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Before the pandemic, the City of Philadelphia had high rates of substance use and reports of poor mental health. While it will be sometime until the full effects of COVID are know, we expect significant increases in the need for services. Philadelphia ranks among the worst of all large cities in binge drinking, tobacco use and substance use. The City is considered the epicenter of the Nation's opioid epidemic with the highest rate of overdose deaths of any big city in America. The primary goal of this project is to identify and effectively intervene with adolescents and adults who are at moderate to high risk for psychosocial or health care problems related to their alcohol, tobacco, or substance use. To achieve this goal we have the following objectives: increase the number of community settings where SBIRT is provided; develop a quality improvement plan to ensure model fidelity across all sites; increase the number of unique population groups receiving services including adolescents, pregnant women, interconception women and underserved primary care patients. This project will serve 219,678 unduplicated individuals over five years. Einstein Healthcare Network is a private, non-profit multi facility network serving one of the most disadvantaged populations in the nation. Einstein is considered a private healthcare safety-net, bearing a large share of responsibility for caring for the poor as measured by service to Medicare, Medicaid and uninsured. Einstein's mission is With humanity, humility and honor, to heal by providing exceptional healthcare and education for as many as we can reach.

The Douglas County Community Services Board’s (DCCSB), "Screening, Brief Intervention, and Referral to Treatment in Douglas County, GA", proposes to help 8,790 justice-involved youth and adults ages 15 and up that are at-risk of substance abuse or dependency as identified by a project partner or network affiliate. DCSSB internal data shows that a significant number of Douglas County residents suffer from alcohol dependency as well - as such, this SBIRT will embed evidence-based interventions and treatments specifically to treat those at risk of alcohol, opioid, and heroin abuse. DCCSB's goals and objectives are as follows: Goal 1: Decrease rates of overdose and morbidity due to SUD in Douglas County, Georgia. Objective 1.1: Exponentially increase early intervention screening and activities by establishing three pilot screening sites through county-based agencies; Objective 1.2: Screen up to 1,000 people annually to identify those at-risk of SUD; Objective 1.3: Provide up to 250 people annually at least one brief intervention and/or treatment option for residents suffering from SUD. Goal 2: Establish a comprehensive and uniform pre-screening and referral protocol among disparate county entities to ensure saturation of early identification procedures throughout the county. Objective 2.1: Create at least one training and referral protocol to be facilitated by DCCSB staff at all pilot screening sites; Objective 2.2: Conduct annual audits at individual site services and population served to establish unique barrier mitigation and intervention activities to complement standardized services; Objective 2.3: Expand screening services by up to five additional sites (year two of grant term only). Goal 3: Establish a comprehensive communication plan among all participating county entities to ensure that the pipeline of screening, intervention, and treatment is viable, sustainable, and expandable. Objective 3.1: Convene site participants up to four times annually, through either an advisory council or workgroup, to manage and oversee all SBIRT site screening and referral implementation; Objective 3.2: Develop up to three county-wide collaborative impact goals to address SUD related health crises and disparities, including, but not limited to: Early intervention strategies for youth, transitions for recovering and justice-involved residents, assistance addressing psychosocial needs/barriers, including homelessness, aging out of foster care, and unemployment. All of the above goals and objectives fully align with the identified needs of the community.

