Implementation research and practice最新文献

Background: Facilitation is an effective strategy to implement evidence-based practices, often involving external facilitators (EFs) bringing content expertise to implementation sites. Estimating time spent on multifaceted EF activities is complex. Furthermore, collecting continuous time-motion data for facilitation tasks is challenging. However, organizations need this information to allocate implementation resources to sites. Thus, our objectives were to conduct a time-motion analysis of external facilitation, and compare continuous versus noncontinuous approaches to collecting time-motion data. Methods: We analyzed EF time-motion data from six VA mental health clinics implementing the evidence-based Collaborative Chronic Care Model (CCM). We documented EF activities during pre-implementation (4-6 weeks) and implementation (12 months) phases. We collected continuous data during the pre-implementation phase, followed by data collection over a 2-week period (henceforth, "a two-week interval") at each of three time points (beginning/middle/end) during the implementation phase. As a validity check, we assessed how closely interval data represented continuous data collected throughout implementation for two of the sites. Results: EFs spent 21.8 ± 4.5 h/site during pre-implementation off-site, then 27.5 ± 4.6 h/site site-visiting to initiate implementation. Based on the 2-week interval data, EFs spent 2.5 ± 0.8, 1.4 ± 0.6, and 1.2 ± 0.6 h/week toward the implementation's beginning, middle, and end, respectively. Prevalent activities were preparation/planning, process monitoring, program adaptation, problem identification, and problem-solving. Across all activities, 73.6% of EF time involved email, phone, or video communication. For the two continuous data sites, computed weekly time averages toward the implementation's beginning, middle, and end differed from the interval data's averages by 1.0, 0.1, and 0.2 h, respectively. Activities inconsistently captured in the interval data included irregular assessment, stakeholder engagement, and network development. Conclusions: Time-motion analysis of CCM implementation showed initial higher-intensity EF involvement that tapered. The 2-week interval data collection approach, if accounting for its potential underestimation of irregular activities, may be promising/efficient for implementation studies collecting time-motion data.

Background: Achieving high quality outcomes in a community context requires the strategic coordination of many activities in a service system, involving families, clinicians, supervisors, and administrators. In modern implementation trials, the therapy itself is guided by a treatment manual; however, structured supports for other parts of the service system may remain less well-articulated (e.g., supervision, administrative policies for planning and review, information/feedback flow, resource availability). This implementation trial investigated how a psychosocial intervention performed when those non-therapy supports were not structured by a research team, but were instead provided as part of a scalable industrial implementation, testing whether outcomes achieved would meet benchmarks from published research trials.

Method: In this single-arm observational benchmarking study, a total of 59 community clinicians were trained in the Modular Approach to Therapy for Children (MATCH) treatment program. These clinicians delivered MATCH treatment to 166 youth ages 6 to 17 naturally presenting for psychotherapy services. Clinicians received substantially fewer supports from the treatment developers or research team than in the original MATCH trials and instead relied on explicit process management tools to facilitate implementation. Prior RCTs of MATCH were used to benchmark the results of the current initiative. Client improvement was assessed using the Top Problems Assessment and Brief Problem Monitor.

Results: Analysis of client symptom change indicated that youth experienced improvement equal to or better than the experimental condition in published research trials. Similarly, caregiver-reported outcomes were generally comparable to those in published trials.

Conclusions: Although results must be interpreted cautiously, they support the feasibility of using process management tools to facilitate the successful implementation of MATCH outside the context of a formal research or funded implementation trial. Further, these results illustrate the value of benchmarking as a method to evaluation industrial implementation efforts.Plain Language Summary: Randomized effectiveness trials are inclusive of clinicians and cases that are routinely encountered in community-based settings, while continuing to rely on the research team for both clinical and administrative guidance. As a result, the field still struggles to understand what might be needed to support sustainable implementation and how interventions will perform when brought to scale in community settings without those clinical trial supports. Alternative approaches are needed to delineate and provide the clinical and operational support needed for implementation and to efficiently evaluate how evidence-based treatments perform. Benchmarking findings in the community against findings of more rigorous clinical

