Research shows that many physicians are unprepared for conducting behavioral health screening and brief interventions.
This article was first published by PSQH on August 29, 2019.
By Megan Headley
Behavioral health is getting big attention, but one of the biggest attention-grabbers is the realization that few primary care providers (PCP) know how to address it.
An estimated 65 million Americans will have a mental health or substance use disorder in their lifetime, which raises the risk of disease and mortality as well as increases healthcare costs.
A recent survey of physicians found 57% reported that they don’t feel adequately prepared to screen patients for substance use or mental health disorders or to provide patients with information about the associated health impacts.
The survey's report, "Are Healthcare Professionals Ready to Address Patients' Substance Use and Mental Health Disorders?" was co-authored by Deborah Finnell, DNS, faculty consultant at Johns Hopkins School of Nursing, and Glenn Albright, PhD, co-founder and director of research for the health simulation company Kognito.
The authors note that at a time when the prevalence of drug overdoses is contributing to a reduction in life expectancy, when alcohol accounts for one in every 10 adult deaths in the United States, and when depression and suicide rates continue to rise at an unprecedented rate, there is renewed impetus to treat substance use and mental health issues like other health conditions. The authors suggest that better-prepared PCPs can make a bigger dent in lowering these statistics.
"There is … evidence that people with substance use disorders are more willing to enter treatment in a primary care setting than in a specialty setting," the report says. "For healthcare providers to keep pace with this need, they must have the knowledge and skills to address the needs of patients with behavioral health conditions as part of routine practice and on par with any physical illness."
SBIRT model of care
With the prevalence of behavioral health and substance abuse problems among Americans, it is more important than ever for caregivers to become competent in using screening and brief intervention (SBI) techniques that can help identify patients who may need treatment.
The Institute of Medicine recommends the Screening, Brief Intervention, and Referral to Treatment (SBIRT) model of care as an approach to identifying people at risk of substance abuse disorders. The model features three components:
1. Screening: A healthcare professional assesses a patient for risky substance use behaviors using standardized screening tools.
2. Brief intervention: A healthcare professional engages a patient showing risky substance use behaviors in a short conversation, providing feedback and advice.
3. Referral to treatment: A healthcare professional provides a referral to brief therapy or additional treatment to patients who screen in need of additional services.
Despite the value in this approach, the Kognito report reveals the concerns physicians have about implementing SBI such as adding time to patient visits and problematic reimbursement of these services. Instead of SBI, many physicians opt to skip straight to referral, hoping for adherence as they shift the burden to other caregivers.
Despite feeling unprepared, 84% of the Kognito survey respondents reported they were likely to use the SBIRT model for some patients. While this may indicate a willingness to help, it also can yield healthcare cost increases due to unnecessary specialist billing.
Barriers to successful screening
World Health Organization guidelines for identifying alcohol use disorders suggest that only about 5% of the total population will require a brief intervention and referral to a specialist, but an additional 25% would benefit from a brief intervention.
Early identification of people at risk for substance abuse, as well as countless others suffering from mental health disorders, can be lifesaving and cost-effective. Kognito points to research indicating that every dollar spent on SBI for alcohol use can lead to $4 in savings on future healthcare costs. Team-based care for depression integrated into primary care can save up to $6 for every dollar invested. And yet, the survey clearly demonstrates that few PCPs feel comfortable with screening techniques.
Chris Dorval, MSW, LICSW, became project coordinator of the Rhode Island College School of Social Work SBIRT Training and Resource Center after years of working in the substance abuse world, where he often wondered how many of his patients could have benefited from much earlier interventions.
"It happened time and again, where people came to me with multiple health complications like hypertension, Type 2 diabetes, and kidney or liver issues, which were all related to their substance use," he says. "I would ask if they had spoken about the relationship between their health conditions and their substance use with their healthcare professional, and they would almost always say, 'No, it never came up' or, 'They didn’t ask, so I didn’t tell.' "
A lack of training and education on available resources is one significant obstacle for PCPs, but there may be other factors holding physicians back.
"I think sometimes primary care physicians don't ask because the stigma around substance use is still very much there and creates an uncomfortable situation for both patient and provider," Dorval says. "It is unfortunate, because not asking the questions and normalizing the questions themselves covertly reinforces that stigma by suggesting that asking that question is somehow 'bad' or 'taboo.' Others don't ask because they are not trained how to ask, or what to do if the patient does indicate that they are using in an unhealthy way.
Dorval offers a few tips for normalizing questions during the screening process because "asking people about substance use is only as uncomfortable as we make it out to be.” He suggests physicians:
- Be assumptive with open-ended questions. Ask, "How often do you drink alcohol?" not "Do you drink alcohol?" Ask, "How often do you use drugs?" not "Do you use drugs?" Asking in this way normalizes the behavior and allows for conversation. The patient can always say, "I don’t drink or use drugs," but this phrasing gets the conversation started.
