What gets noticed: how barrier and facilitator perceptions relate to the adoption and implementation of innovative mental health practices

„Ich sehe es tatsächlich als Zwischenschritt“ – eine qualitative Analyse der Implementierungsbedingungen und -hürden von Stationsäquivalenter Behandlung in Berlin und Brandenburg

Ziel Untersucht werden die Bedingungen und Hürden der Einführung von Stationsäquivalenter Behandlung nach § 115d SGB V (StäB).

Methode Qualitative Analyse von Interviews und Fokusgruppen mit Mitarbeitenden (n = 43) an 11 psychiatrischen Kliniken in Berlin/Brandenburg.

Ergebnisse Auf Systemebene wird die Implementierung u. a. durch eine inadäquate Leistungsdefinition, fehlende Vorgaben auf Landesebene, Personalmangel und MDK-Prüfungen erschwert. Dies führt bei Kliniken zu zurückhaltender Umsetzung mit teilweise unzureichender personeller Ausstattung der StäB-Teams. Weitere Barrieren betreffen das Fehlen mobiler Lösungen zur Dokumentation und Teamkommunikation. Auf Ebene der Mitarbeitenden wirken sich ein Mangel an Information und Kooperation sowie unklare Aufgaben und Rollen hinderlich aus.

Schlussfolgerungen Für eine bedürfnisorientierte, flexible und flächendeckende Einführung von StäB sind Nachbesserungen an den Rahmenbedingungen sowie weitere Forschung zur Wirksamkeit und Implementierung notwendig.

New directions for psychiatric rehabilitation in the USA

American researchers have led the world in developing, evaluating, and disseminating evidence-based psychiatric rehabilitation practices for people with serious mental illness. Paradoxically, however, the USA lags behind most industrialized nations in providing access to high-quality mental health and psychiatric services. This essay examines several evidence-based practices developed in the USA, the spread of these practices, the barriers to ensuring availability to people who could benefit from these services, and some promising directions for overcoming the barriers. Factors influencing the growth and sustainment of effective client-centred practices include the availability of adequate and stable funding, committed leadership, and the influence of vested interests. Two strategies for promoting the spread and sustainment of well-implemented evidence-based practices are the adoption of fidelity scales and learning communities.

Integrating care for frequent users of emergency departments: implementation evaluation of a brief multi-organizational intensive case management intervention

Background

Addressing the needs of frequent users of emergency departments (EDs) is a health system priority in many jurisdictions. This study describes stakeholder perspectives on the implementation of a multi-organizational brief intervention designed to support integration and continuity of care for frequent ED users with mental health and addictions problems, focusing on perceived barriers and facilitators to early implementation in a large urban centre.

Methods

Coordinating Access to Care from Hospital Emergency Departments (CATCH-ED) is a brief case management intervention bridging hospital, primary and community care for frequent ED users experiencing mental illness and addictions. To examine barriers and facilitators to early implementation of this multi-organizational intervention, between July and October 2012, 47 stakeholders, including direct service providers, managers and administrators participated in 32 semi-structured qualitative interviews and one focus group exploring their experience with the intervention and factors that helped or hindered successful early implementation. Qualitative data were analyzed using thematic analysis.

Results

Stakeholders valued the intervention and its potential to support continuity of care for this population. Service delivery system factors, including organizational capacity and a history of collaborative relationships across the healthcare continuum, and support system factors, such as training and supervision, emerged as key facilitators of program implementation. Operational challenges included early low program referral rates, management of a multi-organizational initiative, variable adherence to the model among participating organizations, and scant access to specialty psychiatric resources. Factors contributing to these challenges included lack of dedicated staff in the ED and limited local system capacity to support this population, and insufficient training and technical assistance available to participating organizations.

Conclusions

A multi-organizational brief intervention is an acceptable model to support integration of hospital, primary and community care for frequent ED users. The study highlights the importance of early implementation evaluation to identify potential solutions to implementation barriers that may be applicable to many jurisdictions.

Implementing Housing First Across Sites and Over Time: Later Fidelity and Implementation Evaluation of a Pan-Canadian Multi-site Housing First Program for Homeless People with Mental Illness

This article examines later fidelity and implementation of a five-site pan-Canadian Housing First research demonstration project. The average fidelity score across five Housing First domains and 10 programs was high in the first year of operation (3.47/4) and higher in the third year of operation (3.62/4). Qualitative interviews (36 key informant interviews and 17 focus groups) revealed that staff expertise, partnerships with other services, and leadership facilitated implementation, while staff turnover, rehousing participants, participant isolation, and limited vocational/educational supports impeded implementation. The findings shed light on important implementation "drivers" at the staff, program, and community levels.

