SBIRT
Demonstrating Viability in an
Integrated Care World
Jake Bowling, MSW
Director of Practice Improvement
Pam Pietruszewski, MA
Integrated Health Consultant
SBIRT
• Screening to identify patients at-risk for developing
substance use disorders.
• Brief Intervention to raise awareness of risks and
consequences, internal motivation for change, and help
set healthy lifestyles goals.
• Referral to Treatment to facilitate access to
specialized treatment services and coordinate care
between systems for patients with higher risk and/or
dependence.
Wilk, J Gen Int Med, 1997; Bien, Addiction, 1993; Cuijpers, Addiction, 2004; Kahan, Canadian Med Assoc J, 1995; Madras,
Drug and Alcohol Dep, 2009; Moyer, Addiction, 2004; Kaner, Cochrane Database, 2007; Whitlock, Ann Int Med, 2004;
Bertholet, Arch Int Med, 2005; Vasilaki, Alcohol and Alcoholism, 2006
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Distribution of Alcohol Use
40%
35%
20%
Abstinent/
Low risk
Moderate risk
5%
High Risk
Abuse/Dep.
SBIRT
Target
Population
Specialized Treatment
Brief Intervention
Primary Prevention
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Effectiveness
At 6 months:
• Heavy alcohol use lower 39%
• Drug use lower by 68%
Madras, Drug Alcohol Dependence 2008.
Madras, Drug and Alcohol Dependence, 2009
Bernstein, Drug and Alcohol Dependence, 2005
Copeland, J Substance Abuse Treatment, 2001
Stephens, J Clin Consult Psychology, 2000
U.S. Preventive Services Task Force
Recommendation 2013
Screening and brief behavioral
counseling interventions to reduce
misuse by adults in primary care
(Grade B)
High certainty that the net benefit is moderate or
there is moderate certainty that the net benefit is
moderate to substantial.
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Benefits
• Addresses prevalence of co-occurring disorders
and meets the individual where they are
• Lessen complications from medical conditions
such as diabetes, heart disease, hypertension
• Reduce hospital and ER visits
• Cost savings to the health care system
• Model for health care integration, whole-health
viability
SBIRT Paradigm Shift
• Not looking for addiction
• Looking for individuals with unhealthy
substance use patterns
• Looking for opportunities for intervention
• “Meeting patients where they are”
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SBIRT Model
Screening
Negative Screen 77%
Mild/Moderate use 15.9%
Brief
Intervention
1 session
Positive Screen 23%
Moderate/High use 3.2%
Dependence 3.7%
Extended Intervention
up to 4 sessions
Referral to
Treatment
Madras et al, Drug and Alcohol Dependence, 2009
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Screening
A systematic way of asking questions to
determine the presence or absence of
symptoms or risky behaviors using
standardized, reliable and valid tools
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Example Screening Tools
AUDIT
Alcohol
Adults
DAST
Drugs
Adults
ASSIST
Alcohol, Drugs, Tobacco Adults
CRAFFT
Alcohol & Drugs
Adolescents
http://www.integration.samhsa.gov/clinical-practice/sbirt/screening-page
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Brief Screening
How many times in the past year have you had 4 or more
(females) / 5 or more (males) drinks in a day?
Source: NIAAA
How many times in the past year have you used an illegal
drug or used a prescription medication for non-medical
reasons?
Source: NIDA
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Low-Risk Drinking
Guidelines
NIAAA, 2010
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Brief Intervention
Process of sharing information, offering
advice, and engaging patients in the
management of their clinical issues to
achieve their personal health goals
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Goal is to enhance motivation for behavior change
Averages 15-30 minutes
– Discuss pros and cons
– Offer feedback
– Ask about readiness & importance
– Negotiate a specific goal
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What are the things you enjoy about marijuana? What
are the things you enjoy less or dislike about marijuana?
Can I share with you some information on low-risk
drinking?
So where does this information sit with you?
On a scale of 0 to 10, how confident are you that you can
make a change?
What is your next step?
