Abstract
Background:
In 2019, the Agency for Healthcare Research and Quality (AHRQ) funded 6 grantee teams to evaluate the effectiveness of practice facilitation (PF) as an implementation approach for improving the delivery of U.S. Preventive Services Task Force-recommended unhealthy alcohol use (UAU) services in primary care. This report characterizes practice facilitators’ first-hand experiences with implementation.
Methods:
We invited practice facilitators from each grantee team to participate in group interviews focused on facilitation strategies employed, facilitators and barriers encountered, adaptations made, and practice transformation observed. Interview transcripts were thematically coded using inductive and deductive methods and analyzed using immersion-crystallization.
Results:
Seventeen practice facilitators who worked with ~300 practices participated. PF was perceived as effective in overcoming barriers to improve screening and counseling for UAU in varied settings and contexts. Practice-centered strategies that personalized practice engagement, met practices “where they are at,” tailored to local context, and fostered deep cultural change were highlighted as instrumental to the multilevel changes needed to transform practice workflow around management of UAU. Facilitator quotes, strategies, and multiple facilitation resources are provided.
Conclusions:
Practice facilitators’ collective perspectives paint a more complete picture of the processes, adaptations, and outcomes associated with this substantial practice-based research effort. PF is a versatile, flexible, and adaptable implementation approach to improve management of UAU in primary care that provides pragmatic strategies for care teams, practice leaders, researchers, and funders. Practice facilitators’ collective perspectives paint a more complete picture of the processes, adaptations, and outcomes associated with this substantial practice-based research effort.
Introduction
Unhealthy alcohol use (UAU) is the third-leading cause of preventable death in the U.S., directly impacting 1 in 3 adults and leading to $250 billion per year in related expenses. The U.S. Preventive Services Task Force (USPSTF) recommends that screening and brief intervention (SBI) for UAU be provided in the primary care setting 1 but this service is infrequently and inconsistently administered.2 -6 Clinician-reported barriers to the delivery of SBI include limited resources (eg, lack of time and insufficient electronic health record [EHR] capabilities), inadequate knowledge or skills, and anticipated lack of acceptance by patients.7 -9 As previous approaches to improving screening and counseling for UAU have been only modestly effective, further efforts to enhance implementation of USPSTF-recommended SBI for UAU are needed.10,11 To respond to this need, the Agency for Healthcare Research and Quality (AHRQ) launched the EvidenceNOW: Managing Unhealthy Alcohol Use (EvidenceNOW: UAU) collaborative in 2019. 12
The EvidenceNOW: UAU collaborative was comprised of 6 U.S.-based grantee teams, each conducting practice facilitation (PF) initiatives to improve SBI for UAU in primary care practices in their region (Table 1). PF is an implementation approach that engages external change agents (eg, practice facilitators) to deploy a variety of support strategies and services (eg, education, workflow coaching/redesign, performance feedback, information technology support, data management) to assist practices in achieving quality improvement goals.13 -16 A substantial body of literature describes the effectiveness of PF for enhancing quality improvement capacity and for improving the adoption of evidence-based recommendations, although limited literature about PF for improving SBI for UAU is available.15,17 -25 Grounded in relationship-building, tailoring to practice needs, and iterative refinement of clinic processes and workflows,26 -29 PF is a promising approach for the implementation of strategies to improve SBI for UAU in primary care.
Program Profiles.
Abbreviation: SBIRT, screening, brief intervention, and referral to treatment.
Grantee teams partnered with many types of primary care practices, including hospital or health system-owned practices, health maintenance organizations, clinician-owned solo or group practices, academic health centers, Federally Qualified Health Centers, Rural Health Clinics, Indian Health Service, and other government clinics. For additional information, see https://www.ahrq.gov/evidencenow/projects/alcohol/index.html.
To evaluate the effectiveness of external PF, each EvidenceNOW: UAU grantee team documented changes in quantitative measures of screening and counseling for UAU, referrals for the management of UAU, and the prescribing of medications for alcohol use disorder (AUD), results of which are reported elsewhere.33 -36 However, deeper understanding of the PF intervention delivered to the >300 participating primary care practices, the contextual factors associated with the PF intervention, and processes implemented by practice facilitators to adapt and tailor the intervention to local context is needed to guide the design, planning, and implementation of future PF efforts. The purpose of this report is to detail practice facilitators’ experiences with PF to improve SBI for UAU in primary care practices throughout the U.S. This behind-the-scenes qualitative snapshot provides primary care teams, practice leaders, researchers, and facilitators with practical information to inform subsequent efforts to implement SBI for UAU and to leverage PF for primary care practice improvement.
