The Four Processes: Focusing

By Mia Croyle, MA

In the third edition of Motivational Interviewing: Helping People Change (Miller & Rollnick, 2013), we are introduced to the four processes. In our newsletter, we discussed the first of these, engaging. The second of the four processes is focusing. Our objective in this process is the collaborative, ongoing process of seeking and maintaining direction. 

In Motivational Interviewing. there are three main sources of focus, and in almost every instance. we rely on some combination of them all:

01. The other person (the “patient”): people generally have concerns, preferences, ideas, and values that influence our focusing process. For example, in BSI, if a patient screens positive for potential risk in the areas of tobacco use and depression, the patient will have some ideas about where he or she would like to start, and we certainly give priority to those ideas.

02. The setting: in BSI, we are in a healthcare context and generally, our health educators have a pre-established list of behaviors that they are trained and sanctioned to address. If patients have concerns that fall outside these areas, the health educator can refer patients to other resources.

03. The helping professional’s clinical expertise: in BSI, this is informed by the results of the screen and brief assessment. Other members of the healthcare team, such as the physician, may also have clinical expertise that informs our focusing process.

Like each of the four processes, focusing is an ongoing process. Once we have established a focus, we continue to attend to focusing throughout our interaction. We may need to revisit our focus at times to make sure we are still on the same page with the other person.

WIPHL/WCHQ Symposium Planned on Spreading BSI


By Richard L. Brown, MD, MPH

I’m pleased to announce that WIPHL and the Wisconsin Collaborative for Healthcare Quality (WCHQ) will host a day-long symposium on behavioral screening and intervention (BSI) in Madison this upcoming September 17.

The goals of the meeting are to discuss the documented improvements in health and cost savings of BSI, the current state of BSI delivery in Wisconsin healthcare settings and together, plan how to accelerate the spread of BSI all across our state.

The conference is targeted at a diverse array of audiences, including individuals and representatives of organizations in both the private and public sectors, that:

  • Purchase healthcare
  • Pay or help contract for healthcare
  • Provide healthcare
  • Influence healthcare policy – or would like to do so
  • Advocate for the health and well-being of Wisconsinites

Our keynote speaker will be John Torinus, Chairman of the Board of Serigraph, Inc., and author of The Company That Solved Healthcare. Mr. Torinus will discuss why mainstream healthcare payers and providers are losing market share among large- and medium-sized US corporations, and what can be done to win back those customers.

I will discuss BSI, its health and economic benefits, and a model for delivering BSI that has worked well in dozens of Wisconsin healthcare settings. Kevin Moore, Deputy Secretary of Wisconsin’s Department of Health Services, will provide commentary on the prior sessions.

Mia Croyle, MA, WIPHL’s Director of Operations, will facilitate a panel of healthcare professionals who will discuss their personal experiences in delivering BSI.

Throughout the rest of the day, there will be additional sessions designed to foster a rich exchange of information, experience and new ideas on various aspects of BSI, including:

  • Delivering BSI in primary care settings
  • BSI and the business case for employers
  • BSI and other models of primary care/mental health integration
  • BSI-related national and state health policy
  • BSI and the prevention of heart disease
  • BSI in schools and colleges
  • BSI and federally qualified health centers

At the end of the day, there will be a plenary discussion of ideas that came out of each session, how to move BSI forward in Wisconsin and the various roles that participants can play. There will be ample opportunities to participate in discussions in the large groups and small groups as well at network throughout the day.

This symposium is sure to be an exciting and enriching experience, so be sure to save Tuesday, September 17 on your calendar. It will take place at the Monona Terrace. Lunch and refreshments will be provided. All symposium expenses will be funded by WIPHL and WCHQ’s current grant from the US Agency for Healthcare Research and Quality (AHRQ).

There is no fee to attend the symposium but registration is required, and there will be a registration cap. Be sure to register at, and tell your friends and colleagues.

We hope to see you there!

Q+A With Gundersen Health System’s Health Education Team

Today, we’re interviewing Rachael Garbers and Lindsay Seccombe to hear more about their real-world experiences implementing SBIRT (Screening, Brief Intervention and Referral to Treatment).


Rachael currently is employed as a Wellness Specialist at Gundersen Health System Trauma services department. Lindsay is completing her preceptorship with Gundersen this semester. As preceptee (teacher) and preceptor (student intern), they work together to screen incoming trauma patients for behavioral risks, utilizing behavioral screening and intervention (SBIRT) practices.

To start, tell us about what you do and how you came to work as Wellness Specialists in Gundersen’s Trauma services department.

