Transcript State Forum on Screening, Brief Intervention and Referral to Treatment

Delivering SBIRT:
A “How To” on
Screening, Brief Intervention, and Referral to Treatment
Presented by
Acknowledgements
Many persons have provided input into the content and to the creation of this
series, including:
Dan Alford, MD
Edward Bernstein, MD, FACEP
David Feillin, MD
Joe Hyde, MA, LMHC, CAS
Jennifer Kasten, PhD
Mike Lardiere, LICSW
Paula Lum, MD
Bill McFeature, PhD
John Muench, MD, MPH
Michael Pantalon, PhD
Janice Pringle, PhD
Rich Saitz, MD
James Paul Seale, MD
Daniel Vinson, MD, MSPH
Welcome
Housekeeping
Today’s Agenda
• 9:00 a.m.—What Is SBIRT and Why?
• 10:15 a.m.—Break
• 10:30 a.m.—The Business of SBIRT
– Implementation in diverse practice settings
– Billing and reimbursement
• 12:00 p.m.—Lunch (on your own)
• 1:30 p.m.—Orientation to the SBIRT Clinical Intervention
• 3:00 p.m.—Break
• 3:15 p.m.—Continue program
• 5:00 p.m.—Adjourn
Session 1: What Is SBIRT and Why?
By the end of this session participants will able to:
• Describe what SBIRT is and its supporting evidence.
• Describe its value for patients, payers, policymakers,
physicians, and allied health and human service
professionals.
• Better answer the question: Why might I choose to
support SBIRT implementation?
SBIRT Defined
Screening, Brief Intervention, and Referral to Treatment
(SBIRT) is a comprehensive, integrated, public health
approach to the delivery of early intervention and
treatment services
– For persons with substance use disorders.
– For those whose use is at higher levels of risk.
Primary care centers, hospitals, and other community
settings provide excellent opportunities for early
intervention with at risk substance users and for
intervention for persons with substance use disorders.
Question?
Why might I choose to support SBIRT implementation?
Continuum of Substance Use
Severity
ABSTAINERS &
LOW RISK USERS
(70%)
MODERATE TO
HIGHER RISK
25%
SEVERE and
DEPENDENT
(5%)
Why is SBIRT Important?
• Unhealthy and unsafe alcohol and drug use
are major preventable public health problems
resulting in more than 100,000 deaths each
year.
• The costs to society are more than $600 billion
annually.
• Effects of unhealthy and unsafe alcohol and
drug use have far-reaching implications for the
individual, family, workplace, community, and
the health care system.
Harms Related to Hazardous
Alcohol and Substance Use
Increases the risk for:
• Injury/trauma
• Criminal justice involvement
• Social problems
• Mental health consequences (e.g., anxiety, depression, etc.)
• Increased absenteeism and accidents in the workplace
Unfortunately, These Kinds of
Experiences Remain too Commonplace
Medical and Psychiatric Harm
of High Risk Drinking
And the Evidence Indicates That Moderate Risk and High
Risk Drinkers Account for the MOST Problems
High Risk Drinker
Moderate Drinkers
Health
Spouse
Light Drinkers
100%
80%
60%
40%
20%
0%
Aggression
Job
Friends
Accidents
Historic Response to Substance Use
Previously, substance use intervention and treatment
focused primarily on substance abuse universal
prevention strategies and on specialized treatment
services for those who met the abuse and dependence
criteria.
There was a significant gap in service systems for at risk
populations.
In the Emerging Public Health Paradigm,
All Services Are Aligned
Primary Prevention
Early Intervention
Universal Prevention
Selective Prevention
Indicated Prevention
SBIRT
and other brief interventions
Treatment
Evidence-based practices with
recovery supports (ROSC)
Maintenance
Recovery supports, self-help,
etc. (ROSC)
Goal
The primary goal of SBIRT is to identify
and effectively intervene with those who
are at moderate or high risk for psychosocial or health care problems related to
their substance use.
Research Demonstrates Effectiveness
• A growing body of evidence about SBIRT’s
effectiveness—including cost-effectiveness—
has demonstrated its positive outcomes.
