Screening, brief intervention and referral to treatment (SBIRT): implementation barriers, facilitators and model migration

Abstract

Aims To identify barriers and facilitators associated with initial implementation of a US alcohol and other substance use Screening, Brief Intervention, and Referral to Treatment (SBIRT) grant program, and to identify modifications in program design that addressed implementation challenges. Design A mixed-method approach used quantitative and qualitative data, including SBIRT provider ratings of implementation barriers and facilitators, staff interview responses and program documentation. Setting Multiple sites within the first seven programs funded in a national demonstration program in the United States. Participants One hundred and two SBIRT providers were surveyed; 221 SBIRT stakeholders and staff were interviewed. Measurements Mean ratings of barriers and facilitators were calculated using provider survey responses. An inductive content analysis of interview responses identified factors perceived to support and challenge implementation; program modifications that occurred over time were recorded. Findings Providers rated pre-selected implementation facilitators higher than barriers. Content analysis of interview responses revealed six themes: committed leaders; intra-and inter-organizational communication/collaboration; provider buy-in and model acceptance; contextual factors; quality assurance; and grant requirements. Over time, programs tended to: adopt more efficient 'pre-screen' item sets; screen for risk factors in addition to alcohol/substance use; use contracted specialists to deliver SBIRT services; conduct services in high-volume emergency department and trauma center settings; and implement on-site and telephonic treatment delivery. Conclusions Screening, Brief Intervention and Referral to Treatment program implementation in the United States is facilitated by committed leadership and the use of substance use specialists, rather than medical generalists, to deliver services. Many implementation challenges can be addressed by an adequate start-up phase focused on comprehensive education and training, and on the development of intra-and inter-organizational communication and collaboration; opinion leader support; and practitioner and host site buy-in.

The influence of state‐level policy environments on the activation of the Medicaid SBIRT reimbursement codes

“…Qualitative evidence of policy entrepreneurs has been noted elsewhere in studies of successful health-care reforms at the state level [52]. This finding is not measured directly by the model, but findings from a SAMHSA crosssite evaluation have noted the importance of SBIRT 'champions' that are critical to implementation and sustainability [53,54]. An alternative and complementary explanation for slow activation after 2008 is the Great Recession.…”

Screening, Brief Intervention and Referral to Treatment: implications of SAMHSA's SBIRT initiative for substance abuse policy and practice

“…Applying this model, Vendetti et al [22] used a mixedmethod approach to study implementation barriers and facilitators in SAMHSA's cohort 1 programs, as well as changes that occurred over time ('model migration'), partly in response to operational challenges. Whereas, historically, SBI programs tended to recruit on-site medical staff to conduct services [in-house generalist (IHG) model], Vendetti et al [22] found that the programs tended instead to hire specifically trained health educators (in-house specialist, IHS) or to contract services through independent addiction treatment agencies (contracted specialist, CS) to provide the expanded continuum of SBIRT services.…”

“…Whereas, historically, SBI programs tended to recruit on-site medical staff to conduct services [in-house generalist (IHG) model], Vendetti et al [22] found that the programs tended instead to hire specifically trained health educators (in-house specialist, IHS) or to contract services through independent addiction treatment agencies (contracted specialist, CS) to provide the expanded continuum of SBIRT services. Although four programs used IHG models for some pre-screening and other SBIRT functions, all cohort 1 programs migrated toward CS models to increase screening rates and reduce the burden on medical staff.…”

Screening, Brief Intervention and Referral to Treatment (SBIRT): rationale, program overview and cross‐site evaluation

“…Differences between cohorts reflect changing SAMHSA mandates, as well as alterations based on the experience of earlier funding recipients (see [21]). Although pre-screening was performed at some cohort 1 sites, this service was conducted universally in cohort 3, and there was a tendency to screen for more risk factors.…”

“…The process evaluation collected information about which SBIRT services were performed, where they were provided, who delivered them, how they were organized and managed and to whom they were administered. Further, it investigated barriers to, and facilitators of, program implementation and examined how the grant recipients' initially proposed models were actually implemented in the field and how they changed or evolved over time [21]. Finally, the cross-site evaluators developed, tested and implemented a new methodology for assessing the degree of adherence to the evidenced-based protocols that were adopted by the SAMHSA programs [26], an issue critical to the interpretation of analyses of patient/client outcomes.…”