- 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.
- Hannan M, Freeman J: Organizational Ecology. 1989, Cambridge, MA: Harvard University PressGoogle Scholar
- Burke W: Organizational Change: Theory and Practice. 2002, Thousand Oaks: SageGoogle Scholar
- Kotter J: Leading change: why transformation efforts fail. Harvard Business Review. 1996, 73: 59-67.Google Scholar
- Pritchett P, Pound R: The employee handbook for organizational change. 1996, Dallas: Pritchett & AssociatesGoogle Scholar
- Larson M: The Rise of Professionalism. 1977, Berkeley: University of California PressGoogle Scholar
- Fact Sheet: Facts About the Department of Veterans Affairs. [http://www1.va.gov/opa/fact/vafacts.asp]
- Kotler P: Marketing management. 2003, Upper Saddle River, NJ: Prentice Hall, 11Google Scholar
- Andreasen A: Marketing Social Change. 1995, San Francisco: Jossey-BassGoogle Scholar
- Kotler P, Roberto N, Lee N: Social marketing: Improving the quality of life. 2002, Thousand Oaks: SageGoogle Scholar
- Parrino TA: Controlled trials to improve antibiotic utilization: a systematic review of experience, 1984-2004. Pharmacotherapy. 2005, 25: 289-298. 10.1592/phco.25.2.289.56951.View ArticlePubMedGoogle Scholar
- Simon SR, Majumdar SR, Prosser LA, Salem-Schatz S, Warner C, Kleinman K, Miroshnik I, Soumerai SB: Group versus individual academic detailing to improve the use of antihypertensive medications in primary care: a cluster-randomized controlled trial. Am J Med. 2005, 118: 521-528. 10.1016/j.amjmed.2004.12.023.View ArticlePubMedGoogle Scholar
- Demakis JG, McQueen L, Kizer KW, Feussner JR: Quality Enhancement Research Initiative (QUERI): A collaboration between research and clinical practice. Med Care. 2000, 38: I17-25. 10.1097/00005650-200006001-00003.View ArticlePubMedGoogle Scholar
- McQueen L, Mittman BS, Demakis JG: Overview of the Veterans Health Administration (VHA) Quality Enhancement Research Initiative (QUERI). J Am Med Inform Assoc. 2004, 11: 339-343. 10.1197/jamia.M1499.View ArticlePubMedPubMed CentralGoogle Scholar
- Stetler CB, Mittman BS, Francis J: Overview of the VA Quality Enhancement Research Initiative (QUERI) and QUERI theme articles: QUERI Series. Implement Sci. 2008, 3: 8-10.1186/1748-5908-3-8.View ArticlePubMedPubMed CentralGoogle Scholar
- MH-QUERI Update: Improving Treatment for Depression in Primary Care. [http://www.queri.research.va.gov/about/factsheets/mh_factsheet.pdf]
- Gilbody S, Bower P, Fletcher J, Richards D, Sutton AJ: Collaborative care for depression: a cumulative meta-analysis and review of longer-term outcomes. Arch Intern Med. 2006, 166: 2314-2321. 10.1001/archinte.166.21.2314.View ArticlePubMedGoogle Scholar
- Gilbody S, Bower P, Whitty P: Costs and consequences of enhanced primary care for depression: systematic review of randomised economic evaluations. Br J Psychiatry. 2006, 189: 297-308. 10.1192/bjp.bp.105.016006.View ArticlePubMedGoogle Scholar
- Unutzer J, Katon WJ, Fan MY, Schoenbaum MC, Lin EH, Della Penna RD, Powers D: Long-term cost effects of collaborative care for late-life depression. Am J Manag Care. 2008, 14: 95-100.PubMedPubMed CentralGoogle Scholar
- Hedrick SC, Chaney EF, Felker B, Liu CF, Hasenberg N, Heagerty P, Buchanan J, Bagala R, Greenberg D, Paden G, Fihn SD, Katon W: Effectiveness of collaborative care depression treatment in Veterans' Affairs primary care. J Gen Intern Med. 2003, 18: 9-16. 10.1046/j.1525-1497.2003.11109.x.View ArticlePubMedPubMed CentralGoogle Scholar
- Unutzer J, Katon W, Callahan CM, Williams JW, Hunkeler E, Harpole L, Hoffing M, Della Penna RD, Noel PH, Lin EH, Arean PA, Hegel MT, Tang L, Belin TR, Oishi S, Langston C: Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial. Jama. 2002, 288: 2836-2845. 10.1001/jama.288.22.2836.View ArticlePubMedGoogle Scholar
- Stetler CB, Legro MW, Wallace CM, Bowman C, Guihan M, Hagedorn H, Kimmel B, Sharp ND, Smith JL: The role of formative evaluation in implementation research and the QUERI experience. J Gen Intern Med. 2006, 21 (Suppl 2): S1-8. 10.1007/s11606-006-0267-9.View ArticlePubMedPubMed CentralGoogle Scholar
- Smith JL, Williams JW, Owen RR, Rubenstein LV, Chaney E: Developing a national dissemination plan for collaborative care for depression: QUERI Series. Implement Sci. 2008, 3: 59-10.1186/1748-5908-3-59.View ArticlePubMedPubMed CentralGoogle Scholar
- American Marketing Association cited in P Kotler: Kotler on marketing: how to create, win, and dominate markets. 1999, New York: Free PressGoogle Scholar
- Andreasen A: Marketing Social Marketing in the Social Change Marketplace. Journal of Public Policy & Marketing. 2002, 21: 3-13. 10.1509/jppm.220.127.116.1102.View ArticleGoogle Scholar
- Bandura A: Self-efficacy: The Exercise of Control. 1997, New York: W. H. Freeman and CompanyGoogle Scholar
