S39 System determinants of treatment impact: A configurational analysis of weight management programming within the veterans health administration
Laura Damschroder1, Edward J. Miech2, Richard R. Evans1, Michelle B. Freitag1, Jennifer A. Burns1, Susan D. Raffa3, Michael G. Goldstein3, Ann Annis4, Stephanie A. Spohr3, Wyndy L. Wiitala1
1VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Veterans Health Administration, Ann Arbor, MI, USA; 2VA EXTEND QUERI, Veterans Health Administration, Indianapolis, IN, USA; 3VA National Center for Health Promotion and Disease Prevention (NCP), Veterans Health Administration, Ann Arbor, MI, USA; 4Michigan State University East Lansing, MI, USA
Correspondence: Edward J. Miech (edward.miech@va.gov)
Background:
Obesity is a well-established risk factor for increased morbidity, particularly diabetes and hypertension, and increased mortality. Although behavioral weight loss programs, pharmacotherapy, and bariatric surgical procedures are effective treatments for obesity, effectively implementing integrated weight management care poses a major challenge to healthcare systems, including the Veterans Health Administration (VHA). The aim of this study was to explore the relationship between weight management program options, facility characteristics, and outcomes across VHA facilities using a novel configurational analysis methodology.
Methods:
A systemwide survey of all VHA medical centers was conducted in 2017 to elicit program structural characteristics and options for weight management. Survey responses were linked with facility-level population impact, which was computed as a product of reach (patients who participated in treatment as a percentage of overweight/obese patients) and weight loss (prevalence of patients who lost at least 5% of their baseline body weight at 12 months). Facilities in the top two impact quintiles were compared to those in the bottom two quintiles. Coincidence Analysis methods were used to identify program conditions led to highest impact.
Findings:
Of 140 facilities with complete survey data, 69 were included in the analyses with n=33 in the higher impact category and n=36 in the lower impact category. Nine conditions across four categories of factors (facility complexity/size, CLI, pharmacotherapy, and bariatric surgery options) were represented by five different configurations with overall 91% consistency (29 of 32 facilities identified by the model were higher impact) and 88% coverage (29 of the 33 higher impact facilities were explained by the model). Conditions leading to higher impact included configurations of CLI maintenance programming, pharmacotherapy and/or bariatric surgery offered within CLI programs, prescription restrictions, and bariatric surgery referrals. Notably, every configuration was dependent on facility complexity/size.
Implications for D&I Research:
No single condition explained implementation of program components across the 33 facilities with higher population impact. Configurational pathways revealed the importance of context and that specific combinations of specific program conditions consistently and uniquely distinguished higher impact facilities from lower impact facilities. These analyses demonstrate how context interplays with local programming decisions, leading to optimal outcomes.
Primary Funding Source: Department of Veterans Affairs
S40 Increasing universal autism screening in primary care: A pragmatic trial with an 18-month follow-up
Lisa Ibanez1, Wendy Stone2
1University of Washington, Seattle, WA, USA; 2Seattle, WA, USA
Correspondence: Lisa Ibanez (libanez1@uw.edu)
Background: The American Academy of Pediatrics recommends universal autism-specific screening starting at 18 months, yet compliance by primary care providers (PCPs) is limited due to time constraints, lack of comfort identifying early signs, and hesitancy to discuss concerns with parents. These issues have interfered with the adoption of existing validated screeners including the Modified Checklist for Autism in Toddlers–Revised with Follow-up (M-CHAT-R/F; Robins et al., 2014). This two-stage screener comprises a 20-item parent checklist and a time-intensive follow-up interview for positive initial screens (critical for reducing false positives). This pragmatic trial examines the “real world” effectiveness of a system-level intervention that provides a digital version of the M-CHAT-R/F (i.e., webM-CHAT-R/F) to automate and shorten the screening process--along with a training workshop on early autism signs, resources, and communication strategies--for increasing routine autism screening at 18 months.
Methods: Fifty-nine PCPs from 10 practices across four Washington State counties participated. A stepped-wedge, RCT design was used to randomly assign counties to the timing of the intervention, which comprised a two-hour workshop focused on early detection of autism and use of the webM-CHAT-R/F. PCPs’ perceived self-efficacy regarding autism detection and screening practices were measured by self-report surveys at baseline (T1, T2) and 6-, 12-, 18-months post-training (T3-T5); webM-CHAT-R/F use was measured via REDCap records.
Findings: The percent of PCPs using the M-CHAT correctly (i.e., with the follow-up interview) increased from 37% at T1 to 89% at T5, p<.01. A multi-level model indicated that PCPs had higher levels of self-efficacy regarding autism detection relative to baseline at T3-T5, ps< .02. While 7/10 practices were using the webM-CHAT-R/F at T3, 6 practices continued their use through T5, reaching over 7,000 patients. Reasons for discontinuing use were workflow issues (e.g., not integrated with electronic medical records systems), wifi issues, and access to behavioral health staff who conduct the M-CHAT-R/F follow-up interview in person.
Implications for D&I Research: This brief system-level intervention may provide a scalable template for increasing adoption of evidence-based practices and tools. It will be critical to identify practice factors associated with early and sustained adoption and identify additional supports/features that may lead to more widespread uptake.
Primary Funding Source: National Institutes of Health
S41 Strategies for successful implementation of advance care planning conversations in primary care clinics
Seiko Izumi1, Chrystal Barnes1, Jeanette Daly2, Megan Schmidt2, Shelbey Hagen3, Kylie Lanman4, Taryn Bogdewiecz5, Jessica Ma6, Rowena Dolor7
1Oregon Health & Science University, Portland, OR, USA; 2University of Iowa, Iowa City, IA, USA; 3University of Wisconsin, Madison, WI, USA; 4Oregon Rural Practice and Research Network, La Grand, OR, USA; 5University of Colorado, Denver, CO, USA; 6Duke University, Durham, NC, USA; 7Duke University, Duke Clinical & Translational Science Institute, Durham, NC, USA
Correspondence: Seiko Izumi (izumis@ohsu.edu)
Background: Initiating advance care planning (ACP) conversations in primary care is recommended as best practice to support patient-centered care. Yet, many clinics struggle to implement ACP into routine practice. As part of PCORI funded trial (PLC-1609-36277) comparing two approaches to facilitate ACP, we implemented the Serious Illness Care Program (SICP: ariadnelabs.org), an evidence-based ACP intervention, in 30 primary care clinics across the US. We tracked implementation process and outcomes in each clinic to identify strategies for successful implementation of ACP in primary care.
