Screening, Brief Intervention, and Referral to Treatment Model Takes Off in Vermont

In 2013, SAMHSA’s Center for Substance Abuse Treatment (CSAT) funded a sixth cohort of 5-year ($10 million) state cooperative agreements with five states. Recently, Minority Fellowship Enews conducted an interview with a representative from one of those states, Dr. Win Turner, clinical psychologist and project director of the Vermont Department of Health’s Screening, Brief Intervention, and Referral to Treatment (SBIRT) program (VT–SBIRT). He and his team—including a lead evaluator, data analysts, and a trainer—are based at the Center for Behavioral Health Integration (C4BHI), an organization that provides consultation, evaluation, and training services to nonprofit and other behavioral healthcare organizations to foster and support best practices around addiction and mental health care.

The SAMHSA grant supports C4BHI in its work to train Vermont’s healthcare professionals in SBIRT, to evaluate SBIRT, and to provide grants to healthcare sites around Vermont that fund the hiring of fulltime interventionists to conduct SBIRT. SAMHSA also funds the technical assistance for this effort, which is conducted by an outside contractor. The VT–SBIRT intervenes with persons who screen at risky levels of alcohol use, tobacco use, drug use, or mood disorder symptoms. Turner estimates that this group comprises 42 percent of all Vermonters seeking medical care.

The primary goal of the SAMHSA grant is to prevent behavioral health disorders by integrating SBIRT into the routine care being provided at primary care settings such as community health centers, medical centers, and outpatient clinics. To do so, the program trains medical professionals to assess the risk of substance misuse, along with other behavioral symptoms, just as they would assess risk for medical disorders. In the past year alone, C4BHI has conducted 74 trainings, reaching more than 1,000 medical professionals.

The SBIRT program started in January 2014, 6 months after receipt of the grant award. The grant objective was to serve 95,000 adults ages 18 and older by the summer of 2018. By November 2017, the program had already reached 100,000 adult residents of Vermont (about one of every five adults statewide), including refugee populations, across 18 sites. The most recent study, which included data from 74,448 screens conducted from February 2014 to July 2017, suggests that about one patient in three in Vermont (33 percent) is at risk for an alcohol, tobacco, or drug use disorder, with young adults ages 18 to 28 at greatest risk. VT-SBIRT was able to deliver treatment to approximately 66 percent of patients who were referred to treatment for risky alcohol/drug use (C4BHI Data Brief, August 2017).

What Is SBIRT?

SBIRT is an integrated-care public health model for preventing behavioral health issues that triages mild- to moderate-risk patients being seen at primary care settings into behavioral health care. It differs from routine primary care in that it provides a more rigorous and systematic screening for drug, alcohol, and mental health problems and implements a standardized protocol for determining whether treatment is needed. In addition, rather than just referring patients to specialized services, SBIRT provides brief intervention and treatment within the primary care setting, to allow for a more seamless, patient-centered experience and increasing the chances that the patient will receive needed treatment.

All patients entering healthcare settings are screened at intake for problematic levels of substance use behaviors, mental health symptoms, or both. Next, patients who report a clinically significant level of risk receive a brief intervention that uses motivational interviewing techniques to assess their recognition of the problem and willingness to change risky behavior. For patients with mild risk levels, the brief intervention may be the only contact they have with a clinician to discuss the problem, whereas patients with moderate risk levels are triaged to receive a brief treatment (no more than 15 sessions) to be delivered by a behavioral health clinician. Those in need of greater support are referred to more intensive levels of treatment.

What Is the Vermont SBIRT Program?

The Vermont Department of Health uses multiple evidence-based screening tools and interventions to conduct VT–SBIRT. At intake, interventionists conduct a universal screening to identify problematic substance use and mental health issues. Before a patient is asked about these more serious issues, the screen begins with a set of questions related to more benign risk behaviors, such as not wearing a seatbelt and driving after drinking. Patients with mental health symptoms, drug use, and problematic drinking levels—14 drinks a week for males (with no more than 5 in a day) and 7 drinks a week for females (with no more than 4 in a day)—are then screened using the Alcohol Use Disorders Identification Test—Consumption (known as the AUDIT–C), to assess level of risk.

