1
|
Woodward EN, Cornwell BL, Wray LO, Pomerantz AS, Kirchner JE, McCarthy JF, Kearney LK. Impact of Primary Care-Mental Health Care Integration on Mental Health Care Engagement Across Racial and Ethnic Groups. Psychiatr Serv 2024; 75:369-377. [PMID: 38321918 DOI: 10.1176/appi.ps.20220631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
OBJECTIVE Receiving mental health services as part of primary care in the Veterans Health Administration (VHA) might increase engagement in specialty mental health care. The authors reexamined the association between primary care-mental health integration (PCMHI) and continued engagement in specialty mental health care for VHA patients and assessed differences by race and ethnicity. METHODS The study included 437,051 primary care patients with a first in-person specialty mental health encounter in 2015-2016 (no specialty mental health encounters in prior 12 months), including 46,417 patients with new PCMHI encounters in the year before the first specialty mental health encounter. Multivariable logistic regression assessed odds of follow-up specialty mental health care within 3 months of the first specialty mental health encounter. The dependent variable was care engagement (attending a second specialty mental health appointment); independent variables were whether patients were seen by PCMHI on the same day as the primary care appointment ("same-day access"), the time between PCMHI and first specialty mental health appointments, and race and ethnicity. RESULTS PCMHI was associated with increased engagement in specialty mental health care for all patients, with a greater likelihood of engagement among non-Hispanic White patients. Same-day access to PCMHI was positively associated with care engagement, with no significant differences by race or ethnicity. PCMHI care within 3 months before a first specialty mental health encounter was associated with greater care engagement. CONCLUSIONS PCMHI, especially same-day access to PCMHI care, may boost engagement in mental health care, although the study design precluded conclusions regarding causal relationships.
Collapse
Affiliation(s)
- Eva N Woodward
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, U.S. Department of Veterans Affairs (VA), and Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock (Woodward); Serious Mental Illness Treatment Resource and Evaluation Center, Office of Mental Health and Suicide Prevention, Veterans Health Administration, Ann Arbor (Cornwell); VA Center for Integrated Healthcare and Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo (Wray); Office of Mental Health and Suicide Prevention, Veterans Health Administration, Washington, D.C., and Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire (Pomerantz); VA Behavioral Health Quality Enhancement Research Initiative, Central Arkansas Veterans Healthcare System, North Little Rock, and Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock (Kirchner); Center for Clinical Management Research, VA, and Department of Psychiatry, University of Michigan, Ann Arbor (McCarthy); Office of Mental Health and Suicide Prevention, VA, Washington, D.C., and University of Texas Health Science Center at San Antonio, San Antonio, Texas (Kearney)
| | - Brittany L Cornwell
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, U.S. Department of Veterans Affairs (VA), and Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock (Woodward); Serious Mental Illness Treatment Resource and Evaluation Center, Office of Mental Health and Suicide Prevention, Veterans Health Administration, Ann Arbor (Cornwell); VA Center for Integrated Healthcare and Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo (Wray); Office of Mental Health and Suicide Prevention, Veterans Health Administration, Washington, D.C., and Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire (Pomerantz); VA Behavioral Health Quality Enhancement Research Initiative, Central Arkansas Veterans Healthcare System, North Little Rock, and Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock (Kirchner); Center for Clinical Management Research, VA, and Department of Psychiatry, University of Michigan, Ann Arbor (McCarthy); Office of Mental Health and Suicide Prevention, VA, Washington, D.C., and University of Texas Health Science Center at San Antonio, San Antonio, Texas (Kearney)
| | - Laura O Wray
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, U.S. Department of Veterans Affairs (VA), and Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock (Woodward); Serious Mental Illness Treatment Resource and Evaluation Center, Office of Mental Health and Suicide Prevention, Veterans Health Administration, Ann Arbor (Cornwell); VA Center for Integrated Healthcare and Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo (Wray); Office of Mental Health and Suicide Prevention, Veterans Health Administration, Washington, D.C., and Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire (Pomerantz); VA Behavioral Health Quality Enhancement Research Initiative, Central Arkansas Veterans Healthcare System, North Little Rock, and Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock (Kirchner); Center for Clinical Management Research, VA, and Department of Psychiatry, University of Michigan, Ann Arbor (McCarthy); Office of Mental Health and Suicide Prevention, VA, Washington, D.C., and University of Texas Health Science Center at San Antonio, San Antonio, Texas (Kearney)
| | - Andrew S Pomerantz
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, U.S. Department of Veterans Affairs (VA), and Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock (Woodward); Serious Mental Illness Treatment Resource and Evaluation Center, Office of Mental Health and Suicide Prevention, Veterans Health Administration, Ann Arbor (Cornwell); VA Center for Integrated Healthcare and Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo (Wray); Office of Mental Health and Suicide Prevention, Veterans Health Administration, Washington, D.C., and Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire (Pomerantz); VA Behavioral Health Quality Enhancement Research Initiative, Central Arkansas Veterans Healthcare System, North Little Rock, and Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock (Kirchner); Center for Clinical Management Research, VA, and Department of Psychiatry, University of Michigan, Ann Arbor (McCarthy); Office of Mental Health and Suicide Prevention, VA, Washington, D.C., and University of Texas Health Science Center at San Antonio, San Antonio, Texas (Kearney)
| | - JoAnn E Kirchner
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, U.S. Department of Veterans Affairs (VA), and Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock (Woodward); Serious Mental Illness Treatment Resource and Evaluation Center, Office of Mental Health and Suicide Prevention, Veterans Health Administration, Ann Arbor (Cornwell); VA Center for Integrated Healthcare and Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo (Wray); Office of Mental Health and Suicide Prevention, Veterans Health Administration, Washington, D.C., and Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire (Pomerantz); VA Behavioral Health Quality Enhancement Research Initiative, Central Arkansas Veterans Healthcare System, North Little Rock, and Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock (Kirchner); Center for Clinical Management Research, VA, and Department of Psychiatry, University of Michigan, Ann Arbor (McCarthy); Office of Mental Health and Suicide Prevention, VA, Washington, D.C., and University of Texas Health Science Center at San Antonio, San Antonio, Texas (Kearney)
| | - John F McCarthy
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, U.S. Department of Veterans Affairs (VA), and Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock (Woodward); Serious Mental Illness Treatment Resource and Evaluation Center, Office of Mental Health and Suicide Prevention, Veterans Health Administration, Ann Arbor (Cornwell); VA Center for Integrated Healthcare and Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo (Wray); Office of Mental Health and Suicide Prevention, Veterans Health Administration, Washington, D.C., and Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire (Pomerantz); VA Behavioral Health Quality Enhancement Research Initiative, Central Arkansas Veterans Healthcare System, North Little Rock, and Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock (Kirchner); Center for Clinical Management Research, VA, and Department of Psychiatry, University of Michigan, Ann Arbor (McCarthy); Office of Mental Health and Suicide Prevention, VA, Washington, D.C., and University of Texas Health Science Center at San Antonio, San Antonio, Texas (Kearney)
| | - Lisa K Kearney
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, U.S. Department of Veterans Affairs (VA), and Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock (Woodward); Serious Mental Illness Treatment Resource and Evaluation Center, Office of Mental Health and Suicide Prevention, Veterans Health Administration, Ann Arbor (Cornwell); VA Center for Integrated Healthcare and Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo (Wray); Office of Mental Health and Suicide Prevention, Veterans Health Administration, Washington, D.C., and Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire (Pomerantz); VA Behavioral Health Quality Enhancement Research Initiative, Central Arkansas Veterans Healthcare System, North Little Rock, and Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock (Kirchner); Center for Clinical Management Research, VA, and Department of Psychiatry, University of Michigan, Ann Arbor (McCarthy); Office of Mental Health and Suicide Prevention, VA, Washington, D.C., and University of Texas Health Science Center at San Antonio, San Antonio, Texas (Kearney)
| |
Collapse
|
2
|
Woodward EN, Castillo AIM, True G, Willging C, Kirchner JE. Challenges and promising solutions to engaging patients in healthcare implementation in the United States: an environmental scan. BMC Health Serv Res 2024; 24:29. [PMID: 38178131 PMCID: PMC10768202 DOI: 10.1186/s12913-023-10315-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 11/13/2023] [Indexed: 01/06/2024] Open
Abstract
BACKGROUND One practice in healthcare implementation is patient engagement in quality improvement and systems redesign. Implementers in healthcare systems include clinical leadership, middle managers, quality improvement personnel, and others facilitating changes or adoption of new interventions. Patients provide input into different aspects of health research. However, there is little attention to involve patients in implementing interventions, especially in the United States (U.S.), and this might be essential to reduce inequities. Implementers need clear strategies to overcome challenges, and might be able to learn from countries outside the U.S. METHODS We wanted to understand existing work about how patients are being included in implementation activities in real world U.S. healthcare settings. We conducted an environmental scan of three data sources: webinars, published articles, and interviews with implementers who engaged patients in implementation activities in U.S. healthcare settings. We extracted, categorized, and triangulated from data sources the key activities, recurring challenges, and promising solutions using a coding template. RESULTS We found 27 examples of patient engagement in U.S. healthcare implementation across four webinars, 11 published articles, and seven interviews, mostly arranging patient engagement through groups and arranging processes for patients that changed how engaged they were able to be. Participants rarely specified if they were engaging a population experiencing healthcare inequities. Participants described eight recurring challenges; the two most frequently identified were: (1) recruiting patients representative of those served in the healthcare system; and (2) ensuring processes for equitable communication among all. We matched recurring challenges to promising solutions, such as logistic solutions on how to arrange meetings to enhance engagement or training in inclusivity and power-sharing. CONCLUSION We clarified how some U.S. implementers are engaging patients in healthcare implementation activities using less and more intensive engagement. It was unclear whether reducing inequities was a goal. Patient engagement in redesigning U.S. healthcare service delivery appears similar to or less intense than in countries with more robust infrastructure for this, such as Canada and the United Kingdom. Challenges were common across jurisdictions, including retaining patients in the design/delivery of implementation activities. Implementers in any region can learn from those in other places.
