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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.

Keywords

primary care alcohol use disorder preventive service implementation USPSTF AHRQ

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 setting¹ 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.

Table 1.

Program Profiles.

Grantee team	Program name	Program overview
Colorado	Facilitating Alcohol Screening and Treatment (FAST)	Facilitated quality improvement program to address unhealthy alcohol use. Practices^a received virtual sessions with a practice facilitator, group learning sessions, and follow-up assessments. The effectiveness and costs of virtual facilitation using e-learning modules were also evaluated.
Illinois and Wisconsin	Intervention in Small Primary Care Practices to Implement Reduction in Unhealthy Alcohol Use (INSPIRE)	Evidence-based quality improvement support to increase screening, brief intervention, treatment, and referral to treatment for unhealthy alcohol use in the primary care setting. Practices receive online and in-person education promoting the use of related workflows in the electronic health record systems.
Michigan	Michigan Sustained Patient-centered Alcohol-Related Care (MI-SPARC) Trial	Practice-based training and coaching to support practices in the implementation of evidence-based approaches to alcohol-related care. The training incorporates shared decision-making and a novel decision aid.
North Carolina	STop UNhealthy Alcohol Use Now Trial (STUN)³⁰	PF provided by North Carolina Area Health Education Centers to support workflow revision, enhance documentation and reimbursement, and access referral resources. A specific focus was on optimizing the use of electronic health record systems and data registries.
Oregon	Partnerships to Enhance Alcohol Screening, Treatment, and Intervention (ANTECEDENT)³¹	PF guided by a hybrid framework³¹ to support the implementation of SBIRT and medications for unhealthy alcohol use. The study design enabled practice facilitators to customize outreach to participating practices. All clinics received foundational support. In addition, interested clinics could participate in supplemental support. Foundational support included baseline assessment, guided overview of an SBIRT implementation toolkit (SBIRTOregon.org) and exit assessment. Supplemental support included ongoing PF support, Health Information Technology support, expert consultation, data review, and peer-to-peer learning.
Virginia	PF to Promote Evidence-based Screening and Management of Unhealthy Alcohol Use in Primary Care³²	PF leveraging team education, expert consultation, clinician and patient resources, online toolkit, performance feedback, and workflow coaching to support improvement in the management of unhealthy alcohol use in primary care. Patient surveys assessed patients’ experience with alcohol screening and counseling.

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.

Table 2.

Key Definitions of Terms Presented in the Order They Appear in the Text.

Term	Definition
PF	implementation approach that engages external change agents (eg, practice facilitators, practice coaches, quality improvement consultants) to deploy a variety of support strategies and services to guide and assist practices in achieving quality improvement goals.^13,14
Practice facilitator	specially trained individuals who work with healthcare practices to support evidence-based quality improvement and practice transformation.³⁷
Support Strategy	methods or techniques used by practice facilitators to support practices in adopting, implementing, and sustaining evidence-based quality improvement; examples include workflow coaching, project management, education, academic detailing, performance feedback, information technology support, and data management.¹³
EvidenceNOW Model	blueprint for delivering PF; the EvidenceNOW model has been previously used to enhance practice capacity for quality improvement and implement evidence-based care for cardiovascular health and urinary incontinence.¹²
Unhealthy alcohol use (UAU)	a range of alcohol use, from risky drinking to alcohol use disorder, that is associated with safety risks and poor health outcomes. The National Institute for Alcohol Abuse and Alcoholism describes unhealthy alcohol use as consuming more than 4 drinks on any day or more than 14 drinks per week (men under 65 years of age) or more than 3 drinks on any day or more than 7 drinks per week (women and men 65 years and older).³⁸
Alcohol use disorder (AUD)	pattern of drinking that significantly impairs health and functioning; positive for 2 or more of the 11 DSM-5 criteria for alcohol dependence in the previous year.^39,40
Key drivers	factors that contribute to the achievement of quality improvement goals through driving specific practice change.⁴¹
Screen, Brief Intervention, Referral for Treatment (SBIRT)	comprehensive, integrated approach to the delivery of early intervention and treatment services; patients are screened for unhealthy alcohol use, provided with motivational interviewing-inspired brief counseling (if needed), and referred for more extensive treatment (if needed).⁴²
Medication for AUD	prescription drugs approved by the Food & Drug Association for treatment of AUD: acamprosate, naltrexone, and disulfiram⁴³
Motivational interviewing	collection of strategies that can help patients identify and resolve ambivalence to health behavior change.⁴⁴

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.

