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2/17/15 IMPLEMENTING SBIRT IN Webinar Facilitator HEALTH CENTERS: EXAMPLES FROM THE Tracy McPherson, PhD FIELD Senior Research Scientist Substance Abuse, Mental Health and Criminal Justice Studies NORC at the University of Chicago

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IMPLEMENTING SBIRT IN HEALTH CENTERS: EXAMPLES FROM THE FIELD

Presented By: NAADAC, THE BIG Initiative, National SBIRT ATTC, NORC at the University of Chicago, National Council, and SAMHSA

February 18, 2015

Webinar Facilitator

Tracy McPherson, PhD

Senior Research Scientist Substance Abuse, Mental Health and Criminal Justice Studies NORC at the University of Chicago 4350 East West Highway 8th Floor, Bethesda, MD 20814 esap1234@gmail.com

Produced in Partnership… 2015 SBIRT Webinar Series

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2/18/15 - Implementing SBIRT in Health Centers: Examples from the Field

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3/18/15 - SBIRT: A Brief Clinical Training for Adolescent Providers

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4/15/15 - All About SBIRT for Teens

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4/29/15 - Understanding the Affordable Care Act (ACA) and SBIRT

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5/13/15 - SBI in Primary Care and Senior Care Facilities for Older Adults at Risk for Possible Substance Use Disorders and/or Depression

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6/10/15 - A Military Culture Approach to SBIRT for Veterans & Active Duty Personnel

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7/22/15 - Drugs are a Local Phenomenon for LGBTQ Populations: Implications for SBIRT

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8/19/15 - Integrating SBI for Alcohol & Other Drugs in Behavioral Health Settings Serving College Students

¨ hospitalsbirt.webs.com/webinars.htm

Access Materials

¨ PowerPoint Slides ¨ CE Quiz ¨ Recording ¨ Free CEs

hospitalsbirt.webs.com/health-centers-sbirt

Ask Questions

Ask questions through the “Questions” Pane Will be answered live at the end

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Technical Facilitator

Misti Storie, MS, NCC

Director of Training & Professional Development NAADAC, the Association for Addiction Professionals misti@naadac.org

SBIRT with National Council

Part One Presenter #1

Aaron M. Williams, MA

Director of Training and Technical Assistance for Substance Abuse SAMHSA/HRSA Center for Integrated Health Solutions National Council aaronw@thenationalcouncil.org

The Coalition for Drug Free Greater Cincinnati Experience

Grant funded 6 month technical assistance project
Initial SBIRT training plus one on one follow-up
Agencies implementing SBIRT in various settings:

– Schools – FQHC – Community anti-drug coalition

Through this and several other projects came a number
f points of consideration in implementation

Core Areas of Consideration

Workforce
Referral/Partnership building
Workflow Development

Workforce Considerations

Understanding of roles and responsibilities within the care team is critical to success. Considerations include: § Type of providers (Drs’, nurses, behavioral health specialist etc..) providing the services § Licensure and credentialing of staff

ü Can they bill for services

§ Skill and comfort level of team members providing each services § Knowledge of the relationship between substance use and other health conditions

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Partnership Development Considerations

§ Availability of resources for treatment ü Who is in your network? ü What services are provided? ü Do you need other services? § Staff knowledge of available resources § Who will coordinate care between your organization and outside resources § What is the communication loop between your agency and outside resources ü How is information shared?

Workflow Development

§ Identify how best to integrate SBIRT in existing operation of the health center by conducting a walk-through and discuss how clients flow through the daily

perations

§ Develop flow charts documenting existing flow

Implementation Planning Process Steps

§ Assemble a planning team

Ø Select screening instruments Ø Consider referral/system of care needs Ø Conduct a workflow analysis Ø Address/communication and documentation concerns Ø Consider data collection methods Ø Develop comprehensive policies and procedures Ø Design training for staff Ø Discuss billing financial implications

Continuous Quality Improvement

“If the plan doesn't work change the plan but never the goal.”-Unknown

SBIRT at Southwest Virginia Community Health Systems

Part Two Presenter #2

Marcy Rosenbaum, LCSW, CSAC

Behavioral Health Director Southwest Virginia Community Health Systems, Inc. mrosenbaum@svchs.com

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Southwest Virginia Community Healthcare Systems, Inc.

