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Landes SJ, Matarazzo BB, Pitcock JA, Drummond KL, Smith BN, Kirchner JE, Clark KA, Gerard GR, Jankovsky MC, Brenner LA, Reger MA, Eagan AE, Raciborski R, Painter J, Townsend JC, Jegley SM, Singh RS, Trafton JA, McCarthy JF, Katz IR. Impact of Implementation Facilitation on the REACH VET Clinical Program for Veterans at Risk for Suicide. Psychiatr Serv 2024:appips20230277. [PMID: 38444365 DOI: 10.1176/appi.ps.20230277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/07/2024]
Abstract
OBJECTIVE In 2017, the Veterans Health Administration (VHA) implemented a national suicide prevention program, called Recovery Engagement and Coordination for Health-Veterans Enhanced Treatment (REACH VET), that uses a predictive algorithm to identify, attempt to reach, assess, and care for patients at the highest risk for suicide. The authors aimed to evaluate whether facilitation enhanced implementation of REACH VET at VHA facilities not meeting target completion rates. METHODS In this hybrid effectiveness-implementation type 2 program evaluation, a quasi-experimental pre-post design was used to assess changes in implementation outcome measures evaluated 6 months before and 6 months after onset of facilitation of REACH VET implementation at 23 VHA facilities. Measures included percentages of patients with documented coordinator and provider acknowledgment of receipt, care evaluation, and outreach attempt. Generalized estimating equations were used to compare differences in REACH VET outcome measures before and after facilitation. Qualitative interviews were conducted with personnel and were explored via template analysis. RESULTS Time had a significant effect in all outcomes models (p<0.001). An effect of facilitation was significant only for the outcome of attempted outreach. Patients identified by REACH VET had significantly higher odds of having a documented outreach attempt after facilitation of REACH VET implementation, compared with before facilitation. Site personnel felt supported and reported that the external facilitators were helpful and responsive. CONCLUSIONS Facilitation of REACH VET implementation was associated with an improvement in outreach attempts to veterans identified as being at increased risk for suicide. Outreach is critical for engaging veterans in care.
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Affiliation(s)
- Sara J Landes
- Central Arkansas Veterans Healthcare System, Little Rock (Landes, Pitcock, Drummond, Smith, Kirchner, Raciborski, Painter, Townsend, Jegley, Singh); Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock (Landes, Drummond, Kirchner, Painter, Singh); Rocky Mountain Mental Illness Research, Education, and Clinical Center, U.S. Department of Veterans Affairs (VA), Aurora, Colorado (Matarazzo, Clark, Gerard, Jankovsky, Brenner); Departments of Psychiatry and Physical Medicine and Rehabilitation, University of Colorado School of Medicine, Aurora (Matarazzo, Brenner); Veterans Integrated Service Network 19 Clinical Resource Hub, Salt Lake City (Clark); VA Puget Sound Health Care System, Seattle (Reger); VA Office of Mental Health and Suicide Prevention, Washington, D.C. (Eagan, Trafton, McCarthy, Katz)
| | - Bridget B Matarazzo
- Central Arkansas Veterans Healthcare System, Little Rock (Landes, Pitcock, Drummond, Smith, Kirchner, Raciborski, Painter, Townsend, Jegley, Singh); Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock (Landes, Drummond, Kirchner, Painter, Singh); Rocky Mountain Mental Illness Research, Education, and Clinical Center, U.S. Department of Veterans Affairs (VA), Aurora, Colorado (Matarazzo, Clark, Gerard, Jankovsky, Brenner); Departments of Psychiatry and Physical Medicine and Rehabilitation, University of Colorado School of Medicine, Aurora (Matarazzo, Brenner); Veterans Integrated Service Network 19 Clinical Resource Hub, Salt Lake City (Clark); VA Puget Sound Health Care System, Seattle (Reger); VA Office of Mental Health and Suicide Prevention, Washington, D.C. (Eagan, Trafton, McCarthy, Katz)
| | - Jeffery A Pitcock
- Central Arkansas Veterans Healthcare System, Little Rock (Landes, Pitcock, Drummond, Smith, Kirchner, Raciborski, Painter, Townsend, Jegley, Singh); Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock (Landes, Drummond, Kirchner, Painter, Singh); Rocky Mountain Mental Illness Research, Education, and Clinical Center, U.S. Department of Veterans Affairs (VA), Aurora, Colorado (Matarazzo, Clark, Gerard, Jankovsky, Brenner); Departments of Psychiatry and Physical Medicine and Rehabilitation, University of Colorado School of Medicine, Aurora (Matarazzo, Brenner); Veterans Integrated Service Network 19 Clinical Resource Hub, Salt Lake City (Clark); VA Puget Sound Health Care System, Seattle (Reger); VA Office of Mental Health and Suicide Prevention, Washington, D.C. (Eagan, Trafton, McCarthy, Katz)
| | - Karen L Drummond
- Central Arkansas Veterans Healthcare System, Little Rock (Landes, Pitcock, Drummond, Smith, Kirchner, Raciborski, Painter, Townsend, Jegley, Singh); Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock (Landes, Drummond, Kirchner, Painter, Singh); Rocky Mountain Mental Illness Research, Education, and Clinical Center, U.S. Department of Veterans Affairs (VA), Aurora, Colorado (Matarazzo, Clark, Gerard, Jankovsky, Brenner); Departments of Psychiatry and Physical Medicine and Rehabilitation, University of Colorado School of Medicine, Aurora (Matarazzo, Brenner); Veterans Integrated Service Network 19 Clinical Resource Hub, Salt Lake City (Clark); VA Puget Sound Health Care System, Seattle (Reger); VA Office of Mental Health and Suicide Prevention, Washington, D.C. (Eagan, Trafton, McCarthy, Katz)
| | - Brandy N Smith
- Central Arkansas Veterans Healthcare System, Little Rock (Landes, Pitcock, Drummond, Smith, Kirchner, Raciborski, Painter, Townsend, Jegley, Singh); Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock (Landes, Drummond, Kirchner, Painter, Singh); Rocky Mountain Mental Illness Research, Education, and Clinical Center, U.S. Department of Veterans Affairs (VA), Aurora, Colorado (Matarazzo, Clark, Gerard, Jankovsky, Brenner); Departments of Psychiatry and Physical Medicine and Rehabilitation, University of Colorado School of Medicine, Aurora (Matarazzo, Brenner); Veterans Integrated Service Network 19 Clinical Resource Hub, Salt Lake City (Clark); VA Puget Sound Health Care System, Seattle (Reger); VA Office of Mental Health and Suicide Prevention, Washington, D.C. (Eagan, Trafton, McCarthy, Katz)
| | - JoAnn E Kirchner
- Central Arkansas Veterans Healthcare System, Little Rock (Landes, Pitcock, Drummond, Smith, Kirchner, Raciborski, Painter, Townsend, Jegley, Singh); Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock (Landes, Drummond, Kirchner, Painter, Singh); Rocky Mountain Mental Illness Research, Education, and Clinical Center, U.S. Department of Veterans Affairs (VA), Aurora, Colorado (Matarazzo, Clark, Gerard, Jankovsky, Brenner); Departments of Psychiatry and Physical Medicine and Rehabilitation, University of Colorado School of Medicine, Aurora (Matarazzo, Brenner); Veterans Integrated Service Network 19 Clinical Resource Hub, Salt Lake City (Clark); VA Puget Sound Health Care System, Seattle (Reger); VA Office of Mental Health and Suicide Prevention, Washington, D.C. (Eagan, Trafton, McCarthy, Katz)
| | - Kaily A Clark
- Central Arkansas Veterans Healthcare System, Little Rock (Landes, Pitcock, Drummond, Smith, Kirchner, Raciborski, Painter, Townsend, Jegley, Singh); Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock (Landes, Drummond, Kirchner, Painter, Singh); Rocky Mountain Mental Illness Research, Education, and Clinical Center, U.S. Department of Veterans Affairs (VA), Aurora, Colorado (Matarazzo, Clark, Gerard, Jankovsky, Brenner); Departments of Psychiatry and Physical Medicine and Rehabilitation, University of Colorado School of Medicine, Aurora (Matarazzo, Brenner); Veterans Integrated Service Network 19 Clinical Resource Hub, Salt Lake City (Clark); VA Puget Sound Health Care System, Seattle (Reger); VA Office of Mental Health and Suicide Prevention, Washington, D.C. (Eagan, Trafton, McCarthy, Katz)
| | - Georgia R Gerard
- Central Arkansas Veterans Healthcare System, Little Rock (Landes, Pitcock, Drummond, Smith, Kirchner, Raciborski, Painter, Townsend, Jegley, Singh); Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock (Landes, Drummond, Kirchner, Painter, Singh); Rocky Mountain Mental Illness Research, Education, and Clinical Center, U.S. Department of Veterans Affairs (VA), Aurora, Colorado (Matarazzo, Clark, Gerard, Jankovsky, Brenner); Departments of Psychiatry and Physical Medicine and Rehabilitation, University of Colorado School of Medicine, Aurora (Matarazzo, Brenner); Veterans Integrated Service Network 19 Clinical Resource Hub, Salt Lake City (Clark); VA Puget Sound Health Care System, Seattle (Reger); VA Office of Mental Health and Suicide Prevention, Washington, D.C. (Eagan, Trafton, McCarthy, Katz)
| | - Molly C Jankovsky
- Central Arkansas Veterans Healthcare System, Little Rock (Landes, Pitcock, Drummond, Smith, Kirchner, Raciborski, Painter, Townsend, Jegley, Singh); Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock (Landes, Drummond, Kirchner, Painter, Singh); Rocky Mountain Mental Illness Research, Education, and Clinical Center, U.S. Department of Veterans Affairs (VA), Aurora, Colorado (Matarazzo, Clark, Gerard, Jankovsky, Brenner); Departments of Psychiatry and Physical Medicine and Rehabilitation, University of Colorado School of Medicine, Aurora (Matarazzo, Brenner); Veterans Integrated Service Network 19 Clinical Resource Hub, Salt Lake City (Clark); VA Puget Sound Health Care System, Seattle (Reger); VA Office of Mental Health and Suicide Prevention, Washington, D.C. (Eagan, Trafton, McCarthy, Katz)
| | - Lisa A Brenner
- Central Arkansas Veterans Healthcare System, Little Rock (Landes, Pitcock, Drummond, Smith, Kirchner, Raciborski, Painter, Townsend, Jegley, Singh); Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock (Landes, Drummond, Kirchner, Painter, Singh); Rocky Mountain Mental Illness Research, Education, and Clinical Center, U.S. Department of Veterans Affairs (VA), Aurora, Colorado (Matarazzo, Clark, Gerard, Jankovsky, Brenner); Departments of Psychiatry and Physical Medicine and Rehabilitation, University of Colorado School of Medicine, Aurora (Matarazzo, Brenner); Veterans Integrated Service Network 19 Clinical Resource Hub, Salt Lake City (Clark); VA Puget Sound Health Care System, Seattle (Reger); VA Office of Mental Health and Suicide Prevention, Washington, D.C. (Eagan, Trafton, McCarthy, Katz)
| | - Mark A Reger