• The research shows that SBIRT is an effective
way to reduce drinking and substance abuse
problems.
Research Shows
Brief Interventions:
• Are low cost and effective.
• Are most effective among persons with less severe
problems.
• “Brief interventions are feasible and highly effective
components of an overall public health approach to
reducing alcohol misuse.”
(Whitlock et al. 2004, for US Preventive Services Task Force)
Making a Measurable Difference
• Since 2003, SAMHSA has supported SBIRT
programs with over 1.5 million persons screened.
• Outcome data confirm a 40% reduction in
harmful use of alcohol by those drinking at risky
levels and a 55% reduction in negative social
consequences.
• Outcome data also demonstrate positive benefits
for reduced illicit substance use.
Based on review of SBIRT GPRA data (2003-2011).
SBIRT is a Highly Flexible Intervention
SBIRT Settings
Aging/Senior Service
Behavioral Health Clinic
Community Health Center
Community Mental Health Center
Drug Abuse/Addiction Services
Emergency Room
FQHC
Homeless Facility
Hospital
Inpatient
Primary Care Clinic
Psychiatric Clinic
School-Based/Student Health
Trauma Centers/Trauma Units
Urgent Care
Veteran’s Hospital
Other Agency Sites
Medical Specialty Areas
So What Is SBIRT?
An intervention based on “motivational interviewing” strategies
• Screening: Universal screening for quickly assessing use and
severity of alcohol, illicit drugs, and prescription drug abuse.
• Brief Intervention: Brief motivational and awareness-raising
intervention given to risky or problematic substance users.
• Referral to Treatment: Referrals to specialty care for patients
with substance use disorders.
Treatment can consist of brief treatment or specialty AOD
treatment.
Why Universally Screen?
• To detect current health problems related to at risk
alcohol and substance use at an early stage, before
they result in more serious disease or other health
problems.
• To detect alcohol and substance use patterns that can
increase future injury or illness risks.
• To intervene and educate about at risk alcohol and
other substance use.
Rationale for Universal Screening
• Drinking and drug use are common.
• Drinking and drug use can increase the risk
for health problems, safety risks, and a host
of other issues.
• Drinking and drug use often go undetected.
• People are more open to change than you
might expect.
Patients Are Open to Discussing Their
Substance Use to Help Their Health
Survey on Patient Attitudes:
Agree/Strongly Agree
“If my doctor asked me how much I drink, I would give an
honest answer.”
92%
“If my drinking is affecting my health, my doctor should advise
me to cut down on alcohol.”
96%
“As part of my medical care, my doctor should feel free to ask
me how much alcohol I drink.”
93%
Disagree/Strongly Disagree
“I would be annoyed if my doctor asked me how much alcohol
I drink.”
86%
“I would be embarrassed if my doctor asked me how much
alcohol I drink.”
78%
Source: Miller, PM, et al. Alcohol & Alcoholism; 2006
Adapted from The Oregon SBIRT Primary Care Residency Initiative training curriculum (www.sbirtoregon.org)
Based on Findings of Screening
SBIRT Reduces Short- and Long-Term
Healthcare Costs
• By intervening early, SBIRT saves lives and money.
• Late-stage intervention and substance abuse
treatment is expensive, and the patient has often
developed co-morbid health conditions.
SBIRT Decreases the Frequency and
Severity of Alcohol and Drug Use
Primary care is one of the most convenient points of
contact for substance issues. Many patients are more
likely to discuss this subject with their family
physician than a relative, therapist, or rehab
specialist.
SBIRT Integrates Primary Care With
Behavioral Health in a Medical Home Model
Given how widespread substance abuse is nationwide, it
makes good sense for primary care practitioners—rather
than trauma centers or rehab specialists—to be the first
line of substance abuse response. In many areas,
primary care practitioners are the only healthcare
providers.
SBIRT Is an Important Part of Wellness
and Prevention Programs
• Patients often don’t understand how alcohol and drug use
impacts their health, or if the amounts they use are
dangerous.
