Dr. Julie Maslowsky reports from the Improving Population Health Conference October 2-4, 2017, in Austin, Texas: From evidence-based to widespread implementation: The case for substance use Screening, Brief Intervention, and Referral to Treatment (SBIRT).
Over the past three decades, substantial rigorous evidence has shown that Screening, Brief Intervention, and Referral to Treatment (SBIRT) is time- and cost-efficient and effective at both preventing and reducing problematic substance use. This symposium examined the question: How does an evidence-based practice make its way into widespread and sustainable implementation?
Implementing evidence-based interventions at a broad scale is a persistent challenge in population health. This symposium contained three studies focused on three aspects of scaling up: achieving universal implementation outside clinical settings, testing the impact of widespread implementation on subsequent health services utilization, and structuring SBIRT to fit within the shift to a value-based payment structure in healthcare.
SBIRT in high school
The first paper, presented by Dr. Julie Maslowsky (Assistant Professor of Health Behavior and Health Education, University of Texas at Austin) “Universal school-based implementation of Screening Brief Intervention and Referral to Treatment to reduce and prevent alcohol, marijuana, and other drug use” described the development and effectiveness of a model for universal SBIRT implementation in high schools in order to maximize SBIRT’s ability to prevent substance use and reduce it among those who already used problematically. Twenty-five hundred ninth and tenth grade students in ten Wisconsin high schools participated in brief (15-20 minute) SBIRT sessions. Students rated SBIRT positively and indicated substantial intentions to reduce or delay substance use following SBIRT. About 85% of non-substance-using students reported they were more likely to remain abstinent and about half of substance-using students reported that they intended to reduce their substance use after participating in SBIRT. The results supported the feasibility of universal school-based SBIRT and its potential to delay substance use among current abstainers in addition to reducing substance use among current users.
SBIRT and health-care utilization and costs in a low-income population
The second paper, presented by Dr. Jason Paltzer (Assistant Professor of Public Health, Grand Canyon University and Assistant Research Scientist, University of Wisconsin-Madison) “Paraprofessional-led substance use screening, brief intervention, and referral to treatment among a low-income population” examined whether SBIRT’s reductions in substance use translate to changes in healthcare utilization in treatment and control clinics in the two years following the introduction of Medicaid reimbursement for substance use screening and brief intervention services among low-income patients in Wisconsin. The authors found that Medicaid beneficiaries receiving SBIRT significantly increased their annual outpatient visits but decreased their inpatient days, resulting in an annual cost savings of about $700 per patient.
Barriers to SBIRT under value-based reimbursement
The third paper, presented by Dr. Richard Brown (Professor of Family Medicine, University of Wisconsin Madison) “SBIRT: Barriers to dissemination, progress and solutions under value-based reimbursement” examined healthcare system barriers that prevent dissemination of SBIRT (clinicians’ limited time, insufficient reimbursement, need to address multiple behavioral health problems at once). The author discussed behavioral screening and intervention (BSI; a category of interventions that includes SBIRT) as a potential solution to those barriers.
BSI involves expanding healthcare teams with coaches who are trained in motivational interviewing and behavior change planning to address unhealthy behaviors, and the IMPACT model of Collaborative Care to address depression and other mental health disorders. Under value-based reimbursement, financial incentives for BSI are substantial and continue to grow. Accountable Care Organizations (and other alternative payment models) would benefit from improved performance on many quality measures and would retain a substantial portion of the healthcare cost savings generated by BSI. Under bundled payment programs for joint replacement surgeries and cardiovascular disease, BSI would address important contributors to poor outcomes and higher costs. Dissemination could be enhanced by educating healthcare organization leaders and by implementing quality measures that reflect the reach of BSI and the extent to which primary care settings attain behavioral outcomes demonstrated possible in prior research.
Audience members representing state health departments, private health insurance plans, and state and federal Medicaid and Medicare offices praised the robust evidence offered for the effectiveness and cost-effectiveness of SBIRT and BSI. Overall, there was a sense that SBIRT is a promising strategy for promoting population health and also an informative case study on how an evidence-based intervention can be moved into widespread implementation.