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


The economic, political, and social contexts within which an organization resides. These may include constrained funding, billing rules, and the influence of policies related to treatment and targeted populations.

  • Standardize substance use SBI metrics for 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. The barriers that could be removed include restrictions on "incident to" and non-physician payments for SBI preventive services, absence of coverage for same-day services, and low relative values for SBI and pharmacotherapy procedures to increase reimbursement rates. Restrictions on pharmacotherapy for SUDs such as episode limits should be discouraged, and inclusion of FDA-approved medications for SUDs in formularies should be strongly encouraged.

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

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

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