Knowledge and beliefs about the intervention, self-efficacy, individual readiness to change, individual identification with the organization, and other personal attributes.
The CFIR points to the critical role that the individuals who make up organizations play in implementing and sustaining SBIRT, and it emphasizes five domains related to individuals: (1) knowledge; (2) self-efficacy; (3) readiness to change; (4) individual identification with the organization; and (5) other attributes.70
Knowledge and Beliefs
Many PCPs lack knowledge of substance use screening tools and healthy versus unhealthy drinking guidelines,91, 116, 124 risks associated with episodic and chronic drinking and drug use,13, 131, 160, 183, 201, 203 screening and interpretation of screening results,59, 91, 116, 133, 166, 169, 185, 203, 246 counseling and motivational interviewing techniques with high-risk and dependent patients,13, 91, 103, 106, 118, 120, 156, 166, 183, 185, 186, 246, 247, 248 pharmaceutical treatments for dependence,118, 124 referral processes, and community substance use treatment and recovery support resources.246 Many feel unprepared and unwilling to ask about patients' substance use or to treat the problems that screening may disclose.15, 160, 169, 179, 203, 219, 249, 250, 251, 252, 253 Few are aware of research evidence on the differences between effective and ineffective therapies119, 126 or on the effectiveness of psychosocial interventions by non-medical clinicians.124, 204, 246 Many believe that if they administered SBI, they would provoke negative reactions from patients,8, 117 and without appropriate skills, they might.135, 186, 187, 207
FQHCs employ few substance use treatment specialists. More than 80 percent employ none.254 The absence of substance use specialists in FQHCs may contribute to medical staffs' lack of knowledge about substance use issues. A recent FQHC behavioral health staffing needs assessments by the NACHC found that health centers would have needed to employ an additional 931 FTE substance use treatment specialists to meet current patient needs in 2010. Health centers would need to employ nearly 4,000 more substance use specialists to meet expected projected need by 2015.255, 256
A survey of medical residency training program directors in seven medical specialties found that although 56 percent reported having received required curriculum content in preventing and treating addiction, the median number of hours ranged from 3 (emergency medicine and obstetrics/gynecology) to 12 (family medicine).257, 258 Only about 20 percent of practicing physicians report feeling very prepared to discuss drug and alcohol issues with their patients.259
Some suggest that assigning SBI as a standard of practice for nurses may fit with core nursing principles and training.120, 133, 159 Presently, baccalaureate nursing students receive an average of 11 hours of education on substance use issues, not enough to effectively deliver substance use screening and treatment according to nursing workforce researchers.260, 261, 262, 263 Social work students receive little formal SBI training in BSW and MSW programs.264, 265, 266, 267, 268 More than half of practicing clinical social workers report that they need more training in substance use issues.267 In most states, addiction is not a required element of psychologists' training.269 Health centers that wish to take a team approach to SBI may find few staff prepared to assist.77, 157, 169 One FHQC, intent on developing an integrated behavioral health service, collaborated with a local university to start an integrated care psychologist training program and offered itself as an internship and practicum site.270
Improving the preparation of primary care professionals to screen and treat patients' substance use issues is a priority of several federal agencies. HRSA and SAMHSA supported a faculty development and mentoring program that reached more than 10,000 PCPs between 1999 and 2005. SAMHSA funds medical residency and interdisciplinary health education programs to provide substance use SBI education.271 SAMHSA also supports a national SBIRT training program, the National SBIRT Addiction Technology Transfer Center, which is charged with educating students in health care disciplines and practicing clinicians.272 In addition, SAMHSA supports continuing education for PCPs on the use of medications to treat opioid dependence.273 The NIAAA developed a series of online training guides and videos for clinicians.274 NIDA has also developed NIDA-MED, an online source of tools, resources, and trainings to support physicians and other health professionals to screen and treat their patients with SUDs,275 and it awarded a contract in 2014 to train at least 28,000 health professionals on adolescent SBIRT.276 More than 30 nursing schools, social work departments, and their accrediting bodies are collaborating to develop and test substance use prevention, screening, and treatment curricula.
