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Adeniran E, Quinn M, Wallace R, Walden RR, Labisi T, Olaniyan A, Brooks B, Pack R. A scoping review of barriers and facilitators to the integration of substance use treatment services into US mainstream health care. DRUG AND ALCOHOL DEPENDENCE REPORTS 2023; 7:100152. [PMID: 37069961 PMCID: PMC10105485 DOI: 10.1016/j.dadr.2023.100152] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 03/22/2023] [Accepted: 03/23/2023] [Indexed: 04/19/2023]
Abstract
Background Following the national implementation of the Affordable Care Act (ACA) in 2014, barriers still exist that limit the adoption of substance use treatment (SUT) services in mainstream health care (MHC) settings in the United States. This study provides an overview of current evidence on barriers and facilitators to integrating various SUT services into MHC. Methods A systematic search was conducted with the following databases: "PubMed including MEDLINE", "CINAHL", "Web of Science", "ABI/Inform", and "PsycINFO." We identified barriers and/or facilitators affecting patients, providers, and programs/systems. Results Of the 540 identified citations, 36 were included. Main barriers were identified for patients (socio-demographics, finances, confidentiality, legal impact, and disinterest), providers (limited training, lack of time, patient satisfaction concerns, legal implications, lack of access to resources or evidence-based information, and lack of legal/regulatory clarity), and programs/systems (lack of leadership support, lack of staff, limited financial resources, lack of referral networks, lack of space, and lack of state-level support). Also, we recognized key facilitators pertaining to patients (trust for providers, education, and shared decision making), providers (expert supervision, use of support team, training with programs like Extension for Community Health Outcomes (ECHO), and receptivity), and programs/systems (leadership support, collaboration with external agencies, and policies e.g., those expanding the addiction workforce, improving insurance access and treatment access). Conclusions This study identified several factors influencing the integration of SUT services in MHC. Strategies for improving SUT integration in MHC should address barriers and leverage facilitators related to patients, providers, and programs/systems.
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Affiliation(s)
- Esther Adeniran
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, United States
- Department of Biostatistics and Epidemiology, College of Public Health, East Tennessee State University, Johnson City, TN 37614, United States
- Corresponding author at: Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, United States.
| | - Megan Quinn
- Department of Biostatistics and Epidemiology, College of Public Health, East Tennessee State University, Johnson City, TN 37614, United States
| | - Richard Wallace
- Quillen College of Medicine Library, East Tennessee State University, Johnson City, TN 37614, United States
| | - Rachel R. Walden
- Quillen College of Medicine Library, East Tennessee State University, Johnson City, TN 37614, United States
| | - Titilola Labisi
- Department of Health Promotion, College of Public Health, University of Nebraska Medical Center, Omaha, NE 68198, United States
| | - Afolakemi Olaniyan
- Department of Health Promotion and Education, School of Human Sciences, University of Cincinnati, Cincinnati, OH 45221, United States
| | - Billy Brooks
- Department of Biostatistics and Epidemiology, College of Public Health, East Tennessee State University, Johnson City, TN 37614, United States
| | - Robert Pack
- Department of Community and Behavioral Health, College of Public Health, East Tennessee State University, Johnson City, TN 37614, United States
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Reif S, Brolin M, Beyene TM, D’Agostino N, Stewart MT, Horgan CM. Payment and Financing for Substance Use Screening and Brief Intervention for Adolescents and Adults in Health, School, and Community Settings. J Adolesc Health 2022; 71:S73-S82. [PMID: 36122974 PMCID: PMC9945348 DOI: 10.1016/j.jadohealth.2022.04.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 04/01/2022] [Accepted: 04/27/2022] [Indexed: 10/14/2022]
Abstract
Screening and brief intervention (SBI) is an evidence-based, cost-effective practice to address unhealthy substance use. With SBI services expanding beyond healthcare settings (e.g., schools, community organizations) and reaching younger populations, sustainability efforts must consider payment and financing. This narrative review incorporated rapid scoping review methods and a search of the gray literature to determine payment and financing approaches for SBI with adolescents and to describe related barriers and facilitators for its sustainability. We sought information relevant to adolescents and settings in which they receive SBI, but also reviewed sources with an adult focus. Few peer-reviewed articles met inclusion criteria, and those mostly highlighted healthcare settings. School-based settings were better described in the gray literature; little was found about community settings. SBI is mostly paid through grant funding and public and commercial insurance; school-based settings use a range of approaches including grants, public insurance, and other public funding. We call upon researchers and providers to describe the payment and financing of SBI, to inform how the uptake of SBI may be practicable and sustainable. The increasing activation and use of insurance billing codes, and the expansion of SBI beyond healthcare, is encouraging to address unhealthy substance use by adolescents.
