This survey measures the benefits of SBIRT services to a health plan by estimating the cost of health services avoided by reducing patients' substance abuse.   The survey is completed in two section.  First section gathers demographics and assumptions made in estimating service utilization.  The second section collects probability of use of a health service and its per occasion per person cost.

1. What is your data access code?

This is a 6 character long text or number that you used to enter data in step 1, Definition of SBIRT.  You must enter exactly same access code, otherwise your responses will not be linked together. 

2. Enter your organization code:

3.  How many patients participated in surveys used to report the patient demographics?

4.  What was the gender of patients?

5.  What was the age of the patients?

	Baseline
Average age	years

6. What was the number of years of education for the patients?

	Baseline
Average years of education	years

7. What was the race of the patients?

Race	Baseline
Percent white	%
Percent Black or African American	%
Percent Asian	%
Percent American Indian	%
Percent Native Hawaiian or other Pacific Islanders	%
Percent Alaska native	%
Percent other	%
Total	100%

8.  Were the patients Hispanic or Latino?

	Baseline
Percent Hispanic or Latino	%

9.  In the past 30 days, where had the patients lived most of the time?

Residence	Baseline
Percent in shelter	%
Percent in street	%
Percent owned or rented	%
Percent someone else's apartment, room or house	%
Percent halfway house	%
Percent residential treatment	%
Percent other	%
Total	100%

10.  What percent of patients served in the SBIRT program are Medicaid eligible?  If this estimate is not readily available, survey 15-30 most recent patients.

%

11.  Source of data for the probability of events (use one of the following drafts):

1. Clients reported their utilization of health care services.  No medical or insurance records were examined to collaborated the clients' self report.  The probability of hospital and clinic visits were based on self-reported experiences of the clients participating in the study using the CSAT GPRA Client Outcome Measures for Discretionary Programs.  Clients were asked to report the number of times they were hospitalized or visited a clinic in the 30 day before their baseline and follow-up interview interview.  
2. Clients utilization of health services was established by examining the administrative records for clients one year prior and one year after receiving SBIRT services.  These records included hospitalization, clinic visits and emergency room visits but did not include mental hospitalization and substance abuse residential treatment services.  Clients may have received services outside the provider organization and therefore their utilization may have not been recorded.   Table 1 summarizes the data. 
    

12.  What were assumptions made in estimating the probability and cost per service (sample responses are provided):

The study did not include cost of mental health hospitalizations and residential treatment as these services are not reimbursed by the same insurance plan and we wished to project the impact of SBIRT on a plan that pays only for physical hospitalization, outpatient visits and emergency room visits.

13.  What were your sources for the data for cost per unit of services (Sample responses follow, re-word if necessary and add any assumptions made in estimating the cost per service):

1. The per day cost of hospitalization and the per visit cost of clinic visits were estimated based on the average reimbursement rate of Medicaid.  When data were not available these estimates were based on national rates.  If Medicaid did not reimburse the service (e.g. inpatient residential treatment), then a cost of $0 was assumed.
2. Cost of reimbursement was estimated by hospital and outpatient charges for patients receiving SBIRT services.    Costs were estimated per day (per visit) and per person.

After completing this section you would be asked to report utilization patterns.