Erum Nadeem

Understanding the Components of Quality Improvement Collaboratives: A Systematic Literature Review

CONTEXT In response to national efforts to improve quality of care, policymakers and health care leaders have increasingly turned to quality improvement collaboratives (QICs) as an efficient approach to improving provider practices and patient outcomes through the dissemination of evidence-based practices. This article presents findings from a systematic review of the literature on QICs, focusing on the identification of common components of QICs in health care and exploring, when possible, relations between QIC components and outcomes at the patient or provider level. METHODS A systematic search of five major health care databases generated 294 unique articles, twenty-four of which met our criteria for inclusion in our final analysis. These articles pertained to either randomized controlled trials or quasi-experimental studies with comparison groups, and they reported the findings from twenty different studies of QICs in health care. We coded the articles to identify the components reported for each collaborative. FINDINGS We found fourteen crosscutting components as common ingredients in health care QICs (e.g., in-person learning sessions, phone meetings, data reporting, leadership involvement, and training in QI methods). The collaboratives reported included, on average, six to seven of these components. The most common were in-person learning sessions, plan-do-study-act (PDSA) cycles, multidisciplinary QI teams, and data collection for QI. The outcomes data from these studies indicate the greatest impact of QICs at the provider level; patient-level findings were less robust. CONCLUSIONS Reporting on specific components of the collaborative was imprecise across articles, rendering it impossible to identify active QIC ingredients linked to improved care. Although QICs appear to have some promise in improving the process of care, there is great need for further controlled research examining the core components of these collaboratives related to patient- and provider-level outcomes.

Consultation as an Implementation Strategy for Evidence-Based Practices Across Multiple Contexts: Unpacking the Black Box

There is great interest in the dissemination and implementation of evidence-based treatments and practices for children across schools and community mental health settings. A growing body of literature suggests that the use of one-time workshops as a training tool is ineffective in influencing therapist behavior and patient outcomes and that ongoing expert consultation and coaching is critical to actual uptake and quality implementation. Yet, we have very limited understanding of how expert consultation fits into the larger implementation support system, or the most effective consultation strategies. This commentary reviews the literature on consultation in child mental health, and proposes a set of core consultation functions, processes, and outcomes that should be further studied in the implementation of evidence-based practices for children.

Providing Evidence-Based Practice to Ethnically Diverse Youths: Examples from the Cognitive Behavioral Intervention for Trauma in Schools (CBITS) Program.

At first glance, implementing evidence-based treatments for ethnically diverse youth may appear to raise some concerns. Do manualized treatments work for the diverse youth we see in our communities? Should clinicians only use culturally-specific treatments? Unfortunately, the literature is not definitive. Several studies have found that tailoring interventions for specific populations can increase their effectiveness1–5 while others have found that cultural adaptations of an intervention may actually dilute the effectiveness of the original treatment even though retention is improved.6 What appears to be important is to strike a balance between fidelity to evidence-based treatment and culturally-informed care. This paper provides illustrations from a school-community-academic partnership’s dissemination of the Cognitive-Behavioral Intervention for Trauma in Schools7 program to ethnically diverse communities nationwide. CBITS is an evidence-based intervention program initially developed for ethnic minority and immigrant youth exposed to trauma. CBITS was created to decrease the negative effects of trauma exposure in an ethnically and linguistically diverse group of primarily low-income children while being delivered in the real-world setting of schools. 8, 9 In a randomized controlled study, Mexican and Central American youth showed significant reduction in post-traumatic stress and depressive symptoms.10, 11 Similar positive effects have been found in dissemination evaluations of CBITS in other communities12, including urban African American13, Native American14, and rural communities.15 Although our CBITS partnership recommends program evaluations, we recognize that it is not always feasible for each community to do systematic evaluation for each adaptation or modification of CBITS. In delivering CBITS, we have confronted common issues that arise when trying to deliver an evidence-based intervention to youth from a broad range of ethnic and socioeconomic backgrounds. We present several examples of how we use community partnerships throughout all phases of dissemination, from program development, pre-implementation planning, to delivery of CBITS groups (see Figure 1). Community partnerships refer to collaboration between key stakeholders from the local school and its surrounding community including school personnel, parents, community organizations, faith-based groups, clinicians and researchers. This approach addresses contextual and cultural issues at every stage so that CBITS is tailored for each unique community. We have found this to be a promising model for reaching diverse and underserved populations and increasing community engagement.8, 16 Figure 1 Model for Using Community Partnerships to Provide Culturally-Sensitive Evidence-Based Treatment

