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Service Delivery Innovation Profile

With Support From Collaborative, Primary Care Practices Identify and Address Behavioral Health Issues, Reducing Binge Drinking, Marijuana Use, and Depression Symptoms


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Snapshot

Summary

The Wisconsin Initiative to Promote Healthy Lifestyles supports primary care practices in identifying and addressing various behavioral health issues in patients, including drug, alcohol, and tobacco use; depression; and obesity. Patients complete a screening form each year, and those who screen positive are referred to a trained health educator employed by the practice. The educator conducts a formal assessment using validated tools and provides protocol-driven interventions onsite and via telephone to patients at mild to moderate risk. Standard interventions include motivational interviewing and behavior change planning for risky or unhealthy behaviors; and counseling, medical therapy, and psychiatrist oversight for depression. High-risk patients receive referrals to outside specialty providers, with the educator following up to ensure that the patient receives these services. The program has reduced binge drinking, marijuana use, and symptoms of depression and has generated high levels of patient satisfaction.

Evidence Rating (What is this?)

Suggestive: The evidence consists of trends in rates of binge drinking, marijuana use, and symptoms of depression, along with post-implementation patient satisfaction data and anecdotal reports of positive financial return.
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Developing Organizations

Wisconsin Initiative to Promote Healthy Lifestyles
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Date First Implemented

2006

Problem Addressed

As in most of the nation, depression; obesity; and risky behaviors such as alcohol, tobacco, and drug use remain common, costly problems in Wisconsin. Yet before implementation of this initiative, most primary care practices in the state did not have formal programs or adequate staffing to identify and proactively address these problems.
  • Common, costly problems: Wisconsin residents exhibit many risky health-related behaviors. For example, rates of risky and problem drinking are quite high,1 including binge/risky drinking (with 26 percent of residents reporting in the previous month—the highest in the nation) and drunk driving (26 percent—also highest in the nation). Many Wisconsin residents use tobacco and illicit drugs (19 percent and 8 percent, respectively), and many experience depression (8 percent).2 In Wisconsin, alcohol and drug use represent the fourth-leading cause of death and hospitalization, costing the state more than $5 billion a year.1 Furthermore, approximately 36 percent of State residents are overweight and 28 percent are obese, comparable with national figures.3
  • Failure of primary care practices to intervene: Behavioral screening and intervention (BSI) programs offer formal screening and assessment, intervention, and specialty referrals for behavioral health conditions. These programs have been shown to reduce illicit drug and alcohol use, injuries, inpatient and emergency department (ED) use, and total care costs, and they generate a positive return on investment.4,5,6,7 Despite this evidence, BSI programs remain rare in primary care practice because of inadequate staff resources and training. Before implementation of this program, for example, some Wisconsin primary care practices offered a brief screen for behavioral issues and depression. However, they generally did not fully assess patients or provide any interventions onsite to low- or moderate-risk patients. And although high-risk patients sometimes received referrals to specialty providers, most practices did not follow up to ensure that these patients actually accessed these services.

What They Did

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Description of the Innovative Activity

