15 Apr 09 16:18 | JonathanHolly said...:
We are developing a "SBI in a box" tool for primary care settings, that explores the efficacy of bundling preventive health screens, and delivering them with web-based tablet PCs using an ACASI format. Self-completion rates are remarkable when language and literacy barriers are addressed as part and parcel to the encounter. In addition to the patient centered protocols, another component of the system addresses issues cited as barriers for the providers, including anticipatory guidance when risk alerts occur, referral resource mining, and billing recommendations (where applicable). This tool may also be useful in other settings, including trauma and hospital locations. However, our primary goal is to increase prevention at the primary care level initially. We would like to prove the tool's efficacy with primary care docs, and then examine whether the tool can be adapted for other health care settings. For more information about "SBI In a Box" go to www.preventionpays.org

09 Oct 08 03:46 | TaylorBob said...:
I feel it's a nice article where a lot of valuable information is available. =========== Taylor

http://www.alcoholtreatmentclinics.com

23 Jul 08 22:38 | EricGoplerud said regarding ScreeningAndBriefInterventionBHC:
At the policy meeting in early July of the National Council for Community Behavioral Health, there was strong support for routine screening for alcohol problems and provision of brief motivational counseling for patients patients presenting with mental illnesses for these community-based mental health programs.

08 Jul 08 15:32 | LarryGentilello said...:
SBI in the ED
I work in an emergency department that has over 130,000 visits per year. We have had a successful SBI program for injured patients, numbering about 35,000 per year. About one-third are intoxicated. The American College of Surgeons Committee on Trauma (COT) SBI mandate for level 1 trauma centers, does not fall on the trauma surgeon or ED physician. The mandate states that "Level 1 trauma centers must have a mechanism in place" to perform SBI. It is up to each facility to determine how it can best meet the requirement by using available or new staff. The proposed Joint Commission standard is similar. It would be a hospital, not a provider level requirement. SBI is also not directed at treating a "chronic" disease in the ED. Most alcohol related deaths are due acute intoxication. Of the 75,766 alcohol-related deaths that occur each year, 54% are due to acute conditions such as an injury. Alcohol causes more deaths by injury than by all chronic diseases such as hepatitis, pancreatitis, dementia, oropharyngeal cancers, combined (46%). 100% of these acute deaths are due to intoxication, not chronic alcoholism. The modal patient is a 23 year old male involved in a car crash, who does not have a chronic disease. Given the prevalence, it should be a standard to screen for alcohol use. The screen rate in some studies is as low as 4%. It takes less than a minute, only requires asking a few questions, and doesn't have to be performed by the ED physician. Most hospitals with a busy ED will not expect the ED physician to be the one who provides the brief intervention, and the proposed code doesn't require that. Any patient who has put his or herself in harm's way by alcohol use deserves to have at least a brief discussion about it. As to who should personally do it, there are many potential models that would not burden ED staff, or disrupt patient flow.

08 Jul 08 13:50 | EricGoplerud said...:
Several emergency physicians have commented that the hospital emergency departments are horribly overburdened, and that as laudable as the goal of alcohol and drug screening is, that there is just too much going on and too many demands on their time to be asked to do even one more thing. A recent report found that wait times in EDs is increasing, and that patients with heart attacks often must wait 20 minute or more before initiating treatment.

Hospital emergency department or trauma center SBI should not be seen as yet another burden put on the physician. Rather it is a function that the hospital as an organization should be addressing, perhaps through a hospital social worker, nurse, health educator, or even, as is being done in some facilities, by bedside computer or by a peer counselor (a trained person in recovery). Paper and pencil or computer administered standardized screening questionnaires such as the AUDIT, the DAST or ASSIST, or the very brief one-question heavy alcohol use pre-screener recommended by NIAAA, a single question pre-screener of prescription medication misuse being tested by NIDA, or blood or urine tests can be administered with very minimal time or resource commitment. Brief counseling or brief referral for specialty treatment should be a facility responsibility of the ED, Trauma Center or inpatient service, not an added burden to the physician.

08 Jul 08 13:46 | LauraVeach said...:
Support for Joint Commission Standards for SBI
Yes, the Joint Commission standards are needed for ensuring the quality healthcare that alcohol screening and brief interventions (SBI) provide. I endorse SBI in the ED, inpatient & outpatient hospital settings, and OB/GYN clinics (especially regarding reducing & preventing Fetal Alcohol Disorders). I continue to be a part of a unique 2 year collaboration between an affiliated teaching hospital and my university academic department, a graduate program in counseling, where counseling students with specialized training in Motivational Interviewing, Substance Use Disorders, and SBI assist the Level I Trauma Center. This translational approach offers cost-effective and evidence-based care for patients and significant learning for graduate students. Since reimbursement mechanisms, substantial evidence throughout the world and model SBI programs exist, it makes sense that the leading accreditation body be at the forefront of establishing clear and efficient quality standards which can best guide hospital systems in providing the most effective SBI services for adolescents and adults to address primarily risky drinking, but also dependent drinking. I base this endorsement on over 25 years of clinical work in substance abuse and addiction counseling in hospital and healthcare settings, over 10 years as a counselor educator and researcher, and a leader in the International Association of Addictions and Offender Counselors. Laura Veach, PhD, Licensed Clinical Addiction Specialist, LPC, CCS Associate Professor, Wake Forest University

27 Jun 08 15:32 | ThomasSweeney said...:
Although universal screening for alcoholism is a laudable goal, great caution must be urged before laying further mandates onto emergency departments. These mandates should not come without the resources to carry them out. Currently resources are shrinking, the number of patients is growing. Many Emergency Departments in the United States are struggling to provide a basic level of evaluation and treatment within a time frame that might still do a patient some good. Although screening for issues such as domestic violence and alcoholism are good public health initiatives, they should not distract us from our primary objective of providing basic emergency care. If society values these as secondary objectives, then they must be financially supported. The Joint Commission would be wrong to lay unfunded mandates onto hospitals that are struggling to provide basic emergency care in a timely fashion.

13 Jun 08 01:44 | TimNoonan said...:
Considering that the problem of access to care is limited by the overcrowding of the emergency departments, how will this help to improve care?

Emergency department personnel are already spending far too much time on tasks that are not directly related to patient care. Some would say that the only relation to patient care is that they are performed by people who should be performing patient care, instead.

I understand the desire to improve the lot of those who are not able to care adequately for themselves, but this is the wrong way to do it. Emergency care requires experts in patient care, not screeners for chronic conditions.

Emergency departments are for acute care. Screening the chronically ill, because they have acute exacerbations is something that would be better performed by those trained to provide care to the chronically ill.

If you arrive in the emergency department with a life threatening condition, you do not want someone cross-trained in half a dozen different screening techniques to be the one making treatment decisions. You want someone who is specialized in emergency care.

Cross-training leads to a dilution of skill. Some people do well when cross-trained, but that is not the way to improve skill. If you have a problem of nurses and physicians being too skilled, if they need to be distracted from patient care, then this is the right approach. That is not the case. This will not improve patient care. This will help to drive out those who do provide excellent patient care.

This makes me wonder where the teachable moment is for those who are not regular providers of acute care? Why would you implement such a plan?

02 Jun 08 22:50 | StevenBernstein said...:
I have developed SBIRT interventions for cigarette smokers in the emergency department. These interventions are effective, particularly with smokers presenting with tobacco-related conditions such as exacerbations of asthma. This lends credence to the teachable moment concept. Insofar as tobacco remains the most commonly used harmful substance, I would urge that tobacco be considered, along with alcohol and illicit drugs, in SBIRT policies.