- Central Arkansas Veterans Healthcare System, Little Rock (Landes, Pitcock, Drummond, Smith, Kirchner, Raciborski, Painter, Townsend, Jegley, Singh); Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock (Landes, Drummond, Kirchner, Painter, Singh); Rocky Mountain Mental Illness Research, Education, and Clinical Center, U.S. Department of Veterans Affairs (VA), Aurora, Colorado (Matarazzo, Clark, Gerard, Jankovsky, Brenner); Departments of Psychiatry and Physical Medicine and Rehabilitation, University of Colorado School of Medicine, Aurora (Matarazzo, Brenner); Veterans Integrated Service Network 19 Clinical Resource Hub, Salt Lake City (Clark); VA Puget Sound Health Care System, Seattle (Reger); VA Office of Mental Health and Suicide Prevention, Washington, D.C. (Eagan, Trafton, McCarthy, Katz)
| | - Aaron E Eagan
- Central Arkansas Veterans Healthcare System, Little Rock (Landes, Pitcock, Drummond, Smith, Kirchner, Raciborski, Painter, Townsend, Jegley, Singh); Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock (Landes, Drummond, Kirchner, Painter, Singh); Rocky Mountain Mental Illness Research, Education, and Clinical Center, U.S. Department of Veterans Affairs (VA), Aurora, Colorado (Matarazzo, Clark, Gerard, Jankovsky, Brenner); Departments of Psychiatry and Physical Medicine and Rehabilitation, University of Colorado School of Medicine, Aurora (Matarazzo, Brenner); Veterans Integrated Service Network 19 Clinical Resource Hub, Salt Lake City (Clark); VA Puget Sound Health Care System, Seattle (Reger); VA Office of Mental Health and Suicide Prevention, Washington, D.C. (Eagan, Trafton, McCarthy, Katz)
| | - Rebecca Raciborski
- Central Arkansas Veterans Healthcare System, Little Rock (Landes, Pitcock, Drummond, Smith, Kirchner, Raciborski, Painter, Townsend, Jegley, Singh); Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock (Landes, Drummond, Kirchner, Painter, Singh); Rocky Mountain Mental Illness Research, Education, and Clinical Center, U.S. Department of Veterans Affairs (VA), Aurora, Colorado (Matarazzo, Clark, Gerard, Jankovsky, Brenner); Departments of Psychiatry and Physical Medicine and Rehabilitation, University of Colorado School of Medicine, Aurora (Matarazzo, Brenner); Veterans Integrated Service Network 19 Clinical Resource Hub, Salt Lake City (Clark); VA Puget Sound Health Care System, Seattle (Reger); VA Office of Mental Health and Suicide Prevention, Washington, D.C. (Eagan, Trafton, McCarthy, Katz)
| | - Jacob Painter
- Central Arkansas Veterans Healthcare System, Little Rock (Landes, Pitcock, Drummond, Smith, Kirchner, Raciborski, Painter, Townsend, Jegley, Singh); Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock (Landes, Drummond, Kirchner, Painter, Singh); Rocky Mountain Mental Illness Research, Education, and Clinical Center, U.S. Department of Veterans Affairs (VA), Aurora, Colorado (Matarazzo, Clark, Gerard, Jankovsky, Brenner); Departments of Psychiatry and Physical Medicine and Rehabilitation, University of Colorado School of Medicine, Aurora (Matarazzo, Brenner); Veterans Integrated Service Network 19 Clinical Resource Hub, Salt Lake City (Clark); VA Puget Sound Health Care System, Seattle (Reger); VA Office of Mental Health and Suicide Prevention, Washington, D.C. (Eagan, Trafton, McCarthy, Katz)
| | - James C Townsend
- Central Arkansas Veterans Healthcare System, Little Rock (Landes, Pitcock, Drummond, Smith, Kirchner, Raciborski, Painter, Townsend, Jegley, Singh); Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock (Landes, Drummond, Kirchner, Painter, Singh); Rocky Mountain Mental Illness Research, Education, and Clinical Center, U.S. Department of Veterans Affairs (VA), Aurora, Colorado (Matarazzo, Clark, Gerard, Jankovsky, Brenner); Departments of Psychiatry and Physical Medicine and Rehabilitation, University of Colorado School of Medicine, Aurora (Matarazzo, Brenner); Veterans Integrated Service Network 19 Clinical Resource Hub, Salt Lake City (Clark); VA Puget Sound Health Care System, Seattle (Reger); VA Office of Mental Health and Suicide Prevention, Washington, D.C. (Eagan, Trafton, McCarthy, Katz)
| | - Susan M Jegley
- Central Arkansas Veterans Healthcare System, Little Rock (Landes, Pitcock, Drummond, Smith, Kirchner, Raciborski, Painter, Townsend, Jegley, Singh); Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock (Landes, Drummond, Kirchner, Painter, Singh); Rocky Mountain Mental Illness Research, Education, and Clinical Center, U.S. Department of Veterans Affairs (VA), Aurora, Colorado (Matarazzo, Clark, Gerard, Jankovsky, Brenner); Departments of Psychiatry and Physical Medicine and Rehabilitation, University of Colorado School of Medicine, Aurora (Matarazzo, Brenner); Veterans Integrated Service Network 19 Clinical Resource Hub, Salt Lake City (Clark); VA Puget Sound Health Care System, Seattle (Reger); VA Office of Mental Health and Suicide Prevention, Washington, D.C. (Eagan, Trafton, McCarthy, Katz)
| | - Rajinder Sonia Singh
- Central Arkansas Veterans Healthcare System, Little Rock (Landes, Pitcock, Drummond, Smith, Kirchner, Raciborski, Painter, Townsend, Jegley, Singh); Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock (Landes, Drummond, Kirchner, Painter, Singh); Rocky Mountain Mental Illness Research, Education, and Clinical Center, U.S. Department of Veterans Affairs (VA), Aurora, Colorado (Matarazzo, Clark, Gerard, Jankovsky, Brenner); Departments of Psychiatry and Physical Medicine and Rehabilitation, University of Colorado School of Medicine, Aurora (Matarazzo, Brenner); Veterans Integrated Service Network 19 Clinical Resource Hub, Salt Lake City (Clark); VA Puget Sound Health Care System, Seattle (Reger); VA Office of Mental Health and Suicide Prevention, Washington, D.C. (Eagan, Trafton, McCarthy, Katz)
| | - Jodie A Trafton
- Central Arkansas Veterans Healthcare System, Little Rock (Landes, Pitcock, Drummond, Smith, Kirchner, Raciborski, Painter, Townsend, Jegley, Singh); Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock (Landes, Drummond, Kirchner, Painter, Singh); Rocky Mountain Mental Illness Research, Education, and Clinical Center, U.S. Department of Veterans Affairs (VA), Aurora, Colorado (Matarazzo, Clark, Gerard, Jankovsky, Brenner); Departments of Psychiatry and Physical Medicine and Rehabilitation, University of Colorado School of Medicine, Aurora (Matarazzo, Brenner); Veterans Integrated Service Network 19 Clinical Resource Hub, Salt Lake City (Clark); VA Puget Sound Health Care System, Seattle (Reger); VA Office of Mental Health and Suicide Prevention, Washington, D.C. (Eagan, Trafton, McCarthy, Katz)
| | - John F McCarthy
- Central Arkansas Veterans Healthcare System, Little Rock (Landes, Pitcock, Drummond, Smith, Kirchner, Raciborski, Painter, Townsend, Jegley, Singh); Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock (Landes, Drummond, Kirchner, Painter, Singh); Rocky Mountain Mental Illness Research, Education, and Clinical Center, U.S. Department of Veterans Affairs (VA), Aurora, Colorado (Matarazzo, Clark, Gerard, Jankovsky, Brenner); Departments of Psychiatry and Physical Medicine and Rehabilitation, University of Colorado School of Medicine, Aurora (Matarazzo, Brenner); Veterans Integrated Service Network 19 Clinical Resource Hub, Salt Lake City (Clark); VA Puget Sound Health Care System, Seattle (Reger); VA Office of Mental Health and Suicide Prevention, Washington, D.C. (Eagan, Trafton, McCarthy, Katz)
| | - Ira R Katz
- Central Arkansas Veterans Healthcare System, Little Rock (Landes, Pitcock, Drummond, Smith, Kirchner, Raciborski, Painter, Townsend, Jegley, Singh); Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock (Landes, Drummond, Kirchner, Painter, Singh); Rocky Mountain Mental Illness Research, Education, and Clinical Center, U.S. Department of Veterans Affairs (VA), Aurora, Colorado (Matarazzo, Clark, Gerard, Jankovsky, Brenner); Departments of Psychiatry and Physical Medicine and Rehabilitation, University of Colorado School of Medicine, Aurora (Matarazzo, Brenner); Veterans Integrated Service Network 19 Clinical Resource Hub, Salt Lake City (Clark); VA Puget Sound Health Care System, Seattle (Reger); VA Office of Mental Health and Suicide Prevention, Washington, D.C. (Eagan, Trafton, McCarthy, Katz)
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Bokhour BG, DeFaccio R, Gaj L, Barker A, Deeney C, Coggeshall S, Gelman H, Taylor SL, Thomas E, Zeliadt SB. Changes in Patient-Reported Outcomes Associated with Receiving Whole Health in the Veteran Health Administration (VHA)'s National Demonstration Project. J Gen Intern Med 2024; 39:84-94. [PMID: 37653207 PMCID: PMC10817883 DOI: 10.1007/s11606-023-08376-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 08/10/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND Whole Health (WH) is a patient-centered model of care being implemented by the Veterans Health Administration. Little is known about how use of WH services impacts patients' health and well-being. OBJECTIVE We sought to assess the association of WH utilization with pain and other patient-reported outcomes (PRO) over 6 months. DESIGN A longitudinal observational cohort evaluation, comparing changes in PRO surveys for WH users and Conventional Care (CC) users. Inverse probability of treatment weighting was used to balance the two groups on observed demographic and clinical characteristics. PARTICIPANTS A total of 9689 veterans receiving outpatient care at 18 VA medical centers piloting WH. INTERVENTIONS WH services included goal-setting clinical encounters, Whole Health coaching, personal health planning, and well-being services. MAIN OUTCOME MEASURES The primary outcome was change in pain intensity and interference at 6 months using the 3-item PEG. Secondary outcomes included satisfaction, experiences of care, patient engagement in healthcare, and well-being. KEY RESULTS By 6 months,1053 veterans had utilized WH and 3139 utilized only CC. Baseline pain PEG scores were 6.2 (2.5) for WH users and 6.4 (2.3) for CC users (difference p = 0.028), improving by - 2.4% (p = 0.006) and - 2.3% (p < 0.001), respectively. In adjusted analyses, WH use was unassociated with greater improvement in PEG scores compared to CC - 1.0% (- 2.9%, 1.2%). Positive trends were observed for 8 of 15 exploratory outcomes for WH compared to CC. WH use was associated with greater improvements at 6 months in likelihood to recommend VA 2.0% (0.9%, 3.3%); discussions of goals 11.8% (8.2%, 15.5%); perceptions of healthcare interactions 2.5% (0.4%, 4.6%); and engagement in health behaviors 2.2% (0.3%, 3.9%). CONCLUSION This study provides early evidence supporting the delivery of WH patient-centered care services to improve veterans' experiences of and engagement in care. These are important first-line impacts towards the goals of better overall health and well-being outcomes for Veterans.
