Using human-centered design to develop and implement a pediatric mental health care access program.

In 2019, the University of California at San Francisco (UCSF) launched the Child and Adolescent Psychiatry Portal (CAPP), a pediatric mental health care access (PMHCA) program providing remote mental health consultation services to pediatric primary care providers (PCPs) throughout Northern and Central California. The development and implementation of CAPP was guided by Human-Centered Design (HCD), an iterative, rapid-paced innovation process focusing on stakeholders' needs and experiences, which shaped the development of CAPP's programs. The resulting key programmatic elements are designed for pediatric workforce development: (1) PCP consultation with a child and adolescent psychiatrist via a telephone warmline; and (2) training and education for providers. CAPP has grown rapidly since its launch, having enrolled 1,714 providers from 257 practices spread across 36 counties and provided 3,288 consults on 2,703 unique lives as of August 2023. Preliminary evaluation findings indicate high PCP satisfaction with CAPP's services, despite continued challenges of integrating behavioral health into primary care. Throughout the HCD and implementation process, multidisciplinary partnerships have proven critical in providing end-user input to inform and improve program design. This growing network of partnerships, developed through the cultivation of personal relationships and trust over time, has also proven essential for CAPP's rapid growth and sustainability. Overall, this Community Case Study highlights the critical role of partnerships and the importance of taking a people-centered approach, as captured in CAPP's motto, "Connecting for Care."

Systematic Review: Child Psychiatry Access Program Outcomes.

Objective: There has been an increase in Child Psychiatry Access Programs (CPAP) across the United States to address the national child and adolescent psychiatry workforce shortage by supporting pediatric primary care providers (PCPs) in providing mental health services. The objective of this systematic review is to synthesize the expanding literature on CPAPs. Method: A systematic literature search was conducted in PubMed, PsycInfo, Embase, and Web of Science databases to identify articles published from database inception to April 6, 2022, to identify CPAPs, defined as programs with mental health specialists providing rapid remote mental health consultation services to pediatric PCPs. Study outcomes included program adoption, provider experience, patient and caregiver experience, program cost, and patient mental health. Results: None of the 33 included studies were randomized controlled trials. Most of the studies (n = 30) focused on program adoption and provider experience (n = 18). Few studies examined patient and caregiver experience (n = 2), program cost(n = 4), or patient mental health (n = 4) outcomes. CPAPs showed year-over-year growth in adoption and were generally well-received by providers and caregivers. Health care provision costs were quite varied. No articles reported on changes in patient mental health according to validated measures. Heterogeneity in the methodological quality, study design, and outcomes used to evaluate CPAPs hindered comparison among programs. Conclusion: Rigorous research on the impact of CPAPs is lacking. Findings show high provider satisfaction with CPAPs, yet few studies examine patient-level mental health outcomes. CPAPs and funding agencies should consider prioritizing and investing in research to build the evidence base for CPAPs. Diversity & Inclusion Statement: One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented racial and/or ethnic groups in science. We actively worked to promote inclusion of historically underrepresented racial and/or ethnic groups in science in our author group. One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented sexual and/or gender groups in science. Clinical trial registration information: Child Psychiatry Access Programs: A Systematic Review; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020146410; CRD42020146410.

Leveraging Technology to Increase Behavioral Health Services Access for Youth in the Juvenile Justice and Child Welfare Systems: a Cross-systems Collaboration Model.

Behavioral health services access for justice- and child welfare-involved youth is limited despite significant need. Structural interventions to address limited access are nascent. Technology can advance access, but few interventions focus on system-impacted youth and their mental health needs and challenges. This article describes the development, process, and initial outcomes of the Youth Justice and Family Well-Being Technology Collaborative (JTC) that was formed to leverage technology within and across public health and justice-related systems to promote increased behavioral health services access. Cross-system considerations are identified for public health, court, and other key stakeholders to successfully integrate technology into practice to expand access to these critical services.

Addressing adolescent substance use in an urban pediatric federally qualified health center.

