APNC Fall Conference 2012
SBIRT : Strategies for Implementation
Carolina Beach, NC
October 17, 2012
John Femino, MD, FASAM, MRO
Medical Consultant, Dominion Diagnostics
Medical Director, Meadows Edge Recovery Center
NE Regional Director, American Society of Addiction Medicine
Sponsored by:
Dominion Diagnostics
Treatment Gap: Hidden and Underserved
It has been known for many years that
the "treatment gap" is massive—that is,
among those who need treatment for a
substance use disorder, few receive it.
In 2007, 23.2 million persons aged 12 or
older needed treatment for an illicit drug
or alcohol use problem, but only 3.9
million received treatment at a specialty
substance abuse facility.
•
NIDA. Principles of Drug Addiction Treatment: A Research Based Guide;
http://www.drugabuse.gov/PODAT/faqs2.html#faq7 , accessed : December 9, 2010.
Reasons for Screening
• High prevalence in population
– 10-20% of outpatient PCP patient settings
– 20-40% of inpatient hospital settings
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Leading cause of morbidity/mortality
Most problems are behavioral
Most problems are hidden
Provider underestimation of prevalence
Lower PCP referral rate to substance
abuse and mental health programs
– <5% of SA referrals come from health providers
Early Symptoms of Substance Abuse
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•
•
•
Primarily behavioral
Usually hidden unless specifically asked for
Requires careful history taking
Few physical findings
• Most routine hematology and chemistry tests
are normal
• Laboratory tests of most value for improved
diagnosis are drug and alcohol testing
The Hidden Problem and Solution
• Rhode Island ranks #1 in the nation for last 7 years for
underage drinking and fatal auto accidents
• <5% of substance abuse treatment referrals come from
physicians
• Screening for behavioral problems (alcohol and drug use,
anxiety, depression and eating disorder) in a primary care
office is effective for identification and referral into behavioral
health treatment
• Screening and brief intervention (SBI) are recommended for
well child and routine medical visits by multiple professional
national associations and governmental agencies
• Total cost of untreated behavioral health problems exceed that
of direct treatment costs
• SBI is cost effective and saves $2 to $7 for each $1 spent
• Despite cost effectiveness and benefits, SBI is underutilized
with multiple barriers for implementation within PCP and
Pediatricians practices
Use
Consequences
Repetition
ABST
NONPROB
USE
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+
-
ATRISK ABUSE DEP
USE
+
-/+
-
+
+
+
+
++
+
Loss of control, preoccupation, compulsivity, physical dependence +
General Hospital Intervention Program
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Physician leadership
Administrative support
Self help groups on location
On site treatment resources
Employee policy and EAP services
Screening of admissions
Staff integrated within hospital systems
Employee education – awareness
week
• Ongoing medical / professional
education
• Recovering staff as advisory group
Definition: SBIRT
SBIRT = integration of systematic
screening for early intervention and
treatment
– For patients with or at high risk for
substance use and mental health disorders
– Multiple health care settings
– Before more severe consequences occur
SBIRT : Core Components
• Screening: Questions to identify problems
• Brief Intervention: Education and feedback
about risk status
• Brief Treatment: Discussion of need for change
• Referral:
Referral to substance abuse and
mental health therapist/program for
specialized evaluation and treatment
Why Care About Mild-Moderate
Cases?
Primary Prevention
SBIRT
SBIRT
Brief
Intervention
Specialized Treatment
Referral
Challenges
Adapted from Broadening the Base of Alcohol Treatment
(IOM)
Effective Identification of
Substance Use Disorders
• Always screen for disorders
• Recognize prevalence of problems
• Look for associated conditions /
problems
• Take personal and family history
• Corroborate results
• Have non-judgmental attitude
• Drop stereotypes
• Motivational counseling + brief
intervention
Who Should Be Screened?
