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Maximizing care for the most vulnerable: Implementing substance use Screening, Brief Intervention, and Referral to Treatment (SBIRT) in New York City STD clinics Anthony Freemana, Shanequa Highsmitha, Brett Harrisb, Raffaella Espinozac, Meighan Rogersc, Carrie Davisa, John Yub Gay, Bisexual & Transgender Community Center, New York, NY bNew York State Office of Alcoholism and Substance Abuse Services, Albany, NY, cBureau of STD Control, New York City Department of Health and Mental Hygiene, New York, NY

ISSUE • Alcohol and other drug (AOD) use has been associated with increased sexual risk taking and higher rates of sexually transmitted disease (STD), including HIV. • Previous research has shown that 20% of NYC STD clinic patients screen positive for AOD disorders, but only 1% receive treatment services. • Identifying AOD use among STD clinic patients and providing timely intervention and linkage to treatment could help decrease STD acquisition in this population.

PROJECT LINK

RESULTS

Six-month Follow-up Assessment • To assess change in AOD use, risky behaviors and social outcomes, Project LINK staff contact patients referred to treatment 6-months later for an interview. • Incentives are offered to patients who complete an interview at time of treatment referral (intake) and at the 6 month interview.

Figure 1. SBIRT results from the three NYC STD clinics^, (February, 2008- June, 2011), N= 124,557

Figure 2. Project LINK 6-Month Follow-Up Rates 90% 75.3%

70% 60% 50% 40%

37.8%

39.4%

2008

2009

30% 20% 10%

PROJECT LINK

0%

Funding •

84.8%

80%

Follow-up Rate

aLesbian,

2010

Federal Fiscal Year (Oct. 1 - Sept. 30)

Substance Abuse and Mental Health Services Administration (SAMHSA) Targeted Capacity Expansion HIV grant

*Horizontal line demarks 80% follow-up rate goal

Table 3. Health, behavioral, and social outcomes at 6-month follow-up (February, 2008- June, 2011) N

Collaborators • NYS Office of Alcoholism and Substance Abuse Services (OASAS) • NYC Department of Health and Mental Hygiene (DOHMH) • The Lesbian, Gay, Bisexual, and Transgender Community Center (The Center)

Goal

• Screening, Brief Intervention, and Referral to Treatment (SBIRT) services are offered at 3 NYC STD clinics using a self-administered assessment (CAGE-AID). • Identifies AOD users in public health settings who may not recognize that they have a problem. • Brief interventions are offered to AOD users to prevent further abuse as well as associated risky behavior. • During intervention sessions, referrals to formal AOD treatment are provided when necessary.

Services • DOHMH operates 9 STD clinics throughout NYC providing free and confidential STD testing and treatment. • Since February 2008, Project LINK counselors provide SBIRT services in 3 NYC STD clinics (on-site) located in neighborhoods with high rates of STI (see HIV map).

Risky Behaviors Injection drug use Unprotected sexual contact Unprotected sexual contact with one who has HIV/AIDS Unprotected sexual contact with someone while high Personal Information Abstinence: did not use alcohol or illegal drugs Employment/Education: Currently employed/attending school

^ HIV data were obtained by matching patients to the DOHMH STD EMR beginning May 2008. *Referrals include; AOD treatment (inpatient/outpatient/self-help groups), mental health care, and non alcohol/drug related referral Map: NYC Department of Health and Mental Hygiene HIV Epidemiology and Field Services Semiannual Report.

Increasing Follow-up at 6-months

RESULTS

• Between February 2008- June 2011, 124,557 patient visits • To prevent transmission of sexually transmitted infections included screening for AOD use. (STI) by reducing AOD use and associated risky behavior • 98,585 were matched to DOHMH STD Electronic Medical through early intervention. Records (EMR) • 98,585 patient visits represented 84,319 patients

Intervention

2011

Table 1. Demographics of patients completing a CAGE-AID (May, 2008- June, 2011), N= 98,585* Patient Visits One Visit Multiple Visits Age (median) Sexual Behavior by Gender Heterosexual Homosexual Bisexual Unknown HIV Information HIV Status (newly or previously diagnosed) Positives Negatives Race Hispanic NH Black/African American NH White Asian/Pacific Islander Multi-racial Other

