SBIRTTraining

Stephen FerranteSharday Lewis Angela Ventura

September 5, 2014

Training Components Review & Practice

• Overview

• Prescreening

• Full Screening

• Motivational Interviewing

• Brief Intervention

• Brief Therapy & Treatment

• Treatment Referral

• Evaluation

• Database

• Billing

• Organizational Adoption

http://sbirt.samhsa.gov/about.htm

Substance Abuse Severity & Level of Care Adapted from the SAMHSA TIP #34 (1999) and Institute of Medicine (1990)

None

Mild

Moderate

Substantial

Severe

Specialized Treatment

Brief

Intervention

Primary

Prevention

Substance Abuse Severity

Provide Positive Reinforcement

PositiveScreen

CRAFFT & ASSIST

Low Risk: Education

Moderate Risk: Brief Intervention

Moderate to High-Risk: Brief Therapy

High Risk: Refer to Treatment

Negative ScreenCRAFFT & ASSIST

SBIRT PROCESS•Engagement & Introduction•Consent•Pre-Screening (CRAFFT & ASSIST)

•Full Screening (CRAFFT & ASSIST)

• Individualized Plan • Intervention, Therapy or Treatment •Record Activity & Process•Follow-up Screening •Reporting & Evaluation

DEMONSTRATION Scenario A

http://www.youtube.com/watch?v=ZGETDcFcAbI

Scenario B

http://www.youtube.com/watch?v=uL8QyJF2wVw

Prescreening • First Stage in SBIRT Process

• With Universal Screening - Most people screen negative for substance misuse

• Screening is designed to be Brief & Determines: oAny use versus no useoPotential for risky use or serious substance use

• Demographics & Prescreen used to establish the “Denominator” of the program:oTotal people approached & interviewed?

CRAFFT Screening Tool

• CRAFFT is an evidence based six question behavioral health screening TOOL for youth under 21

• Developed by the Center for Adolescent Substance Abuse Research (CeASAR), Children’s Hospital, Boston, in affiliation with Harvard Medical School

• Recommended by the American Academy of Pediatrics Committee on Substance Abuse for adolescents

• Available for use in multiple languages in either a self-administered or clinically administered version

SBIRT Preliminary Questions

1. Drink any alcohol? (more than a few sips)

2. Smoke any marijuana or hashish?

3.Use anything else to get high?

(includes illegal drugs, over-the-counter and prescription drugs and inhalants)

The SBIRT screening protocol begins with 3 questions.

During the last 12 months, did you:

If YES is given to any of these questions, then the CRAFFT questions are administered.

CRAFFT Assessment Tool

C Have you ever ridden in a CAR Driven by someone (includingyourself) who was “high” or had been using Alcohol/ Drugs?

R Do you ever use Alcohol or Drugs to RELAX ,feel better aboutyourself, or fit in?

A Do you ever use Alcohol/ Drugs while you are by yourself, ALONE?

F Do you ever FORGET things you did while using Alcohol or Drugs?

F Do your FAMILY or FRIENDS ever tell you that you should cutdown on your Drinking or Drug Use?

T Have you ever gotten into TROUBLE while you were using Alcoholor Drugs?

Each positive answer, scores one point.

Interpreting CRAFFT Scores

1. Positive Reinforcement – Give positive feedback on current behaviors2. Brief Advice – Use medically based information to advise abstinence3. Brief Intervention – Educate clients and increase motivation to reduce risky behavior

(Usually 1 to 5 sessions lasting 5 mins. to 1hr .)4. Brief Therapy - Help patients address unhealthy cognitions and behaviors associated

with current use patterns and adopt change through a limited number (typically 6 to 20) of evidence-based sessions

5. Referral to Treatment- Patients identified as needing more intensive treatment than BI are referred to specialty SUD treatment providers

S2BI:Screening to Brief Intervention

• Developed by the Center for Adolescent Substance Abuse Research (CeASAR), Children’s Hospital Boston, in affiliation with Harvard Medical School

• Frequency screen that triages adolescents into risk categories based on the DSM-5 diagnoses for SUDs• Frequency questions are recommended for screening adults and are used in the NIAAA Youth Alcohol Screen. A small study at BCH also suggested they are also accurate with teens.

©  Boston  Children’s  Hospital  2013.  All  Rights  Reserved.  For  permissions  contact  SBIRT  project  manager  at  www.CeASAR.org.

S2BIIn the past year, how many times have you used

• Tobacco?

• Alcohol?

• Marijuana?

STOP if  all  “Never.” Otherwise, CONTINUE.

• Prescription drugs that were not prescribed foryou (such as pain medication or Adderall)?

• Illegal drugs (such as cocaine or Ecstasy)?

• Inhalants (such as nitrous oxide)?

