Implementing a team-based SBIRT model in primary care clinics

Strategies to promote the implementation of Screening, Brief Intervention, and Referral to Treatment (SBIRT) in healthcare settings: a scoping review

Background

Screening, brief intervention, and referral to treatment (SBIRT), is an approach for the prevention and treatment of substance use disorders, but is often underutilized in healthcare settings. Although the implementation of SBIRT is challenging, the use of multi-faceted and higher intensity strategies are more likely to result in the successful incorporation of SBIRT into practice in primary care settings. SBIRT may be used in different healthcare settings, and the context for implementation and types of strategies used to support implementation may vary by setting. The purpose of this scoping review is to provide an overview regarding the use of strategies to support implementation of SBIRT in all healthcare settings and describe the associated outcomes.

Methods

A scoping review was conducted using CINAHL Complete, HealthBusiness FullTEXT, PsycINFO, PubMed, and Embase to search for articles published in English prior to September 2019. The search returned 462 citations, with 18 articles included in the review. Two independent reviewers extracted data from each article regarding the theory, design, timeline, location, setting, patient population, substance type, provider, sample size and type, implementation strategies, and implementation outcomes. The reviewers entered all extracted data entered into a table and then summarized the results.

Results

Most of the studies were conducted in the United States in primary care or emergency department settings, and the majority of studies focused on SBIRT to address alcohol use in adults. The most commonly used strategies to support implementation included training and educating stakeholders or developing stakeholder interrelationships. In contrast, only a few studies engaged patients or consumers in the implementation process. Efforts to support implementation often resulted in an increase in screening, but the evidence regarding the brief intervention is less clear, and most studies did not assess the reach or adoption of the referral to treatment.

Discussion

In addition to summarizing the strategies used to increase reach and adoption of SBIRT in healthcare settings, this scoping review identified multiple gaps in the literature. Two major gaps include implementation of SBIRT in acute care settings and the application of implementation theories to inform healthcare efforts to enable use of SBIRT.

Toxic compounds produced by cyanobacteria belonging to several species of the order Nostocales: A review

Cyanobacteria are well recognised as producers of a wide range of natural compounds that are in turn recognised as toxins that have potential and useful applications in the future as pharmaceutical agents. The order Nostocales, which is largely overlooked in this regard, has become increasingly recognised as a source of toxin producers including Anabaena, Nostoc, Hapalosiphon, Fischerella, Anabaenopsis, Aphanizomenon, Gloeotrichia, Cylindrospermopsis, Scytonema, Raphidiopsis, Cuspidothrix, Nodularia, Stigonema, Calothrix, Cylindrospermum and Desmonostoc species. The toxin compounds (i.e., microcystins, nodularin, anatoxins, ambiguines, fischerindoles and welwitindolinones) and metabolites are about to have a destructive effect on both inland and aquatic environment aspects. The present review gives an overview of the various toxins that are extracted by the order Nostocales. The current research suggests that these compounds that are produced by cyanobacterial species have promising future considerations as potentially harmful algae and as promising leads for drug discovery.

Implementing SBIRT for adolescents within community mental health organizations: A mixed methods study

OBJECTIVE

Many adolescents with substance use problems remain untreated, leading to increased risk for the development of substance use disorders. One response is Screening, Brief Intervention, and Referral to Treatment (SBIRT)-an evidence-based, early intervention that can be tailored for adolescents. This mixed methods study examined the implementation of SBIRT across 27 community mental health organizations (CMHOs) serving adolescents.

METHODS

Organizations completed surveys on the adoption of SBIRT and implementation barriers during the study period. Quantitative data were analyzed to examine the frequency of screening, brief intervention, and referrals. Qualitative data were coded using an iterative process that focused on barriers categorized according to the Conceptual Framework for Implementation Research (CFIR) constructs.

RESULTS

A total of 2873 adolescents were screened for alcohol and drug use with 1517 (52.8%) receiving a positive drug or alcohol screen. Positive screens that received brief intervention (BI)/referral to treatment (RT) had a significantly greater mean drug score and overall scores at baseline. The most salient implementation barriers were adaptability and complexity of SBIRT, policies related to funding and licensing, staff turnover, and implementation climate.

DISCUSSION

Nearly half of the adolescents scored positive for problematic substance use demonstrating the unmet need among this population. Future implementation efforts should focus on coordinating program demands, securing funding, integrating SBIRT into clinical workflows, retaining staff, and improving referral to treatment processes.