 2011 nominee by HRSA’s (Health Resources

Services Administration) Office on Rural Health Policy as one of the best practices in the nation for providing integrated behavioral health/ primary care services.

 Composed of 4 PCP clinics and one dental clinic in

SWVA staffed with behavioral health providers (4 LCSWs), psychiatrist, dentist, eye doctor, PCPs, and Migrant Health Outreach Workers.

Behavioral Healthcare Physical Healthcare

Service Delivery System Primary Care and Behavioral Health Care Integration Why integrate behavioral and physical care?

Most psychiatric treatment is provided by non-psychiatric medical providers. 70% of primary care appointments are related to psychosocial issues.

Approx. 1 out of 4 patients will make it to a behavioral health

appointment referred to a setting outside of PCP office. Less stigma and discrimination to go to PCP office for care. Adults with any mental illness are more likely than adults without a mental illness to have chronic health conditions.

Why Integrate Behavioral and Physical Healthcare

Reduces burden of care Improves Funding and access Better

utcomes

Complexity of Intersecting Diagnoses in Integrated Care

High blood pressure Alcohol abuse Depression Hepatitis PTSD Xanax abuse

Integrated SA and PC Services improve Quality of Treatment

Screening identifies high risk SA behaviors to target prevention of SA disorders. Integrated treatment is a preferred and evidenced based model of care. Brings SA expert into treatment plan quickly. (exam room consults) Specifically identify withdrawal or overdose issues that may need outpatient or inpatient treatment.

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Benefits of Integration for Patients

Reduce psychosocial distress Prevent further illness or slow progression “One stop shop” Identify BH issues and diagnoses Less stigma Timely access to services Improve overall health

Purpose of SBIRT

A model of service delivery, not a specific technique or program An early intervention approach Aimed at people who may not meet diagnostic level of abuse/dependence Use evidenced based practice to identify, reduce, and prevent problematic substance use

How do we use SBIRT?

Screening Brief Intervention Referral to Treatment Example of use in an FQHC’s integrated primary and behavioral health program

Screening Tools

AUDIT C CAGE AID DAST Drug screens and alcohol testing Medical assessment for substance abuse related medical issues Biopsychosocial assessment SASSI (Substance Abuse Supplemental Screening Instrument) ASAM-PPC (American Society Addiction Medicine Patient Placement Criteria)

Must use at least a standardized assessment

r screening instrument

In the past year, how often do you have a drink containing alcohol? never(0), monthly(1), weekly(2), some days each week(3), most days each week(4) How many drinks did you have on a typical day when you were drinking? 1or2(0), 3or4(1), 5or6(2), 7-9(3), more than 10(4) How often did you have six or more drinks on one occasion? never(0), <monthly(1), monthly(2), some days a week(3), most days each week(4)

AUDIT C

Positive screen for hazardous or abuse of alcohol: Men > 4 Women > 3

Nurse does PHQ2 and Audit C screens

Screen POSITIVE

Recommend Patient see Behavioral Health Consultant

Screens both NEGATIVE PCP examination Any indication of BH issue

Snapshot of Initial BH Screening

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 In the exam room the PCP introduces BHC to

the patient as part of the treatment team and the expert on BH.

 PCP leaves the room and BHC conducts

consultation

 Best referral method for integrated care when

schedule allows.