Background: Tailoring implementation strategies to local contexts is a promising approach to supporting implementation and sustainment of evidence-based practices in health settings. While there is increasing research on tailored implementation of mental health interventions, implementation research on suicide prevention interventions is limited. This study aimed to evaluate implementation and subsequently develop a tailored action plan to support sustainment of an evidence-based suicide prevention intervention; Collaborative Assessment and Management of Suicidality (CAMS) in an Australian public mental health service. Methods: Approximately 150 mental health staff working within a regional and remote Local Health District in Australia were trained in CAMS. Semi-structured interviews and focus groups with frontline staff and clinical leaders were conducted to examine barriers and facilitators to using CAMS. Data were analysed using a reflexive thematic analysis approach and mapped to the Exploration, Preparation, Implementation and Sustainment (EPIS) framework and followed by stakeholder engagement to design a tailored implementation action plan based on a 'tailored blueprint' methodology. Results: A total of 22 barriers to implementing CAMS were identified. Based on the perceived impact on implementation fidelity and the feasibility of addressing identified barriers, six barriers were prioritised for addressing through an implementation action plan. These barriers were mapped to evidence-based implementation strategies and, in collaboration with local health district staff, goals and actionable steps for each strategy were generated. This information was combined into a tailored implementation plan to support the sustainable use of CAMS as part of routine care within this mental health service. Conclusions: This study provides an example of a collaborative approach to tailoring strategies for implementation on a large scale. Novel insights were obtained into the challenges of evaluating the implementation process and barriers to implementing an evidence-based suicide prevention treatment approach within a geographically large and varied mental health service in Australia. Plain language abstract: This study outlines the process of using a collaborative stakeholder engagement approach to develop tailored implementation plans. Using the Exploration Preparation Implementation Sustainment Framework, findings identify the barriers to and strategies for implementing a clinical suicide prevention intervention in an Australian community mental health setting. This is the first known study to use an implementation science framework to investigate the implementation of the clinical suicide prevention intervention (Collaborative Assessment and Management of Suicidality) within a community mental health setting. This work highlights the challenges of conducting implementation research in a dynamic public health servi

Background: There is a substantial mental health treatment gap globally. Increasingly, mental health treatments with evidence of effectiveness in western countries have been adapted and tested in culturally and contextually distinct countries. Findings from these studies have been promising, but to better understand treatment outcome results and consider broader scale up, treatment acceptability needs to be assessed and better understood. This mixed methods study aimed to examine child and guardian acceptability of trauma-focused cognitive behavioral therapy (TF-CBT) in two regions in Tanzania and Kenya and to better understand how TF-CBT was perceived as helpful for children and guardians.

Methods: Participants were 315 children (7-13), who experienced the death of one or both parents and 315 guardians, both of whom participated in TF-CBT as part of a randomized controlled trial conducted in Tanzania and Kenya. The study used mixed methods, with quantitative evaluation from guardian perspective (N=315) using the Treatment Acceptability Questionnaire (TAQ) and the Client Satisfaction Questionnaire-8 (CSQ-8). Acceptability was assessed qualitatively from both guardian and child perspectives. Qualitative evaluation involved analysis using stratified selection to identify 160 child and 160 guardian interviews, to allow exploration of potential differences in acceptability by country, setting (urban/rural), and youth age (younger/older).

Results: Guardians reported high acceptability on the TAQ and, using an interpretation guide from U.S.-based work, medium acceptability on the CSQ-8. Guardians and children noted high acceptability in the qualitative analysis, noting benefits that correspond to TF-CBT's therapeutic goals. Analyses exploring differences in acceptability yielded few differences by setting or child age but suggested some potential differences by country.

Conclusion: Quantitative and qualitative data converged to suggest high acceptability of TF-CBT from guardian and child perspectives in Tanzania and Kenya. Findings add to accumulating evidence of high TF-CBT acceptability from Zambia and other countries (United States, Norway, Australia).Plain Language Summary: Evidence-based treatments have been shown to be effective in countries and regions that are contextually and culturally distinct from where they were developed. But, perspectives of consumers on these treatments have not been assessed regularly or thoroughly. We used open-ended questions and rating scales to assess guardian and youth perspectives on a group-based, cognitive behavioral treatment for children impacted by parental death, in regions within Tanzania and Kenya. Our findings indicate that both guardians and youth found the treatment to be very acceptable. Nearly all guardians talked about specific benefits for the child, followed by benefits for the family and themsel

Background: This qualitative study aims to identify facilitators of and barriers to the implementation of Meaning-Centered Psychotherapy (MCP) by providers of mental health services to Latinos in the US and Latin America using the practical, robust implementation and sustainability model (PRISM). This information will be used to increase usability and acceptability of MCP for Latino patients with cancer and their providers in Latin America and the US.