Methods: This cluster randomized trial assigned 15 clinics to one of two SICP arms. The research team developed standardized SICP training, plus provided materials/resources to support implementation of the intervention (e.g., implementation practice facilitators). Practice facilitators worked with each clinic to adapt SICP to fit to their needs, resources, and workflow through regular visits facilitating, monitoring, and documenting the process of adaptation and implementation. Visit documents were coded using a modified list of the Expert Recommendations for Implementing Change (ERIC)1, 2 and qualitatively analyzed to identify strategies used to implement SICP in each clinic. This study is approved by the Trial Innovation Network Single IRB at Vanderbilt University Medical Center (IRB#181084).
Findings: The number and types of strategies used by each clinic varied greatly (median number of strategies used=11.5: IQR=10-17). Implementation strategies used in all clinics included: 1) Distributing standardized educational materials, 2) assessing the readiness and identifying barriers/facilitators, and 3) promoting adaptability. Most clinics (66%) used strategy 4) assessing and redesigning workflow. Clinics that successfully implemented SICP had conducted in-depth and continuous assessments of barriers/facilitators and engaged multiple team members to redesign their clinic workflow.
Implications for D&I Research: Clear descriptions of strategies for successful implementation are an important goal of implementation research. This presentation will provide specific descriptions of strategies for successful implementation of ACP in primary care clinics with hopes to increase uptake of ACP implementation in primary care settings.
Primary Funding Source: Patient-Centered Outcomes Research Institute
S42 Primary care team perspectives on integrating opioid use disorder treatment into care delivery via collaborative care
Elizabeth Austin1, Elsa Briggs1, Lori Ferro2, Paul Barry1, Geoffrey Curran3, Andrew Saxon4, John Fortney1, Dr. Anna Ratzliff1, Emily Williams5
1University of Washington, Seattle, WA, USA; 2University of Washington, Seattle, USA; 3University of Arkansas for Medical Sciences, Little Rock, AR, USA; 4VA Center of Excellence in Substance Addiction Treatment and Education, Seattle, WA, USA; 5VA Puget Sound Health Care System, Health Services Research & Development, Center of Innovation for Veteran-Centered & Value-Driven Care, Veterans Health Administration, Seattle, WA, USA
Correspondence: Elizabeth Austin (austie@uw.edu)
Background: With rising incidence of opioid use disorder (OUD) and availability of effective medication treatment (MOUD), there is an urgency to identify best practices for implementing MOUD in clinical care. The collaborative care model (CoCM) is an evidence-based approach to behavioral health care delivery within primary care settings and could extend to address co-occurring disorders (CD), such as OUD. However, the integration of OUD care with CoCM (CoCM-CD) will require engagement and buy-in among primary care teams, and their perspectives are not well explored.
Methods: We utilized formative mixed methods evaluation to understand clinic experiences among 10 clinics preparing to implement CoCM-CD. We observed and took careful fieldnotes on implementation calls (held remotely due to the COVID-19 pandemic) over 8 months. Fieldnotes were analyzed weekly using a Rapid Assessment Process, where data were coded using structured templates guided by the Consolidated Framework for Implementation Research (CFIR) and iteratively reviewed with multiple team members. We surveyed primary care team members (n=51) involved in the delivery of CoCM-CD, including primary care providers, behavioral health care managers, and psychiatrists. Survey and qualitative data were triangulated to assess primary care team perspectives on integrating CoCM-CD.
Findings: Qualitative data illuminated that providers recognized the need for OUD services in their patient populations, but expressed stigma and hesitancy to treat OUD because they felt it was beyond the scope of their role. Similarly, survey data (85% response rate) found that 96% of providers agreed that CoCM-CD was important and 98.1% believed that providing MOUD saved lives. However, many providers also believed that treating OUD was time consuming (68.6%), that it detracted from other clinical responsibilities (11.8%), was more dangerous than providing care for other chronic conditions (11.8%), and felt discomfort working with patients with OUD (27.4%). Qualitative work that spanned early implementation found that establishing clinical champions, connecting CoCM-CD to the organizational missions of each clinic, and providing access to OUD knowledge experts, all worked to facilitate greater CoCM-CD acceptance.
Implications for D&I Research: In order to leverage the opportunity to expand access to OUD care via primary care delivery, greater attention is needed to address stigma, role clarity, comfort, and clinic priorities.
Primary Funding Source: National Institutes of Health
S43 Systemwide external validation of an acute ambulatory antibiotic stewardship implementation toolkit
Gregory Tchakalian1, Apurva Barve2, Ross Fleischman1, Larissa May3, Daniella Meeker4, Kim Newton5, Breena Taira6, Kabir Yadav1
1Harbor-UCLA Medical Center, Torrance, CA, USA; 2Hack for LA, Fremont, CA, USA; 3UC Davis School of Medicine, Sacramento, CA, USA; 4University of Southern California, Los Angeles, CA, USA; 5LAC+USC Medical Center, Los Angeles, CA, USA; 6Olive View-UCLA Medical Center, Los Angeles, CA, USA
Correspondence: Kabir Yadav (kabir@emedharbor.edu)
Background: Inappropriate antibiotic use within emergency department (ED) and urgent care center (UCC) settings remains a major public health concern. Our group previously published a proof-of-concept implementation toolkit to adapt the CDC outpatient stewardship campaign (Get Smart) for academic EDs and UCCs using behavioral nudges. Here we conduct a rigorous implementation adaptation validation for the toolkit in diverse acute care settings within the second largest public health system in the country.
Methods: The previously published acute ambulatory care antibiotic stewardship implementation toolkit (http://tinyurl.com/mitigatetoolkit) was applied to the 9 highest inappropriate prescribing sites throughout Los Angeles County. We first conducted a mixed-methods analysis of the barriers and facilitators to adapt stewardship programs for diverse settings and provider types (academic, non-teaching, public employee, contractor, physicians, advanced practice providers). Then, effectiveness of the adapted program, along with implementation outcomes, was measured through a 12-month cluster randomized stepped wedge implementation of stewardship interventions.
Findings: Adoption of the intervention was 100% at the site level, with fidelity to the toolkit components being 100% identification of local champions, 97% completion of stakeholder interviews, 58% response rate of confidential surveys from frontline providers, and 100% sending of monthly individualized peer comparison emails. Grounded theory content analysis of interviews was triangulated with survey results to guide all-setting and setting-specific adaptations of the stewardship intervention. Across 584 providers and 67,767 patient encounters, there was a decrease in prescribing from 8.1% to 4.3%, with an adjusted decrease of 2.1% (95% CI 1.6-2.5) in inappropriate antibiotic prescribing. Penetrance of the intervention, as measured by consent of providers at each site was median 53% (IQR 26-74). According to the survey, acceptability of the intervention was 92% and appropriateness was 93%.
