The economic, political, and social contexts within which an organization resides (e.g., constrained funding, billing rules, and the influence of policies related to treatment and targeted populations).
Adolescents and their families may be ambivalent about SBI. Gordon and his colleagues322 found that parents, families, and PCPs who perceived social norms to be tolerant of adolescent substance use; a community culture of alcohol use and positive attitudes toward drinking; parental drinking and willingness to provide adolescents with access to alcohol; and the lack of non-drinking alternative programs and activities for adolescents inhibited the acceptance of adolescent SBI in rural communities.
States that foster state-community initiatives on adolescent substance use and that support connecting school and pediatric practices with community substance use programs increase the uptake of adolescent screening. Kuhlthau and colleagues327 suggest that a multiyear effort to forge relationships between BHPs and PCPs who treated adolescents in Massachusetts, in addition to PCPs' access to an enhanced array of adolescent behavioral health services (emergency services, mobile crisis teams with 72-hour follow-up support, intensive care coordination, in-home care teams, and behavioral health consultation teams) encouraged PCPs and pediatricians to screen their adolescent patients. State Medicaid mandates to use specific screening instruments increase provider screening and the rates of identifying youth with risky substance use and referring them to specialty services.327
Getting paid is key to adolescent SBI. The financial sustainability of SBI is a consistent problem in school-based health programs.319, 324 Clark and Moss's study of adolescent SBI across a wide array of settings308 found that even when payment is available, reimbursement rates and actual payments received for adolescent SBI services delivered are rarely sufficient to cover the skills and time required to deliver the services. Health insurance and Medicaid reimbursement for school or health center screening and treatment strongly predict uptake.319 In one project, despite Medicaid reimbursement rates that were adequate to sustain SBI counselors and a supervisor in a school-based health clinic, insurance requirements that parents/guardians be notified nearly defeated the program. The SBI program was successfully implemented because great attention was given to informing all stakeholders about it (the school board, teachers, parent organizations, individual parents), the offer to parents of an easy "opt-out" from screening, and a strong positive relationship between the school system and a local substance abuse treatment program that staffed the SBI program in the school health center; all were regarded as essential to successfully opening SBI in school health clinics. The absence of readily available referral sources for adolescents identified as needing specialty care is frequently cited as a barrier to implementing adolescent SBI programs.322, 328 Support from outside the school or health center, from parents, the government, or community organizations, may be essential for getting schools or PCPs to start SBI programs.320