Implementing a Digital Tool to Support Shared Care Planning in Community-Based Mental Health Services: Qualitative Evaluation

Supported decision-making interventions in mental healthcare: A systematic review of current evidence and implementation barriers

BACKGROUND

There is a growing momentum around the world to foster greater opportunities for the involvement of mental health service users in their care and treatment planning. In-principle support for this aim is widespread across mental healthcare professionals. Yet, progress in mental health services towards this objective has lagged in practice.

OBJECTIVES

We conducted a systematic review of quantitative, qualitative and mixed-method research on interventions to improve opportunities for the involvement of mental healthcare service users in treatment planning, to understand the current research evidence and the barriers to implementation.

METHODS

Seven databases were searched and 5137 articles were screened. Articles were included if they reported on an intervention for adult service users, were published between 2008 and October 2023 and were in English. Evidence in the 140 included articles was synthesised according to the JBI guidance on Mixed Methods Systematic Reviews.

RESULTS

Research in this field remains exploratory in nature, with a wide range of interventions investigated to date but little experimental replication. Overarching barriers to shared and supported decision-making in mental health treatment planning were (1) Organisational (resource limitations, culture barriers, risk management priorities and structure); (2) Process (lack of knowledge, time constraints, health-related concerns, problems completing and using plans); and (3) Relationship barriers (fear and distrust for both service users and clinicians).

CONCLUSIONS

On the basis of the barriers identified, recommendations are made to enable the implementation of new policies and programs, the designing of new tools and for clinicians seeking to practice shared and supported decision-making in the healthcare they offer.

PATIENT OR PUBLIC CONTRIBUTION

This systematic review has been guided at all stages by a researcher with experience of mental health service use, who does not wish to be identified at this point in time. The findings may inform organisations, researchers and practitioners on implementing supported decision-making, for the greater involvement of people with mental ill health in their healthcare.

Barriers and facilitators to the implementation of digital technologies in mental health systems: a qualitative systematic review to inform a policy framework

BACKGROUND

Despite the potential for improved population mental health and wellbeing, the integration of mental health digital interventions has been difficult to achieve. In this qualitative systematic review, we aimed to identify barriers and facilitators to the implementation of digital technologies in mental healthcare systems, and map these to an implementation framework to inform policy development.

METHODS

We searched Medline, Embase, Scopus, PsycInfo, Web of Science, and Google Scholar for primary research articles published between January 2010 and 2022. Studies were considered eligible if they reported barriers and/or facilitators to the integration of any digital mental healthcare technologies. Data were extracted using EPPI-Reviewer Web and analysed thematically via inductive and deductive cycles.

RESULTS

Of 12,525 references identified initially, 81 studies were included in the final analysis. Barriers and facilitators were grouped within an implementation (evidence-practice gap) framework across six domains, organised by four levels of mental healthcare systems. Broadly, implementation was hindered by the perception of digital technologies as impersonal tools that add additional burden of care onto both providers and patients, and change relational power asymmetries; an absence of resources; and regulatory complexities that impede access to universal coverage. Facilitators included person-cantered approaches that consider patients' intersectional features e.g., gender, class, disability, illness severity; evidence-based training for providers; collaboration among colleagues; appropriate investment in human and financial resources; and policy reforms that tackle universal access to digital health.

CONCLUSION

It is important to consider the complex and interrelated nature of barriers across different domains and levels of the mental health system. To facilitate the equitable, sustainable, and long-term digital transition of mental health systems, policymakers should consider a systemic approach to collaboration between public and private sectors to inform evidence-based planning and strengthen mental health systems.

PROTOCOL REGISTRATION

The protocol is registered on PROSPERO, CRD42021276838.

The use of augmented reality for patient and significant other stroke education: a feasibility study

BACKGROUND

Stroke education is a key factor in minimising secondary stroke risk, yet worldwide stroke education rates are low. Technology has the potential to increase stroke education accessibility. One technology that could be beneficial is augmented reality (AR). We developed and trialled a stroke education lesson using an AR application with stroke patients and significant others.

