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5/20/2013
Acknowledgments
Project LINK: An Early Model of
Screening, Brief Intervention and
Referral to Treatment Services in NYC
STD Clinics
• Authors thank Shirley DeStafeno for contributing
valuable material to this presentation.
Philip Appel, Ph.D.,
Shanequa Highsmith, B.S.,
Brett Harris, M.P.H.,
Shazia Hussain, M.P.H.,
John Yu, Ph.D.
• Project LINK is funded by SAMHSA (TI018746,
Dr. Ed Craft, Government Project Officer).
Alcoholism & Substance Abuse Providers of New York State
14th Annual Conference
May 7th, 2013
What is SBIRT?
Objectives
• SBIRT: What? & Why?
Screening, Brief Intervention and Referral to Treatment (SBIRT) is an
evidence-based public health approach to delivering early intervention
and treatment services based on an award winning NY State initiative
called the Healthcare Intervention Service (HIS)(1).
• Project LINK: Integrating SBIRT
Services in NYC STD Clinics
•
Screening for problematic alcohol and other drug (AOD) use.
•
Brief intervention to advise positively screened patients and raise
their awareness of risks of AOD use and motivate patients toward
behavior change.
•
Referral to treatment for patients with severe abuse or
dependence.
• SBIRT Expansion in New York State
• Implementation, Training , & Billing
SBIRT Targeted Intervention
Dependent Use
Brief Intervention and
Referral to Treatment
Harmful
At Risk Use
Brief Intervention
Low Risk Use
Abstention
No
Intervention
Brief Advice
Why SBIRT?
• Offers early intervention services for risky substance
use behavior.
• Decreases usage among patients (1).
• Reduces healthcare cost and public health burden
for treating conditions exacerbated by underlying
substance use disorders(SUD)(2).
• Increases the number of referrals to treatment
providers.
1. 7 Babor TF, McRee BG, Kassebaum PA, Grimaldi PL, Ahmed K, Bray J. Screening, brief intervention, and referral to treatment (SBIRT):
Toward a public health approach to the management of substance abuse. Substance Abuse,2007. 28(3): 7-30
2. Estee, S., He, L., Mancuso, D., & Felver, B.(2006).Medicaid cost outcomes.Department of Social and Health Services, Research and Data
Analysis Division: Olympia, Washington.
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Research to Practice
CREATION OF PROJECT LINK
Service Needs in NYC STD Clinics
OASAS worked with the NYC Department of Health and Mental Hygiene
(DOHMH) since 1993 on issues of substance abuse, HIV/AIDS, and other
STDs among NYC STD clinic patients
– In a 2000 assessment of AOD problems among STD clinic patients
• An estimated 20% screened positive for possible AOD issues, less
than 2% were currently engaged in treatment
• An estimated 11,000 NYC STD clinic patients could benefit from
AOD intervention services per year (1)
• A 2005 pilot study in the Chelsea STD clinic showed SBIRT could
be integrated and accepted in the STD clinic setting (2)
1. Appel PW, Piculell R, Jansky HK, Griffy K. Assessing alcohol and other drug (AOD) problems among sexually transmitted disease (STD)
patients with a modified CAGE-A: Implications for AOD intervention services and STD prevention. American Journal of Drug and Alcohol Abuse ,
2006;32: 225-236.
2. Yu J, Appel PW, Warren BE, Rubin S, Gutierrez R, Larson B, Robinson H. Substance abuse intervention services in public sexually
transmitted disease clinics: A pilot experience. Journal of Substance Abuse Treatment, 2008;34:356-362.
Project LINK Service Model
Screening
Identify patients who have or are at risk of developing SUDs.
Conduct preliminary assessments with patients who screen
positive to determine whether an SUD exists.
Brief
Intervention
Determine nature and extent of substance use.
Increase patient awareness of substance use.
Advise on risk behavior reduction.
Full
Intervention
Determine level of care.
Referrals for treatment and/or
other appropriate services.
Project LINK
• In October 2007, SAMHSA awarded $2.5 million over 5
Years to NYS OASAS for Project LINK.
• Project LINK is a partnership among:
 The New York City Department of Health and Mental Hygiene(NYC
DOHMH)- provided access to NYC STD clinics and assisted with
integrating SBIRT into clinic registration protocol.
 The New York City Lesbian, Gay, Bisexual and Transgender
Community Center (LGBT Center)- provided clinical expertise on
Brief Motivational Interviewing (BMI) and LGBT-sensitive treatment
services.
 64 local AOD treatment & HIV/AIDS service
providers.
New York City STD Clinics
• 3 full time Project LINK interventionists worked
in 3 NYC STD clinics
– Chelsea (Manhattan)
– Morrisania (Bronx)
– Fort Greene (Brooklyn)
• 60,000 patient visits
annually across the 3 clinics.
