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

2. 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

3. 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

4. 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.

5. 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.

6. 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

7. 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 - + - +
-/+ - + + ++

8. 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?

9. 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

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

11. 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

12. 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%)

14. 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

15. 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