1. The Power of Protocols for Sustaining SBIRT
National Council for Behavioral Health
Year Two Summit
Aaron Williams, MA
The National Council for Behavioral Health
2/17/2019

2. Expansion and Sustainability Objectives
SBIRT pilot interventions proven successful
Practice culture ready to SBIRT to scale
SBIRT adoption as a routine part of care across all of the appropriate clinical areas
Organizational infrastructure and capacity built to sustain SBIRT practice

3. What We Know About Practice Adoption and Sustainability
Culture ready and willing
Leadership supportive
Workflow drives practice integration
Training and re-training essential
Data driven monitoring critical early and ongoing
Clinical decision support and reminder systems through EHR key facilitator
Guidelines or Protocols documenting procedures for all aspects of practice mandatory

4. Group Discussion Do currently have protocols or guidelines?
Describe your current SBIRT protocols or guidelines
Are there any challenges to the development of protocols?

5. What are Practice Guidelines and Operating Protocols?
Based on scientific evidence about SBIRT intervention – TIP, other research studies
Systematically developed into organizational policy that guides clinical decision making
Allows for measurement of the impact of care through written definition of intervention
Reduces variation in practice through effort to define standardization of interventions

6. What are Practice Guidelines and Operating Protocols?
Operating Policies and Procedures:
Provide standardization for essential operational activities within the clinical practice
Provide clarity on how to execute activities that are important to practice and necessary for regulatory, reimbursement or other accountability factors
Define roles and responsibilities of team members
Help assure execution of key activities when daily practice burden may hinder implementation
Transcends transitions in leadership and staff – written and approved regardless of changes Nd

7. Key SBIRT Guidelines and Protocols
Clinical guideline or SBIRT implementation
Referral to treatment
Documentation through EHR
Quality improvement
On boarding of new staff
Competency-based evaluation

8. Clinical Guideline for SBIRT Implementation
Defines the clinical pathway or protocol for SBIRT practice
Identifies policy for SBIRT:
Target population for screening and intervention
Screening frequency
Purpose of intervention
Defines screening instruments
Defines positive and negative screening result interpretation
Identifies roles and responsibilities of staff for all components of the SBIRT process
Establishes decision pathway for various patient presentations to guide staff interventions

9. Group Discussion
How are you communicating your protocols or guidelines to staff?
How are you communicating with senior management about this project?

10. Referral to Treatment

11. Referral to Treatment
The primary goals of referral to treatment (RT)are to identify an appropriate treatment program and to facilitate engagement of the patient in treatment.*
RT can be a complex process involving coordination across different types of services.
It requires a proactive and collaborative effort between SBIRT providers and those providing specialty treatment to ensure that a patient, once referred, has access to and engages in the appropriate level of care.
*Tap 33 Systems-Level Implementation of Screening, Brief Intervention, and Referral to Treatment

12. Referral to Treatment
Defines process to facilitate hand-off from brief intervention to steps required for successful referral to treatment
Addresses roles and responsibilities of various staff
Defines process for staff tasked with RT responsibility to refer or assist patient in referrals:
Identifies process for each type/category of treatment resource (public, private, crisis, information-line)
Provides guidance on referral options for different patient preferences (MAT for opioid addicted, inpatient for complex patients)
Provides detailed listing and profiles of different treatment resources
Identifies protocol for follow-up by referring provider
Defines documentation
Provides a tool for assessing barriers to access requiring assistance by the practice

13. Referral to Treatment: Considerations
Availability of resources for treatment
Knowledge by staff on available resources
Relationships with treatment providers
Personalizing the process:
Facilitate call to the treatment provider with patient
Assure the appointment is made
Assist with barriers to accessing treatment
Avoid just handing patient “a piece of paper”
Document referral source and date of appointment
Follow-up and provide reminders –release of information to follow-up
On-site availability or in system support optimal – develop systems for personalized referral

14. Key Questions
Are you able to track a referral to more formal substance use treatment?
How can the use of technology (EHRs, registries, CCD, NWIN Direct) help facilitate the communication of information between your organization and specialty providers?
Are you notified if a client misses an referral appointment?
What are your referral mechanisms and relationships?
What services are provided through your network?
What is your relationship with your referral providers? Are they new partners or long standing ones?
Is your treatment team aware of the services offered by your partners?
Do you have a access to different levels of care through your provider networks?