Fairbanks Native Association (FNA) has developed the Fairbanks North Star Borough (FNSB) Early Intervention Project (Early Intervention) to provide Screening, Brief Intervention and Referral to Treatment (SBIRT) services to all ethnicities of children, adolescents, and adults in Alaska’s FNSB region. This project will expand and enhance the FNSB’s behavioral health (BH) continuum of care through the leadership of its community coalition (BH Council). While FNA is an Alaska Native non-profit and some funding is American Indian/Alaska Native-specific, Early Intervention will, like many FNA projects, serve all ethnicities. FNA is ideally placed due to its 50 year tenure in the FNSB. During two of these decades, FNA served as the only substance abuse provider in the region. The FNSB has a high at risk population due to significant rates of BH problems, as documented in Section A of this proposal. FNA is the lead agency for Early Intervention. FNA will initially provide SBIRT services in two Specialist and two Generalist settings and will add four Generalist settings in the middle of year one. Specialist settings are 1) the FNA BH Center Prevention Department, and 2) Interior AIDS Association, a medication-assisted treatment provider. Generalist settings are 1) Thriv, an Early Childhood/Family provider and 2) the Effie Kokrine Charter School, which serves at-risk adolescents. Four new Generalist settings will come on-line during project year two. Settings are selected to achieve maximum early intervention coverage for all age groups in the FNSB. Early Intervention will be guided by the FNA-established BH Council. The BH Council’s 18 members provide System of Care and recovery support services in the FNSB in the following service domains: Substance Abuse, Mental Health, Juvenile and Criminal Justice, Child Welfare, Head Start, Education/Employment, Spiritual/Religious, Housing, and Social Services. The goal of Early Intervention is to reduce alcohol and other drug use through early intervention. It is guided by three phases with outcomes identified for each phase. Phase I: Project Planning and Start-Up outcomes are 1) organizational structure results in smooth operations and 2) Quality Improvement results in required Government Performance and Results Act (GPRA) outcomes. The Phase II: Operations outcome is to achieve positive change in required GPRA outcomes (abstinence, housing status, employment and/or education, criminal or juvenile justice involvement, social connectedness, at-risk behaviors, emergency department use, hospitalization for SUD or mental, suicide attempts, utilization, and retention in services). The Phase III: Phase Out outcome is the project is sustained in 100% of the specialist sites and in 50% of Generalist sites. Early Intervention’s two highly qualified evaluators will guide improvement, ensuring this project is assessed and adjusted to achieve designated outcomes. Early Intervention will serve 885 unduplicated individuals over the five year project period intervening at the problem drinking stage to avoid long-term addiction.

Centerstone Screening, Brief Intervention, and Referral to Treatment (C-SBIRT) will enhance and expand the continuum of care for substance use disorder services by integrating SBIRT in 6 Tennessee counties (Cheatham, Dickson, Houston, Montgomery, Robertson, Stewart). C-SBIRT will pre-screen an unduplicated total of 35,000 individuals (ages 12+) presenting in primary care/community health settings (Y1: 3,000; Y2: 7,000; Y3: 10,000; Y4: 11,000; Y5: 4,000). C-SBIRT’s focus population demographics are expected to mirror the catchment area’s 320,500 children, adolescents, and adults (ages 12+): 48% male, 52% female, 76% white, 12% African American, and 6% Hispanic/Latino individuals. Subpopulations include the 45% of catchment area individuals who live in rural areas, the 14% who are Veterans, and the 18% who are racial/ethnic minorities. Consistent with the area’s clinical characteristics, over 21,000 catchment area individuals are expected to have a substance use disorder (SUD), including 126 with opioid use disorder, and 11,000 catchment area adults, co-occurring disorder (COD). More than 14,800 catchment individuals are expected to have an alcohol use disorder (AUD). C-SBIRT’s strategies/interventions include expanding screenings to identify risky substance use and alcohol/other drug consumption and initiate appropriate evidence-based response. C-SBIRT will use validated screening instruments, including the National Institute of Drug Abuse’s and National Institute of Alcoholism and Alcohol Abuse’s Single Question Screen universal pre-screenings, as well as the AUDIT, DAST-10, and PHQ-9, as indicated, among adults. Youth will receive the Brief Screener for Tobacco, Alcohol, and Other Drugs (BSTAD) pre-screening, as well as the PHQ-A and Car, Relax, Alone, Friends/Family, Forget, Trouble (CRAFFT) full screening, as indicated. SAMHSA’s Treatment Improvement Protocol (TIP) 34: Brief Interventions and Brief Therapies for Substance Abuse will provide a framework for delivering the evidence-based brief intervention, Brief Negotiated Interview, and evidence-based brief treatments, Cognitive Behavioral Therapy, Motivational Interviewing, and Multidimensional Family Therapy (MDFT). Project goals include: 1) Implement a project to provide comprehensive, cost-effective SBIRT services; 2) Develop a sound infrastructure and capacity to enhance, expand, and sustain SBIRT services; 3) Improve outcomes among participants receiving brief intervention, brief treatment, and treatment via referrals; and 4) Develop/disseminate a documented service model for statewide and national replication/adoption. Measurable objectives include: reduce reported days of alcohol/ substance use by 60%; reduce reported days experiencing mental health symptoms by 40% among those with COD; reduce reported days of opioid use by 60% among those who screen positive for opioid use; increase reported abstinence from use by 60%; reduce reported inpatient an ER utilization by 40%; and achieve 80% client retention rate. C-SBIRT has secured commitments from partners dedicated to the project’s success, and will collaborate with primary care providers, including pediatric providers, specialty treatment providers, and key community stakeholders.

