Session # F5a
October 29, 2011
1:30 PM
SBIRT Protocol in Primary Care
Settings: An Integrated Care Design
Jennifer Hodgson, PhD, LMFT, East Carolina
University
Marina Stanton, MS, East Carolina University
Leigh Atherton, MA, East Carolina University
Paul Toriello, RhD, East Carolina University
Collaborative Family Healthcare Association 13th Annual Conference
October 27-29, 2011 Philadelphia, Pennsylvania U.S.A.
Faculty Disclosure
We have not had any relevant financial relationships
during the past 12 months.
Need/Practice Gap & Supporting Resources
What is the scientific basis for this talk?
The SBIRT protocol is a SAMSHA endorsed method of
improving the Screening, Brief Intervention, and
Referral to Treatment processes needed in healthcare
settings.
SBIRT is evidence-based and practical as it draws from
the Transtheoretical Model (Prochaska & DeClemente,
1983) and Motivational Interviewing (Miller & Rollnick,
2002) methods.
Objectives
Participants will….
Learn the infrastructure to the SBIRT protocol used in an
FQHC and an academic integrated primary care setting.
Understand the basics of how to use the Transtheoretical
Model and Motivational Interviewing method with patients
who are identified as at risk for or diagnosable with a
substance abuse issue.
Identify the successes and barriers found when
implementing the SBIRT method by drawing from this
team’s qualitative and quantitative research findings
Discuss the next steps needed to sustain this type of
protocol in FQHC and academic primary care settings.
Expected Outcome
What do you plan for this talk to change in the
participant’s practice?
Participants will learn some of the core
infrastructure necessary to implementing the SBIRT
protocol in a FQHC or academic medical center
setting
Participants will draw from the experience of the
presenters to identify possible conduits and barriers
to successfully implementing the SBIRT method
TODAY’S TALK
• Highlight the problem and proposed solution to
addressing substance abuse issues in the primary
care setting
• Identify the settings and infrastructure needed to
implement the SBIRT protocol
• Discuss methods of implementation in each
setting
• Provide a sample of the outcome data from this
project
• Address next steps to enhancing and expanding
this project
Problem
• Substance use disorders (SUD) are recognized as a multi-factorial
health disorder, involving a complex interaction between
individuals’ biological, psychological, and social factors.
• Specifically, the interplay of SUDs and medical issues is well
documented in the literature.
• Researchers have estimated that there are 23.3 million people age
12 or older who meet criteria for a substance use disorder (SUD) –
nearly 9% of the United States population.1
• Untreated, SUDs may account for a disproportionate amount of
medical and mental health concerns.2
• The failure to recognize and appropriately address SUDs can lead to
negative effects within the individual, family, and society.
Solution
• Early detection of SUDs, particularly within the primary care setting,
can lead to successful management, and may prevent progression
of both mental health and medical concerns.
• Researchers have demonstrated that the SBIRT protocol in the
primary care setting is an effective method for identifying and
treating patients with SUDs. 3,4
• The stigma of treatment can frequently prevent those suffering
from substance use disorders from seeking treatment within
