, (503)228-8852
Jim Winkle, MPH Jim Winkle has trained hundreds of physicians and clinic personnel on how to conduct SBIRT in primary care settings. As Project Director for the SBIRT Oregon Initiative, he has designed clinic tools, screening forms, and training videos that have been widely adopted by health professionals around the country.
503-720-8605, [email protected] www.sbirtoregon.org
Links to all SBIRT resources on the Institute website: http://www.pcpci.org/search?search_api_views_fulltext=SBIRT
Questions?
Zoe O’Neill
Oregon Primary Care Association
Community Health Center Operations Manager
[email protected], (503)228-8852
Closing
• Please fill out the survey after this presentation – you can send us additional questions
• Webinar materials can be retrieved from our website, www.pcpci.org/webinars
• Additional questions?
