Screening Brief Intervention and Referral to Treatment SBIRT

Screening, Brief Intervention, and Referral to Treatment (SBIRT) Erich Kleinschmidt May 19, 2014

CDC report – Jan. 2012 • One in six Americans binge drinks four times per month • Average number of drinks during binge is 8 • 40, 000 deaths per year (binge-specific) • 2006 - $167. 7 billion alcohol-related costs • Age group that binge drinks most often – 65+ • Income group with most binge drinkers - $75 K+ CDC Morbidity & Morality Weekly Report, Jan. 10, 2012 Vol. 61

CDC Report continued – binge drinking responsible for: • Risk factor for motor vehicle accidents, violence, suicide, hypertension, heart attack, STDs, unintended pregnancy, FAS, SIDS • 85% of all alcohol-impaired driving episodes involved binge drinking (2010) • Accounted for 50% of all alcohol consumed by adults; 90% of youth • Most binge drinkers are not dependent CDC Morbidity & Morality Weekly Report, Jan. 10, 2012 Vol. 61

Focus of SBIRT Dependent Use 4% Harmful or Risky Use Low Risk Use or Abstention 25% 71% Brief Intervention and Referral to Treatment Brief Intervention No Intervention

What exactly is SBIRT? • SBIRT—Screening, Brief Intervention, and Referral to Treatment • Universal screening of pts within medical settings • If screened positive – brief intervention (guided discussion) with medical provider occurs • If screening reveals dependence – referral to specialty substance abuse treatment provider

SBIRT & Medical Connection § Takes advantage of the “teachable moment” § Patients aren’t seeking treatment but screening opens door for awareness & education § Increases access to clinically appropriate care for nondependent as well as dependent persons in a non-drug treatment setting

Ranked in top ten of prevention services 1. Discuss daily use of aspirin 2. Childhood immunization Series 3. Tobacco use screening and brief intervention 4. Colorectal cancer screening 5. Hypertension screening 6. Influenza immunization 7. Pneumococcal immunization 8. Problem drinking screening & brief intervention 9. Vision screening – adults 10. Cervical cancer screening (Partnership for Prevention – Priorities for America’s Health: Capitalizing on Life-Saving, Cost Effective Prev Services, 2006)

SBIRT “Patient Flow” Brief Treatment Cognitive behavioral treatment with multiple sessions available Screen Identification of substance related problems Brief Intervention Raises awareness of risks and motivates client toward concrete goals/actions Referral to Tx Referral of those with more serious abuse/dependency

Universal Prescreen • (-) Negative Provide positive reinforcement (+) Positive Low risk: Provide positive reinforcement Further screening with • ASSIST • AUDIT • CRAFFT • DAST Moderate risk: Provide Brief Intervention Moderate high-risk: Provide Brief Therapy High risk: Refer to treatment

Screening Tools • Four commonly used screening instruments: - Alcohol Use Disorders Identification Test (AUDIT or AUDIT – C) - Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) - Drug Abuse Screening Test (DAST) - CRAFFT (for adolescents) - All can be found online and downloadable

Effective Screening Program Typically Yields… • Approximately 25% of all patients will screen positive for some level of substance misuse or abuse • Of those, the approximately 70% will be “at-risk” drinkers • Most will be open to addressing their substance abuse problems (if discussed in a non-judgmental manner)

Identify Referral Resources Short-term and long-term residential treatment centers Community agencies for referrals Hospital inpatient and outpatient centers State treatment centers

Has been implemented in many settings • Thus far, SAMHSA has funded 26 states, 2 tribal organizations, and 12 colleges since 2003 (five yr grants to states; 3 yr to colleges) • States currently includes: IN, TN, SC, NC, VT, NY, WA, IL, CO, Am Samoa, AZ, IA, NJ, NM, OH • Clinical sites include: trauma centers, EDs, inpatient units, community health centers, FQHCs, tribal health centers, elder services agencies, adolescent care clinics, college health centers, VA clinics, urban STD clinics, National Guard installations, others…

SBIRT Training Programs • SBIRT training of resident physicians (19 grantees) since Sept ’ 08 (five yr grants) • New SBIRT Training for Medical Professionals (residents, social wk, nursing, counseling, others) started in Sept. 2013 (14 grantees including U. Miami – Coral Gables) for 3 years

Additional Initiatives • Youth Build USA – recent funding from Hilton Foundation – at risk program for older adolescents & young adults construction skills • New York – School-based health centers (high schools) • National Guard units – IA, KY, TN, CT, LA, IN

Payer Reimbursement for SBIRT Services Commercial Insurance Medicare Medicaid Code Description Fee Schedule CPT 99408 Alcohol and/or substance abuse structured screening and brief intervention services; 15 to 30 minutes $33. 41 CPT 99409 Alcohol and/or substance abuse structured 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

SBIRT reimbursement is available but… • Need to set up system for submitting claims (typically complex for start up) • Can be restrictions as to type of health professional that can bill (licensed vs unlicensed, etc…) • May get resistance from medical providers to add SBIRT to already heavy workload

Key Considerations for Starting SBI Program ü Develop a Screening protocol ü Develop a Brief Intervention protocol ü Monitor and evaluate program (strong QI mgt essential) ü Identify community referral resources, protocols, & tracking ü Reimbursement strategy & considerations (work with billing dept to establish reimbursement lines) ü Staff training needs and supervision ü Program “champions” and buy-in from CEO/Admin staff

Additional Considerations Who Will Do the Screening and Brief Intervention? • • “SBIRT” counselors/health educator model Social Workers Registered Nurses Psychologists Physicians Dedicated contracted personnel Medical Assistants Para-professionals

Challenges & Lessons Learned • Buy-in issues from existing medical staff (time/work load, don’t want to deal with “addicts”, now that we’ve identified them, now what? , etc. . ) • Funding for additional staffing (or train existing staff) • Need for management to be supportive and influence implementation (important to have “champions”) • Consistent training available for new staff • “Drift” from universal screening to “case finding” approach

SBIRT Websites/Resources http: //beta. samhsa. gov/sbirt http: //www. attcnetwork. org/regcenters/index_ nfa_sbirt. asp

Questions/Discussion For further information, etc…contact: erich. kleinschmidt@samhsa. hhs. gov