At the same time, as a practicing emergency physician I am well aware of how another 'unfunded mandate' would be perceived by my colleagues. It is important that any SBIRT standard of care be sensitive to the very real constraints of time and resources that EDs have.

I am pleased that The Joint Commission is considering this vital matter.

27 May 08 18:01 | DianeRiibe said...:
Our organization is supportive of the Joint Commission adopting quality standards for Screening and Brief Intervention (SBI) in medical settings. We feel strongly that all adolescents should be screened for underage drinking in emergency departments, as well as inpatient and primary care settings. In Nebraska, patients aged 18 to 24 are the most likely age group to have alcohol in their system at the time of trauma center hospitalizations. Young people have the highest binge drinking rates, and often seek treatment in the emergency department. Brief interventions have been shown to reduce drinking and its negative consequences among adolescents. We understand that time constraints and limited resources are often a concern in medical settings; however, this is an initiative that is both cost-effective and has the potential to prevent further injuries and save lives.

Diane Riibe, Executive Director Project Extra Mile

23 May 08 13:55 | HollyDelaney said...:
I have been involved with the SBIRT study in Washington state for four years both as a Screener providing brief intervention and a brief therapist offering follow-up services.

The logic of implementing screening and brief interventions in medical settings seems obvious – It is strange to think that it has taken so long to provide any mainstream attention and avenues for people with substance issues. It is somewhat like not screening blood pressure until someone has a stroke or a heart attack. By not asking about substance use in medical settings, the covert message is, “Don’t tell.” This only increases the significant stigma and marginalization surrounding substance abusers, and results in postponing treatment and increasing social costs on every level.

Even non-users benefit in becoming more aware of substance abuse as a health issue. The opportunity to open a dialogue with those who have family members or friends with substance issues is another side benefit from this type of intervention. Further, the knowledge gained by the medical community and providers as they uncover and become more familiar with the links and overlaps contained in this multi-faceted problem also offers substantial benefits and opportunities in setting and implementing health care policies and approaches.

Medical education and intervention for substance abusers is long overdue. It is also important to maintain and expand alternative treatment options, brief therapy being key among them. I strongly support any actions that mandate AND fund these important services....

22 May 08 16:38 | DianeShannon said...:
As a Wasbirt counselor for three years in an emergency department setting, I strongly support this initiative. I have had the opportunity to approach patients at a teachable moment regarding prevention, brief intervention, harm reduction and early detection/referrals for at-risk patients. Through motivational interviewing one is able to raise awareness which initiates change.

22 May 08 12:00 | DulceRodriguez said...:
I agree, SBI services should be a requirement at all hospitals. This past year I have had the opportunity to work with CASBIRT in San Diego. I am a Health Educator Supervisor and I am screening patients in the Trauma, Burn unit department and ED at two different hospitals and one clinic. I can say from first hand experience that these services are very beneficial and needed everywhere. Doctors, nurses, other health care workers and patients are very appreciative of these services, especially when I am able to make referrals. Many patients I have spoke to who had substance abuse problems in the past have expressed to me that they wished that the program was there in their time of need. The information I provide to the patients provides awareness and also help for the patient or their families. SBI services are not only cost-effective, but very helpful in the community.

21 May 08 20:21 | GailFernandes said...:
I have a dual role as I am involved with SBI at our local Community College (Bristol Community College)from a data point of view but I am so a Substance Abuse Counselor at a Outpatient Mental Health Clinic that works with a College on this grant using the SBI. The screening was used along with the AUDIT and DAST. It was amazing the response we received from students and those that welcome the help from staff and counselors. We also used Motivational Interviewing which we feel also helps to engage people. I saw it as such an asset to the counseling center and health clinic at the campus. Helping to educating anyone to how drugs can affect their lives is always a good thing! For me I see it as such a valuable tool because it opens the door to discussion then to possible treatment if so needed. I can only hope that this can be used more often in ER rooms along with MI(motivational interviewing) for as we all know, not everyones approach to patients with substance abuse, addiction, or the potential for either is always empathic, non blaming, non judging.

21 May 08 17:39 | LeighFischer said...:
Over the past year, SBIRT Colorado has assisted a variety of clinics and hospitals across our state in implementing screening and brief intervention procedures. Overall we have encountered minimal barriers in trying to implement change in large healthcare settings, in part due to expectations from the American College of Surgeons and the recent release SBI billing codes. Data has demonstrated that screening and brief intervention reduces morbidity and mortality related to the misuse of alcohol, and points to the tremendous costs that are saved due to prevention and early intervention. Similarly, anecdotes shared by providers, health educators, administrators, and patients in Colorado indicate that screening and brief intervention is changing lives and saving costs. It seems that for too many years, providers have grappled with how to identify and assist their patients who are using alcohol and other substances at risky levels. Routine screening and brief intervention offers a time-efficient and cost-effective solution.

If we hope to continue to prevent and reduce injury and illness caused by alcohol, tobacco, and other drugs, healthcare facilities need to implement policies and standardized procedures for screening patients and for providing brief interventions when needed. SBI protocols are more likely to be integrated and sustained through support and accreditation standards established by the Joint Commission.

21 May 08 16:31 | RobertBaize said...:
The Teachable Moment
The emergency department is what can be described as a ‘teachable moment’. It is a point in time where the individual is vulnerable and has been forced to face one’s own mortality or denial systems. When a person has been admitted in to the ER for a situation related to chemical use, they are no longer able to deny negative impact upon themselves or others. The ‘teachable moment’ is upon them. It would be impossible to recount the times where the patient not only was open to take the screen but was grateful for the opportunity. We do not simply provide referral for treatment, we provide hope.

21 May 08 15:22 | KimMuramoto said...:
The incredible gift of SBIRT
As a supervisor of SBIRT and Director of a Level II Trauma Program, I can only say that this opportunity is a fabulous gift. In health care, we really are not afforded the time to be able to discuss in a down to earth level, the use of intoxicants and the impact on one's lives. The health educators are skilled in motivational interviewing and have offered treatment to more people in the 3 months they have been at our hospital than the 6 yrs I have known previously. It is an effective program!

21 May 08 15:17 | RayDiCiccio said...:
HE model of SBI
As Project Director of a Screening & Brief Intervention project in San Diego County I have observed several important issues related to SBI. SBI can be done cost effectively on a regional level. Highly trained and well managed Health Educators can integrate SBI services into a wide variety of primary health care settings including Hospital Emergency and Trauma Departments, Burn Units and Health Care Clinics. When a motivational interviewing (MI)model is used and MI techniques are infused throughout the process patients are very likely to respond to screening and provide more in depth information. The result has been better information for the health care provider for diagnosis and treatment and a patient with higher motivation to change unhealthy behaviors.

Using "Teachable Moments" and Health Educators trained in motivational techniques provides a opportunity for the US Health Care to transform in a way that places more emphasis on prevention and early intervention without necessarily moving to a single payer system. That transformation could help us begin to catch up with other Western Industrialized Nations in providing high quality health care for less in per person expenditures.

21 May 08 13:18 | ByrdF said...:
Screening, Brief Intervention, and Referral to Treatment
I am the Program Developer for the SDSURF CASBIRT Project. This initiative has my full support. Our Peer Health Educators conduct screening, using the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST). We find that the ED visit is the perfect teachable moment and opportunity to intervene and educate a patient. I encourage the Joint Commission to support continued funding and the establishment of billing codes for these cost effective services.

