Journal of Substance Abuse Treatment xxx (2015) xxxxxx

Contents lists available at ScienceDirect

Journal of Substance Abuse Treatment

Implementation of a Brief Treatment Counseling Toolkit in Federally

Qualied Healthcare Centers: Patient and Clinician Utilization
and Satisfaction
Adam C. Brooks, Ph.D. a,, Jaclyn E. Chambers, M.S.W. a, Jennifer Lauby, Ph.D. b, Elizabeth Byrne, N.C.C, L.P.C. a,
Carolyn M. Carpenedo, M.H.S. a, Lois A. Benishek, Ph.D. a,c, Rachel Medvin, Psy.D. a,d,
David S. Metzger, Ph.D. a,c, Kimberly C. Kirby, Ph.D. a,c
a
Treatment Research Institute, 600 Public Ledger Building, 150 S. Independence Mall West, Philadelphia, PA 19106, USA
b
Public Health Management Corporation, Centre Square East, 1500 Market St. 15th Floor, Philadelphia, PA 19102, USA
c
University of Pennsylvania School of Medicine, Department of Psychiatry, 3900 Chestnut Street, Philadelphia, PA 19104, USA
d
Widener University, The Institute for Graduate Clinical Psychology, One University Place, Chester, PA, 19013

a r t i c l e i n f o a b s t r a c t

Article history: Introduction: The need to integrate behavioral health care within medical settings is widely recognized, and
Received 9 March 2015 integrative care approaches are associated with improved outcomes for a range of disorders. As substance use
Received in revised form 14 August 2015 treatment integration efforts expand within primary care settings, training behavioral health providers in
Accepted 28 August 2015 evidence-based brief treatment models that are cost-effective and easily t within the medical ow is essential.
Available online xxxx
Methods: Guided by principles drawn from Diffusion of Innovations theory (Rogers, 2003) and the Consolidated
Framework of Implementation Research (Damschroder et al., 2009), we adapted elements of Motivational En-
Keywords:
Brief intervention
hancement Therapy, cognitivebehavioral therapy, and 12-step facilitation into a brief counseling toolkit. The
SBIRT toolkit is a menu driven assortment of 35 separate structured clinical interventions that each include client take-
Brief treatment away resources to reinforce brief clinical contacts. We then implemented this toolkit in the context of a random-
Substance abuse ized clinical trial in three Federally Qualied Healthcare Centers. Behavioral Health Consultants (BHCs) used a
Satisfaction pre-screening model wherein 10,935 patients received a brief initial screener, and 2011 received more in-
Primary care depth substance use screening. Six hundred patients were assigned to either a single session brief intervention
or an expanded brief treatment encompassing up to ve additional sessions. We conducted structured interviews
with patients, medical providers, and BHCs to obtain feedback on toolkit implementation.
Results: On average, patients assigned to brief treatment attended 3.29 sessions. Fifty eight percent of patients
reported using most or all of the educational materials provided to them. Patients assigned to brief treatment
reported that the BHC sessions were somewhat more helpful than did patients assigned to a single session
brief intervention (p = .072). BHCs generally reported that the addition of the toolkit was helpful to their
work in delivering screening and brief treatment.
Discussion: This work is signicant because it provides support to clinicians in delivering evidence-based brief inter-
ventions and has been formatted into presentation styles that can be presented exibly depending on patient need.
2015 Elsevier Inc. All rights reserved.

1. Introduction health conditions are at risk to be undiagnosed or undertreated (Hine,

The need to integrate behavioral health care within medical settings
is widely recognized among health care professionals (O'Donohue,
Cummings, & Cummings, 2009; Robinson & Reiter, 2007) as well as
government and international organizations (Agency for Healthcare
Research Quality, 2008; Presidents New Freedom Commission on
Mental Health, 2003; World Health Organization, 2008), as behavioral
Corresponding author. Tel.: +1 215 399 0980; fax: +1 215 399 0987.
E-mail addresses: abrooks@tresearch.org (A.C. Brooks), jchambers@tresearch.org
(J.E. Chambers), jennifer@phmc.org (J. Lauby), ccarpenedo@tresearch.org
(C.M. Carpenedo), lbenishek@tresearch.org (L.A. Benishek), rmedvin@tresearch.org
(R. Medvin), dsm@mail.med.upenn.edu (D.S. Metzger), kkirby@tresearch.org (K.C. Kirby).
Howell, & Yonkers, 2008; Mitchell, Vaze, & Rao, 2009). In general, sys-
tematic reviews suggest that integrative care approaches are associated
with improved physical, mental, and quality of life outcomes for a range
of disorders including chronic illness (Bradford et al., 2013; Martinez-
Gonzalez, Berchtold, Ullman, Busato, & Egger, 2014), mental illness
(Bradford et al., 2013), substance use disorders (Fiellin et al., 2006;
Oslin et al., 2006) as well as disorders that often co-occur with
substance use disorders (SUDs) such as depression (Archer et al.,
2012; Butler et al., 2008) and anxiety (Archer et al., 2012). The presence
of on-site mental health providers is also associated with referral to off-
site mental health care and a reduction in medications (Harkness &
Bower, 2009). Support for integrated models, however, is tempered by
clinical and implementation concerns. For instance, modest short-

http://dx.doi.org/10.1016/j.jsat.2015.08.005
0740-5472/ 2015 Elsevier Inc. All rights reserved.