The Wisconsin Initiative to Promote Healthy Lifestyles (WIPHL, pronounced “wiffle”) supports primary care practices in identifying and addressing behavioral health issues in patients. Patients complete a screening form each year, and those who screen positive are referred to a trained health educator employed by the practice. The educator conducts a formal assessment using validated tools and provides protocol-driven interventions onsite and via telephone to patients at mild to moderate risk. High-risk patients receive referrals to outside specialty providers, with the educator following up to ensure that the patient accesses these services. To date, 44 practices have participated in WIPHL, with 8 taking part as of early 2013. Key program elements are detailed below:
  • Annual screening: Each year, patients complete a standardized screening form in the waiting room before a preventive care or acute care visit. The form screens patients for excessive drinking, drug use, depression, tobacco use, diet, physical activity, and obesity. After the patient completes the form, a medical assistant escorts him or her to the examination room, takes the patient’s vital signs, and quickly reviews the screening form.
  • Assessment by onsite, trained educator: If there are any positive responses, the medical assistant alerts the practice’s health educator about the need for further assessment. Trained by WIPHL (see the Planning and Development Process section for more details), the health educator conducts a more formal assessment, either in the examination room before the physician sees the patient (if the physician is running late) or in a separate, private room afterwards. For those screening positive for obesity risk, the health educator computes the patient’s body mass index. For those screening positive for other conditions, the educator uses the following validated tools as appropriate: the Alcohol Use Disorder Identification Test (AUDIT), the Fagerstrom Test for Nicotine Dependence, the Drug Abuse Screening Test (DAST), or the Patient Health Questionnaire-9 (PHQ-9) that screens for depression.
  • Onsite intervention for moderate-risk patients: The assessment generally indicates a mild to moderate level of risk for most patients. For these individuals, the health educator provides protocol-guided intervention(s) during multiple onsite visits or via telephone, with the number of sessions varying according to patient preferences and needs. Typical interventions for major types of behavioral health issues are outlined below:
    • Risky or unhealthy behaviors: The health educator uses motivational interviewing techniques designed to help patients identify reasons to change that are consonant with their own goals and values. Once the patient has committed to doing so, the health educator and patient jointly develop a behavior change plan that includes setting goals and rewards for achieving them, placing limits on risky behaviors, identifying triggers for the behavior(s) in question and strategies for avoiding them, and making necessary environmental changes. During ongoing visits or telephone calls, the health educator assesses patient progress, provides coaching and support, and helps the patient adjust the plan as necessary.
    • Depression: Health educators coordinate a team-based intervention for patients with mild to moderate depression. For patients with minor depression, the health educator delivers behavior activation, which involves engaging patients in behaviors that help lift depressive symptoms such as exercise, socializing, and sleep hygiene; behavioral activation can prevent minor depression from progressing to major depression. The primary care provider prescribes antidepressant therapy. As part of this intervention, a consultant psychiatrist reviews the patient’s care and recommends adjustments to medical therapy and other management strategies as necessary. Typically, the health educator remains in contact with the patient for approximately 6 months.
  • Referral and follow up for high-risk patients: The health educator refers patients with serious disorders (e.g., major depression, alcoholism, drug addiction, and obesity) to outside specialty services as defined by each primary care practice. Depending on the resources available, the health educator might refer the patient to private practitioners or programs run by hospitals, health plans, or community organizations. The health educator refers patients with major depression for pharmacotherapy or counseling; he or she educates patients about depression, instills optimism for treatment, helps keep patients engaged in treatment, tracks depression symptom scores, and alerts other treaters to consider revising the treatment plan when depression symptom scores do not drop as quickly as expected. The health educator stays in contact with all referred patients to ensure that they pursue the referral and obtain needed services.
  • Documentation of service delivery: The health educator documents all patient interactions in the medical record, with the documentation being cosigned by a licensed and credentialed provider to ensure eligibility for third-party reimbursement.

Context of the Innovation

Part of the Department of Family Medicine at the University of Wisconsin School of Medicine and Public Health, WIPHL provides training, consultation services, and support to health care professionals in Wisconsin interested in implementing BSI programs. WIPHL was launched in 2006 when Wisconsin obtained funding from the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) to develop and disseminate the evidence-based Screening, Brief Intervention, and Referral to Treatment (SBIRT) program in the primary care setting.

WIPHL staff found that primary care practices sometimes resisted SBIRT, primarily because it focused only on alcohol and drug use. They found that BSI programs, which focused on a broader scope of behavioral issues, were more appealing to primary care providers than SBIRT for alcohol and drugs. WIPHL currently supports BSI as part of Partners in Integrated Care, a 3-year initiative supported by the Agency for Healthcare Research and Quality (AHRQ) and administered by the Pittsburgh Regional Health Initiative, which promotes use of evidence-based services for identifying and addressing depression and substance abuse in primary care settings.

Did It Work?

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Results

The program has reduced binge drinking, marijuana use, and symptoms of depression and has generated high levels of patient satisfaction and a small positive financial return.
  • Fewer risky behaviors and symptoms of depression: During the program's first years, patients who received services exhibited a 20-percent decline in binge drinking, a 48-percent drop in regular marijuana use, and a 15-percent decline in total marijuana use. Over the same time period, symptoms of depression fell by 55 percent.
  • High patient satisfaction: Patients have been highly satisfied with the program throughout the 5-year period, rating their degree of satisfaction between 4.2 and 4.9 on a 5-point scale.
  • Positive financial return: Participating practices that keep their health educators fairly busy are able to generate fee-for-service revenue that exceeds health educators' compensation. Many WIPHL practices have continued to employ health educators and deliver services after termination of seed grant funding.

Evidence Rating (What is this?)

Suggestive: The evidence consists of trends in rates of binge drinking, marijuana use, and symptoms of depression, along with post-implementation patient satisfaction data and anecdotal reports of positive financial return.

