SBIRT Administration Dr Larry Schonfeld Stephen Ferrante SBIRT

SBIRT Administration Dr. Larry Schonfeld Stephen Ferrante SBIRT Summit May 19, 2014

Training Components Review & Practice • Prescreening • Full Screening Assessment • Brief Intervention • Brief Therapy & Treatment • Treatment Referral • Evaluation • Billing • Organizational Adoption

http: //sbirt. samhsa. gov/about. htm

Substance Abuse Severity & Level of Care Adapted from the SAMHSA TIP #34 (1999) and Institute of Medicine (1990) None Sub Mild stan ce A buse Moderate Sev erity Substantial Severe Specialized Treatment Brief Intervention Primary Prevention

Prescreening • First Stage in SBIRT Process • With Universal Screening - Most people screen negative for substance misuse • Screening is designed to be Brief & Determines: o Any use versus no use o Potential for risky use or serious substance use • Demographics & Prescreen used to establish the “Denominator” of the program: o Total people approached & interviewed?

Prescreening • ASSIST Question #1 o In your life, which of the following substances have you ever used • Negative Screen? o Inquire (probe) if all answers negative o Provide feedback about the results o Offer prevention-focused educational materials • Positive Screen? o Administer Full ASSIST & Determine Level of Service • Brief intervention • Brief treatment • Referral to treatment

PRESCREENING ACTIVITY

The ASSIST (World Health Organization) • Developed by the ASSIST Working Group in 2002 • Used Primarily to Assess: o Frequency of substance use o Category/type of substances used o Risk level of alcohol, illicit drugs & tobacco in past 3 months • Illicit substances (drug use) are weighted differently for men & women • Use “response card” to help people being interviewed to focus on the questions being asked

The ASSIST V 3. 0 – Series of 8 Questions 1. In your life, which of the following substances have you ever used? (NONMEDICAL USE ONLY) (yes/no response) PRESCREENING 2. In the past three months, how often have you used the substances you mentioned (FIRST DRUG, SECOND DRUG, etc. )? 3. During the past three months, how often have you had a strong desire or urge to use (FIRST DRUG, SECOND DRUG, etc. )? 4. During the past three months, how often has your use of (FIRST DRUG, SECOND DRUG, ETC) led to health, social, legal or financial problems? 5. During the past three months, how often have you failed to do what was normally expected of you because of your use of (FIRST DRUG, SECOND DRUG, ETC)? 6. Has a friend or relative or anyone else ever expressed concern about your use of (FIRST DRUG, SECOND DRUG, ETC. )? 7. Have you ever tried and failed to control, cut down or stop using (FIRST DRUG, SECOND DRUG, ETC. )? 8. Have you ever used any drug by injection? (NON-MEDICAL USE ONLY)

ASSIST: Introduction Read to Person Thank you for agreeing to take part in this brief interview about alcohol, tobacco products and other drugs. I am going to ask you some questions about your experience of using these substances across your lifetime and in the past three months. These substances can be smoked, swallowed, snorted, inhaled, injected or taken in the form of pills (show drug card). Some of the substances listed may be prescribed by a doctor (like amphetamines, sedatives, pain medications). For this interview, we will not record medications that are used as prescribed by your doctor. However, if you have taken such medications for reasons other than prescription, or taken them more frequently or at higher doses than prescribed, please let me know. While we are also interested in knowing about your use of various illicit drugs, please be assured that information on such use will be treated as strictly confidential. NOTE: BEFORE ASKING QUESTIONS, GIVE ASSIST RESPONSE CARD TO CLIENT

ASSIST Questions 6 -8 focus on: 1. Others’ expressing concern about his/her substance use 2. Individual’s failed attempts to stop/cut down, 3. Injection of drugs

Example of Scoring: Cocaine/Crack Item (past 3 months) Frequency Score Weekly 6 Once or Twice 4 Monthly 5 Once or Twice 4 Q 6 -d (friend or relative concern? ) Yes, but not in past 3 months 3 Q 7 -d (tried, but failed to cut down) No, Never 0 Q 2 -d (used ? ) Q 3 -d (urge/desire? ) Q 4 -d (health, social, legal, financial problems) Q 5 -d (failed to do what was expected of you) Total 22

Low Risk Moderate to High Risk Alcohol 0 -10 11 -19 20 -26 27+ Any other Substance 0 -3 4 -19 20 -26 27+ No Brief Intervention Treatment Referral to Treatment Highest Risk

Providing Feedback • Low: You are at low risk of health & other problems from your current pattern of use. • Moderate: You are at risk of health & other problems from your current pattern of substance use • High: You are at high risk of experiencing severe problems (health, social, financial, legal, relationship) as a result of your current pattern of use & are likely to be dependent Ask: Are you concerned about your substance use?

