Assessing Collaborative Care in Mental Health Teams: Qualitative Analysis to Guide Future Implementation

Sustaining the collaborative chronic care model in outpatient mental health: a matrixed multiple case study

BACKGROUND

Sustaining evidence-based practices (EBPs) is crucial to ensuring care quality and addressing health disparities. Approaches to identifying factors related to sustainability are critically needed. One such approach is Matrixed Multiple Case Study (MMCS), which identifies factors and their combinations that influence implementation. We applied MMCS to identify factors related to the sustainability of the evidence-based Collaborative Chronic Care Model (CCM) at nine Department of Veterans Affairs (VA) outpatient mental health clinics, 3-4 years after implementation support had concluded.

METHODS

We conducted a directed content analysis of 30 provider interviews, using 6 CCM elements and 4 Integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) domains as codes. Based on CCM code summaries, we designated each site as high/medium/low sustainability. We used i-PARIHS code summaries to identify relevant factors for each site, the extent of their presence, and the type of influence they had on sustainability (enabling/neutral/hindering/unclear). We organized these data into a sortable matrix and assessed sustainability-related cross-site trends.

RESULTS

CCM sustainability status was distributed among the sites, with three sites each being high, medium, and low. Twenty-five factors were identified from the i-PARIHS code summaries, of which 3 exhibited strong trends by sustainability status (relevant i-PARIHS domain in square brackets): "Collaborativeness/Teamwork [Recipients]," "Staff/Leadership turnover [Recipients]," and "Having a consistent/strong internal facilitator [Facilitation]" during and after active implementation. At most high-sustainability sites only, (i) "Having a knowledgeable/helpful external facilitator [Facilitation]" was variably present and enabled sustainability when present, while (ii) "Clarity about what CCM comprises [Innovation]," "Interdisciplinary coordination [Recipients]," and "Adequate clinic space for CCM team members [Context]" were somewhat or less present with mixed influences on sustainability.

CONCLUSIONS

MMCS revealed that CCM sustainability in VA outpatient mental health clinics may be related most strongly to provider collaboration, knowledge retention during staff/leadership transitions, and availability of skilled internal facilitators. These findings have informed a subsequent CCM implementation trial that prospectively examines whether enhancing the above-mentioned factors within implementation facilitation improves sustainability. MMCS is a systematic approach to multi-site examination that can be used to investigate sustainability-related factors applicable to other EBPs and across multiple contexts.

Interdisciplinary behavioral health provider perceptions of implementing the Collaborative Chronic Care Model: an i-PARIHS-guided qualitative study

BACKGROUND

The evidence-based Collaborative Chronic Care Model (CCM), developed to help structure care for chronic health conditions, comprises six elements: work role redesign, patient self-management support, provider decision support, clinical information systems, linkages to community resources, and organizational/leadership support. As the CCM is increasingly implemented in real-world settings, there is heightened interest in understanding specific influences upon implementation. Therefore, guided by the Integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework, we (i) identified innovation-, recipient-, context-, and facilitation-related influences on CCM implementation and (ii) assessed the influences' relationship to each CCM element's implementation.

METHODS

Using semi-structured interviews, we examined interdisciplinary behavioral health providers' experiences at nine VA medical centers that implemented the CCM. We used i-PARIHS constructs as a priori codes for directed content analysis, then analyzed the data for cross-coding by CCM element and i-PARIHS construct.

RESULTS

Participants (31 providers) perceived the CCM innovation as enabling comprehensive care but challenging to coordinate with existing structures/procedures. As recipients, participants recounted not always having the authority to design CCM-consistent care processes. They perceived local leadership support to be indispensable to implementation success and difficult to garner when CCM implementation distracted from other organizational priorities. They found implementation facilitation helpful for keeping implementation on track. We identified key themes at the intersection of i-PARIHS constructs and core CCM elements, including (i) the CCM being an innovation that offers a formal structure to stepping down care intensity for patients to encourage their self-management, (ii) recipients accessing their multidisciplinary colleagues' expertise for provider decision support, (iii) relationships with external services in the community (e.g., homelessness programs) being a helpful context for providing comprehensive care, and (iv) facilitators helping to redesign specific interdisciplinary team member roles.

