Critical Factors Influencing Successful Implementation of SBIRT into Rural Clinical Practice
Addiction Science Made Easy
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What’s the Question?
SBIRT (Screening, Brief Intervention, and Referral to Treatment) is an evidence-based process clinicians can use to first identify and then address alcohol and other substance use risk in patients.
In the SBIRT process, validated screening tools are used to identify patients’ risk levels, which in turn are matched with appropriate interventions. For example, patients who screen low to moderate may receive a brief intervention (BI), which can often be conducted at the time of screening. Those scoring high, on the other hand, will need a referral to treatment (RT) and further assessment and care.
With the ongoing overdose crisis, and increased rates of substance use overall since COVID-19, it’s increasingly important to effectively identify and help people with substance use problems. This is especially true in rural areas, where there are generally fewer services available to serve individuals spread across wider geographical terrain, often making prevention and treatment resources harder to access and deliver.
SBIRT implementation efforts are taking shape around the U.S. through Substance Abuse and Mental Health Services Administration (SAMHSA)-funded grants, state programs, and other funding and technical assistance mechanisms. The SBIRT framework is also recognized as a strategy for rural communities to target substance use. However, despite a growing body of research demonstrating its efficacy in addressing substance use in medical settings, the use of SBIRT is still not widespread, often due to implementation challenges.
Most SBIRT implementation studies to date have focused on identifying barriers to screening and brief intervention; fewer have looked at the full SBIRT process, or at the role of state and local health system transformation efforts on SBIRT implementation, particularly in rural settings. Identifying key components of successful implementation, as well as what barriers might impede that implementation, is an important step toward better understanding what does and doesn’t work well when an organization wants to add SBIRT services to their practice.
How Was This Study Conducted?
This study focused on a statewide SBIRT implementation initiative in Vermont, which received a 5-year SAMHSA grant to support SBIRT implementation with a goal of screening 15% of the state’s adult population.
Participating sites were provided with orientation training and planning modules for leadership, administrative, and clinical staff. During the first few months of implementation at a new location, project staff were on-site to support technical assistance and coaching as SBIRT services were delivered. Ongoing training and TA opportunities were also offered, including continuous quality assurance, clinical supervision, and on-site coaching.
Researchers used both quantitative patient-level data to assess characteristics associated with implementation and key informant interviews conducted with stakeholders to better understand the implementation process and identify barriers and facilitators.
What Did Researchers Find Out?
Though previous studies had identified provider acceptance or “buy-in” as a key component of successful implementation, this study went further, looking more in-depth at how that buy-in manifested. In this study group, buy-in of SBIRT involved a philosophical belief in SBIRT as not only an effective tool for addressing alcohol and other substance use, but, more importantly, as integral to promoting patient wellness.
SBIRT buy-in and acceptance among providers and other clinical team members in this study were fostered by strong, committed leadership, which also mirrors other studies from the field.
Flexibility was another vital component of successful implementation – the SBIRT process includes more than one intervention and often involves multiple team members, departments, or even partnerships with other organizations, making flexibility and adaptability important for success. Sites using multiple team members and/or electronic screening versus only the SBIRT clinician reported more success with universal screening. On the other hand, sites relying solely on SBIRT clinicians to deliver all elements of the SBIRT process expressed that they had more staffing time for brief treatment and referral linkages, leading to greater reported success in engaging patients with more severe use patterns.
Also important was the external environment, or outer context/setting. Implementation efforts have a greater chance for success when they align with – and occur within – larger statewide or system-wide transformation. In this study, Vermont’s statewide adoption of SBIRT, including how sites implemented the process within a largely rural state, helped spearhead effective implementation in medical settings.
What Are the Implications for the Workforce?
SBIRT is an effective process for addressing unhealthy alcohol and other substance use in medical settings, but it often falls short of being successfully implemented due to barriers and other challenges. The results of this study echo and expand on other implementation findings from the field by adding important lessons, within a rural state context, for stakeholders engaged in SBIRT implementation.
Knowing what factors are key for successful implementation – a favorable health reform outer context supportive of behavioral health integration; key implementation facilitators like buy-in, strong leadership/champions, and communication; flexibility of model and workflow; and a positive perception of the SBIRT process among medical team members -- can help organizations better plan for, implement, and ultimately move SBIRT into routine practice.