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Affiliation(s)
- Barbara G Bokhour
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA.
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, USA.
| | - Rian DeFaccio
- VA Center of Innovation (COIN) for Veteran-Centered and Value-Driven Care, VA Puget Sound Healthcare System, Seattle, WA, USA
| | - Lauren Gaj
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
| | - Anna Barker
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
| | - Christine Deeney
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
| | - Scott Coggeshall
- VA Center of Innovation (COIN) for Veteran-Centered and Value-Driven Care, VA Puget Sound Healthcare System, Seattle, WA, USA
| | - Hannah Gelman
- VA Center of Innovation (COIN) for Veteran-Centered and Value-Driven Care, VA Puget Sound Healthcare System, Seattle, WA, USA
| | - Stephanie L Taylor
- Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Department of Medicine, Department of Health Policy and Management, UCLA, Los Angeles, CA, USA
| | - Eva Thomas
- VA Center of Innovation (COIN) for Veteran-Centered and Value-Driven Care, VA Puget Sound Healthcare System, Seattle, WA, USA
| | - Steven B Zeliadt
- VA Center of Innovation (COIN) for Veteran-Centered and Value-Driven Care, VA Puget Sound Healthcare System, Seattle, WA, USA
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, USA
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Gréaux M, Moro MF, Kamenov K, Russell AM, Barrett D, Cieza A. Health equity for persons with disabilities: a global scoping review on barriers and interventions in healthcare services. Int J Equity Health 2023; 22:236. [PMID: 37957602 PMCID: PMC10644565 DOI: 10.1186/s12939-023-02035-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 10/11/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND Persons with disabilities experience health inequities in terms of increased mortality, morbidity, and limitations in functioning when compared to the rest of the population. Many of the poor health outcomes experienced by persons with disabilities cannot be explained by the underlying health condition or impairment, but are health inequities driven by unfair societal and health system factors. A synthesis of the global evidence is needed to identify the factors that hinder equitable access to healthcare services for persons with disabilities, and the interventions to remove these barriers and promote disability inclusion. METHODS We conducted a scoping review following the methodological framework proposed by Arksey and O'Malley, Int J Soc Res Methodol 8:19-32. We searched two scholarly databases, namely MEDLINE (Ovid) and Web of Science, the websites of Organizations of Persons with Disabilities and governments, and reviewed evidence shared during WHO-led consultations on the topic of health equity for persons with disabilities. We included articles published after 2011 with no restriction to geographical location, the type of underlying impairments or healthcare services. A charting form was developed and used to extract the relevant information for each included article. RESULTS Of 11,884 articles identified in the search, we included 182 articles in this review. The majority of sources originated from high-income countries. Barriers were identified worldwide across different levels of the health system (such as healthcare costs, untrained healthcare workforces, issues of inclusive and coordinated services delivery), and through wider contributing factors of health inequities that expand beyond the health system (such as societal stigma or health literacy). However, the interventions to promote equitable access to healthcare services for persons with disabilities were not readily mapped onto those needs, their sources of funding and projected sustainability were often unclear, and few offered targeted approaches to address issues faced by marginalized groups of persons with disabilities with intersectional identities. CONCLUSION Persons with disabilities continue to face considerable barriers when accessing healthcare services, which negatively affects their chances of achieving their highest attainable standard of health. It is encouraging to note the increasing evidence on interventions targeting equitable access to healthcare services, but they remain too few and sparce to meet the populations' needs. Profound systemic changes and action-oriented strategies are warranted to promote health equity for persons with disabilities, and advance global health priorities.
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Affiliation(s)
- Mélanie Gréaux
- Faculty of Education, University of Cambridge, Cambridge, UK.
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Bowersox NW, Browne J, Grau PP, Merrill SL, Haderlein TP, Llorente MD, Washington DL. COVID-19 mortality among veterans with serious mental illness in the veterans health administration. J Psychiatr Res 2023; 163:222-229. [PMID: 37230006 PMCID: PMC10171776 DOI: 10.1016/j.jpsychires.2023.05.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 03/31/2023] [Accepted: 05/01/2023] [Indexed: 05/27/2023]
Abstract
OBJECTIVE Persons with serious mental illness (SMI: schizophrenia-spectrum disorders, bipolar disorder) experience increased risk of mortality after contracting COVID-19 based on the results of several international evaluations. However, information about COVID-19 mortality risk among patients with SMI in the Veterans Health Administration (VHA) has been limited, precluding identification of protective factors. The current evaluation was conducted to assess COVID-19 mortality risk among VHA patients with SMI and to evaluate potential protective factors in mitigating mortality risk following a positive COVID-19 diagnosis. METHODS National VHA administrative data was used to identify all patients (N = 52,916) who received a positive COVID-19 test result between March 1, 2020, and September 30, 2020. Mortality risk was assessed by SMI status via bivariate comparisons and multivariate regression analyses. RESULTS In unadjusted analyses, VHA patients with SMI overall and patients with bipolar disorder in particular did not experience increased mortality risk in the 30 days following a positive COVID test, although patients with schizophrenia had increased risk. Within adjusted analyses, patients with schizophrenia remained at increased mortality risk (OR = 1.38), but at reduced levels relative to previous evaluations in other healthcare settings. CONCLUSIONS Within VHA, patients with schizophrenia, but not those with bipolar disorder, experience increased mortality risk in the 30 days following a positive COVID-19 test. Large integrated healthcare settings such as VHA may offer services which may protect against COVID-19 mortality for vulnerable groups such as persons with SMI. Additional work is needed to identify practices which may reduce the risk of COVID-19 mortality among persons with SMI.
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Affiliation(s)
- Nicholas W Bowersox
- Serious Mental Illness Treatment Resource and Evaluation Center, Office of Mental Health and Suicide Prevention, Department of Veterans Affairs Central Office, Washington DC, USA; Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA.
| | - Julia Browne
- Research Service, VA Providence Healthcare System, Providence, RI, USA; Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI, USA
| | - Peter P Grau
- Serious Mental Illness Treatment Resource and Evaluation Center, Office of Mental Health and Suicide Prevention, Department of Veterans Affairs Central Office, Washington DC, USA; Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Stephanie L Merrill
- Serious Mental Illness Treatment Resource and Evaluation Center, Office of Mental Health and Suicide Prevention, Department of Veterans Affairs Central Office, Washington DC, USA
| | - Taona P Haderlein
- Veterans Health Administration Health Services Research and Development Center for the Study of Healthcare Innovation, Implementation, and Policy, Los Angeles, CA, USA; Veterans Emergency Management Evaluation Center, Department of Veterans Affairs, North Hills, CA, USA
| | - Maria D Llorente
- Patient Care Services, Department of Veterans Affairs, Washington DC, USA; Department of Psychiatry, Georgetown University School of Medicine, Washington DC, USA
| | - Donna L Washington
- Veterans Health Administration Health Services Research and Development Center for the Study of Healthcare Innovation, Implementation, and Policy, Los Angeles, CA, USA; Division of General Internal Medicine and Health Services Research, Department of Medicine, University of California Los Angeles Geffen School of Medicine, Los Angeles, CA, USA
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Smith SN, Almirall D, Choi SY, Koschmann E, Rusch A, Bilek E, Lane A, Abelson JL, Eisenberg D, Himle JA, Fitzgerald KD, Liebrecht C, Kilbourne AM. Primary aim results of a clustered SMART for developing a school-level, adaptive implementation strategy to support CBT delivery at high schools in Michigan. Implement Sci 2022; 17:42. [PMID: 35804370 PMCID: PMC9264291 DOI: 10.1186/s13012-022-01211-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 05/11/2022] [Indexed: 11/10/2022] Open
Abstract
Background Schools increasingly provide mental health services to students, but often lack access to implementation strategies to support school-based (and school professional [SP]) delivery of evidence-based practices. Given substantial heterogeneity in implementation barriers across schools, development of adaptive implementation strategies that guide which implementation strategies to provide to which schools and when may be necessary to support scale-up. Methods A clustered, sequential, multiple-assignment randomized trial (SMART) of high schools across Michigan was used to inform the development of a school-level adaptive implementation strategy for supporting SP-delivered cognitive behavioral therapy (CBT). All schools were first provided with implementation support informed by Replicating Effective Programs (REP) and then were randomized to add in-person Coaching or not (phase 1). After 8 weeks, schools were assessed for response based on SP-reported frequency of CBT delivered to students and/or barriers reported. Responder schools continued with phase 1 implementation strategies. Slower-responder schools (not providing ≥ 3 CBT components to ≥10 students or >2 organizational barriers identified) were re-randomized to add Facilitation to current support or not (phase 2). The primary aim hypothesis was that SPs at schools receiving the REP + Coaching + Facilitation adaptive implementation strategy would deliver more CBT sessions than SPs at schools receiving REP alone. Secondary aims compared four implementation strategies (Coaching vs no Coaching × Facilitation vs no Facilitation) on CBT sessions delivered, including by type (group, brief and full individual). Analyses used a marginal, weighted least squares approach developed for clustered SMARTs. Results SPs (n = 169) at 94 high schools entered the study. N = 83 schools (88%) were slower-responders after phase 1. Contrary to the primary aim hypothesis, there was no evidence of a significant difference in CBT sessions delivered between REP + Coaching + Facilitation and REP alone (111.4 vs. 121.1 average total CBT sessions; p = 0.63). In secondary analyses, the adaptive strategy that offered REP + Facilitation resulted in the highest average CBT delivery (154.1 sessions) and the non-adaptive strategy offering REP + Coaching the lowest (94.5 sessions). Conclusions The most effective strategy in terms of average SP-reported CBT delivery is the adaptive implementation strategy that (i) begins with REP, (ii) augments with Facilitation for slower-responder schools (schools where SPs identified organizational barriers or struggled to deliver CBT), and (iii) stays the course with REP for responder schools. Trial registration ClinicalTrials.gov, NCT03541317, May 30, 2018. Supplementary Information The online version contains supplementary material available at 10.1186/s13012-022-01211-w.
