Increased capacity for prevention and youth access
An important component of the evaluation was to determine whether SBIRT could be implemented in a variety of settings to expand youth access to prevention and intervention services, and as a result, impact youth substance use more broadly.
The evaluation involved 56 grantees implementing SBIRT in more than 1,266 sites across the country. These sites represented settings where youth routinely interact with adults, as well as places with the potential for reaching youth at higher risk. Table 1
represents the number of sites implementing SBIRT by setting: pediatric and primary care, schools and school-based health centers, community-based organizations, community behavioral health organizations, and juvenile justice programs.
Table 1Number of sites implementing SBIRT by setting
Sites incorporated SBIRT into existing workflows and underwent training to increase providers’ SBIRT delivery skills such as utilizing a validated screening tool and evidence-based brief intervention approaches such as motivational interviewing. Over 37,000 youth-serving providers, including frontline staff such as nurses, doctors, and social workers, were trained through the Initiative. Training efforts through the Initiative also included addiction medicine fellowships and prevention and intervention curricula for medical, nursing, and social work students.
All the sites were implementing SBIRT for the first time; therefore, the evaluation focused heavily on measuring implementation success (described in this paper) rather than tracking outcomes by following youth served. However, some of the grantees had the resources and ability to track outcomes of youth over time, and select results are presented in subsequent articles in this supplement, as well as in other journals. We discuss the RE-AIM components Reach and Implementation in this paper. Effectiveness is covered in other papers in this supplement and was part of the overall evaluation. Adoption of the protocol is reflected in the many programs and sites under the auspices of each grantee who was successful in executing the SBIRT protocol. The evaluation was not able to follow grantees beyond 2019, and therefore, we are not able to address Maintenance.
Each setting in the Initiative reached large numbers of youth (Table 2
). The variation in the proportion of youth who received a BI and/or an RT represents not only variation in the proportion of higher risk youth screened at each setting (i.e., juvenile justice programs vs. primary care) but also relates to capacity of providers to implement in different settings, i.e., low reimbursement potential, competing demands, time limitations. Grantees did not report how many youths they could have potentially screened, but rather just those that they actually screened. We discuss each setting below.
Table 2Number of youth reached per setting
Pediatric and general primary care practices are logical sites to screen a broad swath of youth, as youth receive routine health services in these settings. But SBIRT has not been widely adopted in pediatric primary care due in part to the belief expressed by many physicians that specialized behavioral healthcare providers (i.e., drug and alcohol counselors, social workers, and psychologists) are better suited to dealing with the issues like drug and alcohol use [
] than physicians. However, the Initiative was able to expand SBIRT to over 392 primary care settings, including pediatric clinics and health centers where over 56,000 youth were screened; 5% of those screened received a BI, and 1% received an RT. Factors that influenced the degree to which SBIRT services were successfully implemented in primary care include limits on provider time, workflow integration, staff turnover, organizational buy-in, availability of technology (e.g. tablets for screening, electronic health records), access to specialty treatment networks, and the potential for reimbursement for services.
Community behavioral health organizations (CBHOs) are advantageous locations to reach youth as they include adolescents already accessing mental health services. Through the Initiative, CBHOs screened a total of 4,987 youth at 32 sites, provided BI to 37%, and provided an RT to 8% of those screened.
SBIRT has not been widely utilized in juvenile justice programs despite the large numbers of high-risk youth in these settings. The higher concentration of youth in this setting that may need services was evident in high rates of brief interventions and referrals to treatment uncovered in this setting. Through the Initiative, SBIRT was implemented in 24 sites serving justice-involved youth. More than 490 youth were screened in these sites; 92% received a BI, and 47% were referred to more formal treatment.
SBIRT was also successfully implemented in 478 schools and school-based health centers where 74,908 youth were screened, 4% were provided a BI, and 1% were provided an RT. Schools are a logical setting to introduce the full spectrum of prevention activities, but traditionally schools have relied predominantly on primary prevention activities such as educational messaging. Having counselors, school nurses, and providers in school-based health centers administer SBIRT, both prevention messages and direct health services could be made available to youth.
Through the 326 community-based organizations implementing SBIRT, 4,240 youth were screened, 87% received a BI, and 13% received an RT. The community-based programs of this grantee were part of a nationwide network focused on providing job skills training and leadership development opportunities for youth from high-risk circumstances. Like the juvenile detention sites, community-based organizations’ screenings resulted in a higher percentage of youth screened as in need of either a BI or an RT.
Increasing access by expanding the SBIRT workforce
A core part of the Initiative’s strategy was to increase the capacity of the youth-serving workforce through SBIRT training. While youth routinely cross paths with providers in each of these settings, we found that few providers had been trained to identify and respond to youth substance use once identified. This was due in part to little standardized training curricula or approaches designed especially for youth, although there are curricula appropriate for adults. One of the Hilton Foundation’s first areas of investment was to support activities to (1) educate youth-serving providers about adolescent substance use as a health concern, and (2) teach providers in multiple settings how SBIRT could serve as a framework to prevent initiation and reduce escalation of use. Grantees disseminated specially developed information and training materials to more than one million individuals, including an implementation checklist; an interactive, online SBIRT training technology platform; toolkits and an adolescent SBIRT implementation guide providing operational and clinical guidance and benchmarks; fact sheets; evaluation tools; case studies; and guidance around billing and reimbursement for SBIRT services.
