Journal of Adolescent Health 71 (2022) S9eS14

www.jahonline.org

Original article

Substance Use Screening, Brief Intervention, and Referral to

Treatment in Multiple Settings: Evaluation of a National Initiative
Dana Hunt, Ph.D. a, Leigh Fischer, M.P.H. a, Kaitlin Sheedy, M.P.H. a, *, and Samantha Karon, M.P.H. b
a
Abt Associates, Cambridge, Massachusetts
b
Abt Associates, Rockville, Maryland

Article history: Received July 26, 2021; Accepted March 10, 2022
Keywords: Substance-related disorders; Adolescent; Health services

A B S T R A C T
IMPLICATIONS AND
CONTRIBUTION
Purpose: This study evaluated the implementation and outcomes of a multisite initiative to
identify and intervene in adolescent substance use across the many settings where youth interact.
While most prior work has
This paper focuses on the implementation and intermediate outcomes of the initiative, while focused on adults, this
others in the supplement address impact and ultimate outcomes. study presents findings
Methods: A mixed-methods cross-grantee evaluation was conducted from 2014 to 2019 among 56 around the implementa-
recipients of funding from the Conrad N. Hilton Foundation to implement screening, brief inter- tion of SBIRT in the
vention, and referral to treatment (SBIRT) across more than 1,266 youth-facing settings. Qualitative adolescent population.
and quantitative data were collected from grantees on a quarterly basis, as well as from grantee Results highlight consid-
proposals, progress reports, monthly grantee monitoring calls, and survey findings. erations for implementa-
Results: Grantees reported increased capacity to provide SBIRT to youth across various settings: tion of SBIRT in the
pediatric and primary care practices, community behavioral health organizations, juvenile justice settings where youth
programs, schools, and community-based organizations. Collectively, grantees screened 141,230 interact and present
youth for substance use, 12,272 received a brief intervention, and 2,212 were referred to treatment. grantees’ achievements in
As part of the initiative, grantees provided SBIRT training to over 37,000 nursing and social work increasing access to
students, medical residents, addiction medicine fellows, and others. Implementation challenges screening and early inter-
included fitting screening into the workflow of primary care settings, confidentiality and consent vention and preliminary
in schools, reimbursement, and lack of specialist providers to refer to for substance use disorder outcomes for youth sub-
treatment. Intermediate outcomes collected include total numbers of youth screened, received a stance use.
brief intervention, and/or referred to more intensive treatment based on their screening scores.
Conclusions: Research on SBIRT in adolescents has been limited to date despite positive outcomes
reported in adults. This mixed-methods evaluation of an initiative to expand SBIRT implementa-
tion demonstrates feasibility of expanding access to substance use screening and intervention for
youth across multiple settings and identifies challenges of implementation that differ somewhat
based on settings.
Ó 2022 Society for Adolescent Health and Medicine. Published by Elsevier Inc. This is an open
access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Conflict of interest: The authors have no conflicts of interest to disclose.

Alcohol and drug use among youth continues to be a critical
Disclaimer: This article was published as part of a supplement supported by the problem in the United States, fueled in the last decade by the rise
Conrad N. Hilton Foundation through a grant to Abt Associates. The opinions or of misuse of prescription opioids. The 2020 National Survey
views expressed in this article are those of the authors and do not necessarily on Drug Use and Health indicates 8.2% or 2.1 million youth aged
represent the official position of the funder.
12e17 reported drinking alcohol in the month prior to the sur-
* Address correspondence to: Kaitlin Sheedy, M.P.H., Abt Associates, 10 Faw-
cett St, Cambridge, Massachusetts 02138, USA. vey. One percent or one million reported binge drinking, that is,
E-mail address: [email protected] (K. Sheedy). consuming three or more drinks for female youth or three to five

1054-139X/Ó 2022 Society for Adolescent Health and Medicine. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
https://doi.org/10.1016/j.jadohealth.2022.03.002

