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Illustration of Statewide Adoption of NQF Standards: Identification of Substance Use Conditions Rachel Gonzales, Ph.D. Thomas E. Freese, Ph.D. UCLA ISAP.

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Presentation on theme: "Illustration of Statewide Adoption of NQF Standards: Identification of Substance Use Conditions Rachel Gonzales, Ph.D. Thomas E. Freese, Ph.D. UCLA ISAP."— Presentation transcript:

1 Illustration of Statewide Adoption of NQF Standards: Identification of Substance Use Conditions Rachel Gonzales, Ph.D. Thomas E. Freese, Ph.D. UCLA ISAP Substance Abuse Research Consortium 2009 Meeting Series

2 Presentation Objectives Provide you with an overview of the NQF Domain I: Identification of Substance Use in relation to: –What we know? – –California’s Response History of SBIRT development Current efforts The future

3 What do we know?

4 NQF: Identification Domain Screening & Case Finding – –Evaluation process allows for determining whether an individual is at risk for or has an alcohol or drug problem Assessment & Diagnosis – –In-depth clinical process to determine the specific tx needs of the individual when “screening” identifies risk for an alcohol or drug problem

5 Identification of Substance Use is a Public Health Priority…

6 Challenges Striking disconnect between the proportions of individuals reporting misuse of substances or diagnosed with substance abuse/dependence and those receiving treatment Little attention has been paid to the latter “risk groups” (Klitzner et al., 1992; Fleming, 2002) In Treatment ~1.8 million Abuse/Dependence ~22.3 million Misuse of alcohol ~ 126.8 million Misuse of Illicit Drugs ~ 19.9 million

7 Targeting Latter Risk Groups AOD risk settings….

8 AOD Risk Settings Health (including mental) Care – –Primary care –40% of visits are injury-related and 50% of them are alcohol-related (Nilsen et al., 2008)] –Emergency Rooms/Trauma Centers [40% of visits are injury-related and 50% of them are alcohol-related (Nilsen et al., 2008)] Educational institutions Criminal justice settings Others… – –Dental offices

9 Research of Identification in Health Care Settings CASA Health care study: included 650 primary care physicians with over 500 patients in tx for chronic diseases: Findings: – –LESS than 1/3 of PCP’s Screen for Substance Use – –~50% of patients said “PCP asked nothing of AOD use” – –10% said “PCP asked, but did nothing” Missed Opportunity: National Survey of Primary Care Physicians and Patients, the National Center on Addiction and Substance Abuse (CASA) @ Columbia University, NY 2000

10 Results from a member survey of American Association for the Surgery of Trauma: – –Majority (~50%) screen LESS than 25% of their patients – –Issues: >80 % no training in AOD screening 75% not familiar with standard screening instruments Research of Identification in Health Care Settings Arch. Surg. Vol 134, May 1999

11 Why SBIRT? A Public Health Early Intervention Solution: Screening, Brief Intervention & Referral to Treatment - SBIRT Identify patients who may not perceive a need for behavior change Approaches are clinically effective and cost-efficient Focus on at-risk vs. dependent individuals Approaches are deemed an evidence based practice

12 SBIRT Approaches: Definitions Screening: assesses the severity of substance use & identifies the appropriate response Brief Intervention: focuses on increasing insight & awareness regarding substance use and motivation toward behavioral change: Give feedback about screening results, inform patient about consuming substances, advise on and assess readiness to change, establish goals and strategies for change, and follow-up

13 SBIRT Approaches: Definitions Brief Treatment: consists of a limited number of highly focused and structured clinical sessions with the purpose of eliminating hazardous and/or harmful substance use -- usually increased intensity and shorter duration than traditional treatment Referral to Treatment: provides those identified as needing more extensive treatment with increased access to specialty treatment

14 Screening Score SBIRT Approach Framework: Response Depends on Score* Negative Screen Positive Reinforcement Brief Intervention Brief Treatment Referral to Treatment Moderate Use Moderate/High UseAbuse/Dependence *Severity & Consequences of use Positive Screen

15 Overall SBIRT Goals Increases access to care for persons with or at-risk for substance use disorders Improves linkages between at-risk & AOD settings Fosters a continuum of care: integrates prevention, intervention, and treatment services Takes advantage of the “intervention moment…”

