Federally qualified health centers (FQHCs) are non-profit, community-directed health centers that provide comprehensive health care to patients without regard for income or insurance coverage. These safety net providers offer primary and preventive care, mental health, substance use, dental, and pharmacy services to patients in high-need communities. Beginning in 2011, the Patient Protection and Affordable Care Act provided $9.5 billion in funding over five years through a dedicated health center fund to allow health centers to expand their operational capacities, with the goal of ensuring that the newly insured would have access points for care. There are currently over 1,200 health center organizations providing care to more than 20 million patients in over 8,100 locations dispersed across the nation.20
FQHCs often see and treat patients with substance use and other behavioral health concerns. FQHCs are positioned to routinely screen and provide brief counseling for risky substance use as part of primary care. A number of FQHCs around the country have been working to identify how best to integrate substance use prevention, early intervention, and treatment services into existing health care service delivery and how to adapt service delivery to minimize disruptions in health center operations. In doing so, the FQHCs have identified key barriers and facilitators that shape how and the extent to which substance use screening and brief counseling services can be routinely delivered. This project aims to better understand what those barriers and facilitators are and to identify opportunities for diminishing the barriers and best practices that facilitate the routine implementation of substance use screening and brief counseling. This report begins by briefly discussing the context of delivering behavioral health services, in particular, substance use in FQHCs, including the need for and evidence to support the use of evidence-based screening and brief counseling. This is followed by a description of the project and study methods as well as a discussion of findings synthesized from three primary activities: a literature review and environmental scan, key informant interviews, and FQHC site visits.
Federally Qualified Health Centers and Behavioral Health
All FQHCs that receive HHS Health Resources and Services Administration (HRSA) grant funding under Section 330 of the Public Health Service Act are required to provide referrals to substance use providers. With more than 75 percent of health centers providing onsite mental health and substance use services, more than 5.2 million encounters occurred in 2010.20 Given that most FQHC patients are uninsured or Medicaid-insured, many of these patients likely would have gone unserved were the health centers not available. Further, a 2004 survey of health center directors revealed that centers without onsite behavioral health services reported more difficulty accessing specialty behavioral health services compared with those with onsite services, particularly for their uninsured and Medicaid patients.21 NORC's published study that projected FQHC behavioral health workforce needs found that in 2010, 98,760 patients received substance use treatment (only 0.05 percent of the 19.5 million persons served by FQHCs that year).22 Of the 46,543 medical service full-time equivalents (FTEs) employed by the FQHCs, 854 FTEs were substance abuse treatment providers (1.8 percent). To meet the current need for substance use services for the estimated 357,632 patients with substance use disorders (SUDs) who used the health centers in 2010, an additional 931 FTE substance use treatment providers would be needed. To meet the substance use treatment needs of FQHC patients by 2015, we estimate that health centers would need to employ an additional 3,967 FTE substance use treatment providers, a 465 percent increase.22 Yet in 2011, approximately 93,600 FQHC patients received at least one substance use service, down from 2010 figures, further exemplifying the vast need for substance use services.23
