Scope of Analysis and Discussion of the Methods
The NORC team utilized multiple qualitative methods to identify and analyze SBIRT implementation strategies and barriers in FQHCs. Conducting an in-depth literature review and environmental scan summarized research and evaluations in five core areas: evidence of the effectiveness of SBIRT on patient and cost outcomes; the prevalence of SBIRT practices in FQHCs and primary care settings; implementation challenges and barriers experienced by FQHCs and primary care; factors that support SBIRT implementation and sustainability including organization, reimbursement, and staffing; and reimbursement methods, components of electronic health records (EHRs), quality indicators and accountability systems that could be used to promote more widespread use of SBIRT.
Literature Review and Environmental Scan
In an effort to capture all relevant literature pertaining to implementation barriers to and facilitators of SBIRT in primary care and FQHCs, the research team completed literature searches in Medline (Ovid), CINAHL, PsycINFO, Web of Science, Embase, the Cochrane Library, Scopus, and WorldCat, as well as in various unpublished "grey" literature repositories qualified by language (English) and publication years (2002-2013). No geographic qualifiers were introduced. In addition, NORC incorporated a rolling "snowball" search of references of identified articles in order to identify any additional germane articles and conducted interviews with recognized experts in the field to identify additional literature. After multiple trial checks, the term "brief intervention" was determined to be the most effective way to retrieve relevant articles. The details of the literature search strategy are provided in an appendix to this report.
Articles were sorted into three categories that reflect the structure of the subsequent summary of findings:
SBIRT implementation in adult populations in primary care and community health centers.
SBIRT implementation in adolescent populations in primary care, community health settings, and school-based networks.
Medically assisted treatment (MAT) or pharmacotherapy integration in primary care and community health settings.
The review of articles and relevant materials resulted in 410 research articles and reviews pertaining to substance use/SBIRT implementation barriers and facilitators: 288 substance abuse/SBIRT implementation articles (adult), 31 MAT implementation articles, 38 substance abuse/SBIRT implementation articles (adolescent) in primary care/community health/school-based settings, five cost analysis articles examining SBIRT integration in primary care, 53 implementation science articles on substance use integration in primary care, and 19 international articles on substance use integration.
Key Informant Interviews and FQHC Site Visits
The research team also interviewed 30 experts who had applied and research experience with integrating substance use services into primary care settings and visited four FQHCs to conduct semi-structured interviews with clinical, administrative, operations, quality, and financial staff. Discussion guides for key informant and site visit interviews covered integrated service characteristics; billing, reimbursement, and funding climates; leadership support; training; staffing; relationships with SUD treatment and specialty care providers; health information technology and EHRs; outcomes and monitoring; and policies and procedures.
Key informants were recruited from a range of settings including FQHCs, primary health care associations, departments of family medicine, independent psychologists, primary care-behavioral health integration (PCBHI) consultants, SBIRT consultants, FQHC technical assistance providers, and government representatives (among others). Areas of expertise included knowledge of SBIRT, knowledge of SBIRT barriers and implementation strategies, knowledge of topics for at-risk substance use populations, knowledge of primary care delivery systems including FQHCs, implementation of evidence-based practices, knowledge of health care quality measures and reimbursement systems for SBIRT, knowledge of SBIRT implementation strategies by demographics (region, size, population), knowledge of "Healthcare for the Homeless" and other health care supplement programs, knowledge of substance use topics in disparity populations, knowledge of HRSA medically underserved areas and populations research, and experience conducting qualitative research (general, site visits, telephonic).
