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 • to 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 • As well as those with dependency and in need of specialty referral/treatment.

4. A Public Health Perspective

5. Why SBIRT is being Adopted • Risky and harmful levels of drinking are very common • Alcohol is a contributing factors to many injuries as well as other chronic and acute care concerns. • Dependence usually be identified, but risky and harmful levels of alcohol use most often go unaddressed • People are more open to discussion and change than you might expect • It is efficient and effective

6. JAMA Psychiatry. 2017;74(9):911-923. doi:10.1001/jamapsychiatry.2017.2161 Published online August 9, 2017.

7. Increases of these outcomes were greatest among • Women • Older adults • Racial/ethnic minorities • Individuals with lower educational level and family income JAMA Psychiatry. 2017;74(9):911-923. doi:10.1001/jamapsychiatry.2017.2161 Published online August 9, 2017.

8. 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.

9. Universal Screening • Results in earlier detection • Helps determine provider response • Normalizes the Screening and subsequent discussion • Ques the client/patient on importance • Often initiates reflection by the client/patient • Increases efficiency

10. Pre-Screening • The Audit-C is being used and information gathered by admitting nurse. • The Audit-C has been normed and found to be a valid and reliable tool in healthcare settings. • When a response is positive, further screening and/or discussion is indicated. • Best practice is to conduct a brief review of the screen with client/patient - even if there are no areas of concern.

11. Based on Findings of Initial or Pre- Screening • A positive response initiates a full screen-the Audit • The Audit –C and Audit supply valuable client/patient self-reported information that can be used as the basis for the brief intervention. • Often the process of screening sets in motion client/patient reflection on their substance use behavior.

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

15. What is a standard drink?

16. Scoring and interpreting the audit

17. Screening, Brief Intervention, and Referral to TreatmentOU SBIRT Collaborative CATEGORIES OF DRINKING LOW-RISK DRINKING LIMITS IV DEPENDENT: 5% III HARMFUL: 8% II RISKY: 9% I HEALTHY: 78%

18. Brief intervention in Health care Settings -Usually last from 5 to 15 minutes. -Not intended to treat people with serious substance dependence. -Motivational Interviewing skills are the underpinnings ge.

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

20. A Word about Best Outcomes from the SBIRT process • The likelihood of the client/patient taking steps to decrease alcohol consumption will be enhanced by a team approach. • The doctors, nurses, social work staff and clergy should seize opportunities to reinforce the work of the lead SBIRT professional. • Very brief-thirty seconds to three minutes • Use MI skills • Encourage and listen • Reinforce

22. During the Brief Intervention you help the client/patient to: • Find personal and compelling reasons to change • Build readiness to change • Make commitment to change

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

24. Initiating Reflective Discussion • Start the reflective discussion asking permission of our clients/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?”

25. 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

26. 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. ) • What relationship might there be between drinking 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?

27. Enhancing motivation • Uses skills to move client/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

28. Negotiating Commitment • Simple • Realistic • Specific • Attainable • Follow-up/timeline Negotiating a PLAN

29. Follow Up Ideas:-Client/Patient discharge instruction sheets are useful They should contain at minimum: • The agreed upon plan • Information regarding any referrals/resources • Tips on cutting back -A follow up phone call after discharge in addition would be another useful reinforcer.

30. Motivational Interviewing:The Basics

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

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

33. “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

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

35. 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

36. Remember “Readiness to change” State Trait

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

38. This video illustrates An effective discussion about overuse of alcohol with a Patient. Look for: -the steps of a Brief Intervention -Use of Motivational Interviewing skills https://youtu.be/uL8QyJF2wVw

39. Referral to Treatment Referral

40. Overview • Substance abuse treatment works! • Following are strategies to realize the greatest likelihood of a successful treatment referral.

41. What Is Treatment? • Treatment may include— • Counseling and Therapy on an outpatient basis • Various levels of inpatient/residential care • other psychosocial rehabilitation services • Medications • Involvement with self-help (AA, NA, Al-Anon) • Complementary wellness (diet, exercise, meditation) • Combinations of the above

42. What Is Treatment? (continued) • Treatment is provided within levels of care often available in multiple treatment settings. • Level of care is determined by severity: Is the client/patient a dependent or nondependent substance abuser, are they of danger to self or others, and are there medical or psychiatric comorbidities? • Inpatient treatment is reserved for those with more serious illness (dependence, Severe psychosis, Active suicidal/homicidal ideation).

43. Referral Guidelinesfor Greatest Success • Determine if client/patient is drug or alcohol dependent and needs medical detoxification (usually inpatient care). • Determine if client/patient is a serious threat to self or others. • A nondependent substance abuser is usually treated as an outpatient unless there are other risk factors.

44. A Strong Referral to Appropriate Treatment Is Key • When your client/patient is ready— • Make a plan with the client/patient. • You or your staff should actively participate in the referral process. The warmer the referral handoff, the better the outcome. • Decide how you will communicate with the provider to whom you are referring. • Confirm your follow-up plan with the client/patient. • Decide on the ongoing followup support strategies you will use.

45. Common Mistakes To Avoid • Rushing into “action” and making a referral when the client/patient isn’t interested or ready • Referring to a program that is full or does not take the client/patient’s insurance • Seeing the client/patient as “resistant” or “self-sabotaging” instead of having a chronic disease

46. NIAAA Treatment Navigator • Navigator home https://alcoholtreatment.niaaa.nih.gov/ • Treatment finder https://alcoholtreatment.niaaa.nih.gov/how-to-find-alcohol-treatment/find-alcohol-treatment-programs • Treatment toolkit page https://alcoholtreatment.niaaa.nih.gov/toolkit-niaaa-alcohol-treatment-navigator

47. Role Play

48. Tips for Being the Client/Patient • Do respond with information provided on the AUDIT • Do respond with your feelings related to how you believe the patient would • Don’t create extra “turns” or conflict in the case • Don’t break character

49. Contact information • Terrie Fritz • Email: terrie.fritz@ou.edu • Katrina Meyers • Email: katrina.meyers@ou.edu