Please cite this article as: Brooks, A.C., et al., Implementation of a Brief Treatment Counseling Toolkit in Federally Qualied Healthcare Centers:
Patient and Clinician Utilizatio..., Journal of Substance Abuse Treatment (2015), http://dx.doi.org/10.1016/j.jsat.2015.08.005
2 A.C. Brooks et al. / Journal of Substance Abuse Treatment xxx (2015) xxxxxx
term improvements in mental health outcomes and social functioning
resulting from integrated care are not always maintained over time
(Bower, Knowles, Coventry, & Rowland, 2011; Jonas et al., 2012).
Without well-conducted effectiveness trials, integration strategies can
be prematurely adopted and then discarded.
The integration of SBIRT for SUDs in primary care is one potential ex-
ample wherein systems might be moving forward with broad adoption
ahead of the evidence for broad effectiveness. Medical patients are brief-
ly Screened for risky substance use; patients with risky use are provided
with a Brief Intervention (BI) to help them reduce substance use; and pa-
tients with moderate to severe substance use are Referred to specialty
Treatment (SBIRT; Babor et al., 2007). Early efcacy trials demonstrated
moderate-to-high efcacy of BIs for reducing hazardous drinking in pri-
mary care settings (Bien, Miller, & Tonigan, 1993). Additional reviews
have demonstrated comparable treatment outcomes for patients treat-
ed with BIs and patients treated with more extensive and traditional
treatments, adding support for this model (Ballesteros, Duffy, Querejeta,
Arino, & Gonzalez-Pinto, 2004; Kahan, Wilson, & Becker, 1995; Moyer,
Finney, Swearingen, & Vergun, 2002; Whitlock, Polen, Green, Orleans,
& Klein, 2004; Wilk, Jensen, & Havighurst, 1997) and leading to wide-
spread calls for broad implementation. Furthermore, the majority of re-
search examining the effectiveness of SBIRT has been conducted with
hazardous drinking; fewer studies have supported its utility with illicit
drug use. While initial early results were promising (Bernstein et al.,
2005), the most recent well controlled studies have not demonstrated
BI efcacy for illicit drug use (Hingson & Compton, 2014; Marsden et al.,
2006; Roy-Byrne et al., 2014; Saitz et al., 2014). In this case, SBIRT for ad-
dressing risky alcohol use is supported by an evidence base, particularly
when the interventions are brief but include multiple contacts (Jonas
et al., 2012) while using the techniques to address illicit drug use is not.
Additionally, SBIRT for alcohol use may not be the easiest prevention
strategy to implement, and elements of the approach do not always
work as advertised. Three recent effectiveness trials attempting to im-
plement SBIRT using standard strategies in medical settings demon-
strated little evidence for SBIRT in reducing hazardous or harmful
drinking (Butler et al., 2013; Kaner et al., 2013; van Beurden et al.,
2012). Furthermore, SBIRT interventions are intended to motivate
more moderate and severe patients to engage in additional specialty
SUD care, but a recent meta-analysis demonstrated that patients receiv-
ing a brief intervention are no more likely to participate in specialty care
(Glass et al., 2015). These studies and others have also raised implemen-
tation concerns. For example, van Beurden et al. (2012) noted difcul-
ties in recruiting physicians and motivating them to participate in the
patient-tailored parts of the program. Other studies have shown that
concerns about SBIRT implementation exist among providers, patients,
and administrators alike. Medical providers worry about the logistics
of tting SBIRT into their busy daily clinical ow and lack condence
about their knowledge related to substance abuse problems (Broyles
et al., 2012). Patients may have concerns about privacy and condenti-
ality when discussing their substance use with a medical provider
(Rahm et al., 2014). On a broader level, integrating substance abuse
screening and treatment with primary care can pose nancing and doc-
umentation problems for health systems, as administrators may strug-
gle with sustainability nancing these interventions and integrating
them with electronic health records (Padwa et al., 2012).
While brief counseling for patients at risk for illicit drug use has not
delivered on its early promise and has posed some implementation
problems, it is possible that more intensive integration of SUD care
with medical treatment might yield more consistent results. Research
trials that have integrated more intensive treatments such as medica-
tions for addiction into medical care have typically yielded more robust
ndings (Center for Integrated Health Solutions, 2013; Fiellin et al.,
2006; Hesse, 2009; O'Malley et al., 2003; Oslin et al., 2014). Further-
more, studies that have brought primary care into treatment settings
have also resulted in improved health outcomes for patients with
SUDs (Saxon et al., 2006; Weisner, Mertens, Parthasarathy, Moore, &
Please cite this article as: Brooks, A.C., et al., Implementation of a Brief Treatment Counseling Toolkit in Federally Qualied Healthcare Centers:
Patient and Clinician Utilizatio..., Journal of Substance Abuse Treatment (2015), http://dx.doi.org/10.1016/j.jsat.2015.08.005
Lu, 2001). However, the efcacy of intensive integrated care for SUD
in primary care is not a settled matter, as one well-designed and inten-
sive trial yielded no patient improvements (Saitz et al., 2013).
As SUD treatment integration efforts expand within primary care
settings, training behavioral health providers in evidence-based
brief treatment models that easily t within the medical ow is essen-
tial. Reductions in resources for training and counselor turnover neces-
sitating frequent re-training have left the eld searching for more cost-
effective training strategies. Continuing education workshops, the most
widely used method of training counselors on evidence-supported
treatments (ESTs), are insufcient to signicantly change clinical
practice unless followed by coaching, feedback, or supervision (Baer
et al., 2004; Beidas & Kendall, 2010; Carroll et al., 2002; Miller &
Mount, 2001; Miller, Yahne, Moyers, Martinez, & Pirritano, 2004;
Morgenstern, Morgan, McCrady, Keller, & Carroll, 2001; Schoener,
Madeja, Henderson, Ondersma, & Janisse, 2006; Sholomskas et al.,
2005; Smith et al., 2007; Walters, Matson, Baer, & Ziedonis, 2005). To
counter the workforce training burden and improve patients under-
standing of their treatment choices in specialty care SUD settings, we
have developed EST toolkits consisting of multimedia tools
(e.g., videos, colorful posters) and brief, exible counselor guides. The
toolkit strategy enables trainers to introduce an EST to counselors,
provides concrete tools and immediate in-session prompts
(i.e., graphic novels) to maintain its use, and promotes active learning
on the part of the counselor and patient (Beidas & Kendall, 2010).
In our past work, our team developed toolkits focused on group de-
livery of cognitive behavioral relapse prevention (CB/RP) and 12-Step
Facilitation (12SF), and tested these training strategies in specialty
care substance treatment settings. Our EST Toolkits have been created
with signicant end-user and patient feedback. We conducted numer-
ous focus groups and end-user interviews (Brooks, 2013; Brooks et al.,
2012; Brooks, Laudet, et al., 2013) to adapt evidence-based approaches
(Carroll, 1998; Marlatt & Gordon, 1985; Nowinski & Baker, 1992) into
counselor/patient friendly presentations that would require minimal
counselor training. We prioritized formats and communication strate-
gies that were important to the patients (e.g., using serial, ctional nar-
ratives and maximizing the multimedia presentation) while carefully
focusing on counselor usability (i.e., developing products that t the
workow). In two NIDA-/NIAAA-funded counselor training trials,
Toolkit training resulted in signicant, enduring counselor improve-
ment after only brief training (Brooks, Carpenedo, et al., 2013; Brooks,
Laudet, Carpenedo, Carise, & Kirby, 2014; Brooks et al., 2012).
Additionally, our 12-Step Toolkit changed counselor practice, resulting
in some marginal improvement (i.e., non-signicant trends in days of
heavy drinking) among exposed patients (Brooks et al., 2014).
In the current project, in order to implement brief intervention and
augment it with practical brief treatment approaches in primary care
settings, our team adapted elements of Motivational Enhancement
Therapy (MET; Miller, Zweben, DiClemente, & Rychtarik, 1995),
cognitivebehavioral therapy (CBT; Carroll, 1998) and 12-Step Facilita-
tion (12SF; Nowinski & Baker, 1992) into a brief counseling toolkit ap-
propriate for use to address mild and moderate substance use over
multiple interventions. The SBIRT+ Toolkit is a menu driven assort-
ment of 35 separate structured clinical interventions that each include
client takeaway resources to reinforce brief clinical contacts. The mate-
rials are designed to address neutral habit behaviors (e.g., breaking bad
habits, setting positive habits) so that the Toolkit can be exibly applied
to multiple problems that present in primary care (e.g., medication ad-
herence, smoking cessation). We designed the SBIRT+ Toolkit to be