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Affiliation(s)
- Shawna N Smith
- Department of Health Management and Policy, School of Public Health, University of Michigan, SPH II, 1415 Washington Heights, Ann Arbor, MI, 48109, USA. .,Department of Psychiatry, Michigan Medicine, University of Michigan, Ann Arbor, USA.
| | - Daniel Almirall
- Survey Research Center, Institute of Social Research, University of Michigan, Ann Arbor, USA.,Department of Statistics, University of Michigan, Ann Arbor, USA
| | - Seo Youn Choi
- Department of Health Management and Policy, School of Public Health, University of Michigan, SPH II, 1415 Washington Heights, Ann Arbor, MI, 48109, USA
| | - Elizabeth Koschmann
- Department of Psychiatry, Michigan Medicine, University of Michigan, Ann Arbor, USA
| | - Amy Rusch
- Department of Health Management and Policy, School of Public Health, University of Michigan, SPH II, 1415 Washington Heights, Ann Arbor, MI, 48109, USA
| | - Emily Bilek
- Department of Psychiatry, Michigan Medicine, University of Michigan, Ann Arbor, USA
| | - Annalise Lane
- Department of Health Management and Policy, School of Public Health, University of Michigan, SPH II, 1415 Washington Heights, Ann Arbor, MI, 48109, USA
| | - James L Abelson
- Department of Psychiatry, Michigan Medicine, University of Michigan, Ann Arbor, USA
| | - Daniel Eisenberg
- Department of Health Policy and Management, UCLA, Los Angeles, USA
| | - Joseph A Himle
- Department of Psychiatry, Michigan Medicine, University of Michigan, Ann Arbor, USA.,School of Social Work, University of Michigan, Ann Arbor, USA
| | - Kate D Fitzgerald
- Department of Psychiatry, Columbia University Irving Medical Center/New York State Psychiatric Institute, New York City, USA
| | - Celeste Liebrecht
- Department of Learning Health Sciences, Michigan Medicine, University of Michigan, Ann Arbor, USA
| | - Amy M Kilbourne
- Department of Learning Health Sciences, Michigan Medicine, University of Michigan, Ann Arbor, USA.,Quality Enhancement Research Initiative (QUERI), US Department of Veterans Affairs, Washington, D.C., USA
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Kolko DJ, McGuier EA, Turchi R, Thompson E, Iyengar S, Smith SN, Hoagwood K, Liebrecht C, Bennett IM, Powell BJ, Kelleher K, Silva M, Kilbourne AM. Care team and practice-level implementation strategies to optimize pediatric collaborative care: study protocol for a cluster-randomized hybrid type III trial. Implement Sci 2022; 17:20. [PMID: 35193619 PMCID: PMC8862323 DOI: 10.1186/s13012-022-01195-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 01/31/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Implementation facilitation is an effective strategy to support the implementation of evidence-based practices (EBPs), but our understanding of multilevel strategies and the mechanisms of change within the "black box" of implementation facilitation is limited. This implementation trial seeks to disentangle and evaluate the effects of facilitation strategies that separately target the care team and leadership levels on implementation of a collaborative care model in pediatric primary care. Strategies targeting the provider care team (TEAM) should engage team-level mechanisms, and strategies targeting leaders (LEAD) should engage organizational mechanisms. METHODS We will conduct a hybrid type 3 effectiveness-implementation trial in a 2 × 2 factorial design to evaluate the main and interactive effects of TEAM and LEAD and test for mediation and moderation of effects. Twenty-four pediatric primary care practices will receive standard REP training to implement Doctor-Office Collaborative Care (DOCC) and then be randomized to (1) Standard REP only, (2) TEAM, (3) LEAD, or (4) TEAM + LEAD. Implementation outcomes are DOCC service delivery and change in practice-level care management competencies. Clinical outcomes are child symptom severity and quality of life. DISCUSSION This statewide trial is one of the first to test the unique and synergistic effects of implementation strategies targeting care teams and practice leadership. It will advance our knowledge of effective care team and practice-level implementation strategies and mechanisms of change. Findings will support efforts to improve common child behavioral health conditions by optimizing scale-up and sustainment of CCMs in a pediatric patient-centered medical home. TRIAL REGISTRATION ClinicalTrials.gov, NCT04946253 . Registered June 30, 2021.
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Affiliation(s)
- David J Kolko
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Elizabeth A McGuier
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Renee Turchi
- Department of Pediatrics, Drexel University College of Medicine and St. Christopher's Hospital for Children, Philadelphia, PA, USA
| | - Eileen Thompson
- PA Medical Home Program, PA Chapter, American Academy of Pediatrics, Media, PA, USA
| | - Satish Iyengar
- Department of Statistics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Shawna N Smith
- Department of Health Management & Policy, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Kimberly Hoagwood
- Department of Child and Adolescent Psychiatry, New York University Langone Health, New York, NY, USA
| | - Celeste Liebrecht
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Ian M Bennett
- Departments of Family Medicine and Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
| | - Byron J Powell
- Center for Mental Health Services Research, Brown School, Washington University in St. Louis, One Brookings Drive, St. Louis, MO, 63130, USA
- Division of Infectious Diseases, John T. Milliken Department of Medicine, Washington University School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Kelly Kelleher
- Department of Pediatrics, College of Medicine, The Ohio State University, Columbus, OH, USA
- Nationwide Children's Hospital Research Institute, Columbus, OH, USA
| | - Maria Silva
- Allegheny Family Network, Pittsburgh, PA, USA
| | - Amy M Kilbourne
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, MI, USA
- VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
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Gaynes BN, Akiba CF, Hosseinipour MC, Kulisewa K, Amberbir A, Udedi M, Zimba CC, Masiye JK, Crampin M, Amarreh I, Pence BW. The Sub-Saharan Africa Regional Partnership (SHARP) for Mental Health Capacity-Building Scale-Up Trial: Study Design and Protocol. Psychiatr Serv 2021; 72:812-821. [PMID: 33291973 PMCID: PMC8187465 DOI: 10.1176/appi.ps.202000003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Depression is a leading cause of death and disability worldwide, including in low- and middle-income countries (LMICs). Depression often coexists with chronic medical conditions and is associated with worse clinical outcomes. This confluence has led to calls to integrate mental health treatment with chronic disease care systems in LMICs. This article describes the rationale and protocol for a trial comparing the clinical effectiveness and cost-effectiveness of two different intervention packages to implement evidence-based antidepressant management and psychotherapy into chronic noncommunicable disease (NCD) clinics in Malawi. METHODS Using constrained randomization, the Sub-Saharan Africa Regional Partnership (SHARP) for mental health capacity building will assign five Malawian NCD clinics to a basic implementation strategy via an internal coordinator, a provider within the chronic care clinic who champions depression services by providing training, supervision, operations, and reporting. Another five clinics will be assigned to depression services implementation via an internal coordinator along with an external quality assurance committee, which will provide a quarterly audit of intervention component delivery with feedback to providers and the health management team. RESULTS The authors will compare key implementation outcomes (fidelity to intervention), clinical effectiveness outcomes (patient health), and cost-effectiveness and will assess characteristics of clinics that may influence uptake and fidelity. NEXT STEPS This trial will provide key information to guide the Malawi Ministry of Health in scaling up depression management in existing NCD settings. The SHARP trial is anticipated to substantially contribute to enhancing both mental health treatment and implementation science research capacity in Malawi and the wider region.
