As states continue to advance behavioral health integration efforts, many are exploring ways to strengthen how primary care providers connect patients with substance use disorder (SUD) treatment and recovery supports.
While screening and brief intervention models have expanded in primary care settings, states continue to identify challenges related to referral pathways, care coordination, and timely access to specialty behavioral health treatment.
SBIRT (Screening, Brief Intervention, and Referral to Treatment)
SBIRT is an evidence-based public health approach to identify and provide early intervention for individuals with risky substance use and connect those with substance use disorders to treatment. SBIRT, particularly the “referral to treatment” component, however, is not consistently used in practice. States can strengthen this part of the model as part of their behavioral health integration efforts by aligning training, financing, partnerships, and referral infrastructure to help primary care providers connect patients to timely substance use treatment.
This blog post outlines key considerations for strengthening the referral-to-treatment component of Screening, Brief Intervention, and Referral to Treatment (SBIRT). It highlights policy and operational approaches, including state examples, to strengthen referral pathways between primary care and substance use treatment systems. This article also examines considerations related to Medicaid financing, workforce capacity, referral infrastructure, managed care expectations, and cross-system coordination.
Key Takeaways for States
- Shape referral to treatment (RT) as an active, warm hand-off. States can align coverage and contracting policies to support real-time linkages during a visit (scheduling and navigation), authorize peer support specialists/community health workers to support engagement and follow-up, and establish closed-loop referral networks.
- Strengthen infrastructure that reduces friction at the point of referral. States can designate centralized access points, technology solutions, and treatment availability dashboards to make it easier for primary care providers to identify appropriate services and facilitate timely connections to care.
- Embed follow-up into RT. States can reimburse outreach and care coordination after referral and align managed care or value-based payment incentives with treatment initiation and engagement to reduce drop-off.
Why Primary Care Matters for Substance Use Treatment
Substance use disorders (SUDs) remain common, yet treatment access continues to lag. In 2024, approximately 48.4 million people had a past-year substance use disorder (SUD), but only one in five of them received any kind of treatment. Untreated SUD contributes to significant health and economic consequences, including an estimated 7.7 million drug-related emergency department (ED) visits in the U.S and nearly $820 billion annually in health care costs, lost productivity, and other societal impacts.
Because many people with SUD receive care in primary care settings; even if they never seek specialty treatment; primary care offers an important opportunity to identify substance use concerns early and connect patients to appropriate care. SBIRT can help identify patients who would benefit from treatment, but referral to treatment is often the weakest component of implementation.
To that end, states can strengthen implementation of SBIRT into primary care settings to identify alcohol and drug use concerns early and provide brief interventions in a trusted health care setting. Evidence suggests these interventions can reduce unhealthy alcohol use and helps identify individuals who may benefit from specialty substance use treatment. States can further strengthen the impact of SBIRT by supporting referral pathways and partnerships between primary care and specialty providers to facilitate access to appropriate treatment and recovery supports.
National and state experts are prioritizing advancing behavioral health integration in primary care. See NASHP’s Primary Care Policy Menu, which highlights policy options for states to strengthen connections between primary care and behavioral health services.
State Strategies to Support Key Components
Referral to treatment often requires coordination beyond a single primary care practice. Patients may need help navigating treatment options, scheduling services, or addressing barriers that prevent them from engaging in care. States can strengthen these connections by aligning policies, workforce supports, and referral infrastructure that help primary care providers connect patients to appropriate substance use treatment.
Key considerations for implementation of referral to treatment in SBIRT include:
- Training providers and care teams
- Supporting team-based care models
- Enabling warm hand-offs
- Making treatment resources easy to access
- Coordinating follow-up
The following examples highlight how states are strengthening these components to improve access to substance use treatment through SBIRT. The appendix provides more details on each component.
SBIRT Training
Several states have taken an active role in making SBIRT training available to primary care practices:
New Hampshire
The state supported implementation of Screen and Intervene a SBIRT initiative used in medical facilities across the state. The initiative is supported by the Center for Excellence on Addiction and was established with funding from the New Hampshire Department of Health and Human Services, Bureau of Drug and Alcohol Services. The center provides implementation support through tailored training, technical assistance, and practice-specific consultation to help providers integrate SBIRT into routine clinical workflows. Resources include on-site and virtual training as well as practical implementation tools, such as step-by-step SBIRT playbooks, to support adoption across a variety of care settings
Oregon
Oregon’s SBIRT efforts demonstrate how states can scale prevention and early intervention by aligning academic partnerships with policy and payment incentives. The Oregon Health & Science University initially developed SBIRT training through a grant from the Substance Abuse and Mental Health Services Administration, which later expanded into a statewide resource.
