Screening, Brief Intervention, and Referral to Treatment (SBIRT) is a public health approach to the delivery of early intervention, treatment, and referral services for people with substance use disorder (SUD) and those at risk for developing it.1 In February 2018, SBIRT was integrated into a local community health center that mainly serves unstably housed and vulnerable people. The center uses an interprofessional model of care. As part of an interprofessional process improvement project, the authors sought to determine referral and follow-up rates of individuals participating in nonpharmacologic substance use outpatient treatment within the clinic. The goal of this project was to evaluate and improve the SBIRT process within the clinic to better serve a vulnerable patient population.
Substance use disorder
SUD is an umbrella term created by the American Psychiatric Association and described in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Each specific substance is addressed as a separate use disorder (for example, alcohol use disorder and stimulant use disorder), but nearly all substances are diagnosed based on the same main criteria.2-4 For the diagnosis to be made, at least 2 of 11 diagnostic criteria must be present in a 12-month period, including hazardous use, interpersonal problems related to use, neglecting major roles secondary to use, withdrawal, tolerance (needing more to achieve the desired effect), repeated attempts to control use or quit, excessive time spent in using, substance used in larger amounts or for longer periods than intended, physical or psychological problems related to use, withdrawing from previously enjoyable activities, and cravings.2,4
In addition, SUD is associated with impaired functioning and decreased quality of life, leading to considerable physical, financial, and social burdens. Left untreated, this chronic, relapsing mental illness can lead to devastating psychological and physical sequelae.5-7 Researchers have revealed a positive correlation between SUD and an increased rate of suicidality, illegal activity, neuropsychological regression, and infectious diseases.8,9 This phenomenon occurs when the recurrent use of alcohol or drugs causes significant clinical and functional impairment, such as health problems, disability, and failure to meet substantial responsibilities at work, school, or home.2,10
The nonmedical use and abuse of prescription drugs, including the use of medications in higher quantities than prescribed, or the use of medications prescribed for someone other than the individual using them, has grown into a significant public health concern. Approximately 16.9 million people, or 6.2% of the US population 12 years and older, misused prescription medications in 2018.11 According to the CDC, between 1999 and 2010, the number of opioid prescriptions sold in the US nearly quadrupled.12 This number peaked in 2012; however, in 2018 the opioid prescribing rate fell to its lowest in over 10 years.13
In Tennessee, the number of all opioid overdose deaths increased with an age-adjusted rate of 11.0 per 100,000 in 2012 and an age-adjusted rate of 18.1 per 100,000 in 2016.14 Within the same time frame, Northeast Tennessee had multiple adjacent counties with a greater than 100% increase in opioid-related mortalities.14 In 2017, Tennessee had an opioid-involved overdose death rate of 19.3 deaths per 100,000, which is higher than the national rate of 14.6 deaths per 100,000 persons.15 The percentage of patients filling opioid prescriptions who had concomitant benzodiazepine prescriptions (>1 overlapping day) decreased gradually from 9.8% in early 2013 to 7.1% at the end of 2017.14 However, deaths secondary to combined opioid and benzodiazepine use continued to increase, with an age-adjusted rate of 4.0 per 100,000 in 2012 and 8.1 per 100,000 in 2016.14 The most significant rise in opioid-related deaths comes from illegal opiates such as heroin. The rate of heroin overdose deaths has increased by over 300% between 2013 and 2016.14
Social health is integral to understanding the link between SUD and homelessness. Data on over 500,000 homeless people in the US (including all states, territories, Puerto Rico, and the District of Columbia) aggregated by the U.S. Department of Housing and Urban Development found that 15.6% of homeless individuals also had chronic SUD.16 However, various sources have historically cited much higher rates of SUD among the homeless population, ranging from 33% to 78.3%.17,18 Also, living without stable housing is a significant risk factor for resultant SUD.18 The National Coalition for the Homeless estimated that 38% of homeless people were dependent on alcohol and 26% used other drugs.19 Similarly, SUD was found to be much more common in people facing homelessness than in people with stable housing.18
East Tennessee is composed of 33 counties and sits in the heart of central Appalachia, which has some of the nation's highest rates of substance use and mortality.20-23 Additionally, in 2017, East Tennessee had a total of 260 drug overdose deaths.24 East Tennessee overdose mortality has steadily climbed from 23 per 100,000 people in 2013 to 36 per 100,000 people in 2017.13 Alcohol consumption over the same 4 years has not increased at such an alarming rate.25 From 2013 to 2016, Tennessee had adult alcohol use rates below the national average.25 However, heavy alcohol consumption, defined as drinking five or more drinks for males and four or more drinks for females on the same occasion 5 or more days in the past month, has been on the rise.25 Prevalence rates of heavy alcohol use in the eastern regions of Tennessee have increased by 21% over the same 3-year period.25
