SBIRT: Behavioral Health Screenings & Patient- Centered Care. Presented By: Zoe O Neill July 24, 2013

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1 SBIRT: Behavioral Health Screenings & Patient- Centered Care Presented By: Zoe O Neill July 24, 2013

2 Welcome! Type questions into the Questions Pane

3 Patient-Centered Primary Care Institute History and Development Launched in 2012 Public-private partnership Broad array of technical assistance for practices at all stages of transformation Learning Collaboratives Website ( Webinars & Online Learning Ongoing mechanism to support practice transformation and quality improvement in Oregon

4 PCPCH Model of Care Oregon s PCPCH Model is defined by six core attributes, each with specific standards and measures Access to Care Be there when we need you Accountability Take responsibility for us to receive the best possible health care Comprehensive Whole Person Care Provide/help us get the health care and information we need Continuity Be our partner over time in caring for us Coordination and Integration Help us navigate the system to get the care we need safely and timely manner Person and Family Centered Care Recognize we are the most important part of the care team, and we our responsible for our overall health and wellness Read more:

5 Welcome! Introductions OPCA Zoe O Neill SBIRT Presentation Objectives Overview of SBIRT Evidence of effectiveness! Example Workflows SBIRT billing Implementation best practices and available resources

6 Introduction to SBIRT Screening Brief Intervention Referral to Treatment

7 Why Screen? SBIRT has been identified by SAMHSA as a comprehensive, integrated, public health approach to the delivery of early intervention for individuals with risky alcohol and drug use, and the timely referral to more intensive substance abuse treatment for those with substance abuse disorders The issue: Tobacco use, risky drinking, drug use, and depression cost our country $872 Billion a year in healthcare, productivity, and societal costs Patients with chronic illness and untreated substance use or mental health disorder are hospitalized times more each year than those with the chronic illness alone. In Oregon currently, only 0.42% of patients identified as having an alcohol or drug disorder are treated. SAMHSA s National Registry for Evidence-Based Programs and Practices (2008). Brief alcohol screening and intervention. Dr. Rich Brown, Wellsys, Behavioral Screening and Intervention

8 Why Screen? The outcomes following universal SBIRT implementation: Significant reduction in 7-day alcohol use and frequency of excessive drinking Fewer days of hospitalizations $523 reduction in healthcare costs per risky drinking patient $4,392 reduction in total healthcare costs per dual-eligible patient 20% reduction in binge drinking 15% reduction in marijuana use 55% reduction in depression symptoms. Increased patient satisfaction! Fleming MF, et all Brief Physician Advice for problem drinkers: long term efficacy and benefit-cost analysis Brown, Richard, University of Wisconsin and Wisconsin Medical Society, 2010.

9 Overview of Process Annual Screen AUDIT-3 DAST PHQ-2 Full Screen AUDIT DAST PHQ-9 Brief Intervention Referral to Treatment If patient answers yes to any initial screening question, full screening is administered If patient response indicates risky or harmful use, a brief intervention is performed If patient response indicates dependence refer to treatment

10 Screening tools Annual Patient Questionnaire PHQ Questions on alcohol use 1-2 Questions on drug use Question on tobacco How many times in the past year have you had 5 or more drinks in a day? During the past two weeks, have you been bothered by little interest or pleasure in doing things?

11 Annual Screening Form Example MEN: How many times in the past year have you had 5 or more drinks in a day? WOMEN: How many times in the past year have you or more drinks in a day? Alcohol: One drink = 12 oz. beer 5 oz. wine 1.5 oz. liquor (one shot) None 1 or more MEN: How many times in the past year have you had 5 or more drinks in a day? WOMEN: How many times in the past year have you had 4 or more drinks in a day?

12 Annual Screening Results Did the patient answer no to all questions? Did the patient answer yes to any question? Fantastic! Congratulate patient and reinforce healthy behaviors. Patient should be re-screened in 12 months If yes to mood questions, administer PHQ-9 If yes to alcohol questions, administer AUDIT If yes to drug question(s), administer DAST

13 Full Screen: DAST 1. Have you used drugs other than those required for medical reasons? 2. Do you abuse more than one drug at a time? 3. Are you unable to stop using drugs when you want to? 4. Have you ever had blackouts or flashbacks as a result of drug use? 5. Do you ever feel bad or guilty about your drug use? 6. Does your spouse (or parents) ever complain about your involvement with drugs? 7. Have you neglected your family because of your use of drugs? 8. Have you engaged in illegal activities in order to obtain drugs? 9. Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs? 10. Have you had medical problems as a result of your drug use (e.g. memory loss, hepatitis, convulsions, bleeding)? Do you inject drugs? How often do you use drugs

