2 Attachment C: Key Informant Interview Guides - Practices

Draft Key Informant Interview Guide: Practices

Thank you for taking the time to speak with us today. Our aims are to engage in a discussion about your practice’s participation in the [Grantee] initiative targeting screening and management of unhealthy alcohol use in primary care for adults aged 18 and up. We are interested in hearing about your practice’s experiences, including clinical and non-clinical staff involvement, changes in workflow, patient experience, and data monitoring and reporting. We have developed a set of questions to guide our discussion, but please feel free to raise additional issues or elaborate on areas you feel are important to our understanding of the initiative and your experiences with it.

[Interviewer note: Numbered questions can be used to guide the interview and conversation. Based on background data already collected, not all questions will be asked of every interviewee. Sub-bullets beneath questions are prompts to assist you and need only be asked when additional information is needed.]

Practice Setting and Team

1. Briefly describe your patient population.

   • Prompts, if needed: For example, what type of insurance do patients use? Medicare, Medicaid, private insurance?

   • What is the general racial and ethnic make-up of your patient population? Age distribution?

2. Please describe the practice setting, including roles of various clinical and non-clinical staff involved in the implementation of SBI/RT and MAT processes into the practice.

   • Prompts, if needed: Does your practice have any residents or students in training?

   • Describe any changes to roles for clinical or non-clinical staff working on the UAU initiative/study over the past year?

Intervention Characteristics

3. How did the practice first learn about the initiative/study, and what was your initial response?

This survey is authorized under 42 U.S.C. 299a. The confidentiality of your responses to this survey is protected by Sections 944(c) and 308(d) of the Public Health Service Act [42 U.S.C. 299c-3(c) and 42 U.S.C. 242m(d)].  Information that could identify you will not be disclosed unless you have consented to that disclosure. Public reporting burden for this collection of information is estimated to average XX minutes per response, the estimated time required to complete the survey. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 5600 Fishers Lane, Room #07W42, Rockville, MD 20857.

4. What motivated the practice to participate in the initiative/study?

• Prompts, if needed: Does the practice and/or staff receive any incentives for participating in the study?

• Do the activities included in the study/initiative align with any SBIRT quality measures your practice reports?

5. What are the biggest changes or adjustments the practice had to make to participate in the initiative/study?

   • Prompt if needed: changes to workflow, clinical and non-clinical staff time and availability, documentation in the medical records, etc.

6. Have you found any ways to make these necessary adjustments less burdensome or more efficient in your practice?

Screening, Brief Intervention, Referral to Treatment (SBI/RT) and MAT

7. Please walk me through the process the practice uses for screening patients for unhealthy alcohol use and for identifying patients who may benefit from a brief intervention.

• What type of clinical or non-clinical staff member does the screening? At what point during a visit?

• What screening tool(s) do you use to identify unhealthy alcohol use?

• What technology (if any) is used for screening?

• How is the screening process documented?

• What handoffs between clinical and/or non-clinical staff occur during the screening process?

• What is the process for reviewing and interpreting alcohol screening results?

• What is the next step in the process when a patient screens positive for unhealthy alcohol use?

• If a brief intervention is conducted, who conducts it?

• What (if any) technology is used to deliver brief intervention elements (e.g., screening score feedback, alcohol education, or brief advice)?

• For those who screen positive, what (if any) particular model of brief intervention is implemented (e.g., Brief Negotiated Interview, 5A’s, FLO, FRAMES, or other model)?

• For those who screen positive for unhealthy alcohol use, what assessment tools are used to determine one’s need for treatment, including MAT?

• What is the process for following up with patients who receive a brief intervention?

8. Please walk me through the process the practice uses with patients who screen positive for unhealthy alcohol use and are referred to specialty care for alcohol use.

   • How is the decision made to refer a patient to specialty care?

   • What type of staff member makes the referral? How is it made? What are staff members’ comfort/confidence levels in making these referrals?

   • To what types of services are patients referred and are these sufficient for the needs of those patients? Are they able to get into services when they are referred?

   • What is the process for following up with patients who receive a referral?

9. Please walk me through the process the practice uses for patients who might benefit from medication-assisted therapy (MAT).

   • What diagnostic or assessment tools are used to identify patients who may benefit from MAT identified (e.g., ASAM)?

   • What type of staff member presents options to patients?

   • What is the process for patients who initiate MAT?

   • What is the follow-up process for patients once they have initiated MAT?

10. Finally, from the patient perspective, please walk me through the screening process for identifying unhealthy alcohol use and for identifying patients who may benefit from a brief intervention or MAT.

• How is this process different since implementation of SBI/RT and MAT took place?

• What feedback has the practice received from patients?

11. How is the approach to screening, referral to treatment, brief intervention, or MAT tailored or adjusted based on particular patient populations?

• For example, are any adjustments or special considerations made for patients based on age (e.g., adolescents, young adults, or older adults)?

• Are any adjustments or special considerations made for patients based on race or ethnicity (e.g., Hispanic, Black/African American, White)?

• Are any adjustments or special considerations made for patients based on language preference or proficiency (e.g., limited English proficiency)?

• Are any adjustments or special considerations made for patients based on sex or gender (e.g., male, female, transgender, gender non-conforming)?

• Are any adjustments or special considerations made for women of childbearing age (i.e. those who could become or are potentially pregnant)?

• Are any adjustments or special considerations made for patients based on visual or auditory disabilities (e.g. blindness, deafness)?

• Are any adjustments or special considerations made for patients who have or are experiencing trauma or adverse childhood experiences?

• Are adjustments or special considerations made for any other patient populations?

