Reducing Adolescent Substance Abuse Initiative

Guidance for DataCollectionand Reporting

Contents

I.Introduction

II.Target Population for Screenings and Treatment

III.ClinicalIndicators

a)Patient Information

b)Clinical Indicators

IV.Action Taken

V.Follow Up Screening

VI.Office Use Only Section

VII.Disenrollment

VIII.Report Submissions

IX.KeyContacts

X.Data Collection Form

XI.CRAFFT Questionnaire

XII.Sample Scenarios

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I.Introduction

This guidance is for participants of the Reducing Adolescent Substance Abuse Initiative.

The goal of clinical data reporting for RASAI sites is to learn more about: the young people we serve, SBIRT’s effectiveness in community behavioral health settings, and the challenges and successes of SBIRT implementation. To meet that goal, sites will track and report a small number of at the patient level, using standard indicators across all RASAI sites.

This guidance is designed for sites using paper forms and the RASAI database for data collection and submission. The paper forms have been released and the database, with corresponding guidance, will be released in late January.

FOR THOSE USING ELECTRONIC HEALTH RECORDS

If you are using your Electronic Health Records, there may be limits to what you can collect. For instance, standard EHRs do not collect “transgender” as a gender and have different responses for “smoking status.” If there is variance among what your EHR collects and our data form, that is completely fine. Those using certified EHRs should continue to follow the national data standards in data collection and reporting, using the paper-based form for guidance on the nature of data to be collected, and the Excel spreadsheet as the format for data submission. Data leads should have received the Excel spreadsheet via email, but if not, please visit the Data Lead section of the File sharing website: assistance related to collecting RASAI data in your organization’s EHR, please contact Colleen O’Donnell at or 202-684-7457 X278. Colleen has also prepared an EHR FAQ document for your use.

II.Target Population for Screenings and Treatment

Screeningsshouldbeadministeredtothe clients who participate in the programs you have selected for RASAI.

  • Datashouldbecollectedfromallpatients in the programs that you have selected.
  • Datacollectionshouldnotbelimitedto any certain population or group, except for cases when programs serve both adults 23 and older and individuals 22 and under. In that case, only collect and submit data for individuals 22 and under.
  • Datashouldnotbesubmittedforpatientsseenoutsideofthescopeofthisproject.

III.ClinicalIndicators

AsampleoftheclinicalindicatorscollectionformisincludedinSectionX.

a)Patient Information

  • Screening Date:Thisisthedatethattheinformationiscollectedorthepatientisscreened (evenifthedataisenteredintothedatabaseat alaterdate).Thisdatewill beusedtodetermine“NextAssessmentDate”.
  • PatientName:firstnameandlastname
  • Patient Record Number: complete information. This is optional.
  • DateofBirth:completeinformation
  • Gender Identity:completeinformation
  • Ethnicity: complete information
  • Race:completeinformation
  • Smoking:
  • Never smoked
  • Currenteverydaysmoker(atrisk)
  • Currentsomedaysmoker(atrisk)
  • Formersmoker
  • Diagnosis Code ORBehavioral Health Diagnosis (Check all that apply)
  • Anxiety
  • Depression
  • Bipolar disorder
  • Schizophrenia
  • Conduct disorder/ODD
  • Learning/ADHD
  • Eating disorder
  • Something else: complete information
  • Diagnosis code: complete either DSM (4R or 5 is permissible)or ICD-9 diagnosis code

b)Clinical Indicators

  • CRAFFT Score:

Under 21: /
  • If score is 0:
/ Give praise and encouragement.
  • If score is 1:
/ Perform at least one brief intervention and reassess at next visit to see if patient has reduced or stopped substance use.
  • If score is 2-6
/ Perform at least one brief intervention to further assess alcohol or drug use and to see if patient will agree to stop or discontinue use. If not, consider referring to specialty treatment.
Over 21: /
  • If score is 0:
/ Give praise and encouragement.
  • If score is 1:
/ Perform at least one brief intervention and reassess at next visit to see if patient has reduced or stopped substance use.
  • If score is 2 -6:
/ Perform at least one brief intervention to further assess alcohol or drug use and to see if patient will agree to stop or discontinue use. If not, consider referring to specialty treatment.
  • Alcohol Use Score:
  • Drug Use Score:

IV.Action Taken

  • Score warrants Brief Intervention (BI) or Referral to Treatment (RT): Yes/No
  • Yes: If CRAFFT score from section III (b) indicate(s)BI or RT
  • No: If CRAFFT score from section III (b) do not indicate BI or RT.
  • Score warrants BI or RT, but BI or RT were not pursued:Yes/No
  • Yes: If CRAFFT score from section III (b) indicate(s) BI or RT, but neither was pursued.
  • No: If CRAFFT score from section III (b) either do not indicate BI or RT, or BI/RT were pursued following indication.
  • Date of Brief Intervention #1:Completedate of first brief intervention if pursued
  • Date of Brief Intervention #2:Completedate of second brief intervention if pursued
  • Date of Brief Intervention #3:Completedate of third brief intervention if pursued

Date of Brief Intervention #4:Completedate of fourth brief intervention if pursued. Four brief interventions are not required. At least two are recommended.

