Encompasses the steps taken to introduce and sustain the innovation.
The fifth domain relates to the implementation process itself. The CFIR framework identifies four essential activities: planning, engaging, executing, andreflecting and evaluating.83
A common deficiency in SBI implementation is insufficient time and attention devoted to workflow, to building cross-disciplinary relationships, and to educating and preparing staff who will not jeopardize implementation.77, 284 Interviews with leaders and staff involved in the first cohort of SAMHSA SBIRT grants157 determined that programs had too little time between the grant award and the required start of clinical services to train the staff who would be implementing the SBIRT services or to prepare other staff for the innovation. Short start-up time hindered the programs in developing the trust and partnerships with community substance use treatment programs that would be needed once the programs started for referrals of difficult cases identified by screening.
Helpful engagement strategies include involving opinion leaders, internal champions, and external change agents; obtaining clear mandates and consistent support from senior administrative and clinical leadership; maintaining stable clinic leadership; setting regular meetings to review implementation; facilitating new ways of working together for various staff segments; and intentionally supporting camaraderie and culture change.83, 91, 101, 129, 160, 200, 203, 207, 285, 286, 287, 288 Clinic leaders should engage in on-the-job coaching with actual patients, discuss worst-case scenarios, and employ impromptu coaching.94, 105, 129, 135, 160, 161, 287 External change agents can help by using their personal influence to elicit support and cooperation, conducting staff training, helping to sustain fidelity to the intervention model, and participating in the project launch.232, 284
Few programs are implemented exactly as planned, and flexibility is key. Vendetti et al.157 observed that SBI programs make significant modifications over time in response to unanticipated challenges. To increase the likelihood that SBI will be sustained once it is undertaken, programs have built screening and brief counseling prompts into their EHRs,285, 287 provided hands-on consultation and coaching over time,161, 169, 285 changed incentives,124 and provided timely feedback to clinicians and supervisors.77, 91, 116, 124, 160, 286, 288
Facilitators: Recommendations from Key Informants and FQHCs
Interviews with key informants and discussions with health center staff yielded a number of recommendations related to facilitating the implementation and sustainability of SBIRT in health centers:
Provide education prior to and during implementation to address the clinical benefits of the model, and teach providers ways to talk to patients about sensitive issues. Encourage a functional approach: not treating a disease but improving functioning and quality of life.
Utilize robust tracking systems. Organizations that monitor substance use screening and treatment produce higher SBI rates, more positive screens, and better patient outcomes. Reward providers for improved performance measured through tracking systems. But avoid tracking overload and creating time-consuming data entry.
Provide the tools to effectively implement SBIRT, such as readiness rulers and decisional balance tools. Use pocket-sized decision support guides such as the Brief Negotiated Interview.
Provide onsite behavioral health trainers during implementation to assist in tweaking interventions to the site's workflow, staffing, and priorities and to problem solve EHR and tracking issues as they emerge.