Collapse
Affiliation(s)
- Eva N Woodward
- VA Center for Mental Healthcare and Outcomes Research, 2200 Fort Roots Drive, Building 11, North Little Rock, AR, 72114, USA.
- Department of Psychiatry, University of Arkansas for Medical Sciences, 4301 W Markham St, Little Rock, AR, 72205, USA.
| | - Andrea Isabel Melgar Castillo
- VA Center for Mental Healthcare and Outcomes Research, 2200 Fort Roots Drive, Building 11, North Little Rock, AR, 72114, USA
- Graduate School, University of Arkansas for Medical Sciences, 4301 W Markham St, Little Rock, AR, 72205, USA
| | - Gala True
- South Central Mental Illness Research Education and Clinical Center, Southeast Louisiana Veterans Health Care System, 2400 Canal St, New Orleans, LA, 70119, USA
- Section on Community and Population Medicine, School of Medicine, Louisiana State University, 2400 Canal St (11F), New Orleans, LA, USA
| | - Cathleen Willging
- Pacific Institute for Research and Evaluation, 851 University Boulevard, Suite 101, Albuquerque, NM, 87106, USA
| | - JoAnn E Kirchner
- Department of Psychiatry, University of Arkansas for Medical Sciences, 4301 W Markham St, Little Rock, AR, 72205, USA
- Behavioral Health Quality Enhancement Research Initiative (QUERI), Central Arkansas Veterans Healthcare System, 2200 Fort Roots Drive, Building 11, North Little Rock, AR, 72114, USA
| |
Collapse
|
3
|
Woodward EN, Lunsford A, Brown R, Downing D, Ball I, Gan-Kemp JM, Smith A, Atkinson O, Graham T. Pre-implementation adaptation of suicide safety planning intervention using peer support in rural areas. Front Health Serv 2023; 3:1225171. [PMID: 38188615 PMCID: PMC10766826 DOI: 10.3389/frhs.2023.1225171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 12/08/2023] [Indexed: 01/09/2024]
Abstract
Introduction Currently, seventeen veterans die by suicide daily in the United States (U.S.). There are disparities in suicide behavior and access to preventative treatment. One disparity is the suicide rate in rural areas, including the state of Arkansas-suicide deaths among rural veterans increased 48% in the last 2 decades, double that of urban veterans. One major challenge for veterans in rural areas is the lack of healthcare providers to provide Safety Planning Intervention, which is an effective intervention to reduce suicide attempts in the general adult population and among veterans. One solution is more broadly implementing Safety Planning Intervention, by using peers to deliver the intervention in rural communities. Before implementation, the intervention needs to be adapted for peer-to-peer delivery, and barriers and facilitators identified. Methods Since January 2021, using community-based participatory research, we collaboratively developed and executed a 1 year study to adapt Safety Planning Intervention for peer-to-peer delivery in rural communities and identified implementation barriers and facilitators prior to spread. From July 2022 to February 2023, we conducted group interviews with 12 participants: rural veterans with prior suicidal thoughts or attempts in one U.S. state, their support persons, and healthcare professionals with expertise in veteran suicide prevention, Safety Planning Intervention, and/or peer delivery. We collected qualitative data through interviews during nine, 2 h meetings, and quantitative data from one anonymous survey and real-time anonymous voting-all on the topic of core and adaptable components of Safety Planning Intervention and implementation barriers and facilitators for peer delivery in rural communities. Questions about adaptation were designed according to processes in the ENGAGED for CHANGE community-engaged intervention framework and questions about facilitators and barriers were designed according to the Health Equity Implementation Framework. Participants categorized which Safety Planning Intervention components were core or adaptable, and how freely they could be adapted, using the metaphor of a traffic light in red (do not change), yellow (change with caution), and green (change freely) categories. Results Participants made few actual adaptations (categorized according to the FRAME modification system), but strongly recommended robust training for peers. Participants identified 27 implementation facilitators and 47 barriers, organized using the Health Equity Implementation Framework. Two example facilitators were (1) peer-to-peer safety planning intervention was highly acceptable to rural veterans; and (2) some state counties already had veteran crisis programs that could embed this intervention for spread. Two example barriers were (1) some community organizations that might spread the intervention have been motivated initially, wanting to help right away, yet not able to sustain interventions; and (2) uncertainty about how to reach veterans at moderate suicide risk, as many crisis programs identified them when suicide risk was higher. Discussion Our results provide one of the more comprehensive pre-implementation assessments to date for Safety Planning Intervention in any setting, especially for peer delivery (also referred to as task shifting) outside healthcare or clinical settings. One important next step will be mapping these barriers and facilitators to implementation strategies for peer-to-peer delivery. One finding surprised our research team-despite worse societal context in rural communities leading to disproportionate suicide deaths-participants identified several positive facilitators specifically about rural communities that can be leveraged during implementation.
Collapse
Affiliation(s)
- Eva N. Woodward
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, United States
- VA Center for Mental Healthcare & Outcomes Research, Central Arkansas Veterans Healthcare System, Little Rock, AR, United States
| | - Amanda Lunsford
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Rae Brown
- Arkansas Freedom Fund, Little Rock, AR, United States
| | | | - Irenia Ball
- VA Center for Mental Healthcare & Outcomes Research, Central Arkansas Veterans Healthcare System, Little Rock, AR, United States
| | - Jennifer M. Gan-Kemp
- Department of Medical Humanities and Bioethics, Center for Health Literacy, University of Arkansas for Medical Sciences, Little Rock, AR, United States
- College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Anthony Smith
- Arkansas Freedom Fund, Little Rock, AR, United States
| | | | - Thomas Graham
- College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| |
Collapse
|
4
|
Woodward EN, Ball IA, Willging C, Singh RS, Scanlon C, Cluck D, Drummond KL, Landes SJ, Hausmann LRM, Kirchner JE. Increasing consumer engagement: tools to engage service users in quality improvement or implementation efforts. Front Health Serv 2023; 3:1124290. [PMID: 37560195 PMCID: PMC10407803 DOI: 10.3389/frhs.2023.1124290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 07/05/2023] [Indexed: 08/11/2023]
Abstract
Introduction Engaging service users or consumers in quality improvement or implementing a new service is important across settings and may reduce health inequities. Implementation strategies leveraging consumer engagement are neither commonly used nor robustly operationalized in implementation science. Implementers (e.g., middle managers, facilitators) want to involve consumers in implementation activities, but do not always feel confident in how to proceed. We developed a compendium of tools called Consumer Voice to guide others how to engage consumers in design/delivery of implementation strategies. Although generalizable to other settings, we developed Consumer Voice within the context of implementing suicide prevention treatments in healthcare to reach rural U.S. military veterans, as there are suicide inequities for people in rural areas. Methods We developed Consumer Voice using a multistep process and human-centered design methods. In between steps, a design team met to generate insights from data, and decide which prototypes to create/refine. In preliminary work, we conducted a scan of examples in healthcare of patient engagement in implementation activities and interviewed two implementation experts about preferred learning styles. In Step 1, we interviewed 26 participants with experience in community engagement, implementation, or lived experience as a rural U.S. veteran with suicidal thoughts/behavior. In Step 2, 11 implementers beta tested prototypes then share feedback in focus groups. In Step 3, we reconvened participants from prior steps to review tools and, using nominal group technique, prioritized remaining recommendations. Results Consumer Voice is online, modular, and nonlinear for self-guided learning tailored to beginner, intermediate, or advanced experience with consumer engagement. Tools consist of slides, audiovisual content with written text, and templates. Findings indicated there is not one "right" way to engage consumers in implementation activities, rather that implementers wanted tools showcasing core principles for consumer engagement and practical ideas. Discussion Consumer Voice can be used by implementers to reflect and decide on how to apply consumer engagement implementation strategies to improve equitable dissemination and uptake of evidence-based practices. Most insights generated by user data were explicitly to build trust between consumers and professionals representing institutions, which may be one component to reducing healthcare inequities.