An individual's belief in his own capabilities to screen or manage patients with risky alcohol or drug use affects decisions to do so and to commit to using SBI even in the face of obstacles.169, 172, 185 A review of systematic reviews by Hyman169 identified six obstacles to competent delivery of brief intervention that revolved around lack of self-efficacy and knowledge: confusion regarding the content of brief intervention, lack of belief that the PCP could do it, insufficient time, lack of simple guidelines, perceived difficulty identifying risky use, and uncertainty about justification for starting the discussion. Kaner and her colleagues96 found that 77 percent of PCPs surveyed reported that it was important or very important to intervene with patients who report unhealthy alcohol use, but only 21 percent of physicians felt that they could do so.
Readiness to Change
Training increases the delivery of brief interventions by PCPs who are already committed to working with drinkers,16, 110, 172, 219 but many primary care clinicians do not perceive substance use screening or counseling as something they care to do or need to learn.171 A study of the 340 PCPs who participated in the WHO multinational study of SBI found that training and support only increased SBI rates for those who were already committed to change.15 For those who were not committed to change and secure in the belief that their roles included attention to patients' substance use, SBI training failed to increase willingness to deliver SBI services, and it actually decreased providers' confidence in doing so.15 Training, experience, seniority, and organizational support for SBI do increase clinicians' motivations to deliver SBI and to act on those motivations.8, 119, 184, 277 Pre-professional training260, 264, 265, 266, 267, 268, 269 and continuing education for practicing clinicians do result in small changes in knowledge, skills, attitudes, and activities.119, 278 Training appears to be more effective in changing knowledge and behaviors than attitudes, beliefs, and readiness to change.278
Individual Identification with Organization
How individuals perceive their organizations and how willing they are to put in extra effort speak well of the organization, and individuals' willingness to take risks in their organizations could influence their willingness to embrace an innovation if their organization adopted it.83 This area has received little attention in the SBI implementation research literature. There is some evidence that PCPs who perceive that their organizations support and encourage working with substance users are more willing to treat patients with substance use problems279 and are more likely to report satisfaction with their interactions with these patients.279 Feeling that one's organization supports SBI is associated with greater self-esteem, perceived knowledge, and feelings of empowerment among health professionals.279, 280, 281
Other Personal Attributes
Although there is not a great deal of attention being paid to other personal attributes of PCPs that may influence their willingness to deliver SBI, there are indications that clinicians judge patients' drinking against their own personal use of alcohol.127, 282 Five studies have confirmed that primary care clinicians with more personal or work experience with people with alcohol or drug use disorders report more positive attitudes towards treating patients with substance use risks.219 There is some evidence that female PCPs and older clinicians are better at identifying problem drinkers.283
Facilitators: Recommendations from Key Informants and FQHCs
Interviews with key informants and health center staff yielded a number of recommendations related to individual characteristics for facilitating the implementation and sustainability of SBIRT in health centers:
Revamp primary care training. Approach PCPs using their language and from the point of view of a provider. Utilize role-based protocols for training and a strong PCP orientation to behavioral health screening, brief intervention, and treatment. Conduct behaviorally based conversation training with standardized dialogues to increase patient and provider comfort. Frame SBIRT as a natural part of what a PCP already does.
Revamp behavioral health clinician training to make clinicians consultants. Place greater emphasis on brief intervention. Behavioral health clinicians must know how to communicate and work in an integrated, fluid, medical setting; have skills in motivational interviewing and cognitive behavioral therapy; and know how to record primary care notes and use medical terminology.
Create a sustained substance use and behavioral health training and consultation center, with a common SBIRT and behavioral health training curriculum and organizational consultation capacity. State primary care associations can identify FQHCs that excel in SBIRT and behavioral health; encourage staff from other clinics to learn by observing and getting consultation.