Beliefs and Attitudes About the Dissemination and Implementation of Internet-Based Self-Care Programs in a Large Integrated Healthcare System

Comparing Federal Communications Commission and Microsoft Estimates of Broadband Access for Mental Health Video Telemedicine Among Veterans: Retrospective Cohort Study

BACKGROUND

The COVID-19 pandemic highlighted the importance of telemedicine in health care. However, video telemedicine requires adequate broadband internet speeds. As video-based telemedicine grows, variations in broadband access must be accurately measured and characterized.

OBJECTIVE

This study aims to compare the Federal Communications Commission (FCC) and Microsoft US broadband use data sources to measure county-level broadband access among veterans receiving mental health care from the Veterans Health Administration (VHA).

METHODS

Retrospective observational cohort study using administrative data to identify mental health visits from January 1, 2019, to December 31, 2020, among 1161 VHA mental health clinics. The exposure is county-level broadband percentages calculated as the percentage of the county population with access to adequate broadband speeds (ie, download >25 megabits per second) as measured by the FCC and Microsoft. All veterans receiving VHA mental health services during the study period were included and categorized based on their use of video mental health visits. Broadband access was compared between and within data sources, stratified by video versus no video telemedicine use.

RESULTS

Over the 2-year study period, 1,474,024 veterans with VHA mental health visits were identified. Average broadband percentages varied by source (FCC mean 91.3%, SD 12.5% vs Microsoft mean 48.2%, SD 18.1%; P<.001). Within each data source, broadband percentages generally increased from 2019 to 2020. Adjusted regression analyses estimated the change after pandemic onset versus before the pandemic in quarterly county-based mental health visit counts at prespecified broadband percentages. Using FCC model estimates, given all other covariates are constant and assuming an FCC percentage set at 70%, the incidence rate ratio (IRR) of county-level quarterly mental video visits during the COVID-19 pandemic was 6.81 times (95% CI 6.49-7.13) the rate before the pandemic. In comparison, the model using Microsoft data exhibited a stronger association (IRR 7.28; 95% CI 6.78-7.81). This relationship held across all broadband access levels assessed.

CONCLUSIONS

This study found FCC broadband data estimated higher and less variable county-level broadband percentages compared to those estimated using Microsoft data. Regardless of the data source, veterans without mental health video visits lived in counties with lower broadband access, highlighting the need for accurate broadband speeds to prioritize infrastructure and intervention development based on the greatest community-level impacts. Future work should link broadband access to differences in clinical outcomes.

Barriers and facilitators to the implementation of digital technologies in mental health systems: a qualitative systematic review to inform a policy framework

BACKGROUND

Despite the potential for improved population mental health and wellbeing, the integration of mental health digital interventions has been difficult to achieve. In this qualitative systematic review, we aimed to identify barriers and facilitators to the implementation of digital technologies in mental healthcare systems, and map these to an implementation framework to inform policy development.

METHODS

We searched Medline, Embase, Scopus, PsycInfo, Web of Science, and Google Scholar for primary research articles published between January 2010 and 2022. Studies were considered eligible if they reported barriers and/or facilitators to the integration of any digital mental healthcare technologies. Data were extracted using EPPI-Reviewer Web and analysed thematically via inductive and deductive cycles.

RESULTS

Of 12,525 references identified initially, 81 studies were included in the final analysis. Barriers and facilitators were grouped within an implementation (evidence-practice gap) framework across six domains, organised by four levels of mental healthcare systems. Broadly, implementation was hindered by the perception of digital technologies as impersonal tools that add additional burden of care onto both providers and patients, and change relational power asymmetries; an absence of resources; and regulatory complexities that impede access to universal coverage. Facilitators included person-cantered approaches that consider patients' intersectional features e.g., gender, class, disability, illness severity; evidence-based training for providers; collaboration among colleagues; appropriate investment in human and financial resources; and policy reforms that tackle universal access to digital health.

CONCLUSION

It is important to consider the complex and interrelated nature of barriers across different domains and levels of the mental health system. To facilitate the equitable, sustainable, and long-term digital transition of mental health systems, policymakers should consider a systemic approach to collaboration between public and private sectors to inform evidence-based planning and strengthen mental health systems.

PROTOCOL REGISTRATION

The protocol is registered on PROSPERO, CRD42021276838.

Barriers and facilitators to acceptance and implementation of eMental-health intervention among older adults: A qualitative systematic review

Objective

Electronic mental health interventions are effective but not well promoted currently among older adults. This study sought to systematically review and summarize the barriers and facilitators of accepting and implementing electronic mental health interventions among older adults.

