1. 2/1/2012
Craig Field, PhD, MPH
Associate Professor Program Director
Screening & Brief Intervention
Health Behavior Research
& Training Institute Trauma Department
UT Austin University Medical Center at
Brackenridge
craig.field@austin.utexas.edu
2
Source: JAMA, 2004.
Source: CASA Columbia University, 1994. 3
1

2. 2/1/2012
Source: Closing the Addiction Treatment Gap, 2010. 4
 Substance use services have been focused in two areas:
 Primary Prevention – Delaying onset of substance use.
 Tertiary Prevention (Treatment) – Providing time, cost,
and labor intensive services to patients who are acutely
or chronically ill.
5
Substance Dependent
No Problem
6
2

3. 2/1/2012
Substance Dependent Treatment
No Problem No Intervention
7
U.S. Population
8
Dependent
9
3

4. 2/1/2012
Excessive
10
dependent 4%
dependence symptoms
harmful 25%
hazardous
low risk
71%
current abstinence
lifetime abstinence
11
6
1
12
4

5. 2/1/2012
We could provide a 100% cure to every substance
dependent person in the United States we wouldn’t be
close to curing most of the substance related problems
in our country.
13
4% Dependent
25% Heavy Drinkers
71% Low or No Risk
14
 The health care system routinely screens for potential
medical problems (cancer, diabetes, hypertension),
provides preventative services prior to the onset of
acute symptoms, and delays or precludes the
development of chronic conditions.
15
5

6. 2/1/2012
Substance Use Is
A Public Health Problem 16
# Service Preventable Cost
Burden Effectiveness
1 Aspirin: Men 40+ Women 50+ 5 5
2 Childhood Immunizations 5 5
3 Smoking Cessation 5 5
4 Screening & Brief Intervention 4 5
5 Colorectal Cancer Screening 4 4
6 Hypertension Screening and 5 3
Treatment
Source: Am J Prev Med 2006; 31 (1) 52-61 17
6

7. 2/1/2012
Maximum Daily Limits Maximum Weekly
Limits
Women 3 7
Men 4 14
Men >65 3 7
Less is Better!
Source: NIAAA, 2009 19
 Our prime directive should no longer be limited to
identifying people who are dependent and need higher
levels of care.
 Our prime directive should also be to identify those
who are at moderate or high risk for psycho‐social or
health care problems related to their substance use
choices.
20
 SBIRT uses a public health approach to universal
screening for substance use problems.
 SBIRT provides:
 Immediate rule out of non‐problem users;
 Identification of levels of risk;
 Identification of patients who would benefit from brief
intervention, and;
 Identification of patients who would benefit from higher
levels of care.
21
7

8. 2/1/2012
Brief
Brief Out‐ Hospital‐
Screening Interven‐ ization Inpatient
Therapy patient
tion
22
 Stepped‐Care Model
 Try to intervene with the least complicated and/or
least costly intervention.
 Proceed to the next level of intervention only if the
student fails to respond to the first.
 Requires follow‐up to determine if the intervention
was effective.
SBIRT is a primary, secondary,
and tertiary prevention and
treatment strategy designed to
intervene based on patient need
and prevent/treat substance use
problems at various levels.
24
8

9. 2/1/2012
 Pre‐screening (universal).
 Full screening (for those with a positive pre‐
screen).
 Brief Intervention (for those scoring over the cut
off point).
25
 Brief Treatment (for those who have moderate risk,
high risk, abuse, or dependence, would benefit from
ongoing, targeted interventions, and are willing to
engage).
 Traditional Treatment (for those who are dependent
and are willing to engage).
26
Universal Brief Screen
Positive Reinforcement
Negative
Low Risk:
Positive Positive Reinforcement
Moderate Risk:
Brief Intervention
Further
Moderate – High Risk:
Screening Referral to Brief Therapy
High Risk:
Referral to Treatment
27
9

10. 2/1/2012
Severity of Alcohol Problems
Dependent drinking/Alcoholism SBIRT
Harmful drinking/Abuse SBI
Risky/Hazardous drinking
Safe drinking
Screen
Abstinent
 SBIRT is an evidenced based practice that is supported
by:
 Center for Substance Abuse Treatment
 The World Health Organization
 The American Preventative Task Force
 The American Trauma Nurses Association
 The American Medical Association
 The American College of Surgeons
 The Office of National Drug Control Policy
29
 DUI
 Injury
 Violence
 Pregnancy
 STD
 Substance Dependence
 Health Care Problems
30
10