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S10 D. Hunt et al. / Journal of Adolescent Health 71 (2022) S9eS14

or more drinks for male youth in a two-hour period (This defi- schools and school-based health centers, juvenile justice pro-
nition is provided by the National Institute on Alcohol Abuse and grams, community behavioral health organizations, and
Alcoholism:.niaaa.nih.gov/publications/brochures-and-fact- community-based organizations. Abt Associates began the
sheets/binge-drinking). In addition, 13.8% of those or 3.4 million, evaluation of the implementation and outcomes resulting from
adolescents aged 12e17 reported illicit drug use in the year prior the Initiative in 2014 and concluded in 2019.
to the survey [1]. The evaluation questions addressed in this paper include:
While substance misuse poses risks for all Americans, it is
particularly dangerous for youth and young adults. Decades of  Can SBIRT increase capacity for prevention and youth access to
research highlight the critical health and safety concerns services in these settings?
involving substance use during adolescence, a period critical for  What are the challenges of using SBIRT in these settings?
brain development and characterized by experimentation and
risk-taking [2]. It is a period when substance use can precipitate Other papers by Hilton grantees in this supplement address
behaviors with serious and even long-term consequencesd the third evaluation question:
traffic accidents, poor school performance, family problems, and
involvement in the criminal justice system [3]. Intervention at  Can using SBIRT with youth in these settings prevent, delay
this point is particularly critical as research has shown that onset, or reduce youth substance use?
persons who misuse substances in adolescence are at greater risk
of developing substance use disorders as adults [4].
Substance use among adolescents occurs along a continuum, Methods
from experimentation to increased use, and for many youths, it
never progresses beyond experimentation. This progression de- The authors conducted a mixed-methods cross-grantee
pends on a wide range of factors: the substances consumed, in- evaluation of the Initiative from 2014 to 2019. Evaluation com-
dividual resiliency, mental health, and family, peer, and ponents included (1) coding and analysis of independent grantee
community norms around substance use [5]. This paper provides evaluation reports, grantee proposals, and annual progress
findings from a multisite initiative funded by the Conrad N. report to the Foundation using NVIVO software; (2) standardized
Hilton Foundation to explore the ability to identify and intervene quarterly process and outcome measures collected across all
in adolescent substance use along that continuum by reaching grantees using a common excel format; (3) monthly monitoring
youth across the multiple settings where they routinely interact. phone conversations between site liaisons and grantee staff
It focuses on the results of Hilton Foundation grantees’ imple- checking in on data reporting, quality and challenges; and (4) a
mentation and intermediate outcomes of implementation. Other survey of grantee leadership to gain a better understanding of
papers in this supplemental volume draw on additional infor- the various approaches to implementation of youth SBIRT being
mation gathered as part of the evaluation and deal with the utilized across the Foundation’s diverse grantees in the Initiative.
