Form Performance Site S Performance Site S Performance Site Survey

OMB No. XXXX-XXXX

Expiration Date: XX/XX/XX

SBIRT Performance Site Survey

Funding for data collection provided by the

Center for Substance Abuse Treatment,

Substance Abuse and Mental Health Services Administration (SAMHSA),

U.S. Department of Health and Human Services

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is XXXX-XXX. Public reporting burden for this collection of information is estimated to average 13 minutes per respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 2-1057, Rockville, Maryland, 20857.

Please complete this confidential survey to provide SAMHSA with information about the Screening, Brief Intervention, and Referral to Treatment (SBIRT) program and the use of health information technology (IT) at @ORGANIZATION.

The survey takes an average of 13 minutes to complete.

No identifying information is collected in this survey.

If you have any questions or concerns regarding this survey at any time, please contact Jesse Hinde at RTI International (jhinde@rti.org).

Section I: Staff Roles and Demographics

1. Please indicate which title best describes your job:

Intake/front office staff

Administrative/managerial staff

Medical provider (e.g., physician, nurse, medical assistant, dentist, pharmacist)

Behavioral health provider (e.g., health educator, psychologist)

Social worker

1a. Are you a licensed or certified medical provider?

No

Yes

1b. Are you a licensed or certified behavioral health provider?

No

Yes

2. Do you provide SBIRT services (i.e., prescreening, screening, brief intervention, brief treatment, referral to treatment) directly to patients?

No

Yes

IF Q2=Yes, THEN ASK Q3, ELSE GO TO Q4.

3. What SBIRT services do you provide on a regular basis? Please check all that apply.

Prescreen or initial screen (e.g., AUDIT-C for alcohol)

Full screen or assessment (e.g., AUDIT for alcohol)

Brief intervention

Brief treatment

Referral to treatment

[FILL] @ORGANIZATION: Pre-fill based on performance site

4. How long have you worked at @ORGANIZATION?

___YEARS ___MONTHS

IF Q2=Yes, THEN ASK Q5, ELSE GO TO Q6.

5. How long have you been involved with the SBIRT program at @ORGANIZATION?

___YEARS ___MONTHS

6. Has @ORGANIZATION ever received technical assistance from SAMHSA for SBIRT?

No

Yes

Don’t Know

IF Q6=Yes, THEN ASK Q7, ELSE GO TO Section II

7. To what extent was the technical assistance @ORGANIZATION received helpful?

Not at all

A little

Somewhat

Very much

Section II: SBIRT Implementation

This section asks you about the implementation of SBIRT at @ORGANIZATION. The questions focus on the SBIRT program in general and on each component of SBIRT specifically.

Please indicate the extent to which you disagree or agree with the following statements.

The SBIRT Program		Strongly Disagree	Disagree	Neither Disagree nor Agree	Agree	Strongly Agree
1.	I am involved in the implementation of the SBIRT program in this organization.
2.	This organization has a clear plan for implementing SBIRT.
3.	The SBIRT program is well integrated into patient care in this organization.
4.	Staff in this organization are encouraged to recommend ways to improve SBIRT implementation.
5.	I feel confident that leadership here will support SBIRT staff as staff adjust to change in their workplace.
6.	The leadership here trusts staff’s professional judgment to implement SBIRT.
7.	Staff in this organization are committed to implementing SBIRT.
8.	It is difficult to change procedures in this organization to meet new conditions.
9.	Staff in this organization can manage the processes for implementing SBIRT.
10.	Staff in this organization can handle the challenges that might arise in implementing SBIRT.
11.	Staff in this organization coordinate tasks so that SBIRT implementation goes smoothly.

12. Are you familiar with the screening component of SBIRT at @ORGANIZATION?

No <Ask 21>

Yes <Ask 13–20>

IF Q12=Yes, THEN ASK Q13-20, ELSE GO TO Q21

Please indicate the extent to which you disagree or agree with the following statements about the screening component of SBIRT at @ORGANIZATION.

