1
|
Ritchie MJ, Parker LE, Kirchner JE. Facilitating implementation of primary care mental health over time and across organizational contexts: a qualitative study of role and process. BMC Health Serv Res 2023; 23:565. [PMID: 37259064 DOI: 10.1186/s12913-023-09598-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 05/25/2023] [Indexed: 06/02/2023] Open
Abstract
BACKGROUND Healthcare organizations have increasingly utilized facilitation to improve implementation of evidence-based practices and programs (e.g., primary care mental health integration). Facilitation is both a role, related to the purpose of facilitation, and a process, i.e., how a facilitator operationalizes the role. Scholars continue to call for a better understanding of this implementation strategy. Although facilitation is described as dynamic, activities are often framed within the context of a staged process. We explored two understudied characteristics of implementation facilitation: 1) how facilitation activities change over time and in response to context, and 2) how facilitators operationalize their role when the purpose of facilitation is both task-focused (i.e., to support implementation) and holistic (i.e., to build capacity for future implementation efforts). METHODS We conducted individual monthly debriefings over thirty months with facilitators who were supporting PCMHI implementation in two VA networks. We developed a list of facilitation activities based on a literature review and debriefing notes and conducted a content analysis of debriefing notes by coding what activities occurred and their intensity by quarter. We also coded whether facilitators were "doing" these activities for sites or "enabling" sites to perform them. RESULTS Implementation facilitation activities did not occur according to a defined series of ordered steps but in response to specific organizational contexts through a non-linear and incremental process. Amount and types of activities varied between the networks. Concordant with facilitators' planned role, the focus of some facilitation activities was primarily on doing them for the sites and others on enabling sites to do for themselves; a number of activities did not fit into one category and varied across networks. CONCLUSIONS Findings indicate that facilitation is a dynamic and fluid process, with facilitation activities, as well as their timing and intensity, occurring in response to specific organizational contexts. Understanding this process can help those planning and applying implementation facilitation to make conscious choices about the facilitation role and the activities that facilitators can use to operationalize this role. Additionally, this work provides the foundation from which future studies can identify potential mechanisms of action through which facilitation activities enhance implementation uptake.
Collapse
Affiliation(s)
- Mona J Ritchie
- VA Behavioral Health Quality Enhancement Research Initiative (QUERI), Central Arkansas Veterans Healthcare System, 2200 Fort Roots Dr, North Little Rock, AR, 72114, USA.
- Department of Psychiatry and Behavioral Sciences, College of Medicine, University of Arkansas for Medical Sciences, 4301 W. Markham St, Little Rock, AR, 72205, USA.
| | - Louise E Parker
- VA Behavioral Health Quality Enhancement Research Initiative (QUERI), Central Arkansas Veterans Healthcare System, 2200 Fort Roots Dr, North Little Rock, AR, 72114, USA
- Department of Management, University of Massachusetts, 100 Morrissey Blvd, Boston, MA, 02125, USA
| | - JoAnn E Kirchner
- VA Behavioral Health Quality Enhancement Research Initiative (QUERI), Central Arkansas Veterans Healthcare System, 2200 Fort Roots Dr, North Little Rock, AR, 72114, USA
- Department of Psychiatry and Behavioral Sciences, College of Medicine, University of Arkansas for Medical Sciences, 4301 W. Markham St, Little Rock, AR, 72205, USA
| |
Collapse
|
2
|
Martens N, De Haeck E, Van De Vondel E, Destoop M, Catthoor K, Dom G, Van Den Broeck K. Physical Healthcare for People with a Severe Mental Illness in Belgium by Long-Term Community Mental Health Outreach Teams: A Qualitative Descriptive Study on Physicians', Community Mental Health Workers' and Patients' Perspectives. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:811. [PMID: 36613132 PMCID: PMC9819842 DOI: 10.3390/ijerph20010811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 12/23/2022] [Accepted: 12/28/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND People with a severe mental illness (pSMI) often have comorbid physical health problems, resulting in a lower life expectancy compared to the global population. In Belgium, it remains unclear how to approach health disparities in pSMI in a community setting. This study explores the perspectives of both care professionals and patients on physical healthcare in Belgian community mental services, aiming to identify good practices, barriers and points of improvement. METHODS An exploratory qualitative design that used a semi-structured focus group interview with physicians combined with individual face-to-face interviews with physicians, mental health professionals and patients. RESULTS We identified care professional-, patient-related and organizational factors, as well as points of improvement. The identified themes linked to care professionals were communication, task distribution, knowledge, time and stigmatization. The co-location of services was the main theme on an organizational level. CONCLUSIONS As community-based mental health services in Belgium emerged in the past decade, addressing physical health in pSMI is still challenging. Our findings suggest that there is a need for improvement in the current healthcare provision. Multidisciplinary guidelines, shared patient records, enlarging nurses' tasks, providing financial incentives and a structural integration of primary and psychiatric care were perceived as major points of improvement to the current Belgian healthcare organization.