Implications for D&I Research: We validated an effective, generalizable framework for adaptation of existing antibiotic stewardship strategies to match the clinical workflow of acute ambulatory care settings that accounts for the unique challenges inherent within those environments. We also explore potential setting- and provider-level factors that could better inform where and to whom to apply targeted behavioral interventions.
Primary Funding Source: National Institutes of Health
S44 How does the eric typology apply to implementation of clinical decision support for genomic medicine?: Specifying and reporting implementation strategies for desired outcomes among a genomic medicine implementation network
Nina Sperber1,2,3,4, Olivia Dong5, Megan Roberts6, Paul Dexter7,8, Amanda Elsey9, Geoffrey Ginsburg3, Carol Horowitz10, Julie Johnson9, Ken Levy11, Henry Ong12, Josh Peterson13, Toni Pollin14, Tejinder K. Rakhra-Burris3, Michelle Ramos10, Todd Skaar11, Lori Orlando3
1Duke University School of Medicine, Department of Population Health Sciences, Durham, USA; 2Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Veterans Health Administration, Durham, NC, USA; 3Duke University School of Medicine, Durham, NC, USA; 4Duke-Margolis Center for Health Policy, Durham, NC, USA; 5RTI Health Solutions, Durham, NC, USA; 6University of North Carolina at Chapel Hill Eshelman School of Pharmacy, Chapel Hill, NC, USA; 7Regenstrief Institute, Inc., Indianapolis, IN, USA; 8Clem McDonald Center for Biomedical Informatics, Indianapolis, USA; 9University of Florida, Gainesville, FL, USA; 10Icahn School of Medicine at Mount Sinai, New York, NY, USA; 11Indiana University School of Medicine, Indianapolis, USA; 12Vanderbilt University Medical Center,, Nashville, USA; 13Vanderbilt University Medical Center, Nashville, USA; 14University of Maryland School of Medicine, Baltimore, USA
Correspondence: Nina Sperber (nina.sperber@duke.edu)
Background: Emergence of genomic medicine as a new approach to healthcare follows technological advances in sequencing the human genome and harnessing big datasets. Clinical decision support (CDS) commonly guides clinicians in use and interpretation of personalized data; however, best strategies for integrating into routine care need an evidence-base. We sought to identify and describe core implementation strategies for desired outcomes among members of the Implementing Genomics in Medicine (IGNITE) network.
Methods: Participants included six diverse projects led by academic medical centers allied with community healthcare systems. All projects implemented CDS tools into an EHR system: three implemented different pharmacogenomics (PGx) CDS interventions in the EHR and three focused on disease risk or etiology. To obtain detail about implementation strategies and desired outcomes, we adapted a published survey derived from a typology of 73 implementation strategies grouped into thematic clusters, the Expert Recommendations for Implementing Change (ERIC), and conducted follow-up interviews guided by implementation strategy reporting criteria (Proctor 2013) and a planning framework, RE-AIM.
Findings: On average, the projects implemented 32 ERIC strategies (range 11–47). The three PGx projects each used more strategies (40-47) compared to the disease-focused ones (11–29). Despite diverse project goals and approaches, all six projects commonly used four strategies from three clusters: (1) developing strategies to obtain and use stakeholder feedback (cluster—using evaluative and iterative strategies), (2) identifying early adopters (cluster—developing stakeholder interrelationships), (3) conducting educational meetings (cluster—training and educating stakeholders), and (4) having an expert meet with clinicians to educate them (cluster—training and educating stakeholders). Detailed reporting criteria revealed different manifestations of the strategies across the projects and a need to integrate the training and educating stakeholder strategies in reporting.
Implications for D&I Research: This project represents the first application of the full ERIC typology in conjunction with Proctor’s detailed reporting criteria to genomic medicine implementation. ERIC, developed in the context of mental health research and practice, provides a useful guide for highlighting generalizable core strategies as a starting point; however, it did not capture all relevant strategies. We present ideas for future work to develop a version of the ERIC typology specifically for genomic medicine implementation.
Primary Funding Source: National Institutes of Health
S45 Residual influences of quality improvement collaboratives on practice change: A longitudinal study of Maryland hospitals participating in a collaborative to reduce primary cesarean delivery
Jennifer Callaghan-Koru1, Inaya Wahid2, Andreea Creanga3, Bonnie DiPietro4, Geoffrey Curran5
1Sociology, Anthropology, and Health Administration and Policy, University of Maryland-Baltimore County, Baltimore, MD, USA; 2University of Maryland, Baltimore County, Baltimore, MD, USA; 3Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; 4Maryland Patient Safety Center, Elkridge, MD, USA; 5University of Arkansas for Medical Sciences, Little Rock, AR, USA
Correspondence: Jennifer Callaghan-Koru (jck@umbc.edu)
Background: Quality improvement collaboratives (QICs) are a common implementation strategy for evidence-based practices, and state-based QICs are a key component of the national strategy to improve perinatal health. The mechanisms of QICs are thought to include shared learning across participating hospitals and positive peer pressure that result from collaborative activities like performance reporting and expert seminars. The extent to which participating organizations continue to make new practice changes after collaborative activities have ended is not well studied.
Methods: Between June 2016 and December 2018, 31 birthing hospitals in Maryland voluntarily participated in a statewide QIC to reduce primary cesarean deliveries. As a condition of participation, hospitals agreed to implement new practices from a consensus patient safety bundle with 23 recommended unit-level practices. To assess hospitals’ adoption and maintenance of practices in the bundle, we distributed surveys to the hospital-designated collaborative leads at the end of the collaborative (November 2018) and sixteen months later (March 2020).
Findings: Full responses to both surveys were obtained from 27 hospitals (87% response rate). Respondents for 24 of these hospitals (89%) indicated that their labor & delivery unit continued working on bundle implementation after the formal end of the collaborative. The median number of practices implemented was 12 (range: 0 to 22) at the end of the collaborative, and 17 (range: 9 to 22) at the follow up survey. At follow up, hospitals also reported discontinuing a median of 1 practice that was in place at the end of the collaborative (range: 0 to 12). Practices with the highest post-collaborative adoption were protocols to encourage early labor at home (15 hospitals) and ongoing staff training on labor support techniques (14 hospitals). The practice with the highest discontinuation (9 hospitals) was training on external cephalic version technique.
Implications for D&I Research: These data suggest that QICs may have residual impacts on practice changes after the completion of planned activities. Follow up assessments of QICs should measure adoption of new practices in addition to maintenance of practice changes. More research is needed to understand whether this effect is widespread and the implications for the design of QICs (e.g., activities, length) to maximize their impact.
