'All Aboriginal and Torres Strait Islander children should have access to the ASQ-TRAK': Shared vision of an implementation support model for the ASQ-TRAK developmental screener

ISSUE ADDRESSED

The ASQ-TRAK, a strengths-based approach to developmental screening, has high acceptability and utility across varied Aboriginal and Torres Strait Islander contexts. While substantive knowledge translation has seen many services utilise ASQ-TRAK, we now need to move beyond distribution and support evidence-based scale-up to ensure access. Through a co-design approach, we aimed to (1) understand community partners' perspectives of barriers and enablers to ASQ-TRAK implementation and (2) develop an ASQ-TRAK implementation support model to inform scale-up.

METHODS

The co-design process had four phases: (i) partnership development with five community partners (two Aboriginal Community Controlled Organisations); (ii) workshop planning and recruitment; (iii) co-design workshops; and (iv) analysis, draft model and feedback workshops.

RESULTS

Seven co-design meetings and two feedback workshops with 41 stakeholders (17 were Aboriginal and Torres Strait Islander), identified seven key barriers and enablers, and a shared vision - all Aboriginal and Torres Strait Islander children and their families have access to the ASQ-TRAK. Implementation support model components agreed on were: (i) ASQ-TRAK training, (ii) ASQ-TRAK support, (iii) local implementation support, (iv) engagement and communications, (v) continuous quality improvement and (vi) coordination and partnerships.

CONCLUSIONS

This implementation support model can inform ongoing processes necessary for sustainable ASQ-TRAK implementation nationally. This will transform the way services provide developmental care to Aboriginal and Torres Strait Islander children, ensuring access to high quality, culturally safe developmental care. SO WHAT?: Well-implemented developmental screening leads to more Aboriginal and Torres Strait Islander children receiving timely early childhood intervention services, improving developmental trajectories and optimising long-term health and wellbeing.

Stir-up Regimen After General Anesthesia in the Postanesthesia Care Unit: A Nurse Led Stepped Wedge Cluster Randomized Control Trial

PURPOSE

To implement a standardized Stir-up Regimen (deep breathing, coughing, repositioning, mobilization [moving arms/legs], assessing and managing pain and nausea) within the first 30 minutes of arrival in the postanesthesia care unit (PACU), with a goal of decreasing recovery time in the immediate postanesthesia period (Phase I).

DESIGN

A pragmatic stepped wedge cluster randomized control trial. Initially, data were collected on time in Phase I in three PACUs (control). Subsequently, the same three units were randomized to sequentially transition to the Stir-up Regimen (intervention).

METHODS

A stepped wedge cluster randomized control trial design was used to implement a standardized Stir-up Regimen in three PACUs in an academic hospital for adult patients who received at least 30 minutes of general anesthesia. The measured outcome was the PACU time in minutes from patient arrival to when the patient met Phase I discharge criteria. Differences between intervention and control groups were evaluated using a generalized mixed-effects model. Nurses were educated about the Stir-up Regimen in team huddles, in-services, video demonstrations, email notifications and reminders, and immediate feedback at the bedside. Implementation science principles were used to assess the adoption of the Stir-up Regimen through a presurvey, postsurvey and spot-check observations in all three PACUs.

FINDINGS

A total of 5,809 PACU adult patient admissions were included: control group (n = 2,860); intervention group (n = 2,949); males (n = 2,602), and females (n = 3,206). The intervention was associated with a reduction in overall mean Phase I recovery time of 4.9 minutes (95% CI: -8.4 to -1.4, P = .007). One PACU decreased time by 9.6 minutes (95% CI: -15.3 to -4.0, P < .001). The other units also reduced Phase I recovery time, but this did not reach statistical significance. The spot-check observations confirmed the intervention was adopted by the nurses, as most interventions were nurse-initiated versus patient-initiated during the first 30 minutes in PACU.

CONCLUSIONS

Standardization of a Stir-up Regimen within 30 minutes of patient PACU arrival resulted in decreased Phase I recovery time.

The 2023 Addiction Health Services Research Conference: Back in Person and Taking a Bite of the Big Apple

The Addiction Health Services Research (AHSR) Conference has been held since 2002. This Conference brings together researchers, graduate students, policymakers, and treatment providers to focus improving the organization, distribution, and financing of healthcare resources for prevention/care of SUD. The AHSR 2023 Conference took place in New York City, October 18-20th, and was hosted by the Center for Health Economics of Treatment Interventions for Substance Use Disorder, HCV, and HIV (CHERISH; cherishresearch.org). Attended by more than 300 participants, the Conference comprised several themes relating to the latest research on addiction health services delivery, financing, and impact. The agenda also included pre-conference workshops, distinguished plenary speakers, a multitude of networking opportunities, and career support for early-stage and minority investigators. AHSR 2023 featured 3 plenary sessions, 120 oral presentations, and 143 poster presentations from academics throughout the world. Overall, AHSR 2023 provided numerous opportunities to advance the field of addiction health services research. The state-of-the-art techniques and insights gained by attending scholars will position them to be change-agents in the addiction field going forward.

