Expanding primary care teams with trained and supported paraprofessionals enables systematic delivery of widely recommended, evidence-based, cost-saving alcohol, drug, and depression screening and intervention services.
Published Online: April 17, 2014
Richard L. Brown, MD, MPH; D. Paul Moberg, PhD; Joyce B. Allen, MSW; Candace T. Peterson, PhD; Laura A. Saunders, MSSW; Mia D. Croyle, MA; Robin M. Lecoanet, JD; Sarah M. Linnan, BS; Kim Breidenbach, MD, MPH; and Scott B. Caldwell, MS
Objectives: Unhealthy behaviors are responsible for most chronic disease, ample healthcare costs, and around 40% of deaths. This study assessed patient satisfaction and behavioral outcomes for a program that enables healthcare settings to deliver evidence-based, cost-saving behavioral screening and intervention (BSI) services, as recommended by the US Preventive Services Task Force and others.
Study Design: Pre-post program evaluation.
Methods: Thirty-one diverse primary care clinics and 2 other sites participated. Over 110,000 patients completed multibehavioral screening questionnaires. Those with positive alcohol or drug screens met with dedicated, on-site health educators for further assessment, and then received either reinforcement, brief intervention, or referral. Over 300 patients completed satisfaction questionnaires during year 3 of the program. A pseudo-randomly selected group of 675 patients participated in a 6-month follow-up telephone interview. In addition, for a short time in a pilot project at 3 clinics, 29 patients received depression screening, collaborative care, and behavioral activation, and 22 completed a 3-month follow-up telephone interview.
Results: Mean patient satisfaction scores for all services exceeded 4.2 on a 5-point scale. Over 6 months, binge drinking episodes declined by over 20% for most subgroups. Recent marijuana use decreased by 15%. Depression symptom scores decreased by 55%.
Conclusions: With intensive training and ongoing support, cost-efficient paraprofessionals can deliver effective alcohol, drug, and depression screening and intervention services in busy healthcare settings. The approach holds promise for systematically addressing on a population-wide basis a variety of important behavioral health determinants and reducing related healthcare costs.
Am J Manag Care. 2014;20(4):e113-e121
This article describes a program that successfully delivers evidence-based, costsaving alcohol, drug, and depression screening and intervention services in primary care settings.
Ample research has documented the effectiveness of these services and their return on investment, yet they are seldom delivered, largely because of provider and staff time pressures.
Trained and supported, cost-efficient paraprofessionals can deliver these services, elicit high patient satisfaction, and attain substantial declines in risky drinking, illicit drug use, and depressive symptoms.
Over time, clinical settings were able to modify work flow so that most patients received recommended services.
Several federal agencies and other authorities recommend that primary care providers conduct systematic tobacco, alcohol, depression, and obesity screening and intervention1-8: henceforth, behavioral screening and intervention (BSI). Dozens of randomized controlled trials and meta-analyses have demonstrated the efficacy of these services. Most such studies addressed 1 behavioral issue, involved selected consenting patients, and delivered services with more resources and tighter quality controls than most clinical settings could typically offer. Because of such studies, these services carry Grade A or B ratings from the US Preventive Services Task Force (USPSTF) and are consequently being advanced by the Affordable Care Act (ACA). Indeed, BSI could help reduce the $500 billion annual economic loss from tobacco use, alcohol use, and depression,9,10 as for every dollar spent, $4 is saved in 1 year through BSI for alcohol,8 $6.50 in 4 years for depression,11 and likely more for tobacco.12
BSI starts with a few screening questions to identify patients who likely have behavioral risks or disorders.1 Positive screens require further assessment, which guides further service delivery, as per prior research. Low-risk drinkers or tobacco and alcohol abstainers receive reinforcement. Tobacco users and high-risk drinkers receive on-site interventions and ongoing support. Nicotine-dependent patients are offered pharmacotherapy. Patients with possible alcohol dependence, and patients with the desire but not the ability to modify tobacco or alcohol use, are referred for specialty care or other resources. In addition to usual pharmacotherapy and/or counseling, depressed patients receive collaborative care, in which typically a nurse or mental health professional coordinates management, promotes patient engagement in treatment during and in between visits, tracks depression symptom scores, and alerts treatment professionals to reconsider treatment plans if scores are not improving as expected.13 Collaborative care can also include behavioral activation, in which patients are engaged in behaviors that ameliorate depression symptoms.14
Two major sets of barriers impede BSI implementation. Financial barriers are waning, as fee-for-service reimbursement for BSI is expanding under the ACA, and shared savings models are taking hold. Staff time is a more stubborn barrier. A primary care clinician would need 7.4 hours every work day to deliver all recommended preventive services, including BSI, leaving little time to address acute concerns and chronic illness.15 A potential solution is team-based care. Indeed, if the nation’s undersized primary care workforce will be able to serve the growing numbers of insured, elderly, and chronically ill patients, then primary care clinicians may need to delegate preventive services to other team members.16
The US Substance Abuse and Mental Health Services Administration (SAMHSA) administers grants for demonstration projects to advance delivery of its alcohol and drug Screening, Brief Intervention, and Referral to Treatment (SBIRT) services. Successful projects develop a feasible service delivery model, serve a large number of patients, demonstrate patient satisfaction, and document reductions in substance use. Between 2006 and 2011, with SAMHSA grant funding, the Wisconsin Initiative to Promote Healthy Lifestyles (WIPHL) helped 33 clinical sites deliver SBIRT by expanding their healthcare teams with trained and supported “health educators” of varied backgrounds. WIPHL obtained separate funding to support delivery of depression screening and collaborative care for a short time at 3 sites. This paper reports on service delivery, patient satisfaction, and pre-/postintervention changes in behavioral outcome measures at the participating sites. The intent of this paper is to inform the design and implementation of programs that are intended to systematically identify and address multiple behavioral issues among large numbers of unselected patients, respect healthcare provider time constraints, help clinical settings meet several USPSTF recommendations, and serve the triple aim of improved health, patient experience, and cost control.
