Delivering SBIRT: A “How To” on Screening, Brief Intervention, and Referral to Treatment Presented by

2. Delivering SBIRT: A “How To” on Screening, Brief Intervention, and Referral to TreatmentPresented by

3. Acknowledgements Many persons have provided input into the content and to the creation of this series, including:

4. Session 1: What Is SBIRT and Why? By the end of this session participants will able to: Describe what SBIRT is and its supporting evidence. Describe its value for patients, payers, policymakers, physicians, and allied health and human service professionals. Better answer the question: Why might I choose to support SBIRT implementation?

5. SBIRT Defined Screening, Brief Intervention, and Referral to Treatment (SBIRT) is a comprehensive, integrated, public health approach to the delivery of early intervention and treatment services • For persons with substance use disorders. • For those whose use is at higher levels of risk. Primary care centers, hospitals, and other community settings provide excellent opportunities for early intervention with at risk substance users and for intervention for persons with substance use disorders.

6. Question? Why might I choose to support SBIRT implementation?

7. Continuum of Substance Use Severity ABSTAINERS & LOW RISK USERS (70%) MODERATE TO HIGHER RISK 25% SEVERE and DEPENDENT (5%)

8. Why is SBIRT Important? Unhealthy and unsafe alcohol and drug use are major preventable public health problems resulting in more than 100,000 deaths each year. The costs to society are more than $600 billion annually. Effects of unhealthy and unsafe alcohol and drug use have far-reaching implications for the individual, family, workplace, community, and the health care system.

9. Harms Related to Hazardous Alcohol and Substance Use Increases the risk for: • Injury/trauma • Criminal justice involvement • Social problems • Mental health consequences (e.g., anxiety, depression, etc.) • Increased absenteeism and accidents in the workplace

10. Unfortunately, These Kinds of Experiences Remain too Commonplace

11. Medical and Psychiatric Harmof High Risk Drinking

12. And the Evidence Indicates That Moderate Risk and High Risk Drinkers Account for the MOST Problems

13. Historic Response to Substance Use Previously, substance use intervention and treatment focused primarily on substance abuse universal prevention strategies and on specialized treatment services for those who met the abuse and dependence criteria. There was a significant gap in service systems for at risk populations.

15. In the Emerging Public Health Paradigm, All Services Are Aligned

16. Goal The primary goal of SBIRT is to identify and effectively intervene with those who are at moderate or high risk for psycho-social or health care problems related to their substance use.

17. Research Demonstrates Effectiveness • A growing body of evidence about SBIRT’s effectiveness—including cost-effectiveness—has demonstrated its positive outcomes. • The research shows that SBIRT is an effective way to reduce drinking and substance abuse problems.

18. Research Shows Brief Interventions: • Are low cost and effective. • Are most effective among persons with less severe problems. • “Brief interventions are feasible and highly effective components of an overall public health approach to reducing alcohol misuse.” (Whitlock et al. 2004, for US Preventive Services Task Force)

19. Making a Measurable Difference Since 2003, SAMHSA has supported SBIRT programs with over 1.5 million persons screened. Outcome data confirm a 40% reduction in harmful use of alcohol by those drinking at risky levels and a 55% reduction in negative social consequences. Outcome data also demonstrate positive benefits for reduced illicit substance use. Based on review of SBIRT GPRA data (2003-2011).

20. SBIRT is a Highly Flexible Intervention

21. Medical Specialty Areas

22. So What Is SBIRT? An intervention based on “motivational interviewing” strategies Screening: Universal screening for quickly assessing use and severity of alcohol, illicit drugs, and prescription drug abuse. Brief Intervention: Brief motivational and awareness-raising intervention given to risky or problematic substance users. Referral to Treatment: Referrals to specialty care for patients with substance use disorders. Treatment can consist of brief treatment or specialty AOD treatment.

23. Why Universally Screen? To detect current health problems related to at risk alcohol and substance use at an early stage, before they result in more serious disease or other health problems. To detect alcohol and substance use patterns that can increase future injury or illness risks. To intervene and educate about at risk alcohol and other substance use.

24. Rationale for Universal Screening • Drinking and drug use are common. • Drinking and drug use can increase the risk for health problems, safety risks, and a host of other issues. • Drinking and drug use often go undetected. • People are more open to change than you might expect.

25. Patients AreOpen to Discussing Their Substance Use to Help Their Health Survey on Patient Attitudes: Source: Miller, PM, et al. Alcohol & Alcoholism; 2006 Adapted from The Oregon SBIRT Primary Care Residency Initiative training curriculum (www.sbirtoregon.org)

26. Based on Findings of Screening

28. SBIRT Reduces Short- and Long-Term Healthcare Costs By intervening early, SBIRT saves lives and money. Late-stage intervention and substance abuse treatment is expensive, and the patient has often developed co-morbid health conditions.

29. SBIRT Decreases the Frequency and Severity of Alcohol and Drug Use Primary care is one of the most convenient points of contact for substance issues. Many patients are more likely to discuss this subject with their family physician than a relative, therapist, or rehab specialist.

