Comprises features of structural, political, and cultural contexts through which the implementation process will proceed.
The CFIR model identifies five features of organizations' inner settings that influence their capacity to implement and sustain innovations: (1) structural characteristics of the setting; (2) networks and communications; (3) culture; (4) implementation climate; and (5) readiness for implementation. These characteristics describe whether the structures, internal communications mechanisms, resources, leadership, and culture facilitate or frustrate adopting innovation and its fit into the organization.
Although there is little systematic analysis of the structural characteristics of the settings in which SBI is attempted, there are good reasons to believe that size increases the likelihood that SBIRT will be adopted.130, 136, 187, 200, 207, 212, 213, 214, 215, 216 A 2011 survey by the National Association of Community Health Centers (NACHC)215 found that FQHCs that integrated health and behavioral health care services had larger budgets, had more staff, and served more patients than did FQHCs that had more limited or no internal behavioral health services. Of the 1,199 FQHCs that reported service and budget data to HRSA in 2012, 229 reported employing substance use treatment specialists. On average, these 229 FQHCs had budgets that were nearly $7 million higher, employed more medical staff (77 versus 58), treated more patients (18,830 versus 15,091), and provided more service visits (64,532 versus 50,801).216
A second structural factor, workload, is the second most frequently cited barrier after reimbursement to adopting SBI.13, 17, 45, 117, 124, 126, 158, 217, 218 Providers and primary care administrators repeatedly cite the high productivity requirements of their settings, the conflicting priorities that demand providers' time, and pressure to address patients' presenting complaints in the very brief time available in clinical visits as reasons that SBIRT is not done.8, 13, 56, 71, 77, 101, 110, 117, 120, 124, 130, 156, 160, 179, 181, 186, 187, 212, 217, 219, 220, 221, 222
Taking screening out of the physicians' hands and making it part of the routine rooming process was considered key to successful implementation in several projects.8, 160, 200, 220 A number of key informants and findings from the literature suggested delegating routine substance use screening and counseling to nurses, who see health promotion and care management as central to their training and organizational roles.8, 159, 220, 223 Primary care physicians may be unwilling to screen, but in several studies, PCPs report that brief counseling and patient referral are appropriate responsibilities for physicians.8, 160, 220 Health workforce analysts are suggesting that primary care clinicians delegate preventive services--SBI, smoking, and depression and obesity screening and counseling--to non-medical staff.212, 224, 225
Other factors that inhibit integrating SBI into routine practice are high staff turnover and organizational instability.103, 116, 133, 135, 182 Some FQHCs experienced turnover and difficulty hiring and training replacements. The literature and site visits also indicated that settings with low staff and leadership turnover appear to have less difficulty implementing SBI.14, 100, 101, 133, 156, 213 Office space is a significant issue in some settings.82, 136, 215 One site suggested that infrastructure funds are needed to expand and reconfigure space to facilitate integrated care, including SBIRT services.
Network and Communication
In order for networking and communication to occur around patients' substance use risks and treatment, two types of communication may be needed: first, networking within the clinical team about patients' substance use risk and treatment, and second, communication between PCPs and substance use specialists. For the latter to occur, it is necessary that clinicians have opportunities to interact. Presently, opportunities for interaction between PCPs and SUD specialists are quite limited in FQHCs. NORC analyses of health centers' 2009-2012 annual reports to HRSA found that only 11 percent employed any substance use specialists.215, 216 While the average number of medical staff employed by FQHCs increased 16 percent from 2009 to 2012, and their medical patients increased by 28 percent to 15,091 in 2012, the number of substance use staff remained at low, stable levels, and the average number of substance use patients never exceeded 150.
