Genesee County and Its Drug Use in 2010

Transcription

1 Genesee County Community Mental Health (GCCMH) MI-SBIRT Grant Proposal, 5/14/12 The Genesee County SBIRT Project 1. Abstract Genesee County, Michigan is a depressed county with incomparable socioeconomic and health disparities. For averages, past month illicit drug use within the county (10.25%) has remained higher than Michigan and national averages 1. Genesee County had the second highest percentage of use in Michigan. More than 7% of Genesee County residents need, but are not receiving, treatment for alcohol use in the past year; approximately 3% of residents need, but are not receiving, treatment for illicit drug use in the past year 1. The purpose of the proposed project is to improve community health and wellness by decreasing AOD consumption in the county. The Greater Flint Health Coalition will continue to act as the convener of the task force and steering committee to facilitate collaborative, community based success of the project. The applicant, Genesee County Community Mental Health, will manage the Genesee County SBIRT project with local physical and behavioral health care providers, which will provide universal screening for substance use as well as for co-occurring disorders for those in need of treatment. Pregnant women, adolescents and adults will be seen within OB/GYN, Internal and Family Medicine clinics; and the Urban Health and Wellness Center. In Genesee County and the City of Flint, respectively, African Americans comprise 20.7/56.6% of the population, 74.5/37.4% are White, 2.6/3.9% are more than one race, and 3.0/3.9% are Hispanic or Latino of any race 2. Universal screening creates awareness about the number-one preventable health issue substance use 3. The grant aims to motivate Genesee County residents to make changes to improve their health and life through universal screening and early substance use intervention. Medical residents, nurse practitioners and other allied health professionals will be trained on screening for substance use and using motivational interviewing to provide brief intervention. Screenings and assessments for alcohol, illicit, prescription and OTC drugs; and co-occurring disorders will allow for brief intervention, brief treatment, or referral to treatment as needed. Brief treatment and referral to treatment and recovery services will be facilitated by imbedded clinical Behavioral Health Consultants and a Peer Recovery Coach. Data will regularly be collected and performance continually assessed in order to evaluate and improve upon the effectiveness of the project. Community awareness about substance use and co-occurring disorders will increase. The continuum of care for substance misuse services and access to behavioral services will be enhanced. Genesee County SBIRT will provide training on SBIRT components to approximately 70 medical residents, and over 30 nurse practitioners and allied health services staff. Approximately 20,000 patients will be screened within the four clinic sites. 1 National Survey on Drug Use and Health (NSDUH), U.S. Census Bureau: State and County QuickFacts. Data derived from Population Estimates, American Community Survey, Census of Population and Housing, County Business Patterns, Economic Census, Survey of Business Owners, Building Permits, Consolidated Federal Funds Report, Census of Governments 3 The Robert Wood Johnson Foundation, Schneider Institute for Health Policy, Brandeis University (2001). Substance Abuse, the Nation s Number One Health Problem. 1

2 2. Statement of Need Alcohol, marijuana, cocaine, and prescription drugs are the primary substance abuse problems in Genesee County. In Genesee County, past month illicit drug use and past month illicit drug use other than marijuana has remained higher than Michigan and national averages. Illicit drugs include marijuana, cocaine (including crack), heroin, hallucinogens, inhalants, and prescriptiontype psychotherapeutics used non-medically. The most recent National Survey on Drug Use and Health (NSDUH) county level results ( averages) reported past month illicit drug use among those ages 12 and over in Genesee County was 10.25%, with 4.04% using an illicit drug other than marijuana. Genesee County had the second highest percentage of use in Michigan. In 2006, a study by the Centers for Disease Control and Prevention estimated that excessive drinking cost $746 for every person in the US. This number indicates that alcohol misuse costs Genesee County approximately $317 million each year. Substance use in Genesee County has led to many problems, including arrests, traffic crashes, HIV/AIDS, hospitalizations, emergency department visits, deaths, dependence, treatment, and many years of potential life lost. Arrests: There were 3,984 alcohol/drug related arrests in 2010 in Genesee County, representing 37.5% of all arrests in Genesee County. Traffic Crashes: In 2010, there were 394 alcohol-related crashes (3.7% of all crashes) in Genesee County, resulting in 11 fatalities, and 34 incapacitating injuries. Over a quarter of fatal crashes involved alcohol, and over a fifth of incapacitating