• Research from the World Health Organization and the Centers
for Disease Control and Prevention has shown that alcohol is a
major risk factor for a number of medical, social, and legal
problems.
• SBIRT opens up a dialogue that can improve your patients’
overall health.
So Why is SBIRT Important for Payers
and Policymakers?
For Payers and Policymakers,
SBIRT Makes Good Financial Sense
Summary of Findings of the Alcohol Misuse Screening and
Behavioral Counseling: Technical Report* submitted to the US
Preventative Services Task Force.
 Average cost for SBIRT intervention: $44.91
 Net healthcare cost savings annually per person: $254.00
 Net healthcare cost savings per million adults: $254,000,000
*Alcohol Misuse Screening and Behavioral Counseling: Technical Report Prepared for the National Commission
on Prevention Priorities (2008), (pp. 20‒22). Michael V. Maciosek, PhD*, Leif I. Solberg, MD*, Nichol M.
Edwards, MS*, and Dana A. McGree* under contract from the Centers for Disease Control and Prevention (CDC)
and the Agency for Healthcare Research and Quality (AHRQ).
SBIRT and Cost
Wisconsin SBIRT Cost Benefit Studies
• Reduction in hospital costs, ED visits, and associated problems resulted in
$1,000 savings per person screened (Primary Care Setting. Fleming, M.F., Med
Care, 2000).
Texas SBIRT Cost Benefit Studies
• A net savings of $4.00 in ED costs for every $1.00 invested in SBIRT screening
and brief intervention. ED saw a 50% reduction in recurrent alcohol-related
injuries (Gentilello, L.M., Ann Surg, 1999) .
Washington State Cost Benefit Studies
• Reduction in Medicaid-specific expenditures $185.00 per month per patient
who received SBIRT screening and brief intervention (Disabled Medicaid
patients in emergency room setting. Estee S. Medicaid Cost Outcomes, Interim
Report 4.61.1.2007.2, Washington State Department of Social and Health
Services).
SBIRT Improves the Health and
Welfare of the Whole Community
• Improves public safety
• Reduces social and workplace problems with
at risk users
• Reduces family conflict
• Supports health and wellness of the whole
community
Lessons Learned
• SBIRT is a brief and highly adaptive evidencebased practice with demonstrated results.
• SBIRT has been successfully implemented in
diverse sites across the lifespan.
• Patients are open to talk with trusted helpers
about substance use.
• SBIRT can make a difference in the lives of the
people you serve.
Question?
Why might you want to implement SBIRT?
After Break We Will Discuss
•
•
•
•
•
•
The business of implementing
Readiness
Who needs to be involved
What's needed to be successful
What a successful practice model looks like
Billing and reimbursement
Break Time
Session 2
The Business of SBIRT…
SBIRT Implementation in Diverse
Practice Settings
Session Objectives
•
•
•
•
•
Review the business side of implementing SBIRT.
Evaluate program readiness.
Who needs to be involved?
What does a successful practice model look like?
What is a successful business model?
Building Readiness
Is there:
1.
2.
3.
4.
5.
Program leadership buy-in?
Sufficient key stakeholder buy-in?
A recognized problem/need/issue?
A clearly defined benefit/outcome?
A sufficient business case to be made?
1. Program Leadership Buy-in
•
•
•
•
•
•
•
Consistent with the mission
Adds value to services
Fits with operations and population served
Sufficient business case
Champion
Recognize problem/need/issue?
Understand benefit/outcome?
2. Stakeholder Involvement
• Stakeholder involvement is critical.
• Substance abuse is a much larger problem than
can be solved by one single agency, and it
affects the well-being of the entire community.
• Empowering stakeholders:
– Builds shared ownership.
– Aligns the efforts of all community stakeholders.
– Increases access to resources.
– Supports sustainability.
Building Supportive Partnerships
Who are the stakeholders you want to engage?