Another opportunity for interaction between PCPs and SUD specialists in FQHCs is through common health records. These interactions generally do not take place in FQHCs.136, 172 In a 2012 study of 230 FQHCs that had integrated behavioral health and primary care, Goplerud and colleagues215 found that three out of five FQHCs had integrated physical and MH records, but only three in ten integrated substance use information in their EHRs.215 Few health centers include substance use diagnostic or treatment information in their EHRs.82, 203, 209, 215
Researchers and primary care practices are exploring the use of online substance use screeners and EHR prompts to deliver brief interventions.91, 103, 104, 160, 187, 201, 204, 213, 220 The evidence to date is mixed about the efficiency of pre-encounter substance use screening.162, 226 A recent series of meta-analyses227, 228, 229, 230, 231 found that computer-delivered screening for risky alcohol use and computer-delivered feedback interventions reduced the quantity and frequency of drinking in student populations compared with assessment-only controls, and these computer-assisted interventions were as effective as other face-to-face alcohol interventions.
Peter Drucker once remarked: "Culture eats strategy for breakfast." The culture of primary care "specialist generalists," who manage a wide breadth of problems that are treated episodically, primarily in response to patient-initiated concerns and discomforts, may not fit the prevention and early intervention model envisioned by SBI advocates.187 Primary care clinicians have little time to pay much attention to prevention or to ongoing care management for non-symptomatic conditions, whether related to the elevated risk of substance use-related harm or for other behavioral risks.207 Inserting grant-funded, specially trained community health workers and health educators into primary care practices to screen for behavioral risks often is not sustained by practices once grant and start-up funds are exhausted.71, 77, 232, 233
Organizational development consultation is being tried to assist health settings in redesigning their workflows to fit SBI into their cultures.234, 235 A workflow redesign process was used in 14 Baltimore FQHCs235 to create site-specific SBI delivery models. In some, MAs administered the screening and risk assessment tools with patients and then the PCP reviewed the information and conducted the brief intervention. In others, the PCP conducted only part of the brief intervention for each patient and referred patients to internal behavioral health professionals for completion.
Six features of organizations' ability to embrace new ideas and face change shape FQHCs' ability and willingness to adopt SBIRT: (1) the degree to which stakeholders perceive that the current situation needs to change; (2) the fit between an innovation and the organization's values and workflow; (3) the perceived importance of implementing the innovation; (4) organizational incentives and rewards; (5) agreement on goals and feedback on performance; and (6) learning climate.14, 71, 83, 86, 100, 117, 126, 165, 166, 168, 169, 185, 201, 218
Need for Change: Studies of PCP attitudes about implementing substance use screening and treatment suggest that few feel any great urgency to change.14, 126, 185, 236 In focus groups and surveys of PCPs, many feel that other health problems are more urgent or important,185, 236 that drinking is a personal problem for their patients to deal with,185 and that substance use is a primarily a public health concern, not a clinical problem.14, 126 Concern about patients' risk of misusing prescription opioids and the responsibility that the health care system shares for contributing to patients' misuse may lead to a greater sense that current practices are unsustainable and need to change.130, 184
Fit: PCPs consistently reported being under constant pressure to keep patients moving quickly through their examination rooms100, 166, 168 and found that provider-initiated SBI was too onerous.168 However, several studies suggest that SBI might be accepted if it fits into routine clinic workflows, does not disrupt the rapid movement of patients through the clinic, and does not compete with other organization priorities.14, 100, 101, 126, 200, 211 ,218, 232, 233, 236, 237 Similarly, key informants and site staff reported that as SBIRT services were piloted and the model was adjusted to fit into clinic workflows, the practice of SBIRT became part of routine operations.
Perceived Importance: Many researchers have described competing organizational priorities that derail SBIRT implementation.100, 101, 110, 127, 133, 181, 204, 218 Changes in the external environment can change perceptions of importance. Requirements by the American College of Surgeons Committee on Trauma and the VA system have enhanced perceptions of the importance of SBI delivery in trauma centers and VA health care settings.97, 98, 190, 238, 239, 240, 241 HRSA has focused health center attention on SBI by requiring annual reporting and offering supplemental grant support, but requirements akin to those that affect trauma centers and VA settings are lacking.
