Evaluating Fidelity to a Modified NIATx Process Improvement Strategy for Improving HIV Services in Correctional Facilities

The application of implementation science methods in correctional health intervention research: a systematic review

BACKGROUND

Improving access to high-quality healthcare for individuals in correctional settings is critical to advancing health equity in the United States. Compared to the general population, criminal-legal involved individuals experience higher rates of chronic health conditions and poorer health outcomes. Implementation science frameworks and strategies offer useful tools to integrate health interventions into criminal-legal settings and to improve care. A review of implementation science in criminal-legal settings to date is necessary to advance future applications. This systematic review summarizes research that has harnessed implementation science to promote the uptake of effective health interventions in adult criminal-legal settings.

METHODS

A systematic review of seven databases (Academic Search Premier, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, Social Work Abstracts, ProQuest Criminal Justice Database, ProQuest Sociological Abstracts, MEDLINE/PubMed) was conducted. Eligible studies used an implementation science framework to assess implementation outcomes, determinants, and/or implementation strategies in adult criminal-legal settings. Qualitative synthesis was used to extract and summarize settings, study designs, sample characteristics, methods, and application of implementation science methods. Implementation strategies were further analyzed using the Pragmatic Implementation Reporting Tool.

RESULTS

Twenty-four studies met inclusion criteria. Studies implemented interventions to address infectious diseases (n=9), substance use (n=6), mental health (n=5), co-occurring substance use and mental health (n=2), or other health conditions (n=2). Studies varied in their operationalization and description of guiding implementation frameworks/taxonomies. Sixteen studies reported implementation determinants and 12 studies measured implementation outcomes, with acceptability (n=5), feasibility (n=3), and reach (n=2) commonly assessed. Six studies tested implementation strategies. Systematic review results were used to generate recommendations for improving implementation success in criminal-legal contexts.

CONCLUSIONS

The focus on implementation determinants in correctional health studies reflects the need to tailor implementation efforts to complex organizational and inter-agency contexts. Future studies should investigate policy factors that influence implementation success, design, and test implementation strategies tailored to determinants, and investigate a wider array of implementation outcomes relevant to criminal-legal settings, health interventions relevant to adult and juvenile populations, and health equity outcomes.

TRIAL REGISTRATION

A study protocol (CRD42020114111) was registered with Prospero.

Opening the "black box" of organizational coaching for implementation

BACKGROUND

Organizational coaching to promote the implementation of evidence-informed interventions is becoming more popular in healthcare organizations. In order to open the "black box" of coaching for implementation, we first developed, then tested the rigor and utility of a model of coaching for implementation.

METHODS

Interviews with nine experienced coaches were conducted and inductively coded to develop a model of coaching for implementation. Later, forty coaching calls with behavioral health organizations in Ohio, Wisconsin, and Florida were analyzed with directed content analysis using a priori codes based on this model.

RESULTS

The coaching work that occurred during these calls aligned closely with the model of coaching for implementation developed by our team. Most coaching work was devoted to building capacity; almost as much work focused on building relationships. Very little coaching work was dedicated to building sustainability. Use of tools for organizational change and implementation remained relatively consistent across all coaching periods.

CONCLUSION

Understanding what occurs during a successful coaching intervention will improve the effectiveness of coaching as an implementation strategy. Future research should focus on which processes and patterns make coaching more likely to promote specific implementation outcomes.

Interventions to improve the implementation of evidence-based healthcare in prisons: a scoping review

BACKGROUND

There are challenges to delivering high quality primary care within prison settings and well-recognised gaps between evidence and practice. There is a growing body of literature evaluating interventions to implement evidence-based practice in the general population, yet the extent and rigour of such evaluations in incarcerated populations are unknown. We therefore conducted a scoping literature review to identify and describe evaluations of implementation interventions in the prison setting.

METHODS

We searched EMBASE, MEDLINE, CINAHL Plus, Scopus, and grey literature up to August 2021, supplemented by hand searching. Search terms included prisons, evidence-based practice, and implementation science with relevant synonyms. Two reviewers independently selected studies for inclusion. Data extraction included study populations, study design, outcomes, and author conclusions. We took a narrative approach to data synthesis. We followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidance for scoping reviews.

RESULTS

Fifteen studies reported in 17 papers comprised one randomised controlled trial, one controlled interrupted time series analysis and 13 uncontrolled before and after studies. Eight studies took place in the US and four in the UK. Ten studies evaluated combined (multifaceted) interventions, typically including education for staff or patients. Interventions most commonly targeted communicable diseases, mental health and screening uptake. Thirteen studies reported adherence to processes of care, mainly testing, prescribing and referrals. Fourteen studies concluded that interventions had positive impacts.