Example for providing feedback: Alcohol Your risk of experiencing these harms is: Low Regular excessive alcohol use is associated with: • • • Moderate (tick one) High Hangovers, aggressive and violent behaviour, accidents and injury Reduced sexual performance, premature ageing Digestive problems, ulcers, inflammation of the pancreas, high blood pressure Anxiety and depression, relationship difficulties, financial and work problems Difficulty remembering things and solving problems Deformities and brain damage in babies of pregnant women Stroke, permanent brain injury, muscle and nerve damage Liver disease, pancreas disease Cancers, suicide

FULL SCREENING & ASSESSMENT ACTIVITY

BRIEF INTERVENTION • 1 to 5 Sessions • Advise o Review screening results o Provide direct advice to make a change o Educate on substances & substance use/abuse o Consequences of use & benefits of change • Assess o Determine how willing the client is to change his/her behavior o Reinforce client’s capacity for change • Agree o Set concrete goals • Assist o Help client to make change if he/she is ready o Outline strategies for success & relapse prevention

Brief Intervention Tools • Individual Record & Plan • Health Promotion Workbook • Brief Negotiated Interview Tips • Educational Materials: Drug Fact Sheets

BRIEF INTERVENTION ACTIVITY

BRIEF TREATMENT A 16 -session curriculum manual for conducting brief treatment Dupree & Schonfeld (CSAT, 2005)

Cognitive-Behavioral/Self-Management Treatment Approach • Developed from our work in the Gerontology Alcohol Project 1979 -1981 & the Substance Abuse Program for the Elderly 1986 -1994 at FMHI/USF. • Modified to a 16 -session manual for SAMHSA (2005) • Replications o Chelsea Arbor Older Adult Recovery Center in Ann Arbor, Michigan (1990’s) o 16 session outpatient program at the West Los Angeles VA Hospital “GET SMART Program” 2000 -2011) (Schonfeld et al. 2000) o Zablocki VA Medical Center (Milwaukee, 2006) o Older Adult Substance Abuse Treatment Program – Tennessee (2005 - 2008) (Outlaw et al. 2012)

A Three Stage CBT/Self-Management Treatment Approach (Dupree & Schonfeld, CSAT 2005) 1. For each person in treatment, begin by conducting an analysis of the antecedents & consequences for substance use to create an individualized “substance use behavior chain” Substance Abuse Profile for the Elderly 2. Teach the person how to identify the components of that chain so that he or she can understand the high risk situations for alcohol or drug use. 3. Teach specific skills to address these high risk situations to prevent relapse.

Stage 1: Conduct Behavior Analysis of High Risk Situations: The SAPE Questionnaire • Substance Abuse Profile - an interview questionnaire to identify the “A-B-C’s” or the Substance Use Behavior Chain • Antecedents: o High Risk Situations led to drinking or drug use in the recent past o Likely to be repeated & lead to relapse after treatment • Behavior: Identify the most problematic substance (e. g. , alcohol) & focus on the first use on a “typical day” of use. • Consequences: What events are likely to reinforce the person to drink/use substances again & again?

Stage 2 : Teaching Clients to Identify his/her High Risk Situations • Now that we (staff) understand the substance use behavior chain… o Teach it to the person o Verify that the client knows which events are likely to lead to his/her first drink or use of drugs

Stage 2: Teach Participants to understand their individual behavior chain • Review substance abuse profile responses • Individual should be able to diagram “A-B-C’s” from simple examples to more complex examples & finally their own chain • Recognize antecedents & consequences • Learn to keep weekly logs to record urges to use alcohol or drugs - What they did/did not do when facing those urges • Identify antecedents to slips

“A-B-C” Approach to Treatment: The Substance Use Behavior Chain Antecedents Situations/ + Feelings + Cues + Urges Thoughts Behavior 1 st drink or Use of drug Consequences Immediate Positive or Negative Long Term Negative Consequences Home/alone + bored and depressed + beer in refrigerator + “A drink will help me forget my troubles. ” First sip of beer Feel happier Continue drinking, anger her children, and impair health

Stage 3: Teaching the Skills Necessary to Prevent Relapse Once the person demonstrates an understanding of his/her personal substance use behavior chain, teach specific skills to address his or her high risk situations CBT & Self-Management Skills High Risk Situation Social Pressure Loneliness Depression Anxiety Anger/Frustration Cues Urges Slips Skills Taught Drink Refusal Rebuild Social Network Cognitive Restructuring Thought-stopping Relaxation, Problem solving Thought-stopping Assertiveness Training How to dispose, avoid, rearrange Thought-stopping, Learn to Delay Relapse Training