PRO: Implementation Science Has Value in Anesthesiology and Cardiothoracic Surgery

Implementation science is a nascent field that aims to study the factors that influence the effectiveness of a given clinical intervention, such as the characteristics of the individuals involved, the internal and external settings, the process of implementation, and other factors. Overall, implementation science aims to increase the extent to which an intervention is practiced, and the quality of its delivery to a patient. Although still in its infancy, the applications of implementation science in anesthesiology and cardiothoracic surgery abound. Whether used to adopt novel innovations, avoid the use of obsolete practices, or redeploy existing interventions to improve quality, implementation science holds promise in optimizing how we bring the latest in clinical science to produce tangible benefits to patients and create sustainable change.

Application of a user experience design approach for an EHR-based clinical decision support system

Objective

We applied a user experience (UX) design approach to clinical decision support (CDS) tool development for the specific use case of pediatric asthma. Our objective was to understand physicians' workflows, decision-making processes, barriers (ie, pain points), and facilitators to increase usability of the tool.

Materials and methods

We used a mixed-methods approach with semi-structured interviews and surveys. The coded interviews were synthesized into physician-user journey maps (ie, visualization of a process to accomplish goals) and personas (ie, user types). Interviews were conducted via video. We developed physician journey maps and user personas informed by their goals, systems interactions, and experiences with pediatric asthma management.

Results

The physician end-user personas identified were: efficiency, relationship, and learning. Features of a potential asthma CDS tool sought varied by physician practice type and persona. It was important to the physician end-user that the asthma CDS tool demonstrate value by lowering workflow friction (ie, difficulty or obstacles), improving the environment surrounding physicians and patients, and using it as a teaching tool. Customizability versus standardization were important considerations for uptake.

Discussion

Different values and motivations of physicians influence their use and interaction with the EHR and CDS tools. These different perspectives can be captured by applying a UX design approach to the development process. For example, with the importance of customizability, one approach may be to build a core module with variations depending on end-user preference.

Conclusion

A UX approach can drive design to help understand physician-users and meet their needs; ultimately with the goal of increased uptake.

Closing the Tobacco Treatment Gap: A Qualitative Study of Tobacco Cessation Service Implementation in Community Pharmacies

Tobacco use remains a leading preventable cause of morbidity and mortality, with pharmacotherapy and counseling recognized as effective cessation aids. Yet, the potential role of pharmacists and pharmacy technicians in tobacco cessation services is underutilized. This study explores the integration of such services in community pharmacies, identifying facilitators and barriers to their implementation. A qualitative study was conducted across seven community pharmacies in California that were affiliated with the Community Pharmacy Enhanced Services Network. Participants included 22 pharmacists and 26 pharmacy technicians/clerks who completed tobacco cessation training. Data were collected through semi-structured interviews, focusing on experiences with implementing cessation services. The analysis was guided by Rogers' Diffusion of Innovations Theory. MAXQDA software was used for data management and thematic analysis. Sixteen pharmacy personnel participated in the study, highlighting key themes around the integration of cessation services. Compatibility with existing workflows, the importance of staff buy-in, and the crucial role of pharmacy technicians emerged as significant facilitators. Challenges included the complexity of billing for services, software limitations for documenting tobacco use and cessation interventions, and gaps in training for handling complex patient cases. Despite these barriers, pharmacies successfully initiated cessation services, with variations in service delivery and follow-up practices. Community pharmacies represent viable settings for delivering tobacco cessation services, with pharmacists and technicians playing pivotal roles. However, systemic changes are needed to address challenges related to billing, documentation, and training. Enhancing the integration of cessation services in community pharmacies could significantly impact public health by increasing access to effective cessation support.

A Mobile App (Concerto) to Empower Hospitalized Patients in a Swiss University Hospital: Development, Design, and Implementation Report

BACKGROUND

Patient empowerment can be associated with better health outcomes, especially in the management of chronic diseases. Digital health has the potential to promote patient empowerment.

OBJECTIVE

Concerto is a mobile app designed to promote patient empowerment in an in-patient setting. This implementation report focuses on the lessons learned during its implementation.

METHODS

The app was conceptualized and prototyped during a hackathon. Concerto uses hospital information system (HIS) data to offer the following key functionalities: a care schedule, targeted medical information, practical information, information about the on-duty care team, and a medical round preparation module. Funding was obtained following a feasibility study, and the app was developed and implemented in four pilot divisions of a Swiss University Hospital using institution-owned tablets.

IMPLEMENTATION (RESULTS)

The project lasted for 2 years with effective implementation in the four pilot divisions and was maintained within budget. The induced workload on caregivers impaired project sustainability and warranted a change in our implementation strategy. The presence of a killer function would have facilitated the deployment. Furthermore, our experience is in line with the well-accepted need for both high-quality user training and a suitable selection of superusers. Finally, by presenting HIS data directly to the patient, Concerto highlighted the data that are not fit for purpose and triggered data curation and standardization initiatives.

CONCLUSIONS

This implementation report presents a real-world example of designing, developing, and implementing a patient-empowering mobile app in a university hospital in-patient setting with a particular focus on the lessons learned. One limitation of the study is the lack of definition of a "key success" indicator.