The state helped drive adoption by incorporating substance use screening into Oregon’s Patient-Centered Primary Care Home Program recognition standards, making SBIRT a key tool for meeting requirements related to screening, referral, and care coordination. Oregon also included SBIRT in coordinated care organization incentive measures, creating Medicaid-aligned financial incentives for implementation. The state further supported adoption through learning collaboratives and technical assistance, including coaching provided through the Patient-Centered Primary Care Institute.
Team-Based Care
States are supporting team-based care models that help primary care practices implement SBIRT and connect individuals to specialty SUD treatment. The following examples highlight state approaches:
Massachusetts
The Massachusetts nurse care manager (NCM) model was created to increase the number of primary care practices willing to prescribe buprenorphine to patients with opioid dependence. As with SBIRT, providers were reluctant to implement office-based opioid treatment due to time constraints. State grants offer providers free training and technical assistance, as well as funding for dedicated nursing staff to assess and monitor patients and coordinate their care. Providers are incentivized for participation through adequate reimbursement, as the Medicaid prospective payment system for Community Health Centers and Federally Qualified Health Centers (FQHCs) allows NCMs to bill at the same rate as physicians for an individual medical visit. Massachusetts uses a mix of state general funds and federal dollars — including the Substance Use Prevention, Treatment, and Recovery Services Block Grant and the State Opioid Response Grant — to pay for services not covered by Medicaid. Based on its success, the state expanded eligibility for the NCM model to include alcohol and stimulants.
Kentucky
Like Massachusetts, Kentucky uses a blended funding approach to integrate peer support specialists into FQHCs and rural health clinics (RHCs) and as members of the Kentucky Primary Care Association (KPCA). In this partnership between KPCA and the Kentucky Overdose Response Effort (KORE), the state leverages State Opioid Response dollars to support salaries and activities not covered by the FQHC/RHC rate. KORE acts as the payer of last resort when insurers do not cover the services necessary for integrated behavioral health care. Peers with lived experience of substance use are valued as full team members and provide non-clinical support, such as recovery coaching and outreach, to others experiencing similar challenges.
Warm Hand-Off Partnerships
State and local governments, as well as individual providers, can play an active role in developing critical partnerships between primary care and specialty substance use treatment, thereby supporting the warm hand-off process.
Ohio
The Alcohol Drug Addiction and Mental Health Services (ADAMHS) Board of Cuyahoga County funds a collaborative grant program that embeds state-certified peer support specialists in the emergency department and in inpatient and outpatient units of the MetroHealth Medical Center. Peers are available 24/7 and offer on-demand warm hand-offs to recovery services and substance use treatment, working closely with the advanced practice registered nurse case manager to facilitate linkages to internal and external resources. In Ohio, the ADAMHS boards serve as the local planning and funding bodies for addiction services across the state and coordinate with the Ohio Department of Behavioral Health.
Massachusetts
Through an SBIRT grant, the Mercy Hospital SBIRT program developed working relationships with social workers from other area hospitals and ongoing relationships with SUD treatment providers from Western to Central Massachusetts. The program is a member of the Western Massachusetts Substance Abuse Providers Association and the Massachusetts Organization for Addiction Recovery (MOAR). MOAR is funded by the Massachusetts Bureau of Addiction Services, in part to foster these kinds of community connections. SBIRT staff members toured many sites where they refer patients and met with nearly every admissions director and coordinator for those programs. Referral relationships include local counseling agencies, transitional programs, the Department of Public Health regional office, Health Care for the Homeless and other nonprofit health care sites, withdrawal management hospitals, and residential substance use treatment programs.
Rhode Island
The state leverages existing structures to forge relationships between primary care and substance use providers. The Governor’s Overdose Task Force was launched to create linkages across systems, and, in addition to substance use treatment providers, includes representation from the community health center association, state hospital association, and state nursing association. Substance use and primary care providers routinely participate in major health care planning initiatives such as the Medicaid Accountable Entity program. State certification standards for accountable entities require that SUD capacity be demonstrated through evidence of partnerships with SUD service providers.
Tennessee
Recognizing the need for better integration of behavioral and physical health, the Tennessee Commissioners of the Department of Mental Health and Substance Abuse Services (DMHSAS) and the Department of Health came together to develop strategies to leverage local departments of health to increase access to behavioral health services. The state provided funding for Community Mental Health Centers to embed mental health staff in local health departments that provide health care services across the state. Using Rural Health Transformation funding, the state is planning to expand this program to include access to SUD care first by training on SBIRT and then embedding SUD professionals on-site. In addition, DMHSAS funds Project Rural Recovery, a program that expands primary care access to rural communities using mobile health clinics. These clinics provide an array of physical and behavioral health services, including SUD screening, assessment, treatment, and connection to care.
