Research and Engagement Considerations for Alcohol Use Telehealth Services within HIV Care: A Qualitative Exploration in Federally Qualified Health Centers

Abstract

The prevalence of alcohol misuse is high among people with HIV (PWH), however access to and utilization of evidence-based alcohol misuse interventions remain limited. Telehealth is one treatment approach with potential for enhancing substance use disorder treatment utilization for PWH served by Federally Qualified Health Centers (FQHCs). However, questions remain regarding barriers to alcohol-focused telehealth service integration and telehealth research in FQHCs. This study employed qualitative methods, guided by the Dynamic Sustainability Framework, to evaluate barriers and cultural factors impacting FQHC telehealth integration. Eighteen qualitative interviews were completed with staff and leaders across four FQHCs. Interviews were analyzed using directed content analysis, and codes were organized into a priori and emergent themes. Key themes included: the presence of common workflows for referring clients to substance use disorder treatment; existing research workflows and preferences for active project staff involvement; telehealth barriers including exacerbation of healthcare disparities and high provider turnover; and importance of cultural humility and telehealth adaptations for sexual, gender, racial, and ethnic minority clients. Findings from this study will inform the development of an alcohol-focused telehealth implementation strategy for a Hybrid Type 1 implementation effectiveness trial to enhance FQHC substance use disorder treatment.

A recent systematic review suggests that as many as 42% of people with HIV (PWH) in developed countries meet criteria for alcohol use disorder (AUD; Duko et al., 2019; Fisher et al., 2007). Despite potential harms from alcohol misuse (National Institute on Alcohol Abuse and Alcoholism, 2020), including increased HIV disease progression (Durvasula & Miller, 2014), substance use disorder (SUD) treatment is generally underutilized by PWH, and especially by individuals who identify as sexual and gender minorities (SGM; Orwat et al., 2011). This limited utilization of SUD treatment is a substantial concern given the high prevalence of HIV among SGM (Baral et al., 2013; Crepaz et al., 2019).

Federally Qualified Health Centers (FQHCs; U.S. Health Resources & Services Administration, 2021) are a common clinical site where PWH may receive HIV and behavioral health/SUD treatment services. FQHCs are frequently located in underserved communities and provide enhanced Medicare/Medicaid reimbursement and sliding-scale fees. Advances in technology make telehealth a promising strategy for increasing the uptake of alcohol misuse interventions in FQHCs (Grasso et al., 2021; Lin et al., 2019; Ramsey et al., 2019). Telehealth interventions for SUDs face numerous barriers including insufficient reimbursement, technical challenges, and clinician concerns about rapport (Lin et al., 2019; Lin et al., 2020; Uscher-Pines et al., 2020). Although the COVID-19 pandemic led to increased adoption of telehealth services and increased treatment access (Rogers et al., 2020; Uscher-Pines et al., 2020), regulatory guidelines that shifted during COVID-19 may need to be maintained for telehealth to continue. Given these barriers, there is a strong need for research to evaluate the effectiveness and implementation of SUD-focused telehealth services in FQHCs.

A first step to integration and evaluation of alcohol-focused telehealth services in FQHCs is to assess integration targets and barriers within current SUD and HIV treatment workflows. The present study used qualitative interviews to understand FQHC HIV and SUD treatment and referral workflows, evaluate research capacity and potential for telehealth research integration, identify FQHC barriers to telehealth services and research procedures, and identify potential targets for telehealth adaptation to meet the needs of underserved populations (SGM, racial/ethnic minority groups). The overarching goal of this work is to address barriers to research and telehealth integration for alcohol misuse and AUD in FQHCs. Findings from this study will guide the development of an implementation strategy to be tested in a Hybrid Type 1 effectiveness implementation trial (Curran et al., 2012).

Materials and Methods

Participants

Clinical staff and leadership (N = 18) were recruited from four FQHCs to complete 60-minute, audio-recorded qualitative interviews guided by the Dynamic Sustainability Framework (Chambers et al., 2013), an implementation science framework identifying domains impacting intervention sustainability in routine care settings. These FQHCs were participating in the Reducing Alcohol use and related Comorbidities in HIV care study (Project ReACH; PI: Kahler P01AA019072) evaluating alcohol-focused telehealth counseling for PWH (ClinicalTrials.gov Registry ID: NCT02563574). Staff providing HIV and behavioral health treatment were nominated for interviews by FQHC leadership. Leadership nomination was selected as the sampling approach to ensure interviews were completed with individuals that leadership felt were most likely to deliver or oversee telehealth services. Leadership nomination enabled the identification of clinical staff with the most important and influential views about telehealth services in line with a purposeful sampling approach (Moser & Korstjens, 2017; Palinkas et al., 2015). The majority of nominated staff (85.7%) agreed to participate. All completed informed consent and were made aware that data were confidential and not shared with FQHC leadership. This study was reviewed by the Brown University IRB and determined not to be human subjects research. Participants were considered key informants reporting on current agency practices.

