Adolescent Substance Use Screening, Brief Intervention, And Referral To .

EXHIBIT 1: THE INITIATIVE’S THEORY OF CHANGE Expand SBIRT education andtraining of youth providers Expand settings where SBIRTis adopted: schools, healthcenters, community programsIncrease SBIRT for Integrate behavioralhealth systems with primaryyouth access andIncrease health andcapacitycare for youth through SBIRTimplementation Eliminate systems barriers toDiffusion of program andwellness and reducesystems policysubstance use initiationimplementation modelsand use of youththrough earlyreimbursement andidentification,implementation of SBIRTprevention, andthrough policy changeIncrease the quality andintegration of primary care and Create youth SBIRT curriculabehavioral health systemsand state-of-the-art trainingbehaviorial healthproblemsand innovation disseminationIncrease evidence basematerialsand identify promising Support basic research intreatment of substanceuse disorders and relatedpractices for youth SBIRTSBIRT implementation andeffectivenesswellbeing of youth age 15-22. To achieve this goal the youth-servingworkforce must be equipped with the needed knowledge and skills toprovide SBIRT, and policies and practices must be adjusted or changedto increase access to quality, efficient services.including the Substance Use Prevention strategy under which theSBIRT work is funded. As a result, the Foundation will reorient its focusduring this final phase towards: summarizing the areas of investment,analyzing key contributions to the field, and disseminating findings.The Initiative’s theory of change was designed to achieve individualand systems-level impact. At the individual level, SBIRT provides anopportunity to normalize conversations for youth and young adults aspart of routine service delivery in the many systems where they receiveservices, including physicians’ offices, schools, and school-basedhealth centers, JJ and other community-based programs. In this way,youth-serving providers can reach a large, often previously unidentified,segment of the population before substance use risks escalate.GUIDING QUESTIONSAt the systems level, in the past the SBIRT framework has primarily beenapplied in the healthcare system, and the Foundation’s Initiative hasexpanded that reach to community programs and other systems suchas JJ, education, and mental health. The Initiative’s systems-level workalso focused on those policies that affect the likelihood of whetherSBIRT can be implemented, sustained, and given the support neededto flourish in healthcare and the new settings.Since the Initiative was launched, much of the initial evaluationfocused on education and awareness about youth SBIRT, field building,including the development and dissemination of training and technicalassistance resources, and investing in implementation and evaluationprojects to better understand how well SBIRT works in the real world.Following an organizational decision in May 2018, the Foundationis slowly phasing out of four program areas over the next few years,The intent of this initial phase was to explore feasibility and applicationof youth SBIRT in different settings. As the Foundation started theexpansion of SBIRT, testing new approaches in new settings, it is notsurprising that few programs were positioned in this early period foran outcomes evaluation. However, as grantees now begin to wrap uptheir work under the Initiative, an important goal of the evaluation is tosupport the grantees and the Foundation in synthesizing and sharingkey learnings and preliminary results to inform future discussionsabout youth substance use prevention policy and practice. This paperreviews key contributions the Initiative has made to the substanceuse prevention field and explores how the Initiative has added to theknowledge base for youth SBIRT.In the following section, learnings are presented in response to thesekey evaluation questions: Can SBIRT be successfully implemented in a variety of youthserving settings? What are the essential elements of that success? What contributions has the Initiative made to the evidence basefor youth SBIRT?3

WHAT WE’VE LEARNEDSBIRT CAN BE SUCCESSFULLY IMPLEMENTED IN A VARIETYOF YOUTH-SERVING SETTINGSOne of the primary aims of the Initiative was to investigate whetherSBIRT can be successfully implemented in a variety of settings to 1)expand youth access to prevention and intervention services and2) prevent, delay the onset of, or reduce youth substance use. Toaddress these questions, grantees designed and conducted multipleimplementation and research projects; some of these projects andstudies have reported final results, but some are still underwaywith completion to occur prior to the end of the Initiative. In thissection, we review the findings from projects that have completedimplementation, as well as preliminary findings from studies thatare still in the implementation or analysis stages. After reviewing thestate of implementation to date and discussing elements of success,we will describe ongoing research