- Use recovery-friendly language. Avoid words like "clean," "dirty," "alcoholic," or "addict." Words like this can reinforce stigma and make conversations more difficult. An August 2018 article on substance use, recovery, and linguistics shows just how much language matters. Certain terms, including "substance abuser," "addict," "alcoholic," and "opioid addict," elicit strong negative biases, the article says. Changing language is a first step toward removing the stigma around substance abuse and developing a mindset for both client and clinician that the client can benefit from treatment.
The Center for Integrated Health Solutions, funded by the Substance Abuse and Mental Health Services Administration and the Health Resources and Services Administration, provides a number of screening tools online. The American Mental Wellness Association provides additional resources.
Collaborate on brief interventions
Screening is daunting but starting a conversation around behavioral health can seem like even more of a challenge. Yet having a conversation is the key to a successful intervention. A brief intervention should not be a lecture on the need to "break a bad habit" or seek treatment. Instead, experts advise using a collaborative communication style, such as motivational interviewing.
Motivational interviewing is a client-centered counseling style in which the client, not the clinician, voices the reasons for change. It may seem a foreign concept for physicians accustomed to giving instructions. Confusion about how to intervene left 64% of the Kognito survey respondents feeling inadequately prepared to use motivational interviewing to enhance their patients' motivation to change their behavior or seek help. Likewise, 62% reported that they did not feel adequately prepared to collaborate with their patients to create an action plan.
Kathleen Sciacca, who provides consulting and training on dual diagnosis and motivational interviewing, explains in her video series for the Motivational Interviewing Network of Trainers that the collaborative style behind motivational interviewing is vastly different from the authoritarian approach of most client-provider relationships. "An authoritarian approach is simply telling, without doing very much listening. That tends to put the person out of the process and will likely result in non-adherence or a discordant relationship," she says.
Sciacca offers four guidelines for effective motivational interviewing:
- Ask permission: When giving advice or expertise, always ask permission. For example, a clinician might say, "Would you like to learn more about the aids that are out there for smoking cessation?"
- Give reflective feedback: Reflective listening is about listening for the patient's experiences and perceptions and reflecting those back. This helps patients feel heard and know that what they say is important.
- Try elicit-provide-elicit: Rather than heading right into treatment advice, the clinician should find out what the client already knows to avoid providing repetitive information that the client might tune out. The clinician can then give information, and finish by asking again how the client sees options working for him or her.
- Grow more directive as the relationship grows: The goal in SBI is to facilitate change. However, this process needs to focus on why change is beneficial to the client rather than why the clinician thinks it is beneficial. If a client engages in sustained talk such as "Things are OK the way they are," it's up to clinicians to steer the client toward change talk such as "Is there anything at all that concerns you about leaving things this way?”
Referrals to the right partner
About 5% of the total population will require referral to a specialist, but Kognito's survey found a 25% referral rate to be more typical. The result, in many cases, is systematic referral of patients to specialists who could benefit from a brief intervention and treatment in primary care, leading to higher costs and a decreased likelihood of patients pursuing follow-up care.
While improving the SBI process can help, it also is critical that PCPs connect early on with behavioral health experts or substance use treatment providers so that when they do start screening, they can get people into treatment quickly.
“Substance use treatment is unique from many other healthcare treatments in that many people who need it do not necessarily want it. Providers making a referral need to make the referral quickly before the patient's window of willingness closes. The referral needs to stick as well. Handing them a card or a number to call is not enough. They need to schedule the appointment with the patient at the substance use treatment facility before they leave the office," Dorval says.
Brent Westhoven, CFO of Arlington, Virginia-based Advantia Health, noted at a recent event that a warm handoff to a mental health professional within the same building has a much higher compliance rate. One expert with whom he worked saw her patients' compliance rate in pursuing psychiatric care jump from 10% to 70% following a warm handoff.
As the focus on behavioral health grows across the country, training and educational opportunities are likely to increase as well. Ongoing education on new ways to interact with and serve patients will be critical in expanding care.
"Providers, patients, and communities need to be educated on what addiction is, what recovery is, and what treatment is," Dorval says. "This is a big undertaking, but it needs to be done if we are ever going to make a dent in the progressive growth of substance use in our society."
Dorval encourages clinicians to reach out to state health departments, professional development agencies, or colleges to find resources offering training and information on SBIRT. And the burden should not fall on the PCP alone.
"Many primary care offices are lacking in the resources to be able to provide integrated behavioral health services," Dorval says. "Managed care organizations need to make these integrated services a billable service compensated at a reasonable rate so that providers are able to offer a full continuum of services to their primary care patients."
Megan Headley is a freelance writer and owner of ClearStory Publications. She has covered healthcare safety and operations for numerous publications. Headley can be reached at email@example.com.
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