Standardized Versus Tailored Implementation of Measurement-Based Care for Depression in Community Mental Health Clinics

Personalized and collaborative use of digital measurement-based care tools enhances engagement among young adults: a mixed-methods study

BACKGROUND

Measurement-based care (MBC) enables personalised and proactive mental healthcare through regular symptom monitoring and review, allowing clinicians to make timely adjustments to clients' interventions for improved outcomes. Yet, its uptake in youth mental health services remains minimal. This study aims to explore perceived barriers and facilitators for sustained use of MBC and potential of digital technologies to enhance its engagement in young adults.

METHODS

A mixed-methods study, comprising focus groups and surveys, was conducted with young adults who had previously accessed mental health services. Template analysis was used to analyze qualitative data, and descriptive analyses were performed with quantitative data.

RESULTS

Eighteen young adults (mean age = 21.7 years; SD = 3.4) participated in this study. Survey results showed that young adults agreed with the value of MBC in their care (15/18) and reported low rates of discomfort with progress evaluation (11/18). Focus groups revealed collaborative data review with clinicians as a key facilitator in MBC uptake, driving repeated engagement with data input and review. Participants expressed that generalized interpretation of data that does not consider individual context, and the use of standard measures that were perceived to be irrelevant to their personal treatment goals discouraged their future engagement with MBC. Digital features that improve accessibility and data interpretation were expected to enhance consistent engagement with MBC.

CONCLUSIONS

The findings indicate that the motivation and sustained engagement in MBC stem from young adults' comprehension of how collected data fosters shared decision-making and personalize treatment. Therefore, regular, collaborative data reviews would be crucial in cultivating a sense of autonomy and purpose within MBC for young adults. This study highlights the importance of data review in enhancing the uptake of MBC, a factor that is often overlooked. By demonstrating this, the study provides a deeper understanding of motivators in MBC and valuable insights for mental health services to explore strategies that could support clinicians to integrate data review as part of routine care. To this end, one effective approach could be developing technologies that facilitate client-clinician communication and empower young adults to advocate for personalized care.

Effects of an Organizational Implementation Strategy on Sustainment of Measurement-Based Care in Community Mental Health

OBJECTIVE

Little is known about how to sustain evidence-based interventions with fidelity in community mental health settings. Phase 1 of the Working to Implement and Sustain Digital Outcome Measures (WISDOM) trial showed that an organizational strategy improved the implementation of measurement-based care (MBC) in mental health services for youths 1-12 months after clinician MBC training. The authors report results from phase 2 of the trial, in which the strategy's effects on MBC sustainment 13-26 months after clinician MBC training were examined.

METHODS

Twenty-one outpatient mental health clinics were randomly assigned to MBC training and technical assistance plus the Leadership and Organizational Change for Implementation (LOCI) strategy (11 clinics) or to training and technical assistance only (10 clinics). In phase 2, the primary outcomes of MBC completion rate, youth symptom improvement, and MBC fidelity were examined for 452 youths who entered treatment 13-26 months after clinician MBC training.

RESULTS

No differences were found in MBC completion rate or symptom improvement between the two conditions; however, among the 81 youths who received MBC, fidelity was significantly higher at LOCI sites relative to control sites (24%, SE=11.1 vs. 1%, SE=1.0, respectively; p=0.003).

CONCLUSIONS

During phase 2, LOCI sites (vs. control sites) sustained superior MBC fidelity when MBC was used; however, superior MBC completion rates and clinical outcomes were not sustained. Sustainment of MBC may require strategies that improve its fit with regulatory and reimbursement environments in addition to strategies that develop clinic infrastructure.

Randomized Trial of an Organizational Implementation Strategy to Improve Measurement-Based Care Fidelity and Youth Outcomes in Community Mental Health

OBJECTIVE

Measurement-based care (MBC), which collects session-by-session symptom data from patients and provides clinicians with feedback on treatment response, is a highly generalizable evidence-based practice with significant potential to improve the outcomes of mental health treatment in youth when implemented with fidelity; however, it is rarely used in community settings. This study tested whether an implementation strategy targeting organizational leadership and organizational implementation climate could improve MBC fidelity and clinical outcomes for youth in outpatient mental health clinics.

METHOD

In a cluster randomized trial, 21 clinics were assigned to the Leadership and Organizational Change for Implementation strategy plus training and technical assistance in MBC (k = 11, n = 117) or training and technical assistance only (k = 10, n = 117). Primary outcomes of MBC fidelity (assessed via electronic metadata) and youth symptom improvement (assessed via caregiver-reported change on the Shortform Assessment for Children Total Problem Score) were collected for consecutively enrolled youths (ages 4-18 years) who initiated treatment in the 12 months following MBC training. Outcomes of each youth were assessed for 6 months following baseline.

RESULTS

A total of 234 youths were enrolled and included in intent-to-treat analyses. At baseline, there were no significant differences by condition in clinic, clinician, or youth characteristics. Youths in clinics using the Leadership and Organizational Change for Implementation strategy experienced significantly higher MBC fidelity compared with youths in control clinics (23.1% vs 3.4%, p = .014), and exhibited significantly greater reductions in symptoms from baseline to 6 months (d = 0.31, 95% CI: 0.04-0.58, p = .023).

