1. Replicating SBIRT Success: Promoting better health outcomes through integrated, whole-person care.

2. Today’s Presentation What is SBIRT? Why do we need SBIRT?
SBIRT outcomes and provider experiences
How does SBIRT work?
Why integrate SBIRT into your practice or clinic?
What does it take to be an SBIRT practice?
What can you do as an SBIRT champion?

3. SBIRT removes subjectivity and inconsistency in substance-abuse and mental health screening, interventions and referrals to treatment.
What is sbirt?

4. What is SBIRT?
SBIRT is a proven clinical approach to identifying, triaging, and treating at-risk patients, while removing subjectivity and inconsistency, and delivering predictability and efficiency.
SBIRT includes universally screening as well as delivering immediate matched interventions and treatment services for people with substance, mood and other behavioral risks affecting their outcome from chronic diseases (such as CHF, COPD, and Diabetes).

5. 3 Main Components of SBIRT
Screening Universal screening for effective and efficient risk stratification
Brief Intervention
Brief and immediate motivational interventions
Referral to Treatment
Warm referrals to follow-up treatment
SBIRT stands for Screening, Brief Intervention, and Referral to Treatment, with the Brief Intervention including embedded treatment of 4-12 sessions. This speaks to the process that patients follow, depending on their risk scores.
The SBIRT strategy offers clinical tools for effective and efficient risk stratification, brief motivational interventions, and follow-up or linked referrals to specialty care.

6. Locations 4 Free clinics 6 primary care centers 5 hospitals
SBIRT can be performed in nearly any healthcare access point but has typically been done in hospital emergency and other departments, primary care facilities (FQHCs) and college health centers.
To date, SBIRT has been implemented at four free clinics, six primary care centers, and four hospitals in Vermont.

7. SBIRT has been effective in improving outcomes for patients and also reducing costs.
Why do we need sbirt?

8. Why Do We Need SBIRT?
Because “Psychosocial Vital Signs” are recommended for EHR screening measures:
Race/Ethnicity
Tobacco Use
Alcohol Use (+ drug use, including opiate misuse)
Residential Address
Educational Attainment
Financial Resource Strain
Stress
Depression
Physical Activity
Social Isolation
Intimate Partner Violence
Neighborhood Median-Household Income
In 2014, The Institute of Medicine (IOM) recommended a common set of 12 "Psychosocial Vital Signs“ to help foster better clinical care of patients and populations and to help build research on determinants of health and treatment effectiveness. These include the following measures:
Race/ethnicity
Tobacco use
Alcohol use (and increasingly drug use, including opiate misuse)
Residential address
Educational attainment
Financial resource strain
Stress
Depression
Physical activity
Social isolation
Intimate partner violence for women of reproductive age
Neighborhood median-household income

9. Why Do We Need SBIRT?
Because mental health and substance use disorders are common—and have serious consequences.
Behavioral problems are the largest contributor to premature death (40%), compared to genetic distribution (30%), social circumstances (15%), environmental exposure (5%) and health care (10%).
Medicaid data indicate most patients with hypertension, diabetes, coronary heart disease, and COPD/asthma, also have a mental health disorder and/or substance use disorder. These data also suggest that those with mental health and substance use comorbidities comprise the largest number of hospitalizations, compared to those without a comorbidity.
In addition, death rates are rising for middle-aged white Americans, while declining in other wealthy countries and among other races and ethnicities. The rise appears to be driven by suicide, drugs, and alcohol abuse—and is highest in rural areas of the country.
Adapted from McGinnis et al.

10. Why Do We Need SBIRT?
Because most people with substance use problems do not seek formal treatment. But they DO visit their general practitioner.
Yet screenings and brief interventions for substance use are rarely performed in primary care.
2/3 individuals with substance use problems visit their general practitioner each year
Most people with substance use problems do not seek formal treatment. But, while risky substance users are often reluctant to seek specialist addiction treatment, about two-thirds do visit their general practitioner each year.
Substance use problems are overrepresented in populations seeking medical care but screening and brief interventions for substance use are rarely performed in primary care.
2/3

11. Why Do We Need SBIRT?
Because screenings and brief interventions work—across settings and across populations.
Even a 5-minute intervention reduces risky substance use.
SBIRT in medical settings reduces health-related diseases and consequences related to risky substance use.
Screening and brief interventions work across a variety of medical settings and populations—from pregnant women to college students.
Even a 5-minute intervention reduces risky substance use. And screening itself can be an intervention as it raises awareness for the patient.
Simple feedback on risky substance use based on a brief screening is one of the most important factors in why people change.

12. SBIRT Offers a Systematized Approach
Removes:
Subjectivity
Inconsistency
Introduces:
Predictability
Efficiency
SBIRT provides a systematized approach to detecting and treating at-risk individauls, one that removes subjectivity and inconsistency, and introduces predictability and efficiency.
Depending on the initial screening tools used, the SBIRT process can identify and help individuals with a variety of health concerns—including mental health risks as well as behavioral health risks like substance abuse.

