Practice Facilitation Archives - Page 2 of 2 - Implementation Science at UW

✪ A strategy to implement the American College of Sports Medicine’s Exercise is Medicine® (EIM) initiative in a community oncology clinic

✪ Perspectives of clinical stakeholders and patients from four VA liver clinics to tailor practice facilitation for implementing evidence-based alcohol-related care

Abstract:

Background

Unhealthy alcohol use (UAU) is particularly dangerous for people with chronic liver disease. Liver clinics may be an important setting in which to provide effective alcohol-related care by integrating evidence-based strategies, such as brief intervention and medications for alcohol use disorder. We conducted qualitative interviews with clinical stakeholders and patients at liver clinics in four Veterans Health Administration (VA) medical centers to understand barriers and facilitators of integrating alcohol-related care and to support tailoring of a practice facilitation implementation intervention.

Methods

Data collection and analysis were guided by the Consolidated Framework for Implementation Research (CFIR). Interviews were transcribed and qualitatively analyzed using a Rapid Assessment Process (RAP) guided by the CFIR.

Results

We interviewed 46 clinical stakeholders and 41 patient participants and analyzed findings based on the CFIR. Clinical stakeholders described barriers and facilitators that ranged from operations/clinic resource-based (e.g., time and capacity, desire for additional provider types, referral processes) to individual perspective and preference-based (e.g., supportiveness of leadership, individual experiences/beliefs). Patient participants shared barriers and facilitators that ranged from relationship-based (e.g., trusting the provider and feeling judged) to resource and education-based (e.g., connection to a range of treatment options, education about impact of alcohol). Many barriers and facilitators to integrating alcohol-related care in liver clinics were similar to those identified in other clinical settings (e.g., time, resources, role clarity, stigmatizing beliefs). However, some barriers (e.g., fellow-led care and lack of integration of liver clinics with addictions specialists) and facilitators (e.g., presence of quality improvement staff in clinics and integrated pharmacists and behavioral health specialists) were more unique to liver clinics.

Conclusions

These findings support the possibility of integrating alcohol-related care into liver clinics but highlight the importance of tailoring efforts to account for variation in provider beliefs and experiences and clinic resources. The barriers and facilitators identified in these interviews were used to tailor a practice facilitation implementation intervention in each clinic setting.

^{**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**}

✪ Project MIMIC (Maximizing Implementation of Motivational Incentives in Clinics): results of a 28-site cluster-randomized type 3 hybrid trial

Abstract:

Background

Contingency management (CM), a behavioral treatment that incentivizes patients for attaining treatment goals, is a highly effective adjunct to medication for opioid use disorder. However, CM is rarely offered in opioid treatment programs in the United States. In a prior pilot trial, the implementation strategy (didactic workshop + feedback + consultation) delivered by the Addiction Technology Transfer Centers (ATTC strategy) promoted CM adoption more effectively than didactic training, but the speed and duration of implementation were sub-optimal. This 28-site type 3 hybrid trial tested the comparative effectiveness of the ATTC strategy versus an Enhanced-ATTC (E-ATTC) strategy that contained two theory-driven techniques targeting implementation climate to improve acceleration and sustainment, respectively: a provider-focused incentivization strategy and a team-focused facilitation strategy. We hypothesized that the E-ATTC strategy would be associated with superior implementation and patient outcomes.

Methods

Twenty-eight opioid treatment programs, 186 providers, and 592 patients were cluster-randomized to receive either the ATTC or E-ATTC strategy. Providers logged their CM sessions in an online CM Tracker and submitted audio-recorded CM sessions, and patients completed surveys about their opioid use at three timepoints. Intention-to-treat analyses examined impacts of the two multi-level strategies on implementation outcomes (CM Exposure, CM Competence, CM Sustainment) and patient outcomes (Opioid Abstinence, Opioid Related Problems).

Results

The pattern of results was identical across unadjusted, propensity score-adjusted, and covariate-adjusted general linear mixed models, though significance varied slightly. Relative to providers receiving the ATTC strategy, those receiving the E-ATTC strategy had significantly higher odds of CM Exposure (covariate adjusted OR = 3.21, p < 0.05) and of attaining the Excellent CM Competence benchmark (propensity-adjusted OR = 4.07, p < 0.05). Patients at the E-ATTC sites had significantly greater likelihood of Opioid Abstinence over time (OR = 2.04, p < 0.05). There were no significant conditional differences in CM Sustainment, though data were measured at the program-level, which limited power to detect differences.

Conclusions

The theory-driven E-ATTC strategy, which targeted implementation climate via facilitation and incentivization, had superior implementation and patient outcomes relative to the ATTC strategy. Results of this study can help inform ongoing CM implementation efforts across the United States.

