Screening for Behavioral Health

1
Screening for Behavioral Health

• Martha Kurgans, L.C.S.W.
• Department of Behavioral Health and Developmental
  Services
• January 30, 2015

2
Identifying Women at Risk

• Substance use, emotional problems and intimate
  partner violence threaten the health and safety
  of women and their newborns.
• Women who experience one or more of these
  problems are often reluctant to acknowledge it.
• These risks often co-occur - placing women at
  even greater risk.
• The best way to identify who is at risk is to
  routinely screen all women at regular intervals.

3
Pregnancy Increases Risks

• Pregnant women are at greater risk to experience
  depression and/or domestic violence than
  non-pregnant women.
• Pregnant women who use drugs and alcohol place
  their unborn infant at risk.
• 2013 National Survey Drug Use and Health (NSDUH)
  Substance Use During Pregnancy
• Alcohol use 9.4 (VA9,575)
• Tobacco use15.4 (VA15,687)
• Illicit drug use 5.4 (VA5,501)

4
Virginias PRAMS Data

• During Pregnancy
• 2007 2008
• Physical abuse 4.8
• Alcohol use 8.6
• Tobacco use12.5
• Reported depression 26
• 2010 -2011
• Physical abuse 3.4
• Alcohol use11.5
• Tobacco use 8.3

5
Recent Virginia Reports

• Sleep Related Infant Deaths in Virginia (2014),
  Child Fatality Review Team
• Reviewed 119 cases of sleep related infant
  deaths determined substance use was a major
  factor that contributed to these deaths.
• Maternal Mortality Review Team will soon
  release their report on unintentional overdose
• Reviewed 397 cases of maternal deaths that
  occurred between 1999-2007. Determined that
  substance use contributed to 96 of these deaths
  (24.4).
• 41 of the 397 women overdosed (10) 34 of these
  overdoses were unintentional.

6
Similar Conclusions

• Earlier identification of substance use and
  referral to treatment might have prevented these
  deaths.
• Providers failed to implement Virginia laws which
  were designed to identify and refer pregnant and
  postpartum substance using women to needed
  treatment and services.

7
Screening, Brief Intervention, Referral to
Treatment (SBIRT)

• SBIRT a public health model intended to
  identify individuals who may have or be at risk
  to develop a substance use disorder (S.U.D.)
• SBIRT identifies those at risk of developing
  substance use disorders and provides brief
  intervention on the spot.

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What is SBIRT ?

• Draws on principles of motivational interviewing
  when conducting a brief intervention
• Builds upon the idea that those with few problems
  or mild problems who are at risk may benefit
  from a brief intervention with a non-substance
  abuse specialist
• Acknowledges that those with significant problems
  usually need specialty care, like addiction
  treatment services and encourages their referral
  to specialty care.

9
What is SBIRT?

• Model can also be used to identify and refer
  individuals who experience other behavioral
  health risks
• Emotional problems, including perinatal
  depression
• Intimate partner violence
• Tobacco use
• In Virginia, SBIRT has already been used in
  primary care, mental health, and community
  settings to intervene with women who may have
  co-occurring behavioral risks.

10
SBIRTs Core Components

• Screening Administer a brief screening tool that
  can identify if a woman may have a behavioral
  health problem.
• Brief Intervention If she screens as at risk,
  in 3-5 minutes, elicit the womans perspective on
  her problem and what risks she may experience if
  her situation continues and doesnt change. The
  intervention is matched to her level of knowledge
  and motivation. Only bits of information are
  provided to supplement what she knows. No pushing
  or arguing is involved. Invite her to discuss
  again at next visit.
• Referral to Treatment If she screens as
  dependent/ having a problem and is receptive to
  being referred, refer her for an assessment to
  determine appropriate treatment and services.