and the open questions still beinginvestigated by grantees.INCREASING ACCESS AND CAPACITY FOR YOUTH SBIRT:NEW SETTINGSThrough implementation and research projects, grantees have pilotedthe implementation of SBIRT in new settings and developed andrefined SBIRT tools and models for subpopulations of youth. Since2013, the Initiative has partnered with grantees in their expansionof SBIRT to more than 900 sites across the country. These sitesrepresent settings where youth routinely interact with adults andplaces with high concentrations of at-risk youth, such as healthcaresettings, schools and school-based health centers, community-basedorganizations, community behavioral health organizations, andJJ programs. Through the Initiative, sites from all of these sectorsincorporated SBIRT into their workflow, trained staff, and screenedand provided services to youth either onsite or through referral, withmany sites utilizing the SBIRT approach for the first time (described infurther detail below).Pediatric primary care practices, including community healthcenters, are well suited for SBIRT as youth routinely receive otherhealth screenings in these settings, and substance use screening canbe integrated into existing workflows. Through the Initiative, severalgrantees expanded the implementation of youth SBIRT in pediatricprimary care settings, and over 37,500 youth were screened as a result.Of those screened, five percent received a BI and one percent receiveda RT. Grantees found that multiple factors influence the degree to whichSBIRT services can be implemented in primary care, including limits onprovider time, staff turnover, changes in workflow, organizational buyin, availability of technology (e.g. tablets for screening, electronic healthrecords), access to specialty treatment networks, and reimbursementfor services. By identifying these factors and testing strategies toaddress them, grantees were largely successful in extending the reachof adolescent SBIRT in primary care settings.Community behavioral health organizations (CBHOs) are effectivelocations to reach youth, including those who come in repeatedlyover time for routine mental health related visits, as well as those whocome in for acute care. Under the Initiative, CBHOs screened a totalof 4,987 youth, and providers at these sites provided BI to 37 percentand a RT to eight percent of those screened. One grantee examined theimpact of BI in reducing or delaying substance use among youth whoreceive services at the CBHOs operating as part of its grant; findingsindicated that among the youth screened at these CBHOs, 44 percenthad reduced screening scores when assessed at a subsequent visit.Juvenile justice programs are an area where it is critical to identifyand provide information and support to youth who are at high riskof developing SUD, but where SBIRT has not been widely utilized.Through the Initiative, SBIRT was implemented in 17 sites servingjustice-involved youth. More than 490 youth were screened in thesesites. One study in JJ programs assessed the impact of SBIRT notonly on substance use but also on repeat arrests, school disciplinaryactions, and internal and external disorder scores among youthsserved. Results from this work showed that a large proportion of youthscreened in JJ settings scored in need of a referral to treatment; ofthose referred and attending treatment, there was a significant changein the substance use and related mental health symptom scores duringat least one of the two follow-up periods (three and six months).SBIRT was also successfully implemented in 290 schools and schoolbased health centers. As a result, 42,904 youth were screened in thesesettings, seven percent were provided a BI and one percent a RT. In NewMexico, SBIRT was implemented in 32 school-based health centersacross the state. In this project researchers compared reductions insubstance use between sites that utilized the SBIRT protocol and sitesthat did not. Results showed that there were statistically significantdecreases in 30 day use of tobacco, alcohol and marijuana in the youthbeing served at SBIRT protocol sites compared to no decreases in thenon-SBIRT sites.Schools are a logical setting to introduce prevention messages,administer BIs, and identify youth in need of more formal treatment.Traditionally, schools have relied on educational messaging alone.In exploring the effect of a more traditional approach (educationalmaterials) versus a BI after screening, one grantee assigned youthin schools either to screening and BI or to a screening and briefeducation. The goal was to determine whether there were significantdifferences between those students screened and provided BI versusthose screened and provided educational materials on subsequentsubstance use. Both groups were followed at six and 12 months, anddifferences in frequency of use as well as school performance outcomessuch as number of days suspended, days in detention, and missedschool were compared. The differences between the two groups werein most cases small; in