1. SBIRT Implementation Clayton Chau, MD, PhD Medical Director, Behavioral Health Services cchau@lacare.org Updated 04/21/2014

2. Goals Definition Understanding the benefit The tool and the process The training requirements 2

3. Definition 3

4. Screening, Brief Intervention & Referral to Treatment (SBIRT) 4

6. 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 6

8. Routine and universal screening Inconsistent and selective assessment Validated screening tools Non‐systematized narrative questions Alcohol use seen as a continuumAlcohol 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

9. NIAAA. Manwell, 1998 Low risk or abstention: 78% Unhealthy use: 22%

10. Manwell, et. al, 1998 Low risk: 38% Abstain: 40% 5%5% 8%8% 9%9% Dependent Harmful Risky

11. I II III IV Risky

12. I II III IV Harmful Donovan, et al. 2006

13. I II III IV Dependent Donovan, et al. 2006

14. MMWR Weekly, 2004, Naimi, 2002

16. Grant., et al, 2004

18. Moyer et al, 2002; Whitlock et al, 2004; Bertholet et al, 2005

19. USPSTF, 2004 and 2013

20. Fleming, et al, 2002

21. Estee, et al, 2008

22. CDC, 2011

23. Friedman et al., 2000; Yersin et al., 1995; Wilson et al., 2002.

24. CASA, 2000

25. 57.7%Belief that patients lie35.1%Time constraints29.5%Fear that it will question patient’s integrity25% Fear of frightening/angering patient15.7%Uncertainty about treatments12.6%Personally uncomfortable with subject11%May encourage patient to see other MD10.6%Insurance doesn’t reimburse PCP time CASA: Missed Opportunity: National Survey of Primary Care Physicians and Patients on Substance Abuse, April 2000

26. Miller, et al. 2006 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%

27. Understanding The Benefit 27

28. 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 28

29. 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 29

30. 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 30

31. 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 31

32. 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 32

33. 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 33

34. Behavior change Awareness of problem Motivation Presenting problem Screening results

35. 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 35

36. 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 36

38. 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 pre- screen 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). 38

39. The tool 39

40. 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 = 122 oz = 2 16 oz = 1.340 oz = 3.3  Table wine: a 5 oz glass = 1 a standard 750 ml (25 oz) bottle = 5  Malt liquor: 12 oz = 1.522 oz = 2.5 16 oz = 240 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 40

41. The AUDIT Tool 41

42. AUDIT Scores *Continue monitoring with each intervention 42 Risk LevelAUDIT ScoreIntervention Zone I 0-7Alcohol Education Zone II 8-15Simple Advice Zone III 16-19Brief Intervention Zone IV 20-40Referral to Treatment

43. The Training Requirements 43

44. 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 44

45. 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. 45

46. 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. 46

47. SBIRT Training SAMHSA funded – Addiction Technology Transfer Center Network: “Foundations of SBIRT” at http://www.attcelearn.org/ 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-and- manuals/niaaa-clinicians-guide-online-training http://www.niaaa.nih.gov/publications/clinical-guides-and- manuals/niaaa-clinicians-guide-online-training SBIRT Core Training Program: Screening, Brief Interventions, and Referral to Treatment at http://www.sbirttraining.com/sbirtcore 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 http://www.naadac.org/theaddictionprofessionalsminiguidetosbirt SBIRT Oregon Training Curriculum for Primary Care at http://sbirtoregon.org/training.php http://sbirtoregon.org/training.php Institute for Research, Education & Training in Addictions – SBIRT in Action – Another Vital Sign at http://ireta.org/webinarlibraryhttp://ireta.org/webinarlibrary New York State’s SBIRT Training Provider Certification at http://www.oasas.ny.gov/workforce/training/SBIRTCert.cfm http://www.oasas.ny.gov/workforce/training/SBIRTCert.cfm *Other trainings resources can be found on DHCS website at www.dhcs.ca.govwww.dhcs.ca.gov 47

48. L.A. Care Behavioral Health Contacts Leilanie Mercurio, Health Services Coordinator, 213-694-1250 x4456, lmercurio@lacare.org lmercurio@lacare.org Clayton Chau, Medical Director, cchau@lacare.orgcchau@lacare.org Suzie Matsuda, Director of Clinical Services, smatsuda@lacare.orgsmatsuda@lacare.org Nicole Lehman, Director of Operations, nlehman@lacare.orgnlehman@lacare.org Anthony Perera, Administrative Manager, aperera@lacare.orgaperera@lacare.org Robert (RJ) Key, Program Manager, rkey@lacare.orgrkey@lacare.org Torhon Barnes, Care Coordination Manager, tbarnes@lacare.orgtbarnes@lacare.org Hieu Nguyen, Strategic Initiatives Manager, hnguyen@lacare.orghnguyen@lacare.org 48

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