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

Teamwork and implementation of innovations in healthcare and human service settings: a systematic review

BACKGROUND

Implementation of new practices in team-based settings requires teams to work together to respond to new demands and changing expectations. However, team constructs and team-based implementation approaches have received little attention in the implementation science literature. This systematic review summarizes empirical research examining associations between teamwork and implementation outcomes when evidence-based practices and other innovations are implemented in healthcare and human service settings.

METHODS

We searched MEDLINE, CINAHL, APA PsycINFO and ERIC for peer-reviewed empirical articles published from January 2000 to March 2022. Additional articles were identified by searches of reference lists and a cited reference search for included articles (completed in February 2023). We selected studies using quantitative, qualitative, or mixed methods to examine associations between team constructs and implementation outcomes in healthcare and human service settings. We used the Mixed Methods Appraisal Tool to assess methodological quality/risk of bias and conducted a narrative synthesis of included studies. GRADE and GRADE-CERQual were used to assess the strength of the body of evidence.

RESULTS

Searches identified 10,489 results. After review, 58 articles representing 55 studies were included. Relevant studies increased over time; 71% of articles were published after 2016. We were unable to generate estimates of effects for any quantitative associations because of very limited overlap in the reported associations between team variables and implementation outcomes. Qualitative findings with high confidence were: 1) Staffing shortages and turnover hinder implementation; 2) Adaptive team functioning (i.e., positive affective states, effective behavior processes, shared cognitive states) facilitates implementation and is associated with better implementation outcomes; Problems in team functioning (i.e., negative affective states, problematic behavioral processes, lack of shared cognitive states) act as barriers to implementation and are associated with poor implementation outcomes; and 3) Open, ongoing, and effective communication within teams facilitates implementation of new practices; poor communication is a barrier.

CONCLUSIONS

Teamwork matters for implementation. However, both team constructs and implementation outcomes were often poorly specified, and there was little overlap of team constructs and implementation outcomes studied in quantitative studies. Greater specificity and rigor are needed to understand how teamwork influences implementation processes and outcomes. We provide recommendations for improving the conceptualization, description, assessment, analysis, and interpretation of research on teams implementing innovations.

TRIAL REGISTRATION

This systematic review was registered in PROSPERO, the international prospective register of systematic reviews.

REGISTRATION NUMBER

CRD42020220168.

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.

Adaptation for sustainability in an implementation trial of team-based collaborative care

Background

Sustaining healthcare interventions once they have been implemented is a pivotal public health endeavor. Achieving sustainability requires context-sensitive adaptations to evidence-based practices (EBPs) or the implementation strategies used to ensure their adoption. For replicability of adaptations beyond the specific setting in question, the underlying logic needs to be clearly described, and adaptations themselves need to be plainly documented. The goal of this project was to describe the process by which implementation facilitation was adapted to improve the uptake of clinical care practices that are consistent with the collaborative chronic care model (CCM).

Method

Quantitative and qualitative data from a prior implementation trial found that CCM-consistent care practices were not fully sustained within outpatient general mental health teams that had received 1 year of implementation facilitation to support uptake. We undertook a multistep consensus process to identify adaptations to implementation facilitation based on these results, with the goal of enhancing the sustainability of CCM-based care in a subsequent trial. The logic for these adaptations, and the resulting adaptations themselves, were documented using two adaptation-oriented implementation frameworks (the iterative decision-making for evaluation of adaptations [IDEA] and the framework for reporting adaptations and modifications to evidence-based implementation strategies [FRAME-IS], respectively).

Results

Three adaptations emerged from this process and were documented using the FRAME-IS: (a) increasing the scope of implementation facilitation within the medical center, (b) having the internal facilitator take a greater role in the implementation process, and (c) shortening the implementation timeframe from 12 to 8 months, while increasing the intensity of facilitation support during that time.

Conclusions

EBP sustainability may require careful adaptation of EBPs or the implementation strategies used to get them into routine practice. Recently developed frameworks such as the IDEA and FRAME-IS may be used to guide decision-making and document resulting adaptations themselves. An ongoing funded study is investigating the utility of the resulting adaptations for improving healthcare.