Determine Roles and Responsibilities
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!