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Transcript of HOW TO PITCH SBIRT TO PAYORS PRESENTED BY: THE BIG INITIATIVE, NATIONAL SBIRT ATTC, NORC, and NAADAC...
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HOW TO PITCH SBIRT TO PAYORS
PRESENTED BY:THE BIG INITIATIVE, NATIONAL SBIRT ATTC, NORC, and NAADAC
May 8, 2014
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HOW TO PITCH SBIRT TO PAYORS
PRESENTED BY:THE BIG INITIATIVE, NATIONAL SBIRT ATTC, NORC, and NAADAC
May 8, 2014
![Page 3: HOW TO PITCH SBIRT TO PAYORS PRESENTED BY: THE BIG INITIATIVE, NATIONAL SBIRT ATTC, NORC, and NAADAC May 8, 2014.](https://reader035.fdocuments.net/reader035/viewer/2022062312/551c3f975503467b488b4a64/html5/thumbnails/3.jpg)
Webinar Facilitator and Presenter
Eric Goplerud Senior Vice President
Director, Substance Abuse, Mental Health and Criminal Justice Studies
301-634-9525
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Produced in Partnership…
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2014 SBIRT Webinar Series
Archived - ACA and Addiction Treatment: Implications, Policy and Practice Issues
Archived - Overview of SBIRT: A Nursing Response to the Full Spectrum of Substance Use
Archived - SBIRT in the Criminal Justice System Archived - Reducing Opioid Risk with SBIRT Today – How to Pitch SBIRT to Payors 5/14/14 - Treatment of Tobacco Dependence in
the Healthcare Setting: Current Best Practices 6/11/14 - Applying SBIRT to Depression,
Prescription Medication Abuse, Tobacco Use, Trauma & Other Concerns
7/9/14 - Training Integrated Behavioral Health in Social Work
8/6/14 - Why Integrative Care?
hospitalsbirt.webs.com/webinars.htm
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Access Materials
PowerPoint Slides
CE Quiz
Recording
hospitalsbirt.webs.com/pitchingsbirt.htm
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Ask Questions
Ask questions through the “Questions” Pane
Will be answered live at the end
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Technical Facilitator
Misti Storie, MS, NCCDirector of Training & Professional Development
NAADAC, the Association for Addiction Professionals
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HOW TO PITCH SBIRT TO PAYORS
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Footer Information Here 10
Alcohol as a cause or contributor to more than 70 diseases and injuries
Under 35 Yrs
Over
35
yrs
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Top 10 Leading Causes of Death in the United States for 2005 (CDC)
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Estimated Percentage of Adolescents and Adults with a Substance Use Disorder (primarily alcohol use disorders)
Recent estimates suggest that almost 8% of the US adults has a diagnosable substance use disorder (NSDUH, 2011)
92%
8%
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How Many Get Identified?
<0.8% of commercial health plan members, 1.2% Medicaid plan members are diagnosed (NCQA, 2010)
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Substance use screening and treatment in health care: Adding burdens or solving problems
14: Guwande’s Handwashing and Anaesthetics
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Where are the patients?
