SBIRT Screening, Brief Intervention, & Referral to Treatment

1. SBIRTScreening, Brief Intervention, & Referral to Treatment Terrie Fritz, LCSW ANNE AND HENRY ZARROW SCHOOL OF SOCIAL WORK CENTER FOR SOCIAL WORK IN HEALTHCARE

2. Screening Brief Intervention and Referral to Treatment IS : • An evidence based, comprehensive, integrated approach to identify and provide brief and effective early intervention for: • Alcohol misuse • Substance use • Tobacco use • Depression/anxiety • Carried out at in primary care, specialty care, hospital E/D, and other health care and community settings. • Based on Motivational Interviewing strategies

3. Goal of sbirt • Identify and effectively/efficiently intervene with those who are at risk for health problems related to one or more of those conditions • Seeks to identify those in the ‘risky or harmful’ use categories • Not only those with dependency and in need of specialty referral/treatment

4. A Public Health Perspective

5. Why SBIRT is being Adopted • Drinking, drug use, and depression are VERY common • They are Contributing factors to many chronic and acute care concerns • Drinking, drug use, and depression often go undetected • People are more open to discussion and change than you might expect • SBIRT is efficient and effective

6. Screening Universal Screening is the first step of SBIRT. The result of a screen allows the provider to determine if a brief intervention or referral to treatment is necessary.

7. Universal First Level Screening • Results in earlier detection • Reduces Risk of future injury or illness • Helps determine provider response • Normalizes the Screening and subsequent discussion • Cues the patient on importance • Often initiates reflection by the patient • Increases efficiency

8. Patient Stress Questionnaire

9. This tool incorporates: • For Anxiety – Gad-2 • For Depression – PHQ-2 • For suicidality – accepted single question • For Alcohol – Audit-C • For illicit and prescription drug abuse – Single question (prescreen) • A personal violence question • PTSD screen

10. More Points on Screening • The questions have been normed and have been found to be valid and reliable indicators when used in healthcare settings. • The tool is generally self administered using paper or electronic tool such as tablet. • When a response is positive to any question, further screening and/or discussion is indicated. • Best practice is to conduct a brief review of the screen with patient – even if there are no areas of concern.

11. Based on Findings of Initial or Pre-Screening • A positive response on any section will initiate a full screen. • The clinician has valid, patient self-reported information that can be used as the basis for the brief intervention. • Often the process of screening sets in motion patient reflection on their substance use behavior.

14. Scoring and interpreting the audit

15. Screening for Alcohol Use When Screening, It’s Useful To Clarify What One Drink Is!

16. What is a standard drink?

17. CATEGORIES OF DRINKING LOW-RISK DRINKING LIMITS IV DEPENDENT: 5% III HARMFUL: 8% II RISKY: 9% I HEALTHY: 78%

18. Categories of Response CATEGORIES OF DRINKING ACTION • Refer to Assessment or Treatment • Brief Intervention or Refer to Assessment • Brief Intervention • Support and Education IV DEPENDENT: 5% III HARMFUL: 8% II RISKY: 9% I HEALTHY: 78%

19. Depression • Symptoms can include anxiety, irritability, restlessness, fatigue, difficulty concentrating, feelings of hopelessness, etc. • People with other chronic medical conditions have a higher risk of depression (including: cancer, coronary heart disease, diabetes, etc.) • People with depression are at higher risk for other medical conditions • Up to 80% of new mothers experience “baby blues” and postpartum depression occurs in nearly 15% of births • Depression IS treatable even when other illness is present

20. Behavioral Tactics for Improving Symptoms of Depression • Positive Activity Planning (engaging in activities/hobbies that make the patient happy – you might need to engage the patient by asking about his/her hobbies) w/the goal of at least 1 positive activity planned per day • Increasing Physical Activity (walking, jogging, walking the dog, stretching – again, the patient will need to be engaged about what movement he/she enjoys) • Sleep (setting a schedule, focusing on sleep hygiene, avoid alcohol before bed) • Eating habits (plan meals, avoid skipping meals, avoid eating for comfort or convenience – minimize sugar & refined carbs) • Friendships (reconnect or engage in opportunities to make new friends – avoid isolation, stay connected)

22. Scoring and Interpreting the PHQ-9 • Each question has a set of responses to choose from • Response Scores range from 0 to 3 • Add scores for all questions • Scoring: • 1-4=Minimal depression • 5-9=Mild depression • 10-14=Moderate depression • 15-19=Moderately severe depression • 20-27=Severe depression

