Course 3: Organizational SBIRT
In the coming decade, we anticipate that SBIRT will become as much a part of routine medical encounters as checking vital signs.
BUT… Someone has to make it happen.
What if YOU are called on to not only do SBIRT in your work
but to actually help get SBIRT up and running in your workplace?
- You may find yourself in an organization which hasn’t taken the steps to implement SBIRT….
- You may be the most experienced individual or one of a small number who could take the lead in the creation of a new program…
- You may even be told you have to do it…
What would you do?
Probably freak out, but you really shouldn’t. This module is designed to help you take what you have learned about doing SBIRT and help others do it in different places.
One Size Doesn’t Fit All…
One of the most important, fundamental principles of implementing in different places is that the exact form the SBIRT will take when introduced in a new organization depends on “local factors”– for instance, the availability of behavioral health specialists, the type of medical record system used, the ability to bill for the service in your State, and so on. To be successful, you have to understand those local factors and work with them.
…But it’s All Basically the Same Shape!
However, SBIRT is SBIRT! The idea of screening all patients regularly, of assessing key substance use behaviors, and having systems in place to address results is always the same. The pieces may not be exactly alike but the general approach is. Once you have the general approach well in hand, the pieces can fall into place, with a little groundwork to understand the ‘local factors.’
So, What will you do?
Not How to but How to Decide How to…
So, this learning module is the 16,000 foot view regarding what you need to do to develop an SBIRT program in a venue that doesn’t already have one. It’s not a lock step “How to” but rather “How to go about deciding how to.” Which is a really important difference because such a meta-approach allows you to assess local conditions, decide how best select and tailor from among existing SBIRT approaches and resources, and how to monitor and continually react to ever changing implementation conditions.
You have to start somewhere, right?
We suggest that you start with an organizational assessment, assemble a team interested in making this happen, identify the stakeholders in your organization and determine the readiness of the organization to implement SBIRT. Once you get this far, you can get into the operational details. If you hit a wall, it may be worth trying in implement SBIRT in a much smaller unit in which you work, to gain experience and data to make a later approach to the leadership of your organization.
The organizational assessment need not be complicated. You basically need to ask around to find out what resources are available. For all you know, there may be many others who have received training like you have, are enthusiastic about the potential benefits of SBIRT, and can facilitate the work with you. You may simply be the first to take the initiative to get things moving.
What’s Being Done?
Is general health screening being done? You might be able to piggy back onto this. There may an SBIRT program in some part of the organization: perhaps the ED or the mental health system. Some of the work of setting up infrastructure or tapping the medical record system may have already been done. System leadership may already buy into the need for and advantages of SBIRT (for instance, the leaders may have come from a system that implemented SBIRT).
What is Available?
There may be training modules in use at your institution for parts of the SBIRT curriculum (and those we have created at IU are available for your use at www.iusbirt.org). Are there behavioral health specialists imbedded in the clinic where you work or are they geographically close by? What are the mental health services capacity of your system?
What’s the Organization’s Mood Regarding Change?
The notion of introducing SBIRT may play well if the organization has realized that substance abuse is contributing to quality of care issues, such as hospital readmissions or medication adherence problems. Accountable care organizations may be particularly interested in identifying and managing substance use problems because of the complications of substance misuse. A well-publicized tragedy (alcohol-related automobile accident, death of an undergraduate by alcohol poisoning, or domestic violence) might motivate an organization to begin to address this problem.
Are There Other Health Care Professionals Who have had Training in SBIRT Already, and Can Thus Be Your Allies?
This is an obvious benefit, but the question is how to identify them?
Perhaps a note in a medical or nursing staff newsletter, or, with permission, a question or two sent by way of the organizational email distribution system. You might wish to inquire about experience with training in or implementation of SBIRT, and interest in being part of the planning team.
Who are the Key Players?
As this will depend on your circumstances, it is important to first identify all the stakeholders and understand the role of each stakeholder in development & implementation of your plans (and anticipate that they will have important insights for you as well). Likely stakeholders include: clinic managers, supervisors of the outpatient department of the hospital, the practice managers for a private practice, and educational supervisors, as well as the leaders of the physician and nursing staff. In more complex systems (e.g., in hospitals at an academic health center), the hospital leadership (CEO, CMO, director of nursing services, director of mental health services, informatics officer, residency program director, etc.) need to at least tacitly agree with the benefits of implementing SBIRT and understand the changes that they will need to accommodate for the system.
What’s being done?
- What’s available?
- What’s the organization’s mood regarding change?
- Are there other health care professionals who have had training in SBIRT already, and can thus be your allies?
- Who are the key players?
That’s it! Not too tough. Just ask some basic questions about what’s going on, document your results, and you are well on your way!