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•
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All patients
Positive family history of abuse/addiction
With risk factors (including ADD)
Associated problems
– Accidents - overdoses
– Emotional and behavioral problems –
• Anxiety, depression, eating disorders and substance
abuse
– Family problems
• Kids already in trouble
– Juvenile justice systems
– Identified in schools – SAP
• Oppositional and problem kids
• Special education – ADD
• Involved in drug culture
– School drop outs
– Child welfare involvement
SCPI – Goal & Mission
• Assist and support medical community
– Education and information about substance abuse
and behavioral health problems
– Early Identification of behavioral health problems
through screening and brief intervention
– Assessment, treatment recommendations and
intervention
– Referral to behavioral health specialists
– Monitor compliance with behavioral health
treatments
Goals of Behavioral Health
Screening Project
• Develop pilot project in pediatrician and primary care physicians
offices in South County to implement screening and brief
intervention (SBI)
• Develop screening tool for substance abuse, depression, anxiety
and eating disorder
• Train staff on screening and brief intervention
• Implement screening protocol at selected practices
– New or established patients for annual well child visits
• Collect prevalence data
• Conduct key informant interviews to determine implementation
issues and barriers towards expansion of program to all
pediatricians and PCP’s in Rhode Island
• Document impact of SBI on rates of identification and referral
• Monitor patient compliance with referral recommendations
Provider Barriers to Screening
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Time constraints – extend routine office visit
Money – how to reimburse for screening
Stigma-Fear of alienating patient or family
Hopelessness re: treatment effectiveness
Inadequate training on substance abuse
Inadequate dissemination of information
about effectiveness of treatment and
consequences of failure to treat
• Lack of knowledge of local resources
Parental Barriers to Screening
• Belief that use of drugs and alcohol =
experimentation
• Time constraints will interfere with well child visit
• Stigma-Fear of labeling patient or family
• Insurance labeling via Medical Information Bureau
(MIB) create lifelong stigmatization and place in
high risk category for life, disability or health
insurance eligibility or premium ratings
• Confidentiality and self incrimination issues
• Lack of knowledge about effectiveness of treatment
and consequences of failure to treat
Screening Instruments
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Evidence for reliability and validity
Which population utilized?
Setting under which developed
Intended use of instrument
Ease and manner of use
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Trained staff
Costs of materials to administer and score
Self administered, computer assisted
Subject self assessment vs. family evaluation
• Substance abuse or general problems
– Focused vs. multidimensional
Screening and Brief Intervention
• Screen for hidden condition by use of
standardization screening instrument
– CAGE
– MAST
– DAST
– AUDIT
– CRAFFT
– SCPI – RISAM
– Any other instrument with documented
validity and accepted through literature
CRAFFT (Riggs & Alario; Knight)
Driven car while intoxicated?
Use to relax, feel better or fit in?
Ever use while you are alone?
Do any close friends use?
Do any close family members have problems
from using?
Ever gotten in trouble from using?
2+ endorsements
Medical v. Non-Medical Screening Issues
• Knowledge of patient and family over time
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Genetic and family history known to clinician
Screening questions compared to medical record
Past treatment or referral known
Problematic behaviors recognized or treated in past
Older sibs may have received treatment
Parent or grandparents may be in recovery
Snapshot vs. movie – context of screening in relation
to knowledge of family
– Hidden indicators of problems – missed appointment,
lack of follow up of previous recommendations, high
risk behaviors
Development of BHS Instrument
• Need for one page with estimated testing time < 10 min
• Self administered, assisted by staff is necessary
• Combined mental health & substance abuse screening
instrument
• Multidimensional assessment scales
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Depression
Anxiety
Eating disorder
Alcohol abuse
Drug Abuse
Associated conditions
BHS-Crafft, SA, Depression+Anxiety
BHS-Audit + Eating Disorder
Psychometric Valid v. Clinician Concern
• Anxiety and depression scores developed from validated
scales
• Individual item severity vs. total score
• Cutoff scores – sensitivity and specificity are established
for non-medical and can be lowered for individual items
or high risk patients i.e. – patient with family history of
alcoholism/substance abuse who is actively using - ?
