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Sarah T. Melton, PharmD,BCACP, BCPP,CGP,FASCP

Screening, Brief Intervention and Referral to Treatment (SBIRT) in the Primary Care Setting. Sarah T. Melton, PharmD,BCACP, BCPP,CGP,FASCP. 16th Annual Primary Care Conference Monday , March 26, 2012 Millennium Centre, Johnson City, TN.

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Sarah T. Melton, PharmD,BCACP, BCPP,CGP,FASCP

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  1. Screening, Brief Intervention and Referral to Treatment (SBIRT) in the Primary Care Setting Sarah T. Melton, PharmD,BCACP, BCPP,CGP,FASCP 16th Annual Primary Care Conference Monday , March 26, 2012 Millennium Centre, Johnson City, TN

  2. ObjectivesAt the completion of this presentation, the participant will be able to: • Describe the steps involved in proper screening, brief intervention, and referral to treatment (SBIRT) for substance abuse in the primary care setting. • Select the appropriate tools to screen for alcohol and drug abuse in the primary care setting. • Apply the principle of motivational interviewing and stages of change in the SBIRT process. • Examine principles of coding, billing and reimbursement for SBIRT in the primary care setting.

  3. What is SBIRT? SBIRT is a comprehensive, integrated, public health approach to the delivery of early intervention and treatment services For persons with substance use disorders Those who are at risk of developing these disorders Primary care centers, trauma centers, and other community settings provide opportunities for early intervention with at-risk substance users Before more severe consequences occur

  4. SBIRT: Core Clinical Components Screening: Very brief screening that identifies substance-related problems Brief Intervention: Raises awareness of risks and motivates patient toward acknowledgement of problem Brief Treatment: Cognitive behavioral work with patients who acknowledge risks and are seeking help Referral: Referral of those patients with more serious addictions for outpatient or inpatient treatment

  5. Nationwide Movement Toward Standard of Care US Preventive Services Task Force The Patient Protection and Affordable Care Act 2010 $240 million in federal SBIRT funding to states and residency training programs (ETSU!) NIH funding JACHO – proposed standard Reimbursement codes - Centers for Medicare & Medicaid Services; the AMA (CPT codes) and E&M codes

  6. Evidence to Support SBIRT in Primary Care • Systematic review of 22 randomized controlled trials (RCT) of brief alcohol interventions in primary care settings • 15 minutes or less • At least one follow-up • Average number of drinks/week reduced by 4 drinks over controls • 10-19% more participants drinking at moderate or safe levels than controls • One study showed maintenance of improved drinking for up to 48 months Whitlock EP, Polen MR, Green CA, et al. Annals Int Med 2004;104(7):557-580. Kaner EF, Dickinson HO, Beyer F, et al. Drug Alcohol Rev 2009; 28(3):301-23.

  7. Evidence to Support SBIRT in Primary Care Burke BL, Arowitz H, Menchola M.Consult Clin Psychol 2003;71(5):843-6; Babor TF, Higgins-Biddle JC. Addiction 2000;95(5):677-86. Fleming M, Manwell LB. Alcohol Res Health 1999;23(2):128-37. A meta-analysis suggests an overall reduction of 56% in number of drinks consumed per week The effect size for a brief motivational intervention of all types ranged from 0.25 to 0.57, with participants followed from 3 to 24 months Research has shown brief interventions can reduce alcohol use for at least 12 months in patients who are not alcohol dependent 10-30% of patients can be expected to change their drinking behaviors as a result of a brief intervention

  8. SBIRT Prospective Cohort Study 6 clinical sites 459,599 patients screened Hazardous use or current substance abuse disorder: 22.7% At 6-month follow up Drug use 67.7% ↓ Alcohol use 38.6% ↓ Self reported improvement in general health, mental health, employment, housing status and criminal behavior Madras BK, Compton WM, Avula D, et al., Drug Alcohol Depend 2009;99:280-95.