So, what do you do with the information? You get the ball rolling!
Once you have done the organizational assessment, you should have some help.
Seriously. You’ll need help. And, from the assessment, you probably already identified a few compatriots to assist you.
At this point, you need a general idea of what you want to do. This doesn’t have to be detailed, but you should have enough of a idea to be able to convey what you are up to to others who you’ll need from whom you’ll need support. What are you up to, how do you think you will approach it, and why should others care?
And, you really need to get buy-in at the top if you hope to get very far.
Sure, you could decide that you will use a screening instrument, say the AUDIT questionnaire, with your patients and provide BI when needed. But how will the screening result be kept in the medical record, aside from your office note? If you detect worrisome levels of use or suspect dependence, to whom will you refer the patient and how will you ensure effective collaboration with the addiction specialists? The point is simply that public health measures like SBIRT really benefit the patients when broadly implemented. Plus, everyone’s experience with change is that you WILL encounter resistance, problems with implementation, and you will need resources!
If the solo act described above is all you can do, by all means do it! Because something is better than nothing, and maybe that little solo act can snowball into a much bigger production but let’s shoot for the whole enchilada (to fully mix multiple metaphors!)!
Your job is to sell SBIRT. Everybody selling something has something they can give someone.
These are sometimes called cutsheets in the marketing game. Having a cutsheet both physical and in electronic form, maybe even as a web page, can help you share what you are trying to accomplish and why.
Some of the things you should do in the cutsheet include:
- State your desire to integrate SBIRT in our organization.
- Define SBIRT (and briefly cite references for effectiveness).
- Explain how SBIRT will it help your patients.
- Explain how SBIRT fits your organization’s mission and processes.
- State what you need from people at this stage. This is the call to action!
Some things you can include are evidence for the effectiveness of the process, the anticipation that the Joint Commission will soon require SBIRT in the hospital, the opportunity for billing for SBIRT services, the long term benefits such as improvement in patient outcomes (medication adherence, potential for reduced readmissions, fewer ED visits, better patient satisfaction), and the role of SBIRT in an accountable care organization (reduction of overall health costs). Further, you may point out that SBIRT screening can be integrated with general health questionnaires (with depression, anxiety, domestic violence, tobacco use, dietary screens, etc.). You will also need to describe the resources needed to build such a program: redesign of physician and nursing work, the need for training of current and future staff), information systems’ needs, and the demands that may be placed on addiction services.
the driving force behind the effort. Projects need personalities: people who keep things going. That’s where you come in, Dr. Vision!
Someone who can throw the support of the organization behind the effort and has the authority to not just suggest but to enforce decisions. Having this person engaged will help get things done. Its great to motivate people, but there’s nothing better than someone saying: this is how we will be doing it!
This should include those who work in any area implementing SBIRT: those working in the outpatient clinics (family medicine, internal medicine, pediatrics, gynecology) and in the emergency department. In the future, SBIRT may become a standard procedure for all admissions, in which case the hospitalist service may need to be involved.
Your initial group should involve people from each level of the organization that will be affected. This can include:
Mental health providers:
You have to have people to refer to or it won’t work. This may include social workers with training in substance abuse, counselors (and other trained staff who may go by other titles), and psychiatrists.
Information tech/data folks
Someone’s in charge of paper and electronic records. Engage them. They can help you decide how best to track your results. They will also help you create forms if you use paper documents.
Got Team? Terrific! Now what? How about a timeline?
Time, and timing, and money, oh my!
So, you have a team, with stakeholders from many of the affected parts of your organization. You’ve brought them up to speed and they are sold (if perhaps a little tentatively). What do they do first? Ah… timelines and money.
- How much financial support is there, if any?
- What’s your timeframe for getting things done?
Secure time (and money) to meet, educate about & pilot SBIRT
Based on our experience at Indiana University and Wishard Hospital, we anticipate that it will take about 6 months to establish SBIRT in a reasonably busy internal medicine practice. This estimate is based on our experiences training residents in SBIRT and also introducing SBIRT in a free standing community health center. The latter occurred after the experience of implementing SBIRT in a resident teaching clinic with the support of behavioral health specialists paid for by a grant and with additional grant-supported infrastructure for tracking and training. This well-supported implementation was achieved in about 4 months. This is probably the shortest time in which this could be accomplished in such a context; however, more agile organizations and smaller systems make be able to kick off rapidly in a few weeks and implement iteratively, so your mileage is likely to vary considerably!
Set key dates with milestones
It will help you to set milestones at the beginning (your choice: simple calendar, Gantt chart, whatever works- spreadsheets make this simple). It will help to be rather granular in your milestones, because it is easy to miss a big goal if you aren’t making progress with the small stuff. Throughout our planning and implementation phases, we met every two weeks for an hour to keep people on track, encourage each other, and learn where additional support was needed from the larger institution.