OBJECTIVE: Screening, brief intervention, and referral to treatment (SBIRT) is a systematic approach to identification and intervention for individuals at risk for substance use disorders. Prior research indicates that SBIRT is underutilized in pediatric primary care. Yet few studies have examined procedures for identifying and addressing substance use in clinics that serve publicly insured adolescents (i.e., federally qualified health centers [FQHC]). This descriptive, multi-method study assessed adolescent substance use frequency and provider perspectives to inform SBIRT implementation in an urban pediatric FQHC in California. METHODS: A medical record review assessed substance use frequency and correlates among publicly insured adolescents aged 12-17 years who completed a well-child visit in pediatric primary care between 2014 and 2017 (N = 2252). Data on substance use (i.e., alcohol, illicit drugs, and tobacco) were from a health assessment tool mandated by Medicaid. Semi-structured interviews with 12 providers (i.e., pediatricians, nurse practitioners, behavioral health clinicians) elicited information about the current clinic workflow for adolescent substance use and barriers and facilitators to SBIRT implementation. RESULTS: Of 1588 adolescents who completed the assessment (70.5%), 6.8% reported current substance use. Self-reported use was highest among non-Hispanic Black (15.2%) adolescents and those with co-occurring depressive symptoms (14.4%). Provider-reported challenges to implementing SBIRT included a lack of space for confidential screening and a lack of referral options. Providers favored implementing technology-based tools such as tablets for adolescent pre-visit screening and electronic medical record-based decision support to facilitate brief intervention and treatment referrals. CONCLUSIONS: This study fills a substantial research gap by examining factors that impede and support SBIRT implementation in pediatric FQHC settings. Successful SBIRT implementation in these settings could significantly reduce the unmet need for substance use treatment among uninsured and publicly insured adolescents. Pediatric primary care and urgent care providers perceived SBIRT to be feasible, and health information and digital technologies may facilitate the integration of SBIRT into clinic workflows. Ensuring confidentiality for screening and expanding referral options for adolescents in need of community-based addiction treatment are also critical to increasing SBIRT uptake.

The Ethical Implications of Using Social Media to Engage and Retain Justice-Involved Youth in Behavioral Health Research.

Given its popularity among youth ages 13-17, social media is a promising avenue for engaging and retaining historically hard-to-reach youth in longitudinal research. Social media use in longitudinal research involving youth, however, has preceded development of best practices for ethical use. This article describes the ethical challenges and considerations of using social media to engage and retain youth within the context of a randomized controlled trial of a group-based adolescent substance use intervention. Best practices for addressing ethical challenges are also provided using the Belmont Principle as a guiding framework. As social media becomes more commonly used to engage and retain youth in clinical research studies, researchers must address emerging ethical concerns within project protocols.

Smoking reduction is associated with lower alcohol consumption and depressive symptoms among young adults over one year.

BACKGROUND: This secondary analysis examined whether smoking reduction among young adults participating in a Facebook-based smoking cessation intervention study was associated with corresponding reductions in alcohol consumption and depressive symptoms. METHODS: Participants were young adults who smoked and engaged in heavy episodic drinking (HED). Alcohol consumption (AUDIT-C, days of HED), depressive symptoms (PHQ-2), and past-month cigarettes per day (CPD) were self-reported at baseline and 12 months (N = 150). Linear regression estimated the relationship between the mean change in CPD and mean changes in alcohol consumption and depressive symptoms. RESULTS: CPD, alcohol consumption, and depressive symptoms decreased significantly between baseline and 12 months. The adjusted mean reduction in CPD was significantly associated with mean reductions in AUDIT-C (Beta [ß] = 0.09, 95 % confidence interval [CI] = 0.04-0.14), days of HED (ß = 0.17, 95 % CI = 0.04-0.29) and PHQ-2 (ß = 0.05, 95 % CI = 0.01-0.08). Smoking abstinence (n = 48) was associated with a significantly larger mean reduction in AUDIT-C compared to a ≥50 % reduction (n = 45) (-2.9 vs -1.7 points, p = 0.03) or <50 % reduction in CPD (n = 57) (-2.9 vs -1.1 points, p < 0.01). The mean reduction in AUDIT-C did not differ between a ≥50 % reduction and <50 % reduction in CPD (-1.7 vs.-1.1 points, p = 0.18). Mean reductions in days of HED and the PHQ-2 did not differ according to the level of reduction in CPD. CONCLUSION: Smoking reduction was associated with reductions in alcohol consumption and depressive symptoms. Reductions appeared to be greater for those who achieved abstinence compared to a reduction in smoking.

The Relationship of E-Cigarette Use to Tobacco Use Outcomes Among Young Adults Who Smoke and Use Alcohol.