Co-design of a paediatric oncology medicines database (ProCure) to support complex care provision for children with a hard-to-treat cancer

Objectives

Paediatric oncologists often encounter challenges when seeking compassionate access to off-label therapies for their patients. This study employed implementation science and co-design techniques to develop the ProCure medicines database, with the goal of streamlining the application process and addressing identified barriers in paediatric oncology.

Methods

This study utilised an exploratory qualitative research design. Seventeen healthcare providers, including oncologists, nurse consultants, and allied health professionals, participated in semi-structured interviews guided by the Consolidated Framework for Implementation Research (CFIR) and a visual process map aid. Deductive qualitative data analysis, according to the CFIR constructs, identified key barriers and facilitators. Collaborative design sessions engaged multidisciplinary teams to develop the ProCure beta version.

Results

Barriers to off-label therapy access included resource-intensive applications, time sensitive decision-making, and complex pharmaceutical information. Facilitators included Drug Access Navigators, Molecular Tumour Boards, and a multi-disciplinary approach. ProCure addressed end-user needs by centralising medicines information. Additional features suggested by healthcare providers included blood-brain-barrier penetrability data and successful application examples.

Conclusion

ProCure represents a promising solution to the challenges paediatric oncologists face in accessing off-label therapies. By centralising information, it simplifies the application process, aids decision-making, and promotes a collaborative approach to patient care. The potential of the database to stream and enhance off-label therapy access underscores its relevance in improving paediatric oncology practise. Further research and implementation efforts are warranted to assess ProCure's real-world impact and refine its features based on user feedback.

Patient Education and Decision Support for Long-Acting Injectable HIV Antiretroviral Therapy: Protocol for Tool Development and Pilot Testing with Ryan White HIV/AIDS Program Medical Case Management Programs in New York

BACKGROUND

Long-acting injectable (LAI) HIV antiretroviral therapy (ART) presents a major opportunity to facilitate and sustain HIV viral suppression, thus improving health and survival among people living with HIV and reducing the risk of onward transmission. However, realizing the public health potential of LAI ART requires reaching patients who face barriers to daily oral ART adherence and thus can clinically benefit from alternative treatment modalities. Ryan White HIV/AIDS Program Part A medical case management (MCM) programs provide an array of services to address barriers to HIV care and treatment among economically and socially marginalized people living with HIV. These programs have demonstrated effectiveness in improving engagement along the continuum of care, but findings of limited program impact on durable viral suppression highlight the need to further innovate and hone strategies to support long-term ART adherence.

OBJECTIVE

This study aims to adapt and expand Ryan White MCM service strategies to integrate LAI ART regimen options, with the larger goal of improving health outcomes in the populations that could most benefit from alternatives to daily oral ART regimens.

METHODS

In 3 phases of work involving patient and provider participants, this study uses role-specific focus groups to elicit perceptions of LAI versus daily oral ART; discrete choice experiment (DCE) surveys to quantify preferences for different ART delivery options and related supports; and a nonrandomized trial to assess the implementation and utility of newly developed tools at 6 partnering Ryan White HIV/AIDS Program Part A MCM programs based in urban, suburban, and semirural areas of New York. Findings from the focus groups and DCEs, as well as feedback from advisory board meetings, informed the design and selection of the tools: a patient-facing, 2-page fact sheet, including frequently asked questions and a side-by-side comparison of LAI with daily oral ART; a patient-facing informational video available on YouTube (Google Inc); and a patient-provider decision aid. Implementation outcomes, measured through provider interviews, surveys, and service reporting, will guide further specification of strategies to integrate LAI ART options into MCM program workflows.

RESULTS

The study was funded in late April 2021 and received approval from the institutional review board in May 2021 under protocol 20-096. Focus groups were conducted in late 2021 (n=21), DCEs ran from June 2022 to January 2023 (n=378), and tools for piloting were developed by May 2023. The trial (May 2023 through January 2024) has enrolled >200 patients.

CONCLUSIONS

This study is designed to provide evidence regarding the acceptability, feasibility, appropriateness, and utility of a package of patient-oriented tools for comparing and deciding between LAI ART and daily oral ART options. Study strengths include formative work to guide tool development, a mixed methods approach, and the testing of tools in real-world safety-net service settings.

TRIAL REGISTRATION

Clinicaltrials.gov NCT05833542; https://clinicaltrials.gov/study/NCT05833542.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/56892.

Equity-Centered Postdischarge Support for Medicaid-Insured People: Protocol for a Type 1 Hybrid Effectiveness-Implementation Stepped Wedge Cluster Randomized Controlled Trial

BACKGROUND

Disparities in posthospitalization outcomes for people with chronic medical conditions and insured by Medicaid are well documented, yet interventions that mitigate them are lacking. Prevailing transitional care interventions narrowly target people aged 65 years and older, with specific disease processes, or limitedly focus on individual-level behavioral change such as self-care or symptom management, thus failing to adequately provide a holistic approach to ensure an optimal posthospital care continuum. This study evaluates the implementation of THRIVE-an evidence-based, equity-focused clinical pathway that supports Medicaid-insured individuals with multiple chronic conditions transitioning from hospital to home by focusing on the social determinants of health and systemic and structural barriers in health care delivery. THRIVE services include coordinating care, standardizing interdisciplinary communication, and addressing unmet clinical and social needs following hospital discharge.