some cases the differences were counterintuitiveand due to methodological limitations, inconclusive. At the six-monthfollow-up, there was a small difference in the rate of students initiatingmarijuana use, between those receiving the BI and those receivingbrief educational intervention, but the positive direction favored thebrief education group. In the case of alcohol initiation at a six-monthfollow-up, however, the BI group showed small but more improvedresults over the brief education group.Through the 312 community-based organizations that implementedSBIRT through the Initiative, 4,240 youth were screened, and ofthose, 87 percent received a BI and 13 percent a RT. The communitybased programs funded by the Initiative were part of a nationwidenetwork (YouthBuild USA) focused on providing job skills training andleadership development opportunities for youth from low income, andhigher risk, circumstances. These programs implemented SBIRT insettings where no such substance use prevention screening had beentried before.4

INCREASING ACCESS AND CAPACITY FOR YOUTH SBIRT:TRAINING THE WORKFORCEFundamental to the Initiative’s strategy was training youth-servingproviders on SBIRT, including the use of validated screening toolsand evidence-based motivational interviewing techniques. Whileyouth routinely cross paths with providers in each of these settings,few providers had been trained in using structured SBIRT techniquesto identify and respond effectively to youth substance use, once itwas identified. This was due in part because a standardized trainingapproach or curricula for use with youth populations had not beendeveloped for widespread use. Consequently, one of the Foundation’sfirst areas of investment was to support a range of activities to educateproviders about the importance of addressing adolescent substance useas a health concern and how SBIRT could serve as a framework for themto address it. Grantees disseminated information about youth substanceuse risk and SBIRT to more than 900,000 providers and trained nearly42,000 individuals, including those in the youth-serving workforce, as wellas nursing and social work students, medical residents, and addictionmedicine fellows. Informational and training materials developed bygrantees included an implementation checklist; an interactive, onlineSBIRT training technology platform; toolkits and an adolescent primarycare change package (i.e. SBIRT implementation guide that providesoperational and clinical guidance and benchmarks) fact sheets abouteffects of alcohol and marijuana use; evaluation tools; case studies; andguidance around billing and reimbursement for SBIRT services.The Foundation is laying the groundwork for continued workforceexpansion through dissemination of well-developed curricula and theestablishment of addiction medicine fellowship programs across thecountry. In collaboration with the Foundation, the American Collegeof Academic Addiction Medicine (ACAAM) has taken important stepstoward this goal. In 2016, its efforts to formally certify addiction medicineas a subspecialty by the American Board of Medical Specialties wassuccessful, and in 2018 the Accreditation Council for Graduate MedicalEducation opened a pathway for a subspecialty training program inaddiction medicine. Thus far, 70 Addiction Medicine Fellowship programshave been accredited, and by the end of this year, nearly 300 fellows willhave completed training. Most importantly, these addiction medicinefellowship programs now include educational modules on preventionand early intervention for the first time. NORC at the University of Chicago(NORC) designed and implemented a classroom-based curriculum andvirtual patient-provider simulation program in more than 80 schools ofnursing and social work, through which nearly 16,000 students receivededucation on adolescent SBIRT. ACAAM and NORC continue to expandtheir efforts, bringing competency-based SBIRT training to a wideaudience of current and future health professionals.THE ESSENTIAL ELEMENTS OF SUCCESSThe Initiative has successfully extended the reach of the SBIRT frameworkthrough the projects described above, however, as with any practicechange effort, implementation requires a thoughtful approach in orderto anticipate and address challenges. Some of the most common includeissues related to change in workflow, confidentiality, reimbursement,and the availability of treatment options in their area. For example, inprimary care settings, practices learned they need to dedicate sufficienttime to creating a usable workflow to determine which staff shouldadminister the screen, when it should occur, and how to fit the protocolinto daily routine. Practices developed innovative solutions, such asimplementing a tablet-based screening while the youth waits for theappointment and incorporating a brief screen administered by alliedhealth professionals rather than primary care providers.Confidentiality also needed to be addressed across settings,particularly in schools, where grantees faced questions regardingwhether