Facilitating Change for Excellence in SBIRT (FaCES), was a four-year initiative from 2016 – 2020 that was executed by the National Council with funding from the Conrad N. Hilton Foundation. to develop an evidence-informed, standardized, and flexible approach to adolescent SBIRT implementation in primary care.
Change Package Development
During the first phase of the FaCES initiative, the National Council developed an implementation guide, or change package, for YSBIRT in primary care. They did so in coordination with a team of national experts who ensured the resource was informed by the latest research and evidence in the field. The change package comprises 11 specific recommendations – or change concepts – that marry high-level implementation guidance with the actual operational changes required for effective practice transformation, painting a picture of the ideal and actionable state.
To test the efficacy of the change package, the National Council, in partnership with Friends Research Institute and Aurora Research Institute, conducted an 18-month pilot program with 12 Federally Qualified Health Centers (FQHCs) from across the country. Selected sites had diversity of readiness for implementation, geographic location and setting, center size and patient population demographics to ensure the change package was nationally applicable. Sites received training on a range of topics from a dedicated practice coach, regular group webinars and a series of in-person meetings/site visits.
Results of a comprehensive evaluation found that pilot sites screened 91 percent of all adolescents who visited their clinics for well visits, exceeding the 90 percent benchmark. This represents a significant improvement, as many sites were not screening at all prior to change package implementation. In addition, examination of EHR data indicated fidelity to the change package protocol and that providers were delivering the appropriate intervention based on screening results. In addition to improvements around screening and intervention delivery, sites saw an overall increase in the level of behavioral health and primary care integration. Sites scoring higher on measures of integrated care were also viewed by a sample of surveyed personnel to have better communication and cohesion. This supports the idea that greater integration supports FQHCs in being more responsive to the needs of both patients and staff members. Clinicians who perceived more supportive organizational structures also reported greater confidence in properly conducting SBIRT. Lastly, when compared to other roles, nurses saw the greatest increase in completion of SBIRT training and greatest gains in positive attitudes toward screening and brief intervention, indicating they are critical stakeholders and champions for adolescent SBIRT.
Sites experienced challenges documenting SBIRT practices in their EHRs (especially with brief interventions), navigating confidentiality and patient-parent dynamics and establishing effective workflows and billing practices. Overall, sites learned that implementation required a high level of leadership and provider buy-in at project initiation and, in order to sustain practice, it was imperative to motivate, educate and communicate with staff about the importance of SBIRT. Other general learnings include:
- Screening: It is critical to be aware of emerging trends in substance use, so providers are asking the right questions.
- Anticipatory guidance was not consistently delivered by pilot sites for all adolescents whose screen indicated “no use.” It is important to clarify this requirement, so providers take advantage of the prevention opportunity.
- Brief interventions need to be brief enough to account for the time constraints experienced in the primary care setting. It is ideal to give providers a range of potential scenarios in delivering a brief intervention so that the conversation is flexible, efficient, and responsive to each adolescent’s needs.
- Referral to Treatment: This step requires strong relationships with both internal and external partners and a dedication to documenting follow-up steps. It is also important to stress the responsibility that primary care providers have in managing and addressing substance use, so adolescents receive comprehensive and integrated care.
The National Council continues to promote the change package nationwide and offers ongoing training opportunities.