Primary Funding Source: National Institutes of Health
S46 Refining implementation of complex clinical practices addressing VA clinical priorities: A dynamic diffusion network to address moral injury and suicide
George Jackson1,2, Melissa Smigelsky1,3, Keith Meador3,4, Summer Anderson1, Victoria Trimm1,3, Ryan Vega5, Blake Henderson5, Jason Nieuwsma1,2,3
1Durham Veterans Affairs Health Care System, Veterans Health Administration, Durham, NC, USA; 2Duke University, Durham, NC, USA; 3VA Integrative Mental Health, Durham, NC, USA; 4Vanderbilt University, Nashville, TN, USA; 5Veterans Health Administration Innovation Ecosystem, Washington, DC, USA
Correspondence: George Jackson (george.l.jackson@duke.edu)
Background: The Dynamic Diffusion Network (DDN) implementation strategy brings together healthcare facilities seeking to address a shared, complex, clinical challenge for which there are core evidence-based principles and/or practices (EBPs) available. However, the challenge is a lack of clarity concerning the specific ways in which application of EBPs can or should vary across facilities to ensure effective implementation.
Methods: The first DDN occurred from June 2019-November 2020 with the goal of refining suicide prevention strategies and moral injury care practices being conducted by 12 chaplain-mental health provider teams across the Veterans Health Administration (VHA). It included a cyclical improvement model based on: identifying quality goals; describing practices; measuring impact; quality improvement; and telling the improvement story. This was combined with structured facilitation calls, subject matter expertise, and shared accountability. The DDN was evaluated based on analysis of improvement and clinical activities (733 weekly reports and 46 quarterly phase summary reports (~4 per team). All participants completed a program satisfaction survey (n=22) and 20 participated in a semi-structured qualitative interview.
Findings: Participants reported: 1) improvements in facility practices (more clearly defined clinical practices and materials, refined quality/practice objectives, identification of core and adaptable components, and sustainability efforts); 2) feeling “part of something” (opportunity and accountability to make changes, access to constructive, outside perspectives, broader applicability of improvement process, being part of a “greater good”); and 3) coping with COVID-19 through an established network with structural support. All participants agreed or strongly agreed (SA) that they were confident practices improved (SA=82%), were proud of DDN work (SA=77%), and would recommend DDN participation to a colleague (SA=85%). Cross-pollination of ideas was most beneficial when practices shared commonalities in objectives and procedures (i.e., groups addressing moral injury). Despite COVID-19, 87 “products” (e.g., papers, reports, presentations) have resulted from the DDN, an indication of the reach of the effort.
Implications for D&I Research: Even during COVID-19, the DDN was an effective strategy for supporting implementation and refinement of complex clinical interventions aimed at addressing VA clinical priorities. It provides a mechanism to address the uncertainty and need for continuous learning as complex innovations spread across health system sites.
Primary Funding Source: Department of Veterans Affairs
S47 Change in implementation leadership, climate, and provider reach for motivational interviewing: A cluster randomized trial of the leadership and organizational change for implementation (LOCI) strategy in substance use disorder treatment
Marisa Sklar1,2,3, Mark Ehrhart4, Scott Roesch5, Gregory Aarons6,7,8
1University of California, San Diego, La Jolla, CA, USA; 2Child and Adolescent Services Research Center, San Diego, CA, USA; 3UC San Diego ACTRI Dissemination and Implementation Science Center, La Jolla, CA, USA; 4University of Central Florida, Orlando, FL, USA; 5San Diego State University, San Diego, CA, USA; 6UC San Diego, San Diego, CA, USA; 7UC San Diego Altman Clinical and Translational Research Institute Dissemination and Implementation Science Center, La Jolla, CA, USA; 8UC San Diego, La Jolla, CA, USA
Correspondence: Marisa Sklar (masklar@health.ucsd.edu)
Background: Successful implementation and sustainment of evidence-based practice (EBP) requires alignment of effective leadership at multiple organization levels. Leadership and Organizational Change for Implementation (LOCI) is a multifaceted implementation strategy to support the implementation and sustainment of EBPs. By engaging and developing leadership at clinic and organization levels, LOCI aims to develop a climate for EBP implementation and sustainment within organizations.
Methods: The effect of LOCI on the implementation of motivational interviewing (MI) for substance use disorder treatment was tested in a cluster randomized trial. Sixty clinics from nine agencies were randomly assigned to either LOCI, or a leadership webinar condition (control). Repeated survey measures from clinic providers (n=380; nControl=179, nLOCI=201) assessed implementation leadership of clinic leaders, and implementation climate of clinics, during engagement in the assigned condition across four timepoints. Three-level multilevel modeling wherein repeated measures (Level-1) were nested within providers (Level-2), nested within clinics (Level-3), was used to assess polynomial trends in leadership and climate over time, and whether these trends differed as a function of condition. Chi-square was used to assess between condition differences in MI reach as defined as the number of providers who engaged in fidelity monitoring.
Findings: Between condition differences in quadratic trends were found for supportive (βhat=-.22, p<.05) and proactive (βhat=-.22, p<.05) leadership, and the educational support dimension (βhat=-.15, p<.05) of implementation climate. Follow-up simple slope analyses revealed significant negative quadratic trends for LOCI, but non-significant change over time for the control condition. Reach of MI was significantly greater in LOCI (n=134) than control (n=101) (Χ2=4.21, p=.040).
Implications for D&I Research: LOCI was effective in enhancing implementation leadership and climate within organizations, and in enhancing MI reach. Limitations and future directions will be discussed.
Primary Funding Source: National Institutes of Health
S48 Transforming VA to a whole health system of care: The use of implementation strategies to drive national change
Rendelle Bolton1,2, Juliet Wu1, Aishwarya Khanna1, A. Rani Elwy1,3, Barbara Bokhour1, Justeen Hyde1
1VA Bedford Healthcare System, Veterans Health Administration, Bedford, MA, USA; 2Brandeis University Heller School for Social Policy and Management, Waltham, MA, USA; 3Warren Alpert Medical School of Brown University, Providence, RI, USA
Correspondence: Rendelle Bolton (Rendelle.Bolton@va.gov)
Background: Since 2011, the Veterans Health Administration (VA) has been transforming to a Whole Health System of Care (WHS) to optimize the health and wellbeing of Veterans and staff alike. This transformation is defined by patient-centered clinical encounters and implementation of discrete services (e.g., complementary integrative health therapies, health coaching), requiring new infrastructure, trainings, and policy. We sought to understand how VA’s national Office of Patient-Centered Care and Cultural Transformation (OPCC&CT) supported transformation across VA’s 170 medical centers (VAMCs) and >1200 community-based clinics.
