Moving from Implementation Science to Implementation Practice: The Need to Solve Practical Problems to Improve Behavioral Health Services

Consultation Content and Techniques for measurement-Based Care Implementation in Youth Community Mental Health Settings

Measurement-based care (MBC) is an evidence-based practice (EBP) focused on regularly administering outcome measures to clients to inform clinical decision making. While MBC shows promise for improving youth treatment outcomes, therapist adoption remains low. Clinical consultation is one strategy that improves MBC implementation, but our limited understanding of consultation hinders the ability to optimize its impact. This research explored the content of, and techniques used during MBC consultation calls. Therapists (N = 55) in a randomized controlled trial treating adolescents with anxiety and/or depression were trained to utilize MBC with usual treatment using the Youth Outcome Questionnaire (YOQ) through an online measurement feedback system (MFS). Weekly ongoing consultation followed an initial workshop training in MBC. Case discussions (N = 294) during consultation calls were coded using a developed codebook, including 12 content and 10 consultant techniques. Results indicated that content focused predominantly on interpretation of client symptom and alliance report, planning for YOQ administration, and discussion of data with clients in session. Common consultant techniques included modeling and eliciting report viewing and interpretation, making clinical suggestions, and didactics about clinical and technical issues. Notably, role-play/behavioral rehearsal was not used. The prevalence of passive consultation techniques (suggestions, didactics) suggests a focus on teaching rather than active techniques (behavioral rehearsal, modeling), potentially influenced by the novelty of MBC and MFS. Technical aspects of MBC, such as measure administration and system usage, emerged as key consultation content, highlighting an unanticipated emphasis on logistics over clinical implementation. These findings underscore the evolving role of consultation in supporting MBC implementation and suggest that addressing technical challenges early in training might enhance adoption.

Implementation processes and capacity-building needs in Ontario maternal-newborn care hospital settings: a cross-sectional survey

BACKGROUND

Maternal-newborn care does not always align with the best available evidence. Applying implementation science to change initiatives can help move evidence-informed practices into clinical settings. However, it remains unknown to what extent current implementation practices in maternal-newborn care align with recommendations from implementation science, and how confident nurses, other health professionals, and leaders are completing steps in the implementation process. We aimed to understand Ontario maternal-newborn teams' (1) approaches to implementing practice changes and the extent to which their implementation processes aligned with an implementation science planned-action framework; and (2) perceptions of importance and confidence completing implementation activities.

METHODS

We conducted a cross-sectional survey between September-November 2023. Using purposive sampling, we invited Ontario maternal-newborn nurses, other healthcare professionals, and leaders who had experience participating in or leading implementation projects to complete an online questionnaire. The questionnaire was informed by an implementation science framework, which includes three core phases (identify issue; build solutions; implement, evaluate, sustain). The questions probed respondents' perceptions of frequency of completion, importance, and confidence for each of the 28 implementation activities. We used descriptive statistics for the closed-ended questions and grouped the written responses into categories.

RESULTS

We received 73 responses from 57 Ontario maternal-newborn hospitals, the majority being nurses in point-of-care and leadership roles. Nearly all respondents agreed that each of the 28 implementation activities were important. Respondents reported always completing a median of 8 out of 28 activities, with the number of activities completed declining from phase 1 through to 3. Most respondents indicated they were somewhat confident completing the implementation activities and agreed their teams would benefit from increasing their knowledge and skills to use an evidence-informed approach to implementing practice changes.

CONCLUSIONS

Despite viewing implementation activities as important, many teams are not consistently doing them and lack confidence, particularly in later phases of the implementation process. These findings inform where further capacity-building and supports may be needed to enable maternal-newborn nurses, other healthcare professionals, and leaders to apply implementation science to their change initiatives.

Study Protocol for the Healing Opioid Misuse and Pain Through Engagement Trial: Integrated Treatment for Individuals With Co-occurring Chronic Pain and Opioid Use Disorder

Chronic pain and opioid use disorder (OUD) are public health crises and their co-occurrence has led to further complications and public health impacts. Provision of treatments for comorbid chronic pain and OUD is paramount to address these public health crises. Medications for OUD (MOUD) are gold standard treatments for OUD that have also demonstrated benefit in pain management. However, clinics that provide MOUD for chronic pain or OUD often lack behavioral treatments to address the challenges experienced by individuals with both conditions. Developing and implementing a behavioral treatment that complements MOUD may better equip clinics to provide comprehensive care to the growing proportion of clients who present with comorbid chronic pain and OUD. In the Healing Opioid misuse and Pain through Engagement (HOPE) Trial, we are using an effectiveness-implementation hybrid design to examine the benefits of an integrated behavioral treatment and to determine the feasibility of implementing the integrated treatment into clinics that provide MOUD. The treatment integrated 2 evidence-based treatments-Acceptance and Commitment Therapy and Mindfulness-Based Relapse Prevention-to target the emotional, behavioral, and physiological sequelae of OUD and chronic pain. Implementation feasibility will include assessing changes in implementation readiness and identifying facilitators and barriers to implementing the integrated treatment among all personnel employed in clinics that provide MOUD. This commentary offers an overview of the study and design and details adaptations we made to our study protocol, based largely on clinic personnel time constraints and variable clinic procedures during the COVID-19 pandemic.

