Louise E. Parker

Outcomes of a Partnered Facilitation Strategy to Implement Primary Care-Mental Health

ABSTRACTBACKGROUNDImplementing new programs and practices is challenging, even when they are mandated. Implementation Facilitation (IF) strategies that focus on partnering with sites show promise for addressing these challenges.OBJECTIVEOur aim was to evaluate the effectiveness of an external/internal IF strategy within the context of a Department of Veterans Affairs (VA) mandate of Primary Care–Mental Health Integration (PC-MHI).DESIGNThis was a quasi-experimental, Hybrid Type III study. Generalized estimating equations assessed differences across sites.PARTICIPANTSPatients and providers at seven VA primary care clinics receiving the IF intervention and national support and seven matched comparison clinics receiving national support only participated in the study.INTERVENTIONWe used a highly partnered IF strategy incorporating evidence-based implementation interventions.MAIN MEASURESWe evaluated the IF strategy using VA administrative data and RE-AIM framework measures for two 6-month periods.KEY RESULTSEvaluation of RE-AIM measures from the first 6-month period indicated that PC patients at IF clinics had nine times the odds (OR=8.93, p<0.001) of also being seen in PC-MHI (Reach) compared to patients at non-IF clinics. PC providers at IF clinics had seven times the odds (OR=7.12, p=0.029) of referring patients to PC-MHI (Adoption) than providers at non-IF clinics, and a greater proportion of providers’ patients at IF clinics were referred to PC-MHI (Adoption) compared to non-IF clinics (β=0.027, p<0.001). Compared to PC patients at non-IF sites, patients at IF clinics did not have lower odds (OR=1.34, p=0.232) of being referred for first-time mental health specialty clinic visits (Effectiveness), or higher odds (OR=1.90, p=0.350) of receiving same-day access (Implementation). Assessment of program sustainability (Maintenance) was conducted by repeating this analysis for a second 6-month time period. Maintenance analyses results were similar to the earlier period.CONCLUSIONThe addition of a highly partnered IF strategy to national level support resulted in greater Reach and Adoption of the mandated PC-MHI initiative, thereby increasing patient access to VA mental health care.

A social marketing approach to implementing evidence-based practice in VHA QUERI: the TIDES depression collaborative care model

Collaborative care models for depression in primary care are effective and cost-effective, but difficult to spread to new sites. Translating Initiatives for Depression into Effective Solutions (TIDES) is an initiative to promote evidence-based collaborative care in the U.S. Veterans Health Administration (VHA). Social marketing applies marketing techniques to promote positive behavior change. Described in this paper, TIDES used a social marketing approach to foster national spread of collaborative care models.TIDES social marketing approachThe approach relied on a sequential model of behavior change and explicit attention to audience segmentation. Segments included VHA national leadership, Veterans Integrated Service Network (VISN) regional leadership, facility managers, frontline providers, and veterans. TIDES communications, materials and messages targeted each segment, guided by an overall marketing plan.ResultsDepression collaborative care based on the TIDES model was adopted by VHA as part of the new Primary Care Mental Health Initiative and associated policies. It is currently in use in more than 50 primary care practices across the United States, and continues to spread, suggesting success for its social marketing-based dissemination strategy.Discussion and conclusionDevelopment, execution and evaluation of the TIDES marketing effort shows that social marketing is a promising approach for promoting implementation of evidence-based interventions in integrated healthcare systems.

Using a Multi-Level Approach To Implement a Primary Care Mental Health (PCMH) Program

Successfully spreading innovation across large health care systems is a complex process requiring participation of stakeholders from a broad spectrum of professional backgrounds, skill sets, and organizational levels. We describe a process for engaging and activating stakeholders across individual, team, organization, and system levels to implement primary care-mental health integrated care programs in one regional Veterans Affairs health care network. Key stakeholders and researchers collaborated to propose and implement the program. Preliminary findings indicate that the program may reduce referrals to specialty mental health care.

Balancing health care evidence and art to meet clinical needs: policymakers' perspectives

Rationale, aims and objectives Although many believe that evidence-based practice (EBP) has great potential, critics have identified limitations including a focus on randomized clinical trial (RCT) evidence to the exclusion of other evidence types and a disregard for the art of medicine. Others have argued, however, that proper application of EBP involves reasoned consideration of a wide variety of information; thus, the dichotomy between medical science and art may be false. We explore the views of executive-level policymakers from the Veterans Health Administration, a leader in the EBP movement, regarding what constitutes evidence and the relative importance of evidence versus practical needs when determining clinical policy. Method We conducted 26 semi-structured qualitative interviews and performed a content analysis. Results Although informants generally believed in the value of EBP and the role of RCTs within it, they also valued other types of evidence. Further, they had concerns that were sometimes antithetical with strict adherence to an evidence-based approach. These included practical concerns, fit with organizational values and with local circumstances, resources, political pressures and patient needs. They were especially concerned about how to address medical conditions that affect many individuals or high-risk populations that have no evidence-based treatment. Conclusion When possible, health care practice should be evidence-based. When this is not possible, health care providers must turn to the art of medicine by using consensus-based best practices. Further, it is important for policymakers and researchers to work in concert to develop EBPs that are practical and meet needs.

