2/26/13 Webinar Facilitator Eric Goplerud Senior Vice President - - PDF document

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The BIG Hospital SBIRT Initiative Monthly Webinar Series

Wednesday, February 27, 2013

Webinar Facilitator

Eric Goplerud

Senior Vice President Substance Abuse, Mental Health and Criminal Justice Studies NORC at the University of Chicago 4350 East West Highway 8th Floor, Bethesda, MD 20814 goplerud-eric@norc.org

http://hospitalsbirt.webs.com Asking Questions

Ask questions through the Questions Pane

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First Presenter

Les Sperling

Chief Executive Officer Central Kansas Foundation lsperling@c-k-f.org www.c-k-f.org

SBIRT Partnerships

Les Sperling Central Kansas Foundation Salina, Kansas

Central Kansas Foundation

CKF is a not-for-profit corporation whose mission, since its inception in 1967, has been to provide both quality and affordable alcohol and other drug education and treatment services.

— Community Based — 65 employees — 5 locations — Services include: All levels of Outpatient Therapy,

Detox, Medication Assisted Withdrawal, Residential Treatment, and Prevention/Education Programs

CKF STRATEGY

1)

Become integral part of Health Home

2)

Implement SBIRT in Primary and Acute Care Settings

3)

Reduce recidivism to High Cost Care Settings

4)

Demonstrate impact of SUD on general health

5)

Increase capacity for SUD patients to access primary health and oral health care

6)

Full integration of SUD services into Primary and Acute Care Settings

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Salina Regional Health Center Outcomes

• 199 Bed Acute Care Regional Health

Center-Level III Trauma Center

• 27,000 ED presentations per year
• Alcohol/Drug DRG was 2nd most

frequent re-admission

• Services provided

ü 24-7 coverage of ED ü Full time SUD staff on medical and surgical floors ü Warm hand off provided to all SUD/MH services ü Universal Screening and SBI beginning in 2013

• Re-admission DRG moved from 2nd

to 13th

• 70% of alcohol/drug withdrawal

LOS were 3 days or less

• 83% of SUD patients triaged in ED

were not admitted

• 58% of patients recommended for

further intervention attended first two appointments (warm hand off)

• Adverse patient and staff incidents

decreased by 60%.

• CKF detox admissions increased

450% in first year

• 300% increase in commercial

insurance reimbursement Salina Family Healthcare/Smoky Hill Residency Program Outcomes

— 10,000 unique patients, 13 Family

Medicine Residents, 10 dental chairs

— Universal Screening of every

patient annually

— ASAM Level I and II provided on-

site

— 2 FTE Licensed Addiction

Counselors located at FQHC.

• 23% screening positive on Audit-C
• Average daily census in treatment

groups is 12.5

• Residents and other practitioners

becoming interested in SUD interventions

• Level III Person Centered Medical

Home accreditation received

• SUD staff a key component of

Medical Home Personnel Essential Staff Attributes

• Licensed Addiction

Counselors

• Licensed Clinical Marriage

and Family Therapists

• Licensed Specialist Clinical

Social Worker

• Person Centered Case

Managers

• Recovery Coaches and Peer

Mentors (Recovery Health Coaches)

• Trained in motivational

interviewing and brief

• intervention. (Stages of

change, FRAMES)

• Able to thrive in fast paced

medical settings

• Understand medical cultures

and can adapt

SBIRT in Kansas

Effective 1-1-2013, SBIRT billing codes are active for Kansas Medicaid Codes are available on both medical and behavioral health sides Eligible SBIRT Provider Panel: Physicians, P . A., A.R.N.P , Psychiatrist, Registered Nurse, any behavioral health professional licensed by the Kansas Behavioral Sciences Regulatory Board (includes Licensed Addiction Counselors), and Health Coaches Training requirements vary from 2 hours for Physician to 12 hours for Health Coaches Active Codes H0049 Screening $24 H0050 Brief Intervention $24/15 min. (Capped at 4 hours annually) 99408 Screening $24 99409 Brief Intervention $24/15 min. (Capped at 4 hours annually)

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CKF LESSONS LEARNED

1) Research and understand the external

and internal constraints experienced by safety net clinics and acute care hospitals.

2) Understand reimbursement and funding

challenges for clinics and hospitals.