  9. Major Impact on Public Health? • Stem progressionto dependence • Improve medical conditions exacerbated by substance abuse • Prevent medical conditions resulting from substance abuse or dependence • Reduce drug-related infections and infectious diseases • Improve response to medications • Identify those at higher risk of abusing prescription drugs • Identify abusers of prescription drugs or OTC drugs • Have positive influence on social function

  10. Characteristics of a Good Screening Tool • Brief (10 or fewer questions) • Flexible • Easy to administer, easy for patient • Addresses alcohol & other drugs • Indicates need for further assessment or intervention • Has good sensitivity and specificity

  11. Sensitivity and specificity • Sensitivity refers to the ability of a test to correctly identify those people who actually have a problem, e.g., “true positives” • Specificity is a test’s ability to identify people who do not have a problem, e.g., “true negatives” • Good screening tools maximize sensitivity and reduce “false positives”

  12. SBIRT Goals Increase access to care for persons with substance use disorders and those at risk of substance use disorders Foster a continuum of care by integrating prevention, intervention, and treatment services Improve linkages between health care services and alcohol/drug treatment services

  13. Poll the Audience • What percentage of your primary care patients would be classified with alcohol abuse or dependence? • What percentage would be classified as “at risk” drinkers? • What percentage of your primary care patients have used illicit drugs in the past month?

  14. Compare Demographics • How did your answers compare with statistics for the general population? • Percent with alcohol abuse or dependence • 7% or about 1 in 14 • Percent “at risk” drinkers • 23% or nearly 1 in 4! • Percent using illicit drug • 8% or about 1 in 12 SAMHSA, National Survey on Drug Use and Health, 2008 Ages 12+ in the United States

  15. Why Screen? SCREENING WIDENS THE NET AT-RISK ALCOHOL & DRUG USE ABSTAINERS & LOW RISK USE ABUSE/ DEPENDENCE Specialized Treatment Brief Intervention Primary Prevention

  16. Annual Screen • Description • One question regarding alcohol use • One question regarding drug use • Method • Written form given once a year by front office at check-in • Verbally once a year at triage or by nursing when patient is being roomed • Pre-screens are NOT reimbursable • Purpose • Quickly identify patients at risk of misusing alcohol or drug and warrant further screening

  17. Annual Screening Once a year, all our patients are asked to complete this form because drug use, alcohol use, and mood can affect your health as well as medications you may take. Please help us provide you with the best medical care by answering the questions below.

  18. Full Screen • Description • The AUDIT (Alcohol Disorder Identification Tool) is a 10-item questionnaire for alcohol use • The DAST-10 (Drug Abuse Screening Tool) is a 10-item questionnaire for drugs • Method • Given to patients who are positive on annual screen • Written form(s) given when patient is taken into exam room by nursing • Purpose • Stratify patients into zones of substance use and informing the clinician who does a brief intervention

  19. The AUDIT • Developed by World Health Organization • Accurate measure of risk across gender, age, & cultures • 3 domains of drinking • Scores 8 > indicate risky drinking • Scores 20 > may indicate need of treatment

  20. The AUDIT Advantages: • Validated on primary health care patients in six countries • Identifies hazardous and harmful alcohol use as well as possible dependence • Brief, rapid, and flexible • Can be administered as questionnaire or interview

  21. The AUDIT Limitations: • Limited to alcohol screening • May be too lengthy for some situations (e.g. emergency department) • Not enough research has been completed to determine precise cut-off points

  22. DAST-10

  23. DAST-10 Advantages: Brief and inexpensive Provides a quantitative index of the extent of problems related to drug abuse Can be administered to adults as well as adolescents Can be administered as questionnaire or interview

  24. DAST-10 Limitations: Does not screen for alcohol use/abuse Clients may “fake” results Scores may be misinterpreted Should NOT be administered to persons actively under the influence of drugs or who are undergoing drug withdrawal reaction

  25. Scoring the DAST-10 For questions 1 & 2, score “1” for every “YES” response For question 3, score “1” for a “NO” response For questions 4-10, score “1” for every “YES” response