OBJECTIVE

The study's objectives are to (1) examine referral patterns, 30-day readmission, and emergency department use for participants who receive THRIVE support services compared to those receiving usual care and (2) evaluate the implementation of the THRIVE clinical pathway, including fidelity, feasibility, appropriateness, and acceptability.

METHODS

We will perform a sequential randomized rollout of THRIVE to case managers at the study hospital in 3 steps (4 in the first group, 4 in the second, and 5 in the third), and data collection will occur over 18 months. Inclusion criteria for THRIVE participation include (1) being Medicaid insured, dually enrolled in Medicaid and Medicare, or Medicaid eligible; (2) residing in Philadelphia; (3) having experienced a hospitalization at the study hospital for more than 24 hours with a planned discharge to home; (4) agreeing to home care at partner home care settings; and (5) being aged 18 years or older. Qualitative data will include interviews with clinicians involved in THRIVE, and quantitative data on health service use (ie, 30-day readmission, emergency department use, and primary and specialty care) will be derived from the electronic health record.

RESULTS

This project was funded in January 2023 and approved by the institutional review board on March 10, 2023. Data collection will occur from March 2023 to July 2024. Results are expected to be published in 2025.

CONCLUSIONS

The THRIVE clinical pathway aims to reduce disparities and improve postdischarge care transitions for Medicaid-insured patients through a system-level intervention that is acceptable for THRIVE participants, clinicians, and their teams in hospitals and home care settings. By using our equity-focused case management services and leveraging the power of the electronic medical record, THRIVE creates efficiencies by identifying high-need patients, improving communication across acute and community-based sectors, and driving evidence-based care coordination. This study will add important findings about how the infusion of equity-focused principles in the design and evaluation of evidence-based interventions contributes to both implementation and effectiveness outcomes.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/54211.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05714605; https://clinicaltrials.gov/ct2/show/NCT05714605.

Adopting the RE-AIM analytic framework for rural program evaluation: experiences from the Advance Care Planning via Group Visits (ACP-GV) national evaluation

Introduction

To support rigorous evaluation across a national portfolio of grants, the United States Department of Veterans Affairs (VA) Office of Rural Health (ORH) adopted an analytic framework to guide their grantees' evaluation of initiatives that reach rural veterans and to standardize the reporting of outcomes and impacts. Advance Care Planning via Group Visits (ACP-GV), one of ORH's Enterprise-Wide Initiatives, also followed the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. ACP-GV is a national patient-centered intervention delivered in a large, veterans integrated healthcare system. This manuscript describes how RE-AIM was used to evaluate this national program and lessons learned from ORH's annual reporting feedback to ACP-GV on their use of the framework to describe evaluation impacts.

Methods

We used patient, provider, and site-level administrative health care data from the VA Corporate Data Warehouse and national program management databases for federal fiscal years (FY) spanning October 1, 2018-September 30, 2023. Measures included cumulative and past FY metrics developed to assess program impacts.

Results

RE-AIM constructs included the following cumulative and annual program evaluation results. ACP-GV reached 54,167 unique veterans, including 19,032 unique rural veterans between FY 2018 to FY 2023. During FY 2023, implementation adherence to the ACP-GV model was noted in 91.7% of program completers, with 55% of these completers reporting a knowledge increase and 14% reporting a substantial knowledge increase (effectiveness). As of FY 2023, 66 ACP-GV sites were active, and 1,556 VA staff were trained in the intervention (adoption). Of the 66 active sites in FY 2023, 27 were sites previously funded by ORH and continued to offer ACP-GV after the conclusion of three years of seed funding (maintenance).

Discussion

Lessons learned developing RE-AIM metrics collaboratively with program developers, implementers, and evaluators allowed for a balance of clinical and scientific input in decision-making, while the ORH annual reporting feedback provided specificity and emphasis for including both cumulative, annual, and rural specific metrics. ACP-GV's use of RE-AIM metrics is a key step towards improving rural veteran health outcomes and describing real world program impacts.

The Effect of an Electronic Medical Record-Based Clinical Decision Support System on Adherence to Clinical Protocols in Inflammatory Bowel Disease Care: Interrupted Time Series Study

Background

Clinical decision support systems (CDSSs) embedded in electronic medical records (EMRs), also called electronic health records, have the potential to improve the adoption of clinical guidelines. The University of Alberta Inflammatory Bowel Disease (IBD) Group developed a CDSS for patients with IBD who might be experiencing disease flare and deployed it within a clinical information system in 2 continuous time periods.

Objective

This study aims to evaluate the impact of the IBD CDSS on the adherence of health care providers (ie, physicians and nurses) to institutionally agreed clinical management protocols.

Methods

A 2-period interrupted time series (ITS) design, comparing adherence to a clinical flare management protocol during outpatient visits before and after the CDSS implementation, was used. Each interruption was initiated with user training and a memo with instructions for use. A group of 7 physicians, 1 nurse practitioner, and 4 nurses were invited to use the CDSS. In total, 31,726 flare encounters were extracted from the clinical information system database, and 9217 of them were manually screened for inclusion. Each data point in the ITS analysis corresponded to 1 month of individual patient encounters, with a total of 18 months of data (9 before and 9 after interruption) for each period. The study was designed in accordance with the Statement on Reporting of Evaluation Studies in Health Informatics (STARE-HI) guidelines for health informatics evaluations.