21 May 08 12:46 | JenPicci said...:

At Northeastern University, we have implemented screening and brief intervention within the University Health and Counseling Services funded by a SAMHSA grant. As the nurse who conducts the intervention, BASICS (Brief Alcohol Screening and Intervention in College Students), I have seen and heard first hand the positive impact on college students.

The brief intervention (two one-hour sessions) with a nurse is suitable for college students because of their busy lifestyles and there is no stigma around meeting with a nurse compared to being referred to speak with a mental health therapist about alcohol and drugs. Some student responses shared with us: “I need you to know that I have talked with friends about my conversation with you, and I feel like I have taken so much away from this BASICS service and I am able to see now how my drinking is related to many other parts of what’s going on.” ”I am glad to know it was not counseling…I think this was good, I never have talked with anyone not even friends about my drug/alcohol use-like why I use and all….”

Clinicians have embraced the SBI as it allows them to address their concern with the student and easily refer to BASICS without taking away from the purpose of the medical appointment. The supportive close working relationship between the clinicians and I have been instrumental in also allowing for me to have a referral source when medical/mental health concerns arise as a result of students’ use.

I have been the first point of contact for many students who need further services to talk about their alcohol and drug use. The ability to refer a student to medical and mental health services, assist them in making an appointment, and follow up on their experience all under the same roof is beneficial in providing the best care for the students. The feedback from student referrals has shown they are pleased as well: “If it was not for going through that research study, I am not too sure I would have made an appointment here to talk. (about sex assault)” “Thanks for setting me up with him, he is great and it has been helpful” (student is referring to the alcohol and drug counselor at the University Health and Counseling Services)

First hand, I have seen the rise in awareness and motivation to change while sitting in sessions with the college students. And the great part of it all is the students enjoy the conversation and growth just as much as I enjoy seeing it. “I think it is a good service, helped me to get some ideas to try and slow down with drinking. I really need to try pacing my drinks out more and consuming more water in between so I feel better in the morning. Thanks…”

I strongly encourage and support standards for SBI in college settings as well as community clinical settings. SBI has the ability to help the nation turn to more prevention work which is cost effective and beneficial for all.

21 May 08 08:46 | SallyLinowski said...:
SBI for mandated college students works
At UMass Amherst, the state's flagship university with an undergraduate population of 18,500, we have implemented SBI for all alcohol policy violators as a judicial intervention since January 2006. Ninety-five percent of our caseload of 2600 to date, are mandated referrals, with the remainder comprised of protective custody, medical transports for acute alcohol overdose, mental health and medical provider referral, or self-referral. We are using the Brief Alcohol Screening and Intervention for College Students modality, an evidence-based Tier 1 strategy by NIAAA. We have implemented the program with integrity to theory and its intended implementation of two individual sessions with a prevention specialist and have 6 month follow- up data on participants. Results from a quasi-experimental design indicate that students who participate in BASICS show significant reductions in high risk drinking rates and connsequences compared to those who did not receive the intervention. At six months, there are statistically significant reductions in number of drinks when partying, peak number of drinks, typical and peak BAC, binge drinkking and frequent binge drinking. Non participants show an increase in these measures over six month follow-up. An important aspect of our SBI is that it is situated within a comprehensive, environmental approach to reduce high risk drinking among UMass students. An individual intervention of this type is supported on the campus by enhanced alcohol policy and enforcement, new town bylaws requiring keg registration, social host/nuisance house ordinance, open container bylaws, a social norms marketing campaign with 96% visibility, a retail partners committee, and an online alcohol course requirement for all first year and transfer students. These strategies combined have resulted in a 33% reduction in heavy episodic drinking, frequent heavy episodic drinking down by 26% and a 14% drop in underage HED. Our program evaluation reveals that a mandated population is in fact a high risk drinking population, as 86% score 8 or higher on the AUDIT at intake. This has been instrumental in convincing residence life and judicial staff to hold students accountable for alcohol policy violations, as they now have data to disprove the misbelief that students are just caught doing something stupid, that they really are not high risk drinkers. SBI has changed the way our campus treats alcohol abuse, leads to stepped care referrals and is well supported by students.

20 May 08 14:10 | VanceBurns said...:
Florida's Brief Intervention and Treatment for Elders (BRITE) project, funded by SAMHSA and using the SBIRT model, serves adults 55 years and older in a variety of specialist and generalist settings, including emergency room, trauma center, hospital, mobile medical unit, and soon to operate in two senior-specific urgent care centers. With technical assistance from BRITE project staff, our providers and primary care administrative staff negotiated the implementation of services in these settings during the past 6-7 months. Negotiations included the development of a business process analysis to identify client flow through a particular primary care system. Through these negotiations, and making the most of “teachable moments”, we overcame most of the institutional barriers to implementation of the screening and brief intervention model in these settings. Once that was accomplished, most personal barriers soon followed. JCAHO accreditation standards aside – as well as options for CPT, Medicaid and Medicare reimbursement for SBI – implementing the SBI model in ED and other primary care settings is possible. Florida’s efforts in doing so notwithstanding, SBI is an effective and cost-effective model for identifying at-risk substance users who are not in need of deep-end treatment services.

20 May 08 10:19 | DoloresCimini said...:
SBI can make a difference in the lives of our nation's college students...
Within our large public university, we have reached nearly 6,000 graduate and undergraduate students with evidence-based alcohol screening, and, as indicated, brief intervention. With our intervention strategy, the Brief Alcohol Screening and Intervention for College Students (BASICS), we have seen both clinically and statistically significant changes within our student population at six-month follow-up, including the following:

*15% reduction in drinks consumed per week *11% reduction in heavy episodic drinking episodes in the past two weeks *9% reduction in peak drinking amount during the past 30 days *17% reduction in peak BAC *29% correction of student misperceptions about peers’ drinking

Our SAMHSA-CSAT-supported college-based screening and brief intervention program is serving to change the culture on our campus toward an environment that supports reduced alcohol use and associated negative consequences and enhanced use of protective behaviors. I would encourage enhanced support for such campus-based screening and brief intervention programs across the nation so that we can reach a greater percentage of our 17 million college students before they experience the deleterious effects of alcohol abuse across the academic, physical, legal, social, and psychological areas – at a time when we can make a difference and potentially save lives with early assessment and intervention.

20 May 08 05:48 | SamFred said...:
People believe that only illegal drugs are harmful for health and legal drugs will not affect them even if they use it for a long time and that too without taking prescription from any doctor. But it’s untrue and the results can be fatal.

16 May 08 16:20 | TedDiedrich said...:
As a Coordinator for a SAMHSA-funded SBIRT Program in Colorado, I have seen positive short-term outcomes for our patients. A high priority for our program is to ensure the sustainability of SBI services in clinical settings once the grant cycle has expired. A chief focus for me is to overcome barriers to implementation and change. My hope is that the Joint Commission does the same by supporting continued funding, health education, and the establishment of billing codes for these essential services.

16 May 08 09:28 | KayDoughty said regarding ScreeningAndBriefInterventionBHC:
Brief interventions are highly effective, based on extensive research and my own experience with S-BIRT, particularly with Older Adults. Many individuals presenting at medical facilities are there because of their use of alcohol and other drugs. Frequently, these individuals are not asked the appropriate questions that will elicit this use. Time is always a consideration, yet given the ever increasing costs of deep end care, there is a good 'business' case for providing a mechanism to intervene early in the development of addiction or problem use.