The goal of Project Screen Engage and Treat for Success (SETS) is to increase access to person-centered and culturally/linguistically appropriate screening, early identification, intervention and treatment for substance use problems in youth ages 13-17 and their families, and adults in primary care and community health settings. The geographic catchment area includes Lake, Sumter, and Marion, three adjoining counties located North West of Orlando in Florida’s Circuit 5 region. The project will screen at least 3,500 unduplicated individuals per year in years 1 and 5 (to account for program start-up and phase out activities) and 6,000 per year in years 2-4 for a total of 25,000 over the 5-year period of the grant. Our SBIRT teams will have the capacity to provide brief intervention, brief treatment or referral to treatment to approximately 10% of those screened, or 600 patients per year. Obj 1: A minimum of 25,000 individuals will be screened within the catchment area by the end of the grant period. Obj 2: LSF will increase the number of community settings where SBIRT services are provided by at least 5 sites (health center departments, clinics, etc.) by the end of the grant period. Obj 3: At least 30% of youth and families and 45% of adults who are referred for brief treatment or specialty SUD treatment will successfully engage in treatment services. Obj 4: 85% of patients receiving brief intervention, brief treatment or referral to treatment will evidence reduced Alcohol and Other Drug (AOD) use within six months of admission into the program. Obj 5: 75% of the SBIRT grant population successfully engaged in brief treatment or specialty SUD treatment will demonstrate a greater reduction in AOD use in relation to a non-SBIRT comparison group drawn from provider agencies within the LSF catchment area. To implement the required activities, LSF Health Systems (LSF), a not-for-profit, behavioral health Managing Entity contracted by the State of Florida to manage the state-funded system of behavioral healthcare in Northeast Florida, will partner with Langley Health Services (FQHC), LifeStream Behavioral Center, Park Place Behavioral Healthcare and a team of SBIRT subject matter experts to achieve full integration of evidence-based Screening, Brief Intervention, and Referral to Treatment (SBIRT) in participating community health centers.

