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Patient Safety Monitor Journal Patient Safety Monitor Journal Volume 20 Issue No. 12 December 2019 Behavioral health INSIDE THIS ISSUE P5 PSMJ Decade Review Arming PCPs to screen and intervene A look back at the last 10 years of patient safety, and what’s on behavioral health coming up in 2020. Research shows many healthcare professionals unprepared for P7 Safety polarity A new way of looking at “unsolv- conducting screening and brief interventions able” problems in patient safety. P9 12 days of Christmas Safety gifts we’d like to get this year. P12 Keep it simple Strip down your patient safety process of needless complexity— it could save lives. It’s our last newsletter of 2019, how did we do? Credit: AlexLMX. Image Source: www.gettyimages.com Did we meet your needs? Write about things that by Megan Headley mattered to you? Is there Behavioral health is getting big attention, but one of the biggest attention a way we could improve? grabbers is the realization that few primary care providers (PCP) know how Let us know by filling out this to address it. In fact, a recent survey of physicians found 57% reported that short survey: https://www.survey- they don’t feel adequately prepared to screen patients for substance use or monkey.com/r/SVPK68X mental health disorders or to provide patients with information about the This is your chance to influence associated health impacts. Patient Safety Monitor Journal in The report—Are Healthcare Professionals Ready to Address Patients’ 2020 and beyond! Substance Use and Mental Health Disorders?—was co-authored by Deborah S. Finnell, DNS, CARN-AP, FAAN, faculty consultant at Johns Hopkins 2 | Patient Safety Monitor Journal December 2019 School of Nursing, and Glenn Albright, PhD, treatment to patients who screen in need of addi- cofounder and director of research for the health tional services simulation company Kognito. The authors note that at Despite the value in this approach, the Kognito report a time when the prevalence of drug overdoses is reveals a range of physician concerns about implement- contributing to a reduction in life expectancy, when ing SBI—from added time to patient visits to potential alcohol accounts for one in every 10 adult deaths in the problems getting reimbursed for these services. Instead United States, and when depression and suicide rates of SBI, many opt to skip straight to referral, hoping for continue to rise at an unprecedented rate, there is adherence as they shift the burden downstream. renewed impetus to treat substance use and mental health issues like other health conditions. The authors Despite feeling unprepared, 84% of the Kognito suggest that better-prepared PCPs can make a bigger survey respondents reported they are nevertheless dent in lowering these statistics. likely to use an SBIRT model for some patients. While this may indicate a willingness to help, it also can yield “There is … evidence that people with substance use a 25% referral rate that is five times higher than disorders are more willing to enter treatment in a expected, along with associated healthcare cost primary care setting than in a specialty setting,” the increases due to unnecessary specialist billing. report states. “For healthcare providers to keep pace with this need, they must have the knowledge and Barriers to successful screening skills to address the needs of patients with behavioral health conditions as part of routine practice and on par World Health Organization guidelines for identifying with any physical illness.” 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 The SBIRT model benefit from a brief intervention. Early identification of About 65 million Americans will experience a mental people at risk for substance abuse, as well as countless health or substance use disorder in their lifetime, others suffering from mental health disorders, can be according to the Substance Abuse and Mental Health lifesaving and very cost-effective. Kognito points to Services Administration. So it’s more important than research indicating that every dollar spent on SBI for ever for caregivers to become competent in using alcohol use can lead to $4 in savings on future healthcare screening and brief intervention (SBI) techniques that costs. Team-based care for depression integrated into can help identify patients who may need treatment. primary care can save up to $6 for every dollar invested. And yet, the survey clearly demonstrates that few PCPs The Institute of Medicine recommends an SBIRT feel comfortable conducting screening techniques. model (screening, brief intervention, and referral to treatment) as a public health approach to identifying Chris Dorval, MSW, LICSW, LCDCS, LCDP, came health risk behaviors. The model’s three major compo- to his position as project coordinator of the Rhode nents include: Island College School of Social Work SBIRT Training • Screening: A healthcare professional assesses a and Resource Center after years of working in the patient for risky substance use behaviors using substance use world, where he often wondered how standardized screening tools many of his patients could have benefited from much earlier interventions related to their substance use. • Brief intervention: A healthcare professional en- gages a patient showing risky substance use be- “It happened time and again where people came to me haviors in a short conversation, providing with multiple health complications like hypertension, feedback and advice Type 2 diabetes, kidney or liver issues, which were all • Referral to treatment: A healthcare professional related to their substance use,” he says. “I would ask if provides a referral to brief therapy or additional they had spoken about the relationship between their HCPRO.COM © 2019 HCPro, a Simplify Compliance brand. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or 978-750-8400. December 2019 Patient Safety Monitor Journal | 3 health conditions and their substance use with their Administration and the Health Resources and Ser- healthcare professional, and they would almost always vices Administration, provides a number of screening say, ‘No, it never came up’ or, ‘They didn’t ask, so I didn’t tools online at https://www.integration.samhsa.gov/ tell’ or, ‘It never seemed like the right time/place.’ ” clinical-practice/screening-tools. The American Mental Wellness Association provides additional A lack of training and education on available resources resources at www.americanmentalwellness.org/ is one significant obstacle for PCPs, but there may be intervention/screening-tools. other factors holding physicians back. “I think sometimes primary care physicians don’t ask Collaborate on a brief intervention because the stigma around substance use is still very If screening is daunting, starting a conversation around much there and creates an uncomfortable situation for behavioral health can seem like even more of a chal- both patient and provider,” Dorval says. “It is unfortu- lenge. Yet having a conversation is the key to a success- nate, because not asking the questions and normalizing ful intervention. A brief intervention shouldn’t be a the questions themselves covertly reinforces that stigma lecture on the need to “break a bad habit” or seek by suggesting that asking that question is somehow ‘bad’ treatment. Instead, experts advise using a collaborative or ‘taboo.’ Others don’t ask because they are not trained communication style, such as motivational interviewing. how to ask, or what to do if the patient does indicate that they are using in an unhealthy way.” Motivational interviewing is a client-centered counseling style in which the client, not the clinician, voices the Dorval offers a few tips for normalizing questions during reasons for change. It may seem a foreign concept for the screening process because, as he puts it, “Asking physicians accustomed to giving instructions. Confusion people about substance use is only as uncomfortable as about how to intervene left 64% of the Kognito survey we make it out to be.” He suggests physicians: respondents feeling inadequately prepared to use motiva- • Be assumptive with open-ended questions. Ask tional interviewing to enhance their patients’ motivation “How often do you drink alcohol?” not “Do you to change their behavior or seek help. Likewise, 62% drink alcohol?” Ask “How often do you use reported that they don’t feel adequately prepared to drugs?” not “Do you use drugs?” Asking in this collaborate with their patients to create an action plan. way normalizes the behavior and allows for con- versation. The patient can always say, “I don’t Kathleen Sciacca, who provides consulting and train- drink or use drugs,” but this phrasing gets the ing on dual diagnosis and motivational interviewing, conversation started. explains in her video series for the Motivational Interviewing Network of Trainers that the collabora- • Use recovery-friendly language. Avoid words like tive style behind motivational interviewing is vastly “clean,” “dirty,” “alcoholic,” or “addict.” Words different from the authoritarian approach of most like this can reinforce stigma and make conversa- client-provider relationships. “An authoritarian tions more difficult. An August 2018 article on approach is simply telling, without doing very much substance use, recovery, and linguistics shows just listening. That tends to put the person out of the how much language matters. Certain terms, in- process and will likely result in nonadherence or a cluding “substance abuser,” “addict,” “alcoholic,” discordant relationship,” she says. and “opioid addict,” elicit strong negative biases. Changing language is a first step toward removing Sciacca offers some guidelines for effective motiva- the stigma around substance abuse and developing tional interviewing: a mindset for both client and clinician that the cli- • Ask permission. When giving advice or expertise, ent can benefit from treatment. always ask permission.
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