13 May 08 23:47 | BerniceCarver said...:
Screenings and referrals needed...
If we are serious about classifying alcoholism and drug addiction diseases, we should definately screen and do treatment referrals for them like any other disease that is so prevalent and treatable. We should also raise alcohol taxes to fund prevention, treatment and education, as well as defray the enormous costs to society that are inflicted alcohol addiction.

13 May 08 16:20 | PamelaGillen said...:
Individuals often don’t seek out help for substance abuse problems until it is a crisis. Many of these same patients are often seen by their primary care physician, specialty clinics and hospital emergency rooms. It is important that all medical clinics implement screening and brief intervention for substance use into their clinics. In addition to screening for drugs, providers need to look at the both adults and adolescents for risky and dependent use of alcohol. Fifty percent of all pregnancies are unintended. Woman who are risk drinking need to know the dangers of drinking and using drugs during pregnancy. With universal alcohol and drug screening in all clinics, brief intervention and referral can occur and help reduce the incidence of alcohol and drug exposed pregnancies. Fetal alcohol spectrum disorders are a direct result of woman drinking during pregnancy and it is 100% preventable if woman do not drink during pregnancy.

13 May 08 16:06 | WarenJones said...:
almost 1/3 of the patient in the hospital has a health related problems due to over use of drugs and alcohol.Emergency services patients with untreated alcohol problems are 81% more likely to be admitted to the hospital and 46% more likely to report at least one prior emergency service. This is a comprehensive addiction portal focusing on topics of alcohol and drug abuse. http://www.alcoholaddiction.org

12 May 08 21:04 | MichaelGrazier said...:
This initiative has my full support. ED visits are often represent the first encounter in which problem drinkers see a health care profession. It would be a shame to let an opportunity to intervene pass by. Additionally, SBIRT has shown to be cost effective and beneficial to patients quality of life.

12 May 08 16:30 | CarolynnMorris said...:
In favor of SBI I am a Trauma Educator/Outreach Coordinator for a Level II Trauma ystem in Tacoma WA. I am fully in favor of JCAHO requiring screening and brief intervention (SBI) as a prerequisite for accreditation of hospitals. Our WASBIRT program has successfully implemented alcohol and drug SBIR services and recently (2007) expanded services to include youth between 13 and 17. SBIR not only provides great benefits to patients/families, it has proven to reduce health care costs.

12 May 08 11:05 | EricaChristie said...:
All for SBIRT
I work with women who are recovering addicts who have lost their children to foster care due to their addiction. Now that they are sober, they have worked to reunite with their children. Working with these families who are directly impacted by addiction has opened my eyes to new initiatives that must be implemented to create change. I am a strong supporter of SBIRT and all it has to offer. Chemical dependency professionals who can intervene and screen individuals with possible addictions in the emergency rooms will increase the follow-up to treatment and begin the cycle of change and healing. The evidence shows that the majority of emergency room visits are individuals under the influence; the revolving door in the ER's is greatly related to substance abuse. Not only will it help the individual initially and assist in their recovery, it will positively impact the whole family. I believe that less children will enter the foster care system if the issue of addiction is addressed at the frontlines, which is our emergency rooms.

12 May 08 09:06 | MichaelSinclair said...:
Too many requirements...
It is difficult in a busy emergency department to DOCUMENT compliance with Joint Commission requirements. I already screen every patient during my social history, and I always offer a brief intervention (30 seconds to a minute) during the patient encounter and once again during discharge. I always note this in the chart, but this will never suffice by Joint Commission standards. By their standards, I would need to complete a form that would take 5 minutes to complete in order to be compliant by stating that I screened the patient and offered intervention.

The Joint Commission has really gone overboard with its requirements. This is about as brilliant an idea as their pharmacist prospective validation of all medication orders in the ED.

09 May 08 17:41 | HelmutMEISL said...:
Screening and treatment for alcohol related disorders is a desirable objective, but the scope should be placed where there can be the most benefit, and where there is ongoing care. This should be for community physician offices, and admitted hospital inpatients. To include all Emergency Department patients, would seriously impair ED flow, and the ability to effectively treat all the patients who need care in the ED. Requiring such screening for all or many ED patients, including those with minor or unrelated conditions in the ED, would expend too much time and resources, when Emergency Departments are already are overcrowed, and often overwhelmed. The ED is well aware of the alcohol problem, as we see so many of these conditions, and do treat these patients. Another real issue is that there are so few community resources to care for these patients, after they are discharged from the ED. Many have no insurance and community physician or clinic referral is difficult to impossible.

08 May 08 22:06 | KenRoymd said...:
In favor of SBRIT
Research is clear on the cost benefit and cost savings related to Screening and Brief Intervention (SBI) and Referral to Treatment (SBIRT). Because of generations of undereducation in medical training about addiction and persistent moral model thinking about addiction, physicians tend to blame patients for having addiction and paradoxically don't wnat their patients to be "tainted" with the documentation of an addiction process. Requirement for accreditation will identify a greater number of people with addiction at an earlier stage in the disease process and provide disease and treatment information to them. I am very much in favor of requiring SBRIT practices for accreditation.

Ken Roy MD New Orleans, LA

08 May 08 15:58 | RonaldHellstern said...:
This is yet another laudable but unfunded mandate about to be dumped on the ED. The only reasons the ED is being considered is that: (1) the primary care providers who are supposed to do this kind of thing aren't, and (2) TJC can impose things like this on the ED by fiat. EDs are already in crowding crisis with increasing throughput times and decreasing reimbursements. Where is the over-arching healthcare "system" authority whose job it is to prioritize the demands on EDs? There is none. As a result every regulatory body feels it has the liberty to pile every great idea on the ED without regard to its primary mission or all of the other unfunded mandates already imposed on it. Given the current trendlines for ED care pretty soon each ED visit will be a comprehensive healthcare assessment and treatment plan taking 4-6 hours and thousands of dollars to complete with no reimbursement whatsoever. Instead of looking to the ED to fill all the gaps in the otherwise broken healthcare "system" TJC ought to be lobbying for better primary care pay so things like immunizations and alcohol inteventions could get done in the PCP's office where they belong. These comments are my own and not necessarily those of ACEP. Ronald A. Hellstern, MD, FACEP

08 May 08 15:38 | DanielAlford said...:
As a primary care general internist at Boston Medical Center and the medical director of the Massachusetts SBIRT (MASBIRT) program, I am fully in favor of JCAHO requiring screening and brief intervention (SBI) as a prerequisite for accreditation of hospitals. Our MASBIRT program has successfully implemented alcohol and drug SBI services in multiple inpatient, outpatient and emergency room settings. However, I am extremely concerned that these services will not be sustained once SAMHSA funding ends. It has become clear to me that sustainability of SBI services in general healthcare settings will require 3 major changes: 1) ability to get reimbursed for SBI services (currently being implemented in multiple states); 2) a JCAHO accreditation prerequisite for SBI services and 3) ability to document confidential substance abuse treatment issues in general healthcare settings without having to create a separate medical recording system to satisfy 42 CFR part 2.

Daniel P. Alford, MD, MPH, FACP Associate Professor of Medicine, Boston University Medical Director, MASBIRT, Boston Medical Center

07 May 08 15:06 | IleanaArias said...:
Thank you for the opportunity to encourage the Joint Commission to adopt quality standards for the practice of Screening and Brief Intervention (SBI) in hospitals. For over a decade, CDC has invested in SBI-related research and implementation efforts and, as a result, is aware of how this standard could play a vital role in preventing injuries and re-injury. We know that alcohol misuse is the third leading cause of preventable death and annually accounts for more than 75,000 deaths. An alcohol-related motor vehicle crash kills someone every half hour and injures someone every two minutes. Alcohol misuse is a major risk factor for chronic disease and serious injuries.