Rachael: For almost four years, I have worked as a Wellness Specialist at Gundersen Health System. I received motivational interviewing training under WIPHL’s previous grant and worked in family medicine before starting in trauma services. Here, I service all inpatients admitted with positive screens for at-risk alcohol consumption, tobacco, and/or illicit drug use.

Lindsay: I am a Wellness Specialist preceptee and work with Rachael to ensure maximum screening and intervention for Gundersen’s trauma patients. On a personal level, I am currently finishing my bachelor’s degree at University of Wisconsin-La Crosse. I have been accepted into a Master’s program for Public Health, and plan to continue on for medical school after that. Gundersen was an opportune facility to both gain experience and valuable one-on-one time with patients, which will make me a better doctor.

What is a typical day like in trauma services?

Rachael: Every morning, I begin my day running a screening report, which gives me a list of patients still needing to be screened and seen for the day. I also follow-up with patients via phone. Patients usually receive one-week, one-month, six-month, and one-year follow-up calls to provide them with additional assistance in making healthy lifestyle choices.

As a Wellness Specialist, you cannot directly prescribe medicine. What are some things you provide for patients?

Rachael: I am able to provide patients with compassionate care, opportunities for follow-up, and resources for help. This includes providing patients with recommendations and ways in which to promote their own health. Being that extra resource and support for patients is the one of the things I enjoy most about my job. Encouraging patients to take an active role in pursuing a healthy lifestyle is very rewarding.

How does Motivational interviewing (MI) fit in with what you do? Can you tell me a little more about what MI is?

Rachael: Motivational interviewing is the foundation for meeting with my patients. Being in a hospital bed can pose as a vulnerable time for people. It is often unexpected and can be life changing, that being said I do my best to put myself in the patient’s shoes.

Lindsay: Motivational interviewing provides us the opportunity to talk with patients about sensitive topics. Rachael and I use MI because it allows us to listen to patients. Many times in the health care field patients are told what to do and how to do it, without personalizing it. This often leaves patients frustrated and unsure about making changes. We collaborate with patients to meet them where they’re at. Giving patients the opportunity to actively participate in their own care can build confidence and promote change if the patient decides they are ready.

Is it difficult to work with patients who may need help but don’t necessarily want help?

Lindsay: I think that MI is especially important in these circumstances because again, our job is not to change people or force them to change. Learning MI has taught me to appreciate where people are at in their lives and that change doesn’t happen for everyone at the same time. With this mind set we are able to provide appropriate resources while respecting their autonomy.

Recently, the Wall Street Journal published an article about the benefit of using MI in clinical settings. What do you think of MI and its use in behavioral screening and intervention?

Rachael: MI is an efficient way to implement behavioral screenings and interventions in both clinical and inpatient settings, because it provides the opportunity to make a plan of action with the patient. My job helps bridge the gap between the provider and the patient. Being that the patients immediate needs are met by the providers, time can often be a barrier. As part of the healthcare team, I am able to help patients make further plans for change.

Lindsay: Taking the time to sit down with patients and engage in a conversation using MI gives us the opportunity to understand where the patient is at in regards to a healthy lifestyle. Rachael and I use MI to promote wellness without forcing information on the patients. By understanding what the patient is going through and where they are at in regards to making changes, or not, in their life helps us provide the most relevant information to benefit the patient.

Behavioral risks, like binge drinking, are extremely common in Wisconsin. How do you think BSI has the potential to change these common behaviors?

Lindsay: Being that Wisconsin has a high prevalence of at-risk alcohol consumption, we often see a significant amount of alcohol related traumas. Here at Gundersen we are taking those opportunities to educate, should the patient be open to it, about healthier lifestyle choices in an effort to prevent something worse from happening.

Rachael: Providing SBIRT services does help change the culture of risky drinking – it really just ties in beautifully to what we do and hope to continue doing.

Spring Brings New Policy Developments in SBIRT


By Richard L. Brown, MD, MPH

One of the exciting aspects of serving as the WIPHL’s director has been witnessing the rapid growth and depth of support for healthcare settings to deliver behavioral screening and intervention (BSI).  In just the past few months, there has been several important policy developments regarding the recommendation and delivery of alcohol and drug screening, brief intervention and referral-to-treatment (SBIRT), both on a national and state level.

Every year, the White House and Director of the Office of National Drug Policy (also known as the “drug czar”) release an update of the nation’s strategy to address its drug problems. Chapter two of the newly-released National Drug Control Policy of 2013 is titled “Seek Early Intervention Opportunities in Healthcare” and details steps the federal government is taking to promote delivery of  SBIRT. These efforts include promoting better education for healthcare professionals, enhancing fee-for-service reimbursement for services, and updating educational resources. The document cites WIPHL and its partnerships with universities and employers as a “model public-private collaboration.”