longer-term outcomes and impact of the screening, brief inter- The quarterly data collection instrument each grantee filled out
vention, and referral to treatment (SBIRT) protocols. followed the RE-AIM framework, developed by Glasgow and
SBIRT is a public health approach designed to identify and colleagues, that collects data on multiple programs within the
address substance use risk. The underlying logic of SBIRT is categories of Reach, Adoption, Implementation, and Mainte-
simple: by routinely screening youth for substance use, youth- nance (The RE-AIM framework organizes the components of
serving providers can identify risk and provide basic education, program evaluation into basic data collection elements collected
intervene in an early phase of substance use, and facilitate a across all grantee programs. See Glasgow RE, Vogt TM, Boles SM.
referral for those in need of formal treatment. The SBIRT Evaluating the public health impact of health promotion in-
framework has been used effectively with adults, primarily in terventions: the RE-AIM framework. Am J Public Health. 1999;
medical settings [6], but has been less frequently used with 89(9):1322e1327). Data collected quarterly from each grantee
youth or in youth-serving settings [7e11]. included contextual information on grantee setting; staff work-
The first step of the process involves screening using a brief, flow and staff training; screening and brief intervention (BI)
validated instrument designed to quickly identify any potential instrumentation; numbers of youth screened, receiving a BI, or
risk and aid the provider in determining the next steps. For ad- referral to treatment (RT); and (for a subset of grantees) numbers
olescents indicating no substance use, the response is to rein- of youth rescreened/followed-up on to measure changes in
force current positive behaviors and share educational materials. outcomes. Monthly monitoring calls between site liaisons and
If the screening score indicates low to moderate risk, a brief grantee staff included a set of questions to track progress
intervention (BI) is provided. If the screening indicates more (e.g., What phase of the project are you in currently? What ac-
acute risk, the provider refers the adolescent to specialty treat- tivities are you currently working on? Have you engaged in any
ment (RT) services for further assessment and care. This dissemination activities since our last call? Have you conducted
sequence enables providers to screen large numbers of youth at any trainings or meetings? Are you on track to meet your target
varying stages of risk. numbers?), address any data collection issues, and discuss
Based on early research, the American Academy of Pediatrics implementation successes and challenges. Notes from these
released a policy statement in 2011 recommending the use of conversations were recorded in a data collection database each
SBIRT as part of routine pediatric care. In 2013, the Conrad N. month. The evaluation team regularly reviewed these notes but
Hilton Foundation launched a Youth Substance Use Prevention did not code them due to the wide variation in responses.
and Early Intervention Strategic Initiative (the Initiative) focused Grantees submitted annual progress reports to the Hilton
on advancing the SBIRT framework in multiple youth-serving Foundation, which we reviewed, coded, and analyzed using
settings. The Foundation awarded more than $81 million to 56 NVIVO software. The Abt Institutional Review Board reviewed
grantees across the country implementing SBIRT in primary care, and approved all aspects of the project.

