SBIRT Promising Practices: Community Health Center Inc.

Location: Connecticut
Type of practice: Federally qualified health center

Community Health Center Inc. is a federally qualified health center providing medical, dental and behavioral health services at more than 200 locations throughout Connecticut. More than 90% of patients are covered by Medicare/Medicaid.

Community Health Center Inc. participated in the inaugural Practice Improvement to Address Adolescent Substance Use (PIAASU) learning collaborative beginning in 2014. The PIAASU project aimed to increase the use of the SBIRT approach to address adolescent substance use in pediatric practices. Today, use of SBIRT is a clinical expectation for pediatricians, family practitioners and pediatric nurse practitioners throughout the agency.

Community Health Center chose the CRAFFT (Car, Relax, Alone, Forget, Friends/Family, Trouble) assessment tool for its ease of use and because it includes an assessment step that helps determine the level of intervention to follow. (One Community Health Center physician considers assessment such a crucial part of the process that he believes the letter ‘A’ should be incorporated into the SBIRT acronym.) CRAFFT was easy to incorporate into the suite of other screenings that are administered at regular visits in the practice.

For patients whose screens are negative, the Brief Intervention step typically focuses on positive reinforcement for the healthy choices they have made, sometimes including role play about what to do in situations where others are using drugs.

At Community Health Center, the most common substance identified through screening is marijuana, which is legal for adult recreational use in Connecticut. For some adolescents who use marijuana, this reinforces a belief that marijuana is not dangerous, and patients resist a recommendation to stop or reduce use.

In those cases, the physician will apply brief interventions, including Motivational Interviewing, to shift to a discussion of harm reduction measures, negotiating an agreement for the teen to call an adult or stay with a friend instead of driving, for example.

Most patients whose screens reveal mild to moderate substance use can be referred to behavioral health therapists within the practice. Patients also may be referred to a nurse practitioner at a school-based health center affiliated with the practice.

Incorporating SBIRT into this high-volume, multi-site health center was a yearslong process that began with a single pediatrician acting as “champion.” SBIRT was introduced at two sites to fine-tune the workflow. Policies were submitted to a Quality Improvement Committee before being rolled out through the entire agency. SBIRT now is standard practice at every site that treats adolescents.

Adolescents who are referred to treatment don’t always follow through, and monitoring compliance is a challenge for pediatricians. If the patient is being treated within the Community Health Center, a physician can proactively check the integrated health record. For a patient who needs to be monitored carefully, a physician or nurse may set an electronic reminder to follow up personally.

A warm handoff is an effective strategy employed by the practice to prevent patients from falling through the cracks: after the patient consents to counseling, a behavioral therapist comes to the exam room to meet with the teen and set up an appointment to begin treatment. This instant connection has reduced no-shows to follow-up appointments by 25 percent. For telehealth visits, these referrals are facilitated by an intake coordinator instead of in person, a process that typically takes one to two days.

• Incorporating SBIRT into your practice will help you think about your entire approach to adolescent care and how you interact with teens.
• Beginning when patients are 10 or 11, let the parents/caregivers know that the physician will meet privately with adolescents as part of an annual visit. A routine screen sets the expectation that a confidential, non-judgmental discussion of substance use is part of every physical.
• Adding a substance use screen to the stack of other screens (including depression, domestic violence, sexual identity and others) at every annual health supervision visit increases pressure around productivity. Every practice needs its own well-developed process.
• Experiment with different screening tools and workflows. High-volume practices especially can benefit from a system that allows patients to complete the screens electronically.
• Multiple screens provide a more comprehensive picture. A patient who may be missed by a substance use screen may be identified as depressed or anxious on another screen.