Toward enhancing the delivery of SBIRT services, the Center for Medicare and Medicaid Services recently released a plan to update its rules on reimbursing hospitals for services delivered to Medicare patients. An exciting aspect of the plan is to require hospitals to report to Medicare the proportion of Medicare patients who have received SBIRT services and to institute strong financial incentives based on quality metric reporting. This aspect of the proposal would be implemented in 2016, which gives hospitals liberal lead time to plan how they will deliver these services.

Finally, at the state level, Wisconsin’s State Council on Alcohol and Other Drug Abuse (SCAODA) is charged with making recommendations to the Governor and legislature on preventing and addressing alcohol and drug problems in our state. SCAODA will soon consider adopting its subcommittee recommendations intended to help make BSI a routinely delivered service in primary healthcare settings, emergency departments and hospital inpatient units throughout the state. Recommendations include eliciting the support of the Governor’s Office in convening representatives of private and public healthcare  purchasers, and requiring payers to publicize fee-for-service reimbursement policies for behavioral screening and intervention.

Also at the state level, the Wisconsin Department of Health Services submitted a grant application to the US Substance Abuse and Mental Health Services Administration for approximately $8 million to continue disseminating alcohol, drug, tobacco and depression screening and intervention in primary care clinics throughout the state. The Wisconsin Primary Health Care Association (WPHCA) would be a lead organization in this project. Although WPHCA serves as an umbrella organization for Wisconsin’s federally-qualified health centers, all primary care clinics will be invited to participate. Notification of a funding decision will likely come in the early fall, and service delivery will start at some clinics by early 2014.

These exciting developments are further evidence of momentum for behavioral screening and intervention. If your clinic and hospital aren’t yet delivering BSI, they will in the future. Please contact WIPHL if you have any questions on how to get BSI started in your clinic or hospital, or on what you can do to accelerate implementation of evidence-based, cost-saving BSI in your community.


More Than 12,000 Patients Have Been Screened Under WIPHL’s Current Grant

More than 12,000 brief screens for alcohol, drugs, tobacco and depression have been completed by WIPHL’s first three Partners in Integrated Care project clinics since November 2011. Bellin Health – Howard, Bellin Health – Ashwaubenon and Northern Health Center clinics screened patients for unhealthy drinking and drug use, tobacco use and depression, providing intervention and referral to treatment, if needed.

Administered by a trained health educator, BSI is proven to reduce alcohol and drug use – the fourth leading cause of death in Wisconsin – and healthcare costs. Behavioral screening and intervention (BSI) is top-tier recommended service and endorsed by the CDC, Joint Commission, National Business Group on Health, NIH, US Preventive Services Task Force and Wisconsin Medical Society.

A brief intervention results in positive patient changes

A health educator who delivers SBIRT services in a Wisconsin healthcare clinic tells the story of how a brief intervention a patient getting much-needed mental health and financial help. (Some details have been changed to protect patient confidentiality.)

The health educator met with a male patient who scored high on the risk assessment and indicated he was a daily drinker, typically consuming 5 to 8 drinks per day and 10 or more during the weekends. He had experienced several significant consequences from his alcohol use – including a DUI and a fall that led to a significant injury.

Despite the negative impacts he was experiencing from his drinking, he initially had no intention of making any changes when he first met with the health educator. The health educator engaged with him in an exploration of his motivation for drinking, and he agreed to a follow-up phone call. When the health educator reached him by phone several weeks late,r he surprised her by sharing that he had not had a drop to drink in 18 days!

May is Mental Health Awareness Month

May is Mental Health Month 2013 horizontal banner
May is Mental Health Awareness Month and an important time to continue the conversation about mental health treatment. Anxiety, depression, bipolar disorder, schizophrenia and other disorders too often go undiagnosed or misdiagnosed, keeping patients from living a full, productive life. This year alone, one in five Wisconsinites will be affected by a mental illness.

At WIPHL, we know first-hand how detrimental mental health disorders can be in patients’ lives. That’s why we work with primary care settings to implement behavioral screening and intervention (BSI), which helps address depression and other mental health disorders by screening all patients annually, making frequent contacts with patients and providing interventions to maximize engagement in and promotion of behaviors that lift symptoms. BSI would help uncover almost all cases of depression, double response to treatment and increase complete remission by 77%.

This May, get educated and raise awareness by observing Mental Health Awareness Month. You can attending local events in your area or visit Mental Health America for more information.