A key tool for the workforce expansion was the wide dissemination of curricula in health professional training programs and the establishment of addiction medicine fellowship programs. The grantees trained over 37,000 individuals, including nursing and social work students, medical residents, and addiction medicine fellows. One grantee designed and implemented a classroom-based curriculum and virtual patient-provider simulation program in more than 80 schools of nursing and social work, through which nearly 16,000 students received education on adolescent SBIRT. In addition, to date, 83 Addiction Medicine Fellowship programs have been accredited by Accreditation Council for Graduate Medical Education. Given the scope of the audiences involved in the training, the grantee was not able to follow up with an assessment of information gains or implementation of the techniques posttraining.
Challenges to implementation
Each setting provided important new access to youth. The challenges of implementing SBIRT differed across the settings, though there were common issues: difficulty with adjusting changes to workflow, confidentiality, reimbursement, the availability of referral options in their geographic area, and the need to address mental health concerns as a critical part of adolescent substance use prevention.
Pediatric primary care settings found it particularly challenging to find sufficient time to create a useable and sustainable workflow and often struggled to fit the SBIRT protocol smoothly into an already established routine of intake and various developmental and preventive screening questions. In the case of physicians conducting the protocol, the time needed in addition to the health visit proved challenging due to time constraints in primary care settings. In an implementation survey of leadership at sites, 83% of the pediatric primary care clinics reported that the primary care provider was responsible for substance use screening, and behavioral health providers (social workers, counselors, or psychologists) did the screening in 16% of primary care practices. Similarly, in 83% of the school-based health centers, primary care providers were responsible for screening. This placed the burden of finding time for the screening and potential intervention on the physicians and/or nursing staff in the majority of these often time-constrained settings. Some sites mitigated this challenge by training intake staff in the screening protocol relieving the physician of this component of the process; one site used a tablet for the initial screening but then had a staff member (nurse or physician) take further action with the individual if needed based on screening results.
Confidentiality was also a challenge across the settings, particularly in schools, where grantees faced the issue of whether they could screen youth without notifying parents. Some schools addressed this through “passive consent” procedures that send general notices regarding a universal screening plan; if a parent does not specifically object to the screening for their child, then screening can occur. Other schools sent home a more formal consent document to parents asking for consent for a universal health screening for their child that included alcohol and substance use questions; these sites found that the majority of, although not all, parents consented when it was framed in a broader health context.
Reimbursement for SBIRT was another persistent challenge to implementation in a grant-supported arena. Billing differences by state, provider, and setting type, along with the complexity of Medicaid and licensing restrictions, made navigating this issue challenging. For example, while school health practitioners (school nurses) were generally able to use time already designated as part of their regular activities for SBIRT, pediatricians had to determine how the time could be reimbursed through specific Medicaid or insurance categories available in their state. Although many states now have approved Medicaid codes for the reimbursement for SBIRT, some do not; and in some states, the codes may only be used in medical settings, are restricted to certain professionals to use, and/or are time-based. The Initiative invested in policy analysis, advocacy, and dissemination of information regarding the use of cost-reimbursement codes and strategies across the states for reimbursement. For example, a grantee created an online, interactive map with information on billing for substance use prevention and early intervention, including information on each state’s Medicaid coverage.
The referral to the treatment portion of SBIRT was a significant challenge for many sites for several reasons. First, many providers and programs had never interacted with the specialty substance use disorder service system before. Second, the availability of treatment for adolescents is more limited than what is available for adults. Third, there are often few guidelines for managing what can be a complex process of steering high-risk youth into the appropriate treatment program [
]. While it is important to note that only a relatively small proportion of youth screened required formal substance use disorder treatment, many providers felt that they had limited knowledge of available treatment options, which options are evidence-based, and the best match for the youth. As a result, many providers felt unprepared to determine the most appropriate type of referral for the youth and their families based on screening results. In some instances, grantees reported that potential sites declined to participate in SBIRT programs because they felt they did not have an adequate referral network. To address this barrier, one grantee developed a youth-specific referral network across the state, resulting in nearly 70% of participating practice sites building relationships or partnerships with other organizations, including treatment centers, behavioral health providers, and school-based student assistance program counselors.
Given that an estimated one in eight adolescents and young adults suffers from depression [
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- et al.
Drug use and the risk of major depressive disorder, alcohol dependence and substance use disorders.
], it is not surprising that grantees repeatedly noted the need to address mental health issues as part of adolescent substance use prevention efforts. The literature highlights this need [
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- Schinke S.
- Trent D.
Substance use among late adolescent urban youths: mental health and gender influences.
]. The implementation survey of grantees asked programs what other health and social issues they should address when screening youth for substance use (i.e., mental health, intimate partner violence, food/housing insecurity/safety, legal problems, and school conduct/performance). Across settings, respondents identified screening for mental health issues as the most critical need, although the rate of mental health screening varied considerably across settings. Ninety-five percent of primary care or pediatric settings indicated that they screen for mental health issues. School programs and school-based health centers also have high screening rates for mental health issues at 90% and 83%, respectively. However, only 76% of community-based programs were conducting mental health screenings.
The last phase of the evaluation focused on the ultimate impact of SBIRT to delay or eliminate initiation and/or reduce substance misuse. Some grantees collected short- and long-term outcomes, including using electronic health records to track outcomes for large numbers of youth over time. Other grantees conducted traditional randomized controlled studies of varying elements of SBIRT practice. Several grantees were able to follow-up with youth who had received the SBIRT protocol, while others did not have sufficient resources to conduct this type of follow-up. The results addressing the outcomes and impact of the Initiative (i.e., “Can using SBIRT for youth in these settings prevent, delay onset, or reduce youth substance use?”) are presented in subsequent articles in this supplement.