Table 3.

Examples of Practice Facilitation Support Strategies Employed by Practice Facilitators.

Strategy	Examples
Academic detailing and care team education	Guided by the Colorado team, FAST offered 9 e-learning modules for self-guided education and training related to the management of unhealthy alcohol use. The Virginia team offered on-demand consultations with experts in preventive care, motivational interviewing, medication-assisted therapy, and reimbursement for unhealthy alcohol use, in addition to related online educational resources.
Clinician resources	As part of MI-SPARC, the Michigan team produced a Primary Care Provider Toolbox with resources for alcohol screening and management of unhealthy alcohol use. The toolbox includes screening instruments, a medication guide, decision aids, and strategies for workflow modification. The North Carolina team’s Stop Unhealthy Alcohol Use Now Website contains clinician resources, videos and podcasts, and downloadable materials for enhancing the management of unhealthy alcohol use. Also includes a searchable registry of local resources and referral options. For use with ANTECEDENT, the Oregon team offered multiple online clinician resources and an SBIRT training curriculum, and an SBIRT app.
Patient resources	The Illinois and Wisconsin team featured a repository of patient resources for use with INSPIRE. A decision aid to facilitate shared decision-making between clinicians and care teams was integrated by MI-SPARC (Michigan). The Oregon team offers patient handouts to supplement, but not replace, brief interventions for unhealthy alcohol use.
Performance feedback	Practice performance reports provided by the Virginia Team at baseline, during, and after the active facilitation periods summarized practice-level data related to alcohol screening, counseling, referrals, and medications for AUD, in addition to results of patient surveys.
Electronic health records and data management support	INSPIRE facilitated the use of evidence-based electronic health records workflows in Illinois and Wisconsin. The Oregon team included a team member with expertise in Information Technology and electronic health record systems for support of workflow integration and documentation within the medical record. Through FAST, the Colorado team offered online resources for data collection and management.
Workflow coaching	Swim lane diagrams and workflow coaching were provided by the Virginia Team. Sample documentation templates were provided for Oregon practices within ANTECEDENT. STUN offered billing and reimbursement guidance for practices in North Carolina.

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.

Table 4.

Interview Themes: Practice Facilitators’ Experiences With Practice Facilitation to Improve Management of Unhealthy Alcohol Use in Primary Care.