Methods

We comprehensively retrieved six electronic databases from January 2012 to September 2022: PubMed, Web of Science, Embase, Scopus, PsycINFO, and CINAHL. The JBI-QARI was used to assess the quality of the research methodology of each publication. Eligible studies underwent data coding and synthesis aligned to inductive and deductive methods. The Consolidated Framework for Implementation Research 2.0 was used as a deductive framework to guide a more structured analysis.

Results

The systematic review screened 4309 articles, 17 of which were included (eight with mixed methods and nine with qualitative methods). We identified and extracted the barriers and facilitators of accepting and implementing electronic mental health interventions among older adults: (1) innovation: technology challenges, optimized functions, and contents, security and privacy; (2) outer setting: community engagement and partnerships, financing; (3) inner setting: leadership engagement, available resources, incompatibility, intergenerational support, training and guidance; (4) individuals: perceptions, capability, motivation of older adults and healthcare providers; and (5) implementation process: recruit, external assistance, and team.

Conclusion

These findings are critical to optimizing, promoting, and expanding electronic mental health interventions among older adults. The systematic review also provides a reference for better evidence-based implementation strategies in the future.

Facilitators, barriers and considerations for the implementation of healthcare innovation: A qualitative rapid systematic review

Family caregiving scholars recommend that health providers receive competency-based education to partner with and support family caregivers to care and to maintain their own health. While it may be relatively easy to develop competency-based education for healthcare providers, ensuring widespread uptake and spread and scale of healthcare education is critical to ensuring consistent person-centered support for all family caregivers (FCGs) throughout the care trajectory. The development of novel healthcare innovations requires implementation strategies for uptake and spread, with implementation involving the use of strategies to integrate a novel innovation into healthcare. Research suggests that there are many factors involved in successful implementation and a synthesis of potential factors is warranted. The purpose of this review is to provide an in-depth examination of facilitators, barriers and considerations for implementation of a novel healthcare innovation that will be used to develop an implementation plan for spread and scale of our competency-based education for health providers to learn about person-centered care for FCGs. A systematic review of published and grey literature was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA [Moher et al., 2015]) guidelines. The systematic review involved searching four databases for original research articles that described barriers, facilitators and/or other considerations when implementing innovations. Twenty-eight articles were included in the qualitative thematic analyses and described three areas of implementation research: barriers, facilitators and recommendations. There were major and parallel themes that emerged under facilitators and barriers. There were a wide variety of strategies that were identified as recommendations. The findings were synthesised into five considerations for implementation: Research and information sharing, intentional implementation planning, organisational underpinnings, creating the clinical context and facilitative training. This review provides an integrative overview of identified facilitators, barriers and recommendations for implementation that may aid in developing implementation strategies that can be tailored to the local context or innovation being implemented.

The Implementation and Effectiveness of Digital Cognitive Behavioral Therapy for Insomnia in Primary Care: A Pilot Study

Background

Digital interventions delivering Cognitive Behavioral Therapy for insomnia (Digital CBTi) may increase utilization of effective care for a common and serious condition. A low-intensity implementation strategy may facilitate digital CBTi use in healthcare settings. This pilot study assessed the feasibility of implementing a digital CBTi in Veterans Health Administration (VA) primary care through iterative modifications to a low-intensity implementation strategy, while evaluating clinical outcomes of a specific digital CBTi program.

Methods

A self-directed digital CBTi was implemented in the primary care clinics of a single VA facility using a cohort trial design that iteratively modified an implementation strategy over three 8-month phases. The phase 1 implementation strategy included (1) provider education; (2) point-of-care information via pamphlets; and (3) provider referral to digital CBTi through phone calls or messages. Phases 2 and 3 maintained these activities, while (1) adding a clinic-based coach who performed initial patient education and follow-up support contacts, (2) providing additional recruitment pathways, and (3) integrating the referral mechanism into provider workflow. Implementation outcomes included provider adoption, patient adoption, and acceptability. Clinical outcomes (insomnia severity, depression severity, and sedative hypnotic use) were compared among enrollees at baseline and 10 weeks.