Individuals who seek behavioral health care overwhelmingly seek it from primary care providers (PCPs).24 Decades of research have demonstrated the inseparability of behavioral and physical health, and new models that bring behavioral health providers (BHPs) into the primary care setting as members of the health care team are increasing the access to and acceptability of behavioral health treatment.25 In fully integrated care, patients become accustomed to behavioral health care as a routine part of primary care.26 Care provided in this manner has been shown to reduce stigma for patients, increase patient engagement, and reduce attrition after care is initiated.27 Rural areas and underserved urban areas also benefit significantly from integrated care, since shortages of BHPs create long wait times for patients who need appointments.28
When behavioral health care is delivered in primary care, the quality of that care is frequently substandard and characterized by inadequate patient follow-up and monitoring,29 especially among low-income populations and racial and ethnic minorities.30 The National Comorbidity Survey-Replication31 found that only 32.7 percent of patients who were receiving behavioral health services in primary care received at least "minimally adequate treatment."32 Even more disturbing, a study of concordance between evidence-based primary care and the services actually delivered to a nationally representative sample found that the quality of care for patients with alcohol use disorders was the poorest among the 25 conditions studied; only 10.5 percent of patients with alcohol use disorders received recommended care.33 A survey of primary care patients with diagnosable SUDs found that more than half reported that their physicians had done nothing about their substance abuse; 43 percent said their physicians never diagnosed their condition.34 Only 10-20 percent of patients in primary care settings are screened for alcohol misuse,35 making it one of the least commonly performed of the U.S. Preventive Services Task Force (USPSTF)-recommended clinical preventive services.36 In the absence of screening, clinicians cannot reliably identify those with risky alcohol or SUDs.37 Millstein and Arik found that between 23 percent and 43 percent of pediatricians and 14 percent to 27 percent of family physicians ask adolescents whether they use alcohol or drugs, but only 17 percent inquire more fully and systematically about substance use through a standardized screening instrument.38
The lack of regular substance use screening is not due to the absence of scientifically sound assessment and treatment technologies. In 2004, the USPSTF-recommended:
"To prevent or reduce alcohol misuse, the USPSTF recommends screening and behavioral counseling for all adults, including pregnant women, in the primary care setting."39
A meta-analysis of the literature on the clinical efficacy and cost-effectiveness of the USPSTF prevention recommendations ranked screening and behavioral counseling in the top five.4 The evidence-based approach to screening and behavioral counseling is commonly referred to as screening, brief intervention, referral, and treatment (SBIRT). SBIRT is a public health approach to the delivery of early intervention and treatment services for people with SUDs and those at risk for developing them (HHS Substance Abuse and Mental Health Services Administration [SAMHSA] http://www.samhsa.gov/sbirt). Screening (S) quickly assesses the severity of substance use and identifies the appropriate level of treatment. Brief intervention (BI) focuses on increasing insight and awareness regarding substance use and motivation for behavioral change. Referral to treatment (RT) provides those identified as needing more extensive treatment with access to specialty care.
Effectiveness of Opportunistic Screening, Brief Intervention, and Treatment in Practical, Real-World Primary Care Settings
After a comprehensive review of the primary care research on alcohol screening and brief intervention (SBI), the USPSTF recommendations39 mirror those of the 1990 Institute of Medicine panel:
Behavioral counseling interventions for risky/harmful alcohol use among adult primary care patients could provide an effective component of a public health approach to reducing risky/harmful alcohol use. Future research should focus on implementation strategies to facilitate adoption of these practices into routine health care.
The present report focuses on facilitators of and barriers to the adoption of SBIRT and ways to overcome those barriers. It is not a study of the effectiveness of assessing primary care patients for risky substance use and subsequent counseling, medical treatment, or specialty care. However, it is important to note briefly that these issues are not settled.