Policymakers
Community
Treatment
Providers
Payers
Leadership
Successful
Implementation
Others
Population
Served
Business
Staff
Clinicians
Each Stakeholder Has a Vested Interest
in Improved Health Outcomes
•
•
•
•
•
Primary care
Treatment providers
Government and private payer entities
Patients
Employers
Each understands the problem, measures value,
and correlates costs differently.
Stakeholder Communication
• Government and private payer entities
analyze the cost: benefit ratios of SBIRT in
comparison with or contrast to other public
health initiatives.
• If you show these stakeholders cost without
the benefit part of the ratio, you will fall
behind a long line of competitors for scarce
resources.
Clearly Defined Benefit/Outcome
Payers and Policymakers
• SBIRT makes good financial sense.
• SBIRT reduces short- and long-term healthcare
costs.
• SBIRT has demonstrated positive outcomes.
Clearly Defined Benefit/Outcome
Clinicians
• SBIRT decreases the frequency and severity of
drug and alcohol use.
• SBIRT is an important part of wellness and
prevention programs.
• Adequate resources
Remember To Align Your Message
Not
Small Group Discussions
• Identify leaders or key stakeholders of your
choice.
• Brainstorm information and strategies that
you can provide to support your case.
• Identify data gaps that you need to fill in order
to strengthen your case.
Making a Business Case
Key questions to answer…
Does your program have:
1. A sufficient workforce?
2. A supportive policy environment?
3. Supportive infrastructures?
And Are There Sufficient Resources?
• If SBIRT billing codes are not activated in your
State, investigate what, and whom, it would
take to activate codes or what alternative
codes or funding can be used (behavioral
health, prevention, etc.).
• This process will take considerable effort.
• If there are not sufficient resources,
implementation and sustainability are
seriously challenged.
Goal
Thoughts and Questions About
Readiness Factors
Essentials of
Successful Practice Models
Lessons Learned From the Trenches:
• Adequate staffing and leadership are in place.
• Who delivers the intervention and how they do it is
influenced by the facility’s unique context.
• Based on an analysis of the workflow and clinic
systems, develop an implementation model for your
site.
• Most commonly, the model involves collaboration
between a primary care provider and allied staff.
Example
Clinic A has integrated SBIRT within the patientcentered medical home model. Within this
team-oriented approach, the front desk staff,
allied staff, and the clinician together carry out
the SBIRT intervention.
Staffing Models
Integrated Behavioral Health
Allied Health:
Medical Assistants and Health
Educators
Consider the staffing options available for implementing
your model.
Will you use health educators and allied staff or licensed
behavioral health care professionals to screen, conduct
brief intervention, and manage referral to treatment?
Will brief treatment be delivered by staff within the practice
or referred to a specialty treatment provider?
Integrated Behavioral Health
Strengths
• Integrated care
• More responsive
• Broader range of skills
• Able to bill a wider range of codes
• Revenue-generating position
• Consistent with ACA
Limitations
• Higher expense for position
• Modified billing procedures
• May have to expand areas of accreditation
• May involve different sets of regulations (HIPPA and 42CFR pt2)
Medical Assistant or Health Educator
Strengths
• Easier fit with traditional staffing models
• Affordable
• Flexible credentialing
• No modification of accreditation required
Limitations
• Reimbursement
• Full utilization of the position
Questions About Practice Models
Financing and Reimbursement
Financial modeling can help you consider
adaptations to your SBIRT model to support a
more sustainable service design.
What Is Financial Modeling?
• Financial modeling is building a mathematical
model designed to represent the performance of
an intervention or a project to help assess
feasibility.
• SBIRT should not be considered as a stand-alone
service, just as treating a sinus infection is not a
stand-alone service. These are interventions that
are part of a routine menu of services.
