A quality improvement approach is helpful to support the testing and implementation of a new process or practice change. For the Practice Improvement to Address Adolescent Substance Use project, quality improvement measures were identified and used to assess the implementation of SBIRT components for consistency and reliability.

The measures set developed for the Practice Improvement to Address Adolescent Substance Use project is for reference, adaptation and use in your practice.

SBIRT Measures Grid

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Ref #

Measures Name

Measures Definition

Measure Calculation (Numerator/Denominator)

Measure Benchmark

Measure Target/Goal (%)

Collection Frequency

1

Substance Use
Screening Results

Percentage of adolescents with medical record documented results from a substance use screening tool administered within the past 12 months consistent with AAP recommendations

Target Population: All patients ages 11y – 21y seen in practice for health supervision care or appropriate acute care visit.
Numerator: # of patients ages 11y – 21y with medical record documented results (no use or use) from a substance use screening tool administered within the past 12 months consistent with AAP recommendations.
Denominator: All patients ages 11y – 21y seen in practice for health supervision care or appropriate acute care visit whose records are reviewed.

Baseline rates 

90%

Volume: First 20 charts

Frequency: Monthly

2

Substance Use Frequency

Percentage of patients with identified substance use who have medical record documentation of the frequency of substance use.

Target Population: All patients ages 11y – 21y seen in practice for health supervision care or appropriate acute care visit.
Numerator: # of patients ages 11y – 21y with identified substance use and documentation in record of frequency of substance use.
Denominator: All patients ages 11y – 21y seen in practice for health supervision care or appropriate acute care visit with identified substance use whose records are reviewed

Baseline rates 

90%

Volume: First 20 charts

Frequency: Monthly

3

Substance Use
Risk Level

Percentage of patients with identified substance use who have the substance use problem risk level (as defined in the EQIPP “SU Frequency and Risk Level” document) documented in the medical record.

Target Population: All patients ages 11y – 21y seen in practice for health supervision care or appropriate acute care visit.
Numerator: # of patients ages 11y – 21y with identified substance use and the risk
level for the substance use problem documented in the medical record.
Denominator: All patients ages 11y – 21y seen in practice for health supervision care or appropriate acute care visit with identified substance use whose records are reviewed


Baseline rates 

90%

Volume: First 20 charts

Frequency: Monthly

4

Substance Use Brief Intervention

Percentage of patient records that have documentation that brief intervention ensued and was based on frequency and risk level, including
Positive reinforcement for patients with no substance use identified.

Target Population: All patients ages 11y – 21y seen in practice for health supervision care or appropriate acute care visit.
Numerator: # of patients ages 11y – 21y with identified substance use and brief intervention based on frequency and risk level or positive reinforcement for patients with no substance use identified and
documented in the medical record. Denominator: All patients ages 11y – 21y seen in practice for health supervision care or appropriate acute care visit whose records are reviewed

Baseline rates 

90%

Volume: First 20 charts

Frequency: Monthly

5

Substance Use Educational Materials

Percentage of patients who have medical record documentation that educational materials about substance use were provided to them and discussed.

Target Population: All patients ages 11y – 21y seen in practice for health supervision care or appropriate acute care visit.
Numerator: # of patients ages 11y – 21y with identified substance use or no substance use with documentation in the medical record that educational materials were provided and discussed.
Denominator: All patients ages 11y – 21y seen in practice for health supervision care or appropriate acute care visit whose records are reviewed

Baseline rates 

90%

Volume: First 20 charts

Frequency: Monthly

6

Substance Use Behavioral Change Goals

Percentage of patients with identified use who have specific behavioral change goals set that include a plan for follow-up.

Target Population: All patients ages 11y – 21y seen in practice for health supervision care or appropriate acute care visit.
Numerator: # of patients ages 11y – 21y with identified substance use who have specific behavioral change goals set that include a plan for follow-up documented in the medical record.
Denominator: All patients ages 11y – 21y seen in practice for health supervision care or appropriate acute care visit with identified substance use whose records are reviewed

Baseline rates 

90%

Volume: First 20 charts

Frequency: Monthly

7

Substance Use Recommendations/Referral

Percentage of patients with identified use who are given recommendations or formal referral to any new or continuing substance use/mental/behavioral health evaluation, intervention and/or treatment, whether in the same practice setting or an outside/specialized care setting.

Target Population: All patients ages 11y – 21y seen in practice for health supervision care or appropriate acute care visit.
Numerator: # of patients ages 11y – 21y with identified moderate or severe substance use who have recommendations or formal referral to any new or continuing substance use/mental/behavioral health evaluation, intervention and/or treatment, whether in the same practice setting or an
outside/specialized care setting, documented in the medical record.
Denominator: All patients ages 11y – 21y seen in practice for health supervision care or appropriate acute care visit with identified moderate or severe substance use whose records are reviewed

Baseline rates 

90%

Volume: Referral Log Population

Frequency: Monthly

8

Substance Use Recommendation/ Referral Documentation

Percentage of patients with recommendation/ referral information
entered into their medical record and/or referral log

Target Population: All patients ages 11y – 21y seen in practice for health supervision care or appropriate acute care visit.
Numerator: # of patients ages 11y – 21y with identified moderate or severe substance use who have recommendations or formal referral entered into the medical record and/or referral log.

Baseline rates 

90%

Volume: Referral Log Population

Frequency: Monthly

 

The Practice Improvement to Address Adolescent Substance Use project was funded by generous support from the Conrad N. Hilton Foundation.