13. INTERVENTIONS COMPLETED
SBIRT Outcomes
AS OF OCTOBER 2017:
100,000+
SCREENS COMPLETED
6,000+
INTERVENTIONS COMPLETED
In Vermont, as of June 2017, 72,448 screens have been completed in 18 practices and clinics.
Of those screens, 6, 000 interventions have been completed.

14. SBIRT Outcomes
Vermont data indicate one of every five individuals who received an intervention for risky drug use were abstinent from drugs or had significantly reduced their marijuana use at the 6 month follow up.

15. SBIRT Outcomes
Data from SBIRT use in Vermont indicate that at six-month follow-up, significant reductions occurred in risky alcohol use and prescription drug misuse.
One of every two individuals who received an intervention for risky alcohol use were either abstinent or within recommended drinking limits at the 6 month follow up.

16. SBIRT Outcomes
National research on the cost effectiveness of SBIRT has found that for every $1 spent on brief intervention, cost savings range from $3.80 to $5.60.
Based on the number of interventions conducted in VT SBIRT and the estimated cost of those services, the estimated cost savings range from $547 to $806 per person. Flemming et al., 2000, 2002, Gentilello et al., 2005
A major limitation includes differences in costs of healthcare and social services across states and even counties. Additional research on the cost savings of SBIRT are summarized at

17. SBIRT Provider Experiences
Dr. Heather Stein, family medicine physician at Community Health Centers of Burlington

18. SBIRT Provider Experiences
Dr. Mark Depman, emergency department medical director at Center Vermont Medical Center

19. SBIRT Provider Experiences
Dr. Cheryl Flynn, student health medical director at UVM’s Center for Health & Wellbeing

20. Screening, Brief Intervention & Referral to Treatment
How does sbirt work?

21. Step 1: Initial, Universal Triage Screening
Asks questions about:
General wellness
Alcohol frequency and amount
Use of:
Cannabis
Tobacco
Illegal drugs
Prescription drug misuse
Mood (PHQ-2)
Initial Triage Screening
No Risk
Affirm Positive Behaviors Linked to Wellness
Any Risk
Secondary Screening
Like routine blood work, universal screening is used as a “psycho social vital sign” and preventative screening measure. SBIRT is performed to identify risky substance use among patients and provide them with appropriate interventions.
The initial screening can be automated via a tablet for patient self-report, or can be administered by a healthcare assistant, nurse, or doctor.
The screening starts with wellness questions to break the ice with the patient, then moves into questions regarding:
Alcohol frequency and amount
Use of cannabis, prescription drug misuse, and illegal drug use
Mood (via the PHQ-2)
Tobacco use
A patient’s score on these tests determines if a secondary and more in-depth screening is needed.

22. Step 2: Patients with Risk Identified = Secondary Screening
No Risk
No Further Intervention
Affirm
Low Risk
Secondary Screening & Brief Intervention
Moderate Risk
Brief Intervention & Brief Imbedded Treatment Scheduled
High Risk
Brief Intervention & Referral to Specialty Treatment
Tools include:
Complete Drug Abuse Screening Test (DAST-10)
Complete Alcohol Use Disorder Test (AUDIT-10)
Complete Patient Health Questionnaire (PHQ-9)
Fagerstrom (Tobacco Risk)
The secondary screening may also be automated via a tablet, but more often includes a health educator, medical assistant, triage nurse, social worker, psychologist, or doctor administering tools like the:
Complete Drug Abuse Screening Test (DAST-10)
Complete Alcohol Use Disorder Test (AUDIT-10)
Complete Patient Health Questionnaire (PHQ-9)

23. Step 3: Low Risk = Brief Intervention
Secondary Screening
No Risk
No Further Intervention
Affirm
Low Risk
Secondary Screening & Brief Intervention
Moderate to High Risk
Brief Intervention & Brief Imbedded Treatment Scheduled
Severe Risk, Dependency
Brief Intervention & Referral to Specialty Treatment
Includes:
Reflective discussion of screening results
Structured intervention including 4 phases of motivational interviewing (engagement, focus, motivate & plan)
Follow-up on positive and “red flag” behaviors
During and after the administration of the secondary screening a provider—which again, can be a behavioral health provider, nurse, physician, physician’s assistant or nurse practitioner)—will employ motivational interviewing skills to increase the patient’s insight and awareness regarding risky behaviors and his or her motivation surrounding behavioral change.
Providers have been trained via motivational interviewing to use nonjudgmental, empathic verbal and non-verbal behaviors during this intervention.
The provider will use these skills to follow-up on positive and “red flag” behaviors by asking for details and probing consequences.
Brief intervention should be tailored to the population or setting and can be used as a stand-alone intervention for a number of identified health risks as well as a strategy for engaging those in need of continued care, including brief embedded treatment or referral to specialty care.