Scaling Up Evidence-Based Practices for Children and Families in New York State: Toward Evidence-based Policies on Implementation for State Mental Health Systems

Dissemination of innovations is widely considered the sine qua non for system improvement. At least two dozen states are rolling out evidence-based mental health practices targeted at children and families using trainings, consultations, webinars, and learning collaboratives to improve quality and outcomes. In New York State (NYS) a group of researchers, policymakers, providers, and family support specialists have worked in partnership since 2002 to redesign and evaluate the childrens mental health system. Five system strategies driven by empirically based practices and organized within a state-supported infrastructure have been used in the child and family service system with more than 2,000 providers: (a) business practices, (b) use of health information technologies in quality improvement, (c) specific clinical interventions targeted at common childhood disorders, (d) parent activation, and (e) quality indicator development. The NYS system has provided a laboratory for naturalistic experiments. We describe these initiatives, key findings and challenges, lessons learned for scaling, and implications for creating evidence-based implementation policies in state systems.

Perceived Need for Care among Low-Income Immigrant and U.S.-Born Black and Latina Women with Depression

PURPOSE To examine perceived need for care for mental health problems as a possible contributor to ethnic disparities in receiving care among low-income depressed women. METHODS The role of ethnicity, somatization, and stigma as they relate to perceived need for care is examined. Participants were 1577 low-income women who met criteria for depression. RESULTS Compared with U.S.-born depressed white women, most depressed ethnic minority women were less likely to perceive a need for mental health care (black immigrants: OR 0.30, p < 0.001; U.S.-born blacks: OR 0.43, p < 0.001; immigrant Latinas: OR 0.52, p < 0.01). Stigma-related concerns decreased the likelihood of perceiving a need for mental health care (OR 0.80, p < 0.05). Having multiple somatic symptoms (OR 1.57, p < 0.001) increased the likelihood of endorsing perceived need. CONCLUSIONS Findings suggest that there are ethnic differences in perceived need for mental healthcare that may partially account for the low rates of care for depression among low-income and minority women. The relations among stigma, somatization, and perceived need were strikingly similar across ethnic groups.

Adverse Childhood Experiences and Mental Health, Chronic Medical Conditions, and Development in Young Children.

OBJECTIVE To determine the relationships between adverse childhood experiences (ACEs) and mental health, chronic medical conditions, and social development among young children in the child welfare system. METHODS This cross-sectional study used a nationally representative sample of children investigated by child welfare (National Survey of Child and Adolescent Well-Being II) from 2008 to 2009. Our analysis included caregiver interviews and caseworker reports about children aged 18 to 71 months who were not in out-of-home care (n = 912). We examined the associations between ACEs and mental health (measured by the Child Behavior Checklist [CBCL]), reported chronic medical conditions, and social development (measured by the Vineland Socialization Scale) in bivariate and multivariate analyses. RESULTS Nearly all children (98.1%) were reported to have had an ACE in their lifetime; the average number of ACEs was 3.6. For every additional reported ACE, there was a 32% increased odds of having a problem score on the CBCL (odds ratio [OR] 1.32, 95% confidence interval [CI] 1.14, 1.53) and a 21% increased odds of having a chronic medical condition (OR 1.21, 95% CI 1.05, 1.40). Among children aged 36 to 71 months, for every additional reported ACE, there was a 77% increased odds of a low Vineland Socialization score (OR 1.77, 95% CI 1.12, 2.78). CONCLUSIONS ACEs were associated with poor early childhood mental health and chronic medical conditions, and, among children aged 3 to 5, social development. Efforts are needed to examine whether providing early intervention to families with multiple stressors mitigates the impact of ACEs on childrens outcomes.

