SBIRT pushes healthcare integration, heightens awareness of behavioral health problems

Editor’s note: SBIRT stands for Screening, Brief Intervention and Referral to Treatment. Learn more about it here.

dr. dwinnells

Dr. Ron Dwinnells

We’ve featured the work of Dr. Ron Dwinnells at the federally-qualified health center ONE Health Ohio before.

A couple years ago, we wrote about ONE Health Ohio’s partnership with Gateway Rehab subsidiary Neil Kennedy Recovery Clinic to demonstrate that SBIRT can be a collaborative win-win-win process–that is, it has benefits for the primary health center, the specialty addiction treatment provider, and the patient.

In the intervening years, we’ve gotten a chance to connect more substantially with the folks who are using SBIRT in northeast Ohio, including ONE Health Ohio CEO Ron Dwinnells.

This month was the first time I’d seen Dwinnells speak in person. And what a treat to hear his ignite talk at the ATTC Network Forum in Baltimore. (For the unfamiliar, an ignite talk is a hip and geeky presentation format whereby 20 slides automatically advance every 15 seconds during a 5 minute talk.)

Here are Dwinnells’s slides. Without his narration, you won’t grasp the whole story, but you will get an important portion of it: the way his personal experiences feed into his commitment to expanding the use of SBIRT in primary care clinics.

In each of his SBIRT-related articles, webinars, and presentations (that I’ve seen), Dwinnells tells the story of his father’s depression and eventual suicide. He suggests that a health clinician might have intervened to address the depression before his father died–an unrealized possibility, he says, that has guided his efforts to integrate behavioral health into primary care settings in his own work.

Dr. Dwinnells parents

Dwinnells’s parents before his father’s death

SBIRT at ONE Health Ohio

ONE Health Ohio is an FQHC that operates six primary care clinics in a three-county northeast Ohio area. In 2013, Dwinnells helped implement SBIRT in two clinics and used one of them as a control to determine if the identification, diagnosis, and treatment referrals of patients with behavioral health conditions increased in settings where SBIRT was used.

Staff at the intervention sites use a pre-screening tool consisting of five questions with every medical visit. “Patients are informed that this is a vital sign; no different than taking a blood pressure, heart rate or respiratory rate,” explained Dwinnells.

Demographically, the intervention and control sites were similar. Most patients’ annual income was below $25,000 and Medicaid was the most common payer for services. After six months, the data showed that the rates of behavioral health condition identification, diagnosis, and treatment referral were indeed quite different.

Evaluation Results

In the sites implementing SBIRT screening, 1,570 (63%) of the patients were positively identified with depression, alcohol, or a substance use problem, with a subsequent diagnosis of 627 (25%), whereas only 192 (11%) of the control site patients were found to have a depression, alcohol, or substance use problem.

However, one measurement was actually similar between the two groups: the percentage of patients referred to treatment who actually went. Only 30 SBIRT intervention patients (24%) and three control site patients (18%) kept the referral appointments for follow up treatment.

The evaluation also showed that doctors’ average time with patients did not increase as the result of using SBIRT and that patients did not find the substance use and mental health screening questions to be intrusive or unpleasant.

clinic flow

Flow chart of the results of the SBIRT intervention sites versus control site. The rate of positive diagnosis was more than twice as high among the screened patients.

Based in part on these strong evaluation results, in July of 2014, ONE Health Ohio received a two-year, $1.1 million grant from the state of Ohio and the federal Health Resources & Services Administration to improve the efficiency of SBIRT in their clinics and increase care integration between physical and behavioral health.

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Below are some ideas that Dwinnells has shared (in print and in person) based on his experience with SBIRT so far. We’re sharing them because we think his perspectives can help other organizations understand why and how to use SBIRT.

On his personal connection to his work

“My dad was depressed—it was obvious—but not one doctor ever broached the subject. Vital signs, blood sugar levels and weight checks were routine for those visits. Exploring behavioral status—for example, ‘…how do you feel?’ were not.”

On recent research showing that BIs for risky drug use didn’t reduce patients’ levels of use or improve other health and healthcare-seeking related outcomes

“I don’t see the brief intervention as an end-all cure-all. I see SBIRT as an awareness kind of thing. From a practical clinician’s perspective, before I can do anything, I need to be aware of it. So SBIRT is a tool for knowing if the person has another problem, a co-morbid condition. As a physician, shouldn’t I be aware of that?

I don’t put all my eggs in one basket in terms of the intervention being what’s going to fix things. In these two articles [Saitz et al. and Roy-Byrne et al.), the BI doesn’t really do anything. Okay, well, I can see that. Of greater importance is that now I’m aware and can help this person get the help that he or she really needs.”

On how to interpret low rates of kept-appointments after referral to treatment

“From a practical front-lines clinical perspective, to me, the most important thing is recognition and the timeliness of the help that we give them.

It takes an average of three weeks to get our patients into local behavioral health clinics. These patients are already sick and in three weeks they’re not going to go.  We’re working on developing our own inpatient behavioral health program so that we can do warm handoffs and real-time counseling.

We know that there’s a high rate of co-morbidity between chronic disease and behavioral health problems. We know that people with diabetes have a higher rate of depression than the general population and that the conditions are related. Isn’t it important that a doctor seeing a patient for diabetes investigates depression? And if the medical doctor does realize that this patient suffers from depression, why shouldn’t he have resources immediately accessible? To me, that’s why integration is so important.”

On being a physician and a CEO

“I’m in a unique position where I’m both a doctor and administrator.

I wanted to see how many medical patients who came in also had behavioral health issues, so I went and looked at the data. We get federal dollars to see uninsured and under-insured folks. We have reporting requirements to the feds, so we have all kinds of data. Before we started using SBIRT, our rate of diagnosis for behavioral health problems was consistently less than two percent. That was out of 60-some thousand patients we interface with.  I know from the literature that at least 25% of the population have some kind of depression problems.

Of course, the doctors didn’t want to do SBIRT. They said it would take too much time and patients wouldn’t tell us anything if we asked. The cool thing is that I’m the boss. And so we did it.”

On why he’s optimistic about the use of SBIRT to improve patients’ health

“I believe that’s the problem with us as medical providers: most of the time we’re not aware. Out of sight, out of mind. If you’re aware, then you can solve pretty much any problem.”

 Additional Resources

SBIRT in Action, SBIRT as the Fifth Vital Sign (On-demand webinar recorded November 2013)

The Fifth Vital Sign: SBIRT – Screening, Brief Intervention and Referral to Treatment (Fall 2014 newsletter article beginning on page 6)

Ignite Talk slideset (Presentation from November 2014)