Behavior Change Interventions

1. Feasibility of SBIRT at KPCO
Carmen R Martin, MPH
Jennifer Boggs, MSW
HMORN Conference
May 2nd, 2012

2. 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)

3. 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
Members
English-Speaking Spanish-Speaking
Behavioral Health
Behavioral Medicine
Mental Health
Chemical Specialists
Dependency
Primary Care
Physicians Nurse Managers Front Line Nurses
4

5. Member Focus Groups
• Well visit in past 3 months
Participants • 2 groups, various membership duration
• Privacy concerns in medical record
English-Speaking • Pre-screen…“ would help realize what
‘too much’ is”
• Asked at every visit, including Rx use
Spanish-Speaking • “Grateful” because doc is best person to
help & direct to resources
• Decision support in EMR for positive
screening/Brief intervention use
Recommendations • Normalize as standard care for all; avoid
“profiling”
5

6. Behavioral Health
Behavioral Chemical Mental Health
Medicine Dependency
Specialists
• MDs, RNs, • Supervisors, psyc
• Psychologists counselors hologists, counsel
• Clinic-based • Moderate risk ors, therapists
• All follow-up after should be • Brief Intervention
PCP prescribes followed in impossible unless
meds Primary Care done by BMS
• Want to prove • Referral stigma to • Need workflow
value to KPCO CD pre-defined
• SBIRT good fit • “providers don’t

7. 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

8. 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.

9. REFERRALS REFERRALS
“What relationship?”
Need more MI training
CD shuts down pt
Prior CD Individual
BMS Supervisor
MH CD BMS
D
Overwhelmed with Crisis only setup Want closer
oe
sn
Referrals that Not open to relationship w/ CD
’t
should go to CD moderate risk Open to CD training
kn
ow
ho
w
to
ge
tt
o
C
D
REFERRALS REFERRALS
May be stigma
associated w/
referral to CD
Primary
Care

10. 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

11. 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

12. 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

13. 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.

14. Pilot 1 recommendations vs. REALITY
Gain high level leadership Hard to do with short time
involvement and support. line, important to start small and gain
clinic support.
Recommendation to insert Px Vital Sign had high level
SBIRT into a new initiative (Px support, but lacked clinic
Vital Sign) that had high level support, ended up going grass roots
support already. with clinics choosing to implement or
not.
Stakeholders should create
workflow In order to have Stakeholders wanted input on
“ownership” of workflow. workflow, but wanted detailed draft
to start with from research team.

15. 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.
Questions?