CONCLUSION

Implementation strategies targeting organizational leadership and focused implementation climate can improve fidelity to evidence-based practices and clinical outcomes of youth mental health services.

PLAIN LANGUAGE SUMMARY

Measurement-based care is an evidence-based intervention that has been shown to improve the outcomes of mental health services in dozens of randomized trials; however, it is not widely used in routine practice. In this randomized controlled trial of 21 outpatient mental health clinics and 234 youth, the authors found an organizational intervention which trained clinic leaders in skills to support the use of measurement-based care increased the extent to which patients received measurement-based care compared to control clinics where clinic leaders did not receive this training (23% vs. 3%). Youth receiving services in the clinics that received the organizational intervention also had greater reductions in mental health symptoms.

CLINICAL TRIAL REGISTRATION INFORMATION

Working to Implement and Sustain Digital Outcome Measures (WISDOM); https://clinicaltrials.gov/; NCT04096274.

A research agenda to advance the study of implementation mechanisms

BACKGROUND

Implementation science scholars have made significant progress identifying factors that enable or obstruct the implementation of evidence-based interventions, and testing strategies that may modify those factors. However, little research sheds light on how or why strategies work, in what contexts, and for whom. Studying implementation mechanisms-the processes responsible for change-is crucial for advancing the field of implementation science and enhancing its value in facilitating equitable policy and practice change. The Agency for Healthcare Research and Quality funded a conference series to achieve two aims: (1) develop a research agenda on implementation mechanisms, and (2) actively disseminate the research agenda to research, policy, and practice audiences. This article presents the resulting research agenda, including priorities and actions to encourage its execution.

METHOD

Building on prior concept mapping work, in a semi-structured, 3-day, in-person working meeting, 23 US-based researchers used a modified nominal group process to generate priorities and actions for addressing challenges to studying implementation mechanisms. During each of the three 120-min sessions, small groups responded to the prompt: "What actions need to be taken to move this research forward?" The groups brainstormed actions, which were then shared with the full group and discussed with the support of facilitators trained in structured group processes. Facilitators grouped critical and novel ideas into themes. Attendees voted on six themes they prioritized to discuss in a fourth, 120-min session, during which small groups operationalized prioritized actions. Subsequently, all ideas were collated, combined, and revised for clarity by a subset of the authorship team.

RESULTS

From this multistep process, 150 actions emerged across 10 priority areas, which together constitute the research agenda. Actions included discrete activities, projects, or products, and ways to shift how research is conducted to strengthen the study of implementation mechanisms.

CONCLUSIONS

This research agenda elevates actions to guide the selection, design, and evaluation of implementation mechanisms. By delineating recommended actions to address the challenges of studying implementation mechanisms, this research agenda facilitates expanding the field of implementation science, beyond studying what works to how and why strategies work, in what contexts, for whom, and with which interventions.

Provider Use of, Attitudes Towards, and Self-efficacy with Key Measurement-based Care Practices in Youth Mental Health Treatment: A Multi-site Examination

Measurement-based care (MBC) is an underutilized evidence-based practice, and current implementation efforts demonstrate limited success in increasing MBC use. A better understanding of MBC implementation determinants is needed to improve these efforts, particularly from studies examining the full range of MBC practices and that span multiple samples of diverse providers using different MBC systems. This study addressed these limitations by conducting a multi-site survey examining MBC predictors and use in youth treatment. Participants were 159 clinicians and care coordinators working in youth mental health care settings across the United States. Participants were drawn from three program evaluations of MBC implementation. Providers completed measures assessing use of five MBC practices (administering measures, viewing feedback, reviewing feedback in supervision, sharing feedback with clients in session, and using feedback to plan treatment), MBC self-efficacy, and MBC attitudes. Despite expectations that MBC should be standard care for all clients, providers reported only administering measures to 40-60% of clients on average, with practices related to the use of feedback falling in the 1-39% range. Higher MBC self-efficacy and more positive views of MBC practicality predicted higher MBC use, although other attitude measures were not significant predictors. Effects of predictors were not moderated by site, suggesting consistent predictors across implementation settings. Implications of study findings for future research and for the implementation of MBC are discussed.

Study protocol: Novel Methods for Implementing Measurement-Based Care with youth in Low-Resource Environments (NIMBLE)

BACKGROUND

For youth receiving care in community mental health centers, comorbidities are the rule rather than the exception. Using measurement-based care (MBC), or the routine evaluation of symptoms to inform care decisions, as the foundation of treatment for youth with comorbid problems significantly improves the impact of psychotherapy by focusing care and building engagement and alliance. MBC increases the rate of symptom improvement, detects clients who would otherwise deteriorate, and alerts clinicians to non-responders. Despite its demonstrated utility, MBC is rarely implemented with fidelity; less than 15% of providers report using MBC per recommendations. Previous efforts to support MBC implementation have yielded suboptimal outcomes, in part, due to organizations' challenges with identifying and prioritizing barriers and selecting and developing strategies to overcome them. New methods are needed for identifying and prioritizing barriers, and matching strategies to barriers to optimize MBC implementation and treatment quality to improve youth mental health outcomes in community settings.