A comprehensive analysis of 361 controlled clinical trials of treatments for alcohol use disorders found that SBI in primary care was the strongest of more than 40 alcohol treatment modalities studied.40 Other primary care studies concluded that reductions in substance-related health problems may exceed reductions in alcohol and drug consumption itself.41 For example, one randomized study that assessed the effects of SBI after a 48-month follow-up found that the intervention group had a 20 percent reduction in emergency department visits, a 33 percent reduction in non-fatal injuries, 37 percent fewer hospitalizations, 46 percent fewer arrests, and 50 percent fewer motor vehicle crashes compared with controls.42 Relating to treatment methods, a meta-analytic review of 54 randomized control trials (RCTs) of primary care substance use brief interventions found moderate effect sizes (0.67) for alcohol consumption at three months.43 Further, with a meta-analysis of controlled trials using clinical motivational interviewing, a core therapeutic technique in SBIRT, Burke and his colleagues identified five studies that examined the clinical and social impact of motivational interviewing on drug use: moderate effect sizes (d=0.56) on drug use and large effect sizes (d=0.90) on social outcomes such as substance-related work impairment, physical symptoms, and legal problems.44
An analysis of 24 systematic reviews that covered 56 RCTs of opportunistic SBI in primary care45 found consistent evidence that brief alcohol interventions are effective at reducing hazardous and harmful drinking in primary health care.39, 43, 46, 47, 48, 49, 50 The amount of the reduction of alcohol consumption after brief, risk-focused counseling is usually statistically significant, but it is not generally large.51 How long reductions in risky drinking persist is poorly understood. Effect sizes are largest at the earliest follow-up points (3-6 months), and effects decay over time.43, 52, 53, 54 Nor is it clear how many brief sessions or how long individual sessions must run in order to reliably achieve reductions in risky alcohol use.51, 53, 54 Generally, there are no differences in the positive effects of SBI delivered across a range of clinical professions from physicians to community health workers,55 although one review found evidence that effect sizes are larger if SBI is delivered by physicians.56 SBI appears to be equally effective for male and female risky drinkers,39, 48, 57 although it may not be as consistently effective with women as with men.58 Although there is some evidence of effectiveness among youths in college, the USPSTF determined that there is insufficient evidence to recommend SBI for adolescents.51, 52, 59 Few studies have examined the impact of SBI for older adults.51, 53, 54
Several well-designed studies have found few or no differences between brief interventions and control conditions in reductions in risky use.4, 53, 54, 57 Three systematic reviews of SBI studies reached the same conclusion: patients enrolled in the control conditions who received only the screening and feedback or screening and information about risky drinking consistently reduced their at-risk alcohol use.60, 61, 62 These results raise questions about whether the effect of SBI on risky drinking may be associated with a "Hawthorne effect" of being asked about drinking by a trusted authority. Another explanation could be regression toward a less risky drinking mean since heavy drinking can spontaneously decrease over time.60, 61, 62
The USPSTF did not find sufficient research to make positive recommendations about the effectiveness of SBI for reducing health risks with non-treatment-seeking alcohol-dependent or drug-dependent patients in primary care or with patients who used illicit drugs or prescription opioids in a risky manner.4, 43, 47, 49, 59, 63 There is little evidence that brief interventions alone for non-treatment-seeking primary care patients with alcohol or drug dependence or with substance-using patients with comorbid medical or psychiatric conditions47, 53, 54, 59 are sufficient to reduce risk or improve functioning.64 Pharmacotherapy, either alone or with medical advice or specialty care, can reduce substance consumption and reduce other health risks among patients with SUDs.65, 66, 67
Purpose of this Project
This project seeks to identify barriers to and facilitators of integrating SBIRT services into FQHCs, a setting that frequently encounters and treats patients who are coping with SUDs. Integrating behavioral health care, specifically substance use screening and treatment, into routine health center practices presents significant challenges. Commonly reported barriers include overloaded practices struggling to provide prompt access to medical care68 and the concern that the time required for counseling and monitoring behavioral health patients will disrupt patient flow. Competing clinical and organizational priorities for PCP time and attention and the absence of patient demand for substance use services are often reported.59, 69, 70 Many providers lack training and are uncomfortable dealing with substance use issues.71, 72 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.28, 73, 74, 75, 76 Reimbursement barriers are pervasive, including: low reimbursement rates; inability to be reimbursed for a primary care and a behavioral health service on the same day; absence of reimbursement mechanisms for team-based care and care coordination activities; and provider panels that are restricted by managed care.72, 77, 78, 79, 80, 81, 82 NORC's team, led by Drs. Goplerud and McPherson, utilized various qualitative research methods--a literature review and environmental scan, key informant interviews, and site visits to FQHCs--to illuminate key facilitators of and barriers to implementing SBIRT in FQHCs. Below is an overview of the study methods including the scope of analysis and descriptions of the key informant interviews and site visits. Study methods are followed by a synthesis of key findings and recommendations from the methods employed.