CONCLUSIONS

There is a paucity of high-quality evidence to inform strategies to implement evidence-based health care in prisons, and an over-reliance on weak evaluation designs which may over-estimate effectiveness. Whilst most evaluations have focused on recognised priorities for the incarcerated population, relatively little attention has been paid to long-term conditions core to primary care delivery. Initiatives to close the gaps between evidence and practice in prison primary care need a stronger evidence base.

Adapting the stages of implementation completion to an evidence-based implementation strategy: The development of the NIATx stages of implementation completion

Background

Dissemination and implementation frameworks provide the scaffolding to explore the effectiveness of evidence-based practices (EBPs) targeting process of care and organizational outcomes. Few instruments, like the stages of implementation completion (SIC) examine implementation fidelity to EBP adoption and how organizations differ in their approach to implementation. Instruments to measure organizational competency in the utilization of implementation strategies are lacking.

Method

An iterative process was utilized to adapt the SIC to the NIATx implementation strategies. The new instrument, NIATx-SIC, was applied in a randomized controlled trial involving 53 addiction treatment agencies in Washington state to improve agency co-occurring capacity. NIATx-SIC data were reported by state staff and external facilitators and through participating agency documentation. Proportion and duration scores for each stage and phase of the NIATx-SIC were calculated for each agency. Competency was assessed using the NIATx fidelity tool. Comparisons of proportion, duration, and NIATx activities completed were determined using independent sample t-tests by agency competency level.

Results

The NIATx-SIC distinguished between agencies achieving competency (n  =  23) and those not achieving competency (n  =  26). Agencies achieving competency completed a greater proportion of implementation phase activities and had a significantly longer Stage 7 duration. These agencies participated in significantly more individual and group coaching calls, attended more in-person meetings, implemented more change projects, and spent approximately 64 more days, on average, engaging in all NIATx activities.

Conclusions

Organizational participation in dissemination and implementation research requires a significant investment of staff resources. The inability of an organization to achieve competency when utilizing a set of implementation strategies waste an opportunity to institutionalize knowledge of how to apply implementation strategies to future change efforts. The NIATx-SIC provides evidence that competency is not an attribute of the organization but rather a result of the application of the NIATx implementation strategies to improve agency co-occurring capacity.

Trial Registration

ClinicalTrials.gov, NCT03007940. Registered January 2, 2017, https://clinicaltrials.gov/ct2/show/NCT03007940.

Implementation for Sustained Impact in Teleophthalmology (I-SITE): applying the NIATx Model for tailored implementation of diabetic retinopathy screening in primary care

Background

Teleophthalmology provides evidence-based, telehealth diabetic retinopathy screening that is underused even when readily available in primary care clinics. There is an urgent need to increase teleophthalmology use in the US primary care clinics. In this study, we describe the development of a tailored teleophthalmology implementation program and report outcomes related to primary care provider (PCP) adoption.

Methods

We applied the 5 principles and 10 steps of the NIATx healthcare process improvement model to develop and test I-SITE (Implementation for Sustained Impact in Teleophthalmology) in a rural, the US multi-payer health system. This implementation program allows patients and clinical stakeholders to systematically tailor teleophthalmology implementation to their local context. We aligned I-SITE components and implementation strategies to an updated ERIC (Expert Recommendations for Implementing Change) framework. We compared teleophthalmology adoption between PCPs who did or did not participate in various components of I-SITE. We surveyed PCPs and clinical staff to identify the strategies they believed to have the highest impact on teleophthalmology use.

Results

To test I-SITE, we initiated a year-long series of 14 meetings with clinical stakeholders (n=22) and met quarterly with patient stakeholders (n=9) in 2017. Clinical and patient stakeholder groups had 90.9% and 88.9% participant retention at 1 year, respectively. The increase in teleophthalmology use was greater among PCPs participating in the I-SITE implementation team than among other PCPs (p < 0.006). The proportion of all PCPs who used the implementation strategy of electing diabetic eye screening for their annual performance-based financial incentive increased from 0% (n=0) at baseline to 56% (n=14) following I-SITE implementation (p = 0.004). PCPs and clinical staff reported the following implementation strategies as having the highest impact on teleophthalmology use: reminders to ask patients about diabetic eye screening during clinic visits, improving electronic health record (EHR) documentation, and patient outreach.

Conclusions

We applied the NIATx Model to develop and test a teleophthalmology implementation program for tailored integration into primary care clinics. The NIATx Model provides a systematic approach to engaging key stakeholders for tailoring implementation of evidence-based telehealth interventions into their local context.