Screening		Strongly Disagree	Disagree	Neither Disagree nor Agree	Agree	Strongly Agree
13.	Staff in this organization are expected to screen patients for substance use.
14.	Staff providing SBIRT services have the necessary skill level/proficiency to implement screenings effectively.
15.	Staff providing SBIRT services have received the necessary training to implement screenings effectively.
16.	Staff providing SBIRT services have the necessary knowledge to implement screenings effectively.
17.	Staff providing SBIRT services have the necessary time to implement screenings effectively.
18.	Staff get the leadership support they need to conduct screenings.
19.	Staff providing SBIRT services have all of the resources necessary to implement screenings effectively.
20.	Sufficient staff are available to make the implementation of screening work.

21. Are you familiar with the brief intervention component of SBIRT at @ORGANIZATION?

No <Ask 30>

Yes <Ask 22–29>

IF Q21=Yes, THEN ASK Q22-29, ELSE GO TO Q30

Please indicate the extent to which you disagree or agree with the following statements about the brief intervention component of SBIRT at @ORGANIZATION.

Brief Intervention		Strongly Disagree	Disagree	Neither Disagree nor Agree	Agree	Strongly Agree
22.	Staff in this organization are expected to conduct brief intervention sessions with eligible patients.
23.	Staff providing SBIRT services have the necessary skill level/proficiency to implement brief interventions effectively.
24.	Staff providing SBIRT services have received the necessary training to implement brief interventions effectively.
25.	Staff providing SBIRT services have gained the necessary knowledge to implement brief interventions effectively.
26.	Staff providing SBIRT services have the necessary time to implement brief interventions effectively.
27.	Staff get the leadership support they need to conduct brief interventions with eligible patients.
28.	Staff providing SBIRT services have all of the resources necessary to implement brief interventions effectively.
29.	Sufficient staff are available to make the implementation of brief interventions work.

30. Are you familiar with the brief treatment component of SBIRT at @ORGANIZATION?

No <Ask 39>

Yes <Ask 31–38>

IF Q30=Yes, THEN ASK Q31-38, ELSE GO TO Q39

Please indicate the extent to which you disagree or agree with the following statements about the brief treatment component of SBIRT at @ORGANIZATION.

Brief Treatment		Strongly Disagree	Disagree	Neither Disagree nor Agree	Agree	Strongly Agree
31.	Staff in this organization are expected to conduct brief treatment sessions with eligible patients.
32.	Staff providing SBIRT services have the necessary skill level/proficiency to implement brief treatment sessions effectively.
33.	Staff providing SBIRT services have received the necessary training to implement brief treatment sessions effectively.
34.	Staff providing SBIRT services have gained the necessary knowledge to implement brief treatment sessions effectively.
35.	Staff providing SBIRT services have the necessary time to implement brief treatment sessions effectively.
36.	Staff get the leadership support they need to conduct brief treatment sessions for eligible patients.
37.	Staff providing SBIRT services have all of the resources necessary to implement brief treatment sessions effectively.
38.	Sufficient staff are available to make the implementation of brief treatment sessions work.

39. Are you familiar with the referral to treatment component of SBIRT at @ORGANIZATION?

No <Go to Section III>

Yes <Ask 40–47>

IF Q39=Yes, THEN ASK Q40-47, ELSE GO TO Section III

Please indicate the extent to which you disagree or agree with the following statements about the referral to treatment component of SBIRT at @ORGANIZATION.

Referral to Treatment		Strongly Disagree	Disagree	Neither Disagree nor Agree	Agree	Strongly Agree
40.	Staff in this organization are expected to conduct referrals to treatment with eligible patients.
41.	Staff providing SBIRT services have the necessary skill level/proficiency to conduct referrals to treatment effectively.
42.	Staff providing SBIRT services have received the necessary training to implement referrals to treatment effectively.
43.	Staff providing SBIRT services have gained the necessary knowledge to implement referrals to treatment effectively.
44.	Staff providing SBIRT services have the necessary time to conduct referrals to treatment sessions effectively.
45.	Staff get the leadership support they need to conduct referrals to treatment for eligible patients.
46.	Staff providing SBIRT services have all of the resources necessary to implement referrals to treatment effectively.
47.	Sufficient staff are available to make the implementation of referrals to treatment work.