Themes	Exemplary quotes
Personalizing practice recruitment and engagement
• Recruitment materials strategically highlighted the increasing importance of addressing UAU in primary care • Recruitment efforts heavily leaned on personal connections to practice teams • Building and maintaining close relationships with practice team members was crucial to success • Applying reasonable flexibility in recruitment protocols was important	• “Sometimes we are able to recruit just based on the relationship we have.” • “I think some did it because it’s us. ‘We’ve been working together for so many years and now you asked me to do it, and we’ll help you out.’” • “Build that relationship first. As a practice facilitator, to provide value you have to show them the value of your relationship and what you can help them with.” • When COVID hit . . .we were still in the process of recruitment. . .It was like, wow, we didn’t have things going yet and we had to postpone and elongate our recruitment, because everybody was overwhelmed with COVID.”
Meeting practices “where they are at”
• Identifying practice priorities and motivations essential to securing and maintaining buy-in • Clinicians largely motivated by a sense of personal duty to improve their clinical practice around UAU • EHR challenges severely challenged practice engagement and motivation throughout the study • Follow team members’ lead regarding practice goals ensures continued engagement	• “Sometimes they do it for the [continuing medical education (CME) or maintenance of certification (MOC) credit, or sometimes they do it because they truly believe in the topic and they know that they need to make a change.” • “One of the first activities that I would usually do with clinics is just have them talk about why this is important, like why they signed up for this project. And usually there was a deep well of things that would come up. . .they usually were pretty quick to come up with examples of stories both personal and in the clinic of why addressing unhealthy alcohol use mattered.” • “Not everything works the same way in every practice. You try to discern whether or not you can read the look on people’s faces when you’re trying to implement something that it just isn’t going to work for them. They decided for themselves what was going to work for them.” • “The thing that I think my practices really struggled with the most was they didn’t even have the ambition of getting it in their EHR in a systematic way, they just had written that off as impossible.”
Tailoring change strategies to match local conditions
• Delivery of educational content was tailored to each practice’s unique goals, priorities, and interests • Occasional need to add academic detailing sessions with specialists or professionals to address complex topics • Some educational content offered via asynchronous online videos, informational packets or in website form • Important to assess care team members’ baseline understanding of best practices to tailor goals • Adapting the EHR to meet the care team’s needs	• “I was thinking how much our entire intervention was practice-centered and practice-driven and individually tailored around a framework - not a rigid framework - a framework that was flexible.” • “Keep it customizable, meet them where they’re at, make it so that if they can’t implement it the exact way that we’ve got it designed, try to help them find a solution.” • “Sometimes, such strict adherence to [protocols] is at the detriment of actually doing all the things that we needed to do to have a successful intervention with the practices.” • “We all pretty much delivered all of the education topics in some way, but not necessarily in the same order at the same time, or the same emphasis on it, or time spent on it.” • “One of the things that I will push for in future projects that are research that have that need for some fidelity is a way to write into a proposal, the level of flexibility that we know, pragmatically, practices need. . .Because I think we can get really caught up in making things so linear when they just never ever are.” • “A lot of clinics wanted HIT support. They felt like they were already doing a lot of SBIRT related things, but that for whatever reason, they weren’t getting credit for it in their EHR. And so what they were reporting was drastically different from what they were doing. . .we had a full HIT expert, who by the end of the project actually was on the study team.” • “You can’t document the AUDIT-C and track it in some EHRs . . . So what I did was collected [paper AUDIT-C forms] in a basket and then went out there [to the practice] once a month and took those and we created a manual spreadsheet and tracked it that way for that practice. . .and then from there, I would backfill the EHR.”
Effecting cultural change and clinician empowerment
• Initial marked reluctance among some clinicians to talk with patients about their alcohol use • Clinicians became more comfortable and confident in having open conversations with patients • Ability to address UAU gave a sense of empowerment and professional satisfaction • Opened the door for practices to begin addressing previously unidentified behavioral and mental health concerns • Facilitation provided opportunity to reflect on practice team dynamics and processes	• “Rewarding to see that it kind of opened the door to greater awareness that this affects so many aspects of health, and we miss it very often in primary care.” • “I had a provider who was excited because they were identifying patients that were engaging in risky drinking, and also identified someone with alcohol use disorder and prescribed medicine for that patient. And that patient emailed through the portal and said, “You saved my life.” That’s a little win for us, but that’s a big deal for the providers.” • “A university clinic hadn’t been doing any SBIRT screening before. Then fast forward to many months later, once they were doing it, they were able to have a pretty meaningful conversation with a student. While they talked about his unhealthy alcohol use it turned out he also had suicidal ideation that wouldn’t have necessarily come up otherwise.” • “They were empowered to talk about other unhealthy, risky behaviors as well. . .it just opened up conversations that the provider said they’d never had before. So I think it changed the culture.” • “It really helped practices think about workflow for telehealth visits, even though the focus of what they were actually there for was unhealthy alcohol use.”

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 outcomes^33
-35 (rates of UAU screening, counseling, referrals, and medications for AUD) and other grantee findings^45,46,50,51 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.