injury crashes involved alcohol. Dependence: According to the NSDUH survey, the percentage of persons with alcohol dependence or abuse in the past year in Genesee County is similar to state and national percentages (7.59% in Genesee County, 7.79% in Michigan, 7.53% in US). Illicit drug dependence or abuse in the past year in Genesee County is higher than state and national statistics (3.46% in Genesee County, 2.88% in Michigan, 2.82% in US). Treatment: In Genesee County, there were 5,350 admissions/transfers in publicly funded alcohol and drug treatment programs during the 2011 fiscal year. The highest percentage of admissions was for alcohol (30%), followed by heroin (23%), marijuana (20%), other opiates (13%), and cocaine (12%). Genesee County has had a large increase in prescription drug admissions for treatment over the past 7 years, from 538 admissions in 2005 to 1486 admission in 2011 (a 176% increase). Emergency Department Visits: A 2009 chart review from a local hospital revealed that over 1 in 20 (5.4%) emergency department visits involved drug misuse or abuse. Of these misuse/abuse visits, 82.1% involved an illicit drug, 36.5% involved a pharmaceutical, and 33.7% involved alcohol (patient excluded if alcohol only and patient 21). Over half (54.2%) of the misuse/abuse visits involved more than one drug. Hospitalizations: In 2010, there were 56 hospitalizations for alcohol dependence syndrome, 33 hospitalizations for drug dependence, and 21 hospitalizations for nondependent abuse of drug. The rate of hospitalizations per 100,000 persons is lower than the state average for these three diagnoses. Deaths: In 2009, there were 56 alcohol-induced deaths and 96 drug-induced deaths in Genesee County, which represents 3.7% of all deaths. Since 1999, the number of drug-induced deaths per 100,000 persons has been rapidly rising in Genesee County (7.6 in 1999, 22.6 in 2009). The number of alcohol-induced deaths per 100,000 persons has also been rising, and is at the highest 2

3 rate since 1999 (7.8 in 1999, 13.2 in 2009). The rate of drug-induced and alcohol-induced deaths in Genesee County is higher than the state rate (22.6 vs and 13.2 vs. 8.9, respectively). Genesee County had the 4 th highest rate of alcohol-induced deaths and the 6 th highest rate of drug-induced deaths in the state of Michigan in Years Potential Life Lost: Genesee County had 1,030 years of potential life lost (YPLL) due to chronic liver disease and cirrhosis, 1,214 YPLL due to suicide, and 2,478 YPLL due to homicide in The rate of YPLL in Genesee County for chronic liver disease/cirrhosis (258.8 per 100,000) and homicide (622.6 per 100,000) is higher than Michigan s rate (185.3 and respectively). This burden of substance use in Genesee County demonstrates the need for SUD treatment. In addition, many persons needing treatment have not received treatment. According to the NSUDH averages, just over 7% of Genesee County residents need, but are not receiving treatment for alcohol use in the past year, and 2.8% of residents need, but are not receiving treatment for illicit drug use in the past year. A potential screening location for these residents is in the primary care clinic. However, many primary care physicians have not received sufficient training to screen for or intervene with substance misuse. In this way, existing services are inadequate to respond to the needs of the population. In 2008, a local survey on substance use was developed and mailed to all area physicians. A follow-up survey was distributed to physicians attending a continuing medical education session in Almost all physicians responding to the 2011 survey stated that substance abuse and nonmedical use of prescription drugs is a significant problem in Genesee County. Physicians attitudes remained similar in 2011 to the 2008 survey. Many physicians expressed that they are not adequately prepared, and have low feelings of competency to treat patients with alcohol- and drug-related disorders. Over half of the physicians surveyed agreed that physicians routinely screen and counsel patients about prevention of substance abuse and alcoholism. They stated a low satisfaction for caring for patients with substance problems, and high skepticism about the probability of influencing or improving outcomes for this group of patients. Physicians expressed a learned feeling of helplessness in working with substance abuse patients because there are inadequate services available to meet their patient s needs. Physicians also feel that a lack of insurance coverage prevents many patients from seeking treatment for addiction. Over 90% of the physicians agreed that patients with substance use disorders are prevalent in most hospitals and emergency departments and that alcohol, tobacco, and other drug abuse undermine the physical and psychological wellbeing of patients, contributing to many illnesses that result in admission to acute care settings. Knowledge and skills identifying misuse and abuse are also lacking among area physicians. Almost a quarter of physicians responded that they do not know where to make referrals for patients who are struggling with alcohol or drugs. Just under half responded that they do not feel confident identifying a person who is misusing prescription drugs. Although physicians do not feel adequately prepared to identify and treat prescription drug misuse, 85% stated interest to aid community efforts to reduce nonmedical use of prescription drugs. This demonstrates the readiness and need for training physicians in the use of SBIRT. 3