OBJECTIVES: E-cigarette use is increasing among young adults in the U.S. However, longitudinal research studies examining associations between e-cigarette use and combustible cigarette use among young adults are limited. This study assessed the relationship of e-cigarette use to smoking reduction and cessation among young adults. METHODS: This is a secondary analysis of a randomized controlled social media-based smoking cessation trial comprising adults ages 18 to 25 who smoked cigarettes and engaged in heavy episodic drinking (N = 179). Over 12 months, participants reported past month e-cigarette use with nicotine or tetrahydrocannabinol, cigarette quantity in the past week, quit attempts, and cessation strategies including nicotine e-cigarettes. Longitudinal regression models estimated associations between e-cigarette use, smoking reduction, and 7-day abstinence. RESULTS: Past-month nicotine e-cigarette use prevalence ranged from 53.1% at baseline to 50.3% at 12 months. Over 70% of participants who reported past month nicotine e-cigarette use also smoked cigarettes (ie, dual use). Neither past month nicotine nor tetrahydrocannabinol e-cigarette use was associated with smoking reduction or cessation. However, use of nicotine e-cigarettes as a cessation strategy among participants attempting to quit (N = 137) was positively associated with abstinence (adjusted odds ratio = 2.47, 95% CI = 1.20-5.09) and ≥50% reduction in cigarettes per week from baseline (aOR = 2.36,95% CI = 1.08-5.18), relative to other strategies. CONCLUSIONS: Nicotine e-cigarettes were significantly associated with improved tobacco use outcomes when used as a cessation strategy, but not when used apart from trying to quit smoking. Dual use may not be an effective path to achieve smoking cessation.

Key Components of Effective Pediatric Integrated Mental Health Care Models: A Systematic Review.

Importance: Emerging evidence suggests that integrated care models are associated with improved mental health care access and outcomes for youths (children ≤12 years and adolescents 12-21 years) served in pediatric primary care settings. However, the key components of these complex models remain unexamined. Objective: To identify and describe the key components of effective pediatric integrated mental health care models. Evidence Review: The PubMed, Embase, PsycINFO, and Cochrane Controlled Register of Trials electronic databases were searched for relevant peer-reviewed articles published between January 1, 1985, and April 30, 2019. Articles were restricted to those published in the English language. Eligible articles reported original data on youths 17 years or younger, implemented an integrated mental health care model in a pediatric primary care setting, and assessed the model's association with primary outcomes (eg, mental health symptom severity) and secondary outcomes (eg, functional impairment and patient satisfaction). Articles that specified some degree of systematic coordination or collaboration between primary care and mental health professionals were included in the final review. Two independent reviewers extracted data on study design, model type, model components, level of integration, and outcomes. Study quality was assessed using the Jadad scale. Data were analyzed between January 1, 2018, and May 31, 2019. Findings: Eleven randomized clinical trials involving 2190 participants were included. Three studies focused on youths with depression, 3 on youths with attention-deficit/hyperactivity disorder, and 5 on youths with behavioral disorders. Most studies (9 of 11) implemented either the collaborative care model (n = 3), a slightly modified version of the collaborative care model (n = 2), or colocated care (n = 4). The most commonly reported components of effective pediatric integrated mental health care models were population-based care, measurement-based care, and delivery of evidence-based mental health services; all 3 components were present in studies reporting clinical improvement of mental health symptoms. Other model components, such as treatment-to-target or team-based care, were common in studies reporting specific outcomes, such as functional impairment. Conclusions and Relevance: This review is the first to date to systematically search and qualitatively synthesize information on the key components of effective pediatric integrated mental health care models. This knowledge may be especially useful for pediatric primary care administrators in the selection of an integrated care model for their setting.

Community Efforts to Reduce Racial and Ethnic Health Disparities: Challenges and Facilitators Identified by 16 Multistakeholder Alliances.

The Robert Wood Johnson Foundation's Aligning Forces for Quality (AF4Q) program aimed to improve health care quality and reduce racial and ethnic disparities in 16 diverse communities in the United States from 2006 to 2015; yet most communities failed to make substantive progress toward advancing health care equity by the program's end. This qualitative analysis of key stakeholder interviews aims to identify the major contributors to success versus failure in addressing local health disparities during AF4Q and identified five major themes. Three themes highlight challenges related to collecting local data on racial and ethnic health disparities and transitioning from data collection to action. Two themes capture the critical contribution of stakeholder engagement and access to technical expertise to successful efforts. The challenges and facilitators experienced by these 16 AF4Q communities may help inform the disparities reduction efforts of other communities and guide state or federal policies to reduce health disparities.

Factors Associated With Use of Mental Health and Substance Use Treatment Services by Justice-Involved Youths.

