Bringing Healthy Aging to Scale: A Randomized Trial of a Quality Improvement Intervention to Increase Adoption of Evidence-Based Health Promotion Programs by Community Partners

Barriers and facilitators for implementation of a combined lifestyle intervention in community-dwelling older adults: a scoping review

Background

Lifestyle interventions, combining nutrition and exercise, are effective in improving the physical functioning of community-dwelling older adults and preventing healthcare risks due to loss in muscle mass. However, the potential of these types of interventions is not being fully exploited due to insufficient implementation. Having insight into the determinants that could hinder or facilitate the implementation of a combined lifestyle intervention could improve the development of matching implementation strategies and enhance the implementation of such lifestyle interventions. The aim of this study was to identify barriers and facilitators for the successful implementation of a combined lifestyle intervention for community-dwelling older adults.

Method

A scoping review was conducted. A literature search was conducted in four electronic databases, and references were checked for additional inclusion. Studies were screened if they met the inclusion criteria. Barriers and facilitators were extracted from the included studies. To validate the results of the literature search, healthcare professionals and community-dwelling older adults were interviewed. Barriers and facilitators were categorized by two researchers according to the constructs of the Consolidated Framework for Implementation Research (CFIR).

Results

The search identified 12,364 studies, and 23 were found eligible for inclusion in the review. Barriers and facilitators for 26 of the 39 constructs of the CFIR were extracted. The interviews with healthcare professionals and older adults yielded six extra barriers and facilitators for implementation, resulting in determinants for 32 of the 39 CFIR constructs. According to literature and healthcare professionals, cosmopolitanism (network with external organizations), patient needs and resources, readiness for implementation, costs, knowledge and beliefs about the intervention, network and communication, and engaging were found to be the most important determinants for implementation of a combined lifestyle intervention.

Conclusion

A broad range of barriers and facilitators across all domains of the CFIR framework emerged in this study. The results of this review reflect on determinants that should be taken into account when planning for the implementation of a combined lifestyle intervention. A further step in the implementation process is the development of implementation strategies aiming at the identified determinants to enhance the implementation of a combined lifestyle intervention in community care.

Student coaching in a rural community fall prevention program: An exploratory study

Falls are a significant cause of disability internationally. The purpose of this exploratory study was to examine the effectiveness of a community fall prevention program, Stepping On (SO), using nine student physical therapists and program faculty in a rural setting. A mixed-methods design was utilized. Students partnered with older adults to master exercises, demonstrate floor recovery techniques, and manage community navigation in line with program fidelity. A descriptive survey assessed program outcomes. Students participated in a follow-up focus group to discuss perspectives on their role in the program. One hundred and seventeen community-dwelling older adults (mean age: 75.2 ± 8.5) completed the program. Participants who lived alone were likely to limit their activities because of fear of falling (p = .045). Following SO most subjects (87.7%) described having a better understanding of falls and their causes, with a plan to arise from the floor (82.6%). Focus group themes underscored students' opportunity to facilitate, reinforce safety during mobility activities, and motivate participants. Furthermore, an increased awareness of other professions' contribution to fall prevention was noted. Following a community fall prevention program, older adults have a better understanding of fall prevention and plan for floor recovery. In turn, student coaching skills are reinforced.

Fall-related health service use in Stepping On programme participants and matched controls: a non-randomised observational trial within the 45 and Up Study

BACKGROUND

Falls and fall-related health service use among older adults continue to increase. The New South Wales Health Department, Australia, is delivering the Stepping On fall prevention programme at scale. We compared fall-related health service use in Stepping On participants and matched controls.

METHODS

A non-randomised observational trial was undertaken using 45 and Up Study data. 45 and Up Study participants who did and did not participate in Stepping On were extracted in a 1:4 ratio. Rates of fall-related health service use from linked routinely collected data were compared between participants and controls over time using multilevel Poisson regression models with adjustment for the minimally sufficient set of confounders identified from a directed acyclic graph.