How Can Implementation Science Advance Behavioral Interventions in Preschool? A Scoping Review and Recommendations

Behavioral interventions delivered in preschools can help young children who need support for their behavior. However, preschool teachers face barriers to implementing behavioral interventions, leading to a research-to-practice gap. To better understand how to support preschool teachers, we conducted a scoping review of determinants (i.e., barriers and facilitators) and strategies used to support the implementation of behavioral interventions in preschool settings. A systematic search identified peer-reviewed manuscripts describing the implementation of teacher-delivered behavioral interventions in preschools. Each included manuscript was evaluated to answer the following questions: (1) what determinants to teacher implementation of behavioral interventions have been explored and (2) what strategies have been identified as promising in addressing determinants (i.e., implementation strategies)? Twenty-two manuscripts met inclusion criteria. Data extraction and synthesis were used to summarize key findings. Results indicate that few studies have explored determinants of implementation, and while these determinants span numerous implementation domains, there was little consensus on common determinants. In contrast, all the included studies deployed an implementation strategy, and there were two clear foci of the strategies: training and quality monitoring. Implications and recommendations are discussed for both the preschool context and the implementation science field.

The BSSO Foundry: A community of practice for ontologies in the behavioural and social sciences

There has been a rapid expansion in the quantity and complexity of data, information and knowledge created in the behavioural and social sciences, yet the field is not advancing understanding, practice or policy to the extent that the insights warrant. One challenge is that research often progresses in disciplinary silos and is reported using inconsistent and ambiguous terminology. This makes it difficult to integrate and aggregate findings to produce cumulative bodies of knowledge that can be translated to applied settings. Ontologies can address these challenges; their development and use have the potential to accelerate the behavioural and social sciences. Ontologies can facilitate communication through precise specification and dissemination of terms, and enable efficient data integration, sharing, comparison and analysis. The widespread use of ontologies in the biomedical and biological sciences has led to multiple successes. It is time now for the behavioural and social sciences to follow that lead. In recent years, a number of ontologies have been developed within the behavioural and social sciences; however, efforts have tended to be isolated, with limited resources to support developers and those who work (or would like to work) with and use ontologies. There is a need for coordination and exchange to reduce duplication of work and leverage the value of a community to support the interoperability of these ontologies (linking of entities across domains and datasets). We have therefore initiated the Behavioural and Social Sciences Ontology (BSSO) Foundry, a community of practice and online repository for the development, adoption and use of ontologies in the behavioural and social sciences. The BSSO Foundry aligns with and builds upon the model provided by the Open Biological and Biomedical Ontology Foundry. We describe this new initiative and how to join and contribute to the community of interoperable ontologies for the behavioural and social sciences.

Supporting psychosis research, implementation, and training through an academic intermediary-purveyor organization

Intermediary-purveyor organizations (IPOs) are a type of dissemination support system that are intended to enhance the adoption and sustainment of empirically supported treatments (ESTs) by deploying empirically supported strategies to remediate implementation challenges. Despite the recent proliferation of government-funded IPOs for other psychiatric populations, IPOs that can redress the substantial science-to-practice gap among clients who experience psychotic disorders are not well documented. This article provides an overview of an IPO in an R1 academic medical center whose mission is to enhance access to evidence-based interventions for individuals who have or are at risk for a psychotic disorder. The article spotlights the functions of an IPO and illustrates these functions with a use case, cognitive behavioral therapy for psychosis. We highlight IPO-led activities related to cognitive behavioral therapy for psychosis purveyance, professional development, quality improvement, public awareness education and training, research and evaluation, as well as program and policy development. Finally, we address the advantages and disadvantages of establishing IPOs of this nature in academic medical centers, the importance of academic-community partnerships in advancing EST implementation, and present considerations for replication. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

A Qualitative Study of National Perspectives on Advancing Social Prescribing Using Co-Design in Canada

INTRODUCTION

Social prescribing offers a formal pathway of connecting patients in the health system with sources of support within the community to help improve their health and well-being. Since its launch in March 2022, the Canadian Institute for Social Prescribing has acted as a collective impact network to identify, connect and build upon established social prescribing initiatives using a co-design methodology. The institute received input from a participant advisory council, co-design partners and several communities of interest groups. This study aimed to describe the perceptions of the Canadian Institute for Social Prescribing's role in advancing social prescribing using a co-design approach and the barriers and facilitators to implementing social prescribing in Canada.