Qualitative Interview Guide Development

The qualitative interview guide was informed by the three DSF domains: intervention characteristics, practice setting, and ecological system. Intervention characteristics questions focused on current telehealth delivery, SUD treatment, and research engagement (see Appendix for interview guide). Practice setting questions included information about the client population and available treatment resources. Finally, ecological system questions focused on how the FQHC interfaces with other treatment facilities and the impact of legislative/regulatory issues.

Qualitative Analysis

We used a directed content analysis approach to analyze the qualitative interview data (Asarnow et al., 2009; Finlay, 2016; Hsieh & Shannon, 2005). A qualitative coding dictionary was developed using both a priori codes (the three DSF domains of intervention characteristics, practice setting, and ecological system) and emergent codes identified through an initial review of all transcripts by the first author (KS, a PhD clinical psychologist) and three coders (two postdoctoral fellows [AG, DZ], one graduate student [AS]) on the coding team. The first author then generated definitions for each a priori and emergent code included in the coding dictionary, and all code definitions were reviewed and approved by the full coding team prior to initiating formal coding. All coding for this project was completed using NVivo software.

The three coders were then trained in the coding dictionary during a one-hour training meeting conducted by the first author. Following training, each coder applied the coding dictionary to one transcript in NVivo. Each coder’s first transcript was also coded by the first author to establish initial inter-rater reliability, and the first author and each coder met weekly to review initial transcript coding discrepancies and come to 100% consensus via discussion. Following establishment of initial inter-rater reliability, each coder completed coding on five additional transcripts (n = 6 total transcripts per coder). To ensure ongoing reliability across coders, the first author coded a second, randomly selected transcript from each coder such that one-third of all transcripts (n = 2 total per coder) were double coded. The first author held continued weekly coding meetings with each coder to review coding discrepancies, modify the coding dictionary to include additional emergent themes, and come to 100% consensus via discussion for each transcript.

Frequently endorsed a priori and emergent codes were then reviewed by the full coding team to identify overarching themes/subthemes. The first author (KS) collapsed all codes into initial themes and discussed theme fit with the full coding team to achieve consensus. Queries were then run in NVivo to identify exemplar quotes for each of the four key themes identified: FQHC SUD/HIV treatment referral workflow; existing research recruitment workflows; barriers to telehealth integration and research; and potential telehealth adaptation needs when working with SGM and/or racial and ethnic minority clients.

Results

Participants

Participants were distributed across four FQHCs in Chicago (N = 7), Washington D.C. (N = 5), Los Angeles (N = 3) and Tucson (N = 3). Distribution of participants across sites varied due to FQHC program size (range = 3 – 8 nominated staff across FQHCs). Mean age for participants was 39 (SD = 8.83) and the majority identified as female (77.8%), White (50.0%), and SGM (61.2%). Participants had been in their current role for approximately 5.8 years (SD = 6.11) and at their FQHC for 5.5 years (SD = 3.90). Participants were members of Behavioral Health/Substance Use (N = 8), HIV Medical (N = 7), and Case Management (N = 3) treatment teams (see Table 1 for demographics). All participants reported providing nearly all treatment via telehealth due to COVID-19.

Table 1.

Demographic information for participants (N = 18)

	Participant N (%) or M(SD, Range)
Age (Years)	39.0 (8.8, 25 – 59)
Gender identity
Female	14 (77.8%)
Male	3 (16.7%
Transgender Man/Trans man	1 (5.6%)
Race
White	9 (50.0%)
Black/African American	1 (5.6%)
Hispanic/Latino	5 (27.8%)
Mixed Race	2 (11.1%)
Other	1 (5.6%)
Sexual Identity/Orientation
Heterosexual/Straight	7 (38.9%)
Gay or Lesbian	5 (27.8%)
Bisexual	1 (5.6%)
Queer	4 22.2%)
Declined	1 (5.6%)
Role
Medical Director	2 (11.1%)
Associate Director	1 (5.6%)
Program Manager/Coordinator	2 (11.1%)
Behavioral Health Consultant	2 (11.1%)
Counselor/Therapist	5 (27.8%)
Case/Integrated Care Manager	4 (22.2%)
Physician Assistant	1 (5.6%)
Medical Attending	1 (5.6%)
Time in Role (Years)	5.8 (6.1, 0.08 – 19.0)
Time at FQHC (Years)	5.5 (3.9, 1.0 – 14.0)

SUD and Behavioral Health Workflows for HIV Treatment

Participants across all FQHCs reported integrating behavioral health and SUD treatment into the HIV treatment workflow. All sites had behavioral health specialists, counselors, or case managers embedded in their HIV medical clinics and noted a common set of referral steps: 1) HIV medical team members connect client to onsite behavioral health/SUD specialists at initial medical appointments through a “warm handoff”; 2) behavioral health specialist completes an intake assessment evaluating substance use using a range of approaches (e.g. validated screening tools, idiographic questions, space for client substance use disclosure); and 3) behavioral health specialist connects client to in-house (or outside referral) behavioral health and/or SUD treatment teams (see Table 2 for exemplar quotes for each theme).