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Results Table 2
Number of youth reached per setting

Increased capacity for prevention and youth access Setting Total Total BI Total
screened RT
An important component of the evaluation was to determine Primary Care 56,605 2,992 659
whether SBIRT could be implemented in a variety of settings to Schools and School-Based Health Centers 74,908 3,305 390
expand youth access to prevention and intervention services, Community-Based Organizations 4,240 3,681 550
Community Behavioral Health 4,987 1,844 385
and as a result, impact youth substance use more broadly.
Organizations
The evaluation involved 56 grantees implementing SBIRT in Juvenile Justice Programs 490 450 228
more than 1,266 sites across the country. These sites represented Total 141,230 12,272 2,212
settings where youth routinely interact with adults, as well as
places with the potential for reaching youth at higher risk.
Table 1 represents the number of sites implementing SBIRT by
setting: pediatric and primary care, schools and school-based services in these settings. But SBIRT has not been widely adopted
health centers, community-based organizations, community in pediatric primary care due in part to the belief expressed by
behavioral health organizations, and juvenile justice programs. many physicians that specialized behavioral healthcare providers
Sites incorporated SBIRT into existing workflows and under- (i.e., drug and alcohol counselors, social workers, and psycholo-
went training to increase providers’ SBIRT delivery skills such as gists) are better suited to dealing with the issues like drug and
utilizing a validated screening tool and evidence-based brief alcohol use [12] than physicians. However, the Initiative was able
intervention approaches such as motivational interviewing. Over to expand SBIRT to over 392 primary care settings, including
37,000 youth-serving providers, including frontline staff such as pediatric clinics and health centers where over 56,000 youth
nurses, doctors, and social workers, were trained through the were screened; 5% of those screened received a BI, and 1%
Initiative. Training efforts through the Initiative also included received an RT. Factors that influenced the degree to which SBIRT
addiction medicine fellowships and prevention and intervention services were successfully implemented in primary care include
curricula for medical, nursing, and social work students. limits on provider time, workflow integration, staff turnover,
All the sites were implementing SBIRT for the first time; organizational buy-in, availability of technology (e.g. tablets for
therefore, the evaluation focused heavily on measuring imple- screening, electronic health records), access to specialty treat-
mentation success (described in this paper) rather than tracking ment networks, and the potential for reimbursement for
outcomes by following youth served. However, some of the services.
grantees had the resources and ability to track outcomes of youth Community behavioral health organizations (CBHOs) are ad-
over time, and select results are presented in subsequent articles vantageous locations to reach youth as they include adolescents
in this supplement, as well as in other journals. We discuss the already accessing mental health services. Through the Initiative,
RE-AIM components Reach and Implementation in this paper. CBHOs screened a total of 4,987 youth at 32 sites, provided BI to
Effectiveness is covered in other papers in this supplement and 37%, and provided an RT to 8% of those screened.
was part of the overall evaluation. Adoption of the protocol is SBIRT has not been widely utilized in juvenile justice pro-
reflected in the many programs and sites under the auspices of grams despite the large numbers of high-risk youth in these
each grantee who was successful in executing the SBIRT protocol. settings. The higher concentration of youth in this setting that
The evaluation was not able to follow grantees beyond 2019, and may need services was evident in high rates of brief in-
therefore, we are not able to address Maintenance. terventions and referrals to treatment uncovered in this setting.
Each setting in the Initiative reached large numbers of youth Through the Initiative, SBIRT was implemented in 24 sites
(Table 2). The variation in the proportion of youth who received a serving justice-involved youth. More than 490 youth were
BI and/or an RT represents not only variation in the proportion of screened in these sites; 92% received a BI, and 47% were referred
higher risk youth screened at each setting (i.e., juvenile justice to more formal treatment.
programs vs. primary care) but also relates to capacity of pro- SBIRT was also successfully implemented in 478 schools and
viders to implement in different settings, i.e., low reimbursement school-based health centers where 74,908 youth were
potential, competing demands, time limitations. Grantees did screened, 4% were provided a BI, and 1% were provided an RT.
not report how many youths they could have potentially Schools are a logical setting to introduce the full spectrum of
screened, but rather just those that they actually screened. We prevention activities, but traditionally schools have relied pre-
discuss each setting below. dominantly on primary prevention activities such as educa-
Pediatric and general primary care practices are logical sites tional messaging. Having counselors, school nurses, and
to screen a broad swath of youth, as youth receive routine health providers in school-based health centers administer SBIRT, both
prevention messages and direct health services could be made
available to youth.
Table 1 Through the 326 community-based organizations imple-
Number of sites implementing SBIRT by setting
menting SBIRT, 4,240 youth were screened, 87% received a BI,
Setting type Number of sites and 13% received an RT. The community-based programs of this
Primary Care 392 grantee were part of a nationwide network focused on providing
Schools and School-Based Health Centers 478 job skills training and leadership development opportunities for
Community-Based Organizations 330 youth from high-risk circumstances. Like the juvenile detention
Community Behavioral Health Organizations 42
sites, community-based organizations’ screenings resulted in a
Juvenile Justice Programs 24
Total 1,266 higher percentage of youth screened as in need of either a BI or
an RT.

