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SBIRT Implementation Clayton Chau, MD, PhD SBIRT Implementation Clayton Chau, MD, PhD

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SBIRT Implementation Clayton Chau, MD, PhD - PPT Presentation

Medical Director Behavioral Health Services cchaulacareorg Updated 04212014 Goals Definition Understanding the benefit The tool and the process The training requirements 2 Definition ID: 679119

sbirt alcohol health training alcohol sbirt training health services licensed screening intervention care treatment org referral zone lacare drink

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Slide1

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

Updated 04/21/2014Slide2

GoalsDefinition

Understanding the benefit

The

tool and the processThe training requirements

2Slide3

Definition3Slide4

Screening, Brief Intervention& Referral to Treatment(SBIRT)4Slide5

SBIRT

Screening

Referral to Treatment

Brief Intervention

An evidence-based method

to intervene in

unhealthy alcohol

and

drug use, but underemployed in medical settings.Slide6

Key TermsScreening – 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

6Slide7

Why implement SBIRT?

High prevalence of unhealthy alcohol and drug use

Significant morbidity, mortality, and cost

S

creening instruments work

Brief interventions effective, inexpensive, and acceptableSlide8

VS.

Routine and universal screening

I

nconsistent and selective assessment

SBIRT

Business as usual

Validated screening tools

Non‐systematized narrative

questions

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

upSlide9

NIAAA. Manwell, 1998Unhealthy alcohol use among PC patients

Low risk or

abstention:

78%

Low-risk limits

Drinks

per

week

Drinks

per

day

Men

14

4

Women

7

3

All age >65

7

3

Unhealthy

use: 22%Slide10

Stratified prevalence of alcohol use among PC patients

Manwell, et. al, 1998

Low risk: 38%

Abstain: 40%5%

8

%

9

%

Dependent

Harmful

RiskySlide11

Risky zone

I

II

III

IV

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 riskySlide12

Repeated negative consequences

Failure to fulfill major obligations

Use continues despite persistent problems

Associated with “alcohol abuse”

The Harmful zone

I

II

III

IV

Harmful

Donovan, et al. 2006Slide13

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

II

III

IV

Dependent

Donovan, et al. 2006Slide14

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:Slide15

Risks of unhealthy drinking, cont.Slide16

Disorder

Odds

Anxiety Disorders

2.6x

Mood 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)Slide17

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 useSlide18

Evaluations of SBIRT

M

eta-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

Slide19

USPSTF, 2004 and 2013

For both alcohol screening and brief intervention

Adults and pregnant women

Insufficient evidence for adolescents

USPSTF on SBI

Class

B

ratingSlide20

SBIRT effectiveness

Fewer hospitalizations & ER visits

Cost savings:

Fleming, et al,

2002Slide21

Washington state SBIRT ER project

2003-2008 study implementing SBIRT in ER depts.

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

member per monthDue to less inpatient

hospitalizations from

ER admissions

Estee, et al, 2008Slide22

Missed opportunities in primary care

P

revalence

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, 2011Slide23

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.Slide24

Hypothetical patient:

Top 5 physician diagnoses

(Survey of 648 PCPs)

Male

vs

Female

CASA, 2000Slide25

Clinician barriers to discussing alcohol with patients

CASA: Missed Opportunity: National Survey of Primary Care Physicians and Patients on Substance Abuse, April 2000Slide26

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 Dis

agree

“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 attitudesSlide27

Understanding The Benefit27Slide28

The PolicyIn

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

28Slide29

ProcessPre-screen

(Expanded) Screening

Brief intervention: One to three 15-minute sessions

Referral to Treatment: the Department of Public Health/Substance Abuse Prevention & Control program29Slide30

Pre-ScreenA

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

30Slide31

ScreenScreen 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))

D

eveloped 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

31Slide32

Brief InterventionMembers 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 memberBrief 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

32Slide33

The EffectsBrief

i

n

terventions trigg

er

c

h

a

n

g

e

A

li

t

t

l

e

c

o

uns

e

li

n

g

can lead t

o significa

nt change,

e.g.,

5 min. has same

impact as

20

mi

n

.

S

BI

can reduce accidents, injuries, trauma, emergency department visits, depression, drug- related i

nfectio

ns

a

n

d

i

n

f

e

ct

io

u

s

d

i

seases

S

B

I

f

o

r

al

c

o

h

ol

s

a

v

es

$2

-

$4

f

o

r

ea

c

h $1.

00

e

x

p

e

n

d

ed

R

esea

r

c

h

is l

ess

e

x

t

e

n

si

v

e

f

o

r

illi

c

i

t

d

r

u

gs,

bu

t

p

r

o

m

i

s

i

n

g

33Slide34

Be

h

a

vi

or

c

h

a

n

g

e

A

w

a

r

e

n

e

ss

of

p

r

o

ble

m

M

o

t

i

v

a

t

io

n

P

r

e

s

enting problemScreening re

sultsSlide35

Referral to TreatmentMembers 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

35Slide36

Referral to TreatmentAppro

xi

m

ately 5% of patien

ts

sc

r

ee

n

e

d

will

r

e

qu

i

r

e

r

e

f

er

ral

to s

ubstance u

se evaluati

on and tr

eatment

A patie

n

t

m

a

y

be appropriate for referral when:Assessment of the patient’s responses to the screening reveals serious me

dical, s

ocial, le

g

al,

or i

n

t

e

rp

e

r

s

o

nal

c

o

n

s

e

quenc

e

s

a

ss

o

c

i

a

t

e

d

with

th

e

i

r

s

u

b

s

t

anc

e

u

s

e

T

h

e

s

e

h

i

g

h

ri

s

k

p

a

tie

n

ts

will

r

e

c

e

i

v

e

a

b

ri

e

f

i

n

t

e

r

v

e

n

tio

n

f

o

ll

o

w

e

d

by

r

e

f

er

r

al

36Slide37

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 treatmentSlide38

The ReimbursementScreen, 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 providerFor 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

).

38Slide39

The tool39Slide40

Standard Drink in the US1 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 = 3.3Table 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

40Slide41

The AUDITTool41Slide42

AUDIT Scores

*

Continue monitoring with each intervention

42

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 TreatmentSlide43

The Training Requirements43Slide44

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 providerNon-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

44Slide45

Training Requirements for Licensed ProvidersAt 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 trainingAt all times, rendering licensed providers are highly encouraged, but not required,to take training in order to provide the servicesA 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.

45Slide46

Training Requirements for Non-licensed ProvidersTrained 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 theirrespective 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.

46Slide47

SBIRT TrainingSAMHSA 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

47Slide48

L.A. Care Behavioral Health ContactsLeilanie Mercurio, Health Services Coordinator, 213-694-1250 x4456,

lmercurio@lacare.org

Clayton Chau, Medical Director,

cchau@lacare.orgSuzie 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

48Slide49

49