CONCLUSIONS

Future CCM implementation would benefit from (i) facilitating strategic development of supportive maintenance plans for patients' self-management, (ii) collocating multidisciplinary staff (on-site or virtually) to enhance provider decision support, (iii) keeping information on available community resources up to date, and (iv) making clearer the explicit CCM-consistent care processes that work roles can be designed around. This work can inform concrete tailoring of implementation efforts to focus on the more challenging CCM elements, which is crucial to better account for multiple influences that vary across diverse care settings in which the CCM is being implemented.

Sustainability of the Collaborative Chronic Care Model in Outpatient Mental Health Teams Three Years Post-Implementation: A Qualitative Analysis

Our goal was to investigate the sustainability of care practices that are consistent with the collaborative chronic care model (CCM) in nine outpatient mental health teams located within US Department of Veterans Affairs (VA) medical centers, three to four years after the completion of CCM implementation. We conducted qualitative interviews (N = 30) with outpatient mental health staff from each of the nine teams. We based our directed content analysis on the six elements of the CCM. We found variable sustainability of CCM-based care processes across sites. Some care processes, such as delivery of evidence-based psychotherapies (EBPs) and use of measurement-based care (MBC) to guide clinic decision-making, were robustly maintained or even expanded within participating teams. In contrast, other care processes-which had in some cases been developed with considerable effort-had not been sustained. For example, care manager roles were diminished in scope or eliminated completely in response to workload pressures, frontline care needs, or the COVID-19 pandemic. Similarly, processes for engaging Veterans more fully in decision-making had generally been scaled back. Leadership support in the form of adequate team staffing and time to conduct team meetings were seen as crucial for sustaining CCM-consistent care. Given the potential impact of leadership turnover on sustainability in mental health, future efforts to implement CCM-based mental health care should strive to involve multiple leaders in implementation and sustainment efforts, lest one key departure undo years of implementation work. Our results also suggest that implementing CCM processes may best be conceptualized as a partnership across multiple levels of medical center leadership.

Characterization of multilevel influences of mental health care transitions: a comparative case study analysis

PURPOSE

Mental health care transitions are increasingly prioritized given their potential to optimize care delivery and patient outcomes, especially those focused on the transition from inpatient to outpatient mental health care. However, limited efforts to date characterize such mental health transition practices, especially those spanning multiple service setting contexts. Examination of key influences of inpatient to outpatient mental health care transitions across care contexts is needed to inform ongoing and future efforts to improve mental health care transitions. The current work aims to characterize multilevel influences of mental health care transitions across three United States-based mental health system contexts.

METHODS

A comparative multiple case study design was used to characterize transition practices within the literature examining children's, non-VA adult, and VA adult service contexts. Andersen's (1995) Behavioral Health Service Use Model was applied to identify and characterize relevant distinct and common domains of focus in care transitions across systems.

RESULTS

Several key influences to mental health care transitions were identified spanning the environmental, individual, and health behavior domains, including: community capacity or availability, cross-system or agency collaboration, provider training and experience related to mental health care transitions, client care experience and expectations, and client clinical characteristics or complexity.

CONCLUSIONS

Synthesis illustrated several common factors across system contexts as well as unique factors for further consideration. Our findings inform key considerations and recommendations for ongoing and future efforts aiming to plan, expand, and better support mental health care transitions. These include timely information sharing, enhanced care coordination and cross setting and provider communication, continued provider/client education, and appropriate tailoring of services to improve mental health care transitions.

Time-motion analysis of external facilitation for implementing the Collaborative Chronic Care Model in general mental health clinics: Use of an interval-based data collection approach

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.