Methods
This qualitative study reflects a collaborative effort from the 6 grantee teams. Key definitions used throughout the manuscript are shown in Table 2. The Institutional Review Board of Carilion Clinic determined this study exempt from human subjects’ review. The Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist guided the preparation of this report.
Key Definitions of Terms Presented in the Order They Appear in the Text.
A cross-grantee practice facilitator collaborative met regularly throughout the project period (February 2020-July 2023) for learning, exchange of resources, and collaborative problem-solving. Practice facilitators perceived that the collaborative’s collective “behind-the-scenes” experiences may inform future facilitation efforts. As such, a volunteer sub-group formed to collect, integrate, and report on practice facilitators’ observations of factors associated with successful PF during the project period. The sub-group convened multiple times to devise a study plan and interpret findings. A semi-structured interview guide was iteratively developed and refined through facilitated brainstorming within the sub-group and feedback from grantee teams.
A convenience sample of practice facilitators or other members of each of the 6 grantee teams (including PF managers, a quality improvement advisor, and a data analyst; referred to as “practice facilitators” hereafter) were invited to participate in a team-specific 60-min virtual interview to share details about their team’s experience with PF. Interviews were facilitated by a male cultural anthropologist with doctoral training and extensive experience with qualitative interviews and analysis. Practice facilitators were introduced to the interviewer’s background and experiences, affiliation (Virginia Commonwealth University), and interview style prior to the start of the interviews. Interviews were audio recorded and auto-transcribed using Otter.ai. Transcripts were manually cleaned and de-identified for analysis.
Data Analysis
Interviews were analyzed using both deductive and inductive approaches in 2024. Four members of the working group (representing 3 grantee teams) participated in the analysis, with one of the senior authors completing all training (EB). Two members conducted thematic template-based coding using an a priori codebook, partially informed by the work of Sweeney et al, 45 who identified successful approaches to PF in a previous EvidenceNOW study. The other 2 members then independently coded the transcripts to identify emergent themes using an inductive, immersion-crystallization approach. 46 Coding discrepancies were resolved by consensus during discussion with one of the senior authors (EB). Preliminary results were shared across the grantee teams via email and in a virtual group meeting as part of a member checking process to confirm understanding, elicit feedback, and refine the organization of results.
Results
Seventeen practice facilitators who collectively partnered with close to 300 U.S. primary care practices participated in interviews. Support strategies employed by practice facilitators are highlighted in Table 3. Interview themes are described below and summarized in Table 4.
Examples of Practice Facilitation Support Strategies Employed by Practice Facilitators.
Abbreviations: ANTECEDENT, partnerships to enhance alcohol screening, treatment, and intervention; AUD, medication-assisted therapy; FAST, facilitating alcohol screening and treatment; INSPIRE, Intervention in Small Primary Care Practices to Implement Reduction in Unhealthy Alcohol Use; MI-SPARC, Michigan sustained patient-centered alcohol-related care trial; SBIRT, screening, brief intervention, and referral to treatment; STUN, stop unhealthy alcohol use now.
Interview Themes: Practice Facilitators’ Experiences With Practice Facilitation to Improve Management of Unhealthy Alcohol Use in Primary Care.
Personalizing Practice Recruitment and Engagement
Practice facilitators recounted the COVID-19 pandemic as influencing “every aspect of the project”, starting with the initial stages of practice recruitment and engagement. With practices severely strained by resource shortages and staff turnover, many were hesitant to enroll in a quality improvement project. To accommodate practices with these challenges, recruitment periods were lengthened and recruitment strategies were modified. Practice facilitators strategically highlighted the importance of assessing UAU by emphasizing its prevalence and rise during the pandemic, providing practice-specific data to support the need for improved alcohol screening, or the opportunity for practices to tentatively engage with the study to assess potential need and value.