Tarzana Treatment Centers, Inc. (TTC), one of the largest integrated healthcare providers in Los Angeles County (LAC), will implement Screening, Brief Intervention, and Referral to Treatment (SBIRT) services for adolescents and adults in five (5) of TTC’s Federally Qualified Health Center (FQHC) Look-Alike clinics located in diverse LAC communities (Northridge, Reseda, Palmdale, Lancaster and Long Beach). The overall purpose of TTC’s SBIRT Project is to reduce underage drinking, opioid use, and other substance use among a low-income, high-risk population of primary care patients in LAC by integrating universal screening and SBIRT services in TTC’s FQHC Look-Alike clinics, where TTC provides a full continuum of preventative, acute, and chronic medical care services across the lifespan. In 2020, TTC provided primary medical care for 7,902 unduplicated patients; of these, 8% were 0-17, 26% were 18-34, 17% were 35-44, 41% were 45-64, and 8% were 64+. Some 87% of patients were living under the federal poverty level (FPL) with the remainder living at 100-138% FPL. More than half (54%) were female, at least 58% were racial/ethnic minorities (49% Latino; 14% White; 4% Asian/Pacific Islander; 4% Black; 1% American Indian; 28% Other/Unknown), and 22% were primary Spanish speakers. The proposed project will address increased substance use disorder (SUD) prevalence in LAC, including a 48% increase in accidental drug overdose deaths in LAC during the first five months of the COVID-19 pandemic compared to the same period in 2019, as well as identified service gaps within TTC’s integrated care system. Specific goals and objectives will be accomplished by: 1) building agencywide awareness and commitment to SBIRT principles and evidenced-based practices; 2) conducting a pilot phase to introduce SBIRT in two TTC clinics during Year 1 before expanding to three (3) additional TTC clinics by the end of Year 3; 3) instituting universal screening for all primary care patients (ages 12 and older) for a total of 10,000 unduplicated individuals served during the 5-year project (Year 1: 1,600; Year 2: 2,400; Years 3-5: 2,000 each); 4) integrating behavioral health (SBIRT) specialists into each clinic site to provide Brief Assessment, Intervention, and Treatment and ensure linkage to TTC’s specialty SUD treatment programs for patients assessed with moderate to severe SUDs; and 5) developing a system (including modifying the agency’s Electronic Health Record) to track SBIRT services provided in the clinics and monitor outcomes achieved for each individual screening positive for risky use or an SUD. TTC will utilize evidenced based screening and assessment tools, including validated single-question pre-screeners for alcohol and drug use, AUDIT and DAST-10 for adults 18+, S2BI for youth 12- 17, and brief assessment tools utilized as provisional referral tools for recommending American Society of Addiction Medicine (ASAM) levels of care. Key outcomes include increased abstinence or reduced use of alcohol/drugs, improved social connectedness, increased linkage to specialty SUD treatment services including medications for addiction treatment (MAT) for opioid and alcohol use disorder, and a reduction in Emergency Department and hospital utilization for SUD.

There are more than 420,000 children in foster care in the United States; 38% are aged 10 years or older. This high-risk group has been identified to have increased health problems compared with peers in the general population and, due to a lack of coordinated prevention services, increased exposure to poverty and maltreatment, and other systemic challenges, are up to 5 times more likely to receive a substance use disorder (SUD) diagnosis by age 18 compared to the general population. However, SBIRT has had limited impact on youth in foster care. This is related to a failure to spread SBIRT in specialized foster care health centers in pediatric settings, few effective implementation efforts with children’s services, and frequent disruptions in behavioral healthcare and school experienced by foster youth. This study seeks to increase abstinence of alcohol and other drug (AOD) use among adolescents in foster care, reduce frequency of AOD use among foster youth who have initiated use, and increase referral to treatment for adolescents at highest risk for SUD through standardized implementation of SBIRT into specialized foster care health centers in our region. In partnership with children’s services and community behavioral health, including organizations providing substance use disorder treatment to youth in foster care, we will screen all youth in foster care in our region (N = 2240) and provide brief intervention during mandated visits for physical health concerns that occur when children 10 and older enter foster care or experience a change in placement setting. When clinically indicated, youth will also be referred to treatment. An evaluation of SBIRT for foster youth with N = 832 youth will include a comparison sample collected in years 1-3 at a site delaying implementation of SBIRT. Results will demonstrate that 1) SBIRT can be effectively implemented and sustained in settings tailored to meet the unique needs of foster youth; 2) Existing community behavioral health services for foster youth can be enhanced to address treatment needs with this population, in partnership with foster youth healthcare centers; and 3) When standardized substance use screening and response (SBIRT) is implemented, it is associated with an increase in abstinence, a reduction in the frequency of AOD use, and an increase in youth who are successfully referred and receive treatment for SUD. Additional efforts focused on training providers and stakeholders who work with foster youth in SBIRT (e.g., clinicians, therapists, caseworkers) and in demonstrating sustainability through standardized automation of screening and referral practices and modifications to billing and reimbursement will promote generalizability of the findings from this project to the more than 50 specialized foster care clinics across the US, ensuring further benefit of this proposed work.