Content of 16 Sessions Topics # Sessions Introduction to Analysis of Behavior (“A-B-C’s” of Substance Abuse) 2 Social Pressure 2 At Home and Alone 1 Depression 2 Managing Anxiety & Tension 3 Managing Anger & Frustration 3 Controlling Cues 1 Coping with Urges 1 Preventing a Slip from Becoming A Relapse 1

Referral to Treatment • Arrange o Treatment & Supportive Service Referrals & Linkages o Based on Client Risks & Needs o Confirm Connections • Broward County Treatment Providers • Established Relationships o Referral Agreements • Follow-up RE: Treatment Completion & Outcome • Offering Continued Availability & Support

SBIRT Evaluation (2 years) • Evaluating Output o Client Reach o Productivity • Evaluating Outcome o Compare baseline with 60 day post intervention/treatment follow-up • Evaluating Process o Adoption strategies o Protocols o Challenges & Success

Evaluation Tools • Voluntary Content • Follow-up Consent • Individual Record & Plan • Monthly Report • Provider Meetings • Stakeholder Interviews / Focus Groups • Steering & Advisory Council

SBIRT Billing & Reimbursement • Affordable Care Act Recommended Service • Screening & Brief Intervention Reimbursement o Commercial insurance CPT codes o Medicare G codes o Medicaid HCPCS codes • Florida Medicaid Billing Codes not approved

Payer Commercial Insurance Code Fee Schedule Alcohol and/or substance abuse structured CPT 99408 screening and brief intervention services; 15 to 30 minutes $33. 41 Alcohol and/or substance abuse structured CPT 99409 screening and brief intervention services; greater than 30 minutes $65. 51 G 0396 Alcohol and/or substance abuse structured screening and brief intervention services; 15 to 30 minutes $29. 42 G 0397 Alcohol and/or substance abuse structured screening and brief intervention services; greater than 30 minutes $57. 69 H 0049 Alcohol and/or drug screening $24. 00 H 0050 Alcohol and/or drug service, brief intervention, per 15 minutes $48. 00 Medicare Medicaid Description

Common Behavioral Health Codes CPT Code Description 90801 Diagnostic interview 90804 Individual psychotherapy, 20‒ 30 minutes 90806 Individual psychotherapy, 45‒ 50 minutes

SBIRT Billing Codes • October 14, 2011 CMS began covering annual alcohol screening & for those that screen positive up to 4 brief, face-to-face behavioral counseling interventions annually for Medicare beneficiaries including pregnant women. Each of the 4 behavioral counseling interventions must be consistent with the 5 As approach: • Assess: Ask about/assess behavioral health risk(s) and factors affecting choice of behavior change goals/methods. • Advise: Give clear, specific, and personalized behavior change advice, including information about personal health harms and benefits. • Agree: Collaboratively select appropriate treatment goals and methods based on the patient’s interest in and willingness to change the behavior. • Assist: Using behavior change techniques (self-help and/or counseling), aid the patient in achieving agreed-upon goals by acquiring the skills, confidence, and social/environmental supports for behavior change, supplemented with adjunctive medical treatments when appropriate. • Arrange: Schedule follow-up contacts (in person or by telephone) to provide ongoing assistance/support and to adjust the treatment plan as needed, including referral to more intensive or specialized treatment.

Health Care Providers can provide SBIRT services under Medicare • Medicare pays for medically reasonable & necessary SBIRT services in physicians’ offices & outpatient hospitals • Physicians, Physician Assistants, Nurse Practitioners, Clinical Nurse Specialists, Clinical Psychologists, or Clinical Social Workers can bill for SBIRT • To bill Medicare, providers of MH services must be: o Licensed or certified to perform mental health services by the state in which they perform the services; o Qualified to perform the specific mental health services rendered; and o Working within their State Scope of Practice Act http: //www. cms. gov/Outreach-and-Education/Medicare-Learning-Network. MLN/MLNProducts/Downloads/SBIRT_Factsheet_ICN 904084. pdf

Centers for Medicare & Medicaid (CMS) SBIRT Billing Codes – October 2011 • Two new G codes, G 0442 (Annual Alcohol Misuse Screening, 15 minutes), and G 0443 (Brief face-to-face behavioral counseling for Alcohol Misuse, 15 minutes) • Provider specialty types that may submit claims under these codes: 01 -General Practice 08 -Family Practice 11 -Internal Medicine 16 -Obstetrics/Gynecology 37 -Pediatric Medicine 38 -Geriatric Medicine 42 -Certified Nurse Midwife 50 -Nurse Practitioner 89 -Certified Clinical Nurse Specialist 97 -Physician Assistant

Organization Adoption • Information & Knowledge Sharing • Commitment & Buy-In • Protocols • Tools & Materials • Practice Integration • Fidelity Checks • Professional Development & Competence • Data Management • Continuous Quality Improvement • Sustainability • Coaching & Technical Assistance