The adoption of SBI as a quality standard for hospitals will not only help to identify patients who are addicted to alcohol, but also the much larger number of patients who are not addicted but sustained their injuries as a result of their drinking. The introduction of SBI as a routine element of hospital care will help to save lives, to reduce injuries, and contribute toward the building of safer and healthier communities. In addition to preventing injuries, it can decrease healthcare utilization and prevent lifelong emotional and physical disability.

The research conducted by CDC and its partners has shown that SBI is effective in a variety of medical settings. It was found to significantly reduce subsequent alcohol use and decrease the chance of repeat trauma center admission by nearly 50%. SBI can capitalize on the “teachable moment” that admission to a hospital provides.

The Joint Commission’s step to require SBI in hospital settings will help to broaden and multiply SBI’s current impact. For all of these reasons, DC joins its partners in supporting the implementation of SBI as a quality standard for hospitals.

Ileana Arias, Director, CDC National Center for Injury Prevention and Control

07 May 08 10:12 | MichaelEllis said...:
A very positive step forward
As a public health consultant, the benefit of screening and brief interventions (SBI) for substance abuse is clear. All hospitals would be advised to implement SBI in emergency departments, inpatient units, and ambulatory primary care and OB/GYN clinics. If all adults and adolescents were routinely screened for dangerous and dependent drinking or drug use, our nation would help many, many people avoid longer term substance abuse difficulties in the future. Optimally, health care facilities, especially hospitals and their emergency room, as well as public health clinics, walk-in clinics and other spots where the public meets with health care practitioners, should be required to show evidence of appropriate brief intervention and referral for alcohol and drug problems.

06 May 08 20:14 | MonikaKoch said...:
I would like to support this initiave. It is very clear that ER visits are a window of opportunity to engage a patient in treatment and too often it is missed. I agree with prior comments that laws discouraging addressing substance use by permitting insurance companies to deny payment should be changed as soon as possible. In the meantime if JCAHO requires SBIRT more momentum to change this law will be created and patients will be treated as comprehensively as they deserve.

06 May 08 14:00 | DianeLia said...:
The Oregon Governor’s Council on Alcohol and Drug Abuse Programs express support for the adoption of quality standards for the practice of Screening and Brief Intervention (SBI) in medical settings. SBI for alcohol and drug problems has now been implemented in enough hospitals to show that it is feasible, cost-effective and of high benefit to patients and hospitals based on CADCA information.

05 May 08 15:15 | RonaldStewart said...:
Support SBIRT--Also ensure health care facilities are protected from denial of payment from insurers
I am very supportive of SBIRT. We currently do SBIRT in our trauma patients at our Level I trauma center. There is still a lingering concern about the issue of denial of payment by insurers, when patients test positive for alcohol or drugs. This is generally overstated, and rarely happens; however, when it does happen, it usually is in a very costly patient with an extremely large hospital bill. As SBIRT continues to gain momentum and support from organized medicine, compliant facilities and physicians should not be penalized for doing the right thing. Although not common now, if SBIRT essentially becomes mandatory, it would not be out of the realm of possibility for insurers to become more aggressive in denying payments. Protection of hospitals and care providers from denial of payment related to SBIRT should go hand in hand with adoption of SBIRT in health care institutions.

04 May 08 10:33 | DonaldKurth said...:
Support SBIRT
At Loma Linda University in southern California we have been using SBIRT for several years. With the help and direction of Chris Dunn and Larry Gentilello, it was simple and easy to implement. There is no doubt that filling this "practice gap" has saved lives.

The Loma Linda University Medical Center Level I Trauma Center serves more than 25% of the state of California. Of all the trauma patients admitted, a full 50% have alcohol in their bloodstream. If we look at drugs and/or alcohol, this figure reaches 70%. How on earth can we not at least make an attempt to intervene on the underlying etiology of their presenting illness?

Let me simplify this. Let's say we have an orthopedic clinic set up at the base of a waterfall. Every day, all day long, people are careening over the falls in their boats and crashing on the rocks below. They are brought to us with broken arms, fractured legs, and crushed vertabrae. To improve health care we buy more plaster and a better X-ray machine. But they just keep coming. Then, we build more modern surgical suites and get a better MRI machine. Still, the people keep crashing over the falls--often the very same people we just patched up last week or last month. The good, hard working physicians and nurses in our clinic are overworked, overwhelmed and besides themselves with frustration, struggling to find a way to help these poor people with their broken bones. The costs of patching them up over and over again are breaking the clinic. What are we to do?

Finally, the smart people at the Joint Commission look at the situation and say, "Hey, why don't we set up a program to recommend to every injured boater, now while they are open to suggestions, that they take a boating safety course? Then, if we can teach them how to sail their boats better, they won't float over the falls in the first place. If they don't crash their boats, you won't have to fix their bones!"

Will everyone follow the recommendations? No, probably not. But many will. And, the SBIRT intervention has proven to be so cheap and effective, that it is well worth giving it a try in every case we can. The money to be saved is enormous. The cost-benefit ratio is so persuasive that the intervention cannot be ignored. In terms of preventing human suffering and death, the savings are even greater.

The next step, of course, is to develop easily accessable and more effective boater safety courses. And perhaps, in time, we can develop a referral system that is activated before they go over the falls for the first time! But, maybe an idea like that is for a later discussion. Let's focus on first things first and get the SBIRT in place and operational in every ER across the nation, then we can move on to bigger and better things.

Donald J. Kurth, MD, MBA
Fellow of the American Society of Addiction Medicine
Chief of Addiction Medicine,
Lome Linda University Behavioral Medicine Center,
Associate Professor, Preventive Medicine and Psychiatry,
Loma Linda University,
MPA Candidate, Kennedy School of Government, Harvard University,
Fellow, Robert Wood Johnson Foundation,
Developing Leadership in Reducing Substance Abuse 2003-06,
Past President, California Society of Addiction Medicine,
Mayor, City of Rancho Cucamonga

03 May 08 11:41 | JeanMarsters said...:
In favor of SBIRT...
I am a physician in the Addictions field and feel strongly that the Joint Comission is in a unique position to take quality, evidence-based healthcare a step further in the United States by adding Screening and Brief Intervention to the list of services expected in order to qualify for accreditation.

Jean Marsters, M.D. Oakland, CA

02 May 08 22:40 | ElizabethHowell said...:
SBIRT is not complicated or very time-consuming, and begins a conversation with a health care professional about alcohol and/or drug use. SBIRT is a simple, cost-effective way to save lives and decrease suffering. As others have said, sometimes it takes a "mandate" from Joint Commission or some other entity to make something happen. I strongly encourage the Joint Commission to add SBI to accreditation requirements.

02 May 08 17:04 | DenisePiastrelli said...:
SBIR Program Development
SBIR Program Development

The development of the SBIR program was relatively easy at our health center and did not require a lot of effort.

An interdepartmental group made up of representatives from Case Management, Addiction Medicine, Trauma Program, and Emergency Medicine, determined that the Social Workers and the Injury Prevention RN would conduct screenings on all persons who meet trauma patient criteria who are >14 years of age.

The AUDIT tool was selected for the screening of our patients.

Staff attended training conducted by Dr. Gentilello, Chris Dunn, PhD, and Craig Field, PhD, MPH.

