APNC Fall Conference 2012

John Femino, MD, FASAM, MROMedical Consultant, Dominion Diagnostics

Medical Director, Meadows Edge Recovery CenterNE Regional Director, American Society of Addiction Medicine

SBIRT : Strategies for Implementation

Carolina Beach, NCOctober 17, 2012

Sponsored by:Sponsored by:

Dominion DiagnosticsDominion Diagnostics

It has been known for many years that the "treatment gap" is massive—that is, among those who need treatment for a substance use disorder, few receive it. In 2007, 23.2 million persons aged 12 or older needed treatment for an illicit drug or alcohol use problem, but only 3.9 million received treatment at a specialty substance abuse facility.

• NIDA. Principles of Drug Addiction Treatment: A Research Based Guide; http://www.drugabuse.gov/PODAT/faqs2.html#faq7 , accessed : December 9, 2010.

Treatment Gap: Hidden and Underserved

Reasons for Screening• High prevalence in population

– 10-20% of outpatient PCP patient settings– 20-40% of inpatient hospital settings

• Leading cause of morbidity/mortality

• Most problems are behavioral

• Most problems are hidden

• Provider underestimation of prevalence

• Lower PCP referral rate to substance abuse and mental health programs– <5% of SA referrals come from health providers

Early Symptoms of Substance Abuse

• Primarily behavioral• Usually hidden unless specifically asked for• Requires careful history taking • Few physical findings

• Most routine hematology and chemistry tests

are normal

• Laboratory tests of most value for improved diagnosis are drug and alcohol testing

The Hidden Problem and Solution• Rhode Island ranks #1 in the nation for last 7 years for underage

drinking and fatal auto accidents• <5% of substance abuse treatment referrals come from

physicians• Screening for behavioral problems (alcohol and drug use,

anxiety, depression and eating disorder) in a primary care office is effective for identification and referral into behavioral health treatment

• Screening and brief intervention (SBI) are recommended for well child and routine medical visits by multiple professional national associations and governmental agencies

• Total cost of untreated behavioral health problems exceed that of direct treatment costs

• SBI is cost effective and saves $2 to $7 for each $1 spent• Despite cost effectiveness and benefits, SBI is underutilized with

multiple barriers for implementation within PCP and Pediatricians practices

ABSTABSTNON-NON-PROBPROBUSEUSE

AT-AT-RISKRISKUSEUSE

ABUSEABUSE DEPDEP

UseConsequencesRepetitionLoss of control, preoccupation, compulsivity, physical dependence

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+--

+-/+-

+++

+++++

General Hospital Intervention Program

• Physician leadership• Administrative support• Self help groups on location• On site treatment resources• Employee policy and EAP services• Screening of admissions• Staff integrated within hospital systems• Employee education – awareness week• Ongoing medical / professional education• Recovering staff as advisory group

Definition: SBIRTSBIRT = integration of systematic screening for early intervention and treatment

– For patients with or at high risk for substance use and mental health disorders

– Multiple health care settings

– Before more severe consequences occur

SBIRT : Core Components

• Screening: Questions to identify problems

• Brief Intervention: Education and feedback about risk status

• Brief Treatment: Discussion of need for change

• Referral: Referral to substance abuse and mental health therapist/program for specialized evaluation and treatment

Why Care About Mild-Moderate Cases?

Primary Prevention

Abstinence Infrequent use Problem users - Abuse Dependence

BriefIntervention

Specialized Treatment

ReferralChallenges

Drug Involvement

Adapted from Broadening the Base of Alcohol Treatment (IOM)

SBIRT SBIRT

Effective Identification of Substance Use Disorders• Always screen for disorders• Recognize prevalence of problems• Look for associated conditions / problems• Take personal and family history• Corroborate results• Have non-judgmental attitude• Drop stereotypes • Motivational counseling + brief intervention

Who Should Be Screened?• All patients • Positive family history of abuse/addiction• With risk factors (including ADD)• Associated problems

– Accidents - overdoses– Emotional and behavioral problems –

• Anxiety, depression, eating disorders and substance abuse

– Family problems• Kids already in trouble

– Juvenile justice systems– Identified in schools – SAP

• Oppositional and problem kids• Special education – ADD• Involved in drug culture