Share data with stakeholders
Later, we talk about continually sharing progress with those affected at the clinic levels. Here, you should remember that initial buy-in needs to be stoked! Keep your core team apprised your progress.
You will have experienced set-backs, perhaps obtained some preliminary data on the prevalence of substance abuse in your population and may have done focus groups or surveys with the clinical staff and physicians to decide how best to implement in your clinic(s). Do not expect this to be easy, and if there is turnover in your team, anticipate the need to “re-recruit” champions. One of your milestones (which will keep your feet to the fire) is to schedule continual (reasonably spaced!) reporting meetings with the stakeholders. And what will you share? All sorts of outcome data is available to you, and you need to decide what you will track and how to track it (which is discussed later in this course) but at this stage its as simple as “have we met our deadlines? If not, why not and what are we going to do about it!”
So, you began your organizational assessment and you know have a much better idea of what the challenges and opportunities are for your organizational.
In fact, you now hopefully have some support, a team, and a general timeline!
So, what next?
You need to continue your organizational assessment. There’s a lot you need to know in order to make really good design decisions.
Without this upfront information, you probably will run into issues where your perfect design doesn’t fit the real world of your organization.
The more you know up front, the less you may have to return to the drawing board later!
First, understand a few important details about your patient population.
- Is English a second language for a large proportion of your patients? This will impact the languages chosen for your given screening method (telephone, paper, electronic or face-to-face).
- What is the level of literacy and health literacy in your population? How does your organization determine literacy level for individual patients? This may influence your choice of screening method or increase your need to identify alternative screening methods when they arise for these patients. Additionally, you may need to provide more training for those in your organization who are doing the screening or brief intervention to effectively communicate with patients with varying levels of health literacy.
- How have your patients responded to phone calls or mailings from your clinic or department in the past? For example, some organizations have attempted to use pre-visit telephone-based screening or post-visit telephone brief intervention. Both have met with varying degrees of success. These interventions can be costly to set up so doing some homework including patient surveys or small pilots can be helpful for you to understand how your patients will respond before you launch into a broader program.
- What is the age range and gender of your patient population? While some substance use screening tools have been validated in adults such as the AUDIT, other screens may be more appropriate for other demographic groups such as elderly, adolescent or pregnant patients. As yet, there is no one-size-fits-all for screening for all substances in all patients. Like many organizations, you and your team need to determine which screen is the best fit for your patients and your organization.
Next, consider some key features of your clinic or department.
- Map out the current patient flow. This may seem obvious but you might be surprised to find out how many steps are involved from making the appointment to completing the appointment. For example, does your patient normally get a reminder call or reminder mailing about their appointment? This may be an opportunity for screening. Does your patient have their vital signs checked in a private room or in a common area? These privacy issues may influence whether you choose a face-to-face or self-administered screen.
- Who normally interacts with the patient beyond the physician? This is the human part of the patient flow map mentioned above. If you can identify all those team members who have interaction with the patient, you can better plan for every team member to take part in planning and delivering SBIRT, even if it just having the front desk person smile and say “thanks” for filling out a written screening. All these little details can impact the attitude the patient has about being asked and given feedback on their substance use.
Finally, identify, understand, and engage your healthcare team
- What role does each team member play in caring for your patients? It may sound strange, but each team member from the front desk to the phone room may not see their role in the same way as you or the clinic management does. Do they see themselves as part of a team with the same mission or do they see themselves as a worker on an assembly line who never gets to see the finished product. Laying the groundwork of defining your team and their roles as individuals as well as their part in comprehensive patient care may be necessary before going forward.
- What are their attitudes toward asking “personal” questions about substance use? Some organizations have begun their implementations by first discussing team members’ personal attitudes towards substance use to help them overcome a feeling of resistance or discomfort about asking about use when they themselves use various substances. Adopting the right attitude toward your team can help them adopt the right attitude toward your patients. In other words, if SBIRT champions within the clinic or organization focus more on improving patient health by reducing risky behavior rather than eliminating it, this may be a more adoptable approach for your staff who may not feel that they are in a position to “judge” patients based on their own imperfect health behaviors. Additionally, sharing data that moving patients toward less risk (rather than no risk) can help. One major study that shows this approach can work is The Cutting Back Study (http://www.health.ny.gov/professionals/ems/state_trauma/docs/cutting_back.pdf )
- What resources do you have at the ready to begin screening, brief intervention and referral to treatment? You can begin with identifying technical support: do you have EMR or other technical support to implement or capture screening data?
