InSight Objectives: 1. Screen all patients for problematic use of alcohol and drugs 2. Provide all patients with brief advice on healthy choices about alcohol and drugs 3. Refer patients who screen positive to SBIRT specialists 4. Provide a team of SBIRT specialists for intervention, follow-up, and if necessary, treatment placement

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We have implemented services within the Harris County Hospital District and The Council on Alcohol and Drugs Houston. HCHD is the publicly funded safety net health care system that includes Houston, Texas. The Council is a non profit community organization which provides chemical dependency treatment services and referrals, serving as the OSARS for our area. Within the HCHD, we provide services at both hospital pavilions including Ben Taub General Hospital, a level 1 trauma center and LBJ Hospital. We also provide on site services at a Community Health Center and a School Based Clinic and accept referrals from all 13 CHCs and 9 SBCs in our system.

Patients are screened with 3 questions, one about tobacco use, one about alcohol use based on the NIAAA single question screen, and one about marijuana, cocaine and other drugs. Patients are asked these questions by the patient care technician who rooms patients at the CHCs, by their primary care physician, by their nurse in the EC or inpatient units of the hospital or by their resident or attending physician in the hospital. Patients screening positive are referred to our specialists who conduct an assessment utilizing the AUDIT, DAST and K6 as well as a clinical interview. Patients are offered the highest level of service they are eligible for based on their assessment and are provided the highest level of service they are eligible for and agree to. In general, patients with dependency are offered referral to treatment, patients with abuse are offered brief treatment and patients with problematic use are offered brief intervention.

Brief intervention consists of up to 6 15-30 minute sessions with any of our specialists utilizing Motivational Interviewing techniques.

Brief treatment consists of up to 12 45-60 minute sessions with our specialists that are licensed mental health professionals, both onsite within HCHD and also located at The Council. Again, Motivational Interviewing techniques are utilized.

Referral to treatment is done by our specialists at The Council. Patients are referred to intensive outpatient or inpatient treatment providers within our community.

We have trained HCHD staff and physicians in our SBIRT model and the 3 question screen. We have developed a training module that is included in the orientation program of all incoming HCHD employees.

We have incorporated our screening into the EMR which has been fully implemented in the CHCs and SBCs during the latter years of our grant and thus far only partially implemented within the hospital pavilions (we still use a paper screen at the hospitals, but referrals to our program are made via the EMR).

We provide training in Motivational Interviewing to our specialists including didactic sessions as well as standardized patient interactions. We also provide ongoing coaching and supervision in Motivational Interviewing to our specialists throughout their employment with us. Each specialist is assigned an MI expert who listens to tapes of their BI and BT sessions and provides feedback on their MI skills. This has helped us maintain a high fidelity to the MI model.

We have found that having the medical providers conduct the initial screen has helped integrate our program into the routine care of patients and the functioning of the health care team.

We have found that our CHCs have a more stable patient population than we initially predicted, and therefore are not able to sustain a full time specialist on site at each site. We have also found that, when a specialist is not on site, many referred patients are difficult to engage in our program. We are thus beginning a partnership with the behavioral health program that serves each clinic to integrate our service delivery.

We have found that the 3 question screen is much more readily embraced and utilized by our medical providers than any longer screening instruments.

These are some of our lessons learned during implementation.

Our 6 month follow up data has shown a reduction in heavy drinking days, days using drugs and smoking rates in our follow up sample. Data analysis is ongoing.

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Grant years 1 through 4: 76,106 patients screened in total 54,296 patients screened negative 21,810 patients screened positive 14,812 patients received services (68% of those screening positive)

Analysis of 853 InSight patients: $4,104,656 net cost savings to HCHD Increase of 1308 visits to HCHD Emergency Center and Inpatient utilization decreased Outpatient and Community Health Center visits increased

This analysis, the American College of Surgeons mandate for an SBIRT program to maintain Level I Trauma Center status, as well as the support our program has engendered from our "generalists" by serving their patients well has led the HCHD board and administration to fund continuation of our program after grant funding ends.