Methods: A total of 14 Latino cancer patient mental health providers completed in-depth semi-structured interviews. Participants were recruited from 9 countries and 12 different sites. They provided feedback about barriers to and facilitators of implementation of MCP at the patient, provider, and clinic levels in their clinical setting. The qualitative data from the interviews was coded according to PRISM domains. Three analysts independently coded the transcripts; discrepancies between analysts were resolved through discussion and consensus.

Results: Based on PRISM, themes were: clinic environment (protected time for training and supervision), intervention characteristics (adapt the intervention using more simple language, include more visual aids, include more family-oriented content), patient (develop materials for the identification and screening of patients, provide educational materials, increase motivation and knowledge about psychotherapy, assess commitment to psychotherapy, adapt for the inpatient vs. outpatient setting), provider (receive interactive/participatory training, educational materials, ongoing supervision, have flexibility of delivering the intervention in a less structured manner, theoretical framework of the provider) and external environment (work at policy level to integrate services for oncology patients).

Conclusion: These qualitative data revealed potential facilitators and barriers of this intervention (MCP) on an international scale. Identified cultural, contextual, and healthcare systems factors illustrated the importance of examining pre-implementation needs prior to implementing a trial. We will design and plan a future RCT using the PRISM framework and these pre-implementation data.

Plain language summary: This study integrates frameworks of implementation science and cultural adaptation through the examination of pre-implementation contextual issues at the preparation phase of a cultural adaptation of a psychotherapeutic intervention, Meaning-Centered Psychotherapy (MCP), for Latinos with advanced cancer. By examining implementation needs early in the implementation process, during preparation, the intervention can be adapted in a way that attends to and addresses the providers' most cited challenges in implementation: having a rigid protocol/structure, complexity of the intervention, disease burden preventing adherence to the intervention, transportation

Background: Digital interventions, such as smartphone apps, can be effective in treating alcohol use disorders (AUD). However, efforts to integrate digital interventions into primary care have been challenging. To inform successful implementation, we sought to understand how patients and clinicians preferred to use apps in routine primary care.

Methods: This study combined user-centered design and qualitative research methods, interviewing 18 primary care patients with AUD and nine primary care clinicians on topics such as prior experiences with digital tools, and design preferences regarding approaches for offering apps for AUD in primary care. Interviews were recorded and transcribed for template analysis whereby a priori codes were based on interview topics and refined through iterative coding. New codes and cross-cutting themes emerged from the data.

Results: Patient participants with AUD indicated they would be more likely to engage in treatment if primary care team members were involved in their use of apps. They also preferred to see clinicians "invested" and recommended that clinicians ask about app use and progress during follow-up appointments or check-ins. Clinician participants valued the opportunity to offer apps to their patients but noted that workflows would need to be tailored to individual patient needs. Time pressures, implementation complexity, and lack of appropriate staffing were cited as barriers. Clinicians proposed concrete solutions (e.g., education, tools, and staffing models) that could improve their ability to use apps within the constraints of primary care and suggested that some patients could potentially use apps without clinician support.

Conclusions: A user-centered approach to engaging patients in digital alcohol interventions in primary care may require personalized support for both initiation and follow-up. Meeting patients' needs likely require increased staffing and efficient workflows in primary care. Health systems should consider offering multiple pathways for enrolling patients in apps to accommodate individual preferences and contextual barriers.

Plain language summary: Healthcare systems have begun using app-based treatments to help patients manage their health conditions, including alcohol use disorders. Some apps have been tested in research studies and appear to be effective. However, it is difficult for healthcare teams to offer apps to patients. Clinicians must engage in new activities that they have not done before, such as "teaching" patients to use apps and checking in on their use of the apps. Identifying how to use apps in routine healthcare is critical to their successful implementation. This study interviewed 27 people, including healthcare providers and patients in primary care, to uncover the most optimal ways to offer apps to patients with alcohol use disorders. The interviews

Background: Telemedicine outreach for posttraumatic stress disorder (TOP) is a virtual evidence-based practice (EBP) involving telephone care management and telepsychology that engages rural patients in trauma-focused psychotherapy. This evaluation examined implementation and intervention costs attributable to deploying TOP from a health system perspective.