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Perceptions &
Unconscious
Biases
• Often underestimated– we all carry unconscious biases
• Staff messaging: “This is part of our overall commitment to
your health.”
• Linkages: Substance use, emotional & physical health
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Referral to Treatment
1855 adult patients with likely dependency (Brown, 2014)
 24% expressed initial interest in a referral
 10% entered treatment
• Motivational Interviewing skills
• Reliable follow-up, ongoing support, and/or adjustments
to treatment
Nuts and Bolts of SBIRT
Implementation
Jake Bowling, MSW
Director of Practice Improvement
National Council for Behavioral Health
Why SBIRT?
• Improve overall clinical care
• Reach adults and adolescents at higher risk for substance abuse
issues due to mental health conditions
• Position your CBHO for partnership with primary care or prepare for a
fuller integration project, which creates new business opportunities
• Build overall co-occurring capability in a concrete way, and provide a
gateway to developing co-occurring services and new business
opportunities
• Fortify your CBHO as a line of defense against addictions through an
evidence-based prevention and early intervention protocol that any
provider – even those with little experience with addictions – can
successfully implement SBIRT
8 Key Implementation Questions
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Who needs to be at the table?
Where does SBIRT fit in?
What is the plan?
How do we pay for it?
How do we entrench SBIRT into our protocols?
What staff training is needed?
How do we track SBIRT and know it’s working?
How do we know if we need to change course?
Who needs to be convinced and at the table?
• Leadership
• Clinical staff
• IT/ EHR staff
• Billing staff
• HR
• Training
• Office Staff
How do you communicate with key stakeholders &
speak to their priorities?
Where does SBIRT fit in?
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Intake
Outpatient Therapy
Day Treatment
Residential
School-based
ACT
Peer support
Primary care
Remember, SBIRT is a 3 part process.
Workflow Redesign
What is the plan?
The PDSA Cycle
Act
• What changes
are to be made?
• Next cycle?
Study
• Complete the
Plan
• Objective
• Questions and
predictions (why)
• Plan to carry out
the cycle (who,
what, where, when)
Do
• Carry out the plan
analysis of the data • Document problems
and unexpected
• Compare data to
observations
predictions
• Summarize what • Begin analysis
of the data
was learned
Repeated Use of the
Cycle
Changes That
Result in
Improvement
Hunches
Theories
Ideas
A P
S D
Rapid Cycle Change Plans
• Select one or two programs in your organization
• Focus on building SBIRT into the ecosystem and
day-to-day tasks of those programs
• Enhance existing workflows & protocols
• Have monthly check-ins with core team
• Don’t be afraid to go back to the drawing boards
and make course corrections
• Collect robust data and qualitative feedback
• Celebrate successes
How do we pay for it?
• Integrated into billable encounters
• Covered by base, contract, or grant dollars
• Reimbursed through Medicaid or Medicare SBI
codes
 At least 22 states Medicaid or CPT codes
 29 states using HBAI codes
 Restrictions based on setting and provider types
Explore your state’s SBIRT financing environment:
http://my.ireta.org/sbirt-reimbursement-map
What staff training is needed?
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Why SBIRT: Implementation Strategies
Doing SBIRT: Clinical Training
Brief Intervention Fidelity Coaching
OASAS 4 &12 Hour Training
https://www.thenationalcouncil.org/topics/screeningbrief-intervention-referral-treatment-sbirt/
How do we build protocols?
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Screening
Brief intervention
Referral to treatment
Follow-up
Training
Data collection
Quality improvement
How do we know if we need to change course?
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What are your quality measures?
Who is monitoring process?
How do we deal with setbacks?
How does data guide process?
How do we communicate with team?
Summary
1. SBIRT is an early intervention &
prevention model for risky substance
use
2. Can improve clinical care and reduce
health costs
3. Implementation and clinical skills benefit
from planning, practice and PDSA’s
Questions?
Pam Pietruszewski
Integrated Health Consultant
[email protected]
Jake Bowling
Director of Practice Improvement
[email protected]