30. SBIRT Integrates Primary Care With Behavioral Health in a Medical Home Model Given how widespread substance abuse is nationwide, it makes good sense for primary care practitioners—rather than trauma centers or rehab specialists—to be the first line of substance abuse response. In many areas, primary care practitioners are the only healthcare providers.

31. SBIRT Is an Important Part of Wellness and Prevention Programs Patients often don’t understand how alcohol and drug use impacts their health, or if the amounts they use are dangerous. Research from the World Health Organization and the Centers for Disease Control and Prevention has shown that alcohol is a major risk factor for a number of medical, social, and legal problems. SBIRT opens up a dialogue that can improve your patients’ overall health.

32. So Why is SBIRT Important for Payers and Policymakers?

33. For Payers and Policymakers,SBIRT Makes Good Financial Sense *Alcohol Misuse Screening and Behavioral Counseling: Technical Report Prepared for the National Commission on Prevention Priorities (2008), (pp. 20‒22). Michael V. Maciosek, PhD*, Leif I. Solberg, MD*, Nichol M. Edwards, MS*, and Dana A. McGree* under contract from the Centers for Disease Control and Prevention (CDC) and the Agency for Healthcare Research and Quality (AHRQ). Summary of Findings of the Alcohol Misuse Screening and Behavioral Counseling: Technical Report* submitted to the US Preventative Services Task Force. • Average cost for SBIRT intervention: $44.91 • Net healthcare cost savings annually per person: $254.00 • Net healthcare cost savings per million adults: $254,000,000

34. SBIRT and Cost • Wisconsin SBIRT Cost Benefit Studies • Reduction in hospital costs, ED visits, and associated problems resulted in $1,000 savings per person screened (Primary Care Setting. Fleming, M.F., Med Care, 2000). • Texas SBIRT Cost Benefit Studies • A net savings of $4.00 in ED costs for every $1.00 invested in SBIRT screening and brief intervention. ED saw a 50% reduction in recurrent alcohol-related injuries (Gentilello, L.M., Ann Surg, 1999) . • Washington State Cost Benefit Studies • Reduction in Medicaid-specific expenditures $185.00 per month per patient who received SBIRT screening and brief intervention (Disabled Medicaid patients in emergency room setting. Estee S. Medicaid Cost Outcomes, Interim Report 4.61.1.2007.2, Washington State Department of Social and Health Services).

35. SBIRT Improves the Health and Welfare of the Whole Community Improves public safety Reduces social and workplace problems with at risk users Reduces family conflict Supports health and wellness of the whole community

36. Lessons Learned SBIRT is a brief and highly adaptive evidence-based practice with demonstrated results. SBIRT has been successfully implemented in diverse sites across the lifespan. Patients are open to talk with trusted helpers about substance use. SBIRT can make a difference in the lives of the people you serve.

37. Question? Why might you want to implement SBIRT?

38. After Break We Will Discuss The business of implementing Readiness Who needs to be involved What's needed to be successful What a successful practice model looks like Billing and reimbursement

39. SBIRT Implementation at ACCESS

40. Break Time

41. Session 2The Business of SBIRT… SBIRT Implementation in Diverse Practice Settings

42. Session Objectives Review the business side of implementing SBIRT. Evaluate program readiness. Who needs to be involved? What does a successful practice model look like? What is a successful business model?

43. Building Readiness Is there: • Program leadership buy-in? • Sufficient key stakeholder buy-in? • A recognized problem/need/issue? • A clearly defined benefit/outcome? • A sufficient business case to be made?

44. 1. Program Leadership Buy-in • Consistent with the mission • Adds value to services • Fits with operations and population served • Sufficient business case • Champion • Recognize problem/need/issue? • Understand benefit/outcome?

45. 2. Stakeholder Involvement • Stakeholder involvement is critical. • Substance abuse is a much larger problem than can be solved by one single agency, and it affects the well-being of the entire community. • Empowering stakeholders: • Builds shared ownership. • Aligns the efforts of all community stakeholders. • Increases access to resources. • Supports sustainability.

46. Building Supportive Partnerships Policymakers Community Treatment Providers Payers Leadership Successful Implementation Others Population Served Business Staff Clinicians Who are the stakeholders you want to engage?

47. Each Stakeholder Has a Vested Interest in Improved Health Outcomes • Primary care • Treatment providers • Government and private payer entities • Patients • Employers Each understands the problem, measures value, and correlates costs differently.

48. Stakeholder Communication Government and private payer entities analyze the cost: benefit ratios of SBIRT in comparison with or contrast to other public health initiatives. If you show these stakeholders cost without the benefit part of the ratio, you will fall behind a long line of competitors for scarce resources.

49. Clearly Defined Benefit/Outcome Payers and Policymakers SBIRT makes good financial sense. SBIRT reduces short- and long-term healthcare costs. SBIRT has demonstrated positive outcomes.

50. Clearly Defined Benefit/Outcome Clinicians SBIRT decreases the frequency and severity of drug and alcohol use. SBIRT is an important part of wellness and prevention programs. Adequate resources