Results

Following manual screening, 623 flare encounters were confirmed and designated for ITS analysis. The CDSS was activated in 198 of 623 encounters, most commonly in cases where the primary visit reason was a suspected IBD flare. In Implementation Period 1, before-and-after analysis demonstrates an increase in documentation of clinical scores from 3.5% to 24.1% (P<.001), with a statistically significant level change in ITS analysis (P=.03). In Implementation Period 2, the before-and-after analysis showed further increases in the ordering of acute disease flare lab tests (47.6% to 65.8%; P<.001), including the biomarker fecal calprotectin (27.9% to 37.3%; P=.03) and stool culture testing (54.6% to 66.9%; P=.005); the latter is a test used to distinguish a flare from an infectious disease. There were no significant slope or level changes in ITS analyses in Implementation Period 2. The overall provider adoption rate was moderate at approximately 25%, with greater adoption by nurse providers (used in 30.5% of flare encounters) compared to physicians (used in 6.7% of flare encounters).

Conclusions

This is one of the first studies to investigate the implementation of a CDSS for IBD, designed with a leading EMR software (Epic Systems), providing initial evidence of an improvement over routine care. Several areas for future research were identified, notably the effect of CDSSs on outcomes and how to design a CDSS with greater utility for physicians. CDSSs for IBD should also be evaluated on a larger scale; this can be facilitated by regional and national centralized EMR systems.

Mending the gap: Measurement needs to address policy implementation through a health equity lens

Policies represent a key opportunity to improve the health outcomes of populations, and if implemented well, can reduce disparities affecting marginalized populations. Many policies are only evaluated on whether they elicit their intended health outcome. However, a lack of understanding regarding if and how they are implemented may hinder the intended impact overall and on addressing health disparities. Implementation science offers an array of frameworks and methodological approaches for assessing policy delivery, yet few examples exist that meaningfully include health equity as a core focus. This commentary describes the importance of equity-informed implementation measurement by providing case examples and implications for assessment. In addition, we highlight examples of emerging work in policy implementation grounded in health equity with suggested steps for moving the field forward. The ultimate goal is to move toward open-access measurement approaches that can be adapted to study implementation of a variety of policies at different stages of implementation, driven by input from marginalized populations and implementation practitioners, to move the needle on addressing health disparities.

Food is Medicine and implementation science: A recipe for health equity

Diet-related chronic diseases such as Type II diabetes, cardiometabolic diseases, and cancer are among the leading causes of death in the USA. Nutrition security has emerged as a target outcome and a national priority for preventative medicine and the treatment of diet-related chronic diseases. Food is Medicine (FIM) initiatives encompass programs and interventions to meet priority population's needs across food and nutrition security continuums as a mechanism to address persistent food and nutrition inequities. In this position statement, we draw on implementation science, specifically the Exploration, Preparation, Implementation, and Sustainment (EPIS) Framework and health equity principles to provide guidance on FIM initiatives. As the FIM evidence base continues to grow, we encourage the EPIS framework be applied as one lens through which we can improve our understanding of FIM implementation among multiple contexts to understand what works, for whom, and under what circumstances. Ultimately, this position statement aims to call to action the incorporation of implementation science and equity principles into FIM efforts.

Implementation science for cancer control: One center's experience addressing context, adaptation, equity, and sustainment

Implementation science (IS) has great potential to enhance the frequency, speed, and quality of the translation of evidence-based programs, policies, products, and guidelines into practice. Progress has been made, but with some notable exceptions, this promise has not been achieved for cancer prevention and control. We discuss five interrelated but conceptually distinct, crosscutting issues important to accelerate IS for cancer prevention and control and how our Colorado Implementation Science Center in Cancer Control (COISC3) addressed these issues. These needs and opportunities include more fully addressing changing, multi-level context; guiding rapid, iterative adaptations; evaluating innovative approaches to engagement and health equity; greater attention to costs and economic issues; and sustainability. We summarize conceptual issues; evaluation needs and capacity building activities and then provide examples of how our IS center addressed these five needs for cancer prevention and control. We discuss changes made to address priorities of (i) guiding adaptations of implementation strategies to address changing context and (ii) working on issues identified and prioritized by our primary care partners rather than the research team. We conclude with discussion of lessons learned, limitations, and directions for future research and practice in IS to enhance cancer prevention and control as well as translational behavioral medicine more generally.

Using a Rapid Learning Health System for Stratified Care in Emerging Adult Mental Health Services: Protocol for the Implementation of Patient-Reported Outcome Measures

BACKGROUND

Mental illness among emerging adults is often difficult to ameliorate due to fluctuating symptoms and heterogeneity. Recently, innovative approaches have been developed to improve mental health care for emerging adults, including (1) implementing patient-reported outcome measures (PROMs) to assess illness severity and inform stratified care to assign emerging adults to a treatment modality commensurate with their level of impairment and (2) implementing a rapid learning health system in which data are continuously collected and analyzed to generate new insights, which are then translated to clinical practice, including collaboration among clients, health care providers, and researchers to co-design and coevaluate assessment and treatment strategies.

