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Screening, Brief Intervention, and Referral to Treatment for Alcohol and Drugs: Applications to Emer

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Title: Screening, Brief Intervention, and Referral to Treatment for Alcohol and Drugs: Applications to Emer


1
Screening, Brief Intervention, and Referral to
Treatment for Alcohol and DrugsApplications to
Emergency Care Settings
Jack B. Stein, MSW, Ph.D. Director Division of
Services Improvement Center for Substance Abuse
Treatment Substance Abuse and Mental Health
Services Administration
2009 Academic Emergency Medicine Consensus
ConferenceMay 13, 2009 - New Orleans, LA  
2
Todays Topics
  • What Do We Know (What Do We Think)?
  • The SAMHSA Response
  • Findings and Lessons Learned
  • Implementing SBIRT into Emergency Care Settings
  • Conclusions

3
What Do We Know, (What Do We Think)?
4
Most People in Need of Treatment Do Not Seek
It
21.1 Million Needing But Not Receiving Treatment
for Illicit Drug or Alcohol Use
SAMHSA, 2007
5
Emergency Care Settings
  • 40 of ED visits are injury-related and 50
    of them are alcohol-related (Nilsen et al.,
    2008).
  • 400,000 ED visits involved alcohol in
    combination with another drugs with increasing
    mentions of prescription drug misuse (SAMHSA,
    2006).
  • Pts with substance use and mental health
    conditions have a greater frequency of repeat ED
    visits than those with other diagnoses (SAMHSA,
    2008).

6
Traditional Approach
Public Health Approach
High-Risk
At-Risk
Low Risk
Abstainers
Adapted from Babor,T,F., Higgins-Biddle,J.C.,
(2001), Brief Intervention for Hazardous and
Harmful Drinking A manual for use in primary
care . p 33. WHO/MSD/MSB/01.6b World Health
7
Screening, Brief Intervention, and Referral to
Treatment (SBIRT)Major Goals
  • Identify patients who may not perceive a need for
    behavior change.
  • Provide brief motivational counseling to alter
    negative behaviors.
  • Link to other needed services.

8
SBIRT What Do We Know?
  • Well supported in primary care and hospital
    settings with respect to heavy alcohol use (Babor
    Kadden, 2005).
  • US Preventive Services Task Force recommends
    routine SBI for alcohol in primary care settings.
  • SBI for alcohol required for certification of all
    Level I Trauma Centers.
  • Each 1 spent on SBI saves 4 in other
    health-related costs (Gentilello et al, 2005).

9
The SAMHSA Response
10
(No Transcript)
11
College SBI Programs(2005-2008)
12
SBI Medical Residency Grants(2008-2012)
  • Natividad Medical Center (CA)
  • University of California, San Francisco
  • Yale University (CT)
  • Access Community Health Network (IL)
  • Childrens Hospital Corp (MA)
  • Albany Medical College (NY)
  • Kettering Medical Center (Ohio)
  • Oregon Health and Science University (OR)
  • University of Pittsburgh (PA)
  • University of Texas
  • Howard University (DC)

13
Findings and Lessons Learned
14
SBIRT Model Matrix
Alcohol Use
Risk factors assessed
Drug Use
Tobacco Use
ATOD Use
Services
ATOD Use
Screening
Brief Intervention
Referral to Treatment
Brief Treatment
In-house Generalist
Primary Care or Clinic
Implementation Model
Settings
Emergency/Trauma
In-house Specialist
Hospital Inpatient
Contracted Specialist
15
Settings for Cohort 1 Grantees
16
Program Data, Six SAMHSA SBIRT Sites, Baseline
and F/U Substance Use
Among Those Screening Positive At Baseline (N
6,262)

P lt 0.001
Madras et al., (2008)
17
Practitioner Time Required for each SBIRT Service
in ED(Contracted Specialist Model)
RT data combines service and support into one
referral activity time. All times are rounded to
the nearest half-minute.
18
Medicaid Cost Outcomes Washington State SBIRT
(Estee, et al, 2006)
  • Medicaid costs among 1,315 ED patients receiving
    at least a Brief Intervention were compared to
    8,972 patients who did not receive a BI.
  • Medicaid savings 185 per member per month.
  • Most reductions due to decline in costs
    associated with inpatient hospitalizations from
    ED admissions.

19
Implementing SBIRT into Emergency Care Settings
20
Challenges to Implementing SBIRT into Emergency
Care Settings
  • Competing Priorities Staff doesnt want to be
    asked to do additional duties nor do they want to
    modify something they are already doing.
  • Attitudes Not a population of patients that ED
    staff have a ton of compassion for.
  • Staff Turnover We train our residents, but
    they rotate through the hospital system, so you
    are constantly having to retrain new ones.

21
Challenges to Implementing SBIRT into Emergency
Care Settings(continued)
  • Environment Specialist staff have to be the
    right fit for working within an ED setting
    which is very different from working in a typical
    substance abuse treatment office.
  • Privacy SBIRT specialists became adept at
    creating privacy with their voices and bodies

22
Facilitators to Implementing SBIRT in Emergency
Care Settings
  • Training In the beginning, the ED staff did not
    think that SBIRT was in their job description,
    but staff education has helped them to think on
    those terms.
  • Data Cost savings (including decreased ED
    volume) data are more effective in communicating
    the benefits for SBIRT with legislators and
    hospital administrators than patient outcome
    data.
  • Policy American College of Surgeons/Committee on
    Trauma endorsement of screening for at-risk
    alcohol use within Level 1 trauma centers.

23
SustainabilityEstablishment of SBIRT Billing
Codes
  • HCPCS Codes (Medicaid)
  • - H0049 Alcohol /or Drug Screening (24)
  • - H0050 Brief Intervention15 mins. (48)
  • CMS G-Codes (Medicare)
  • - G0396 15-30 mins (29.42)
  • - G0397 gt 30 mins (57.69)
  • CPT Codes (Commercial Health Plans)
  • - 99408 15-30 mins (33.41)
  • - 99409 gt 30 mins (65.51)

24
Conclusions
  • ED settings provide a high volume of at-risk
    alcohol and substance use patients.
  • The ED provides a robust setting for the
    teachable moment.
  • Cost savings and new procedural billing codes are
    potential incentives for implementation.
  • Evidence is compelling for SBIRTs application to
    various settings.
  • Continued collaborative process between research
    and practice.

25
SBIRT and Emergency Care SettingsKey Questions
  • Is SBIRT effective/cost-effective in emergency
    care settings?
  • What are the most effective and efficient models
    of implementing SBIRT into emergency care
    settings?
  • What incentives promote adoption of SBIRT in
    these settings?
  • What are best/efficient ways to train providers
    in SBIRT in emergency care settings?

26
CSAT SBIRT Website
http//sbirt.samhsa.gov
  • Information regarding the
  • SBIRT Initiative, core clinical
  • components, and screening
  • instruments, and how to
  • establish an SBIRT program.
  • Online resources (e.g.,
  • training guides) links to
  • curricula, organizations,
  • publications, and
  • references.
  • SAMHSA/CSAT specific
  • information, such as SBIRT
  • Cooperative Agreements,
  • grantee profiles, key CSAT
  • SBIRT staff, meetings,
  • training opportunities, and
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