SBIRT Implementation

Clayton Chau, MD, PhDMedical Director, Behavioral Health Servicescchau@lacare.org

Updated 04/21/2014

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Goals

DefinitionUnderstanding the benefit The tool and the processThe training requirements

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Definition

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Screening, Brief Intervention& Referral to Treatment

(SBIRT)

SBIRT

Screening

Referral to

Treatment

Brief Interventi

on

An evidence-based method to intervene in unhealthy alcohol and drug use, but underemployed in medical settings.

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Key Terms

• Screening – A brief set of questions that identifies risks of substance use related problems

• Brief intervention – Brief counseling that raises awareness of risks and motivates client/patient toward acknowledgment of problem and initiates changes

• Referral – Procedures to help client/patient to access specialized care

Why implement SBIRT?

High prevalence of unhealthy alcohol and drug use

Significant morbidity, mortality, and cost

Screening instruments work

Brief interventions effective, inexpensive, and acceptable

VS.Routine and universal screening

Inconsistent and selective assessment

SBIRT Business as usual

Validated screening toolsNon‐systematized narrativequestions

Alcohol use seen as a continuum

Alcohol use seen as dichotomous

Evidence-based, patient-centered change talk

Ineffective, directive style of communication

Transition between primary care and treatment

Dis-coordinate/unclear referrals and follow up

NIAAA. Manwell, 1998

Unhealthy alcohol use among PC patients

Low risk or abstention:

78%

Low-risk limits

Drinks

per week

Drinksper day

Men 14 4

Women 7 3

All age >65 7 3

Unhealthy use: 22%

Stratified prevalence of alcohol

use among PC patients

Manwell, et. al, 1998

Low risk: 38%Abstain: 40%

5%8%9%

Dependent

HarmfulRisk

y

Risky zone

I

IIIIIIV

Risky

• Risky drinking likely leads to new health problems or makes existing ones worse

• This zone defined by quantity alone

• Any illicit drug use is risky

• Repeated negative consequences

• Failure to fulfill major obligations

• Use continues despite persistent problems

• Associated with “alcohol abuse”

The Harmful zone

I

IIIIIIV

Harmful

Donovan, et al. 2006

The Dependent zone

• Patient’s life orbits around use

• Distress or disability

• Tolerance and withdrawal

• Use in larger amounts or longer period than intended

• Persistent desire to quit (or failed efforts)

I

IIIIIIVDepende

nt

Donovan, et al. 2006

MMWR Weekly, 2004, Naimi, 2002

• Chronic liver disease & cirrhosis

• Eight specific cancers

• Heart disease• Pancreatitis• Stroke• Injuries• Pneumonia• Seizures

• Gastritis/PUD• Alcoholic

Cardiomyopathy• Interacts with many

medications • Exacerbates

numerous chronic medical conditions (HTN, DM, PUD, etc.)

Unhealthy alcohol use associated with:

Risks of unhealthy drinking, cont.

Disorder Odds

Anxiety Disorders 2.6xMood Disorders (especially Major

Depression) 4.1x

Personality Disorders 4.0x

Antisocial Personality Disorder 7.1x

Drug Dependence 36.9x

Nicotine Dependence 6.4x

Grant., et al, 2004

Alcohol: Psychiatric co-morbidity

Odds of co-occurrence of Current (12-month)

NY Times 2009:•Government spending related to

substance use reached $468 billion

in 2005.

•Most spending went toward direct health care costs or law enforcement,

including incarceration.

•Just over 2% of the total went to prevention, treatment and addiction

research.

Public spending on substance use

Evaluations of SBIRTMeta-analyses & reviews: More than 34 randomized

controlled trials Focused primarily on at-risk and

problem drinkers

Result: 13-34% reduction in alcohol consumption at 12 months

Moyer et al, 2002; Whitlock et al, 2004; Bertholet et al, 2005

USPSTF, 2004 and 2013

• For both alcohol screening and brief intervention

• Adults and pregnant women

• Insufficient evidence for adolescents

USPSTF on SBI

Class B

rating

Screening &

intervention cost per pt.:

$177

Cost savings per

patient

$1170

Benefit / cost ratio:6.6/1

SBIRT effectiveness

• Fewer hospitalizations & ER

visits

• Cost savings:

Fleming, et al, 2002

Washington state SBIRT ER

project• 2003-2008 study implementing

SBIRT in ER depts.

• Medicaid savings from pts receiving BI: $185-192 per member per month

• Due to less inpatient hospitalizations from ER admissions

Estee, et al, 2008

Missed opportunities in primary care

Prevalence of ever discussing alcohol use with a health professional:

• 16% of U.S. adults overall

• 17% of current drinkers

• 25% of binge drinkers

• 35% of those who reported binge drinking ≥10 times in the past month

CDC, 2011

Missed opportunities in primary care

Most patients (68-98%) with alcohol abuse or dependence are not detected by physicians

Physicians are less likely to detect alcohol problems:

• When screening tools are not used universally

• In patients who they do not expect to have alcohol problems: whites, women, higher SES

Friedman et al., 2000; Yersin et al., 1995; Wilson et al., 2002.

