1. Evaluation of a Telephonic Alcohol Screening & Brief Intervention (SBI) Pilot Program for At-Risk Drinking in an Employee Assistance Program (EAP) Tracy L. McPherson, PhD 1, Dennis Derr, EdD 2, Judy Mickenberg, LICSW 2, Eric Goplerud, PhD 1, Sherry Courtemanche, LCSW 2, Laura Chaney, LMFT 2, and Jessica Thompson, LCSW 2 1 Center for Integrated Behavioral Health Policy, Department of Health Policy, The George Washington University Medical Center (GWUMC); 2 Aetna Behavioral Health. Abstract Objective: Substantial empirical support exists for SBIRT – screening, brief intervention, and referral to treatment - in medical, but not non-medical settings such as the workplace. Workplace settings remain underutilized for delivering evidenced-based health services. This research aims to translate medical research into behavioral healthcare practice in a work-related setting (the EAP). The primary objective is to assess the feasibility and impact of implementing systematic, routine alcohol SBIRT on key performance measures (e.g., rates of screening, alcohol problem identification). Methods: A pretest- posttest, one-group, pre-experimental design is used to examine the impact of a telephonic-based EAP alcohol SBIRT pilot program in one call center serving one large client business. The intervention is adapted based on the World Health Organization (WHO, Babor et al., 2001, 2004) alcohol SBIRT protocol. It includes systematic routine alcohol screening using the AUDIT-C/AUDIT during clinical intake, brief counseling using motivational interviewing, alcohol education, referral to treatment as appropriate (e.g., face-to-face counseling, alcohol disease management), and telephonic clinical follow- up at 30, 60, and 90 days to address alcohol use and original presenting problem. Results: At the end of the 5 month pilot, 274 (93%) of 295 members who contacted the EAP for services completed the AUDIT-C prescreen: 40% (110) prescreened positive, almost all (87%) agreed to complete the remaining 7 AUDIT items; 52% (50) went on to screen at moderate or high risk for hazardous or harmful drinking, or alcohol dependence. Brief intervention was offered to all who screened positive. At 3½ and 5 months, overall estimates of identification approached those in the general population, 23.5% and 18.23% respectively. Most (78%) members offered SBIRT at intake agreed to clinical follow-up and 72% set an appointment with a face-to-face counselor to further address issues discussed during the telephonic consultation. Follow-up data collection is ongoing. Conclusions: Findings suggest that the integration of routine alcohol SBIRT by EAP clinical consultants at intake is not only feasible in a telephonic delivery system, but also increases alcohol problem identification and opportunity for brief motivational counseling for risky drinking. Furthermore, it is clear that when SBIRT is integrated as part of routine clinical EAP practice, members are willing to answer questions about their alcohol use and participate in follow-up. Sponsor: Aetna Behavioral Health. Introduction Alcohol is the most widely used drug in the nation with more than half of the U.S. population aged 12 years and older reporting current alcohol use (SAMHSA, 2007). It is estimated that the healthcare costs associated with alcohol problems amount to almost $36 billion annually and, as almost 80% of problem drinkers are employed full- or part-time, these costs extend to employers. There is a substantial body of peer-reviewed literature demonstrating that alcohol SBIRT is an effective technique to employ in healthcare settings for detecting and treating people who have alcohol problems. Miller & Wilbourne (2002) analyzed more than 360 controlled trials on treating alcohol use disorders and found that SBIRT was the single, most effective treatment method of more than 40 methods studied. Return on investment for alcohol SBIRT typically exceeds 2:1, consistent with the savings associated with diabetes or depression disease management programs (Fleming et al. 2000, 2002). Thus, implementing SBIRT can potentially save employers and health plans millions of dollars. As part of their ongoing commitment to provide evidence-based practice and as a means of optimizing their ability to improve member health and well-being, Aetna has teamed with GWUMC to integrate alcohol SBIRT into existing telephonic EAP services. An effort which is aligned with Aetna’s current behavioral health initiatives to integrate alcohol and depression SBIRT as a routine practice with primary care and affiliate providers. Research Objectives: To develop and pilot an in-service training program for telephonic EAP clinical consultants designed to increase SBIRT knowledge and skills (e.g., motivational interviewing) and to develop training processes and protocols for ongoing quality and fidelity monitoring. To assess the preliminary impact of implementing systematic, routine alcohol SBIRT on key EAP program performance measures, including rates of screening and BI for at-risk drinking; alcohol problem identification; referral for face-to-face counseling and/or disease management for moderate and high risk cases; clinical follow-up at 30, 60, and 90 days post intake; and rates of refusal for these services. To assess the preliminary impact of alcohol SBIRT on member alcohol consumption (quantity/ frequency) at follow-up. Design and Methods Design: Pre-test post-test, one group pre-experimental design Target Population: Large U.S. employer: ~367,500 covered lives (147,000 employee members + dependents). Demographics: Age: 33% young adults (≤ 30 yrs), 53% adults (age 31-50 yrs), 14% older adults (≥51 