SBIRT Promising Practices: Wellstar Kennestone Pediatric Associates

Location: Marietta, Georgia
Type of practice: Pediatric group practice

Wellstar Kennestone Pediatric Associates serves a suburban community northwest of Atlanta. The area is home to many Spanish-speaking immigrant families, and the practice includes three bilingual physicians. About 40 percent of patients are covered by Medicaid. The practice serves patients ages birth to 21.

Wellstar Kennestone Pediatrics was among the inaugural practices to participate in the Practice Improvement to Address Adolescent Substance Use (PIAASU) learning collaborative, beginning in 2015. The PIAASU project aimed to increase the use of the SBIRT approach (Screening, Brief Intervention, Referral to Treatment) to address adolescent substance use in pediatric practices. Today, SBIRT is well integrated into the practice and part of every patient’s annual health supervision visit starting at age 11.

The practice uses the CRAFFT (Car, Relax, Alone, Forget, Friends/Family, Trouble) as a tool to assess substance use. It was chosen because it is a single tool that both identifies adolescent substance use and helps assess risk to guide next steps.

Wellstar Kennestone Pediatrics values SBIRT as a prevention tool and places strong emphasis on the Brief Intervention step for all patients. Roughly 70% of patients screen negative for substance use. The annual screening provides an opportunity for the Wellstar Kennestone pediatricians to give positive reinforcement: to praise patients for making healthy decisions, educate them about the risks of substance use, and encourage them to continue to abstain. This sets the expectation that no amount of substance use is appropriate for adolescents. By “planting the seed” in early adolescence and revisiting it at every annual health supervision visit, pediatricians also signal that they are invested in the patient’s health and can be trusted to discuss any substance use issues that arise.

Patients whose screening reveals mild or moderate substance use are counseled about the risks and advised to stop using. Pediatrician and patient then negotiate a plan to reduce or stop. Physicians are trained to use Motivational Interviewing for this step. The goal is to have a conversation that provokes cognitive dissonance — the adolescent is encouraged to weigh the perceived benefits of substance use vs. the costs and risks. A high-performing student who uses marijuana to relieve stress, for example, can be coached to consider the harm to his/her developing brain and the possible consequences of continued use, including drug dependency and lower grades. Motivational Interviewing promotes a sense of autonomy and agency and guides the patient to make a decision in his/her best interests.

About 5 percent of patients have substance use disorders that call for treatment outside the practice. These patients typically are using multiple times a week, sometimes daily. Facilitating these referrals is one of the biggest challenges reported by pediatricians in the original PIAASU cohort. Factors include determining the appropriate treatment option, availability of treatment and insurance coverage issues. Wellstar Kennestone made a concerted effort to identify and build relationships with local providers, including psychologists and psychiatric hospitals, with the credentials to treat adolescents with substance use disorders.

Challenges encountered by Wellstar Kennestone Pediatrics in the SBIRT process with adolescent patients are missed follow up appointments or lack of follow through for referrals. Wellstar Kennestone does not automatically discharge a patient after three or four no-shows. Patients sometimes reappear, ready to engage — and may find it easier to do so once they are legally adults.

• To implement SBIRT into your practice: Go slow. Start small and gradually integrate it so that it becomes part of the normal workflow. Make sure the workflow facilitates confidentiality.
• Prepare yourself so you are confident. Learn one screening tool and become good at it. Take a course in Motivational Interviewing. Take advantage of AAP resources, tools and training.
• Adolescents are more comfortable (and more honest) when they are allowed to complete the screening tool independently rather than having a doctor or nurse ask the questions. The pediatrician or other provider can then review the answers and conduct the brief intervention.
• Be prepared to deal with setbacks. Sometimes patients don’t fulfill their end of a negotiated contract; sometimes they improve and then have a setback. Having a regular conversation as part of an annual health supervision visit means you can get back on course without starting from zero.