- Bickel W, Vucinich R: Reframing Health Behavior Change with Behavioral Economics. 2000, Mahwah, NJ: Lawrence Erlbaum AssociatesGoogle Scholar
- Green LW, Kreuter MW: Health promotion planning: an educational and ecological approach. 1999, Mountain View, CA: Mayfield Pub. Co, 3Google Scholar
- Grol R, Wensing M, Eccles M: Improving Patient Care: The Implementation of Change in Clinical Practice. 2005, Butterworth-HeinemannGoogle Scholar
- Linden A, Roberts N: Disease management interventions: what's in the black box?. Dis Manag. 2004, 7: 275-291. 10.1089/dis.2004.7.275.View ArticlePubMedGoogle Scholar
- Greenhalgh T, Robert G, Macfarlane F, Bate P, Kyriakidou O: Diffusion of innovations in service organizations: systematic review and recommendations. Milbank Q. 2004, 82: 581-629. 10.1111/j.0887-378X.2004.00325.x.View ArticlePubMedPubMed CentralGoogle Scholar
- Grier S, Bryant CA: Social Marketing in Public Health. Annual Review of Public Health. 2005, 26: 319-339. 10.1146/annurev.publhealth.26.021304.144610.View ArticlePubMedGoogle Scholar
- Pirani S, Reizes T: The Turning Point Social Marketing National Excellence Collaborative: Integrating Social Marketing Into Routine Public Health Practice. Journal of Public Health Management & Practice. 2005, 11: 131-138.View ArticleGoogle Scholar
- Gordon R, McDermott L, Stead M, Angus K: The effectiveness of social marketing interventions for health improvement: What's the evidence?. Public Health. 2006, 120: 1133-10.1016/j.puhe.2006.10.008.View ArticlePubMedGoogle Scholar
- The Seven Doors Social Marketing Approach. [https://www.comminit.com/en/node/201090]
- Bandura A: Social Learning Theory. 1977, Englewood Cliffs, N.J.: Prentice HallGoogle Scholar
- Bandura A: Social foundations of thought and action: A social cognitive theory. 1986, Englewood Cliffs, NJ: Prentice HallGoogle Scholar
- Liu CF, Rubenstein LV, Kirchner JE, Fortney JC, Perkins MW, Ober SK, Pyne JM, Chaney EF: Organizational cost of quality improvement for depression care. Health Serv Res. 2009, 44: 225-244. 10.1111/j.1475-6773.2008.00911.x.View ArticlePubMedPubMed CentralGoogle Scholar
- Fixsen DL, Naoom SF, Blase KA, Friedman RM, Wallace F: Implementation Research: A Synthesis of the Literature. Book Implementation Research: A Synthesis of the Literature (Editor ed.^eds). 2005, City: University of South Florida, Louis de la Parte Florida Mental Health Institute, The National Implementation Research NetworkGoogle Scholar
- Rubenstein LV, Meredith LS, Parker LE, Gordon NP, Hickey SC, Oken C, Lee ML: Impacts of Evidence-Based Quality Improvement on Depression in Primary Care: A Randomized Experiment. J Gen Intern Med. 2006, 21: 1027-1035. 10.1111/j.1525-1497.2006.00549.x.View ArticlePubMedPubMed CentralGoogle Scholar
- Rubenstein LV, Parker LE, Meredith LS, Altschuler A, dePillis E, Hernandez J, Gordon NP: Understanding team-based quality improvement for depression in primary care. Health Serv Res. 2002, 37: 1009-1029. 10.1034/j.1600-0560.2002.63.x.View ArticlePubMedPubMed CentralGoogle Scholar
- Rubenstein LV, Fink A, Yano EM, Simon B, Chernof B, Robbins AS: Increasing the impact of quality improvement on health: an expert panel method for setting institutional priorities. Jt Comm J Qual Improv. 1995, 21: 420-432.PubMedGoogle Scholar
- Liu CF, Hedrick SC, Chaney EF, Heagerty P, Felker B, Hasenberg N, Fihn S, Katon W: Cost-effectiveness of collaborative care for depression in a primary care veteran population. Psychiatr Serv. 2003, 54: 698-704. 10.1176/appi.ps.54.5.698.View ArticlePubMedGoogle Scholar
- Sherman SE, Fotiades J, Rubenstein LV, Gilman SC, Vivell S, Chaney E, Yano EM, Felker B: Teaching systems-based practice to primary care physicians to foster routine implementation of evidence-based depression care. Acad Med. 2007, 82: 168-175. 10.1097/ACM.0b013e31802d9165.View ArticlePubMedGoogle Scholar
- Clift E: Social marketing and communication: Changing health behavior in the third world. Am J Health Prom. 1989, 3: 17-24.View ArticleGoogle Scholar
- Parker LE, Kirchner JE, Bonner LM, Fickel JJ, Ritchie MJ, Simons CE, Yano EM: Creating a quality-improvement dialogue: utilizing knowledge from frontline staff, managers, and experts to foster health care quality improvement. Qual Health Res. 2009, 19: 229-242. 10.1177/1049732308329481.View ArticlePubMedGoogle Scholar
- Yano E, Luck J, Hagigi F, Liu C: Building the Business Case for QI and Health Services Research. Book Building the Business Case for QI and Health Services Research, (Editor ed.^eds.). City. 2005Google Scholar
- Nisbett R, Ross L: Human inference: Strategies and shortcomings of social judgment. 1980, Englewood Cliffs, NJ: Prentice HallGoogle Scholar
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