SBIRT implementation varied across sites. The description of the site and the SBIRT processes for each participating FQHC are summarized below.
This site employs licensed behavioral health clinicians and contracts with local mental health centers to provide integrated care services. The mental health centers fund the integrated behavioral health clinicians as a means to increase their penetration rates. The focus of the integrated care program is mental health care, and there are no designated SUD treatment services offered within the organization. It is uncommon for one of their integrated BHPs to work with a patient with a SUD unless the patient also has a comorbid mental health condition. BHPs who are employed by the FQHC do not bill for behavioral health services through the Medicaid system, although uninsured patients are charged based on a minimal sliding fee scale of $0-$15 per visit. The cost of the integrated care services is absorbed by the organization because the services have demonstrated value, with some additional support from HRSA grant funding.
The BHPs maintain three roles within each clinic: (1) they verbally screen patients for life stressors, including anxiety, depression, substance use, and trauma; (2) they provide consultations, up to 20 minutes, based on screening results and referrals from the PCP; and (3) they offer therapy. Over the past several years, this site has implemented components of the substance use SBIRT process. In 2008, the BHPs received SBIRT training and began to incorporate SBIRT into their visits with certain patients using the Alcohol Use Disorder Identification Test (AUDIT) screening instrument; prior to this time, substance use was not formally assessed or addressed.
In 2012, the site received a contract from a local service provider to participate in the SBIRT Colorado initiative funded by SAMHSA. Through the contract, the site employs two full-time health educators, located in two clinic locations, to implement SBIRT and collect data for the initiative. In spring 2014, all medical assistants (MAs) were trained to briefly screen patients annually for substance use (tobacco, alcohol, misuse of prescription medications, and illicit drugs) and depression. The MAs currently ask each patient age 12 and older to complete a paper screening questionnaire that includes substance use questions and the Patient Health Questionnaire-2 (PHQ-2) depression screen. The MAs enter the responses into the patients' EHR. Patients who are scheduled for adult preventive appointments, well-child checks, chronic disease management, and obstetric visits are prioritized. BHPs are expected to follow up with patients who score positive in order to provide a brief intervention. At this site, SBIRT has been implemented in some clinic locations without the assistance of specific grant or research funding. The site visit interview discussions focused on how the SBIRT model is utilized in clinic locations outside of the SAMHSA-funded SBIRT Colorado initiative.
The leadership, providers, and staff of this clinic strongly recognize the importance of integrating behavioral health care into primary care. The integration process began with co-location and over time emerged as integration; this has taken several years, but at the time of the site visit, behavioral health services were seamlessly integrated into physical health services. Integrating SBIRT and other behavioral health services has not been without challenges including a lack of available providers to hire and a lack of access to specialty referral resources (e.g., psychiatrists). The clinic is set up to provide telehealth and intends to hire a psychiatrist and pediatrician who can provide onsite and telehealth services, including SBIRT. Hiring is difficult because salaries are lower and few professionals live in the area, and it is also difficult to recruit providers to relocate to the area. Despite challenges, it is clear that providing SBIRT and other behavioral health services routinely to patients within the existing capacity is a high priority.
There are several specialized mental health and alcohol and drug services available in the region; however, the clinic finds that many of the clients they serve often experience a number of personal challenges (e.g., reliable transportation, need for child or other family member care) that make it difficult for them to initiate or engage in mental health (and physical health) referrals. The health center has not been a recipient of a large, federally funded SBIRT grant. They previously received funding for a small pilot study several years ago to explore integrating behavioral health services, and their effort to integrate SBIRT was driven by this exploratory effort and by champions at the highest level of leadership, who recognized and promoted its use throughout the health center. Physicians, nurses, and licensed social workers received training in SBIRT--fortunately, turnover has not been a significant issue--creating program continuity and opportunity for continuous growth.
The integrated behavioral health director is a highly experienced licensed clinical social worker (LCSW) and is integral to the delivery of all SBIRT services. The current director worked under the direction of the previous director, who led the initial effort to integrate SBIRT services across the FQHC. Physicians and nurses are engaged in screening and handing off patients to behavioral health staff to provide further SBIRT services. For medical appointments, clients are escorted to the exam room. As part of checking vital signs and recording the clients' concerns, the PCP (typically the nurse) is prompted by the EHR to ask about substance use and mental health using standardized questionnaires. Screening for risky alcohol use, drug use, prescription medication misuse, tobacco use, and depression is a routine part of care. Brief screening questions (e.g., the AUDIT-C and PHQ-2) are asked by the PCPs. If responses are positive, the client is immediately linked to an onsite BHP (typically an LCSW). Behavioral health staff introduce themselves and their role to patients with positive screens. They administer the full screening questionnaires and, if warranted, provide brief intervention, brief treatment, and referral to treatment. Behavioral health staff maintain a statewide list of treatment resources and have established relationships with treatment providers. While patients may wait for services, the BHP can provide support by phone and additional intervention and counseling sessions onsite as part of subsequent follow-up visits. None of the clinics and few providers in the surrounding area have the capacity to provide MAT services for alcohol and opioid dependence.
