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Adding SBIRT to the Process

SBIRT is intended to be a standard of care, and as such, it should be incorporated into your standard patient procedure. The SBIRT process does not require a large time investment per patient. It is feasible to fit the various SBIRT actions into the "gaps" in your current flow in a manner that is minimally disruptive. The goal of this article is to guide you through the steps of developing an SBIRT procedure that is tailored to your clinic.

When designing a procedure, the following elements must be included:

  1. Action Steps - Decide which screening and intervention actions to include in the procedure.
  2. Staffing and Timing - Select which staff roles will complete those actions. Choose a time and place in your current patient flow to insert those actions.
  3. Documentation and Communication - Plan how the SBIRT data generated by those actions will be documented in the electronic health record (EHR) and communicated between staff members.

These decisions must be made for each of the three key components of SBIRT: Prescreening, Full Screening, and Intervention. Click on the sections below to learn about each component.

You can also watch our 20 minute webinar on procedure design for further information.

Prescreening

Prescreening is a brief questionnaire that quickly and accurately separates your patient population into two segments: those that need SBIRT services and those that don't.

Prescreening is a time-saving mechanism. The 4-question prescreener recommended by IndianaSBIRT takes approximately 30 seconds to administer, whereas a full screening and brief intervention can take between 10 and 30 minutes. It enables you to spend your limited resources in the most effective manner.

Recommended Instrument

The recommended prescreening consists of a single validated question each for alcohol and drugs, and the two-question PHQ2 for depression.

Prescreen Questions

Alternatively, a 2-question prescreener containing only the alcohol and drugs questions can be used if your clinic does not plan to include depression screening in its SBIRT procedure.

Scoring the Prescreen

A "negative" prescreen means that the patient answered negatively to all prescreen questions and is therefore likely at minimal risk for substance-related issues. A "positive" prescreen means that at least one answer was positive.

In terms of patient flow, the SBIRT process ends for negative-scoring patients at this stage. Positive patients continue on to receive a full SBIRT screening.

Who will perform the prescreening?

IndianaSBIRT has had success using both patient self-administered prescreens and MA-administered prescreens. Both methods have advantages and disadvantages.

Patient self-administered prescreens reduces the burden of SBIRT on your MA staff. A clipboard with a paper form can be handed to the patient in the waiting room by front desk staff or a greeter. The patient completes the prescreening in the waiting room and then hands it to either the front desk or the MA when the patient is called back to do intake. Patients may also be more honest about alcohol or drug use when completing a self-administered form. When IndianaSBIRT clinics switched from MA-administered to self-administered, positive prescreen rates increased.

MA-administered prescreens are verbally asked by the MA after the patient has been taken to an exam or triage room. An advantage of this method is that the MA can directly enter a patient's responses into the EHR without the use of any paper forms. A disadvantage is that MAs will require additional training to ask the questions in an accurate and unbiased manner. The questions should be read word for word, because paraphrasing such as "You haven't done drugs in the past year, have you?" can bias a patient's response.

Time and Place

A self-administered prescreen can be given to the patient in the waiting room after front desk check-in but before an MA does intake. Or it can be given to the patient in an exam/triage room after an MA does intake but before the provider visit.

An MA-administered prescreen should be completed in an exam/triage room during intake but before the provider visit.

Identifying who needs to be prescreened

Prescreening (and SBIRT in general) is an annual, once-per-year process. If a patient has multiple visits within a year, SBIRT should be performed during only one of those visits. As such, a mechanism is necessary to notify staff members when they should do SBIRT and when they should not.

If your EHR supports timed alerts, they are an ideal solution. When a patient is prescreened, create an alert (or update an existing one) for one year after the current day. If the patient returns in less than a year, the alert will not appear, and SBIRT will not be performed. If the patient returns after a year, the alert will pop up, notifying the staff member to initiate the SBIRT process.

Alternatively, if your EHR does not have timed alerts but does have a date or text field in an easily accessible place in the EHR, a staff member can manually look at that date during a patient's visit to see if the patient is due for SBIRT. When prescreening is performed, that date field is updated to be one year later.

