SBIRT Implementation Clayton Chau, MD, PhD Medical Director, Behavioral Health Services

1. SBIRT Implementation Clayton Chau, MD, PhD Medical Director, Behavioral Health Services cchau@lacare.org Updated 04/21/2014

2. Goals • Definition • Understanding the benefit • The tool and the process • The training requirements

3. Definition

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

5. SBIRT Referral to Treatment Screening Brief Intervention • An evidence-based method to intervene in unhealthy alcohol and drug use, but underemployed in medical settings.

6. Key Terms • Screening – 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

7. Why implement SBIRT? • High prevalence of unhealthy alcohol and drug use • Significant morbidity, mortality, and cost • Screening instruments work • Brief interventions effective, inexpensive, and acceptable

8. Business as usual SBIRT VS. Routine and universal screening Inconsistent and selective assessment 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 up

9. Unhealthy alcohol use among PC patients Unhealthy use: 22% Low risk or abstention: 78% NIAAA. Manwell, 1998

10. Stratified prevalence of alcohol use among PC patients 5% Dependent 8% Harmful 9% Risky Low risk: 38% Abstain: 40% Manwell, et. al, 1998

11. Risky zone • • Risky drinking likely leads to new health problems or makes existing ones worse • This zone defined by quantity alone • Any illicit drug use is risky IV III Risky II I

12. The Harmful zone • Repeated negative consequences • Failure to fulfill major obligations • Use continues despite persistent problems • Associated with “alcohol abuse” IV Harmful III II I Donovan, et al. 2006

13. 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) Dependent IV III II I Donovan, et al. 2006

14. Unhealthy alcohol use associated with: • 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.) MMWR Weekly, 2004, Naimi, 2002

15. Risks of unhealthy drinking, cont.

16. Alcohol: Psychiatric co-morbidity • Odds of co-occurrence of Current (12-month) Grant., et al, 2004

17. 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 use

18. Evaluations of SBIRT Meta-analyses & reviews: • More than 34 randomized controlled trials • Focused primarily on at-risk and problem drinkers • Result: 13-34% reductionin alcohol consumption at 12 months Moyer et al, 2002; Whitlock et al, 2004; Bertholet et al, 2005

19. USPSTF on SBI • For both alcohol screening and brief intervention • Adults and pregnant women • Insufficient evidence for adolescents Class B rating USPSTF, 2004 and 2013

20. SBIRT effectiveness • Fewer hospitalizations & ER visits • Cost savings: Fleming, et al, 2002

21. Washington state SBIRT ER project • 2003-2008 study implementing SBIRT in ER depts. • Medicaid savings from pts receiving BI: $185-192 per member per month • Due to less inpatient hospitalizations from ER admissions Estee, et al, 2008

22. Missed opportunities in primary care • Prevalence 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, 2011

23. 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.

24. Hypothetical patient: Top 5 physician diagnoses (Survey of 648 PCPs)Male vs Female CASA, 2000

25. Clinician barriers to discussing alcohol with patients CASA: Missed Opportunity: National Survey of Primary Care Physicians and Patients on Substance Abuse, April 2000

26. Survey on patient attitudes Miller, et al. 2006

27. Understanding The Benefit

28. The Policy • In 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

29. Process • Pre-screen • (Expanded) Screening • Brief intervention: One to three 15-minute sessions • Referral to Treatment: the Department of Public Health/Substance Abuse Prevention & Control program

30. Pre-Screen • Asingle 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

31. Screen • Screen 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)) • Developed 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

32. Brief Intervention • Members 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 member • Brief 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

33. The Effects • Briefinterventionstriggerchange • Alittle counselingcanleadtosignificant change, e.g., 5 min. hassameimpactas 20 min. • SBIcanreduceaccidents,injuries,trauma, emergency departmentvisits, depression,drug- relatedinfections andinfectiousdiseases • SBI foralcoholsaves$2-$4foreach $1.00expended • Researchis lessextensiveforillicit drugs,but promising

34. Awareness ofproblem Behavior change Motivation Presentingproblem Screeningresults

35. Referral to Treatment • Members 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

36. Referral to Treatment • Approximately5%ofpatients screenedwillrequirereferral tosubstanceuseevaluationandtreatment • Apatientmaybe appropriatefor referralwhen: • Assessmentofthepatient’sresponsestothescreening • revealsseriousmedical,social,legal,or interpersonal • consequencesassociatedwiththeir substanceuse • These highrisk patientswill receivea briefintervention followedby referral

37. Substance abuse treatment 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

38. The Reimbursement • Screen, 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 provider • For 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).

39. The tool

40. Standard Drink in the US • 1 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 = 3.3 • Table 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

41. The AUDIT Tool

42. AUDIT Scores *Continue monitoring with each intervention

43. The Training Requirements

44. 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 provider • Non-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

45. Training Requirements for Licensed Providers • At 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 training • At all times, rendering licensed providers are highly encouraged, but not required, to take training in order to provide the services • A 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.

46. Training Requirements for Non-licensed Providers • Trained 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 their respective 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.

47. SBIRT Training • SAMHSA 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

48. L.A. Care Behavioral Health Contacts • Leilanie Mercurio, Health Services Coordinator, 213-694-1250 x4456, lmercurio@lacare.org • Clayton Chau, Medical Director, cchau@lacare.org • Suzie 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