METHODS

A feasibility study design was used. Following development of the AR stroke education lesson, 19 people with stroke and three significant others trialled the lesson then completed a customised mixed method questionnaire. The lesson involved narrated audio while participants interacted with a model brain via a tablet. Information about participant recruitment and retention, usage, and perceptions were collected.

RESULTS

Fifty-eight percent (n = 22) of eligible individuals consented to participate. Once recruited, 100% of participants (n = 22) were retained. Ninety percent of participants used the lesson once. Most participants used the application independently (81.82%, n = 18), had positive views about the lesson (over 80% across items including enjoyment, usefulness and perception of the application as a good learning tool) and reported improved confidence in stroke knowledge (72.73%, n = 16). Confidence in stroke knowledge post-lesson was associated with comfort using the application (p = 0.046, Fisher's exact test) and perception of the application as a good learning tool (p = 0.009, Fisher's exact test).

CONCLUSIONS

Technology-enhanced instruction in the form of AR is feasible for educating patients and significant others about stroke. Further research following refinement of the lesson is required.

A scoping review of applications of the Consolidated Framework for Implementation Research (CFIR) to telehealth service implementation initiatives

BACKGROUND

The Consolidated Framework for Implementation Research (CFIR), introduced in 2009, has the potential to provide a comprehensive understanding of the determinants of implementation-effectiveness of health service innovations. Although the CFIR has been increasingly used in recent years to examine factors influencing telehealth implementation, no comprehensive reviews currently exist on the scope of knowledge gained exclusively from applications of the CFIR to telehealth implementation initiatives. This review sought to address this gap.

METHODS

PRISMA-ScR criteria were used to inform a scoping review of the literature. Five academic databases (PUBMED, PROQUEST, SCIDIRECT, CINAHL, and WoS) were searched for eligible sources of evidence from 01.01.2010 through 12.31.2021. The initial search yielded a total of 18,388 records, of which, 64 peer-reviewed articles met the inclusion criteria for the review. Included articles were reviewed in full to extract data, and data collected were synthesized to address the review questions.

RESULTS

Most included articles were published during or after 2020 (64%), and a majority (77%) were qualitative or mixed-method studies seeking to understand barriers or facilitators to telehealth implementation using the CFIR. There were few comparative- or implementation-effectiveness studies containing outcome measures (5%). The database search however, revealed a growing number of protocols for implementation-effectiveness studies published since 2020. Most articles (91%) reported the CFIR Inner Setting domain (e.g., leadership engagement) to have a predominant influence over telehealth implementation success. By comparison, few articles (14%) reported the CFIR Outer Setting domain (e.g., telehealth policies) to have notable influence. While more (63%) telehealth initiatives were focused on specialty (vs primary) care, a vast majority (78%) were focused on clinical practice over medical education, healthcare administration, or population health.

CONCLUSIONS

Organized provider groups have historically paid considerable attention to advocating for telehealth policy (Outer Setting) reform. However, results suggest that for effective telehealth implementation, provider groups need to refocus their efforts on educating individual providers on the complex inter-relationships between Inner Setting constructs and telehealth implementation-effectiveness. On a separate note, the growth in implementation-effectiveness study protocols since 2020, suggests that additional outcome measures may soon be available, to provide a more nuanced understanding of the determinants of effective telehealth implementation based on the CFIR domains and constructs.

Stakeholders barriers and facilitators for the implementation of a personalised digital care pathway: a qualitative study

OBJECTIVE

A prerequisite for patient-centredness in healthcare organisations is offering patients access to adequate health information, which fits their needs. A personalised digital care pathway (PDCP) is a tool that facilitates the provision of tailored and timely information. Despite its potential, barriers influence the implementation of digital tools in healthcare organisations. Therefore, we investigated the perceived barriers and facilitators for implementation of the PDCP among stakeholders.