4 A. Specific information regarding alcohol, prescription, and over-the-counter drug use. Alcohol, prescription, and other drug use are prevalent in Genesee County. Alcohol: The 2009 Speak to Your Health survey of Genesee Co. 18 years and older reported that 50% of residents drink alcohol. The average number of days per month consuming at least one alcoholic drink doubled from three days in 2003 to seven days in On days drinking alcohol, an average of three drinks was consumed. This average has remained stable since Heavy drinking (4.8%) and binge drinking (16%) are lower than the state average (5.4% and 16.6% respectively), according to the Michigan Behavioral Risk Factor Survey of residents age 18 years and older. However, both heavy drinking and binge drinking rates in Genesee County have increased from averages, and have remained at these high levels since averages. The average number of binge drinking occasions in the past month among Genesee County residents who drink alcohol has increased from 1.42 days in 2005 to 2.00 days in Many people do not acknowledge the risk associated with binge drinking. Less than half (39.8%) of Genesee County residents perceive great risk of having five or more drinks once or twice a week. Marijuana Use: According to the NSUDH averages, 7.6% of residents reported past month use, and 12.2% reported past year use of marijuana. Past month use of marijuana in Genesee County is higher than the state and national average, and is the second highest percentage in the state. There is a lack of perception of risk. Only 34.3% of Genesee County residents 12 and older perceived a great risk in smoking marijuana once a month. In addition, pregnant women are at risk, and putting their unborn baby at risk. At a local community hospital obstetric clinic in Genesee County, approximately 30% of pregnant women test positive for tetrahydrocannabinol (THC) during intake. National studies have reported an increase in substance abuse in pregnancy, resulting in 225,000 infants born annually with prenatal exposure to illicit drugs. Cocaine: The NSDUH survey reported 2.41% of residents age 12 and older used cocaine in the past year, which is higher than Michigan and national averages. Prescription Drugs: Pain relievers are prescription drug most often abused. Nonmedical use of pain relievers in the past year among Genesee County residents has remained higher than state and national averages. The NSDUH reported 6.01% of residents used pain relievers non-medically in the past year. Over-the-Counter Drugs: Limited data is available on OTC drug misuse/abuse in Genesee County. On average from , there were six treatment admissions with OTC drug involvement in publicly funded alcohol and drug treatment programs in Genesee County. The number of admissions has been decreasing slightly, and in 2011, there was only one admission for OTC drugs (primary, secondary or tertiary drug of choice). B. Available medical services, relationship to the SUD service system and barriers. There are three hospital systems in Genesee County, with a total of 1,161 licensed hospital beds. As of 2007, there are 179 licensed physicians per 100,000 population in Genesee County. The 2010 American Community Survey estimates that 10.3% of Genesee County residents are 4

5 uninsured (15.3% of those age years). Since, from a prevention perspective, this project is a community-based initiative focused on environmental change, the overall population of focus is Genesee County residents. The Statement of Need reveals the high rates and the need for reduction of AOD misuse in Genesee County overall. One clinic at each hospital system was selected, one OB/GYN, one Family Practice and one Internal Medicine. OB/GYN was selected as the clinic at Hurley, the City Hospital, because staff has noted an increase in drug involved pregnancies including high rates of marijuana use. The selected clinics were recommended by behavioral health and research directors in the respective systems, due to recognized physician champions for AOD focused initiatives. Lessons learned from SAMHSA funded projects indicate the presence of a physician project champion can greatly influence success. All hospital medical resident programs and clinics selected expressed great interest and excitement with the prospect of involvement in the project. The physician surveys conducted revealed that one barrier to treatment was their perception that there is no SUD treatment available for uninsured patients and that they lacked information regarding referral processes. Educating physicians will facilitate reducing this barrier. GCCMH Fiscal Year 2011 data reveals that 2043 admissions reported having no physician. The