Clinic-Level Process of Care for Depression in Primary Care Settings

Multi-component models for improving depression care target primary care (PC) clinics, yet few studies document usual clinic-level care. This case comparison assessed usual processes for depression management at 10 PC clinics. Although general similarities existed across sites, clinics varied on specific processes, barriers, and adherence to practice guidelines. Screening for depression conformed to guidelines. Processes for assessment, diagnosis, treatment, and follow-up varied to different degrees in different clinics. This individuality of usual care should be defined prior to quality improvement interventions, and may provide insights for introducing or tailoring changes, as well as improving interpretation of evaluation results.

Evaluation of an implementation facilitation strategy for settings that experience significant implementation barriers.

Panel overview Though several implementation and quality improvement strategies have been shown to be effective in implementing programs and practices in routine clinical settings [1,2], little work has been done in developing and testing implementation strategies in settings that experience significant implementation barriers. This VA funded study evaluated a highly partnered implementation facilitation (IF) strategy [3] within the context of a Department of Veteran Affairs (VA) mandate for implementation of Primary Care-Mental Health Integration (PC-MHI) [4]. The IF strategy consisted of a national expert external facilitator (EF) and two internal regional facilitators (IRFs) who partnered with regional, medical center, and clinic leadership and staff in two VA regional networks to implement PC-MHI. Facilitators helped partners design/adapt their PC-MHI programs, develop site-specific implementation plans, and identify/address implementation barriers. They also identified and engaged key stakeholders at all organizational levels; conducted academic detailing, marketing, staff training, patient education, formative evaluation, and audit and feedback; assisted with technical issues; and established learning collaboratives. The EF had expertise in the evidence-base for PC-MHI and implementation activities. The IRF had protected time to support implementation activities, was embedded within the clinical organization at the regional level, and was familiar with local and regional organizational structures, procedures, culture, and clinical processes. We used a quasi-experimental, Hybrid Type III design [5] and mixed methods to test effectiveness of the IF strategy and document IF activities. National VA MH leadership has adopted this IF strategy for sites facing challenges to adopting evidencebased practices [4,6,7]. This panel presents findings from the project’s three components: A quantitative study of facilitation outcomes, a qualitative study of the facilitation process and its outcomes, and a qualitative study of facilitation skill transfer.

Improving care quality through hybrid implementation/effectiveness studies: Best practices in design, methods, and measures

Improving care quality through hybrid implementation/effectiveness studies: Best practices in design, methods, and measures Amy N Cohen, Alison B Hamilton, Mona Ritchie, Brian S Mittman, JoAnn E Kirchner , Gail E Wyatt, John C Fortney, Gerhard Hellemann, Honghu Liu, Geoffrey M Curran, Fiona Whelan, Alicia M Eccles, Louise E Parker, Kirk McNagny, Craig S Hutchinson, Annapurni B Teague, Christopher Reist, Alexander S Young

Using implementation facilitation to foster clinical practice quality and adherence to evidence in challenged settings: a qualitative study

BackgroundWe evaluated a facilitation strategy to help clinical sites likely to experience challenges implement evidence-based Primary Care-Mental Health Integration (PC-MHI) care models within the context of a Department of Veterans Affairs (VA) initiative. This article describes our assessment of whether implementation facilitation (IF) can foster development of high quality PC-MHI programs that adhere to evidence, are sustainable and likely to improve clinical practices and outcomes.MethodsUtilizing a matched pair design, we conducted a qualitative descriptive evaluation of the IF strategy in sixteen VA primary care clinics. To assess program quality and adherence to evidence, we conducted one-hour structured telephone interviews, at two time points, with clinicians and leaders who knew the most about the clinics’ programs. We then created structured summaries of the interviews that VA national PC-MHI experts utilized to rate the programs on four dimensions (overall quality, adherence to evidence, sustainability and level of improvement).ResultsAt first assessment, seven of eight IF sites and four of eight comparison sites had implemented a PC-MHI program. Our qualitative assessment suggested that experts rated IF sites’ programs higher than comparison sites’ programs with one exception. At final assessment, all eight IF but only five comparison sites had implemented a PC-MHI program. Again, experts rated IF sites’ programs higher than their matched comparison sites with one exception. Over time, all ratings improved in five of seven IF sites and two of three comparison sites.ConclusionsImplementing complex evidence-based programs, particularly in settings that lack infrastructure, resources and support for such efforts, is challenging. Findings suggest that a blend of external expert and internal regional facilitation strategies that implementation scientists have developed and tested can improve PC-MHI program uptake, quality and adherence to evidence in primary care clinics with these challenges. However, not all sites showed these improvements. To be successful, facilitators likely need at least a moderate level of leaders’ support, including provision of basic resources. Additionally, we found that IF and strength of leadership structure may have a synergistic effect on ability to implement higher quality and evidence-based programs.