RESULTS

Data from 1,452 Stepping On participants and 5,799 controls were analysed. Health service use increased over time and was greater in Stepping On participants (rate ratios (RRs) 1.47-1.82) with a spike in use in the 6 months prior to programme participation. Significant interactions indicated differential patterns of health service use in participants and controls: stratified analyses revealed less fall-related health service use in participants post-programme compared to pre-programme (RRs 0.32-0.48), but no change in controls' health service use (RRs 1.00-1.25). Gender was identified to be a significant effect modifier for health service use (P < 0.05 for interaction).

DISCUSSION

Stepping On appeared to mitigate participants' rising fall-related health service use. Best practice methods were used to maximise this study's validity, but cautious interpretation of results is required given its non-randomised nature.

Patterns of health service use before and after a statewide fall prevention initiative for older adults at risk of falls

OBJECTIVE

To understand health-care burden from fall-related injury, we investigated patterns of health service use in participants of the Australian statewide Stepping On fall prevention program.

METHODS

Routinely collected ambulance, emergency, hospital and mortality data for 9163 participants across NSW Local Health Districts between 2009 and 2015 were analysed for patterns in fall-related health service use three years before and after the Stepping On program using negative binomial regression analyses.

RESULTS

Overall fall-related health service use increased over the 6-year study period. There was a high period of usage prior to program participation, which decreased postprogram, then appeared to increase again after 12-15 months. Subgroup analysis showed strongest postprogram reductions for women.

CONCLUSIONS

Patterns of service usage suggest initial program benefits that taper off over time. The results of this observational study need to be interpreted with caution. Investment in ongoing fall prevention programs may be needed for lasting impacts.

Age-friendly interventions in rural and remote areas: A scoping review

OBJECTIVES

In 2007, the World Health Organization published a guide on age-friendly cities. However, little is known about interventions that have been implemented to promote age-friendly communities in rural and remote areas. This paper presents the findings from a scoping review undertaken to locate available evidence of interventions, strategies, and programs that have been implemented in rural and remote areas to create age-friendly communities.

METHODS

This scoping review used the Joanna Briggs Institute (JBI) methodology.

RESULTS

A total of 219 articles were included in this review. No intervention studies were referred to as 'age-friendly'. However, there were interventions (mostly healthcare-related) that have been implemented in rural and remote areas with older people as participants. There were also non-evaluated community programs that were published in the grey literature. This review identified the common health interventions in older people and the indirect relevance to the WHO age-friendly framework domains in rural and remote contexts.

CONCLUSIONS

The eight age-friendly domains were not explicitly utilised as a guide in the development of interventions for older people in rural and remote settings. Implementation of age-friendly interventions in rural and remote areas requires a multisectoral approach that is tailored to address the specific needs of individual communities. Age-friendly interventions also need to consider socio-ecological factors to adequately and holistically address community needs and ensure long-term sustainability.

A scoping review of the use of quality improvement methods by community organizations in the United States, Australia, New Zealand, and Canada to improve health and well-being in community settings

Background

Health-care facilities have used quality improvement (QI) methods extensively to improve quality of care. However, addressing complex public health issues such as coronavirus disease 2019 and their underlying structural determinants requires community-level innovations beyond health care. Building community organizations’ capacity to use QI methods is a promising approach to improving community health and well-being.

Objectives

We explore how community health improvement has been defined in the literature, the extent to which community organizations have knowledge and skill in QI and how communities have used QI to drive community-level improvements.

Methods

Per a published study protocol, we searched Scopus, Web of Science, and Proquest Health management for articles between 2000 and 2019 from USA, Australia, New Zealand, and Canada. We included articles describing any QI intervention in a community setting to improve community well-being. We screened, extracted, and synthesized data. We performed a quantitative tabulation and a thematic analysis to summarize results.

Results

Thirty-two articles met inclusion criteria, with 31 set in the USA. QI approaches at the community level were the same as those used in clinical settings, and many involved multifaceted interventions targeting chronic disease management or health promotion, especially among minority and low-income communities. There was little discussion on how well these methods worked in community settings or whether they required adaptations for use by community organizations. Moreover, decision-making authority over project design and implementation was typically vested in organizations outside the community and did not contribute to strengthening the capability of community organizations to undertake QI independently.

Conclusion

Most QI initiatives undertaken in communities are extensions of projects in health-care settings and are not led by community residents. There is urgent need for additional research on whether community organizations can use these methods independently to tackle complex public health problems that extend beyond health-care quality.