Settings where Unhealthy or Dependent Use is common
0%
10%
20%
30%
40%
50%Ambulatory Medical
Inpatient Medical
Emergency Dept
Outpatient MentalHealth
Inpatient Psychiatry
Trauma Center
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Hotspot 1: Hospitals
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Cochrane Collaboration review (McQueen et al, 2011)
14 RCTs, adults and adolescents
Outcomes favor BI over non-treatment controls• Significant drop in 6 month alcohol consumption • Significant drop in alcohol
consumption at 9 months• Self Report at 1 year favor BI• Significantly fewer deaths at
6 months and 1 year
17
Screening and Treating Acutely Ill and Injured Patients with Comorbid Substance Use
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Alcohol Disease Management Utilization and Costs to a
Health Insurance Plan• Rehabilitation facilities days decreased 67%
• BH inpatient days decreased 68%
• Medical inpatient days decreased 4%
• ER visits decreased 24%
• Partial Hospital and IOP visits decreased 69%
• Psychiatrist visits increased 44%
• Therapist visits increased 35%
• AUDIT score decrease 80%
Net total medical cost savings (ROI 2:1) 34%
(N = 358, 12 month continuous enrollment prior and post enrollment)
Trauma Centers: 60% injured have substance use disorders
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Trauma Recidivism - Statewide
0
0.025
0.05
0 250 500 750 1000
intervention control
injuryrecurrence
days follow-up
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Changes in Alcohol Intake
0
-21.6
02.3
-17.9
-14.1
-25
-15
-5
5
15
25intervention control
6 month follow-up 12 month follow-up
(p = 0.01)
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Net cost savings -- $89/patient screened, or $330/patient offered a brief intervention
Savings of $3.81/$1 spent
Potential savings if universal trauma center SBI -- $1.82 billion annually (2000 $)
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9 NNT to reduce 1 DUI arrest
~2000 DUI incidents/arrestee
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Screening and Brief Interventions in Hospital Emergency Departments
Systematic review of ED SBI
12 RCTs with pre- and post-BI results 11 or 12 observed significant effects on alcohol intake, risky drinking practices, alcohol related negative consequences, injury frequency
Nilsen et al, J Sub Ab Treat. 2008
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Consequences that matter to hospitalsUnstable discharges, rehospitalization risk
Crude Rates and Risks of Recurrent Acute Care Hospital Utilization Within 30 Days After Index Hospitalization
No SUDs (n = 615) SUDs(n = 123) P Rates of reutilization
Acute care reutilizations*: visits/patient/30 days 0.32 0.63 <0.01 ED visits: no. visits/patient/30 days 0.16 0.37 0.02 Rehospitalization: visits/patient/30 days 0.16 0.26 0.09
Risks of reutilization
Subjects with any acute care reutilization* in 30 days 38% 52% <0.01 Subjects with any ED visit in 30 days 23% 34% <0.01 Subjects with any rehospitalization in 30 days 23% 33% 0.02
Forsythe S, Chetty VK, Mitchell S, Jack BW. Acute care hospital utilization among medical inpatients discharged with a substance use disorder diagnosis. J Addict Med 2012;6:50-56. Rubinsky AD, Sun H, Blough D et al. AUDIT-C alcohol screening results and postoperative inpatient health care use. J Am Coll Surg 2012;213:296-305.
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American College of Surgeons-Committee on Trauma
Accreditation Requirements
Joint Commission SBIRT Metrics
25
Hospital Accreditation and Performance Metrics
CMS Inpatient Psych Incentive 2014 SUB-1
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• Falmouth Hospital (MA)• Denver General Hospital (CO)• Gunderson Lutheran Hospital (WI)• Oregon Health Sciences University (OR)• Christiana Hospital (DE)• Salina Regional Hospital (KS)• Temple University Hospital (PA)
26
Practical Examples of Hospital SBIRT
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Collaborations between Substance Use Programs and Hospitals: Gosnold-Falmouth Hospital
100 Bed Med-Surg Hospital; 50 Bed Addiction Treatment Center
Courteous but Distant Neighbors since 1982
Mutually Necessary but not Collaborative
Gosnold “a place to send ‘those’ people”
SO WHAT CHANGED???
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ICU Transfers -- Pre & Post Project
Cost per day Med-Surg Floor vs. ICU
30%-40% LOWER IN MED-SURG
Did not go to ICU
50%
Went to ICU
50%
Did not go to ICU
90%
Went to ICU
10%
PRE POST
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Average Length of Stay
0 2 4 6 8 10 12 14 16
Before Collaboration14.6 Days
After Collaboration6.2 Days
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Project Engage at Christiana (DE) Hospital
•Targeting hospitalized substance users at withdrawal risk, significant comorbid addiction
•Bedside Peer-to-Peer intervention using Motivational Interviewing
•Addictions Community Social Worker to assist in removing barriers to transition to care and help with integration into the hospital milieu
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Preliminary Claims Analysis
Modified from Wright, Delaware Physicians Care Inc, 2010
Claims from June 1, 2009 - November 30, 2009 3 months before and after claims review, n = 18
Metric Pre Post Finding
Medical inpatient admits 12 8
33% decrease $35,938
ER visits 54 33 38% decrease $4,248
BH/SA inpatient admits 7 10 43% increase ($1,579)
BH/SA outpatient visits 12 16 33% increase ($847)
PCP office visits 27 51 88% increase ($1,281)
Total Savings = $36,479
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Claims From Next 2 Cohorts
Modified from Wright, Delaware Physicians Care Inc, 2010
Claims from January 1, 2010 - December 30, 2010 6 months before and after claims review, n = 25
Metric Pre Post Finding
Medical inpatient admits 17 7 58% decrease : $68,422 saved
ER visits 133 116 12.7% decrease : $3,308 saved
Total Savings = $71,730
Claims from January 1, 2011 - December 30, 2011 6 months before and after claims review, n = 30
Metric Pre Post Finding
Medical inpatient admits 42 2248% decrease : $184,236 saved
ER visits 153 151 1% decrease : $8,690 saved
Total Savings = $192,926
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Salina Regional Health Center Outcomes
• 199 Bed Acute Care Regional Health Center-Level III Trauma Center
• 27,000 ED presentations per year
• Alcohol/Drug DRG was 2nd most frequent re-admission
• Services provided
24-7 coverage of ED
Full time SUD staff on medical and surgical floors
Warm hand off provided to all SUD/MH services
Universal Screening and SBI beginning in 2013
• Re-admission DRG moved from 2nd to 13th
• 70% of alcohol/drug withdrawal LOS were 3 days or less
• 83% of SUD patients triaged in ED were not admitted
• 58% of patients recommended for further intervention attended first two appointments (warm hand off)
• Adverse patient and staff incidents decreased by 60%.