  26. Scoring the DAST-10 ScoreDegree of Problem 0 None Reported 1-2 Low Level 3-5 Moderate Level 6-8 Substantial Level 9-10 Severe Level

  27. DAST Interpretation Guide ASAM = American Society of Addiction Medicine level/category ScoreActionASAM 0 Monitor None 1-2 Brief Counseling Level I 3-5 Outpatient Level I or II 6-8 Intensive Level II or III 9-10 Intensive Level III or IV

  28. Brief Intervention • Description • Evidence-based and can be performed in as little as 3 minutes, typically 5-15 minutes • Based on motivational interviewing • Method • Delivered by the clinician after the full screen has been scored • Purpose • Motivate patients to reduce their use, abstain, or accept a referral to treatment

  29. Effectiveness of Brief Intervention • 32 controlled studies found brief interventions often as effective as more extensive treatments • Reduction in the following as a result of brief intervention: • Alcohol and other substance consumption/use • Harmful physical consequences • Social consequences • Sick days, missed work • Hospitalizations • Trauma/accidents/injuries Fleming M, Manwell LB. Alcohol Res Health 1999;23(2):128-37.

  30. What is Motivational Interviewing? Helps identify and encourage behavior change Increase patient’s awareness of problems, consequences, and risks related to behavior Assists patient to explore and resolve ambivalence toward behavior and increase motivation to change Motivation to change is elicited from the person, not mandated from the outside

  31. Principles of Motivational Interviewing Express empathy Develop discrepancy Roll with resistance Support self-efficacy

  32. Four Components of Brief Intervention Raise the subject Provide feedback Enhance motivation Negotiate and advise

  33. Raising the Subject Would you mind taking a few minutes to talk about your [X] use? Before we go further, I’d like to learn a little more about you. What is a typical day like for you? Where does your [X] use fit in? • Build rapport 2. Ask about Pros & Cons Help me understand through your eyes the good things about using [X]? What are some of the not so good things about using [X]? So on the one hand you said <PROS>, and on the other hand <CONS>. Summarize

  34. Providing Feedback 3. Feedback • I have some information on low-risk guidelines for drinking, would you mind if I shared them with you? • We know that drinking • 4 or more (F)/ 5 or more (M) drinks in 2 hours • more than 7(F)/14(M) drink in a week • use of illicit drugs • can put you at risk for illness and injury. It can also cause health problems like [insert medical information]. • What are your thoughts on that? Ask permission Give information Elicit reaction

  35. Assessing Readiness to Change 4. Readiness to Change This Readiness Ruler is like the Pain Scale we use to measure pain levels. On a scale from 1-10, with one being not ready at all and 10 being completely ready, how ready are you to change your [X] use? You marked ___. That’s great. That means you’re ___% ready to make a change. Why did you choose that number and not a lower one like a 1 or 2? Readiness ruler Reinforce positives

  36. SBIRT READINESS RULER Categories of drinking Low-risk drinking limits Dependent: 5% IV III Harmful: 8% II Risky: 9% I Low risk or Abstain: 78% Not at all 0cm 1 2 3 4 5 6 7 8 9 10 Very Raise the subject • “If it’s okay with you, let’s take a minute to talk about the annual screening form you’ve filled out today.” • “As your doctor, I can tell you that drinking (drug use) at this level can be harmful to your health and possibly responsible for the health problem you came in for today.” Provide feedback SAMHSA Referral Helpline 1-800-662-HELP • “On a scale of 0-10, how ready are you to cut back your use?” • If >0: “Why that number and not a ____ (lower one)?” • If 0: “Have you ever done anything while drinking (using drugs) that you later regretted?” Enhance motivation • “What steps can you take to cut back your use?” • “How would your drinking (drug use) have to impact your life in order for you to start thinking about cutting back?” Negotiate plan