Over five years, Drexel University aims to screen nearly 28,000 adolescents and provide at least brief intervention to nearly 5,000 youth and their parents. We will use a family centered care model and host most of our screening and data collection (GPRA) on a web-based, informatics platform called BH-Works. Our target population is adolescents aged 12-18 years being served in outpatient behavioral and health specialty care services. Adolescents will be initially screened with the CRAFT for risk of substance use. Based on our community survey data, we estimate about 30% of youth will be in need of services. Unfortunately, Philadelphia has very few treatment programs and even fewer early intervention programs for youth at risk. To address this significant need, we propose implementing a family-based, adolescent, co-occurring SBIRT project in settings beyond where SBIRT has traditionally been used. We have partnered with three community-based agencies that, combined, have over 25 unique programs ranging from traditional outpatient to crisis, to home-based services for children in the welfare system. We have 15 years of experience implementing screening, assessment, treatment, and referral programs across the state of Pennsylvania and feel confident we can adapted SBIRT to these various settings. Each agency will be trained in the SBIRT model. We will integrate our web-based clinical management system with the EMR at each agency. For brief intervention, we will train staff in motivational interviewing. We will also provide an online support/psycho education group for parents of these youth. For adolescents in need of brief intervention, the CMHC agencies will learn to deliver attachment based family therapy, an empirically-supported therapy that addresses trauma, family distress and other co-occurring challenges. We will also offer this treatment as an online option. We anticipate screening 600 youth in year one, 2,460 in year two, 6,860 in year three, 8,960 in year four, and 8,960 in year five for a total of nearly 28,000 youth over the course of five years.

Avenue 360 Health and Wellness (Avenue 360) proposes to provide Screening, Brief Intervention, and Referral to Treatment (SBIRT) substance use disorder (SUD) treatment services for residents of the Greater Houston metro area, including pediatric patients under 21 years of age, with a special emphasis on low-income residents and under-served populations. Avenue 360 is a Federally Qualified Health Center (FQHC) operating seven clinics in the Greater Houston area. Its patient population primarily includes low-income families and individuals, uninsured and underinsured patients, ethnic minorities, and LGBTQ+ patients. Currently, Avenue 360 is the only FQHC in the Greater Houston area that has dedicated substance use disorders services in-house. Avenue 360 anticipates serving 45,861 patients with substance use screening over the five-year project period. Approximately 10% of program participants will be pediatric (ages 12-20). Goal #1: Avenue 360 Health and Wellness will implement routine, evidence-based substance use disorder screenings using the SBIRT technique to our patient population receiving medical care, housing services, and/or mental health treatment on an annual basis. Goal #2: Avenue 360 Health and Wellness will improve health outcomes for patients by reducing alcohol and other drug (AOD) use, increasing abstinence, and addressing the negative health impact of AOD use through increased peer recovery support services and clinical treatment services. Goal #3: Avenue 360 Health and Wellness will implement specialized screening practices for pediatric patients to address current harmful patterns of substance use by initiating SUD treatment and recovery support services at the earliest stages of substance use disorder development. Medical assistants routinely take patient vital signs at the beginning of each appointment; they will be trained to ask a few basic pre-screening questions regarding substance use at the same time, and to record results in the patient medical record. If the pre-screening indicates a potential issue with substance use, the medical assistant will notify the SBIRT program staff. A substance use disorder clinician, intern, and/or a peer support specialist will immediately follow up with the patient with a brief intervention. This is a short patient-centered motivational interview that determines the patient’s attitude toward their substance use and the psycho-social/ emotional/ physical needs prompting it. The SBIRT team member has the opportunity to educate the patient about the negative health impacts of substance use and set one or more goals for reducing substance use. Patients whose screening indicates severe risk will receive an immediate intervention (within one week; on the spot if possible) and referral to treatment services, which may include Medication Assisted Therapy, inpatient detox, or short inpatient or outpatient treatment. Avenue 360 will coordinate all program services with state and local health agencies as appropriate, including two-way referrals for services.