Further, you can determine what human resources you have: do you have staff who are already about to do screening or brief intervention? Do you have someone in- or outside of your clinic who can train your staff to do screening and/or brief interventions? Do you have referral support for those who need further, more specialized intervention?
Note, if you did a really thorough assessment earlier in preparation for starting things up, you may already know a lot about these areas. That’s great!
What’s next? You need a plan!
That’s where design comes in…
…and you have already started the first step in design: organizational assessment.
The next step is to decide how you want to implement SBIRT…
Once you “know” your patients, place and people, it becomes easier to answer those checklist questions of What? Where? When? Who? How?
- What screening tool? What method of screening (paper vs. electronic; self-administered vs. face-to-face)?
- Where will the screening and brief intervention take place?
- When will the screen and brief intervention happen (every visit, yearly, etc)?
- Who will administer the screening? Who will conduct the brief intervention? Who will call the substance use counselor, if needed?
- How will the screening results be recorded? How will the information be passed on to the next team member? How will we know who to refer to? How will we know our system is working?
…and a GREAT way to do that is to start with how other people have done it!
Even though there is no one size fits all approach, there are guidelines and suggestions for SBIRT in a variety of locations. A great place to start is SAHMSA.
Roles and Responsibilities: Who does what to whom, when?
Perhaps surprisingly, one of the hardest issues is how to fit SBIRT into the existing flow of the patients and the work of the nurses and assistants. Simply stated, the work flow becomes second nature in a clinic and is hard to change. Establishing clear protocols or algorithms for clinic flow will help eliminate confusion and may increase uptake and sustainability.
Once you have established that everyone has a role to play in patient care, give every team member a meaningful role and be explicit in what they should do. First, let everyone from the front desk to the phone room know their role as well as the role of other team members so they can see their part in the larger view. Next, let them know what to do in various situations. For example, let your front desk staff know that they are expected to provide the patient a screening form at every visit. Further, let them know what to do and how to respond if a patient declines to fill out that form. Make sure the medical assistant who checks in the patient is familiar with the screening tool and what constitutes a positive screen. The medical assistant should know who to alert upon learning that a patient has screened positive for hazardous use.
The NIAAA plan calls for the physician seeing the patient to provide positive feedback for those drinking at a safe level, and to strongly advise those drinking at hazardous level that they should cut down. Physician brief intervention is likely to be the requirement for billing in a fee-for service environment but this could change with accountable care. For patients with more markedly positive screens (or those with additional co-morbidities like depression or other substance abuse), referral to the behavioral health specialist (BHS) may be more appropriate. Referral might be made by the physician or another health care provider. Patient care will benefit from a plan for tracking: a) if the patient met with the BHS, b) how information from the BHS will be communicated to the PCP and vice versa; c) how return visits can be coordinated and who should see the patient first on a return visit; and d) what to do with a patient who fails to return for a visit.
Does your plan to manage the patients vary by risk of serious substance abuse problem? In discussions with the mental health partner, it is important to address your approach for low, moderate & high risk patients.
The less guesswork and more protocolized your program is, the higher the likelihood of it being sustained.
In one of our efforts, for example, the who does what to whom when ended up looking like the following chart (which, by the way, is a very useful thing to build!).
What’s next? You need some tools! Lots of tools!
Got Protocol. Need Stuff!
So, you know who is doing what to whom… the next question is: With what resources?!
Having the screening forms available in paper or in your EMR or online is crucial to beginning the process of screening. Adapting these forms for your patient population may ease use for your patients and staff but may affect validity of the screening form since the language used in these forms has been tested for reliability and reproducibility. It is best to use the available instruments without modification.
You may have to get approval of the form from a larger governing body, such as a hospital or health system Forms Committee. You may need to acquire access for certain healthcare team members if the online form is housed on a secure website.
Knowing how to resupply the forms and where to put the forms when they have been completed is also important. Will they be scanned into a computer or placed in a paper chart? Who will make copies? Who will record, review or track the data? A breakdown in any one of these areas can mean the loss of important data to help you carry out the process of screening, know who needs intervention or know if your entire system is effective.
The forms in our project are continually evolving as they are integrated with other data collection and tracking efforts and with migration toward paperless electronic records. Some examples of our forms however include:
We found it very helpful to create a poster (available at iusbirt.org) that was prominently displayed, saying “We Ask Everyone.” We wanted to be sure that no one felt stigmatized by being screened. An additional patient resource is the NIAAA pamphlet entitled “Rethinking Drinking” that might be made available in the waiting rooms. We feel that simply reminding patients of safe limits to drinking may help them avoid hazardous drinking – it doesn’t matter if this results from seeing a poster, reading a brochure, or filling out a screener. Remember that the BHS is also a resource to provide education to the patient. Often, the BHS has had not only college education in behavioral health, but career experience in substance use treatment.