Collapse
Affiliation(s)
- Eva N. Woodward
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, United States
- VA Center for Mental Healthcare & Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, AR, United States
| | - Irenia A. Ball
- VA Center for Mental Healthcare & Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, AR, United States
| | - Cathleen Willging
- Pacific Institute for Research and Evaluation, Southwest Center, Albuquerque, NM, United States
| | - Rajinder Sonia Singh
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, United States
- VA Center for Mental Healthcare & Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, AR, United States
| | - Celia Scanlon
- VA Center for Mental Healthcare & Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, AR, United States
| | - Damon Cluck
- Arkansas National Guard Foundation, North Little Rock, AR, United States
| | - Karen L. Drummond
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, United States
- VA Center for Mental Healthcare & Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, AR, United States
| | - Sara J. Landes
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, United States
- Behavioral Health Quality Enhancement Research Initiative (QUERI), Central Arkansas Veterans Healthcare System, North Little Rock, AR, United States
- South Central Mental Illness Research Education and Clinical Center (MIRECC), Central Arkansas Veterans Healthcare System, North Little Rock, AR, United States
| | - Leslie R. M. Hausmann
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA, United States
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - JoAnn E. Kirchner
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, United States
- Behavioral Health Quality Enhancement Research Initiative (QUERI), Central Arkansas Veterans Healthcare System, North Little Rock, AR, United States
| |
Collapse
|
5
|
Woodward EN, Ball IA. Perspectives on learning to practice reflexivity while engaging communities in implementation science. Front Health Serv 2023; 2:1070444. [PMID: 36925788 PMCID: PMC10012695 DOI: 10.3389/frhs.2022.1070444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 12/07/2022] [Indexed: 01/18/2023]
Abstract
Background As implementation scientists and practitioners engage community members and service users, reflexivity rises as a critical approach for managing power imbalances and effective collaborative work to promote equity. Reflexivity is an approach for acknowledging scientists' own positions, including their understanding and limits of how they view their phenomena of inquiry. We describe our perspective practicing reflexivity as an implementation science team new to community engagement. Methods We spent over two years learning principles of Community-Based Participatory Research (CBPR) to inform implementation science and practice, then applied CPBR principles into a new community-academic partnership in August 2020 for and with veterans of the United States Military living in rural Arkansas. We used five methods to practice reflexivity for the first time: identifying positionality, writing fieldnotes, obtaining mentorship on technical aspects, comparing head notes, and consulting reference materials. Discussion We found multiple methods for practicing reflexivity to be feasible, although difficult to stay consistent with busy schedules. Fieldnotes especially required commitment and were important not to minimize. Written fieldnotes enabled us to reflect on successes and missteps, funneling into action planning. Head notes allowed emotional catharsis and to generate insights based on each other's perspectives. Referencing books or course modules reminded us of ideal CBPR principles. Discussion with mentors helped us with technical aspects and balancing real-world challenges with ideal CBPR principles. Our methods to practice reflexivity were valuable and directly impacted process and research outcomes. Future training for implementation science and practice might consider reflexivity practice as a core competency.
Collapse
Affiliation(s)
- Eva N. Woodward
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Irenia A. Ball
- VA Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, AR, United States
| |
Collapse
|
6
|
Hayes CJ, Gannon MA, Woodward EN, Long CR, George M, Ray-Griffith S, Tobey LR, Goree J. Implementation and Preliminary Effectiveness of a Multidisciplinary Telemedicine Pilot Initiative for Patients with Chronic Non-Cancer Pain in Rural and Underserved Areas at a Major Academic Medical Center. J Pain Res 2023; 16:55-69. [PMID: 36636266 PMCID: PMC9831086 DOI: 10.2147/jpr.s383212] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 11/24/2022] [Indexed: 01/06/2023] Open
Abstract
Background Arkansas lacks adequate access to high-quality pain care, as evidenced, in part, by it having the second highest opioid prescribing rate in the United States. To improve access to high-quality treatment of chronic pain, we developed the Arkansas Improving Multidisciplinary Pain Care and Treatment (AR-IMPACT) Telemedicine Clinic, a multidisciplinary and interprofessional team of specialists who provide evidence-based pain management for patients with chronic pain. Methods We conducted a single-arm pilot trial of the AR-IMPACT Telemedicine Clinic with rural, university-affiliated primary care clinics. We assessed the AR-IMPACT Telemedicine Clinic using an implementation framework and preliminary effectiveness measures. Specifically, we assessed 5 of the 8 implementation outcomes of the framework (ie, penetration, adoption, acceptability, appropriateness, and feasibility) using a mixed methods approach. To evaluate implementation outcomes, we used surveys, interviews, and administrative data. We used electronic health record data to measure preliminary effectiveness (ie, changes in average morphine milligram equivalents per day and pain and depression scores). Results The AR-IMPACT team saw 23 patients that were referred by 13 primary care physicians from three rural, university-affiliated primary care clinics over one year. Of the 19 patients willing to participate in the pilot study, 12 identified as women, 31.6% identified as Black, and over 50% had less than a bachelor's level education. Patients rated the clinic positively with high overall satisfaction. Referring physicians indicated high levels of appropriateness, acceptability, and feasibility of the program. AR-IMPACT team members identified several barriers and facilitators to the feasibility of implementing the program. No changes in preliminary effectiveness measures were statistically significant. Conclusion Overall, the AR-IMPACT Telemedicine Clinic obtained moderate penetration and adoption, was highly acceptable to patients, was highly acceptable and appropriate to providers, and was moderately feasible to providers and AR-IMPACT team members.
