SBIRT Protocol & FLO Negotiated Interview
Step-by-step NIAAA/NIDA pre-screening, Feedback-Listen-Options framing, and pharmacotherapy escalation pathways.
Teaching Hospital Outpatient Reference
SBIRT Bedside Scoring & Behavioral Health Residency Pocket Manual
Score AUDIT-C, DAST-10, and Motivational Readiness in real time at the exam room door, map actions directly to ACGME residency milestones, and execute warm handoffs without workflow delay.
Bedside SBIRT Scoring Workbench
Zero-Telemetry · Client-Side
Patient Cutoff Group (Sex / Age)
1. Frequency of alcohol-containing drinks
2. Typical standard drinks on a drinking day
3. Frequency of 6+ drinks on one occasion
AUDIT-C 4/12
CPT 99408
Select DAST-10 Positive Item Count (Past 12 Months Non-Medical Drug Use)
DAST-10 2/10
Brief Advice
Patient Readiness Ruler: "How ready are you to make a change right now?" (1-10)
Readiness 6/10
MI Focus
Tabular Screening Threshold Triage Matrix
Primary care teams triage alcohol and non-medical substance exposure into four actionable severity tiers. Always pair elevated screens with Readiness Ruler scaling before initiating pharmacotherapy or warm handoff.
| Instrument | Low Risk | Hazardous / Moderate | High Risk / Likely SUD | Required Resident Action & Coding |
|---|---|---|---|---|
| AUDIT-C (3 items, 0-12) | 0-2 F / 0-3 M | 3-7 F / 4-7 M | 8-12 | FLO Brief Negotiated Interview (5-15 min); CPT 99408 / G0396 at 15+ min; evaluate AUD meds at >=8. |
| Full AUDIT-10 (0-40) | 0-7 | 8-15 | 16-40 (Zone III-IV) | Score >=20 warrants diagnostic AUD workup, withdrawal screening (CIWA-Ar), and warm handoff (CPT 99409). |
| DAST-10 (0-10) | 0 | 1-5 | 6-10 | Check PDMP, offer intranasal naloxone for opioid/polysubstance risk, initiate same-day behavioral handoff. |
| CRAFFT 2.1+N (Age 12-21) | 0-1 | 2+ (No Car Risk) | 2+ with Car / Blackout | Confidential adolescent brief intervention, safety planning for impaired driving, caregiver engagement when safe. |
| PHQ-4 (Co-Occurring) | 0-2 | 3-8 | 9-12 | Screen for suicide risk if depressed; co-occurring distress raises SBIRT drop-off without immediate warm handoff. |
Warm-Handoff Clinical Pathway
Static referral slips lose up to two-thirds of patients before intake. Introducing an integrated behavioral health clinician inside the exam room during the medical visit converts positive screens into same-day engagement.
Teaching Clinic Workflow & Precepting
Residency clinics achieve sustainable SBIRT delivery when medical assistants complete the 60-second universal pre-screen at rooming, residents apply the 5-minute FLO interview during the visit, and behavioral health educators stand by for warm handoffs.
Historically, statewide Wisconsin primary care clinics documented over 110,000 screens and 25,000 brief interventions, demonstrating measurable reductions in binge drinking, trauma crashes, and healthcare utilization.
Read the Complete SBIRT Protocol Handbook · View Warm-Handoff Checklist
Pocket Triage Summary
Adult primary care SBIRT pairs annual universal pre-screening with AUDIT-C and DAST-10 scoring. Scores of 3 or higher for women and older adults, or 4 or higher for adult men, trigger a 5-to-15 minute FLO Brief Negotiated Interview, while scores of 8 or higher or DAST-10 scores of 3 or higher initiate a same-day warm handoff.
Pocket Reference Note: Standard Drink Equivalents & Clinical Disclaimer
One U.S. standard drink contains 14 grams of pure ethanol: 12 fl oz regular beer (5% ABV), 5 fl oz table wine (12% ABV), or 1.5 fl oz 80-proof distilled spirits (40% ABV). All client-side calculations execute locally with zero data transmission. Independent educational handbook; see historical provenance disclosure.
Core Clinical Handbook Modules
SBIRT Coding, Billing & ROI Manual
Time-based rules for CPT 99408/99409, Medicare G0396/G0397, Medicaid H0049/H0050, and Modifier 25 pairing.
Warm-Handoff Integration Playbook
4-stage exam room transfer protocol, script templates, and clinic readiness audit for same-day behavioral support.
Trauma-Informed & Perinatal SBIRT
SAMHSA six trauma-informed principles, 4P's Plus prenatal screening, and person-first charting swaps.
Frequently Asked Clinical Questions
What AUDIT-C threshold triggers a positive alcohol screen in adult primary care?
An AUDIT-C score of 3 or higher for women and adults aged 65 or older, or 4 or higher for adult men under 65, indicates hazardous drinking or active alcohol use disorder and warrants a brief intervention.
When should a resident physician initiate a warm handoff instead of brief advice alone?
Initiate a same-day warm handoff to integrated behavioral health whenever AUDIT-C is 8 or higher, DAST-10 is 3 or higher, co-occurring depression or trauma symptoms are present, or the patient expresses readiness for structured change support.