Styles of communication University of Florida, Psychiatry Dept. .

Part II:Performing brief interventions

and referrals to treatment

GuidingDirecting Following

Communication styles during the patient visit

Styles of communication

Using a directive style towards behavior change

Styles of communication

University of Florida, Psychiatry Dept.

http://www.youtube.com/watch?v=2fdfzUS1qDc

Directive communication towards behavior change

• Explaining why

• Telling how

• Emphasizing importance

• Persuading

Styles of communication

Rollnick, et al., 2008

Characteristics ofguiding communication

• Respect for autonomy, goals, values

• Readiness to change

• Ambivalence

• Patient is the expert

• Empathy, non-judgment, respect

Styles of communication

Brief Interventions

• 3 minutes or more

• Aimed to motivate behavior change

• Designed to:

• Provide personal feedback; enhance motivation; promote self-efficacy; promote behavior change

Brief interventions

Steps of the brief intervention:

Steps of the brief intervention

Raise the subject

Provide feedback

Enhance motivation

Negotiate plan

D`Onofrio, et al., 2005

Brief intervention: “Steve”

Steps of the brief intervention

http://www.youtube.com/watch?v=b-ilxvHZJDc

• Simple step, but important

• Screening forms as conversation starters

• Asking permission

Raise the subject

Steps of the brief intervention

Steps of the brief intervention

• State Zone of use

• Address or ask about possible connection to health issues

• State low risk limits

• Give recommendation

Provide feedback

Steps of the brief intervention

Steps of the brief intervention

Enhance motivation

Steps of the brief intervention

Steps of the brief intervention

• Use the 0 – 10 scale

• “Why not a lower number?”

• Explore pros and cons

• If pt is ready: “What would that look like for you?”

• Plan to reduce use, abstain and/or seek referral

• Re-state recommendation

• Schedule follow-up

Negotiate plan

Steps of the brief intervention

Steps of the brief intervention

Readiness Ruler: front

Clinic tools

Readiness Ruler: back

Clinic tools

Reference sheet: front

Clinic tools

Reference sheet: back

Clinic tools

Practice: Jill

Groups of three:

• Physician

• Patient

• Observer

Practice

Billing the Brief intervention

Brief intervention

Service Payer Code Description

Medicaid & Commercial 99408 • 15-30 minutes spent administrating

and interpreting a full screen, plus performing a brief intervention.

Medicare G0396

Medicaid & Commercial 99409

• Same as above, only ≥ 30 minutes.Medicare G0397

Full screen +

Brief intervention

• Use a 25 modifier

• Counts towards Oregon SBIRT incentive measure

• Reimbursement: $26 - $30 and $52 - $65

Incentive measure billingService Payer Code Description

Medicaid & Commercial

99420Plus

V79.1 or V82.9

• Administration and interpretation of a full screen.

Medicaid & Commercial 99408 • 15-30 minutes spent

administrating and interpreting a full screen, plus performing a brief intervention.Medicare G0396

Medicaid & Commercial 99409 • Same as above, only ≥ 30

minutes.Medicare G0397

Full screen only

Full screen + Brief

intervention

Purpose: determine diagnosis and appropriate level of care:

• Level I: Outpatient treatment

• Level II: Intensive outpatient treatment

• Level III: Residential/inpatient treatment

• Level IV: Medically managed intensive inpatient treatment

Substance abuse treatment

Referring your patient

Making the referral

• Sponsored by AMHD

• Database of facilities and resources

• Often staffed by volunteers in recovery

Referring your patient

800-923-4357

SBIRT incentive measure

Billing

All Medicaid pts 18 and over

Ratio:

99420, 99408, 99409, G0396, G0397

• Benchmark: 13%

• Improvement target for 2013: 3%

Stages of change

How ready are you to

change your behavior?

Cell phone use

increases cancer risk

International Agency for Research on Caner (IARC)

Pre-contemplation

Contemplation

Preparation

Action

Maintenance

Relapse

Stages of change

Stages of change

The patient is not thinking about changing and perhaps

is unaware that a problem exists.

Pre-contemplation

It isn’t that they can’t see the solution. It is that they can’t see the problem.

Stages of change

• “I want to stop feeling so stuck”

• Contemplators are struggling to understand their problem, see its causes, wonder about solutions

• They may be far from making a commitment to taking action about their problem

In the contemplation stage, people acknowledge that they have a problem and begin to think seriously about solving it.

Contemplation

Stages of change

• Preparation is the cornerstone of effective action

• Commitment is the most important change process in the preparation stage

Preparation takes your patient from decision making in the contemplation stage to the specific steps for solution in the action phase.

Preparation

Stages of change

The process of action includes:

•Countering, control & reward•Continued reliance on helping relationships

Effective action begins with commitment. Once the commitment to change is made, it is time to move.

Action

Stages of change

The first two months of maintenance is the most likely time for relapse.

• Acknowledge vulnerability to the problem behavior, even while building a new life-style

• Develop confidence in ability to succeed

• Find few, if any, temptations to misuse substances

Maintenance

Stages of change

Meds for substance dependence, in general

The most powerful role a primary care provider can fill in treating alcohol and drug problems is that of a motivator, an educator, and a provider of referrals to treatment – SBIRT.

Should they choose, providers may enhance the services they provide through the use of medications for substance dependence

Medications

MedsNaltrexone

(Revia)

InjectableNaltrexone

(Vivitrol)

Acamprosate (Campral)

Disulfiram (Antabuse)

Action

Blocks opioid receptors. Thought to interfere with reward pathways important in alcohol dependence.Same as oral naltrexone; 30-day duration

Affects glutamate and GABA and neurotransmitter systems but its alcohol-related action is unclear.

Inhibits intermediate metabolism of alcohol, causing a buildup of acetaldehyde and reactions if a patient drinks alcohol. Dosage 50 mg QD 380 mg IM monthly 333 mg tabs, 2 tabs TID 250 QD or 500 3X/wkBenefits

Modest reductions in relapse rates and severityModest reductions in relapse rates and severity

Modest reductions in relapse rates and severity Modest reductions in relapse rates and severitySide effects

• Nausea (10%)• LFT elevations (uncom.)

• Nausea (~10%)• LFT elevations and sterile abscess (uncom.)

• Diarrhea (16% vs. 10% in placebo) • Liver problems including (rare) fulminant hepatitisCost $4/day $25/day $4/day $4/day

Meds for treating EtOH dependence

Medications

Meds for treating opiate dependence

• Methadone maintenance

• Buprenoprhine treatment

• Psychosocial treatment alone

• Illicit drugs other than opiates: No proven medications

Medications

Recommendation for Illicit drug use: abstain

IIIII

IV

Making recommendations

• No Zone I for drug use

• Casual marijuana use still carries consequences

• Medical marijuana possible exception

IIIII

IV

Making recommendations

Abstain

Reduce useReduce use / Abstain

Recommendations for alcohol use:

Low riskor abstention

Other factors behind recommending abstention

• Prior history of substance dependence

• Pregnancy

• Medications

• Serious mental illness, medical condition

Making recommendations

Practice: Tom

Groups of three:

• Physician

• Patient

• Observer

Practice

Brief intervention: “Tom”

Practice

http://www.youtube.com/watch?v=1kalMZCelNw&feature=related

Workflow resembles a pipeline

Pipeline

Installing the pipeline

• Buy-in

• Clinic champions

• Training

• Tools

• EMR

Pipeline

Jim Winkle, MPH

OHSU Family Medicine

Phone: 503-720-8605

[email protected]

www.sbirtoregon.org www.sbirtoregon.org

Questions?