Leveraging relationships with practices developed during previous PF and research efforts was described as instrumental to recruitment. Practice facilitators reported that it was often only because of this deep rapport, cultivated over time, that study recruitment proved successful. As one stated,
Some practices participated solely because it was me. . . They were a little leery. I had one [physician] who looked me in the face and said, ‘Are you kidding me right now?’ I’m like, ‘Dude, you can do this, you can do this.’ And he tried it because of me and then was just vastly successful. –Practice Facilitator #2
Practice facilitators noted a spirit of familiarity, collegiality, and that “we are all in this hard time together” among their teams and practices with which they had pre-existing relationships.
Fostering close relationships with practice staff throughout the study was also a key component of maintaining practice engagement and supporting meaningful changes in alcohol-related workflows. Compared with pre-pandemic facilitation experiences, building personal rapport with individual practice members who could serve as “practice champions” to disseminate information and provide updates and feedback on implementation progress was even more crucial during the pandemic because, as 1 facilitator stated, “it’s not like we could just drop by the practice to check in or follow up” (Practice Facilitator #16). Notably, while the pandemic greatly increased the frequency of staff turnover and threatened to undermine these relationships, it also reportedly provided unexpected opportunities for facilitators to build relationships with previously unengaged practices as new personnel brought different personalities and priorities to the fore.
Meeting Practices and Care Teams “Where They Are At”
Practice facilitators emphasized that identifying practice priorities and motivations early in the study was essential to securing and maintaining buy-in from care team members. With practices’ stress levels high, it was crucial to explicitly discuss how improving alcohol screening and treatment, and engaging in the practice facilitation process more generally, could help alleviate practice stresses and bring added value to their work. “You have to go in and bring something that’s of value”, a practice facilitator reported.
I think starting with open-ended questions is always good. ‘You know, what’s important to you? What are you working on? What measure is giving you the biggest headache right now?’ And being there to support them with that (Practice Facilitator #4).
Practice facilitators explained their role in supporting practices in cross-walking quality measures or achieving payers’ alcohol screening initiatives in effort to add value. However, practice facilitators found that most clinicians were primarily motivated by a sense of personal duty to improve their clinical practice around UAU to better serve their patients, rather than financial incentives.
Project goals were adapted to local conditions, capacities, and challenges, which facilitators described as “meeting practices where they’re at”. Frequently this meant taking extra time and attention to assess care team members’ baseline understanding of best practices for addressing UAU and following their lead regarding realistic practice goals. Occasionally, the most achievable study goal was simply introducing clinicians to the recommended screening instruments and gaining comfort interacting with patients on the topic of UAU. For other practices, this meant having the flexibility to decide when and how to implement alcohol screening into their workflow, choosing which patient populations to focus on, and what benchmarks of success to aim for. Occasionally during this process, practice facilitators had to mediate difficult conversations among care team members who disagreed about best practices for managing UAU and what workflow modifications were needed. To do this, some practice facilitators provided summary data and clinician performance feedback reports, leveraging care team members’ “competitive sides” to motivate improvements in project metrics. “We were successful because we did true practice-based research. We did work that the practices wanted to do, and we did it the way that they wanted to” (Practice Facilitator #17).
Tailoring Facilitation Strategies and Resources to Local Context
Practice facilitators reported that they adapted to highly diverse circumstances as facilitators worked with practices across a wide variety of settings, sizes, EHR platforms, pre-existing workflows, and previous knowledge and interest in the study topic. 47 As one practice facilitator stated, “There is not a one-size-fits-all PF notebook. It’s about having empathy with what they’re going through right now and trying to be creative on the value I bring to them” (Practice Facilitator #3). While most grantee teams planned to deliver their educational material following structured curricula, practice facilitators emphasized the value of tailoring content to each practice’s specific goals, priorities, and interests. For example, ad-hoc academic detailing sessions were leveraged to address questions on complex topics, such as prescribing medications for AUD or billing for alcohol-related services.
Although 1 grantee team planned to use virtual, computer-based education modules even before the onset of the pandemic, most practice facilitators detailed the extemporaneous adoption of a mix of facilitation modalities and support strategies. Practice facilitators who were accustomed to providing extensive in-clinic workflow coaching, data management, and other project support abruptly pivoted to providing concise and flexible virtual facilitation or telephone sessions, or to supplying pre-recorded modules to practices with internet connectivity challenges. To accommodate unpredictable scheduling challenges, academic detailing and education sessions were offered at varied intervals, in repeated sessions, or as one practice facilitator put it, “absolutely any time of day that the practices wanted them”. Another practice facilitator led 30 meetings for small groups within the same large practice, while others provided videos, articles, and notes for clinician self-study.
