Rachel Yard and Pamela Winkler Tew, MSS, LSWAugust 13, 2019
While experimentation with drugs and alcohol is often characteristic of the adolescent years, there are many risks associated with this behavior. Not only are adolescents more vulnerable to addiction than adults, but they are also at a high risk of experiencing lifelong chronic health issues related to substance use. This is especially alarming in the context of the growing opioid epidemic, which claims about 130 lives every day across the country.
Early identification of risky substance use is critical to prevent addiction and long-term health and social issues for adolescents. Screening, Brief Intervention, and Referral to Treatment (SBIRT), an evidence-based prevention and treatment strategy, is a promising intervention for at-risk adolescents, as well as for youth who already suffer from substance use disorder (SUD). Though originally developed for identifying risky alcohol use among adults, SBIRT is a useful tool for building trust between providers and youth and can open up a dialogue between adolescent patients and their doctors on a range of other health-related topics that may be difficult to discuss, such as obesity, mental health and sexual orientation/gender identity.
Hillary Whonder-Genus, MD, medical director at Virginia Premier Neighborhood Health Center and practicing pediatrician, championed Virginia Premier Health Plan’s participation in Improving Access to SBIRT Services for Adolescents, a learning collaborative led by the Center for Health Care Strategies (CHCS) in partnership with the Association for Community Affiliated Plans through funding from the Conrad N. Hilton Foundation. CHCS recently spoke with Dr. Whonder-Genus to discuss her experience implementing the SBIRT framework, with insight as both a pediatrician and health plan medical director.
Q: How were you first introduced to the SBIRT framework?
A: The chief medical officer at Virginia Premier and I were discussing the opioid epidemic occurring in the southwestern region of Virginia, where I practice. She had heard of the CHCS collaborative and thought it might be a good fit for the organization and our integrated primary care/behavioral health practice. I was not aware of SBIRT’s potential for use in the primary care setting — but my interest was piqued.
Q: How has SBIRT been valuable to your work as a primary care provider working with adolescents?
Integrating the SBIRT screen during these visits opened up a whole new world to explore with teen patients. It provided an opportunity to dive deeper into what was going on in their lives, not just about substance use, but the current social determinants of health affecting their daily lives.
A: It has been amazing. Prior to implementing SBIRT, adolescent wellness visits were fairly routine, focusing primarily on completing sports pre-participation exams and other related activities such as immunizations. Integrating the SBIRT screen during these visits opened up a whole new world to explore with teen patients. It provided an opportunity to dive deeper into what was going on in their lives, not just about substance use, but the current social determinants of health affecting their daily lives. It is a chance to address their ability to cope with depression and/or anxiety and determine what in their social environments may predispose them to a higher risk for SUD — so many things that, as a pediatrician, I would not necessarily have time to consider during those visits. With SBIRT, a positive screen is right in front of you on a piece of paper, “This adolescent is at risk for substance abuse,” and as his or her pediatrician, what are you going to do about it? That was extremely valuable.
The other piece I found especially valuable was learning how to use motivational interviewing with adolescents. The technique is applicable beyond SBIRT screenings, and was a truly valuable addition to my skillset as a pediatrician. It has provided me an opportunity to enhance the care I provide — it has made visits so much more meaningful for both the patient and provider. I feel I am a better provider and communicator following SBIRT implementation.
Q: In addition to SBIRT, your practice screens for anxiety, depression, and adverse childhood experiences. Has the SBIRT framework changed how you approach any of those screenings?
Since implementing SBIRT, I have found myself better able to identify at-risk teens, and do something for them right there in my office — help them to think of ways that they might handle their lives differently without substances, or get them to think about how their substance use is affecting their lives in general.
A: Before implementing SBIRT, I automatically referred all patients who screened positive for any of these behavioral health issues to a licensed behavioral health provider knowing that the majority of patients would not follow through on the referral. I would follow-up at appointments to ensure they were not getting worse to the point of needing to be admitted to inpatient care, but otherwise did not feel there was much else I could do for them. Since implementing SBIRT, I have found myself better able to identify at-risk teens, and do something for them right there in my office — help them to think of ways that they might handle their lives differently without substances, or get them to think about how their substance use is affecting their lives in general, especially for those with depression or anxiety, and understanding how their substance use may be related to those things. This has been a huge game-changer for me. Now I can impact these teens’ lives right then and there, rather than just give them a referral and hope they follow through with it.
Q: What challenges have you faced in implementing SBIRT from a health plan perspective?
A: As a health plan, the challenging piece has been to develop a sustainable program where network providers understand the promise and potential of SBIRT in the primary care setting. Schedules are packed, and it can be difficult to convince a provider that he or she should add another ‘task’ to their workload. While training providers as part of our pilot program, we found that some were just uncomfortable discussing the difficult topic of substance use with their adolescent patients. It was easier to ask the patient if he or she smoked, drank, or did drugs, and if they said no, move on with the appointment. We overcame this challenge during training sessions by using role play activities to give the providers practice having these tough conversations, and they ultimately realized it was something they could handle.
Q: What incentive do health plans have for integrating SBIRT into their network of providers? What is the argument to engage providers?
A: Implementing SBIRT ultimately impacts health outcomes, and every health plan is concerned with improving their members’ health outcomes. Identifying the barriers to care and being able to motivate members to change a negative behavior ultimately leads to better health outcomes. Health plans also want to decrease the rate of loss of life, particularly in the substance abuse era of opioid overdoses. There could be factors of depression, reckless behavior, or other contributing issues to substance use, all of which can be addressed to some degree using SBIRT.
Q: What advice would you give a health plan or provider interested in implementing SBIRT?
Ultimately there is a lot that can be achieved using SBIRT in the primary care setting that may have gone undone if there is only a screen and non-specific referral. Your quality of work will get better with SBIRT, and you will potentially get better outcomes, too.
A: Be prepared to spend a little more time with patients and prioritize the reason you are investigating and using this technique. Ultimately there is a lot that can be achieved using SBIRT in the primary care setting that may have gone undone if there are only a screen and non-specific referral. Your quality of work will get better with SBIRT, and you will potentially get better outcomes, too. Most importantly, you will develop a trust with each member, which I think is equally important as any HEDIS measure or data point that you can gather from that encounter.