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SBIRT Implementation
Clayton Chau, MD, PhD
Medical Director, Behavioral Health Services
[email protected]
Updated 04/21/2014
Goals
 Definition
 Understanding the benefit
 The tool and the process
 The training requirements
2
Definition
3
Screening, Brief Intervention
& Referral to Treatment
(SBIRT)
4
Key Terms
• Screening – A brief set of questions that identifies risks of
substance use related problems
• Brief intervention – Brief counseling that raises awareness
of risks and motivates client/patient toward
acknowledgment of problem and initiates changes
• Referral – Procedures to help client/patient to access
specialized care
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Routine and universal screening
Inconsistent and selective
assessment
Validated screening tools
Non‐systematized narrative
questions
Alcohol use seen as a continuum
Alcohol use seen as dichotomous
Evidence-based, patient-centered
change talk
Ineffective, directive style of
communication
Transition between primary care
and treatment
Dis-coordinate/unclear referrals
and follow up
Low-risk limits
Drinks
per
week
Drinks
per
day
Men
14
4
Women
7
3
All age
>65
7
3
Unhealthy
use: 22%
Low risk or
abstention:
78%
NIAAA. Manwell, 1998
Dependent
Harmful
Risky
5
8%%
9%
Low risk: 38%
Abstain: 40%
Manwell, et. al, 1998
IV
III
Risky
II
I
Harmful
IV
III
II
I
Donovan, et al. 2006
Dependent
IV
III
II
I
Donovan, et al. 2006
MMWR Weekly, 2004, Naimi, 2002
Disorder
Odds
Anxiety Disorders
2.6x
Mood Disorders (especially Major Depression)
4.1x
Personality Disorders
4.0x
Antisocial Personality Disorder
7.1x
Drug Dependence
36.9x
Nicotine Dependence
6.4x
Grant., et al, 2004
Moyer et al, 2002; Whitlock et al, 2004; Bertholet et al, 2005
USPSTF, 2004 and 2013
Fleming, et al, 2002
Estee, et al, 2008
CDC, 2011
Friedman et al., 2000; Yersin et al., 1995; Wilson et al., 2002.
100
Percent
80
60
40
20
8% 2%
0
CASA, 2000
57.7% Belief that patients lie
35.1% Time constraints
29.5% Fear that it will question patient’s integrity
25%
Fear of frightening/angering patient
15.7% Uncertainty about treatments
12.6% Personally uncomfortable with subject
11%
May encourage patient to see other MD
10.6% Insurance doesn’t reimburse PCP time
CASA: Missed Opportunity: National Survey of Primary Care Physicians and Patients on Substance Abuse, April 2000
Agree/Strongly Agree
“If my doctor asked me how much I drink, I would
give an honest answer.”
92%
“If my drinking is affecting my health, my doctor
should advise me to cut down on alcohol.”
96%
“As part of my medical care, my doctor should
feel free to ask me how much alcohol I drink.”
93%
Disagree/Strongly Disagree
“I would be annoyed if my doctor asked me how
much alcohol I drink.”
86%
“I would be embarrassed if my doctor asked me
how much alcohol I drink.”
78%
Miller, et al. 2006
Understanding The Benefit
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The Policy
•
In 2013, the USPSTF recommended that clinicians screen adults
age 18 years or older for alcohol misuse and provide persons engaged
in risky or hazardous drinking with brief behavioral counseling
interventions to reduce alcohol misuse
•
Effective January 1, 2014, California offers Alcohol Screening, Brief
Intervention, and Referral to Treatment (SBIRT) benefit in primary care
settings to all Medi-Cal beneficiaries, 18 years and older
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Process
•
•
•
•
Pre-screen
(Expanded) Screening
Brief intervention: One to three 15-minute sessions
Referral to Treatment: the Department of Public
Health/Substance Abuse Prevention & Control program
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Pre-Screen
• A single alcohol screening question included in the Staying
Healthy Assessment (SHA) which must be conducted within
120 days of enrollment and every three years with annual
reviews of the member’s answer
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Screen
• Screen members 18 years of age and older who answer
“yes” to the alcohol question in the SHA or at any time the
PCP identifies a potential alcohol misuse problem.
