Trajectories and strategies in implementing screening, brief intervention, and referral to treatment for substance use in primary care within public hospitals: a longitudinal qualitative study.

BACKGROUND: Screening, brief intervention, and referral to treatment (SBIRT) is an evidence-based approach to identify and initiate treatment for alcohol and substance use in primary care settings. Among 22 public hospitals incentivized to implement SBIRT as part of a value-based Medicaid waiver program over five years, this study examined trajectories, strategies, and challenges in standardizing SBIRT within primary care. METHODS: This study utilized data from narrative reports completed by hospital leadership, obtained from the evaluation of the Public Hospital Redesign and Incentives in Medi-Cal (PRIME) program in California. Following the Multi-Level Health Outcomes Framework, template analysis was used to characterize SBIRT implementation. Content analysis was used to catalogue implementation strategies using the Expert Recommendations for Implementing Change Framework. To assess trajectories (i.e., longitudinal implementation outcomes) of SBIRT implementation, we categorized standardized adoption of sequential SBIRT processes (screening only; screening and brief intervention; screening, brief intervention, and referral to treatment) and reach (limited vs. full primary care population). RESULTS: Hospitals used a wide variety of measures, personnel, platforms, and workflows in screening for substance use within primary care settings. Brief intervention was conducted by primary care or behavioral health care team members who had received targeted training. Hospitals implemented a wide range of treatment options to address substance use, including referral to co-located or contracted/partnered behavioral health providers. By the end of the first implementation year, only one hospital had standardized screening processes, and none had standardized brief intervention or referral. At the end of the fifth year, 20 of 22 hospitals had standardized screening, 15 had standardized brief intervention, and 12 had standardized referral among their full primary care populations. Strategies and challenges in planning, education, and restructuring processes (e.g., integration of screening processes within electronic health records and clinical workflows) were particularly influential in facilitating implementation. CONCLUSIONS: This study highlighted significant progress made by public hospitals in implementing standardized SBIRT processes among their primary care populations within a value-based program. However, hospitals experienced delays and challenges, highlighting key areas in which additional support or investment may be needed to sustain and promote long-term progress in SBIRT implementation.