Experimentation or early development of problems
• Pattern analysis between scales
– Substance abuse, affective and high risk behavior
• Knowledge of genetic type of parental problem – ie early
onset addiction in context of adolescent using and
involved in other high risk and problematic behavior =
problem until proven otherwise
Screening Score Interpretation
• Set point of threshold = positive
– Below cutoff = no problem
– Above cutoff = problem or potential problem
• Set point dependent upon selection biases
• Lower cutoff = increase sensitivity, lower specificity
(higher false positive rate)
• Raise cutoff – decrease sensitivity & increase
specificity (increase false negative rate)
Receiver Operating Characteristics: ROC
• Set point of threshold of positive
– Below cutoff = no problem
– Above cutoff = problem or potential problem
• Set point dependent upon selection biases
• Lower cutoff = increase sensitivity, lower
specificity
• Raise cutoff – decrease sensitivity and
increase specificity
• Positive predictive value
Screening & Brief Intervention Procedure
• Determine eligibility for screening
• Identify primary prevention office visits
• Provide screening instrument instructions prior to
provider examination
• Monitor or assist patient self administration
• Review, score and interpret guestionnaire results
• Discussion of test results with patient and family
• Provide education and instruction by risk category
• Hand out educational and interventional packages
• Referral to behavioral health treatment provider
Screening Procedure
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Determine eligibility for screening
Ask patient/parent to sign permission form
Hand out primary prevention educational packages
Provide screening instrument to patient
– Two sites – attach to chart
– One site – keep in exam room
• Have physician score form in office
• Physician discuss results with patient/parent
• Education and referral
Onsite Education v. Return Visit
• Primary prevention material to all patients
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Package obtained from community TASC force
National Clearinghouse
Local resources
Insurers
• Secondary prevention –targeted
information
– Optional and individualized
– Read
Training of Office Staff
Overview of SBI project
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SCPI description and role in community
Review of screening instrument
Screening protocols – who does what when
Referral options
Data collection
Location of screening tool- notebook binder or chart
Consent form and confidentiality issues
Identify concerns and training needs
Training on Motivational Interviewing
– Two hour introduction and one hour advanced skill training
Usual Patient – Physician Discussion
 Physician Role
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Most often pattern = Don’t Ask, Don’t Tell
Judgmental style of questioning – “Do you drink too much”
Focus on symptoms and not feelings and behaviors
Confrontational – Shame and Blame
Tell the patient – direct instruction vs. listening to conflict
 Patient Role
– Most patients are not resistant to honestly answering questions
about feelings and behaviors
– Fear of being rejected or change in physician behavior
– Want to understand PCP role and relation to specialist
Five Principles of
Motivational Interviewing
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Express Empathy
Avoid Argumentation
Develop Discrepancy
Roll with Resistance
Support Self-efficacy
(Miller and Rollnik)
Stages of Changes & SBIRT
Scoring & Intervention Recommendation
Preliminary Data (N=886)
• Total Number of eligible patients
• % refused to sign permission
• % exceeded threshold (screened in)
– One scale
– Two scales
– Three scales
• Relationship between scales
• Relationship between individual items
(deferred)
Age Distribution : All Sites
Rate of Screening Positive by Test type
Screening Tests
% At Risk
Substance Abuse
8.4
CRAFFT
14.4
Eating Disorder
25.3
One of: Severe depression, anxiety or AUDIT
4.3
Screened in in at least 1 area
36.4
Screened in in 2 or more areas
12.5
Screened in in 3 or more areas
3.2
Sample size = 866 51% were age 15 or younger
Process Evaluation-Screening Procedure
• Office manager / parent advocate
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Acceptance of appointment for return office visit
Provide information / contact referral source
Contact with insurer – behavioral health authorization
Document availability and timing of referral appointment
• Monitor referral compliance
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Contact family to verify compliance with appointment
Ask family if insurance coverage problems
Ask family if treatment recommendations accepted
Time required for office staff to monitor compliance
Checklist and Qualitative Key
Informant Interviews
• Purpose – capture process of using BHS tool
– Length of time to take
– Need for parental assistance
– Section for office staff, provider, and