METHODS

We used a qualitative descriptive study design, document analysis, participant observation and semi-structured individual interviews (n = 7) with members of the Canadian Institute for Social Prescribing co-design group and the institute's leadership. We also analysed documents, field notes and transcripts using codebook thematic analysis.

RESULTS

Four themes were developed representing the facilitators of implementing the Canadian Institute for Social Prescribing to support social prescribing: Creating relational mechanisms (i.e., partnerships and connections), Bringing awareness to social prescribing and contributing to the evidence (i.e., values and beliefs), Addressing systemic conditions (i.e., having a common language for social prescribing and organizing the community health sector) and Enabling funding and policy to drive social prescribing initiatives (i.e., shifting evidence into policy and securing sustainable funding).

CONCLUSION

Participants' reflections on the co-design process demonstrated that the Canadian Institute for Social Prescribing development provided networking opportunities and shared resources relevant to social prescribing. Co-design efforts also fostered relational and informational support, which laid the necessary groundwork in Canada to overcome the complex interplay between the macro- and micro-level settings in which social prescribing is practiced.

PATIENT OR PUBLIC CONTRIBUTION

The interviews and observations involved participants with lived experience of delivering, receiving or advocating for social prescribing.

Action recommendations review in community-based therapy and depression and anxiety outcomes: a machine learning approach

BACKGROUND

While the positive impact of homework completion on symptom alleviation is well-established, the pivotal role of therapists in reviewing these assignments has been under-investigated. This study examined therapists' practice of assigning and reviewing action recommendations in therapy sessions, and how it correlates with patients' depression and anxiety outcomes.

METHODS

We analyzed 2,444 therapy sessions from community-based behavioral health programs. Machine learning models and natural language processing techniques were deployed to discern action recommendations and their subsequent reviews. The extent of the review was quantified by measuring the proportion of session dialogues reviewing action recommendations, a metric we refer to as "review percentage". Using Generalized Estimating Equations modeling, we evaluated the correlation between this metric and changes in clients' depression and anxiety scores.

RESULTS

Our models achieved 76% precision in capturing action recommendations and 71.1% in reviewing them. Using these models, we found that therapists typically provided clients with one to eight action recommendations per session to engage in outside therapy. However, only half of the sessions included a review of previously assigned action recommendations. We identified a significant interaction between the initial depression score and the review percentage (p = 0.045). When adjusting for this relationship, the review percentage was positively and significantly associated with a reduction in depression score (p = 0.032). This suggests that more frequent review of action recommendations in therapy relates to greater improvement in depression symptoms. Further analyses highlighted this association for mild depression (p = 0.024), but not for anxiety or moderate to severe depression.

CONCLUSIONS

An observed positive association exists between therapists' review of previous sessions' action recommendations and improved treatment outcomes among clients with mild depression, highlighting the possible advantages of consistently revisiting therapeutic homework in real-world therapy settings. Results underscore the importance of developing effective strategies to help therapists maintain continuity between therapy sessions, potentially enhancing the impact of therapy.

Mis-implementation of evidence-based behavioural health practices in primary care: lessons from randomised trials in Federally Qualified Health Centers

Background

Implementing evidence-based practices (EBPs) within service systems is critical to population-level health improvements - but also challenging, especially for complex behavioral health interventions in low-resource settings. "Mis-implementation" refers to poor outcomes from an EBP implementation effort; mis-implementation outcomes are an important, but largely untapped, source of information about how to improve knowledge exchange.

Aims and objectives

We present mis-implementation cases from three pragmatic trials of behavioral health EBPs in U.S. Federally Qualified Health Centers (FQHCs).

Methods

We adapted the Consolidated Framework for Implementation Research and its Outcomes Addendum into a framework for mis-implementation and used it to structure the case summaries with information about the EBP and trial, mis-implementation outcomes, and associated determinants (barriers and facilitators). We compared the three cases to identify shared and unique mis-implementation factors.

Findings

Across cases, there was limited adoption and fidelity to the interventions, which led to eventual discontinuation. Barriers contributing to mis-implementation included intervention complexity, low buy-in from overburdened providers, lack of alignment between providers and leadership, and COVID-19-related stressors. Mis-implementation occurred earlier in cases that experienced both patient- and provider-level barriers, and that were conducted during the COVID-19 pandemic.