What long-term care interventions have been published between 2010 and 2020? Results of a WHO scoping review identifying long-term care interventions for older people around the world

OBJECTIVE

The global population is rapidly ageing. To tackle the increasing prevalence of older adults' chronic conditions, loss of intrinsic capacity and functional ability, long-term care interventions are required. The study aim was to identify long-term care interventions reported in scientific literature from 2010 to 2020 and categorise them in relation to WHO's public health framework of healthy ageing.

DESIGN

Scoping review conducted on PubMed, CINHAL, Cochrane and Google Advanced targeting studies reporting on long-term care interventions for older and frail adults. An internal validated Excel matrix was used for charting.Setting nursing homes, assisted care homes, long-term care facilities, home, residential houses for the elderly and at the community.

INCLUSION CRITERIA

Studies published in peer-reviewed journals between 1 January 2010 to 1 February 2020 on implemented interventions with outcome measures provided in the settings mentioned above for subjects older than 60 years old in English, Spanish, German, Portuguese or French.

RESULTS

305 studies were included. Fifty clustered interventions were identified and organised into four WHO Healthy Ageing domains and 20 subdomains. All interventions delved from high-income settings; no interventions from low-resource settings were identified. The most frequently reported interventions were multimodal exercise (n=68 reports, person-centred assessment and care plan development (n=22), case management for continuum care (n=16), multicomponent interventions (n=15), psychoeducational interventions for caregivers (n=13) and interventions mitigating cognitive decline (n=13).

CONCLUSION

The identified interventions are diverse overarching multiple settings and areas seeking to prevent, treat and improve loss of functional ability and intrinsic capacity. Interventions from low-resource settings were not identified.

Relevance, resilience, and ageism: A bright future for occupational therapy and healthy ageing, Sylvia Docker Lecture 2021

Our core professional values have been enduring and remarkably relevant to decades past and times present. Our values ensure the currency of our professional contribution, our resilience, readiness, and adaptability, to meet the challenges as we move into the next decade and beyond. In this Sylvia Docker lecture, I draw on my career experience from practice and academic research to examine this premise. The social isolation during the COVID-19 pandemic gave us all a picture of what our clients experience in an enduring way and the challenges of maintaining healthy lifestyles, meaningful occupations, and life roles. One of the greatest population challenges of this century is healthy ageing and the impact that ageism has on health. We live in a society that is ageist, and such cultural thinking impacts our beliefs and expectations as it does for older adults themselves. As occupational therapists, we strive to maintain our relevance, and we drive transformational change through using research-informed evidence-based approaches and adopting enablement programmes that meet the needs of people who are ageing. While prominent in enablement and therapeutic approaches, we are not immune to ageism. Being exposed to ageist views throughout our lives means, we internalise these and believe that ageing is a process of decline. Such self-perceptions and stereotyping impact the health of older people and influence the choices we make in our everyday practice. There are examples of emerging evidence and approaches that will meet these challenges and ways to re-frame ageist thinking. Occupational therapy values of working with people's strengths, what they can do, indicates we are well placed to engage and provide leadership in moving societal views. Addressing ageism requires self-reflection and action in order to be part of changing the narrative on ageing.

Applying the lessons of implementation science to maximize feasibility and usability in team science intervention development

The Science of Team Science (SciTS) has generated a substantial body of work detailing characteristics of effective teams. However, that knowledge has not been widely translated into accessible, active, actionable, evidence-based interventions to help translational teams enhance their team functioning and outcomes. Over the past decade, the field of Implementation Science has rapidly developed methods and approaches to increase the translation of biomedical research findings into clinical care, providing a roadmap for mitigating the challenges of developing interventions while maximizing feasibility and utility. Here, we propose an approach to intervention development using constructs from two Implementation Science frameworks, Consolidated Framework for Implementation Research, and Reach, Effectiveness, Adoption, Implementation, and Maintenance, to extend the Wisconsin Interventions for Team Science framework described in Rolland et al. 2021. These Implementation Science constructs can help SciTS researchers design, build, test, and disseminate interventions that meet the needs of both adopters, the institutional leadership that decides whether to adopt an intervention, and implementers, those actually using the intervention. Systematically considering the impact of design decisions on feasibility and usability may lead to the design of interventions that can quickly move from prototype to pilot test to pragmatic trials to assess their impact.