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Increasing access by expanding the SBIRT workforce intervention on the physicians and/or nursing staff in the ma-
jority of these often time-constrained settings. Some sites miti-
A core part of the Initiative’s strategy was to increase the gated this challenge by training intake staff in the screening
capacity of the youth-serving workforce through SBIRT training. protocol relieving the physician of this component of the pro-
While youth routinely cross paths with providers in each of these cess; one site used a tablet for the initial screening but then had a
settings, we found that few providers had been trained to iden- staff member (nurse or physician) take further action with the
tify and respond to youth substance use once identified. This was individual if needed based on screening results.
due in part to little standardized training curricula or approaches Confidentiality was also a challenge across the settings,
designed especially for youth, although there are curricula particularly in schools, where grantees faced the issue of
appropriate for adults. One of the Hilton Foundation’s first areas whether they could screen youth without notifying parents.
of investment was to support activities to (1) educate youth- Some schools addressed this through “passive consent” proced-
serving providers about adolescent substance use as a health ures that send general notices regarding a universal screening
concern, and (2) teach providers in multiple settings how SBIRT plan; if a parent does not specifically object to the screening for
could serve as a framework to prevent initiation and reduce their child, then screening can occur. Other schools sent home a
escalation of use. Grantees disseminated specially developed more formal consent document to parents asking for consent for
information and training materials to more than one million a universal health screening for their child that included alcohol
individuals, including an implementation checklist; an interac- and substance use questions; these sites found that the majority
tive, online SBIRT training technology platform; toolkits and an of, although not all, parents consented when it was framed in a
adolescent SBIRT implementation guide providing operational broader health context.
and clinical guidance and benchmarks; fact sheets; evaluation Reimbursement for SBIRT was another persistent challenge
tools; case studies; and guidance around billing and reimburse- to implementation in a grant-supported arena. Billing differ-
ment for SBIRT services. ences by state, provider, and setting type, along with the
A key tool for the workforce expansion was the wide complexity of Medicaid and licensing restrictions, made navi-
dissemination of curricula in health professional training pro- gating this issue challenging. For example, while school health
grams and the establishment of addiction medicine fellowship practitioners (school nurses) were generally able to use time
programs. The grantees trained over 37,000 individuals, already designated as part of their regular activities for SBIRT,
including nursing and social work students, medical residents, pediatricians had to determine how the time could be reim-
and addiction medicine fellows. One grantee designed and bursed through specific Medicaid or insurance categories
implemented a classroom-based curriculum and virtual patient- available in their state. Although many states now have
provider simulation program in more than 80 schools of nursing approved Medicaid codes for the reimbursement for SBIRT,
and social work, through which nearly 16,000 students received some do not; and in some states, the codes may only be used in
education on adolescent SBIRT. In addition, to date, 83 Addiction medical settings, are restricted to certain professionals to use,
Medicine Fellowship programs have been accredited by and/or are time-based. The Initiative invested in policy analysis,
Accreditation Council for Graduate Medical Education. Given the advocacy, and dissemination of information regarding the use
scope of the audiences involved in the training, the grantee was of cost-reimbursement codes and strategies across the states
not able to follow up with an assessment of information gains or for reimbursement. For example, a grantee created an online,
implementation of the techniques posttraining. interactive map with information on billing for substance use
prevention and early intervention, including information on
Challenges to implementation each state’s Medicaid coverage.
The referral to the treatment portion of SBIRT was a signifi-
Each setting provided important new access to youth. The cant challenge for many sites for several reasons. First, many
challenges of implementing SBIRT differed across the settings, providers and programs had never interacted with the specialty
though there were common issues: difficulty with adjusting substance use disorder service system before. Second, the
changes to workflow, confidentiality, reimbursement, the avail- availability of treatment for adolescents is more limited than
ability of referral options in their geographic area, and the need what is available for adults. Third, there are often few guidelines
to address mental health concerns as a critical part of adolescent for managing what can be a complex process of steering high-
substance use prevention. risk youth into the appropriate treatment program [12]. While
Pediatric primary care settings found it particularly chal- it is important to note that only a relatively small proportion of
lenging to find sufficient time to create a useable and sustainable youth screened required formal substance use disorder treat-
workflow and often struggled to fit the SBIRT protocol smoothly ment, many providers felt that they had limited knowledge of
into an already established routine of intake and various devel- available treatment options, which options are evidence-based,
opmental and preventive screening questions. In the case of and the best match for the youth. As a result, many providers
physicians conducting the protocol, the time needed in addition felt unprepared to determine the most appropriate type of
to the health visit proved challenging due to time constraints in referral for the youth and their families based on screening re-
primary care settings. In an implementation survey of leadership sults. In some instances, grantees reported that potential sites
at sites, 83% of the pediatric primary care clinics reported that the declined to participate in SBIRT programs because they felt they
primary care provider was responsible for substance use did not have an adequate referral network. To address this bar-
screening, and behavioral health providers (social workers, rier, one grantee developed a youth-specific referral network
counselors, or psychologists) did the screening in 16% of primary across the state, resulting in nearly 70% of participating practice
care practices. Similarly, in 83% of the school-based health cen- sites building relationships or partnerships with other organi-
ters, primary care providers were responsible for screening. This zations, including treatment centers, behavioral health pro-
placed the burden of finding time for the screening and potential viders, and school-based student assistance program counselors.