A guideline for SBIR was developed along with an AUDIT form flow chart.

The individual who screens the patient provides the intervention and referral when a patient screens positive.

02 May 08 13:49 | PeterCohen said...:
A good idea carried out can also have unintended negative consequences
Change is hard enough to accomplish in a hospital, even when it's the right thing to do. An ED, for example, has tremendous financial and service pressures and mandatory accountability in place that have multiplied in this fragmented system of care in our country, worsened by a recession. They have become the point of last resort for non-insured patients. Adding something so sound without a design that considers the context and systems of care is like applying a patch without enough glue and supporting cloth to make it stick to the fabric. In essence you have an unfunded mandate even with CMS reimbursement.

So how could one carry this SBIRT? 1. Differentiate the screening instrument according to the treatment setting. An ED has different time and emergent pressures versus a stepdown hospital floor. 2. Introduce criteria that trigger screening. Must you screen everyone? 3. Screening is as good as the interviewer's ski and ability to establish rapport. Timing: while a patient is withdrawing from alcohol vs. intoxicated vs. experiencing pain? At what point in the interview? Who is going to do the screening? 4. Referral process: does the hospital have a process and infrastructure to interview, refer and follow-up? Aggressive care management and followup is required. ED's, trauma centers and other somatic care units are not equipped nor are their staff trained to know or do they have the time to do much beyond screening. Available behavioral health staff are indispensable. Work closely with the local public private systems of substance abuse care. Otherwise, you will have a patient occupying space in a hospital without accessible services. Finally, one outcome should measure the percentage who attend the referral program. 5. Information technology: can analyze this effort regarding outcomes and prevention of cost-shifting and overutilization of care? Creation of a system of intervention without outcome measures derived from a medical record database may be expensive but mandatory. 6. Going for perfection stifles innovation. Sure the drug screening measures are lacking but don't let that deter you. Screen and assess you results. Eventually those instruments will become available. In the meantime, based upon your outcomes, you can decide what to do if the screening instrument is not sensitive enough. Also, measure how many repeat patients got past the screening during previous treatment episodes.

In conclusion, avoid the piecemeal initiative of SBIRT unless you can add these other elements. And then make sure you can show that it's cost-effective. Without incentives and outcome measurement, you'll only get resistance and mediocre efforts.

Peter R. Cohen MD Medical Director Maryland Alcohol and Drug Abuse Administration Catonsville, MD

02 May 08 12:58 | XiaVu said...:
If there is not a current standard for primary care physicians to periodically screen for prescription addictions, there should be one.

01 May 08 08:47 | MarjorieJoseph said...:
As part of the CSAT-funded Campus SBI Project, we have developed a protocol for screening and brief intervention at Bristol Community College in Fall River, MA. SBI services are provided by Masters-level behavioral health clinicians and CADAC-level substance abuse counselors. It is essential to the effectiveness of an SBI program that staff be thoroughly trained in screening, assessment and brief intervention techniques. Equally critical is ongoing supervision to ensure fidelity to the model. Although it is crucial that SBI providers develop a strong collaboration with healthcare providers, we strongly recommend that the standards include the role of behavioral health and substance abuse professionals in the implementation guidelines.

01 May 08 07:04 | MichaelMiller said...:
The Joint Commission is in a unique position to improve patient safety, improve health outcomes, and promote cost effectiveness in health care by creating a Standard to assure that healthcare organizations screen for alcohol and other drug use and addiction.

The participation of senior leadership of The Joint Commission in the 3rd National Leadership Conference on Medical Education sponsored by the Office of National Drug Control Policy (ONDCP) in the Executive Office of the President, served to clarify the role that The Joint Commission can play in increasing the rate of screening and brief interventions for alcohol problems and in promoting healthcare organizations to establish processes for Screening, Brief Intervention, and Referral to Treatment (SBIRT) for the persons they serve.

SBIRT is one of the most effective clinical preventive services yet identified, more effective even than colorectal cancer screening, cervical cancer screening, vision screening in older adults, and pneumococcal immunizations in older adults (http://www.prevent.org/content/view/43/71/; see also “Primary Care Intervention to Reduce Alcohol Misuse: Ranking Its Health Impact and Cost Effectiveness,” Leif I. Solberg, MD, Michael V. Maciosek, PhD, Nichol M. Edwards, MS; American Journal of Preventive Medicine, 2008.) It is cost-effective as well (see “Brief physician advice for problem drinkers: long-term efficacy and benefit-cost analysis,” Fleming MF, Mundt MP, French MT, Manwell LB, Stauffacher EA, Barry KL, Alcoholism: Clinical and Experimental Research 2002;26:36–43; and “Alcohol Interventions for Trauma Patients Treated in Emergency Departments and Hospitals: A Cost Benefit Analysis” Larry M. Gentilello, Beth E. Ebel, MD, MPH, Thomas M. Wickizer, MPH, PhD, David S. Salkever, PhD, and Frederick P. Rivara, MD, MPH, Annals of Surgery 2005;241: 541–550).

Hospitals, including their emergency departments, are not conducting Screening, Brief Intervention, and Referral to Treatment currently except in unusual circumstances. Level I Trauma Centers are now required to have some process in place to address alcohol use and addiction among patients admitted for trauma. But there are other settings where SBIRT should be employed. Early identification of addiction, problem drinking, and at risk drinking in primary care, prenatal care, emergency care and geriatric care settings can reduce the burden of disease and the overall costs of medical care. The Joint Commission should establish a Standard for at least its Hospital Accreditation Program to require hospitals to establish processes for screening, brief intervention, and referral to treatment. The unfortunate reality is that there is ample evidence that practicing physicians do not engage in SBIRT or similar activities related to patients’ alcohol and other drug use and addiction; they do not feel skilled or comfortable in doing so; they don’t have the knowledge to be aware that they should do so; and medical school and residency training did not provide them such knowledge and skills. Thus, the American healthcare system must remediate itself to bring practitioners up to standards of practice supported by the evidence about SBIRT. Having a Joint Commission Standard will assure that practices occur, and in order to meet the standard, clinicians will be prompted to acquire the requisite knowledge and skills to be effective practitioners of the components of SBIRT. The tiny fraction of Americans with addiction who receive treatment for their addiction (contrasted with treatment for the medical/surgical/psychiatric complications of chronic substance use and addiction) would likely increase were hospitals and other healthcare organizations to effectively screen for these conditions, conduct brief interventions, and, when indicated, refer persons on to treatment for addiction. This would undoubtedly improve the health status of Americans overall.

With SBIRT, we have identified a practice gap within the healthcare system. The gap can be closed by encouragement, and by requirements. The Joint Commission is uniquely placed to be a driver of positive change in this area. The knowledge, skills, and performance of physicians and other healthcare professionals will surely improve, and patients will benefit directly, once The Joint Commission begins surveying healthcare organizations to assure that they have processes in place for SBIRT and that they are in fact utilizing those processes appropriately for the benefit of the persons they serve.

Michael M. Miller, MD, FASAM, FAPA
President and Board Chair, American Society of Addiction Medicine
Associate Clinical Professor, University of Wisconsin School of Medicine and Public Health
Medical Director, NewStart Alcohol/Drug Treatment Program, Meriter Hospital, Madison, Wisconsin
Past Chair, Professional-Technical Advisory Committee (PTAC), Hospital Accreditation Program (HAP), Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

01 May 08 00:05 | CarmonWilson said...:
In January, 2008 I started my third year with WASBIRT at Yakima Regional Hospital (Washington). My experience and skills as an MSW and CDP, have been helpful in presenting the screening, brief intervention and referral process. I have been implementing WASBIRT in the Emergency room and upper floors of the hospital. Hospital doctor's, nurses, case managers and social workers have also asked if I could see certain patients in conjunction with WASBIRT. I have also been invited to attend the Social Work/Case Manager meetings on a weeking basis for the past year.

