Evaluation of a Telephonic Alcohol Screening & Brief

Evaluation of a Telephonic Alcohol Screening & Brief

Evaluation of a Telephonic Alcohol Screening & Brief Intervention (SBI) Pilot Program
for At-Risk Drinking in an Employee Assistance Program (EAP)
Tracy L. McPherson, PhD , Dennis Derr, EdD , Judy Mickenberg, LICSW , Eric Goplerud, PhD ,
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Sherry Courtemanche, LCSW , Laura Chaney, LMFT , and Jessica Thompson, LCSW
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Center for Integrated Behavioral Health Policy, Department of Health Policy, The George Washington University Medical Center (GWUMC); 2Aetna Behavioral Health.
SBIRT Training:
Self-directed pre-training (e.g. alcohol education, fundamentals of motivational interviewing, NIAAA
Clinicians Guide)
2-day intensive in-person training (alcohol SBIRT and motivational interviewing)
2-3 one-hour individual telephonic coaching sessions
Ongoing telephonic coaching for SBIRT program supervisors
Follow-up training activities (individual, small group, supervisor observation)
1-day intensive in-person booster training (~4 months after 2-day training)
Measures:
AUDIT-C, AUDIT (Babor et al., 2001)
SBIRT Intervention:
Alcohol screening is integrated into a comprehensive assessment conducted by EAP clinical
consultants.
3-item AUDIT-C prescreen is administered. Positive result prompts administration of
remaining 7 items of the AUDIT.
AUDIT score classifies member at low, moderate or high risk.
All risk levels receive BI at appropriate level.
Low risk = normative feedback and alcohol education
Moderate & high risk = normative feedback, alcohol education, simple advice + BI with MI,
and referral to face-to-face counseling, disease management, or other treatment as
appropriate.
Follow-up offered at 30, 60 and 90 days.
EAP consultants conduct follow-up screening using the AUDIT-C, offer brief motivational
counseling and referral as appropriate; and re-address original presenting problem at intake.
Alcohol education offered to all members.
EAP consultants offer materials (by email, mail, and online) during intake and follow-up to all
members who use alcohol at any level of risk e.g., Aetna EAP member website, NIAAA
consumer brochures (TIPS for Cutting Down on Drinking, Rethinking Drinking: Alcohol and
Your Health, Family History of Alcoholism: Are you at Risk?, Making a Difference: Talking
to your Teen about Alcohol, Harmful Interactions: Mixing Alcohol with Medicines).

Abstract
Objective: Substantial empirical support exists for SBIRT screening, brief intervention, and referral to
treatment - in medical, but not non-medical settings such as the workplace. Workplace settings remain
underutilized for delivering evidenced-based health services. This research aims to translate medical
research into behavioral healthcare practice in a work-related setting (the EAP). The primary objective
is to assess the feasibility and impact of implementing systematic, routine alcohol SBIRT on key
performance measures (e.g., rates of screening, alcohol problem identification). Methods: A pretestposttest, one-group, pre-experimental design is used to examine the impact of a telephonic-based EAP
alcohol SBIRT pilot program in one call center serving one large client business. The intervention is
adapted based on the World Health Organization (WHO, Babor et al., 2001, 2004) alcohol SBIRT
protocol. It includes systematic routine alcohol screening using the AUDIT-C/AUDIT during clinical
intake, brief counseling using motivational interviewing, alcohol education, referral to treatment as
appropriate (e.g., face-to-face counseling, alcohol disease management), and telephonic clinical followup at 30, 60, and 90 days to address alcohol use and original presenting problem. Results: At the end of
the 5 month pilot, 274 (93%) of 295 members who contacted the EAP for services completed the
AUDIT-C prescreen: 40% (110) prescreened positive, almost all (87%) agreed to complete the
remaining 7 AUDIT items; 52% (50) went on to screen at moderate or high risk for hazardous or harmful
drinking, or alcohol dependence. Brief intervention was offered to all who screened positive. At 3 and
5 months, overall estimates of identification approached those in the general population, 23.5% and
18.23% respectively. Most (78%) members offered SBIRT at intake agreed to clinical follow-up and 72%
set an appointment with a face-to-face counselor to further address issues discussed during the
telephonic consultation. Follow-up data collection is ongoing. Conclusions: Findings suggest that the
integration of routine alcohol SBIRT by EAP clinical consultants at intake is not only feasible in a
telephonic delivery system, but also increases alcohol problem identification and opportunity for brief
motivational counseling for risky drinking. Furthermore, it is clear that when SBIRT is integrated as part
of routine clinical EAP practice, members are willing to answer questions about their alcohol use and
participate in follow-up. Sponsor: Aetna Behavioral Health.