Table 2.

Summary of identified themes and exemplar quotes.

Theme		Exemplar Quotes
1. Substance Use Disorder Workflow for HIV Treatment
Connection to behavioral health specialist in medical care		“The way it works at [FQHC] is that for each of our medical floors, there is a specific behavioral health specialist that’s effectively embedded when we’re in the same space, embedded with medical providers. What happened is that somebody, there could be potentially a warm handoff, or at least a referral if it’s not a warm handoff, from a medical provider.” “Internally say if a patient shows up for an appointment with a primary care doctor and they assess them and determine, hey, this person has some substance use or alcohol use issues going on. Let’s refer them to behavioral health. What they will do is send a referral within our messaging system called [name of system], to the behavioral health department.”
Behavioral health specialist intake/assessment completion		“We are looking to try to use the—we are an SBIRT model, so we’ve piloted it with some of our MAT [Medication Assisted Treatment] providers, but probably AUDIT, like the AUDIT—the brief.” “Really, it’s just direct interviewing. I think most of the providers at our clinic are very comfortable discussing issues that I think a lot of providers may shy away from. Sexual histories, substance use histories. We often ask more than in one way about how people drink.”
Behavioral health specialist referral to substance use disorder treatment		“That person [the outreach specialist] then calls the client and says, “…Let’s talk about what your use is right now. Let’s talk about what kinda services we have and what you would be interested in,” and that’s how they get connected.” “We have a recovery [name of program] program, which is one of our internal behavioral health programs that’s focused on substance reduction or total abstinence, depending on what the person’s requesting.”
2. Research Recruitment Workflow
Presence of existing research recruitment protocols		“Our research team does a pretty good job. I think they must do reports through our EMR to try to identify patients, but they also—at least when we were in the office they had a strong presence at our quarterly social services meetings where they’d give us a rundown of what services, or sorry, what studies are going on in house and who would be eligible. They’re also just extremely accessible.” “I know we have a research department, and they’re often in our management meetings. They’re frequently, you know, how I heard about you and your program. They’re often just getting the word out and sending emails to us…”
Staff Involvement in research recruitment		“Probably the provider who would be doing the screen or collect the data…and then having them either sent—most likely probably send a referral, or we call it a TE, a telephone encounter, to your point of contact at [name of FQHC], who then would supply the information to whoever’s gonna do the intervention or be the point of contact to talk more in-depth to the patient…” “Also I think that also having the provider be in the know just because the providers are the ones spending time with the patients and could let them know during their medical visit if this [the research project] is something that they can benefit from.”
Research team informs staff about recruitment		“We’ve had a lot of people Zoom in and be either meeting teams or departments that are promoting services or talking about new services. I think that face-to-face interaction, although it can be lengthy and time-consuming, I think makes it more viable that we will remember the service.” “The easiest things with them [treatment providers] is to make sure they have the information, know what the program or project is about, and then identifying a contact person. Because if they have to figure out who to contact to make it happen, they’re not gonna do it…”
Use of signed release of information (ROI) from clients for research		“I feel like the best way would be to have a specific name and person that we can email to. That’s how we’ve also received external referrals for therapy services through a case manager or a family that says, “Hi, I think I have a person who can benefit from some services.” Then we do the ROI [release of information] piece and refer ‘em that way.” “I think the best way would be for us to have a referral form from you guys and a release of information…and then you can reach out to them.”
3. Barriers to Telehealth Services
3a. Intervention Barriers
Impact of telehealth on healthcare disparities		“A lot of clients, especially the monolingual Spanish speakers, do not have smartphones, so they prefer phone in order to let—or bad internet, or just not a lot of data, so a lot of them have preferred phone sessions versus Zoom.” “A lot of us were still moving about in-clinic interacting with them [individuals with unstable housing] and trying to support them the best way that we could, but the telehealth issue was something that was a barrier”
Client willingness/ability to engage in telehealth		“It’s a mix of things. Some people have access to reliable internet service. I would say it’s 50/50. Some people are more comfortable with telephone, so I think on a given day, I’ll have 50 percent of each.” “Lots of our patients won’t do video…When I asked, it was, phone wasn’t working. There wasn’t a camera on my phone, or they didn’t want me to see where they were staying ‘cause they were embarrassed, or they weren’t in a safe place, and so they didn’t want someone seeing that they were talking to their doctor.”
Challenges building rapport		“Interestingly, I think that it can be communicated care, attunement, empathy can be communicated via Zoom. In fact, it brings us into focus so that our reach is so focused here that I think in some ways, in some cases, it’s actually better.” “Speaking to my previous role, from going from being embedded in a clinic to being virtually embedded in a clinic when a job was not built for that… I am well used to building trust with a stranger in a room and via phone becomes a lot more difficult.”
3b. Setting Barriers