Depending on scores from the initial screen, patients may receive a secondary screen that asks more detailed questions about their specific area of risk. In addition to screening for alcohol problems, VT–SBIRT screens for tobacco use, cannabis use, depression, and, at some clinics, anxiety. All patients at or above clinical thresholds then receive a brief motivational interviewing intervention. The VT–SBIRT program uses an evidence-based intervention called the Brief Negotiation Interview, which teaches patients to recognize that they have behaviors that could lead to more risk.

For the brief treatment, the program uses a SAMHSA–approved intervention called Integrated Change Therapy, which is based on motivational enhancement theory/cognitive–behavioral therapy, since this has been found to be most effective for patients with co-occurring disorders. Thus far, the program has gathered some evidence of impact. In a 6-month follow-up interview conducted with 262 patients, 62 percent of them reported that the intervention made them think differently about their alcohol/drug use and 55 percent reported that they made or planned to make changes to substance use because of the discussion.

Why Vermont SBIRT Has Been So Successful

Win Turner thinks the reason for the program’s success lies in the confluence of multiple factors, including being able to involve key stakeholders and medical champions (many of whom are now on the C4BHI Board), having a commissioner who is on the same page with the others, the close work alliance with the Vermont Blueprint for Health (a nationally recognized initiative that offers a support structure for the implementation community-led, health promotion strategies), the availability of outside technical assistance, and the fact that Vermont’s healthcare reimbursement system now uses global payment methods (like Medicaid and Medicare) to fund population-based care.

Another reason Dr. Turner cites is that… well, it’s Vermont.

Vermonters like to call their homeland “the brave little state,” because its citizenry are not afraid to tackle big issues such as healthcare reform and integrating behavioral health strategies into primary care. For example, Vermont was first state to organize the hub-and-spoke model, setting up pharmacotherapy hubs for the delivery of buprenorphine and methadone and licensing primary care physicians in satellite primary care settings (the spokes) to deliver important medication-assisted treatments to create greater access to opioid treatment. Vermont was also one of first states to develop opioid-prescribing regulations. All of these things combined make Vermont a great place to implement a program like SBIRT.

What Is Needed to Sustain the Vermont SBIRT Program?

Vermont Blueprint for Health program, influenced by its collaboration with VT–SBIRT, has decided to help disseminate SBIRT and integrate behavioral health throughout participating medical settings. This will help in sustaining SBIRT beyond the SAMHSA grant, which ends in July 2018. However, scaling up and sustaining statewide dissemination is dependent on securing funding for SBIRT and for the quality improvement, coaching, training, and evaluation necessary for implementing SBIRT with fidelity and success. Several sources of funding can be sought out to sustain VT–SBIRT:

• A. Fixed hospital payments for Medicaid and Medicare
• B. Blue Cross Blue Shield and other private insurance
• C. Funds from the Vermont Department of Health block grant
• D. State (or possibly foundation) funds to match innovation dollars available from the Center for Medicare & Medicaid Innovation

To raise needed funds, grant stakeholders are doing their best in the remaining 7 months of the grant to estimate the program’s cost savings, so Vermont’s policymakers can use return on investment data to support healthcare funding decisions.

This initiative really makes us proud, because we have helped so many patients—many of whom would likely have not received treatment otherwise…. We have received so much positive feedback from everyone involved. What is most encouraging is that interest in the program has spread organically and has led to the development and expansion of regional networks focused on integrated care.

Vermont appears to have come a long way in the past 3 years when it comes to coordinating care for patients in need of substance use treatment. The SBIRT program has contributed greatly to this progress.

For more about the VT–SBIRT program, go to http://sbirt.vermont.gov/