Tarrant County Hospital District (dba JPS Health Network) Utilizing Professional Liaisons for Intervention and Referral to Treatment (UPLIFT) program will increase identification and treatment of individuals with substance use disorder and/or use of alcohol and other drugs. The UPLIFT program will implement screening, brief intervention, and referral to treatment (SBIRT) services in two JPS Community Health Centers (CHC) in low-income neighborhoods and in JPS Hospital. JPS is the publicly supported safety-net health system in Tarrant County, Texas. The populations to be served are adults in ZIP codes identified as high-risk for substance use disorder (SUD) and patients being admitted to JPS Hospital through the Trauma Department. More than two-thirds of the patients at the CHCs and JPS Hospital are BIPOC (Black, Indigenous, or People of Color), with the majority being Black or Hispanic. Five percent of patients served at JPS are persons experiencing homelessness. At JPS, opioid use disorder (OUD) was related to 302 admissions, 6,737 outpatient encounters, and 76 emergency room overdoses during a six month period of 2020. This project will allow SAMHSA to evaluate the effectiveness of enhanced and expanded SBIRT services among diverse high-risk populations and in a safety-net hospital. Strategies and interventions include all grant-required activities. Infrastructure development includes build-out of JPS Epic Electronic Medical Record to integrate evidence-based screening tools (CAGE-AID, AUDIT, and DAST) and the ability to monitor and track program patients through treatment and follow-up. SBIRT services will be implemented in two JPS CHCs and JPS Hospital by hiring and training a Clinical Director who will oversee three full-time and one part-time Licensed Clinical Social Workers (LCSW). One full-time LCSW will be embedded in each CHC and one full-time and one part-time LCSW will be stationed at JPS Hospital. JPS Family Medicine physicians will partner with the Project Director, Clinical Director, LCSWs, JPS Behavioral Health Services, and JPS Bridge Clinic (MAT services) to provide a continuum of care for patients identified with SUD and/or AOD use. Evidence-based practices to be used include Motivational Interviewing, Cognitive-Behavioral Therapy, and Medication-Assisted Treatment (MAT). JPS will sub-contract with MHMR of Tarrant County to provide a 30-day intensive residential treatment program for 24 unduplicated patients needing more intensive services. MHMR will also provide outpatient treatment services for 60 unduplicated patients annually. JPS has built SBIRT services within its Trauma Department and this project builds on that success by enhancing and expanding SBIRT services within CHCs. The goal of the UPLIFT program is to support the stabilization and community reintegration of individuals who present with substance use disorder in the JPS Health Network Community Health Centers and Hospital by providing them with a continuum of care from screening, brief intervention, brief treatment, and referral to services. Measurable objectives include: 1) Provide SBIRT services to 876 individuals over five years, 2) 20% of program participants will show a decline in substance use at 6-month follow-up, 3) 15% of participants will show reduced alcohol use at 6-month follow-up, 4) 20% of participants will show an improvement in their physical and behavioral health, and 5) Reduce JPS Hospital Emergency Department visits and costs for program participants. The total unduplicated number of patients served is 876 over the grant period (108 patients in year 1, 192 patients in year 2 through year 5).

