Implementation of Alcohol Screening, Brief Intervention, and Referral in Primary Care

Abstract

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.