OBJECTIVE: Nonincarcerated (community-supervised) youths who are first-time offenders have high rates of mental and substance use disorders. However, little is known about their use of psychiatric services (mental health and substance use) or factors associated with service use. This study examined the prevalence, determinants, and barriers to service use among community-supervised youths. METHODS: Data were from a longitudinal study of mental health and substance use outcomes among adolescents ages 12-18 from a northeastern family court in which caregivers and youths completed assessments (N=423 dyads). The Behavior Assessment System for Children, Second Edition, assessed youths' psychiatric symptoms. The Child and Adolescent Services Assessment assessed service use and barriers. Family functioning and caregiver-adolescent communication were assessed with the McMaster Family Assessment Device and the Parent-Adolescent General Communication Scale, respectively. Multivariable regression analyses examined the cross-sectional relationship between youths' service use and determinants of use at baseline. RESULTS: Of the 423 youths, 49% experienced psychiatric symptoms and 36% used psychiatric services in the past 4 months. The highest adjusted odds of service use were associated with youths' psychiatric symptoms and caregivers' history of a psychiatric diagnosis. The lowest odds were associated with caregivers' identifying as being from racial and ethnic minority groups. Caregiver-reported barriers to service use differed according to prior service use and by caregiver race-ethnicity. CONCLUSIONS: Results suggest a need for interventions to increase access to and engagement in psychiatric services for community-supervised youths and the importance of caregiver factors in designing such interventions.

Text Messaging to Enhance Behavioral Health Treatment Engagement Among Justice-Involved Youth: Qualitative and User Testing Study.

BACKGROUND: Mental health and substance use disorders are highly prevalent in justice-involved youth, yet only 8% of court-involved, nonincarcerated (CINI) youth in need of treatment receive it. Dual diagnosis (co-occurring psychiatric and substance use disorders) in justice-involved youth is highly predictive of recidivism. Identifying novel approaches, such as the use of mobile health (mHealth) technologies, to close this gap between need and receipt of behavioral health treatment for the CINI population could potentially offset rates of reoffending into adulthood. Text-messaging (short message service, SMS) interventions have demonstrated efficacy in improving treatment adherence and other associated outcomes in other vulnerable youth populations, but development and testing of mHealth interventions to improve behavioral health treatment rates and outcomes for CINI youth are lacking. OBJECTIVE: This study aimed to collect qualitative data from key stakeholders to inform the development of a theoretically grounded, family-based text-messaging (SMS) intervention targeting CINI youth's behavioral health treatment engagement; additionally, the aim was to conduct end-user testing over 6 months with CINI youth and caregivers to determine intervention feasibility and acceptability. METHODS: CINI youth and caregivers were referred from a California-based Juvenile Probation Department and community-based provider organizations providing services for justice-involved youth. Eligibility criteria included the following: being a justice-involved youth or a caregiver of a justice-involved youth, English speaking, youth aged 13 to 17 years old and either referred to or currently attending mental health or substance use treatment, and youth and caregiver have access to a cell phone with text-messaging capability. RESULTS: Overall, 28 individuals participated in focus groups and interviews-8 youth, 5 caregivers, and 15 juvenile justice (JJ) personnel. Three major themes emerged: (1) texting among JJ personnel and CINI youth and caregivers in their caseload is common but not systematic, (2) stigma and privacy are perceived as barriers to texting youth about behavioral health treatment appointments, and (3) messages should be short, simple, relatable, positive, and personalized. In total, 9 participants (7 youth and 2 caregivers) participated in end-user testing and rated the intervention as useful, helpful, and supportive. CONCLUSIONS: Text messaging (SMS) is an acceptable and feasible means of reminding CINI youth to attend behavioral health treatment appointments. Future implementation challenges include making text messaging (SMS) personalized and tailored but not resource intensive (eg, requiring one-to-one, 24/7 human contact) and identifying which systems will deliver and sustain the intervention. Text messaging (SMS) among justice personnel, youth, and their caregivers is already widespread, but lack of clear guidelines about privacy, confidentiality, and information sharing poses ethical conundrums. Future hybrid-type research designs that explore the efficacy of the intervention while also studying ethical, system, and policy-level factors associated with using digital health interventions to improve CINI youth outcomes is a key next step.

Patient-Centered Medical Home Care for Adolescents in Need of Mental Health Treatment.

