MIDD Strategy 1c: Emergency Room Substance Abuse Early Intervention Program Program Performance Overview June 28, 2012

MIDD 1C The program is delivered by integrating chemical dependency professionals into the multidisciplinary team within emergency rooms. Service design includes the following: Maximize the number of emergency room patients who are identified through screening to have substance abuse problems; Deliver brief counseling, or “brief interventions,” to patients who screen positive for substance use disorders; Increase referrals of chemically dependent people from the generalist medical setting to CD community treatment agencies; Reduce subsequent emergency room use rates, medical costs, criminal behavior, disability, and death for patients with alcohol and drug problems of all severity levels; and Improve the links between the medical and chemical dependency treatment communities so that providing screenings and interventions for substance use disorders become routine.

Where and How Much? Harborview Medical Center (5 FTE) 325 Ninth Ave. Seattle, WA Highline Medical Center/Main Campus (1 FTE) Sylvester Rd SW Burien, WA St. Francis Hospital (1 FTE) Ninth Ave. S. Federal Way, WA Valley Medical Center Emergency Department (1 FTE) 400 South 43rd Street Renton, WA

Overview Number of Clients Served Since Start of MIDD Funding Service Encounter Statistics per Quarter (to 12/31/2010) New Performance Measurement Targets Client Demographics and Regional Distribution Intervention Types and Average Service Minutes Frequency of Substance Use Substance Abuse Screening Drug vs. Alcohol Risk, Service Time, & Presenting Problems Brief Therapy at Harborview Initial Outcomes Next Steps and Conclusions

Number of Clients Served by SBIRT Since Start of MIDD Funding Between 1/1/2009 and 9/30/2011: 9,337 unduplicated individuals (67% male) served through over 15,000 total encounters at Harborview and three South King County hospitals 352 individuals saw multiple SBIRT providers MIDD performance measures: – 2,255 clients in MIDD Year 1 (42% of goal*) – 3,177 clients in MIDD Year 2 (62% adjusted) – 5,198 clients in MIDD Year 3 (targets were changed to count number of screens and brief interventions)

Service Encounters per Quarter (to 12/31/2010) Average without start-up 1,255 Average without start-up 224

New Performance Measurement Targets King County Council acceptance of the MIDD Third Annual Report will support adoption of performance measurement targets reflective of contracted minimums: – 6,400 screens per year with 8 FTE (~4/day* each) – 4,340 brief interventions per year (2-3/day each) This change acknowledges the nature of repeated encounters with some individuals In MIDD Year 3 ( to ), conducted (with 7.5 FTE): – 4,649 screens (77% of adjusted target) – 5,475 brief interventions (135% of adjusted target)

Primary Race and Ethnicity of Unduplicated Clients Served (N=9,337) Hispanic Origin?? No = 86% Yes = 7% Unknown = 7%

Other Client Demographics Age GroupFrequencyPercentage Less than , , , , and older  English was the primary language spoken by 94% of unduplicated clients.  92 people required the services of an interpreter.  569 had served in the United States military.  35 were known family members of those who had served in the military.  Fourteen percent of those served had documented disabilities.  2,034 (22%) were HOMELESS at the time of their first program encounter.

Percent of Clients from Each King County Region by Provider

Percentage of Total Services per Provider by Type of Intervention

Average Service Minutes* by Intervention Intervention Type Average Range (Minutes) Overall Average (Minutes) Declined 7.55 – Screen Only – Screen & Brief Intervention – Screen, Brief Intervention, and Referrals – Follow-up Brief Intervention – Brief Therapy * Service minutes may represent face-to-face only or include charting, depending on provider.

Frequency of Substance Use* Reported SubstanceCasesNo UseAny Use Daily Use ( As Subset of Any Use) Alcohol 13,82448%52%4,441/7,148 (62%) Marijuana 13,82586%14%824/1,872 (44%) Cocaine 13,82788%12%690/1,671 (41%) Amphetamine/ Meth 13,82895%5%306/663 (46%) Opiates/Heroin 13,82889%11%1,169/1,560 (75%) Tobacco 13,82974%26%3,383/3,571 (95%) Other (Benzos+) 11,77296%4%216/524 (41%) * Multiple substances per encounter possible.

Alcohol Abuse Screening Valid AUDIT scores were available for 11,291 SBIRT service encounters. Note: Zeros are treated as valid (N= 4,922) unless Intervention = Declined. AUDIT scores were found to be highly correlated with days of alcohol use (r =.790). Significant difference in average AUDIT scores associated with days of alcohol use.

Drug Abuse Screening Valid DAST scores were available for 11,090 SBIRT service encounters. Note: Zeros are treated as valid (N= 6,072) unless Intervention = Declined. DAST scores were found to be significantly correlated with days of substance use. Average DAST Scores for Use of Various Substances

Drug vs. Alcohol Risk Valid scores for both the AUDIT and DAST were available for 10,984 SBIRT service encounters. About 15% of encounters characterized clients as being at higher risk for BOTH drug and alcohol abuse.