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Affiliation(s)
- Sharon Reif
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts.
| | - Mary Brolin
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, 415 South Street, Waltham, MA, 02453, USA
| | - Tiginesh M. Beyene
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, 415 South Street, Waltham, MA, 02453, USA
| | - Nicole D’Agostino
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, 415 South Street, Waltham, MA, 02453, USA
| | - Maureen T. Stewart
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, 415 South Street, Waltham, MA, 02453, USA
| | - Constance M. Horgan
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, 415 South Street, Waltham, MA, 02453, USA
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Broughton-Miller KD, Urquhart GE. Improving acute pain management of trauma patients on medication-assisted therapy. J Am Assoc Nurse Pract 2022; 34:924-931. [PMID: 35580281 DOI: 10.1097/jxx.0000000000000730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 03/31/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Approximately 9,500,000 people in the United States misused opioids in 2020. Many people manage their opioid use disorder (OUD) with medication-assisted treatment (MAT). Using MAT to address OUD adds to the complexities and challenges of adequate acute pain control. LOCAL PROBLEM Chart review indicated only 20% of trauma patients on MAT achieved adequate pain control on the trauma service at the University of Louisville Hospital. This quality initiative aimed to increase patient pain control to 50% in 90 days. METHODS A rapid cycle quality improvement project with four plan-do-study-act (PDSA) cycles was conducted over 8 weeks. Four core interventions were implemented concurrently, with tests of change biweekly. Qualitative and qualitative data analyses were completed at each cycle. INTERVENTIONS The core interventions included a risk assessment tool, shared decision-making (SDM) tool, provider checklist, and a team engagement plan. RESULTS The number of patients with a pain score of ≤5 (scale 0-10) increased to 78% from 20%. The mean pain score decreased from 8 to 4.6. The fourth PDSA cycle results showed a 92% patient engagement with SDM and 100% utilization of the provider checklist. Team engagement scores greater than 4 on a 5-point Likert scale were 86%. CONCLUSIONS Effective patient-centered acute pain control for trauma patients on MAT is achievable. The combined use of an SDM tool and a provider checklist was an efficient way to provide effective and patient-centered care and positively affected patient outcomes.
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Olmstead TA, Yonkers KA, Forray A, Zimbrean P, Gilstad-Hayden K, Martino S. Cost and cost-effectiveness of three strategies for implementing motivational interviewing for substance misuse on medical inpatient units. Drug Alcohol Depend 2020; 214:108156. [PMID: 32659637 PMCID: PMC7448551 DOI: 10.1016/j.drugalcdep.2020.108156] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 06/22/2020] [Accepted: 06/24/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND This study conducted cost and cost-effectiveness analyses of three strategies for implementing motivational interviewing for substance misuse on general medical inpatient units: workshop, apprenticeship, and consult. METHODS The economic analyses were conducted prospectively alongside a type 3 hybrid effectiveness-implementation randomized trial comprising 38 medical providers, 1173 inpatients, and four consultation-liaison motivational interviewing experts. The trial took place in a university affiliated teaching hospital in New Haven, CT, USA. After completing a 1-day workshop on motivational interviewing, providers were randomized to conditions. The primary outcome measure was the number of study-eligible patients who received a motivational interview. The economic analyses included the costs of both start-up and on-going activities in each condition. Incremental cost-effectiveness ratios were used to determine cost effectiveness. Results are presented from the healthcare provider (i.e., hospital) perspective in 2018 US dollars. RESULTS The total cost per patient receiving a motivational interview averaged $804.53, $606.52, and $185.65 for workshop, apprenticeship, and consult, respectively. Workshop and apprenticeship were extended dominated by the combination of consult and doing nothing. Doing nothing is cost effective when the willingness-to-pay for an additional patient receiving a motivational interview is less than $185.65, and consult is cost-effective when the willingness-to-pay for an additional patient receiving a motivational interview is greater than $185.65. CONCLUSIONS Given that typical reimbursements for brief intervention services for substance misuse are $35-$65, none of the three implementation strategies is likely to be economically viable from the healthcare provider perspective.