3) Develop a champion within the clinic

• staff. Ultimately has to be MD or CEO,

but tell your story to nurses and mid- level practitioners.

4) Request data and use it.

CKF LESSONS LEARNED

5) Be prepared to do the administrative

work and be the “go to” person for all problem solving.

6) Be persistent, but lean instead of push.

Double the time you think it will take to

• perationalize.

7) Don’t waste medical staff’s time. Be

prepared for meetings. Keep e-mail and

• ther communications focused and
• brief. Always respond to their requests

immediately.

8) Focus on addiction as chronic illness

CKF LESSONS LEARNED

9)

Prepare and use cost-benefit data.

10) Have a good plan to increase income

• ver the long term with specific billing

codes, grants, etc. to shoot for.

11) Increase your capacity to effectively

treat and manage co-occurring and chronic illness.

12) Build mental health services capacity

via contract or staff.

Contact Information

Les Sperling Central Kansas Foundation 1805 S. Ohio Salina, KS 67401 785-825-6224 620-242-7923 cell lsperling@c-k-f.org

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Questions? Second Presenters

Marla Oros

President Mosaic Group moros@groupmosaic.com

Colleen Hosler

Senior Associate Mosaic Group hosler1@umbc.edu

M A R L A O R O S , R N , M S C O L L E E N H O S L E R , M A F E B R U A R Y 2 7 , 2 0 1 3

IMPLEMENTATION PLANNING FOR SBIRT IN HOSPITAL AND HEALTH CARE SETTINGS

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Need for SBIRT in Baltimore

— Significant disparity between those needing treatment and

those in treatment:

¡ Baltimore estimates 70,000 individuals needing treatment and only 22,000

received in FY 2008

¡ According to National Survey on Drug Use and Health, close to 10% of

Baltimore’s population reported illicit drug use in the past month

¡ Heroin remains the number one drug associated with treatment admissions

and accounts for 60% of intoxication deaths

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Readiness for SBIRT in Baltimore City

— Baltimore Buprenorphine Initiative:

¡ Increase in physicians with waiver to prescribe- 50 in 2006,

• ver 200 in 2011

¡ Engage all city health center physicians as continuing care

providers

¡ Develop new models of induction in primary care

— State and city focus on integration of behavioral

health with primary care

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Planning Process Goals

— Select early adopter health settings with committed

leadership and interest

— Institutionalize SBIRT into existing patient flow without

significant new staff resources

— Develop model clinical protocols using evidence-based

tools

— Develop training materials — Develop program documents — Pilot program and evaluate for full implementation and

expansion

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Scale of SBIRT in Baltimore City

— BSAS, through its consulting partner, The Mosaic Group, had been

planning and delivering SBIRT programs in community health centers, high schools and nursing homes across Baltimore for the past 18 months:

¡ 24 health centers ¡ 4 high schools ¡ 1 hospital

— The results of these programs were:

¡ Integration of SBIRT as a routine practice ¡ Incorporation of SBIRT into health center EMRs ¡ Catalyst for behavioral health integration with primary care at a

number of sites

¡ Development of enhanced systems to support fast track referral to

treatment

¡ Development of new partnerships with referral sources to expand

access

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Need for SBIRT Hospital Program in Baltimore

— Older Adult Needs Assessment- 2011 hospital data analysis

¡ Approximately 43,000 patients are admitted per year to

Baltimore City hospitals and in 2010 52.5% of those patients had a substance abuse related diagnosis

— Healthy Baltimore 2015 Goal to reduce hospital admissions

related to substance abuse

— New initiative for hospitals to reduce 30 day re-admission

rates

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Goals of Hospital SBIRT Program

• Increase the number of patients who are identified at high

risk for drug and alcohol abuse or who are actively abusing drugs or alcohol on admission

— Increase the number of patients who are referred and

linked to drug treatment services as a part of their discharge plan

— Reduce the rates of hospital re-admissions for those

patients that are provided interventions for identified drug and alcohol problems

— Demonstrate the value of peer recovery support as a key

component of a hospital-based SBIRT intervention

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PLANNING PROCESS STEPS

— Select early adopter hospital — Organize multi-disciplinary planning team — Conduct patient flow analysis — Identify operational protocol to integrate SBIRT into existing

