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Top down initiatives, even when supplemented with academic detailing and training, are frequently not sufficient to implement sustained clinical practice change. This is particularly true when sites have limited resources and/or are implementing complex programs that require engagement and support from multiple care specialties, changes in provider attitudes, organizational structure, and clinical processes, and participation of stakeholders from a broad spectrum of professional backgrounds, skill sets, and organizational levels. While continuous quality improvement (CQI) methods explicitly include broad-based participation, they require significant infrastructure and an organizational culture committed to quality improvement. Small hospitals and community-based outpatient clinics (CBOCs) may be unable to provide such resources. Even in large VA facilities, many providers have little time beyond their clinical responsibilities to focus on CQI efforts.
Implementation facilitation (IF) - a multi-faceted process of enabling and supporting stakeholders that bundles an integrated set of implementation interventions - is a promising strategy for supporting complex practice change. Facilitators, who may be internal and/or external to the organization, focus on: building relationships, partnering with stakeholders, and flexibly applying discrete implementation strategies, such as interactive problem solving, goal-setting, and academic detailing, based on site-level context, need, and stage of implementation.
Within the context of the VA mandate to implement Primary Care-Mental Health Integration (PC-MHI), investigators from the QUERI for Team-Based Behavioral Health recently completed a study comparing eight VA primary care clinics (two VAMCs and six CBOCs) receiving external/internal facilitation and national support with eight comparison clinics receiving national support only. This study targeted sites Network leadership identified as being unable to implement PC-MHI without assistance.
Using VA administrative data, QUERI investigators compared seven IF clinics with seven non-IF clinics. Findings show that IF clinic primary care patients were nine times more likely to be seen in PC-MHI (Reach). Primary care providers were seven times more likely to refer patients and a greater proportion of their patients were referred to PC-MHI (Adoption). The analysis was repeated a year later with similar results (Maintenance). We also conducted qualitative assessments and expert ratings of all 16 PC-MHI programs at two time points. Preliminary findings of this data suggest that facilitation improved PC-MHI program uptake, quality and adherence to evidence at IF sites (Implementation).
It is likely that sites receiving facilitation plus national support showed higher reach, adoption and implementation of PC-MHI because the IF strategy engaged stakeholders at all levels, helped them learn about and adapt PC-MHI to their local context, needs, and preferences, and address barriers to implementation. Because this facilitation strategy was embedded within the national rollout of PC-MHI, this now evidence-based implementation strategy has been replicated by our clinical operations partners. The Office of Mental Health Operations (OMHO) is applying this strategy to assist PC-MHI implementation at sites identified through OMHO site visits, standardized data review of performance in PC-MHI, and by Network level mental health leadership.
JoAnn Kirchner, MD
QUERI for Team-Based Behavioral Health