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Affiliation(s)
- Todd A. Olmstead
- The University of Texas at Austin, Lyndon B. Johnson School of Public Affairs, Sid Richardson Hall, Unit 3, Austin, TX 78712, USA,Corresponding Author: Todd Olmstead, The University of Texas at Austin, LBJ School of Public Affairs, Sid Richardson Hall, Unit 3, Austin, TX, 78712, USA, ; 512.471.8456
| | - Kimberly A. Yonkers
- Yale School of Medicine, Department of Psychiatry, 300 George Street, Suite 901, New Haven, CT 06520, USA,Yale School of Medicine, Department of Obstetrics, Gynecology & Reproductive Sciences, 333 Cedar Street, New Haven, CT 06510, USA,Yale School of Epidemiology and Public Health Division of Chronic Disease, 60 College Street, New Haven, CT 06520, USA
| | - Ariadna Forray
- Yale School of Medicine, Department of Psychiatry, 300 George Street, Suite 901, New Haven, CT 06520, USA
| | - Paula Zimbrean
- Yale School of Medicine, Department of Psychiatry, 300 George Street, Suite 901, New Haven, CT 06520, USA
| | - Kathryn Gilstad-Hayden
- Yale School of Medicine, Department of Psychiatry, 300 George Street, Suite 901, New Haven, CT 06520, USA
| | - Steve Martino
- Yale School of Medicine, Department of Psychiatry, 300 George Street, Suite 901, New Haven, CT 06520, USA,VA Connecticut Healthcare System, Psychology Service, 950 Campbell Avenue (116B), West Haven, CT 06516, USA
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Olmstead TA, Yonkers KA, Ondersma SJ, Forray A, Gilstad-Hayden K, Martino S. Cost-effectiveness of electronic- and clinician-delivered screening, brief intervention and referral to treatment for women in reproductive health centers. Addiction 2019; 114:1659-1669. [PMID: 31111591 PMCID: PMC6684836 DOI: 10.1111/add.14668] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 11/01/2018] [Accepted: 05/13/2019] [Indexed: 12/29/2022]
Abstract
AIMS To determine the cost-effectiveness of electronic- and clinician-delivered SBIRT (Screening, Brief Intervention and Referral to Treatment) for reducing primary substance use among women treated in reproductive health centers. DESIGN Cost-effectiveness analysis based on a randomized controlled trial. SETTING New Haven, CT, USA. PARTICIPANTS A convenience sample of 439 women seeking routine care in reproductive health centers who used cigarettes, risky amounts of alcohol, illicit drugs or misused prescription medication. INTERVENTIONS Participants were randomized to enhanced usual care (EUC, n = 151), electronic-delivered SBIRT (e-SBIRT, n = 143) or clinician-delivered SBIRT (SBIRT, n = 145). MEASUREMENTS The primary outcome was days of primary substance abstinence during the 6-month follow-up period. To account for the possibility that patients might substitute a different drug for their primary substance during the 6-month follow-up period, we also considered the number of days of abstinence from all substances. Incremental cost-effectiveness ratios and cost-effectiveness acceptability curves determined the relative cost-effectiveness of the three conditions from both the clinic and patient perspectives. FINDINGS From a health-care provider perspective, e-SBIRT is likely (with probability greater than 0.5) to be cost-effective for any willingness-to-pay value for an additional day of primary-substance abstinence and an additional day of all-substance abstinence. From a patient perspective, EUC is most likely to be the cost-effective intervention when the willingness to pay for an additional day of abstinence (both primary-substance and all-substance) is less than $0.18 and e-SBIRT is most likely to be the cost-effective intervention when the willingness to pay for an additional day of abstinence (both primary-substance and all-substance) is greater than $0.18. CONCLUSIONS e-SBIRT could be a cost-effective approach, from both health-care provider and patient perspectives, for use in reproductive health centers to help women reduce substance misuse.