One of the greatest threats to achieving project goals stemmed from widespread challenges with EHR functionality, which facilitators perceived as weakening practice motivation, stymying workflow changes, and hampering data gathering capabilities. Many facilitators addressed this challenge through workarounds, such as developing paper screening tools or adding the screening instrument to paper-based forms or screeners already used by the practice. Others promoted the documentation of alcohol-related activities in an alternate area of the EHR, which could then be subsequently backfilled into patients’ visit notes. Such were the pervasive challenges with EHR systems, and the importance of addressing them, that successes customizing systems to align with project goals often felt like a “big win” to practice team members who had previously, in dismay, “written off the EHR as incompatible and impossible”.
Affecting Cultural Change and Clinician Empowerment
Practice facilitators observed fundamental shifts in clinicians’ knowledge, attitudes, and behaviors regarding SBI and substance use throughout the project. They reported that there was initially marked reluctance among some clinicians to talk with patients about their alcohol use due to general stigma around behavioral health topics or cultural norms concerning appropriate alcohol use. Some clinicians were described as intimidated by the potential for negative reactions from patients, leading some to reportedly state that “this isn’t something we deal with in [primary care]”. However, through coaching, education on motivational interviewing, and in some cases, the use of mock patient conversations, practice facilitators reported that most clinicians overcame their hesitation and became more comfortable and confident in conversations about UAU. As one practice facilitator noted, “So the fear, just boom, was gone. Once they tried it. It was just fear of the unknown”. (Practice Facilitator #8).
Throughout the PF process, clinicians and other care team members were described as motivated to better understand other team members’ roles and routines in effort to streamline workflows. For example, practice facilitators observed multiple instances when care team members realized how unfamiliar they were with fellow team members’ roles related to delivery of alcohol screening and other preventive services. In some practices, medical assistants and clinicians were duplicating efforts, unaware that the other was also completing alcohol screenings and documenting results in separate areas of the medical chart.
Discussion
Practice facilitation is a recognized approach for implementing primary care practice change. Further understanding of the experiences of the primary change agents – the practice facilitators themselves – is imperative to advancing the science and application of PF. 48 In this study, practice facilitators from AHRQ’s EvidenceNOW: UAU collaborative described their experiences with employing PF to improve implementation of SBI for UAU in almost 300 primary care practices throughout the U.S. Practice facilitators leveraged numerous evidence-based strategies to address multilevel targets.10,11,49 In addition, PF frameworks enabled practice facilitators to personalize recruitment and engagement, accommodate practices’ readiness to change, and tailor strategies to match local context. These efforts were associated with outcomes that carry potential for meaningful impact related to the management of UAU and beyond (eg, reduced stigma around substance use disorders, increased comfort with motivational interviewing, openness to other quality improvement efforts, and enhanced capacity for practice change). Outcomes of this qualitative study may be aligned with quantitative outcomes33 -35 (rates of UAU screening, counseling, referrals, and medications for AUD) and other grantee findings45,46,50,51 to enhance understanding of the complexity of managing UAU in primary care and the value of PF for improving management of UAU in primary care. Clinical teams, practice leaders, funders, and researchers may use the strategies, resources, examples, and nuanced perspectives shared in this report to enhance the delivery of USPSTF-recommended services for UAU in primary care.