Figure 1. Aetna Telephonic EAP Approach

Introduction
Alcohol is the most widely used drug in the nation with more than half of the U.S. population aged 12
years and older reporting current alcohol use (SAMHSA, 2007). It is estimated that the healthcare costs
associated with alcohol problems amount to almost $36 billion annually and, as almost 80% of problem
drinkers are employed full- or part-time, these costs extend to employers. There is a substantial body of
peer-reviewed literature demonstrating that alcohol SBIRT is an effective technique to employ in
healthcare settings for detecting and treating people who have alcohol problems. Miller & Wilbourne
(2002) analyzed more than 360 controlled trials on treating alcohol use disorders and found that SBIRT
was the single, most effective treatment method of more than 40 methods studied. Return on
investment for alcohol SBIRT typically exceeds 2:1, consistent with the savings associated with
diabetes or depression disease management programs (Fleming et al. 2000, 2002). Thus, implementing
SBIRT can potentially save employers and health plans millions of dollars. As part of their ongoing
commitment to provide evidence-based practice and as a means of optimizing their ability to improve
member health and well-being, Aetna has teamed with GWUMC to integrate alcohol SBIRT into existing
telephonic EAP services. An effort which is aligned with Aetnas current behavioral health initiatives to
integrate alcohol and depression SBIRT as a routine practice with primary care and affiliate providers.

Analysis
Quantitative analysis of process evaluation data (e.g., rates of screening, identification) to assess
program performance.
Quantitative analysis of member follow-up data to assess proximal impact on self-reported alcohol
consumption.

Findings

Figure 2. AUDIT Screening Questions

Rates of Alcohol Screening and Identification:
During the 5 month pilot program, 295 members who contacted the EAP for services were offered
alcohol screening during clinical intake assessment.
Alcohol prescreening: Of the 295, 93% (n=274) completed AUDIT-C (7% not appropriate or refused).
Of the 274, 40% (n=110) prescreened positive for at-risk drinking (Figure 3).
Alcohol screening: Of the 110 prescreen positives, 87% (n=96) agreed to complete the remaining 7
AUDIT items, 52% (n=50) went on to screen at moderate risk (8-19, hazardous or harmful drinking)
or high risk (20-40, alcohol dependence) (Figure 4).
Brief intervention for alcohol use was offered to all members who screened positive.
Pre-post comparisons yielded baseline pre-intervention (service-as-usual) identification rate of <1% compared to post-intervention rate of 18.25%. Rate of agreement to clinical follow-up: 78% of members who contacted EAP. Rates of referral: 72% set an appointment with a face-to-face counselor to further address issues discussed during the telephonic consultation. Member outcomes: Alcohol use consumption at follow-up not yet available. Figure 3. AUDIT-C Identification Overall 60% 40% Research Objectives: To develop and pilot an in-service training program for telephonic EAP clinical consultants designed to increase SBIRT knowledge and skills (e.g., motivational interviewing) and to develop training processes and protocols for ongoing quality and fidelity monitoring. To assess the preliminary impact of implementing systematic, routine alcohol SBIRT on key EAP program performance measures, including rates of screening and BI for at-risk drinking; alcohol problem identification; referral for face-to-face counseling and/or disease management for moderate and high risk cases; clinical follow-up at 30, 60, and 90 days post intake; and rates of refusal for these services. Negative Conclusions Positive Result of Prescreen 40% of cases prescreened positive on AUDIT-C To assess the preliminary impact of alcohol SBIRT on member alcohol consumption (quantity/ frequency) at follow-up. Figure 4. AUDIT Identification Design and Methods Design: Pre-test post-test, one group pre-experimental design Target Population: Large U.S. employer: ~367,500 covered lives (147,000 employee members + dependents). Demographics: Age: 33% young adults ( 30 yrs), 53% adults (age 31-50 yrs), 14% older adults (51 yrs) Gender: 70% female, 30% male Call types: 93% self or management referral Eligibility criteria: non-emergent, self or management referral cases Expected penetration rate ~3% = ~10,500 contact EAP annually Expected identification rate of 7-8% = ~735-850 identified annually EAP clinical consultants: ~20 consultants participated in 2 day training; 4 licensed clinicians (e.g., LCSW, LMFT) located in one EAP call center participated in full SBIRT training protocol. More information about Aetnas Behavioral Health Program: www.aetna.com/ Ongoing Activities 48% 41% 11% Low Integration of evidence-based alcohol SBIRT into existing EAP business practices is feasible, but presents a number of challenges, including the need for adaptation into existing new hire training procedures and materials and re-allocation of staff time for ongoing training activities; adaptations to IT/ data infrastructure and reporting protocols; and adaptations to quality and fidelity monitoring processes. Routine alcohol screening using a standardized self-report measure yields moderate-high risk identification rates approaching prevalence estimates in the general U.S. adult population (Drinkers Pyramid, Higgins-Biddle et al., 1997). Members who receive SBIRT are amenable to clinical follow-up to discuss alcohol use. Moderate High Level of Risk 52% of cases that prescreened positive on AUDIT-C were at moderate or high risk for an alcohol problem Contacting Author: Tracy L. McPherson, PhD [email protected] Creation of a sustainable SBIRT program for phased roll-out to book of business. Refinements of training materials and protocols Adaptation of quality monitoring infrastructure and procedures Peer-support, in-service training activities Dissemination plan Refinement of assessment procedures. Building consistency in practice Strengthening assessment process with use of evidence-based Work Limitations Questionnaire (WLQ presenteeism scale, Lerner et al, 2003) Examination of rates of identification and intervention over time, and how SBIRT impacts worker presenteeism. Participation in a NHTSA/CSAT-funded multi-site case study conducted by George Washington University, Washington, DC. More information on SBI in the workplace: www.integratedbehavioralhealth.org

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