Elements in Financial Model
Costs
• Time of
• Physician
• Allied staff
• Support
staff
• BH staff
• Operating
expenses
Revenue
• Insurance
reimbursement
• Other income
Other Benefits
• Patient
outcomes
• Risk
management
• Other benefits to
the organization
SBIRT Coding
http://sbirt.samhsa.gov/coding.htm
Common Behavioral Health CPT Codes
CPT Code
Description
90801
Diagnostic interview
90804
Individual psychotherapy, 20‒30 minutes
90806
Individual psychotherapy, 45‒50 minutes
90847
90846
90849
Family psychotherapy with patient present
Family psychotherapy without patient present
Multiple-family group psychotherapy
90853
Group psychotherapy
Other ICD-9 Codes Used for SBIRT
ICD-9 Codes
Description
V82.9
Screening for unspecified condition
V28.9
Unspecified antenatal screening
V65.40
Other counseling, not otherwise specified
(NOS)
V65.42
Other counseling, substance use and abuse
V65.49
Other specified counseling
http://www.wiphl.com/uploads/media/SBIRT_Manual.pdf
A Simple Billing/Revenue
Model for SBIRT
New patient
25% of all
patients
Patent prescreened as
part of admissions
Patient with positive
screen completes AUDIT
with staff (#99408)
Need for BI
BI conducted
(#99408 or #99409)
Follow up BI or TX
(#99408 or #99409)
(#90801, 90806, etc.)
Summary of Business Model
• Essentials of successful practice models
• Based on an analysis of the workflow and clinic systems,
develop an implementation model for your site
• Most commonly, the model involves teaming between a
primary care provider and allied staff
• Financing and reimbursement
• SBIRT should not be considered as a stand alone service
• Elements in financial model—costs, revenues, and other
benefits
⁻ Billing/revenue model for SBIRT
Questions and Comments
Integrating SBIRT Into the EMRs
• Has multiple dimensions of value.
• Supports quality documentation and
coordinated communication among providers.
• Prompts screening and followup activities.
• Supports monitoring, fidelity of implementation,
and billing.
SBIRT and EMRs
Electronic medical record tools can also remind
providers and encourage billing for
reimbursement when an SBIRT intervention is
performed.
SBIRT and EMRs
One program developed an SBIRT “Smart Set” to
facilitate data entry, screening information, BI
information, physician notes, billing information,
and prescription notes.
Documentation Should Include
• Standardized screening tool results
• Feedback
• Discussion of negative consequences
• Motivation
• Behavior change options
• Agreed upon behavior change
• Followup plan
Source: http://www.wiphl.com/uploads/media/SBIRT_Manual.pdf
In Conclusion: If You Are Planning on
Implementing SBIRT
Convene an implementation team that includes:
• Leadership
• Business office
• Medical staff leadership
• Allied staff
• Administrative staff
• QI
Develop a Plan
• Seek guidance from a place similar to yours.
• Take a road trip.
• Most important of all……get started!
Questions?
After Lunch
Session 3:
• An orientation to the SBIRT intervention
• A primer in motivational interviewing
• Use of standardized screening tools
• An introduction to a BI model—the Brief
Negotiated Interview
• An opportunity to practice SBIRT Skills
Session 3
Screening, Brief Intervention, and Referral to
Treatment
Objectives
•
•
•
•
Orient to the SBIRT intervention
Primer in motivational interviewing
Review use of standardized screening tools
Introduce a model of brief intervention—the
Brief Negotiated Interview
• Practice SBIRT skills
SBIRT
Screening, Brief Intervention, and Referral to
Treatment is defined by SAMHSA as an
integrated and comprehensive intervention for
substance use disorders.
This intervention, otherwise known as SBIRT,
makes use of public health approaches,
including universal screening and interventions
based on motivational interviewing strategies.
So What Is the SBIRT Intervention?
An intervention based on “motivational interviewing” strategies
1.
Screening: Universal screening for quickly assessing use
2.
Brief Intervention: Brief motivational and awareness-
3.
Referral to Treatment: Referrals to specialty care for
and severity of potential alcohol, illicit drugs, and
prescription drug abuse.
raising intervention given to risky or problematic substance
users.
patients with substance use disorders. Treatment can be
brief treatment or specialty AOD treatment.
Goal of SBIRT
The primary goal of SBIRT is to identify
and effectively intervene with those who
are at moderate or high risk for psychosocial or health care problems related to
their substance use.