A Review of Recent HIV Prevention Interventions and Future Considerations for Nursing Science

ABSTRACT

As our knowledge of HIV evolved over the decades, so have the approaches taken to prevent its transmission. Public health scholars and practitioners have engaged in four key strategies for HIV prevention: behavioral-, technological-, biomedical-, and structural/community-level interventions. We reviewed recent literature in these areas to provide an overview of current advances in HIV prevention science in the United States. Building on classical approaches, current HIV prevention models leverage intimate partners, families, social media, emerging technologies, medication therapy, and policy modifications to effect change. Although much progress has been made, additional work is needed to achieve the national goal of ending the HIV epidemic by 2030. Nurses are in a prime position to advance HIV prevention science in partnership with transdisciplinary experts from other fields (e.g., psychology, informatics, and social work). Future considerations for nursing science include leveraging transdisciplinary collaborations and consider social and structural challenges for individual-level interventions.

Improving Medication Access within Integrated Treatment for Individuals with Co-Occurring Disorders in Substance Use Treatment Agencies

BACKGROUND

The best approach to provide comprehensive care for individuals with co-occurring disorders (CODs) related to substance use and mental health is to address both disorders through an integrated treatment approach. However, only 25% of behavioral health agencies offer integrated care and less than 7% of individuals who need integrated treatment receive it. A project used a cluster-randomized waitlist control group design to evaluate the effectiveness of Network for the Improvement of Addiction Treatment (NIATx) implementation strategies to improve access to addiction and psychotropic medications.

METHODS

This study represents a secondary analysis of data from the NIATx project. Forty-nine agencies were randomized to Cohort1 (active implementation group, receiving the NIATx strategy [n=25]) or Cohort2 (waitlist control group [n=24]). Data were collected at three time points (Baseline, Year1 and Year2). A two-level (patient within agency) multinomial logistic regression model investigated the effects of implementation strategy condition on one of four medication outcomes: both medication types, only psychotropic medication, only addiction medication, or neither medication type. A per-protocol analysis included time, NIATx fidelity, and agency focus as predictors.

RESULTS

The intent-to-treat analysis found a statistically significant change in access to addiction versus neither medication, but Cohort1 compared to Cohort2 at Year1 showed no differences. Changes were associated with the experimental intervention and occurred in the transition from Year 1 to Year 2, where greater increases were seen for agencies in Cohort2 versus Cohort1. The per-protocol analysis showed increased access to both medications and addiction medications from pre- to post-intervention for agencies in both cohorts; however, differences in change between high- and low-implementation agencies were not significant.

CONCLUSIONS

Access to integrated services for people with CODs is a long-standing problem. NIATx implementation strategies had limited effectiveness in improving medication access for individuals with CODs. Implementation strategy adherence is associated with increased medication access.

Using NIATx strategies to implement integrated services in routine care: a study protocol

Background

Access to integrated services for individuals with co-occurring substance use and mental health disorders is a long-standing public health issue. Receiving integrated treatment services are both more effective and preferred by patients and families versus parallel or fragmented care. National policy statements and expert consensus guidelines underscore the benefits of integrated treatment. Despite decades of awareness, adequate treatment for individuals with co-occurring substance use and mental health disorders occurs infrequently. The underlying disease burden associated with alcohol, illicit and prescription drug problems, as well as mental health disorders, such as depression, posttraumatic stress disorder and schizophrenia, is substantial.

Methods

This cluster randomized controlled trial (RCT) is designed to determine if the multi-component Network for the Improvement of Addiction Treatment (NIATx) strategies are effective in implementing integrated services for persons with co-occurring substance use and mental health disorders. In this study, 50 behavioral health programs in Washington State will be recruited and then randomized into one of two intervention arms: 1) NIATx implementation strategies, including coaching and learning sessions over a 12-month intervention period to implement changes targeting integrated treatment services; or 2) wait-list control. Primary outcome measures include: 1) fidelity - a standardized organizational assessment of integrated services (Dual Diagnosis in Addiction Treatment [DDCAT] Index); and 2) penetration - proportion of patients screened and diagnosed with co-occurring disorders, proportion of eligible patients receiving substance use and mental health services, and psychotropic or substance use disorder medications. Barriers and facilitators, as determinants of implementation outcomes, will be assessed using the Consolidated Framework for Implementation Research (CFIR) Index. Fidelity to and participation in NIATx strategies will be assessed utilizing the NIATx Fidelity Scale and Stages of Implementation Completion (SIC).

Discussion

This study addresses an issue of substantial public health significance: the gap in access to an evidence-based practice for integrated treatment for individuals with co-occurring mental health and substance use disorders. The study utilizes rigorous and reproducible quantitative approaches to measuring implementation determinants and strategies, and may address a longstanding gap in the quality of care for persons with co-occurring disorders.

Trial registration

ClinicalTrials.gov NCT03007940. Registered 02 January 2017 – Retrospectively Registered

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3241-4) contains supplementary material, which is available to authorized users.