SBIRT. The SBIRT model stemmed from World Health Organization (WHO) efforts in 1982 to create a standardized screening tool for harmful and hazardous drinking and to develop an approach to treatment that could be delivered in the primary care setting.26,27 Researchers determined that a plethora of evidence supported the finding that primary care providers (PCPs) were not equipped with the tools needed to identify and intervene with those who had SUD.27 Thus, the SBIRT movement evolved. Current recommendations encourage PCPs to implement a brief intervention for low-risk patients, which is aimed at increasing insight and personal awareness into risky use patterns. Conversely, high-risk patients are promptly referred to a specialized treatment provider.28
Substance Abuse and Mental Health Services Administration (SAMHSA) has been the most significant funding source for SBIRT proliferation in the US.29 Since 2003, SAMHSA has funded 17 Medical Residency Cooperative Agreements, 32 State Cooperative Agreements, 12 Targeted Capacity Expansion Campus Screening and Brief Intervention Grants, and 14 SBIRT Medical Professionals Training grants.29 These grants expand the continuum of care for SUD, including hazardous, harmful, and dependent use, and promote the integration of SUD treatment into the traditional medical care community.30 Madras and colleagues conducted the most extensive study to date, which examined the efficacy of the SBIRT grants using a sample of 459,599 patients, and concluded that SBIRT could produce significant improvements in self-reported patient status for illicit drug and heavy alcohol use across a range of healthcare settings and patient populations.31 Further, it has been shown that settings that included onsite treatment specialists saw a reduction in outside referrals, thereby reducing barriers to patient treatment access.27
Discouragingly, PCPs fail to routinely screen, refer, and treat patients with SUD despite multiple recommendations from various federal agencies.1,32 Lack of training and knowledge regarding addiction, as well as limited referral services, are regularly cited as barriers to SBIRT implementation.1,33
Substance use treatment in the homeless population. Given the transient nature of individuals without stable housing combined with reduced funding, it is often challenging to implement empirically driven interventions for substance use in this population.18,34,35 Common patterns and trends among addiction treatment in the homeless population were identified to be 12-step programs such as Alcoholics Anonymous and Narcotics Anonymous.36-39 Multiple studies, mostly qualitative in design, have examined different aspects of 12-step recovery groups and their impact on the homeless population.36,37,40 Twelve-step groups are a viable treatment option because they require no financial obligation and are readily available, but have produced mixed results.35,38,40 Twelve-step programs have a morality-based model, and some successes are found in regions where religion and culture are intertwined.38 Flanagan and Briggs described the importance of religious and spiritual principles in maintaining sobriety in people living with homelessness and addiction in Atlanta, Ga.36 However, the spiritual component of the 12 steps is cited as a barrier for many adults who are homeless and seeking help with addiction.38 Gender differences suggest a need for more individualized, holistic options.36,37 Upshur and colleagues concluded that homeless women with SUD need more comprehensive whole-person services to help address the co-occurring problems that homelessness and substance addiction precipitate.32 They also found that these women were more willing to talk about substance addiction than they were actually asked about the issue by healthcare providers, highlighting the need for more effective screening and intervention.32
SBIRT is a validated, cost-effective tool for screening and managing SUD that is highly effective in the general public with resources including access to healthcare.9,31,33 The WHO, National Institute on Alcohol Abuse and Alcoholism, SAMHSA, and American Academy of Family Physicians all make recommendations to use SBIRT for secondary prevention in the primary care setting.28,41-44 There has been limited evaluation of the efficacy of SBIRT use in primary care settings serving vulnerable populations and in those who suffer from both SUD and homelessness. Self-Management and Recovery Training (SMART Recovery) is a nationwide, nonprofit organization that offers evidence-based support groups to individuals who desire freedom from any addictive behavior. SMART Recovery is not a 12-step program but instead assists in problem management, conflict resolution, and the development of a positive, balanced, and healthy lifestyle. In short, it is a mental health and educational program focused on altering human behavior.45 SMART Recovery helps people stay motivated to continually abstain, manage urges, and cope with emotions.45,46 The program has a scientific foundation as opposed to the spiritual framework often found in 12-step programs.37,45 Similarly, SMART Recovery avoids labeling any individual as an addict or alcoholic.46 There are over 2,000 free live meetings each week in the US, 40 weekly interactive online meetings as well as 24/7 support via chatrooms and message boards.47 To our knowledge, no prior studies have examined SMART Recovery with homeless individuals with SUD.