Adoption of care management activities by primary care nurses for people with common mental disorders and physical conditions: A multiple case study

WHAT IS KNOWN ON THE SUBJECT?: The collaborative care model is a well-known model to improve care quality for people with common mental disorders and physical conditions in primary care. The role of care manager is central to the collaborative care model, and primary care nurses are well-positioned to play that role. Adopting the role of care manager by primary care nurses is challenging due to several contextual factors; however, few implementation studies examined the context and current practices before implementing the role of care manager and the collaborative care model. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: The paper contributes to the advancement of knowledge about the pre-assessment of current practices before implementing the collaborative care model and the role of care manager. The paper offers a better understanding of the relationships between the context and the performance of care management activities by primary care nurses. The paper describes an innovative analysis technique to assess the gap between care management activities recommended in the collaborative care model and actual nursing activities. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Primary care nurses would benefit from having timely access to clinical support from mental health nurse practitioners in order to build their competency. Determinants of practice and the analysis technique to assess current practices will help other researchers or quality improvement teams to develop their plan when implementing the role of care manager. ABSTRACT: Introduction Few studies assessed current nursing practices before implementing the collaborative care model and the role of care manager for people with common mental disorders (CMDs) and physical conditions in primary care settings. Aim Evaluate the main determinants of practice that influence the adoption of care management activities by primary care nurses for people with CMDs and physical conditions. Methods A qualitative multiple case study was conducted in three primary care clinics. A total of 33 participants were recruited. Various data sources were combined: interviews (n = 32), nurse-patient encounters' observations (n = 7), documents and summaries of meetings with stakeholders (n = 8). Results Seven determinants were identified (1) access to external mental health resources; (2) clarification of local CMD care trajectory; (3) compatibility between the coordination of nursing work and the role of care manager; (4) availability of mental health resources within the primary care clinic; (5) competency in care management and competency building; (6) responsibility sharing between the general practitioner and the primary care nurse; and (7) common understanding of the patient treatment plan. Implications for practice To build their competency in care management for people with CMDs, primary care nurses would benefit from having clinical support from mental health nurse practitioners.

Implementation of Integrated Behavioral Health Care in a Large Medical Center: Benefits, Challenges, and Recommendations

Integrated behavioral health care (IBHC) models in primary care are positioned to address the unmet needs of traditional behavioral health models. However, research support is limited to specific populations, settings, and behavioral health conditions. Empirical evidence is lacking for expansion to larger health systems and diverse behavioral health conditions. This study examines perspectives on IBHC implementation in a large medical center. Semi-structured interviews were conducted with 24 health providers and administrators in two primary care clinics with IBHC. Thematic analysis demonstrated that participants had an overall favorable perception of IBHC, but also perceived implementation challenges, including difficulties with access, underutilization, team dynamics, and financial and interdepartmental issues. The findings suggest that IBHC implementation barriers in existing large health systems risk diminishing potential benefits and successful adoption. These barriers can be combated by incorporating systems change strategies into implementation frameworks, with a focus on barrier prevention and detection and long-term sustainability.

The Influence of Contextual Factors on the Process of Formulating Strategies to Improve the Adoption of Care Manager Activities by Primary Care Nurses

Background:

Primary care nurses are well-suited to provide care management for common mental disorders, but their practices depend on context. Various strategies can be considered to improve the adoption of nursing care manager activities, but data from implementation studies rarely address strategy formulation.

Aim:

To analyze the influence of contextual factors on strategy formulation to improve the adoption of care manager activities by primary care nurses.

Method:

A qualitative multiple case study in three primary care clinics was carried out. Data were collected through individual interviews (n = 32) and observations (n = 7), working group meetings, and relevant documents. Thematic analysis was conducted.

Results:

Contextual factors influenced strategy formulation through organizational readiness for change, which resulted from tension for change and perceived organizational ability to implement change. Tension for change was generated through the perceived gap between patient needs and service availability, perceived compatibility with the nurses work environment, and their assessment of their capacity to perform care manager activities or acquire the necessary skills.

Conclusion:

Future studies should give sufficient attention to implementation strategy formulation and consider the dynamic role of organizational readiness for change when facilitating the adoption of evidence-based practices for common mental disorders in primary care.