Discussion and conclusion

Multi-level determinants contributed to EBP mis-implementation in FQHCs, limiting the ability of these health systems to benefit from knowledge exchange. To minimize mis-implementation, knowledge exchange strategies should be designed around common, core barriers but also flexible enough to address a variety of site-specific contextual factors and should be tailored to relevant audiences such as providers, patients, and/or leadership.

A Randomized Control Trial of a Digital Health Tool for Safer Firearm and Medication Storage for Patients with Suicide Risk

Most patients with suicide risk do not receive recommendations to reduce access to lethal means due to a variety of barriers (e.g., lack of provider time, training). Determine if highly efficient population-based EHR messaging to visit the Lock to Live (L2L) decision aid impacts patient-reported storage behaviors. Randomized trial. Integrated health care system serving Denver, CO. Served by primary care or mental health specialty clinic in the 75-99.5th risk percentile on a suicide attempt or death prediction model. Lock to Live (L2L) is a web-based decision aid that incorporates patients' values into recommendations for safe storage of lethal means, including firearms and medications. Anonymous survey that determined readiness to change: pre-contemplative (do not believe in safe storage), contemplative (believe in safe storage but not doing it), preparation (planning storage changes) or action (safely storing). There were 21,131 patients randomized over a 6-month period with a 27% survey response rate. Many (44%) had access to a firearm, but most of these (81%) did not use any safe firearm storage behaviors. Intervention patients were more likely to be categorized as preparation or action compared to controls for firearm storage (OR = 1.30 (1.07-1.58)). When examining action alone, there were no group differences. There were no statistically significant differences for any medication storage behaviors. Selection bias in those who responded to survey. Efficiently sending an EHR invitation message to visit L2L encouraged patients with suicide risk to consider safer firearm storage practices, but a stronger intervention is needed to change storage behaviors. Future studies should evaluate whether combining EHR messaging with provider nudges (e.g., brief clinician counseling) changes storage behavior.ClinicalTrials.gov: NCT05288517.

Effectiveness of the Brief Guided Self-Change Therapy Combined with Varenicline under "Real-Life" Conditions and Mediators for Smoking Cessation

Background: Brief therapies have proven to reduce tobacco cost-effectively, however, unsuccessful quit attempts remain notable in real-life conditions, and the underlying mechanisms of treatment success are still unclear. Objectives: We aimed to analyze the effectiveness of the Guided Self-Change (GSC) therapy combined with varenicline (VAR+T) in public health services against varenicline alone (VAR), and to identify mediators of treatment outcomes. We conducted a two-arm quasi-experimental study with 126 treatment-seeking smokers (age=57.3±9.1 years; 59.5% women). Before treatment, and at weeks 12 and 24, we assessed tobacco use and five potential mediators: withdrawal, craving, motivation to quit, anxiety, and depression. Results: Only 25% of participants adhered to varenicline prescription, and 54% to GSC therapy. VAR+T group showed a greater proportion of abstainers compared to VAR group at week 12 (75% vs 57.4%; φc=0.21) and week 24 (62.9% vs 52.5%; φc=0.10). When controlling for weeks taking varenicline, motivation showed a significant indirect effect over abstinence rates in VAR+T compared with VAR (a1b1=1.34; 95%CI=0.04, 5.03). Conclusions: The GSC effectiveness seems to increase motivation which in turn contributes to reducing tobacco use. The implementation of GSC therapy in public health services could minimize treatment duration and increase smoking abstinence in 'real-life' conditions where varenicline adherence remains low.

Planning and implementing practice changes in Ontario maternal-newborn hospital units: a secondary qualitative analysis

BACKGROUND

Moving evidence into practice is complex, and pregnant and birthing people and their infants do not always receive care that aligns with the best available evidence. Implementation science can inform how to effectively move evidence into practice. While there are a growing number of examples of implementation science being studied in maternal-newborn care settings, it remains unknown how real-world teams of healthcare providers and leaders approach the overall implementation process when making practice changes. The purpose of this study was to describe maternal-newborn hospital teams' approaches to implementing practice changes. We aimed to identify what implementation steps teams take (or not) and identify strengths and potential areas for improvement based on best practices in implementation science.

METHODS

We conducted a supplementary qualitative secondary analysis of 22 interviews completed in 2014-2015 with maternal-newborn nursing leaders in Ontario, Canada. We used directed content analysis to code the data to seven steps in an implementation framework (Implementation Roadmap): identify the problem and potential best practice; assemble local evidence; select and customize best practice; discover barriers and drivers; tailor implementation strategies; field-test, plan evaluation, prepare to launch; launch, evaluate, and sustain. Frequency counts are presented for each step.