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Affiliation(s)
- Bradley N Gaynes
- Department of Psychiatry (Gaynes) and Department of Medicine (Hosseinipour), School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill; Department of Health Behavior (Akiba) and Department of Epidemiology (Pence), Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill; Department of Mental Health and Psychiatry, University of Malawi College of Medicine, Blantyre, Malawi (Kulisewa); Partners in Hope, Lilongwe, Malawi (Amberbir); Malawi Ministry of Health, Lilongwe, Malawi (Udedi, Masiye); University of North Carolina Project-Malawi, Lilongwe, Malawi (Zimba); Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi (Crampin); National Institute of Mental Health, Bethesda, Maryland (Amarreh)
| | - Christopher F Akiba
- Department of Psychiatry (Gaynes) and Department of Medicine (Hosseinipour), School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill; Department of Health Behavior (Akiba) and Department of Epidemiology (Pence), Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill; Department of Mental Health and Psychiatry, University of Malawi College of Medicine, Blantyre, Malawi (Kulisewa); Partners in Hope, Lilongwe, Malawi (Amberbir); Malawi Ministry of Health, Lilongwe, Malawi (Udedi, Masiye); University of North Carolina Project-Malawi, Lilongwe, Malawi (Zimba); Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi (Crampin); National Institute of Mental Health, Bethesda, Maryland (Amarreh)
| | - Mina C Hosseinipour
- Department of Psychiatry (Gaynes) and Department of Medicine (Hosseinipour), School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill; Department of Health Behavior (Akiba) and Department of Epidemiology (Pence), Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill; Department of Mental Health and Psychiatry, University of Malawi College of Medicine, Blantyre, Malawi (Kulisewa); Partners in Hope, Lilongwe, Malawi (Amberbir); Malawi Ministry of Health, Lilongwe, Malawi (Udedi, Masiye); University of North Carolina Project-Malawi, Lilongwe, Malawi (Zimba); Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi (Crampin); National Institute of Mental Health, Bethesda, Maryland (Amarreh)
| | - Kazione Kulisewa
- Department of Psychiatry (Gaynes) and Department of Medicine (Hosseinipour), School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill; Department of Health Behavior (Akiba) and Department of Epidemiology (Pence), Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill; Department of Mental Health and Psychiatry, University of Malawi College of Medicine, Blantyre, Malawi (Kulisewa); Partners in Hope, Lilongwe, Malawi (Amberbir); Malawi Ministry of Health, Lilongwe, Malawi (Udedi, Masiye); University of North Carolina Project-Malawi, Lilongwe, Malawi (Zimba); Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi (Crampin); National Institute of Mental Health, Bethesda, Maryland (Amarreh)
| | - Alemayehu Amberbir
- Department of Psychiatry (Gaynes) and Department of Medicine (Hosseinipour), School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill; Department of Health Behavior (Akiba) and Department of Epidemiology (Pence), Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill; Department of Mental Health and Psychiatry, University of Malawi College of Medicine, Blantyre, Malawi (Kulisewa); Partners in Hope, Lilongwe, Malawi (Amberbir); Malawi Ministry of Health, Lilongwe, Malawi (Udedi, Masiye); University of North Carolina Project-Malawi, Lilongwe, Malawi (Zimba); Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi (Crampin); National Institute of Mental Health, Bethesda, Maryland (Amarreh)
| | - Michael Udedi
- Department of Psychiatry (Gaynes) and Department of Medicine (Hosseinipour), School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill; Department of Health Behavior (Akiba) and Department of Epidemiology (Pence), Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill; Department of Mental Health and Psychiatry, University of Malawi College of Medicine, Blantyre, Malawi (Kulisewa); Partners in Hope, Lilongwe, Malawi (Amberbir); Malawi Ministry of Health, Lilongwe, Malawi (Udedi, Masiye); University of North Carolina Project-Malawi, Lilongwe, Malawi (Zimba); Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi (Crampin); National Institute of Mental Health, Bethesda, Maryland (Amarreh)
| | - Chifundo C Zimba
- Department of Psychiatry (Gaynes) and Department of Medicine (Hosseinipour), School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill; Department of Health Behavior (Akiba) and Department of Epidemiology (Pence), Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill; Department of Mental Health and Psychiatry, University of Malawi College of Medicine, Blantyre, Malawi (Kulisewa); Partners in Hope, Lilongwe, Malawi (Amberbir); Malawi Ministry of Health, Lilongwe, Malawi (Udedi, Masiye); University of North Carolina Project-Malawi, Lilongwe, Malawi (Zimba); Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi (Crampin); National Institute of Mental Health, Bethesda, Maryland (Amarreh)
| | - Jones K Masiye
- Department of Psychiatry (Gaynes) and Department of Medicine (Hosseinipour), School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill; Department of Health Behavior (Akiba) and Department of Epidemiology (Pence), Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill; Department of Mental Health and Psychiatry, University of Malawi College of Medicine, Blantyre, Malawi (Kulisewa); Partners in Hope, Lilongwe, Malawi (Amberbir); Malawi Ministry of Health, Lilongwe, Malawi (Udedi, Masiye); University of North Carolina Project-Malawi, Lilongwe, Malawi (Zimba); Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi (Crampin); National Institute of Mental Health, Bethesda, Maryland (Amarreh)
| | - Mia Crampin
- Department of Psychiatry (Gaynes) and Department of Medicine (Hosseinipour), School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill; Department of Health Behavior (Akiba) and Department of Epidemiology (Pence), Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill; Department of Mental Health and Psychiatry, University of Malawi College of Medicine, Blantyre, Malawi (Kulisewa); Partners in Hope, Lilongwe, Malawi (Amberbir); Malawi Ministry of Health, Lilongwe, Malawi (Udedi, Masiye); University of North Carolina Project-Malawi, Lilongwe, Malawi (Zimba); Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi (Crampin); National Institute of Mental Health, Bethesda, Maryland (Amarreh)
| | - Ishmael Amarreh
- Department of Psychiatry (Gaynes) and Department of Medicine (Hosseinipour), School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill; Department of Health Behavior (Akiba) and Department of Epidemiology (Pence), Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill; Department of Mental Health and Psychiatry, University of Malawi College of Medicine, Blantyre, Malawi (Kulisewa); Partners in Hope, Lilongwe, Malawi (Amberbir); Malawi Ministry of Health, Lilongwe, Malawi (Udedi, Masiye); University of North Carolina Project-Malawi, Lilongwe, Malawi (Zimba); Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi (Crampin); National Institute of Mental Health, Bethesda, Maryland (Amarreh)
| | - Brian W Pence
- Department of Psychiatry (Gaynes) and Department of Medicine (Hosseinipour), School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill; Department of Health Behavior (Akiba) and Department of Epidemiology (Pence), Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill; Department of Mental Health and Psychiatry, University of Malawi College of Medicine, Blantyre, Malawi (Kulisewa); Partners in Hope, Lilongwe, Malawi (Amberbir); Malawi Ministry of Health, Lilongwe, Malawi (Udedi, Masiye); University of North Carolina Project-Malawi, Lilongwe, Malawi (Zimba); Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi (Crampin); National Institute of Mental Health, Bethesda, Maryland (Amarreh)
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McGinty EE, Murphy KA, Dalcin AT, Stuart EA, Wang NY, Dickerson F, Gudzune K, Jerome G, Thompson D, Cullen BA, Gennusa J, Kilbourne AM, Daumit GL. A Model for Advancing Scale-Up of Complex Interventions for Vulnerable Populations: the ALACRITY Center for Health and Longevity in Mental Illness. J Gen Intern Med 2021; 36:500-505. [PMID: 32869192 PMCID: PMC7878664 DOI: 10.1007/s11606-020-06137-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Accepted: 08/11/2020] [Indexed: 12/17/2022]
Abstract
Many of the most pressing health issues in the USA and worldwide require complex, multi-faceted solutions. Delivery of such solutions is often complicated by the need to reach and engage vulnerable populations facing multiple barriers to care. While the fields of quality improvement and implementation science have made valuable gains in the development and spread of individual strategies to improve evidence-based practice delivery, models for coordinated deployment of numerous strategies to simultaneously implement multiple evidence-based interventions in vulnerable populations are lacking. In this Perspective, we describe a model for this type of comprehensive research-practice translation effort: the Johns Hopkins ALACRITY Center for Health and Longevity in Mental Illness, which is focused on reducing premature mortality in the population with serious mental illness. We describe the Center's conceptual framework, which is built upon an integrated set of quality improvement and implementation science frameworks, provide an overview of the Center's organizational structure and core research-practice translation activities, and discuss our vision for how the Center may evolve over time. Lessons learned from this Center's efforts could inform models to address other critical health issues in vulnerable populations that require multi-component solutions at the policy, system, provider, and patient levels.
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Affiliation(s)
- Emma E McGinty
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Karly A Murphy
- Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Arlene T Dalcin
- Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Elizabeth A Stuart
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Nae-Yuh Wang
- Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | | | - Kim Gudzune
- Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Gerald Jerome
- Department of Kinesiology, Towson University, Towson, MD, USA
| | - David Thompson
- Department of Anesthesiology and Critical Care and Armstrong Institute for Patient Safety and Quality, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Bernadette A Cullen
- Department of Psychiatry & Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Joseph Gennusa
- Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Amy M Kilbourne
- Health Services Research and Development Service, Veterans Health Administration, US Department of Veterans Affairs and Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MD, USA
| | - Gail L Daumit
- Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
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Landes SJ, Jegley SM, Kirchner JE, Areno JP, Pitcock JA, Abraham TH, McBain SA, Singh RS, Bollinger MJ, Painter J, Woods JA, Curtis ND, Jones DE, Matarazzo BB, Reger MA, Comtois KA. Adapting Caring Contacts for Veterans in a Department of Veterans Affairs Emergency Department: Results From a Type 2 Hybrid Effectiveness-Implementation Pilot Study. Front Psychiatry 2021; 12:746805. [PMID: 34721114 PMCID: PMC8548725 DOI: 10.3389/fpsyt.2021.746805] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Accepted: 09/13/2021] [Indexed: 12/02/2022] Open
Abstract
Transitions in care, such as discharge from an emergency department (ED), are periods of increased risk for suicide and effective interventions that target these periods are needed. Caring Contacts is an evidence-based suicide prevention intervention that targets transitions, yet it has not been widely implemented. This pilot study adapted Caring Contacts for a Department of Veterans Affairs (VA) ED setting and population, created an implementation toolkit, and piloted implementation and evaluation of effectiveness. To inform adaptation, qualitative interviews were conducted with stakeholders. Data were used by an advisory board comprised of stakeholders, experts, and veterans to make adaptations and develop an implementation planning guide to delineate steps needed to implement. Key decisions about how to adapt Caring Contacts included recipients, author, content, and the schedule for sending. Pilot implementation occurred at one VA ED. Caring Contacts involved sending patients at risk of suicide brief, non-demanding expressions of care. Program evaluation of the pilot used a type 2 hybrid effectiveness-implementation design to both pilot an implementation strategy and evaluate effectiveness of Caring Contacts. Evaluation included qualitative interviews with veteran patients during implementation. VA electronic health records were used to evaluate VA service utilization in the 6-month periods immediately before and after veterans were delivered their first Caring Contact. Hundred and seventy-five veterans were mailed Caring Contacts and the facility continued adoption after the pilot. Participants were positive about the intervention and reported feeling cared about and connected to VA as a result of receiving Caring Contacts. This project developed an implementation planning process that successfully implemented Caring Contacts at one site. This can be used to further implement Caring Contacts at additional VA or community EDs.