How They Did It

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Planning and Development Process

Selected steps included the following:
  • Creating advisory council: WIPHL created an advisory council to help define strategy for the program. The council is made up of government officials, medical professionals, and business representatives.
  • Hiring program staff: WIPHL hired approximately 10 program staff to take on responsibilities related to clinical care, training and support of health educators, clinic workflow, information technology, and administrative issues.
  • Recruiting practices: The WIPHL clinical director used his many contacts across the state to reach out to and recruit the 36 practices that agreed to participate in the initial program.
  • Identifying assessment tools, designing protocols: Guided by grant requirements, WIPHL staff identified appropriate assessment tools and designed protocols to guide the health educators in providing interventions.
  • Hiring health educators: WIPHL helped participating practices hire health educators by offering guidance on position requirements, suggesting interview questions, and funding their compensation during the early years of the program. (See Funding Sources section for more details.)
  • Training health educators: WIPHL provides 2 weeks of training to newly hired health educators. The program includes modules related to screening, assessment, interpretation of results, motivational interviewing, and behavior change planning. Health educators also learn to use project reporting software. In addition to this initial training, WIPHL staff host weekly conference calls with health educators to discuss difficult cases and share best practices.
  • Helping practices optimize workflow: WIPHL provided practices with onsite technical assistance to help them incorporate the program into the existing practice workflow.
  • Securing third-party reimbursement: After the program had been operating successfully for several years, WIPHL staff contacted Medicaid and commercial payer representatives to discuss the possibility of them providing reimbursement for health educator services. To help make their case, staff presented data showing the positive behavior changes achieved by program participants. These efforts proved to be successful, with many payers agreeing to reimburse practices for some (but not all) services provided by the health educators. (See Funding Sources section for more details.)
  • Obtaining funding to expand program: Because of WIPHL's success on its SAMHSA grant, the Pittsburgh Regional Health Initiative invited WIPHL to participate in its Partners in Integrated Care program, which is funded by AHRQ. The AHRQ grant requires alcohol and depression screening and intervention; WIPHL also focuses on tobacco and drugs, but some clinics may choose to focus on diet, exercise, and obesity. Of the 18 clinics participating at the end of the SAMHSA grant, 10 assumed the cost of health educator compensation and continued delivering services after grant funding expired. Eight clinics did not do so because they found fee-for-service reimbursement insufficient. In the AHRQ grant, all participating clinics agreed up front to hire health educators, as the AHRQ grant did not support this expense. The Wisconsin Partnership Program has since provided additional funding to cover the costs of health educator training and explore the potential to expand the program to sites serving adolescents.
  • Expanding BSI program: WIPHL is working with Transform Wisconsin to expand its BSI program to improve outcomes for patients with hypertension, lipid disorders or type 2 diabetes mellitus.

Resources Used and Skills Needed

  • Staffing: The central program office employs three part-time, director-level staff: one each to oversee clinical issues, operations, and development. Each participating primary care practice employs a full-time health educator.
  • Costs: Program-related costs have totaled approximately $13.6 million since inception (see the Funding Sources section for more information). In addition, practices currently pay health educators between $35,000 and $45,000 a year in salary, plus benefits. As noted, these compensation costs are more than made up for by reimbursement from third-party payers. To date, practices have received technical assistance from WIPHL at no charge, thanks to grant funding.
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Funding Sources

Agency for Healthcare Research and Quality; Substance Abuse and Mental Health Services Administration (U.S.); Wisconsin Partnership Program
Major sources of program funding include the following:
  • A 5-year, $12.5 million SAMHSA grant supported initial development and operations (2006 to 2011).
  • A 3-year, $800,000 subcontract of a larger AHRQ grant (R18HS019943) supports recruitment of primary care clinics throughout the state (2010 to 2013).
  • A 3-year, $300,000 grant from the University of Wisconsin’s Wisconsin Partnership Program supports health educator training provided by the University of Wisconsin–La Crosse Graduate Community Health Programs (2011 to 2014).
  • Under a separate, 1-year, $50,000 planning grant from the Wisconsin Partnership Program, the Alliance for Wisconsin Youth–Southeast is developing a plan to deliver tobacco, alcohol, and drug screening and intervention services in schools and other organizations serving teens in eight southeastern Wisconsin counties. If this process proves successful, the Alliance will seek additional funds to support service delivery.
  • As noted, the Wisconsin Medicaid program and several Wisconsin commercial insurers provide reimbursement for different components of the program. Medicaid covers services related to alcohol and drug screening and intervention, whereas 13 commercial plans cover services related to alcohol, drug, and tobacco cessation screening and intervention. To date, none of these payers covers services related to depression or weight counseling, nor do they cover telephone-based interventions.
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Tools and Other Resources

