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
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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