Substance Use Continuum
Ranging from:
• Abstinence
• Moderate use (lower risk use)
• “At risk” use (higher risk use)
• Abuse
• Dependence
Substance Use
Disorders (SUD)
Rationale for Universal Screening
• Drinking and drug use is common.
• Drinking and drug use can increase risk for
health problems, safety risks, and a host of
other issues.
• Drinking and drug use often go undetected.
• Patients are more open to discuss their use
and change than you might expect.
Prescreening
Prescreen: Do you sometimes drink beer,
wine, or other alcoholic beverages?
NO
YES
NIAAA Single Screener: How many
times in the past year have you had
5 (men) or 4 (women or patients
over age 65) drinks or more in a day?
Sensitivity/Specificity: 82%/79%
If one or more affirmative answers
move on to full screen.
Source: Smith PC, Schmidt SM, Allensworth-Davies D, Saitz R. Primary care validation of a
single-question alcohol screening test. J Gen Intern Med 2009; 24(7):783-8
Screening Strategy
Use brief yet valid
screening questions:
Negative
• Based on previous
experiences with
SBIRT, screening will
yield 75% negative
responses.
Positive
• If you get a positive
screen, you may ask
further assessment
questions.
• The NIAAA Single
Question Screener
• The Single Question
Drug Screener
Drinking Limits
Recommended Limits
Men = 2 per day/14 per week
Women/anyone 65+ = 1 per day or 7 drinks per week
Determine the average drinks
per day and average drinks per
week, and ask:
> Regular Limits = At Risk Drinker
On average, how many days a week
do you have an alcoholic drink?
On a typical drinking day, how many drinks
do you have? (Daily average)
Weekly average = days X drinks
A Positive Alcohol Screen
= At Risk Drinker
Binge drink
(5 for men or 4 for women/anyone 65+)
Does patient exceeds regular limits?
(Men: 2/per or 14/week
Women/anyone 65+: 1/day or 7/week)
NO
Patient is at low risk. Move to drug
screen.
YES
Patient is at risk. Screen for maladaptive
pattern of use and clinically significant
alcohol impairment using AUDIT.
It’s Useful to Clarify What is One Drink!
How Much Is “One Drink”?
5-oz glass of wine
(5 glasses in one bottle)
1.5-oz spirits
80-proof
1 jigger
12-oz glass of beer (one can)
Equivalent to 14 grams pure alcohol
AUDIT
Alcohol Use Disorders Identification Test
What is it?
• Ten questions, self-administered or through an interview, addresses recent
alcohol use, alcohol dependence symptoms, and alcohol related problems
• Developed by World Health Organization (WHO)
What are the strengths?
• Public domain—test and manual are free
• Validated in multiple settings including primary care
• Brief, flexible
• Focuses on recent alcohol use
• Consistent with ICD-10 and DSM IV definitions of alcohol dependence, abuse,
and harmful alcohol use
Limitations?
• Does not screen for drug use or abuse, only alcohol
AUDIT Questionnaire
WHO, 1992
AUDIT Domain
WHO, 1992
Scoring the AUDIT
Dependent Use (20+)
Harmful Use (16‒19)
At Risk Use (8‒15)
Low Risk (0‒7)
Screening for Drugs
“How many times in the past year have you used an illegal drug or used a
prescription medication for non-medical reasons?”
(…for instance because of the feeling it caused or experiences you have…)
If response is “None,” screening is complete.
If response contains suspicious clues, inquire further.
Sensitivity/Specificity: 100%/74%
Source: Smith P.C., Schmidt S.M., Allensworth-Davies D, Saitz R. A single-question screening test for drug
use in primary care. Arch Intern Med 2010; 170(13):1155-60.
A Positive Drug Screen
ANY positive on the drug screen question puts the patient in an “at
risk” category. The followup questions are to assess impact and
whether or not use is serious enough to warrant a substance use
disorder diagnosis.
Ask which drugs the patient has been using, such as:
cocaine, meth, heroin, ecstasy, pot, vicodin, valium, etc.
Determine frequency and quantity.
Ask about negative impacts.
DAST (10)
What is it?