This site identified the need to integrate behavioral health into physical health care more than 15 years ago. At that time, the site contracted for a full-time social worker from a local addiction counseling and referral agency. Agency staff identified that the impetus for integrating SBIRT grew out of the clinical need of the migrant population. Starting as a migrant worker FQHC, this site identified this need when making home visits and providing services to migrant workers. They saw the effects of substance use on the population and also identified cultural issues around substance use. They also identified that even when they could engage patients in accepting substance use treatment, patients did not want to go to the addiction counseling and referral offices for services because of the stigma attached to a substance use problem.
This FQHC recognized that if they were going to provide effective substance use treatment, it needed to be incorporated within their service delivery system. Thus, this site started incorporating SBIRT before it became popular as an intervention. The site described what they were doing back then as "SBIRT lite." The focus was to assist the migrant population in understanding the consequences of alcohol use for the workers and their families when they went home. The SBIRT process has since been expanded and is fully integrated in only one clinic, where the substance use provider is located. The two other sites also have integrated behavioral health, although these sites have more of a mental health services focus and SBIRT for substance use is not as fully incorporated. This FQHC is taking action to improve the skills of the staff and to expand SBIRT more fully in the other medical sites. There are three LCSWs across six sites. Screenings are conducted on a routine basis, and if a problem is identified, the patient is introduced to the social worker, who will conduct a more thorough assessment to identify if there is a problem. Once a problem is identified, the social workers will determine whether the situation can be handled on a short-term basis at the site or if a referral is needed. Behavioral health and medical staff make joint decisions on treatment, which is facilitated by frequent hall discussions. The social worker is responsible for making any referrals that might be required.
The clinic leadership at this site strongly recognizes the importance of integrating behavioral health care into primary care, but they have felt hamstrung by a lack of available providers to hire and a lack of access to referral resources. The clinic previously had a psychiatric nurse practitioner on staff and now hopes to hire at least one mental health professional in the wake of its expansion, but hiring is difficult because few professionals live in the area. Thus, the clinic currently does not offer mental health services other than those delivered by its PCPs and the SBIRT services delivered by its health educator. The clinic finds it very difficult to make effective mental health referrals for its patients because there are few specialized mental health, alcohol, and drug services available in the six-county region it serves. Counties are obligated to provide services but only when sufficient funding is available, and often funding is lacking. Except for patients in crisis, waiting lists are common, and services lack breadth and depth. Finding services is especially difficult for patients who only speak Spanish.
The clinic was an early participant in the Wisconsin Initiative to Promote Healthy Lifestyles (WIPHL), which was established by a five-year SAMHSA state-based SBIRT grant between 2006 and 2011, and served as the primary training resource, training several health educators at the clinic over that grant period because there was high turnover. The most recent health educator left two months prior to the site visit. A MA is now filling that role but lacks the confidence to deliver services. The clinic has found that having only one health educator at a time has limited the number of patients served because the clinic is configured into two pods. The clinic hopes to hire a second MA and intends to have both formally trained in SBIRT, if funding or training resources become available. WIPHL no longer has grant support to provide training, and the site hopes to find support from the Wisconsin Primary Health Care Association, where WIPHL-trained staff currently work. This site attributes the start-up and ongoing implementation of SBIRT to its involvement with WIPHL's SAMHSA grant project; before that grant, the clinic employed health educators to help with health education, and SBIRT is now seen as an integral health education activity.
Prior to SBIRT, clinic receptionists asked all adult and teenage patients to complete an annual health history questionnaire, and before the clinic had an EHR, receptionists tracked questionnaire completion on chart folders; now the EHR prompts receptionists to ask patients to complete their annual questionnaires. As part of the national effort to enhance depression care through depression collaboratives several years ago, the clinic has also added the PHQ-2 to its annual questionnaire. As part of the process of escorting patients to exam rooms, checking vital signs, and recording patients' concerns, MAs check patients' responses to the questionnaires. If the alcohol/drug screen is positive, MAs notify the health educator that the patient needs to be seen. MAs ask patients with positive PHQ-2 screens to complete PHQ-9 questionnaires, and the PCPs address possible depression. Health educators introduce themselves and their role to patients with positive alcohol/drug screens. They administer the AUDIT and the Drug Abuse Screening Test (DAST) and deliver brief intervention as appropriate.
During the SAMHSA grant, likely dependent patients who were willing to obtain treatment were referred by phone to a centralized treatment liaison who maintained a statewide list of treatment resources, had established relationships with treatment providers, and excelled at matching patients with appropriate resources. While patients waited for treatment, the liaison provided support by phone. Since the grant expired, the health educators now notify their PCPs when patients' AUDIT or DAST scores suggest dependence. The PCP and health educator work together to find treatment for interested patients, but the referral process can take hours because access is so limited. During the SAMHSA grant, it became apparent that only about 10 percent of likely dependent patients were successfully referred to treatment. WIPHL recognized the need to bolster primary care services for dependent patients and offered training in pharmacotherapy to its participating clinics; this site was one of three clinics that participated. As a result, one physician was inspired to get trained to prescribe buprenorphine for opioid dependence, and he treated several patients; unfortunately, that physician is no longer with the clinic. Another physician has continued to deliver pharmacotherapy for alcohol dependence to several patients but is not interested in learning to prescribe buprenorphine.
The next section of this report provides a summary of findings organized by three focus areas: adult SBIRT, adolescent SBIRT, and MAT.