Care team and practice-level implementation strategies to optimize pediatric collaborative care: study protocol for a cluster-randomized hybrid type III trial

Community-based integrated care for patients with diabetes and depression (CIC-PDD): study protocol for a cluster randomized controlled trial

BACKGROUND

Managing the multimorbidity of diabetes and depression remains a clinical challenge for patients and healthcare professionals due to the fragmented healthcare delivery system. To effectively cope with multimorbidity, there is an urgent need for the health system to transform into people-centered integrated care (PCIC) system globally. Therefore, this paper describes the protocol of community-based integrated care for patients with diabetes and depression (CIC-PDD) project, an integrated and shared-care intervention project.

METHODS/DESIGN

CIC-PDD project is conducted in two phases, namely "care model development" and "implementation and evaluation." In the first phase, CIC-PDD model was designed and developed based on the four criteria of collaborative care model (CCM) and was subsequently adjusted to align with the context of China. The second phase entails a pragmatic, two-arm, cluster randomized controlled implementation trial, accompanied by parallel mixed-methods process evaluation and cost-effectiveness analysis.

DISCUSSION

We anticipate CIC-PDD project will facilitate the development and innovation of PCIC model and related theories worldwide, particularly in low- and middle-income countries (LMICs). In addition, CIC-PDD project will contribute to the exploration of primary health care (PHC) in addressing the multimorbidity of physical and mental health issues.

TRIAL REGISTRATION

ClinicalTrials.gov registration ChiCTR2200065608 (China Clinical Trials Registry https://www.chictr.org.cn ). Registered on November 9, 2022.

A randomized controlled clinical trial to improve health outcomes in youth with type 1 diabetes: Study design and baseline characteristics

Most adolescents with T1D do not meet glycemic recommendations or consistently perform the required self-management behaviors to prevent acute- and long-term deleterious health outcomes. In addition, most youth with T1D do not have access to behavioral health services to address T1D management barriers. Thus, delivering behavioral interventions during routine medical appointments may hold promise for improving T1D outcomes in adolescents. The overall objective of this study was to examine the effect of behavioral interventions, either a Personalized T1D Self-Management Behaviors Feedback Report or Problem-Solving Skills, delivered by a T1D behavioral health provider and a T1D medical provider during a joint, fully integrated appointment to improve health outcomes in youth with T1D. This paper describes the study rationale, design, and baseline characteristics for the 109 adolescent-caregiver dyads who participated. Primary and secondary outcomes include hemoglobin A1c (A1C), T1D self-management behaviors, and biological indicators of complications.

How does facilitation in healthcare work? Using mechanism mapping to illuminate the black box of a meta-implementation strategy

BACKGROUND

Healthcare facilitation, an implementation strategy designed to improve the uptake of effective clinical innovations in routine practice, has produced promising yet mixed results in randomized implementation trials and has not been fully researched across different contexts.

OBJECTIVE

Using mechanism mapping, which applies directed acyclic graphs that decompose an effect of interest into hypothesized causal steps and mechanisms, we propose a more concrete description of how healthcare facilitation works to inform its further study as a meta-implementation strategy.

METHODS

Using a modified Delphi consensus process, co-authors developed the mechanistic map based on a three-step process. First, they developed an initial logic model by collectively reviewing the literature and identifying the most relevant studies of healthcare facilitation components and mechanisms to date. Second, they applied the logic model to write vignettes describing how facilitation worked (or did not) based on recent empirical trials that were selected via consensus for inclusion and diversity in contextual settings (US, international sites). Finally, the mechanistic map was created based on the collective findings from the vignettes.

FINDINGS

Theory-based healthcare facilitation components informing the mechanistic map included staff engagement, role clarification, coalition-building through peer experiences and identifying champions, capacity-building through problem solving barriers, and organizational ownership of the implementation process. Across the vignettes, engagement of leaders and practitioners led to increased socialization of the facilitator's role in the organization. This in turn led to clarifying of roles and responsibilities among practitioners and identifying peer experiences led to increased coherence and sense-making of the value of adopting effective innovations. Increased trust develops across leadership and practitioners through expanded capacity in adoption of the effective innovation by identifying opportunities that mitigated barriers to practice change. Finally, these mechanisms led to eventual normalization and ownership of the effective innovation and healthcare facilitation process.

