Implementation research and practice最新文献

Background: Rising rates of adolescent depression in the wake of COVID-19 and a youth mental health crisis highlight the urgent need for accessible mental healthcare and prevention within primary care. Digital mental health interventions (DMHIs) may increase access for underserved populations. However, these interventions are not well studied in adolescents, nor healthcare settings. The purpose of this study was to identify barriers and facilitators to screening and recruitment activities for PATH 2 Purpose (P2P): Primary Care and Community-Based Prevention of Mental Disorders in Adolescents, a multi-site adolescent depression prevention trial comparing two digital prevention programs within four diverse health systems in two U.S. states.

Method: This qualitative study is a component of a larger Hybrid Type I trial. We conducted semi-structured key informant interviews with clinical and non-clinical implementers involved with screening and recruitment for the P2P trial. Informed by the Consolidated Framework for Implementation Research (CFIR), interviews were conducted at the midpoint of the trial to identify barriers, facilitators, and needed adaptations, and to gather information on determinants that may affect future implementation.

Findings: Respondents perceived the P2P trial as valuable, well aligned with the mission of their health systems. However, several barriers were identified, many of which stemmed from influences outside of the healthcare settings. Universal and site-specific outer setting influences (COVID-19 pandemic, youth mental health crisis, local community conditions) interacted with Inner Setting and Innovation domains to create numerous challenges to the implementation of screening and recruitment.

Conclusion: Our findings emphasize the need for ongoing, comprehensive assessment of dynamic inner and outer setting contexts prior to and during implementation of clinical trials, as well as flexibility for adaptation to unique clinical contexts. The CFIR is useful for assessing determinants during times of rapid inner and outer setting change, such as those brought on by the COVID-19 pandemic, youth mental health crisis, and the corresponding exacerbation of resource strain within healthcare settings.

Clinical trial registration: PATH 2 Purpose: Primary Care and Community-Based Prevention of Mental Disorders in Adolescents https://www.clinicaltrials.gov/study/NCT04290754.

Background: Few "intervention agnostic" strategies have been developed that can be applied to the broad array of evidence-based practices (EBPs) in schools. This paper describes two studies that reflect the initial iterative redesign phases of an effective leadership-focused implementation strategy-Leadership and Organizational Change for Implementation (LOCI)-to ensure its acceptability, feasibility, contextual appropriateness, and usability when used in elementary schools. Our redesigned strategy-Helping Educational Leaders Mobilize Evidence (HELM)-is designed to improve principals' use of strategic implementation leadership to support the adoption and high-fidelity delivery of a universal EBP to improve student outcomes.

Method: In Study 1, focus groups were conducted (n = 6) with 54 district administrators, principals, and teachers. Stakeholders provided input on the appropriateness of original LOCI components to maximize relevance and utility in schools. Transcripts were coded using conventional content analysis. Key themes referencing low appropriateness were summarized to inform LOCI adaptations. We then held a National Expert Summit (Study 2) with 15 research and practice experts. Participants provided feedback via a nominal group process (NGP; n = 6 groups) and hackathon (n = 4 groups). The research team rated each NGP suggestion for how actionable, impactful/effective, and feasible it was. We also coded hackathon notes for novel ideas or alignment with LOCI components.

Results: Study 1 suggestions included modifications to LOCI content and delivery. Study 2's NGP results revealed most recommendations to be actionable, impactful/effective, and feasible. Hackathon results surfaced two novel ideas (distributed leadership teams and leaders' knowledge to support educators EBP use) and several areas of alignment with LOCI components.

Conclusion: Use of these iterative methods informed the redesign of LOCI and the development of HELM. Because it was collaboratively constructed, HELM has the potential to be an effective implementation strategy to support the use of universal EBP in schools.

Background: Although studies have demonstrated that implementation leadership and climate are important constructs in predicting evidence-based practice (EBP) implementation, concrete descriptions of how they operate during organizational implementation efforts are lacking. This case study fills that gap through an in-depth description of an organization with effective implementation leadership that successfully built a strong implementation climate. This case study provides an illustration of implementation leadership and climate in tangible, replicable terms to assist managers, practitioners, and researchers in addressing the organizational context in their own implementation projects.