University of Michigan-Flint urban Health and Wellness Center was selected, because they serve a primarily economically disadvantaged population as a designated site for Genesee Health Plan patients and have a low self-pay visit fee. 3. Proposed Evidence-Based Service/Practice The purpose of the proposed project is to meet the public health goal of reducing the harms and societal costs associated with risky substance use. We aim to motivate Genesee County residents to make changes to improve their health and life through screening and early substance use intervention. Genesee County SBIRT will improve community health and wellness by decreasing AOD consumption in the county. The grant will provide training to approximately 100 medical residents and allied health services staff on SBIRT components. The goal of Genesee County SBIRT is to integrate SBIRT into the standard delivery of healthcare. Brief intervention will be provided utilizing motivational interviewing techniques focused on raising subject awareness, providing feedback, and enhancing motivation to change behavior. Motivational elements of brief interventions have been found to be effective in primary health care settings and when provided by physicians (Bien, 1993; Kahan, 1995). Enhancing motivation through brief intervention has also been proven in women, and specifically low-income urban women (Fleming, 1997; Carey, 1997). These demographics reflect the composition of many patients who will be screened in OB/GYN clinics within Genesee County. The efficacy of motivational interviewing and intervention techniques has been shown in alcohol (Wilk, 1997), prescription (Zahradnik, 2009; Daley, 1998) and over-the-counter drug use (Peterson, 2006). BT will use motivational enhancement therapy (MET) and cognitive behavioral therapy (CBT) components. At least one study has concluded that urban participants receiving CBT for cocaine abuse were significantly more likely to result in abstinence than those with other treatments (Maude-Griffin, 1998). CBT has also been shown to be effective in low-income and minority patients in a public hospital-based clinic (Organista, 1994). Self-efficacy is a crucial component of MET and CBT; and its role has been assessed in use of alcohol (Evans, 1994; Solomon, 1990), cocaine (Coon, 1998; Rounds-Bryant, 1997), marijuana (Stephens, 1993) and opioids (Reilly, 1995). Patients who are identified by the medical staff as needing BT or RT will be referred to the imbedded behavioral health Consultant (BHC) on the team. This master s level clinician will 5

6 determine if BT or RT is appropriate. If BT is appropriate, s/he will provide it on site and if RT is needed, the BHC will facilitate a phone screen with the GCCMH Access Center for referral to treatment in the GCCMH publically funded system as determined to be medically necessary. If identified patients in need of treatment have private insurance, the BHC will facilitate contact with the patients insurance companies. The ACORN will be used to screen for co-occurring disorders. This tool is currently utilized as part of the process for screening individuals entering SUD treatment in the GCCMH system. 4. Proposed Implementation Approach Genesee County has a long-standing interest in SBIRT through the Greater Flint Health Coalition (GFHC). The GFHC is an established, non-profit coalition with a multi-sector partnership that includes GCCMH PIHP and CA, the three hospital/health systems, physicians, business, public health department, FQHC, labor, education, the community s major commercial and health maintenance organization insurers, residents and government policy makers. GFHC s mission is to improve the health status of community residents and the quality and cost effectiveness of the community s health care delivery system. GFHC is recognized locally as the neutral convener of collaborative health care and public health initiatives. The CA and the PIHP have been continuous members of the Mental Health & Substance Use Task Force of GFHC since its founding in The Task Force was first introduced to the concept of SBIRT through a small five year DEMAND TREATMENT! grant from Join Together that ended in In 2011, the interest in pursuing an SBIRT project was rekindled and discussions were crystallizing when the MDCH opportunity for funding was released. The PIHP/CA s partnership with the GFHC and its members will play a crucial role in the community based system transformation process that underlies the Genesee SBIRT initiative. The Coalition, with its well-respected 15- year track record of achieving collective action, will facilitate convening the organizations for the community-wide effort to implement SBIRT. The Task Force has a successful history of integrating mental health and substance use medicine into the vision and activities of the GFHC and will serve as the steering committee for the Genesee County SBIRT effort. GCCMH and its partners in the GFHC endeavor to accomplish true community based change by embracing the SBIRT concept of universal screening of patients entering clinical services within all three local hospitals (Hurley Medical Center, McLaren Flint and Genesys Health System), as well as the Urban Health and Wellness Center at the U of M-Flint. Physician surveys conducted in 2008 and 2011 as part of the PIHP/CA s needs assessment revealed that physicians have limited knowledge, competency and efficacy expectations to deal with substance use disorders and referrals for treatment. Genesee SBIRT will impact these deficits by educating medical residents and other health professionals that serve a large cross section of health care consumers in Genesee County. We endeavor to change the prevailing established medical community norm in the community that results in patient substance misuse and dependence often going unidentified and untreated due to lack of training/education and professional satisfaction among physicians. In 2008, key findings and recommendations from a community physician survey examined barriers in managing or providing treatment to patients with SUD. Two of these barriers were professional satisfaction and training/education. Regarding professional satisfaction, area physicians expressed low levels of contentment in caring for patients with substance problems (only 13% expressed positive feelings) with the majority expressing skepticism with the likelihood of influencing or improving outcomes for these patients. 84% felt that patients who present with substance problems generally generate a significant workload. The 6

7 majority of respondents (70%) did not feel that physicians were competent to manage or treat patients with alcohol and drug-related disorders. 85% expressed the need for more education and training. Finally, only a small percentage of respondents (20%) expressed physicians routinely screen and counsel patients about prevention of substance problems. Since recipients of medical care in hospital run and other area clinics are not actively screened for SUD (i.e. when information is collected the norm is that nothing is done with it), many residents at risk of SUD have limited access and availability of SUD services, simply by virtue of health care providers failing to detect or address substance related issues. This project will increase access to services by training health care providers to screen for substance misuse and dependence, improving identification of these issues, applying BI and/or BT as appropriate, and by increasing referral to treatment for those for which this is warranted. SBIRT funds will be used to complement existing PIHP/CA funds received from the MDCH through CA and PIHP contracts. MI-SBIRT funds will be used for training of healthcare staff to implement screening and BI utilizing motivational interviewing principals. They will also be used to contract with a provider to be selected via RFP to hire masters level clinicians as imbedded BHCs at the healthcare sites (the smallest volume clinic will have.5 FTE). These staff will be part of the team with health care providers and function as the go-to SUD expert. When the need for BT or RT is identified, these clinicians will provide these services on site as needed. Research and experience has demonstrated that when a BH staff is part of the team and can be called upon for immediate assistance, AOD misuse decreases. A contracted provider will also employ 1 Peer Recovery Coach that will be called on by the BHC, when RT patients are identified to be in need of support including a ride home or to subsequent appointments. The peer will also facilitate linking and coordinating individuals with recovery support in the community. S/he will play a role of educating patients regarding available recovery support and function as a role model for individuals in need of recovery. The transition from MI-SBIRT funds to existing funding will occur when patients are referred into the PIHP/CA system. Prevention Services will be utilized in the aspects of screening brief intervention and referral in the sense that the Genesee County SBIRT project endeavors to use environmental change strategies to alter the community norms within hospital and healthcare systems that contribute to an environment in which SUDs go undetected, are sometimes ignored if detected and addicts and alcoholics are sometimes seen as difficult, time consuming or to be avoided. We are resolved to create a system in which these reactions are replaced with open discussion of AOD and the belief that substance misuse, when identified and addressed, can be altered. Preventionists will not be utilized for direct SBIRT service provision, as the literature reviewed demonstrated and advocated the efficacy of health care providers learning and implementing these skills. Clients are screened and assessed for co-occurring disorders. The information gathered through the GCCMH Access Center and at the provider level are used to develop appropriate treatment approaches. Since one must be identified as having a SUD in order to have a disorder with which to co-occur, this provision applies to the Referral to Treatment group only. Healthcare clinic patients screened for SUD and identified for BI or BT are categorized with misuse and not disorder. All individuals referred to the GCCMH Access Center receive a universal MH screen. All prospective clients are asked a series of mental health screening questions. If they are requesting SUD and the answers to the questions do not indicate severe mental illness, the rest of the mental health screen is omitted, the SUD screen is completed and a client is referred to 7