yrs) Gender: 70% female, 30% male Call types: 93% self or management referral Eligibility criteria: non-emergent, self or management referral cases Expected penetration rate ~3% = ~10,500 contact EAP annually Expected identification rate of 7-8% = ~735-850 identified annually EAP clinical consultants: ~20 consultants participated in 2 day training; 4 licensed clinicians (e.g., LCSW, LMFT) located in one EAP call center participated in full SBIRT training protocol. SBIRT Training: Self-directed pre-training (e.g. alcohol education, fundamentals of motivational interviewing, NIAAA Clinician’s Guide) 2-day intensive in-person training (alcohol SBIRT and motivational interviewing) 2-3 one-hour individual telephonic coaching sessions Ongoing telephonic coaching for SBIRT program supervisors Follow-up training activities (individual, small group, supervisor observation) 1-day intensive in-person booster training (~4 months after 2-day training) Measures: AUDIT-C, AUDIT (Babor et al., 2001) SBIRT Intervention: Alcohol screening is integrated into a comprehensive assessment conducted by EAP clinical consultants. 3-item AUDIT-C prescreen is administered. Positive result prompts administration of remaining 7 items of the AUDIT. AUDIT score classifies member at low, moderate or high risk. All risk levels receive BI at appropriate level. Low risk = normative feedback and alcohol education Moderate & high risk = normative feedback, alcohol education, simple advice + BI with MI, and referral to face-to-face counseling, disease management, or other treatment as appropriate. Follow-up offered at 30, 60 and 90 days. EAP consultants conduct follow-up screening using the AUDIT-C, offer brief motivational counseling and referral as appropriate; and re-address original presenting problem at intake. Alcohol education offered to all members. EAP consultants offer materials (by email, mail, and online) during intake and follow-up to all members who use alcohol at any level of risk – e.g., Aetna EAP member website, NIAAA consumer brochures (“TIPS for Cutting Down on Drinking”, “Rethinking Drinking: Alcohol and Your Health”, “Family History of Alcoholism: Are you at Risk?”, “Making a Difference: Talking to your Teen about Alcohol”, “Harmful Interactions: Mixing Alcohol with Medicines”). Analysis Quantitative analysis of process evaluation data (e.g., rates of screening, identification) to assess program performance. Quantitative analysis of member follow-up data to assess proximal impact on self-reported alcohol consumption. Findings Rates of Alcohol Screening and Identification: During the 5 month pilot program, 295 members who contacted the EAP for services were offered alcohol screening during clinical intake assessment. Alcohol prescreening: Of the 295, 93% (n=274) completed AUDIT-C (7% not appropriate or refused). Of the 274, 40% (n=110) prescreened positive for at-risk drinking (Figure 3). Alcohol screening: Of the 110 prescreen positives, 87% (n=96) agreed to complete the remaining 7 AUDIT items, 52% (n=50) went on to screen at moderate risk (8-19, hazardous or harmful drinking) or high risk (20-40, alcohol dependence) (Figure 4). Brief intervention for alcohol use was offered to all members who screened positive. Pre-post comparisons yielded baseline pre-intervention (service-as-usual) identification rate of <1% compared to post-intervention rate of 18.25%. Rate of agreement to clinical follow-up: 78% of members who contacted EAP. Rates of referral: 72% set an appointment with a face-to-face counselor to further address issues discussed during the telephonic consultation. Member outcomes: Alcohol use consumption at follow-up not yet available. Conclusions Integration of evidence-based alcohol SBIRT into existing EAP business practices is feasible, but presents a number of challenges, including the need for adaptation into existing new hire training procedures and materials and re-allocation of staff time for ongoing training activities; adaptations to IT/data infrastructure and reporting protocols; and adaptations to quality and fidelity monitoring processes. Routine alcohol screening using a standardized self-report measure yields moderate-high risk identification rates approaching prevalence estimates in the general U.S. adult population (Drinker’s Pyramid, Higgins-Biddle et al., 1997). Members who receive SBIRT are amenable to clinical follow-up to discuss alcohol use. Ongoing Activities Creation of a sustainable SBIRT program for phased roll-out to book of business. Refinements of training materials and protocols Adaptation of quality monitoring infrastructure and procedures Peer-support, in-service training activities Dissemination plan Refinement of assessment procedures. Building consistency in practice Strengthening assessment process with use of evidence-based Work Limitations Questionnaire (WLQ presenteeism scale, Lerner et al, 2003) Examination of rates of identification and intervention over time, and how SBIRT impacts worker presenteeism. Participation in a NHTSA/CSAT-funded multi-site case study conducted by George Washington University, Washington, DC. More information about Aetna’s Behavioral Health Program: www.aetna.com/ Contacting Author: Tracy L. McPherson, PhD tracym@gwu.edu More information on SBI in the workplace: www.integratedbehavioralhealth.orgwww.aetna.com/tracym@gwu.eduwww.integratedbehavioralhealth.org Figure 1. Aetna Telephonic EAP Approach Figure 2. AUDIT Screening Questions Figure 3. AUDIT-C Identification Figure 4. AUDIT Identification 52% of cases that prescreened positive on AUDIT-C were at moderate or high risk for an alcohol problem 40% of cases prescreened positive on AUDIT-C