ORCID iDs

Michelle S. Rockwell

Alex H. Krist

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.

References

US Preventive Services Task Force. Screening and behavioral counseling interventions to reduce unhealthy alcohol use in adolescents and adults: US preventive services task force recommendation statement. JAMA. 2018;320(18):1899-1909. doi:10.1001/jama.2018.16789

Chatterton

Agnoli

Schwarz

Fenton

JJ.

Alcohol screening during US primary care visits, 2014–2016. J Gen Intern Med. 2022;37(15):3848-3852. doi:10.1007/s11606-021-07369-1

Bachhuber

O’Grady

Chung

, et al. Delivery of screening and brief intervention for unhealthy alcohol use in an urban academic Federally Qualified Health Center. Addict Sci Clin Pract. 2017;12(1):33. doi:10.1186/s13722-017-0100-2

Subbaraman

Lui

Karriker-Jaffe

Greenfield

Mulia

Predictors of alcohol screening quality in a US general population sample and subgroups of heavy drinkers. Prev Med Rep. 2022;29:101932. doi:10.1016/j.pmedr.2022.101932

Anderson

Bendtsen

Spak

, et al. Improving the delivery of brief interventions for heavy drinking in primary health care: outcome results of the Optimizing Delivery of Health Care Intervention (ODHIN) five-country cluster randomized factorial trial. Addiction. 2016;111(11):1935-1945. doi:10.1111/add.13476

Huffstetler

Villalobos

Brooks

, et al. The current state of alcohol screening and management in Virginia primary care practices: an evaluation of preventive service use. Med Clin North Am. 2023;107(6S):e1-e17. doi:10.1016/j.mcna.2023.07.001

Rosário

Santos

Angus

Pas

Ribeiro

Fitzgerald

Factors influencing the implementation of screening and brief interventions for alcohol use in primary care practices: a systematic review using the COM-B system and Theoretical Domains Framework. Implement Sci. 2021;16(1):6. doi:10.1186/s13012-020-01073-0

Huffstetler

Epling

Krist

AH.

The need for electronic health records to support delivery of behavioral health preventive services. JAMA. 2022;328(8):707-708. doi:10.1001/jama.2022.13391

Johnson

Jackson

Guillaume

Meier

Goyder

Barriers and facilitators to implementing screening and brief intervention for alcohol misuse: a systematic review of qualitative evidence. J Public Health. 2011;33(3):412-421. doi:10.1093/pubmed/fdq095

10.

Dzidowska

Lee

KSK

Wylie

, et al. A systematic review of approaches to improve practice, detection and treatment of unhealthy alcohol use in primary health care: a role for continuous quality improvement. BMC Fam Pract. 2020;21(1):33. doi:10.1186/s12875-020-1101-x

11.

Keurhorst

van de Glind

Bitarello do Amaral-Sabadini

, et al. Implementation strategies to enhance management of heavy alcohol consumption in primary health care: a meta-analysis. Addiction. 2015;110(12):1877-1900. doi:10.1111/add.13088

12.

Agency for Healthcare Research and Quality. EvidenceNOW. 2021. Accessed September 5, 2023. https://www.ahrq.gov/evidencenow/index.html

13.

Solberg

Kuzel

Parchman

, et al. A taxonomy for external support for practice transformation. J Am Board Fam Med. 2021;34(1):32-39. doi:10.3122/jabfm.2021.01.200225

14.

Walunas

Bannon

, et al. Does coaching matter? Examining the impact of specific practice facilitation strategies on implementation of quality improvement interventions in the Healthy Hearts in the Heartland study. Implement Sci. 2021;16(1):33. doi:10.1186/s13012-021-01100-8

15.

Alagoz

Chih

Hitchcock

Brown

Quanbeck

The use of external change agents to promote quality improvement and organizational change in healthcare organizations: a systematic review. BMC Health Serv Res. 2018;18(1):42. doi:10.1186/s12913-018-2856-9

16.