• Shortened version of DAST 28, containing 10 items, completed as selfreport or via interview. DAST(10) consists of screening questions for at
risk drug use that parallel the MAST (an alcohol screening instrument).
• Developed by Addiction Research Foundation, now the Center for
Addiction and Mental Health.
• Yields a quantitative index of problems related to drug misuse.
What are the strengths?
• Sensitive screening tool for at risk drug use.
What are the weaknesses?
• Does not include alcohol use.
DAST(10) Questionnaire
Source: Yudko et al., 2007
DAST(10) Interpretation
Yudko et al., 2007
Scoring the DAST(10)
High Risk (6+)
Harmful Use (3‒5)
Hazardous Use (1‒2)
Abstainers (0)
Key Points for Screening
•
Screen everyone.
•
Screen both alcohol and drug use including Rx abuse and
tobacco.
•
Use a validated tool.
•
Prescreening is usually part of another health and wellness
survey.
•
Explore each substance; many patients use more than one.
•
Follow up positives or "red flags" by assessing details and
consequences of use.
•
Use your MI skills and show nonjudgmental, empathic verbal
and non-verbal behaviors during screening.
Questions/Discussion About Screening
An Accelerated Course in
Motivational Interviewing (MI)
Brief Intervention Is Based in MI
• “MI is a directive, client-centered method for
enhancing intrinsic motivation for change by
exploring and resolving ambivalence” (Miller
and Rollnick, 2002).
• “MI is a way of being with a client, not just a
set of techniques for doing counseling” (Miller
and Rollnick, 1991).
Adapted from NIDASAMHSA Blending Initiative
MI—The Spirit (1): Style
•
•
•
•
•
•
Nonjudgmental and collaborative
Based on client and clinician partnership
Gently persuasive
More supportive than argumentative
Listens rather than tells
Communicates respect for and acceptance of
clients and their feelings
MI—The Spirit (2): Style
• Explores client’s perceptions without labeling
or correcting them.
• Involves no teaching, modeling, or skilltraining.
• Resistance is seen as an interpersonal
behavior pattern influenced by the clinician’s
behavior.
• Resistance is met with reflection.
Where Do I Start With a Patient?
• What you do depends on where the patient is
in the process of changing.
• The first step is to engage the patient
respectfully to be able to identify where the
client is coming from.
Stages of Change
Prochaska and DiClemente
The Concept of Ambivalence
• Ambivalence is normal.
• Patients usually have fluctuating and
conflicting motivations.
• Patient “wants to change and doesn’t want to
change.”
• “Working with ambivalence is working with
the heart of the problem.”
Activity 1: Reflection
• Take some time to think about a
difficult change that you had to
make in your life.
• How much time did it take you
to move from considering that
change to actually taking action.
Principles of
Motivational Interviewing
“People are better persuaded by the reasons
they themselves discover than by those that
come into the minds of others.”
—Blaise Pascal
MI: Principles
Motivational interviewing is founded on four basic
principles:
Express empathy.
Develop discrepancy.
Roll with resistance.
Support self-efficacy.
Reflective Listening Key Concepts
• Listen to both what the person says and to what
the person means.
• Check out assumptions.
• Create an environment of empathy
(nonjudgmental).
• You do not have to agree.
• Be aware of intonation (statement, not question).
Core MI Skills




Open-ended questions
Affirmations
Reflections
Summaries
Providing Feedback
1. Elicit (ask for permission).
2. Give feedback or advice.
3. Elicit again (the person’s view of how the
advice will work for him/her).
SBIRT Brief Intervention Based in MI
• There are a number of examples for brief
intervention including the “Brief Negotiated
Interview” (BNI), originally developed by Gail
D’Onofrio MD, Ed Bernstein MD, and Steven Rollnick
MD.
• The BNI is a semi structured interview process based
in motivational interviewing that is a proven
evidence-based practice that can be completed in 5
to 15 minutes.
Goals of Brief Intervention
• For the at risk user: The goal is to negotiate a
reduction in use to lower risk levels.