Most individuals leading an implementation of SBIRT will not have the time or resources to create their own training modules, and there are many available, including those we created at IU. However, it will be necessary to create some educational content describing the specifics of the process you design. A combination of online modules (covering principles) with face-to-face training (to demonstrate the process and patient flow you create) seems optimal.
You are inside some of those modules right now, but we also had face-to-face training sessions and handouts for introducing the effort. For example, for the launch at one site, we used the following presentation and handouts.
Ready, right? Not Quite.
So, now you have who, what they do, and with what they do it, ready, right? Not quite! You have one final pre-launch checklist item. If you haven’t already, you have to decide what to track and how to track it, not just for helping the patients, but for evaluating your progress.
With who, what, when, where, and why all squared away. You have one more thing to lock down. “To what effect?” That is, how will you know you are making progress? By sense of feel? No, that’s bad. You need metrics!
What to track?
We would suggest the key metrics include numbers of patients screened (and tracked against the number of patients who arrive in clinic), the rates of positive screens, and the outcome of the positive screens: was a brief intervention recorded? A referral? And if a referral was made, did the patient keep the appointment or meet with the behavioral health specialist?
The integration of a process like SBIRT into a clinic can produce a surprising volume of data in terms of processes and outcomes, and it will be important to monitor all of this data in order to ensure your project’s success.
If you opt to include a prescreening process in your SBIRT protocol (that is, asking a single question such as whether the patient binge drinks), then you will have this sector of data for every SBIRT patient. Prescreening data should be separated by type (i.e., alcohol, drugs, tobacco, depression, etc…). In many cases, these data will be binary (1,0 or T,F) because they will either present as ‘Positive’ or ‘Negative.’ These data can provide you and your stakeholders with a broad picture of the level of a given morbidity in a population (i.e., “XX% of your patients prescreening positive for problematic alcohol use” is a quick and easy way to conceptualize the burden of use in your patient population). If the number pre-screening positive is too low, you may suspect a problem in the prescreening process or the patients’ understanding of the question.
Depending on the screening tool that you choose to use, these data also can be used to check for discrepancies in application. For example, prescreening and screening data can be checked for logical impossibilities to find errors in the patient flow within a clinic (for example, most alcohol prescreening questions preclude the possibility of that patient scoring a “0” on the AUDIT. If such an instance occurs, then there is a problem with the system).
If you use a prescreening process, then you will have screening data only for patients who prescreen positive or who are assigned to complete a screening by a physician or other concerned medical party. If you use a screening-only process, then you will have screening data for all patients. These data will cluster across a range of values which are dependent on the screening tool. For example, the AUDIT is scored from 0 to 40. Within that range, there are four zones of use, each of which suggests the need for a different SBIRT process regarding the patient’s alcohol use. These data can be very useful to stakeholders.
For example, if your organization uses a prescreening process, then the screening data will exist only for patients who are likely to exhibit problematic, risky, or dependent use. It is possible to both provide a sense of the severity of a given morbidity in the patient population (i.e., “of the XX% of patients who prescreened positive for alcohol use, the mean AUDIT score was XX, indicating…”) and to separate patients by zone (providing frequency data by zone… “XX% of patients fell into Zone 1, XX% fell into Zone II, etc…”). This illustrates both the prevalence (breadth) and the severity (depth) of a screenable condition within a patient population.
You will likely keep track of the services provided to patients.
Depending on the type of SBIRT project you implement, these may include brief intervention (BI), brief treatment (BT; a less common modality), and referral to treatment (RT). Most validated screening tools provide recommended levels of services based on screening scores. Not only can this data inform stakeholders of the work being completed as part of your SBIRT project, you can also match these data to screening scores in order to determine whether appropriate actions are being taken by caregivers (if not, why not?). Be alert to the very common problem of patients being given appointments for followup but not keeping the appointment: thus, tracking appointments made and kept are both useful to assessing your program.
After outcome data we also can examine more basic process data, which can be equally important for stakeholders when attempting to justify and/or support an existing project.
Of all of the patients who were registered for the clinic in such a way that they should have received SBIRT (i.e., patient over age 18 if the criterion is only adult patients), how many actually received SBIRT? This data can be difficult to capture because our experience (and that of other clinic sites) has been that physicians often fail to record SBIRT processes. It can be important to capture this data at multiple levels (i.e., front desk, MA station during triage, and at the physician level). This requires cross-checking but can be instrumental in determining whether SBIRT coverage at a clinic is adequate.