A third option is to not use dates for scheduling but instead perform SBIRT only for new patients and during annual-type visits. If your clinic performs annual wellness visits, for example, you could always conduct SBIRT during those visits and not during any other types of visits (except for new patients). This makes identifying who needs SBIRT simpler, but you will miss patients that do not attend those annual-type visits

Documentation and Communication

The results of the prescreen should be recorded in the EHR. Record Yes or No for each question as the numerical score is not important. Or you can record Positive or Negative for the overall prescreen result.

A positive prescreen result must be communicated to the staff member responsible for the full screening. This communication can be done passively by recording the result in the EHR and having the next staff member check the EHR before interacting with the patient. Or it can be done actively by sending a message via the EHR, putting the paper prescreening form in a the exam room door slot, or paging the provider.

Decisions Recap

  1. Will you use the 4-question prescreener, the 2-question prescreener, or a different instrument?
  2. Will the prescreening be patient self-administered or MA-administered?
  3. Where will the prescreening occur: the waiting room, the triage room, or the exam room?
  4. How will staff know if the patient should be prescreened or not: timed alerts, a date field, or a type of visit?
  5. How will the prescreening results be recorded in the EHR: question answers or overall result?
  6. How will the prescreening results be communicated: passively or actively?

Full Screening

The principle behind screening is to administer one or more short screening tools that identify a patient's probabilistic level of risk and suggest what type of intervention that patient should receive. Screening is a procedure guiding mechanism.

An AUDIT score of 11, for example, indicates that a patient most likely is drinking at a risky level and should receive a brief intervention. It is always up to a provider's clinical judgment, however, to select which services to provided.

Recommended Instruments

IndianaSBIRT recommends the Alcohol Use Disorders Identification Test (AUDIT) for alcohol, the 10-question Drug Abuse Screening Test (DAST-10) for drugs, and the Patient Health Questionnaire (PHQ9) for depression. If your SBIRT process does not include depression, the PHQ9 is not required.

View the instruments:

Which full screenings should be conducted?

A full screening should be administered only if its associated prescreen question was positive. For example, if a patient prescreened positive for alcohol and depression, but negative for drugs, the AUDIT and PHQ9 should be administered, but the DAST10 should not be administered.

Scoring the full screenings

The AUDIT and the DAST-10 both have four scoring ranges or modalities that indicate a certain level of risk and a recommended service. After administering a screening, the score should be tallied to determine which modality it falls into.

AUDIT Score

DAST-10 Score

Modality

0-7

0

Education and Positive Reinforcement

8-15

1-2

Brief Intervention

16-19

3-5

Brief Treatment

20-40

6-10

Referral to Treatment

If the AUDIT and DAST-10 are both administered, use the higher of the two modalities to determine the most important service to provide.

The PHQ9 does not have treatment modalities. Instead, its scoring ranges indicate the severity of depression. IndianaSBIRT generally does not use SBIRT to provide treatment for depression by itself. Depression is considered only when it is a co-occurring condition with alcohol or drug use.

Who will perform the full screenings?

The full screenings can be patient self-administered, MA-administered, or provider-administered.

IndianaSBIRT has predominantly used provider-administered full screenings. An advantage of this method is that the screenings are a chance for the provider to build rapport with the patient before beginning the intervention.

The screenings are also a chance to garner additional information about a patient's substance use. When a patient responds to the screening questions, he or she may elaborate about his or her usage habits or personal situation. If the patient or an MA completed the screening, that extra information may never reach the provider.

A downside is that the screenings take approximately 3-5 minutes to complete, and the provider may be unable to spare that extra time.

If provider-administered is not feasible, patient self-administered is the recommended second choice as it avoids the need for MA training and administration.

Time and Place

If the provider administers the full screening, it can be conducted in the exam room during the provider visit. If the patient or MA completes the full screening, it should be done before the provider visit.