Collapse
Affiliation(s)
- Corey J Hayes
- Department of Biomedical Informatics, University of Arkansas for Medical Sciences, Little Rock, AR, 72205, USA,Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, AR, 72114, USA,Correspondence: Corey J Hayes, Department of Biomedical Informatics, University of Arkansas for Medical Sciences, 4301 West Markham, Slot 782, Little Rock, AR, 72205, USA, Tel +501 526-8113, Email
| | - Matthew A Gannon
- Office of Community Health and Research, College of Medicine, University of Arkansas for Medical Sciences, Fayetteville, AR, 72701, USA
| | - Eva N Woodward
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, AR, 72114, USA,Center for Health Services Research, Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, 72205, USA
| | - Christopher R Long
- Office of Community Health and Research, College of Medicine, University of Arkansas for Medical Sciences, Fayetteville, AR, 72701, USA
| | - Masil George
- Department of Geriatrics, University of Arkansas for Medical Sciences, Little Rock, AR, 72205, USA
| | - Shona Ray-Griffith
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, 72205, USA,Department of Obstetrics and Gynecology, University of Arkansas for Medical Sciences, Little Rock, AR, 72205, USA
| | - Leah R Tobey
- Center for Health Services Research, Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, 72205, USA
| | - Johnathan Goree
- Department of Anesthesiology, University of Arkansas for Medical Sciences, Little Rock, AR, 72205, USA
| |
Collapse
|
7
|
Nagy GA, Cassiello-Robbins C, Anand D, Arnold ML, Coleman JN, Nwosu J, Singh RS, Woodward EN. Building a multicultural peer-consultation team: Planning, implementing, and early sustainment evaluation. Transcult Psychiatry 2022; 59:844-862. [PMID: 35866216 DOI: 10.1177/13634615221105117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
This article represents an implementation-focused evaluation of a multicultural peer-consultation team situated within a psychiatry department in a large academic medical center in the Southern United States. The evaluation comprised anonymous self-report questionnaires (n = 14) as well as individual (n = 3) or group interviews (n = 10) conducted by outside independent evaluators. Participants were current and former team members (i.e., graduate trainees, mental health care providers, clinical and research staff members) who voluntarily participated in this multimethod implementation evaluation. Results indicated that attendance on the team had several important impacts on members, and most notably an increased ability to provide multiculturally competent care, that is treatment that carefully and routinely considers the influence of culture and context on patients and therefore their clinical presentation. Further, no negative impacts from participating on the team were noted. A primary strength of the team's sustainability is that participation on the team was deemed to be relevant and useful by current and former team members. A major barrier to participation on the team is competing demands, such as high clinical loads. We conclude that this model for multicultural peer-consultation holds promise as an effective and implementable educational method for mental health care professionals. We discuss strengths, limitations, and future directions for research.
Collapse
Affiliation(s)
- Gabriela A Nagy
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine & School of Nursing, Durham, NC, USA
| | - Clair Cassiello-Robbins
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Deepika Anand
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Macey L Arnold
- Department of Psychology, University of North Texas, Denton, TX, USA
| | - Jessica N Coleman
- Duke University Department of Psychology and Neuroscience, Durham, NC, USA
| | - Joshua Nwosu
- Psychology Service, Washington DC Veterans Affairs Health Center, Washington, DC, USA
| | - R Sonia Singh
- VA Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, Little Rock, AR, USA.,Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Eva N Woodward
- VA Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, Little Rock, AR, USA.,Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| |
Collapse
|
8
|
Baumann AA, Woodward EN, Singh RS, Adsul P, Shelton RC. Assessing researchers' capabilities, opportunities, and motivation to conduct equity-oriented dissemination and implementation research, an exploratory cross-sectional study. BMC Health Serv Res 2022; 22:731. [PMID: 35650573 PMCID: PMC9161573 DOI: 10.1186/s12913-022-07882-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 03/30/2022] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND A recent paradigm shift has led to an explicit focus on enhancing health equity through equity-oriented dissemination and implementation (D&I) research. However, the integration and bidirectional learning across these two fields is still in its infancy and siloed. This exploratory study aimed to examine participants' perceived capabilities, opportunities, and motivations to conduct equity-oriented D&I research. METHODS We conducted an exploratory cross-sectional survey distributed online from December 2020 to April 2021. Participants were recruited at either D&I or health disparities-oriented conferences, meetings, through social media, or personal outreach via emails. Informed by the Capability, Opportunity, and Motivation Model (COM-B), the survey queried respondents about different aspects of engaging in and conducting equity-oriented D&I research. All analyses were conducted in SPSS Version 27.0. RESULTS A total of 180 participants responded to the survey. Most participants were women (81.7%), white (66.1%), academics (78.9%), and faculty members (53.9%). Many reported they were advanced (36.7%) or advanced beginners (27.8%) in the D&I field, and a substantial proportion (37.8%) reported being novice in D&I research that focused on health equity. Participants reported high motivation (e.g., 62.8% were motivated to apply theories, models, frameworks for promoting health equity in D&I research), but low capability to conduct equity-oriented D&I research (e.g., 5% had the information needed for promoting health equity in D&I research). Most participants (62.2%) reported not having used measures to examine equity in their D&I projects, and for those who did use measures, they mainly used individual-level measures (vs. organizational- or structural-level measures). When asked about factors that could influence their ability to conduct equity-oriented D&I research, 44.4% reported not having the skills necessary, and 32.2% stated difficulties in receiving funding for equity-oriented D&I research. CONCLUSIONS Study findings provide empirical insight into the perspectives of researchers from different backgrounds on what is needed to conduct equity-oriented D&I research. These data suggest the need for a multi-pronged approach to enhance the capability and opportunities for conducting equity-oriented D&I work, such as: training specifically in equity-oriented D&I, collaboration between D&I researchers with individuals with expertise and lived experience with health equity research, funding for equity-oriented D&I research, and recognition of the value of community engaged research in promotion packages.
Collapse
Affiliation(s)
- Ana A. Baumann
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO USA
| | - Eva N. Woodward
- Center for Mental Healthcare and Outcomes Research, U.S. Department of Veterans Affairs, North Little Rock, AR USA
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR USA
| | - Rajinder Sonia Singh
- South Central Mental Illness Research, Education and Clinical Center, U.S. Department of Veterans Affairs, North Little Rock, North Little Rock, AR USA
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR USA
| | - Prajakta Adsul
- Department of Internal Medicine, School of Medicine, University of New Mexico, Albuquerque, NM USA
| | - Rachel C. Shelton
- Department of Sociomedical Sciences, Columbia University, Mailman School of Public Health, New York, NY USA
| |
Collapse
|
9
|
Woodward EN, Willging C, Landes SJ, Hausmann LRM, Drummond KL, Ounpraseuth S, Ball IA, Kirchner JE. Determining feasibility of incorporating consumer engagement into implementation activities: study protocol of a hybrid effectiveness-implementation type II pilot. BMJ Open 2022; 12:e050107. [PMID: 35042705 PMCID: PMC8768923 DOI: 10.1136/bmjopen-2021-050107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION Implementation researchers could draw from participatory research to engage patients (consumers of healthcare) in implementation processes and possibly reduce healthcare disparities. There is a little consumer involvement in healthcare implementation, partially because no formal guidance exists. We will create and pilot a toolkit of methods to engage consumers from the US' Veterans Health Administration (VHA) in selecting and tailoring implementation strategies. This toolkit, Consumer Voice, will provide guidance on what, when, where, how and why an implementer might engage consumers in implementing treatments. We will pilot the toolkit by implementing Safety Planning Intervention for suicide prevention with rural veterans, a population with suicide disparities. Safety Planning Intervention is effective for reducing suicidal behaviours. METHODS AND ANALYSIS In Aim 1, we will use participatory approaches and user-centred design to develop Consumer Voice and its methods. In Aim 2, we will pilot Consumer Voice by implementing the Safety Planning Intervention in two clinics serving rural VHA patients. One site will receive a current implementation strategy (Implementation Facilitation) only; the second will receive Implementation Facilitation plus Consumer Voice. We will use mixed methods to assess feasibility and acceptability of Consumer Voice. We will compare sites on preliminary implementation (reach, adoption, fidelity) and clinical outcomes (depression severity, suicidal ideation, suicidal behaviour). In Aim 3, we will evaluate Aim 2 outcomes at 20 months to assess sustained impact. We will gather qualitative data on sustainability of the Safety Planning Intervention. ETHICS AND DISSEMINATION These studies are overseen by the Institutional Review Board at the Central Arkansas Veterans Healthcare System. We plan to use traditional academic modalities of dissemination (eg, conferences, publications). We plan to disseminate findings through meetings with other trainers in implementation practice so they may adopt Consumer Voice. We plan to share results with local community boards.