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Project LINK Goals
I
n
c
r
e
a
s
e
-Identification of risky substance use and SUDs
in STD clinics.
-Engagement of HIV/STD at-risk populations
into appropriate levels of SUD treatment.
-Connection of HIV positive populations into
early medical and SUD treatment services.
D
e
c
r
e
a
s
e
-Incidence of HIV and other STDs through
early substance use interventions.
-Reduce risky substance use & sexual
behavior among at risk groups such as
minorities and MSM.
Data Collection
• STD clinic patients were screened using a modified CAGE-A
screening tool. Demographics and prior history of substance
abuse treatment were also collected.
• Disposition forms were completed for patients who screened
positive documenting whether or not a BI was given, outcomes
of BIs, and insurance status.
• Patients referred to formal substance abuse treatment
completed a SAMHSA questionnaire at referral and again, 6
months later. The questionnaire covers:
– AOD use, Family & Living Conditions, Education & Employment, Crime
& Criminal Justice, Mental & Physical Health, and Social Connectedness.
Meeting & Surpassing Project Goals
PROJECT LINK OUTCOMES
CUMULATIVE PROJECT RESULTS
FEBRUARY 2008 – SEPTEMBER 2012
Services Provided
Service Goals
Actual Services
Delivered
Patients Screened
75,000
151,457
Patients Receiving an
Intervention
15,000
15,721
Patients Given a Referral to
Substance Abuse Treatment
1,050
955
-
2,899
Patients Given a Referral to
other Social, Mental Health,
HIV, and AOD Support Services
Reach of Project LINK
Across New York City
PATIENT DEMOGRAPHICS (N=151,457)
Male
Patients Screened
(N=151,457)
Patients Screening
Positive
(N=26,377)
58 %
70 %
Patients Receiving Brief
Intervention
(N=15,721)
73 %
Age 18 - 35 years
73 %
76 %
78 %
LGBT
20 %
23 %
26 %
Black
41 %
38 %
37 %
Hispanic
26 %
25 %
26 %
White
20 %
25 %
26 %
Has some kind of health insurance
-
-
41%
Alcohol*
-
-
60 %
Marijuana*
-
-
27 %
Cocaine/Crack*
-
-
6%
Methamphetamine*
-
-
1%
% in substance abuse treatment
before
-
-
19 %
% received some sort of referral
-
-
24 %
*Substance use reported by patients during Brief intervention. Substances were mentioned but not systemically
covered.
Patients referred to treatment
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Project LINK Patients Admitted to
Substance Abuse Services
169 individuals (17%) have connected to treatment
Program Type
Outpatient
Detox
Inpatient/Residential
Methadone
Total
N
%
108
64 %
31
18 %
24
14 %
6
169
4%
Referrals to Additional Services
Interventionists made 2,899 additional
referrals to other appropriate services such as:
– 74% AOD and other Support Groups
– 13% Mental Health Services
– 3% Medical & HIV/AIDS Services
– 10% Social Services
100%
Patient Interest in Addressing
Alcohol/Drug Use Following SBIRT
Intervention N=11,101
Changes in National Outcome
Measures (N= 445a)
*Abstinence: did not use alcohol or illegal drugs; ** Were currently employed or attending school; †were socially connected; ‡Experienced
no alcohol or illegal drug related health, behavioral, social consequences; ¥ Has no involvement with the criminal justice system
Patients Alcohol and Drug Use during the
Past 30 Days at Intake & Follow-up (N=448)
Change in Reported Mental Health Problems in
the Past 30 Days at Intake & Follow-up (N=445)
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Changes in Risky Sexual Behavior in the Past
30 Days at Intake & Follow-up (N=500)
STD Outcomes
• Fewer new STDs occurred for patients who received a BI*
than for patients who did not (7% vs. 8.8%, p < .005).
• Reduced odds of getting a new (non-AIDS) STD held for
males, non-Hispanic blacks, men who have sex with females
only, and those with no prior history of STD infection.
• There was no difference in new HIV diagnoses between
patients who received a BI and those who did not.
• Multivariate analyses suggest that receiving a brief
intervention is protective against acquiring a new STD for
males.
* Brief Intervention
Project LINK Expansion and Sustainability
Based on Project LINK’s demonstrated success, NYC
DOHMH funded an expansion of services into 3
additional STD clinics (2010)
• Crown Heights (Brooklyn)
• Jamaica (Queens)
• Central Harlem (Manhattan)
Expansion of SBIRT Services Throughout New York State
PROJECT LINK EXPANSION
& NYSBIRT
New York Screening Brief Intervention and
Referral to Treatment Project (NYSBIRT)
• SAMHSA Awarded $8.3 million to NYS OASAS for 5
Years: September 2011 to August 2016
• Collaboration between OASAS, NYC DOHMH,
Jefferson County Community Services & SAMHSA
• NYSBIRT delivers SBIRT services in six NYC STD
clinics in addition to military personnel, veterans, and
their families in emergency departments in Jefferson
County, NY
Year
Jan
2010Jan 2012
Total
Screened
Positive
Screens
27,889
4,769
SUD
Treatment
Brief
Other
Interventions Referrals Referrals
2,870
69
505
NYSBIRT Service Model
• Universal Screenings using the AUDIT for alcohol and the
DAST for drug use. The AUDIT-C (1st 3 questions) and DAST-1
(1st question) are used as prescreens.