24. Step 3: Moderate Risk = Brief Intervention & Embedded Brief Treatment Scheduled
Secondary Screening
No Risk
No Further Intervention
Affirm
Low Risk
Secondary Screening & Brief Intervention
Moderate to High Risk
Brief Intervention & Brief Imbedded Treatment Scheduled
Severe Risk, Dependency
Brief Intervention & Referral to Specialty Treatment
For patients who:
Are at moderate risk
Cannot be referred to outside specialty provider
In many settings, embedded Brief Treatment is part of the SBIRT model.
Brief treatment is used for those with moderate risk; as well as those patients with higher risk for whom referral to an outside specialty provider is not possible due to a variety of reasons: rural location, transportation difficulties, or lack of patient interest.
In these cases, an embedded behavioral health clinician delivers outpatient treatment, which can also have a positive impact on patient outcomes.

25. Step 3: High Risk = Referral to Treatment
Secondary Screening
No Risk
No Further Intervention
Affirm
Low Risk
Secondary Screening & Brief Intervention
Moderate to High Risk
Brief Intervention & Brief Imbedded Treatment Scheduled
Severe Risk, Dependency
Brief Intervention & Referral to Specialty Treatment
For patients who:
Are identified as needing more extensive treatment than offered by the SBIRT approach
Referral to specialized treatment is provided to those identified as needing more extensive treatment than offered by the SBIRT approach.
This step requires a proactive and collaborative relationship between SBIRT providers and those providing treatment to ensure access to the appropriate level of care.

26. Implementing & championing SBIRT
Why and how to help strength SBIRT across Vermont
Implementing & championing SBIRT

27. Why Implement SBIRT?
Helps further goals of prevention and broad population health
Achievable, flexible, and efficient integration into the clinical setting
Can be customized to fit structure and available resources
Established reimbursement codes
Free training provided
SBIRT is a good fit for any clinic or practice dedicated to prevention and broad population health.
SBIRT integration into a clinical setting is achievable, flexible, and efficient. It can be customized to fit a practice or clinic’s unique structure and available resources.
Generally, there are two main approaches to SBIRT implementation:
Team-based integrated care including behavioral health clinicians in the medical team to deliver the behavioral health interventions as risks are identified, or
Existing medical staff deliver the behavioral health interventions as part of routine care,
Or a combination of the two
Regarding reimbursement for SBIRT, Vermont Medicaid has activated CPT codes for primary care physicians a number of other healthcare provider types ( such as LICSW, LCMH, LADC, Psychologists, and others) when billing for alcohol and substance abuse screening and intervention services by structured assessment tools (e.g., AUDIT, DAST, ASSIST) for appropriate patients age 13 years or older.
In addition, Vermont Medicaid will reimburse face-to-face counseling for smoking cessation for eligible beneficiaries of any age who use tobacco.
Free in-person training is available to healthcare providers delivering SBIRT.

28. What Does It Take To Be An SBIRT Practice?
Institutional buy-in—with champions across the organization
Ongoing training for skill development and maintenance
Quality assurance and data collection
Office space for screening and interventions
EHR integration and IT communication
Regional network partnerships and unified consent
When considering whether to incorporate the SBIRT approach into your practice, you’ll want to think about the factors that lead to successful integration. These are:
Institutional buy-in: You’ll need to have SBIRT champions across all levels of your organization, from your front desk personnel to your CMO.
Training: You’ll need to consider the minimum training requirements, and the time it takes to meet those requirements as well as to help your staff develop and maintain their skills.
Quality assurance and data collection
Office space for screening and interventions
EHR integration and IT communication
Regional network partnerships and unified consent

29. What Can You Do As An SBIRT Champion?
Build awareness
Be an advocate for SBIRT:
In your organization
In the larger healthcare community
Call/visit practices not currently participating in SBIRT to introduce behavioral integration
Lead 1 or more informational presentations per year in the healthcare community
In order to continue expanding the success of SBIRT throughout Vermont, we need the help of champions like you. When thinking of becoming an SBIRT champion, consider what specifically you can commit to in two very important areas.
The first is building awareness. As an SBIRT champion, you may commit to:
Being an advocate for integrated, whole-person health care in your organization—or in the larger healthcare community
Calling or visiting practices not currently participating in SBIRT to introduce this approach
Leading one or more informational presentations per year in the healthcare community
Or other activities that can help promote SBIRT
We’ll provide you with helpful materials to help you spread the word about SBIRT.

30. What Can I Do As An SBIRT Champion?
Strengthen skills
Identify yourself as the SBIRT expert:
In your organization
Within the SBIRT community
Lead 1 or more ongoing staff training sessions per year at your organization
Lead 1 or more introductory training seminars per year for practices new to SBIRT
The other key area is skill-building. You can help strengthen the behavioral health integration skills of Vermont providers by:
Identifying yourself as the SBIRT expert at your organization—or within the larger SBIRT community—and serve as the touchpoint for provider questions.
Leading one or more ongoing staff training sessions per year at your organization
Leading one or more introductory training seminars per year for practices new to SBIRT
We’ll help provide you with the materials you’ll need for training others.

31. Want To Learn More?
For general or implementation information on SBIRT:
Sbirt.vermont.gov
integration.samhsa.gov
medicine.yale.edu/sbirt
bu.edu/bniart For information on regional training opportunities and resources: