A Texas Health Steps Provider’s Role: Screening and Referral

Young adult female patient smiles while listening to the nurse

Screening and anticipatory guidance are required components of every Texas Health Steps preventive medical checkup. Screening during a checkup is covered later in this section. Anticipatory guidance should be individualized based on exam results, parent or patient concerns, or provider observation. Discussion of drug, tobacco and alcohol use and peer pressure are recommended for adolescents beginning at the 11-year checkup or when developmentally appropriate.

Screening: Evidence-based Tools to Assess for Substance Use

Office-based use of Screening, Brief Intervention and Referral to Treatment (SBIRT) is a Medicaid benefit to identify, reduce or prevent substance abuse in children and youth beginning at age 12. Texas Health Steps requires an annual mental health screening for all adolescents ages 12 through 18 years using one or more of the eight validated, standardized mental health screening tools recognized by Texas Health Steps. The tools recognized by Texas Health Steps are:

Pediatric Symptom Checklist (PSC-17)
Pediatric Symptom Checklist (PSC-35)
Pediatric Symptom Checklist Youth Report (Y-PSC)
Patient Health Questionnaire (PHQ-9)
CRAFFT (Car, Relax, Alone, Forget, Friends, Trouble) Screening Questionnaire
Patient Health Questionnaire for Adolescents (PHQ-A) – Depression screen
Patient Health Questionnaire for Adolescents (PHQ-A) – Anxiety, eating problem, mood problem and substance use screen
Rapid Assessment for Adolescent Preventive Services (RAAPS)

If the mental health screening indicates further assessment for substance use, the AAP recommends the following screens:

S2BI (Screening to Brief Intervention)
A brief screening to assess whether further assessment is needed.
BSTAD (Brief Screener for Tobacco, Alcohol, and other Drugs)
Screens for problematic substance use.
HEEADSSS 3.0
For use as part of an initial psychosocial assessment. Assesses for Home environment, Education and employment, Eating, peer-related Activities, Drugs, Sexuality, Suicide/depression, and Safety from injury and violence and includes media use.

Barriers to Appropriate Use of Screening Tools

According to AAP data, many providers are not screening children enough; and when they do screen, it's not always with recommended screening tools (2016). Providers can take a more active role in reducing substance misuse by being more familiar with substance use screens and more by proactively using them.

Pediatricians’ self-reported rates of routine substance use screening vary from less than 50% to 86%, although few physicians reported using a validated screening tool, and most relied on clinical impressions. The most frequently cited barriers to screening were lack of time, insufficient training, and lack of familiarity with standardized tools. ... Experienced pediatricians have failed to detect mild, moderate, and sometimes even severe SUDs [substance use disorders] when relying on clinical impressions alone.
AAP Clinical Report on SBIRT, 2016

For guidance and additional information on screening tools, see the AAP Clinical Report, Substance Use Screening, Brief Intervention, and Referral to Treatment, available in the Resources section.

Brief Intervention: To Reduce Risk of Fentanyl Use

The brief intervention segment of SBIRT should involve a short conversation with the adolescent, focusing on rapport, that increases their awareness about their substance use and understanding of its health implications. Devise a plan with the adolescent based on an understanding of their motivations and options.

ORT-OUD (Opioid Risk Tool – Opioid Use Disorder)

This tool can be helpful in assessing patients when beginning or continuing opioid therapy for pain management. The tool assesses family history, personal history and psychological factors to indicate whether in individual has a high risk for opioid use disorder. A link is provided in the Provider Resources.

Referral to Treatment

Referral options may include:

Substance use treatment provider
Addiction specialist
Peer mentor/peer recovery coach (PM/PRC)
Peer recovery support specialist (PRS)
Licensed chemical dependency counselor (LCDC)
Treatment center

The PM/PRC designation and the PRS credential standardize qualifications of those working in peer recovery support within the field of chemical dependency, mental health and/or co-occurring disorders. The guidelines were developed by the Texas Certification Board of Addiction Professionals, DSHS and identified stakeholders.

To locate an LCDC, visit the HHSC Licensed Chemical Dependency Counselor web page.

State-Sponsored Support Programs That Address Substance Use

Youth Substance Use Treatment & Recovery Services
Recovery-Oriented Systems of Care (ROSC)

Recovery-oriented systems of care (ROSC) are part of the Texas Recovery Initiative, coordinated by HHSC’s Mental Health and Substance Use division.

ROSC provides a “framework for coordinating multiple systems, services and supports that are person-centered, self-directed and designed to readily adjust to meet the individual’s needs and chosen pathway to recovery. The system builds upon the strengths and resilience of individuals, families and communities to take responsibility for their sustained health, wellness, recovery from substance use disorders and improved quality of life” (HHSC, 2021).
Outreach, Screening, Assessment and Referral (OSAR)
Finding a Medicaid Provider
Finding an SUD provider that accepts traditional Medicaid or your patient’s Medicaid health plan:
- As a primary care provider, you can receive guidance on “in-network” providers for Medicaid managed care organizations (MCOs) by contacting the patient’s MCO or searching the MCO’s online provider directory. Call the provider hotline on the patient’s MCO identification card.
- For traditional Medicaid, use the Texas Medicaid & Healthcare Partnership (TMHP) online provider search.

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