8 medically necessary SUD services. Additional mental health screening is universally completed for all clients entering a GCCMH contracted SUD provider; the ACORN mental health screening instrument is part of the biopsychosocial assessment at the provider level. This additional screen for MH issues within the SUD clinical EMR creates another opportunity to identify a cooccurring disorder and triggers inclusion of identified issues in the treatment plan and/or referral as appropriate, if serious mental illness is identified. After the funding period ends, the project s sustainability will be facilitated by the GCCMH s strong relationships with its community partners. GFHC s continuing involvement and established relationships with the key partners, namely the three hospital systems is critical to the sustainability of the project. The infrastructure that already exists for convening and maintaining SBIRT focused initiatives will remain in place. Sustainability is more likely to be assured, once SBIRT training is introduced in the residency programs at all three hospitals, training materials are available, and buy in to the concept is secured and institutionalized through inclusion in records processes. The Train the Trainer model will be used to enhance sustainability within the health systems by promoting capacity for in-house training. Since just one clinic at each hospital was selected, it is hoped that additional clinics will be added after the efficacy of the SBIRT is established. It is also believed that the use of cutting edge technology in the form of on-line, simulated, interactive training modules designed by SiMmersion which also makes interactive, simulation training for the military and federal law enforcement entities will be especially attractive to young, tech savvy medical residents. The cost if split by the three hospital systems after the grant period would be extremely affordable. Additionally, over the course of the grant period, the GFHC, GCCMH directly and through the BHCs on site via the contracted provider, will educate health care providers regarding the ability to bill some insurances for SBIRT services as well as Medicaid when the codes come on line. It is also expected that the value of the BHCs will be demonstrated and that the hospital systems may consider employing such staff or incorporating their functions into the roles of current behavioral health staff within their systems. The effectiveness of the peer recovery coach will be evaluated by the CA and consideration for continued funding will occur. The population of focus will not be recruited in the general meaning of this word. The PIHP/CA and our community partners agree that changing the community norm to value the identification, brief intervention and referral to treatment of those in need to attention to substance misuse or dependence will create a lasting and meaningful transformation. Hence, there is no recruitment of participants, but identification through universal screening of all clinic patients. We believe that the norm is more likely to experience a real and then sustained shift via routine and on-going practice of these techniques, so that it becomes a habit for health care practitioners. As medical residents graduate from their medical residency programs and begin to practice independently, our hospital partners report that they may stay in our local community. Producing a new crop of physicians that have incorporated SBIRT into their routine medical practice to treat Genesee County residents is the best way to sustain an improved rate of identification of misuse, decrease the probability that misuse will become problematic due to their ability to provide brief interventions, as well as their on-going enhanced capacity to refer those with identified problems for appropriate assessment and treatment. There has been an increase in research that examines the role of the patient-physician relationship. It is felt that we need to identify and study strategies to intervene in this relationship to bring about positive behavioral changes in both patient and practitioner that will lead to better health outcomes. 8