implementable after modest clinician training, and also developed a
self-help graphic novel to accompany the clinician interventions as an
additional resource for primary care clinicians to provide to clients to
jumpstart behavioral change between sessions. This Toolkit approach
incorporates patient-centered health communications strategies that
facilitate evidence-based practice with sustainable delity, and promote
dissemination and transportability.
 A.C. Brooks et al. / Journal of Substance Abuse Treatment xxx (2015) xxxxxx
The focus of our teams implementation efforts, and the main
thrust of this report, emphasized the development of the intervention
(innovation characteristics) to maximize the chances that it would be
adopted both in the core hybrid-effectiveness trial and then throughout
other FQHC settings. Our development efforts were informed by
overlapping elements from both Rogers (2003) Diffusion of Innovation
Theory and from the Consolidated Framework for Implementation
Research (Damschroder et al., 2009). We also report on our implemen-
tation approach in the present project, which was informed by both
planning strategies and educating strategies, as explored by Powell
et al. (2012).
Our implementation efforts took place in the context of a random-
ized clinical trial funded by the Commonwealth of Pennsylvania Depart-
ment of Health. Our investigation can be conceptualized as a hybrid
effectivenessimplementation study rather than a traditional phased
research program that is often used to develop, test, and ultimately dis-
seminate interventions, allowing the evaluation and actual utilization of
an intervention to take place in a more timely manner (Curran, Bauer,
Mittman, Pyne, & Stetler, 2012; Kessler & Glasgow, 2011). This type of
study design is appropriate when there is adequate face validity for
the intervention, some previous albeit indirect support for the imple-
mentation strategy (e.g., previous studies), minimal risk of the interven-
tion, solid support within the organizational system, and existing
mandates promoting the intervention (Curran et al., 2012).
In this report, we will 1) describe the SBIRT+ Toolkit structure and
design, 2) report on our implementation efforts with this Toolkit in
three FQHCs in North Philadelphia, and 3) present provider and patient
feedback, satisfaction, and utilization data on the Toolkit materials.
2. Methods
2.1. Overview
In this trial, patients at three Federally Qualied Healthcare Centers
(FQHCs) in North Philadelphia were screened for risky and problematic
alcohol and illicit drug use using the AUDIT and the DAST, and were ran-
domly assigned to receive a 1-session brief intervention (SBIRT) or to
receive expanded brief intervention/brief treatment, encompassing up
to ve additional in-person sessions (SBIRT+). Our Toolkit was adapt-
able to be used in either condition (i.e., clients in the SBIRT condition
could only receive a restricted sampling of the resources). We trained
two professional behavioral health counselors (BHCs) at each of the
three FQHC locations (5 LCSWs and 1 Psy.D.) to use the Toolkit, and
each center set up a pre-screeningscreening procedure to detect cli-
ents with risky to severe drug and alcohol use problems. In the months
prior to and then 12 months after systems implementation, our team
conducted structured interviews with medical providers and with
BHCs to determine how their settings were responding to the provision
of brief intervention/brief treatment onsite, and the extent to which the
clinical tools were helping or hindering their process. Additionally, prior
to receiving brief intervention, patients with detected substance use
problems were given the opportunity to receive their intervention in
the context of an ongoing research study. Consenting patients were ran-
domized to conditions. As part of their scheduled 3-month research in-
terviews, patients completed satisfaction forms and provided feedback
on their experience of receiving brief treatment in primary care.
2.2. Development of a brief intervention and treatment Toolkit
Our brief intervention Toolkit assists counselors to screen for
risky use, and then to conduct 35 separate interventions based on
the patients motivation level and severity of use. The Toolkit includes
communication strategies for providers to use with patients
(e.g., educational takeaway cards and talking points), as well as
brief training supplements to aid counselors to implement the Toolkit
with delity.
Please cite this article as: Brooks, A.C., et al., Implementation of a Brief Treatment Counseling Toolkit in Federally Qualied Healthcare Centers:
Patient and Clinician Utilizatio..., Journal of Substance Abuse Treatment (2015), http://dx.doi.org/10.1016/j.jsat.2015.08.005
3
2.2.1. Toolkit design grounded in implementation theory
Common considerations across implementation theories that center
on the characteristics of the innovation (Rogers, 2003) or the interven-
tion (Damschroder et al., 2009) guided our development work. Rogers
Diffusion of Innovation Theory (Rogers, 2003) focuses on ve character-
istics associated with increasing the likelihood that an innovation would
be adopted. We designed the Toolkit to be (a) relatively advantageous
the off-the-shelf Toolkit should assist counselors in more efciently
delivering interventions in formats that patients can retain, potentially
leading counselors to perceive that a structured tool-driven approach
is preferable to a less structured intervention strategy when less patient
contact time is available; (b) highly compatible with counselors values
and needs counselors working in primary care value behavioral strat-
egies that can be presented quickly; (c) simplistic the materials are not
complex to either understand or use, (d) trialable counselors can ex-
periment with and/or modify the ways they use the Toolkit during the
study so that they can determine their degree of satisfaction with and
the perceived utility of the interventions; and (e) observable coun-
selors and medical providers can see the differences in their clinical
practice with patients with SUDs, such as greater willingness to discuss
use and efforts quit/reduce or access treatment.
The Consolidated Framework for Implementation Research (CFIR;
Damschroder et al., 2009) includes elements that overlap with Rogers
Diffusion of Innovations model: relative advantage and trialability.
However, there are other elements focused on the characteristics of
the intervention that we considered in our development work. The
CFIR model also includes an additional six considerations of interven-
tion source, evidence strength and quality, adaptability, complexity, de-
sign quality, and cost. In our design efforts, we attended to (a) evidence
strength and quality we selected only ofce-based EBPs with strong
track records, and shared this evidence with stakeholders;
(b) adaptability the different elements of the Toolkit can be mixed
and matched, and used in total or in part at the counselors discretion;
(c) complexity the Toolkit elements were designed to t into the
brief consult model that was already in place in these FQHC settings;
(d) design quality the Toolkit materials employ exciting, high quality
graphic design and illustrations; and (e) cost we included interven-
tions that could be billed in primary care, and developed a model that
supports ongoing sustainability at low cost. Our design efforts also
included some considerations of intervention source; while we were
settled on the core of the intervention content, we consulted with the
end-users to ask them their preferences on design and additional
content elements we had not considered, so that the end-product met
their specications.
2.2.2. Selecting curricula approach and content
Primary care patients exhibit substance use ranging from risky to se-
vere, and we adapted an approach that could assist patients with begin-
ning the change process using their own strategies in primary care. We
organized the clinical interventions on the evidence-based model of
Motivational Enhancement Therapy (MET) (Miller et al., 1995). The pri-
mary aim of MET is to help patients resolve ambivalence about change
and to develop a strong, well-negotiated, and realistic change plan.
MET is intended to be delivered in three to four sessions, two of which
occur in the rst two weeks of treatment. Sessions are approximately
40 min in length and emphasis is placed on the patients reaction to
feedback. Counselors then conduct follow-up at weeks 6 and 12 to ex-
amine patient progress, renew motivation, and evaluate if a further re-
ferral is needed. We chose to focus on MET when developing the
Toolkit, given its relationship to motivational interviewing (Miller &
Rollnick, 2007), the underpinning of the brief intervention component
of SBIRT.
For this project, our team developed the SBIRT+ Toolkit which is
centered on the FRAMES model that guides MET (Miller et al., 1995),
and it is intended to support counselors throughout each step of the fol-
lowing process: the counselor provides Feedback about the patients
4 A.C. Brooks et al. / Journal of Substance Abuse Treatment xxx (2015) xxxxxx

