Screening, Brief Intervention, and Referral to

Treatment (SBIRT) Erich Kleinschmidt

May 19, 2014

CDC report – Jan. 2012

• One in six Americans binge drinks four times per month

• Average number of drinks during binge is 8• 40,000 deaths per year (binge-specific)• 2006 - $167.7 billion alcohol-related costs • Age group that binge drinks most often – 65+ • Income group with most binge drinkers - $75K+CDC Morbidity & Morality Weekly Report, Jan. 10, 2012 Vol. 61

CDC Report continued – binge drinking responsible for:

• Risk factor for motor vehicle accidents, violence, suicide, hypertension, heart attack, STDs, unintended pregnancy, FAS, SIDS

• 85% of all alcohol-impaired driving episodes involved binge drinking (2010)

• Accounted for 50% of all alcohol consumed by adults; 90% of youth

• Most binge drinkers are not dependentCDC Morbidity & Morality Weekly Report, Jan. 10, 2012 Vol. 61

Focus of SBIRT

Dependent Use

4%

25%

71%

Brief Intervention

Brief Intervention andReferral to Treatment

No Intervention

Harmful orRisky Use

Low Risk Useor Abstention

What exactly is SBIRT?

• SBIRT—Screening, Brief Intervention, and Referral to Treatment

• Universal screening of pts within medical settings

• If screened positive – brief intervention (guided discussion) with medical provider occurs

• If screening reveals dependence – referral to specialty substance abuse treatment provider

SBIRT & Medical Connection

Takes advantage of the “teachable moment”

Patients aren’t seeking treatment but screening opens door for awareness & education

Increases access to clinically appropriate care for nondependent as well as dependent persons in a non-drug treatment setting

Ranked in top ten of prevention services

1. Discuss daily use of aspirin 2. Childhood immunization Series3. Tobacco use screening and brief

intervention4. Colorectal cancer screening5. Hypertension screening6. Influenza immunization7. Pneumococcal immunization8. Problem drinking screening & brief

intervention9. Vision screening – adults10.Cervical cancer screening

(Partnership for Prevention – Priorities for America’s Health: Capitalizing on Life-Saving, Cost Effective Prev Services,

2006)

SBIRT “Patient Flow”

Screen

Identification of substance related

problems

Brief InterventionRaises awareness of risks and motivates

client toward concrete

goals/actions

Referral to Tx Referral of those with more serious

abuse/dependency

Brief Treatment Cognitive behavioral

treatment with multiple sessions

available

Universal Prescreen

Provide positive reinforcement

(+) Positive

Further screening with• ASSIST• AUDIT

• CRAFFT• DAST

Low risk: Provide positive reinforcement

Moderate risk: Provide Brief Intervention

Moderate high-risk: Provide Brief Therapy

High risk: Refer to treatment

• (-) Negative

Screening Tools

• Four commonly used screening instruments:

- Alcohol Use Disorders Identification Test (AUDIT or AUDIT – C)

- Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST)

- Drug Abuse Screening Test (DAST)

- CRAFFT (for adolescents)

- All can be found online and downloadable

Effective Screening Program Typically Yields…

• Approximately 25% of all patients will screen positive for some level of substance misuse or abuse

• Of those, the approximately 70% will be “at-risk” drinkers

• Most will be open to addressing their substance abuse problems (if discussed in a non-judgmental manner)

Identify Referral Resources

Community agencies for referrals

Short-term and long-term residential treatment centers

Hospital inpatient and outpatient centers

State treatment centers

Has been implemented in many settings

• Thus far, SAMHSA has funded 26 states, 2 tribal organizations, and 12 colleges since 2003 (five yr grants to states; 3 yr to colleges)

• States currently includes: IN, TN, SC, NC, VT, NY, WA, IL, CO, Am Samoa, AZ, IA, NJ, NM, OH

• Clinical sites include: trauma centers, EDs, inpatient units, community health centers, FQHCs, tribal health centers, elder services agencies, adolescent care clinics, college health centers, VA clinics, urban STD clinics, National Guard installations, others…

SBIRT Training Programs

• SBIRT training of resident physicians (19 grantees) since Sept ’08 (five yr grants)

• New SBIRT Training for Medical Professionals (residents, social wk, nursing, counseling, others) started in Sept. 2013 (14 grantees including U.Miami – Coral Gables) for 3 years

Additional Initiatives

• Youth Build USA – recent funding from Hilton Foundation – at risk program for older adolescents & young adults construction skills

• New York – School-based health centers (high schools)

• National Guard units – IA, KY, TN, CT, LA, IN

Reimbursement for SBIRT Services

Payer Code Description Fee Schedule

Commercial Insurance

CPT 99408

Alcohol and/or substance abuse structured screening and brief intervention services; 15 to 30 minutes $33.41

CPT 99409

Alcohol and/or substance abuse structured screening and brief intervention services; greater than 30 minutes $65.51

Medicare

G0396

Alcohol and/or substance abuse structured screening and brief intervention services; 15 to 30 minutes $29.42

G0397

Alcohol and/or substance abuse structured screening and brief intervention services; greater than 30 minutes $57.69

Medicaid

H0049 Alcohol and/or drug screening $24.00

H0050Alcohol and/or drug service, brief intervention, per 15 minutes $48.00

SBIRT reimbursement is available but…

• Need to set up system for submitting claims (typically complex for start up)

• Can be restrictions as to type of health professional that can bill (licensed vs unlicensed, etc…)

• May get resistance from medical providers to add SBIRT to already heavy workload

Key Considerations for Starting SBI Program

Develop a Screening protocol

Develop a Brief Intervention protocol

Monitor and evaluate program (strong QI mgt essential)

Identify community referral resources, protocols, & tracking

Reimbursement strategy & considerations (work with billing dept to establish reimbursement lines)

Staff training needs and supervision

Program “champions” and buy-in from CEO/Admin staff

Additional Considerations

Who Will Do the Screening and Brief Intervention?

• “SBIRT” counselors/health educator model• Social Workers• Registered Nurses• Psychologists• Physicians • Dedicated contracted personnel• Medical Assistants • Para-professionals

Challenges & Lessons Learned

• Buy-in issues from existing medical staff

(time/work load, don’t want to deal with “addicts”, now that we’ve identified them, now what?, etc..)

• Funding for additional staffing (or train existing staff)

• Need for management to be supportive and influence implementation (important to have “champions”)

• Consistent training available for new staff

• “Drift” from universal screening to “case finding” approach

SBIRT Websites/Resources

http://beta.samhsa.gov/sbirt

http://www.attcnetwork.org/regcenters/index_nfa_sbirt.asp

Questions/Discussion

For further information, etc…contact:erich.kleinschmidt@samhsa.hhs.gov