Space challenges		Interviewer: “If we potentially were able to provide the stations, do you think that your agency would be able to give us a little space to set up the station for folks to come in and participate?” Interviewee: “No, especially now with us not being able to use all of our spaces. Before we were pretty packed in, but now, I wonder if we would be able to. I think this is more relevant to the [FQHC site name] space or a smaller space to begin with, but I think that that would be great.” “If it was pre-pandemic times, I would say meeting spaces because we’re always running out of—we were [laughter] and we will again someday. We were always running out of group spaces to meet because there’s so much going on that it was a little bit of a fight to reserve those group rooms…”
High demands on treatment providers		“Right now because our behavioral health system is still kind of overwhelmed, and we do have a waitlist for behavioral health patients, our behavioral health consultants are doing some interim visits with folks just to try to provide that support that people really need right now while they’re waiting to find a full-time therapist.” “We are totally closed to new therapy patients right now and psychiatry, other than people under the age of 30 is closed. We just don’t have enough staff. Enough funding for staff to be able to meet the demand.”
High treatment provider turnover		It’s just a matter of folks being busy and overworked. Add COVID…I would say there’s just continually—I don’t know what the turnover rate is compared to other comparable organizations, but I can say every week I get emails about new staff….” “I feel like maybe I don’t know if this is just a [FQHC city] thing or if it’s all around the nation…. I think that the biggest thing is that there’s a lot of turnover in a lot of these agencies. Right when you feel that you have the connection with the staff and you have a system in place, boom. Everything changes because now they’re under a new leadership.”
Difficulty introducing new clinic practices		“…I think there’s a lot of therapists that have been around that do things the way that they’ve done things without really an intention to shift. I don’t mean that in a negative way at all. I would say there’s an openness, but that’s not necessarily the culture or the norm.” “One thing I’ve learned with the providers at [FQHC] is anything that is too complicated or has too many steps, they’re not gonna do it. That’s the culture. It is what it is, and it has been. That has been one of the biggest barriers.”
3c. Ecological Barriers
Concerns about insurance coverage and compensation for telehealth		“…Whether or not there’s a pot for those who are uninsured and may not have insurance. Yes, depending on the financial circumstances of the client or the patient themselves, it might be a big deal. I will say happily that for most people who want to engage in therapy, there seems to always be a way to do it…” “My understanding is that it will probably—my guess is it might depend on insurance companies, on what they’re willing to reimburse. If they’re continue to reimburse that [telehealth], it will likely be some part of how we move forward as an agency because clients have actually really enjoyed it, for the most part…”
Burden of FQHC paperwork and reporting requirements		“Oh, yeah, right. In the state of [state], right, there is a reporting structure specific to substance use treatment as far as expectations for documentation, timeliness, sign-off by a medical provider for level of care. There is a substantial administrative load for every single client.”
4. Working with SGM Clients
Cultural Humility		“Trans and non-binary clients don’t like to have to educate their providers, and they often have to do it a lot of the time….You don’t wanna have to do that with your provider, and being informed about the issues, why trans people might use substances and the challenges that they may face in making those changes.” “I think having some geographical knowledge of what the [SGM] community in [a specific city] is facing.”
Service Adaptations		“Well, I think that’s a issue regardless of telehealth or in person because this community is generally burdened, given their experiences in the world…I think that, one—again, big picture—one is just I do think that having members of the [LGBT] community as clinicians does help.” “…I think when we talk about substance abuse, specifically within the trans community, it’s hard to isolate one particular challenge of an individual, who’s also facing homelessness and who’s also considering a transition, or who’s working on their homelessness…I think somehow integrating those different components doesn’t mean providing an intervention to all of those components, but finding a way to really integrate these interventions with the different services that the patients are receiving…”
Knowledge about Substance Use among SGM Individuals		“We don’t have good literature about going on and off hormones, but then I also don’t have good literature around using alcohol with the hormones…often what I’m having is how do you safely take your hormones? How do you safely inject? How do you safely while you’re using?” “Someone’s probably not seeking support related to their gender, but it’s related to the alcohol and being treated like any other client. I’ve seen that as a barrier. Then additionally, in the ways that maybe alcohol shows up differently in maybe a queer relationship”
5. Working with Clients from Diverse Racial/Ethnic Backgrounds
Cultural Humility		“That people in our communities, they are so accustomed to scanning the horizon for indicators of nonacceptance that the qualities that people bring, the listening that we bring is so incredibly important from the very first contact…that it have kind of a real human touch that’s present there in an affirming way. I think that’s vital for the people that we work with.” “Expressing a familiarity with working with people of color, expressing the desire to work with people of color. I think people can sense your intentions face to face and maybe even screen to screen…”
Service Adaptations		Definitely making sure that there’s a staff that speak the languages of our patients. I’ve noticed that with patients who are Spanish speaking, once they’ve made a connection with one of our staff that speaks their language, that’s who they go to for everything.” “I really think that part of that is really being inclusive with your service providers. I think having folks of color on staff, folks who potentially identify with the community on staff to, you know, on the backend provide that level of information and insight…”