level of use, Responsibility is placed on the patient to make a change, Table 1

the counselor gives clear Advice to quit or cut back, the counselor The SBIRT + Toolkit.

then provides a Menu of options demonstrating how the patient could Topic Area Guiding MET Toolkit Cards
make a change, the counselor exhibits Empathy toward the patient Principle
and uses a non-judgmental approach, and nally the counselor encour- SBIRT Feedback/education What is a Standardized Drink?
ages the patients Self-efcacy and also helps the patient arrange Sup- Binge Drinking/Alcohol Poisoning
port to make the change. Marijuana Use Pyramid
SBIRT Resolving ambivalence Decisional Balance
Our interventions were designed for use by BHCs. BHCs are psychol-
Reasons Im Changing
ogists or licensed clinical social workers working in primary care or SBIRT Making decisions, My Change Plan
other medical settings. For patients who exhibit risky alcohol or drug planning steps Tips on Cutting Back (Drugs)
use, the BHCs role is to help the patient consider reducing use and po- Tips on Cutting Back (Alcohol)
tentially seek further treatment. BHCs typically provide between one Building Motivation Increasing My Agenda
readiness How Habits Crowd Out Health
and four brief sessions (515 min) of goal-oriented behavioral health
to change Top Priorities
counseling for each patient, which are typically dovetailed with primary Happiness Scale
care visits. Patients with more severe substance use are generally Building Motivation Preparing to Self-Monitoring
referred to specialty care. make a change Build a Good Habit in 28 Days
Building Motivation Building social support My Support System
Our preparatory work for developing the SBIRT + Toolkit included
Coaching Your Coaches
a close examination of typical BHC tasks, through job shadowing and Relapse Prevention Reducing Functional Analysis
consultation with experienced BHCs and clinical supervisors. BHC infor- use/quitting Planning for Triggers
mants stressed the need for interventions to be brief (1015 min) and Scheduling Pleasant Activities
provided feedback on various presentation strategies. We also exam- Relapse Prevention Managing Coping with Craving
complications Handling Drug Offers
ined behavioral health texts and found that common and appropriate
from quitting Coping in a Using Relationship
interventions for BHCs applied across multiple problem areas included Managing Feelings
techniques such as relaxation training, goal setting, cognitive disputa- Managing Stress
tion, motivational interviewing, problem solving, self-monitoring, Managing Sleep
12-Step Facilitation Increasing support 12-Step Sampling
antecedentbehaviorconsequences analyses, stimulus control, and as-
through 12-step What to Expect at a First Meeting
sertive communication (Hunter, Goodie, Oordt, & Dobmeyer, 2009). We facilitation Spirituality
then identied parallel practices and interventions found in several Check Yourself,
manualized evidence-based outpatient treatments for substance abuse Check Your Meeting
treatment that aligned with these tasks and developed materials to as- Seeking Treatment Connecting Finding the Right
to treatment Treatment For You
sist the BHCs in addressing substance use in primary care settings.
Medication to Treat Addiction
Seeking Managed Medication
2.2.3. Content presentation strategies Making Treatment Work for You
The SBIRT + Toolkit includes 35 take-home tools for patients, Marijuana Withdrawal
Coping with Withdrawal
which we grouped into ve categories: Brief Intervention, Building Mo-
tivation, Relapse Prevention, 12-Step Facilitation, and Seeking Treat-
ment. Each of these categories has between four and nine tools for
counselors to utilize with their patients (see Table 1 for a detailed list change. For each stage in this process, the Toolkit take-home cards pres-
of the SBIRT + Toolkit take-home tools). In line with the core concepts ent psycho-educational material, evidence-based tips and strategies for
and principles of MET, the SBIRT + Toolkit was designed for BHCs to reducing drug or alcohol use, and/or exercises that patients can com-
use in two to six sessions with patients who screened positive for plete to support their change goals. In order to enhance the compatibil-
risky alcohol or drug use. The Toolkit contains numerous tools that sup- ity and adaptability of the intervention (Damschroder et al., 2009), the
port MET, and the majority of the take-home tools for patients are based SBIRT + Toolkit Toolkit was designed with exibility and brevity at
on MET techniques and strategies. For patients who need additional its core. Counselors can use the cards in any order, use only a particular
guidance and skill-building or would benet from a complementary ap- section of the Toolkit, or select whichever individual cards are most
proach such as 12-Step, the Toolkit also includes CB/RP and 12SF com-
ponents. Additionally, the Toolkit is designed to prompt conversation
about setting or breaking habits, rather than focusing only on substance
use. Consequently, a BHC who is comfortable with conversing with pa-
tients about behavioral habits could potentially use most of the Toolkit
to cross over to other types of behavior change that would be relevant
to primary care work (i.e., dietary change, medication adherence).
This feature was designed to enhance the perceived compatibility of
the intervention (Damschroder et al., 2009).
In consideration of design quality (Damschroder et al., 2009), each of
the 35 take-home tools is printed on a 5-inch by 7-inch colored heavy
cardstock card, and the cards feature a combination of appealing infor-
mational images, easily digestible text that presents key information,
and questions or prompts (written at a 6th grade level) for the patient
to consider as they contemplate making a change. See Fig. 1 for an ex-
ample of one of our patient take-home cards, Planning for Triggers. As
the SBIRT + Toolkit is grounded in MET, the Toolkit in its entirety
guides the counselor and patient through the process of 1) feedback
and education about safe substance limits, 2) resolving ambivalence, Fig. 1. The Planning for Triggers patient take-home card from the SBIRT + Toolkit Toolkit.
3) making a decision to change and planning steps for the change, 4) in- This card provides patients with tips to avoid, prepare for, and deal with triggers. 2012
creasing readiness to change, and 5) building support to sustain that Treatment Research Institute. All Rights Reserved.

Please cite this article as: Brooks, A.C., et al., Implementation of a Brief Treatment Counseling Toolkit in Federally Qualied Healthcare Centers:
Patient and Clinician Utilizatio..., Journal of Substance Abuse Treatment (2015), http://dx.doi.org/10.1016/j.jsat.2015.08.005
 A.C. Brooks et al. / Journal of Substance Abuse Treatment xxx (2015) xxxxxx 5