Methods: During a multi-year ethnographic evaluation of VA’s WHS implementation, we conducted semi-structured interviews with 20 OPCC&CT leaders/staff to identify implementation activities at the VAMC, regional, and national levels. We coded activities into a priori categories aligned with 73 implementation strategies recognized by the Expert Recommendations for Implementing Change group. Inductive coding captured barriers/facilitators to strategy use, organizational context, and transformation approach.
Findings: OPCC&CT used 64 of 73 implementation strategies with key stakeholders across all levels of VA (central/regional offices, VAMCs, consumers, policy makers, and community partners). Strategies were often bundled or nested together. To facilitate WHS implementation in VAMCs, OPCC&CT conducted trainings/education, readiness assessments, and repeated evaluations; provided resources, implementation guidance, and interactive/technical assistance; and prepared champions, leaders, early adopters, and local workgroups. Regionally and nationally, strategies created a context which enabled system transformation by changing policies, developing infrastructure (e.g., VA-wide records/billing mechanisms, new position descriptions), and establishing relationships and buy-in among key stakeholders. Organizationally, OPCC&CT developed matrixed workgroups to coordinate strategy use among its 70-person staff. National champions and subject-matter experts spanned boundaries between OPCC&CT and the field, providing input on implementation priorities and disseminating information outward. OPCC&CT iteratively developed, piloted, evaluated, refined, and tailored the WHS and the implementation strategies used. Barriers included promoting WHS uptake among front-line staff due to regional priorities that limited OPCC&CT’s ability to directly support clinicians and implement incentives locally.
Implications for D&I Research: Findings extend the use of implementation strategies beyond local evidence-based practice implementation to the system level. When paired with supportive organizational structures and continuous learning processes, these strategies can facilitate system transformation by creating policies, infrastructure, and engaging stakeholders to enable implementation.
Primary Funding Source: Department of Veterans Affairs
S49 Project MIMIC: Preliminary data from the first two cohorts of a hybrid type 3 effectiveness-implementation trial
Sara Becker1, Bryan Garner2
1Brown School of Public Health, Providence, RI, USA; 2RTI International, Research Triangle Park, NC, USA
Correspondence: Sara Becker (sara_becker@brown.edu)
Background: Contingency management (CM) is the most effective behavioral adjunctive treatment in combination with medication for opioid use disorders, but is one of the least available treatments in opioid treatment programs. Project MIMIC (Maximizing Implementation of Motivational Incentives in Clinics) is a 30-site, multi-cohort, hybrid effectiveness-implementation cluster randomized trial testing two multi-level strategies to help opioid treatment programs (OTPs) implement CM. This submission examines process data from Project MIMIC’s first two cohorts of OTPs.
Methods: One hundred thirty staff from 18 OTPs were cluster randomized to receive either the Addiction Technology Transfer Center (ATTC) strategy (workshop + feedback + coaching) or the Enhanced ATTC (E-ATTC) strategy, which layered in two additional theory-driven strategies: Pay-For-Performance and Implementation Sustainment Facilitation. Consistent with the exploration, preparation, implementation, and sustainment (EPIS) framework, OTPs engaged in 5 months of preparation and 7 months of implementation activities.
Findings: All 18 OTPs completed preparation activities and advanced to the implementation phase. During the preparation phase, a significantly greater proportion of E-ATTC staff completed the didactic CM workshop than ATTC staff (98% vs. 85%, χ2(1)=7.0, p=.008). Additionally, skill ratings of CM role plays submitted at the end of the Preparation phase were significantly higher among E-ATTC than ATTC staff, (t(62)=2.59, p=.01). In the implementation phase, each OTP sought to enroll 25 patients: OTPs in the E-ATTC condition enrolled a greater proportion of the target than those in the ATTC condition (87% vs. 77%, χ2(1)=7.6, p=.006). In addition, a greater proportion of E-ATTC staff met the CM exposure benchmark (28% vs. 12%, χ2(1)=5.2, p=.02) Measurement of sustainment is ongoing.
Implications for D&I Research: Preliminary process data from 18 OTPs indicate that the theory-driven E-ATTC strategy has been associated with higher training engagement, CM skill on a role play, patient enrollment, and CM exposure. These results suggest that the ATTC implementation strategy, a real-world strategy widely used by a network of SAMHSA-funded training and technical assistance centers, can potentially be enhanced by the inclusion of Pay-for-Performance and Implementation Sustainment Facilitation. Future work is needed to provide a more comprehensive assessment of the E-ATTC strategy's effect on patient-level outcomes, long-term sustainment, and cost effectiveness.
Primary Funding Source: National Institutes of Health
S50 Learning health system programs in delivery systems - contributions and limitations of externally-funded implementation research
Michael I. Harrison, Amanda Borsky
Agency for Healthcare Research and Quality, Rockville, MD, USA
Correspondence: Michael Harrison (Michael.Harrison@ahrq.hhs.gov)
Background: Learning Health System (LHS) programs deploy researchers in fields like health services, implementation science, human factors, and engineering to address improvement priorities of delivery system leaders (clinicians and administrators). We examine contributions to LHS work and limitations of externally-funded research on implementation of care-delivery change.
Methods: Conducted 44 hour-long, semi-structured interviews with 41 system leaders, LHS directors, LHS investigators – reached through snowballing. Rapid qualitative analysis: interviews summarized in structured templates; templates consolidated into study-site matrices. Additional sources: interviews with 12 LHS experts and practitioners, published/grey literature. Examined LHS program profiles: 34 successful LHS projects (including 12 with external funding); 15 projects described as failures or examples of major challenges.
Findings:
Multi-year cycles and strict methodological standards limited value of externally-funded LHS projects for system leaders, who often sought rapid responses to problems and were not focused on scientific rigor. Gaps in communication and understanding emerged between system leaders and LHS researchers dedicated to traditional research. In successful projects, LHS investigators often met system needs through short-term applications of pragmatic practices (e.g., rapid analysis of available data, quality improvement, implementation facilitation, human factors analysis). These required additional skills and more collaborative work styles than traditional research and yielded less scientific recognition and funding.
When turnaround time was not critical, some LHS projects constructively used external funding on implementing care-delivery change. The funding supported evaluating current practices; identifying, developing, and implementing care or operational redesigns; deploying practice guides/tools. Additionally, externally-supported projects used internal funding to implement and sustain changes. Sometimes, after internally-funded, quality improvement projects, LHS researchers obtained external funding for multi-site improvement testing and spread.
Regardless of funding source, successful LHS initiatives responded to system priorities by acting quickly and pragmatically. Impactful LHS programs developed strong formal and informal ties to system leaders; proactively identified leaders’ needs and priorities; and translated these into doable project proposals.
