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Implementing Substance Use Screening Toolkit

Toolkit/Guide
Linkages to Primary Care and Other Services

Data from the Substance Abuse and Mental Health Services Administration (SAMHSA) indicates that in 2018 there were an estimated 32.1 million adult women who have a mental illness or substance use disorder.1 Additionally, about 15% of young adults ages 18 to 25 needed treatment for substance use but did not get it in 2019.2 Title X-funded agencies are well positioned to screen for substance use, as they are the usual source of care for six in 10 women and are a primary entry point to the health care system.3

The goal of substance use screening is to identify “individuals who have or are at risk for developing alcohol-or drug related problems.”4 Screening for substance use is not diagnosing someone with a substance use disorder. Diagnosing someone with a substance use disorder should be done by a trained behavioral health provider.

 

Illustration of a seated female doctor and a standing male patient in an exam room talking.

The purpose of this toolkit is to support Title X grantees, subrecipients, and service sites in implementing the Title X priority to screen family planning clients for substance use.

The toolkit is organized by the following steps:

  • Assess Need for Services
  • Integrate Substance Use Screening into a Family Planning Visit
  • Train Staff to Understand Addiction and Substance Use
  • Adapt Workflow Changes
  • Evaluate Screening and Conduct Quality Improvement

 

In preparing to implement substance use screening, family planning agencies should assess the need for substance use services in their communities. Consider the community’s need for a broad range of substance use services including screening, brief intervention, referral to treatment or on-site treatment, etc. Information about the prevalence of use of various substances (e.g. alcohol, drugs, marijuana, tobacco, etc.) will inform decisions around what screening tools are needed and how best to incorporate screening into the family planning visit.

Action Steps Supportive Resources

Form a change team including clinical, management, front desk, and other staff to lead implementation.

Implementing Sustainable Quality Improvement eLearning (Module 4)

Review state and local data to understand substance use rates in the community such as the National Survey on Drug Use and Health, Behavioral Risk Factor Surveillance System, Youth Risk Behavior Surveillance System, and data from state departments of health.

Complete a readiness assessment and review results with the change team and other key stakeholders.

 

After identifying a need for substance use screening, it is important to decide how the screening will be integrated in a family planning visit. A commonly used screening model is the SBIRT model (Screening, Brief Intervention, and Referral to Treatment). Screening for mental health disorders should also be considered, as many people who develop a substance use disorder also have mental health needs.1 Additionally, common risk factors can contribute to both mental illness and substance use disorders.

Action Steps Supportive Resources

Learn about SBIRT and how it can be implemented in a Title X setting.

Substance Use & Family Planning Webinar Part 2

As appropriate, train staff on the SBIRT model.

Determine which substance use screening tool(s) to use.

Conduct a process map (or process flow) to determine when, where, and how screening will be integrated into the family planning visit.

Flowchart Worksheet

Spaghetti Diagram Worksheet

Determine which screening tool will be used, if at all, for mental health disorders. One option is the Patient Health Questionnaire (PHQ)-9. An agency’s electronic health record that may have built-in screening tools.

Develop a referral list of substance use (or mental health) providers in the community.

Develop a policy to refer clients to additional care.

 

Substance Use & Family Planning Webinar Part 3

Establishing and Providing Effective Referrals for Clients: A Toolkit for Family Planning Providers

After assessing the need for screening services and determining how a Title X agency will integrate screening for substance use in a family planning visit, it is important to train any and all staff who may be impacted by this change. If an agency is also going to screen for mental health, this should also be addressed in the training. As the body of evidence and understanding of substance use disorders has changed significantly over time, providing overviews of substance use and person-centered language is critical.

Action Steps Supportive Resources

Provide staff training on an overview of substance use disorders.

Substance Use & Family Planning Webinar Part 1

As needed, conduct training on person-centered language, harm reduction, trauma-informed care, addiction and the brain, and other related topics.

Providing Trauma-Informed Care in Family Planning Clinics Webinar

Conduct training on how to identify, understand, and respond to a mental health crisis, the importance of screening, and how to screen for mental health disorders.

Depression Screening in Family Planning Settings Webinar Part 1

Depression Screening in Family Planning Settings Webinar Part 2

Conduct training (or refresh knowledge with a podcast) on motivational interviewing in the context of substance use.

Train clinical staff to ensure they are documenting and coding screening in electronic health records.

 

Coding with Ann: Coding for SBIRT - Episode 11

With the addition of screening for substance use in Title X settings, there will be workflow changes that will impact delivery of care. These may include changes to an agency’s electronic health record software, documentation and coding for screening, along with billing and reimbursement processes. Other policies and procedures may need to be updated, including how to discuss screening with clients and reimbursement terms outlined in contracts with third-party payers. Finally, all changes must ensure client confidentiality.

Action Steps Supportive Resources

Modify the electronic health record to include substance use screening, if needed.

Update policies and procedures as needed to reflect new screening protocols.

Provide scripts, as needed, for front desk staff and other staff who are involved in screening.

Review contracts with third-party payers to see if substance use screening services are reimbursable. Renegotiate, if needed.

Financial Management Toolkit

Develop a plan to ensure client confidentiality with regards to 42 CFR Part 2 program compliance.

Assess the impact of screening on clinic flow measures like cycle time, wait time, and client stops.

 

Clinic Efficiency Dashboard

Clinic Flow Assessment

After starting to implement screening for substance use, it is important to conduct quality improvement and evaluate the impact of screening. Improvement of substance use services is an ongoing effort as research and our shared understanding of the causes of historic and persistent disparities evolves. As we gain a greater understanding of historical disparities in how substance use disorders were viewed and services were delivered, Title X agencies may want to examine and implement new evidence-based practices. Consider conducting client satisfaction surveys and/or other quality improvement efforts.

Action Steps Supportive Resources

Determine how performance and success (e.g., number/percentage of clients screened) will be measured. Consider SAMHSA, Rural Health Information Hub, and American Society of Addiction Medicine (ASAM) resources and measures.

Conduct client and/or staff satisfaction surveys to evaluate the consistency and quality of screening for substance use.

Conduct quality improvement efforts to continuously improve screening for substance use.

 

Introduction to Quality Improvement for Family Planning eLearning (Module 1)

  1. SAMHSA. 2018 National Survey on Drug Use and Health: Women. SAMHSA, US Department of Health and Human Services; 2020.
  2. SAMHSA. Key Substance Use and Mental Health Indicators in the United States: Results from the 2018 National Survey on Drug Use and Health. SAMHSA, US Department of Health and Human Services; August 2019.
  3. Guttmacher Institute. The Role of Family Planning Centers as Gateways to Health Coverage and Care. Guttmacher Policy Review, 14:2; June 2011.
  4. SAMHSA. A Guide to Subs Screening for Substance Abuse Services for Primary Care Clinicians. Treatment Improvement Protocol Series, 24; 1997.