12. What types of telehealth services does your practice offer, if any?

    • Is telehealth used to deliver any part of the SBIRT or MAT services related to this initiative? If so, please walk me through the process.

Outer Setting

13. How have regional or statewide initiatives or policies influenced the practice’s decision to participate in this initiative/study (either positively or negatively)?

    • If so, what initiatives?

    • How were they influential?

• How have reimbursement or payer issues affected the practice’s ability to participate in this initiative/study? (6A & 6B)Do providers use SBIRT billing codes for reimbursement of SBIRT or MAT services? Why or why not?

• [If practice indicates they use telehealth services related to SBIRT or MAT] How have reimbursement or payer issues for telehealth appointments (e.g. coding for telehealth screening/brief intervention) affected the practice’s ability to participate in this initiative/study?

14. What additional factors influenced the practice’s decision to participate or affected its practice ability to participate in this initiative/study?

Inner Setting

15. What features of the practice have made it easier or more challenging to implement an initiative/study such as this one?

    • Prompt, if needed: features related to practice size, geographic region, ownership, patient population, other?

16. What internal practice infrastructure, policies, capabilities, or other factors related to the practice have proven helpful in implementing the initiative/study in your practice? (6A & 8A)

    • Prompts, if needed: Does your electronic health record provide capabilities that have been helpful in this initiative?

    • What additional infrastructure or capabilities would be helpful?

17. What internal practice infrastructure, policies, capabilities, or other factors have proven challenging in implementing the initiative/study in your practice?

18. What has been your experience with the practice facilitator or coach who has worked with the practice on this initiative/study?

    • How has engagement with clinical or non-clinical staff continued throughout the period of active implementation?

    • How often do practice facilitators engage with the practice?

☐ Daily ☐ Weekly ☐ Monthly ☐ Quarterly ☐ Other (specify)

• Is this amount of time sufficient to address your needs?

• What benefits (if any) do practice facilitators add in helping the practice to implement SBI/RT and MAT?

• What would you have done differently or changed, if anything? Why?

Characteristics of Individuals

Practice Staff

19. How did your practice decide to participate in this initiative? What staff member was the key driver behind participating?

20. What barriers have you encountered engaging clinical or non-clinical staff members in the initiative/study? (6B)

    • Prompt, if needed: barriers might include knowledge (thoughts), and beliefs (feelings) about the intervention, staff’s sense of self-efficacy, comfort level, confidence, preparedness, buy-in, or thoughts about the relative advantage of the intervention, and evidence strength and quality

Practice Facilitators

21. What qualifications do the practice facilitators need to ensure successful implementation of the implementation of SBI/RT and MAT?

22. What characteristics facilitate successful engagement between practice facilitators and clinical and non-clinical staff?

Patients

23. What kind of response do you get from patients who are being screened for unhealthy alcohol use?

    • Do you find that patients respond differently based on age (e.g. adolescents, young adults, or older adults)?

    • Do you find that patients respond differently based on race or ethnicity (e.g., Hispanic, Black/African American, White)?

    • Do you find that patients respond differently based on language preference or proficiency (e.g., limited English proficiency)?

    • Do you find that patients respond differently based on sex or gender (e.g., male, female, transgender, gender non-conforming)?

24. For which patients with unhealthy alcohol use does the brief intervention work particularly well? For which patients does brief intervention pose challenges?

25. For which patients who screen positive for an alcohol use disorder does MAT work particularly well? For which patients does it pose challenges?

26. What barriers or facilitators impact patient engagement with SBI/RT or MAT?

Implementation

Training/Practice Facilitation

27. What kind of training is provided to clinical and non-clinical staff on implementing the initiative/study? (8A)

28. What kind of training is provided by practice facilitators to clinical and non-clinical staff on implementing SBI/RT and MAT into the practice?

    • How often is this training offered?

    • What type of training do practice facilitators provide to new clinical and non-clinical staff on implementing SBI/RT and MAT in the practice?

29. Please describe the practice’s clinical and non-clinical training protocols on SBI/RT and MAT over the life of this initiative (e.g., prior to implementation, during implementation, and post-implementation)?

30. What opportunities exist for clinical and non-clinical staff to continue to engage with those training materials or practice facilitators/coaches throughout the period of initiative/study implementation?

    • What made the training opportunities helpful or unhelpful?

    • What about after the implementation period ends?

Data and Quality Improvement

31. Please describe the data the practice receives on its performance in implementing SBI/RT and MAT? Who (e.g., quality director, clinical director, etc.) is responsible for sharing the performance data within the practice? How is performance data shared with clinical and non-clinical staff?

    • How often is performance data provided to practices? How does the practice and clinical and non-clinical staff respond to and/or use these data?

    • What types, if any, of incentives/rewards/awards are provided for clinical and non-clinical staff who successfully integrate SBI/RT and MAT into practice?

32. What challenges has the practice encountered in documenting patients that have been screened for unhealthy alcohol use, received a brief intervention, were referred to treatment, or initiated medication-assisted therapy?

    • Which metric(s) has/have been the most challenging to document?

    • What could make the challenging metric(s) easier to document?

Evaluation

33. In addition to the process measures, what other primary outcome measures is the practice documenting and reporting to grantees?

34. What analyses has the practice performed on data to date?

    • Describe any general trends or findings that you feel comfortable sharing at this time.

    • What have you found to be surprising or unexpected?

35. What challenges have you encountered in submitting data?

Wrap Up

36. Are there any additional key lessons learned or best practices you would like share with us?

37. What other experiences would you like to share with us regarding your experience with implementing this initiative?

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