Context. The project took place at a nurse-managed clinic in Northeast Tennessee that provides integrated interprofessional primary care, mental health, and social work case-management services to homeless and underserved people with difficulty accessing traditional systems. The care model was specifically designed for the population served and is based on the following concepts: easy accessibility, patient-centered care, safe environment, interprofessional delivery, flexibility, and nonjudgmental support.
Screening for SUD in primary care is a major recommendation from SAMHSA.28 In accordance with these recommendations, all of the primary care patients at this clinic are screened annually for SUD. Because of the exponential rise in substance use in the Appalachian region, the clinic providers and staff initiated SBIRT as a recommended standard of care on February 12, 2018.
Process improvement. The purpose of the project was to evaluate the use of SBIRT at the clinic by examining the referral process and determining follow-up rates of those who received SBIRT.
Intervention. The unlicensed assistive personnel (UAP) employed at the clinic administered the screening tests and maintained a Health Insurance Portability and Accountability Act-compliant Excel spreadsheet within the clinic. If a patient had a positive screen indicating SUD, the UAP relayed that information to the primary care NP who then conducted a brief intervention and/or referral to treatment. Treatment referral options included SMART recovery meetings or consultation with the psychiatric mental health nurse practitioner (PMHNP), both of which were available within the clinic.
The clinical social worker at the site conducted the SMART Recovery group and kept weekly attendance. The social worker and UAP collectively discussed their data. The UAP developed and maintained a frequency table of patients who screened positive and attended at least one SMART Recovery meeting. The PMHNP reviewed the screening data and determined the number of patients who screened positive and kept a follow-up appointment for substance-related issues between March and October 2018. Also, the PMHNP determined the number of patients who screened positive and attended both SMART Recovery and a mental health consultation. The UAP collected and organized anonymized data into a spreadsheet for analysis.
Inclusion criteria included those screened who were age 18 and older and who demonstrated a willingness to be screened during a clinic visit. Exclusion criteria included age younger than 18 years old, refusal to be screened, and results not documented.
Measures and analysis. The following outcome measures were used: screens administered; positive screens; referrals to either SMART Recovery or the PMHNP; participation in at least one follow-up for either modality; and participation in at least one follow-up for both modalities.
The screening tools used included Alcohol Use Disorders Identification Test (AUDIT) and the Drug Abuse Screening Test (DAST-10). AUDIT has been repeatedly validated and has a sensitivity of over 90%, and specificity over 80% in populations tested in six countries, including testing of the cutoff score.26,27 Likewise, DAST-10 has a sensitivity from 95% to 41% and specificity from 68% to 99% as measured across a broad range of groups of different ages, ethnicities, educational levels, psychiatric diagnoses, clinical characteristics, and scoring thresholds.48 The threshold for a positive screen using the DAST-10 was greater than 3. Likewise, for the AUDIT, a score greater than 8 was considered a positive screen.