Taylor

Genevro

Peikes

Geonnotti

Wang

Meyers

. Building Quality Improvement Capacity in Primary Care: Supports and Resources. Mathematica Policy Research Reports ede06423e0cf43c18c1827895, Mathematica Policy Research. https://ideas.repec.org/p/mpr/mprres/ede06423e0cf43c18c1827895074e31a.html

17.

Fagnan

Ramsey

Dickinson

Kline

Parchman

ML.

Place matters: closing the gap on rural primary care quality improvement capacity—the healthy hearts northwest study. J Am Board Fam Med. 2021;34(4):753-761. doi:10.3122/jabfm.2021.04.210011

18.

Coleman

Krakauer

Anderson

, et al. Improving quality improvement capacity and clinical performance in small primary care practices. Ann Fam Med. 2021;19(6):499-506. doi:10.1370/afm.2733

19.

Solberg

Crain

Jaeckels

, et al. The DIAMOND initiative: implementing collaborative care for depression in 75 primary care clinics. Implement Sci IS. 2013;8:135. doi:10.1186/1748-5908-8-135

20.

Baskerville

Liddy

Hogg

Systematic review and meta-analysis of practice facilitation within primary care settings. Ann Fam Med. 2012;10(1):63-74. doi:10.1370/afm.1312

21.

Siantz

Redline

Henwood

Practice facilitation in integrated behavioral health and primary care settings: a scoping review. J Behav Health Serv Res. 2021;48(1):133-155. doi:10.1007/s11414-020-09709-1

22.

Lindner

Balasubramanian

Marino

, et al. Estimating the cardiovascular disease risk reduction of a quality improvement initiative in primary care: findings from EvidenceNOW. J Am Board Fam Med. 2023;36(3):462-476. doi:10.3122/jabfm.2022.220331R1

23.

Parchman

Penfold

Ike

, et al. Team-based clinic redesign of opioid medication management in primary care: effect on opioid prescribing. Ann Fam Med. 2019;17(4):319-325. doi:10.1370/afm.2390

24.

Morley

Schad

Tumiel-Berhalter

, et al. Improving cancer screening rates in primary care via practice facilitation and academic detailing: a multi-PBRN quality improvement project. J Patient-Centered Res Rev. 2021;8(4):315-322. doi:10.17294/2330-0698.1855

25.

Wang

Pollack

Kadziel

, et al. Impact of practice facilitation in primary care on chronic disease care processes and outcomes: a systematic review. J Gen Intern Med. 2018;33(11):1968-1977. doi:10.1007/s11606-018-4581-9

26.

Nguyen

Cuthel

Padgett

, et al. How practice facilitation strategies differ by practice context. J Gen Intern Med. 2020;35(3):824-831. doi:10.1007/s11606-019-05350-7

27.

Meyers

Miller

Genevro

, et al. EvidenceNOW: balancing primary care implementation and implementation research. Ann Fam Med. 2018;16(Suppl 1):S5-S11. doi:10.1370/afm.2196

28.

Hemler

Hall

Cholan

, et al. Practice facilitator strategies for addressing electronic health record data challenges for quality improvement: EvidenceNOW. J Am Board Fam Med. 2018;31(3):398-409. doi:10.3122/jabfm.2018.03.170274

29.

Sutton

Richman

Rees

, et al. Successful trial of practice facilitation for plan, do, study, act quality improvement. J Am Board Fam Med. 2021;34(5):991-1002. doi:10.3122/jabfm.2021.05.210140

30.

Jonas

Barclay

Grammer

, et al. The STUN (STop UNhealthy) alcohol use now trial: study protocol for an adaptive randomized trial on dissemination and implementation of screening and management of unhealthy alcohol use in primary care. Trials. 2021;22(1):810. doi:10.1186/s13063-021-05641-7

31.