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Affiliation(s)
- Todd A. Olmstead
- The University of Texas at Austin, Lyndon B. Johnson School of Public Affairs, 2300 Red River Street, Austin, TX 78713, USA
| | - Kimberly A. Yonkers
- Yale University School of Medicine, Department of Psychiatry, 40 Temple Street, Suite 6B, New Haven, CT 06510, USA,Yale University School of Medicine, Department of Obstetrics, Gynecology & Reproductive Sciences, 333 Cedar Street, New Haven, CT 06510, USA,Yale University School of Epidemiology and Public Health, Division of Chronic Disease, 60 College Street, New Haven, CT 06520, USA
| | - Steven J. Ondersma
- Wayne State University, Department of Psychiatry & Behavioral Neurosciences & Merrill-Palmer Skillman Institute, 71 E. Ferry Ave., Detroit, MI 48202, USA
| | - Ariadna Forray
- Yale University School of Medicine, Department of Psychiatry, 40 Temple Street, Suite 6B, New Haven, CT 06510, USA
| | - Kathryn Gilstad-Hayden
- Yale University School of Medicine, Department of Psychiatry, 40 Temple Street, Suite 6B, New Haven, CT 06510, USA
| | - Steve Martino
- Yale University School of Medicine, Department of Psychiatry, 40 Temple Street, Suite 6B, New Haven, CT 06510, USA,VA Connecticut Healthcare System, 950 Campbell Avenue (116B), West Haven, CT 06516, USA
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Barbosa C, Wedehase B, Dunlap L, Mitchell SG, Dusek K, Schwartz RP, Gryzcynski J, Kirk AS, Oros M, Hosler C, O'Grady KE, Brown BS. Start-Up Costs of SBIRT Implementation for Adolescents in Urban U.S. Federally Qualified Health Centers. J Stud Alcohol Drugs 2018; 79:447-454. [PMID: 29885153 DOI: 10.15288/jsad.2018.79.447] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Understanding the costs to implement Screening, Brief Intervention, and Referral to Treatment (SBIRT) for adolescent substance use in primary care settings is important for providers in planning for services and for decision makers considering dissemination and widespread implementation of SBIRT. We estimated the start-up costs of two models of SBIRT for adolescents in a multisite U.S. Federally Qualified Health Center (FQHC). In both models, screening was performed by a medical assistant, but models differed on delivery of brief intervention, with brief intervention delivered by a primary care provider in the generalist model and a behavioral health specialist in the specialist model. METHOD SBIRT was implemented at seven clinics in a multisite, cluster randomized trial. SBIRT implementation costs were calculated using an activity-based costing methodology. Start-up activities were defined as (a) planning activities (e.g., changing existing electronic medical record system and tailoring service delivery protocols); and (b) initial staff training. Data collection instruments were developed to collect staff time spent in start-up activities and quantity of nonlabor resources used. RESULTS The estimated average costs to implement SBIRT were $5,182 for the specialist model and $3,920 for the generalist model. Planning activities had the greatest impact on costs for both models. Overall, more resources were devoted to planning and training activities in specialist sites, making the specialist model costlier to implement. CONCLUSIONS The initial investment required to implement SBIRT should not be neglected. The level of resources necessary for initial implementation depends on the delivery model and its integration into current practice.
