• Implementation of SBIRT Services for Individuals with Substance Use Disorder in Urgent Care

      Mincin, Michael L.; Burda, Charon (2019-05)
      Background Statistics indicate that nearly 21 million Americans in 2015 suffered from Substance Use Disorder. Alcohol is the third leading cause of preventable death in the United States with nearly 88,000 people dying annually. Roughly 115 individuals within the United States die daily from an opioid overdose. Local Problem In 2017, Baltimore City, Maryland experienced 761 alcohol and drug related deaths. Patients with Substance Use Disorder continue to go undetected and do not receive appropriate care. The purpose of this project was to implement the SBIRT program as a quality improvement project to provide screening, a brief intervention, and referral to treatment for patients with Substance Use Disorder. Interventions This quality improvement project took place within a Baltimore City urgent care clinic that lacked an existing program screening for Substance Use Disorder. Team members included licensed practitioners, medical assistants, peer counselors, and front desk personnel. The project extended over a twelve-week period. Initial preparation required confirming staff roles, reviewing procedures, and identifying project champions. The subsequent period was spent disseminating project details as well as training staff members. All staff were trained by the project leader. The process of screening, brief intervention, and referral to treatment for Substance Use Disorder began in week five and continued through week twelve. The AUDIT-C questionnaire and a single substance use question were utilized as the screening tool. When a patient screened positive for Substance Use Disorder, the patient received a brief intervention by an SBIRT trained peer counselor. Patients received a referral for outside treatment depending upon the magnitude of substance use as well as the patient’s readiness for intervention. Results The implemented quality improvement project screened (n=556) patients or 38.6% of registered patients for Substance Use Disorder. Of those patients screened, (n=45) 8.1% screened positive for either alcohol or other substance misuse. Of the patients that screened positive (n=17) 37.8% received a brief intervention from a trained peer counselor or licensed provider. SBIRT screening as well as data collection and analyses processes were successfully implemented within the clinic’s electronic health record. Clinic administrators elected long-term adoption of the SBIRT program by making the SBIRT program a fixed function within the clinic. Conclusion This project indicated that nearly 10% of the population in Baltimore City continue to go unrecognize and untreated for Substance Use Disorder. Seventeen patients (37.8%) that screened positive for SUD received a brief intervention from a trained peer counselor or licensed provider and were provided with appropriate resources for treatment. The achievements of this quality improvement project demonstrate that the SBIRT program can be successfully implemented within an urgent care. The extension of similar programs is highly recommended to further reach out to this vulnerable population. Continuation of the program will allow an opportunity to refine processes, address the role of peer counselors, further train licensed providers to administer brief interventions, and work toward increasing the number of screenings, brief interventions, and referrals to treatment.
    • Implementation of Alcohol Screening, Brief Intervention, and Referral in Primary Care

      Kelso, Shannon M.C.; Wiseman, Rebecca Fortune (2019-05)
      Background: Excessive alcohol use is associated with many short- and long-term health risks. The U.S. Preventive Services Task Force recommends that all adults age 18 and over be screened for alcohol misuse in a primary care setting and that those who display risky or hazardous drinking receive brief counseling interventions. However, only around half of primary care providers report screening patients for substance use, with even fewer providing brief interventions or referrals to treatment. Local Problem: A mobile primary care clinic in Maryland serves an uninsured, immigrant, primarily Hispanic population. The majority of patients speak Spanish with limited English proficiency. Prior to this project, there was no formal protocol in place for alcohol screening. Patients were intermittently screened with an informal question, with no evidence-based screening tool or plan for intervention or referral in use. Interventions: The purpose of this quality improvement project was to pilot the implementation of a protocol for alcohol screening using the Alcohol Use Disorders Identification Test (AUDIT) and its short form (AUDIT-C), brief intervention consisting of simple advice, and referral to treatment (SBIRT). The project was implemented over a 15-week period. Inclusion criteria for screening included all new intake patients age 18 or older with no cognitive impairment and the ability to understand and speak English and/or Spanish. The University of Maryland Baltimore Institutional Review Board provided a Non-Human Subjects Research determination for project implementation. Included patients were screened according to the SBIRT protocol. The AUDIT-C was administered by the staff member assisting the patient with admission paperwork. In the event of a positive score on the AUDIT-C, the provider screened the patient with the remaining questions of the AUDIT. For patients with positive scores on the AUDIT, the provider then delivered a brief intervention and referral to community resources. Data collection was conducted via weekly chart audits throughout the pilot period. Results: Of the new intake patients meeting inclusion criteria (n=46), 97.8% (n=45) were screened with the AUDIT-C according to the protocol. Of these, 6.7% (n=3) scored positive for risky drinking. All patients with positive scores were screened with the full AUDIT, and 2 (66.7%) were documented as receiving an intervention. While no referrals were documented, conversations with staff indicated that referrals were given to these patients but not documented. Conclusions: The results demonstrated the feasibility of incorporating an alcohol SBIRT protocol into a mobile primary care clinic. The clinic staff felt the SBIRT protocol improved alcohol screening and confidence in handling patients with risky drinking behaviors, and they intend to continue utilizing the alcohol SBIRT protocol to screen all new intake patients. The clinic director plans to integrate the SBIRT tools into the clinic’s electronic health record, which is expected to improve documentation, and to ultimately initiate annual screening of existing patients using the alcohol SBIRT protocol to further improve behavioral health integration and improve quality of care.
    • Improving Inpatient Substance Use Screening and Referral to an Addiction Consult Team

