Implementation Barriers to and Facilitators of Screening, Brief Intervention, Referral, and Treatment (SBIRT) in Federally Qualified Health Centers (FQHCs). Appendix A. Literature Review and Interview Strategy


The overall research literature review strategy started with Medline, the main research data resource, and attempted to first capture a set of SBIRT-related records qualified by language (English) and publication years (2002-2013); no geographic qualifiers were introduced. After multiple trial checks, "brief intervention"--which implies a method of detection or screening and of actual or possible follow-up to referral--was determined to be the most effective way to retrieve relevant articles. Search terms included SBIRT, "screening, brief intervention and referral to treatment," and various permutations such as brief adj3 intervention*, brief adj2 counseling, and others. Once this set of records was identified, additional terms were searched against it to yield articles that were relevant to the five issues. These included terms and permutations of: (1) health care setting (e.g., exp primary health care/, primary adj2 care, primary healthcare, federally qualified health center*, FQHC*, exp community health centers, etc.); (2) treatment outcomes and cost benefits (e.g., exp outcome and process assessment (health care), exp cost-benefit analysis, cost* adj3 saving*, and other MeSH and keyword terms); (3) substance abuse and mental health (e.g., exp substance-related disorders/, exp alcohol drinking/, alcohol, alcohol drinking, alcoholic*, alcoholism, etc.); (4) implementation; and (5) terms that might have revealed articles about direct and indirect ways to initiate, promote, and sustain SBIRT efforts in the future (e.g., keywords and MeSH headings for benchmarking, quality indicators, accountability, health information technology, health care quality, information dissemination, reimbursement, etc.). After Medline records were excluded, a similar search of subsequent databases (CINAHL, Psych Info, Cochrane Library (Wiley) was conducted. Cited reference searches in the Web of Science database of key articles were further refined by search criteria (e.g., implement* or adopt* or disseminat* or innovat*). The Embase search used criteria parallel to those searched in Medline to retrieve the initial set of SBIRT-related publications.

Additional Search Strategies

All retrieved citations and corresponding articles were placed in EndNote, and a "snowball" search was performed by project director Eric Goplerud, project manager Tracy McPherson, and lead research analyst Christina Cruz to identify additional relevant articles. In addition to the systematic search and subsequent snowball searches, germane literature was also gathered through personal communications and discussions with leading experts in the field.

Relevant Literature Identification Process

Articles identified in the search were then reviewed by project director Eric Goplerud to narrow search results to include only articles pertaining to: SBIRT implementation, integration of SBIRT into primary care and community health settings, barriers to and facilitators of SBIRT, barriers to and facilitators of substance abuse treatment (including MAT) implementation in primary care and community health settings, and implementation science for evidence-based practice. Articles were then sorted by topic and setting by project director Eric Goplerud and lead analyst Christina Cruz. Articles were sorted into three categories that reflected the structure of the subsequent literature review: SBIRT implementation in adult substance abuse populations in primary care and community health centers; SBIRT implementation in adolescent populations in primary care, community health settings, and school-based networks; and pharmacotherapy integration in primary care and community health settings.

The review of articles and relevant materials (e.g., personal communications) resulted in 410 research articles and reviews pertaining to substance abuse/SBIRT implementation barriers and facilitators: 288 substance abuse/SBIRT implementation articles (adult), 31 MAT implementation articles, 38 substance abuse/SBIRT implementation articles (adolescent) in primary care/community health/school-based settings, five cost analysis articles that examined substance abuse/SBIRT integration in primary care/community health settings, 53 implementation science articles (with emphasis on substance use integration in primary care/community health settings), and 19 international articles (emphasis on substance use integration in primary care/community health centers).

The research team also interviewed 30 experts who had practical and research experience integrating substance use services into primary care settings, and the team visited four FQHCs to conduct semi-structured interviews with clinical, administrative, and financial staff. Discussion guides for the expert and site visit interviews covered integrated service characteristics; billing, reimbursement, and funding climate; leadership support; training; staffing; relationships with SUD treatment and specialty care providers; health information technology and EHRs; outcomes and monitoring; and policies and procedures. Information from interviews and site visits is integrated into the literature review. Working with the ASPE, the team identified 30 key informants who were interviewed by either Dr. Goplerud or Dr. McPherson in semi-structured one-hour telephone interviews. The following informants were interviewed: Stephanie Harrison, executive director, Wisconsin Primary Health Care Association; Virna Little, senior vice president, Psychosocial Services and Community Affairs, the Institute for Family Health; Mia Croyle, behavioral health program manager, Wisconsin Primary Health Care Association; Ted A. Kay, president and CEO, Family Health/La Clínica; Jeffrey Goodie, board-certified clinical health psychologist, associate professor, Department of Family Medicine, Uniformed Services University; Marla Oros RN, MS, president, Mosaic Group; Jeff Reiter, PCBHI/SBIRT consultant and director of behavioral health; Jim Werth, board-certified in counseling psychology, behavioral health and wellness services director, Stone Mountain Health Services; Tillman Farley, executive vice president for medical services, Salud Family Health Centers; Katrin Seifert, Director of Integrated Services and Psychology Training, Salud Family Health Centers; Ariel Singer, MPH, technical assistance curriculum manager, Oregon Primary Care Association; Arne Beck, research, Kaiser Permanente, Colorado; Brenda Reiss-Brennan, RN, Intermountain Health; Kirk Stohsal, behavioral health consultant, Rocky Mountain; Nicolas Serriano, psychologist and consultant, FQHC in Madison, Wisconsin; and Tom Backer, Human Interaction Research Institute. In addition, Dr. Goplerud and Dr. McPherson interviewed knowledgeable personnel from SAMHSA, NIAAA, NIDA, HRSA, CDC, CMS and ASPE.

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