  37. Stages of ChangeProchaska & DiClemente Precontem- plation Contemplation Recurrence Preparation Maintenance Action

  38. Creating an Action Plan Create action plan What are some options/steps that will work for you? What do you think you can do to stay healthy and safe? Tell me about a time when you overcame challenges in the past. What kinds of resources did you call upon then? Which of those are available to you now? You have some great ideas, would you mind if we wrote them down on to keep with you as a reminder? Will you summarize the steps you will take to change your [X] use? Identify strengths & supports 5. Prescription for Change Write down action plan

  39. How does it all fit together?

  40. Video Demonstration http://www.sbirtnc.org/

  41. Brief Intervention and Referral • Description • Clinician advises further assessment and treatment from a specialized facility or resource • Method • Referrals can be advised as part of the intervention • Clinic staff will actively facilitate the referral • Purpose • Motivate and engage patients to see further assessment and/or treatment as part of the brief intervention.

  42. Does Treatment Work? Providers sometimes feel discouraged about referring patients for substance abuse treatment. Sometimes it seems like it just isn’t worth the effort. But relapse rates are really no different than other chronic diseases: http://www.nida.nih.gov/PODAT/faqs.html#Comparison

  43. Referral to Treatment Guidelines • To maximize the likelihood of success, assess level of care needed • Determine if patient is drug or alcohol dependent (and needs medical withdrawal) (inpatient) or is a substance abuser (outpatient unless has other risk factors) • Determine if patient has other risk factors that would make them better candidates for inpatient treatment than outpatient treatment: • Co-occurring mental illness (may need a psychiatry consult) • Polysubstance use and dependence on multiple substances • Serious medical illnesses that may be exacerbated when substance use changes

  44. Other Factors to Consider • Insurance coverage • Private: must check with insurer to determine what kind of treatment and what facilities they will pay for • Public assistance (VA vs. TN Medicaid) • Language ability/cultural competence • Treatment history (have they failed outpatient treatment in past?) • Location/transportation: can the patient and their family easily access the treatment facility?

  45. Other Factors to Consider Family support Can the facility treat both substance use disorders and mental illness? Can the facility treat both substance use disorders and medical illness? Does the facility offer/support pharmacotherapy for maintenance of abstinence? Does the facility have a good record of keeping referring medical staff informed of patient progress and ongoing needs?

  46. Common Roadblocks/Mishandling • PCP rushes into “action” and makes referral when the patient has no interest • PCP refers to an program unable to accept patient due to capacity or doesn’t take the patient’s insurance • Patient feels unheard and frustrated • PCP doesn’t create a referral “package” • Other strategies/programs patient can try while they are on a program • PCP doesn’t consider pharmacotherapy to reduce cravings and/or reduce suffering • PCP gets frustrated and sees the patient as “resistant” or “self-sabotaging” • Versus having a difficult chronic disease What could you do to avoid each of these mistakes? How will you assess your success?

  47. Key Points for Billing • Pre-screen • Front desk personnel, triage nurses, etc. • Not reimbursable SBIRT services • Full Screen • Physicians, physician assistant, nurse practitioner • Licensed behavioral health care practitioner • Clinical social worker • Psychologist • Professional counselor

  48. Key Points for Billing - Scenario • PCP sees a new patient with a chief complaint relating to physical health • Primary care office administers pre-screen for drug and alcohol abuse • Negative – document negative pre-screen and do not pursue further SBIRT services; no SBIRT billing • Positive – may conduct Full Screen and Brief Intervention Service • Bill under regular E&M code for the primary complaint • SBIRT service code either 99408 or 99409, depending on time

  49. Key Points for Billing - Scenario • If Full Screen is negative • May choose not to pursue further SBIRT services • No billing would occur • Billing for services would be under E&M billing codes, depending on time and complexity of primary health service • May choose to provide general feedback, prevention counseling, discuss risky lifestyle choices, self-management • Bill under SBIRT codes • 99408 (15-30 minutes) • 99409 (greater than 30 minutes)

  50. Key Points for Billing - Scenario • If Full Screen is positive • May provide more complete screening and brief intervention services • Billing under SBIRT codes may occur AND • Billing for primary health services under E&M codes may occur

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