Part II: Performing brief interventions and referrals to treatment

1. Part II: Performing brief interventions and referrals to treatment

2. Styles of communication Communication styles during the patient visit Following Guiding Directing

3. Using a directive style towards behavior change Styles of communication http://www.youtube.com/watch?v=2fdfzUS1qDc University of Florida, Psychiatry Dept.

4. Directive communication towards behavior change Styles of communication • Explaining why • Telling how • Emphasizing importance • Persuading Rollnick, et al., 2008

5. Respect for autonomy, goals, values Readiness to change Ambivalence Patient is the expert Empathy, non-judgment, respect Characteristics ofguiding communication Styles of communication

6. 3 minutes or more Aimed to motivate behavior change Designed to: Provide personal feedback; enhance motivation; promote self-efficacy; promote behavior change Brief Interventions Brief interventions

7. Steps of the brief intervention: Steps of the brief intervention Raise the subject Provide feedback Enhance motivation Negotiate plan D`Onofrio, et al., 2005

8. Brief intervention: “Steve” Steps of the brief intervention http://www.youtube.com/watch?v=b-ilxvHZJDc

9. Simple step, but important Screening forms as conversation starters Asking permission Steps of the brief intervention Steps of the brief intervention Raise the subject

10. State Zone of use Address or ask about possible connection to health issues State low risk limits Give recommendation Steps of the brief intervention Steps of the brief intervention Provide feedback

11. Steps of the brief intervention Steps of the brief intervention Enhance motivation • Use the 0 – 10 scale • “Why not a lower number?” • Explore pros and cons

12. If pt is ready: “What would that look like for you?” Plan to reduce use, abstain and/or seek referral Re-state recommendation Schedule follow-up Steps of the brief intervention Steps of the brief intervention Negotiate plan

13. Clinic tools • Readiness Ruler: front

14. Clinic tools • Readiness Ruler: back

15. Clinic tools • Reference sheet: front

16. Clinic tools • Reference sheet: back

17. Practice: Jill Practice • Groups of three: • Physician • Patient • Observer

18. Brief intervention Billing the Brief intervention Full screen + Brief intervention • Use a 25 modifier • Counts towards Oregon SBIRT incentive measure • Reimbursement: $26 - $30 and $52 - $65

19. Incentive measure billing Full screen only Full screen +Brief intervention

20. 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 Referring your patient Substance abuse treatment

21. Referring your patient Making the referral 800-923-4357 • Sponsored by AMHD • Database of facilities and resources • Often staffed by volunteers in recovery

22. Billing • SBIRT incentive measure • Ratio: • 99420, 99408, 99409, G0396, G0397 • Benchmark: 13% • Improvement target for 2013: 3% • All Medicaid pts • 18 and over

23. Stages of change International Agency for Research on Caner (IARC) How ready are you to change your behavior? Cell phone use increases cancer risk

24. Stages of change Stages of change Pre- contemplation Relapse Contemplation Maintenance Preparation Action

25. Stages of change The patient is not thinking about changing and perhaps is unaware that a problem exists. Pre- contemplation It isn’t that they can’t see the solution. It is that they can’t see the problem.

26. Stages of change In the contemplation stage, people acknowledge that they have a problem and begin to think seriously about solving it. Contemplation • “I want to stop feeling so stuck” • Contemplators are struggling to understand their problem, see its causes, wonder about solutions • They may be far from making a commitment to taking action about their problem

27. Stages of change Preparation takes your patient from decision making in the contemplation stage to the specific steps for solution in the action phase. Preparation • Preparation is the cornerstone of effective action • Commitment is the most important change process in the preparation stage

28. Stages of change Effective action begins with commitment. Once the commitment to change is made, it is time to move. Action • The process of action includes: • Countering, control & reward • Continued reliance on helping relationships

29. Stages of change • The first two months of maintenance is the most likely time for relapse. Maintenance • Acknowledge vulnerability to the problem behavior, even while building a new life-style • Develop confidence in ability to succeed • Find few, if any, temptations to misuse substances

30. Medications Meds for substance dependence, in general • The most powerful role a primary care provider can fill in treating alcohol and drug problems is that of a motivator, an educator, and a provider of referrals to treatment – SBIRT. • Should they choose, providers may enhance the services they provide through the use of medications for substance dependence

31. Medications Meds for treating EtOH dependence Meds

32. Medications Meds for treating opiate dependence • Methadone maintenance • Buprenoprhine treatment • Psychosocial treatment alone • Illicit drugs other than opiates: No proven medications

33. Making recommendations Recommendation for Illicit drug use: abstain IV • No Zone I for drug use • Casual marijuana use still carries consequences • Medical marijuana possible exception III II

34. Making recommendations Recommendations for alcohol use: Abstain IV Reduce use / Abstain III Reduce use II Low risk or abstention

35. Prior history of substance dependence Pregnancy Medications Serious mental illness, medical condition Other factors behind recommending abstention Making recommendations

36. Practice: Tom Practice • Groups of three: • Physician • Patient • Observer

37. Brief intervention: “Tom” Practice http://www.youtube.com/watch?v=1kalMZCelNw&feature=related

38. Pipeline • Workflow resembles a pipeline

39. Pipeline Installing the pipeline • Buy-in • Clinic champions • Training • Tools • EMR

40. Jim Winkle, MPH OHSU Family Medicine Phone: 503-720-8605 winklej@ohsu.edu www.sbirtoregon.org Questions? www.sbirtoregon.org