Clinical Preventive Services in Substance Abuse and Mental Health Update: From Science to Services

XVI. Appendix D: Procedures for Implementation and Evaluation of Preventive Services

Preventive services, unlike therapeutic services, are provided to persons who currently do not show evidence of disease. As a result, those persons who might benefit from such services often cannot be identified through claims data, but rather by identifying risk and protective factors. This creates a situation where health care delivery systems need policies and procedures for preventive services (both behavioral and medical) and quality assurance services (both behavioral and medical) that rely on data systems other than health care claims. This chapter provides general information regarding the implementation of preventive behavioral services. Additional information appears in Appendix B: Policy and Management Issues Guidelines; and in Appendix C: Billing for Preventive Behavioral Services.

Basic Principles

Those most in need of preventive behavioral services often are those least likely to volunteer for such services. Addressing this issue requires assertiveness on the part of both the health plan and provider.
Not all persons provided preventive services will have experienced the disease or complication the service was intended to prevent.
The literature indicates that interview and counseling-based preventive services are far less than 100 percent effective in securing the desired risk modification or behavior change.
Most of the preventive behavioral services intended to prevent onset of the behavioral disorder are provided in school and community settings. Preventive behavioral services offered in clinical settings tend to detect those at high risk or those who are in the early stages of illness, and they tend to reduce health care costs of other illnesses.
As with other preventive services and quality assurance programming, more than claims data are needed to identify those in need of services. Most often, patient interview is required for case finding, and record review and special physician and patient surveys are needed for program planning and evaluation.

Steps To Be Taken at the Level of the Health Care Delivery System

Policies, procedures, and quality assurance guidelines can be in place for all clinical preventive behavioral services that are to be implemented within the health care delivery system.
When dealing with multiple screening procedures for a single age/life-cycle group, it may be helpful to have a single policy statement/document dealing with the entire set of screening procedures for that group.
These policies and procedures can be summarized in posters and other reminders to cue the clinical staff.
Physicians, nurses, and other staff as appropriate can be trained in screening, follow-up, and other policies and procedures.
Printed informational materials specific to preventive services can be distributed to all primary care providers.
The health care system may wish to have the capability to provide—directly or indirectly—all needed follow-up services.
Quality assurance programming can be in place to track the provision of each screening, preventive, and follow-up intervention, and the impacts and outcomes of each service on behaviors, clinical outcomes, and use of other health care resources.
Each preventive service for each age/lifecycle group may be tracked separately. Although the data to be tracked are similar for tobacco, alcohol, and illicit drugs, separate data can be gathered for each substance. Data pooled across multiple substances are of little practical value. The same is true when dealing with screening and other preventive services, as discussed in this report.

The Role of the Primary Care Practitioner

The physician or other health care provider can briefly screen each person for all the topics for which screening is indicated on the basis of his or her lifecycle group (age and/or pregnancy).
The initial set of screening questions for each life-cycle group may be organized so that the screening can be completed in less than 3 minutes.
Follow-up on positive findings may be considered a diagnostic activity and will take as long as required to rule out the problem, treat the disorder, or identify the need for referral to a mental health professional. Initial follow-up can be done by the primary care practitioner. Patients may be referred to mental health practitioners with initial confirmation of the need to do so by the primary care practitioner.
Primary care practitioners can follow up at subsequent outpatient visits to monitor behavioral change and assure that mental health professionals have provided appropriate services.
Provisions might be made for the clinician to record the screening, the findings, and the various levels and types of follow-up.
- In health care systems with electronic medical records, specific fields can be provided.
- In health care systems without electronic medical records—
  - Dummy billing codes can be developed (to record the provision of the service on the billing form, even though it is not separately reimbursed).
  - Specific space can be provided on the medical record to facilitate medical record review.

Assessment of Need for Programming

Assessment of need may not be required to initiate the preventive behavioral services suggested for universal implementation. The needed data can be secured in the process of identifying the number and percentage of patients who screen positive and require some form of follow-up service.
Special assessment of needs can be done by contacting the local or State health department and requesting data available on prevalence of substance use disorder within the community(ies) being served by the health care delivery system. All States and some localities will have such data, and some may have data specific to substance use disorder in pregnancy through the Behavioral Risk Factor Surveillance Survey (BRFSS) and locally conducted surveys.
Claims data can be reviewed for data relating to the prevalence of substance use disorders, depression, and behavioral disorders.
Claims and medical records data can be reviewed for patients with diabetes, asthma, and other chronic diseases to determine whether it is appropriate to invest in preventive behavioral programming to improve patient compliance with prescribed regimens of care.

Assessment of Program Efficacy

Number and percentage of patients screened.
Percentage of those screened with positive findings.
Percentage of patients counseled.
Percentage offered post–initial-screening special education, extended counseling, or other follow-up services.
Documentation of use on each subsequent visit to document changes in behavior, outcomes, quit rates, and relapse rates (medical record reviews).
Comparison of overall health care utilization, including those who screened positive and participated in follow-up, those who screened positive and did not follow up, and those who screened negative.
Comparison of utilization data for before-and-after implementation of the new preventive behavioral programming. Medical records can be reviewed and small surveys of both patients and providers can be conducted to assess the preprogram screening for substance use disorder, depression, and behavioral disorders.
Provider and patient surveys to address behaviors, perceptions, and satisfaction with services.

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