24. Scoring and Interpreting the GAD-7 • Each question has a set of responses to choose from • Response Scores range from 0 to 3 • Add scores for all questions • Scoring: • 5=Mild anxiety • 10=Moderate anxiety • 15=Severe anxiety

25. Instructions • Get with your two neighbors in your triad/set • Review handouts for Low Risk Jill • Take turns being patient, provider, and observer. • Practice giving brief feedback to someone who is below the healthy drinking limits. • Give personal feedback • Use card • Ask their thoughts, any questions • Give brief information/education about how alcohol can play a role in many health conditions/illnesses • No more than one to two minutes • Twos start as provider, threes as patient and ones as observer, then rotate

26. Goal of Brief Interventions Awareness of problem Behavior change Motivation Presenting problem Screening results

28. During the Brief Intervention you help the patient to: • Find personal and compelling reasons to change (NOT YOURS!) • Build readiness to change • Make commitment to change

29. Negotiate commitment Initiate reflective discussion Five steps of Brief intervention Enhance motivation Evoke personal meaning Provide feedback based on screening/ assessment data

30. Initiating Reflective Discussion • Start the reflective discussion by asking permission of our patients to have the conversation. • Example: “Would it be all right with you to spend a few minutes discussing the results of the wellness survey you just completed?”

31. Providing Feedback • Review score • Discuss Level of risk • Provide information about the risk • Share why you would hope to see a reduction Low Moderate High Very High 0 40

32. Evoking Personal Meaning Reflective questions: From your perspective….. • Have you had any thoughts before today about the relationship between alcohol and your health? (or your blood pressure, diabetes, etc.) • Have you had any thoughts before today about the relationship between your mood (feeling down or anxious) and your health? (diabetes, chronic condition, etc.) • What relationship might there be between drinking (or your mood) and ____? • What are your concerns About this? • What are the important reasons for you to decrease use of alcohol? • What are possible benefits you can see from cutting down?

33. Enhancing motivation • Uses skills to move patient along in the change process • Increases the likelihood of taking next steps • Relies on tools such as: • Highlighting Change talk • Developing discrepancy • Readiness assessment

34. Negotiating Commitment • Simple • Realistic • Specific • Attainable • Follow-up time line Negotiating a PLAN

35. Definition of Motivational Interviewing “Motivational interviewing is a client-centered, method for enhancing intrinsic motivation to change by exploring and resolving ambivalence.”

36. Benefits of Using MI E vidence based P atient centered P rovides structure Readily adaptable

37. “People are generally better persuaded by the reasons which they have themselves discovered than by those which have come into the mind of others.” —Blaise Pascal

38. Motivational Interviewing:The Basics

39. Avoid Argumentation • Resistance to change is strongly affected by your response • Normalize to patient that having difficulties while changing is not uncommon

40. Rolling with Resistance • Example 1 : • Patient: I don’t plan to quit drinking anytime soon • Clinician: You don’t think that abstinence would work for you right now • Example 2: • Patient: My husband often brings up my drinking—He says I drink too much. It really bothers me • Clinician: It sounds like he is concerned, but expresses it in a way that makes you angry

41. Remember “Readiness to change” State Trait

42. Core MI • Open-ended questions • Affirmations • Reflections • Summaries

43. Open-Ended Questions (continued) • Why open-ended questions? • They avoid the question/answer trap • Puts patient in an active role • Provides opportunity to explore ambivalence

44. Affirmations • What is an affirmation? • Compliments or statements of appreciation and understanding • Praise • Support • Caveat – Must be done sincerely

45. Reflective Listening ( • Involves listening and understanding the meaning of what the patient says • Accurate empathy is a predictor of behavior change • Demonstrates that you have accurately heard and understood the patient • Strengthens trust and the relationship

46. Summaries • Periodically summarize what has occurred in the Brief Intervention • Summary usages • Begin a session • End a session • Transition

47. Using Rulers: I-C-R Confidence Readiness rulers can address— • Importance • Confidence • Readiness Readiness Importance

48. Enhancing Motivation Readiness Ruler

49. Short Video • Shows many of the points I have made thus far • Is really pretty good, overall • Watch for • the five steps • the OARS • things you want to copy • things you might do differently https://youtu.be/WFjFIuUY8o4

50. Negotiate commitment Initiate reflective discussion Five steps of Brief intervention Enhance motivation • #1s will take 5-7 minutes to do steps 1, 2 and 3. • #2s will perform 3, 4 and 5 Evoke personal meaning Provide feedback based on screening/ assessment data