Collapse
Affiliation(s)
- Eva N Woodward
- VA Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, Arkansas, USA
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Cathleen Willging
- Behavioral Health Research Center of the Southwest, Pacific Institute for Research and Evaluation, Albuquerque, New Mexico, USA
| | - Sara J Landes
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
- Behavioral Health Quality Enhancement Research Initiative (QUERI), Central Arkansas Veterans Healthcare System, North Little Rock, Arkansas, USA
- South Central Mental Illness Research Education and Clinical Center (MIRECC), Central Arkansas Veterans Healthcare System, North Little Rock, Arkansas, USA
| | - Leslie R M Hausmann
- Department of Medicine, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Karen L Drummond
- VA Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, Arkansas, USA
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Songthip Ounpraseuth
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Irenia A Ball
- VA Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, Arkansas, USA
| | - JoAnn E Kirchner
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
- Behavioral Health Quality Enhancement Research Initiative (QUERI), Central Arkansas Veterans Healthcare System, North Little Rock, Arkansas, USA
| |
Collapse
|
10
|
Raciborski RA, Woodward EN, Painter JT. Economic analyses of behavioral health intervention implementation: Perspective on stakeholder engagement. Front Psychiatry 2022; 13:1031325. [PMID: 36620658 PMCID: PMC9815616 DOI: 10.3389/fpsyt.2022.1031325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 11/30/2022] [Indexed: 12/24/2022] Open
Abstract
To provide full potential benefits to patients, behavioral health interventions often require comprehensive and systematic implementation efforts. The costs of these efforts should therefore be included when organizations decide to fund or adopt a new intervention. However, existing guidelines for conducting economic analyses like cost-effectiveness analyses and budget impact analyses are not well-suited to the complexity of the behavioral healthcare pathway and its many stakeholders. Stakeholder engagement, when used effectively with recent innovations in economic analysis, advance more equitable access to interventions for individuals living with behavioral health conditions. But early and ongoing stakeholder engagement has not yet been incorporated into best-practice guidelines for economic evaluation. We discuss our perspective, as researchers and clinicians in a large integrated health system, on how the integration of stakeholder engagement with existing economic analysis methods could improve decision-making about implementation of behavioral health interventions.
Collapse
Affiliation(s)
- Rebecca A Raciborski
- VA Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, AR, United States.,Evidence, Policy, and Implementation Center, Central Arkansas Veterans Healthcare System, North Little Rock, AR, United States
| | - Eva N Woodward
- VA Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, AR, United States.,Department of Psychiatry, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Jacob T Painter
- VA Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, AR, United States.,Evidence, Policy, and Implementation Center, Central Arkansas Veterans Healthcare System, North Little Rock, AR, United States.,Division of Pharmaceutical Evaluation and Policy, College of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| |
Collapse
|
11
|
Woodward EN, Drummond KL, Oliver KA, Bartnik MK, Meit SS, Owen RR, Wright BC, Hicks RE, Kirchner J. Lagniappes: "A Little Something Extra" or Unintended Positive Consequences of Implementation Facilitation. Psychiatr Serv 2021; 72:31-36. [PMID: 33138706 DOI: 10.1176/appi.ps.202000151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Implementation facilitation is an effective strategy that increases uptake of behavioral health interventions. Facilitation is grounded in partnerships with leadership and clinical stakeholders. Researchers have documented some negative consequences of facilitation-time, financial, and opportunity costs. Clinical leaders often agree to facilitation with the promise of increased implementation of an intervention. This study examined whether unintended positive consequences of facilitation might offset known costs. METHODS This study was part of a stepped-wedge, hybrid type 2, pragmatic trial that used implementation facilitation to implement primary care mental health integration (PCMHI) via telehealth technology in six satellite Veterans Health Administration (VHA) clinics. Two facilitators provided facilitation for at least 6 months. This study included a focused analysis of an emerging phenomenon captured through weekly debriefing interviews with facilitators: unintended positive consequences of implementation facilitation, termed "lagniappes" here. A rapid content analysis was conducted to identify and categorize these consequences. RESULTS The authors documented unintended positive consequences of the facilitation across the six VHA sites and categorized them into three clinically relevant domains: supporting PCMHI outreach at other clinics not in the original catchment area (e.g., providing tools to other sites), strengthening patient access (e.g., resolving unnecessary patient travel), and improving or modifying work processes (e.g., clarifying suicide assessment protocols). The positive consequences benefited sites and strengthened ongoing partnerships. CONCLUSIONS Documenting unintended positive consequences of implementation facilitation may increase leadership engagement. Facilitators should consider leveraging unintended positive consequences as advantages for the site that may add efficiency to facility processes and workflows.
Collapse
Affiliation(s)
- Eva N Woodward
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock (Woodward, Drummond, Oliver, Bartnik, Owen); Department of Psychiatry, University of Arkansas for Medical Sciences College of Medicine, Little Rock (Woodward, Drummond, Owen, Kirchner); Mental Health Service, Central Arkansas Veterans Healthcare System, North Little Rock (Meit, Wright); Mental Health Service, Jesse Brown VA Medical Center, Chicago (Hicks); Program for Team-Based Behavioral Health, Quality Enhancement Research Initiative, Department of Veterans Affairs Little Rock Regional Office, North Little Rock, Arkansas (Kirchner)
| | - Karen L Drummond
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock (Woodward, Drummond, Oliver, Bartnik, Owen); Department of Psychiatry, University of Arkansas for Medical Sciences College of Medicine, Little Rock (Woodward, Drummond, Owen, Kirchner); Mental Health Service, Central Arkansas Veterans Healthcare System, North Little Rock (Meit, Wright); Mental Health Service, Jesse Brown VA Medical Center, Chicago (Hicks); Program for Team-Based Behavioral Health, Quality Enhancement Research Initiative, Department of Veterans Affairs Little Rock Regional Office, North Little Rock, Arkansas (Kirchner)
| | - Karen Anderson Oliver
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock (Woodward, Drummond, Oliver, Bartnik, Owen); Department of Psychiatry, University of Arkansas for Medical Sciences College of Medicine, Little Rock (Woodward, Drummond, Owen, Kirchner); Mental Health Service, Central Arkansas Veterans Healthcare System, North Little Rock (Meit, Wright); Mental Health Service, Jesse Brown VA Medical Center, Chicago (Hicks); Program for Team-Based Behavioral Health, Quality Enhancement Research Initiative, Department of Veterans Affairs Little Rock Regional Office, North Little Rock, Arkansas (Kirchner)
| | - Mary Kate Bartnik
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock (Woodward, Drummond, Oliver, Bartnik, Owen); Department of Psychiatry, University of Arkansas for Medical Sciences College of Medicine, Little Rock (Woodward, Drummond, Owen, Kirchner); Mental Health Service, Central Arkansas Veterans Healthcare System, North Little Rock (Meit, Wright); Mental Health Service, Jesse Brown VA Medical Center, Chicago (Hicks); Program for Team-Based Behavioral Health, Quality Enhancement Research Initiative, Department of Veterans Affairs Little Rock Regional Office, North Little Rock, Arkansas (Kirchner)
| | - Scott S Meit
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock (Woodward, Drummond, Oliver, Bartnik, Owen); Department of Psychiatry, University of Arkansas for Medical Sciences College of Medicine, Little Rock (Woodward, Drummond, Owen, Kirchner); Mental Health Service, Central Arkansas Veterans Healthcare System, North Little Rock (Meit, Wright); Mental Health Service, Jesse Brown VA Medical Center, Chicago (Hicks); Program for Team-Based Behavioral Health, Quality Enhancement Research Initiative, Department of Veterans Affairs Little Rock Regional Office, North Little Rock, Arkansas (Kirchner)