Methods: Costs were ascertained as part of a stepped wedge cluster randomized trial at five sites within the Veterans Affairs (VA) Healthcare System. All sites initially received a standard implementation strategy, which included internal facilitation, dissemination of an internal facilitators operational guide, funded care manager, care managing training, and technical support. A subset of clinics that failed to meet performance metrics were subsequently randomized to enhanced implementation, which added external facilitation that focused on incorporating TOP clinical processes into existing clinic workflow. We measured site-level implementation activities using project records and structured activity logs tracking personnel-level time devoted to all implementation activities. We monetized time devoted to implementation activities by applying an opportunity cost approach. Intervention costs were measured as accounting-based costs for telepsychiatry/telepsychology and care manager visits, ascertained using VA administrative data. We conducted descriptive analyses of strategy-specific implementation costs across five sites. Descriptive analyses were conducted instead of population-level cost-effectiveness analysis because previous research found enhanced implementation was not more successful than the standard implementation in improving uptake of TOP.

Results: Over the 40-month study period, four of five sites received enhanced implementation. Mean site-level implementation cost per month was $919 (SD = $238) during standard implementation and increased to $1,651 (SD = $460) during enhanced implementation. Mean site-level intervention cost per patient-month was $46 (SD = $28) during standard implementation and $31 (SD = $21) during enhanced implementation.

Conclusions: Project findings inform the expected cost of implementing TOP, which represents one factor health systems should consider in the decision to broadly adopt this EBP. Plain Language Summary: What is already known about the topic: Trauma-focused psychotherapy delivered through telemedicine has been demonstrated as an effective approach for the treatment of post-traumatic stress disorder (PTSD). However, uptake of this evidence-based approach by integrated health systems such as the Veterans Affairs (VA) Health Care System is low. What does this paper add: This paper presents new findings on the costs of two implementation approaches designed to increase adoption telemedicine outreach for PTSD from a health sys

Background: The Veterans Health Administration (VHA) developed the Stratification Tool for Opioid Risk Mitigation (STORM) dashboard to assist in identifying Veterans at risk for adverse opioid overdose or suicide-related events. In 2018, a policy was implemented requiring VHA facilities to complete case reviews of Veterans identified by STORM as very high risk for adverse events. Nationally, facilities were randomized in STORM implementation to four arms based on required oversight and by the timing of an increase in the number of required case reviews. To help evaluate this policy intervention, we aimed to (1) identify barriers and facilitators to implementing case reviews; (2) assess variation across the four arms; and (3) evaluate associations between facility characteristics and implementation barriers and facilitators.

Method: Using the Consolidated Framework for Implementation Research (CFIR), we developed a semi-structured interview guide to examine barriers to and facilitators of implementing the STORM policy. A total of 78 staff from 39 purposefully selected facilities were invited to participate in telephone interviews. Interview transcripts were coded and then organized into memos, which were rated using the -2 to + 2 CFIR rating system. Descriptive statistics were used to evaluate the mean ratings on each CFIR construct, the associations between ratings and study arm, and three facility characteristics (size, rurality, and academic detailing) associated with CFIR ratings. We used the mean CFIR rating for each site to determine which constructs differed between the sites with highest and lowest overall CFIR scores, and these constructs were described in detail.

Results: Two important CFIR constructs emerged as barriers to implementation: Access to knowledge and information and Evaluating and reflecting. Little time to complete the CASE reviews was a pervasive barrier. Sites with higher overall CFIR scores showed three important facilitators: Leadership engagement, Engaging, and Implementation climate. CFIR ratings were not significantly different between the four study arms, nor associated with facility characteristics.Plain Language Summary: The Veterans Health Administration (VHA) created a tool called the Stratification Tool for Opioid Risk Mitigation dashboard. This dashboard shows Veterans at risk for opioid overdose or suicide-related events. In 2018, a national policy required all VHA facilities to complete case reviews for Veterans who were at high risk for these events. To evaluate this policy implementation, 78 staff from 39 facilities were interviewed. The Consolidated Framework for Implementation Research (CFIR) implementation framework was used to create the interview. Interview transcripts were coded and organized into site memos. The site memos were rated using CFIR's -2 to +2 rating system. Ratings did not differ for four study arms related to over