It has been very rewarding to see how well WASBIRT works with the patients. Over time, many pt's have been given brief interventions; and some with referrals for BT counseling. I am convinced that this program should continue and become a part of the hospital staffing. In one example of a referral to BT counseling I saw the pt months later in the ER. The pt thanked me over and over for the help she had received. The pt reported that it had changed her life and that of her children. To me, there's nothing like seeing a changed life.

Thank you for letting me share.

Carmon L. Wilson

30 Apr 08 16:48 | TeriJohnson said...:
I have been a lead counselor for a SBIRT site hospital in washington for the last three years. I think the brief intervention for hospitalized patients is very important. Here are some of the professionals who have asked for sbirt services for their patients within the hospital: Social workers, Discharge planners for Psychiatric inpatient, Trauma specialists, and our Sexual assault clinic. It is obvious to me that there is a huge need for intervention specialists in the hospital setting. We have data that shows emergency room patients had reduced drug and alcohol use after participating in brief interventions. Our SBIRT program used Chemical Dependency Profeesionals(CDPS) to provide services, a choice that I would recommend. CDP's have the background and experience to identify and recommend chemical dependency Treatment for people that need it. Also, it helps to have a person with professional experience give interventions. CDP's have a good understanding of abuse verse dependent behaviors and dual disorder populations.

Also, motivational interviewing works well as a counseling style in this format, and I would also recommend this for any hospital considering sbirt services.

30 Apr 08 14:59 | MichaelBierer said...:
The Devil's in the Details
I am optimistic that a JCAHO standard will change organizational behavior rapidly and in general for the better. That being stated, I think it will be important to have anticipated operational problems that standards may impose. Poorly defined or rolled-out standards can serve to increase opposition to important, and otherwise embraceable goals. Appropriate and robust SBIRT for alcohol and tobacco use is much needed.

FIRST: Over-generalization to diagnoses or sites not supported by the weight of evidence will be a mistake. Miss-application will be futile and wasteful. As Dr Kertesz has described, illicit drug use is less well supported than that of tobacco and alcohol. Similarly, are we confident that BI is as efficacious for DSMIV Dependence as for Abuse or harmful use? What about untested settings such as specialty clinics, pre-operative evaluation services or others?

SECOND: The standards should encourage meaningful and therapeutic activities, rather than administrative efforts to put on a good show. What will organizations present as acceptible evidence of meeting SBIRT standards? The mandated pain scale at our institution is an example of busywork, wasted paper and ink, and vague processes that often yield unusable or inappropriate data, ignored by practitioners. A more appropriate roll-out of a laudable activity like SBIRT is more complex that a circled "smiley-face," and evaluation of the quality of such a process is similarly challenging.

THIRD: How well will this be supported? Do the billing codes actually translate to revenue sufficient to hold harmless those providers and organizations that spend the time to perform SBIRT well? Will organizations providing poorly-reimbursed care suffer disproportionate opportunity costs?

30 Apr 08 14:50 | JeffGeibel said...:
The PA Department of Health, Bureau of Drug & Alcohol Programs, has for the past 5 years, with federal funding been involved with Screening, Brief Intervention, Referral and Treatment (SBIRT).

As considerable progress has been made in expanding the continuum of care within the Substance Abuse System to include Screening and Brief Intervention (SBI), we must continue to impact on these clients, as we do in all other areas of health care.

The implementation nationally of an SBI model will improve the identification of substance misuse, decrease alcohol and drug use and increase the number of individuals receiving the appropriate recommended level of treatment.

Screening procedure results are reliable and valid if carried out with standardized instruments and Brief Interventions have now been standardized. Such interventions lead to positive health outcomes and reduce alcohol related morbidity.

30 Apr 08 13:51 | JoseEsquibel said...:
JACHO SBI standards an important step in making SBI a standard of care in our nation's health care system
I am Director of Interagency Prevention Systems with the Colorado Department of Public Health and Environment and I serve as the Project Director for the SBIRT Colorado initiative supported with funds from SAMHSA/CSAT.

We have an ambitious vision for SBI in Colorado that health care providers routinely screen all patients and provide interventions as a means of mitigating the progression of substance abuse into addiction and improving the general health of the residents of our state. Already, SBIRT Colorado is implementing SBI in 15 sites across the state, including several major hospitals, and there are plans to expand to more hospitals.

The development of clinical guidelines for SBIRT in partnership with the Colorado Clinical Guidelines Collaborative is a critical component for promoting and instituting SBI as a standard of care in Colorado’s health care settings. The Joint Commission’s work in the area of standards development for SBI is not only complementary to the work being done in Colorado, but will serve as an important catalyst for ensuring that SBI becomes a standard of care in our nation and for addressing substance abuse like the health problem that it is.

Colorado SBIRT is actively seeking to activate the HCPCS codes and will be forming partnerships with representatives of those health plans that will cover SBI. Again, the work of the Joint Commission will further facilitate efforts to ensure the SBI is a billable service in the public and private health care systems. This is essential for promoting and sustaining the practice of SBI.

There is considerable effort still needed in introducing the value and benefits of substance abuse screenings and brief interventions to health care practitioners, and a need for training in conducting screenings and interventions and entrenched ideas and fears about directly addressing substance abuse. Certainly, the standards put forth by the Joint Commission will provide guidance in regard to the practice of SBI, and that guidance should keep in mind the implications for the level of effort needed to implement the standards.

In my opinion, the development of SBI standards by the Joint Commission is favorable for the efforts occurring in the State of Colorado to improve the health of the state’s residents through substance abuse screening and brief interventions by health care professionals.

30 Apr 08 13:26 | GaryHankins said...:
Critical Attitued Encouraged
My main concern is that SBI be viewed critically with an eye toward the long history of misguided and failed efforts in the field of disease screening. SBI can most usefully be viewed is as broad a context as possible including careful consideration of the total local health care delivery system into which the SBI process is to be implimented. To this end I have uploaded a focused literature review report. Because of my unfamiliarity with the WIKI process I uploaded the same document twice under different names. I strongly argee with the position that SBI should be mandated for hospital ERs; however, the devil being in the details very careful consideration needs to be given to the selection of screening and intervention tools and the impact for the process on the rest of the local health care delivery system. My report attempts to explore these concerns. I am aware of instances there institution expended great resources in setting up excellent screening and referral services only to discover there was no treatment provider to receive the patient.

30 Apr 08 10:38 | MaryCurry said...:
SBIRT has been integrated into 35 sites in New Mexico several of which are FQHCs. The SBIRT Brief Intervention, Brief Treatment and Referral to Treatment are provided by a licensed masters level Behavioral Health Consultant (BHC) who communicate verbally and by charting in the medical chart. JACHO regulations that support this integration would be very supportive of increasing the acceptance of SBIRT as an integrated Behavioral Health service. The Behavioral Health Consultants are provided to the medical sites by SDCCHP a sub-contractor. There have been many questions/concerns about the SBIRT BHC fitting into the JACHO regulations. Two of the NM SBIRT sites are hospitals and we are providing the training and consultation to UNMH Trauma Services to begin SBI. There is limited understanding about documenting SBI to reflect adherence to the SBI requirement. Additionally, the UNMH administrators are utilizing the MSW behavioral health staff to implement SBI. I strongly recommend that the role of allied health, behavioral health and medical social workers be identified and defined in the regulations. SBIRT does address JACHO quality indicators. Quality Assurance of SBIRT needs to be defined. The training, supervision, coaching and feedback, support for integrated model development and refreshers to address fidelity drift is also very important.

