Lessons We’ve Learned
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.