The Wisconsin Department of Health Services administered the project, contracted with the University of Wisconsin (UW) School of Medicine and Public Health and the Wisconsin Medical Society to administer a coordinating center, and contracted with the UW Population Health Institute to conduct program evaluation. SAMHSA provided funding and direction.
The Coordinating Center recruited sites through networking and selected them for their diversity in geographic location, population density (urban, suburban, and rural), payer mix, and their readiness to take advantage of the program. Sites were launched in waves to fill 18 slots. Additional sites were recruited as vacancies occurred. Initially, only primary care clinics were recruited. In later years, an emergency department (ED) and a hospital were added.
Site Preparation and Support
Interested sites completed a checklist to assess readiness and guide preparations. Sites instituted annual, universal screening for their entire patient population or for a subpopulation defined by provider or visit purpose. At most sites, receptionists distributed brief screening questionnaires. Sites were encouraged to include questions on multiple behavioral risks, in part to enhance acceptance of alcohol and drug questions.17 Staff members who checked vital signs reviewed questionnaire responses and referred patients with positive alcohol or drug screens to health educators. Consistent with SAMHSA requirements, health educators primarily conducted alcohol and drug assessment, then education, intervention, or referral as appropriate; they provided brief feedback and referral for other behavioral risks. They reported back to providers, who were encouraged to provide additional support and pharmacotherapy.
Sites were encouraged initially to identify champions, establish a quality improvement team with representatives from various staff segments, and design an initial work flow. The coordinating center provided consultation on best practices. Sites were encouraged to engage in monthly plan-do-study-act cycles to optimize 2 metrics: (1) the proportion of eligible patients who completed screens and (2) the proportion of patients with positive alcohol or drug screens who completed health educator– administered brief assessments.
Health Educator Hiring
The coordinating center guided each clinical site in hiring a health educator—a term that carries no legal implialcations in Wisconsin. Of the 44 health educators hired, 9 were master’s-level counselors or social workers, 33 held bachelor’s degrees, and 2 were high school graduates with special language or cross-cultural skills. Seven health educators had a bachelor’s degree in health education, 4 were certified health education specialists, and 1 was a certified chemical dependency counselor.
Health Educator Training and Support
One week of distance training and a subsequent week of face-to-face training emphasized alcohol and drug screening, SBIRT, motivational interviewing, and cultural competence. Learning activities included interactive lectures, discussions, demonstrations, and role-play exercises, sometimes with standardized patients. Health educators had to pass a written examination and skills/ performance assessment. At their clinical sites, they received ongoing support through weekly conference calls and quarterly retreats. Monthly, with patients’ written consent, health educators submitted audiotapes of sessions and received structured feedback from trainers, who completed a modified skills checklist.18 Custom software guided health educators in realtime in delivering high-fidelity, evidence-based services. As they saw patients, health educators entered data, which allowed tracking of service delivery.
As shown in Table 1, the alcohol and drug screen included 3 validated questions on substance use5,19 and a direct question about illicit drug use or nonmedical use of prescription drugs. Questionnaires were available in several languages. For patients with positive screens, health educators administered the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST)20 plus 3 questions on quantity and frequency of alcohol use.21 Based on their responses, patients’ substance use was classified as low risk, risky, harmful, or likely dependent. Health educators asked additional questions as required by SAMHSA and the Governmental Performance Results Act.
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