Research Recruitment Workflows and ReACH Research Integration

Four key themes emerged regarding current research workflows and ReACH research integration: 1) high frequency of existing research protocols; 2) preference for behavioral health specialist/FQHC staff involvement in research recruitment; 3) desire for information from research team; and 4) preferences for signed releases of information for client research contact. All FQHCs had existing workflows for referring clients to research studies, with three sites (Chicago, Los Angeles, and Washington D.C.) reporting the presence of on-site research staff to facilitate client recruitment. Participants reported that their staff prefer to be engaged in research recruitment, as, “I think the best thing would be for staff to refer patients [to research], especially because we know a lot of them and know their history.” Behavioral health specialists were identified as well suited for recruitment given their established role in screening and referral. Participants also noted a preference for having the research team provide study information at staff meetings, provide all research materials to FQHC staff (e.g., study posters and flyers), identifying a research team point person for ongoing communication, and having clients sign a release of information to facilitate research team contact.

Intervention, Setting, and Ecological Barriers to Telehealth Services, as guided by DSF

Intervention.

Participants identified several telehealth barriers, including: 1) concerns about the impact of telehealth on healthcare disparities; 2) client willingness and ability to engage in videoconferencing; and 3) challenges in building rapport and providing effective telehealth care. Participants endorsed concerns that telehealth may exacerbate healthcare disparities, noting that “…I definitely used to see a lot of folks that don’t have reliable access to technology or internet or stable housing. I think there’s a lot that is lost [with telehealth].” They reported that clients, particularly those from underserved groups (i.e., racial and ethnic minorities, people without stable housing), may have difficulty accessing technologies required for telehealth, which may increase disparities in who receives telehealth SUD treatment. However, participants also noted benefits of telehealth, including improved treatment attendance and reductions in treatment barriers such as transportation for appointments.

Several participants raised concerns about engaging and building trust with clients in video conferencing, including that, “You lose the energy of the room and being able to see the little things, the little gestures,” and, “Lots of our patients won’t do video.” Despite these concerns, some participants also reported benefits, including that they could still express empathy, promote client reflection, and see their clients from a distance using videoconferencing.

Setting.

Several barriers to telehealth also emerged focused on the FQHC treatment setting, including: 1) having adequate space for socially-distanced telehealth; 2) high agency demands on treatment providers; 3) high provider turnover; and 4) difficulty introducing new practices into organizational culture. Participants noted difficulties obtaining physical space for treatment provision, and, “Right now, with the pandemic, it is the biggest waitlist we’ve ever had.” They reported that staff are also overworked and a high rate of staff leaving the agency, resulting in challenges building staff relationships and implementing new practices.

Ecological.

Two key ecological barriers to telehealth SUD treatment also emerged: 1) concerns regarding insurance coverage and compensation for SUD treatment and telehealth; and 2) the added burden of paperwork requirements due to FQHC status. Participants noted that, “Once the emergency order is lifted, and they’re not gonna pay us for telehealth…We’ll have to go back to all in-person services…” They also reported that working in an FQHC comes with specific documentation requirements that significantly impact provider workload.

Considerations for Working with SGM Clients

Participants noted key considerations for engaging in alcohol-use focused telehealth services with SGM clients. Three themes were identified, including: 1) need for training in cultural humility; 2) service adaptations to meet SGM client needs; and 3) knowledge about alcohol use among SGM clients. Several participants noted the importance of telehealth service providers receiving ongoing training in and demonstrating cultural humility: “Yes, culture humility, so I really feel that if we’re gonna do a great job in taking care of our patients, everybody has to go through these trainings and not just once.” It may also be important for providers to understand medical-care lived experiences of SGM in a particular context (i.e. experiences in a specific city). Several participants also noted the importance of providers building a safe environment for SGM clients by acknowledging previous mistakes (e.g., mis-gendering or using incorrect pronouns).