Deployment of the consultation-liaison model in adult and child-adolescent psychiatry and its impact on improving mental health treatment

Background

Little information exists on the perceptions of psychiatrists regarding the implementation and various impacts of the consultation-liaison model. This model has been used in Quebec (Canada) through the function of specialist respondent-psychiatrists (SRP) since 2009. This study assessed the main activities, barriers or facilitators, and impact of SRP in adult and child-adolescent psychiatry on the capacity of service providers in primary care and youth centers to treat patients with mental health disorders (MHD).

Methods

Data included 126 self-administered questionnaires from SRP and semi-structured interviews from 48 SRP managers. Mixed methods were used, with qualitative findings from managers complementing the SRP survey. Comparative analyses of SRP responses in adult versus child-adolescent psychiatry were also conducted.

Results

Psychiatrists dedicated a median 24.12 h/month to the SRP function, mainly involving case discussions with primary care teams or youth centers. They were confident about the level of support they provided and satisfied with their influence in clinical decision-making, but less satisfied with the support provided by their organizations. SRP evaluated their impacts on clinical practice as moderate, particularly among general practitioners (GP). SRP working in child-adolescent psychiatry were more comfortable, motivated, and positive about their overall performance and impact than in adult psychiatry. Organizational barriers (e.g. team instability) were most prevalent, followed by system-level factors (e.g. network size and complexity, lack of resources, model inflexibility) and individual factors (e.g. GP reluctance to treat patients with MHD). Organizational facilitators included support from family medicine group directors, collaboration with university family medicine groups and coordination by liaison nurses; at the system level, pre-existing relationships and working in the same institution; while individual-level facilitators included SRP personality and strong organizational support.

Conclusion

Quebec SRP were implemented sparingly in family medicine groups and youth centers, while SRP viewed their overall impact as moderate. Results were more positive in child-adolescent psychiatry than in adult psychiatry. Increased support for the SRP function, adapting the model to GP in need of more direct support, and resolving key system issues may improve SRP effectiveness in terms of team stability, coordination among providers, access to MH services and readiness to implement innovations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01437-5.

Collaborative chronic care model implementation within outpatient behavioral health care teams: qualitative results from a multisite trial using implementation facilitation

BACKGROUND

This paper reports on a qualitative evaluation of a hybrid type II stepped-wedge, cluster randomized trial using implementation facilitation to implement team-based care in the form of the collaborative chronic care model (CCM) in interdisciplinary outpatient mental health teams. The objective of this analysis is to compare the alignment of sites' clinical processes with the CCM elements at baseline (time 1) and after 12 months of implementation facilitation (time 2) from the perspective of providers.

METHODS

We conducted semi-structured interviews to assess the extent to which six CCM elements were in place: work role redesign, patient self-management support, provider decision support, clinical information systems, linkages to community resources, and organizational/leadership support. Interviews were transcribed and a priori CCM elements were coded using a directed content analysis approach at times 1 and 2. We sought consensus on, and compared, the extent to which each CCM element was in place at times 1 and 2.

RESULTS

We conducted 27 and 31 telephone interviews at times 1 and 2, respectively, with outpatient mental health providers at nine participating sites. At time 1 and time 2, three CCM elements were most frequently present across the sites: work role redesign, patient self-management support, and provider decision support. The CCM elements with increased implementation from time 1 to time 2 were work role redesign, patient self-management support, and clinical information systems. For two CCM elements, linkages to community resources and organizational/leadership support, some sites had increased implementation at time 2 compared to time 1, while others had reductions. For the provider decision support element, we saw little change in the extent of its implementation.

CONCLUSIONS

Sites increased the extent of implementation on several CCM elements. The most progress was made in the CCM elements where sites had CCM-aligned processes in place at time 1. Teams made progress on elements they could more easily control, such as work role redesign. Our results suggest that maximizing the benefits of CCM-based outpatient mental health care may require targeting resources and training toward specific CCM elements-especially in the use of clinical information systems and linking with community resources.

TRIAL REGISTRATION

Clinical Trials NCT02543840 .