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Moving Beyond Provider Education to Implementation

Monday, March 18, 2019   (0 Comments)
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Moving Beyond Provider Education to Implementation: An Innovative Field-Tested Model for Adolescent SBIRT



Adolescent substance use is a pervasive issue that has long-lasting effects for individuals and society alike. Substance use in youth has been shown to contribute to academic underachievement1, interruption of the natural course of brain maturation2, and is a predictor of substance use disorders in adulthood.3-4  Substance use and misuse also has a long history of being linked to increased expenditures for the healthcare system5. Despite recent declines in use, alcohol remains the substance most widely used by today’s teenagers. In fact, the 2018 Monitoring the Future (MTF) Survey revealed that by the end of high school, six out of every 10 students (59%) have consumed alcohol (more than just a few sips) at some time in their lives; and about a quarter (24%) have done so by eighth grade.6


Substance use in the U.S., especially by youth, has proven to be a rapidly evolving issue requiring frequent monitoring and reassessment to maintain awareness of current trends. The MTF Survey also showed a dramatic increase in vaping by adolescents from 2017 to 2018. Vaping nicotine and marijuana had the largest increase for any adolescent substance use outcome since measurement began in 1975 (nearly doubling from 11% to 21%). In the face of this persistent issue facing our youth, it is critically important to identify effective and sustainable methods for preventing and treating substance use. Our future depends on how vigorously the nation responds to adolescent substance use, how accurately it identifies emerging substance use issues, and how well it understands the effectiveness and sustainability of policy and intervention efforts.


Screening, Brief Intervention, and Referral to Treatment (SBIRT) is a promising solution for early identification and intervention for adolescent substance use. However, broad adoption has been impeded by a lack of specific implementation guidance due to a fragmented medical system that does not universally address substance use on a continuum.


In 2016, the National Council for Behavioral Health (National Council), with funding from the Conrad N. Hilton Foundation, responded to this issue by launching a four-year initiative, Faciliating Change for Excellence in SBIRT (FaCES) to develop a clear, replicable implementation model for adolescent SBIRT. During the first phase of the project, the implementation model, or “Change Package,” was developed with input from a group of national SBIRT experts. The Change Package was then piloted via a national group of primary care providers and administrators who participated in a learning collaborative, which concluded in December 2018. The project is now in its final phase, when the Change Package will be refined and made available to the larger healthcare field.


The Change Package comprises 11 specific recommendations – or change concepts – that marry high-level implementation guidance with the actual operational changes required for effective practice transformation, painting a picture of the ideal and actionable state.



Figure 1



The Change Package is unique in that it offers both clinical and operational change concepts which map to the SBIRT components and come equipped with practical tools and resources for implementation. For example, agencies often struggle to administer brief interventions because there is a lack of clarity on the steps to take. FaCES developed an innovative format for brief interventions, which is outlined in a Conversation Guide for Delivering a Trauma-Informed Brief Intervention, to help providers translate change concepts (Figure 1) into action. Figure 1 is an excerpt from the Change Package and provides clinical change concepts related to brief interventions. Lastly, the Change Package outlines recommended metrics and benchmarks to help clinics continually track, improve, and sustain practice.


To test the efficacy of the Change Package, FaCES conducted an 18-month learning collaborative and pilot program with 12 Federally Qualified Health Centers (FQHCs) from across the country. Selected sites had diversity of readiness for implementation, geographic location and setting, center size, and patient population demographics to ensure the Change Package was nationally applicable. Sites received targeted, multi-modal, and responsive training on a range of topics, including: SBIRT and behavioral health integration, developing and sustaining community partnerships, navigating confidentiality, and data-driven decision-making.


While the pilot phase of the project is presently undergoing a comprehensive evaluation, initial findings and participant anecdotes (Figure 2) demonstrate marked improvements in both operational and clinical domains, indicating that the Change Package is poised to affect innovative and comprehensive change. All pilot sites improved rates of screening and delivery of brief interventions, and clinical data establishes advanced penetration and adherence to the Change Package model. Several sites also increased levels of behavioral health and primary care integration.



The FaCES project team and participating FQHCs have developed and refined a number of resources, including an educational poster and a Change Package quick reference guide. Sites experienced challenges documenting SBIRT practices in their electronic health records systems (especially with brief interventions), navigating confidentiality and patient-parent dynamics, establishing effective workflows, and billing practices. Overall, sites learned that implementation required a high level of leadership and provider buy-in at project initiation and, in order to sustain practice, it was imperative to motivate, educate, and communicate with staff about the importance of SBIRT.


As we progress into the final phase of the project, FaCES is embarking on a process to infuse successes, challenges, and feedback from pilot sites. Data from a comprehensive evaluation of the final version of the Change Package will be available to the public in early 2020. Among the anticipated revisions is the inclusion of tools spanning electronic health record templates, clinical pathways, and workflows and protocols. There will also be guidance on proper documentation of a trauma-informed brief intervention.


The National Council will begin to share additional tools and resources in the months leading up to the release of the complete Change Package. FaCES will also host a webinar series that features experts who contributed to the Change Package that will provide training on the change concepts. To receive information on adolescent SBIRT tools, the webinar series, and the final Change Package, please sign up for YSBIRT (Youth SBIRT) News Alerts by emailing Stephanie Swanson at StephanieS@TheNationalCouncil.org.




Sharday Lewis, MPH

Project Manager, Practice Improvement

National Council for Behavioral Health




Griffin K. W., Botvin, G.J., Scheier, L.M., Epstein, J. A., Doyle, M. M. (2002). Personal competence skills, distress, and well-being as determinants of substance use in a predominantly minority urban adolescent sample. Prevention Science, 3(1): 23–33. Squeglia, L. M., Jacobus, J., Tapert, S. F. (2009). The Influence of Substance Use on Adolescent Brain Development. Clinical EEG and Neuroscience, 40(1): 31-38.

D’Amico, E. J., Ellickson, P. L., Collins, R. L., Martino, S., Klein, D. J. (2005). Processes linking adolescent problems to substance-use problems in late young adulthood. Journal of Studies on Alcohol and Drugs, 66(6): 766-75.

Wills, T. A., Walker, C., Resko, J. A. (2005). Longitudinal studies of drug use and abuse. Epidemiology of Drug Abuse, 177–192.

Monge, P., Fulk, J., Parnassa, C., Flanagan, A., Rumsey, S., Kalman, M. (1999). Cooperative Interagency approaches to the illegal drug problem. International Journal of Police Science and Management, 2: 229–241.

Johnston, L. D., Miech, R. A., O’Malley, P. M., Bachman, J. G., Schulenberg, J. E., & Patrick, M. E. (2019). Monitoring the Future national survey results on drug use 1975-2018: Overview, key findings on adolescent drug use. Ann Arbor: Institute for Social Research, University of Michigan.






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