• The AUDIT and DAST screening scores fall into 4 zones which
identify the appropriate level of service:
-Zone 1: Abstainer or within established limits  provide encouragement
and positive feedback
-Zone 2: Low risk  one brief intervention
-Zone 3: High risk drinker/intermediate level of problem drug use 
extended brief intervention (EBI), or multiple sessions of brief intervention
-Zone 4: High risk drinker/substantial to severe level of problem drug use
 referral to specialty substance abuse treatment
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Sustainability
Policy Advisory Committee (PAC):
Mission: To provide strategic policy guidance for integrating SBIRT
in primary care services offered across the state in a wide array of
settings.
Members: NYS OASAS, NYS Department of Health (DOH), NYS
Office of Mental Health (OMH), NYC DOHMH, The National
Center on Addiction and Substance Abuse at Columbia
University(CASAcolumbia), veterans healthcare, SUD associations,
healthcare providers and associations, county and non-profit
providers, universities, regulatory agencies, and hospitals.
Sustaining SBIRT Services in New York State
POLICY ADVISORY
COMMITTEE
Planning Committees: 1)Marketing, 2) Financing, and
3) Implementation, Expansion, and Leadership.
Clinical & Administrative
Implementation
• Identify:
– Which SBIRT screening tools you will use.
– Which of your staff will deliver SBIRT services.
– How SBIRT services can be integrated into your
program’s setting, operations and billing procedures.
– How will clinical flow change to accommodate time
needed to for SBIRT services.
– Referral sources and partnerships that need to be
developed for patients in need of SUD treatment.
Billing, Training, and Integration
HOW TO IMPLEMENT
SBIRT SERVICES
SBIRT Training
Billing for SBIRT
Payer
Code
Description
CPT 99408 SBIRT; 15 to 30 minutes
Commercial
SBIRT; greater than 30
Insurance CPT 99409
minutes
Medicare
Medicaid
Fee
Schedule
$33.41
$65.51
G0396
SBIRT; 15 to 30 minutes
$29.42
G0397
SBIRT; greater than 30
minutes
$57.69
H0049
Screening only
$24.00
H0050
SBIRT per 15 minutes
$48.00
• 4 & 12 hours Certificate Courses offered by OASAS Certified
SBIRT Training Providers
Provider type
Required
training
Licensed Practical Nurses, Physician Assistants,
Licensed Master Social Worker (LMSW) or Licensed Clinical Social
Worker (LCSW), Licensed Mental Health Counselors, Licensed Marriage
and Family Therapist, Certified School Counselor, Certified
Rehabilitation Counselor, CASACs, Credentialed Prevention
Professionals (CPPs), Credentialed Problem Gambling Counselors,
Physicians, Nurse Practitioners and Registered Nurses
4 hours
Health Educators and unlicensed individuals (may only provide SBIRT
services under the supervision of a licensed health care professional,
following consistent protocols)
12 hours
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Summary
• Derived from New York’s H.I.S. Project (’89 – ’94), Project
LINK, 2008 -2012, used AOD screening, brief intervention
and referrals to treatment, a close parallel to SBIRT services .
• LINK’s success led to further expansion of SBIRT services,
2010 – 2012, and in turn, NYSBIRT extends SBIRT to more
STD clinics and upstate hospital ERs serving military
personnel, 2012 - 2016.
• SBIRT is a billable screening and intervention service,
adaptable to a variety of public health settings that can reduce
healthcare costs and enhance AOD treatment and related
service referrals. Collaboration and partnerships are keys to
its effectiveness.
Resources
• OASAS:
http://www.oasas.ny.gov/AdMed/sbirt/index.cfm
• SAMHSA:
http://www.integration.samhsa.gov/clinicalpractice/sbirt
• Medicaid:
http://www.health.ny.gov/health_care/medicaid/p
rogram/update/2011/2011-06.htm#eme
Contact Information
•John Yu, Ph.D., Project LINK & NYSBIRT Project Director
(518) 457-0053 [email protected]
•Philip Appel, Ph.D., OASAS Research Scientist
(646) 728-4516 [email protected]
•Shanequa Highsmith, Project LINK Evaluator
(646) 728-4600 [email protected]
•Brett Harris, NYSBIRT Project Evaluator
(518) 485-1393 [email protected]
•Shazia Hussain, NY-SAINT Project Coordinator & Evaluator
(518) 473-0988 [email protected]
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