• peration- roles of staff, documentation needs, procedures

— Select screening questions — Develop training — Develop peer coach roles and integration into process and

• verall hospital system

— Pilot and monitor results — Refine program based on data and performance

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Hospital Selection

— Data-driven selection based on high rates of hospital

admissions for substance use related diagnoses

— Short list of three hospitals identified — Meeting with preferred hospital CEO and Medical team –

resulting in lack of sufficient leadership commitment and buy- in

— Second choice – Bon Secours Hospital

¡ Committed leadership by CEO and ED nursing and medical staff ¡ ED nursing staff familiar with SBIRT- using CAGE ¡ Desire to address substance abuse patient issues ¡ Strong commitment to goals of program

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Team Formation

— Multi-disciplinary planning team to guide the design

• f the new program:

¡ Team included the Nursing Director of the ED, the Medical

Director of the ED, the Director of Hospital Behavioral Health Services, the Director of Nursing Staff Development and the ED Nursing Supervisor

¡ Strong commitment and support by ED Medical Director,

Nursing Director and Director of Behavioral Health

¡ Team members attended all meetings and provided oversight

to workflow analysis, tool selection, protocol development and peer recovery coach program design

¡ Facilitation of strong support and buy-in 28

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Workflow Analysis

— Identify how best to integrate

SBIRT in existing operation

— Conduct walk-through of ED

flow

— Develop flow chart

¡ Who greets patient and

completes registration?

¡ What paperwork is completed? ¡ Who conducts triage and what

takes place?

¡ What are roles of existing

staff?

¡ What information does

provider have during encounter?

¡ How are referrals made? ¡ How is discharge or admission

handled?

It was noted that even when substance abuse screening was completed by nurse, there was not formalized protocols in place to assist patient.

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Development of Program Protocols

— Design integration with existing flow:

¡ Roles of staff for screening, BI and referral to treatment ¡ Integration of screening and BI documentation in existing

forms

¡ Location for screening, BI and referral to treatment ¡ Design of protocol for discharge from ED and patients that

are admitted to unit

¡ Integration of SBIRT for direct admit patients ¡ Role of peer recovery coaches and integration with flow in

ED and on units

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Development of Program Protocols

— Planning team assessed high volume times for

patients in ED and determined schedule of maximum coverage of peer recovery coaches:

¡ Monday- Friday 6:00 am- 2:30 am ¡ Sat and Sunday 2:00 pm- 12:30 am

— Services would begin in ED with goal to expand

services to inpatient units of hospital:

¡ Services expanded to the entire hospital in October 2012

— Mosaic Group would train all hospital nurses — Mosaic Group would train all peer recovery coaches

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Identifying Appropriate Roles and Responsibilities

— Avoid duplication of services among, nurses, peer recovery coaches,

social workers, specialized case managers, discharge planner and other community program employees

— Protocol:

¡ Nurses would optimally screen all patients in the ED or directly

admitted

¡ If patients were in a medical crisis and admitted to the hospital,

screening would take place by the unit nurses

¡ Based on a set of criteria peer recovery coaches would be notified to

deliver brief interventions and referrals to treatment

¡ ED medical providers deliver brief advice on positive drug screens ¡ Nurses refer to coaches for BI ¡ Coaches integrate services with other case managers

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Selection of Screening Questions Using Evidenced-based Tools

— Share various evidence-based tools for screening patients — Share lessons learned from tool use in other settings — Work with team to select screening instruments to fit

with patient flow and staffing decisions

— Develop clinical protocol and documents for the ED and

• ther units of the hospital integrated with nursing

assessment and other forms

— Considerations:

¡ Time for screening ¡ Ease of implementation ¡ Target population fit ¡ Score or no score

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Substance Use One drink equals: 12oz beer (5%) 8-9oz malt liquor (7%) 5oz wine (12%) 1.5oz hard liquor (40%) Circle response to add up at the bottom 1 2 3 4 1 How often did you have a drink containing alcohol in the past year? (including beer) Never Monthly 2-4 times/ month 2-3 times/week 4+ times/week If “Never” skip to Drug Use 2 How many alcoholic drinks do you have on a typical day? 1 or 2 3 or 4 5 or 6 7-9 10+ 3 How often do you have six

• r more alcoholic drinks on
• ne occasion?