• CKF detox admissions increased 450% in first year
• 300% increase in commercial insurance reimbursement
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Hotspot 2: Prenatal Screening and Case Management
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Kaiser-Permanente Northern California’s Early Start:A transformational program that is cost beneficial
• Universal Screening of ALL pregnant women
• Screening questionnaire• Urine toxicology (with consent)
• Place a licensed mental health provider in the department of OB/GYN
• Link the Early Start appointments with routine prenatal care appointments
• Educate all women and providers
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Rate of Preterm Delivery (<37 Weeks)
8.1%
9.7%
17.4%
6.8%
0.0%
5.0%
10.0%
15.0%
20.0%
SAF SA S Controls
Note: The rate of Preterm Delivery is 2.1 times higher in S group than SAF (Early Start patients)
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RATE OF NEONATAL ASSISTED VENTILATION
3.2%
4.2%
6.9%
2.2%
0.0%
2.0%
4.0%
6.0%
8.0%
SAF SA S Controls
The rate of the babies needing a ventilator is 2.2 times higher in the S group that the SAF and 3.1 times higher than the controls.
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RATE OF INTRAUTERINE FETAL DEMISE (stillborn)
Stillborns (IUFDs) were 14.2 times more likely in the S group than the SAF or C groups
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Maternal and Infant Mean Costs Comparison
$0
$5,000
$10,000
$15,000
$20,000
$25,000
$30,000
SAF SA S Controls
Maternal Total Costs Infant Total Costs Maternal and Infant Costs Combined
Positive Screen, No SA Treatment
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Hotspot 3: Youth and Young Adult High Risk Users
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Teen and Young Adult School Health and Ambulatory Health SUD Treatment
• Data were pooled from 16,915 adolescents from 148 local CSAT-funded programs and followed quarterly for 6 to 12 months
• In 2009 dollars, adolescents averaged $3,908 in costs to taxpayers in the 90 days before intake ($15,633 in the year before intake).
• This would be $3.9 Million per 1,000 adolescents served.
• Within 12 months, the cost of treatment was offset by reductions in other costs producing a net benefit to taxpayers of $4,592 per adolescent.
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Study Cost Savings Reference
Randomized trial of primary care brief treatment in the UK
Reductions in one-year healthcare costs $2.30 cost savings for each $1.00 spent in intervention
UKATT, 2005
Project TREAT randomized clinical trial: Screening, brief counseling in 64 primary care clinics
Reductions in future healthcare costs
$4.30 cost savings for each $1.00 spent in intervention (48-month follow-up)
Fleming et al, 2003)
Randomized control trial of SBI in a Level I trauma center
Reductions in medical costs
$3.81 cost savings for each $1.00 spent in intervention.
