Building strong research partnerships between public health and researchers: a VA case study

Expanding access to evidence-based psychotherapy in VA settings: implementation of the brief cognitive behavioral therapy for depression program

Introduction

Evidence-based psychotherapies (EBPs) are effective for mental health conditions, but access to these services remains limited and rural Veterans are particularly underserved. Specialized implementation and dissemination programs are needed to improve access to known EBPs.

Methods

The current project sought to improve access to a known EBP-brief Cognitive Behavioral Therapy for depression (Brief CBT). Diverse Veterans and those from rural settings were a focus of this work. Aligned with the RE-AIM framework, a multifaceted implementation program was used to train and support VHA providers in their use of Brief CBT in VHA mental health settings, with specific outreach efforts made to providers at VHA Community-Based Outpatient Clinics (CBOCs) where rural Veterans often receive care. Evaluation included all facets of RE-AIM with a particular focus on adoption, effectiveness, and maintenance.

Results

During the first two years, over 40 VHA facilities adopted the program across four regional networks. Eighty-three providers were approached, and 54 (65.1%) providers completed the training and are delivering the intervention. A total of 688 Veterans, 174 rural (25.7%), received 2,186 sessions (average of 3.5 sessions per Veteran). Veterans receiving Brief CBT with elevated depression scores who completed three or more sessions were found to have significant symptom reductions of 4.6 points (first to last available evaluations).

Discussion

Implementation efforts of Brief CBT resulted in rapid uptake and significant clinical impact on Veterans. Rural outreach efforts, including targeted training for CBOC providers and use of tele-mental health, enhanced availability of EBP services for rural Veterans.

Engaging Operational Partners Is Critical for Successful Implementation of Research Products: a Coincidence Analysis of Access-Related Projects in the Veterans Affairs Healthcare System

BACKGROUND/OBJECTIVE

The Veterans Health Administration (VHA) has prioritized timely access to care and has invested substantially in research aimed at optimizing veteran access. However, implementing research into practice remains challenging. Here, we assessed the implementation status of recent VHA access-related research projects and explored factors associated with successful implementation.

DESIGN

We conducted a portfolio review of recent VHA-funded or supported projects (1/2015-7/2020) focused on healthcare access ("Access Portfolio"). We then identified projects with implementable research deliverables by excluding those that (1) were non-research/operational projects; (2) were only recently completed (i.e., completed on or after 1/1/2020, meaning that they were unlikely to have had time to be implemented); and (3) did not propose an implementable deliverable. An electronic survey assessed each project's implementation status and elicited barriers/facilitators to implementing deliverables. Results were analyzed using novel Coincidence Analysis (CNA) methods.

PARTICIPANTS/KEY RESULTS

Among 286 Access Portfolio projects, 36 projects led by 32 investigators across 20 VHA facilities were included. Twenty-nine respondents completed the survey for 32 projects (response rate = 88.9%). Twenty-eight percent of projects reported fully implementing project deliverables, 34% reported partially implementing deliverables, and 37% reported not implementing any deliverables (i.e., resulting tool/intervention not implemented into practice). Of 14 possible barriers/facilitators assessed in the survey, two were identified through CNA as "difference-makers" to partial or full implementation of project deliverables: (1) engagement with national VHA operational leadership; (2) support and commitment from local site operational leadership.

CONCLUSIONS

These findings empirically highlight the importance of operational leadership engagement for successful implementation of research deliverables. Efforts to strengthen communication and engagement between the research community and VHA local/national operational leaders should be expanded to ensure VHA's investment in research leads to meaningful improvements in veterans' care. The Veterans Health Administration (VHA) has prioritized timely access to care and has invested substantially in research aimed at optimizing veteran access. However, implementing research findings into clinical practice remains challenging, both within and outside VHA. Here, we assessed the implementation status of recent VHA access-related research projects and explored factors associated with successful implementation. Only two factors were identified as "difference-makers" to adoption of project findings into practice: (1) engagement with national VHA leadership or (2) support and commitment from local site leadership. These findings highlight the importance of leadership engagement for successful implementation of research findings. Efforts to strengthen communication and engagement between the research community and VHA local/national leaders should be expanded to ensure VHA's investment in research leads to meaningful improvements in veterans' care.

