This document discusses implementing a sequential process of screening, brief intervention, and referral to treatment for early identification and treatment of substance use issues among homeless individuals living in shelters. It involves using the ASSIST screening tool during intake to screen for alcohol and illicit drug use, providing a brief intervention for moderate to high scorers, and referring those with moderate to heavy use to treatment. The goals are to change current screening processes, identify billing opportunities, and facilitate early identification and treatment through a patient-centered care approach.

1. Langley, G.L., Nolan, K.M., Nolan, T.W., Norman, C.L., & Provost, L.P. (2009). The improvement guide: A
practical approach to enhancing organizational performance, (2nd edition). San Francisco, CA: Jossey-Bass Publishers.
Implement Sequential Process of
Screening, Brief Intervention (BI),
Referral to Treatment (RTT) for Early
Identification/ Early Treatment for
Homeless Individuals living in Shelters
Demographics; Usage patterns
of homeless; Community Services
available; 3rd Party Payer coverage,
etc.
Change in Current Screening Process and Billing Opportunities
Use ASSIST Screening
Tool during Admission
Intake Process;
Score ASSIST;
Provide BI for
Moderate to High Scorers
Per ASSIST Scoring
Moderate to High
Scorers per ASSIST Tool
Will Accept BI and RTT at
Intake

2. Referral to Treatment for
Moderate to Heavy Users
Providing Brief Intervention
for Moderate to Heavy Users
Screening for Alcohol
& Illicit Drugs Using
ASSIST Screening Tool
Patient
Centered
Care
[ASSESSMENT]
[PRIMARY INTERVENTION]
[CUSTOMIZED INTERVENTION]
Early
Identification
/Early
Treatment
Shared
Decision-
Making with
Client
Facilitate
Referral to
Appropriate
Level of Care
Educate
about
Community
Supports
Support Encourage
Avoid
Judgment
SCREENING, BRIEF INTERVENTION, REFERRAL TO TREATMENT
MODEL