| | - Richard R Owen
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock (Woodward, Drummond, Oliver, Bartnik, Owen); Department of Psychiatry, University of Arkansas for Medical Sciences College of Medicine, Little Rock (Woodward, Drummond, Owen, Kirchner); Mental Health Service, Central Arkansas Veterans Healthcare System, North Little Rock (Meit, Wright); Mental Health Service, Jesse Brown VA Medical Center, Chicago (Hicks); Program for Team-Based Behavioral Health, Quality Enhancement Research Initiative, Department of Veterans Affairs Little Rock Regional Office, North Little Rock, Arkansas (Kirchner)
| | - B Cody Wright
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock (Woodward, Drummond, Oliver, Bartnik, Owen); Department of Psychiatry, University of Arkansas for Medical Sciences College of Medicine, Little Rock (Woodward, Drummond, Owen, Kirchner); Mental Health Service, Central Arkansas Veterans Healthcare System, North Little Rock (Meit, Wright); Mental Health Service, Jesse Brown VA Medical Center, Chicago (Hicks); Program for Team-Based Behavioral Health, Quality Enhancement Research Initiative, Department of Veterans Affairs Little Rock Regional Office, North Little Rock, Arkansas (Kirchner)
| | - R Elliott Hicks
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock (Woodward, Drummond, Oliver, Bartnik, Owen); Department of Psychiatry, University of Arkansas for Medical Sciences College of Medicine, Little Rock (Woodward, Drummond, Owen, Kirchner); Mental Health Service, Central Arkansas Veterans Healthcare System, North Little Rock (Meit, Wright); Mental Health Service, Jesse Brown VA Medical Center, Chicago (Hicks); Program for Team-Based Behavioral Health, Quality Enhancement Research Initiative, Department of Veterans Affairs Little Rock Regional Office, North Little Rock, Arkansas (Kirchner)
| | - JoAnn Kirchner
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock (Woodward, Drummond, Oliver, Bartnik, Owen); Department of Psychiatry, University of Arkansas for Medical Sciences College of Medicine, Little Rock (Woodward, Drummond, Owen, Kirchner); Mental Health Service, Central Arkansas Veterans Healthcare System, North Little Rock (Meit, Wright); Mental Health Service, Jesse Brown VA Medical Center, Chicago (Hicks); Program for Team-Based Behavioral Health, Quality Enhancement Research Initiative, Department of Veterans Affairs Little Rock Regional Office, North Little Rock, Arkansas (Kirchner)
| |
Collapse
|
12
|
Woodward EN, Cunningham JL, Flynn AWP, Mereish EH, Banks RJ, Landes SJ, Kirchner JE, Pantalone DW. Sexual minority men want provider behavior consistent with attitudes and norms during patient-provider interactions regarding HIV prevention. PSYCHOL HEALTH MED 2019; 25:354-367. [PMID: 31429323 DOI: 10.1080/13548506.2019.1656338] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
HIV is a health problem for sexual minority men in the United States. One factor among many that contributes to this HIV disparity is poor patient-provider interactions. We focused on specific provider behavior preferred by sexual minority men during patient-provider interactions about HIV prevention. We interviewed 20 HIV-negative sexual minority men who endorsed 1+ psychosocial HIV risk factor. We used follow up interviews and conventional content analysis. Among our sample, 55% identified as White; 50% as bisexual, (Mage = 28.45). Findings suggested even some providers knowledgeable about sexual minority health provided unhelpful care to sexual minority men (knowledge-behavior discrepancy). Some knowledgeable providers engaged in affirmative, tailored treatment (knowledge-behavior consistency). Specific behaviors of preferred patient-provider interactions regarding HIV prevention are reported. Our recommendations are based on patient perceptions, which is a limit and strength. We identified an important type of unhelpful patient-provider interaction for HIV-negative sexual minority men beyond discriminatory experiences. Patient-provider interaction efforts need to go beyond education to help providers practice skills. With increased focus on cultural competency for sexual minority patients, more providers may advertise their practice as affirmative, yet interactions will likely vary, may require lifelong practice of cultural humility, and impact HIV prevention.
Collapse
Affiliation(s)
- Eva N Woodward
- Central Arkansas Veterans Healthcare System, VA Center for Mental Healthcare and Outcomes Research, North Little Rock, AR, USA.,Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | | | - Anthony W P Flynn
- Department of Psychology, University of Massachusetts Boston, Boston, MA, USA.,Department of Counseling Psychology, University of Wisconsin, Madison, WI, USA
| | - Ethan H Mereish
- Department of Health Studies, American University, Washington, DC, USA
| | - Regina J Banks
- Degree Completion Program, Fresno Pacific University, Fresno, CA, USA
| | - Sara J Landes
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, USA.,US Department of Veterans Affairs, VA QUERI for Team Based Behavioral Health, North Little Rock, AR
| | - Joann E Kirchner
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, USA.,US Department of Veterans Affairs, VA QUERI for Team Based Behavioral Health, North Little Rock, AR
| | - David W Pantalone
- Department of Psychology, University of Massachusetts Boston, Boston, MA, USA.,The Fenway Institute, Fenway Health, Boston, MA, USA
| |
Collapse
|
13
|
Owen RR, Woodward EN, Drummond KL, Deen TL, Oliver KA, Petersen NJ, Meit SS, Fortney JC, Kirchner JE. Using implementation facilitation to implement primary care mental health integration via clinical video telehealth in rural clinics: protocol for a hybrid type 2 cluster randomized stepped-wedge design. Implement Sci 2019; 14:33. [PMID: 30898129 PMCID: PMC6429823 DOI: 10.1186/s13012-019-0875-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 02/27/2019] [Indexed: 01/11/2023] Open
Abstract
Background Integrating mental health providers into primary care clinics improves access to and outcomes of mental health care. In the Veterans Health Administration (VA) Primary Care Mental Health Integration (PCMHI) program, mental health providers are co-located in primary care clinics, but the implementation of this model is challenging outside large VA medical centers, especially for rural clinics without full mental health staffing. Long wait times for mental health care, little collaboration between mental health and primary care providers, and sub-optimal outcomes for rural veterans could result. Telehealth could be used to provide PCMHI to rural clinics; however, the clinical effectiveness of the tele-PCMHI model has not been tested. Based on evidence that implementation facilitation is an effective implementation strategy to increase uptake of PCMHI when delivered on-site at larger VA clinics, it is hypothesized that this strategy may also be effective with regard to ensuring adequate uptake of the tele-PCMHI model at rural VA clinics. Methods This study is a hybrid type 2 pragmatic effectiveness-implementation trial of tele-PCMHI in six sites over 24 months. Tele-PCMHI, which will be delivered by clinical staff available in routine care settings, will be compared to usual care. Fidelity to the care model will be monitored but not controlled. We will use the Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) framework to evaluate the patient-level clinical effectiveness of tele-PCMHI in rural VA clinics and also to evaluate the fidelity to and outcomes of the implementation strategy, implementation facilitation. The proposed study will employ a stepped-wedge design in which study sites sequentially begin implementation in three steps at 6-month intervals. Each step will include (1) a 6-month period of implementation planning, followed by (2) a 6-month period of active implementation, and (3) a final period of stepped-down implementation facilitation. Discussion This study will evaluate the effectiveness of PCMHI in a novel setting and via a novel method (clinical video telehealth). We will test the feasibility of using implementation facilitation as an implementation strategy to deploy tele-PCMHI in rural VA clinics. Trial registration ClinicalTrials.gov registration number NCT02713217. Registered on 18 March 2016 Electronic supplementary material The online version of this article (10.1186/s13012-019-0875-5) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Richard R Owen
- VA Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, 2200 Fort Roots Drive, North Little Rock, AR, USA. .,Department of Psychiatry, University of Arkansas for Medical Sciences, 4301 West Markham, Little Rock, AR, USA.