• Herbs or synthetic drugs (such as salvia, "K2", orbath salts)?

Severe SUD

Mild/

Moderate SUD

No SUD

No Use

© Boston Children’s Hospital 2013. All Rights Reserved. For permissions contact SBIRT project manager at www.CeASAR.org.

S2BI discriminatesbetween 4 groupsbased on DSM-5

diagnoses

DSM-5 Criteria for Substance Use Disorders

1 Use in larger amounts or for longer periods of timeThan intended

Severity is determinedthrough number ofrecorded symptoms:

•0-1:No Diagnosis

•2-3: Mild SUD

•4-5: Moderate SUD

•6 or more: Severe SUD

2 Unsuccessful efforts to cut down or quit.

3 Excessive time spent taking the drug

4 Failure to fulfill major obligations

5 Continued use despite problems

6 Important activities given up

7 Recurrent use in physically hazardous situations

8 Tolerance

9 Withdrawal

10

Craving

©  Boston  Children’s  Hospital  2013.  All  Rights  Reserved.  For  permissions  contact  SBIRT  project  manager  at  www.CeASAR.org.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

S2BI Results and Scoring

No Use

• Provide Positive Reinforcement of current behaviors

Couple of Times

• Deliver 2nd set of questions

• Provide Brief Advice

Monthly Use

• Deliver 2nd set of questions

• Assess further using CRAFFT tool

• Perform recommended action based on CRAFFT score

Weekly Use

• Deliver 2nd set of questions

• Assess further using CRAFFT tool

• Perform recommended action based on CRAFFT score

Administer first 3 questions. Stop if all “Never”. Otherwise, administer next set of questions, and follow the instructions below based on the received responses.

No Use

• Provide Positive Reinforcement of current behaviors

Couple ofTImes

• Deliver 2nd set of questions

• Provide Brief Advice

Positive Reinforcement Brief Advice

• Give Positive Feedback/ Words of Encouragement for making good decision to delay initiation of substance use

• Brief, medically-based advice to stop drinking, quit smoking or quit using

marijuana.

• Emphasize teen’s decision NOT to use as appropriate

• Talk about health consequences and relate

advice to patient whenever possible

•For younger  kids  include  “norms  correction”

• Use a Strengths Based Approach, emphasizing patient strengths and the potential impact of alcohol, tobacco and marijuana

© Boston Children’s Hospital 2013. All Rights Reserved. For permissions contact SBIRT project manager at www.CeASAR.org.

Monthly Use Weekly Use

2.Assess Further Using CRAFFT Tool

3. Perform Recommended Action based on CRAFFT Score

1. Administer 2nd Set of Questions

© Boston Children’s Hospital 2013. All Rights Reserved. For permissions contact SBIRT project manager at www.CeASAR.org.

•  The provider has valid, client self-reported informationthat is used in brief intervention.

•  The act of screening sets in motion a process of client reflection on their substance use behavior, and provides a launching point for behavior change.

Prescreening• ASSIST Question #1

o In your life, which of the following substances have you ever used

• Negative Screen? o Inquire (probe) if all answers negativeoProvide feedback about the resultsoOffer prevention-focused educational materials

• Positive Screen? oAdminister Full ASSIST & Determine Level of Service

• Brief intervention • Brief treatment • Referral to treatment

PRESCREENING ACTIVITY

The ASSIST (World Health Organization)• Developed by the ASSIST Working Group in 2002

• Used Primarily to Assess:oFrequency of substance useoCategory/type of substances used oRisk level of alcohol, illicit drugs & tobacco in past 3 months

• Illicit substances (drug use) are weighted differently for men & women

• Use “response card” to help people being interviewed to focus on the questions being asked

The ASSIST V3.0 – Series of 8 Questions

1. In your life, which of the following substances have you ever used? (NON-MEDICAL USE ONLY) (yes/no response) PRESCREENING

2. In the past three months, how often have you used the substances you mentioned (FIRST DRUG, SECOND DRUG, etc.)?

3. During the past three months, how often have you had a strong desire or urge to use (FIRST DRUG, SECOND DRUG, etc.)?

4. During the past three months, how often has your use of (FIRST DRUG, SECOND DRUG, ETC) led to health, social, legal or financial problems?

5. During the past three months, how often have you failed to do what was normally expected of you because of your use of (FIRST DRUG, SECOND DRUG, ETC)?

6. Has a friend or relative or anyone else ever expressed concern about your use of (FIRST DRUG, SECOND DRUG, ETC.)?

7. Have you ever tried and failed to control, cut down or stop using (FIRST DRUG, SECOND DRUG, ETC.)?

8. Have you ever used any drug by injection? (NON-MEDICAL USE ONLY)

ASSIST: Introduction Read to Person

Thank you for agreeing to take part in this brief interview about alcohol, tobacco

products and other drugs. I am going to ask you some questions about your

experience of using these substances across your lifetime and in the past three

months. These substances can be smoked, swallowed, snorted, inhaled, injected or

taken in the form of pills (show drug card).