Incentives: The extent to which health centers reward or provide other incentives for clinicians and administrative staff to screen and treat patients with substance use issues ought to impact uptake. In the VA, achievement of high levels of screening was associated with financial incentives for system leaders. Clinical reminders to screen and treat were adopted more readily by clinicians when the reminders were aligned with performance measures and supported by leadership.242, 243 Absent incentives, simply training staff in SBI and providing prompts to screen through an EHR result in inconsistent uptake.99, 160, 218 It should be no surprise that SBI implementation studies of varied financial incentives found direct, positive correlations between the use of incentives and the proportions of patients who were screened and also who were screened as positive and who completed brief interventions.101
Feedback: Providing PCPs with direct feedback on their performance, when aligned with organizational priorities, can affect providers' behaviors. Williams'91 CFIR analysis of 11 SBI implementation studies found that the VA, which used performance feedback, produced the highest rate of screening and among the highest rates of brief interventions among the programs that were studied. Feedback in the absence of financial incentives and organizational supports for SBI appears to reduce the effectiveness of feedback.168
Learning Climate: Organizations vary in their learning climates and in their receptivity to new knowledge and methods.83 The sophisticated strategies used by the VA's SBI implementation group showed clear understanding of the need to respond to the organizational learning climate.97, 98, 190
Readiness to Implement
Readiness includes the commitment, involvement, and accountability of leaders and managers to implementing the innovation; the levels of resources dedicated for implementation and ongoing operations, including money, training and education, and physical space and time; and access to information and knowledge and how to incorporate it into work tasks.83 Leadership is often cited as the defining characteristic of successful or failed SBI implementation.99, 135, 200, 203, 207, 213, 244, 245 Stable leadership and stable funding made it easier to implement SBI programs and resulted in the delivery of more screens and interventions. Leaving implementation to external experts or to 1-2 low-level staff was associated with struggle, conflict, and failure.135 Williams'91 analysis of SBI implementation studies found that the one that most clearly demonstrated leadership commitment to incorporating evidence-based management of unhealthy alcohol use also had the highest rates of screenings and brief interventions.97, 98, 190, 241 Similarly, garnering top-down support and having a strong internal champion were seen as among the most important factors for successful implementation and sustainability. CEOs and medical directors (not just providers) should participate in training. Familiarity with the organization's SBIRT protocols helps leadership recognize the utility of SBIRT and budget accordingly.
Facilitators: Recommendations from Key Informants and FQHCs
Interviews with key informants and health center staff yielded a number of recommendations that are relevant to the inner setting for facilitating the implementation and sustainability of SBIRT in FQHCs. Those recommendations are highlighted below:
Fully integrate the staff who are responsible for behavioral risk assessment and intervention into the primary care team. Encourage joint treatment planning and shared medical and behavioral health information. Locate staff close to one another. Behavioral health staff should be moving in and out of exam rooms, interacting with PCPs and MAs, rather than sitting in an office.
Integrate all patient notes and treatments into one shared EHR. This improves record access, continuity of care, patient tracking, provider response time, communication between providers, health care costs, record confidentiality, staff efficiency, and the referral process. Build clinical decision support tools into EHRs and develop methods to measure brief intervention, counseling, and outcomes in EHRs.
High-level support and leadership are essential, and champions from medical, information technology, billing, nursing, and education departments are needed to facilitate smooth implementation. If you get the doctors behind you, you are going to be successful. Frame SBIRT as an organizational priority.
Focus on quality, with behavioral health team members taking all clients of any age and with any issue. Initiate a "we ask everybody" campaign.
Clearly define primary care and BHPs' scopes of service and the time to perform defined tasks. Develop workflows so all know who will do what, when, and where, and who the backup person is. The EHR should be built based on the workflow.
Prevent screening overload. Providers often do not have time to address more than what patients present with.
Ensure patient confidentiality in EHR and patient communications. Ensure that behavioral health information, including substance use, is gathered and documented in ways that maximize confidentiality while sharing within the treatment team what is necessary for safe, quality care.