Knowledge and ability to provide SGM individuals with referrals, resources, and service adaptations also emerged as needs for alcohol-focused telehealth services. Participants noted that providers delivering telehealth services should be aware of insurance considerations and integrate services for SGM beyond alcohol-focused treatment, including housing, transportation, and employment support. Participants also reported a need to adapt treatment by determining whether a patient might prefer to meet with an SGM provider and/or a provider of color. Finally, providers noted a need for knowledge regarding how alcohol use patterns may differ among SGM populations.

Considerations for Working with Racial and Ethnic Minority Clients

Two subthemes emerged regarding working with racial and ethnic minority clients that were similar to those regarding SGM clients, including: 1) need for training in cultural humility; and 2) service adaptations to meet needs of clients from marginalized groups. Participants noted the need for training in and demonstrating cultural humility, including familiarity and openness to working with clients of color and the ability to create safe treatment spaces, “Listening, but not making the onus on them to teach me about their life.”

Participants also described the need for service adaptations specifically for clients from minoritized racial or ethnic groups. They highlighted the importance of having treatment providers of color and providers who can speak the language of the clients they serve. They also indicated that, despite potential barriers, telehealth may be a particularly important service to enhance treatment access for clients who do not have clinics in their local communities.

Discussion

The present study was conducted prior to launching a Hybrid Type I effectiveness-implementation trial to understand barriers to engaging in telehealth research and to integration of telehealth services for alcohol misuse and AUD in FQHC-based HIV care. Data collected through this study will inform the development of the implementation and research strategies to be employed in Project ReACH.

The first study aim was to understand current HIV and SUD treatment workflows across four geographically diverse FQHCs. All FQHCs had staff integrated within HIV medical clinics to provide behavioral health referral. However, methods for assessment of SU varied, ranging from validated SU screeners (e.g., the AUDIT; Bohn et al.,1995) to not assessing SU unless the client requested care. These findings highlight a need for more standardized screening and referral to treatment that can facilitate both research assessment and treatment delivery. Evidence-based practices such as Screening, Brief Intervention, and Referral to Treatment (SBIRT; Babor et al., 2007), which includes screening with validated tools, may enhance the early identification and effective treatment alcohol misuse in FQHCs (Agerwala & McCance-Katz, 2012). Screening should also consider SGM-related factors, including impacts of hormone therapy and existing tools’ gender-based score cutoffs (Arellano-Anderson & Keuroghlian, 2020). Telehealth research studies may need to be adapted to include implementation of validated alcohol use screening tools (Babor et al., 2007).

The second aim was to examine FQHC telehealth research capacity. Our findings highlighted that all FQHCs had strong existing research workflows and most had dedicated staff for participant recruitment. Behavioral health specialists emerged as helpful study recruitment resources. Our results suggest that research teams should have an ongoing presence at each FQHC to build rapport and facilitate staff buy-in, including liaising with behavioral health specialists to integrate recruitment procedures. These findings align with research evidence suggesting that active researcher engagement with treatment providers is needed to facilitate research recruitment and to reduce recruitment burden on staff (Adams et al., 2015; Heller et al., 2014; Natale et al., 2021).

The third aim of the study revealed participant concerns that telehealth may further contribute to health disparities and hinder the formation of therapeutic relationships, though some providers expressed fewer concerns about rapport building. These findings align with those by Thomas and colleagues (2021), who reported that behavioral health treatment providers had concerns about building relationships via telehealth. However, Thomas and colleagues (2021) reported no differences in client working alliance ratings between videoconferencing and in-person care, suggesting that providers may overestimate negative impacts of telehealth on rapport. For research teams, it may be particularly helpful to provide FQHCs with resources for telehealth delivery and research, including technology access (i.e. prepaid smartphones with video) and ongoing provider support to effectively build therapeutic relationships.

Identified setting barriers included limited organizational resources, high staff turnover, and difficulties shifting organizational culture for new practices. Broader ecological/system factors further increased barriers to care such as concerns regarding telehealth insurance reimbursement, and increased FQHC reporting requirements. These barriers are frequently endorsed by community treatment providers and can substantially impact new intervention sustainability and successful research (Adams et al., 2015; Glisson et al., 2008; Natale et al., 2021; Woltmann et al., 2008). Research teams likely need to collaborate with FQHC staff to repurpose space for telehealth, provide compensation for staff time spent on telehealth research, and streamline documentation procedures.