11
Screening Versus Assessment

• Screening
• A standardized set of questions you ask not a
  medical test, exam or history.
• Indicates whether a thorough assessment is
  needed.
• Does not determine a diagnosis or what type of
  treatment is needed
• Can be completed by a variety of service
  providers

12
Screening versus Assessment

• A Substance Use or Mental Health Assessment must
  be completed by a qualified service provider
  (QSP) in that field
• To determine an individuals diagnosis and
  develop an initial treatment plan, the QSP
  obtains a comprehensive history of their
• past and current functioning
• other related problems and risks
• social supports and motivation

13
Screening Tool

• A brief instrument or set of questions that is
  intended to detect the possibility of a problem
• Cannot diagnosis a problem but can indicate if
  further assessment is needed
• Ideally, it should be
• Brief and easy to use
• Inexpensive
• Non-intrusive
• Tested (validated) on the population its to be
  used with
• Within the expertise of a wide range of
  professionals

14
Screening Best Practices

• Screen all clients
• Screen for substance use, emotional health and
  intimate partner violence
• Screen periodically
• Utilize a standard tool or protocol
• Ask questions in a health context this lessens
  the stigma
• Use everyday language be honest and direct
• Use a positive, non-judgmental and
  non-confrontational approach

15
Suggested Screening Tools for Pregnant and
Parenting Women

• Substance use, mental health (including perinatal
  depression) and tobacco use Virginias
  Behavioral Health Screening Tool
• Substance Use 4 Ps or 5 Ps
• Mental Health PHQ2 or PHQ9
• Perinatal Depression Edinburgh Depression Scale
  or Edinburgh 3
• Intimate Partner Violence AAS or WEB/RAT

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Virginia BehavioralHealth Risks Screening Tool

• Simple, effective way to screen women for high
  risk behaviors, tobacco use and perinatal
  depression all at one time.
• Combines validated screening tools
• The 5Ps screens for substance use in women
• The Edinburgh 3 screens for perinatal
  depression
• Questions on intimate partner violence (IPV).
• Can be provider or self administered. Available
  in 3 languages.

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SBIRT

• Providing a Brief Intervention

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Brief Intervention

• The SBIRT model incorporates Motivational
  Interviewing (MI), a method to have a
  constructive conversation about change.
• MI is based on the belief that
• people are ambivalent about change and continue
  harmful behaviors because of their ambivalence.
• MI helps people resolve their ambivalence and
  increase their motivation to change.
• Motivation for change can be fostered by an
  accepting, empowering, and safe atmosphere

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Principles ofMotivational Interviewing (MI)

• Empathy (provide support)
• Develop Discrepancy (encourage individuals to
  question their own behavior)
• Roll with Resistance (dont argue)
• Support Self-efficacy (empower)
• No matter whether youre addressing substance
  use, intimate partner violence or a mental health
  concern, the same MI principles apply.

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Can a Brief Intervention Really Help?

• Most women want what is best for their baby
• Sometimes, education alone can be sufficient to
  promote change
• Even brief interventions can trigger change.
  Assess the problem, her motivation to make
  changes and adjust the intervention, Set
  appropriate goals with her.
• If additional services are needed, a warm handoff
  will ensure a successful referral.

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Before Making Referrals

• Providers should be familiar with
• Treatment resources available in their community
  and how to access them.
• Community support services that can help
  individuals overcome barriers they may experience
  related to transportation, child care and/or
  funding.
• Federal confidentiality regulations as well as
  state legislation that may impact on their
  patients and be prepared to discuss them.