– School drop outs– Child welfare involvement

SCPI – Goal & Mission

• Assist and support medical community

– Education and information about substance abuse and behavioral health problems

– Early Identification of behavioral health problems through screening and brief intervention

– Assessment, treatment recommendations and intervention

– Referral to behavioral health specialists– Monitor compliance with behavioral health

treatments

Goals of Behavioral Health Screening Project

• Develop pilot project in pediatrician and primary care physicians offices in South County to implement screening and brief intervention (SBI)

• Develop screening tool for substance abuse, depression, anxiety and eating disorder

• Train staff on screening and brief intervention • Implement screening protocol at selected practices

– New or established patients for annual well child visits• Collect prevalence data • Conduct key informant interviews to determine implementation

issues and barriers towards expansion of program to all pediatricians and PCP’s in Rhode Island

• Document impact of SBI on rates of identification and referral • Monitor patient compliance with referral recommendations

Provider Barriers to Screening

• Time constraints – extend routine office visit • Money – how to reimburse for screening• Stigma-Fear of alienating patient or family• Hopelessness re: treatment effectiveness• Inadequate training on substance abuse• Inadequate dissemination of information

about effectiveness of treatment and consequences of failure to treat

• Lack of knowledge of local resources

Parental Barriers to Screening

• Belief that use of drugs and alcohol = experimentation

• Time constraints will interfere with well child visit• Stigma-Fear of labeling patient or family• Insurance labeling via Medical Information Bureau

(MIB) create lifelong stigmatization and place in high risk category for life, disability or health insurance eligibility or premium ratings

• Confidentiality and self incrimination issues• Lack of knowledge about effectiveness of treatment

and consequences of failure to treat

Screening Instruments• Evidence for reliability and validity• Which population utilized?• Setting under which developed• Intended use of instrument• Ease and manner of use

– Trained staff– Costs of materials to administer and score– Self administered, computer assisted– Subject self assessment vs. family evaluation

• Substance abuse or general problems– Focused vs. multidimensional

Screening and Brief Intervention

• Screen for hidden condition by use of standardization screening instrument– CAGE– MAST– DAST– AUDIT– CRAFFT– SCPI – RISAM– Any other instrument with documented

validity and accepted through literature

CRAFFT (Riggs & Alario; Knight)

Driven car while intoxicated?

Use to relax, feel better or fit in?

Ever use while you are alone?

Do any close friends use?

Do any close family members have problems from using?

Ever gotten in trouble from using?

2+ endorsements

Medical v. Non-Medical Screening Issues

• Knowledge of patient and family over time– Genetic and family history known to clinician– Screening questions compared to medical record– Past treatment or referral known– Problematic behaviors recognized or treated in past– Older sibs may have received treatment– Parent or grandparents may be in recovery– Snapshot vs. movie – context of screening in relation

to knowledge of family– Hidden indicators of problems – missed appointment,

lack of follow up of previous recommendations, high risk behaviors

Development of BHS Instrument

• Need for one page with estimated testing time < 10 min

• Self administered, assisted by staff is necessary

• Combined mental health & substance abuse screening instrument

• Multidimensional assessment scales– Depression– Anxiety– Eating disorder– Alcohol abuse– Drug Abuse– Associated conditions

BHS-Crafft, SA, Depression+Anxiety

BHS-Audit + Eating Disorder

Psychometric Valid v. Clinician Concern

• Anxiety and depression scores developed from validated scales

• Individual item severity vs. total score• Cutoff scores – sensitivity and specificity are established

for non-medical and can be lowered for individual items or high risk patients i.e. – patient with family history of alcoholism/substance abuse who is actively using - ? Experimentation or early development of problems

• Pattern analysis between scales– Substance abuse, affective and high risk behavior

• Knowledge of genetic type of parental problem – ie early onset addiction in context of adolescent using and involved in other high risk and problematic behavior = problem until proven otherwise

Screening Score Interpretation

• Set point of threshold = positive– Below cutoff = no problem– Above cutoff = problem or potential problem