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Affiliation(s)
| | | | - Laura Dunlap
- RTI International, Research Triangle Park, North Carolina
| | | | | | | | | | | | | | | | - Kevin E O'Grady
- Department of Psychology, University of Maryland, College Park, College Park, Maryland
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Babor TF, Del Boca F, Bray JW. Screening, Brief Intervention and Referral to Treatment: implications of SAMHSA's SBIRT initiative for substance abuse policy and practice. Addiction 2017; 112 Suppl 2:110-117. [PMID: 28074569 DOI: 10.1111/add.13675] [Citation(s) in RCA: 134] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
AIMS This paper describes the major findings and public health implications of a cross-site evaluation of a national Screening, Brief Intervention and Referral to Treatment (SBIRT) demonstration program funded by the US Substance Abuse and Mental Health Services Administration (SAMHSA). METHODS Eleven multi-site programs in two cohorts of SAMHSA grant recipients were each funded for 5 years to promote the adoption and sustained implementation of SBIRT. The SBIRT cross-site evaluation used a multi-method evaluation design to provide comprehensive information on the processes, outcomes and costs of SBIRT as implemented in a variety of medical and community settings. FINDINGS SBIRT programs in the two evaluated SAMHSA cohorts screened more than 1 million patients/clients. SBIRT implementation was facilitated by committed leadership and the use of substance use specialists, rather than medical generalists, to deliver services. Although the quasi-experimental nature of the outcome evaluation does not permit causal inferences, pre-post differences were clinically meaningful and statistically significant for almost every measure of substance use. Greater intervention intensity was associated with larger decreases in substance use. Both brief intervention and brief treatment were associated with positive outcomes, but brief intervention was more cost-effective for most substances. Sixty-nine (67%) of the original performance sites adapted and redesigned SBIRT service delivery after initial grant funding ended. Four factors influenced SBIRT sustainability: presence of program champions, availability of funding, systemic change and effective management of SBIRT provider challenges. CONCLUSIONS The US Substance Abuse and Mental Health Services Administration's Screening, Brief Intervention and Referral to Treatment (SBIRT) demonstration program was adapted successfully to the needs of early identification efforts for hazardous use of alcohol and illicit drugs. SBIRT is an innovative way to integrate the management of substance use disorders into primary care and general medicine. Screening, Brief Intervention and Referral to Treatment implementation was associated with improvements in treatment system equity, efficiency and economy.
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Affiliation(s)
- Thomas F Babor
- University of Connecticut School of Medicine, Farmington, CT, USA
| | - Frances Del Boca
- University of Connecticut School of Medicine, Farmington, CT, USA
| | - Jeremy W Bray
- University of North Carolina at Greensboro, Greensboro, NC, USA
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Bray JW, Del Boca FK, McRee BG, Hayashi SW, Babor TF. Screening, Brief Intervention and Referral to Treatment (SBIRT): rationale, program overview and cross-site evaluation. Addiction 2017; 112 Suppl 2:3-11. [PMID: 28074566 DOI: 10.1111/add.13676] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIMS Since 2003, the US Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment (SAMHSA, CSAT) has awarded 32 Screening, Brief Intervention and Referral to Treatment (SBIRT) grants to states, territories and tribal organizations to enhance services for persons with, or at risk for, substance use disorders. The grants supported an expansion of the continuum of care to include screening, brief intervention, brief treatment and referral to treatment in general medical and community settings. This paper describes the SAMHSA SBIRT program in the context of the scientific research that motivated its development, as well as the two cross-site evaluations that are the subject of subsequent papers in this Supplement. METHODS A narrative review of research evidence pertaining to SBIRT and of the cross-site evaluation design that made it possible to determine whether the SAMHSA SBIRT grant program achieved its intended aims. The 11 programs within the two cohorts of grant recipients that were the subject of the cross-site evaluations are described in terms of SBIRT service components, performance sites, providers, management structure/activities and patient/client characteristics. CONCLUSION The US SAMHSA SBIRT program is an effective way to introduce a variety of new services that extend the continuum of care for substance-involved individuals, ranging from early intervention with non-dependent substance users to referral of more serious cases to specialized substance abuse treatment.
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Affiliation(s)
- Jeremy W Bray
- The University of North Carolina at Greensboro, Greensboro, NC, USA
| | - Frances K Del Boca
- UConn Health, Department of Community Medicine and Health Care, Farmington, CT, USA
| | - Bonnie G McRee
- UConn Health, Department of Community Medicine and Health Care, Farmington, CT, USA
| | | | - Thomas F Babor
- UConn Health, Department of Community Medicine and Health Care, Farmington, CT, USA
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