Male 59,716 35,872 23,844 28

% 60.6% 60.1% 39.9%

Female 38,869 22,730 16,139 24

% 39.4% 58.5% 41.5%

42,909 12,076 1,727 1,727

71.9% 20.2% 2.9% 2.9%

34,448 791 2,006 1,624

88.6% 2.0% 5.2% 4.2%

43,420 471 42,949

72.7% 1.1% 98.9%

28,002 51 27,951

72.0% 0.2% 99.8%

14,469 25,786 15,379 1,754 815 1,513

24.2% 43.2% 25.8% 2.9% 1.4% 2.5%

9,935 20,386 5,695 1,349 608 896

25.6% 52.4% 14.7% 3.5% 1.6% 2.3%

• Due to an evaluation conducted in April 2010, the techniques used to reach patients 6-months later for follow-up interviews were revised to increase completion rate. Table 2. List of revised techniques to locate patients for 6-month follow-up interview Action Step Taken Revise locator form completed at intake

Shift focus of locator form from getting more contact information to getting relevant contact information to increase provision of accurate information.

Verify patient information Check all information patient given by patient at time of intake (e.g. verify address in Google Maps, call cell phone number provided). Share agency database

* ~90% of patients who completed CAGE-AID forms were matched to the DOHMH Bureau of STD EMR beginning May 2008.

Description

Access DOHMH STD surveillance database to validate contact information.

Rate patient locator information

Check patient locator information at 1 week, 1 month, and 3 months following visit. Patients with poor contact information (e.g.. disconnected cell phone) are prioritized for more intense follow-up efforts.

Incentive revision

Split gift card incentive amount and distribute throughout the 6 months following referral to increase staff contact with patients so that they are easier to locate for the follow-up interview.

Social networking

Use Facebook, Twitter and other social networking sites to contact patients and schedule follow-up interviews.

Field interviews

Conduct follow-up interviews in the field if requested by patient.

Broaden and strengthen provider network

Hold annual meetings to increase communication between project staff and providers of AOD usage treatment. Efforts help increase linkage from referral to formal treatment programs so that they are more easily located 6 months later to complete follow-up interview.

Technical assistance

Monthly calls with an expert to trouble shoot unreachable cases and revise follow-up protocol as needed.

No alcohol or illegal drug related health, behavioral, or social consequences Mental Health Outcomes Experienced depression Experienced anxiety Experienced hallucination Trouble understanding, concentrating, or remembering Trouble controlling violent behavior Attempted suicide Prescribed medication for psychological or emotional problems

Intake

6-Month %Rate of Follow-Up Change

315 2.5% 219 80.4% 122 10.7% 122 49.2%

1.0% 68.9% 9.0% 28.7%

-62.5% -14.2% -15.4% -41.7%

315

1.3%

18.7%

-

316 55.4%

59.5%

7.4%

315 38.7%

74.0%

91.0%

311 313 312 312 315 315 314

48.6% 56.9% 5.1% 44.9% 14.6% 2.2% 11.8%

-34.3% -26.4% -46.7% -25.5% -40.3% -22.2% 32.1%

74.0% 77.3% 9.6% 60.3% 24.4% 2.9% 8.9%

Next Steps • Patient visits documented by Project LINK will be cross-matched with DOHMH STD/HIV surveillance registry to determine the effects of SBIRT services in reducing STD/HIV infections.

LESSONS LEARNED • Project LINK staff utilized numerous strategies that proved successful in increasing follow-up rates. • Data collected from follow-up interviews helped demonstrate improvement in AOD use and behavioral outcomes. • This highlights the importance of evaluation in order to improve outcome documentation for funding justification and expansion of services to others with similar needs.

ACKNOWLEDGEMENTS Susan Blank, Joanna Adely, Brian Belovitch, Robert Gonzalez, Luke Sleiter, Kimberly Johnson, and NYC STD clinic staff

For more information, please visit http://www.oasas.state.ny.us/hps/research/Projects.cfm