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Funded by: www.sbirtonline.org
J. Paul Seale, MDSylvia Shellenberger, PhD
Southeastern Consortium for Substance Abuse Training – Advanced Practice Registered Nurses
Funded by Grant 1U79T1025372-01 Substance Abuse and Mental Health Services Administration (SAMHSA)
Last revised: March 19, 2014
Implementing SBIRT in Your Future Practice
Funded by:
Armstrong Atlantic UniversityAnita Nivens, PhD, RN, FNP-BCLinda Tuck, DNP, APRN-BC
Emory University, Nell Hodgson WoodsonSchool of NursingCarolyn Clevenger, DNP,GNP-BCUrsula Kelly, PhD, ANP-BC,PMHNP-BCPhyllis Wright, DNP, GNP-BC
Georgia College & State UniversityDeborah MacMillan, PhD, CNMSallie Coke, PhD, APRN, C-PNP, C-FNP
Johns Hopkins UniversityChristine Savage, PhD, RN,CARN, FAANDeborah Finnell, DNS, PHMHP-BC, CARN-AP, FAAN
Mercer University, Georgia Baptist College of Nursing
Frieda Fuller Payne, DSN, FNP-BC
South UniversityLaura McKay, DNP, APRN, CNM
University of Alabama, BirminghamSusanne Fogger, DNP, CRNP,PMHNP-BC
University of North GeorgiaSharon Chalmers , PhD, CNE, APRN-BC, FNP
Mercer University, School of MedicinePrincipal Investigator: J. Paul Seale, MDProject Coordinator: Annie Biers, LPC
Sylvia Shellenberger, PhD
Key Contributors and Site Coordinators
At the end of the session, you will be able to—
• Explore models for integrating SBIRT into practices.
• Describe how to build an implementation team.
• Describe ways to monitor and provide feedback to
providers and staff regarding SBIRT implementation.
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Learning Objectives
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Step 1: Mandate & MissionSBIRT Works! There is:
Substantial evidence for the effectiveness of BI for harmful drinking.
A growing body of literature showing the effectiveness of SBIRT for risky drug use.
A recommendation from US Preventive Services Task Force (2013) for alcohol screening for all PC patients (Class B like flu).
A requirement for SBIRT from the American College of Surgeons Committee on Trauma .
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Patients’ Sense of Screening’s Importance
01020304050607080
Very Important
Very Unimportant
Diet/Exercise
Smoking
Drinking
Higgins-Biddle, 2005
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Patients’ Comfort with Screening
01020304050607080
Very Comfortable
Very Uncomfortable
Diet/Exercise
Smoking
Drinking
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SBIRT Toolkit on the Web
SBIRT Pocket card
Initial Screening and Screening tools-- AUDIT & DAST
Clinic/Practice Implementation Guides
Program Monitoring Tools e.g., chart audits
Consent forms for research
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SAMHSA Implementation Guides
Website http://www.integration.samhsa.gov/clinical-
practice/sbirt
Includes guides for emergency nurses, trauma centers, community and behavioral health centers, youth, and college and university campuses
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Three Models for Implementing SBIRT into
an APRN’s Practice
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• Involves only the APRN
• Ask a single initial screening question for alcohol and drugs
• If positive, ask patient to complete the AUDIT and/or DAST, while seeing another patient
• Score, conduct brief intervention, refer if indicated
• Return to discussion of alcohol/drugs at next visit
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Overcoming Obstacles As the “Lone Ranger” you may get push back
from others. Keep your pocket card and screening instruments handy on a thumb drive, and perform SBIRT!
As more graduates have these skills and pollinate practice settings, SBIRT will flourish.