youth can be screened without notifying their parents. Someschools found that they were able to send out general notices regardinga universal screening plan and utilize what is termed “passive consent,”that is, if a parent does not specifically object to the screening fortheir child, then screening can occur. Other schools sent home a moreformal consent document to all parents agreeing to a health screeningthat included alcohol and substance use questions. Grantees found themajority of parents did not refuse the screening.Reimbursement, i.e., payment for screening and BI, is anotherimportant consideration for implementation. Grantees expressed thatbilling differences by state, provider, and setting type, along with thecomplexity of Medicaid payments and licensing restrictions, madenavigating this issue challenging for many. For example, while schoolhealth practitioners are generally able to use time already part of theirregular activities for SBIRT, pediatricians had to determine how the timecould be reimbursed through specific Medicaid or insurance categoriesavailable in their state. Though most states have approved Medicaidcodes for the reimbursement for SBIRT for Medicaid patients, somehave not, and in some states, the codes may only be used in medicalsettings or are restricted to certain professional classes, e.g., physicians,for use. The Foundation has invested in increasing understandingof and access to financing for SBIRT through policy analysis anddissemination of information regarding usable cost reimbursementcodes and strategies across the states for increased utilization of codes.In numerous states the Foundation has funded advocacy that hasresulted in activation of Medicaid codes. Georgia is one example; inother states, it has supported creation of other state funding sources.One grantee developed an online, interactive map with information onbilling for substance use prevention and early intervention that includesinformation on which state Medicaid programs have strong preventivesubstance use coverage. This represents one example of how theFoundation’s investment in this area has benefitted the broader field.An important finding from this work is that the referral to treatment(RT) portion of the protocol was a significant challenge for many sitesbecause most had never interacted with the specialty SUD servicesystem before. While it is important to note that only a relatively smallproportion of youth screened required formal SUD treatment, a greaterproportion would benefit from a referral to other types of servicesand supports, such as mental healthcare, prosocial activities, andmentoring programs. Many providers had very limited knowledge ofwhat treatment options were available and what options are consideredevidence-based. In addition, many providers were in areas with limitedaccess to formal treatment services for adolescents. As a result, manyproviders, even those in primary care, felt unprepared to determinewhat type of referral was the most appropriate for the youth and theirfamilies based on screening results. Lack of patient ability to engage intreatment, as well as the absence of high quality, affordable treatmentoptions, were also noted barriers. This remains a source of difficultyfor providers, both in terms of identifying a provider for referral and intracking that referral to ensure that the individual received treatment.In some instances, grantees reported that potential sites declined toparticipate in SBIRT programs because they felt they did not have5

an adequate referral network. An approach that proved successful inNew Hampshire was the development of referral networks across thestate, which resulted in nearly 70 percent of participating practice sitesbuilding new relationships or partnerships with other organizationsincluding treatment centers, behavioral health providers, school-basedstudent assistance program counselors, and primary care practices.INCREASING THE EVIDENCE BASE AND IDENTIFYINGPROMISING PRACTICESOne of the goals of the Initiative is to further the evidence basefor adolescent SBIRT and disseminate findings in the field. In theprevious section, we described results and lessons learned from theimplementation of SBIRT in various settings. Now we will turn to studiesthat are still underway, including some that have kicked off within thepast year. Although the Initiative as a whole has entered its final stage,comparatively, the research component is still in its early stages. TheFoundation has funded rigorous, longitudinal studies designed toanswer complex research questions pertaining to the efficacy andeffects of various SBIRT tools and models. The summaries below provideglimpses of the research questions that will be answ

Adolescent substance use is a leading public health concern and is a predictor of serious long-term physical, mental, and social . their activities and principles of care, laying the groundwork for further dissemination and implementation of SBIRT for youth. THE HILTON FOUNDATION'S PREVENTION STRATEGY