Feasibility of SBIRT at KPCOCarmen R Martin, MPHJennifer Boggs, MSW

HMORN ConferenceMay 2nd, 2012

What is SBIRT?

Screening, Brief Intervention and Referral to Treatment– Broadly supported by SAMHSA; adapted into multiple sets of questions– Validated, now applied millions of times

SBIRT is a universal screening protocol that requires little time of the patient, the provider, or the healthcare system

Target : the 25% of Americans who are “risky’ drinkers/substance users (not the 4% with dependencies, nor the 70% of abstainers/low risk)

One of a class of screener protocols for risks of various kinds (alcohol, drugs, inactivity, poor mental health, etc)

SBIRT Implementation at KPCO

Pilot 1: Implementation Planning

Pilot 2: Pilot Implementation

Pilot 3: Implementation Planning Outside KPCO

Dissemination Studies

4

Design: SBIRT Pilot 1

Primary CarePhysicians Nurse Managers Front Line Nurses

Behavioral Health

Mental Health Chemical Dependency

Behavioral Medicine Specialists

Members

English-Speaking Spanish-Speaking

5

Member Focus Groups

•Well visit in past 3 months

•2 groups, various membership duration

Participants

•Privacy concerns in medical record

•Pre-screen…“ would help realize what ‘too much’ is”

English-Speaking

•Asked at every visit, including Rx use

•“Grateful” because doc is best person to help & direct to resources

Spanish-Speaking

•Decision support in EMR for positive screening/Brief intervention use

•Normalize as standard care for all; avoid “profiling”

Recommendations

Behavioral Health

Behavioral Medicine

Specialists

• Psychologists• Clinic-based• All follow-up after

PCP prescribes meds

• Want to prove value to KPCO

• SBIRT good fit with position

• Trained in MI

Chemical Dependency

• MDs, RNs, counselors

• Moderate risk should be followed in Primary Care

• Referral stigma to CD

• “providers don’t know how to refer to CD”

Mental Health

• Supervisors, psychologists, counselors, therapists

• Brief Intervention impossible unless done by BMS

• Need workflow pre-defined

Primary Care - Nursing

Nurses and Nurse managers– Generally supportive– To gain buy in, need to discuss SBIRT validity – Could be added to workflow of Health Maintenance Visit

(already do PHQ9)– Workflow important: 6-8 min for rooming in a 20 min visit– MD or Behavioral Medicine Specialist for Brief Intervention

and Referral to Treatment, not part of nursing role– Concern: liability

Primary Care - Physicians

“Intellectually” support the idea Where to go for help? (BMS vs MH vs CD) Perceived patient resistance Fear of time sink Motivational interviewing skills Validity of SBIRT tool vs other quicker methodologies

– Cost/benefit analysis – evidence that better then status quo

Confidentiality of patient information for life insurance, or other releases of information.

MH CD BMS

Primary Care

REFERRALS

REFERRALS

REFERRALS

REFERRALS

Overwhelmed with Referrals that should go to CD

· Crisis only setup· Not open to

moderate risk

· Want closer relationship w/ CD

· Open to CD training

“What relationship?”

Need more MI training

CD shuts down pt

May be stigma associated w/ referral to CD

Prior CD Individual

BMS Supervisor

KPCO Systems Issues – Pilot 1

Appropriate timing – Depression Governance Council , Rx Drug Abuse Pilot, KP’s “New Reality.”

Recommendations– Higher level support needed – insert into already existing initiative

that has leadership support (Physical Activity Vital Sign Group) – Clinic champions important– Stakeholders co-create workflow– Pilot in one clinic initially

KPCO Pilot 2 Plan – Implementation at one clinic

– Literature review - Executive Summary for Clinic Staff– Collaboration with SBIRT – Colorado and NIAAA funded

SBIRT KP Northern California region study.– Address stakeholder concerns determined in Pilot 1– Convene stakeholder group to develop workflow– Identify one clinic to pilot for 4-6 months– PDSA Cycles for iterations of workflow – Provider training through SBIRT Colorado program

KPCO Pilot 2 Plan

Evaluation– Members screened vs. members eligible, %BI, %RT– Compare to matched non-implementation clinic with BMS and

one without BMS through chart review Documentation: codes used, screening tools, alerts, after-visit

summary with alcohol/drug advice, variables vs. text. – Pre-implementation survey on teamness and importance of

alcohol and drug screening.– Key informant interviews from clinic leaders (Chief, Nurse

Manager, other leaders).– “What Happened” Qualitative Tracking of Implementation

KPCO Pilot 2 so far…..

Clinic is in midst of new roles from the “New Reality” and trying to introduce SBIRT. “This is overwhelming” vs. “good to do all changes together.”

– How is this different from what I already do?– Role of physician in SBIRT (if BMS going to do the Brief

Intervention) – process of hand-off to BMS?– Scripting for introducing SBIRT and transitions between

staff.

Pilot 1 recommendations vs. REALITYGain high level leadershipinvolvement and support.

Recommendation to insertSBIRT into a new initiative (PxVital Sign) that had high levelsupport already.

Stakeholders should createworkflow In order to have“ownership” of workflow.

Hard to do with short time line, important to start small and gain clinic support.

Px Vital Sign had high level support, but lacked clinic support, ended up going grass roots with clinics choosing to implement or not.

Stakeholders wanted input on workflow, but wanted detailed draft to start with from research team.

Questions?

Thank you to our study team: Alanna Kulchak Rahm, Arne Beck, David Price, James W Dearing, Thomas E Backer, L Kendall Krause.

Thank you to SBIRT Colorado for their collaboration and support of the project.