Collapse
Affiliation(s)
- Nicolaas Martens
- Collaborative Antwerp Psychiatric Research Institute (CAPRI), University of Antwerp, B-2610 Antwerp, Belgium
- Multiversum Psychiatric Hospital, B-2530 Boechout, Belgium
- Department of Nursing, Karel de Grote University of Applied Sciences, B-2018 Antwerp, Belgium
| | - Eline De Haeck
- Multiversum Psychiatric Hospital, B-2530 Boechout, Belgium
- Family and Population Health (FAMPOP), University of Antwerp, B-2610 Antwerp, Belgium
| | | | - Marianne Destoop
- Collaborative Antwerp Psychiatric Research Institute (CAPRI), University of Antwerp, B-2610 Antwerp, Belgium
- Multiversum Psychiatric Hospital, B-2530 Boechout, Belgium
| | - Kirsten Catthoor
- Collaborative Antwerp Psychiatric Research Institute (CAPRI), University of Antwerp, B-2610 Antwerp, Belgium
- ZNA Stuivenberg Psychiatric Hospital, B-2060 Antwerp, Belgium
| | - Geert Dom
- Collaborative Antwerp Psychiatric Research Institute (CAPRI), University of Antwerp, B-2610 Antwerp, Belgium
- Multiversum Psychiatric Hospital, B-2530 Boechout, Belgium
| | - Kris Van Den Broeck
- Collaborative Antwerp Psychiatric Research Institute (CAPRI), University of Antwerp, B-2610 Antwerp, Belgium
- Family and Population Health (FAMPOP), University of Antwerp, B-2610 Antwerp, Belgium
| |
Collapse
|
3
|
Aragonès E, López-Cortacans G, Cardoner N, Tomé-Pires C, Porta-Casteràs D, Palao D. Barriers, facilitators, and proposals for improvement in the implementation of a collaborative care program for depression: a qualitative study of primary care physicians and nurses. BMC Health Serv Res 2022; 22:446. [PMID: 35382822 DOI: 10.1186/s12913-022-07872-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 03/28/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Primary care plays a central role in the treatment of depression. Nonetheless, shortcomings in its management and suboptimal outcomes have been identified. Collaborative care models improve processes for the management of depressive disorders and associated outcomes. We developed a strategy to implement the INDI collaborative care program for the management of depression in primary health care centers across Catalonia. The aim of this qualitative study was to evaluate a trial implementation of the program to identify barriers, facilitators, and proposals for improvement. METHODS One year after the implementation of the INDI program in 18 public primary health care centers we performed a qualitative study in which the opinions and experiences of 23 primary care doctors and nurses from the participating centers were explored in focus groups. We performed thematic content analysis of the focus group transcripts. RESULTS The results were organized into three categories: facilitators, barriers, and proposals for improvement as perceived by the health care professionals involved. The most important facilitator identified was the perception that the INDI collaborative care program could be a useful tool for reorganizing processes and improving the management of depression in primary care, currently viewed as deficient. The main barriers identified were of an organizational nature: heavy workloads, lack of time, high staff turnover and shortages, and competing demands. Additional obstacles were inertia and resistance to change among health care professionals. Proposals for improvement included institutional buy-in to guarantee enduring support and the organizational changes needed for successful implementation. CONCLUSIONS The INDI program is perceived as a useful, viable program for improving the management of depression in primary care. Uptake by primary care centers and health care professionals, however, was poor. The identification and analysis of barriers and facilitators will help refine the strategy to achieve successful, widespread implementation. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT03285659 ; Registered 18th September, 2017.
Collapse
Affiliation(s)
- Enric Aragonès
- Primary Care Area Camp de Tarragona, Catalan Health Institute, Carrer dels Horts, 6, 43120, Constantí, Tarragona, Spain. .,Primary Care Research Institute IDIAP Jordi Gol, Barcelona, Spain.