The fourth aim of our study was to identify telehealth service adaptations for SGM and racial/ethnic minority clients. The most frequently endorsed theme was the need for continuous training in cultural humility (i.e., skills such as openness to client’s diverse identities; McDowell et al., 2020; Mosher et al., 2017). For SGM clients, participants noted a need for expertise in SGM-specific medical care. Notably, training resources exist to enhance treatment provider knowledge around working with SGM clients, including the HRSA-funded National LGBTQIA+ Health Education Center (www.lgbtqiahealtheducation.org). For racial and ethnic minority clients, it is important for providers to understand unique stressors (e.g., immigration experiences) and provide accessible cultural and linguistic services (e.g., Spanish-speaking counselors). Participants also endorsed a need for providers to identify as SGM and/or racial or ethnic minorities to most effectively deliver care. These results align with prior research suggesting that clients prefer a therapist who matches their cultural or SGM identity. (Burckell & Goldfried, 2006; Cabral & Smith, 2011), though there are limited differences in treatment outcomes when clients and counselors are matched on identity factors (Cabral et al., 2011). Given these findings, ReACH and other telehealth research/integration efforts should consider hiring diverse providers and integrating ongoing cultural humility training to meet client needs.

Limitations

Several limitations should be noted for this study. First, the sample size was limited. We may have missed potential key stakeholders with insights into telehealth integration. Second, our sample was recruited through leadership nomination and was imbalanced across FQHCs due to variability in site size and number of clinical staff. These features of our sample may have introduced bias due to leaders nominating staff with specific views and overrepresentation of specific FQHCs. Finally, our results may be prone to social desirability as participants may have perceived interviewers to be invested in telehealth.

Conclusions

Our findings highlight key barriers and cultural factors to consider when integrating alcohol-related telehealth interventions and research into FQHCs. Collaboration between research and FQHC staff already engaging in alcohol screening may be particularly important for success, along with training and support to reduce telehealth disparities and enhance provider cultural humility. Addressing these factors may facilitate successful integration of research into FQHCs, early identification of alcohol misuse, and the implementation of evidence-based telehealth intervention for alcohol misuse and AUD among PWH.

APPENDIX. Qualitative Interview Guide

Note: * Indicates question to be asked only of leaders/management

In this interview today we are hoping to give you some background on our project and also better understand your agency. In brief, Project ReACH is a study of telehealth services for alcohol use reduction in people receiving care for HIV. Six hundred participants will be recruited from HIV care settings in four federally qualified health centers around the U.S. and will be randomly assigned to receive either a brief alcohol intervention or a brief intervention plus telehealth counseling with a trained project counselor, which also includes a text messaging program to help people reduce drinking.

We are specifically interested in learning more about the structure of staff within your agency and current practice so we can understand how our program can fit with your existing practices. Your answers will remain confidential, and your name will not be used in any of our reports. There are no right or wrong answers to our questions; we hope to learn as much as we can from your perspective on your organization, in order to help us plan the most successful study possible. Thank you for taking the time to participate in this interview. Before we begin, I just have a few brief questions for you:

What is your current role within your agency/organization? Do you currently supervise or oversee any other staff?

How familiar are you with telehealth services for behavioral health?

Is your agency currently providing care via telehealth due to COVID-19?

• If yes, do you anticipate continuing to provide telehealth once you’re able to return to in-person care?

Participants might get into the project through one of two ways. One is we would have posters or ads that we put in the waiting room/common areas, in a patient portal, or listed on the agency website with a phone number and website for potential participants to contact us. Additionally, we could have staff at this agency refer clients with unhealthy alcohol use who might benefit from an alcohol-focused telehealth intervention. There will be a staff member in the research department at (AGENCY NAME) who will be helping to publicize the study and connect interested clients to the study.

The Intervention

1. What do you think would work best for your organization when recruiting participants for the study: posters/ads, or staff referral to the project? Why do you think posters/ads/or staff referral would work best?

• 1a. Who in your agency would be best positioned to refer clients to this project (i.e. referral to brief telehealth alcohol counseling) and why?

• 1b. How would these person(s) identify which clients might be appropriate to refer to the project?

• 1c. How should the referral to the project happen? Here are some options: Give client a referral card with contact information to reach out, have client sign a release to have the project contact them? Do you think another process would be better? What would that look like?

• 1c follow up: Would your agency be interested in receiving information from us about the referral process/progress? If yes, how should this information be communicated? Should it be given to a specific person?

• 1d. How is potentially unhealthy alcohol use assessed at (AGENCY)? How often does that happen? How consistently is that documented? – do you document any use? Unhealthy use? A screening form for alcohol use such as the AUDIT?

• 1d follow up: In HIV care, how do clients typically get referred to alcohol use-related services?