Implications for D&I Research: Despite challenges, external funding for D& I research can contribute to LHS work within delivery systems. Additionally, highly responsive and reliable LHS work requires consistent internal funding of services and activities that are not often supported by D&I research awards.
S51 Organizational-level factors associated with provider and staff burnout in HIV clinics at the epicenter of the United States HIV epidemic
Jessica Sales1, Elizabeth Adam2, Chris Root2, Katherine Anderson2, Ameeta Kalokhe1
1Emory University, Rollins School of Public Health, Atlanta, GA, USA; 2Atlanta, GA, USA
Correspondence: Jessica Sales (jmcderm@emory.edu)
Background: The multidimensional needs of people with HIV, some stemming from histories of trauma, have been linked to work overload, stress, and burnout among the healthcare professionals who serve them, thus underscoring the importance of adoption of trauma-informed care (TIC) in HIV clinics. Having organizational practices that help staff manage stress and emotional fatigue that contribute to burnout is a central tenant of TIC. Such practices include trauma training (i.e., how to set healthy professional boundaries) and staff support (e.g., debrief after a difficult patient, resources to manage stress). This study aims to examine the association between adoption of these TIC practices within HIV clinics and burnout among healthcare professionals, and to explore organizational factors associated with adoption of TIC practices supportive of their well-being.
Methods: As part of a larger mixed-methods study, from December 2019-April 2020, we conducted surveys with 318 healthcare professionals of 46 HIV clinics across 8 southeastern states to examine associations between self-reported individual and patient characteristics (i.e., demographics, role, tenure in clinic, perceived trauma among patient population), clinic adoption of TIC practices (training on boundary setting, staff support practices), and burnout (using the ProQOL). We also examined the relationship between organizational factors from the Consolidated Framework for Implementation Research (i.e., leadership engagement, implementation climate, and available resources) and adoption of TIC practices.
Findings: In bivariate analyses, receipt of training on establishing professional boundaries and adoption of more TIC staff support practices were significantly associated with lower burnout scores. In a multivariable regression accounting for significant individual/patient characteristics (race, perceived level of trauma among clinic patients), receipt of training on setting healthy professional boundaries remained significantly associated with lower burnout scores. Greater leadership engagement, more positive implementation climate, and having more available resources (e.g., staff/training/time) were all significantly associated with greater adoption of TIC training and staff support practices.
Implications for D&I Research: HIV healthcare professionals are critical for the delivery of multidimensional evidence-based care to improve patient outcomes; thus, identifying organizational factors associated with adoption of TIC practices that support healthcare professionals’ well-being is urgently needed, yet under studied. Our research begins to fill this gap.
Primary Funding Source: National Institutes of Health
S52 Dynamic experiences of implementation: The role of time in caregivers’ engagement with screening for autism spectrum disorder
Leah Ramella1, Ana Schaefer1, Marisa Petrucelli2, Abbey Eisenhower2, Alice Carter3, R. Chris Sheldrick4, Thomas Mackie1
1SUNY Downstate Health Sciences University School of Public Health, Brooklyn, NY, USA; 2University of Massachusetts Boston, Boston, MA, USA; 3University of Massachusetter Boston, Boston, MA, USA; 4Boston University School of Public Health, Boston, MA, USA
Correspondence: Leah Ramella (leah.ramella@downstate.edu)
Background: System-level interventions to improve child outcomes require sustained engagement of caregivers over time. Yet, as interventions unfold, the factors influential to treatment, engagement and maintenance may vary. Time is central to the conceptualization of many implementation frameworks, but seldom the specific focus of research studies. Empirically, longitudinal qualitative methods offer a tool to assess temporality and to investigate the dynamic nature of interventions. This paper proposes a seven-step framework for qualitative methods to examine dimensions of time during a complex pediatric intervention.
Methods: We engage a seven-step framework tailored to the exploration of time in implementation, ranging from articulation of a time-oriented research question to identification of time-centered analyses. To illustrate application, we offer a case study of the experience of 22 caregivers engaged in a multi-stage autism screening process who participated in a series of longitudinal qualitative interviews (n=63). Our data analyses examined whether factors emerged: (a) across all caregivers at specific intervention stages (pooled cross-sectional analysis), (b) in particular sequences based on the experiences of caregivers over time (trajectory analysis), or (c) a combination of both.
Findings: First, results demonstrate that factors routinely emerged across participants at specific intervention stages. For example, administration of the observation-based screening tool in the second stage of the intervention routinely presented an emotional burden for caregivers that impeded progress towards diagnostic resolution. Second, results demonstrated that prior experiences dynamically influenced caregiver engagement over time. Caregivers who had received a borderline score of concern for autism on an early-stage screening tool proceeded to later stages with unique barriers.
Implications for D&I Research: Longitudinal qualitative interviews facilitate in-depth understanding of caregiver experiences, providing insight into how and when specific barriers arose. The seven-step analytical framework provides a roadmap for employing longitudinal qualitative methods to investigate the role of time in implementation, with guidance on: (a) optimizing the frequency of data collection, (b) handling attrition, and (c) key decision-points in analyzing longitudinal data. By engaging in time-centered investigations, valuable insights are gained in determining under what conditions to implement specific implementation strategies.
Primary Funding Source: National Institute of Mental Health
S53 Delivery of cancer screening and prevention during the COVID-19 pandemic on – mixed methods analysis
Nathalie Huguet, Leah Gordon, Tahlia Hodes, Andrea Baron, Maria Danna, Heather Holderness, Deborah Cohen
Oregon Health & Science University, Portland, OR, USA
Correspondence: Heather Holderness (holdernh@ohsu.edu)
Background: Prior to COVID-19, cancer preventive care was primarily delivered in-person to Community Health Center (CHC) patients. The pandemic elicited dramatic shifts in care delivery. Existing data provide little insight into the types of care delivered during the pandemic and what CHCs implemented, adopted, or adapted to deliver preventive care. The objective of this study is to describe the COVID-19 pandemic’s impact on delivery of cancer preventive care and identify processes CHCs used to implement and adapt cancer preventive care.
Methods: This mixed methods study uses quantitative electronic health record data from 224 CHCs from the OCHIN Network. Qualitative data collection from a subsample of 8 CHCs with high cancer preventive care performance pre-COVID-19. Practices were purposively selected for variation on geographic region, rurality, and patient demographics. Interviews with 26 practice members from these 8 CHCs were conducted. Outcome measures included: telemedicine and in-person visit rates; cervical and colorectal cancer procedures rates; factors influencing adoption and implementation of telemedicine, and changes to cancer preventive care delivery.
