How to "Start Small and Just Keep Moving Forward": Mixed Methods Results From a Stepped-Wedge Trial to Support Evidence-Based Processes in Local Health Departments

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.

Practices Among Local Public Health Agencies to Support Evidence-Based Decision Making: A Qualitative Study

OBJECTIVES

Evidence-based decision making (EBDM) capacity in local public health departments is foundational to meeting both organizational and individual competencies and fulfilling expanded roles. In addition to on-the-job training, organizational supports are needed to prepare staff; yet, less is known in this area. This qualitative study explores supportive management practices instituted as part of a training and technical assistance intervention.

DESIGN

This qualitative study used a semistructured interview guide to elicit participants' descriptions and perceptions via key informant interviews. Verbatim transcripts were coded and thematic analyses were conducted.

SETTING

Local public health departments in a US Midwestern state participated in the project.

PARTICIPANTS

Seventeen middle managers and staff from 4 local health departments participated in remote, audio-recorded interviews.

INTERVENTION

Following delivery of a 3½-day in-person training, the study team met with health department leadership teams for department selection of supportive agency policies and procedures to revise or newly create. Periodic remote meetings included collaborative problem-solving, sharing of informational resources, and encouragement.

MAIN OUTCOME MEASURES

Included management practices instituted to support EBDM and impact on day-to-day work as described by the interview participants.

RESULTS

Leadership and middle management practices deemed most helpful included dedicating staff; creating specific guidelines; setting expectations; and providing trainings, resources, and guidance. Health departments with a preexisting supportive organizational culture and climat e were able to move more quickly and fully to integrate supportive management practices. Workforce development included creation of locally tailored overviews for all staff members and onboarding of new staff. Staff wanted additional hands-on skill-building trainings. Several worked with partners to incorporate evidence-based processes into community health improvement plans.

CONCLUSIONS

Ongoing on-the-job experiential learning is needed to integrate EBDM principles into day-to-day public health practice. Management practices established by leadership teams and middle managers can create supportive work environments for EBDM integration.