Section III: SBIRT Health Information Technology (HIT) (ASK ONLY FOR THOSE WHO REPLY YES TO QUESTION 2 IN SECTION I)

This section focuses on the use of health IT to support SBIRT implementation.

ASK IF S2, Q12=2

1. Please indicate what type(s) of specific HIT is currently used to support prescreenings. Please check all that apply.

Electronic medical record (EMR)/electronic health record (EHR)

Telehealth/telemedicine

Population health management tools

Other electronic data system (e.g., Excel spreadsheet) <Ask 6a.>

Other tools (e.g., tablets) <Ask 6b.>

ASK IF S2, Q12=2

2. Please indicate what type(s) of specific HIT is currently used to screenings. Please check all that apply.

Electronic medical record (EMR)/Electronic health record (EHR)

Telehealth/telemedicine

Population health management tools

Other electronic data system (e.g., Excel spreadsheet) <Ask 6a.>

Other tools (e.g., tablets) <Ask 6b.>

ASK IF S2, Q21=2

3. Please indicate what type(s) of specific HIT is currently used to support brief interventions. Please check all that apply.

Electronic medical record (EMR)/Electronic health record (EHR)

Telehealth/telemedicine

Population health management tools

Other electronic data system (e.g., Excel spreadsheet) <Ask 6a.>

Other tools (e.g., tablets) <Ask 6b.>

ASK IF S2, Q30=2

4. Please indicate what type(s) of specific HIT is currently used to support brief treatments. Please check all that apply.

Electronic medical record (EMR)/Electronic health record (EHR)

Telehealth/telemedicine

Population health management tools

Other electronic data system (e.g., Excel spreadsheet) <Ask 6a.>

Other tools (e.g., tablets) <Ask 6b.>

ASK IF S2, Q39=2

5. Please indicate what type(s) of specific HIT is currently used to support referral to treatments. Please check all that apply.

Electronic medical record (EMR)/Electronic health record (EHR)

Telehealth/telemedicine

Population health management tools

Other electronic data system (e.g., Excel spreadsheet) <Ask 6a.>

Other tools (e.g., tablets) <Ask 6b.>

IF S3, Q1=4 OR Q2=4 OR Q3=4 OR Q4=4 OR Q5=4, THEN ASK S3, Q6a.

6a. What other electronic data system do you use?

Please specify:____________________________

IF S3, Q1=5 OR Q2=5 OR Q3=5 OR Q4=5 OR Q5=5, THEN ASK S3, Q6b.

6b. What other HIT tools do you use?

Please specify:____________________________

IF S3, Q1=1 OR Q2=1 OR Q3=1 OR Q4=1 OR Q5=1, THEN ASK S3, Q7;
ELSE GO TO S3, Q9

7. Do you use your EMR/EHR to share any patient clinical data outside of your health care system or organization?

No

Yes

IF S3, Q7=2, THEN ASK S3, Q8

8. Do you use your EMR/EHR to share any patient SBIRT data or information outside of your health care system or organization?

No

Yes

9. Listed below are 13 factors that describe the use of HIT in medical settings. For each factor, please rate whether the HIT factor significantly hindered, hindered, had no impact, supported, or significantly supported the implementation of SBIRT at @ORGANIZATION.

SBIRT Health IT Factors		Significantly Hindered	Hindered	No Impact	Supported	Significantly Supported		Not Applicable
a.	Using an electronic medical record (EMR)/electronic health records (EHR)
b.	Sharing data with a health information exchange
c.	Overall look and feel of the HIT tools
d.	Using SBIRT HIT tools as a part of direct service delivery
e.	Integrating HIT tools into the SBIRT patient workflow
f.	Staff availability to use the HIT tools
g.	Staff training on the HIT tools
h.	Physical location of HIT tools relative to service delivery
i.	Interacting with HIT support staff
j.	Interacting with HIT vendors
k.	Having a champion supporting the use of HIT tools
l.	Cost of implementing and using HIT tools
m.	Improvements to patient care from using HIT tools

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