Making Resources Easy to Access
Patients assessed as needing specialty SUD treatment and willing to accept a referral need resources to be available in real time. In addition to addressing provider capacity, states can support primary care providers (PCPs) by demystifying the SUD treatment network through registries, real-time databases, and referral platforms.
Delaware
The state created a statewide comprehensive referral network to help manage treatment transitions. The Delaware Treatment and Referral Network (DTRN) automates the referral process using a web-based application that securely connects patients to available SUD care, eliminating the need for back-and-forth calls with multiple treatment centers to place those in need. The network locates the most appropriate and available level of care and sends an electronic referral to a provider 24/7. Using State Opioid Response dollars, the state created a Tier Award Program (TAP) to fund PCPs, FQHCs, and other outpatient medical practices to implement SBIRT. In addition to receiving funding, TAP practices receive training, technical assistance, and incorporation into the DTRN system. In December 2024, Delaware hit a new milestone of 200,000 referrals processed through DTRN. The state also piloted transportation services to Delaware clients receiving SUD treatment, making access to care more convenient. Participating Delaware patient care coordinators and health care providers can order a ride for a client through DTRN and see a client’s real-time status.
New York
The state’s online SBIRT implementation manual emphasizes the importance of warm hand-offs and encourages medical providers to be familiar with the programs to which they are referring patients. In this way, they can ensure these programs are reputable and help patients understand what to expect. State officials note the importance of creating personal connections when possible and having ready “referral bookmarks.” To support educated referrals, the implementation manual describes common treatment services and community resources, along with links to the provider and program lookup and the Office of Addiction Services and Supports Treatment Availability Dashboard. This online search tool helps PCPs identify SUD treatment by type and location. It also provides links to non-treatment support services such as recovery centers, housing providers, and clubhouses. PCPs may also find support through the state’s Open Access Centers, which can provide immediate assessments and referrals to treatment 24/7.
New Hampshire
New Hampshire used State Opioid Response funding to create local access points, called Doorways, so that individuals in need of treatment would never have to drive more than 60 minutes to get help. These one-stop referral resources offer 24/7 access to screening and evidence-based (American Society of Addition Medicine) assessments conducted by licensed staff, relieving PCPs of the need to assess the appropriate level of care and make multiple treatment connections. In 2022, Doorways served an average of 403 new clients and 761 established clients per month, with 20 percent of these referred by medical providers or social service agencies. New Hampshire uses a cost-based reimbursement strategy to support Doorways. The Doorway sites offer more than just assessment, and services may vary by site, but they all include administration of a flexible fund program to address social drivers of health; respite vouchers to provide safe housing for clients awaiting treatment; mechanisms to immediately transport someone to safe housing while awaiting treatment; facilitated referrals; and case management to navigate the treatment system. Each Doorway also identifies local resources and referral agreements to assist with specialized populations (e.g., pregnant women, veterans, families, and people experiencing homelessness). The state also offers an online drug and alcohol treatment locator.
Coordinating Follow-Up
As noted previously, studying the effects of follow-up on SBIRT referrals is relatively new. Noted below are states that have prioritized follow-up care either through PCP settings or through the coordinated care agencies receiving the referrals.
Massachusetts
In practices employing the nurse care manager model, regularly scheduled check-ins to assess progress, adjust treatment plans, and provide ongoing support are essential components of the services offered.
Delaware
Delaware’s Division of Substance Abuse and Mental Health requires medical practices receiving State Opioid Response Tier Award Program (TAP) funding to implement SBIRT to include follow-up strategies for patients referred to treatment or recovery supports. TAP-funded providers are expected to develop approaches to deepen engagement and follow up with individuals with opioid or stimulant use disorders regarding referrals made to treatment or recovery support services.
New Hampshire
Doorway sites are required to conduct recovery monitoring. The Doorway program reported an average of approximately 2,500 recovery monitoring contact attempts each month in 2022. In that year, more than 30,000 recovery contacts were conducted. Doorway sites are also required to conduct engagement and outreach with clients who are not ready to engage in treatment. Through this formal outreach process, individual bridge counseling and recovery planning groups are offered.
Leveraging Technology to Strengthen Referral Pathways
States are increasingly leveraging technology and data-sharing infrastructure to strengthen referral-to-treatment pathways by improving communication among primary care providers, substance use treatment providers, and community-based organizations. Investments in health information exchanges, electronic referral systems, and closed-loop referral platforms can enable providers to exchange information, coordinate care, and monitor whether patients successfully connect to treatment and recovery supports.
As states continue advancing health data interoperability, they may also wish to explore Office of the National Coordinator for Health Information Technology’s Care Coordination for Referrals resources to inform the design and implementation of electronic referral and care coordination infrastructure across health care and community-based settings. While technology alone cannot address workforce shortages or treatment capacity challenges, interoperable systems can help improve care coordination, reduce administrative burden, and better understand where patients encounter barriers to accessing treatment.