      Figiel, Rachel; Jackson-Parkin, Maranda (2022-05)
      Problem: Substance use is associated with poorer hospital outcomes, increased lengths of stay, higher healthcare costs, and increased mortality. On an adult inpatient medical unit, up to 90% of patients did not receive substance use screening per policy. Implementing the evidence-based model of screenings, brief interventions, and referrals to treatment (SBIRT) in this population would serve to optimize quality of care and patient outcomes. Purpose: To purpose of the QI project was to improve substance use screening and referrals to an Addiction Consult Service (ACS) on an adult Medical Intermediate Care Unit. Methods: This QI project was implemented over a 15-week period on a 16-bed adult medical IMC unit. In order to improve substance use screening in newly admitted patients, staff utilized an existing validated single-item screening question in the electronic medical record. Nursing staff notified the attending physicians for all patients who screened positive; the physician further evaluated the patient and placed an order for the ACS if indicated. Data collection was conducted via manual chart audits; run charts were utilized to track process and outcome measures. Process measures included counts (%) of patients who were screened/assessed for substance use. Outcome measures included counts (%) of patients who screened/assessed as positive and received follow up by a physician and counts (%) of patients who screened positive who were referred to ACS. Results: A total of 53 patients were screened or assessed for substance use. Of these, 100% received a screen or assessment, 49.06% (n=26) were screened by nursing, and 50.94% (n=27) who were missed by nursing received assessments from a physician. Of the patients screened or assessed, 13.21% (n=7) were positive, 11.54% (n=3) of patients screened by nursing were positive and 14.81% (n=4) of the patients missed by nursing but assessed by a physician were positive. Of the patients with positive screenings or assessments, 71.43 (n=5) were referred to the ACS. Conclusion: Implementing nurse-lead substance use screening with a validated screening tool in the electronic medical record is feasible on a busy inpatient medical unit, leads to improved detection rates, improves documentation, and makes screening more convenient.
    • Screening, Brief Intervention and Referral to Treatment in an Emergency Room

      Labe, Christopher L.; Rawlett, Kristen (2020-05)
      Background: Alcohol and substance use are leading causes of hospitalizations, injury and death. Individuals increasingly use the emergency room to seek help for their alcohol and substance use related concerns. The purpose of this quality improvement project was to implement a Screening, Brief Intervention and Referral to Treatment intervention (SBIRT) to effectively evaluate at-risk or current individuals with alcohol or substance use in a high-volume emergency room in rural Maryland. Methods: The project was implemented over a 12-week period and included every adult 18 years and older with alcohol or substance use related concerns. All encounters were screened by the Behavioral Health Response Team (BHRT) using the Cut, Annoyed, Guilty, Eye (CAGE) screening tool. The Brief Intervention (BI) included Motivational Interviewing (MI) and was elicited with individuals scoring a 2 or higher on the CAGE screening. Individuals were asked their readiness to change score post-MI intervention. All encounters were referred or given information to access inpatient or outpatient substance use treatment facilities for the next level of care. An Excel spreadsheet and monthly run charts were performed to analyze trends towards percentages of patients receiving motivational interviewing, referrals to treatment and completed SBIRTs. Results: There were 54 (62.7%) males compared to 32 (37.3%) females that completed the SBIRT protocol. The number of individuals who completed the SBIRT process was 86 out of 112 who were eligible (76.7%), a noted increase from the internal data indicating evidence of 54.0% that were properly enrolled in treatment. Conclusion: Successful systematic implementation of an SBIRT can increase access to substance use programs, increase engagement and readiness to change and improve better outcomes in recovery management.
    • Screening, Brief Intervention, and Treatment in a Latina Immigrant Prenatal Clinic