RESULTS

Participants reported completing a median of 4.5 of 7 Implementation Roadmap steps (range = 3-7), with the most common being identifying a practice problem. Other steps were described less frequently (e.g., selecting and adapting evidence, field-testing, outcome evaluation) or discussed frequently but not optimally (e.g., barriers assessment). Participants provided examples of how they engaged point-of-care staff throughout the implementation process, but provided fewer examples of engaging pregnant and birthing people and their families. Some participants stated they used a formal framework or process to guide their implementation process, with the most common being quality improvement approaches and tools.

CONCLUSIONS

We identified variability across the 22 hospitals in the implementation steps taken. While we observed many strengths, we also identified areas where further support may be needed. Future work is needed to create opportunities and resources to support maternal-newborn healthcare providers and leaders to apply principles and tools from implementation science to their practice change initiatives.

When a pandemic and epidemic collide: Lessons learned about how system barriers can interrupt implementation of addiction research

Background

Telehealth technologies are now featured more prominently in addiction treatment services than prior to the COVID-19 pandemic, but system barriers should be carefully considered for the successful implementation of innovative remote solutions for medication management and recovery coaching support for people with opioid use disorder (OUD).

Method

The Centers for Disease Control and Prevention funded a telehealth trial prior to the COVID-19 pandemic with a multi-institution team who attempted to implement an innovative protocol during the height of the pandemic in 2020 in Tampa, Florida. The study evaluated the effectiveness of a mobile device application, called MySafeRx, which integrated remote motivational recovery coaching with daily supervised dosing from secure pill dispensers via videoconference, on medication adherence during buprenorphine treatment. This paper provides a participant case example followed by a reflective evaluation of how the pandemic amplified both an existing research-to-practice gap and clinical system barriers during the implementation of telehealth clinical research intervention for patients with OUD.

Findings

Implementation challenges arose from academic institutional requirements, boundaries and role identity, clinical staff burnout and lack of buy-in, rigid clinical protocols, and limited clinical resources, which hampered recruitment and intervention engagement.

Conclusions

As the urgency for feasible and effective telehealth solutions continues to rise in response to the growing numbers of opioid-related deaths, the scientific community may use these lessons learned to re-envision the relationship between intervention implementation and the role of clinical research toward mitigating the opioid overdose epidemic.

Preliminary effectiveness of the ACT SMART implementation toolkit: facilitating evidence-based practice implementation in community-based autism organizations

Background: Evidence-based practice (EBP) use is varied in autism spectrum disorder community-based organizations (ASD-CBOs) in the United States. Aim: The ACT SMART Implementation Toolkit-a multi-faceted implementation strategy guiding teams through implementation phases-was pilot tested to assess its preliminary effectiveness in increasing EBP use within ASD-CBOs. Method: Six ASD-CBOs participated, and five completed all Toolkit phases. Supervisors and direct providers completed an agency assessment pre- and post-pilot reporting their use of the selected EBP. Results: Effect sizes, examining meaningful changes in reported EBP utilization from pre- to post-pilot, found small effect sizes for supervisor-reported, supervisor-report of direct provider's use, and for direct provider-reported EBP use. Conclusions: Results indicate an increase in reported EBP use post-pilot and signal potential effectiveness of the ACT SMART Toolkit to yield provider-reported behavioral changes. This is the first multi-faceted implementation strategy designed specifically for ASD-CBOs, and findings support its facilitation of EBP uptake to improve community care for autistic individuals.

Evaluating an Implementation Science Training Program: Impact on Professional Research and Practice

Real-world application and implementation of evidence-based practice continue to be a challenge across multiple sectors, including behavioral health settings. Providing the opportunity for future researchers and practitioners to gain capacity and knowledge through structured experiential learning in implementation science is critical to closing the research to practice gap. The Institute for Translational Research Education in Adolescent Drug Abuse (ITRE) is a graduate certificate program that offers specific coursework, a large-scale service-learning project based in the community, and mentorship related to implementation science research and practice. The purpose of this evaluation was to examine, from the perspective of ITRE scholars, the perceived impact on the development of professional research and practice skills once graduated from the ITRE program. Fifty-eight semi-structured interviews across five cohorts were selected randomly for in-depth thematic analysis (n = 58). Results suggest that the ITRE provides a unique approach grounded in implementation science for building robust and transferable skills for future researchers and practitioners working in a variety of behavioral healthcare settings.