Documentation and Communication

If possible, the full screening tools should exist in the EHR. EHR integration allows a screening to be administered without the need for a paper form, and it may calculate the screening's score and modality automatically, speeding up the process.

If the screening tools cannot be programmed into the EHR in their entirety, a field to record the screening's score and/or modality should exist instead.

In terms of communication, none is required if the provider is responsible for both the full screening and the intervention. If the patient or MA completes the screening, however, the screening results must be given to the provider, most likely via the EHR or a paper form.

Decisions Recap

  1. What full screening instruments will you use: AUDIT, DAST-10, PHQ9, or others?
  2. Who will perform the full screenings: provider, patient, or MA?
  3. Will the full screening tools exist in the EHR or will only the modalities be recorded?
  4. If the provider is not conducting the full screening, how will the screening results be communicated to the provider?

Intervention

For positive patients, the SBIRT encounter ends with some type of intervention service. The service provided depends on a patient's level of risk, which is determined by the patient's full screening scores and the provider's clinical judgment.

The levels of service are...

  1. Education - For low risk patients, the provider may hand out educational materials, provide positive reinforcement, and answer questions.
  2. Brief Intervnetion (BI) - For moderate risk patients, this is the most commonly provided service. It is a 5-15 minute conversation focused on behavioral change.
  3. Brief Treatment (BT) - This is an optional level of service between BI and RT. The provider performs a brief intervention and also schedules one or more follow-up visits to continue the intervention over a longer period of time.
  4. Referral to Treatment (RT) - For high risk patients, the provider peforms a brief intervention aimed towards persuading the patient to attend outside specialty care, such as an addiction treatment center.

To learn more about interventions and how they should be performed, take our free interactive 1-hour training modules for motivational interviewing, drug education, and SBIRT.

Who will perform the intervention?

The intervention should be performed by a trained professional such as a physician, nurse, mental health specialist, social worker, or counsellor.

Time and Place

The intervention provider can be same person who is addressing the patient's primary complaint, such as the medical provider. In that case, the intervention should be done during the primary care visit.

If the intervention is performed a different staff member, such as a mental health specialist, the intervention should be done directly before or after the primary care visit. We recommend performing performing the intervention in the exam room, as sending only positive patients to a special location can be stigmatizing.

Documentation and Communication

Record in the EHR the service actually performed by the provider, along with any notes.

The prescreening result, full screening modality, and service provided are all important metrics to store electronically as they can be used in statistics for project evaluation and improvement. For example, if during a month your clinic had 100 positive prescreens but only 50 full screens were administered, you know there is a breakdown in the process between the prescreening and full screening steps.

If the intervention could not be completed for any reason (lack of time or provider unavailability), flag the patient in the EHR and complete the intervention during the patient's next visit.

Decisions Recap

  1. What services will you support?
  2. Who will perform the intervention?
  3. When and where will the intervention be performed?
  4. How will you record the result of the intervention?
  5. How will you track patients that did not complete the intervention?

Example Procedure

As an example, SBIRT has been successfully implemented in a clinic using the following procedure:

Example Procedure

Action Steps

  1. A two-question SBIRT prescreening about alcohol and drugs is performed.
  2. If the prescreening is positive, the corresponding full screening (AUDIT or DAST10) is administered.
  3. Based on the full screening score, a particular level of service (education, brief intervention, brief treatment, or referral to treatment) is provided.

Staff and Timing

  1. A medical assistant (MA) conducts the prescreening during the patient's intake and social history.
  2. A care provider, such as a nurse, physician, social worker, or other behavioral health specialist, administers the full screening and intervention during the patient's provider visit.

Documentation and Communications

  1. A timed alert in the EHR notifies the MA to do the prescreening on an annual basis.
  2. The MA updates the alert's date after doing the prescreening.
  3. The MA communicates the prescreen results to the provider via the EHR.
  4. The provider records the full screening and intervention results in the EHR.
  5. If SBIRT was not finished, the alert date is changed again so that it will trigger on the next visit.
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