Implementation Barriers to and Facilitators of Screening, Brief Intervention, Referral, and Treatment (SBIRT) in Federally Qualified Health Centers (FQHCs). Executive Summary


A range of interventions exists for the prevention and treatment of alcohol-dependent and drug-related risk and harm.1 Primary care settings may be ideal locations for screening for early detection of risky or dependent substance use, conducting brief interventions to reduce individual and population risk, initiating treatment for substance dependence, and managing other comorbid conditions that may benefit from specialist consultation and/or treatment.2 Adolescents and adults with high-risk or dependent use of alcohol and other drugs come into frequent contact with primary care.3 Screening and brief intervention (SBI) for alcohol has emerged as a cost-effective preventive approach4, 5 that is relevant and practicable for delivery in primary health care.6, 7, 8 Substance use SBI is typically short in duration (5-25 minutes) and designed to promote awareness of the negative effects of drinking or drug use and to motivate positive behavior change. Primary care treatments for alcohol and drug dependence include Food and Drug Administration-approved medications for alcohol and opioid dependence and several counseling techniques.

Despite considerable efforts over many years by federal agencies, professional medical associations, and health insurers to persuade primary care providers (PCPs) to routinely screen and treat patients with substance use disorders, few do so. United States and international literature reveal persistent barriers to brief alcohol and drug intervention,9, 10, 11, 12, 13, 14 including lack of time, training, and resources; low or no reimbursement; and the inability to bill for a primary care service and a behavioral health service on the same day; limited referral resources; beliefs that patients will not take advice to change their drinking or drug use behaviors; and concern about offending patients by discussing substance use. Many providers lack training and are uncomfortable dealing with substance use issues. There is a chronic dearth of behavioral health specialists to provide patient consultation and an absence of behavioral health referral sources when they are needed. Competing demands on PCPs' time further slow the process of integrating SBI into routine practice. Getting attention and time from PCPs to deliver any prevention or risk reduction health advice is very difficult.

This paper reviews the research literature on the barriers in primary care and strategies for overcoming those barriers to integrate substance use care into evolving patient-centered medical/health homes (PCMHs). The literature review is supplemented by extensive interviews with experts and site visits to health centers across the country. From these data, several policy and programmatic levers were identified that could help federally qualified health centers (FQHCs) adopt and sustain substance use screening and treatment as a routine part of whole-person care for their patients.

Key elements:

  • Support must come from leaders who are credible to FQHCs: Impetus for integrating substance use treatment must come from the organizations and professional societies that are most salient to health centers.

  • A standard, brief behavioral health screener is needed: A common, simple screener is needed that primary care can use to assess behavioral risks, including alcohol and substance use.

  • Adapt substance use risk assessment and intervention: FQHCs should be encouraged to fit substance use screening and risk reduction interventions into their styles and paces of practice.

  • Standardize substance use SBI metrics for electronic health record (EHR) reporting: Simple electronically specified measures of SBI can be modeled on the depression and tobacco screening and counseling measures that FQHCs already report.

  • Include SBI as an essential element of patient-centered medical homes: Primary care practices that seek certification as PCMHs should demonstrate their ability to provide substance use screening, intervention, and treatment to their patients.

  • Remove restrictions on communication between providers: Clinicians need to be able to readily access all necessary clinical information to assess and treat their patients, including information about patients' substance use.

  • Remove reimbursement barriers: Substance use screening, treatment, and care management, when delivered by credentialed primary care professionals or well-trained non-credentialed paraprofessionals, must be sufficiently reimbursed to be financially sustainable for primary care.

  • Payers should demand accountability: Government and private insurers should require reports on substance use screening and treatment, similar to the requirements to report on diabetes, hypertension, immunization, and other routine primary care clinical services.

  • Direct greater attention to integrating substance use services throughout primary care-behavioral health integration efforts: Service and training grant programs that are designed to increase the integration of primary and behavioral health care services should explicitly require the inclusion of substance use services.

  • Organizational development consultation may result in the better fit of SBI into FQHC workflows: Assisting health centers to infuse substance use screening and treatment into their existing patient flows, EHRs, and accountability structures may increase uptake and sustainability.

  • Behavioral health clinicians working in FQHCs need substance use training and skills: Behavioral health specialists should be skilled in assessing and managing the wide range of behavioral health issues of primary care patients, including their unhealthy use of alcohol and other drugs.

  • Substance use records should be integral to all EHR systems: EHRs should always include fields for substance use risk assessment, diagnosis, and treatment.

  • Continuing education programs for FQHC primary care and behavioral health personnel should include substance use risk assessment and treatment: Workforce development in primary care must include core substance use risk assessment and intervention competencies.

  • Emphasize substance use in pre-professional primary care workforce development: Baccalaureate and advanced health professional education programs should teach core competencies in substance use risk assessment, treatment, and recovery support.

  • Recognize FQHCs that provide outstanding substance use care: Recognize health centers that excel in assessing and managing substance use risk. Their successes should be publicized for others to emulate.

What is clear from an extensive review of the research, the interviews, and the site visits is that wishing and hoping that the evidence of effectiveness will produce widespread uptake is exactly that, wishful hoping: What's needed is action. Fortunately, there are examples of successful adoption that show what can be done. Although there are some areas where additional research could be helpful, the key challenge remains the one described in the Institute of Medicine's landmark 1990 report Broadening the Base for Treatment of Alcohol Problems: "Suitable methods of identification and readily learned brief intervention techniques with good evidence of efficacy are now available. The [IOM] committee recommends that consideration be given to the broad deploying, in a wide variety of community settings, of identification and brief intervention capabilities, coupled with the referral of appropriate individuals to the specialized treatment system for alcohol problems." After 25 years, the present report identifies key barriers that slow the adoption of substance use screening, intervention, and treatment into routine practice. The report points to policies and practices that can speed the widespread use of these evidence-based practices. After a quarter-century, the promise of SBI can become a reality.15, 16, 17, 18, 19

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