Sometimes, the way that SBIRT is integrated into a clinic will allow for the possibility that a physician will interrupt an SBIRT encounter and the counselor/health specialist will need to return to the patient after his/her scheduled medical appointment. This is typically the case when a non-physician is conducting the brief intervention/referral to treatment process. Stakeholders may be interested in how frequently this occurs, and it will be important in these cases to create a process that funnels such patients back into the SBIRT process upon their next visit (if a primary care site or other medical home).
Several publications and/or SBIRT sites have provided data on how long each component of SBIRT is estimated to take. However, stakeholders may be interested in localized data, which is relatively easy to collect. Areas that might reasonably be timed during a pilot test include prescreening time, screening time, and intervention/referral time. These data allow clinic managers and others know how to budget SBIRT within their own process flows.
All of the data listed here is very short term. There are longer term and much more complex means of analysis (i.e., tracking multiple medical variables post-SBIRT) but these data are not utilized immediately upon start up, though your organization may want to plan to collect these data to bolster arguments for program sustainability.
How to Track it?
Some clinics will have all data integrated into the same system (i.e., a clinic that uses all components of the eClinicalWorks software). Others will be paper-based or have multiple electronic systems that may not communicate. It is important to understand where data is collected and who needs to see it. For example, whoever does registration needs to know what forms to give a patient, when that patient is eligible for SBIRT, etc… someone needs to record that data set, and it needs to be useable by whoever completes that process. The same thing is true for whoever completes the prescreening and/or screening, and whoever provides services to the patient. What is the optimal place to locate this data on a case-by-case basis? If it’s not in a shared EHR system, then how will the physician or other care provider be notified of important details?
Incorporate EHR to support implementation (if possible)
One does not need a robust, fully operation electronic health record (EHR) to introduce SBIRT. A paper screening instrument, if kept with a paper chart for patients without complex medical problems (possibly in a pre- and pot-natal obstetrics practice or family practice with a large number of young relatively well patients) may work perfectly well. As more practices turn to electronic records, you will doubtless encounter issues related to the specific system you are using. Some issues we encountered include:
- How to catch up with continually changing systems. The ”moving target” of different electronic records systems (including those which are used for work flow as distinct from the archiving of clinical information). We had several delays because a new version of the EHR was being installed. Often the original targets were missed, leading to longer delays. Hard to see any way around this.
- How to enter data is always a concern. We considered scanning paper forms into the record, using a general health screen administered on tablet computers or kiosks, and with the introduction of screening in the community health centers, we landed (for now) on recording screening result on paper forms with later direct entry of the data into the medical record. In the future, the screens will likely be administered by a medical assistant using a laptop.
- How to display the data for subsequent review, and ways to use it as a flag for at risk drinking or substance use (while avoiding “alert fatigue”) is a subject of research in our group. What is the best way to combine screening data in a flow sheet (and incorporate the data with all the other trends we would like to follow?
None of these are, of course, insurmountable, and we raise them simply so you are aware of them ahead of time in order to watch out for and take steps to mitigate delays caused by these data related issues.
If you don’t know what you did and how well you did it, how can you possibly know whether things are working and how to improve them!? Data. That’s the ticket. NOW you are ready to go live!
All systems go and you are ready for SBIRT launch!? Awesome!
The final checklist…
Set the launch timeline
This is different (well, a subset) of the overall timeframe and EVERYONE needs to know what it is! Generate excitement and expecation. Let’s get ready to rock and roll! Er, screen and intervene!
Conduct public/staff awareness of effort and expectations
Annouce the effort through all your marketing and social media resources. Put up posters in the clinics. The more people see and hear about it, the more they not only know its coming but are also likely to be ready to live with it, we mean adopt it!
Conduct training and establish channels of communication
Train the staff through face to face and/or web based media. An early awareness session and a followup can be really helpful.
Create pathways for feedback from staff/participants
Provide an easy single point of contact for reporting issues and concerns or for asking questions. Ideally, this should be someone not in the local clinic loop but perceived as an advocate that will hear them!
Are all forms in place? Do a trial run a week before hand. Run a few team members through the process as simulated patients. What issues arise? Where are the opportunities to improve efficiency or the patient experience?
Launch day arrives. Have all hands on deck: make sure your organization experts, including much of your core team, is on hand to help with immediate implementation issues and to answer questions. This will not only help ease the implementation but will help you be aware of things you perfect design plans might not have taken into account.
Alrighty! Kick back, relax and enjoy a nice cold… oh wait… no, there’s a lot of work to be done!
Once you go live, it’s time to pay close attention to how well things are working.
Remember those metrics we decided on earlier? Now we have to keep an eye on those. This will be more often at first (maybe weekly) and then monthly long term.
Its also really smart to do some usability studies. This can be as simple as periodically contacting a random sample of the staff and asking them: what’s working, what’s not, and do you have suggestions for change?
