SUMMARY REPORT
MEETING 33
Date: Wednesday, April 23, 2014
Time: 11:00AM – 12:00PM PST
Location: Conference Call
Hosts: UCLA Integrated Substance Abuse Programs (ISAP) & CA Department of Health Care Services (DHCS)
Topic: MH/SUD Screening Program in Orange County: Preliminary Findings in a Primary Health Care Setting
Presenters: Brett O’Brien, Administrator
Cary Clevenger, Service Chief, LCSW
Tawny Moreno, LMFT
Elaine Estrada, LCSW
Alcohol & Drug Abuse Services
Orange County Health Care Agency
Logistics
§ Summary and materials discussed from the previous ILC meetings are available at http://www.uclaisap.org/integration/html/learning-collaborative/. Subsequent meeting materials will continue to be posted on this site.
§ The next ILC meeting will be held on May 21, 2014 at the County Alcohol and Drug Program Administrators' Association of California (CADPAAC) Quarterly Meeting in Sacramento, CA.
§ Future meetings are planned for 11:00AM (PT) on the 4th Wednesday of every month, unless otherwise noted.
ILC Meeting 33 Topic:
MH/SUD Screening Program in Orange County: Preliminary Findings in a Primary Health Care Setting
Topic Introduction – Brandy Oeser, MPH – UCLA ISAP
· For today’s Integration Learning Collaborative, our presenters from Orange County will share their experiences starting a program for screening, brief intervention, and referral to treatment (SBIRT) in a primary care setting. We would like to thank them for taking to the time to share with us their experiences and lessons learned.
Brett O’Brien, Administrator
Summary
· Background
o In 2010, Orange County became interested in creating a screening, brief intervention, and referral to treatment (SBIRT) program in primary care. The SBIRT program would help to:
§ (1) Identify individuals at risk for SUD or MH disorders
§ (2) Begin to integrate the county’s behavioral health services into primary care
o Planning for implementation:
§ The county identified funding from the MHSA Prevention and Early Intervention fund to pay for two clinicians to perform SBIRT at UC Irvine Health Family Health Center (UCI Family Health Center), a federally qualified health center in Santa Ana. The SBIRT staff, Tawny and Elaine, are county employees who would be co-located in the health center.
§ Orange County began working with the health center to develop a screening instrument using previously validated tools. The instrument initially included 9 items and has since expanded to 10 items covering anxiety, depression, alcohol and drug use, domestic violence, and trauma.
o After a great amount of time and effort, the program was approved by the board and began implementation in June 2013.
Cary Clevenger, Service Chief, LCSW
Summary
· Implementation
o After developing the screening instrument, questions remaining included:
§ When and how would patients be screened?
§ How would the screening results be documented?
o It was determined that the best way to conduct the screening was to have Tawny and Elaine personally conduct and score the screenings rather simply handing out the screening instrument for patients to complete.
o To fit the needs of clinic patients, who are predominantly monolingual Spanish-speaking, Tawny and Elaine are both bilingual and are able to interpret and explain items on the screening instrument that may be unclear or confusing to patients.
o Regarding documentation of the results, UCI Family Health Center created a field in their EHR to indicate whether each screening was positive or negative.
o Basic data on screenings were collected early on, and the amount and types of data collected were expanded over time.
Tawny Moreno, LMFT & Elaine Estrada, LCSW
Summary
· Experiences and Lessons Learned
o The screening process was conducted personally by SBIRT staff and involves paying attention to the workflow of the clinic:
§ Either Tawny or Elaine conducts an initial screen with the patient during the waiting time after patients have their vitals taken and before the physician enters the room. When the physician comes into the room, the SBIRT staff member exits and returns again once the physician leaves. If a second-level screening (triggered by a positive result on the initial screen) or brief intervention is needed, that is usually conducted during the waiting time at the end of the appointment.
§ Physicians can also indicate to Tawny and Elaine patients that may need screening or additional follow-up by putting a label into a folder for Tawny and Elaine. Tawny or Elaine will then follow up with patients by conducting the screening over the phone using the SBIRT tool.