Singh

Sanchez

Kenzie

, et al. Improving screening, treatment, and intervention for unhealthy alcohol use in primary care through clinic, practice-based research network, and health plan partnerships: protocol of the ANTECEDENT study. PLoS ONE. 2022;17(6):e0269635. doi:10.1371/journal.pone.0269635

32.

Huffstetler

Kuzel

Sabo

, et al. Practice facilitation to promote evidence-based screening and management of unhealthy alcohol use in primary care: a practice-level randomized controlled trial. BMC Fam Pract. 2020;21(1):93. doi:10.1186/s12875-020-01147-4

33.

Davis

Coury

Sanchez

, et al. Improving screening, brief intervention and referral to treatment for unhealthy alcohol use in diverse, low-resourced primary care clinics. BMC Health Serv Res. 2024;24(1):1384. doi:10.1186/s12913-024-11870-8

34.

Huffstetler

Villalobos

Webel

, et al. Practice facilitation to address unhealthy alcohol use in primary care: a cluster randomized clinical trial. JAMA Health Forum. 2024;5(8):e242371. doi:10.1001/jamahealthforum.2024.2371

35.

Jortberg

Dickinson

Fernald

, et al. Improving care for unhealthy alcohol use: Results from the facilitating alcohol screening and treatment (FAST) colorado study. J Am Board Fam Med. 2024;37(6):1027-1037. doi: 10.3122/jabfm.2024.240048R1. PMID: 40118544

36.

Lee

Bobb

Richards

, et al. Integrating alcohol-related prevention and treatment into primary care: a cluster randomized implementation trial. JAMA Intern Med. 2023;183(4):319-328. doi:10.1001/jamainternmed.2022.7083

37.

AHRQ. Primary Care Practice Facilitation. 2019. Accessed September 17, 2023. https://admin.ahrq.gov/ncepcr/tools/transform-qi/deliver-facilitation.html

38.

National Institute on Alcohol Abuse and Alcoholism. Alcohol Facts and Statistics. 2022. Accessed July 16, 2023. https://www.niaaa.nih.gov/alcohols-effects-health/alcohol-topics/alcohol-facts-and-statistics?utm_source=GoogleAds&utm_medium=cpc&utm_campaign=NIAAA-AlcoholFacts-Statistics&utm_id=NIAAA-Web202&utm_term=GeneralPromo&utm_content=v2&gclid=Cj0KCQjwqs6lBhCxARIsAG8YcDj0xQ8YYm1cQmJxbR4MWljYoqR9dCzUJ5Q7BKkmUkyFlEn18ho2q7YaAhhbEALw_wcB

39.

National Institute on Alcohol Abuse and Alcoholism. Understanding Alcohol Use Disorder. National Institute on Alcohol Abuse and Alcoholism (NIAAA). 2023. Accessed September 17, 2023. https://www.niaaa.nih.gov/publications/brochures-and-fact-sheets/understanding-alcohol-use-disorder

40.

Watkins

Ober

Hunter

, et al. Diagnostic Criteria Checklist: Alcohol Use Disorder. 2021. Accessed June 2025 https://www.rand.org/pubs/tools/TLA928-1.html

41.

IHI. Quality Improvement Essentials Toolkit. IHI - Institute for Healthcare Improvement. 2023. Accessed September 17, 2023. https://www.ihi.org:443/resources/Pages/Tools/Quality-Improvement-Essentials-Toolkit.aspx?utm_campaign=QI-Toolkit-Promotion&utm_medium=Whiteboard-Video&utm_source=ihi

42.

Screening, Brief Intervention, and Referral to Treatment (SBIRT). 2014. Accessed September 17, 2023. https://www.C.gov/sbirt https://www.cdc.gov/alcohol-pregnancy/hcp/alcoholsbi/index.html 2023

43.

Mayo Clinic Proceedings. Evidence-Based Pharmacotherapies for Alcohol Use Disorder. Mayo Clinic Proceedings. 2024. Accessed March 5, 2024. https://www.mayoclinicproceedings.org/article/S0025-6196(20)30088-4/fulltext

44.