Leveraging the ExpandNet framework and operational partnerships to scale-up brief Cognitive Behavioral Therapy in VA primary care clinics

Evidence-based psychotherapies (EBPs) are underused in health care settings. Aligning implementation of EBPs with the needs of health care leaders (i.e., operational stakeholders) can potentially accelerate their uptake into routine practice. Operational stakeholders (such as hospital leaders, clinical directors, and national program officers) can influence development and oversight of clinical programs as well as policy directives at local, regional, and national levels. Thus, engaging these stakeholders during the implementation and dissemination of EBPs is critical when targeting wider use in health care settings. This article describes how research–operations partnerships were leveraged to increase implementation of an empirically supported psychotherapy – brief Cognitive Behavioral Therapy (brief CBT) – in Veterans Health Administration (VA) primary care settings. The partnered implementation and dissemination efforts were informed by the empirically derived World Health Organization’s ExpandNet framework. A steering committee was formed and included several VA operational stakeholders who helped align the brief CBT program with the implementation needs of VA primary care settings. During the first 18 months of the project, partnerships facilitated rapid implementation of brief CBT at eight VA facilities, including training of 12 providers who saw 120 patients, in addition to expanded program elements to better support sustainability (e.g., train-the-trainer procedures).

Quality Enhancement Research Initiative Implementation Roadmap: Toward Sustainability of Evidence-based Practices in a Learning Health System

BACKGROUND

Learning Health Systems strive to continuously integrate innovations and evidence-based practices (EBPs) into routine care settings. Few models provide a specified pathway to accelerate adoption and spread of EBPs across diverse settings.

OBJECTIVE

The US Department of Veterans Affairs Quality Enhancement Research Initiative (QUERI) Implementation Roadmap facilitates uptake of EBPs in routine practice by aligning research and health system priorities.

METHODS

The Roadmap is based on earlier iterations of the QUERI translational research pipeline, incorporating recent advancements in quality improvement and implementation science. Progressive, dynamic phases were operationalized to form an implementation process that promoted a participatory approach which enables stakeholders (health care consumers, clinicians, administrators, and leaders) to systematically plan, deploy, evaluate, and sustain EBPs using implementation strategies within a Learning Health System framework.

RESULTS

The Roadmap consists of Preimplementation, Implementation, and Sustainment phases. Preimplementation identifies a high-priority need, selects EBPs to address the need, engages stakeholders to build implementation capacity, specifies needed EBP adaptions and evaluation goals, and activates leadership support. During Implementation, clinical and research leaders use implementation strategies to promote EBP technical competency and adaptive skills to motivate providers to own and sustain EBPs. Sustainment includes evaluation analyses that establish the EBP business case, and hand-off to system leadership to own EBP implementation maintenance over time.

CONCLUSIONS

The QUERI Implementation Roadmap systematically guides identification, implementation, and sustainment of EBPs, demystifying implementation science for stakeholders in a Learning Health System to ensure that EBPs are more rapidly implemented into practice to improve overall consumer health.

Taking a systems approach to explore the impacts and outcomes of a research and evaluation capacity building partnership: a protocol

INTRODUCTION

Partnership models that bring researchers, policymakers and service providers closer together are gaining traction as a strategy to improve public health practice. Yet, there is little evidence of how these models work, or indeed if they do work. The Sexual Health and Blood-borne Virus Applied Research and Evaluation Network (SiREN) is one such model. SiREN is a partnership between researchers, policymakers and service providers that aims to develop the research and evaluation capacity and evidence-informed decision making capability of professionals working to address sexual health and bloodborne virus issues in Western Australia. This study will use a systems approach to identify the mechanisms of action, impacts and outcomes of SiREN and inform the development of evaluation tools.

METHODS AND ANALYSIS

Data will be collected from organisational documents, surveys, in-depth interviews and a workshop. It will be analysed using a complex adaptive systems lens and findings will be used to inform the development of a type of qualitative systems model called a causal loop diagram. The causal loop diagram will illustrate the: contextual factors influencing engagement; mechanisms of action; and impacts and outcomes of SiREN. Evaluation tools will then be developed that can be used to assess the indicators identified in the causal loop diagram.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the Curtin University Human Research Ethics Committee (approval number: HRE2017-0090). Participants will be free to withdraw from the study at any point and confidentiality will be maintained by de-identifying participant responses in any published or shared data. The findings from this study will be shared in conference presentations, reports, peer-reviewed journals and online through websites and social media.