Echoing the findings of Sweeney et al, 47 practice facilitators associated proactive and tailored approaches to motivating practices, navigating the change process, and addressing barriers and resistance with effective PF. This flexible approach both emphasizes previous PF experiences and challenges some PF and research norms, traditions, and best practices.7,12,14,26,52,53 Continued research is needed to explore variation in the prescriptivity, standardization, and intensity of successful PF approaches. 13 Our findings also suggest that the research community may benefit from consideration of the extent of uniformity and standardization expected for practice-based research initiatives. Research could also further explore how practice facilitator expertise shapes the ability to tailor and adapt support to clinic needs over time. 48
It is well-recognized that changing practice takes time and that transformation may not be linear, especially for complex and sensitive topics, such as UAU.7,10,47 Inclusion of intermediate goals, process measures, and phased behavior change benchmarks may benefit future research efforts. For example, practice facilitators detailed some practices’ incorporation of substantyial EHR modifications to enable care teams to screen patients for UAU. While these practices may not have been able to implement the screening process consistently during the PF period, they may do so with more time. An intermediate structural measure that evaluates EHR functionality for documenting SBI could provide insight into where practices are on the overall change continuum. Key drivers focused on knowledge, ability, and available resources may also be valuable.29,54
Practice facilitators perceived PF as an effective approach for achieving implementation goals despite tremendous challenges and competing priorities, and emphasized the often-overlooked value of longitudinal, personal relationships between primary care teams and facilitators, especially in times of instability and uncertainty.30,51,52 As previously described by Woodward et al, 55 the value of PF is also highlighted by practice facilitators’ observations that the PF process addressed practice needs beyond the specific focus of the intervention (UAU), in many cases developing skills and workflows that may be extended to other practice transformation needs. Moreover, dedicating efforts to enhancing SBI for UAU during unprecedented healthcare strain is a testament to PF’s potential and offers insights for consideration of the cost effectiveness of PF. 56
Limitations
This study had some limitations. First, although all grantee teams were represented, a few practice facilitators were unavailable to participate in interviews. However, participants were asked to represent experiences of others from their grantee team. Second, interviews took place after the project period for most teams, so facilitators were required to rely on their recollection of events. Third, reported PF strategies were not directly linked to or evaluated against the study’s quantitative outcomes. Finally, some successes noted by practice facilitators were not objectively evaluated. Despite these limitations, this study provides important insight into the nuances of PF for improving management of UAU.
Conclusions
Practice facilitators representing the 6 regional grantee teams within AHRQ’s $18 million EvidenceNOW: UAU initiative implemented PF to enhance delivery of SBI for UAU to ~300 U.S. primary care practices. Practice facilitators identified personalized approaches to recruitment and engagement, meeting care teams “where they are at,” and tailoring PF strategies to local context as instrumental to changing culture and empowering care teams to improve the management of UAU in primary care. These themes, in addition to the strategies, resources, examples, and perspectives provided by practice facilitators and included in Tables 1, 3, and 4 can be applied to future efforts to improve SBI for UAU.
Footnotes
Acknowledgements
The authors gratefully acknowledge the following individuals for their contributions to this manuscript and their respective EvidenceNOW: Managing Unhealthy Alcohol Use projects: Cheryl Budimir, Priscilla Castellanoz, Mia Croyle, Deborah Grammer, Jennifer Halfacre, Mark Holmstrom, Darla Parson, Terri Roberts, Victoria Sanchez, Maya Singh, Carolyn Swenson, Eliana Sullivan, Chris Weathington, Ben Webel, and Jessica Reed Williams. Our colleagues at NORC at the University of Chicago provided invaluable collaboration and support throughout the study. Finally, we are thankful to AHRQ for their support of this study, commitment to improving management of unhealthy alcohol use in primary care, and many contributions to the science and application of PF.
Ethical Considerations
The Institutional Review Board of Carilion Clinic determined that this project did not meet the definition of human subjects research under 45 CFR 46.102. Thus, IRB approval and oversight were not required.
Consent to Participate
Consent to participate was waived since this project did not meet the definition of human subjects research under 45 CFR 46.102. All participants provided verbal consent to the recording of interviews.
Author Contributions
MR: conception, design, analysis, interpretation, and manuscript first-draft; GV: conception, design, analysis, and manuscript revisions; JB: conception, design, and analysis; DB: conception, design, and analysis; SK: conception, design, analysis, and manuscript revisions; DJ: conception, interpretation, and manuscript revisions; AK: conception, interpretation, and manuscript revisions; MD: conception, interpretation, and manuscript revisions; EMB: conception, design, acquisition, analysis, interpretation, and manuscript revisions. All authors approved the submitted manuscript and agree to be personally accountable for the accuracy and integrity of all contents of the manuscript.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This project was funded under Contract Numbers HHSP233201500023I and 47QRAA20D001M from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. Readers should not interpret any resources or statements on this site as an official position or endorsement by AHRQ or the U.S. Department of Health and Human Services.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Data Availability Statement
The data generated during the current study are not publicly available to protect the confidentiality of interviewees. An aggregated, de-identified version of the data may be available from the corresponding author on reasonable request.