DESIGN

A qualitative study was conducted to acquire insight into perceptions of the stakeholders involved in the implementation of a digital care pathway in three diverse patient groups.

SETTING

This study is part of the PDCP research project in a large academic hospital in the Netherlands.

PARTICIPANTS

Purposive sampling was used to recruit internal stakeholders (eg, healthcare professionals, employees of the supporting departments) and external stakeholders (eg, employees of the external PDCP supplier). In addition, existing semistructured interviews with patients involved in pilot implementation (n=24) were used to verify the findings.

RESULTS

We conducted 25 semistructured interviews using the Consolidated Framework for Implementation Research. Content analyses yielded four themes: (1) stakeholders' perceptions of the PDCP (eg, perceived usefulness); (2) characteristics of the individuals involved and the implementation process (eg, individuals express resistance to change); (3) organisational readiness (eg, lack of resources); and (4) collaboration within the organisation (eg, mutual communication, multidisciplinary codesign). The main barriers mentioned by patients were duration of first activation and necessity for up-to-date content. In addition, the most facilitating factor for patients was user-friendliness.

CONCLUSION

Our findings emphasise the importance of gaining insights into the various perspectives of stakeholder groups, including patients, regarding the implementation of the PDCP. The perceived barriers and facilitators can be used to improve the PDCP implementation plan and tailor the development and improvement of other digital patient communication tools.

The updated Consolidated Framework for Implementation Research based on user feedback

BACKGROUND

Many implementation efforts fail, even with highly developed plans for execution, because contextual factors can be powerful forces working against implementation in the real world. The Consolidated Framework for Implementation Research (CFIR) is one of the most commonly used determinant frameworks to assess these contextual factors; however, it has been over 10 years since publication and there is a need for updates. The purpose of this project was to elicit feedback from experienced CFIR users to inform updates to the framework.

METHODS

User feedback was obtained from two sources: (1) a literature review with a systematic search; and (2) a survey of authors who used the CFIR in a published study. Data were combined across both sources and reviewed to identify themes; a consensus approach was used to finalize all CFIR updates. The VA Ann Arbor Healthcare System IRB declared this study exempt from the requirements of 38 CFR 16 based on category 2.

RESULTS

The systematic search yielded 376 articles that contained the CFIR in the title and/or abstract and 334 unique authors with contact information; 59 articles included feedback on the CFIR. Forty percent (n = 134/334) of authors completed the survey. The CFIR received positive ratings on most framework sensibility items (e.g., applicability, usability), but respondents also provided recommendations for changes. Overall, updates to the CFIR include revisions to existing domains and constructs as well as the addition, removal, or relocation of constructs. These changes address important critiques of the CFIR, including better centering innovation recipients and adding determinants to equity in implementation.

CONCLUSION

The updates in the CFIR reflect feedback from a growing community of CFIR users. Although there are many updates, constructs can be mapped back to the original CFIR to ensure longitudinal consistency. We encourage users to continue critiquing the CFIR, facilitating the evolution of the framework as implementation science advances.

Mental Health and Addiction Related Emergency Department Visits: A Systematic Review of Qualitative Studies

Mental health and addiction (MHA) related Emergency Department (ED) visits have increased significantly in recent years. Studies identified that a small subgroup of patients constitutes a disproportionally large number of visits. However, there is limited qualitative research exploring the phenomenon from the perspectives of patients who visited ED frequently for MHA reasons, and healthcare providers who provide care to the patients since the overwhelming majority of studies were quantitative based on clinical records. Without input from patients and healthcare providers, policymakers have inadequate information for designing and implementing programs. The purpose of this study was to systematically review the literature of qualitative research on frequent MHA related ED visits. The findings of the review revealed that a lack of community resources and existing community resources not meeting the needs of patients were critical contributing factors for frequent MHA related ED visits.