Ethics and human subjects protections. The university institutional review board (IRB) determined that the project was quality improvement rather than research because the purpose was to assess and evaluate the processes of patient referrals and quantify follow-up into established treatment modalities. In addition, risks to privacy and confidentiality were minimized because the data were collected by clinic staff and the project directors had access only to anonymous numerical data.
A chart review that included patients who had at least one primary care visit between March and October 2018 was used. The frequencies were aggregated, quantifying the total number of screens and the total number of positive screens over 7 months from March 2018 to October 2018. The total number of patients screened over 7 months was 244, and of those, 45 had a positive screening (18%). Of the 45 patients who screened positive for SUD, 73% (n = 33) chose to follow up for more comprehensive treatment. Twenty-seven percent (n = 12) did not follow up. Twenty-four percent (n = 11) attended at least one meeting of SMART Recovery. Similarly, 29% (n = 13) patients with positive screening results had at least one kept appointment with the PMHNP. Twenty percent (n = 9) both attended at least one meeting of SMART Recovery and kept at least one substance-related appointment with the PMHNP. (See Number and percentage of patients receiving SBIRT and follow-up treatment.) The raw data were anonymized before being shared with the project directors. Per IRB requirements, only clinic staff were allowed access to any identifiers. Staff were instructed not to double-count attendance. However, SMART Recovery does not, by design, keep attendance. The UAP verbally cross-checked the spreadsheet with the social worker who ran SMART Recovery. Therefore, the authors were informed by the staff that the number of those who attended both were unique patients.
Summary. This project is important because there is a paucity of evidence evaluating outcomes of SBIRT with homeless and vulnerable populations who have SUD and complex health and social problems. The finding that 73% of participants followed up was encouraging and supports the notion that vulnerable persons with chronic, intractable SUD who are homeless want treatment, and was not found in the existing literature. The findings support the organizational structure of integrated interprofessional care via this clinic that incorporates psychiatric and primary care NPs, social workers, case managers, and mental health counselors practicing as a team. The care team is small, allowing ease of communication and increased social interaction with this at-risk population. In addition, a nonjudgmental atmosphere adopted by providers could also be a factor in the high follow-up percentage.
Interpretation. Dwinnells evaluated SBIRT referral rates with patients, the majority of whom were at or below 200% of the federal poverty level but not necessarily homeless.49 Of the patients who screened positive for alcohol or substance use (N = 777), 11.7% were referred to treatment at outlying facilities, but 0% of referrals were kept. The findings by Dwinnells suggest the value of integration of primary healthcare with behavioral health services, especially within community health centers.49
The findings of this project align with Babor and colleagues and Dwinnells that suggest that people with the most intractable health and social problems are more likely to attend treatment when referral and treatment occurs on site using an interprofessional model of care.27,49 However, engagement into treatment is affected by multiple factors, including the relationships staff have with patients. Positive relationships with those referred could have impacted the findings.
Additionally, outcomes of referral and attendance rates, when compared with the general US population, suggest that homeless people are willing to engage in treatment modalities for SUD when given the opportunity. Aldridge and colleagues evaluated SBIRT efficacy using a large sample (N = 17,575) of US adults from studies conducted in various settings who had screened positive for hazardous or harmful substance use and were recommended for brief intervention, brief treatment, or referral to treatment.30 Referral follow-up was defined differently and varied between the studies evaluated; however, together the overall rate was lower than the current findings. Outcomes for vulnerable groups must be population-specific and tailored to include the social determinants of health. Those who are homeless, living in poverty, and experiencing concurrent SUD need unique, specific models of care that allow for ease and flexibility of treatment.
Given the positive findings of this study, future research should focus on the evaluation of integrated teams responsible for small populations of homeless persons with intractable substance use and chronic health problems. More research is needed to evaluate the long-term outcomes of SMART Recovery. In addition, more resources for societal interventions into interprofessional services are needed for early intervention. Finally, a population needs assessment could prove beneficial in determining the best approach when addressing SUD in the local homeless population. Needs assessments are aimed at gathering environmental baseline information to decide whether program resources are appropriately tailored to fit the local community.50 Determining the needs, values, and opinions of a population is a critical component of evidence-based practice.51 Finding out what treatment approach, if any, those who are vulnerable and homeless are willing to participate in requires future research, including qualitative and intervention studies.