Best practice for referral from PCP to BHC: THE WARM HANDOFF

Brief Intervention Tools

Motivational Interviewing Cognitive Behavioral Therapy Relaxation Training Relapse Prevention Planning Transtheoretical Model of Change Harm Reduction Others

Harm Reduction Approach

Meet person “where they are at” Keep person’s goal in mind Reduce risky SA behaviors Improve mental and physical health Use any evidence based intervention

Referral to Treatment

 Made if patient’s needs are greater than

can/should be provided by practitioner. Examples include:

CSB for intensive outpatient, SA group therapies,

and case management services

Inpatient treatment, often for detox or to begin

recovery in supportive environment

Local support groups such as AA, NA, Al-anon
Psychiatrist
Alternative therapies such as massage therapy,

acupuncture, methadone/suboxone All our practice decisions flow from the medical home model of care. The medical home is best described as a model

r philosophy of primary care that is patient-

centered, comprehensive, team-based, coordinated, accessible, and focused on quality and safety.

(From the Patient-Centered Primary Care Collaborative)

Building the SBIRT Team Building the SBIRT Team

Licensed or certified to provide mental health or substance abuse services (includes physician, PA, NP, CNS, CP, CSW, CSAC) Screenings can be done by non-licensed, paraprofessional healthcare providers. Must be supervised and recommended by a PCP (specific Medicaid requirement) At SVCHS: Initial screening by PCP/RN, further screening by BHC, Interventions by BHC/PCP/RN, referrals by BHC

Check with payer for specific qualifications

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SBIRT Reimbursement Codes

Can be used for reimbursement with VA Medicaid, Medicare, and some commercial insurance carriers Several billing codes can be used (check with payer) Credentialed BH providers and medical providers can both use codes same day of service (LCSW, psychologist, LPC, marriage and family counselor, licensed substance abuse counselor) Same day services: use modifier 25 for unscheduled same day services following PCP services, use modifier 59 for scheduled same day services Can be used with telehealth services: use GT modifier Mental Health Parity and Addiction Equity Act provides for reimbursement same as physical health

SBIRT codes at SVCHS

 99408: Alcohol and/or Substance Abuse

structured screening and brief intervention services (15-30 min.) We use Audit-C and evidenced based interventions.

 99409: Alcohol and/or Substance Abuse

structured screening and brief intervention services (greater than 30 min.) Used by BHC when referred by PCP.

SBIRT Codes Patient Flow

New Patient

MD, PA, Nurse: Medical hx, current meds, health status exam including Audit C SA screen positive Refer to BHC (optional in exam room consult) (bill 99408 or 99409) First visit to BHC for further screening and/or intervention (bill 99408 or 99409) Follow-up visits to BHC for brief interventions (bill 99408 or 99409) SA screen negative Continue with medical exam

Tips From the Field

Challenges for organizations, providers and patients Stigma

Labeling, shame, prevents accessing treatment

Lack of resources

Financial, providers, transportation

Infrastructure

Facility design, location of providers in the building, tech

Disconnected Services

Compartmentalized, turf issues, uncoordinated

Key Education for Staff: Is Substance Abuse a Voluntary Behavior or a Medical Disorder?

 Initial use: mostly voluntary  Continued use: moves toward medical disorder

“When drug abuse takes over, a person’s ability to exert self

control can become seriously impaired.” *NIDA

Initial use Abuse Dependence Social use M e d i c a l D i s

d e r V

u n t a r y

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Resources

Substance Abuse and Mental Health Services Administration

www.samhsa.gov/

National Institute on Drug Abuse

www.drugabuse.gov

Virginia Department of Behavioral Health and Developmental Services

http://www.dbhds.virginia.gov/individuals-and-families/substance-abuse

Community Coalitions Community Services Boards SA treatment programs World Wide Web Recovery groups (etc. AA, NA, Celebrate Recovery)

Program Ideas

Integrate physical and behavioral health care

Tx plan, offices, records, be interruptible

Collaborate with other agencies/providers Telemedicine Collaborate with educational institutions Educate all staff

Special Populations

Dual MH/SA Diagnoses Chronic Pain Patients ADHD Adolescents Migrant Health Network Dual MH/SA diagnoses: Treatment Integration is Key

Includes SA, medical, and MH (whole person) Each disorder can improve or worsen symptoms of the

ther

Treating one disorder while ignoring another is a disservice to the patient Manage co-occurring disorders as all being primary in regards to treatment planning Best treatment for complexity of intersecting diagnoses.