OBJECTIVE

The aim of the study is to determine the feasibility and acceptability of implementing a rapid learning health system to enable a measurement-based, stratified care treatment strategy for emerging adults.

METHODS

This study takes place at a specialty clinic serving emerging adults (age 16-24 years) in Calgary, Canada, and involves extensive collaboration among researchers, providers, and youth. The study design includes six phases: (1) developing a transdiagnostic platform for PROMs, (2) designing an initial stratified care model, (3) combining the implementation of PROMs with stratified care, (4) evaluating outcomes and disseminating results, (5) modification of stratified care based on data derived from PROMs, and (6) spread and scale to new sites. Qualitative and quantitative feedback will be collected from health care providers and youth throughout the implementation process. These data will be analyzed at regular intervals and used to modify the way future services are delivered. The RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework is used to organize and evaluate implementation according to 3 key objectives: improving treatment selection, reducing average wait time and treatment duration, and increasing the value of services.

RESULTS

This project was funded through a program grant running from 2021 to 2026. Ethics approval for this study was received in February 2023. Presently, we have developed a system of PROMs and organized clinical services into strata of care. We will soon begin using PROMs to assign clients to a stratum of care and using feedback from youth and clinicians to understand how to improve experiences and outcomes.

CONCLUSIONS

This study has key implications for researchers and clinicians looking to understand how to customize emerging adult mental health services to improve the quality of care and satisfaction with care. This study has significant implications for mental health care systems as part of a movement toward value-based health care.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/51667.

Trends in publication impact of evidence-based healthcare terminology (2013-2022)

AIMS

This article explored the publication impact of evidence-based healthcare terminology to determine usage and discuss options for low usage terms.

BACKGROUND

A plethora of terms describe the scholarship of evidence-based healthcare. Several terms are synonyms, creating redundancy and confusion. The abundance and overlap of terms may impede the discovery of evidence.

DESIGN

This discursive article explored and discussed publication impact of evidence-based healthcare terms.

METHODS

Evidence-based healthcare terms were identified, and their 10-year (2013-2022) publication impact was assessed in the CINAHL and Medline databases. A card sort method was also used to identify terms with low usage.

RESULTS

A total of 18/32 terms were included in the review. The terms evidence-based practice, quality improvement, research and translational research were the most highly published terms. Publication data were presented yearly over a 10-year period. Most terms increased in publication use over time, except for three terms whose use decreased. Several terms related to translational research have multiple synonyms. It remains unknown whether these terms are interchangeable and possibly redundant, or if there are nuanced differences between terms.

CONCLUSION

We suggest a follow-up review in 3-5 years to identify publication trends to assess context and terms with continued low publication usage. Terms with persistent low usage should be considered for retirement in the reporting of scholarly activities. Additionally, terms with increasing publication trends should be treated as emerging terms that contribute to evidence-based healthcare terminology.

IMPLICATIONS FOR NURSING

Confusion about the use of appropriate terminology may hinder progress in the scholarship of evidence-based healthcare. We encourage scholars to be aware of publication impact as it relates to the use of specific terminology and be purposeful in the selection of terms used in scholarly projects and publications.

Perceptions of facilitators, barriers and solutions when preparing to implement a home visiting program in Sweden: a mixed-methods study

Background

Although there is growing awareness that early childhood development programs are important for a sustainable society, there is a knowledge gap about how to implement such programs. Successful implementation requires attention to implementation drivers (competency, organization, and leadership) during all phases of the implementation. The purpose of this study was to describe cross-sectoral operational workgroups' perceptions of facilitators, barriers and solutions related to implementation drivers in the preparationphase of implementing an evidence-based early childhood home visiting program.

Methods

Quantitative and qualitative data were collected from twenty-four participants, divided into 5 groups, during implementation planning workshops. The workshops were guided by a structured method informed by the principles of Motivational Interviewing and within a framework of implementation drivers. Groups sorted cards with statements representing implementation drivers according to perceptions of facilitators and barriers, and percentages were calculated for each type of implementation determinant, for each type of driver. The groups discussed their card sorting and wrote action plans to address barriers, yielding documentation that was analyzed using deductive qualitative content analysis.

Results

A mixed-methods analysis resulted identification of facilitators, barriers, unknowns and solutions in two to three subcategories under each main category of implementation driver. A competent and confident workforce, and enthusiasm and commitment were key facilitators. Key barriers were unclear roles and responsibilities, and insufficient articulation of local vision and goals. Many factors were described as yet unknown. Specific solutions were generated to support the implementation.

Conclusions

Our study furthers the scientific understanding of how to take evidence-based early childhood programs from research to practice within an implementation drivers framework. Facilitators, barriers and solutions in key areas during the preparation phase were identified with the help of a novel tool. The results provide useful knowledge for decision makers and organizations preparing similar initiatives in communities striving to attain sustainable development goals.

Acceptability of venue-based HIV testing and prevention interventions for men who have sex with transgender women and transgender women in Lima, Perú: a formative, qualitative study

BACKGROUND

Despite being at elevated risk for HIV, men who have sex with transgender women (MSTW) are an overlooked population in the global HIV response. Venue-based HIV interventions have previously had success reaching other HIV priority populations, including transgender women (TW). Similar approaches could be applied for MSTW.