A Literature Review of Learning Collaboratives in Mental Health Care: Used but Untested

OBJECTIVE Policy makers have increasingly turned to learning collaboratives (LCs) as a strategy for improving usual care through the dissemination of evidence-based practices. The purpose of this review was to characterize the state of the evidence for use of LCs in mental health care. METHODS A systematic search of major academic databases for peer-reviewed articles on LCs in mental health care generated 421 unique articles across a range of disciplines; 28 mental health articles were selected for full-text review, and 20 articles representing 16 distinct studies met criteria for final inclusion. Articles were coded to identify the LC components reported, the focus of the research, and key findings. RESULTS Most of the articles included assessments of provider- or patient-level variables at baseline and post-LC. Only one study included a comparison condition. LC targets ranged widely, from use of a depression screening tool to implementation of evidence-based treatments. Fourteen crosscutting LC components (for example, in-person learning sessions, phone meetings, data reporting, leadership involvement, and training in quality improvement methods) were identified. The LCs reviewed reported including, on average, seven components, most commonly in-person learning sessions, plan-do-study-act cycles, multidisciplinary quality improvement teams, and data collection for quality improvement. CONCLUSIONS LCs are being used widely in mental health care, although there is minimal evidence of their effectiveness and unclear reporting in regard to specific components. Rigorous observational and controlled research studies on the impact of LCs on targeted provider- and patient-level outcomes are greatly needed.

Implementing a Measurement Feedback System in Community Mental Health Clinics: A Case Study of Multilevel Barriers and Facilitators

Abstract Measurement feedback systems (MFSs) have been proposed as a means of improving practice. The present study examined the implementation of a MFS, the Contextualized Feedback System (CFS), in two community-based clinic sites. Significant implementation differences across sites provided a basis for examining factors that influenced clinician uptake of CFS. Following the theoretical implementation framework of Aarons et al. (Adm Policy Mental Health Mental Health Serv Res 38(1):4–23, 2011), we coded qualitative data collected from eighteen clinicians (13 from Clinic U and 5 from Clinic R) who participated in semi-structured interviews about their experience with CFS implementation. Results suggest that clinicians at both clinics perceived more barriers than facilitators to CFS implementation. Interestingly, clinicians at the higher implementing clinic reported a higher proportion of barriers to facilitators (3:1 vs. 2:1); however, these clinicians also reported a significantly higher level of organizational and leadership supports for CFS implementation. Implications of these findings are discussed.

The Role of Consultation Calls for Clinic Supervisors in Supporting Large-Scale Dissemination of Evidence-Based Treatments for Children

This study explores the content of consultation provided to clinic supervisors within the context of a statewide training program in an evidence-based practice. Minute-to-minute live coding of consultation calls with clinic supervisors was conducted in order to identify the content and distribution of call topics. Results indicated that approximately half of the total speaking time was spent on a range of clinically relevant topics (e.g., cognitive-behavioral therapy techniques, fidelity to the treatment protocols). The remaining time was spent on program administration and CBT-related supervisory issues. This pilot study has broad implications for structuring the content of consultation process in large-scale dissemination efforts involving multiple portions of the clinical workforce.

Development and Piloting of a Classroom-Focused Measurement Feedback System

The present study used a community partnered research method to develop and pilot a classroom-focused measurement feedback system (MFS) for school mental health providers to support teachers’ use of effective universal and target classroom practices related to student emotional and behavioral issues. School personnel from seven urban elementary and middle school classrooms participated. Phase I involved development and refinement of the system through a baseline needs assessment and rapid-cycle feedback. Phase II involved detailed case study analysis of pre-to-post quantitative and implementation process data. Results suggest that teachers who used the dashboard along with consultation showed improvement in observed classroom organization and emotional support. Results also suggest that MFS use was tied closely to consultation dose, and that broader support at the school level was critical. Classroom-focused MFSs are a promising tool to support classroom improvement, and warrant future research focused on their effectiveness and broad applicability.