§ By personally conducting the SBIRT, Tawny and Elaine can develop rapport with patients and make them feel more comfortable responding to the questions. It is easier to follow up with other resources that patients may need for themselves or their family (for behavioral health services or other social support). Finally, another benefit is that, as licensed behavioral health providers, Tawny and Elaine can better detect issues that would not otherwise be picked up by the screening tool (e.g., schizophrenia, etc.).
o Successful implementation strategies included:
§ (1) Building relationships with clinicians and staff at the health center (e.g., by regularly attending staff meetings, introducing yourself, explaining your role, and generally endearing yourself to the staff)
§ (2) Obtaining buy-in from the leadership (e.g., the medical director and other site administrators)
§ (3) Conducting trainings and other activities to familiarize physicians and clinic staff with the importance of SBIRT
§ (4) Maintaining up-to-date resources for patient referrals
§ (5) Networking with county-contracted and community services in order to provide warm hand-offs for patients
o The clinicians, staff, and patients at the UCI Family Health Center responded very positively to the SBIRT program, and Tawny and Elaine developed good relationships with everyone involved.
Cary Clevenger, Service Chief, LCSW
Summary
· Statistics
o Between July 1, 2013 and February 28, 2014, 99% of patients who visited the UCI Family Health Center were screened through the SBIRT program (a total of 4,300 patients).
o More than 500 patients on average were screened each month, and patients were re-screened if they visited the clinic more than once.
o More than 1 in 4 patients screened positive for mental health, substance use, or domestic violence issues; out of those patients, more than 8 out of 10 had mental health concerns. For half of all positive screens, the identified issues were previously untreated, meaning they had not been addressed at an earlier time.
o Women were slightly more likely than men to screen positive using the SBIRT tool and younger and middle-aged patients were more likely to screen positive than patients who were 50 or older.
o Additional information on screening data can be found in the Orange County SBIRT Program Preliminary Data Report (see Appendix 2: Agenda and Relevant Materials).
Brett O’Brien, Administrator
Summary
· Future Plans
o The program has so far been able to screen for individuals who are at risk for MH/SUD and make linkages with treatment services and other assistance for those patients. Both the county and UCI have been very happy about the program’s initial success and are working to expand it to other health care clinics.
Question and Answer
· Are there any questions that you are revisiting or thinking of adding to the SBIRT screening tool?
o Brett: The included domestic violence item previously focused only on intimate partner abuse. It was changed to a different item in order to pick up on other issues such as elder abuse, as many of the patients seen at the health center are over the age of 50. We would carefully consider whether to add other items because we want to keep the tool brief.
· Have the various different time frames referenced in the screening tool created issues or confusing with conducting the screening?
o Tawny: It’s not a big issue because we’ve memorized the tool and the items are presented to patients in a conversational manner. We help clarify the items to patients if they don’t understand at first.
o Brett: The SBIRT screening tool does contain different time windows, because it was developed by combining different validated tools that already existed. But no, it has not created any issues so far.
· What mechanisms exist for getting patients into detox or residential treatment for SUD when they are determined to need those services?
o Elaine: When we come across patients who require detox or residential services, we refer them to the detox center within the county. Because we initially worked with the county programs during the time before the SBIRT program was implemented, we are very familiar with them.
· Although the program is currently being funded by MHSA funds, are there any plans to take make use of the new SBIRT benefit for alcohol in the future?
o Brett: UCI is interested in expanding in that direction, which is why it is helpful to have licensed therapists already providing the service. If by billing, we’re able to expand the services, that would be great. Both UCI and the county wish to continue the program as long as funding is available, as it has been very successful so far.
APPENDIX 1 – ATTENDEES
COUNTY PARTICIPANTS
Ø Orange County (Brett O’Brien, Cary Clevenger, Tawny Moreno, Elaine Estrada) – Presenters
Ø Los Angeles (Sandy Song)
Ø Cheryl Coopers
DHCS PARTICIPANTS
Ø Craig Chaffee
Ø Jonathan Graham
UCLA PARTICIPANTS
Ø Brandy Oeser
Ø Valerie Pearce Antonini
Ø Cheryl Teruya
Ø Elise Tran
Ø Beth Rutkowski
APPENDIX 2 – Agenda and Relevant Materials
· Topic Discussion – MH/SUD Screening Program in Orange County: Preliminary Findings in a Primary Health Care Setting
· Q and A
Materials for this meeting
§ Orange County Behavioral Health Services Modified SBIRT Screening Tool
§ Orange County SBIRT Collaborative: Screening Overview (SBIRT Screening Tool Crosswalk)
§ Orange County SBIRT Program Preliminary Data Report
Copies of materials can be found at UCLA ISAP’s ACA Resources Website:
http://www.uclaisap.org/integration/html/learning-collaborative/.
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