Gentilello et al, 2005
Propensity matched Medicaid disabled adults in Washington State Emergency Departments,
Reductions in Medicaid costs$336 per member per month post SBI for all patients$542/member/month if no prior SA tx
Estee et al, 2010
Screening and Brief Substance Use Treatment Reduces
Healthcare Costs
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Impact of SBI on Utilization in an Employment-Based Health Plan
• BH inpatient days decreased 63%
• Medical inpatient days decreased 51%
• ER visits decreased 20%
• Partial Hospital and IOP visits increased 81%
• Psychiatrist visits increased 31%
• Therapist visits increased 22%
• Net total medical cost savings 15%
(N = 247, 12 month continuous enrollment prior and post SBI)
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Hotspot 5: Treatment of SUDs with Medications
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Detox/Rehab Inpatient -Opiate Inpatient -Other
Depot NTX 69 93 234
Oral NTX 84 145 387
Bupe 79 249 397
Meth 101 198 561
Drug-free 770 677 731
50
150
250
350
450
550
650
750
850
Admissions in 6 months post index dateA
dm
iss
ion
s/1
00
0 p
ati
en
ts
Baser O, Chalk M, Fielin DA, Gastfriend DR. Cost and utilization outcomes of opioid-dependence treatments. Am J Managed Care, 2011:17(6);S235-248.
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Detox/Rehab Inpatient -Opiate Inpatient -Other
Depot NTX 216 213 2003
Oral NTX 193 137 3428
Bupe 219 440 2290
Meth 264 457 7976
Drug-free 2082 1823 4184
500
1500
2500
3500
4500
5500
6500
7500
8500
Inpatient Costs/Opiate-Dependent Patient in 6 months post index date
Cost
/Pati
ent i
n 6
mon
ths
$
Baser O, Chalk M, Fielin DA, Gastfriend DR. Cost and utilization outcomes of opioid-dependence treatments. Am J Managed Care, 2011:17(6);S235-248.
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1000
3000
5000
7000
9000
11000
13000
15000
17000
Total Cost/Opiate Dependent Patient in 6 months post
Cost
per
pati
ent $
Baser O, Chalk M, Fielin DA, Gastfriend DR. Cost and utilization outcomes of opioid-dependence treatments. Am J Managed Care, 2011:17(6);S235-248.
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Comparison of Massachusetts Medicaid Treatment Alternatives: 2003-2007
Buprenorphine Methadone Drug Free No Tx
Medicaid expenditures/ person/month in 6 months post-index date (average $1,220/month) $0.00 $28.70 $50** $148.5***
Relapse Odds Ratio in 6 months post-index date 1.0 0.72*** 1.25*** 2.97***
Deaths Odds Ratio in 6 months post-index date 1.0 0.91 1.75*** 2.25***
Clark RE, Samnaliev M, Baxter JD, Leung GY. The evidence doesn’t justify steps by state Medicaid programs to restrict opioid addiction treatment with buprenorphine. Health Affairs. 2011:30(8);1425-1433.
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Detox/Rehab Alcohol-related Inpatient Non-alcohol-related Inpa-tient
Depot NTX 42 82 109
Oral NTX 76 184 205
Disulfiram 98 268 250
Acamprosate 120 317 343
Drug-free 563 660 407
50
150
250
350
450
550
650
6 Month Post-index Inpatient Utilization per 1,000 Alcohol-Dependent Patients
visi
ts/1
000
patie
nt in
6 m
onth
s
Baser O, Chalk M, Fiellin DA, Gastfriend DR. Alcohol dependence treatments: comprehensive healthcare costs, utilization outcomes, and pharmacotherapy persistence. Am J Manag Care. 2011:17(8);S222-234.
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Detox/Rehab Alcohol-related Inpatient
Non-alcohol-re-lated Inpatient
Total Inpatient
Depot NTX 105 474 730 1309
Oral NTX 192 618 1092 1902
Disulfiram 203 874 1498 2575
Acamprosate 288 1168 3885 5341
Drug-free 1350 2646 2751 6747
500
1500
2500
3500
4500
5500
6500
7500
6 Month Post-index Inpatient Cost/Alcohol-Dependent Pa-tient
Cost
per
pati
ent
in 6
mon
ths
Baser O, Chalk M, Fiellin DA, Gastfriend DR. Alcohol dependence treatments: comprehensive healthcare costs, utilization outcomes, and pharmacotherapy persistence. Am J Manag Care. 2011:17(8);S222-234.
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$1,000
$3,000
$5,000
$7,000
$9,000
$11,000
$13,000
6 Months Post-index Total Cost/Alcohol Dependent Patient
Cost
per
pati
ent
in 6
mon
ths
Baser O, Chalk M, Fiellin DA, Gastfriend DR. Alcohol dependence treatments: comprehensive healthcare costs, utilization outcomes, and pharmacotherapy persistence. Am J Manag Care. 2011:17(8);S222-234.