16 The Good News… It Works!

17 It Works! Well supported in health care settings – –Major impact on reducing morbidity & mortality – –Saves $: each dollar spent on SBIRT saves 4 dollars in other health-related costs So… – –SBIRT required for certification of all Level I & II Trauma Centers – –U.S. Preventive Services Task Force recommends routine SBIRT in primary care settings Babor & Kadden, 2005; Gentilello et al, 2005

18 Examples of Reductions in Morbidity & Mortality StudyResultsReference Trauma patients 48% fewer re-injury (18 months) 50% reduced re-hospitalizations Gentilello et al, 1999 Hospital ER screening Reduced DUI arrests (1 DUI arrest prevented for 9 screens) Schermer et al, 2006 Physician offices 20% fewer motor vehicle crashes over 48 month follow-up Fleming et al, 2002 Meta- analysis Interventions reduced mortalityCuijpers et al, 2004 Meta- analysis Interventions can provide effective public health approach to reducing risky use. Whitlock et al, 2004

19 Research To date: Mostly Alcohol Evidence for illicit drugs sparse…but promising – –Burke et al. 2003: Meta-analysis – –Bernstein et al. 2005: Randomized Controlled Trial – –WHO study 2008: Randomized Controlled Trial in multiple sites internationally – –Madras et al. 2009: SAMHSA program evaluation at multiple sites (intake vs 6 mo follow-up) Overall Findings: SBIRT efforts related to positive outcomes (abstinence, increased health, social, legal, economic, and vocational outcomes)

20 California Response How has California been responsive to initiatives that use ‘screening & case finding’ techniques to identify individuals with substance use disorders?

21 SBIRT is a system change that will move a core mission of ADP forward… …moving the AOD system to a comprehensive and integrated continuum of services system model Importance of SBIRT in California? Source: UCLA ISAP State Treatment Needs Assessment, 2001.

22 Prevention SBIRT in the AOD Service Delivery Continuum of Care PrimarySecondary Reducing the probability that a substance use problem develops Screening/Assessment Brief Intervention or Referral to Treatment Screening/Assessment Brief Treatment Treatment Continuing Care Care Management Intervention Intervention/Treatment Recovery Support Tertiary Minimizing the severity of a substance use problem if it occurs Minimizing the disability caused by substance use problems

23 Brief History: SBIRT Efforts in CA California was selected as 1 of 7 states to participate in a national SBIRT demonstration project funded by SAMHSA (5-year cooperative agreement) – called CASBIRT CASBIRT initiative – –Administered by CA ADP – –Managed by San Diego County, Alcohol & Drug Services AND San Diego State University, Center on Alcohol and Other Drug Studies & Services

24 What is the CASBIRT Model? SBIRT implemented in trauma, emergency (chest pain urgent care), & primary care settings throughout San Diego County Patients 18+ are routinely screened by certified Health Educators during their visit using a standardized, scripted screening instrument SBIRT service response made depending on score CASBIRT staff: conduct evaluation by tracking patients deemed as “at-risk”, provide follow-up booster calls, and facilitate their participation in appropriate services

25 CASBIRT Effectiveness   To date, over 500,000 patients have received SBIRT services in SD county   Between 2005-06 alone, SBIRT performed with 125,000 patients – –48% of high risk clients completed at least one Brief Treatment session – –74% stopped or reduced their substance use Current status: funding by San Diego county AOD agency supported CASBIRT services through June 2009 (now looking to other grant mechanisms)

26 SBIRT in Educational Settings SAMHSA Cooperative Agreement to implement SBIRT in College setting: UCLA Access to Care Project (2006-2009) 1 st pick: Student Health Center (although not interested) 2 nd pick: Counseling & Psychological Services – –Given the prevalence of co-occurring substance abuse/mental health disorders, counseling centers are good places for early intervention – –Serves over 6,000 students a year Spear & Rawson

27 Access to Care Project Team SBIRT Implementation: UCLA Counseling & Psychological Services center clinical staff (n=28): Psychologists & LCSWs Interns (social work, post-docs) Project Liaison: ensure proper implementation by clinical staff SBIRT Evaluation: UCLA ISAP team (Spear, Rawson, Ransom) Spear & Rawson