Implementing SBIRT (Screening, Brief Intervention and Referral to Treatment) in primary care: lessons learned from a multi-practice evaluation portfolio

Background

Screening, Brief Intervention and Referral to Treatment (SBIRT) is a public health framework approach used to identify and deliver services to those at risk for substance-use disorders, depression, and other mental health conditions. Primary care is the first entry to the healthcare system for many patients, and SBIRT offers potential to identify these patients early and assist in their treatment. There is a need for pragmatic "best practices" for implementing SBIRT in primary care offices geared toward frontline providers and office staff.

Methods

Ten primary care practices were awarded small community grants to implement an SBIRT program in their location. Each practice chose the conditions for which they would screen, the screening tools, and how they would provide brief intervention and referral to treatment within their setting. An evaluation team communicated with each practice throughout the process, collecting quantitative and qualitative data regarding facilitators and barriers to SBIRT success. Using the editing method, the qualitative data were analyzed and key strategies for success are detailed for implementing SBIRT in primary care.

Results

The SBIRT program practices included primary care offices, federally qualified health centers, school-based health centers, and a safety-net emergency department. Conditions screened for included alcohol abuse, drug abuse, depression, anxiety, child safety, and tobacco use. Across practices, 49,964 patients were eligible for screening and 36,394 pre-screens and 21,635 full screens were completed. From the qualitative data, eight best practices for primary care SBIRT are described: Have a practice champion; Utilize an interprofessional team; Define and communicate the details of each SBIRT step; Develop relationships with referral partners; Institute ongoing SBIRT training; Align SBIRT with the primary care office flow; Consider using a pre-screening instrument, when available; and Integrate SBIRT into the electronic health record.

Conclusions and implications

SBIRT is an effective tool that can empower primary care providers to identify and treat patients with substance use and mental health problems before costly symptoms emerge. Using the pragmatic best practices we describe, primary care providers may improve their ability to successfully create, implement, and sustain SBIRT in their practices.

Enhancing alcohol screening and brief intervention among people receiving opioid agonist treatment: qualitative study in primary care

Purpose

Problem alcohol use (PAU) is common and associated with considerable adverse outcomes among patients receiving opioid agonist treatment (OAT). The purpose of this paper is to describe a qualitative feasibility assessment of a primary care-based complex intervention to promote screening and brief intervention for PAU, which also aims to examine acceptability and potential effectiveness.

Design/methodology/approach

Semi-structured interviews were conducted with 14 patients and eight general practitioners (GPs) who had been purposively sampled from practices that had participated in the feasibility study. The interviews were transcribed verbatim and analysed thematically.

Findings

Six key themes were identified. While all GPs found the intervention informative and feasible, most considered it challenging to incorporate into practice. Barriers included time constraints, and overlooking and underestimating PAU among this cohort of patients. However, the intervention was considered potentially deliverable and acceptable in practice. Patients reported that (in the absence of the intervention) their use of alcohol was rarely discussed with their GP, and were reticent to initiate conversations on their alcohol use for fear of having their methadone dose reduced.

Research limitations/impelications

Although a complex intervention to enhance alcohol screening and brief intervention among primary care patients attending for OAT is likely to be feasible and acceptable, time constraints and patients’ reticence to discuss alcohol as well as GPs underestimating patients’ alcohol problems is a barrier to consistent, regular and accurate screening by GPs. Future research by way of a definitive efficacy trial informed by the findings of this study and the Psychosocial INTerventions for Alcohol quantitative data is a priority.

Originality/value

To the best of the knowledge, this is the first qualitative study to examine the capability of primary care to address PAU among patients receiving OAT.

Feasibility of alcohol screening among patients receiving opioid treatment in primary care

Background

Identifying and treating problem alcohol use among people who also use illicit drugs is a challenge. Primary care is well placed to address this challenge but there are several barriers which may prevent this occurring. The objective of this study was to determine if a complex intervention designed to support screening and brief intervention for problem alcohol use among people receiving opioid agonist treatment is feasible and acceptable to healthcare providers and their patients in a primary care setting.

Methods

A randomised, controlled, pre-and-post design measured feasibility and acceptability of alcohol screening based on recruitment and retention rates among patients and practices. Efficacy was measured by screening and brief intervention rates and the proportion of patients with problem alcohol use.

Results

Of 149 practices that were invited, 19 (12.8 %) agreed to participate. At follow up, 13 (81.3 %) practices with 81 (62.8 %) patients were retained. Alcohol screening rates in the intervention group were higher at follow up than in the control group (53 % versus 26 %) as were brief intervention rates (47 % versus 19 %). Four (18 %) people reduced their problem drinking (measured by AUDIT-C), compared to two (7 %) in the control group.

Conclusions

Alcohol screening among people receiving opioid agonist treatment in primary care seems feasible. A definitive trial is needed. Such a trial would require over sampling and greater support for participating practices to allow for challenges in recruitment of patients and practices.