9 (Dave V. McQueen, 2012). Although a large percentage of health care costs are related to such factors as smoking, obesity, and substance abuse most physicians are not confident in their ability to motivate patients to change health behaviors (Academic Psychiatry, 2011). If we can train physicians to identify substance use disorders and to provide an effective intervention, we may increase our chances of producing real change for that patient. It may be possible to initiate patient behavior change with just two power words : I recommend. (ACP Internist, 20120). The number of people for the project was identified by determining the number of unduplicated patients at each selected clinic site, and then applying the average frequencies in the respective SBIRT categories mathematically. The literature in SAMHSA funded research revealed that 17% of the individuals receiving brief screening for alcohol and other drug misuse will be identified as appropriate for Brief Intervention (70% of the 17%), Brief Treatment (19% of the 17%) or Referral to Treatment (11% of the 17%). Performance Assessment and Data Data Collection Procedures Research assistants and an evaluation coordinator from the Research Center at Hurley Medical Center will manage, analyze, and report data. Patient Intake: The brief screening tools (described below under Data Collection Tools ) will be administered to each patient annually during a scheduled visit at the study site clinics. Patients that score positive on the brief screening tool(s) will complete the full screen. Implied consent will be obtained with the brief screening tools by informing patients of the project and use of data. Persons who are screened as not being at risk for substance use or abuse will receive feedback and be classified as screened only. Persons that screen positive for alcohol or drug use or abuse will receive BI, BT, or RT, which will be collected on the patient data collection sheet, along with other demographics. Informed consent will be obtained prior to implementation of BI, BT, or RT, and collection of data. Persons who decline informed consent will be excluded from data collection, but will still receive indicated services. Progress towards the National Outcome Measures will also be recorded during intake using the Government Performance Results Act (GPRA, describe below under Data Collection Tools). Patients that are screened only will complete section A. Patients who receive BI will complete sections A and B. Patients who receive BT or RT will complete all sections. Patient Six-Month Follow-up: A six-month follow-up after intake will be conducted in-person for individuals receiving BI, BT, or RT and giving informed consent. We will attempt to contact every patient receiving BI, BT, or RT who has given informed consent. If we cannot contact the patient directly, we will attempt to contact one of the other three alternative contacts listed during intake. The six-month follow-up will include the alcohol and drug screening tools used during the initial screening process and the number of sessions for BI, BT, or RT. The appropriate sections of the GPRA will be re-administered during the six-month follow-up to assess changes and progress toward the National Outcome Measures. A questionnaire on satisfaction will be administered to assess the patients satisfaction with the process, services, and healthcare professional at the six-month follow-up. A $20 gift card will be offered to patients participating in the data collection follow-up. Patient Intervention Completion: At patient discharge, we will record the number of sessions completed, type of treatment, and length of treatment. 9

10 Healthcare Provider Training and Follow-Up: A pre-knowledge, attitude, and behavior questionnaire on the SBIRT process will be administered prior to training. The same questionnaire will be administered immediately following training (post-test), and at six and twelve months post-training. An inquiry regarding the perceived challenges and barriers they have implementing SBIRT will occur. The healthcare provider questionnaire will be administered electronically using SurveyMonkey, unless the provider requests a paper questionnaire. Data Collection Tools Brief Screen: Brief screening will take place with all patients in the study site clinics. The Alcohol Use Disorders Identification Test Consumption (AUDIT-C) for alcohol misuse will be used and pre-screen for illegal drug or prescription drug misuse with three questions:1) How many times in the past year have you used a recreation drug? 2) How many times in the past year have you used a prescription drug for nonmedical reasons? 3)How many times in the past year have you used an over-the-counter drug for nonmedical reasons?. The AUDIT-C is a three item alcohol screening tool to help identify persons with alcohol misuse. It has been used for alcohol screening in and outside the U.S., and has been validated in primary care settings and the general U.S. population. The AUDIT-C is scored on a scale of 0-12 points. The higher the score, the more likely alcohol is affecting the person s health and safety. Full Screen: Patients that score positive on the brief screening tool(s) will complete the full screen. We will use the Alcohol Use Disorders Identification Test (AUDIT) to identify persons with hazardous and harmful patterns of alcohol consumption. The AUDIT is a 10-item test that was developed by the World Health Organization (WHO). The test has been validated with persons from six countries, and is 92% effective in detecting hazardous or harmful drinking. The higher the score, the more likely to indicate hazardous or harmful drinking. The Drug Abuse Screening Test (DAST) will be used