| | - Eva N Woodward
- VA Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, 2200 Fort Roots Drive, North Little Rock, AR, USA.,Department of Psychiatry, University of Arkansas for Medical Sciences, 4301 West Markham, Little Rock, AR, USA.,Center for Implementation Research, University of Arkansas for Medical Sciences, 4301 West Markham, Little Rock, AR, USA
| | - Karen L Drummond
- VA Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, 2200 Fort Roots Drive, North Little Rock, AR, USA.,Department of Psychiatry, University of Arkansas for Medical Sciences, 4301 West Markham, Little Rock, AR, USA
| | - Tisha L Deen
- Central Arkansas Veterans Healthcare System, 2200 Fort Roots Drive, North Little Rock, AR, USA
| | - Karen Anderson Oliver
- William S. Middleton Memorial Veterans Hospital, 2500 Overlook Terrace, Madison, WI, USA
| | - Nancy J Petersen
- VA HSR&D Center for Innovations in Quality Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, USA.,Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Scott S Meit
- Central Arkansas Veterans Healthcare System, 2200 Fort Roots Drive, North Little Rock, AR, USA
| | - John C Fortney
- Health Services Research and Development, Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA, S-152, USA.,Department of Psychiatry and Behavioral Sciences, University of Washington, 1959 NE Pacific Street, Seattle, WA, USA
| | - JoAnn E Kirchner
- Department of Psychiatry, University of Arkansas for Medical Sciences, 4301 West Markham, Little Rock, AR, USA.,Department of Veterans Affairs, VA Quality Enhancement Research Initiative (QUERI) Program for Team-Based Behavioral Health, 2200 Fort Roots Drive, North Little Rock, AR, USA
| |
Collapse
|
14
|
Woodward EN, Matthieu MM, Uchendu US, Rogal S, Kirchner JE. The health equity implementation framework: proposal and preliminary study of hepatitis C virus treatment. Implement Sci 2019; 14:26. [PMID: 30866982 PMCID: PMC6417278 DOI: 10.1186/s13012-019-0861-y] [Citation(s) in RCA: 174] [Impact Index Per Article: 34.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 01/25/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Researchers could benefit from methodological advancements to advance uptake of new treatments while also reducing healthcare disparities. A comprehensive determinants framework for healthcare disparity implementation challenges is essential to accurately understand an implementation problem and select implementation strategies. METHODS We integrated and modified two conceptual frameworks-one from implementation science and one from healthcare disparities research to develop the Health Equity Implementation Framework. We applied the Health Equity Implementation Framework to a historical healthcare disparity challenge-hepatitis C virus (HCV) and its treatment among Black patients seeking care in the US Department of Veterans Affairs (VA). A specific implementation assessment at the patient level was needed to understand any barriers to increasing uptake of HCV treatment, independent of cost. We conducted a preliminary study to assess how feasible it was for researchers to use the Health Equity Implementation Framework. We applied the framework to design the qualitative interview guide and interpret results. Using quantitative data to screen potential participants, this preliminary study consisted of semi-structured interviews with a purposively selected sample of Black, rural-dwelling, older adult VA patients (N = 12), living with HCV, from VA medical clinics in the Southern part of the USA. RESULTS The Health Equity Implementation Framework was feasible for implementation researchers. Barriers and facilitators were identified at all levels including the patient, provider (recipients), patient-provider interaction (clinical encounter), characteristics of treatment (innovation), and healthcare system (inner and outer context). Some barriers reflected general implementation issues (e.g., poor care coordination after testing positive for HCV). Other barriers were related to healthcare disparities and likely unique to racial minority patients (e.g., testimonials from Black peers about racial discrimination at VA). We identified several facilitators, including patient enthusiasm to obtain treatment because of its high cure rates, and VA clinics that offset HCV stigma by protecting patient confidentiality. CONCLUSION The Health Equity Implementation Framework showcases one way to modify an implementation framework to better assess health equity determinants as well. Researchers may be able to optimize the scientific yield of research inquiries by identifying and addressing factors that promote or impede implementation of novel treatments in addition to eliminating healthcare disparities.
Collapse
Affiliation(s)
- Eva N. Woodward
- Center for Mental Healthcare & Outcomes Research, Central Arkansas Veterans Healthcare System, U.S. Department of Veterans Affairs, 2200 Fort Roots Drive, 152 NLR, North Little Rock, AR 72114 USA
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR USA
| | - Monica M. Matthieu
- Center for Mental Healthcare & Outcomes Research, Central Arkansas Veterans Healthcare System, U.S. Department of Veterans Affairs, 2200 Fort Roots Drive, 152 NLR, North Little Rock, AR 72114 USA
- College for Public Health and Social Justice, School of Social Work, Saint Louis University, St. Louis, MO USA
| | | | - Shari Rogal
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA USA
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA USA
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh, Pittsburgh, PA USA
| | - JoAnn E. Kirchner
- Center for Mental Healthcare & Outcomes Research, Central Arkansas Veterans Healthcare System, U.S. Department of Veterans Affairs, 2200 Fort Roots Drive, 152 NLR, North Little Rock, AR 72114 USA
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR USA
- VA Team-Based Behavioral Health QUERI, U.S. Department of Veterans Affairs, North Little Rock, AR USA
| |
Collapse
|
15
|
Pantalone DW, Valentine SE, Woodward EN, O'Cleirigh C. Syndemic Indicators Predict Poor Medication Adherence and Increased Health Care Utilization for Urban HIV-Positive Men Who Have Sex with Men. J Gay Lesbian Ment Health 2017; 22:71-87. [PMID: 30976378 DOI: 10.1080/19359705.2017.1389794] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Research on men who have sex with men (MSM) has uncovered psychosocial factors (syndemic indicators) that are associated additively with poor health. To test these relations in a sample of HIV-positive MSM, we enrolled 166 patients from two HIV clinics. We investigated relations between syndemic indicators and outcomes including medication nonadherence, condomless anal sex (CAS), and healthcare utilization. A large proportion of participants reported each syndemic indicator: polysubstance use 43%, suicide attempt 28%, childhood sexual abuse 39%, partner abuse 64%. Analyses confirmed an additive effect, whereby endorsing 1+ indicator was associated with increased odds of medication nonadherence and medical hospitalization.
Collapse
Affiliation(s)
- David W Pantalone
- University of Massachusetts Boston, Department of Psychology, Boston, Massachusetts.,Fenway Health, The Fenway Institute, Boston, Massachusetts
| | | | - Eva N Woodward
- Central Arkansas Veterans Healthcare System, South Central VA Mental Illness, Research, and Education Center (MIRECC), Little Rock, Arkansas.,Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Conall O'Cleirigh
- Fenway Health, The Fenway Institute, Boston, Massachusetts.,Massachusetts General Hospital/Harvard Medical School, Department of Psychiatry, Boston, Massachusetts
| |
Collapse
|
16
|
Woodward EN, Banks RJ, Marks AK, Pantalone DW. Identifying Resilience Resources for HIV Prevention Among Sexual Minority Men: A Systematic Review. AIDS Behav 2017; 21:2860-2873. [PMID: 27981398 DOI: 10.1007/s10461-016-1608-2] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Most HIV prevention for sexual minority men and men who have sex with men targets risk behaviors (e.g., condom use) and helps <50% of participants. Bolstering resilience might increase HIV prevention's effectiveness. This systematic review identified resilience resources (protective factors) in high-risk, HIV-negative, sexual minority men. We reviewed PsycINFO, PsycARTICLES, MEDLINE, references, and Listservs for studies including sexual minority men with 1+ HIV risk factor (syndemics): childhood sexual abuse, partner abuse, substance abuse, or mental health symptoms. From 1356 articles screened, 20 articles met inclusion criteria. Across the articles, we identified and codified 31 resilience resources: socioeconomic (e.g., employment), behavioral coping strategies (e.g., mental health treatment), cognitions/emotions (e.g., acceptance), and relationships. Resilience resources were generally associated with lower HIV risk; there were 18 low-risk associations, 4 high-risk associations, 8 non-significant associations). We generated a set of empirically based resilience variables and a hypothesis to be evaluated further to improve HIV prevention.
Collapse
|
17
|
Woodward EN, Walsh JL, Senn TE, Carey MP. Positive social interaction offsets impact of low socioeconomic status on stress. J Natl Med Assoc 2017; 110:371-377. [PMID: 30126563 DOI: 10.1016/j.jnma.2017.07.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Revised: 06/28/2017] [Accepted: 07/09/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND Stress is associated with unhealthy behaviors and premature morbidity and mortality, especially among those of low socioeconomic status (SES). Clarifying the roles of stress-related risk and protective factors can guide interventions designed to reduce stress and improve health among socioeconomically disadvantaged populations. PURPOSE (1) Replicate prior research showing that lower SES is associated with higher stress in a predominantly racial minority, socioeconomically disadvantaged sample, and (2) test the hypothesis that different types of social support (a protective factor) mitigate the deleterious effects of SES on self-reported perceived stress. METHODS Low-income patients (N = 508, 54% male, 68% African American, Mage = 28) from a publicly-funded clinic provided demographic information and then completed measures of perceived stress and social support. Four types of social support were assessed (viz., affectionate, emotional/informational, positive social interaction, and tangible). Structural equation modeling tested the hypothesized associations among SES, social support, and stress. RESULTS Individuals of lower SES, β = -0.27 (0.08), p < 0.01, and lower overall social support, β = -0.47 (0.05), p < 0.001, reported higher stress. Social support moderated associations between SES and stress, with participants with lower SES benefitting the most from social support. Of the four types of social support that were measured, positive social interaction was the strongest moderator, β = 0.20 (0.08), p = 0.01. CONCLUSIONS The associations among SES, stress, and social support corroborate prior research. Positive social interaction was particularly important for decreasing stress among socioeconomically disadvantaged persons.