• Set point dependent upon selection biases

• Lower cutoff = increase sensitivity, lower specificity (higher false positive rate)

• Raise cutoff – decrease sensitivity & increase specificity (increase false negative rate)

Receiver Operating Characteristics: ROC

• Set point of threshold of positive– Below cutoff = no problem– Above cutoff = problem or potential problem

• Set point dependent upon selection biases• Lower cutoff = increase sensitivity, lower

specificity• Raise cutoff – decrease sensitivity and

increase specificity• Positive predictive value

Screening & Brief Intervention Procedure

• Determine eligibility for screening

• Identify primary prevention office visits

• Provide screening instrument instructions prior to provider examination

• Monitor or assist patient self administration

• Review, score and interpret guestionnaire results

• Discussion of test results with patient and family

• Provide education and instruction by risk category

• Hand out educational and interventional packages

• Referral to behavioral health treatment provider

Screening Procedure

• Determine eligibility for screening• Ask patient/parent to sign permission form• Hand out primary prevention educational packages• Provide screening instrument to patient

– Two sites – attach to chart– One site – keep in exam room

• Have physician score form in office• Physician discuss results with patient/parent• Education and referral

Onsite Education v. Return Visit

• Primary prevention material to all patients– Package obtained from community TASC force– National Clearinghouse– Local resources– Insurers

• Secondary prevention –targeted information– Optional and individualized– Read

Training of Office StaffOverview of SBI project

– SCPI description and role in community– Review of screening instrument– Screening protocols – who does what when– Referral options– Data collection – Location of screening tool- notebook binder or chart– Consent form and confidentiality issues– Identify concerns and training needs

Training on Motivational Interviewing– Two hour introduction and one hour advanced skill training

Usual Patient – Physician Discussion

Physician Role– Most often pattern = Don’t Ask, Don’t Tell– Judgmental style of questioning – “Do you drink too much”– Focus on symptoms and not feelings and behaviors– Confrontational – Shame and Blame– Tell the patient – direct instruction vs. listening to conflict

Patient Role– Most patients are not resistant to honestly answering questions

about feelings and behaviors– Fear of being rejected or change in physician behavior– Want to understand PCP role and relation to specialist

Five Principles of Motivational Interviewing

Express Empathy Avoid Argumentation Develop Discrepancy Roll with Resistance Support Self-efficacy

(Miller and Rollnik)

Stages of Changes & SBIRT

Scoring & Intervention Recommendation

Preliminary Data (N=886)

• Total Number of eligible patients

• % refused to sign permission

• % exceeded threshold (screened in)– One scale– Two scales– Three scales

• Relationship between scales

• Relationship between individual items (deferred)

Age Distribution : All Sites

Rate of Screening Positive by Test type

Sample size = 866 51% were age 15 or younger

Screening Tests

Substance AbuseSubstance Abuse 8.48.4

CRAFFTCRAFFT 14.414.4

Eating DisorderEating Disorder 25.325.3

One of: Severe depression, anxiety or One of: Severe depression, anxiety or AUDIT AUDIT

4.34.3

Screened in in at least 1 areaScreened in in at least 1 area 36.436.4

Screened in in 2 or more areasScreened in in 2 or more areas 12.512.5

Screened in in 3 or more areasScreened in in 3 or more areas 3.23.2

% At Risk

Process Evaluation-Screening Procedure

• Office manager / parent advocate– Acceptance of appointment for return office visit– Provide information / contact referral source– Contact with insurer – behavioral health authorization– Document availability and timing of referral appointment

• Monitor referral compliance– Contact family to verify compliance with appointment– Ask family if insurance coverage problems– Ask family if treatment recommendations accepted– Time required for office staff to monitor compliance

Checklist and Qualitative Key Informant Interviews

• Purpose – capture process of using BHS tool

– Length of time to take– Need for parental assistance– Section for office staff, provider, and

manager/researcher– Whether counseling was given for individual items– Need for follow up visit– Referral information– Follow up information