^{**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**}

Cost of Implementing mHealth in Community Mental Health Settings: External Versus Internal Facilitation

✪ Project MIMIC (Maximizing Implementation of Motivational Incentives in Clinics): A cluster-randomized type 3 hybrid effectiveness-implementation trial

Abstract:

Background

Opioid-related overdoses and harms have been declared a public health emergency in the United States, highlighting an urgent need to implement evidence-based treatments. Contingency management (CM) is one of the most effective behavioral interventions when delivered in combination with medication for opioid use disorder, but its implementation in opioid treatment programs is woefully limited. Project MIMIC (Maximizing Implementation of Motivational Incentives in Clinics) was funded by the National Institute on Drug Abuse to identify effective strategies for helping opioid treatment programs improve CM implementation as an adjunct to medication. Specific aims will test the impact of two different strategies on implementation outcomes (primary aim) and patient outcomes (secondary aims), as well as test putative mediators of implementation effectiveness (exploratory aim).

Methods

A 3-cohort, cluster-randomized, type 3 hybrid design is used with the opioid treatment programs as the unit of randomization. Thirty programs are randomized to one of two conditions. The control condition is the Addiction Technology Transfer Center (ATTC) Network implementation strategy, which consists of three core approaches: didactic training, performance feedback, and on-going consultation. The experimental condition is an enhanced ATTC strategy, with the same core ATTC elements plus two additional theory-driven elements. The two additional elements are Pay-for-Performance, which aims to increase implementing staff’s extrinsic motivations, and Implementation & Sustainment Facilitation, which targets staff’s intrinsic motivations. Data will be collected using a novel, CM Tracker tool to document CM session delivery, session audio recordings, provider surveys, and patient surveys. Implementation outcomes include CM Exposure (number of CM sessions delivered per patient), CM Skill (ratings of CM fidelity), and CM Sustainment (number of patients receiving CM after removal of support). Patient outcomes include self-reported opioid abstinence and opioid-related problems (both assessed at 3- and 6-months post-baseline).

Discussion

There is urgent public health need to improve the implementation of CM as an adjunct to medication for opioid use disorder. Consistent with its hybrid type 3 design, Project MIMIC is advancing implementation science by comparing impacts of these two multifaceted strategies on both implementation and patient outcomes, and by examining the extent to which the impacts of those strategies can be explained by putative mediators.

Trial registration

This clinical trial has been registered with clinicaltrials.gov (NCT03931174).

^{**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**}

✪ Practice facilitation to implement alcohol-related care in Veterans Health Administration liver clinics: a study protocol

Abstract:

Background

Alcohol-related care, including screening, brief intervention, and provision of/referral to medication or behavioral treatments for alcohol use disorder, could be delivered in liver clinics to better reach patients with chronic liver conditions. However, the provision of alcohol-related care in liver clinics is currently suboptimal. Practice facilitation is an evidence-based implementation strategy that may address barriers, harness facilitators, and optimize the implementation of alcohol-related care in liver clinic settings using a clinic-centered approach. We report the protocol of a study to test a practice facilitation intervention to implement alcohol-related care in four Veterans Health Administration liver clinics.

Methods

This study will employ a Hybrid Type 3 effectiveness-implementation design, in which implementation outcomes are considered primary and clinical outcomes secondary. Intervention and evaluation design were informed by the Consolidated Framework for Implementation Research. Qualitative data collected from clinical stakeholders and patients were used to tailor the intervention. The intervention involves a 6-month period of external practice facilitation, including regular meetings to identify clinic goals, challenges, and solutions; engagement of clinic champions; provision of training and development of educational materials for clinic staff and patients; and performance monitoring and feedback. Ongoing formative evaluation involves the collection of quantitative facilitator tracking data and qualitative data from meeting notes and patient interviews to describe intervention acceptability, feasibility, and adoption, and adjust implementation as needed. In the summative evaluation, implementation outcomes (clinic rates of screening, brief intervention, and treatment referral/receipt) and clinical outcomes (unhealthy alcohol use, liver health) will be assessed among patients in participating clinics using secondary electronic health record data and interrupted time series analysis.

Discussion

This will be the first study to our knowledge to test practice facilitation to implement alcohol-related care in liver clinic settings. Results from formative and summative evaluation will inform a framework for the successful implementation of effective alcohol-related care through practice facilitation in liver clinics, which may ultimately lead to better health outcomes for patients with chronic liver disease.