Acknowledgments
This brief was coauthored by Rebecca Boss, Senior Consultant for Technical Assistance Collaborative LLC.
Support for this work was provided by West Health.
Appendix: Key Components of Referral to Treatment
Training
Research suggests that the quality of the referral process and the patient-provider relationship are both significant factors in effectively connecting individuals to the treatment they need. In PCP settings implementing SBIRT, referrals should be incorporated into brief interventions using motivational interviewing techniques. The quality of the intervention matters, as one study demonstrated brief interventions consisting only of giving information and advice decreased the likelihood that patients would engage in treatment. In an approach that maintains fidelity to the SBIRT model, clinicians focus on the patient’s goals and explore options for achieving those goals. In that vein, a referral is presented as an option for consideration rather than a provider recommendation, to avoid disengagement should the patient not follow through. Using motivational interviewing techniques, incorporating a patient-centered approach, and including harm reduction are all key tenets of SBIRT. States can support fidelity to the SBIRT model in primary care by providing resources to support both initial and ongoing training in these skills.
Teamwork
Physicians often mention lack of time as a major barrier to SBIRT implementation. An interprofessional team that incorporates staff to take responsibility throughout the SBIRT continuum, including referral to treatment, can reduce the burden on participating doctors. In addition to physicians, staff trained to deliver SBIRT services may include nurses, medical assistants, community health workers, social workers, mental health counselors, substance use specialists, and peer specialists. SBIRT practitioners may be in-house generalists — team members who have other responsibilities within the practice, in-house specialists hired specifically to implement SBIRT and related substance use services, or contracted specialists who are not part of the practice but are brought on specifically to implement SBIRT activities, such as brief interventions or referrals to treatment. States can support PCPs in creating such staffing models to facilitate effective referrals to treatment.
Warm Hand-Offs
A warm hand-off is a patient-centered approach used in health care to ensure a patient’s smooth and well-supported transition from one provider to another. A warm hand-off occurs when the patient’s health care provider personally introduces them to the next care professional they will need to work with (e.g., behavioral health specialist, addiction counselor). A patient’s interest in continuing care is influenced by the quality of their relationships with service providers and referral process offered, both of which can be improved through warm hand-off strategies. To facilitate warm hand-offs, SBIRT practitioners need to establish direct referral pathways to behavioral health or addiction specialists. In making these introductions, language matters; for this reason, it is recommended that the behavioral health care provider be referred to as a “colleague” or a “specialist.”
Core Elements of a Warm Hand-Off
1. Direct In-Person Introduction
- The primary care clinician walks the patient to the behavioral health provider or connects them via phone/video during the visit. This personal introduction builds trust and reduces anxiety.
2. Collaborative Communication
- The primary care provider explains the reason for the referral in front of the patient, ensuring transparency.
- The behavioral health provider acknowledges the patient’s concerns and begins engagement immediately.
3. Immediate Engagement
- The behavioral health provider conducts an initial assessment or schedules the first appointment before the patient leaves the primary care office. This minimizes delays and reduces the risk of the patient being disengaged.
4. Patient-Centered Approach
- The primary care provider emphasizes empathy, works to reduce stigma, and validates the patient’s experience.
- The primary care provider encourages shared decision-making about treatment options.
Benefits of Warm Hand-Offs
- Improves treatment uptake: Patients are more likely to follow through when introduced directly.
- Reduces drop-off: Eliminates barriers such as confusion or procrastination.
- Builds trust: Patients feel supported and cared for by a team.
- Enhances care coordination: Providers share information in real time, improving continuity.
Readily Accessible Resources
Having an initial appointment scheduled within 30 days of a referral significantly increases the likelihood of attendance; that likelihood is even stronger when the initial appointment is scheduled to take place on the same day as the referral. For concerted referral efforts, PCPs should identify and partner with local specialty alcohol addiction treatment. When available, an SBIRT team can successfully implement care coordination by proactively using a treatment registry or real-time treatment availability database, which can guide care and outreach. States have a role in facilitating treatment system navigation and can foster PCP/SUD treatment relationships, as well as create registries and real-time databases that provide on-demand access to local treatment resources.
Follow-Up
Recent studies provide evidence that the referral to treatment component of SBIRT is more effective when combined with “recovery management checkups.” Researchers found that repeated checkups were associated with increased days of treatment for a range of SUDs and reductions in drug use. Using this assertive linkage and engagement intervention, recovery management checkups in primary care settings resulted in 99 percent of patients agreeing to go to treatment and 90 percent attending the treatment intake.