      Kennedy, Jules Q.; Hoffman, Ann G. (2020-05)
      Problem & Purpose: Babies born in Maryland found with drugs in their systems has increased 57.6 percent in the last 9 years. The American College of Obstetricians and Gynecologists recommends universal screening for substance use disorders at first prenatal visit. Substance use disorders are usually interrelated with other behavioral health issues requiring more comprehensive screening at primary care sites for better screening and treatment success. The use of a Screening, Brief Intervention, and Referral to Treatment (SBIRT) protocol combined with motivational interviewing (MI) has shown success in earlier identification and more successful referrals of behavioral health issues. The aim of this MAP-IT guided (Mobilize, Assess, Plan, Implement, Track) quality improvement project is to educate, better detect, and successfully refer out a Latinx immigrant prenatal patient population with suspected behavioral health issues to specialty behavioral health treatment centers to decrease negative long term behavioral health issues occurring in the community. Methods: Implement an SBIRT protocol for behavioral health. Train and use MI techniques when interacting with patients; support patients throughout the specialty referral process by being present and using same-day appointments; increase education about of behavioral health issues and their treatment; and track behavioral health issues from the clinic to the specialty referral site. Results: During the 12-week implementation period, four patients were identified with behavioral health issues with one patient being successfully referred to county behavioral health. Conclusions: The Latinx immigrant culture stigmatizes behavioral health. Increasing education and trust for behavioral health treatment must be a focus. Prenatal clinic employees should be trained in MI techniques and cultural engagement to successfully engage in patient collaboration for behavioral health issues. Repeated behavioral interventions are needed to increase the motivation needed to accept treatment. Behavioral health experts embedded in prenatal clinics would help make referrals and treatment more successful.
    • Substance Screening, Brief Intervention, and Referral to Treatment in Rural Primary Care

      Johnson, Kabrina L.; Fornili, Katherine (2020-05)
      Problem: Providers in a small, rural primary care practice in rural Maryland reported higher rates of alcohol or drug use disorders over the past several years, consistent with county-level data. The lack of screening tools and referral resources was identified as a need (Carroll County Sheriff Office, 2017). Purpose: SBIRT is a comprehensive early intervention approach that includes universal substance screening (S), and depending on problem severity, providing either brief interventions (BI) or referrals to treatment (RT) (SAMHSA, 2019). Methods: Medical assistants (MA) conducted a pre-screen using the first 3 items of the Alcohol Use Disorders Identification Test (AUDIT) and the National Institute on Drug Abuse (NIDA) single item drug screen. For those with positive pre-screens, medical providers completed full screens, using the remaining 7 items of the AUDIT, and the Readiness Ruler to assess for use of other substances and readiness to change. Results: Of 290 eligible patients seen over 10 weeks, 68.6% received a pre-screen. Reasons for missed pre-screens were “too busy” (27.4%); high patient census that day (29.6%) or no MA on duty (42.8%). N=38 patients (19.1%) had a positive pre-screen; all scoring >8 on the full AUDIT received a BI for alcohol misuse (n=6, 15.7%) or an RT for probable alcohol dependence (n=1, 2.6%). All with a positive drug screen (n=4, 2.0 %) received a BI. Low rates of screening may be due to short duration of implementation; low patient census; staffing issues, and possibly, patient under-reporting of substance use. Conclusions: Organizational leadership and physician involvement is necessary for SBIRT implementation. Primary care practices adapting SBIRT into their workflow should implement universal screening with validated, standardized substance use screening tools. SBIRT implementation should be conducted as a team approach. To help alleviate potential time constraints, medical assistants can be utilized to conduct SBIRT screening. SBIRT implementation can help primary care staff increase their knowledge of alcohol and drug use in their patient population and help to reduce the associated stigma.