Table 2.

Qualitative Themes Related to SBIRT Implementation

Themes	Description	Supporting Quotation
Accelerators
Aligned incentivizes	Measuring, tracking, and paying CCOs based on performance on the SBIRT metric has advanced implementation	“I think it's the metric and the focus. We do what we're measured for; it's the right thing to do but let's be clear, this is about the money.”
Internal champions	Support from internal champions, particularly providers, generated buy‐in and helped address concerns and resistance.	“The CCO is blessed with a physician champion who works closely with the chief behavioral health officer to help think about how physicians can screen.”
Workforce development	Initial and continuous training for SBIRT and addictions more broadly has resulted in increased capacity to implement screening and brief intervention.	“What they're training around SBIRT is getting PCPs and other types of providers comfortable with SBIRT. And that has been very helpful in helping those providers understand SBIRT and answering questions when there's concerns about a particular response.”
Workflow redesign	Mapping clinical workflow for integration and efficiency was essential to accommodate SBI and the required documentation.	“What I've heard from my primary care colleagues is that implementing … is a change of workflows, a different approach to practicing, figuring out how to best use it, who does it … but I think trainings have helped”
Roadblocks
Time requirements	Providers struggled to carve out the additional time necessary to complete SBIRT in their already busy schedules.	“ … we're talking about way too many people than what we can handle … primary care has been feeling overwhelmed for some time. So nothing new there. But it was adding a lot of stress to that process, SBIRT was.”
Confusion about coding	The complexity of the metric has resulted in some clinics entering codes that are not counted toward the metrics, leading to their CCOs ultimately losing credit for the work.	“It is tied to billing codes and that is a mistake … We note that the SBIRT codes should not be charged but the coders just delete them because they are billing codes. So we are at zero percent on screening and brief intervention. The CCO gets no credit for our work.”
Questionable efficacy data	The evidence for SBIRT is equivocal for drug use; some respondents question its identification as a metric to push integration and system change.	“The A&D metrics don't go far in terms of driving change in the system. SBIRT is not very helpful.”
Addressing positive screens	SBIRT implies that the complete package, Screening, Brief Intervention, and Referral to Treatment, is present. Our respondents indicate that while screening has increased, the necessary integration and competencies for brief intervention and referral to treatment are not present.	“The continuum of care is not clearly defined for patients and physicians. We need to help primary care providers to know when to refer and where to refer and the expectations they should have from these referrals.”
Systems transformation: positive outcomes
Increased awareness of impact and need for services	There has been an increased awareness of the prevalence and the importance of addressing SUD in primary care. SBIRT has highlighted the need for integration.	“SBIRT is great because it allows us to standardize our discussion of alcohol and drug use. It has become a uniform conversation with every patient—bank president to adolescent.”
Attitudinal shifts	There have attitudinal shifts from why to how; these shifts are essential for health care transformation.	“When I first came on there was a lot of questions  … do we really have to do it … is it really doable? Is it really necessary …  throughout my year here it has changed. People have been asking more, well, how can we do it? I get much less whys, occasionally. But really, it's more like how's.”
Systems transformation: concerns
Interpretation of available data	Participants reported disconnect between the data from the metric and actual clinical practice.	“Just in how they're collected and that sort of thing. So it took me awhile to come to terms with the fact that they are counted by going through claims, because we know that method is so imperfect. [R agreeing] We know the inaccuracies of it.”
Confusion over metric	OHA has changed the way that completed SBIRTs are counted several times.	“But yeah, we've struggled hard on that committee with looking at the denominator. And also trusting why does the denominator constantly change?”
Metric formula	Complicated and confusing requirements for properly documenting and coding for SBIRT have hampered implementation.	“CPT codes are cumbersome measures.”