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Affiliation(s)
- Sara J Landes
- Behavioral Health QUERI, Central Arkansas Veterans Healthcare System, North Little Rock, AR, United States.,South Central Mental Illness Research Education and Clinical Center, Central Arkansas Veterans Healthcare System, North Little Rock, AR, United States.,Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Susan M Jegley
- Behavioral Health QUERI, Central Arkansas Veterans Healthcare System, North Little Rock, AR, United States
| | - JoAnn E Kirchner
- Behavioral Health QUERI, Central Arkansas Veterans Healthcare System, North Little Rock, AR, United States.,Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - John P Areno
- South Central VA Health Care Network, Ridgeland, MS, United States
| | - Jeffery A Pitcock
- Behavioral Health QUERI, Central Arkansas Veterans Healthcare System, North Little Rock, AR, United States
| | - Traci H Abraham
- Center for Mental Healthcare & Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, AR, United States
| | - Sacha A McBain
- South Central Mental Illness Research Education and Clinical Center, Central Arkansas Veterans Healthcare System, North Little Rock, AR, United States.,Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - R Sonia Singh
- South Central Mental Illness Research Education and Clinical Center, Central Arkansas Veterans Healthcare System, North Little Rock, AR, United States.,Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Mary J Bollinger
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, United States.,Center for Mental Healthcare & Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, AR, United States
| | - Jacob Painter
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, United States.,Center for Mental Healthcare & Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, AR, United States
| | - Jack A Woods
- Behavioral Health QUERI, Central Arkansas Veterans Healthcare System, North Little Rock, AR, United States
| | - Nyssa D Curtis
- Behavioral Health QUERI, Central Arkansas Veterans Healthcare System, North Little Rock, AR, United States
| | - Donald E Jones
- Behavioral Health QUERI, Central Arkansas Veterans Healthcare System, North Little Rock, AR, United States
| | - Bridget B Matarazzo
- Rocky Mountain Mental Illness Research Education and Clinical Center, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, CO, United States.,Department of Psychiatry, University of Colorado Anschutz School of Medicine, Aurora, CO, United States
| | - Mark A Reger
- VA Puget Sound Health Care System, Tacoma, WA, United States
| | - Katherine Anne Comtois
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, United States
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10
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Smith SN, Liebrecht CM, Bauer MS, Kilbourne AM. Comparative effectiveness of external vs blended facilitation on collaborative care model implementation in slow-implementer community practices. Health Serv Res 2020; 55:954-965. [PMID: 33125166 DOI: 10.1111/1475-6773.13583] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVE To evaluate the comparative effectiveness of external facilitation (EF) vs external + internal facilitation (EF/IF), on uptake of a collaborative chronic care model (CCM) in community practices that were slower to implement under low-level implementation support. STUDY SETTING Primary data were collected from 43 community practices in Michigan and Colorado at baseline and for 12 months following randomization. STUDY DESIGN Sites that failed to meet a pre-established implementation benchmark after six months of low-level implementation support were randomized to add either EF or EF/IF support for up to 12 months. Key outcomes were change in number of patients receiving the CCM and number of patients receiving a clinically significant dose of the CCM. Moderators' analyses further examined whether comparative effectiveness was dependent on prerandomization adoption, number of providers trained or practice size. Facilitation log data were used for exploratory follow-up analyses. DATA COLLECTION Sites reported monthly on number of patients that had received the CCM. Facilitation logs were completed by study EF and site IFs and shared with the study team. PRINCIPAL FINDINGS N = 21 sites were randomized to EF and 22 to EF/IF. Overall, EF/IF practices saw more uptake than EF sites after 12 months (ΔEF/IF-EF = 4.4 patients, 95% CI = 1.87-6.87). Moderators' analyses, however, revealed that it was only sites with no prerandomization uptake of the CCM (nonadopter sites) that saw significantly more benefit from EF/IF (ΔEF/IF-EF = 9.2 patients, 95% CI: 5.72, 12.63). For sites with prerandomization uptake (adopter sites), EF/IF offered no additional benefit (ΔEF/IF-EF = -0.9; 95% CI: -4.40, 2.60). Number of providers trained and practice size were not significant moderators. CONCLUSIONS Although stepping up to the more intensive EF/IF did outperform EF overall, its benefit was limited to sites that failed to deliver any CCM under the low-level strategy. Once one or more providers were delivering the CCM, additional on-site personnel did not appear to add value to the implementation effort.
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Affiliation(s)
- Shawna N Smith
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, Michigan, USA.,Department of Psychiatry, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Celeste M Liebrecht
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Mark S Bauer
- Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Amy M Kilbourne
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, Michigan, USA.,Quality Enhancement Research Initiative, U.S. Department of Veterans Affairs, Washington, District of Columbia, USA
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Smith SN, Almirall D, Prenovost K, Liebrecht C, Kyle J, Eisenberg D, Bauer MS, Kilbourne AM. Change in Patient Outcomes After Augmenting a Low-level Implementation Strategy in Community Practices That Are Slow to Adopt a Collaborative Chronic Care Model: A Cluster Randomized Implementation Trial. Med Care 2019; 57:503-511. [PMID: 31135692 PMCID: PMC6684247 DOI: 10.1097/mlr.0000000000001138] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Implementation strategies are essential for promoting the uptake of evidence-based practices and for patients to receive optimal care. Yet strategies differ substantially in their intensity and feasibility. Lower-intensity strategies (eg, training and technical support) are commonly used but may be insufficient for all clinics. Limited research has examined the comparative effectiveness of augmentations to low-level implementation strategies for nonresponding clinics. OBJECTIVES To compare 2 augmentation strategies for improving uptake of an evidence-based collaborative chronic care model (CCM) on 18-month outcomes for patients with depression at community-based clinics nonresponsive to lower-level implementation support. RESEARCH DESIGN Providers initially received support using a low-level implementation strategy, Replicating Effective Programs (REP). After 6 months, nonresponsive clinics were randomized to add either external facilitation (REP+EF) or external and internal facilitation (REP+EF/IF). MEASURES The primary outcome was patient 12-item short form survey (SF-12) mental health score at month 18. Secondary outcomes were patient health questionnaire (PHQ-9) depression score at month 18 and receipt of the CCM during months 6 through 18. RESULTS Twenty-seven clinics were nonresponsive after 6 months of REP. Thirteen clinics (N=77 patients) were randomized to REP+EF and 14 (N=92) to REP+EF/IF. At 18 months, patients in the REP+EF/IF arm had worse SF-12 [diff, 8.38; 95% confidence interval (CI), 3.59-13.18] and PHQ-9 scores (diff, 1.82; 95% CI, -0.14 to 3.79), and lower odds of CCM receipt (odds ratio, 0.67; 95% CI, 0.30-1.49) than REP+EF patients. CONCLUSIONS Patients at sites receiving the more intensive REP+EF/IF saw less improvement in mood symptoms at 18 months than those receiving REP+EF and were no more likely to receive the CCM. For community-based clinics, EF augmentation may be more feasible than EF/IF for implementing CCMs.
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Affiliation(s)
- Shawna N Smith
- Department of Psychiatry, University of Michigan Medical School
- Institute for Social Research
| | - Daniel Almirall
- Institute for Social Research
- Department of Statistics, University of Michigan
| | | | - Celeste Liebrecht
- Department of Psychiatry, University of Michigan Medical School
- Quality Enhancement Research Initiative (QUERI), US Department of Veterans Affairs
| | - Julia Kyle
- Department of Psychiatry, University of Michigan Medical School
| | - Daniel Eisenberg
- Department of Health Management and Policy, School of Public Health, University of Michigan Ann Arbor, MI
| | - Mark S Bauer
- US Department of Veterans Affairs, Center for Healthcare Organization and Implementation Research, US Department of Veterans Affairs, Boston Healthcare System and Harvard Medical School, Boston, MA
| | - Amy M Kilbourne
- Department of Psychiatry, University of Michigan Medical School
- Quality Enhancement Research Initiative (QUERI), US Department of Veterans Affairs
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12
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Kilbourne AM, Smith SN, Choi SY, Koschmann E, Liebrecht C, Rusch A, Abelson JL, Eisenberg D, Himle JA, Fitzgerald K, Almirall D. Adaptive School-based Implementation of CBT (ASIC): clustered-SMART for building an optimized adaptive implementation intervention to improve uptake of mental health interventions in schools. Implement Sci 2018; 13:119. [PMID: 30185192 PMCID: PMC6126013 DOI: 10.1186/s13012-018-0808-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 08/15/2018] [Indexed: 12/13/2022] Open
Abstract
Background Depressive and anxiety disorders affect 20–30% of school-age youth, most of whom do not receive adequate services, contributing to poor developmental and academic outcomes. Evidence-based practices (EBPs) such as cognitive behavioral therapy (CBT) can improve outcomes, but numerous barriers limit access among affected youth. Many youth try to access mental health services in schools, but school professionals (SPs: counselors, psychologists, social workers) are rarely trained adequately in CBT methods. Further, SPs face organizational barriers to providing CBT, such as lack of administrative support. Three promising implementation strategies to address barriers to school-based CBT delivery include (1) Replicating Effective Programs (REP), which deploys customized CBT packaging, didactic training in CBT, and technical assistance; (2) coaching, which extends training via live supervision to improve SP competence in CBT delivery; and (3) facilitation, which employs an organizational expert who mentors SPs in strategic thinking to promote self-efficacy in garnering administrative support. REP is a relatively low-intensity/low-cost strategy, whereas coaching and facilitation require additional resources. However, not all schools will require all three strategies. The primary aim of this study is to compare the effectiveness of a school-level adaptive implementation intervention involving REP, coaching, and facilitation versus REP alone on the frequency of CBT delivered to students by SPs and student mental health outcomes. Secondary and exploratory aims examine cost-effectiveness, moderators, and mechanisms of implementation strategies. Methods Using a clustered, sequential multiple-assignment, randomized trial (SMART) design, ≥ 200 SPs from 100 schools across Michigan will be randomized initially to receive REP vs. REP+coaching. After 8 weeks, schools that do not meet a pre-specified implementation benchmark are re-randomized to continue with the initial strategy or to augment with facilitation. Discussion EBPs need to be implemented successfully and efficiently in settings where individuals are most likely to seek care in order to gain large-scale impact on public health. Adaptive implementation interventions hold the promise of providing cost-effective implementation support. This is the first study to test an adaptive implementation of CBT for school-age youth, at a statewide level, delivered by school staff, taking an EBP to large populations with limited mental health care access. Trial registration NCT03541317—Registered on 29 May 2018 on ClinicalTrials.gov PRS Electronic supplementary material The online version of this article (10.1186/s13012-018-0808-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Amy M Kilbourne
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA. .,U.S. Department of Veterans Affairs, Quality Enhancement Research Initiative, Washington D.C., USA.