0

20

40

60

80

100

8%2%

Perc

en

tHypothetical patient: Top 5 physician diagnoses (Survey of 648 PCPs) Male vs Female

CASA, 2000

Clinician barriers to discussing alcohol with

patients57.7%Belief that patients lie

35.1%Time constraints29.5%Fear that it will question patient’s integrity25% Fear of frightening/angering patient15.7%Uncertainty about treatments12.6%Personally uncomfortable with subject11% May encourage patient to see other MD10.6%Insurance doesn’t reimburse PCP time

CASA: Missed Opportunity: National Survey of Primary Care Physicians and Patients on Substance Abuse, April 2000

Miller, et al. 2006

Agree/Strongly Agree

“If my doctor asked me how much I drink, I would give an honest answer.” 92%

“If my drinking is affecting my health, my doctor should advise me to cut down on alcohol.”

96%

“As part of my medical care, my doctor should feel free to ask me how much alcohol I drink.”

93%

Disagree/Strongly Disagree

“I would be annoyed if my doctor asked me how much alcohol I drink.” 86%

“I would be embarrassed if my doctor asked me how much alcohol I drink.” 78%

Survey on patient attitudes

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Understanding The Benefit

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The Policy

•In 2013, the USPSTF recommended that clinicians screen adults

age 18 years or older for alcohol misuse and provide persons engaged

in risky or hazardous drinking with brief behavioral counseling

interventions to reduce alcohol misuse

•Effective January 1, 2014, California offers Alcohol Screening, Brief

Intervention, and Referral to Treatment (SBIRT) benefit in primary care

settings to all Medi-Cal beneficiaries, 18 years and older

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Process

• Pre-screen

• (Expanded) Screening

• Brief intervention: One to three 15-minute sessions

• Referral to Treatment: the Department of Public Health/Substance Abuse Prevention & Control program

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Pre-Screen• A single alcohol screening question included in the Staying

Healthy Assessment (SHA) which must be conducted within 120 days of enrollment and every three years with annual reviews of the member’s answer

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Screen• Screen members 18 years of age and older who answer

“yes” to the alcohol question in the SHA or at any time the PCP identifies a potential alcohol misuse problem.

• Recommended screening tool – the Alcohol Use Disorders Identification Test (AUDIT) (or the Alcohol Use Disorder Identification Test—Consumption (AUDIT-C))

Developed by the World Health Organization (WHO) as a simple method of screening for excessive drinking and to assist in brief assessment

10 questions – multiple choices Accurate across many cultures/nations

Brief Intervention• Members screened positively for risky or hazardous alcohol

use or a potential alcohol use disorder (Zone III) shall be offered up to three 15-minute brief interventions (per member per year)

• Each intervention is limited to one (1) session per unit, 15 minutes per unit, per member

• Brief intervention services may be provided on the same date of service as the expanded screen, or on subsequent days

• Each intervention can be offered in-person or via telephone or telehealth modalities

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The Effects

•Brief interventions trigger change• A little counseling can lead to significant change, e.g., 5 min. has same impact as 20 min.

• SBI can reduce accidents, injuries, trauma, emergency department visits, depression, drug- related infections and infectious diseases• SBI for alcohol saves $2 - $4 for each $1.00 expended

• Research is less extensive for illicit drugs, but promising

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Behavior change

Awareness of problem

Motivation

Presenting problem

Screening results

Referral to Treatment

Members should be referred to the Department of Public Health/SAPC for Drug Medi-Cal SUD services if they:

Didn’t respond to the brief interventions; or Were screened positively for possible alcohol use

disorder (Zone IV); or Whose diagnosis is uncertain

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Referral to Treatment

• Approximately 5% of patients screened will require referral

to substance use evaluation and treatment

• A patient may be appropriate for referral when:• Assessment of the patient’s responses to the screening • reveals serious medical, social, legal, or interpersonal • consequences associated with their substance use

•These high risk patients will receive a brief intervention followed by referral

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Purpose: determine diagnosis and appropriate

level of care:

• Level I: Outpatient treatment

• Level II: Intensive outpatient treatment

• Level III: Residential/inpatient treatment

• Level IV: Medically managed intensive

inpatient treatment

Substance abuse treatment

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The Reimbursement•Screen, using a Medi-Cal approved screening instrument, and billed with HCPCS

code H0049, is limited to one unit per recipient per year, any provider. Note - the pre-

screen or brief screen is not reimbursable. Diagnostic code???

•Brief intervention services may be provided on the same date of services as the full

screen, or on subsequent days, using HCPCS code H0050. The brief intervention is

limited to three sessions per recipient per year, any provider

•For the Federally Qualified Health Centers (FQHCs) and the Rural Health Clinics

(RHC) providers, the costs of providing SBIRT services are included in the all-inclusive

prospective payment systems (PPS) rate. SBIRT services that meet the definition of an

FQHC/RHC visit, as defined in the Rural Health Clinics (RHCs) and Federally Qualified

Health Centers (FQHCs) section of the Part 2 – Medi-Cal Billing and Policy manual, are

billable

•Any claims reimbursed for more than the maximum units per year are subject

to recovery by the Department of Health Care Services (DHCS).