IMPACT

Mapping methodology provides a novel perspective of mechanisms of healthcare facilitation, notably how sensemaking, trust, and normalization contribute to quality improvement. This method may also enable more efficient and impactful hypothesis-testing and application of complex implementation strategies, with high relevance for lower-resourced settings, to inform effective innovation uptake.

Interdisciplinary behavioral health provider perceptions of implementing the Collaborative Chronic Care Model: an i-PARIHS-guided qualitative study

BACKGROUND

The evidence-based Collaborative Chronic Care Model (CCM), developed to help structure care for chronic health conditions, comprises six elements: work role redesign, patient self-management support, provider decision support, clinical information systems, linkages to community resources, and organizational/leadership support. As the CCM is increasingly implemented in real-world settings, there is heightened interest in understanding specific influences upon implementation. Therefore, guided by the Integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework, we (i) identified innovation-, recipient-, context-, and facilitation-related influences on CCM implementation and (ii) assessed the influences' relationship to each CCM element's implementation.

METHODS

Using semi-structured interviews, we examined interdisciplinary behavioral health providers' experiences at nine VA medical centers that implemented the CCM. We used i-PARIHS constructs as a priori codes for directed content analysis, then analyzed the data for cross-coding by CCM element and i-PARIHS construct.

RESULTS

Participants (31 providers) perceived the CCM innovation as enabling comprehensive care but challenging to coordinate with existing structures/procedures. As recipients, participants recounted not always having the authority to design CCM-consistent care processes. They perceived local leadership support to be indispensable to implementation success and difficult to garner when CCM implementation distracted from other organizational priorities. They found implementation facilitation helpful for keeping implementation on track. We identified key themes at the intersection of i-PARIHS constructs and core CCM elements, including (i) the CCM being an innovation that offers a formal structure to stepping down care intensity for patients to encourage their self-management, (ii) recipients accessing their multidisciplinary colleagues' expertise for provider decision support, (iii) relationships with external services in the community (e.g., homelessness programs) being a helpful context for providing comprehensive care, and (iv) facilitators helping to redesign specific interdisciplinary team member roles.

CONCLUSIONS

Future CCM implementation would benefit from (i) facilitating strategic development of supportive maintenance plans for patients' self-management, (ii) collocating multidisciplinary staff (on-site or virtually) to enhance provider decision support, (iii) keeping information on available community resources up to date, and (iv) making clearer the explicit CCM-consistent care processes that work roles can be designed around. This work can inform concrete tailoring of implementation efforts to focus on the more challenging CCM elements, which is crucial to better account for multiple influences that vary across diverse care settings in which the CCM is being implemented.

Advancing research on teams and team effectiveness in implementation science: An application of the Exploration, Preparation, Implementation, Sustainment (EPIS) framework

Background

Effective teams are essential to high-quality healthcare. However, teams, team-level constructs, and team effectiveness strategies are poorly delineated in implementation science theories, models, and frameworks (TMFs), hindering our understanding of how teams may influence implementation. The Exploration, Preparation, Implementation, Sustainment (EPIS) framework is a flexible and accommodating framework that can facilitate the application of team effectiveness approaches in implementation science.

Main Text

We define teams and provide an overview of key constructs in team effectiveness research. We describe ways to conceptualize different types of teams and team constructs relevant to implementation within the EPIS framework. Three case examples illustrate the application of EPIS to implementation studies involving teams. Within each study, we describe the structure of the team and how team constructs influenced implementation processes and outcomes.

Conclusions

Integrating teams and team constructs into the EPIS framework demonstrates how TMFs can be applied to advance our understanding of teams and implementation. Implementation strategies that target team effectiveness may improve implementation outcomes in team-based settings. Incorporation of teams into implementation TMFs is necessary to facilitate application of team effectiveness research in implementation science.