^{**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**}

Targeted Assessment and Context-Tailored Implementation of Change Strategies (TACTICS) to increase evidence based psychotherapy in military behavioral health clinics: Design of a cluster-randomized stepped-wedge implementation study

Authors:

Craig S. Rosen
C. Adrian Davis, David Riggs, Jeffery Cook, Alan L. Peterson, Stacey Young-McCaughan, Katherine Anne Comtois, Christopher K. Haddock, Elisa V. Borah, Katherine A. Dondanville, Erin P. Finley, Sara A. Jahnke, Walker S.C. Poston, Shannon Wiltsey-Stirman, Andrea Neitzer, Capt Rachel Broussard, MAJ Amy Brzuchalski, Maj Spencer P. Clayton, LT Allison M. Conforte, Araceli Flores, Jessica Hein, Capt Felicia Keith, Capt Jeremy Jinkerson, Margaret Letendre, Debra Nofziger, Kirsten Pollick, Capt Kyra Santiago, Lt Col John Waggoner, Craig Woodworth, and Carmen P. McLean for the STRONG STAR Consortium andthe TACTICS Research Group

^{University of Washington affiliated authors are displayed in bold.}

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Published: April 2020

Read the full text in the subscription access journal Contemporary Clinical Trials

✪ Longitudinal Remote Coaching for Implementation of Perinatal Collaborative Care: A Mixed-Methods Analysis

Abstract:

The collaborative care model (CoCM) is a multicomponent, team-based integrated behavioral health framework. Its effectiveness in the treatment of perinatal depression is established, but implementation has been limited. The authors used longitudinal remote coaching (LRC) as a novel implementation strategy to support systematic case review in a multistate cluster-randomized trial of CoCM for perinatal depression. They describe LRC for perinatal CoCM in three clinics and use of a mixed-methods analysis of data from LRC feedback forms and interviews with participants. LRC is a scalable implementation strategy with potential to support complex models of integrated behavioral health, such as perinatal CoCM.

^{**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**}

✪ Using implementation facilitation to implement primary care mental health integration via clinical video telehealth in rural clinics: protocol for a hybrid type 2 cluster randomized stepped-wedge design

Abstract:

Background

Integrating mental health providers into primary care clinics improves access to and outcomes of mental health care. In the Veterans Health Administration (VA) Primary Care Mental Health Integration (PCMHI) program, mental health providers are co-located in primary care clinics, but the implementation of this model is challenging outside large VA medical centers, especially for rural clinics without full mental health staffing. Long wait times for mental health care, little collaboration between mental health and primary care providers, and sub-optimal outcomes for rural veterans could result. Telehealth could be used to provide PCMHI to rural clinics; however, the clinical effectiveness of the tele-PCMHI model has not been tested. Based on evidence that implementation facilitation is an effective implementation strategy to increase uptake of PCMHI when delivered on-site at larger VA clinics, it is hypothesized that this strategy may also be effective with regard to ensuring adequate uptake of the tele-PCMHI model at rural VA clinics.

Methods

This study is a hybrid type 2 pragmatic effectiveness-implementation trial of tele-PCMHI in six sites over 24 months. Tele-PCMHI, which will be delivered by clinical staff available in routine care settings, will be compared to usual care. Fidelity to the care model will be monitored but not controlled. We will use the Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) framework to evaluate the patient-level clinical effectiveness of tele-PCMHI in rural VA clinics and also to evaluate the fidelity to and outcomes of the implementation strategy, implementation facilitation. The proposed study will employ a stepped-wedge design in which study sites sequentially begin implementation in three steps at 6-month intervals. Each step will include (1) a 6-month period of implementation planning, followed by (2) a 6-month period of active implementation, and (3) a final period of stepped-down implementation facilitation.

Discussion

This study will evaluate the effectiveness of PCMHI in a novel setting and via a novel method (clinical video telehealth). We will test the feasibility of using implementation facilitation as an implementation strategy to deploy tele-PCMHI in rural VA clinics.

Trial registration

ClinicalTrials.gov registration number NCT02713217. Registered on 18 March 2016.

^{**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**}

✪ Using Practice Facilitation to Increase Rates of Colorectal Cancer Screening in Community Health Centers, North Carolina, 2012-2013: Feasibility, Facilitators, and Barriers

Abstract:

Introduction

Practice facilitation involves trained individuals working with practice staff to conduct quality improvement activities and support delivery of evidence-based clinical services. We examined the feasibility of using practice facilitation to assist federally qualified health centers (FQHCs) to increase colorectal cancer screening rates in North Carolina.

Methods

The intervention consisted of 12 months of facilitation in 3 FQHCs. We conducted chart audits to obtain data on changes in documented recommendation for colorectal cancer screening and completed screening. Key informant interviews provided qualitative data on barriers to and facilitators of implementing office systems.

Results

Overall, the percentage of eligible patients with a documented colorectal cancer screening recommendation increased from 15% to 29% (P < .001). The percentage of patients up to date with colorectal cancer screening rose from 23% to 34% (P = .03). Key informants in all 3 clinics said the implementation support from the practice facilitator was critical for initiating or improving office systems and that modifying the electronic medical record was the biggest challenge and most time-consuming aspect of implementing office systems changes. Other barriers were staff turnover and reluctance on the part of local gastroenterology practices to perform free or low-cost diagnostic colonoscopies for uninsured or underinsured patients.

Conclusion

Practice facilitation is a feasible, acceptable, and promising approach for supporting universal colorectal cancer screening in FQHCs. A larger-scale study is warranted.

^{**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**}

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✪ Open Access

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