28 SBIRT Implementation in Access to Care Project Pre-screen score tabulated by Kiosk computer If +, clinician conducts ASSIST in 1 st therapy session as well as brief intervention (if deemed appropriate) Clinician refers student to UCLA ISAP Evaluation Student completes pre-screen at routine intake* AUDIT-C plus 1 question on illicit drug use in past 30 days *performed at Kiosk Spear & Rawson Students given ASSIST are GPRA’ed at intake & 6- mo follow-up

29 As of Oct 2008: 6,786 students coming for initial appointments were pre- screened – –38% of students scored positive Of those who scored positive 60% received the ASSIST screen & brief intervention (n=1,442) Access to Care Results Spear & Rawson

30 GPRA Results (2007) Means*Male n=324Female n=495 Gender39.6%60.4% Mean Age21.5 yrs21.6 yrs Avg binging (5+ drinks) past mo 5.3 days3.6 days Marijuana use (past mo)8.9 days5.5 days Cocaine use (past mo)< 1 day Hallucinogen use (past mo) < 1 day Meth use (past mo)<1 day Spear & Rawson

31 GPRA Results: Binge Drinking 85% of binge drinkers (n=425) received a brief intervention 46% of binge drinkers reported no binging at 6-mo follow up Spear & Rawson

32 GPRA Results: MJ Use 37% (n=303) of students reported any marijuana use in past 30 days at intake Of these students, 87% (n=264) received a brief intervention Half (53%) of marijuana users reported no use at 6- month follow up Spear & Rawson

33 Lessons learned: SBIRT in Educational Mental Health Settings Has made mental health staff more aware of substance use issues among students Offers mental health staff a more systematic approach for identification (less of a “judgment call”) Allows college students to: – –express concerns about their substance use – –“shift their thinking” about their use Spear & Rawson

34 Lessons learned: SBIRT in Educational Mental Health Settings Implementation challenges – –Interrupts routine clinical flow: difficulty dedicating 15-20 minutes of customary 50-minute routine intake session to SBIRT – –Not enough time to do (and score) SBIRT in routine assessments (generally 30 minutes) To address: UCLA ISAP team developed & pilot- tested a self-administered computer version of ASSIST (which is now used) – –Briefer, efficient, feasible Spear, S.E., Tillman,S., Moss, C., Gong-Guy, E., Ransom, L., Rawson, R. Another way of talking about substance abuse: Substance abuse screening and brief intervention in a mental health clinic. In press. Journal of Human Behavior in the Social Environment.

35 Sustaining Implementation of SBIRT within College Campuses System-wide training across the State

36 1 st Training: March 2008 CSU Bakersfield UC Merced UC San Diego UC Irvine University of San Diego CSU Long Beach UC Riverside Vanguard University Occidental College UC Santa Barbara Woodbury University UCLA hosted and trained (1 day) 11 counseling centers on SBIRT & use of the ASSIST Spear & Rawson

37 Evaluation of 1 st Training Survey sent assessing implementation of the screening tool at their centers (n=11) 7 centers responded: – –3 reported using the ASSIST – –4 reported not doing any screening, but indicated that they “intend to use” the ASSIST when they have more time and staff to develop a plan Spear & Rawson

38 2 nd Training: Oct 2008 UCLA conducted day long SBIRT training with 7 additional colleges Hosted at UCSF UCSF San Jose State University CSU Sacramento Notre Dame de Namur University San Francisco State University Santa Clara University UC Berkeley Spear & Rawson

39 Evaluation of 2 nd Training Survey sent related to implementation of screening tool – –Only 2 implementing ASSIST Barriers cited included: – –Lack of time – –Short staffed – –Clinicians focused on other priorities – –Limited resources – –Need additional training – –ASSIST doesn’t relate to students Spear & Rawson

40 Integrating SBIRT into California Trauma Centers Timeline: April 09-Nov 09 Under collaboration with ADP, UCLA is conducting large scale SBIRT training effort – –Series of day-long workshops on SBIRT with trauma centers, emergency departments & primary health care settings Trainings offered during Spring, Summer and Fall 2009 Participant Counties (n=9) –Alameda –Ventura –Los Angeles –Santa Clara –Contra Costa –Santa Barbara –Fresno –Solano –Nevada Data collection: GPRA Freese & Rawson