Substance Abuse Risk and Service Time AUDITN1234 Very low risk (0-7)5, Mild to moderate (8-15)1, Moderate to high (16-19) Very high risk (20 or greater)4, DASTN123 Low risk (0-1)7, Moderate risk (2-4)1, High risk (5 or greater)2, Analysis of variance testing showed that, on average, time spent with clients was associated with the severity of their substance abuse risk. Post hoc groupings are shown.

Highest Risk by Presenting Problems Up to three “reasons” for an ER visit can be coded for each service encounter. Altogether, – 8,006 visits were coded as Drug/Alcohol Related (including Acute Intoxication) – 2,043 visits were coded as Mental Health Related (including Suicidal Ideation) – 6,813 visits were coded as Medical. Primary Problem (if known) Screened at Highest Alcohol Risk (AUDIT = 20 or greater) N=3,244 Screened at Highest Drug Risk (DAST = 5 or greater) N=2,229 Medical55%57% Drug/Alcohol38%30% Mental Health6%11% Other1%2%

Most Common Referrals per Encounter Multiple referrals per individual per visit are possible. Those given most frequently include: - Other2,850 (includes Resources, Specific Agencies, VA) - 12-Step or Sober Support 2,450 - Brief Therapy (Harborview)1,792 - Detox1,804 - ADATSA CD Next Day Appts Sobering 441

Brief Therapy at Harborview 1,566 unique clients referred to Brief Therapy (BT). Only 263 of those referred to BT (17%) received at least one BT service. Another 100 received BT without an SBIRT referral. Of the 363 receiving BT services, only 38 had 10 or more sessions (maximum = 48 sessions). A total of 1,489 BT sessions were documented. Analysis of a small sample showed that for those referred to BT, AUDIT and DAST scores did not differ significantly between those who were seen vs. those not seen. Those who received BT without SBIRT referral tended to have significantly higher AUDIT scores (~35) than those referred (~20).

Initial Outcomes – Treatment and Sobering 1,369 SBIRT clients who began services prior to July of 2009 were included in an outcomes analysis. 23% of the sample were admitted to at least one CD treatment program subsequent to SBIRT contact and 21% linked to at least one MH program. In the year prior to their first recorded SBIRT encounter, this group amassed 4,572 days in Sobering compared to 3,976 days in the year that followed. The maximum per person was reduced from 215 (pre) to 126 (post). The average number of days within individuals was reduced from 3.34 to 2.90 (not statistically significant).

Initial Outcomes – Jail Utilization Jail EpisodesJail Days No change43 (12%)6 (2%) Decrease165 (44%)172 (46%) Increase164 (44%)194 (52%) For the 372 of 1,369 who had recorded jail stays:

Next Steps More in-depth outcomes analysis to follow! This is where we link service delivery with outcomes. At what level of service is it reasonable to expect having an impact on jail outcomes, for example. Moving forward, make sure to code AUDIT and DAST as 99 if not administered. When zeros are entered, they are treated as valid (no problems with alcohol or drugs) – zeros entered when no screen is given drag down the average scores in analysis. Continue to find ways to improve the data (ex: duplicate demographics for different Client IDs, same SSN for different people, out of range DOBs)

In Conclusion… (Part I) To meet new performance targets, need to screen about 4 people per day and provide BI to 2 or 3! (These need not be NEW clients; if coding at Level 3 or higher, the visit counts toward both goals.) “Declines” do not count toward performance measurement, but will factor into detailed outcomes, so must continue to collect. No Equity and Social Justice Initiative concerns – serving minority groups at higher rate than population incidence. Still concerned about the number of Pierce Co. residents receiving SBIRT services as only 13% with these zip codes are homeless. How to handle?

In Conclusion… (Part II) 1 of every 3 SBIRT encounters is with daily users of alcohol. Average AUDIT scores are reflective of risk level. Daily use of marijuana was associated with avg. DAST = 5 vs. DAST = ~7 for daily use of other common drugs. Level of risk is related to average time spent per client. Finding the SBIRT “sweet spot” will be key to meeting the performance targets. Of those presenting in the ED as “suicidal” about half are screening at high risk for alcohol and drug abuse. 62% presenting for “acute intoxication” are at high risk for alcohol vs. only 18% at high risk for drugs. Only 16% of those referred to Brief Therapy at Harborview receive these services. How best to utilize this limited resource? SBIRT appears to be helping folks get into treatment (1 of 4 in sample is very encouraging)! More to come on jail…

Questions or Concerns? Data Submissions & Data Quality Issues Kimberly Cisson (206) Data Analysis & Reporting Issues Lisa Kimmerly (206) Program Management Issues Geoff Miller (206)