Method: A single organization, intrinsic case study was employed to paint a multifaceted picture of how one organization leveraged implementation leadership to strengthen a climate for the successful implementation of digital measurement-based care. The case was drawn from a cluster-randomized trial designed to test the effects of a leadership-focused implementation strategy on youth-level fidelity and clinical outcomes of digital measurement-based care. Following the completion of the trial, case study activities commenced. Descriptive summaries of multiple data sources (including quantitative data on implementation leadership and climate, coaching call and organizational alignment meeting recordings and notes, and development plans) were produced and revised iteratively until consensus was reached. Leadership actions were analyzed for corresponding dimensions of implementation leadership and climate.

Results: Specific actions organizational leaders took, as well as the timing specific strategies were enacted, to create a climate for implementation are presented, along with lessons learned from this experience.

Conclusion: This case study offers concrete steps organizational leaders took to create a consistent and aligned message that the implementation of a specific EBP was a top priority in the agency. The general approach taken to create an implementation climate provides several lessons for leaders, especially for EBPs that have broad implications across an organization.

Background: Evidence-based practices (EBPs) improve housing and health for persons who have experienced homelessness with serious mental illness (PEH-SMI) but are challenging to implement. We tested a strategy to support pilot implementation of a 12-session housing skills training intervention for PEH-SMI, tailored from effective social skills training interventions. We aimed to optimize the implementation strategy and intervention prior to an implementation trial.

Method: We provided training and technical assistance to nine providers to support pilot implementation of this intervention to six groups of PEH-SMI (n = 35) engaged in VA Greater Los Angeles' homeless services. We used scales and semi-structured interviews with 14 PEH-SMI and all interventionists to inform implementation strategy adaptations, identify factors that impacted implementation, and assess perceptions of the intervention. Attendance was tracked and we observed a random sample of each interventionist's groups to assess treatment fidelity.

Results: Interventionists perceived the implementation strategy and the intervention favorably. However, interventionists often lacked physical space, staff, and resources (e.g., computers) to conduct the intervention. Interventionists found the content valuable for participants and a few suggested that group engagement should be a prerequisite for obtaining housing services. PEH-SMI were interested in the intervention's content and receptive to the group-based format. Participants attended a mean of 4 ± 3/12 groups; all groups observed had acceptable fidelity. Problems with intervention retention were described, suggesting challenges maintaining group participation when participants transitioned between VA homeless services.

Conclusions: To support the implementation of an EBP for PEH-SMI in homeless programs, these data suggest the value of training/technical assistance and strategies that enhance program-level buy-in to address resource concerns. Intervention adaptations, e.g., using a drop-in, open group format, in community-based settings that are easily accessible to PEH-SMI, may also increase adoption. This project was registered as "Improving Housing Outcomes for Homeless Veterans" Trial registration NCT03646149, registered 8/24/2018.

Background: As the opioid crisis continues to affect communities across the United States, new interventions for screening and prevention are needed to mitigate its impact. Mental health diagnoses have been identified as a risk factor for opioid misuse, and surgical populations and injury survivors are at high risk for prolonged opioid use and misuse. This study investigated the implementation of a novel opioid risk screening tool that incorporated putative risk factors from a recent study in four trauma units across Wisconsin.

Method: The screening tool was implemented across a 6-month period at four sites. Data was collected via monthly meeting notes and "Plan, Do, Study, Act" (PDSA) forms. Following implementation, focus groups reflected on the facilitators and barriers to implementation. Meeting notes, PDSA forms, and focus group data were analyzed using the consolidated framework for implementation research, followed by thematic analyses, to generate themes surrounding the facilitators and barriers to implementing an opioid misuse screener.

Results: Implementation facilitators included ensuring patient understanding of the screener, minimizing staff burden from screening, and educating staff to encourage engagement. Barriers included infrastructure limitations that prevented seamless administration of the screener within current workflows, overlap of the screener with existing measures, and lack of guidance surrounding treatment options corresponding to risk. Recommended solutions to address barriers include careful timing of screener administration, accommodating workflows, integration of the screening tool within the electronic health record, and evidence-based interventions guided by screener results.

Conclusion: Four trauma centers across Wisconsin successfully implemented a pilot opioid misuse screening tool. Trauma providers and unit staff members believe that this tool would be a beneficial addition to their repertoire if their recommendations were adopted. Future research should refine opioid misuse risk factors and ensure screening items are well-validated with psychometric research supporting treatment responses to screener-indicated risk categories.