Results

Across all phases 66 providers (48.9%) made 153 referrals, representing 0.38% of unique clinic patients. Of referrals, 77 (50.3%) enrolled in the study, 45 (29.4%) engaged in the program, and 24 (15.7%) completed it. Provider and patient adoption did not differ meaningfully across phases. Among enrollees, digital CBTi was acceptable and the Insomnia Severity Index decreased by 4.3 points (t = 6.41, p < 0.001) and 13 (18.6%) reached remission. The mean number of weakly sedative-hypnotic doses decreased by 2.2 (35.5%) (t = 2.39, p < 0.02).

Conclusions

Digital CBTi implementation in VA primary care is feasible using low-intensity implementation strategy, resulting in improved clinical outcomes for users. However, iterative implementation strategy modifications did not improve adoption. The trial was registered at clinicaltrials.gov (NCT03151083).

Lessons learned from service design of a trial of a digital mental health service: Informing implementation in primary care clinics

Implementing a digital mental health service in primary care requires integration into clinic workflow. However, without adequate attention to service design, including designing referral pathways to identify and engage patients, implementation will fail. This article reports results from our efforts designing referral pathways for a randomized clinical trial evaluating a digital service for depression and anxiety delivered through primary care clinics. We utilized three referral pathways: direct to consumer (e.g., digital and print media, registry emails), provider referral (i.e., electronic health record [EHR] order and provider recommendation), and other approaches (e.g., presentations, word of mouth). Over the 5-month enrollment, 313 individuals completed the screen and reported how they learned about the study. Penetration was 13%, and direct to consumer techniques, most commonly email, had the highest yield. Providers only referred 16 patients through the EHR, half of whom initiated the screen. There were no differences in referral pathway based on participants' age, depression severity, or anxiety severity at screening. Ongoing discussions with providers revealed that the technologic implementation and workflow design may not have been optimal to fully affect the EHR-based referral process, which potentially limited patient access. Results highlight the importance of designing and evaluating referral pathways within service implementation, which is important for guiding the implementation of digital services into practice. Doing so can ensure that sustained implementation is not left to post-evaluation bridge-building. Future efforts should assess these and other referral pathways implemented in clinical practice outside of a research trial.

Organizational and Policy Barriers to the Use of Digital Mental Health by Mental Health Professionals

Background: Digital mental health (DMH) provides effective methods of overcoming issues of time constraints, accessibility, and availability of mental health care. They can provide a valuable means to deliver mental health care in the present pandemic. However, adoption of these methods has been slow. Mental health professional (MHP) concerns at the organizational and policy level that influence this slow adoption need to be examined. Materials and Methods: A narrative review was conducted to identify the barriers. Searches using the databases Scopus, Embase, and PubMed were conducted to identify research focused on barriers reported by MHPs to use DMH. Results: The search resulted in 356 unique citations, and 21 papers met the inclusion and exclusion criteria. Forward and backward sampling resulted in identifying an additional 19 relevant papers. Discussion: Unmet needs for information, training, and infrastructure, challenges to the workflow and excessive workloads, and ambiguous policies serve as barriers to DMH use. This article recommends strategies for researchers, organizations, DMH designers, and governmental institutions to ensure efficient utilization of DMH. Conclusion: Concerted efforts at individual, organizational, and governmental levels are essential to ensure efficient utilization of DMH.

Implementation strategies for digital mental health interventions in health care settings

U.S. health care systems are tasked with alleviating the burden of mental health, but are frequently underprepared and lack workforce and resource capacity to deliver services to all in need. Digital mental health interventions (DMHIs) can increase access to evidence-based mental health care. However, DMHIs commonly do not fit into the day-to-day activities of the people who engage with them, resulting in a research-to-practice gap for DMHI implementation. For health care settings, differences between digital and traditional mental health services make alignment and integration challenging. Specialized attention is needed to improve the implementation of DMHIs in health care settings so that these services yield high uptake, engagement, and sustainment. The purpose of this article is to enhance efforts to integrate DMHIs in health care settings by proposing implementation strategies, selected and operationalized based on the discrete strategies established in the Expert Recommendations for Implementing Change project, that align to DMHI-specific barriers in these settings. Guidance is offered in how these strategies can be applied to DMHI implementation across four phases commonly distinguished in implementation science using the Exploration, Preparation, Implementation, Sustainment Framework. Next steps to advance research in this area and improve the research-to-practice gap for implementing DMHIs are recommended. Applying implementation strategies to DMHI implementation will enable psychologists to systematically evaluate this process, which can yield an enhanced understanding of the factors that facilitate implementation success and improve the translation of DMHIs from controlled trials to real-world settings. (PsycInfo Database Record (c) 2020 APA, all rights reserved).