11. 2/1/2012
 New Referral Streams
 Evidence‐based Practices
 Improved Outcomes
 Enhanced Relationships with Health Care
 More Inclusive Continuum of Care
 Broader Patient Base
 Alternate Funding Streams
 Larger Role and Increased Credibility
31
• Healthcare reform provides an
opportunity for SBIRT
• Emphasis on preventive care and wellness
• Integration of primary and behavioral
health
• SBI as essential health benefit
32
Screening is a broad term defined as a range of
evaluation procedures and techniques. A screening
instrument does not result in a clinical diagnosis, but
indicates the probability that the condition looked for is
present.
A brief intervention is a short (10‐15 min) conversation
based on motivational interviewing that ends on good
terms and improves chances that the person that is
involved in risky alcohol consumption will alter their
behavior to reduce risk.
11

12. 2/1/2012
Dunn C. et al. Hazardous drinking by trauma patients during the year after injury. J Trauma. 2003;54:707–712.
12

13. 2/1/2012
Precontemplation = Never
Contemplation = Maybe
Preparation = Soon
Action = Now
Dunn C. et al. Hazardous drinking by trauma patients during the year after injury. J Trauma. 2003;54:707–712.
13

14. 2/1/2012
14

15. 2/1/2012
The absolute risk reduction implies that only nine patients
would need to receive a BI to prevent one DUI arrest.
 Level I & II Trauma Hospitals
 “The trauma center does not have a mechanism to identify
patients who are problem drinkers:
 Level I Trauma Hospitals
 “ The trauma center does not have the capability to provide
intervention or referral for patients identified as problem
drinkers”
‐ COT Resources for Optimal Care of the Injured Patient 2006‐
15

16. 2/1/2012
 Substance use screening, brief intervention, referral,
and treatment (SBIRT) is a systems change initiative
requiring us to re‐conceptualize, how we
understand substance use problems,
re‐define how we identify substance use problems,
and re‐design how we treat substance use problems.
48
16

17. 2/1/2012
• Getting buy‐in at all levels
• Administrators
• Clinical
• Business
• Cost savings
• Reimbursement is available
• The Joint Commission
• The American College of Surgeons
• Committee on Trauma
• SBIRT purpose and effectiveness
• Evidence base
The World Health Organization
The American Preventative Task Force
The Emergency Nurses Association
The American Medical Association
The American College of Surgeons/COT
• Patient stories
17

18. 2/1/2012
• Cost savings were $89 for each patient
screened and $330 for each patient provided
with a BI
• Reduced health expenditures were $3.81 for
every $1.00 spent on SBI
• If SBI was routinely offered to eligible injured
adult patients the potential net savings would
exceed $1.5 billion annually.
Source: Gentilello, Eble, Wickizer, et al., (2005). Alcohol Interventions for trauma patients treated in
emergency departments and hospitals: A cost benefit analysis. Annals of Surgery, 241(4):541‐550.
• Needs assessment
• Inform, educate and train staff
• Define your target population
• Develop clear protocols
• Establish relationships
• Develop a charting protocol
• Develop a billing strategy
• Develop a data collection and storage plan
• Develop quality improvement initiatives
• Establish referral network
Conduct a facility needs assessment that
considers patient demographics, patient
flow, time requirements, internal and
external policy, staffing resources, fiscal
resources, space, IRB requirements, and
technology.
54
18

19. 2/1/2012
• Top down and bottom up support
• Internal champion
• Internal and external policy
• Current screening protocols
• Training needs
• Space
• Patient flow
• Patient demographics
• Technology
• Hospital Administration
• Chief of Trauma Surgery
• Trauma Nurse Coordinator
• ER Nurse Manager
• Behavioral Health Staff
• Business office staff
• Medical Records
• Legal department (HIPAA/42 CFR, Part 2).
56
• Who is the population to be served?
• Who will provide the service?
• What tools will they use?
• When/where will the service be
provided?
• How will records be kept?
• How will the services be billed?
19

20. 2/1/2012
 Who, how many, when, and where you screen will affect
the time requirements for interventions.
 Typical patient service sequences and lengths of stay will
influence when interventions can be performed.
 The type and length of intervention you choose will affect
time availability.
 How you will cover different shifts (if necessary) will affect
how many interventionists you need.
 Whether you have intervention personnel also perform
screening or have others do screening will affect time
required.
58
• Which patients will you screen?
• Universal vs. targeted
• Dependent users/Risky users
• Adults/Adolescents (consent)
• Which patients will you exclude from
screening?
• What substances will you screen for
• Will you screen for mental health
• Who will conduct pre‐screen/screen
• When and where will screening be conducted
• How will results be documented
• How will results be communicated
20