• Recommended screening tool – the Alcohol Use Disorders
Identification Test (AUDIT) (or the Alcohol Use Disorder
Identification Test—Consumption (AUDIT-C))
 Developed by the World Health Organization (WHO)
as a simple method of screening for excessive
drinking and to assist in brief assessment
 10 questions – multiple choices
 Accurate across many cultures/nations
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Brief Intervention
• Members screened positively for risky or hazardous alcohol
use or a potential alcohol use disorder (Zone III) shall be
offered up to three 15-minute brief interventions (per
member per year)
• Each intervention is limited to one (1) session per unit, 15
minutes per unit, per member
• Brief intervention services may be provided on the same
date of service as the expanded screen, or on subsequent
days
• Each intervention can be offered in-person or via telephone
or telehealth modalities
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The Effects
• Brief interventions trigger change
• A little counseling can lead to significant change,
e.g., 5 min. has same impact as 20 min.
•
•
SBI can reduce accidents, injuries, trauma, emergency
department visits, depression, drug- related infections
and infectious diseases
SBI for alcohol saves $2 - $4 for each $1.00 expended
•
Research is less extensive for illicit drugs, but promising
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Awareness
of problem
Presenting
problem
Motivation
Screening
results
Behavior
change
Referral to Treatment
Members should be referred to the Department of Public
Health/SAPC for Drug Medi-Cal SUD services if they:
 Didn’t respond to the brief interventions; or
 Were screened positively for possible alcohol use
disorder (Zone IV); or
 Whose diagnosis is uncertain
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Referral to Treatment
• Approximately 5% of patients screened will require referral
to substance use evaluation and treatment
• A patient may be appropriate for referral when:
• Assessment of the patient’s responses to the screening
• reveals serious medical, social, legal, or interpersonal
• consequences associated with their substance use
• These high risk patients will receive a brief intervention
followed by referral
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The Reimbursement
•
Screen, using a Medi-Cal approved screening instrument, and billed with HCPCS
code H0049, is limited to one unit per recipient per year, any provider. Note - the prescreen or brief screen is not reimbursable. Diagnostic code???
•
Brief intervention services may be provided on the same date of services as the full
screen, or on subsequent days, using HCPCS code H0050. The brief intervention is
limited to three sessions per recipient per year, any provider
•
For the Federally Qualified Health Centers (FQHCs) and the Rural Health Clinics
(RHC) providers, the costs of providing SBIRT services are included in the all-inclusive
prospective payment systems (PPS) rate. SBIRT services that meet the definition of an
FQHC/RHC visit, as defined in the Rural Health Clinics (RHCs) and Federally Qualified
Health Centers (FQHCs) section of the Part 2 – Medi-Cal Billing and Policy manual, are
billable
•
Any claims reimbursed for more than the maximum units per year are subject to
recovery by the Department of Health Care Services (DHCS).