OBJECTIVE

To evaluate the prospective acceptability of venue-based HIV testing and prevention interventions for MSTW and TW in Lima, Peru.

METHODS

In this exploratory qualitative study, we conducted in-depth interviews (IDI) and focus group discussions (FGD) with three types of participants: MSTW (7 IDIs, 1 FGD), TW (1 FGD), and owners of social venues frequented by MSTW/TW in Lima (2 IDIs). We elicited participants' attitudes and perceptions related to the following four hypothetical interventions delivered at social venues in Lima: rapid HIV testing; HIV self-test distribution; condom/lubricant distribution; and enrolment in a mobile app supporting HIV prevention. We performed a mixed deductive-inductive thematic analysis using the framework method, then applied the Theoretical Framework of Acceptability to classify the overall acceptability of each intervention.

RESULTS

Condom/lubricant distribution and app-based HIV prevention information were highly acceptable among all participant types. The two HIV testing interventions had relatively lower acceptability; however, participants suggested this could be overcome if such interventions focused on ensuring discretion, providing access to healthcare professionals, and offering appropriate incentives.

CONCLUSIONS

Overall, MSTW and TW shared similar favourable attitudes towards venue-based HIV interventions. Venue-based outreach warrants further exploration as a strategy for engaging MSTW and TW in HIV prevention activities.

Integration of an Electronic Screening, Brief Intervention, and Referral to Treatment Program Into an HIV Testing Program to Reduce Substance Use and HIV Risk Behavior Among Men Who Have Sex With Men: Protocol for Intervention Development and a Pilot Randomized Controlled Trial

BACKGROUND

Men who have sex with men (MSM) are disproportionally affected by HIV and drug and alcohol use; however, few effective HIV prevention interventions for MSM who use substances exist. Screening, Brief Intervention, and Referral to Treatment is an early intervention for non-treatment-seeking individuals with problematic substance use and for timely referral to treatment for those with substance use disorders. Electronic screening and brief interventions (e-SBIs) reduce implementation challenges. An e-SBI tailored for MSM at the time of HIV testing might be particularly opportune to strengthen their motivation to reduce substance use and HIV risk behavior.

OBJECTIVE

This study aims to develop a tailored e-SBI program to reduce substance use and HIV risk behavior among MSM seeking HIV testing at Nexo Asociación Civil, our community partners in Argentina (primary); assess the feasibility and acceptability of integrating the e-SBI into the Nexo HIV testing program (primary); assess the feasibility and acceptability of implementing an adapted Men's Health Project (MHP) at Nexo (secondary); and finally, explore preliminary findings on substance use and sexual risk reduction outcomes (exploratory).

METHODS

This mixed methods study has 2 stages. During stage 1 (development), we will use the User Centered Rapid App Design process consisting of focus groups (n=16), individual interviews (n=24), and a pilot deployment of the e-SBI (n=50) to iteratively develop the e-SBI. Quantitative and qualitative assessments at each step will inform the revision of the e-SBI. Furthermore, we will use the assessment, decision, administration, production, topic experts, integration, training, testing framework to adapt MHP. During stage 2 (pilot randomized controlled trial [RCT]), we will randomize 200 MSM coming to Nexo for HIV testing. They will complete a baseline assessment and then their assigned intervention (e-SBI vs screening only) and will be followed-up for 6 months. We will also conduct in-depth interviews with up to 45 participants: 15 participants from either study condition who entered or completed MHP or other substance abuse treatment and 15 from each arm who met the criteria for MHP but did not request it.

RESULTS

The study began recruitment in October 2022, and the stage-1 pilot study is near completion. Preliminary findings from stage 1 show high e-SBI acceptability. Data analysis of the stage-1 pilot is now beginning. The stage-2 pilot RCT will be launched in March 2024, with all data collection completed by May 2025.

CONCLUSIONS

This study will allow us to assess the acceptability and feasibility of e-SBI implementation during HIV testing encounters. We will also build the necessary research infrastructure for a subsequent RCT to assess the efficacy of e-SBIs in reducing substance use and HIV sexual risk behavior among MSM in this setting.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05542914; https://tinyurl.com/yyjj64dm.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/56683.

Lifestyle Medicine Implementation in 8 Health Systems: Protocol for a Multiple Case Study Investigation

BACKGROUND

Lifestyle medicine (LM) is the use of therapeutic lifestyle changes (including a whole-food, plant-predominant eating pattern; regular physical activity; restorative sleep; stress management; avoidance of risky substances; and positive social connection) to prevent and treat chronic illness. Despite growing evidence, LM is still not widely implemented in health care settings. Potential challenges to LM implementation include lack of clinician training, staffing concerns, and misalignment of LM services with fee-for-service reimbursement, but the full range of factors facilitating or obstructing its implementation and long-term success are not yet understood. To learn important lessons for success and failure, it is crucial to understand the experiences of different LM programs.

OBJECTIVE

This study aims to describe in depth the protocol used to identify barriers and facilitators impacting the implementation of LM in health systems.

