- Research article
- Open Access
- Open Peer Review
A social marketing approach to implementing evidence-based practice in VHA QUERI: the TIDES depression collaborative care model
© Luck et al; licensee BioMed Central Ltd. 2009
- Received: 22 August 2006
- Accepted: 28 September 2009
- Published: 28 September 2009
Collaborative care models for depression in primary care are effective and cost-effective, but difficult to spread to new sites. Translating Initiatives for Depression into Effective Solutions (TIDES) is an initiative to promote evidence-based collaborative care in the U.S. Veterans Health Administration (VHA). Social marketing applies marketing techniques to promote positive behavior change. Described in this paper, TIDES used a social marketing approach to foster national spread of collaborative care models.
TIDES social marketing approach
The approach relied on a sequential model of behavior change and explicit attention to audience segmentation. Segments included VHA national leadership, Veterans Integrated Service Network (VISN) regional leadership, facility managers, frontline providers, and veterans. TIDES communications, materials and messages targeted each segment, guided by an overall marketing plan.
Depression collaborative care based on the TIDES model was adopted by VHA as part of the new Primary Care Mental Health Initiative and associated policies. It is currently in use in more than 50 primary care practices across the United States, and continues to spread, suggesting success for its social marketing-based dissemination strategy.
Discussion and conclusion
Development, execution and evaluation of the TIDES marketing effort shows that social marketing is a promising approach for promoting implementation of evidence-based interventions in integrated healthcare systems.
- Veteran Health Administration
- Social Marketing
- Depression Care
- Collaborative Care Model
- Primary Care Mental Health
Implementing evidence-based interventions in a healthcare provider organization is a challenging endeavor, requiring changes in attitudes, beliefs and behavior . Mandating change may be a seemingly simple course of action, but is rarely effective [2–4], especially because clinicians have a strong occupational culture and enjoy a high degree of professional autonomy in healthcare organizations . Rather, change is most likely to occur when organizational members' attitudes and beliefs are concordant with the desired change, and they are willing to behave accordingly.
These challenges are amplified in an integrated healthcare organization with multiple points of care (sites) that exhibit significant variation in local cultures and circumstances. For example, USA's Veterans Health Administration (VHA) is a nationwide system of outpatient facilities and medical centers, which is organized into 21 regional Veterans Integrated Service Networks (VISNs) and supervised by a national Central Office . Therefore, successful national implementation in VHA depends upon decisions made at local, regional, and national levels. Other large, complex, integrated healthcare systems, such as the British National Health Service and USA staff model health maintenance organizations, face similar challenges.
Marketing is a discipline whose core goal is affecting behavior. Specifically, commercial marketing campaigns aim to influence consumers' purchasing decisions , whereas social marketing campaigns promote socially desirable behaviors such as exercise, recycling, or smoking cessation [8, 9]. Although most healthcare social marketing efforts have been aimed at consumers, recently there has been interest in utilizing these techniques to effect change among healthcare providers [10, 11]. If a social marketing approach can help to address the challenges of decision-making and behavior change in healthcare provider organizations, it may facilitate national implementation of evidence-based interventions.
QUERI and collaborative depression care in VHA
The VA Quality Enhancement Research Initiative (QUERI).
The U.S. Department of Veterans Affairs' (VA) Quality Enhancement Research Initiative (QUERI) was launched in 1998. QUERI was designed to harness VA's health services research expertise and resources in an ongoing system-wide effort to improve the performance of the VA healthcare system and, thus, quality of care of veterans.
QUERI researchers collaborate with VA policy and practice leaders, clinicians, and operations staff to implement appropriate evidence-based practices into routine clinical care. They work within distinct disease- or condition-specific QUERI Centers and utilize a standard six-step process:
1) Identify high-risk/high-volume diseases or problems,
2) Identify best practices,
3) Define existing practice patterns and outcomes across the VA and current variation from best practices,
4) Identify and implement interventions to promote best practices,
5) Document that best practices improve outcomes, and
6) Document that outcomes are associated with improved health-related quality of life.
Within Step 4, QUERI implementation efforts generally follow a sequence of four phases to enable the refinement and spread of effective and sustainable implementation programs across multiple VA medical centers and clinics. The phases include:
1) Single-site pilot,
2) Small-scale, multi-site implementation trial,
3) Large-scale, multi-region implementation trial, and
4) System-wide rollout
Researchers employ additional QUERI frameworks and tools, as highlighted in this Series, to enhance achievement of each project's quality improvement and implementation science goals.
