Three Practices, Three Stories: best practices and unique approaches to substance use screening in rural primary care

Context: Primary care (PC) practices that implement Screening, Brief Intervention, and Referral to Treatment (SBIRT) can identify, reduce, and prevent problematic alcohol use that otherwise could go undetected. While screening and brief counseling in PC is considered best practice, it is not standard practice. To support the integration of SBIRT in rural PC practices, local Practice Facilitators (PF) helped PC practice staff identify and implement tailored approaches that addressed each practice’s capabilities, culture, and needs.

Objective: Describe PC practices’ challenges and tailored approaches to effective SBIRT implementation.

Study Design: Collective case study approach using qualitative summaries of PF field notes.

Setting: Three PC practices (two private and one hospital-based) in the High Plains Research Network and the Colorado Research Network in rural Colorado.

Population Studied: PC clinicians and staff.

Intervention: Tailored, ongoing SBIRT practice facilitation.

Outcome Measures: Qualitative descriptions of issues and proposed strategies and protocols.

Results: Cultivating strong leadership and overcoming staff resistance are common components to success across sites. Responsive approaches included starting with a sub-group of patients (vs universal screening), engaging support staff in protocols, an “SBIRT Olympics” competition, and continued conversations about the impact of substance use on health. One practice developed materials with examples of alcohol-related myths frequently heard from their patients and community and used science-based responses to address stigma and foster conversation around alcohol use. Each practice addressed referral to treatment from behavioral health providers (BHP) uniquely, including care coordination with an external BHP, a new BHP hire, and an existing clinician obtaining psychiatric nurse practitioner degree. Brief intervention strategies, workflows, and additional contextual factors around practice culture, staff knowledge, and EHRs will be described.

Conclusions: Integrating substance use care into PC settings can take years to fully integrate into practice protocols, EHRs, and culture. Tailoring individual strategies can facilitate SBIRT implementation in rural PC practices. Examples of specific challenges and potential solutions from real-world settings can offer insights to support SBIRT implementation and maintenance.