Acceptability of a technology-supported and solution-focused intervention (DIALOG+) for chronic depression: views of service users and clinicians

BACKGROUND

Treating chronic depression represents a significant burden for the NHS, yet there is a lack of evidence-based interventions and research specifically focused on this condition. DIALOG+, a technology-assisted and resource-oriented intervention found effective for people with psychosis, may improve care for this service user group. The aim of this study was to explore the acceptability and relevance of DIALOG+ for the treatment of chronic depression in community-based settings.

METHODS

A convenience sample of 16 mental health professionals and 29 service users with chronic depression tested the DIALOG+ intervention in routine community care appointments for 3 months across 3 different mental health NHS Trusts in England. Of these, 15 clinicians and 19 service users were individually interviewed about their experiences. Interview transcripts were analysed using thematic analysis by an analytic team which included a service user researcher.

RESULTS

Analysis of the combined dataset identified five overarching themes: DIALOG+ Structure; Therapeutic Communication; Reflecting and Monitoring; Empowerment and Powerlessness; and The Impact of Technology. Overall, service users and clinicians were interested in the continued use of DIALOG+ as part of routine care.

CONCLUSIONS

DIALOG+ was viewed as acceptable by both service users with chronic depression and their clinicians who work in community care settings, albeit with some caveats. Clinician training required significant improvements to address the issues that were referenced, most notably around support with using technology.

A Semiautomated Classification System for Producing Service Directories in Social and Health Care (DESDE-AND): Maturity Assessment Study

BACKGROUND

DESDE-LTC (Description and Evaluation of Services and DirectoriEs for Long-Term Care) is an international classification system that allows standardized coding and comparisons between different territories and care sectors, such as health and social care, in defined geographic areas. We adapted DESDE-LTC into a computer tool (DESDE-AND) for compiling a directory of care services in Andalucia, Spain.

OBJECTIVE

The aim of this study was to evaluate the maturity of DESDE-AND. A secondary objective of this study is to show the practicality of a new combined set of standard evaluation tools for measuring the maturity of health technology products.

METHODS

A system for semiautomated coding of service provision has been co-designed. A panel of 23 domain experts and a group of 68 end users participated in its maturity assessment that included its technology readiness level (TRL), usability, validity, adoption (Adoption Impact Ladder [AIL]), and overall degree of maturity [implementation maturity model [IMM]). We piloted the prototype in an urban environment (Seville, Spain).

RESULTS

The prototype was demonstrated in an operational environment (TRL 7). Sixty-eight different care services were coded, generating fact sheets for each service and its geolocation map. The observed agreement was 90%, with moderate reliability. The tool was partially adopted by the regional government of Andalucia (Spain), reaching a level 5 in adoption (AIL) and a level 4 in maturity (IMM) and is ready for full implementation.

CONCLUSIONS

DESDE-AND is a usable and manageable system for coding and compiling service directories and it can be used as a core module of decision support systems to guide planning in complex cross-sectoral areas such as combined social and health care.

The future of community psychiatry and community mental health services

PURPOSE OF REVIEW

The aim of this article is to provide a framework and analysis of a series of critical components to inform the future design, development, sustaining, and monitoring of community mental health services.

RECENT FINDINGS

Many mental health services remain too hospital-centric, often without adequate outreach services. On the basis of outcome evidence, we need to shift the balance of mental health services from hospital-centered with community outreach when convenient for staff, to community-centered and mobile, with in-reach to hospital only when necessary. Too few training programs those with emphasize the macroskills of public advocacy, working with service users, families, social movements, and the media to improve mental health and wellbeing of regional and local communities.

SUMMARY

We should adopt a health ecosystems approach to mental healthcare and training, encompassing nano to macrolevels of service in every region. Catchment mental health services should be rebuilt as community-centric mental health services, integrating all community and inpatient components, but led and integrated from community sites. Community psychiatrists and mental health professionals of the future will need to be well trained in the nano to macroskills required to take responsibility for the mental health and wellbeing of their catchment communities and to provide leadership in service-planning, management, and continuing revision on the basis of rigorous evaluation. These approaches should be the core of all training in psychiatry and all mental health professions prior to any subspecialization.