15. Partnership Development
Start with providers in which you already have a relationship
Use areas of common interest and build on those areas
Go slow
Try out new service delivery process for a short period of time and revisit.
Introduce staff at your agency to referral partners.

16. Group Discussion
What are two concrete steps you could take to improve your referral to treatment process? What resources do you need to add to improve your referral process?

17. Documentation through EHR
Separate protocol/document helps practice understand the following:
Mechanics for modifications/customization of EHR to accommodate tools for SBIRT
Mechanics for future modifications/customization of EHR
Contact information for outside vendors, as appropriate
Data dictionary of operational terms used for coding and documentation
Copies of screen shots
Process for use of the EHR screens for SBIRT documentation (access to different screens required for SBIRT)

18. Quality Improvement SBIRT data collection should become incorporated
as a routine quality indicator
Practices sustain ongoing SBIRT QI by:
Identifying SBIRT measures for screening and brief intervention as part of the practice’s overall QI plan approved by leadership
Protocol developed and approved defining:
Specific indicators and targets (i.e. all patients at every visit will receive a screen – target 75% of patient encounters)
Frequency of data collection
Report format including data dictionary of all indicators
Process for data abstraction from EHR
Roles and responsibilities of staff for data abstraction, data monitoring, and plan of correction
Reporting of measures to medical, administrative and board governance

19. On Boarding of New Staff
Sustaining SBIRT requires that all new staff receive the appropriate training and support to conduct SBIRT
Protocol must be established and reside within the Human Resources department of the organization to address staff and medical provider on boarding process
Ideally SBIRT training should be identified in protocol for orientation of all new staff and the on boarding of all new providers through a checklist or database system, such as Health Stream that document that SBIRT training occurred as part of new staff/provider orientation
Use of in-person trainings or web-based training should be standardized as the mode of training for new staff
An SBIRT Coach identified within the organization is useful to help provide ongoing coaching and support after initial training
All of the above steps should be detailed in the appropriate new staff and provider on boarding policy and procedure manuals of the organization

20. Competency-Based Evaluation
In order to support quality and fidelity of SBIRT implementation, the practice should define in a written protocol the mechanism for regular competency-based evaluation of all staff involved in SBIRT:
Competencies/skills to be evaluated for each component of SBIRT by the appropriate staff member (i.e. assessment of screening broken down by skills required for Medical Assistant evaluation)
Frequency of competency-based evaluation (no less than annually)
Mechanism for evaluation (standardized patient, role play for observation, observation in practice, written test)
Staff member responsible for conducting evaluation
Minimum level of proficiency required
Policy for staff that do not meet standard level of proficiency
Documentation method- preferably incorporated into broader competency-based evaluation instruments

21. Group Discussion
Are there things you would like change about your current protocol?
What are your current challenges to the development of sustainable protocol ?

22. Summary SBIRT practice adoption as a routine,
sustainable part of care is hard work!!!!
Written protocols for key components of SBIRT implementation ensure sustainability and quality:
Prevents selective memory loss of how the team decided to implement various aspects of SBIRT
Withstands changes in key staff positions that hold institutional memory of how SBIRT was implemented
Integrates SBIRT as part of the overall organizational polices, procedures and clinical guidelines that are approved by senior leadership, the organization’s governing board and other regulatory bodies (JCAHO, etc)
Assures standardization of critical components of SBIRT to reduce variation in practice and promote higher quality of care
Allows for changes over time in SBIRT implementation

23. Questions?????

24. Contact Info
Today’s Presenter
Aaron Williams, MA
The National Council for Behavioral Health
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