Assessment tools used by the program are available at the following Web sites:

Adoption Considerations

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Getting Started with This Innovation

  • Help providers recognize value of health educator: Physicians may initially be skeptical about letting a health educator work with patients. To address their concerns, program developers should emphasize the evidence base supporting BSI (including WIPHL) and SBIRT and use storytelling to spread information about the program’s positive impact on patients. Eventually, providers will see data and hear stories about their own patients, which will cement their support of the program.
  • Hire and train full-time health educators: Health educators should be full-time employees, because patients treated throughout the day will screen positive for health risks. All health educators need formal, indepth training related to behavioral health conditions and motivational interviewing.
  • Teach providers to frame BSI as routine preventive care: Patients will not value a BSI program if providers present it as an “extra” component of care. Instead, they should learn to present it as routine preventive care that serves to optimize health. Patient participation is high when BSI is presented as routine preventive care rather than as a special program.
  • Help practices with workflow issues: Primary care physicians may be concerned about how to incorporate a health educator into the existing workflow. To overcome these concerns, assist practices in developing strategies that will minimize the educator's impact on workflow and maximize the educator's productivity. For example, having patients complete the screening form in the waiting room will minimize any negative impact on clinician time. In addition, health educators can be instructed to begin working with patients in the examination room if the physician is running late, thus maximizing educator productivity and minimizing patient waiting time. If the physician comes in before the educator has finished, the interaction can be completed elsewhere following the medical examination, thus ensuring that the physician does not experience any downtime.
  • Designate office space for educator: If possible, the health educator should have a dedicated, private place available to meet with patients.

Sustaining This Innovation

  • Continue supporting educators: Support health educators on an ongoing basis through conference calls and refresher training sessions. This support facilitates their professional development and provides an opportunity to share best practices, thus allowing them to better handle difficult cases.
  • Leverage opportunities to create stronger incentives for sustainability: Although the financial return from the program is generally positive, it remains small in the typical fee-for-service payment environment. Competing practice change mandates often prevent primary care settings from implementing a new BSI program. To avoid this possibility, look for opportunities to offer larger financial incentives for the provision of program-related services. For example, practice leaders could approach local purchasers to urge consideration of BSI programs as part of any ongoing pay-for-performance initiatives. In addition, program leaders could look to leverage funding sources for new care delivery models, such as accountable care organizations and patient-centered medical homes. For example, BSI programs already meet many of the criteria required to achieve designation as a National Committee for Quality Assurance Patient-Centered Medical Home.

More Information

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Contact the Innovator

Richard L. Brown, MD, MPH
Professor of Family Medicine, School of Medicine and Public Health, University of Wisconsin
Director, WIPHL
1100 Delaplaine Court
Madison, WI 53715
(608) 263-9090
E-mail: rlbrown@wisc.edu

Innovator Disclosures

In addition to the external funders listed in the Funding Sources section, Dr. Brown receives financial compensation for consulting services offered to practices interested in adopting the WIPHL model.

References/Related Articles

More information on WIPHL is available at: http://www.wiphl.org/.

Footnotes

1 Wisconsin Initiative to Promote Healthy Living. What is BSI? Available at: http://www.wiphl.org/whatabout.
2 Brown RL. Spreading SBIRT in Wisconsin (Powerpoint presentation). Behavioral Risk Factor Surveillance System, 2009 and 2010 data.
3 Wisconsin Department of Health Services, 2011 data. Wisconsin obesity and physical activity data. Available at: http://www.dhs.wisconsin.gov/physical-activity/Data/WIdata.htm.
4 Madras BK, Compton WM, Avula D, et al. Screening, brief interventions, referral to treatment (SBIRT) for illicit drug and alcohol use at multiple healthcare sites: comparison at intake and 6 months later. Drug Alcohol Depend. 2009;99(1-3):280-95. [PubMed]
5 Estee S, Wickizer T, He L, et al. Evaluation of the Washington state screening, brief intervention, and referral to treatment project: cost outcomes for Medicaid patients screened in hospital emergency departments. Med Care. 2010;48(1):18-24. [PubMed]
6 Gentilello LM, Ebel BE, Wickizer TM, et al. Alcohol interventions for trauma patients treated in emergency departments and hospitals: a cost benefit analysis. Ann Surg. 2005;241(4):541-50. [PubMed]
7 McCance-Katz EF, Satterfield J. SBIRT: a key to integrate prevention and treatment of substance abuse in primary care. Am J Addict. 2012;21(2):176-7. [PubMed]
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: June 19, 2013.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: August 13, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: June 10, 2014.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.