applicable to the patients particular needs and that t into the time
available.
Being conscious of the lack of time and funding for behavioral health
training in many primary care settings, our goal was to create an off-the-
shelf curriculum that counselors could easily and quickly use with very
minimal training, attending to both perceived cost and complexity
(Damschroder et al., 2009). The Toolkit cards are intended to be intro-
duced by the BHC in a counseling session and then handed to the pa-
tients themselves, furthering the self-efcacy of the patients to
manage their own recovery and providing educational materials that
the patients can use as reference resources after they have left the ses-
sion. While there is a manual that accompanies the Toolkit, we devel-
oped a more immediate brief Clinicians Guide that accompanies each
of the 35 interventions. The front of the Clinicians Guide includes
talking points that can enhance the counselors understanding of how
to use the intervention effectively, and the back of the Guide provides
additional guidance for how much the counselor can expect to accom-
plish if they have 15 min or as few as 5 min with a patient.
Finally, to support the counselor in engaging with patients who indi-
cate that they want to engage with these concepts and make a change,
our team developed a companion self-help graphic novel (see Fig. 2).
This health communication comic is based on pamphlet/workbooks
that have been published for nicotine cessation (Channing Bete Compa-
ny, 2003; Mayo Clinic, 2000), which include information and applica-
tion strategies and feature models and exercises germane to the
cessation process. Our health education graphic novel tells the story of
two inner city minority patients who are using substances (alcohol
and marijuana) in a risky way and who are asked to quit or cut down
by their primary care provider. The characters model wrestling with
ambivalence and making the decision to change. As they work toward
reducing their use, and then ultimately quitting, the patients effect
change plans that are essentially MET and CB/RP strategies (e.g., goal
setting, developing a change plan, self-monitoring, coping with Fig. 2. A sample page from the Keep It Moving Graphic Novel. In this section, the character
craving). At key points, the narrative breaks and the reader has an Bill begins tracking his alcohol use, and realizes how much he is drinking. 2013 Treat-
ment Research Institute. All Rights Reserved.
opportunity to interact with and apply the change strategy the charac-
ter just modeled.
Counseling Center, serves approximately 4000 people over 20,000 visits
2.3. Implementation of SBIRT and Brief Treatment (SBIRT +) using the annually; in addition to the above services, they offer prenatal care, outpa-
SBIRT + Toolkit tient behavioral health, dental, pharmacy, diabetes classes, youth pro-
grams, a full service pharmacy, optometry, and podiatry. Each of these
2.3.1. Implementation strategies FQHCs already had at least one BHC addressing behavioral health needs
Our team employed a hybrid of planning and educating strategies as for the patient population, with an emphasis on depression, suicidality,
laid out by Powell et al. (2012). During the design phase, we used our and trauma symptoms, and referring patients to more specialized behav-
BHC informants to determine counselor needs and determine barriers ioral health care when needed. Research funding provided the means to
to implementation. This collaborative consultation on design also hire an additional BHC at each site to implement SBIRT throughout their
helped us to build signicant buy-in and identify champions of the patient population, as well as brief treatment to randomized patients.
intervention at each site; these individuals led teams that planned
how the new intervention would ow and be monitored. Our educa- 2.3.3. Staff preparation and training
tional strategies employed traditional workshop training and ongoing Our team conducted informational meetings with administration,
supervision. providers, behavioral health staff, and medical assistants to determine
what was already being provided for substance using patients prior to
2.3.2. Implementation sites implementation, and to hear concerns about how screening and
Our team worked with three FQHC sites located in North and intervention might affect clinical ow. All of the sites were already
Northwest Philadelphia. These FQHC sites offer a mix of primary and implementing other forms of screening (depression, trauma) and
specialized medical services, including family planning. The rst of bringing in BHC consults based on high scores on mental health screen-
these, the Eleventh Street Family Health Services of Drexel University ing instruments. Generally, asking additional screening questions relat-
(Site 1) offers health services to residents of four public housing ed to drugs and alcohol was seen as needed for the population, but also
communities in a federally-designated medically underserved an additional clinical burden.
neighborhood. The Health Center serves 6500 unique patients, in ap- Each center settled on a starting model of having medical assistants
proximately 23,000 primary care visits. Site 2 (the Public Health Man- administer three pre-screen questions at primary care visits (frequency
agement Corporations Care Clinic) serves 640 unique patients over of drinking, number of days drinking four or more drinks, and whether
approximately 5000 visits annually; their population is primarily indi- the patient used any street drugs in the past year). High scores on this
gent, a disproportionate number of whom (approximately 65%) are pre-screener would lead to notication of the medical provider and
HIV positive. In addition to primary and specialized medical services, one of the BHCs. The provider generally opened up the conversation
they offer a Hepatitis C clinic, support groups, peer counseling, and about concerns related to substance use, and then would hand the pa-
medical case management services. Site 3, the Abbottsford-Falls Family tient off to the BHC. The BHC team member would conduct a further

Please cite this article as: Brooks, A.C., et al., Implementation of a Brief Treatment Counseling Toolkit in Federally Qualied Healthcare Centers:
Patient and Clinician Utilizatio..., Journal of Substance Abuse Treatment (2015), http://dx.doi.org/10.1016/j.jsat.2015.08.005
6 A.C. Brooks et al. / Journal of Substance Abuse Treatment xxx (2015) xxxxxx
assessment, including administering the Alcohol Use Disorder Identi-
cation Test (AUDIT; Saunders, Aasland, Babor, de la Fuente, & Grant,
1993) and/or the Drug Abuse Screening Test (DAST; Skinner, 1982) as
appropriate. A score of 8 or more on the AUDIT or 2 or more on the
DAST triggered eligibility for the study; at this point, the BHC would in-
dicate that they would like to talk to the patient about their substance
use, but that the patient was eligible to receive this service in the con-
text of a research study. Interested patients were given the opportunity
to hear about the study, provide informed consent, and be randomized
to 1 session of SBIRT or 26 sessions of SBIRT+. If patients were not in-
terested in participating in research, the BHC would provide brief inter-
vention as needed.
The protocol that we trained the BHCs to follow in the SBIRT condi-
tion was to provide a Brief Intervention (BI) for Mild Severity patients
(AUDIT scores of 815, or a DAST b 3), and to provide a BI plus treatment
referral for Moderate (AUDIT score 1619, or DAST 38) and Severe Se-
verity patients (AUDIT of 20 or greater, or DAST of 910). In the SBIRT+
condition, BHCs were to deploy expanded brief counseling with Mild
and Moderate Severity patients, and to use the additional sessions to fa-
cilitate the referral process for Severe patients.
To prepare for this clinical ow model, we provided brief in-service
training on pre-screening to the medical assistants (2 h), in-service
training on intervention to the medical providers (2 h), and concentrat-
ed workshop training on SBIRT and brief treatment (SBIRT +) to the
BHCs (24 h, broken into six equal length workshops). Three of the work-
shops focused on screening and intervention practice, and three focused
on motivational enhancement skills as well as various CB/RP and 12SF
interventions. Additionally, because the implementation efforts were
being directed in the context of a randomized clinical trial, we provided
additional training to the BHCs by giving them each 4 sessions of prac-
tice with a standardized patient, and ongoing supervision with tape re-
view. Throughout the trial, each BHC received 45 min of individual
supervision every two weeks from a licensed counselor with expertise
in primary care behavioral health (co-author EB). Following training,
each site began pre-screening.
2.4. Provider reaction and patient satisfaction
Two phases of semi-structured qualitative interviews were conduct-
ed with clinic staff. In Phase One, before project implementation, we
interviewed four clinic staff members at each of the three participating
FQHCs between March 2012 and May 2012, for a total of 12 interviews.
In Phase Two, one year post project implementation, we interviewed
nine clinic staff members from each FQHC between April 2013 and Au-
gust 2013 for a total of twenty-seven key informant interviews; nine
staff members were interviewed at both time points. Administrative,
behavioral health, and medical staff were interviewed at each time
point. Interviews were conducted by members of the research team
who were not involved with staff training or program implementation.
Interviews were audio recorded and lasted between 15 and 50 min de-
pending on the interviewees role on the project. The majority of key in-
formant interviews were conducted in-person at the key informants
clinic setting; three interviews were conducted via telephone. The
major topic areas covered in these interviews included overall progress
of SBIRT, barriers to implementation, benets of screening, screening
saturation, perceived impact of project on clinic staff and patients, im-
pact on patient ow and professional responsibilities, electronic screen-
ing capability, and training or information-sharing needs for clinic staff.
All interviews were transcribed by the project interviewer. The
interviewing research team met periodically to discuss and explore pre-
liminary themes emerging from the semi-structured interviews. After
interviews were transcribed, interviews were reviewed and key prelim-
inary themes and ndings were discussed. Using the semi-structured
interview as a guide, a list of primary themes was developed. A coding
scheme was developed with primary codes based on the interview
topics and secondary codes identied by a preliminary review of all
Please cite this article as: Brooks, A.C., et al., Implementation of a Brief Treatment Counseling Toolkit in Federally Qualied Healthcare Centers:
Patient and Clinician Utilizatio..., Journal of Substance Abuse Treatment (2015), http://dx.doi.org/10.1016/j.jsat.2015.08.005
transcripts. The transcripts were then coded by two evaluation team
members. A sample of one-third of the interviews was coded a second
time by a third team member to check the reliability of coding. Any
discrepancies were discussed by the three members of the coding
team until agreement was reached.
Patient satisfaction data were collected three months after treat-
ment while patients completed a battery of outcome assessments for
the randomized trial. The full version of the questionnaire was intro-
duced after the study had been initiated, and was completed by 274 pa-
tients. We had a 72% follow-up rate at the three-month follow-up point.
The satisfaction instrument included six items on a ten-point Likert
scale assessing patient comfort level with discussing substance use in
primary care, the adequacy of the intervention, and the degree to
which they received and used materials from the SBIRT + Toolkit .
On these items, we analyzed the responses for differences between con-
ditions using simple t-tests. The satisfaction measure also included four
additional questions: whether the patient used any of the materials pro-
vided to them by the BHC outside of the session (responses ranging
from all, most, some, a few, or none); how many educational
materials they had received from their counselor (free response); the
percentage of the graphic novel read, asked only of SBIRT+ patients (re-
sponses ranging from 0, 25, 50, 75, or 100%); and whether the patient
had received a referral from the BHC for SUD or mental health treatment
(yes/no). These four items are presented descriptively.
A small number of patients (N = 6) were randomly selected to re-
spond to a longer, in-depth structured interview about their experi-
ences in the study. Four of the six patients picked did not show up for
their interviews, and replacement patients were randomly selected.
The major topic areas covered in the patient interviews included overall
experience with SBIRT, detailed questions about the intervention com-
ponent (e.g., length of sessions, number of sessions, perceived BHC com-
petence), level of comfort discussing substance use in a medical setting,
experience participating in research, impact of SBIRT on substance use
and health, and how to best reach people in a health clinic setting to
address substance use issues.
3. Results
3.1. Clinical implementation and utilization
Each site differed slightly in how broadly it implemented pre-
screening. Sites 1 and 3 pre-screened all patients at all visits, unless a pa-
tient refused by reminding the medical assistant that they had complet-
ed the paper screener very recently. Site 2, which hosted a large number
of indigent and substance using patients, pre-screened only 25%50% of
the caseload per day, rotating among providers, so as not to be
overwhelmed by cases on any one day. This FQHCs choice to focus on
only a portion of their patients at the site where patients had the
greatest need is certainly noteworthy, and we devote more consider-
ation to this issue in the Discussion. Pre-screening for study recruitment
took place over 22 months, from August 2012 to June 2014. Table 2 cap-
tures pre-screening and screening progress. Across the three sites,
10,935 pre-screeners were administered, with 4232 instances of pa-
tients indicating possible problematic substance use on the pre-
screener questions. Patients were followed up by the BHC for more
in-depth assessment on 2011 occasions. In the 2221 instances where
patients with positive screeners did not receive follow-up, the main rea-
son was that the patients were already in substance use treatment
(1060 cases, 47.7%). Implementation problems, such as the medical pro-
vider not referring the patient to a BHC (451 cases, 20.3%), or the BHC
being unavailable for a consultation (111 cases, 5%), also contributed
to the lack of follow-up. These implementation issues occurred primar-
ily at the beginning of the study when the sites were adjusting to the
new procedures and mainly occurred at two particular sites. These
sites immediately began screening every patient coming through the
center, but had not yet set up communication channels or solid hand
 A.C. Brooks et al. / Journal of Substance Abuse Treatment xxx (2015) xxxxxx 7