Findings: Across the network, telemedicine visit rates increased by 1237% at the onset of the pandemic. By May 2020, rates of cervical and colorectal cancer procedures declined by 61% and 58%, respectively. Interviews showed the importance of Previous Quality Improvement experience, which equipped practices with formal change management tools for introducing alternative care modalities and contributed to staff familiarity and comfort with change. Additionally, CHCs utilized a variety of care-delivery modalities to continue providing cancer preventive screenings not suited to telemedicine (e.g., drive-up and curbside visits, mobile vans, home visits). When hospital referrals for preventive services halted, clinics shifted to offering alternative screening methods that could be managed in-clinic (e.g., mailing fecal kits, arranging on-site mobile mammogram clinics). Lastly, CHCs coordinated outreach efforts to keep patients aware of clinical changes, and managed patient hesitancy about in-person care through a shift in provider messaging.
Implications for D&I Research: Innovative CHCs were able to adapt and iterate care delivery during the pandemic and recover from the initial decline in cancer screenings. Approaches to rapid implementation could inform future non-pandemic practice change.
Primary Funding Source: National Institutes of Health
S54 Mixed methods examination of the acceptability of e-connect: A systems intervention to link youth on probation to behavioral health care, guided by the gateway provider model
Corianna Sichel1, Margaret Ryan1, Gail Wasserman2, Alexandra Arnold1, Kuljit Kaur1, Faye Taxman3, Michael Dennis4, Kate Elkington2
1Columbia University/New York State Psychiatric Institute, New York, NY, USA; 2Columbia University, New York, NY, USA; 3George Mason University, Fairfax, VA, USA; 4Chestnut Health Systems, Bloomington, IL, USA
Correspondence: Corianna Sichel (cs4038@cumc.columbia.edu)
Background: Youth under community supervision (YCS, i.e., on probation) experience disproportionately high levels of suicide risk and behavioral health (BH) need, and low levels of service uptake, in part due to system-level barriers. Addressing the BH needs of YCS requires cross-system linkage as risk is identified in probation and treatment occurs in community-based care systems. Informed by the Gateway Provider Model (GPM) and the EPIS framework, e-Connect, a digital screen, referral, and linkage system, was developed and piloted in New York State (NYS) as a systems-level intervention to identify YCS’s suicide risk and BH need and facilitate cross-system linkage.
Methods: The study was guided by GPM and used a sequential mixed-methods approach for the purpose of complementarity. Surveys from n=58 probation staff, across 10 counties in NYS, who participated in the implementation of e-Connect (36.2% male; 87.9% White/Caucasian; age 24-73, M=43.04, SD=11.08) examined three GPM domains: 1) structural characteristics (e.g., agency communications), 2) psychological climate, and 3) gateway provider perceptions/knowledge, associated with staff ratings of the acceptability of e-Connect. Qualitative data, drawn from six focus groups with n=35 probation and n=11 BH staff, explored acceptability and elaborated on trends in the quantitative data.
Findings: Bivariate analyses identified measures of different GPM factors associated with staff ratings of e-Connect acceptability (measured via a 10-item scale assessing staff perceptions of the system). Structural factors were not significantly associated with acceptability. Two linear regressions with robust standard errors further explored the importance of GPM domains in predicting acceptability of e-Connect. In the model addressing psychological climate, perceptions of time burden (B=-0.60, t(48)=-7.41, p<0.001), and cynicism about the organization (B=-0.26, t(48)=-2.13, p=0.04) were significantly associated with acceptability. In the model addressing gateway provider perceptions/knowledge, only perceived usefulness of the e-Connect referral form significantly predicted acceptability (B=0.75, t(48)=3.06, p=0.004). Qualitative feedback from probation and BH staff provided nuanced information about how and why factors contributed to acceptability of the systems-level intervention.
Implications for D&I Research: Time burden, usefulness, and cynicism should be prioritized as targets in future iterations of e-Connect and similar systems-level interventions to increase acceptability. Additional implications for dissemination and implementation will be discussed.
Primary Funding Source: National Institutes of Health
S55 Beliefs and attitudes for successful implementation in schools (BASIS): A theoretically-driven, pre-implementation strategy targeting front-line practitioners’ motivation to increase the yield of training and consultation
Aaron Lyon
University of Washington, Seattle, WA, USA
Correspondence: Aaron Lyon (lyona@uw.edu)
Background: Even in a conducive organizational context, individual behavior change is required for successful implementation. Focusing on individual-level mechanisms of behavior change represents a parsimonious approach to augment standard implementation supports. The education sector is the most common setting for youth behavioral health services, but evidence-based practices (EBPs) are rarely adopted and delivered. Beliefs and Attitudes for Successful Implementation in Schools (BASIS) is a pragmatic, multifaceted, and intervention-agnostic strategy that augments EBP-specific training and consultation and is designed to target mechanisms derived from the Theory of Planned Behavior (TPB) and Health Action Process Approach (HAPA) (attitudes, social norms, self-efficacy, intentions) to enhance implementation and service recipient outcomes. This presentation will discuss findings to date across a series of federally-funded studies of the BASIS strategy with different populations and EBPs, which have refined our understanding of BASIS’s mechanisms.
Methods: A series of studies have examined the impact of BASIS on its mechanisms of action and implementation outcomes. These include a pre-post study with 1,181 educators and 62 schools implementing universal behavioral health programs, a pilot randomized trial with 25 school-based clinicians implementing an indicated trauma intervention, and a randomized trial of 83 teachers implementing an evidence-based classroom program. Each randomized trial compared BASIS to an attention control and evaluated effects on attitudes, social norms, self-efficacy, intentions, and intervention adoption. Two additional large-scale randomized trials are ongoing.
Findings: BASIS has consistently demonstrated feasibility and acceptability, as well as effects on a subset of target mechanisms and implementation outcomes. For instance, in the pre-post trial, BASIS led to more favorable EBP attitudes (d=1.03), which were associated with two measures of EBP fidelity (d=0.51-0.67). Results have varied, but BASIS has had its strongest and most consistent effects on practitioner self-efficacy and initial adoption of EBPs, although its effects tend to attenuate over time.
Implications for D&I Research: Existing compilations of implementation strategies contain very few individually and motivationally focused techniques, and even fewer are explicitly designed to impact well-specified mechanisms of action. BASIS isolates individual-level mechanisms of implementation; the understanding of which can inform the design and tailoring of efficient strategies across settings and EBPs.