Confidentiality Wording• Lots of discussion re: wording of confidentiality

– Need for absolute confidentiality = secret– Separate confidentiality of questionaire answers from recommendation

for additional info/referral• Return visit = indirect acknowledgement of problems• Confidentiality of patient in revealing parental problems• Requesting additional forms and consent may create less interest in

participating• Honesty of answers may be jeopardized if patient believes that

parents will be told results of testing• Need for separation of BHS questionnaire from medical record

– Progress note report of screen completed with suggested recommendations

– Separate binder/chart of questionnaire• 42 CFR apply to assessment as distinct from treatment for a

diagnosed problem• Need for report from behavioral health provider to be kept in

separate section or along with other consultations

Process Evaluation: Treatment Comliance

• Did patient/family return for office visit to discuss changes based upon SBI

• Were educational materials helpful • Did referral source communicate with referring

physician – telephone, report, interagency• Family satisfaction with referral• Identify barriers to follow up

– Transportation– Lack of coverage and ability to pay for co-pay– Office hours– Treatment resistance

Time Necessary for Self Administration

• Screening administration and scoring– Time to fill out screening instrument

• Age, education, language, reading functions– < 10 minutes if patient is >15 years old– > 15 minutes if patient is <15 years old

– Scoring of tests and documentation of screening results

• Intervention & Referral to treatment– Interpretation and discussion of results

• Low score - Informational and educational• Moderate - Instructional & Interventional• High - Referral to Behavior Health

Impressions of Staff in Utility of SBI

• Two of these practices were considered the “gold standard” of community based pediatricians in awareness of and inclusion of behavioral health questions during their standard well child visit

Despite this sensitivity and skills:• Use of standardized guestionnaire significantly increased

pediatricians ability to conduct interview compared to unstructured clinical interview– “I’ve known this family for two generations and have taken care of this

child since birth and asked behavioral health questions at each visit including today, and I was astonished to see how many positive items were noted on the scale compared to my clinical interview”

– “The guestionnaire helps me during my interview – It warmed the patient up and helped me guide questions to the appropriate area”

– “What I thought was experimentation, was NOT” – “I want to continue to use it, but we can’t afford to continue”

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SBI Use ID Rate KnowledgeReferral

Resources

Referral Rate

Provider Quantitative Data (Jan - Mar 06)

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ConfidentialityConcerns

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Added Time Billing Problems

Practice Qualitative Data (Jan - Mar 06)

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SBI Use ID Rate KnowledgeReferral

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Provider Quantitative Data (Mar-Sep 06)

Pre-Post SBI Implementation Issues

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Added Time BillingProblems

Practice Qualitative Data (Mar-Sep 06)

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Most Effective Interventions

•Training of office staff on SBI implementation and integration into medical office workflow

•Provision of ongoing support to office staff– Provision of educational materials, collection of data and

on-site collaboration with research and support staff

•Focus group presentation and discussion– Review and feedback of study data– Analysis of scheduling and coding procedures – Impact of SBI implementation on office workflow– Costs of resources and time for SBI– Identification and quantification of implementation barriers

Conclusions from Preliminary Study

• Behavioral health problems are common• BHS instrument is easy to implement in PCP’s office practice• Most providers noted significant improvement in identification rate by

using BHS instrument compared to clinical interview

• Success of SBIRT depends upon effect on office flow• Duration of office visit varies upon severity of scoring• Rate of referral for behavioral health evaluation remains lower than

rate of identification

• Coding and reimbursement issues represent #1 barrier for implementation

• Knowledge and availability of behavioral health referrals is still lacking among providers and subscribers

• Designated provider network improves referral rate

Getting Paid for SBI

Insurance Benefit by Provider Type

Behavioral Health Medical

Behavioral

Health

Provider

Use Psych CPT

Use Psych DSM

Paid for SA services

Excluded from Psych CPTMay or may not use Dx DSMASAM Cert –ADM CPT code

Addiction Medical Management

Medical

Provider

May not use Psych CPT

May not use Psych DSM

Non Par with MCO

Not eligible for SA Services

Use E+M codes

Use Medical Diagnosis

Co-morbid+Counseling

Screening + Brief Intervention

Insurance Benefit Type

SBI Options during Office Visits

Evaluation and Management Services• Use screening instrument (self administered) while in exam room• Bill E+M code and add time to length of E+M office visit• Code E+M by convert to timed visit > 50% counseling time• Document in medical record discussion and time spent• Reschedule office visit for ongoing evaluation/treatment or refer