Effective implementation approaches for healthy ageing interventions for older people: A rapid review

BACKGROUND AND OBJECTIVES

Systematic reviews on healthy ageing interventions have primarily focused on assessing their effectiveness, not the implementation processes underpinning them, and the factors influencing program effectiveness. This has created a knowledge gap about what are effective implementation approaches, and how to scale up such interventions at the population level. Our aim in this rapid review was to synthesise the evidence on implementation of effective healthy ageing interventions, and to identify the factors that influence population-level implementation of these interventions.

DESIGN AND METHODS

Following the PRISMA checklist, we searched for papers in six databases: Ovid Medline, Ovid Embase, CENTRAL, CINAHL, PsycArticles and PsycINFO. A narrative synthesis was used to summarise the results.

RESULTS

Twenty-nine articles reporting on 21 healthy ageing interventions (studies) were included in the review. The findings show that a wide range of approaches to implementation were used including collaborative partnership, co-design, use of volunteers, person centred-care, and self-directed/professional-led approaches. The key implementation drivers were the use of behavioural change techniques, social interaction, tailoring of interventions, booster sessions, and multi-component and multi-professional team approach to intervention design and delivery.

CONCLUSION

The effectiveness of healthy ageing interventions is contingent on a number of factors including the type of implementation approaches used, the context in which programs are implemented, and the specific mechanisms that may be at play at the individual older adult level.

Scale-up of the Stepping On fall prevention program amongst older adults in NSW: Program reach and fall-related health service use

ISSUE ADDRESSED

We describe the reach of the scale-up of Stepping On, a fall prevention program targeting community-dwellers aged ≥65 years in NSW, along with fall-related ambulance service use and fall-related hospitalisations after scale-up.

METHODS

Data on program provision were received from Local Health Districts. Routinely collected fall-related ambulance usage and hospital admissions in NSW residents aged ≥65 years between 2009 and 2015 were compared within Statistical Local Areas prior to and following the implementation of Stepping On using multilevel models.

RESULTS

Between 2009 and 2014 the program was delivered in 1077 sites to 10 096 older adults. Rates of fall-related ambulance use and hospital admissions per 100-person-years were 1-2 in people aged 66-74, 4-5 in people aged 75-84 and 12-13 in people aged ≥85. These rates increased over time (P < .001). The interaction between time and program delivery was not significant for fall-related ambulance use or hospital admissions. The time-related increase in fall-related ambulance usage in people aged 75-84 years may have been moderated by the Stepping On program (rate ratio 0.97, 95% CI 0.93-1.00, P = .045).

CONCLUSIONS

There was no indication of a reduced rate of fall-related ambulance use or hospital admissions across the entire sample. Ambulance call-outs for falls in people aged 75-84 years may have reduced following program participation. SO WHAT?: Program scale-ups need to reach a large proportion of the target population with a focus on those groups contributing most to fall-related health service utilisation. Linking individual participants' health data as part of large-scale evaluations may provide better insights into program outcomes.

After the Randomized Trial: Implementation of Community-Based Continence Promotion in the Real World

BACKGROUND/OBJECTIVES

Most women aged 65 and older have incontinence, associated with high healthcare costs, institutionalization, and negative quality of life, but few seek care. Mind over Matter: Healthy Bowels, Healthy Bladder (MOM) is a small-group self-management workshop, led by a trained facilitator in a community setting, proven to improve incontinence in older women.

DESIGN

We used mixed methods to gather information on the real-world adoption, maintenance, and implementation of MOM by community agencies following a randomized controlled trial (RCT) that tested intervention effects on incontinence.

SETTING

Community agencies serving older adults in six Wisconsin communities.

PARTICIPANTS

Community agency administrators and facilitators trained to offer MOM for the RCT.

MEASUREMENTS

Investigators tracked rates of adoption (offering MOM in the 12 months following the RCT) and maintenance (offering MOM more than once in the next 18 months) in six communities. Individual interviews and focus groups (N = 17) generated qualitative data about barriers and facilitators related to adoption and maintenance. Trained observers assessed implementation fidelity (alignment with program protocol) at 42 MOM sessions.