Primary Funding Source: National Institutes of Health
S56 Developing capacity for evidence-based practice (EBP) with leadership and organizational change for implementation (LOCI)
Marisa Sklar1,2, Mark Ehrhart3, Gregory Aarons4
1Child and Adolescent Services Research Center, San Diego, CA, USA; 2University of California, San Diego, La Jolla, CA, USA; 3University of Central Florida, Orlando, FL, USA; 4UC San Diego, San Diego, CA, USA
Correspondence: Marisa Sklar (masklar@health.ucsd.edu)
Background: Implementation of evidence-based practices (EBPs) represents a strategic change in organizations. Leaders across levels within an organization play crucial roles in advancing strategic change initiatives, and effective leadership predicts long-term EBP sustainment. As such, there is a need to combine leadership development with organizational strategies to support EBP implementation. Leadership and Organizational Change for Implementation (LOCI) is a packaged and multifaceted implementation strategy that was developed to support the implementation and sustainment of EBPs. This presentation will review the core principles and components of the LOCI implementation strategy, as well as discrete capacity-building strategies that were employed by participating leaders to develop a climate for EBP implementation and sustainment within their organizations.
Methods: The LOCI implementation strategy has been used in a number of service settings and with a variety of EBPs across four NIH-funded trials, and across health trusts in Norway. By engaging leadership at clinic and organization levels, LOCI helps organizations to develop a climate for EBP implementation and sustainment that communicates to clinical providers that EBP use is expected, supported, and rewarded. LOCI utilizes repeated data collection and feedback cycles, leadership training and coaching, and organizational strategy development. LOCI components are designed to improve participants’ transformational and implementation leadership behaviors, subsequently creating an EBP implementation climate within their organizations such that EBPs are delivered with fidelity.
Findings: Through engagement in LOCI components, participants representing multiple levels of leadership within service organizations were successful in developing strategies to support EBP implementation. Exemplar capacity-building steps that leaders have taken in LOCI include developing provider exchange programs to enhance lateral communication and diverse learning opportunities, adding EBP-specific language to job descriptions and interview guides, and securing 2 hours/month of productivity credit for providers’ EBP skill development.
Implications for D&I Research: Implementation efforts are most successful when leadership, policies, and practices are aligned. Multilevel implementation strategies like LOCI are crucial for establishing alignment for effective implementation and sustainment of EBPs.
Primary Funding Source: National Institutes of Health
S57 “because you can’t rely on just billing:” a fiscal mapping process for sustainable financing of evidence-based practices
Marylou Gilbert
RAND, Santa Monica, CA, USA
Correspondence: Marylou Gilbert (marylou@rand.org)
Background: There are significant cost-related barriers to sustaining evidence-based practices (EBPs) in behavioral health service agencies. Such agencies need to cultivate strategic planning capacities that support sustained funding for EBPs. This project is developing and evaluating the Fiscal Mapping Process: a multi-step, structured tool that guides behavioral health service agencies through coordinating the optimal combination of financing strategies for EBP sustainment.
Methods: We adapted the Fiscal Mapping Process prototype from an established intervention mapping process, and incorporated existing resources into the prototype (e.g., a compilation of 23 financing strategies for behavioral health EBPs). We are engaging 12 behavioral health service agencies in a year-long pilot-test of the Fiscal Mapping Process with either of two youth-focused EBPs: Parent-Child Interaction Therapy (PCIT) or Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT). We provide initial training and monthly coaching for the tool. Throughout the year, we engage service agency representatives and their stakeholder partners (EBP trainers/intermediaries and funding agency representatives; N = 48 participants) in mixed-method data collection activities – surveys, focus groups, document review – to achieve consensus on the Fiscal Mapping Process steps while evaluating initial impacts on sustainment capacities (e.g., strategic planning, financial stability) and outcomes (e.g., intentions to sustain PCIT/TF-CBT).
Findings: Initial recruitment was challenging, but we successfully engaged 12 service agencies by leveraging their relationships with intermediary organizations that provided training/consultation in PCIT or TF-CBT; this represents an important early lesson learned. For this presentation, we anticipate having finished training in the Fiscal Mapping Process; several months of coaching; one round of survey data collection; and potentially some initial focus groups and document review. The presentation will describe the Fiscal Mapping Process prototype and pilot-testing agencies, and detail initial feedback and modifications made to the tool during the early months of pilot-testing.
Implications for D&I Research: This pilot-test will produce a Fiscal Mapping Process that builds behavioral health service agencies’ capacities to sustain funding for EBPs in coordination with stakeholders. We are already gaining insights into how the process and outcomes of Fiscal Mapping unfold within behavioral health service systems, including interactions with other implementation activities (e.g., the benefits of aligning Fiscal Mapping with trusted EBP training/consultation initiatives).
Primary Funding Source: National Institutes of Health
S58 A multiple case study of the collaborative organizational approach to selecting and tailoring implementation strategies (COAST-IS)
Rebecca Lengnick-Hall
Washington University in St. Louis, St. Louis, MO, USA
Correspondence: Rebecca Lengnick-Hall (rlengnick-hall@wustl.edu)
Background: The Collaborative Organizational Approach to Selecting and Tailoring Implementation Strategies (COAST-IS) is an implementation intervention that targets organizational leaders’ and clinicians’ ability to select and tailor implementation strategies that address their site’s needs. COAST-IS was piloted in a matched-pair cluster randomized pilot study of 8 organizations that were implementing trauma-focused cognitive behavioral therapy (TF-CBT), and was found to be acceptable, appropriate, feasible, and useful to leaders and clinicians. This multiple case study of four organizations that received COAST-IS provides an in-depth understanding of how organizations were guided through the process of Implementation Mapping to tailor strategies to their site-specific needs.
Methods: COAST-IS involved site-visits, 5 virtual educational sessions, and 12 coaching sessions which led leaders and clinicians through the Implementation Mapping process (e.g., identifying implementation outcomes, performance objectives, determinants, implementation strategies, and mechanisms). Detailed case summaries were created for each organization so that we could comprehensively review each case and identify similarities and differences across the cases. Data sources included agency websites, site visit notes and recordings, survey data (two time points), coaching session notes and recordings, and implementation plan documents.
Findings: Across the cases, there was variation in the number and nature of performance objectives and strategies discussed. Organizations 1 and 4 had a smaller number of objectives and strategies that primarily focused on continuing or refining existing activities. In contrast, Organizations 2 and 3 discussed a range of objectives and strategies that could affect TF-CBT implementation. Organizations 1 and 3 displayed positive group dynamics that reflected collegiality and psychological safety. Organization 2, however, experienced some discontent and group conflict. Finally, there was variation in terms of the degree to which site visit information and baseline data shed light on how coaching calls and implementation plans unfolded.
Implications for D&I Research: COAST-IS is an implementation intervention that shows promise for strengthening organizations’ capacity to implement and sustain evidence-based practices by improving their ability to tailor strategies effectively. This study demonstrates the problem of “one size fits all” approaches to implementation, and it illustrates a novel application of Implementation Mapping as a method for tailoring implementation strategies.
Primary Funding Source: National Institutes of Health
