# MOSBIRT (Missouri Screening, Brief Intervention, Referral, and Treatment) 

## Program Description

The Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Substance Abuse Treatment (CSAT) has awarded the Missouri Office of the Governor (MOSBIRT) $2.5 million per year for 5years to provide screening, brief intervention, referral and treatment in three general medical settings in the state. Specific sites are CoxSouth ER and Cox Family Medical Care Center in Springfield, Missouri and HeartlandHealth Hospital ER in Saint Joseph, Missouri. 

Unique factors affecting the State include the Missouri Division of Alcohol and Drug Abuse (ADA) estimate that about 12% of Missouri residents need treatment for alcohol or drug dependence or abuse. In FY 2007, ADA programs provided treatment services to 13.1% of individuals needing public sector treatment. The top five drugs of abuse among people treated by ADA were alcohol (37%), marijuana (27%), cocaine (15%), methamphetamines (11%), and heroin (5%). Missouri also leads the nation in methamphetamine abuse. The number of alcohol and drug related hospitalizations and emergency department encounters in Missouri has steadily increased, with over 90,000 in 2005. Additionally, in 2005, hospitalization and emergency department charges exceeded $120 million for those individuals. 

One impetus for Missouri to seek an SBIRT project was the finding that the main referral source to treatment is the court/criminal justice system, which indicates that most of the substance abusers were not screened or treated when their symptoms were mild, but were discovered only after there was a serious level of abuse.

## Program Model

### Screeners

The screeners for the project carry the title of Health Coach and are integrated into the care teams at the general medical sites. The Health Coaches are Masters level in the human services field, have knowledge of substance abuse disorders and their treatment, are proficient in computers, and have the willingness and ability to follow manualized treatment protocols.

### Pre-screen

A five question brief pre-screen, adapted from one used in the Wisconsin project, is used to indentify individuals with substance abuse risk factors. Adaptations have included gathering veteran status and screening explicitly for non-prescription use of prescribed medications. Nurses at each site will complete this pre-screen with the patients.

### Screen tool

Those individuals answering Yes to any one of the five prescreen questions will be administered the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) by a MOSBIRT health coach. 

### Medicaid/Medicare/Insurance reimbursement

Initial meetings have been held with Medicaid staff to start discussions in regard to funding the SBIRT codes in Missouri. While responses received from this staff are favorable, more planning is needed. 

### Brief Intervention 

Brief Interventions are provided using a non-confrontational, patient-centered approach incorporating the Feedback, Responsibility, Advice, Menu, Empathy and Self-Efficacy (FRAMES) model. Health Coaches are trained in Motivational Interviewing techniques and Motivational Enhancement Therapy. Information from the individuals self report is compared to relevant normative information and to the possible health outcomes based on their substance use behavior. 

### Brief Treatment methods

Health coaches will provide 6 sessions of motivational enhancement therapy and cognitive behavioral therapy (MET/CBT). The first 30-50 minute session starts immediately following a positive ASSIST, followed by five additional sessions to be held either face-to-face (at facility) or by phone. 

### Referral to treatment 

Those individuals with an ASSIST score above 27 for alcohol or drugs will receive a referral to a specialized service provider for further evaluation. They are introduced to the treatment liaison who will work to get them connected with an appropriate substance abuse treatment provider. This is expected to be a warm handoff with the staff member being responsible for getting the patient into the hands of the provider. This handoff includes providing transportation or other supports needed to facilitate treatment entry. 

## Service Features 

One of the hallmarks of the MOSBIRT project is the development of the automated Health Coach support system- MOSBIRT in a Box (MOSBOX). This application is being created based on models used in other SBIRT projects. Deployed on a tablet computer, it provides all assessments, manualized brief interventions and brief treatment along with evaluation instruments and consent forms. Additional features will include training videos and other training materials. Information will be initially stored on the individual computers then automatically synched with a centralized database. The development process is incremental with additional questions and instruments being added as the management and intervention development teams direct. The automated Brief Intervention (BI) and Brief Treatment (BT) protocols, developed with input from a team of individuals with expertise in Motivational Interviewing and Motivational Enhancement Therapy/Cognitive Behavioral Therapy are included in MOSBOX. 

### · Evaluation

The MOSBIRT projects calls for the evaluation staff to conduct a site-based needs assessment, a process evaluation, an outcome evaluation, and a cost-effectiveness analysis. 

### · Collaboration

We are in discussions with another state effort, funded by a private foundation, that will provide SBIRT services using physicians and a web based service delivery approach. As the projects mature we hope to share resources and build upon each others efforts. 

## PROGRAM EFFECTIVENESS

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### SCREENING TARGETS

MOSBIRT expects to screen over 80,000 adult Missourians over the 5 year period of the grant.

CONTACT INFORMATION

Barbara KeehnMOSBIRT Project DirectorMissouri Institute of Mental Health5400 ArsenalSt. Louis, MO 63139(314) 877-6445Barbara.keehn@mimh.edu

MARK STRINGERPrincipal InvestigatorDIRECTOR DIVISION OF ALCOHOL AND DRUG ABUSE(573) 751-4942(573) 751-7814 FAXMark.Stringer@dmh.mo.gov