Improving the process. The primary objective of this project was to evaluate SBIRT referral to treatment in a homeless population, but assessing the current process and providing suggestions for improvement was a secondary goal. Various aspects of the referral process could be enhanced to allow for seamless communication between the multiple disciplines involved in SBIRT. Integrating a referral option within the electronic health record to be used by the providers, nurses, and clerical staff would reduce word-of-mouth referrals and streamline the workflow.52 Similarly, an electronic referral would produce tangible, objective data that all interprofessional providers could access. This could result in an additional reminder along with verbal discussion and help reduce miscommunication and the potential for missed interventions and referrals.
Annual SBIRT competency training within the clinic should be implemented for all employees.52 Education should focus on assisting staff with reliable implementation of the SBIRT process. Future outcome evaluation of the process includes assessing patient adherence in long-term interprofessional treatment models, which can potentially reduce recidivism in the most complex, vulnerable groups. In addition, staff education about how improved methods, documentation, and referrals affect coding, billing, and payment is essential to sustainable care provision to vulnerable groups. Also, employee cross-training could help bridge the gap that is present when the clinic is without nursing coverage.
Facilitators and barriers to the success of SBIRT should be explored during monthly interprofessional meetings. Monthly meetings are a way to engage every patient-facing employee and to allow for transparent communication, brainstorming, and knowledge generation. Empowering all employees to help identify problems while encouraging open communication for improvements helps create a culture based on creativity and collaboration. The team can work through identified barriers in the process such as lack of clarity regarding role responsibility, working in silos, and billing/reimbursement issues to ultimately create standardized work. Standardized work is an agreed-upon process that should be completed when executing a particular task.53 More so, designating to specific personnel the responsibility for initiating the SBIRT process could reduce role confusion and lead to better time management and productivity. For example, assigning certain discipline-specific responsibilities pertaining to the execution of SBIRT may allow for more consistent screening and increased referrals.
Several limitations should be accounted for when interpreting these findings. The key limitation was that the project focused on translating and implementing empiric evidence into practice and lacked the academic rigor of a research study. Also, the project lacks external validity because it was piloted at a single clinic and used a convenience sample. Moreover, the small sample is not a representative sample of people with SUD who are homeless, so caution is needed when making generalized inferences.
Various factors made it difficult to correctly calculate the number of brief interventions performed by healthcare providers at the clinic. The death of a PCP may have impacted accurate data input and collection. Also, IRB distinction as a quality-improvement project required anonymization of the data so the project team could not access health records. Ultimately, the one UAP employed at the clinic was responsible for obtaining all of the screening data. Additionally, the UAP was frequently needed to work at other sites, which left a gap in UAP coverage at the clinic. In addition, because of the structured requirements of SMART Recovery, anonymized data were checked verbally, resulting in potential over- or undercount of those who attended both treatment modalities. Last, the omission of screening data from nonparticipants may have influenced outcome measures, as screening is optional.
This project found that homeless individuals with SUD who underwent SBIRT screening had a high rate of follow-up with treatment services, suggesting that this vulnerable group is willing to engage in treatment modalities when given the opportunity. The findings also support the use of permanent, interprofessional, integrated teams including social workers, psychiatric and primary care NPs, nurses, and outreach workers to provide psychiatric, social support, street outreach, and mental health and primary care services. Smaller team panels that allow for consideration of complex individual needs can facilitate participation in treatment. Substance use and wealth disparity are two factors driving the steady rate of homelessness in the US.54 Since screening for substance use is the first step toward treatment, integrating team-based care into traditional primary care, as demonstrated, results in increased access to treatment. The future focus should recognize structural societal inequalities in access to integrated team-based healthcare and other social determinants of health impacting substance use and homelessness.
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