Table 2 10-point scale, 59.7% of participants rated a 10, that it was Very Helpful to
Screening and enrollment rates. be asked about their drug and alcohol use; and 77.4% rated a 10, that they
Site 1 Site 2 Site 3 Total felt Very Comfortable discussing their drug and alcohol use. The majority
Received Initial Screener 5459 1847 3629 10,935
of participants, 95.2%, felt that the BHC was Very Qualied, and 74% report-
Flagged for Drug/Alcohol Use 1431 1555 1246 4232 ed using the skills they learned in their sessions with the BHC. Most partic-
Screened for Study Eligibility 853 494 664 2011 ipants (57%) reported receiving a referral for specialty services, but only
Ineligible 559 186 243 988 40.9% of those that received a referral attended any of those services. As ex-
Eligible 214 280 377 871
pected, there were differences between conditions reecting the number of
Enrolled 117 235 248 600
SBIRT 60 118 123 301 educational materials received (SBIRT M (SD) = 2.21 materials (2.08),
SBIRT+ 57 117 125 299 SBIRT+ M(SD) = 3.26 materials (2.70), t = 2.68, p = 0.001). SBIRT+ pa-
tients reported that they found the materials more helpful (t = 2.68, p =
0.008) than the SBIRT patients, and there was a trend for SBIRT+ patients
off procedures. As the study progressed, these implementation issues to nd the BHC meetings more helpful than did the SBIRT patients (t =
were addressed through ongoing training and consultation. Other rea- 1.808, p = .072). Fifty eight percent of the patients (collapsed across condi-
sons for not following up on positive screeners included the patient re- tions) reported using Most or All of the educational materials provided
fused further assessment (100 cases, 4.5%), a pressing health or to them outside of sessions; forty percent of the SBIRT+ patients reported
psychiatric issue that precluded assessment (76 cases, 3.4%), and other reading the entire Keep It Moving graphic novel, and an additional 30.7% re-
miscellaneous reasons (423 cases, 10%) such as the patients drug or al- ported reading at least half of it. Overall, 68.5% of patients have a rating of 10
cohol use was not current or the patient was already enrolled in the out of 10 (Very Helpful) for how helpful their BHC meetings were.
study. Of the 2011 patients assessed, 988 were determined to be ineligi- Patient quotes from the structured interviews indicated that
ble (AUDIT or DAST score too low, or currently in treatment) and 871 generally, patients found the meetings with the BHCs to be helpful, as
were determined to be in need of intervention and eligible. A total of many reported feeling isolated with no one to talk to about their
600 eligible patients met criteria and enrolled in the study. Enrolled pa- problems:
tients included 181 Mild Severity patients (SBIRT = 90, SBIRT+ = 91),
Just having someone to talk to was a huge benet. I always kept every-
270 Moderate Severity patients (SBIRT = 139, SBIRT+ = 131), and 141
thing in, and I dont really have any friends. She listened.
Severe Severity patients (SBIRT = 67, SBIRT+ = 74).
Patients who were assigned to SBIRT were given a one-session interven-
Additionally, patients voiced the perception that the clinical inter-
tion, and then followed-up briey over the next month in person or by
ventions were helpful, and should be offered more widely.
phone if necessary; generally, these patients may have received one or
two educational materials, including the construction of a Change Plan, Whenever I got angry or was tempted to smoke or drink, I would hear
from the Toolkit. Patients who were assigned to SBIRT+ were able to return her voice inside my head, telling me to calm down and not do anything
for an additional one to ve additional sessions (conducted as needed over that will get me into trouble She made me think about consequences.I
the next three months) focusing on MET, substance use reduction, and wish these programs were at every doctors ofce. I think it would be
treatment referral management. SBIRT+ patients typically received addi- great because there are a lot of people out there like me.
tional educational and intervention materials at follow-up visits, and also
received the Keep It Moving graphic novel at the rst session. The six patients selected for follow-up interviews also responded to
On average, participants in the SBIRT condition received 0.98 session questions about the SBIRT + Toolkit educational materials. Some pa-
(SD = 0.14, 6 participants did not receive their 1 session), and partici- tients reported that they were helpful.
pants in the SBIRT+ condition received 3.29 sessions (SD = 1.78, 3 par-
(My counselor) had books and cards and graphsI have my graph
ticipants did not receive any sessions, Mode = 2, Median = 3).
right here that charts your everyday feelings. I do this every day, and
its helpful to have a visual of your progress. Just talking everything out
3.2. Patient satisfaction and reaction is most helpful, but this makes it so I can actually see the
change.They ask questions that wake your mind up, makes you aware
As described above, patient satisfaction data were collected at the three- of how much you do a certain thing. I could take those answers and
month follow-up point, and six semi-structured qualitative interviews were apply them to my life. They even give you a printout of your progress,
conducted with a random subset of patients. Overall, patients were gener- so you can see improvements. I feel better now that Im cleaner.
ally very positive that it was both helpful and comfortable to be asked Im thinking better.
about and further discuss their drug and alcohol use at the health care cen-
ters (see Table 3), with no signicant differences between conditions. On a But not all patients found that the materials t into their process.