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-016-0548-2) contains supplementary material, which is available to authorized users.

Local Implementation of Alcohol Screening and Brief Intervention at Five Veterans Health Administration Primary Care Clinics: Perspectives of Clinical and Administrative Staff

BACKGROUND AND OBJECTIVE

Population-based alcohol screening, followed by brief intervention for patients who screen positive for unhealthy alcohol use, is widely recommended for primary care settings and considered a top prevention priority, but is challenging to implement. However, new policy initiatives in the U.S., including the Affordable Care Act, may help launch widespread implementation. While the nationwide Veterans Health Administration (VA) has achieved high rates of documented alcohol screening and brief intervention, research has identified quality problems with both. We conducted a qualitative key informant study to describe local implementation of alcohol screening and brief intervention from the perspectives of frontline adopters in VA primary care in order to understand the process of implementation and factors underlying quality problems.

METHODS

A purposive snowball sampling method was used to identify and recruit key informants from 5 VA primary care clinics in the northwestern U.S. Key informants completed 20-30 minute semi-structured interviews, which were recorded, transcribed, and qualitatively analyzed using template analysis.

RESULTS

Key informants (N=32) included: clinical staff (n=14), providers (n=14), and administrative informants (n=4) with varying participation in implementation of and responsibility for alcohol screening and brief intervention at the medical center. Ten inter-related themes (5 a priori and 5 emergent) were identified and grouped into 3 applicable domains of Greenhalgh's conceptual framework for dissemination of innovations, including values of adopters (theme 1), processes of implementation (themes 2 and 3), and post-implementation consequences in care processes (themes 4-10). While key informants believed alcohol use was relevant to health and important to address, the process of implementation (in which no training was provided and electronic clinical reminders "just showed up") did not address critical training and infrastructure needs. Key informants lacked understanding of the goals of screening and brief intervention, believed referral to specialty addictions treatment (as opposed to offering brief intervention) was the only option for following up on a positive screen, reported concern regarding limited availability of treatment resources, and lacked optimism regarding patients' interest in seeking help.

CONCLUSIONS

Findings suggest that the local process of implementing alcohol screening and brief intervention may have inadequately addressed important adopter needs and thus may have ultimately undermined, instead of capitalized on, staff and providers' belief in the importance of addressing alcohol use as part of primary care. Additional implementation strategies, such as training or academic detailing, may address some unmet needs and help improve the quality of both screening and brief intervention. However, these strategies may be resource-intensive and insufficient for comprehensively addressing implementation barriers.

Psychosocial Interventions for Problem Alcohol Use in Primary Care Settings (PINTA): Baseline Feasibility Data

OBJECTIVE

Many individuals receiving methadone maintenance receive their treatment through their primary care provider. As many also drink alcohol excessively, there is a need to address alcohol use to improve health outcomes for these individuals. We examined problem alcohol use and its treatment among people attending primary care for methadone maintenance treatment, using baseline data from a feasibility study of an evidence-based complex intervention to improve care.

METHODS

Data on addiction care processes were collected by (1) reviewing clinical records (n = 129) of people who attended 16 general practices for methadone maintenance treatment and (2) administering structured questionnaires to both patients (n = 106) and general practitioners (GPs) (n = 15).

RESULTS

Clinical records indicated that 24 patients (19%) were screened for problem alcohol use in the 12 months prior to data collection, with problem alcohol use identified in 14 (58% of those screened, 11% of the full sample). Of those who had positive screening results for problem alcohol use, five received a brief intervention by a GP and none were referred to specialist treatment. Scores on the Alcohol Use Disorders Identification Test (AUDIT) revealed the prevalence of hazardous, harmful, and dependent drinking to be 25% (n = 26), 6% (n = 6), and 16% (n = 17), respectively. The intraclass correlation coefficient (ICC) for the proportion of patients with negative AUDITs was 0.038 (SE = 0.01). The ICCs for screening, brief intervention, and/or referral to treatment (SBIRT) were 0.16 (SE = 0.014), -0.06 (SE = 0.017), and 0.22 (SE = 0.026), respectively. Only 12 (11.3%) AUDIT questionnaires concurred with corresponding clinical records that a patient had any/no problem alcohol use. Regular use of primary care was evident, as 25% had visited their GP more than 12 times during the past 3 months.

CONCLUSIONS

Comparing clinical records with patients' experience of SBIRT can shed light on the process of care. Alcohol screening in people who attend primary care for substance use treatment is not routinely conducted. Interventions that enhance the care of problem alcohol use among this high-risk group are a priority.