| | - Germán López-Cortacans
- Primary Care Area Camp de Tarragona, Catalan Health Institute, Carrer dels Horts, 6, 43120, Constantí, Tarragona, Spain.,Primary Care Research Institute IDIAP Jordi Gol, Barcelona, Spain
| | - Narcís Cardoner
- Mental Health Department, University Hospital Parc Taulí, Sabadell, Spain.,Department of Psychiatry and Legal Medicine, Autonomous University of Barcelona, Barcelona, Spain.,Biomedical Research Networking Center Consortium on Mental Health (CIBERSAM), Madrid, Spain
| | - Catarina Tomé-Pires
- Psychology Research Center CIP, Autonomous University of Lisbon, Lisbon, Portugal
| | - Daniel Porta-Casteràs
- Mental Health Department, University Hospital Parc Taulí, Sabadell, Spain.,Department of Psychiatry and Legal Medicine, Autonomous University of Barcelona, Barcelona, Spain
| | - Diego Palao
- Mental Health Department, University Hospital Parc Taulí, Sabadell, Spain.,Department of Psychiatry and Legal Medicine, Autonomous University of Barcelona, Barcelona, Spain.,Biomedical Research Networking Center Consortium on Mental Health (CIBERSAM), Madrid, Spain
| | | |
Collapse
|
4
|
Ritchie MJ, Kirchner JE, Townsend JC, Pitcock JA, Dollar KM, Liu CF. Time and Organizational Cost for Facilitating Implementation of Primary Care Mental Health Integration. J Gen Intern Med 2020; 35:1001-1010. [PMID: 31792866 PMCID: PMC7174254 DOI: 10.1007/s11606-019-05537-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 07/18/2019] [Accepted: 09/30/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND Integrating mental health services into primary care settings is complex and challenging. Although facilitation strategies have successfully supported implementation of primary care mental health integration and other complex innovations, we know little about the time required or its cost. OBJECTIVE To examine the time and organizational cost of facilitating implementation of primary care mental health integration. DESIGN Descriptive analysis. PARTICIPANTS One expert external facilitator and two internal regional facilitators who helped healthcare system stakeholders, e.g., leaders, managers, clinicians, and non-clinical staff, implement primary care mental health integration at eight clinics. INTERVENTION Implementation facilitation tailored to the needs and resources of the setting and its stakeholders. MAIN MEASURES We documented facilitators' and stakeholders' time and types of activities using a structured spreadsheet collected from facilitators on a weekly basis. We obtained travel costs and salary information. We conducted descriptive analysis of time data and estimated organizational cost. KEY RESULTS The external facilitator devoted 263 h (0.09 FTE), including travel, across all 8 clinics over 28 months. Internal facilitator time varied across networks (1792 h versus 1169 h), as well as clinics. Stakeholder participation time was similar across networks (1280.6 versus 1363.4 person hours) but the number of stakeholders varied (133 versus 199 stakeholders). The organizational cost of providing implementation facilitation also varied across networks ($263,490 versus $258,127). Stakeholder participation accounted for 35% of the cost of facilitation activities in one network and 47% of the cost in the other. CONCLUSIONS Although facilitation can improve implementation of primary care mental health integration, it requires substantial organizational investments that may vary by site and implementation effort. Furthermore, the cost of using an external expert to transfer facilitation skills and build capacity for implementation efforts appears to be minimal.
Collapse
Affiliation(s)
- Mona J Ritchie
- VA Quality Enhancement Research Initiative (QUERI) Program for Team-Based Behavioral Health, U.S. Department of Veterans Affairs, North Little Rock, AR, USA.
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
| | - JoAnn E Kirchner
- VA Quality Enhancement Research Initiative (QUERI) Program for Team-Based Behavioral Health, U.S. Department of Veterans Affairs, North Little Rock, AR, USA
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - James C Townsend
- VA Quality Enhancement Research Initiative (QUERI) Program for Team-Based Behavioral Health, U.S. Department of Veterans Affairs, North Little Rock, AR, USA
- Central Arkansas Veterans Healthcare System, North Little Rock, AR, USA
| | - Jeffery A Pitcock
- VA Quality Enhancement Research Initiative (QUERI) Program for Team-Based Behavioral Health, U.S. Department of Veterans Affairs, North Little Rock, AR, USA
| | | | - Chuan-Fen Liu
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA
- Department of Health Services, University of Washington, Seattle, WA, USA
| |
Collapse
|
5
|
Gauthier G, Mucha L, Shi S, Guerin A. Economic burden of relapse/recurrence in patients with major depressive disorder. J Drug Assess 2019; 8:97-103. [PMID: 31192030 PMCID: PMC6542183 DOI: 10.1080/21556660.2019.1612410] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 04/19/2019] [Indexed: 11/20/2022] Open
Abstract
Objective: This study was conducted to determine the incremental healthcare resource utilization (HRU) and costs associated with relapse or recurrence (R/R) in patients with major depressive disorder (MDD) treated with antidepressants (AD) in US clinical practice. Methods: In this retrospective cohort study, adult patients with MDD treated with a branded AD were selected from the Truven Health Analytics MarketScan Databases (January 1, 2004–March 31, 2015). Time to first indicator of R/R was described. Characteristics, HRU, and costs were compared between patients with and without R/R. Among patients with R/R, HRU and costs were also compared between the pre- and post-R/R period. Results: From the 22,236 selected patients, 5,541 had ≥ 1 indicator of R/R and 16,695 did not. The 3-year R/R rate varied between 21.3% and 36.4% based on pattern of AD use (continuous, switch/augmentation, or early discontinuation). Patients with and without R/R presented different characteristics—notably, more intensive prior AD use and a higher comorbidity burden. HRU and costs were high in both patients with and without R/R but substantially higher among those with R/R ($20,590 vs $12,368 per-patient-per-year (PPPY); adjusted difference [aDiff] = $7,037), mainly driven by increased inpatient (IP) services (adjusted incidence rate ratio IP days = 3.95; aDiff IP costs = $3,433 PPPY). Among patients with R/R, emergency department visits, IP days, and IP admissions were over 2-times higher during the post-R/R period and total costs increased by over 50% from $19,267 to $29,419 in the post-R/R period. Conclusions: The economic burden in MDD patients is substantial, but is significantly higher among those who experience R/R.
Collapse
Affiliation(s)
| | - Lisa Mucha
- Takeda Development Center Americas, Inc, Deerfield, IL, USA
| | | | | |
Collapse
|