Please complete this brief survey to enroll with the Colorado AIM: Substance Use Disorder Learning Collaborative!

If you have any questions, please reach out to Valerie Garrison at vgarrison@cpcqc.org.

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* 1. Organization:

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* 2. Please identify your Nurse Champion and their contact information:

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* 3. Please identify your Provider/Clinician Champion and their contact information:

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* 4. Please identify your Social Work/Case Management Champion and their contact information:

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* 5. If desired, please include the name and email address of an additional champion you'd like us to include in communications to your team's project leadership.

SBIRT Readiness Self-Assessment

Next, we will ask you a series of questions related to your current practices surrounding use of the SBIRT framework (Screening, Brief Intervention, and Referral to Treatment). Your answers to these questions will be tabulated to provide your organization a baseline score on the Self-Assessment. You will take this SBIRT Readiness Self-Assessment again after the program to measure your progress.

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* 6. Does your organization have management support for SBIRT implementation? 
(Organizational decision-makers endorse SBIRT implementation)

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* 7. Have you defined your organization's population for screening?
(For example, all patients or selected groups of patients, and all visits or selected visits)

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* 8. Have you selected your organization's screening tools and outlined your screening process for brief screening and further screening for maternal substance use?

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* 9. Have you selected your organization's screening tools and outlined your screening process for brief screening and further screening for maternal mental health?

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* 10. Is your Electronic Health Record (EHR) set up to record screening results (with your selected tools)?

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* 11. Has your SBIRT workflow been defined?
Note, this step has been completed when:
- Staff roles and responsibilities are identified for: brief screening, further screening, brief interventions, coordinating referral to treatment, coordinating follow-up, and billing;
and
- When the SBIRT clinic flow (when and where) is determined for: screening, brief Intervention, and referrals

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* 12. Have you completed the following to support Brief Intervention in your organization?
- Key staff trained,
- Proficiency verified; and
- documentation process established

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* 13. Have you completed all of the following to support Referral to Treatment in your organization? 
- Internal and external treatment services identified
- Clinicians trained to provide MAT
- Business and information sharing agreements with substance use treatment providers established
- Care coordination protocols established
- Documentation of treatment monitoring established
- Community support and recovery services identified.

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* 14. Has your organization taken all of the following steps to integrate and sustain SBIRT in regular practice? 
Organization plans established to:
- Monitor fidelity to SBIRT process
- Train new staff
- Periodically retrain staff
- Monitor and update community referral and support resources
- Monitor SBIRT process and data

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* 15. Has your organization determined a plan for seeking SBIRT reimbursement, including identification of health plan specific procedures and protocols and training key staff?

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* 16. Is there anything else you would like us to know about the current status of your SBIRT implementation?

Thank you for completing your application! You will receive communications from CPCQC soon with next steps.

If you have any questions, please reach out to Valerie Garrison at vgarrison@cpcqc.org.

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