Carefully designed studies have generated clear evidence of the effectiveness  and cost-effectiveness [17, 18] of collaborative care for depression in non-VHA and VHA [19, 20] settings. The TIDES model was first implemented in seven "first-generation" VHA sites in three VISNs during 2002-2004. From 2004 through 2008, implementation was expanded to additional second-generation sites in those VISNs, as well as in one additional VISN. Evaluators concurrently collected data at control sites, and also collected data for cost-effectiveness analyses. The collaborative care model developed by TIDES, in partnership with first- and second-generation sites, was incorporated into a national funding initiative for primary care mental health in 2006, and incorporated into national policy in 2008.
Therefore, TIDES can be described as being in Phase 3 of QUERI Step 4 (see Table 1). Formative evaluation activities , such as a systematic program of stakeholder interviews and measurement of program penetration and utilization, and spread to additional sites are ongoing.
MH-QUERI works actively with VHA leaders and stakeholders to implement the TIDES collaborative depression care model nationally . Thus it developed a TIDES National Dissemination (Spread) Plan that establishes goals in four areas: 1) Guidelines and Quality Indicators, 2) Training in Clinical Processes and Evidence-Based Quality Improvement, 3) Marketing, and 4) Informatics and Logistics Support. This paper describes how a social marketing approach informed the marketing activities performed under that plan, as well as the underlying marketing theory and associated evaluation activities.
Collaborative depression care models have proven effective in improving patient outcomes within and outside VHA. MH-QUERI is engaged in an effort to implement this evidence-based model nationwide, which requires management decision-making at multiple levels of the VHA organization and provider behavior change at hundreds of patient care facilities.
A social marketing approach explicitly informed several TIDES national dissemination activities. Social marketing applies marketing techniques to promote positive behavior change. Although primarily used to promote healthy behaviors in the general population, social marketing can be adapted to promote management, clinician, and patient behavior change in a large integrated healthcare system.
The TIDES model had been extensively evaluated at first-generation sites by an experienced health services research team. This team also used an evidence-based quality improvement (EBQI) method to clarify which elements of the TIDES model should remain standardized and which elements VISNs or facilities could customize to fit local conditions.
Nevertheless, a social marketing perspective allowed the TIDES team to further leverage its expertise and evidence in ways it would not otherwise have done. For example, the TIDES team segmented its target audience into several distinct groups, each with a defined behavior change goal: managers who must decide to implement TIDES and allocate the necessary resources to it, clinicians who refer their patients, and veterans who enroll in the program to treat their depression. The team also utilized its members' experience, as well as qualitative evaluation findings from first-generation TIDES implementation to tailor marketing messages to specific audience segments. MH-QUERI explicitly included measurable marketing goals in its TIDES national dissemination plan.
An important lesson from the TIDES experience is that social marketing efforts should be considered as soon as evidence demonstrating the effectiveness of an intervention becomes available. That way, the research team can help define audience segments crucial for broader implementation, and distill their expertise and data from evaluation of the intervention into marketing materials. Managers and clinicians from early sites also can be recruited as marketing representatives to support implementation at subsequent sites.
The social marketing approach appears applicable to almost any evidence-based intervention, but researchers and QI experts can benefit from consultation with experts in marketing as they embark on using social marketing. For example, marketing experts can help researchers learn to translate often-complex evidence into audience-friendly marketing materials.
However, the marketing activities described above concern one program - TIDES, in one integrated healthcare system - the VHA. The plan is based on mature theory, empirical findings, and the experiences of a very skilled multidisciplinary research team, but positive findings from ongoing evaluation activities will be needed to confirm its generalizability.
Although social marketing has heretofore been used primarily to promote healthy behaviors among consumer populations, it also appears able to amplify the effectiveness of standard evaluation and implementation techniques. We believe this is one of the first formal applications of social marketing to promote the implementation of an evidence-based intervention among managers and providers in the VHA. Further research by other QUERI centers could explore the applicability of the social marketing approach to facilitating implementation of other interventions, as well as the institutional factors at multiple levels of the VHA that enhance or hinder the effectiveness of social marketing. If such research demonstrates that social marketing can be effective even in a large and internally diverse government agency like the VHA, it also may be an effective approach for promoting implementation of evidence-based interventions in other integrated healthcare systems.
This work was funded through a VHA HSR&D supplemental grant for enhancing access to implementation research expertise (Project #IMA 04-161) and a VHA QUERI service-directed project, the Cost and Value of Translating Evidence-based Practices Study (COVES) (Project #MNT 02-029). We thank Jennifer L. Magnabosco, PhD, for her coordination and project management support of the joint marketing effort across these studies. Mona Ritchie, PhD, also has provided valuable support to TIDES implementation and evaluation. John Williams, MD, Ed Chaney, PhD, Jeff Smith, PhD(c), and Susan Vivell, PhD provided valuable information about the TIDES implementation effort. Cheryl Stetler, PhD, RN and Brian Mittman, PhD provided conceptual and structural suggestions that greatly improved the manuscript.
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