An evaluation of documentation and follow-up on the use of SBIRT in an outpatient behavioral health clinic through the use of the CRAFFT tool.

Background: Substance use among adolescents continues to present as a public health concern. Screening, Brief Intervention and Referral to Treatment (SBIRT) is an effective process that has been proven to identify, reduce, and prevent at-risk use of substances when appropriately applied. The CRAFFT tool is an evidence-based screen used to identify substance use in adolescents aged 12-21 years of age.

Purpose: The purpose of this project is to assess the rates of substance use in the adolescent population at a behavioral health clinic through the CRAFFT tool while also assessing for provider documentation compliance and overall revenue benefits of SBIRT.

Methodology: A retrospective chart review was used for this practice evaluation. Descriptive statistics were used through assessing frequencies and averages to gain insight not only on the rates of at-risk substance use and documentation compliance, but also on psychiatric diagnoses and medication regimens.

Results: Three hundred and forty-one patient encounters were reviewed over a 3-month period. Of these 341 encounters, 63.6% of the visits were in-person and 36.4% were conducted virtually. 72.4% of patient encounters had no documented CRAFFT screen, yet 31% of completed CRAFFT screens were positive for substance use or misuse. For those encounters with no completed CRAFFT screen documented, there was an estimated lost income for potential billings at a rate of $33.41 per encounter for a total of $8252.27.

Conclusions: Substance use and misuse in adolescents continues to exist as a public health concern. The CRAFFT tool can be a feasible means of screening for substance use in adolescents when consistently and longitudinally incorporated.