Never Less than monthly Monthly 2-3 times/week 4+ times/week Total scores from responses (write in box) Have you ever used illegal drugs or prescription drugs for nonmedical purposes? No Yes (complete below) Marijuana Last use: Cocaine or Crack Last use: Heroin Last use: Other: Last use: Care Plan Readiness to change (0-10) (write in box) For alcohol score ≥4 and/or yes to drug use—brief intervention by nurse For alcohol score ≥7 and/or cocaine/crack and/or heroin use and readiness to change ≥4, recovery coach contacted Recovery coach is requested by patient or nurse

Bon Secours SBIRT Screening

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Overview of SBIRT Protocol

— Screening by nurses in ED on inpatient units:

¡ AUDIT-C ¡ Two drug questions

— Deliver Brief Interventions:

¡ 4-7 on AUDIT-C- receive BI from Nurse ¡ Peer coach referral: ÷ AUDIT scores 8 or higher or positive to either drug question and ÷ Have a 7 or higher on readiness ruler

— Delivery of BI by coach and determine need and readiness for referral to

treatment

— Referral by coach for ED discharges — Provides additional coach visits to admitted patients and coordinate discharge

plans for referral with hospital social workers

— Provide follow-up coaching and case management after discharge 35 36

Follow-up Protocol

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— Consent form signed for all patients provided a referral to

treatment

— Follow-up visit/call is completed within one day post

discharge

— Minimum of two additional coach visits provided for admitted

patients

— Reminder call to patients 24 hours before treatment

appointments

— Follow-up with treatment program to determine patient

attendance for appointment

— Coach follow-up for missed appointments and continued

needs

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Documentation Needs

— Necessary Forms:

¡ SBIRT screening form ¡ Patient Progress note ¡ Referral form ¡ Consent for the release of information ¡ Referral to treatment log ¡ Follow-up log

— Screening Results:

¡ Final score/outcome or detailed responses ¡ Patient completion or staff completion ¡ Scan paper into EMR, enter data or enter as screen is completed ¡ Method for provider to see results during encounter

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Training of Hospital Nurses

— Mosaic Group conducted two days of hourly training

sessions for all of the hospital nurses

— Training included:

¡ Introduction to disease model of substance abuse ¡ Overview of SBIRT ¡ Introduction to Stages of Changes ¡ Description of Bon Secours Peer Recovery Coach Program ¡ Addressing concerns of nurses 38 39

Peer Recovery Coach Training

— Peer recovery coaches were individually trained — Training was approximately 64 hours — 60 hour core training:

¡ Introduction to peer recovery coach role and functions ¡ Disease model of substance abuse ¡ Introduction to SBIRT ¡ Introduction to stages of change model ¡ Motivational interviewing ¡ Overview of ethics and boundaries of working with patients in a hospital

setting

¡ Overview of substance abuse treatment modalities ¡ Documentation requirements ¡ Introduction to local substance abuse treatment providers and other key

support service providers

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Peer Recovery Coach Training

— Year long training:

¡ Daily emails for trainer consultation, ongoing support and regular

monitoring

¡ Weekly visits for case review and coach observation of practice

— Monthly team meetings:

¡ Share monthly data with coaches ¡ Review as a team any complex cases ¡ Discuss any necessary changes to program policy and procedures ¡ Chart reviews ¡ Meetings with hospital team

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Results to Date (8/12-12/12)

— Screened 1,655 patients by peer recovery coaches — Positive screens: 790 (47.7%) — Scored 4-7 on AUDIT-C:185 (23.4%) — Scored 8 or higher on Audit-C:330 (41.8%) — Total BI administered: 673 (85.2%) — Referrals to treatment: 174

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Lessons Learned

— Committed hospital leadership is essential — Culture supportive of addiction as a chronic disease — Integration of SBIRT into existing workflow — Training alone will not institutionalize practice, SBIRT team must

be visible and available to nurses and providers

— Be flexible and willing to modify protocols as necessary — The use of paraprofessionals requires additional time and oversight — The use of peer recovery coaches in SBIRT model allows some

patients to be more open and honest

— Follow-up monitoring and training is key to successful adoption of

practice as routine

— Development of relationships in community with treatment

providers and other key support services will reduce waiting time for patient intake

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Questions?????

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