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• Staff or medical assistant asks the single initial screening question for alcohol and drugs
• If positive response, staff or medical assistant asks patient to complete AUDIT and/or DAST. Records results in EMR/HER
• APRN performs brief intervention and refers or arranges for follow-up
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• Create a system to support SBIRT using implementation guide in toolkit
• Develop implementation team
• Train clinicians and staff in SBIRT• Assign SBIRT roles
• Assign SBIRT tasks• Set up EMR/HER system to document SBIRT
• Use a monitoring & feedback system to reinforce continued performance of SBIRT
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Pearls for Implementing SBIRT in Your Practice
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Pearl 1: Think Systems!
Think of all the pieces to SBIRT:
Initial screening
Screening
Intervention
Referral
Documentation
Billing & follow-up
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Pearl 2: Identify Power Brokers & Get Their Buy-In!
Identify clinical leaders
Identify key non-clinical leaders
Meet with them individually or as a group
Educate them about SBIRT and ask fortheir support and participation
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Pearl 3: Building the Team
Create a working groupInclude all staff who are responsible for patient care, records, materials, or otheraspects of implementation
Brainstorm: What will it take to implementthis intervention in our practice?
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Pearl 4: Involve Staff Early
Invite participation
Address concerns
Anticipate problems or barriers
Schedule regular meetings
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Pearl 5: Provide TrainingTo team members who may
include MDs, APRNs, PAs, Nurse educators, Mental Health clinicians
Train them on the various components of SBIRT so that they see how every part works together
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Pearl 6: Adapt Procedures to Your Setting
Outline & assign SBIRT tasks
Assignments depend on size of practice
Facilitate adaptation of the process to fit individual practice
needs
Guide & influence this process, keeping your goal in mind
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Assigning TasksTasks Who Where
Initial screening “Do you smoke cigarettes or use tobacco?”(Men) “How many times in the past year have you had more than 5 drinks in a day?” (Women or Seniors) “How many times in the past year have you had more than 4 drinks in a day?”“How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?”
Screening Tool AUDIT/DAST
Intervention Brief Negotiated Interview
Referral
Follow-up Follow up by telephone (optional)Send congratulatory letters (optional)
Documentation Document status for checking at next visit
Billing
Administrative Support
Keep materials stockedCompile follow-up results
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Pearl 7: Look for Allies to Increase SBIRT Capacity
Clinicians’ rates of intervention greatly increased when they worked as a team with
Nurses/medical assistants initiating and recording screening questions with patient’s vital signs
Nurses/medical assistants requesting patients to complete an AUDIT screening questionnaire for the clinician’s review
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Pearl 8: Monitor and Provide Feedback
Most health workers are very busy.
Busy workers stop doing jobs that noone cares about.
Monitoring & Feedback says “This service is important to the health of our patients.”
Possible methods: count AUDIT sheets,include SBIRT measures in routine chartaudits, monitor diagnosis or billing data.
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Pearl 9: Addressing SBIRT Reimbursement
Use Medicare/Medicaid Billing Codes forSBIRT
H0049 Alcohol and Drug ScreeningH0050 Alcohol and Drug Services
(15 minutes)
Bill higher level codes as appropriate for complex patients requiring longer interventions.
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Use What You’ve Learned – Your Patients Need It!
Contact us if we can help!email: [email protected]
All Toolkit Materials available on the web
Good luck!
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QUESTIONS?
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Scenarios to accompany this module
Case to discuss with other students: You recently graduated from APRN school and six months ago joined a group practice. You have learned about the importance of screening and brief intervention for alcohol and substance abuse and would like to incorporate attention to this health issue in your services.
See the list of questions to discuss with your group.
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References
Higgins-Biddle J. 2005
SAMHSA Whitepaper, 2011 (http://www.samhsa.gov/prevention/sbirt/SBIRTwhitepaper.pdf)
Seale JP, Shellenberger S, Velasquez MM, Boltri JM, Okosun I, Guyinn M, Vinson D, Cornelius M, Johnson AJ. Impact of vital signs screening & clinician prompting on alcohol and tobacco screening and intervention rates: a pre-post intervention comparison. BMC Family Practice 2010;11:18