to identify those persons who may have a problem with the use or abuse of drugs. DAST is a 28-items with valid psychometric properties. The higher the score, the higher the likelihood of a SUD. In addition, the substances used will be recorded. National Outcome Measures (NOMS): We will use the GPRA tool to measure NOMS. The GPRA tool was developed by CSAT and consists of questions from other data collection instruments including the Addiction Severity Index, the AIDS Risk Assessment and the Short Form-36 Health Survey. The sections include information on demographics and planned program services (section A); drug and alcohol use (section B); family and living conditions (section C); education, employment, and income (section D); crime and criminal justice status (section E); mental and physical health problems, and treatment/recovery (section F); and social connectedness (section G). Patients who are screened only will complete section A. Patients receiving BI will complete sections A&B. Patients who receive BT or RT complete all sections. Patient Demographics: A patient data collection sheet will include age, gender, race/ethnicity, insurance status, clinic location, health practitioner, type of service received (screened only, BI, BT, RT), contact information for six month follow-up (themselves and three friends/relatives that they are in contact with frequently), and pregnancy status (for women). Patient Satisfaction: Satisfaction level will be measured for persons receiving BI, BT, or RT. A 5-point Likert scale will be used to measure satisfaction with the SBIRT process, services received, and healthcare professional. 10

11 Healthcare Professionals Knowledge: A pre-training, post-training, six-month, and one-year follow-up knowledge test will be used to assess improvement in healthcare providers knowledge of SBIRT process and substance use disorders. Healthcare Professionals Attitudes and Behavior: A 5-point Likert scale will measure healthcare professionals attitudes around the SBIRT process, and their implementation of the SBIRT process and substance use disorders. Healthcare Professionals Satisfaction: A 5-point Likert scale will measure the healthcare professional satisfaction with the SBIRT training, SBIRT process, and substance use disorders. Inquiry about the perceived challenges and barriers they have implementing SBIRT will occur. Process and Outcome Measures Individuals: Performance measures include the number of individuals screened, number of BI patients, number of BT patients, number of RT patients, and number of patients identified with co-occurring disorder. Outcome measures include the change in patients behavior and substance use from initial screening to six month follow-up using the scores from the alcohol and drug screening tools specified above. This will allow us to measure the impact BI, BT, and RT are having on alcohol, illicit drug, prescription drug and OTC drug use and abuse. We will also assess if the number of sessions completed correlate with a reduction in substance use and abuse. Patient satisfaction will be examined to identify areas of success and areas for improvement. Success will be determined by a decrease in screening score (decrease in substance use) at six month follow-up. Healthcare Providers: Performance measures include the number of SBIRT training sessions held, the number of healthcare providers starting the SBIRT training program, the number of healthcare providers completing the SBIRT training program, and scores from the SBIRT training course tests. Outcome measures include the change in knowledge, attitude, and behavior on the BIRT process and substance use disorders. Satisfaction with the training program and SBIRT implementation will also be examined to identify areas of success and areas for improvement. Success will be determined by an increase in healthcare providers knowledge, attitudes, and implementation of the SBIRT process and substance use disorders at post-test, sixmonth, and one-year follow-up. Data Management for Continuous Quality Improvement Six month follow-up satisfaction questionnaire from patients will be used, and the six month and year follow-up knowledge, attitude, behavior, and satisfaction questionnaires from the health care providers to assure continuous quality improvement in the delivery of SBIRT training and implementation. Data will be examined across demographic variables such as gender, race/ ethnicity, and age and any disparate outcomes will be evaluated. All barriers identified during the follow-up will be addressed, and any modifications necessary to the process, including additional training and infrastructure changes will be made. Aggregate results of the follow-up surveys will be provided by to the health care teams and project staff implementing SBIRT on a monthly basis. Additional comments, feedback, and suggestions for improvement will be encouraged after sharing the follow-up survey results. The project staff will meet quarterly to discuss these results and create an action plan to address project improvements. A final report will be submitted to all involved entities. 11