Some of the substances listed may be prescribed by a doctor (like amphetamines,

sedatives, pain medications). For this interview, we will not record medications that

are used as prescribed by your doctor. However, if you have taken such medications

for reasons other than prescription, or taken them more frequently or at higher

doses than prescribed, please let me know. While we are also interested in knowing

about your use of various illicit drugs, please be assured that information on such

use will be treated as strictly confidential.

NOTE: BEFORE ASKING QUESTIONS,

GIVE ASSIST RESPONSE CARD TO CLIENT

ASSIST Questions 6-8 focus on:

1. Others’ expressing concern about his/her substance use 2. Individual’s failed attempts to stop/cut down, 3. Injection of drugs

Item (past 3 months)

Frequency Score

Q2-d (used ?) Weekly 6

Q3-d (urge/desire?) Once or Twice 4

Q4-d (health, social, legal, financial problems)

Monthly 5

Q5-d (failed to do what was expected of you) Once or Twice 4

Q6-d (friend or relative concern?) Yes, but not in past 3 months

3

Q7-d (tried, but failed to cut down) No, Never 0

Total 22

Example of Scoring: Cocaine/Crack

LowRisk

Moderate Risk

Moderateto

High Risk

Referral to

Treatment

Alcohol 0-10 11-19 20-26 27+

Any other Substance

0-3 4-19 20-26 27+

No Intervention

BriefIntervention

Brief Treatment

HighestRisk

Providing Feedback• Low: You are at low risk of health & other problems

from your current pattern of use.

• Moderate: You are at risk of health & other problems from your current pattern of substance use

• High: You are at high risk of experiencing severe problems (health, social, financial, legal, relationship) as a result of your current pattern of use & are likely to be dependent

Ask: Are you concerned about your substance use?

Example for providing feedback: AlcoholYour risk of experiencing these harms is: Low Moderate High (tick one)Regular excessive alcohol use is associated with:

• Hangovers, aggressive and violent behaviour, accidents and injury• Reduced sexual performance, premature ageing• Digestive problems, ulcers, inflammation of the pancreas, high blood pressure• Anxiety and depression, relationship difficulties, financial and work problems• Difficulty remembering things and solving problems• Deformities and brain damage in babies of pregnant women• Stroke, permanent brain injury, muscle and nerve damage• Liver disease, pancreas disease• Cancers, suicide

FULL SCREENING

ACTIVITY

BRIEF INTERVENTION • 1 to 5 Sessions

• Advise o Review screening results o Provide direct advice to make a changeo Educate on substances & substance use/abuse o Consequences of use & benefits of change

• Assess o Determine how willing the client is to change his/her behavioro Reinforce client’s capacity for change

• Agreeo Set concrete goals

• Assisto Help client to make change if he/she is readyo Outline strategies for success & relapse prevention

Brief Intervention Tools • Individual Record & Plan

• Health Promotion Workbook

• Brief Negotiated Interview Tips

• Educational Materials: Drug Fact Sheets

BRIEF INTERVENTION

ACTIVITY

BRIEF TREATMENT

A 16-session curriculum manual for conducting brief treatment

Dupree & Schonfeld (CSAT, 2005)

Content of 16 SessionsTopics #

Sessions

Introduction to Analysis of Behavior (“A-B-C’s” of Substance Abuse) 2

Social Pressure 2

At Home and Alone 1

Depression 2

Managing Anxiety & Tension 3

Managing Anger & Frustration 3

Controlling Cues 1

Coping with Urges 1

Preventing a Slip from Becoming A Relapse 1

“A-B-C” Approach to Treatment: The Substance Use Behavior Chain

Behavior

Antecedents

Long Term NegativeConsequences

Situations/ + Feelings + Cues + Urges Thoughts

Consequences

First sip of beer

Feel happierHome/alone + bored and depressed + beer in refrigerator + “A drink will help me forget my troubles.”