Motivational Interviewing Strategies to Engage Patients. 2023. Accessed September 17, 2023. https://www.ahrq.gov/evidencenow/tools/motivational-interviewing.html

45.

Bishop

Parsons

Villalobos

, et al. Reducing stigma through conversations in primary care about unhealthy alcohol use. Ann Fam Med. 2025;23(1):83-83. doi:10.1370/afm.240384

46.

Balio

Riley

Grammer

Weathington

Barclay

Jonas

DE.

Barriers to recruiting primary care practices for implementation research during COVID-19: a qualitative study of practice coaches from the Stop Unhealthy (STUN) Alcohol Use Now trial. Implement Res Pract. 2022;3:26334895221094297. doi:10.1177/26334895221094297

47.

Sweeney

Baron

Hall

, et al. Effective facilitator strategies for supporting primary care practice change: a mixed methods study. Ann Fam Med. 2022;20(5):414-422. doi:10.1370/afm.2847

48.

Ritchie

Parker

Kirchner

JE.

Facilitating implementation of primary care mental health over time and across organizational contexts: a qualitative study of role and process. BMC Health Serv Res. 2023;23(1):565. doi:10.1186/s12913-023-09598-y

49.

Anderson

Laurant

Kaner

Wensing

Grol

Engaging general practitioners in the management of hazardous and harmful alcohol consumption: results of a meta-analysis. J Stud Alcohol. 2004;65(2):191-199. doi:10.15288/jsa.2004.65.191

50.

Bradley

McCormack

Addis

, et al. Do electronic health records used by primary care practices support recommended alcohol-related care? JAMIA Open. 2024;7(4):ooae125. doi:10.1093/jamiaopen/ooae125

51.

Rockwell

Funk

Huffstetler

, et al. Screening for unhealthy alcohol use among patients with multiple chronic conditions in primary care. AJPM Focus. 2024;3(4):100233. doi:10.1016/j.focus.2024.100233

52.

Cranley

Cummings

Profetto-McGrath

Toth

Estabrooks

CA.

Facilitation roles and characteristics associated with research use by healthcare professionals: a scoping review. BMJ Open. 2017;7(8):e014384. doi:10.1136/bmjopen-2016-014384

53.

McNellis

. Welcome and Overview of AHRQ and Practice Facilitation. 2015. Accessed August 25, 2015. https://www.multiplechronicconditions.org/wp-content/uploads/2023/01/HHS-MMCC-Curriculum.pdf

54.

Agency for Healthcare Research and Quality. EvidenceNow Key Drivers and Change Strategies. Content last reviewed. 2020. Agency for Healthcare Research and Quality. Accessed February 2024. https://www.ahrq.gov/evidencenow/tools/keydrivers/description.html

55.

Woodward

Drummond

Oliver

, et al. Lagniappes: “a little something extra” or unintended positive consequences of implementation facilitation. Psychiatr Serv. 2021;72(1):31-36. doi:10.1176/appi.ps.202000151

56.

Garcia

Bounthavong

Gordon

, et al. Costs of implementing a multi-site facilitation intervention to increase access to medication treatment for opioid use disorder. Implement Sci Commun. 2023;4(1):91. doi:10.1186/s43058-023-00482-8

A Behind-the-Scenes Look at Practice Facilitation to Improve Delivery of Unhealthy Alcohol Use Screening and Management Services in Primary Care: A Qualitative Study

Abstract

Background:

Methods:

Results:

Conclusions:

Keywords

Introduction

Methods

Data Analysis

Results

Personalizing Practice Recruitment and Engagement

Meeting Practices and Care Teams “Where They Are At”

Tailoring Facilitation Strategies and Resources to Local Context

Affecting Cultural Change and Clinician Empowerment

Discussion

Limitations

Conclusions

Footnotes

Acknowledgements

ORCID iDs

Ethical Considerations

Consent to Participate

Author Contributions

Funding

Declaration of Conflicting Interests

Data Availability Statement

References