RESULTS

A total of 67% of communities (four of six) adopted MOM, and 50% (three of six) maintained MOM. No implementation fidelity lapses occurred. Facilitators of adoption and maintenance included MOM's well-organized protocol and lean time commitment, sharing of implementation efforts between partner organizations, staff specifically assigned to health promotion activities, and high community interest in continence promotion. Other than stigma associated with incontinence, barriers were similar to those seen with other community-based programs for older adults: limited funding/staffing, competing organizational priorities, challenges identifying/training facilitators, and difficulty engaging community partners/participants.

CONCLUSION

Using design for dissemination and community engagement, assessment of implementation outcomes is feasible in conjunction with a clinical RCT. Partner-centered implementation packages can address barriers to adoption and maintenance.

Healthy aging through the lens of community-based practitioners: a focus group study

Background

Nearly one in every seven Americans is 65 years and older, facing day-to-day challenge of aging. Although interest in healthy aging is growing, most of the efforts are directed towards understanding the perceptions of older adults. Little is known about the perspectives of community-based practitioners who work with older adults and deliver programs to promote healthy aging. The purpose of this project was to expand knowledge on healthy aging by exploring the perspectives of community-based practitioners working directly with older adults.

Methods

We purposively sampled community-based practitioners (n = 12, including nurses, physician, social workers, and other community services professionals) working with older adults, who then participated in one of three in-depth focus group discussions conducted between March and June 2016. Each focus group discussion lasted for about 2 h. Verbatim transcript data were analyzed in Atlas.ti 7 using a conventional content analysis with an inductive approach, and consensual validation of coding was achieved.

Results

Three core categories of healthy aging were identified: (1) characteristics of healthy aging; (2) healthy aging attainment; and (3) programs and activities for healthy aging. Practitioners identified a number of characteristics of healthy aging under person-specific (physiological, basic, psych-emotional, and cognitive needs), social aspects (creating community and contributing to the community), and spiritual dimensions (cultural views and beliefs) of healthy aging. Healthy aging attainment was represented as facilitators and barriers both with respect to care recipients and care providers, and programs and activities through promoting fitness and wellness.

Conclusions

The rapidly changing demographics and aging population in the United States and their various needs suggest the implications for recognizing opportunities and developing and implementing programs to promote healthy aging. Although practitioners’ perspectives had some overlap with traditional research and medical views on healthy aging, the unique and holistic conceptual framework derived in the study might provide a more refined foundation for delivering appropriate health care services to the American aging population.

Outcomes associated with scale-up of the Stepping On falls prevention program: A case study in redesigning for dissemination

Introduction:

Translating complex behavior change interventions into practice can be accompanied by a loss of fidelity and effectiveness. We present the evaluation of two sequential phases of implementation of a complex evidence-based community workshop to reduce falls, using the Replicating Effective Programs Framework. Between the two phases, workshop training and delivery were revised to improve fidelity with key elements.

Methods:

Stepping On program participants completed a questionnaire at baseline (phase 1: n = 361; phase 2: n = 2219) and 6 months post-workshop (phase 1: n = 232; phase 2: n = 1281). Phase 2 participants had an additional follow-up at 12 months (n = 883). Outcomes were the number of falls in the prior 6 months and the Falls Behavioral Scale (FaB) score.

Results:

Workshop participation in phase 1 was associated with a 6% reduction in falls (RR = 0.94, 95% CI 0.74–1.20) and a 0.14 improvement in FaB score (95% CI, 0.11– 0.18) at 6 months. Workshop participation in phase 2 was associated with a 38% reduction in falls (RR = 0.62, 95% CI 0.57–0.68) and a 0.16 improvement in FaB score (95% CI 0.14–0.18) at 6 months, and a 28% reduction in falls (RR = 0.72, 95% CI 0.65–0.80) and a 0.19 score improvement in FaB score (95% CI 0.17–0.21) at 12-month follow-up.

Conclusions:

Effectiveness can be maintained with widespread dissemination of a complex behavior change intervention if attention is paid to fidelity of key elements. An essential role for implementation science is to ensure effectiveness as programs transition from research to practice.