  • Patient was referred to treatment:Yes/No
  • Yes:If RT was pursued.
  • No:If RT was not pursued.
  • Date: Complete date that the referral to treatment was made.
  • Patient Attended Treatment:Yes/No/Refused
  • Yes:If patient attended treatment
  • No:If no RT was made
  • Refused:If RT was made but patient did not attend treatment
  • Date: Date that patient attended treatment
  • Anticipated Date of Follow Up Screening: Expected date for follow-up screening with patient.
  • Actual Date of Follow Up Screening: Date patient attended follow-up screening.

V.Follow Up Screening

Fill out the screening using the same thresholds used in the original screening in Section III. Follow-up screening should happen between 3-6 months after the initial screening. Given how rapidly the life of an adolescent can change, we recommend that follow-up occurs closer to 3 months.

VI.Office Use Only Section

  • Form Completion Date:Date form was completed

VII.Office Workflow

The recommended workflow, for those using the paper version of the data collection form, is to have the clinician hold onto the form until the ‘Actions Taken’ section is complete (except for the ‘Actual data of follow up screening’). At this point, the clinician should give the form to the data lead to be entered into the database. Once the form has been entered into the database, the form should go back to the clinician so they can collect the follow up screen information. Once the follow up information has been entered, the form should go back to the data lead to enter the follow up information into the original entry for that consumer. At this point, data entry is complete for that consumer.

VIII.Disenrollment

It is unnecessary to use the Data Collection Form to designate when someone has disenrolled from your program or stopped attending your agency. This information is unnecessary for RASAI purposes.

IX.Report Submissions

Data extracts with de-identified patients data should be submitted by the fifteenth of every month (or the following business day if the 15th falls on a week or holiday) to:

X.KeyContacts

Aaron Surma, MSW

Quality Improvement Associate

(248) 345-6535

Jake Bowling, MSW

Director, Practice Improvement

(202) 684-7457

XI.Data Collection Form

XII.CRAFFT Questionnaire

RASAI CRAFFT SCREENING INTERVIEW

Pre-screen (optional, but strongly recommended)

During the PAST 12 MONTHS, didyou:

  1. Drink any alcohol (more than a few sips)?

--Do not count sips of alcohol taken during family or religious events

  1. Use any marijuana or hashish?
  1. Use anything else to get high?

-- “Anything else” includes illegal drugs, over the counter and prescription drugs, and things that you sniff or huff.

If all answered NO If YES to any

Just ask CAR question Ask all Full CRAFFT questions

C / - / Have you ever ridden in a CAR driven by someone (including yourself) who was
"high" or had been using alcohol or drugs?
R / - / Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in?
A / - / Do you ever use alcohol/drugs while you are by yourself, ALONE?
F / - / Do you ever FORGET things you did while using alcohol or drugs?
F / - / Do your family or FRIENDS ever tell you that you should cut down on your drinking or drug use?
T / - / Have you gotten into TROUBLE while you were using alcohol or drugs?

Yes or No

Yes or No

Yes or No

Yes or No

Yes or No

Yes or No

Enter CRAFFT Score (“yes” responses get one point):

If 1+ provide brief intervention, If 2+ consider referral to treatment. Then, ask Alcohol & Drug scale questions.

Alcohol & Drug Scale

1. How often do you have a drink containing alcohol?

(0) Never

(1) Monthly or less(3) 2 to 3 times a week

(2) 2 to 4 times a month(4) 4 or more times a week

2. How many drinks containing alcohol do you have on a typical day when you are drinking?

(0) 1 or 2

(1) 3 or 4 (3) 7, 8, or 9

(2) 5 or 6 (4) 10 or more

3. How often do you have five or more drinks on one occasion?

(0) Never

(1) Less than monthly (3) Weekly

(2) Monthly (4) Daily or almost daily

Enter Alcohol Scale Score =

4. How often do you use marijuana, any other drug, or prescription medication to get high?

(0) Never

(1) Monthly or less (3) 2 to 3 times a week

(2) 2 to 4 times a month (4) 4 or more times a week

Enter Drug Scale Score =

Enter Alcohol and Drug Scale Scores. Responses can be used to elicit motivation for change and goal setting to reduce risk. These questions will be repeated at follow-up to track and monitor patient’s progress and report data

XIII.Sample Scenario

A patient is screened using the CRAFFT. The clinician asks (or looks up in records) all relevant demographic information and diagnosis information. It should look like this:

The clinician then enters the result of the CRAFFT screen:

The clinician reviews the CRAFFT guidance document, which recommends a referral to treatment based on the CRAFFT score. The clinician decides to perform a brief intervention while reviewing the assessment with the consumer, and this will be followed by a referral to treatment. The information should be entered as follows:

Two weeks later, the clinician finds out that the consumer has attended treatment. The clinician will then indicate as such:

The default guidance is to perform a follow up screen 3-6 months after initial screen. The clinician will enter the follow up information as follows:

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