Table 3
Patient satisfaction ratings by study condition.

Item Scalea N Range Mean (SD) t-test p-value

SBIRT SBIRT+

How helpful was it for you to be asked about your use of alcohol and drugs at your health care clinic? 110 273 110 8.61 (2.27) 8.50 (2.44) .387 .699
How comfortable were you discussing your alcohol or drug use at your health care clinic setting? 110 274 110 9.08 (2.16) 9.33 (1.58) 1.108 .269
How helpful to your life were your meetings and conversations with the BHC? 110 269 110 8.68 (2.19) 9.13 (1.84) 1.808 .072
How many materials did you receive? n/a 232 012 2.21 (2.08) 3.26 (2.70) 2.682 .001
How helpful were these materials? 110 205 110 7.40 (2.92) 8.42 (2.26) 2.682 .008
Overall, how satised are you with the TRI Study? 110 271 110 9.22 (1.58) 9.19 (1.49) .186 .853
a
Scale 1 = Not at All, 10 = Very.

Please cite this article as: Brooks, A.C., et al., Implementation of a Brief Treatment Counseling Toolkit in Federally Qualied Healthcare Centers:
Patient and Clinician Utilizatio..., Journal of Substance Abuse Treatment (2015), http://dx.doi.org/10.1016/j.jsat.2015.08.005
8 A.C. Brooks et al. / Journal of Substance Abuse Treatment xxx (2015) xxxxxx
The games and things, writing in journals I didnt really do.
I already had homework for school, so I didnt have the time or desire.
3.3. 12-Month provider and counselor reaction
Two phases of semi-structured qualitative interviews were conducted
with clinic staff: one before project implementation and another
12 months post project implementation, By the 12-month follow-up inter-
views, medical providers were generally favorable about working with
BHCs providing SBIRT and brief treatment on site at the health centers.
Having something that people can actually do to work on their sub-
stance abuseits exciting. Before the BHC could see them and tell them
to go to a program somewhere else, but whether they go or not, who
knows, especially those people who are in between. Its great; its like
having our very own drug & alcohol program.The intervention is not
stopping just at a conversation; theres actually something being done.
Its quick action. Were getting the patients that need help immediate re-
sponse, so theyre not falling through the cracks.Its part of mental
health. It needs to be addressed.
BHCs reported that providing standardized screening and brief
treatment on-site changed their working relationships with medical
providers around substance use.
Clinically, its changed the providers mindset tremendously in terms of
how much or how often they assess for substance abuse/misuse. They
take it more seriously. . . Also, we have a bunch of interventions they
have taught us as well as given us the tools to support them.I (ask) pa-
tients to talk about some of these concerns with their providers and then
(let) the providers know that a client may ask how their drinking may
affect their liver. This way the medical provider can break it down in a
way I cant. It also empowers the client to recognize what theyre doing
to their bodies and speak to their provider.
BHCs reported that for the most part, adding SBIRT and brief treat-
ment was an extension of their existing work and model, and not a
major change.
Our NPs are very holistic; they address the outlying issues that may be
affecting patients all the time Ive been here almost 4 years. This is not
new that we work as a team. Behavioral health issues are completely in-
tegrated the work here.SBIRT is just a regular consult for me, a regular
BHC thing. Follow-up is a challenge with SBIRT+. It does take time out
of my schedule. I need to be available to the NP when theyre seeing pa-
tients, so I try not to pre-book too much.
BHCs generally reported that the addition of the Toolkit was helpful
to their work in delivering SBIRT and brief treatment.
I think overall it was a good tool to anchor the process, to give someone
something to take home. The physical cards really matter to people. I
know people who still have their cards to refer to.I really like the
toolbox. I like formulas. I like the structure of it. I like that patients have
something to take home with thema transitional object.I think the
comic book was helpful, especially for people who were a little more
ambivalent, who wanted to go their own way on it.I think the cards
have been very helpful. I think its a good way to frame the discussion.
However, BHCs also pointed out that using this new, structured in-
tervention did take time and practice, and that it didnt t as naturally
into their counseling process.
Its [the cards] just kind of awkward reallyIm like I think I have a
card for this, hold on let me nd the appropriate card. I dont have time
to really familiarize myself with the cards and because Im not using
them a lot, its just not that natural. When I use them, they are received
Please cite this article as: Brooks, A.C., et al., Implementation of a Brief Treatment Counseling Toolkit in Federally Qualied Healthcare Centers:
Patient and Clinician Utilizatio..., Journal of Substance Abuse Treatment (2015), http://dx.doi.org/10.1016/j.jsat.2015.08.005
pretty well.I hate to say it because I had a love/hate relationship with
them at rst, but the tool cards. They help people stay focused, stay on
track. Theyre concrete . . . theyre a good guide I do have favorites
the 3-month change plan, decisional balance, happiness scale, maps,
triggers, monitoring use, supportive relationships. Clients have been
pretty receptive.It feels formulaic Its someone telling me what to
do with my work. There are a lot of good tips in that recipe box. In
some ways its been helpful having those tips and tools.
4. Discussion
In consultation with established primary care behavioral health coun-
selors, our team developed a comprehensive set of psychoeducational
clinical aids to support the implementation of SBIRT and brief treatment
based on MET, CB/RP, and elements of 12SF in primary care settings.
This toolkit provided signicantly more structure and support to BHC-
delivered substance use interventions in primary care. In the context of
an ongoing randomized clinical trial, our team worked with six BHCs to
implement the SBIRT + Toolkit in three busy FQHCs, and collected sat-
isfaction data from patients and utilization feedback from patients, medi-
cal providers, and BHCs.
This demonstration project adds to the body of knowledge regarding
implementation of SUD intervention in medical settings. In particular,
our efforts point to one viable strategy for attending to the innovation
(Rogers, 2003) or intervention characteristics (Damschroder et al.,
2009) that can greatly assist with implementation efforts in primary
care. Our team has demonstrated that with some buy-in and conceptual
contribution from providers, it is possible to package a signicant
breadth of ofce-based counseling strategies into a exible approach
that can be implemented into an interdisciplinary primary care ow.
Importantly, the Toolkit development process that our team followed
emphasized tailoring the intervention so that the relative advantage to
working with a structured approach is clear, simplicity of intervention
is prioritized, and compatibility/adaptability was enhanced so that the
intervention would t into the existing primary care BHC model. Our
design standards were high to promote the attractiveness of the
intervention, and because of the breadth of the intervention, it would
certainly be possible for clinicians to try portions of it before adopting
it completely.
Pre-screening combined with follow-up screening using the AUDIT
and DAST identied numerous patients eligible for brief intervention
and brief treatment. Patients responded well to the opportunity to dis-
cuss their substance use in primary care, and patients assigned to brief
treatment (SBIRT+) did return for additional sessions (3.29 sessions,
on average), which is important; at outset of the study, our clinical
partners were unsure if patients would even return to talk about
substance use. Generally, patient satisfaction with the intervention
was quite high. Clinicians found the clinical support tools useful (over
time), and reported that the Toolkit t into their pre-existing brief
consultation model.
This work is signicant because it provides support to clinicians in
delivering evidence-based outpatient counseling strategies in brief in-
tervention settings, and has been formatted into presentation styles
that can be presented in bite-size portions (the cards), or in a larger
dose (the graphic novel), depending on which is preferable. The Toolkit
format supports primary care systems in maintaining the delivery of
these interventions. Furthermore, this presentation takes these ofce
