Figure 4

Level of institutionalization of telemedicine-based collaborative care management. Level of Institutionalization survey measured the degree to which the program was institutionalized within the organization. Level of Institutionalization was measured via telephone survey of the Chief of Mental Health or Chief of Primary Care at the VAMC (depending on which service line operated the program). Institutionalization implies that the organization has modified itself to incorporate the innovation and that the innovation has ceased to become novel and has been embedded in standard operating procedures. The Level of Institutionalization instrument measures an innovation's institutionalization among four subsystems: production, maintenance, supportive, and managerial. The production subsystem is responsible for delivering clinical services; to be institutionalized, the innovation must be integrated with other routine clinical services. The maintenance subsystem represents personnel; to be institutionalized, the innovation must be supported by permanent employees. The supportive subsystem represents external organizational forces; to be institutionalized, the innovation must have a stable source of funding and permanent office space. The managerial subsystem represents the executive and supervisory functions; to be institutionalized, the innovation must be assigned to a specific service, staff must have written job descriptions, and performance measures and progress reports must be required. For each subsystem, the Level of Institutionalization survey asks the respondent about the degree to which the organization has institutionalized the innovation (e.g., supported by permanent employees), and the responses are averaged to calculate an overall mean for each subsystem. The Level of Institutionalization instrument has three levels for each subsystem: low institutionalization (mean score ≤ 2), moderate institutionalization (2 < mean score ≤ 3) and high institutionalization (mean score > 3).