1. Who does the screening and brief intervention counseling?
2. How do we screen?
3. How do we do our brief interventions?
4. How do we track our screens and interventions?
5. How do we screen without needing a referral or request to do so from the medical team?
6. How do we bill for SBI?

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1. Two PhD psychologists share 1.0 full time equivalent that is paid by the hospital. Indigent, medically disadvantaged, and substance abusing patients constitute Harborview's mission population. The psychologists not only screen and do all the BI counseling' they also teach 10% on the intervention service, preparing psychiatry and psychology residents to perform BIs throughout their future careers.
2. How do we screen? A computer generated list of all current patients positive for alcohol or drugs by virtue of their BACs and urine tox screens is generated daily. This picks up all trauma patients who were using alcohol/drugs the day of their injuries. This takes less than one minute to generate and print out. To screen patients whose alcohol/tox screens were negative, a separate computer list of all patients on our trauma units is generated (also less than one minute to get) and the psychologists do a rapid alcohol screen of those patients. I can do ten screens in about 20 minutes. I use the AUDIT-C (first 3 questions on AUDIT).
3. How we do our interventions: We follow the "FLO" developed and disseminated in national trainings by SAMHSA" F = feedback to patients on their screening results, L =listen and understand patients views on drinking or using drugs, and O = present a menu of options for change and give advice. This counseling BI protocol is available on SAMHSA's website and COT (Committee on Trauma of Amer. Coll of Surgeons' website also).
4. Tracking our screens and brief interventions: A positive screen means a 3 x 5 index card on that patient is filled out, listing name, room, age, gender, injury and mechanism, screen result, CPT procedure provided , and minutes spent. This card is then used to rapidly chart the patient contact electronically. All cards are collected by administrative assistant and entered into a simple data base that keeps annual productivity figures.
5. To not burden the medical teams, we went to our Trauma Council and told them we wanted to launch a public health program that screened all patients for drugs and alcohol. They simply changed the org chart to include our intervention service as part of the medical team. It is no longer necessary to pester the attendings, residents, or nurses to write an order for a screen/intervention.
6. Billing for SBI? For years, we have billed Medicaid and private insurers for "inpatient psychotherapy' (90816, 20 mminutes). Psychologists and MDs can bill for this. We are waiting for our state to activate the new SBI codes before using them.

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1. Evaluating productivity: Harborview has established productivity requirements for our psychologists, defining how many brief interventions they are required to perform per day covered. We cover the service 8 hours per day, 5 days per week, and a voicemail pager picks up intervention requests on nights and weekends. Quarterly productivity reports are generated for hospital administrators. Ten years ago, we did only 400 brief interventions per year, but we are on schedule for 1000 in 2008.
2. Adding the AUDIT-C (face to face questionnaire of 3 questions) has not been a significant burden. If anything, it increased our number of positive screens and consequently the total number of BIs performed.

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Other observations:

1. Despite our proactive screening system to identify all ranges of substance abuse severity, we always receive about 10 weekly additional intervention requests from non-trauma wards (Neurology and Medicine, dealing with severe alcohol withdrawal cases). The nature of these "consult requests" are always very severe, advanced addiction cases...patients unlikely to benefit from a BI. If we set up our BI service as only a "consult service" answering consult requests, we would only see severe cases.
2. We very seldom refer patients to community substance abuse treatment. They are usually not interested. Instead, we spend our precious few minutes with the patient doing "FLO" and motivating them to want to change. Our philosophy is that patients wanting treatment can get it through public funding. We give them that information, but do not spend our precious minutes "brokering treatment."

This is the exact approach that worked so well in the Gentilello study, also performed at Harborview.

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Gentilello has analyzed the cost-benefit data from his 1999 BI randomized trial at Harborview... "The net cost savings of the intervention was 89 US dollars per patient screened, or 330 US dollars for each patient offered an intervention. The benefit in reduced health expenditures resulted in savings of 3.81 US dollars for every 1.00 US dollar spent on screening and intervention. This finding was robust to various assumptions regarding probability of accepting an intervention, cost of screening and intervention, and risk of injury recidivism. Monte Carlo simulations found that offering a brief intervention would save health care costs in 91.5% of simulated runs. If interventions were routinely offered to eligible injured adult patients nationwide, the potential net savings could approach 1.82 billion US dollars annually.

CONCLUSIONS: Screening and brief intervention for alcohol problems in trauma patients is cost-effective and should be routinely implemented.