1st drink orUse of drug

ImmediatePositive or Negative

Continue drinking, anger her children, and impair health

Teaching the Skills Necessary to Prevent RelapseOnce the person demonstrates an understanding of his/her personal substance use

behavior chain, teach specific skills to address his or her high risk situations

CBT & Self-Management Skills High Risk Situation Skills Taught

Social Pressure Drink Refusal

Loneliness Rebuild Social Network

Depression Cognitive RestructuringThought-stopping

Anxiety Relaxation, Problem solvingThought-stopping

Anger/Frustration Assertiveness Training

Cues How to dispose, avoid, rearrange

Urges Thought-stopping, Learn to Delay

Slips Relapse Training

Referral to Treatment • Arrange

oTreatment & Supportive Service Referrals & LinkagesoBased on Client Risks & Needs oConfirm Connections

• Local County Treatment Providers• Established Relationships

oReferral Agreements

• Follow-up RE: Treatment Completion & Outcome

• Offering Continued Availability & Support

SBIRT Evaluation (2 years)• Evaluating Output

oClient Reach oProductivity

• Evaluating Outcome oCompare baseline with 60 day post intervention/treatment

follow-up

• Evaluating Process oAdoption strategiesoProtocols oChallenges & Success

Evaluation Tools • Voluntary Content• Follow-up Consent• Individual Record & Plan • Monthly Report • Provider Meetings • Stakeholder Interviews / Focus Groups• Steering & Advisory Council

DATABASE DEMONSTRATION

& DIALOGUE

www.collaborateandgrow.com/sbirt

SBIRT Billing & Reimbursement

• Affordable Care Act Recommended Service

• Screening & Brief Intervention Reimbursement oCommercial insurance CPT codesoMedicare G codesoMedicaid HCPCS codes

• Florida Medicaid Billing Codes not approved

Payer Code Description Fee Schedule

CommercialInsurance CPT 99408

Alcohol and/or substance abuse structured screening and brief intervention services; 15 to 30 minutes

$33.41

CPT 99409Alcohol and/or substance abuse structured screening and brief intervention services; greater than 30 minutes

$65.51

MedicareG0396

Alcohol and/or substance abuse structured screening and brief intervention services; 15 to 30 minutes

$29.42

G0397Alcohol and/or substance abuse structured screening and brief intervention services; greater than 30 minutes

$57.69

Medicaid H0049 Alcohol and/or drug screening $24.00

H0050 Alcohol and/or drug service, brief intervention, per 15 minutes $48.00

CPT Code Description

90801 Diagnostic interview

90804 Individual psychotherapy, 20‒30 minutes

90806 Individual psychotherapy, 45‒50 minutes

Common Behavioral Health Codes

SBIRT Billing Codes• October 14, 2011 CMS began covering annual alcohol screening & for those that

screen positive up to 4 brief, face-to-face behavioral counseling interventions annually for Medicare beneficiaries including pregnant women. Each of the 4 behavioral counseling interventions must be consistent with the 5As approach:

• Assess: Ask about/assess behavioral health risk(s) and factors affecting choice of behavior change goals/methods.

• Advise: Give clear, specific, and personalized behavior change advice, including information about personal health harms and benefits.

• Agree: Collaboratively select appropriate treatment goals and methods based on the patient’s interest in and willingness to change the behavior.

• Assist: Using behavior change techniques (self-help and/or counseling), aid the patient in achieving agreed-upon goals by acquiring the skills, confidence, and social/environmental supports for behavior change, supplemented with adjunctive medical treatments when appropriate.

• Arrange: Schedule follow-up contacts (in person or by telephone) to provide ongoing assistance/support and to adjust the treatment plan as needed, including referral to more intensive or specialized treatment.

Health Care Providers can provide SBIRT services under Medicare

• Medicare pays for medically reasonable & necessary SBIRT services in physicians’ offices & outpatient hospitals

• Physicians, Physician Assistants, Nurse Practitioners, Clinical Nurse Specialists, Clinical Psychologists, or Clinical Social Workers can bill for SBIRT

• To bill Medicare, providers of MH services must be:oLicensed or certified to perform mental health services

by the state in which they perform the services;oQualified to perform the specific mental health services

rendered; andoWorking within their State Scope of Practice Act

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/SBIRT_Factsheet_ICN904084.pdf

Centers for Medicare & Medicaid (CMS) SBIRT Billing Codes – October 2011

• Two new G codes, G0442 (Annual Alcohol Misuse Screening, 15 minutes), and G0443 (Brief face-to-face behavioral counseling for Alcohol Misuse, 15 minutes)

• Provider specialty types that may submit claims under these codes:01-General Practice 08-Family Practice 11-Internal Medicine 16-Obstetrics/Gynecology 37-Pediatric Medicine 38-Geriatric Medicine 42-Certified Nurse Midwife 50-Nurse Practitioner 89-Certified Clinical Nurse Specialist 97-Physician Assistant

Organization Adoption • Information & Knowledge Sharing• Commitment & Buy-In• Protocols • Tools & Materials • Practice Integration • Fidelity Checks• Professional Development & Competence• Data Management • Continuous Quality Improvement• Sustainability • Coaching & Technical Assistance

QUESTIONSCOMMENTS

& FEEDBACK

CERTIFICATES & EVALUATIONS