screening and brief intervention partnering with primary care field
DESCRIPTION
TRANSCRIPT
2/1/2012
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Craig Field, PhD, MPH
Associate Professor
Health Behavior Research & Training Institute
UT Austin
Program Director
Screening & Brief Intervention
Trauma Department
University Medical Center at
Brackenridge
2Source: JAMA, 2004.
3Source: CASA Columbia University, 1994.
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4Source: Closing the Addiction Treatment Gap, 2010.
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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.
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Substance Dependent
No Problem
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Substance Dependent
No Problem
Treatment
No Intervention
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U.S. Population
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Dependent
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Excessive
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dependent
dependence symptoms
hazardousharmful
low risk
lifetime abstinencecurrent abstinence
4%
25%
71%
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1
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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.
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4%
25%
71%
Dependent
Heavy Drinkers
Low or No Risk
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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.
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Substance Use Is
A Public Health Problem
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# Service Preventable Burden
Cost Effectiveness
1 Aspirin: Men 40+ Women 50+ 5 5
2 Childhood Immunizations 5 5
3 Smoking Cessation 5 5
4 Screening & Brief Intervention 4 5
5 Colorectal Cancer Screening 4 4
6 Hypertension Screening and Treatment
5 3
Source: Am J Prev Med 2006; 31 (1) 52-61
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Maximum Daily Limits Maximum WeeklyLimits
Women 3 7
Men 4 14
Men >65 3 7
Less is Better!
Source: NIAAA, 2009
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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.
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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.
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ScreeningBrief
Interven‐tion
Brief Therapy
Out‐patient
Hospital‐ization Inpatient
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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.
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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.
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Pre‐screening (universal).
Full screening (for those with a positive pre‐screen).
Brief Intervention (for those scoring over the cut off point).
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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).
Universal Brief Screen
Negative Positive Reinforcement
PositiveLow Risk:
Positive Reinforcement
Moderate Risk: Brief Intervention
Moderate – High Risk:Referral to Brief Therapy
High Risk: Referral to Treatment
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Further Screening
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Severity of Alcohol Problems
Harmful drinking/Abuse
Risky/Hazardous drinking
Safe drinking
Abstinent
Dependent drinking/Alcoholism
SBI
Screen
SBIRT
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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
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DUI
Injury
Violence
Pregnancy
STD
Substance Dependence
Health Care Problems
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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
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• Healthcare reform provides an opportunity for SBIRT
• Emphasis on preventive care and wellness
• Integration of primary and behavioral health
• SBI as essential health benefit
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.
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.
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.
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Dunn C. et al. Hazardous drinking by trauma patients during the year after injury. J Trauma. 2003;54:707–712.
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Precontemplation = Never
Contemplation = Maybe
Preparation = Soon
Action = Now
Dunn C. et al. Hazardous drinking by trauma patients during the year after injury. J Trauma. 2003;54:707–712.
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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‐
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Substance use screening, brief intervention, referral, and treatment (SBIRT) is a systems change initiativerequiring 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.
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• 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 baseThe World Health Organization
The American Preventative Task Force
The Emergency Nurses Association
The American Medical Association
The American College of Surgeons/COT
• Patient stories
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• 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 network
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Conduct a facility needs assessment that
considers patient demographics, patient
flow, time requirements, internal and
external policy, staffing resources, fiscal
resources, space, IRB requirements, and
technology.
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• Top down and bottom up support• Internal champion• Internal and external policy • Current screening protocols• Training needs• Space• Patient flow• Patient demographics• Technology
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• 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).
• 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?
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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 affecthow many interventionists you need.
Whether you have intervention personnel also perform screening or have others do screening will affect time required.
• 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
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• 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
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Payer Code Description Fee
Commercial CPT 99408
CPT 99409
Alcohol and/or substance abuse structured screening and brief intervention services;
15 to 30 minutes
Alcohol and/or substance abuse structured screening and brief intervention services;
greater than 30 minutes
$33.41
$65.51
Medicare G0396
G0397
Alcohol and/or substance abuse structured screening and brief intervention services;
15 to 30 minutes
Alcohol and/or substance abuse structured screening and brief intervention services; greater than 30 minutes
$29.42
$57.69
Medicaid H0049
H0050
Alcohol and/or drug screening
Alcohol and/or drug service, brief intervention, per 15 minutes
$24.00
$48.00
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• 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.
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• 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
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• 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
Screening, Brief Intervention & Referralfor Treatment for Trauma Patients
Brief Interventions Provided
Trauma Patients Meeting Criteria : 187September 16 – October 15, 2011
Summary:• Patients screened 91.4%• Patients had UDS drawn 55.1%• Patients had BAC drawn 64.0%• Brief Interventions provided 77.2%
Self Report/BAC/UDS Outcomes:
Admission Order Set: UDS Collected• Trauma 74.8%• Hospitalist 48.7%• Surgery 8.3%
Positive63
Negative108
Discharge Prior, 12
Discharge Prior, 16
Interventions 44
Unable to Participate, 6
Decline, 1
Screening, Brief Intervention & Referralfor Treatment for Trauma Patients
Brief Interventions Provided
Trauma Patients Meeting Criteria : 1825December 15, 2010 – December 15, 2011
Summary:• Patients screened 93.2 %• Total Urine Drug Screen 52.0 %• Total BAC drawn 63.2%• Brief Interventions provided 84.5%
Self Report/BAC/UDS Outcomes:
Positive,67
Interventions,38
Interventions,533
Decline, 9
Negative, 941
Positive, 765
Discharge prior, 119
Discharge prior, 89
Unable to participate, 92
Shift, 42
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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.
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• What are your outcome measures
• What are your training requirements
• How do you monitor fidelity
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RESOURCES
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Rethinking Your Drinking RethinkingDrinking.niaaa.nih.gov
Physician’s Guide niaaa.nih.gov
Brief Intervention who.int/substance_abuse
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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.