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Given that an estimated one in eight adolescents and young implementation and outcomes are less represented in the liter-
adults suffers from depression [13], it is not surprising that ature. Testing the feasibility of reaching large numbers of youth
grantees repeatedly noted the need to address mental health in different settings was the goal of the Hilton Foundation’s
issues as part of adolescent substance use prevention efforts. The Initiative.
literature highlights this need [14,15]. The implementation sur- The Initiative succeeded in (1) introducing SBIRT into wide-
vey of grantees asked programs what other health and social ranging settings (2) preparing a large number of providers to
issues they should address when screening youth for substance address substance use through training, and (3) disseminating
use (i.e., mental health, intimate partner violence, food/housing findings to the broader field. The Initiative demonstrated that a
insecurity/safety, legal problems, and school conduct/perfor- variety of providers could be specially trained to reach large
mance). Across settings, respondents identified screening for numbers of youth with simple screening techniques, and early
mental health issues as the most critical need, although the rate risk can be addressed through a brief intervention. Additionally,
of mental health screening varied considerably across settings. screening in a variety of youth-serving settings meets youth
Ninety-five percent of primary care or pediatric settings indi- where they are and increases access, potentially uncovering the
cated that they screen for mental health issues. School programs need for services in youth who would otherwise not have been
and school-based health centers also have high screening rates identified. Unfortunately, without widespread screening across
for mental health issues at 90% and 83%, respectively. However, multiple settings, substance use concerns may not be recognized
only 76% of community-based programs were conducting mental until youth face serious consequences. Of the 141,230 youth
health screenings. screened, over 12,000 received a brief intervention, and over
The last phase of the evaluation focused on the ultimate 2,000 received a referral to treatment. Important challenges
impact of SBIRT to delay or eliminate initiation and/or reduce emerged related to implementation: workflow issues, payment
substance misuse. Some grantees collected short- and long-term options, billing, identifying treatment networks, and addressing
outcomes, including using electronic health records to track the role of mental health issues in youth substance use. These
outcomes for large numbers of youth over time. Other grantees challenges present opportunities for future implementation ef-
conducted traditional randomized controlled studies of varying forts: address sustainability of SBIRT in a wide variety of youth-
elements of SBIRT practice. Several grantees were able to follow- serving settings, expand the lens on substance use issues to
up with youth who had received the SBIRT protocol, while others include mental health screening and services, and solidify
did not have sufficient resources to conduct this type of follow- financial support for early intervention services [16].
up. The results addressing the outcomes and impact of the The evaluation also highlighted the often undetected in-
Initiative (i.e., “Can using SBIRT for youth in these settings pre- terventions needed across settings where screening or even
vent, delay onset, or reduce youth substance use?”) are pre- discussion about substance use is not occurring. Not unexpect-
sented in subsequent articles in this supplement. edly, much higher levels of need were found in youth detention
and community-based programming. Other places where
Limitations of the study “upstream” interventions can be useful, like school-based set-
tings and routine primary care, also point to the need for a more
The funding offered by the Foundation as part of this Initiative universal approach to delivering SBIRT. Our results suggest that
was a result of its long-standing interest in preventive substance all of these settings are both feasible and critical intervention
use measures for youth. Grantees submitted proposals with a points.
wide array of goals and plans to implement SBIRT in various
types of settings, ranging in size from programs with a single Acknowledgments
location to sites throughout a community or in multiple states.
Because this effort focused on determining whether the SBIRT We wish to thank Alexa Eggleston and The Conrad N. Hilton
protocol could be implemented for a youth population and in Foundation for their guidance, the grantees of the foundation’s
settings previously not utilized for youth, the Foundation did not Substance Use Prevention strategic initiative, and our other
place data collection requirements on grantees beyond narrative evaluation team members, Bill Villalba and Diane Fraser.
progress reports. When Abt Associates undertook the evaluation
of the initiative, we provided grantees with the RE-AIM structure Funding Sources
to gather common implementation and outcome measures that
we subsequently collected quarterly in simple excel formats. This work was supported by the Conrad N. Hilton Foundation
Grantees that were more accustomed to research collected (Grants 20130435; 16742; and 18447 (PI Hunt). The content is
additional data on things like numbers of youth eligible for solely the responsibility of the authors and does not necessarily
follow-up and their follow-up data and these studies are re- represent the official views of the Conrad N. Hilton Foundation,
ported in this supplement. Other grantees had challenges which had no role in the design and conduct of the study; data
providing data, which resulted in limitations as to what the acquisition, management, analysis, and interpretation of the
overall evaluation could demonstrate. data; and preparation, review, or approval of the manuscript.

Discussion
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