30 Apr 08 10:30 | StefanKertesz said...:
SBI for Illicit Drugs, in contrast to alcohol, is not currently supported by the National Quality Forum or the scientific evidence
The development of JCAHO standards for Screening and Brief Intervention should rely on an accurate portrait of existing scientific consensus, and most particularly on an accurate understanding of the existing recommendations of important evidence-evaluators such as the National Quality Forum and the US Preventive Services Task Force. In this regard, the Introductory essay offers an inaccurate portrait of the recommendations of the National Quality Forum in regard to the issue of screening for illicit drug use. Specifically, it is crucial to underscore that there exists no scientific consensus to support uniform screening for illicit drugs in health care settings, while such consensus does now exist for alcohol and tobacco. The National Quality Forum, like the US Preventive Services Task Force, has NOT endorsed uniform screening for drug use disorders. It has only endorsed screening for alcohol use disorders and tobacco use.

In the available recommendation document (weblink http://216.122.138.39/pdf/reports/sud/sudexesummary.pdf), the recommendation encourages systematic screening for alcohol and tobacco, and applies extremely different language to the issue of illicit drug use. This is evident on the 8th page of the PDF. For persons who wish to learn more, the National Quality Forum’s explanation and justification of its decision NOT to recommend similar screening for drug use disorders is in a predecessor draft document (pages A-18 to A-19 of a lengthier PDF from the National Quality Forum, lines 531 to 576, at http://www.qualityforum.org/pdf/projects/sud/lsENTIREDRAFT1-22-07.pdf).

Whether health providers should engage in uniform screening for illicit drug use remains scientifically unsettled due to lack of evidence and to the distinct risks of such screening. Certain key kinds of evidence that have been accrued for alcohol SBI have not yet been accrued for illicit drug SBI. These include (a) evidence that clinicians can accurately deploy an efficient, accurate method of screening in settings such as primary care clinics; (b) evidence that efforts to alter drug intake among non-dependent users will lead to improvements in human health (with persons who have identified addiction, most agree that specialty treatment is an evidence-supported practice) and (c) evidence that there exist primary care-based interventions that can result in effective reductions in “at-risk” illicit drug use. Item (b) likely will require study of longitudinal epidemiology data about the health outcomes of changes in illicit drug use among adults in the general population (i.e. not the limited subset of addiction patients in treatment settings). Filling out evidence for item (c) will require randomized controlled trials of Screening and Brief Intervention for illicit drug use in primary care. While a large number of such trials have been conducted in relation to alcohol use, to my knowledge NONE have been conducted for the same intervention in relation to illicit drug use.

This massive discrepancy in the strength of the available evidence (strong for alcohol, weak to nonexistent for illicit drugs) did lead to careful differentiation of alcohol/tobacco from illicit drugs in the statements of the National Quality Forum. Similar differentiation should be preserved in the work of the JCAHO, and at present I see no evidence that the JCAHO is aware of this issue, and I'm troubled that the recommendations of the National Quality Forum are mis-stated in the introduction to this Wiki. I hope that the JCAHO will take this into account.

Stefan Kertesz, MD skertesz@uab.edu

30 Apr 08 09:27 | CarolannKaneCavaiola said...:
I agree wholeheartedly that the SBI must become part of the established protocols for collecting patient information in all health care settings. SBIRT is a thoroughly researched best practice and will establish linkages to qualified sustance abuse professionals as determined by the screening itself. These linkages are too ofen window dressing and meet the standard but not the intent which is to improve prognosis for the patient by receiving services that are professional and targeted to a behavior that is complicating or is adversely effecting overall wellness and health. The caution in all this is that the health care provider preforming the screening and possibly the brief intervention is trained by Addiction Professionals either licsensed or credentialed in the state to assess and provide tx for Substance Abuse Disorders. the training must be annual, the linkage to the addiction provider must be evidenced by concrete agreements and a tally of real referrals that resulted in addiction tx services being delivered.

29 Apr 08 23:33 | JmBenkis said...:
There are real reasons for testing. We need to remember that Drug Testing by any means was never intended to include legal, non mind-altering activities and products.

Testing for mind altering substances started because they can and have caused dangerous behavioral changes in certain individuals - something no one can foresee or predict.

Stay away from individual personal freedoms. Too much information can be too easily distributed and abused legally, or accidentally.

I am specifically speaking about the person who smokes regular tobacco. These are dangerous slopes that do not stop, once you start sliding down that slippery slope.

29 Apr 08 19:02 | BarbaraWeiss said...:
California Department of Alcohol and Drug Services supports SBI services as a standard of care
This comment is submitted on behalf of Michael Cunningham, Chief Deputy Director, of the California Department of Alcohol and Drug Programs (ADP):

ADP fully supports the Joint Commission on Accreditation of Healthcare Organizations' (Joint Commission) decision to develop standards for screening and brief intervention (SBI) for alcohol and other drugs (AOD). There is overwhelming evidence that SBI services have the potential to reduce healthcare and other costs associated with AOD use and abuse, and California is involved with several significatnt efforts to promote SBI services in a variety of settings.

On a Statewide level as part of California's Governor's Prevention Advisory Council, ADP leads the CASBIRT Subcommittee, which provides strategic input and assists with strategies to modify policies, systems, and financing mechanisms to include SBIRT in California’s continuum of care for prevention and treatment of alcohol and other drug problems and disorders, and to sustain and expand SBIRT services in general medical and other community settings. ADP has also been providing information to the California Department of Health Care Services as they work to activitate the HCPCS SBI codes that would allow Medi-Caid providers to routinely screen eligible patients for substance use and abuse, and provide appropriate intervention services and referrals to treatment when necessary.

The Substance Abuse and Mental Health Services Agency (SAMHSA)-funded California Screening, Brief Intervention, and Referral to Treatment (CASBIRT) Project has been providing SBI services to patients in San Diego County since 2003.

The Joint COmmission's consideration at this time of developing standards and quality improvement processes for SBI services is a major step in making SBIRT an element of the routine standard of care.

29 Apr 08 18:34 | CydnePerhats said...:
I am a strong supporter of the Joint Commission’s undertaking to develop SBI standards for alcohol and other drugs. Since alcohol misuse/abuse is the single greatest contributing factor to the occurrence of injury (and many other medical conditions), this evidence-based practice has the potential to significantly improve patient care and health outcomes. The establishment of standards would be beneficial to hospitals and other health care providers for many reasons, including 1) providing uniform guidance on implementation of the SBI procedure; 2) helping to generate revenues through reimbursement for accredited providers; and 3) assistance with required quality control and performance measures. In addition, standards regarding documentation of the medical visit in which SBI is conducted would be extremely beneficial to facilities in states that currently have UPPL laws. Uniform Accident and Sickness Policy Provisions Laws (UPPL) allow health insurers to deny reimbursement for patient costs incurred as a result of "the insured's being intoxicated or under the influence of any narcotic." These laws are currently a deterrent for providers to implement SBI and Joint Commission standards could both help to illuminate the issue and provide impetus for UPPL repeal as follows. Basically, the insurer is required to demonstrate that alcohol or drug use to some degree caused