METHODS

The study team comprises team members at the American College of Lifestyle Medicine (ACLM), including staff and researchers with expertise in public health, LM, and qualitative research. We recruited health systems that were members of the ACLM Health Systems Council. From among 15 self-nominating health systems, we selected 7 to represent a diversity of geographic location, type, size, expertise, funding, patients, and LM services. Partway through the study, we recruited 1 additional contrasting health system to serve as a negative case. For each case, we conducted in-depth interviews, document reviews, site visits (limited due to the COVID-19 pandemic), and study team debriefs. Interviews lasted 45-90 minutes and followed a semistructured interview guide, loosely based on the Consolidated Framework for Implementation Research (CFIR) model. We are constructing detailed case narrative reports for each health system that are subsequently used in cross-case analyses to develop a contextually rich and detailed understanding of various predetermined and emergent topics. Cross-case analyses will draw on a variety of methodologies, including in-depth case familiarization, inductive or deductive coding, and thematic analysis, to identify cross-cutting themes.

RESULTS

The study team has completed data collection for all 8 participating health systems, including 68 interviews and 1 site visit. We are currently drafting descriptive case narratives, which will be disseminated to participating health systems for member checking and shared broadly as applied vignettes. We are also conducting cross-case analyses to identify critical facilitators and barriers, explore clinician training strategies to facilitate LM implementation, and develop an explanatory model connecting practitioner adoption of LM and experiences of burnout.

CONCLUSIONS

This protocol paper offers real-world insights into research methods and practices to identify barriers and facilitators to the implementation of LM in health systems. Findings can advise LM implementation across various health system contexts. Methodological limitations and lessons learned can guide the execution of other studies with similar methodologies.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/51562.

Science for behavioral health systems change: evolving research-policy-public partnerships

Potent partnerships among researchers, policymakers, and community members have potential to produce positive changes in communities on a range of topics, including behavioral health. The paper provides a brief illustrative review of such partnerships and then describes the development and evolution of one partnership in particular in Virginia. The origin of the partnership is traced, along with its founding vision, mission, and values. Some of its several projects are described, including (a) needs assessment for implementation of evidence-based programs (EBPs) pursuant to the Family First Prevention Services Act; (b) statewide fidelity monitoring of key EBPs; and (c) projects to synergize state investments in specific EBPs, like multisystemic therapy, functional family therapy, and high fidelity wraparound. The paper concludes with some themes around which the center has evolved to serve the state and its citizens more effectively.

External relationships as implementation determinants in community-engaged, equity-focused COVID-19 vaccination events

Background

While relationships and connectedness among organizations have been included in implementation theories, models, and frameworks, the increased attention to health equity in implementation science raises the urgency of understanding the role of relationships external to the implementing organization. This paper addresses this gap through an exploration of the role of external relationships in community-based, equity-focused interventions.

Methods

This study focuses on an equity-focused, community-based COVID-19 vaccination intervention in Arkansas, drawing upon long-term community-engaged relationships among University of Arkansas for Medical Sciences and the Hispanic and Marshallese Islander communities. We used an exploratory qualitative descriptive design to examine barriers and facilitators to implementation of COVID-19 vaccination events analyzing in-depth qualitative interviews with implementation team members (n = 17).

Results

All participants described pre-existing relationships among the implementing organization, partner organizations, and communities as a key implementation determinant for this equity-focused program. At the inter-organizational level, external relationships included formal connections and informal relationships among staff (e.g., communication channels from prior partnerships). At the individual level, strong external relationships with the community were facilitators leveraging long-term engagement, community familiarity, and staff from the communities of focus. Strong external relationships facilitated program reach in underserved communities through three mechanisms: (1) reduced time required to establish functional working relationships among partners; (2) accessibility and cultural congruence of health services; and (3) increased trust among community members. Barriers to implementation also existed in external relationships, but had less influence than facilitators.

Conclusions

Achieving health equity in implementation science requires greater understanding of external relationships as implementation determinants. This exploratory study makes a significant contribution to the literature by describing the types of external relationships that facilitate equitable implementation and identifying the mechanisms through which they may work. We argue that approaches to community engagement drawn from community-engaged research approaches may be useful, as these processes require investment in building/maintaining formal and informal organizational and interpersonal relationships. Further research is needed to understand connections among external relationships and other implementation determinants.

The long and winding road: Pathways from basic research to implementation and evaluation

In this article, we celebrate Dante Cicchetti's extensive contributions to the discipline of developmental psychopathology. In his seminal article, he articulated why developmental psychopathology was imperative to create research portfolios that could inform the causes, consequences, and trajectories for adults often initiated by early lived experiences (Cicchetti, 1984). In this three-part article, we share our transdisciplinary efforts to use developmental psychopathology as a foundational theory from which to develop, implement, and evaluate interventions for populations who experienced early adversity or who were at risk for child abuse and neglect. After describing interventions conducted at Mt. Hope Family Center that spanned over three decades, we highlight the criticality of disseminating results and address policy implications of this work. We conclude by discussing future directions to facilitate work in developmental psychopathology. Currently, one of three national National Institute of Child Health and Human Development-funded child abuse and neglect centers, we look forward to continuing to build upon Dante's efforts to disseminate this important work to improve society for our children, our nation's often most vulnerable and forgotten citizens.