| | - Shawna N Smith
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Seo Youn Choi
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Elizabeth Koschmann
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Celeste Liebrecht
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Amy Rusch
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA
| | - James L Abelson
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Daniel Eisenberg
- School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Joseph A Himle
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA.,School of Social Work, University of Michigan, Ann Arbor, MI, USA
| | - Kate Fitzgerald
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Daniel Almirall
- Institute for Social Research, University of Michigan, Ann Arbor, MI, USA
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13
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Smith SN, Almirall D, Prenovost K, Goodrich DE, Abraham KM, Liebrecht C, Kilbourne AM. Organizational culture and climate as moderators of enhanced outreach for persons with serious mental illness: results from a cluster-randomized trial of adaptive implementation strategies. Implement Sci 2018; 13:93. [PMID: 29986765 PMCID: PMC6038326 DOI: 10.1186/s13012-018-0787-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 06/26/2018] [Indexed: 01/05/2023] Open
Abstract
Background Organizational culture and climate are considered key factors in implementation efforts but have not been examined as moderators of implementation strategy comparative effectiveness. We investigated organizational culture and climate as moderators of comparative effectiveness of two sequences of implementation strategies (Immediate vs. Delayed Enhanced Replicating Effective Programs [REP]) combining Standard REP and REP enhanced with facilitation on implementation of an outreach program for Veterans with serious mental illness lost to care at Veterans Health Administration (VA) facilities nationwide. Methods This study is a secondary analysis of the cluster-randomized Re-Engage implementation trial that assigned 3075 patients at 89 VA facilities to either the Immediate or Delayed Enhanced REP sequences. We hypothesized that sites with stronger entrepreneurial culture, task, or relational climate would benefit more from Enhanced REP than Standard REP. Veteran- and site-level data from the Re-Engage trial were combined with site-aggregated measures of entrepreneurial culture and task and relational climate from the 2012 VA All Employee Survey. Longitudinal mixed-effects logistic models examined whether the comparative effectiveness of the Immediate vs. Delayed Enhanced REP sequences were moderated by culture or climate measures at 6 and 12 months post-randomization. Three Veteran-level outcomes related to the engagement with the VA system were assessed: updated documentation, attempted contact by coordinator, and completed contact. Results For updated documentation and attempted contact, Veterans at sites with higher entrepreneurial culture and task climate scores benefitted more from Enhanced REP compared to Standard REP than Veterans at sites with lower scores. Few culture or climate moderation effects were detected for the comparative effectiveness of the full sequences of implementation strategies. Conclusions Implementation strategy effectiveness is highly intertwined with contextual factors, and implementation practitioners may use knowledge of contextual moderation to tailor strategy deployment. We found that facilitation strategies provided with Enhanced REP were more effective at improving uptake of a mental health outreach program at sites with stronger entrepreneurial culture and task climate; Veterans at sites with lower levels of these measures saw more similar improvement under Standard and Enhanced REP. Within resource-constrained systems, practitioners may choose to target more intensive implementation strategies to sites that will most benefit from them. Trial registration ISRCTN: ISRCTN21059161. Date registered: April 11, 2013. Electronic supplementary material The online version of this article (10.1186/s13012-018-0787-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Shawna N Smith
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA. .,Department of Internal Medicine, Division of General Medicine, University of Michigan Medical School, Ann Arbor, MI, USA.
| | - Daniel Almirall
- Institute for Social Research and Department of Statistics, University of Michigan, Ann Arbor, MI, USA
| | - Katherine Prenovost
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA.,VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - David E Goodrich
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Kristen M Abraham
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.,Department of Psychology, University of Detroit Mercy, Detroit, MI, USA
| | - Celeste Liebrecht
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA.,VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Amy M Kilbourne
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA.,VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.,Health Services Research and Development, Veterans Health Administration, US Department of Veterans, Washington DC, USA
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Kilbourne AM, Hynes D, O’Toole T, Atkins D. A research agenda for care coordination for chronic conditions: aligning implementation, technology, and policy strategies. Transl Behav Med 2018; 8:515-521. [DOI: 10.1093/tbm/ibx084] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Amy M Kilbourne
- Quality Enhancement Research Initiative (QUERI), Veterans Heath Administration, U.S. Department of Veterans Affairs, Washington DC, USA
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Denise Hynes
- VA Information Resource Center (VIREC), Hines VA Medical Center, Hines, IL, USA
- School of Public Health, University of Illinois, Chicago, USA
| | - Thomas O’Toole
- Providence VA Medical Center and Veterans Health Administration, Providence, RI
- Brown School of Medicine, Providence, RI, USA
| | - David Atkins
- Health Services Research and Development, Veterans Health Administration, U.S. Department of Veterans Affairs, Washington DC, USA
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15
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Ritchie MJ, Parker LE, Edlund CN, Kirchner JE. Using implementation facilitation to foster clinical practice quality and adherence to evidence in challenged settings: a qualitative study. BMC Health Serv Res 2017; 17:294. [PMID: 28424052 PMCID: PMC5397744 DOI: 10.1186/s12913-017-2217-0] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Accepted: 04/01/2017] [Indexed: 12/03/2022] Open
Abstract
Background We evaluated a facilitation strategy to help clinical sites likely to experience challenges implement evidence-based Primary Care-Mental Health Integration (PC-MHI) care models within the context of a Department of Veterans Affairs (VA) initiative. This article describes our assessment of whether implementation facilitation (IF) can foster development of high quality PC-MHI programs that adhere to evidence, are sustainable and likely to improve clinical practices and outcomes. Methods Utilizing a matched pair design, we conducted a qualitative descriptive evaluation of the IF strategy in sixteen VA primary care clinics. To assess program quality and adherence to evidence, we conducted one-hour structured telephone interviews, at two time points, with clinicians and leaders who knew the most about the clinics’ programs. We then created structured summaries of the interviews that VA national PC-MHI experts utilized to rate the programs on four dimensions (overall quality, adherence to evidence, sustainability and level of improvement). Results At first assessment, seven of eight IF sites and four of eight comparison sites had implemented a PC-MHI program. Our qualitative assessment suggested that experts rated IF sites’ programs higher than comparison sites’ programs with one exception. At final assessment, all eight IF but only five comparison sites had implemented a PC-MHI program. Again, experts rated IF sites’ programs higher than their matched comparison sites with one exception. Over time, all ratings improved in five of seven IF sites and two of three comparison sites. Conclusions Implementing complex evidence-based programs, particularly in settings that lack infrastructure, resources and support for such efforts, is challenging. Findings suggest that a blend of external expert and internal regional facilitation strategies that implementation scientists have developed and tested can improve PC-MHI program uptake, quality and adherence to evidence in primary care clinics with these challenges. However, not all sites showed these improvements. To be successful, facilitators likely need at least a moderate level of leaders’ support, including provision of basic resources. Additionally, we found that IF and strength of leadership structure may have a synergistic effect on ability to implement higher quality and evidence-based programs. Electronic supplementary material The online version of this article (doi:10.1186/s12913-017-2217-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Mona J Ritchie
- Department of Veterans Affairs, VA Quality Enhancement Research Initiative (QUERI) Program for Team-Based Behavioral Health, 2200 Ft Roots Dr, Bdg 58, North Little Rock, AR, 72114, USA. .,Department of Psychiatry, University of Arkansas for Medical Sciences, 4301 W Markham St, #755, Little Rock, AR, 72205, USA.
| | - Louise E Parker
- Department of Veterans Affairs, VA Quality Enhancement Research Initiative (QUERI) Program for Team-Based Behavioral Health, 2200 Ft Roots Dr, Bdg 58, North Little Rock, AR, 72114, USA.,Department of Management and Marketing, College of Management, University of Massachusetts, 100 Morrissey Blvd, Boston, MA, 02125, USA
| | - Carrie N Edlund
- Department of Veterans Affairs, VA Quality Enhancement Research Initiative (QUERI) Program for Team-Based Behavioral Health, 2200 Ft Roots Dr, Bdg 58, North Little Rock, AR, 72114, USA.,Department of Psychiatry, University of Arkansas for Medical Sciences, 4301 W Markham St, #755, Little Rock, AR, 72205, USA
| | - JoAnn E Kirchner
- Department of Veterans Affairs, VA Quality Enhancement Research Initiative (QUERI) Program for Team-Based Behavioral Health, 2200 Ft Roots Dr, Bdg 58, North Little Rock, AR, 72114, USA.,Department of Psychiatry, University of Arkansas for Medical Sciences, 4301 W Markham St, #755, Little Rock, AR, 72205, USA
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Atkins D, Kilbourne AM, Shulkin D. Moving From Discovery to System-Wide Change: The Role of Research in a Learning Health Care System: Experience from Three Decades of Health Systems Research in the Veterans Health Administration. Annu Rev Public Health 2017; 38:467-487. [DOI: 10.1146/annurev-publhealth-031816-044255] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The Veterans Health Administration is unique, functioning as an integrated health care system that provides care to more than six million veterans annually and as a home to an established scientific enterprise that conducts more than $1 billion of research each year. The presence of research, spanning the continuum from basic health services to translational research, has helped the Department of Veterans Affairs (VA) realize the potential of a learning health care system and has contributed to significant improvements in clinical quality over the past two decades. It has also illustrated distinct pathways by which research influences clinical care and policy and has provided lessons on challenges in translating research into practice on a national scale. These lessons are increasingly relevant to other health care systems, as the issues confronting the VA—the need to provide timely access, coordination of care, and consistent high quality across a diverse system—mirror those of the larger US health care system.
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Affiliation(s)
- David Atkins
- Veterans Health Administration, US Department of Veterans Affairs, Washington, DC 20420; emails: , ,
| | - Amy M. Kilbourne
- Veterans Health Administration, US Department of Veterans Affairs, Washington, DC 20420; emails: , ,
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, Michigan 48109-5624
| | - David Shulkin
- Veterans Health Administration, US Department of Veterans Affairs, Washington, DC 20420; emails: , ,
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Smith SN, Lai Z, Almirall D, Goodrich DE, Abraham KM, Nord KM, Kilbourne AM. Implementing Effective Policy in a National Mental Health Reengagement Program for Veterans. J Nerv Ment Dis 2017; 205:161-70. [PMID: 27668352 DOI: 10.1097/NMD.0000000000000592] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Policy is a powerful motivator of clinical change, but implementation success can depend on organizational characteristics. This article used validated measures of organizational resources, culture, and climate to predict uptake of a nationwide Veteran's Health Administration (VA) policy aimed at implementing Re-Engage, a brief care management program that reestablishes contact with veterans with serious mental illness lost to care. Patient care databases were used to identify 2738 veterans lost to care. Local recovery coordinators (LRCs) were to update disposition for 2738 veterans at 158 VA facilities and, as appropriate, facilitate a return to care. Multivariable regression was used to assess organizational culture and climate as predictors of early policy compliance (via LRC presence) and uptake at 6 months. Higher composite climate and culture scores were associated with higher odds of having a designated LRC but were not predictive of higher uptake. Sites with LRCs had significantly higher rates of updated documentation than sites without LRCs.
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Abstract
BACKGROUND The movement of evidence-based practices (EBPs) into routine clinical usage is not spontaneous, but requires focused efforts. The field of implementation science has developed to facilitate the spread of EBPs, including both psychosocial and medical interventions for mental and physical health concerns. DISCUSSION The authors aim to introduce implementation science principles to non-specialist investigators, administrators, and policymakers seeking to become familiar with this emerging field. This introduction is based on published literature and the authors' experience as researchers in the field, as well as extensive service as implementation science grant reviewers. Implementation science is "the scientific study of methods to promote the systematic uptake of research findings and other EBPs into routine practice, and, hence, to improve the quality and effectiveness of health services." Implementation science is distinct from, but shares characteristics with, both quality improvement and dissemination methods. Implementation studies can be either assess naturalistic variability or measure change in response to planned intervention. Implementation studies typically employ mixed quantitative-qualitative designs, identifying factors that impact uptake across multiple levels, including patient, provider, clinic, facility, organization, and often the broader community and policy environment. Accordingly, implementation science requires a solid grounding in theory and the involvement of trans-disciplinary research teams. The business case for implementation science is clear: As healthcare systems work under increasingly dynamic and resource-constrained conditions, evidence-based strategies are essential in order to ensure that research investments maximize healthcare value and improve public health. Implementation science plays a critical role in supporting these efforts.