41 Integrating SBIRT in CA Criminal Justice Settings Implementation by CASCs –Homeless Healthcare LA –Behavioral Healthcare Services Community Transition Unit Participants –LA County Jail (Twin Towers) –LA County Police Department (Parker Center) Evaluation: UCLA doing GPRA Rawson & Freese

42 Integrating SBIRT in CA Criminal Justice Settings Under a SAMHSA grant, ADP, LA County (DPH, ADPA) & UCLA are conducting a 2-year pilot demonstration project: – –Implementing SBIRT in 2 Community Transition Units Phase I: training staff on SBIRT & the ASSIST Phase II: Pre-screening all short-term stay detainees to identify AOD risk (low vs high) using AUDIT-C+ (3 etoh/2 drug) Phase III: ASSIST & BL GPRA Phase IV: Follow-Up (6-mo GPRA) Rawson & Freese

43 Criminal Justice SBIRT Flow Chart Parker Center (n=5,000) Information and Referrals Provided Brief Intervention Referral if indicated GPRA 6-Month Follow-up Twin Towers (n=5,000) Rawson & Freese

44 Integrating SBIRT in CA Tribal Settings Under a SAMHSA initiative, UCLA partnered with California Rural Indian Health Board (CRIHB) to provide SBIRT training for tribal organizations – –Phase I: CRIHB identified specific tribal organizations and clinics interested in training (Oct 08 – Mar 09) N=24 – –Phase II: UCLA conducted SBIRT/ASSIST training with identified tribal organizations (2 large trainings: Apr 09 & Aug 09) – –Phase III: ASSIST implementation by tribal organizations Depending on tribal community desires: ASSIST will be conducted with paper and pencil, using a personal interview or via computers – –Phase IV: Evaluation of adoption in tribal communities (future) Rawson, Freese, Dickerson

45 Training Participants* Professional Settings –8 Administration –7 Education –6 Addiction Counselor –5 Social Work/Human Services –2 Medicine –2 Psychology –1 Medicine-Primary Care –5 Other Agencies: 10 Gender: 20 Female; 5 Male Ethnicity/Race: – –3 Hispanic/Latino – –14 American Indian – –6 White – –3 Native Hawaiian/Pacific Islander – –1 Asian *2 nd Training evaluation in progress Rawson, Freese, Dickerson

46 Assessment & Diagnosis

47 What is Assessment/Diagnosis? Gathering information to: Confirm the presence of an AOD problem Identify the severity of the AOD problem & factors that affect AOD problems: – –Social support networks – –Employment – –Health – –Housing – –Motivation to change – –History of physical/sexual abuse – –Mental illness status Determine what services/treatment would be most effective

48 California Illustration II Identification of Substance Use Disorders domain: Diagnosis and Assessment California initiatives that require or recommend the use of a standardized biopsychosocial tool(s) for diagnosing and assessing individuals with substance use disorders

49 Pilot Project Efforts Underway UCLA-ADP COSSR Evaluation work – –Alameda working on developing a framework to address this area Issues: – –Clarity on difference between assessment and diagnosis (where does placement fit in?) – –Identification on specific instrument to use for each – –Who should do the assessing & diagnosing? Issues with staffing, training, conflicts of interest

50 Future Efforts Continuing evaluation of current efforts Establishing more funding to keep activities ongoing Expanding partnerships into other diverse settings, i.e., EDD, dental offices, juvenile justice, high schools, etc. White paper on SBIRT to disseminate CA experience

51 Acknowledgements State ADP Michael Cunningham Tony Becerra UCLA ISAP Richard A. Rawson Suzanne Spear Loretta Ransom Thomas Freese Jerry Cartier Dan Dickerson Anne Bellows

52 For More Information

53 Thank you! Contact: – –Rachel Gonzales (310) 267-5316 – –Thomas Freese (310) 267-5397 “Be kind, for everyone you meet is fighting a great battle.” Philo of Alexandria

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