14 Full Screen: AUDIT 1. How often do you have a drink containing alcohol? Never Monthly or less 2-4 times a month 2-3 times a week 4 or more times a week 2. How many drinks containing alcohol do you have on a typical day when you are drinking? or 4 5 or or more 3. How often do you have six or more drinks on one occasion? Never Less than monthly Monthly Weekly Daily or almost daily 4. How often during the last year have you found that you were not able to stop drinking once you had started? Never Less than monthly Monthly Weekly Daily or almost daily 5. How often during the last year have you failed to do what was normally expected of you because of drinking? Never Less than monthly Monthly Weekly Daily or almost daily 6. How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session? Never Less than monthly Monthly Weekly Daily or almost daily 7. How often during the last year have you had a feeling of guilt or remorse after drinking? Never Less than monthly Monthly Weekly Daily or almost daily 8. How often during the last year have you been unable to remember what happened the night before because of your drinking? Never Less than monthly Monthly Weekly Daily or almost daily 9. Have you or someone else been injured because of your drinking? No Yes, but not in the last year Yes, in the last year 10. Has a relative, friend, doctor, or other health care worker been concerned about your drinking or suggested you cut down? No Yes, but not in the last year Yes, in the last year

15 Full Screen: PHQ-9

16 Primary Care Residency Initiative Low-risk drinking limits Drinks Per week Drinks Per day Men 14 4 Women 7 3 All age > Categories of drinking IV III II I Low risk or Abstain: 78% Dependent: 5% Harmful: 8% Risky: 9% 0cm Very I Low risk/abstain AUDIT: 0 7 DAST: 0 II Risky AUDIT: 8 15 DAST: 1-2 III Harmful AUDIT: DAST: 3-5 IV Dependent AUDIT: 20+ DAST: 6+

17 Brief Interventions Why Brief Intervention? The goal of BI is to educate patients and increase their motivation to reduce risky behavior. BI is conducted with patients who score into risky or harmful use categories.

18 Example 1 Review Video:

19 Example 2 Review Video:

20 Referring to Treatment For patients who score into dependent zones for alcohol or drug use they will need to be referred to more specialized treatment. Examples of referrals include: Medication Assisted Treatment in Primary Care (Suboxone) Referral to outpatient/inpatient/detox facilities in your community Call the State Resource and Crisis line: For patients who indicate suicidality or severe depression, referrals include: Immediate suicide/crisis management Medication Counseling Further diagnostic examinations by mental health provider

21 SBIRT Workflow OPCA s pilot project Reception Health Educator* Provider Annual Screen MA Scores Screen Full Screen (AUDIT, DAST and/or PHQ-9) Brief Intervention Referral to Treatment * Commonly a non-clinically trained, lay person

22 SBIRT Workflow Another common clinical workflow Reception Provider Annual Screen MA Scores Screen Full Screen (AUDIT, DAST and/or PHQ-9) Brief Intervention Referral to Treatment

23 SBIRT Billing Who can bill? Billing codes and the CCO quality measures Code alignment in Oregon! SBIRT billing Full screen + brief intervention: min > 30 min Medicaid Medicare G0396 G0397 Comm. CPT CPT 99408

24 Implementing SBIRT in YOUR primary care clinic! Engagement Training Implementation Executive Sponsorship Primary Care Provider leadership Clinic/Mid-Manager supervision and leadership Care-Team level engagement Initial Screener involvement Financial Viability discussion Organizational alignment Motivational Interviewing training Collaborative Care Model overview Screening tool proficiency Billing for SBIRT EMR/Documentation/Reporting Workflow planning and referral mapping Ongoing and Continuous Improvement Measurement % of total target population screened % of positive screens that receive a brief intervention/total positive screens % of positive screens indicating need for treatment that receive referral/total screens needing referral % of patients with reduction in risky behavior at re-screen Engage Staff in SBIRT project Initiate training for identified staff Identify target population for universal screening Design initial workflow and task assignment Design approach to rapid cycle improvement of SBIRT work Identify billing policies and procedures Standardize EMR Documentation for: When patient is due for screening Results of screening Interaction with Health Educator Referral to Treatment Measurement and Reporting

25 Available Resources Oregon Primary Care Association (OPCA) OPCA is a membership organization that provides technical assistance, policy support and advocacy for Oregon's 31 Federally Qualified Community Health Centers. With a mission of achieving health equity for all, OPCA has partnered with the Oregon Community Foundation to allow for SBIRT engagement, implementation, training, and measurement support to our FQHC sites. (503) Addiction Technology Transfer Care Network (ATTC) The Northwest Addiction Technology Transfer Center (NWATTC) provides SBIRT training and technical assistance to primary care clinics, behavioral health organizations; as well as county and state systems. Located at OHSU in the Public Health & Preventative Medicine department, our workforce development training and consulting services enhance knowledge, skill and service delivery. Denna Vandersloot, M.Ed, the NWATTC Director at (503) or Traci Rieckman, Ph.D., NWATTC PI, at (503) Jim Winkle, MPH Jim Winkle has trained hundreds of physicians and clinic personnel on how to conduct SBIRT in primary care settings. As Project Director for the SBIRT Oregon Initiative, he has designed clinic tools, screening forms, and training videos that have been widely adopted by health professionals around the country , Links to all SBIRT resources on the Institute website:

26 Questions? Zoe O Neill Oregon Primary Care Association Community Health Center Operations Manager (503)

27 Closing Please fill out the survey after this presentation you can send us additional questions Webinar materials can be retrieved from our website, Additional questions?

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