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Affiliation(s)
- Mark S Bauer
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System and Department of Psychiatry, Harvard Medical School, Boston, MA, USA.
- VA Boston Healthcare System, 152M, 150 South Huntington Avenue, Jamaica Plain, MA, 02130, USA.
| | - Laura Damschroder
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.
| | - Hildi Hagedorn
- Substance Use Disorder Quality Enhancement Research Initiative and Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System & Department of Psychiatry, University of Minnesota School of Medicine, Minneapolis, MN, USA.
| | - Jeffrey Smith
- Mental Health Quality Enhancement Research Initiative, Central Arkansas Veterans Healthcare System, North Little Rock, AR, USA.
| | - Amy M Kilbourne
- VA Quality Enhancement Research Initiative (QUERI), VA Office of Research and Development, Washington, DC, USA.
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA.
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Kilbourne AM, Almirall D, Goodrich DE, Lai Z, Abraham KM, Nord KM, Bowersox NW. Enhancing outreach for persons with serious mental illness: 12-month results from a cluster randomized trial of an adaptive implementation strategy. Implement Sci 2014; 9:163. [PMID: 25544027 PMCID: PMC4296543 DOI: 10.1186/s13012-014-0163-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Accepted: 10/21/2014] [Indexed: 12/21/2022] Open
Abstract
Background Few implementation strategies have been empirically tested for their effectiveness in improving uptake of evidence-based treatments or programs. This study compared the effectiveness of an immediate versus delayed enhanced implementation strategy (Enhanced Replicating Effective Programs (REP)) for providers at Veterans Health Administration (VA) outpatient facilities (sites) on improved uptake of an outreach program (Re-Engage) among sites not initially responding to a standard implementation strategy. Methods One mental health provider from each U.S. VA site (N = 158) was initially given a REP-based package and training program in Re-Engage. The Re-Engage program involved giving each site provider a list of patients with serious mental illness who had not been seen at their facility for at least a year, requesting that providers contact these patients, assessing patient clinical status, and where appropriate, facilitating appointments to VA health services. At month 6, sites considered non-responsive (N = 89, total of 3,075 patients), defined as providers updating documentation for less than <80% of patients on their list, were randomized to two adaptive implementation interventions: Enhanced REP (provider coaching; N = 40 sites) for 6 months followed by Standard REP for 6 months; versus continued Standard REP (N = 49 sites) for 6 months followed by 6 months of Enhanced REP for sites still not responding. Outcomes included patient-level Re-Engage implementation and utilization. Results Patients from sites that were randomized to receive Enhanced REP immediately compared to Standard REP were more likely to have a completed contact (adjusted OR = 2.13; 95% CI: 1.09–4.19, P = 0.02). There were no differences in patient-level utilization between Enhanced and Standard REP sites. Conclusions Enhanced REP was associated with greater Re-Engage program uptake (completed contacts) among sites not responding to a standard implementation strategy. Further research is needed to determine whether national implementation of Facilitation results in tangible changes in patient-level outcomes. Trial registration ISRCTN: ISRCTN21059161 Electronic supplementary material The online version of this article (doi:10.1186/s13012-014-0163-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Amy M Kilbourne
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Mailstop 152, Ann Arbor, MI, 48105, USA. .,Department of Psychiatry, University of Michigan Medical School, North Campus Research Complex, 2800 Plymouth Road, Building 16, Ann Arbor, MI, 48109-2800, USA.
| | - Daniel Almirall
- Institute for Social Research, University of Michigan, 426 Thompson Street, Ann Arbor, MI, 48104-2321, USA.
| | - David E Goodrich
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Mailstop 152, Ann Arbor, MI, 48105, USA. .,Department of Psychiatry, University of Michigan Medical School, North Campus Research Complex, 2800 Plymouth Road, Building 16, Ann Arbor, MI, 48109-2800, USA.
| | - Zongshan Lai
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Mailstop 152, Ann Arbor, MI, 48105, USA. .,Department of Psychiatry, University of Michigan Medical School, North Campus Research Complex, 2800 Plymouth Road, Building 16, Ann Arbor, MI, 48109-2800, USA.
| | - Kristen M Abraham
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Mailstop 152, Ann Arbor, MI, 48105, USA. .,University of Detroit Mercy, 4001 West McNichols Road, Detroit, MI, 48221-3038, USA.
| | - Kristina M Nord
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Mailstop 152, Ann Arbor, MI, 48105, USA. .,Department of Psychiatry, University of Michigan Medical School, North Campus Research Complex, 2800 Plymouth Road, Building 16, Ann Arbor, MI, 48109-2800, USA.
| | - Nicholas W Bowersox
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Mailstop 152, Ann Arbor, MI, 48105, USA. .,Department of Psychiatry, University of Michigan Medical School, North Campus Research Complex, 2800 Plymouth Road, Building 16, Ann Arbor, MI, 48109-2800, USA.
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Kilbourne AM, Almirall D, Eisenberg D, Waxmonsky J, Goodrich DE, Fortney JC, Kirchner JE, Solberg LI, Main D, Bauer MS, Kyle J, Murphy SA, Nord KM, Thomas MR. Protocol: Adaptive Implementation of Effective Programs Trial (ADEPT): cluster randomized SMART trial comparing a standard versus enhanced implementation strategy to improve outcomes of a mood disorders program. Implement Sci 2014; 9:132. [PMID: 25267385 PMCID: PMC4189548 DOI: 10.1186/s13012-014-0132-x] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Accepted: 09/19/2014] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Despite the availability of psychosocial evidence-based practices (EBPs), treatment and outcomes for persons with mental disorders remain suboptimal. Replicating Effective Programs (REP), an effective implementation strategy, still resulted in less than half of sites using an EBP. The primary aim of this cluster randomized trial is to determine, among sites not initially responding to REP, the effect of adaptive implementation strategies that begin with an External Facilitator (EF) or with an External Facilitator plus an Internal Facilitator (IF) on improved EBP use and patient outcomes in 12 months. METHODS/DESIGN This study employs a sequential multiple assignment randomized trial (SMART) design to build an adaptive implementation strategy. The EBP to be implemented is life goals (LG) for patients with mood disorders across 80 community-based outpatient clinics (N = 1,600 patients) from different U.S. regions. Sites not initially responding to REP (defined as < 50% patients receiving ≥ 3 EBP sessions) will be randomized to receive additional support from an EF or both EF/IF. Additionally, sites randomized to EF and still not responsive will be randomized to continue with EF alone or to receive EF/IF. The EF provides technical expertise in adapting LG in routine practice, whereas the on-site IF has direct reporting relationships to site leadership to support LG use in routine practice. The primary outcome is mental health-related quality of life; secondary outcomes include receipt of LG sessions, mood symptoms, implementation costs, and organizational change. DISCUSSION This study design will determine whether an off-site EF alone versus the addition of an on-site IF improves EBP uptake and patient outcomes among sites that do not respond initially to REP. It will also examine the value of delaying the provision of EF/IF for sites that continue to not respond despite EF. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02151331.
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Affiliation(s)
- Amy M Kilbourne
- />VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Rd, Mailstop 152, Ann Arbor, 48105 MI USA
- />Department of Psychiatry, North Campus Research Complex, University of Michigan Medical School, 2800 Plymouth Rd, Bldg 16, Ann Arbor, 48109-2800 MI USA
| | - Daniel Almirall
- />Institute for Social Research, University of Michigan, 426 Thompson Street, Ann Arbor, 48104-2321 MI USA
| | - Daniel Eisenberg
- />Department of Health Management and Policy, School of Public Health, University of Michigan, 1415 Washington Heights, Ann Arbor, 48109-2029 MI USA
| | - Jeanette Waxmonsky
- />Colorado Access, 10065 E. Harvard Ave, Suite 600, Denver, 80231 CO USA
- />Department of Psychiatry, University of Colorado School of Medicine, 13199 East Montview Blvd, Mailstop F550, Suite 330, Aurora, 80045 CO USA
| | - David E Goodrich
- />VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Rd, Mailstop 152, Ann Arbor, 48105 MI USA
- />Department of Psychiatry, North Campus Research Complex, University of Michigan Medical School, 2800 Plymouth Rd, Bldg 16, Ann Arbor, 48109-2800 MI USA
| | - John C Fortney
- />Seattle HSR&D Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, 1660 S. Columbian Way, S-152, Seattle, 98108 WA USA
| | - JoAnn E Kirchner
- />VA Mental Health Quality Enhancement Research Initiative (MH QUERI), North Little Rock, 27114 AR USA
- />Department of Psychiatry, College of Medicine, University of Arkansas for Medical Sciences, 4301 W. Markham, Little Rock, 72205 AR USA
| | - Leif I Solberg
- />HealthPartners Institute for Education and Research, 3311 E. Old Shakopee Road, Bloomington, 55425 MN USA
| | - Deborah Main
- />Department of Health and Behavioral Sciences, University of Colorado Denver, Denver, 80217 CO USA
| | - Mark S Bauer
- />VA Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Bldg 9, Jamaica Plain Campus, 150 South Huntington Ave (152 M), Boston, 02130 MA USA
| | - Julia Kyle
- />VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Rd, Mailstop 152, Ann Arbor, 48105 MI USA
- />Department of Psychiatry, North Campus Research Complex, University of Michigan Medical School, 2800 Plymouth Rd, Bldg 16, Ann Arbor, 48109-2800 MI USA
| | - Susan A Murphy
- />Institute for Social Research, University of Michigan, 426 Thompson Street, Ann Arbor, 48104-2321 MI USA
| | - Kristina M Nord
- />VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Rd, Mailstop 152, Ann Arbor, 48105 MI USA
- />Department of Psychiatry, North Campus Research Complex, University of Michigan Medical School, 2800 Plymouth Rd, Bldg 16, Ann Arbor, 48109-2800 MI USA
| | - Marshall R Thomas
- />Colorado Access, 10065 E. Harvard Ave, Suite 600, Denver, 80231 CO USA
- />Department of Psychiatry, University of Colorado School of Medicine, 13199 East Montview Blvd, Mailstop F550, Suite 330, Aurora, 80045 CO USA
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