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The tool

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Standard Drink in the US• 1 standard drink = 14 grams of pure alcohol (about 0.6 fluid

ounces or 1.2 tablespoons)

• Standard drink equivalent: Beer: 12 oz = 1 22 oz = 2

16 oz = 1.3 40 oz = 3.3 Table wine: a 5 oz glass = 1

a standard 750 ml (25 oz) bottle = 5 Malt liquor: 12 oz = 1.5 22 oz = 2.5

16 oz = 2 40 oz = 4.5 Hard liquor or ‘80-proof spirits’:

a pint (16 oz) = 11

a fifth (25 oz) = 17

1.75 L (59 oz) = 39

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The AUDIT

Tool

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AUDIT Scores

*Continue monitoring with each intervention

Risk Level AUDIT Score Intervention

Zone I 0-7 Alcohol Education

Zone II 8-15 Simple Advice

Zone III 16-19 Brief Intervention

Zone IV 20-40 Referral to Treatment

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The Training Requirements

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Requirements• SBIRT services must be provided by a licensed health care

provider (PCP/PA/NP/Psychologist) or a non-licensed staff working under the supervision of the licensed health care provider

• Non-licensed staff must be trained in SBIRT services in order to provide services

• The supervising licensed provider and the non-licensed providers of SBIRT services must attest that they have obtained the required trainings on SBIRT within the first 12 months. The training is a one-time requirement

• The reporting and monitoring requirements will follow as per DHCS

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Training Requirements for Licensed Providers

At least one supervising licensed provider per clinic or practice must take 4 hours of

SBIRT training within 12 months after initiating SBIRT services

*Beyond the first 12 months of providing SBIRT services, at least one

supervising

licensed provider per clinic or practice must have completed training

At all times, rendering licensed providers are highly encouraged, but not required,

to take training in order to provide the services

A minimum of 4 hours of SBIRT training is highly encouraged for both supervising

and rendering licensed providers within the first 12 months; however, the rendering

licensed providers are not required to take the training in order to provide the services

For solo physician practices, the physician is highly encouraged, but not required,

to take the training within the first 12 months.

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Training Requirements for Non-licensed Providers

Trained non-licensed providers: Includes health educators, certified addiction

counselors,

health coaches, medical assistants, and non-licensed behavioral health assistants

Requirements:Be under the supervision of a licensed provider

Complete a minimum of 60 documented hours of professional experience such

as coursework, internship, practicum, education or professional work within their

respective field.

Should include 4 hours of training directly related to SBIRT services

such as Motivational Interviewing

Complete a minimum of 30 documented hours of face-to-face client contact

Within his or her respective field, in addition to the 60 hours of clinical professional

experience described above.

These contact hours may include internship, on-the-job

training, or professional experience and SBIRT services training.

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SBIRT Training•SAMHSA funded – Addiction Technology Transfer Center Network:

“Foundations of SBIRT” at http://www.attcelearn.org/

•NIAAA Clinician’s Guide Online Training “Video Cases: Helping Patients Who Drink Too Much” at http://www.niaaa.nih.gov/publications/clinical-guides-and-manuals/niaaa-clinicians-guide-online-training

•SBIRT Core Training Program: Screening, Brief Interventions, and Referral to Treatment at http://www.sbirttraining.com/sbirtcore

•NAADAC’s The Addiction Professional’s Mini-Guide to Screening, Brief Intervention and Referral to Treatment (SBIRT) at http://www.naadac.org/theaddictionprofessionalsminiguidetosbirt

•SBIRT Oregon Training Curriculum for Primary Care at http://sbirtoregon.org/training.php

•Institute for Research, Education & Training in Addictions – SBIRT in Action – Another Vital Sign at http://ireta.org/webinarlibrary

•New York State’s SBIRT Training Provider Certification at http://www.oasas.ny.gov/workforce/training/SBIRTCert.cfm

*Other trainings resources can be found on DHCS website at www.dhcs.ca.gov

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L.A. Care Behavioral Health Contacts

• Leilanie Mercurio, Health Services Coordinator, 213-694-1250 x4456, lmercurio@lacare.org

• Clayton Chau, Medical Director, cchau@lacare.org

• Suzie Matsuda, Director of Clinical Services, smatsuda@lacare.org

• Nicole Lehman, Director of Operations, nlehman@lacare.org

• Anthony Perera, Administrative Manager, aperera@lacare.org

• Robert (RJ) Key, Program Manager, rkey@lacare.org

• Torhon Barnes, Care Coordination Manager, tbarnes@lacare.org

• Hieu Nguyen, Strategic Initiatives Manager, hnguyen@lacare.org

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