Based on feedback and the data, change things. Don’t do it willy nilly, unless you are a very agile organization, but if things aren’t working… people are always dropping a ball somewhere, or patients are annoyed with answering the same question twice in different parts of the care process, then by all means document the issue and change it!
And, it’s very important you share, share, share. Let people in the local organization know the positive things that are happening. They will feel better about it. Let them know you are responding to their input. It’s not enough to just make a change based on observed problems. You need to tell them about the change, even get their feedback about it prior to implementing it, just to be sure, and then do it. This is good iterative, person-centered design! Moreover, tell the world, or at least your larger organization, if you are part of one, because it not only blows your horn, which is always nice, but it preps others for possible change coming down the pipeline!
Keeping an eye on SBIRT at large
Internal Review is important. Knowing how things are going and responding to implementation is a key to success.
But external review is important too: what’s going on in the world that might influence what you are doing?
SBIRT is a continually changing, and improving, effort, with literally hundreds of thousands of people involved in daily implementation and research. As a result, new and improved approaches, tools, and support resources emerge on a regularly basis.
Your team needs to stay on top of these changes and integrate new resources as they emerge. Well, someone needs to if you really want to be on top of your game.
Similarly, you owe it to your colleagues in other locations to share what you have been acheived. Your lessons learned, your resources, even things as simple as checklists and implementation guides, may be very useful to others would are just getting started.
Several useful places for finding the latest on SBIRT (and for posting what you are doing) include:
SAMHSA. The go-to government agency supporting SBIRT adoption and implementation
SBIRT in Action. A collection of freely adoptable SBIRT resources with available technical assistance.
As well as all these folks conducting localized programs…
- Albany Medical Center
- Baylor College of Medicine
- California SBIRT program
- Colorado SBIRT program
- Florida SBIRT program
- State of Indiana
- State of Iowa
- Mercer U/Wake Forest Medical Residency
- Missouri SBIRT program
- State of Missouri
- Natividad Medical Center
- State of New York
- State of North Carolina
- Oregon SBIRT program
- University of Indiana program
- University of Pittsburgh SMaRT program
- South Texas Area Residency Training (S-START) Program
- Wisconsin SBIRT program (Wisconsin Initiative to Promote Healthy Lifestyles (WIPHL)
- Yale University SBIRT program
While we are all convinced that SBIRT is THE public health response to hazardous substance use, all organizations implementing it run into barriers.
Here is a short list of problems you may encounter (because we did), and how we and others have overcome them. It goes without saying that the list is incomplete!
- “We don’t have time!” Most commonly these relate to clinic overload, and the dismay at “one more preventive health activity I have to deal with”. This is the biggest barrier to implementation we have learned about in questioning our staff and residents.
- “These aren’t reasonable procedures or guidelines.” Some physicians and staff may privately question “are these prudent limits realistic”. This attitude may reflect the physicians’ and staff’s own drinking patterns, and their reluctance to accept the implication that they may be drinking at hazardous levels. Generally, this is worth addressing directly in the initial buy-in process (i.e., by saying that as these programs are started, it is important for the staff to reflect on their own drinking patterns).
- “This screening thing isn’t a valid thing for me to be doing.” We have learned that the cultural backgrounds of the physician may alter the acceptance of screening as a valid medical activity for a physician. This may result from a broader lack of appreciation for the psychosocial model of disease. It may also reflect differing cultural norms related to whether any drinking is acceptable or if it is polite to question patients about their use of alcohol.
- “We can’t manage the data.” Managing the screening data and the results of interventions. Commercial EMRs may not have modules for these data. We have found that the physicians may review the screening questions and provide interventions, but not document this. It may be possible to make this easier through the design of the EMR (e.g., making the screening results have as high a visibility as vital signs in the encounter sheet: this will of course be very system-dependent).
- “Its going to be too much work.” The changes in work flow described in this module, the need to capture the results of screening and track results, the need to engage the physicians and residents and screening will all require sustained support from the implementation team and from those in positions of authority who support the effort.
- “There’s too much involved in changing our workflow.” The moving target concern related to simultaneous redesign of work flow, physical layout of clinic (or a move to another venue), and changes in the EHR.
- Lack of directives or organizational authority. This really affects all the above. In a large organization, the importance of having someone higher up in authority buy in to the project cannot be overstated. You either need one person for who has ultimate authority over everyone who will be affected OR you need the buy in of multiple authorities. Clinic managers, when dealing with a broader structure like a large medical organization, may have insufficient authority to really make SBIRT work as they may receive pushback from those under the authority of others (i.e., medical chart workers or physicians, neither of whom report to the clinic manager). There were several areas in our own project wherein, had we not had the weight of a senior authority behind us, we would potentially have lost months of time.