22
Treatment Resources

• Community Service Boards provide public mental
  health, substance use, and intellectual
  disabilities services
• Required to provide gender specific outpatient
  substance use treatment to pregnant parenting
  women
• Pregnant substance using women receive treatment
  priority. Must be seen within 48 hrs of their
  request for services.
• Services for perinatal depression may be more
  difficult to access
• 6 womens residential substance abuse treatment
  programs in the Commonwealth accept pregnant
  women
• Crisis stabilization units (CSUs) will accept
  pregnant women

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When Making a Referral

• Explain the referral process, the importance of
  sharing information and their role coordinating
  the womans treatment with the new provider
• Explore and address any questions or concerns
  their patient might have about the referral as
  well as how it will or wont affect their work
  with her.
• Discuss confidentiality. Have the woman sign a
  release so they can make the referral and share
  critical information. Encourage the woman to
  sign a release with the new provider as well so
  they will also be able to share information.
• Assist the woman and help her make the
  appointment. Provide support and encouragement.

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After Making a Referral

• Follow up to be sure she contacted the
  organization, received necessary services and was
  helped.
• Continue to support the womans efforts, provide
  encouragement and support any positive efforts to
  change
• Periodically, check back . Stressors and events
  in her life may change over time.

25
Developing SBIRT Skills

• Training regarding SBIRT and implementing M.I.
  techniques is available through face to face and
  web based instruction.
• The SBIRT process gets easier and quicker with
  practice. The more often providers screen
  individuals the more comfortable they will become
  using this approach.
• Screening is intended to stimulate open
  discussion between patient and providers

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What If She Doesnt Identify Any Risk Areas?

• Recognize and support her accomplishments
• Educate her regarding the importance of
  remaining risk free.
• Based on what youve said today, it seems like
  you are not at high risk of substance use
  problems. This could change, and if it does, let
  me know if you want to talk about it.
• Let her know that help is available if something
  changes.

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What if Shes NotHonest or Denies her Problem?

• Screening is intended to encourage discussion
  between a woman and her provider
• These are very difficult issues to discuss.
  Whats most important is that women know their
  provider is familiar with these issues and is
  willing and able to talk about them.
• As women develop trust in their treatment
  provider, they may be more able to acknowledge
  their problems and share concerns.

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What If She DoesntFollow Through With Referrals?

• Continue to encourage her to follow through with
  recommended referrals.
• Empathize with her struggle
• Convey a clear interest in her and her effort
• Help her set achievable goals
• Support any positive attempts to change
• Avoid arguments. The client should be the one
  arguing for change.
• Acknowledge that now may not be the best time,
  but invite her to talk further at another visit.

29
SBI Medicaid Coverage

• Medicaid will reimburse for substance abuse
  screening and brief intervention services 3 times
  per year per provider
• CPT99408 (gt15 min) 25.84
• CPT99409 (gt30min) 50.38
• Client must be Medicaid eligible Provider must
  be Medicaid approved.
• Provider must use a DMAS approved substance use
  screening tool and document their intervention

30
SBIRT Resources

• Screening tools guidance are available on the
  DBHDS website
• http//www.dbhds.virginia.gov/individuals-and-fam
  ilies/substance-abuse/substance-abuse-screening/pr
  egnant-women-childbearing-age
• Virginias Home Visiting Consortium (HVC)
  provides a skill based series for home visitors
  on Screening and Brief Intervention
• Why Screen? (web based)
• Motivational Interviewing (1 day training)
• SBIRT for Risky Health Behaviors (1 day training)

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SBIRT Resources

• SBIRT/ Substance Abuse and Mental Health Services
  Administration
• http//www.samhsa.gov/sbirt
• SBIRT CORE Training Program
• http//www.sbirttraining.com
• SAMSHA HRSA Center for Integrated Health
  Solutions
• http//www.integration.samhsa.gov/clinical-practic
  e/sbirt
• The Big Hospital SBIRT Initiative
• http//hospitalsbirt.webs.com/webinars.htm

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Review

• Behavioral health (substance use, tobacco use,
  emotional health, intimate partner violence)
  impacts on maternal and fetal outcomes.
• Women are receptive to screening when done in a
  health context and presented in a nonjudgmental
  manner.
• Use screening tools suited for pregnant women.
• Screening enables providers to intervene before
  women experience more serious consequences.