METHODS

Pragmatic implementation methods will be piloted in four diverse community mental health centers. Methods include (a) rapid evidence synthesis; (b) rapid ethnography; (c) design kits (e.g., kits with disposable cameras, journals, maps); (d) barrier prioritization, and (e) causal pathway diagramming. These activities will generate actionable barriers; subsequently, we will use facilitated group processes to prioritize barriers and develop causal pathway diagrams to match strategies to barriers to create implementation plans that optimize MBC fidelity (Aim 1). We will track strategy deployment for 6 months, then compare MBC fidelity for another 6 months post-implementation with data from 2 years of historical controls (Aim 2). Finally, we will co-design a toolkit for design kit methods with youth and the practice and scientific communities (Aim 3).

DISCUSSION

Optimizing MBC implementation in community mental health centers could transform youth mental health care by ensuring the most pressing symptoms are targeted early in treatment. The discussion section highlights expected challenges and limits to using the five methods, including recruitment and engagement given the high pressure on community mental health settings.

TRIAL REGISTRATION

Clinicaltrials.gov. NCT05644756 . Registered on 18 November 2022. This trial was retrospectively registered.

The results of clinician-focused implementation strategies on uptake and outcomes of Measurement-Based Care (MBC) in general mental health care

BACKGROUND

Measurement-Based Care (MBC) is the routine administration of measures, clinicians' review of the feedback and discussion of the feedback with their clients, and collaborative evaluation of the treatment plan. Although MBC is a promising way to improve outcomes in clinical practice, the implementation of MBC faces many barriers, and its uptake by clinicians is low. The purpose of this study was to investigate whether implementation strategies that were developed with clinicians and aimed at clinicians had an effect on (a) clinicians' uptake of MBC and (b) clients' outcomes of MBC.

METHODS

We used an effectiveness-implementation hybrid design based on Grol and Wensing's implementation framework to assess the impact of clinician-focused implementation strategies on both clinicians' uptake of MBC and outcomes obtained with MBC for clients in general mental health care. We hereby focused on the first and second parts of MBC, i.e., the administration of measures and use of feedback. Primary outcome measures were questionnaire completion rate and discussion of the feedback with clients. Secondary outcomes were treatment outcome, treatment length, and satisfaction with treatment.

RESULTS

There was a significant effect of the MBC implementation strategies on questionnaire completion rate (one part of clinicians' uptake), but no significant effect on the amount of discussion of the feedback (the other part of clinicians' uptake). Neither was there a significant effect on clients' outcomes (treatment outcome, treatment length, and satisfaction with treatment). Due to various study limitations, the results should be viewed as exploratory.

CONCLUSIONS

Establishing and sustaining MBC in real-world general mental health care is complex. This study helps to disentangle the effects of MBC implementation strategies on differential clinician uptake, but the effects of MBC implementation strategies on client outcomes need further examination.

Measurement feedback system implementation in public youth mental health treatment services: a mixed methods analysis

BACKGROUND

Prior studies indicate the effectiveness of measurement-based care (MBC), an evidence-based practice, in improving and accelerating positive outcomes for youth receiving behavioral health services. MBC is the routine collection and use of client-reported progress measures to inform shared decision-making and collaborative treatment adjustments and is a relatively feasible and scalable clinical practice, particularly well-suited for under-resourced community mental health settings. However, uptake of MBC remains low, so information on determinants related to MBC practice patterns is needed.

METHODS

Quantitative and qualitative data from N = 80 clinicians who implemented MBC using a measurement feedback system (MFS) were merged to understand and describe determinants of practice over three study phases. Quantitative, latent class analysis identified clinician groups based on participants' ratings of MFS acceptability, appropriateness, and feasibility and describes similarities/differences between classes in clinician-level characteristics (e.g., age; perceptions of implementation climate; reported MFS use; phase I). Qualitative analyses of clinicians' responses to open-ended questions about their MFS use and feedback about the MFS and implementation supports were conducted separately to understand multi-level barriers and facilitators to MFS implementation (phase II). Mixing occurred during interpretation, examining clinician experiences and opinions across groups to understand the needs of different classes of clinicians, describe class differences, and inform selection of implementation strategies in future research (phase III).

RESULTS

We identified two classes of clinicians: "Higher MFS" and "Lower MFS," and found similarities and differences in MFS use across groups. Compared to Lower MFS participants, clinicians in the Higher MFS group reported facilitators at a higher rate. Four determinants of practice were associated with the uptake of MBC and MFS in youth-serving community mental health settings for all clinicians: clarity, appropriateness, and feasibility of the MFS and its measures; clinician knowledge and skills; client preferences and behaviors; and incentives and resources (e.g., time; continuing educational support). Findings also highlighted the need for individual-level implementation strategies to target clinician needs, skills, and perceptions for future MBC and MFS implementation efforts.

CONCLUSION

This study has implications for the adoption of evidence-based practices, such as MBC, in the context of community-based mental health services for youth.