• 1e. Outside of this research project, who within your agency is best positioned to track whether clients with unhealthy alcohol use are being screened and referred to alcohol use-related services (i.e. who might benefit from services, whether they received referral, if referral was followed through)

If Yes to posters/ads:

• 1f. Where would be a good location for posters/ads to be posted? For example, in a waiting room, patient portal, and/or agency website?

• 1g. Are you aware of any previous referrals options or resources that have advertised via poster in your agency? Do you know if this method was successful for reaching potential clients?

The Practice Setting/Context

Organizational Structure/Patient Population

2*. Please describe the types of clients typically served at your agency.

• 2a*. How many of the clients receiving HIV care have needs for behavioral health services?

• 2b*. How common is unhealthy drinking in these clients?

• 2c*. How common is unhealthy substance use other than alcohol?

3*. In thinking about rolling out a new study, or in the future, new methods for addressing unhealthy drinking in people with HIV at your center, who are the influential individuals or opinion leaders within the agency?

• 3a*. Who does leadership commonly go to when implementing new workflows, policies, or procedures?

4. What is your perception of the resources available to you/your agency for helping clients with unhealthy alcohol use and/or behavioral health?

• 4a. Are there any resources you wish you had access to?

5. Are there specific populations in your agency who may be underserved or have additional needs in regards to managing drinking?

• 5a. The literature on working with non-binary and transgender people with alcohol problems is not well developed. What particular aspects of care do you think we need to attend to in working with these populations?

6. In conducting counseling remotely, what do you think we should consider when trying to establish trust with gender as well as sexual minorities?

• 6a. How about with clients from racial and ethnic minority groups?

Communication

7. What sort of system do you use for documentation and communication among staff?

• 7a. How do you assess needs for behavioral health intervention?

• 7b. How are those needs documented? How are they communicated?

• 7c. How do referrals to behavioral health happen? Is this procedure different for unhealthy alcohol use referral?

Workflow

8. Can you describe a typical workflow for an existing client appointment?

9. What is the typical workflow for service provision when a new client begins HIV care?

10. Is there an existing workflow for recruiting clients into research studies or projects?

Current Practice

11. What behavioral/therapy treatments do you currently provide at your agency?

12. Does your agency provide evidence based behavioral/therapy treatments? If so, which ones?

The Ecological System

13. How does your agency interface with other agencies and treatment facilities/providers in your area?

14. To what extent do legislative/regulatory issues impact your ability to provide behavioral health treatment services (i.e. do you feel that reimbursement rates/billing environment or regulations about specific treatments impact your care)?

Additional Questions (if time allows)

Culture and Climate

15. How receptive are leaders/other staff in your agency to new practices?

16. Can you tell me about a time when your agency implemented a new workflow, policy, or procedure? How did it go?

• 16a. Any obvious barriers or facilitators?

17. How are new policies and procedures communicated/spread throughout the agency?

18. How receptive are leaders/other staff in your agency to new practices such as retraining staff, changing workflows, or adding new policies and/or procedures?

19. To what extent is leadership at your agency committed to/engaged in the use of evidence-based practices?

• 19a. What about other staff?

• 19b. What specific evidence-based practices are you aware of at your agency?

20. To what extent are evidence-based practices expected in your agency? How are these supported? How are these rewarded? Is your organization held accountable for using evidence-based practices (i.e. by reimbursement requirements)?

Impact of COVID-19

21. How do you feel that practice has changed at your agency as a result of COVID-19?

Culture/Climate – Stress and Burnout

22. To what extent do you feel engaged and supported in your work with clients?

23. To what extent do you feel stressed in your current work?

Is there anything you would like to ask me about this study? Thank you very much for your participation! Before we finish today I would just like to ask you some brief demographic questions:

1. Do you think of yourself as:

   • Male
   • Female
   • Transgender man/trans man/female-to-male (FTM)
   • Transgender woman/trans woman/male-to-female (MTF)
   • Genderqueer/gender nonconforming (neither exclusively male nor female)
   • Additional gender category (or other); please specify:______________________
   • Decline to answer
2. How would you identify your race (select all that apply)?

   • American Indian or Alaska Native
   • Asian
   • Black or African American
   • Hispanic or Latino
   • Native Hawaiian or Other Pacific Islander
   • White
   • Decline to answer
3. What is your current sexual identity? (Select all that apply)

   • Gay or Lesbian
   • Bisexual
   • Heterosexual or Straight
   • Other, please specify: _____________
   • Decline to answer

4. What is your age: __________ years

5. How long have you been working as a [Role]? ___________ years

6. How long have you been working at your current agency? ___________ years

Data Availability Statement

The datasets generated and analyzed during this study are not publicly available due to the data containing information that could compromise research participant consent. Data are available from the first author of this manuscript on reasonable request.