PURPOSE: The patient-centered medical home (PCMH) has emerged as an optimal primary care model for all youth; however, little is known about the extent to which adolescents in need of mental health (MH) treatment receive care consistent with the PCMH. This study assessed (1) 10-year trends in PCMH care among U.S. adolescents according to MH need and (2) variations in PCMH care and its subcomponents among adolescents with MH need, by individual and family characteristics. METHODS: This was a secondary analysis of Medical Expenditure Panel Survey data (2004-2013). The sample included adolescents aged 12-17 years with ≥1 office-based visits in the past year (N = 18,717). Questions assessing a usual source of care and care that is accessible, comprehensive, family-centered, and compassionate were used to define PCMH care. For adolescents with MH needs, multivariable logistic regression was used to describe the association between PCMH care and sample characteristics. RESULTS: Fifty percent of adolescents experienced PCMH care, with little change between 2004 and 2013. Adolescents with MH need (N = 3,794) had significantly lower odds of experiencing PCMH care compared with those without MH need (odds ratio, .78; 95% confidence interval, .69-.87). Among adolescents with MH needs, being uninsured and living with a parent who did not graduate high school were negatively associated with PCMH care, whereas parental usual source of care was positively associated (odds ratio, 1.69; 95% confidence interval, 1.28-2.22). CONCLUSIONS: Increasing care accessibility, integrating MH services into primary care settings, and targeting socioeconomically disadvantaged subgroups could improve rates of PCMH care among adolescents with MH needs.

Lessons learned about advancing healthcare equity from the Aligning Forces for Quality initiative.

OBJECTIVE: The Robert Wood Johnson Foundation's (RWJF's) Aligning Forces for Quality (AF4Q) initiative aimed to advance healthcare quality and equity in 16 communities across the United States through multi-stakeholder alliances of healthcare payers, providers, and consumers. Our objectives are (1) to summarize the major approaches and activities undertaken by the AF4Q alliances that were most successful in tracking and implementing programs that aimed to reduce local healthcare disparities by race, ethnicity, and primary language spoken (REL), and socioeconomic status (SES); and (2) to identify the major lessons learned from the successes and failures of the AF4Q alliances to inform other equity-focused initiatives. METHODS: We analyzed data from 6 rounds of key informant interviews conducted between 2010 and 2015, and triannual progress reports submitted by the alliances to RWJF between 2008 and 2015. RESULTS: Of the 16 AF4Q alliances, 2 succeeded in developing community wide systems to track local healthcare disparities, 5 alliances implemented substantive programs that aimed to reduce local disparities, and 3 alliances were successful in disparity measurement and program implementation. The alliances that were most active in addressing disparities tended to have long-established relationships with relevant community organizations, focused on improving the quality of care provided by safety-net providers, and shifted quickly toward working to address disparities even if their initial efforts to stratify performance measures by REL failed. CONCLUSION: Few alliances were able to develop community wide systems to track local healthcare disparities or implement large-scale initiatives to reduce disparities during the 7 years that these objectives were advanced by the AF4Q initiative. Establishing robust local disparity-tracking systems and establishing productive relationships with key community stakeholders took substantial time. The AF4Q experience suggests that efforts to reduce disparities should not be held up by disparity measurement challenges.

Why and how six aligning forces for quality communities have focused on reducing disparities.

Public reports on provider performance can help guide consumers' health care decisions, yet consumer awareness and use of public reports is low and may be even lower among racial/ethnic minorities. In this qualitative research article, we describe activities implemented by multi-stakeholder alliances in six U.S. communities to increase minorities' awareness of public reports. We also describe alliances' motivation for deliberately targeting greater awareness among minorities. We found that alliances' decision was influenced by the proportion of minorities and perceptions of race-based disparities in care in the community. To raise awareness, alliances collaborated with minority-serving organizations to (a) advertise their web-based public report using ethnic media outlets, (b) present their public reporting website during health education outreach events held in minority communities, and (c) translate their public report into multiple languages. We conclude that community partnerships are a promising mechanism for targeting efforts to increase awareness of public reports in minority communities.

HIV screening practices in U.S. hospitals, 2009-2010.

