Screening, Brief Intervention, Referral to Treatment in a Medical Setting

What is InSight? $17 million five-year SAMHSA grant Program dedicated to early intervention and prevention Creation of a full spectrum of care for district patients with SUD through screening in primary and acute healthcare settings

InSight Partners Texas Department of State Health Services The Council on Alcohol and Drugs-Houston Gulf Coast Addiction Technology Transfer Center UT Health Science Center – Houston Baylor College of Medicine Harris County Hospital District

HCHD InSight Objectives Generalist screen all patients for problematic use of alcohol, drugs and tobacco. Provide patients with brief advice on healthy choices about alcohol, drugs and tobacco. Refer at-risk patients to InSight specialists Provide a team of InSight specialists for intervention, follow-up, and if necessary, treatment placement The goal is to incorporate alcohol and drug screening, intervention, and education into all aspects of HCHD care. We recognize that many healthcare workers already screen and provide assistance, but we would like to make sure that we are all asking the same questions and providing a consistent, appropriate, and quality service.

Efficacy and Cost of Advice At 4 years… Control Intervention Hospital Days (p<0.05) 663 420 ED Visits (p<0.08) 376 302 Risky Drinking* (p<0.001) 35% 23% Do changes persist long-term? In Project Treat, after 4 years, Fleming and colleagues found that the number of hospital days, emergency department visits and risky drinking behaviors all remained lower in the intervention group compared to controls. Moreover even though the cost for the brief intervention was only $166 per patient, the net benefit was medical cost savings of $546 and societal cost savings of $7780 per patient. Therefore this brief advice resulted in healthier patients who drank less at lower cost. Lets now return to case 2 and see what advice was given and how it was done. Pay attention to what the physician did well and what she might have done differently. Cost of intervention: $166 per patient (includes patient costs) Net benefit: $546 in medical costs, $7780 if societal costs included (mainly motor vehicle) *36 months. >20 drinks (men), >13 drinks (women) per week - Fleming MF et al., 2002.

Intervention with Trauma Patients Gentilello et al. (Ann Surg 1999) Admitted trauma patients: 46% screened positive for alcohol problem – 30’ intervention psychologist At 3-year follow-up: 47% i injuries requiring ER visit 48% i hospitalization

USE AT-RISK USE ABUSE DEP Use Consequences Repetition + - A B S T I N Brief Intervention Intervention Referral A B S T I N USE AT-RISK USE ABUSE DEP Use Consequences Repetition Loss of control, preoccupation, compulsivity, physical dependence Slide courtesy of Association for Medical Education and Research in Substance Abuse - + - + -/+ - + + ++

Generalist Screening Do you smoke or use tobacco? When was the last time you had more than four drinks in one day? Do you use marijuana, cocaine, or other drugs?

Promoting Screening and Referral Emphasize integrating screening and referral into the general healthcare setting Support education and skill-building in screening and referring Talk about cost and health benefits of early detection and treatment

Sites Ben Taub General Hospital Community Health Centers Including Emergency Center, Inpatient Services, Internal Medicine Outpatient Clinic Community Health Centers School Based Clinics

Insight Staff “Health Promotion Specialists” Interdisciplinary Team Social Work Nursing Mental Health Psychology LCDCs Varying levels of education RNs, NPs, PAs, LVNs LMSWs, Mental Health Techs, LPCs, LCDCs

SBIRT – patients served to July 12, 2005 State Total Screening only Brief Intervention Brief Treatment Referral to Treatment AK 9508 8,185 (86.1%) 635 (6.7%) 135 (1.4%) 551(5.8%) CA 106,657 87,170 (81.7%) 15,220 (14.3%) 2,486 (2.3%) 1,781 (1.7%) IL 25,029 21,375 (85.4%) 2,136 (8.5%) 373 (1.5%) 1,145 (4.6%) NM 11,659 10,945 (93.9%) 422 (3.6%) 256 (2.2%) 36 (0.3%) PA 12,273 11,500 (93.7%) 762 (6.2%) 1 (0%) 10 (0.1%) TX 25,275 21,630 (85.6%) 2,682 (10.6%) 220 (0.9%) 743 (2.9%) WA 16,038 7,464 (46.5%) 7,745 (48.3%) 610 (3.8%) 219 (1.4%)

Role of the ATTC Management Consultation Evaluation Committee membership – Training, Research & Evaluation Program planning – Core Group membership GPRA Data Reporting to Feds Design of data collection system Training of Insight Specialists in data collection Quality assurance reports to management Evaluation Process Impact

Evaluation Impact Process Annually with feedback to managers Patient data collected in addition to GPRA data Cost-benefit study Process Baseline qualitative interviews Adapted Survey of Organizational Functioning Annually with feedback to managers Stimulating reflection by staff members on organizational issues and changes resulting from Insight implementation Retrospective Case Studies at each medical site Cross site comparison for study of implementation process and degree of institutionalization