The Community-Academic Aging Research Network: A Pipeline for Dissemination

BACKGROUND/OBJECTIVES

The Community-Academic Aging Research Network (CAARN) was created to increase the capacity and effectiveness of Wisconsin's Aging Network and the University of Wisconsin to conduct community-based research related to aging. The purpose of this article is to describe CAARN's infrastructure, outcomes, and lessons learned.

DESIGN

Using principles of community-based participatory research, CAARN engages stakeholders to participate in the design, development, and testing of older adult health interventions that address community needs, are sustainable, and improve health equity.

SETTING

Academic healthcare and community organizations.

PARTICIPANTS

Researchers, community members, and community organizations.

INTERVENTION

CAARN matches academic and community partners to develop and test evidence-based programs to be distributed by a dissemination partner.

MEASUREMENTS

Number of partnerships and funding received.

RESULTS

CAARN has facilitated 33 projects since its inception in 2010 (30 including rural populations), involving 46 academic investigators, 52 Wisconsin counties, and 1 tribe. These projects have garnered 52 grants totaling $20 million in extramural and $3 million in intramural funding. Four proven interventions are being prepared for national dissemination by the Wisconsin Institute for Healthy Aging: one to improve physical activity; one to reduce bowel and bladder incontinence; one to reduce sedentary behavior; and one to reduce falls risk among Latinx older adults. Additionally, one intervention to improve balance using a modified tai chi program is being disseminated by another organization.

CONCLUSION

CAARN's innovative structure creates a pipeline to dissemination by designing for real-world settings through inclusion of stakeholders in the early stages of design and by packaging community-based health interventions for older adults so they can be disseminated after the research has been completed. These interventions provide opportunities for clinicians to engage with community organizations to improve the health of their patients through self-management. J Am Geriatr Soc 68:1325-1333, 2020.

"Pisando Fuerte": an evidence-based falls prevention program for Hispanic/Latinos older adults: results of an implementation trial

Background

We previously developed Pisando Fuerte (PF), a linguistically and culturally appropriate version of “Stepping On”, an evidence-based fall prevention program building on self-efficacy and adult learning principles. The purpose of this study is to describe the implementation of PF at two community organizations in Wisconsin.

Methods

PF consisted of 2 h sessions delivered in Spanish over the course of 8 weeks by two trained leaders, at two community sites in Wisconsin. Participants identified strategies for falls prevention and practiced progressive balance and strength exercises. The RE-AIM framework guided the mixed-methods evaluation. Falls Behavioral Risk Scale (FaB) (Outcomes), and uptake of protective behaviors (Individual Maintenance) were evaluated 6 months after completion. Fidelity of delivery (Implementation) was evaluated by an independent assessor for three sessions at each site using a-priori criteria based on key elements of Stepping On.

Results

Twenty-four Hispanic/Latino individuals, whose primary language is Spanish, were enrolled in two workshops. The mean age was 70.5 years; 71% were female, and five reported a fall in the year prior. Outcomes: There was a non-statically significant decrease in the number of falls per person [RR: 0.33 (95%CI: 0.096–1.13)] at 6 months. There was a statistically significant improvement of the mean Falls Behavioral Risk Scale (FaB) (baseline = 2.69 vs. 6-months post-intervention = 3.16, p < 0.001). Adoption: Barriers to adoption included leader training in English, time to identify Spanish-speaking guest experts, and time to prepare for each session. Implementation: Satisfactory fidelity of delivery was achieved in 69% of the elements; fidelity lapses were more common in the use of adult learning strategies and programmatic aspects. Eighty eight percent of participants completed the program, and 95% of them adequately demonstrated the exercises. Maintenance: At 6 months, 57.9% of participants continued doing exercises, 94% adopted safer walking strategies, and 67% executed at least one home safety recommendation. These results are similar to those seen in the original Stepping On program.

Conclusions

Our study shows good fidelity of delivery with implementation of “Pisando Fuerte”. Pre-post data demonstrate a significant reduction in falls behavioral risk among Hispanic/Latino participants, similar to results with “Stepping On”.

Trial registration

ClinicalTrials.gov, NCT03895021. Registered March 29, 2019.

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.