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Investing in Substance Abuse Treatment Results in a Positive Return on Investment (ROI)
• Substance abuse treatment has an ROI of between $1.28 to $7.26 per dollar invested.
• Consequently, for every treatment dollar cut in the proposed budget, the actual costs to taxpayers will increase between $1.28 and $7.26.
• How will this happen? Individuals needing substance abuse treatment will not disappear but instead interface with much more expensive systems such as emergency rooms and prisons.
Source: Bhati et al., (2008); Ettner et al., (2006)
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Discussion: Practical experiences talking with Payers
Les Sperling Central Kansas FoundationJim Winkler Oregon Health Sciences URoger Kathol Cartesian Solutions
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Citations and a website
• Smyth, Hoffman, Fan, Hser, Years of potential life lost among heroin addicts 33 years after treatment. Prev. Med, 2007; 44(4) 132-140.
• Jones, Moore, Sindelar, O’Connor, Schottenfeld, Fiellin. Cost analysis of clinic and office-based treatment of opioid dependence. Drug Alcohol Depend. 2009;99(1-3): 132-140
• Knudsen HK, Abraham AJ. Perceptions of state policy environment and adoption of medications in treatment of substance use disorders. Psych Services. 2012:63(1);19-25.
• Baser O, Chalk M, Fielin DA, Gastfriend DR. Cost and utilization outcomes of opioid-dependence treatments. Am J Managed Care, 2011:17(6);S235-248.
• Clark RE, Samnaliev M, Baxter JD, Leung GY. The evidence doesn’t justify steps by state Medicaid programs to restrict opioid addiction treatment with buprenorphine. Health Affairs. 2011:30(8);1425-1433.
• Vital Signs: Overdoses of Prescription Opioid Pain Relievers --- United States, 1999—2008 MMWR, November 4, 2011 / 60(43);1487-1492
• Baser O, Chalk M, Fiellin DA, Gastfriend DR. Alcohol dependence treatments: comprehensive healthcare costs, utilization outcomes, and pharmacotherapy persistence. Am J Manag Care. 2011:17(8);S222-234.
• Bhati et al (2008) To Treat or Not To Treat: Evidence on the Prospects of Expanding Treatment to Drug-Involved Offenders. Washington, DC: Urban Institute. Health Serve Res. 2006 February; 41(1): 192–213.
• Susan L Ettner, David Huang, Elizabeth Evans, Danielle Rose Ash, Mary Hardy, Mickel Jourabchi, and Yih-Ing Hser The economic costs of substance abuse treatment: Updated estimates and cost bands for program assessment and reimbursement, Journal of Substance Abuse Treatment(2008)
• Information about the Hospital SBIRT Initiative
is posted at http://hospitalsbirt.webs.com/.
Join in monthly conference calls on integrating
SBIRT into routine hospital practice:
http://hospitalsbirt.webs.com/progress.htm
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Thank You!
Eric Goplerud Senior Vice PresidentSubstance Abuse, Mental Health and Criminal Justice Studies
NORC at the University of Chicago
4350 East West Highway 8th Floor, Bethesda, MD 20814
[email protected] | office 301-634-9525 | mobile 301-852-8427
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Ask Questions
Ask questions through the “Questions” Pane
Will be answered live at the end
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In Our Last Few Moments…
PowerPoint Slides
Recording
Survey
Follow-up Email
hospitalsbirt.webs.com/pitchingsbirt.htm
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2014 SBIRT Webinar Series
Archived - ACA and Addiction Treatment: Implications, Policy and Practice Issues
Archived - Overview of SBIRT: A Nursing Response to the Full Spectrum of Substance Use
Archived - SBIRT in the Criminal Justice System Archived - Reducing Opioid Risk with SBIRT Today – How to Pitch SBIRT to Payors 5/14/14 - Treatment of Tobacco Dependence in
the Healthcare Setting: Current Best Practices 6/11/14 - Applying SBIRT to Depression,
Prescription Medication Abuse, Tobacco Use, Trauma & Other Concerns
7/9/14 - Training Integrated Behavioral Health in Social Work
8/6/14 - Why Integrative Care?
hospitalsbirt.webs.com/webinars.htm
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Thank You for Attending!
www.naadac.org
www.norc.org hospitalsbirt.webs.com www.ireta.org/ATTC