• For the person who appears to have a substance use disorder: The goal is to negotiate a
treatment referral for full assessment and a
level of intervention to be determined.
Starting off….
How Not to Intervene
http://www.bu.edu/bniart/sbirt-in-health-care/sbirteducational-materials/sbirt-videos/
Steps in the BNI
1.
2.
3.
4.
5.
Build rapport—raise the subject.
Discuss the pros and cons of use.
Provide feedback.
Build readiness to change.
Negotiate a plan for change.
1. Build Rapport—Raise the Subject
1. Begin with a general conversation.
2. Ask permission to talk about alcohol or
drugs:
– Would you mind taking a few minutes to talk with
me about your use of alcohol (or X)?
– What’s a normal day look like for you and where
and how does alcohol fit?
2. Discuss the Pros and Cons of Use
1. Help me understand through your eyes. What
are the good things about using alcohol?
2. What are some of the not so good things
about using alcohol?
3. Summarize using a decisional balance…
– So on the one hand “PROS,” and on the other hand
“CONS.”
3. Provide Feedback
1. Ask permission to give information:
– I have some information about guidelines for low•risk
drinking; would you mind if I shared them with you?
– We know that drinking 4 or more (F), 5 or more (M)
drinks in one sitting, or more than 7 (F), 14 (M) in a
week, and/or use of illicit drugs can put you at risk for
illness or injury and other problems.
2. Discuss screening findings.
3. Link use behaviors to any known consequences.
4. Elicit a reaction.
4. Build Readiness to Change
• So could we talk for a few minutes about your interest in making a
change?
• On a scale from 1‒10, with 1 being not ready at all and 10 being
completely ready, how ready are you to make any changes in your
alcohol use?
• You marked (or said)___. That’s great. That means you are ___ %
ready to make change.
• Why did you choose that number and not a lower one like a 1 or a
2? Sounds like you have some important reasons for change.
5. Plan for Change
• A plan for reducing use to low risk levels
OR
• An agreement to follow up with specialty
treatment services
How To Intervene
BNI Video Demonstration
http://www.bu.edu/bniart/sbirt-in-health-care/sbirt-educationalmaterials/sbirt-videos/
BNI Practice Session
•
•
•
•
Roles
Patient
Interviewer
Observer
Process Role Play
Closing Discussion
Why might you choose to implement SBIRT?
Questions?
References
SBIRT Additional Information:
World Health Organization. Brief Intervention for Substance Use: A Manual for Use in Primary Care—
http://www.who.int/substance_abuse/activities/en/Draft_Brief_Intervention_for_Substance_Use.pdf
National Institute on Alcohol Abuse and Alcoholism’s Helping Patients Who Drink Too Much: A Clinician’s
Guide: http://pubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2005/clinicians_guide.htm
Center for Substance Abuse Treatment. Alcohol Screening and Brief Intervention (SBI) for Trauma Patients:
Committee on Trauma Quick Guide, Substance Abuse and Mental Health Services Administration, DHHS
Publication No. (SMA) 07-4266. Washington, DC: U.S. Government Printing Office, 2007. Available at
http://sbirt.samhsa.gov/documents/SBIRT_guide_Sep07.pdf
D’Onofrio G, Bernstein E, Rollnick S. Motivating patients for change: a brief strategy for negotiation. In:
Bernstein E, Bernstein J (eds). Case studies in Emergency Medicine and the health of the Public. Boston:
Jones and Bartlett, 1996, pp. 295‒303
References (cont.)
D’Onofrio G, Pantalon MV, Degutis LC, Fiellin DA, O’Connor PG. Development and implementation of an
emergency practitioner-performed brief intervention for hazardous and harmful drinkers in the emergency
department. Academy of Emergency Medicine 2005; 12: pp. 249‒256
Babor, T.F.; McRee, B.G.; Kassebaum, P.A.; Grimaldi, P.L.; Ahmed, and K.;Bray, J.; Screening, brief
intervention, and referral to treatment (SBIRT): toward a public health approach to the management of
substance abuse. Substance Abuse. 28: pp. 7‒30.