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The tool
39
Standard Drink in the US
• 1 standard drink = 14 grams of pure alcohol (about 0.6 fluid
ounces or 1.2 tablespoons)
• Standard drink equivalent:
 Beer:
12 oz = 1
22 oz = 2
16 oz = 1.3
40 oz = 3.3
 Table wine: a 5 oz glass = 1
a standard 750 ml (25 oz) bottle = 5
 Malt liquor: 12 oz = 1.5
22 oz = 2.5
16 oz = 2
40 oz = 4.5
 Hard liquor or ‘80-proof spirits’:
a pint (16 oz) = 11
a fifth (25 oz) = 17
1.75 L (59 oz) = 39
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The AUDIT
Tool
41
AUDIT Scores
Risk Level
AUDIT Score
Intervention
Zone I
0-7
Alcohol Education
Zone II
8-15
Simple Advice
Zone III
16-19
Brief Intervention
Zone IV
20-40
Referral to Treatment
*Continue monitoring with each intervention
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The Training Requirements
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Requirements
• SBIRT services must be provided by a licensed health care
provider (PCP/PA/NP/Psychologist) or a non-licensed staff
working under the supervision of the licensed health care provider
• Non-licensed staff must be trained in SBIRT services in order to
provide services
• The supervising licensed provider and the non-licensed providers
of SBIRT services must attest that they have obtained the
required trainings on SBIRT within the first 12 months. The
training is a one-time requirement
• The reporting and monitoring requirements will follow as per
DHCS
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Training Requirements for Licensed Providers
At least one supervising licensed provider per clinic or practice must take 4 hours of
SBIRT training within 12 months after initiating SBIRT services
*Beyond the first 12 months of providing SBIRT services, at least one supervising
licensed provider per clinic or practice must have completed training
At all times, rendering licensed providers are highly encouraged, but not required,
to take training in order to provide the services
A minimum of 4 hours of SBIRT training is highly encouraged for both supervising
and rendering licensed providers within the first 12 months; however, the rendering
licensed providers are not required to take the training in order to provide the services
For solo physician practices, the physician is highly encouraged, but not required,
to take the training within the first 12 months.
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Training Requirements for Non-licensed Providers
 Trained non-licensed providers: Includes health educators, certified addiction counselors,
health coaches, medical assistants, and non-licensed behavioral health assistants
Requirements:
 Be under the supervision of a licensed provider
 Complete a minimum of 60 documented hours of professional experience such
as coursework, internship, practicum, education or professional work within their
respective field.
 Should include 4 hours of training directly related to SBIRT services
such as Motivational Interviewing
 Complete a minimum of 30 documented hours of face-to-face client contact
Within his or her respective field, in addition to the 60 hours of clinical professional
experience described above.
These contact hours may include internship, on-the-job
training, or professional experience and SBIRT services training.
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SBIRT Training
• SAMHSA funded – Addiction Technology Transfer Center Network:
“Foundations of SBIRT” at http://www.attcelearn.org/
• NIAAA Clinician’s Guide Online Training “Video Cases: Helping Patients Who
Drink Too Much” at http://www.niaaa.nih.gov/publications/clinical-guides-andmanuals/niaaa-clinicians-guide-online-training
• SBIRT Core Training Program: Screening, Brief Interventions, and Referral to
Treatment at http://www.sbirttraining.com/sbirtcore
• NAADAC’s The Addiction Professional’s Mini-Guide to Screening, Brief
Intervention and Referral to Treatment (SBIRT) at
http://www.naadac.org/theaddictionprofessionalsminiguidetosbirt
• SBIRT Oregon Training Curriculum for Primary Care at
http://sbirtoregon.org/training.php
• Institute for Research, Education & Training in Addictions – SBIRT in Action –
Another Vital Sign at http://ireta.org/webinarlibrary
• New York State’s SBIRT Training Provider Certification at
http://www.oasas.ny.gov/workforce/training/SBIRTCert.cfm
*Other trainings resources can be found on DHCS website at www.dhcs.ca.gov
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L.A. Care Behavioral Health Contacts
• Leilanie Mercurio, Health Services Coordinator, 213-694-1250 x4456,
[email protected]
• Clayton Chau, Medical Director, [email protected]
• Suzie Matsuda, Director of Clinical Services, [email protected]
• Nicole Lehman, Director of Operations, [email protected]
• Anthony Perera, Administrative Manager, [email protected]
• Robert (RJ) Key, Program Manager, [email protected]
• Torhon Barnes, Care Coordination Manager, [email protected]
• Hieu Nguyen, Strategic Initiatives Manager, [email protected]
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