traditional substance abuse facilities.
• SBIRT has been used effectively with a wide range of populations to
address issues including: (a) smoking, (b) alcohol and/or illicit drug
use and abuse, and (c) prescription use and abuse4.
• Early detection of substance use and abuse issues can lead to
successful management, and may prevent progression of both
mental health and medical concerns.
Settings
• Setting #1
– Eastern North Carolina academic family clinic
comprised of four separate treatment teams serving
the needs of approximately 30,000 patients.
• Setting #2
– Eastern North Carolina Community Health Care Center
comprised of four separate primary care clinics
serving the needs of approximately 30,000 patients.
SBIRT Flow Chart
ICARE Substance Abuse Encounter Forms Flowchart
Patient checks in at
front desk
Front Desk
Staff will give
each patient
ICARE
Encounter form
Patient will fill out
assessment and return
clipboard to front desk
Nursing staff will
look over
completed
assessment
form
Did patient answer
“Yes” for question
#2, #3, or #4
NO for EITHER
question
#2, #3, or #4
Please return
completed
form to folder
at Nurses
Station
YES for EITHER
question #2, #3,
OR #4
YES. Nursing staff complete
SECONDARY SCREENING
(assess how much and how
often) Fill out
RECOMMENDATIONS TO
PROVIDERS
Nursing staff place
completed form on
the back of the door
Provider will follow
up with patient
about their
readiness to change
Does patient need additional
follow up or treatment for
substance abuse?
Not at this time.
Yes. Treatment and
referral should be
based on patient’s
needs
Provider will fill out
“Brief Intervention”
completed,
INITIAL FORM
and return
assessment to
nurses station
Provider will fill out
information on
back,
INITIAL FORM
and return
assessment to
nurses station
Patient will give
completed
assessment to
NURSING STAFF
Nursing staff
will fill out
Medical Record
Number
SBIRT Screening Tools
Pre-screening questions (ages 14 and older)
1. Do you drink alcohol?
2. In the past 12 months, have you used any drugs?
3. For prescription drugs, have you ever used more than prescribed, or
used someone else’s prescription drugs?
Secondary Screenings (based on positive pre-screening):
–Adults Only (ages 18 and older)
*
*
AUDIT (10-question alcohol use screen)
DAST-10 (10-question drug use screen)
–Adolescents Only (ages 14-17)
*
CRAFFT (6-question alcohol and drug use screen)
SBIRT MI Card
ICARE – Substance Abuse Screening/Intervention
Short Reference Card
•
5 – Key Questions about Substance Use/Abuse
•
1.
2.
3.
4.
5.
What do you like about using…?
What concerns you about your use of…?
How important is it, at this time, for you to change your use of…?
How would you go about making those changes? What has worked for you in the past?
How can we help you make these changes?
Scaling Question
•
On a scale of 1 to 10, how motivated are you to change your substance use?
Use follow-ups to elicit ‘change talk’:
Why are you a ____ and not a [lower number]?
What would it take for you to go from a ___ to a [higher number]?
Rules of Advice/Suggestion giving
•
Advice/suggestions are given ONLY when:
1.
2.
The patient solicits advice/suggestion; or
The provider asks permission to offer advice/suggestion.
Toriello et al., 2009
SBIRT MI Card (Back)
Stages of Change
Pre-contemplation
Contemplation
Realization
Intervention
Maintenance
1
2
3
4
5
•
Pre-contemplation: Denial of problem