manager/researcher
– Whether counseling was given for individual items
– Need for follow up visit
– Referral information
– Follow up information
Confidentiality Wording
• Lots of discussion re: wording of confidentiality
– Need for absolute confidentiality = secret
– Separate confidentiality of questionaire answers from recommendation
for additional info/referral
• Return visit = indirect acknowledgement of problems
• Confidentiality of patient in revealing parental problems
• Requesting additional forms and consent may create less interest in
participating
• Honesty of answers may be jeopardized if patient believes that
parents will be told results of testing
• Need for separation of BHS questionnaire from medical record
– Progress note report of screen completed with suggested
recommendations
– Separate binder/chart of questionnaire
• 42 CFR apply to assessment as distinct from treatment for a
diagnosed problem
• Need for report from behavioral health provider to be kept in
separate section or along with other consultations
Process Evaluation: Treatment Comliance
• Did patient/family return for office visit to discuss
changes based upon SBI
• Were educational materials helpful
• Did referral source communicate with referring
physician – telephone, report, interagency
• Family satisfaction with referral
• Identify barriers to follow up
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Transportation
Lack of coverage and ability to pay for co-pay
Office hours
Treatment resistance
Time Necessary for Self Administration
• Screening administration and scoring
– Time to fill out screening instrument
• Age, education, language, reading functions
– < 10 minutes if patient is >15 years old
– > 15 minutes if patient is <15 years old
– Scoring of tests and documentation of
screening results
• Intervention & Referral to treatment
– Interpretation and discussion of results
• Low score - Informational and educational
• Moderate - Instructional & Interventional
• High
- Referral to Behavior Health
Impressions of Staff in Utility of SBI
• Two of these practices were considered the “gold standard” of
community based pediatricians in awareness of and inclusion of
behavioral health questions during their standard well child visit
Despite this sensitivity and skills:
• Use of standardized guestionnaire significantly increased
pediatricians ability to conduct interview compared to unstructured
clinical interview
– “I’ve known this family for two generations and have taken care of this
child since birth and asked behavioral health questions at each visit
including today, and I was astonished to see how many positive items
were noted on the scale compared to my clinical interview”
– “The guestionnaire helps me during my interview – It warmed the
patient up and helped me guide questions to the appropriate area”
– “What I thought was experimentation, was NOT”
– “I want to continue to use it, but we can’t afford to continue”
Pre-Post SBI Implementation Issues
Practice Qualitative Data (Jan - Mar 06)
Provider Quantitative Data (Jan - Mar 06)
Pre
100
100
90
90
80
80
70
70
60
60
50
50
40
40
30
30
20
20
10
10
0
0
SBI Use
ID Rate
Knowledge
Referral
Resources
Referral Rate
Confidentiality
Concerns
100
100
90
90
80
80
70
70
60
60
50
50
40
40
30
30
20
20
10
10
0
Added Time
Billing Problems
Practice Qualitative Data (Mar-Sep 06)
Provider Quantitative Data (Mar-Sep 06)
Post
Practice
Acceptance
0
SBI Use
ID Rate
Knowledge
Referral
Resources
Referral Rate
Confidentiality
Concerns
Practice
Acceptance
Added Time
Billing
Problems
Most Effective Interventions
•Training of office staff on SBI implementation and
integration into medical office workflow
•Provision of ongoing support to office staff
– Provision of educational materials, collection of data and
on-site collaboration with research and support staff
•Focus group presentation and discussion
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Review and feedback of study data
Analysis of scheduling and coding procedures
Impact of SBI implementation on office workflow
Costs of resources and time for SBI
Identification and quantification of implementation barriers
50
Conclusions from Preliminary Study
• Behavioral health problems are common
• BHS instrument is easy to implement in PCP’s office practice
• Most providers noted significant improvement in identification rate by
using BHS instrument compared to clinical interview
• Success of SBIRT depends upon effect on office flow
• Duration of office visit varies upon severity of scoring
• Rate of referral for behavioral health evaluation remains lower than
rate of identification
• Coding and reimbursement issues represent #1 barrier for
implementation
• Knowledge and availability of behavioral health referrals is still lacking
among providers and subscribers
• Designated provider network improves referral rate
Getting Paid for SBI
Insurance Benefit by Provider Type
Insurance Benefit Type
Behavioral
Health