21. 2/1/2012
• Who will conduct the brief intervention
• Which BI support materials will be used
• Which patient handouts will be used
• When and where will brief intervention be conducted
• How will goals be documented
• How will goal be communicated
• Knowledge and experience
• Interpersonal skills
• Willingness to take on responsibility
• Flexibility in work schedule
• Where will chart note be kept
• Main medical record
• Locked files
• Separate from the medical record
• What information will be included
related to the screen and/or brief
intervention
• Determine the flow of information,
paperwork, and data
21

22. 2/1/2012
Payer Code Description Fee
Commercial CPT 99408 Alcohol and/or substance abuse structured $33.41
screening and brief intervention services;
15 to 30 minutes
Alcohol and/or substance abuse structured
CPT 99409 screening and brief intervention services;
greater than 30 minutes
$65.51
Medicare G0396 Alcohol and/or substance abuse structured $29.42
screening and brief intervention services;
15 to 30 minutes
Alcohol and/or substance abuse structured
G0397 screening and brief intervention services;
greater than 30 minutes $57.69
Medicaid H0049 Alcohol and/or drug screening $24.00
Alcohol and/or drug service, brief intervention,
H0050 per 15 minutes $48.00
64
• CMS authorized two new HCPCS codes to reimburse
for SBI.
• States may choose not to activate these codes.
• CMS has authorized the use of two new G codes to
reimburse for SBI.
• These codes can be billed beginning January 08.
• The AMA has authorized the use of two new CPT
codes to reimburse for SBI.
• Insurance carriers may choose not to reimburse these codes.
65
• Who will monitor and report SBI productivity
• Who is collecting your trauma data
• What will be reported and to whom
• % of all patients eligible to be screened
• % of all eligible for screening actually screened
• % of all those screened who screened positive
• % of all those positive screens who received a BI
66
22

23. 2/1/2012
• What data do you collect
• How do you collect data
• Can you incorporate your SBI data into the
Trauma Registry
• How do you ensure data security
67
Screening, Brief Intervention & Referral
for Treatment for Trauma Patients
Trauma Patients Meeting Criteria : 187
September 16 – October 15, 2011
Self
Report/BAC/UDS
Brief Interventions Provided
Outcomes: Discharge Prior,
16
Discharge
Negative Interventions Prior, 12
108 44
Positive
Unable to
63 Participate, 6
Decline, 1
Summary: Admission Order Set: UDS Collected
• Patients screened 91.4% • Trauma 74.8%
• Patients had UDS drawn 55.1% • Hospitalist 48.7%
• Patients had BAC drawn 64.0% • Surgery 8.3%
• Brief Interventions provided 77.2%
Screening, Brief Intervention & Referral
for Treatment for Trauma Patients
Trauma Patients Meeting Criteria : 1825
December 15, 2010 – December 15, 2011
Self Brief Interventions Provided
Report/BAC/UDS Discharge prior, 119
Outcomes:
Negative, 941 Discharge
Interventions, prior, 89
Interventions,
38
533
Positive,
Positive, 765 Unable to
67 participate
, 92
Shift, 42
Decline, 9
Summary:
• Patients screened 93.2 %
• Total Urine Drug Screen 52.0 %
• Total BAC drawn 63.2%
• Brief Interventions provided 84.5%
23

24. 2/1/2012
Extrapolating from data presented in peer reviewed
publications, program activities last year are estimated to have
prevented 59 arrests for driving while intoxicated following
discharge and 26 readmissions for treatment of a traumatic
injury. Given that the average cost of admission for a traumatic
injury in a Level 1 Trauma Center is $14,567, $378,742 in
healthcare cost will be avoided in the next three years as the
result of reductions in rates of injury recidivism. Given that
the net cost savings of the intervention has been estimated at
$89 per patient screened or $330 for each patient offered an
intervention, total healthcare cost savings from the program
are conservatively estimated at nearly $250,000. In summary,
screening and brief intervention for at risk drinking fills a gap
in current services, the program has positively impacted the
lives of patients and the surrounding community at no, or
minimal costs to the organization.
• What are your outcome measures
• What are your training requirements
• How do you monitor fidelity
71
24

25. 2/1/2012
RESOURCES
25

26. 2/1/2012
 Rethinking Your Drinking
 RethinkingDrinking.niaaa.nih.gov
 Physician’s Guide
 niaaa.nih.gov
 Brief Intervention
 who.int/substance_abuse
26

27. 2/1/2012
 Health Behavior Change a Guide for Practitioners
 Rollnick, Mason & Butler
 Motivational Interveiewing in Health Care: Help
Patients Change Behavior
 Arkowitz, Westra, Miller & Rollnick
1. One thing you liked.
2. One thing you liked less, thought was missing and/or
would’ve like to heard more about.
27