Explore pros/cons of using

Develop discrepancies between ‘wants & needs’ and ‘cons of current use’
Contemplation: Openness to potential problem

Use of scaling question to explore current level of motivation

Explore patient view of what change will mean for them
Realization: Awareness of problem and ready to make change(s)

Help develop ‘change plan’

Determine appropriate level of care
Intervention: Doing it! Putting change plan into action.

Schedule ‘check-in’ appointment
Maintenance: 6 months or more of sustained ‘change’
Referral Information
•
East Carolina Behavioral Health—LME
1-877- 685-2415
http://www.ecbhlme.org/
The Beacon Center—LME
1-888-893-8640
http://www.thebeaconcenter.net/
SAMHSA—Substance Abuse & Mental Health Online Facility Locator: http://dasis3.samhsa.gov/Default.aspx
Toriello et al., 2009
Outcomes Setting #1
Outcomes Setting #2
Provider Reported Barriers
Time
– “We only have so much time to spend with the patient, only fifteen minutes
for their [physical health concerns] and don’t really have time to spend talking
about [physical health and substance abuse]”
Education
– “All health care providers need more training [about how to address substance
abuse]. Doctors are afraid of opening a door… and not knowing what to do
with those issues.”
Chronic Pain
– “Doctor focus is on medical issues, while patients focus is on obtaining certain
prescription drugs.”
Patient Barriers
– “[We] rarely have patients who are honest about their illegal drug use…”
– “Some of the patients we can’t screen because we don’t know Spanish…we
can’t even ask them the question…”
Provider Reported Benefits
Integrated Care
– “People do come back…They may not be ready for help today, but [may in
future] because of relationships with [staff].”
– “Screening is like prevention. You do screening to prevent things upsetting or
uh complications…I think we should be involved in the screening…”
Education
– “When we first started some of the patients were kind of irritated…but I think
we’re getting better because I really don’t get that sense from the patients
anymore.”
– “A lot [of patients] don’t realize how alcohol especially, but any other drugs,
[affect their medications and their health]. So that’s really an eye-opener for a
lot of folks I think.”
Readiness to Change
– “There might be people who [screen positive] who wouldn’t have brought it
up on their own. Because you brought it up, they do share and they do want
help.”
Team Perspectives
Perceived Barrier
1.
2.
3.
4.
5.
Time limited face-to-face contact
with patients (average 15min) –
difficulty addressing chief
complaint AND SA concerns (if
screened positive)
Providers and clinical staff are not
comfortable addressing SA issues
within SBIRT context due to a lack
of knowledge/expertise of SA
Lack of internal and community
resources for patients with chronic
pain
Stigma of substance abuse can
cause many patients to feel
uncomfortable talking abuse their
substance use
Language barrier between staff
and Latino patient population
Practice Change Innovations
1.
2.
3.
Utilized existing staff resources to assist with follow-up
services; Offered Care Management services
Provided SA trainings ; in-service trainings
and funding for external training
opportunities; Created a referral list and
coordinated with local community
resources
Coordinated with the local Pain
Management referral source to coordinate
services
4.
Trained staff and providers on how to
integrate conversation of SA concerns into
medical service and use of motivational
interviewing
5.
Created screening forms in Spanish; Included
“languages spoken” as an important aspect of
the referral list
Next Steps
Barrier
• Inpatient/residential level
of care referral
Next Steps
• Resources for
uninsured/under-insured
2a. Collaborate with local emergency
departments (ED) to coordinate
‘warm hand-off’- complete referral
on site and ‘hand-off’ to ED for labs
and placement
2b. Collaborate with local mental
health centers and lobby groups to
increase state funding for
uninsured/under-insured population
1. Collaborate with local Alcohol and
Drug Abuse Treatment Centers
(ADATC) and other inpatient facilities
to streamline admissions issues
Recommendations for Implementation
1) Get training in Motivational Interviewing and in the SBIRT Protocol (on
line through SAMSHA website; www.SAMSHA.gov).
2) Get training in working in primary care settings (e.g., medical family
therapy).
3) Contact local primary care practices to see if they have implemented
SBIRT. If not, offer to do trainings and trial runs of it (pro bono if
needed).
4) Collaborate with local substance abuse treatment centers and providers
for referrals to treatment. Get contacts and a referral list together
prior to initiating the SBIRT in any practice.
5) Respond to any barriers that surface within a week! Adjust protocol to
fit needs of setting.
6) Get all screening tools into the electronic health record.
7) Use systems and relational skills to build and maintain patient,
patient’s support system, and provider trust.
References
1. Substance Abuse Mental Health Services Administration. (2007).
Results from the 2006 national survey on drug use and health:
National findings (Office of applied studies, SDUH Series H-30,
DHHS Publication No. SMA 06-4194). MD: Rockville.
2. Samet, J. H., Friedmann, P., & Saitz, R. (2001). Benefits of linking
primary medical care and substance abuse services: Patient,
provider, and societal perspectives. Archives of Internal
Medicine, 161, 85–91.
3. Babor, T.F., McRee, B.G., Kassebaum, P.A., Grimaldi, P.L., Ahmed, K.,
& Bray, J. (2007). Screening, Brief Intervention, and Referral to
Treatment (SBIRT): Toward a public health approach to the
management of substance abuse. Substance Abuse, 28(3), 7–
30.
4. Bien, T.H., Miller, W.R., & Tonigan, J.S. (1993). Brief interventions for
alcohol problems: A review. Addiction, 88, 315–335.
Contact Information
• Jennifer Hodgson, PhD
– hodgsonj@ecu.edu
– 252-328-1349
• Marina Stanton, MS
– Stantonm08@students.
ecu.edu
– 252-702-5044
• Leigh Atherton, MA
– athertonw06@students.
ecu.edu
– 857-498-2512
• Paul Toriello, RhD
– toriellop@ecu.edu
– 252-744-6297
Session Evaluation
Please complete and return the
evaluation form to the classroom monitor
before leaving this session.
Thank you!