Based on recommendations from expert consultants, key informant discussions, the literature review, and input from the U.S. Department of Health and Human Services (HHS), Office of the Assistant Secretary for Planning and Evaluation (ASPE) and stakeholders, NORC developed a list of potential FQHC sites for onsite visits. Consultants and project staff contacted sites to gauge interest in study participation. A list was then prepared and presented to ASPE and stakeholders from which a final list of four recommended sites was determined: one FQHC each in Colorado, Virginia, New York, and Wisconsin. Scheduling the site visits posed challenges due to the nature of health care services at FQHCs; most experience high patient volumes, significant demand for services, and tight scheduling during peak seasons. Thus, staff and time constraints made it difficult for sites to find a half day or longer in which staff and providers could speak with the NORC team without causing disruption to clinical operations. Telephone interview scheduling presented similar issues, due to high patient flow, patient demands on time and resources, and busy clinical operations. Descriptions of the four FQHC sites are included in the Summary of Findings section of this report.
Analysis of the Literature and Qualitative Data
Analysis of the literature and environmental scan, and of the data gathered from FQHC site visit discussions and key informant interviews, was conducted using the Consolidated Framework for Implementation Research (CFIR). The CFIR model is described below. The Summary of Findings section that follows provides a synthesis of the findings; it is organized by CFIR domains and concludes with a synopsis of facilitators, with recommendations and opportunities for improving the integration of SBIRT in FQHCs.
Consolidated Framework for Implementation Research: The Organizing Model for this Review
This report employs the CFIR83, 84 to organize the study findings on barriers to and facilitators of implementing and sustaining primary care screening for substance use risk and dependence, brief intervention, treatment, and care management. The CFIR consolidates multiple conceptual models of the health care diffusion of innovations85, 86, 87, 88 and is consistent with the National Institutes of Health framework for dissemination and implementation.89, 90 The model distinguishes five domains (the intervention, the outer setting, the inner setting, the individuals involved, and the process by which implementation is accomplished) and multiple sub-domains within each.
Intervention characteristics encompass seven sub-domains: the source of the innovation, the strength and quality of the evidence supporting it, the relative advantages the innovation provides, and its adaptability, trial-ability, complexity, design quality and packaging, and cost. The outer setting entails 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. The inner setting comprises features of structural, political, and cultural contexts through which the implementation process will proceed. The characteristics of the individuals involved with the innovation include their knowledge and beliefs about the intervention, self-efficacy, individual readiness to change, individual identification with the organization, and other personal attributes. The implementation process encompasses the steps taken to introduce and sustain the innovation. The sub-domains entail planning; engaging opinion leaders, formally appointed internal implementation leaders, champions and external change agents; executing; and reflecting and evaluating.
Recently, Williams et al.91 applied the CFIR framework to analyze the implementation methods used in eight published studies of alcohol SBI in primary care settings: (1) the World Health Organization (WHO);92, 93, 94, 95, 96 (2) the Veterans Administration (VA);97, 98, 99 (3) Cutting Back;100, 101(4) Sweden;102 (5) Oklahoma;103 (6) Patient Powered Research Network;104 (7) the United Kingdom;105, 106 and (8) Georgia,107, 108 representing 533,903 patients, 2,001 providers, and 1,805 clinics. The SBI implementation studies used between seven and 25 of the 38 CFIR sub-domains. The intervention that achieved the highest percentage of completed substance use screens (93 percent) and that tied for the highest proportion of brief interventions (71 percent) was the VA's alcohol SBI program.98 The VA program used more elements of the inner setting (12 of the 14 sub-domains), implementation (seven of the eight), and outer setting (three of the four) than did any of the other SBI implementation programs.
The present study extends Williams' analyses by using the CFIR framework to systematically assess barriers to implementing substance use screening and treatment in primary care and FQHCs and to detect strategies for overcoming those barriers. We first report our findings for adults. To highlight similarities and differences with adults, we break out separately studies that examined screening and treating adolescent primary care patients and studies of using medications to treat SUDs in primary care. The final section of the report employs the CFIR categories to display specific recommendations for truly integrating substance use screening, brief intervention, treatment, and ongoing care management into the routine practices of FQHCs. Findings from key informant interviews and FQHC site visits are integrated into the research reviews in the summary of findings.