The New York SBIRT Community Outreach Project will implement and evaluate an innovative, culturally responsive model to deliver SBIRT services to underserved adolescent and adult populations historically unlikely to access treatment services (sexual minority [LGBT+]; economically disadvantaged; Latinx immigrant; Native American; and rural) in 4 areas of the State: New York City (NYC); Five Towns, Long Island; Finger Lakes; and St. Regis Mohawk Reservation. SBIRT will be delivered within community-based settings by trained outreach workers from the targeted population. The recommended screening tools to identify substance use (CRAFFT+N 2.1 for adolescents; AUDIT and DAST-10 for adults) and suicide (C-SSRS for adolescents and adults) risk. If screened positive for substance use risk, the individual will receive Brief Intervention (BI) with a Brief Negotiated Interview (BNI) using Motivational Interviewing (MI) techniques. If screened positive for suicide risk, the Safety Planning Intervention (SPI) with follow-up will be used. If brief treatment (i.e., Cognitive Behavioral Therapy) or specialty treatment (i.e., Medication Assisted Treatment [MAT] is warranted, the Active Referral to Treatment (ART) model will be followed to ensure hot handoffs to Substance Use Disorder (SUD), MAT, and/or mental health MH providers. Pre-established and continued collaborations will assist in care transitions. Project goals are to: (1) Develop, refine, and pilot and innovative SBIRT community outreach model to reduces access barriers and increase service use among high-risk populations hesitant to seek services. OASAS will use focus groups and key informant interview data to design a culturally appropriate model, train sites to deliver it, pilot it, and then refine it based on feedback. (2) Deliver the refined model in at least 12 separate community settings documenting cultural modifications to increase service access, decrease health disparities, substance use, risk behaviors, and suicide risk in NYC, Five Towns, the Finger Lakes, and St. Regis Mohawk Reservation. 5,000 screenings, 1,000 BIs, and 350 RTs will be delivered per year. (3) Disseminate our model to other high-risk communities and sustain it. In Years 3-5, at least 3 more providers will implement the SBIRT model and become certified Children and Family Treatment Service Providers. In Years 2-5, new providers will be trained, training materials will be updated and state training capacity increased. In Years 4-5, Training of the Trainer (TOT) will build capacity to sustain our SBIRT model following the grant. (4) Evaluate processes and outcomes of the SBIRT outreach model and impact on service utilization, substance use, and suicide risk. Project sites will collect data by Month 4 and track the number of screens, BIs, RTs, and suicide specific screenings and interventions. Between baseline and 6-month follow-up, OASAS will assess changes in substance use resulting from BI, and starting in Year 2, OASAS will assess increased identification of substance misuse risk and connection to SUD treatment among the target populations as compared to a similar group of individuals receiving only screening and referral.

VA Department of Behavioral Health and Development Services aims to develop a sustainable, statewide infrastructure to increase access to evidence-based screening, early intervention, treatment, and care transition services for substance use and co-occurring problems including depression and suicide for youth age 12-21 via partnerships with pediatric primary care, hospital, and community mental health settings. This project will fill critical service gaps; access to routine and universal risk identification, brief prevention interventions, treatment, and care navigation support in hopes of turning the tide of youth substance use and mental health risk in our state.

Community Health Project, Inc. d/b/a Callen-Lorde Community Health Center (Callen-Lorde) is applying for FY 2021 Screening, Brief Intervention and Referral to Treatment funding from the Substance Abuse and Mental Health Services Administration to implement an agency-wide, multi-site screening, brief intervention, and referral to treatment (SBIRT) program. Callen-Lorde's proposed SBIRT program will be implemented in both adult and pediatric outpatient health care settings. Callen-Lorde's population of focus is comprised of LGBTQ adolescent and adult persons, aged 13 and older, living within the five boroughs of New York City (Bronx, Brooklyn, Manhattan, Queens and Staten Island), with an emphasis on reaching the most underserved members of this population, including those who are people of color, low income, living with HIV or uninsured. Callen-Lorde will employ SBIRT funding to address the demonstrated risk and elevated prevalence of substance misuse and barriers to treatment access among New York City's LGBTQ communities by integrating dedicated SBIRT programming within the agency's routine primary care operations in effort to systematically identify and treat patients at risk of/or living with addiction. Callen-Lorde's proposed SBIRT services will be delivered by an interdisciplinary team of Medical Providers, Behavioral Health Providers, Addictions Coordinators, and Peer Recovery Specialists, who will work together to ensure patients seamlessly transition through all stages of the proposed SBIRT care pathway. Callen-Lorde's proposed SBIRT project will further increase substance use disorder treatment access and engagement for patients living with severe addiction through provision of on-site MAT services, and by leveraging community partnerships with specialty substance use treatment providers with expertise in serving the population of focus. Over the five-year project period, Callen-Lorde expects to serve at least 20,000 SBIRT clients across the agency's city-wide network of Federally Qualified Health Centers.