If you can address these in planning, and keep them in mind as you seek buy in and launch the effort, you will be far more likely to be successful than otherwise. Moreover, just being aware of them may help you, and your team, sustain themselves through adversity as you encounter them.
Because knowing what bad things may get in the way, goes a long way toward being able to handle them if and when the do occur!
Given all that’s been said, we have a few little nuggets, some things to think about, from our experiences implementing SBIRT at IU.
Our lessons learned Top 10!
- Start in a relatively small clinical venue, usually an outpatient office or clinic. Pilot, modify, pilot, modify. Interatively work through issues, then roll out wider.
- Work first with the nursing and medical assistant staff, and physicians, to educate them about the evidence for SBIRT and establish their support for the program. Build this into the time line.
- Build the screening questionnaire into the check in process and have the medical assistants ask the screening questions and complete a paper form (if your check in is entirely paperless, of course build the screening into the electronic check in). (This appears to be the direction that SBIRT is heading, as opposed to depending on physician screening).
- Determine the best way to flag positive screens for physician or other health care provider to see that a brief intervention or a referral is needed.
- Plan initially to screen once a year, and build into the scheduling system and medical record a reminder for this.
- Track the rate of positive screens, brief interventions performed, and referrals made for assessment and treatment. If rates of positive screens are lower than expected, there may be something about your protocol which reduces the likelihood of honest answers to the questions (for instance, screening in an area where answer can be overheard). The numbers of positives will be of interest to the stakeholders as evidence that hazardous alcohol and drug use is prevalent.
- Be alert to the effect of turnover of the office staff- new individuals might be overlooked in the training process, and thus cause a gap in screening. Training in SBIRT needs to be incorporated into the orientation and training of all new staff.
- Determine how to store the results of screening in the EMR. Ultimately, this will be useful in billing for the service and for tracking outcomes of the interventions.
- When the initial site seems to be working well (anticipate a 4-6 month run in period), plan on the expansion to other venues.
- Share data with stakeholders, including the office staff who are putting in the extra effort to do the screening.
Finally, think system-wide: when SBIRT is implemented in the outpatient sites, and it seems to be working, consider extending it to inpatient services, mental health venues (although detailed information about drinking and substance use is far more commonly obtained by mental health workers than general medical staff), and the emergency department (ED). The latter in particular is a site where individuals with alcohol use disorders frequently intersect with the medical establishment. They may use the ED in place of primary care, and thus the ED can be a rich environment for detecting and intervening with patients who drink too much- often the visit is a “teachable moment” after a problem with alcohol.
Keep everyone on the same SBIRT page!
As you roll out in other places system-wide, don’t forget to track and trickle back any new lessons, protocol changes, or resources that come out of the newer implementations.
Implementing SBIRT across an organization is challenging but it is also very worthwhile. You will encounter barriers and you will have to change how you think you are going to do things in order to be responsive to the people in your organization, both patients and providers.
Some of the key things from our efforts include, according to the project lead, Dr. David Crabb:
“One of the things that really increased our likelihood of success was that we had buy in from top to bottom. From the department of medicine, to the mental health system at Midtown, and the leadership of Wishard hospital, everyone became invested in the implementation. We also had a health system partner in Wishard that was already involved in population health before that term became popular, so this was a natural transition for them. Finally, we provided excellent face to face training, with a great motivational interviewing trainer, and ongoing support and check-ins.”
“One thing we found most challenging was the changing nature of the EMR, and competing demands on it that evolved during our period of support. One would think you would have a form and be able to make it electronic, no problem, but systems change, processes change, and this was ongoing during our effort. Other areas we should have paid more attention to included documentation of the screening efforts early on in the process and recognizing earlier than we did that physician (resident) follow through on positive screens was low. In retrospect, we would probably start smaller and do it in a more focused way: perhaps train all of the physicians working in a smaller clinic at once, and then implement that screening; instead, we chose to train all our residents based on the timing of an outpatient education block even though many didn’t work in the clinic in which SBIRT was being introduced. We let timing and convenience rather than need drive education, and that was a mistake.”
“In the end, across the board, we had excellent champions for the process and considerable buy in from many stakeholders. This is the one thing that likely most supported success despite challenges and barriers. Well, this, and a lot of hard work!”
Are you ready? A quick self-assessment is next »
In Conclusion: Go for SBIRT!
Implementing SBIRT in your organization can make a big difference in patient outcomes. Is organization-wide implementation easy? No. Is it doable? Absolutely! And this course provides a road map for getting it done.
Will you get SBIRT done? Try starting with something small, like assessing whether anyone else in the organization is already doing something like SBIRT? Maybe find some SBIRT compatriots!
Go for it! And be sure to let us know how you are doing or how we can help!