Provider
Medical
Provider
Behavioral Health
Medical
Use Psych CPT
Use Psych DSM
Paid for SA services
Excluded from Psych CPT
May or may not use Dx DSM
ASAM Cert –ADM CPT code
Addiction Medical Management
May not use Psych CPT
Use E+M codes
May not use Psych DSM
Non Par with MCO
Not eligible for SA Services
Use Medical Diagnosis
Co-morbid+Counseling
Screening + Brief Intervention
SBI Options during Office Visits
Preventative Health : Annual Physical Exam + Well Child Visit
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Use screening instrument (self administered) while in exam room
Bill preventative health code and add screening instrument code
If score < threshold, advice and retest at periodic intervals
If score > threshold, brief intervention, reschedule or refer
Evaluation and Management Services
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Use screening instrument (self administered) while in exam room
Bill E+M code and add time to length of E+M office visit
Code E+M by convert to timed visit > 50% counseling time
Document in medical record discussion and time spent
Reschedule office visit for ongoing evaluation/treatment or refer
Psychotherapy Codes
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Use screening instrument (self administered) while in exam room
Bill Psych code and include time into timed psychotherapy code
Document in medical record discussion and time spent
Reschedule office visit for ongoing evaluation/treatment or refer
Coding for Screening & Brief Intervention (SBI)
•Screening Procedure
•Instrument needs to be short
•Self Administered or by trained staff
•Scoring needs to be done during office visit
•Feedback of score discussed with patient + family
•Brief Intervention
•Discuss results with patient in detail
•Low scores may allow for risk reduction counseling
•Higher scores may need additional time
•Reschedule patient until evaluation complete
•Refer the patient to behavioral health provider
Coding for Screening & Brief Intervention (SBI)
•Screening Procedure
•Private insurance
•Medicare
•Medicaid
•Brief Intervention
•Private Insurance
•Medicare
•Medicaid
Code
99408
G0396
H0049
99409
G0397
H0050
$ Payment
> $22
$22
$24
>$55
$55
$48
SBI Coding Matrix
Code
CPT
Type
ICD Specialty
-9
Benefit
Limits
Tracking
Stigma
MIB
Preventive
Med
99384- Untimed
99397
No
Dx
Medical
PCP
Not same day None
as E+M
No
Office
Visit
99202- Severity Dx
99215 Or Timed
Medical
PCP
Variable copay by Dx
May be
By Dx
PsychoTx
90801- Timed
90807
Dx
Behavior
Health
Med Provider None
may be Non
Par
Yes
Psych
Testing
96150
No Behavior
Psy Health
ch
Not same day None
as E+M
Yes
Timed
None
Medical Information Bureau (MIB)
Psychiatric Stigmatization
Concern regarding the act of screening patients (especially
adolescents) should not stigmatize them prior to the
establishment of a diagnosis or of providing treatment
Credit Card Bureau Format
– Patient’s CPT + ICD-9 codes transferred from health care insurer to
shared database when patient signs release of information for life
and disability insurance and ?? Health insurance
– For $8.95 patients can access their data on the web (Health care
utilization check)
– Since most insurers do not allow “rule out” diagnosis, can’t use
psych or E+M codes for screening prior to the results of the
screening test
– Need for separate screening code and brief intervention code
• Application to AMA by PLNDP for new codes
– HCPCS level II code H0002 + H0004 has been been approved,
however, restricted to Medicaid agency that handle behavioral
health and not for Medicare or private insurers
Psychiatric Labeling and MIB
• Shared database of CPT codes and ICD-9
Diagnoses
• Give permission to access database upon
application for life, disability and health
insurance
• Since many insurers do not accept rule out
diagnoses, coding for alcohol abuse by
behavioral health provider for an assessment
may result in lifetime “psychiatric labelling”
• Database is accessible through the web, cost
$8.95 to access and check for accuracy (similar
to credit bureau reporting
Video Resources
• Shared database of CPT codes and ICD-9
Diagnoses
• Give permission to access database upon
application for life, disability and health
insurance
• Since many insurers do not accept rule out
diagnoses, coding for alcohol abuse by
behavioral health provider for an assessment
may result in lifetime “psychiatric labelling”
• Database is accessible through the web, cost
$8.95 to access and check for accuracy (similar
to credit bureau reporting
SBIRT Resources
• Shared database of CPT codes and ICD-9
Diagnoses
• Give permission to access database upon
application for life, disability and health
insurance
• Since many insurers do not accept rule out
diagnoses, coding for alcohol abuse by
behavioral health provider for an assessment
may result in lifetime “psychiatric labelling”
• Database is accessible through the web, cost
$8.95 to access and check for accuracy (similar
to credit bureau reporting