Twelve Lessons Learned for Effective Research Partnerships Between Patients, Caregivers, Clinicians, Academic Researchers, and Other Stakeholders

Research increasingly means that patients, caregivers, health professionals, other stakeholders, and academic investigators work in partnership. This requires effective collaboration rooted in mutual respect, involvement of all participants, and good communication. Having conducted such partnered research over multiple projects, and having recently completed a project together funded by the Patient-Centered Outcomes Research Institute, we collaboratively developed a list of 12 lessons we have learned about how to ensure effective research partnerships. To foster a culture of mutual respect, hold early in-person meetings, with introductions focused on motivation, offer appropriate orientation for everyone, and maintain awareness of individual and project goals. To actively involve all team members, it is important to ensure sufficient funding for everyone's participation, to ask for and recognize diverse contributions, and to seek the input of quiet members. To facilitate good communication, teams should carefully consider labels, avoid jargon and acronyms, judiciously use homogeneous and heterogeneous subgroups, and keep progress visible. In offering pragmatic, actionable lessons we have learned through our separate and shared experiences, we hope to help foster more patient-centered research via productive and enjoyable research collaborations.

Partnering to improve care: the case of the Veterans’ Health Administration’s Quality Enhancement Research Initiative

Background

Within many large health care organizations, researchers and operations partners (i.e., policymakers, managers, clinical leaders) join to conduct studies to improve the quality of patient care. Yet optimal approaches to conducting partnership research and evaluation are only beginning to be clearly defined. The Veterans’ Health Administration (VA) Quality Enhancement Research Initiative (QUERI), funded by operations leaders and administered by the VA’s research service, now has nearly two decades of experience in fostering research–operations partnerships for improving quality of VA care. The work reported here is part of a national evaluation of QUERI. Because individuals in research and operations often have differing backgrounds and perspectives, we aim to identify the main sources of tension in research–operations partnerships and strategies for maximizing partnership success, through the eyes of QUERI participants.

Methods

We conducted semi-structured interviews with 116 researchers and operations partners chosen randomly from within pre-identified key participant groups. We conducted inductive qualitative analysis of verbatim interview transcripts, limited to the 89 interviews of individuals reporting at least some familiarity with QUERI.

Results

Tensions in research–operations partnerships were primarily related to diverging incentives and to differing values placed on scientific rigor or integrity versus quick timelines. To alleviate these tensions, operations’ partners highlighted the importance of ‘perspective-taking’ (i.e., putting themselves into the shoes of the researchers) to ensure a mutually beneficial and attractive partnership, whereas researchers identified the importance of overcoming the need for recognition to be apportioned between either research or operations for achieved results. Both researchers and operations participants identified jointly designing each partnership from the beginning, minimizing research bureaucracy burdens, and prioritizing in-person communication and long-term relationships as key partnership building blocks.

Conclusions

QUERI research and operations participants had largely concordant views on partnership tensions and approaches for improving partnership success. The fact that only researchers mentioned moving beyond recognition for the results achieved and only operations staff mentioned the importance of ‘perspective-taking’ suggests, however, that there may be unresolved tensions. These results suggest that researchers may benefit from better aligning of academic incentives with contributions to the health care organization and establishing formal recognition of operational impacts of research, while preserving some flexibility and independence of the research process.

Moving From Discovery to System-Wide Change: The Role of Research in a Learning Health Care System: Experience from Three Decades of Health Systems Research in the Veterans Health Administration

The Veterans Health Administration is unique, functioning as an integrated health care system that provides care to more than six million veterans annually and as a home to an established scientific enterprise that conducts more than $1 billion of research each year. The presence of research, spanning the continuum from basic health services to translational research, has helped the Department of Veterans Affairs (VA) realize the potential of a learning health care system and has contributed to significant improvements in clinical quality over the past two decades. It has also illustrated distinct pathways by which research influences clinical care and policy and has provided lessons on challenges in translating research into practice on a national scale. These lessons are increasingly relevant to other health care systems, as the issues confronting the VA—the need to provide timely access, coordination of care, and consistent high quality across a diverse system—mirror those of the larger US health care system.