based approaches (particularly MET and CB/RP) and, for the most
part, expresses their utility in the context of habit-breaking, rather
than focusing merely on substance use. This facet could potentially
allow this set of clinical tools to be used broadly across primary care
with any patients who are struggling to break negative habits or set
new positive ones.
There are a few limitations to this implementation effort. First of all,
it is unclear if the positive reception from clinicians to the Toolkit would
 A.C. Brooks et al. / Journal of Substance Abuse Treatment xxx (2015) xxxxxx
generalize to other primary care settings. These selected FQHCs had al-
ready demonstrated commitment to the integration of behavioral
health organized around the BHC model. The Toolkit was created to t
into this culture, and its utility might not be as apparent in systems
with less history with behavioral health integration. Furthermore,
while we designed the Toolkit to support clinicians in working with
multiple habits, not all of which are substance use related, we did not
actually collect data to determine if clinicians used the tools in this way.
Additionally, while this is an implementation demonstration that fo-
cuses heavily on innovation/intervention characteristics, we did not at-
tend to the many other facets of implementation science that might be
considered. For example, Damschroder et al. (2009) lay out a ve factor
model in the Consolidated Framework for Implementation Research
that includes the intervention characteristics, but also takes into ac-
count the outer and inner settings in which the implementation will
take place, characteristics of the individuals who are using the innova-
tion, and the process by which it takes place. In this study with only
three sites, it is impossible to draw conclusions that would provide
any systematic information to these broader considerations, nor did
we systematically collect this information as it was not the main focus
of our study.
One other signicant limitation in our study of this Toolkit is the
training context in which it was implemented. In our previous studies
of Toolkit training (Brooks, Carpenedo, et al., 2013; Brooks et al.,
2012), we successfully deployed our clinical tools with minimal training
(3 h) and with no follow-up supervision or feedback to test the limits of
the tool itself on training gains and durability of training effect. As this
was not a training study, we supported the clinicians with signicantly
more training 24 h of workshop training, supervision with a standard-
ized patient, and twice-monthly ongoing supervision bolstered by tape
review. While we designed the SBIRT + Toolkit using similar tech-
niques and in the spirit of our other brief-training multimedia Toolkits,
we do not know if this intervention could be deployed with such brief
training, or even what the minimal level of training would be needed
to reasonably support its use.
Also, in the context of a grant-funded study, this project was able to
provide nancial support for each FQHC to hire one new BHC. Many
health centers considering SBIRT may be concerned about the nancial
sustainability of implementing this intervention without additional
funding. While our study did have start-up funding for the BHC staff,
we found that all sites retained the hired BHC after the study funding
was gone, as they found that their patient population had a signicant
need for these and other additional behavioral health services. Thus in
many FQHCs with adequate patient ow, the interventions are likely
to be nancially sustainable. For health centers considering SBIRT im-
plementation, we suggest training any existing BHCs rst in order to
begin regular screening. This will allow the health center to see how
widespread risky substance use is among their patient population. For
a typical FQHC, this process will illuminate a signicant rate of SUDs.
FQHCs will then be less reluctant to bring on additional staff to help con-
duct SBIRT interventions, as these staff will generate enough billing rev-
enue to be cost effective. In fact, we found that at our FQHC site that
served the greatest number of indigent and substance using patients,
BHCs chose to only pre-screen a portion of their patients in order to
not overwhelm their staff and strain their resources. In preparing to im-
plement SBIRT, health centers should consider how to best balance the
intersection of the needs of their patients, the number of staff that they
can reasonably hire and retain, and other referral options available in
the community.
Finally, while the sites and providers in this study were generally
positive in their attitudes toward SBIRT and implementation went
smoothly on the whole, there were some implementation issues that
warrant further discussion. Namely, implementation problems such as
the medical provider failing to make a referral to the BHC led to
some patients not receiving additional screening and intervention. For
health centers considering SBIRT implementation, we found that close
Please cite this article as: Brooks, A.C., et al., Implementation of a Brief Treatment Counseling Toolkit in Federally Qualied Healthcare Centers:
Patient and Clinician Utilizatio..., Journal of Substance Abuse Treatment (2015), http://dx.doi.org/10.1016/j.jsat.2015.08.005
9
consideration of how SBIRT ts into the health centers clinical ow
and the degree of communication needed between medical providers
and behavioral health staff cannot be stressed enough, as these are cru-
cial elements in determining whether SBIRT implementation will be
successful or not. When there were breakdowns in communications
or the clinical ow process, patients with positive screeners did not re-
ceive follow-up. Additionally, while our team included BHC feedback in
the design of the Toolkit and worked diligently to ensure that the Toolkit
was clinician-friendly, certain BHCs still expressed some challenges with
integrating the materials into their clinical practice. This speaks to the
difculty of crafting an intervention that will be appealing to BHCs
with a wide range of styles and orientations, and the effort needed to
get experienced clinicians accustomed to using new interventions.
Our team is nishing data collection on the core randomized clinical
trial (1-session SBIRT compared to SBIRT+) at the center of this imple-
mentation effort. We will report on whether exposure to the expanded
intervention promoted reductions in alcohol and illicit drug use (as
conrmed by urine samples), as well as whether patients attended sub-
stance treatment at differing rates and intensities. Additionally, we will
examine whether exposure to the SBIRT + condition resulted in any
other differential employment, medical, or psychiatric outcomes over
12 months of follow-up. Our future research efforts and interests in-
clude testing this intervention in other medical settings (e.g., inpatient
hospital settings and during the discharge/follow-up process), and test-
ing whether it can be supported with signicantly reduced training. Ad-
ditionally, provided that the Toolkit demonstrates some efcacy and
utility, TRI will make the Toolkit available for distribution in a similar
fashion to other research-derived products it distributes (see Acknowl-
edgments section).
Acknowledgments
This research was made possible by a Commonwealth Universal
Research Enhancement Program grant awarded by the Pennsylvania
Department of Health (SAP No. 4100055578). These funding
sources were not involved in the studys conceptualization, data analy-
sis/interpretation, or manuscript writing. The authors wish to acknowl-
edge the Directors of the three participating primary care centers,
Patricia Gerrity, Anne Kelly, and Donna Torrisi, along with the Behavior-
al Health Counselors who provided support and were responsible
for implementing the interventions. The authors also acknowledge
Mary Milnamow and Michelle Henry who organized and conducted
many of the staff and patient interviews. Finally, the authors acknowl-
edge the contribution of the research technicians who assisted in
implementing the project at the primary care sites: Roxana Arango,
Meredith Asch, Emily Ball, Christina Cruz, Nicolas Joseph, and Tameka
Williams. This study describes the SBIRT + Toolkit , which is the prop-
erty of the Treatment Research Institute. TRI may market this Toolkit,
and currently distributes other Toolkit products. TRI is a non-prot re-
search organization, and all proceeds are returned to the core mission
of treatment research. While many of the co-authors are employees of
TRI, we do not benet nancially from the sale of its products.
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