Early implementation evaluation of a multi-site housing first intervention for homeless people with mental illness: a mixed methods approach

This research sought to determine whether the implementation of Housing First in a large-scale, multi-site Canadian project for homeless participants with mental illness shows high fidelity to the Pathways Housing First model, and what factors help or hinder implementation. Fidelity ratings for 10 Housing First programs in five cities were made by an external quality assurance team along five key dimensions of Housing First based on 84 key informant interviews, 10 consumer focus groups, and 100 chart reviews. An additional 72 key informant interviews and 35 focus groups yielded qualitative data on factors that helped or hindered implementation. Overall, the findings show a high degree of fidelity to the model with more than 71% of the fidelity items being scored higher than 3 on a 4-point scale. The qualitative research found that both delivery system factors, including community and organizational capacity, and support system factors, training and technical assistance, facilitated implementation. Fidelity challenges include the availability of housing, consumer representation in program operations, and limitations to the array of services offered. Factors that accounted for these challenges include low vacancy rates, challenges of involving recently homeless people in program operations, and a lack of services in some of the communities. The study demonstrates how the combined use of fidelity assessment and qualitative methods can be used in implementation evaluation to develop and improve a program.

The sustainability of new programs and innovations: a review of the empirical literature and recommendations for future research

BACKGROUND

The introduction of evidence-based programs and practices into healthcare settings has been the subject of an increasing amount of research in recent years. While a number of studies have examined initial implementation efforts, less research has been conducted to determine what happens beyond that point. There is increasing recognition that the extent to which new programs are sustained is influenced by many different factors and that more needs to be known about just what these factors are and how they interact. To understand the current state of the research literature on sustainability, our team took stock of what is currently known in this area and identified areas in which further research would be particularly helpful. This paper reviews the methods that have been used, the types of outcomes that have been measured and reported, findings from studies that reported long-term implementation outcomes, and factors that have been identified as potential influences on the sustained use of new practices, programs, or interventions. We conclude with recommendations and considerations for future research.

METHODS

Two coders identified 125 studies on sustainability that met eligibility criteria. An initial coding scheme was developed based on constructs identified in previous literature on implementation. Additional codes were generated deductively. Related constructs among factors were identified by consensus and collapsed under the general categories. Studies that described the extent to which programs or innovations were sustained were also categorized and summarized.

RESULTS

Although "sustainability" was the term most commonly used in the literature to refer to what happened after initial implementation, not all the studies that were reviewed actually presented working definitions of the term. Most study designs were retrospective and naturalistic. Approximately half of the studies relied on self-reports to assess sustainability or elements that influence sustainability. Approximately half employed quantitative methodologies, and the remainder employed qualitative or mixed methodologies. Few studies that investigated sustainability outcomes employed rigorous methods of evaluation (e.g., objective evaluation, judgement of implementation quality or fidelity). Among those that did, a small number reported full sustainment or high fidelity. Very little research has examined the extent, nature, or impact of adaptations to the interventions or programs once implemented. Influences on sustainability included organizational context, capacity, processes, and factors related to the new program or practice themselves.

CONCLUSIONS

Clearer definitions and research that is guided by the conceptual literature on sustainability are critical to the development of the research in the area. Further efforts to characterize the phenomenon and the factors that influence it will enhance the quality of future research. Careful consideration must also be given to interactions among influences at multiple levels, as well as issues such as fidelity, modification, and changes in implementation over time. While prospective and experimental designs are needed, there is also an important role for qualitative research in efforts to understand the phenomenon, refine hypotheses, and develop strategies to promote sustainment.

Building organizational knowledge and value: informed decision making in Kansas children's community-based mental health services

Knowledge is managers' principal asset and knowledge building is managers' primary work. This qualitative study explores knowledge building by directors of children's community-based mental health services in Kansas. Of the state's 27 directors, 25 completed a survey about knowledge building, in their preference of online or telephone format. Fourteen participants took part either in preliminary interviews for study development, or in follow-up interviews for further detail and member checking. Study findings indicate that with requisite resources, directors inform their decision making with streams of information, which they manage and generate to build organizational knowledge and value for local practice effectiveness.

Community Providers' Impression of HIV Prevention Intervention Research in NIDA's Clinical Trials Network

Research-based approaches to HIV risk reduction are available but not readily adopted by community-based treatment programs. This exploratory survey study assessed staff (N=116) attitudes as a function of direct research participation, treatment program type, and study performance within seven methadone maintenance and eight psychosocial outpatient substance abuse treatment programs that participated in the NIDA Clinical Trials Network HIV risk reduction trials. Clinical staff who directly participated in the research reported intervention components as useful and were more likely to report perceived increases in HIV testing/referrals compared to staff who did not directly participate. However, those directly involved reported less positive attitudes about clinical impact and research impression. Results suggest a positive influence of research participation on awareness of program services, but also the need to address practical and professional issues related to research collaboration. Effectiveness trials offer a valuable opportunity to assess provider-level factors associated with adoption and implementation.

Implementing evidence-based practices for people with schizophrenia

Over the last decade, a consensus has emerged regarding a set of evidence-based practices for schizophrenia that address symptom management and psychosocial functioning. Yet, surveys suggest that the great majority of the population of individuals with schizophrenia do not receive evidence-based care. In this article, we review the empirical literature on implementation of evidence-based practices for schizophrenia patients. We first examine lessons learned from implementation studies in general medicine. We then summarize the implementation literature specific to schizophrenia, including medication practices, psychosocial interventions, information technology, and state- and federal-level interventions. We conclude with recommendations for future directions.