Preventative Health : Annual Physical Exam + Well Child Visit• Use screening instrument (self administered) while in exam room• Bill preventative health code and add screening instrument code• If score < threshold, advice and retest at periodic intervals• If score > threshold, brief intervention, reschedule or refer

Psychotherapy Codes• Use screening instrument (self administered) while in exam room• Bill Psych code and include time into timed psychotherapy code• Document in medical record discussion and time spent• Reschedule office visit for ongoing evaluation/treatment or refer

Coding for Screening & Brief Intervention (SBI)

•Screening Procedure•Instrument needs to be short•Self Administered or by trained staff•Scoring needs to be done during office visit•Feedback of score discussed with patient + family

•Brief Intervention•Discuss results with patient in detail•Low scores may allow for risk reduction counseling•Higher scores may need additional time•Reschedule patient until evaluation complete•Refer the patient to behavioral health provider

Coding for Screening & Brief Intervention (SBI)

•Screening Procedure Code $ Payment•Private insurance 99408 > $22•Medicare G0396 $22 •Medicaid H0049 $24

•Brief Intervention•Private Insurance 99409 >$55•Medicare G0397 $55 •Medicaid H0050 $48

SBI Coding Matrix

Code CPT Type ICD-9

Specialty Benefit

Limits

Tracking Stigma

MIB

Preventive Med

99384-99397

Untimed No Dx

Medical

PCP

Not same day as E+M

None No

Office Visit

99202-99215

Severity

Or Timed

Dx Medical

PCP

Variable co-pay by Dx

None May be

By Dx

PsychoTx 90801-90807

Timed Dx Behavior

Health

Med Provider may be Non Par

None Yes

Psych Testing

96150 Timed No Psych

Behavior

Health

Not same day as E+M

None Yes

Medical Information Bureau (MIB)Psychiatric Stigmatization

Concern regarding the act of screening patients (especially adolescents) should not stigmatize them prior to the establishment of a diagnosis or of providing treatment

Credit Card Bureau Format

– Patient’s CPT + ICD-9 codes transferred from health care insurer to shared database when patient signs release of information for life and disability insurance and ?? Health insurance

– For $8.95 patients can access their data on the web (Health care utilization check)

– Since most insurers do not allow “rule out” diagnosis, can’t use psych or E+M codes for screening prior to the results of the screening test

– Need for separate screening code and brief intervention code• Application to AMA by PLNDP for new codes

– HCPCS level II code H0002 + H0004 has been been approved, however, restricted to Medicaid agency that handle behavioral health and not for Medicare or private insurers

Psychiatric Labeling and MIB

• Shared database of CPT codes and ICD-9 Diagnoses

• Give permission to access database upon application for life, disability and health insurance

• Since many insurers do not accept rule out diagnoses, coding for alcohol abuse by behavioral health provider for an assessment may result in lifetime “psychiatric labelling”

• Database is accessible through the web, cost $8.95 to access and check for accuracy (similar to credit bureau reporting

Video Resources

• Shared database of CPT codes and ICD-9 Diagnoses

• Give permission to access database upon application for life, disability and health insurance

• Since many insurers do not accept rule out diagnoses, coding for alcohol abuse by behavioral health provider for an assessment may result in lifetime “psychiatric labelling”

• Database is accessible through the web, cost $8.95 to access and check for accuracy (similar to credit bureau reporting

SBIRT Resources

• Shared database of CPT codes and ICD-9 Diagnoses

• Give permission to access database upon application for life, disability and health insurance

• Since many insurers do not accept rule out diagnoses, coding for alcohol abuse by behavioral health provider for an assessment may result in lifetime “psychiatric labelling”

• Database is accessible through the web, cost $8.95 to access and check for accuracy (similar to credit bureau reporting