OBJECTIVE: A 2004 national survey of hospitals showed that 23.4% of hospitals screened for HIV in at least one department, most frequently in labor and delivery departments. However, less than 2% of these hospitals screened patients in inpatient units, urgent care clinics, or emergency departments. In 2006, the Centers for Disease Control and Prevention (CDC) recommended HIV screening for all individuals 13-64 years of age in health-care settings. We determined the frequency of hospital adoption of these CDC recommendations. METHODS: We surveyed hospital infection-control personnel at a randomly selected sample of U.S. general medical and surgical hospitals in 2009-2010. RESULTS: Of the 1,476 hospitals selected for the survey, 754 (51.1%) responded to the survey; of those responding, 703 (93.2%) offered HIV tests for patients at the hospital and 206 (27.3%) screened for HIV in at least one department. Screening was most common in larger hospitals (45.7%), hospitals in large metropolitan areas (50.5%), and teaching hospitals (44.4%); it was least common in public hospitals (19.1%). By department, screening was most common in labor and delivery departments (34.6%) and substance abuse clinics (20.7%); it was least common in emergency departments (11.9%), inpatient units (9.6%), and psychiatry/mental health departments (9.4%). More than half of hospitals were not considering implementing CDC's recommendations within the next 12 months. CONCLUSIONS: Since 2004, HIV screening in hospitals increased overall and by department. However, the majority of U.S. hospitals have not adopted the CDC recommendations.

Measurement of influenza vaccination coverage among healthcare personnel in US hospitals.

OBJECTIVE: To characterize practices related to measuring influenza vaccination rates among healthcare personnel in US hospitals. DESIGN: Descriptive survey. SETTING: Nonfederal, short-stay hospitals that provide general medical and surgical services, identified by use of the 2004 American Hospital Association Annual Survey Database. PARTICIPANTS: Healthcare personnel from 996 randomly sampled US hospitals stratified by region and bed size. METHODS: A self-administered questionnaire was distributed in 2006 to infection control coordinators to gather data on policies and practices related to the provision of the influenza vaccine and on the measurement and reporting of influenza vaccination rates. Descriptive statistics and associations were calculated, and logistic regression was conducted. RESULTS: The response rate was 56% (ie, 555 of 996 US hospitals responded to the questionnaire). Weighting accounted for sampling design and nonresponse. Most hospitals provided the influenza vaccine to employees (100%), credentialed medical staff (ie, independent practitioners; 94%), volunteers (86%), and contract staff (83%); provision for students and residents was less frequent (58%). Only 69% of hospitals measured vaccination rates (mean coverage rate, 55%). Most hospitals that measured coverage included employees (98%) in the vaccination rates, whereas contract staff (53%), credentialed medical staff (56%), volunteers (56%), and students and residents (30%) were less commonly included. Among hospitals measuring coverage, 44% included persons for which vaccine was contraindicated, and 51% included persons who refused vaccination. After adjustment for region and size, hospitals with vaccination plans written into policy (odds ratio, 2.0 [95% confidence interval, 1.22-7.67]) or that addressed internally reporting coverage (odds ratio, 4.8 [95% confidence interval, 2.97-7.66]) were more likely to measure coverage than were hospitals without such plans. CONCLUSIONS: Hospitals vary in terms of the groups of individuals included in influenza vaccination coverage measurements. Standardized measures may improve comparability of hospital-reported vaccination rates. Measuring coverage in a manner that facilitates identification of occupational groups with low vaccination rates may inform development of targeted interventions.

HIV testing and referral to care in U.S. hospitals prior to 2006: results from a national survey.

OBJECTIVES: We sought to provide a benchmark for human immunodeficiency virus (HIV) testing availability and practices in U.S. hospitals prior to the Centers for Disease Control and Prevention's (CDC's) 2006 revised recommendations. METHODS: We conducted a survey of nonfederal general hospitals in the U.S. in 2004. Chi-square tests detected significant associations with hospital characteristics. Questionnaires were completed electronically via a secure Internet site or on paper. Nonresponse analysis was conducted and data were weighted to adjust for nonresponse. RESULTS: HIV testing (on the basis of clinical symptoms or behavioral risk factors) was available in more than half of hospital inpatient units (62%), employee health departments (58%), and emergency departments (57%). Twenty-three percent offered routine screening (testing for people in a defined population regardless of clinical symptoms or behavioral risk), most commonly in labor and delivery. Teaching status, region, size, and type of metropolitan area were associated with the availability of HIV testing and routine screening (p<0.01). Hospitals used a variety of methods to link patients to care: referral to a hospital-based clinic (36%); on-site, same-day evaluation (35%); and referral to an unaffiliated HIV or community clinic (42%). CONCLUSIONS: Hospitals offered HIV testing on the basis of clinical suspicion or risk, but were far from meeting CDC's current recommendation to routinely test all patients aged 13 to 64. Hospital size, teaching status, and geographic location were associated with HIV testing availability and testing practices. Our understanding of current practice identifies opportunities for public health action at the practitioner, organization, and systems levels.