Chronic Pain Concerns

 Alcohol used by medical providers many

years ago to relieve acute pain.

 Patients may use alcohol and/or street

drugs for relief of medical pain.

 May become dependant on pain

medications that were prescribed.

 Consider using pain management centers.  Suboxone treatment has pros and cons.  BHC can augment pain management by

interventions such as relaxation techniques.

Anxiety Disorder and ADHD Medications

 Anxiolytics and ADHD stimulant medications

generally not good for the addicted brain.

 Try alternative medications: antidepressants,

buspar/vistiril and non-stimulant ADHD medications.

 With integrated services, the BHC can augment

treatment with teaching relaxation technique, and building concentration and coping skills.

 Anxiolytics or Stimulants used as a last resort

will need close monitoring by both the PCP and the BHC.

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Adolescents

 Engagement skills are key  SASSI-A  Include parents while providing as much

confidentiality as possible for the patient

 Use drug screens  Look for associated behaviors  Don’t forget about inhalants and

designer drugs.

Migrant Health Network at SVCHS

The Migrant Health Network (MHN) provides basic health services for migrant and seasonal farm workers and their families in Southwest Virginia. (funded by the Bureau of Primary Care, Migrant Health Division and operated by SVCHS) Migrant and Seasonal farm workers are at risk for health problems due to many factors including: lack of transportation, lack of knowledge of resources, lack of resources to pay for care, language barriers, and their mobile lifestyle. Migrant workers often come from a culture of acceptable heavy alcohol use. Migrant workers often leave their families behind to provide for them resulting in increased depression, decrease in their support system, and an increase in substance abuse.

References

 Medicare Learning Network, Screening, Brief Intervention,

and Referral to Treatment (SBIRT) Services. http:// www.cms.gov/Outreach-and-Education/Medicare-Learning- Network-MLN/MLNProducts/downloads/ SBIRT_Factsheet_ICN904084.pdf

 SAMHA-HRSA Center for Integrated Health Solutions.

http://www.integration.samhsa.gov/sbirt/ reimbursement_for_sbirt.pdf

 Oregon Health & Science University, SBIRT Primary Care.

http://www.sbirtoregon.org/index.php

Robinson, P.JH. &Reiter, J.T. (2007). Behavioral Consultation and Primary Care: A Guide to Integrating Services. New York, NY:Springer.

Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. (April 5, 2012). The NSDUH Report: Physical Health Conditions among Adults with Mental Illnesses. Rockville, MD.

Strosahl, K. (2001). The integration of primary care and behavioral health: Type II change in the era of managed care (pp. 45-70). In N. Cummings, W. O’Donohoe, S. Hayes & V. Follette (Eds.). Integrated behavioral healthcare: Positioning mental health practice with medical/surgical practice. New York: Academic Press.

National Council for Community Behavioral Healthcare. (April 2009). Behavioral Health/Primary Care Integration and the Person-Centered Healthcare Home. Retrieved from www.integration.samhsa.gov/.../Integration%20and %20Healthcare%20Home. Pdf.

Fries, J., Koop, C. &Beadle, C. (1993). Reducing health care costs by reducing the need and demand for medical services. The New England Journal of Medicine, 329, 321-325.

Katon, W., Robinson, P., Von Korff et. al. (1976). A multifaceted intervention to improve treatment of depression in primary care. Archives of General Psychiatry, 53, 924-932. Cited by Strosahl, K. (1997). Building integrated primary care behavioral health delivery systems that work: A compass and a horizon. In N. Cummings, J. Cummings & J. Johnson (Eds.). Behavioral health in primary care; A guide for clinical integration (pp. 37-58). Madison, CN: Psychosocial Press.

References continued

Developing an SBIRT Partnership

Part Three Presenter #3

J Scott Turton, MSW, LICSW

Director of Primary Care Integration and Electronic Medical Records Implementation Gosnold on Cape Cod sturton@gosnold.org

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This ¡way ¡ That ¡way ¡

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Questions from the Audience

Part Four Ask Questions