title: Facilitators and Barriers to Implementing Screening, Brief Intervention, and Referral to Treatment (SBIRT) in Primary Care in Integrated Health Care Settings.
abstract: BACKGROUND
  Substance abuse in the United States is a serious public health concern impacting morbidity and mortality. However, systematic screening and intervention has not been widely adopted into routine practice by health care organizations and routine screening and intervention is not currently in place for primary care at Kaiser Permanente Colorado. Therefore, a formative evaluation was conducted to explore and enhance implementation of the Substance Abuse and Mental Health Services Administration (SAMHSA) screening, brief intervention, and referral to treatment (SBIRT) approach in the organization.
  
  
  METHODS
  Key clinical stakeholders, including internal and family medicine physicians, primary care nurses, mental health therapists, chemical dependency clinicians, and clinic-based psychologists provided feedback. Two focus groups were also conducted with patient stakeholders: one in English and one in Spanish.
  
  
  RESULTS
  All clinical stakeholders promoted clinic-based psychologists to conduct brief intervention and determine referral to treatment as the optimal implementation program. Inclusion of the patient perspective also highlighted the importance of considering this perspective in implementation. Both patient groups were generally supportive of SBIRT, especially the educational value of screening questions defining healthy drinking limits; however, English-speaking patients noted privacy concerns and Spanish-speaking patients noted frequently being asked about drug or alcohol use. Organizationally, systems exist to facilitate drug and alcohol use screening, intervention, and referral to treatment. However, physician time, alignment with other priorities, and lack of consistent communication were noted potential barriers to SBIRT implementation.
  
  
  CONCLUSIONS
  Clinicians expressed concerns about competing priorities and the need for organizational leadership involvement for successful SBIRT implementation. A unique suggestion for successful implementation is to utilize existing primary care clinic-based psychologists to conduct brief intervention and facilitate referral to treatment. Patient stakeholders supported universal screening, but cultural differences in opinions and current experience were noted, indicating the importance of including this perspective when evaluating implementation potential.
authors.affiliation: a Kaiser Permanente Institute for Health Research , Denver , Colorado , USA.
authors.forename: Alanna Kulchak
authors.initials: AK
authors.lastname: Rahm
authors.forename: Jennifer M
authors.initials: JM
authors.lastname: Boggs
authors.forename: Carmen
authors.initials: C
authors.lastname: Martin
authors.forename: David W
authors.initials: DW
authors.lastname: Price
authors.forename: Arne
authors.initials: A
authors.lastname: Beck
authors.forename: Thomas E
authors.initials: TE
authors.lastname: Backer
authors.forename: James W
authors.initials: JW
authors.lastname: Dearing
mesh_terms: D001291:Attitude of Health Personnel; D003120:Colorado; D006297:Health Services Accessibility; D006801:Humans; D008403:Mass Screening; D010358:Patient Participation; D011320:Primary Health Care; D011614:Psychotherapy, Brief; D012017:Referral and Consultation; D019966:Substance-Related Disorders / Q000175:diagnosis* / Q000628:therapy*
keywords: Alcoholism; SBIRT; implementation science; substance abuse detection