Collapse
Affiliation(s)
- Eva N Woodward
- Department of Psychiatry and Human Behavior, The Warren Alpert Medical School of Brown University, Brown University, Box G-BH, Providence, RI 02912, USA.
| | - Jennifer L Walsh
- Department of Psychiatry and Human Behavior, The Warren Alpert Medical School of Brown University, Brown University, Box G-BH, Providence, RI 02912, USA; Centers for Behavioral and Preventive Medicine, The Miriam Hospital, 164 Summit Avenue, Providence, RI 02906, USA; Center for AIDS Intervention Research, Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226, USA; Department of Behavioral and Social Sciences, School of Public Health, Brown University, 121 South Main Street, Providence, RI, 02903, USA
| | - Theresa E Senn
- School of Nursing, University of Rochester, Box SON, Helen Wood Hall, 601 Elmwood Avenue, Rochester, NY 14642, USA
| | - Michael P Carey
- Centers for Behavioral and Preventive Medicine, The Miriam Hospital, 164 Summit Avenue, Providence, RI 02906, USA; Center for AIDS Intervention Research, Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226, USA; Department of Behavioral and Social Sciences, School of Public Health, Brown University, 121 South Main Street, Providence, RI, 02903, USA
| |
Collapse
|
18
|
Kirchner JE, Woodward EN, Smith JL, Curran GM, Kilbourne AM, Owen RR, Bauer MS. Implementation Science Supports Core Clinical Competencies: An Overview and Clinical Example. Prim Care Companion CNS Disord 2016; 18. [PMID: 27959478 DOI: 10.4088/pcc.16m02004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 10/10/2016] [Indexed: 10/20/2022] Open
Abstract
Objective Instead of asking clinicians to work faster or longer to improve quality of care, implementation science provides another option. Implementation science is an emerging interdisciplinary field dedicated to studying how evidence-based practice can be adopted into routine clinical care. This article summarizes principles and methods of implementation science, illustrates how they can be applied in a routine clinical setting, and highlights their importance to practicing clinicians as well as clinical trainees. Method A hypothetical clinical case scenario is presented that explains how implementation science improves clinical practice. The case scenario is also embedded within a real-world implementation study to improve metabolic monitoring for individuals prescribed antipsychotics. Results Context, recipient, and innovation (ie, the evidence-based practice) factors affected improvement of metabolic monitoring. To address these factors, an external facilitator and a local quality improvement team developed an implementation plan involving a multicomponent implementation strategy that included education, performance reports, and clinician follow-up. The clinic remained compliant with recommended metabolic monitoring at 1-year follow up. Conclusions Implementation science improves clinical practice by addressing context, recipient, and innovation factors and uses this information to develop and utilize specific strategies that improve clinical practice. It also enriches clinical training, aligning with core competencies by the Accreditation Council for Graduate Medical Education and American Boards of Medical Specialties. By learning how to change clinical practice through implementation strategies, clinicians are more able to adapt in complex systems of practice.
Collapse
Affiliation(s)
- JoAnn E Kirchner
- Central Arkansas Veterans Healthcare System, QUERI for Team-Based Behavioral Healthcare, 2200 Fort Roots Drive, Bldg 58, 16MIR/NLR, North Little Rock, AR 72114. .,VA Quality Enhancement Research Initiative (QUERI) for Team-Based Behavioral Health, Central Arkansas Veterans Healthcare System, North Little Rock, Arkansas, USA.,Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Eva N Woodward
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.,South Central Mental Illness Research Education and Clinical Centers (MIRECC), Central Arkansas Veterans Healthcare System, North Little Rock, Arkansas, USA
| | - Jeffrey L Smith
- VA Quality Enhancement Research Initiative (QUERI) for Team-Based Behavioral Health, Central Arkansas Veterans Healthcare System, North Little Rock, Arkansas, USA.,Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.,Center for Mental Healthcare & Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, Arkansas, USA
| | - Geoffrey M Curran
- Center for Mental Healthcare & Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, Arkansas, USA.,Center for Implementation Research, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.,Department of Pharmacy Practice and Psychiatry, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Amy M Kilbourne
- Quality Enhancement Research Initiative (QUERI), US Department of Veterans Affairs, Ann Arbor, Michigan, USA.,Department of Psychiatry, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Richard R Owen
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.,Center for Mental Healthcare & Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, Arkansas, USA.,Department of Epidemiology, College of Public Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Mark S Bauer
- VA Quality Enhancement Research Initiative (QUERI) for Team-Based Behavioral Health, Central Arkansas Veterans Healthcare System, North Little Rock, Arkansas, USA.,Department of Psychiatry, Harvard Medical School, Cambridge, Massachusetts, USA.,Center for Healthcare Organization and Implementation Research (CHOIR), US Department of Veterans Affairs, Boston, Massachusetts, USA
| |
Collapse
|
19
|
Abstract
OBJECTIVE Sexual minority (lesbian, gay, bisexual, queer) individuals are regular consumers of psychotherapy, and are more likely to utilize psychotherapy than heterosexually identified individuals. However, there is scant research on sexual minority clients examining their perceptions of therapists' efforts to work successfully with them. METHOD We examined the experiences reported by sexual minority individuals in psychotherapy (N = 77), utilizing an Internet-based survey that asked open-ended questions such as, "How did your therapist address your sexual orientation?" RESULT Using directed content analysis, we derived 19 repeating ideas, which we categorized into five major themes and two overarching concepts, including: (a) participants reported appreciating general person-centered psychotherapy competencies (e.g., active listening, validation, Socratic questioning) and (b) participants reported that various aspects of sexual orientation (e.g., therapist sexual identity, therapist knowledge about sexual minority populations) are relevant to their experiences in therapy and should be addressed directly by therapists. CONCLUSIONS Results indicated that clients want generally competent therapists who understand that a sexual minority identity is only one part of a client's overall identity and not a defining characteristic or psychopathological. We explicate themes and representative quotes, and provide preliminary recommendations for therapists working with sexual minority clients.
Collapse
Affiliation(s)
| | - Eva N Woodward
- a Psychology Department , Suffolk University , Boston , MA , USA
| | - David W Pantalone
- b Psychology Department , University of Massachusetts , Boston , MA , USA.,c The Fenway Institute, Fenway Health , Boston , MA , USA
| |
Collapse
|
20
|
Puckett JA, Woodward EN, Mereish EH, Pantalone DW. Parental Rejection Following Sexual Orientation Disclosure: Impact on Internalized Homophobia, Social Support, and Mental Health. LGBT Health 2015; 2:265-9. [DOI: 10.1089/lgbt.2013.0024] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Julia A. Puckett
- Department of Psychology, University of Massachusetts Boston, Boston, Massachusetts
| | - Eva N. Woodward
- Department of Psychology, Suffolk University, Boston, Massachusetts
| | - Ethan H. Mereish
- Department of Counseling, Educational, and Developmental Psychology, Boston College, Boston, Massachusetts
| | - David W. Pantalone
- Department of Psychology, University of Massachusetts Boston, Boston, Massachusetts
- The Fenway Institute, Fenway Health, Boston, Massachusetts
| |
Collapse
|
21
|
Woodward EN, Wingate L, Gray TW, Pantalone DW. Evaluating thwarted belongingness and perceived burdensomeness as predictors of suicidal ideation in sexual minority adults. Psychology of Sexual Orientation and Gender Diversity 2014. [DOI: 10.1037/sgd0000046] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
22
|
Woodward EN, Pantalone DW, Bradford J. Differential reports of suicidal ideation and attempts of questioning adults compared to heterosexual, lesbian, gay, and bisexual individuals. J Gay Lesbian Ment Health 2013; 17:278-293. [PMID: 24058715 PMCID: PMC3775355 DOI: 10.1080/19359705.2012.763081] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Many sexual minority individuals attempt suicide each year, but little is known about the suicidality of individuals who are questioning their sexual orientation. This study assessed suicidal ideation and attempts of questioning individuals compared to lesbian/gay, bisexual, and heterosexual individuals. This cross-sectional study enrolled participants (N = 2,841) from a community health center. Questioning (OR = 4.286, 95% CI [2.119-8.671]), lesbian/gay (OR = 3.024, 95% CI [2.351-3.890]), and bisexual (OR = 4.389, 95% CI [2.942-6.575]) individuals had significantly greater odds of considering suicide compared to heterosexuals. However, questioning individuals had non-significant odds of attempting suicide compared to heterosexuals. We discuss possible explanations for these findings.
Collapse
|
23
|
Woodward EN, Pantalone DW. The role of social support and negative affect in medication adherence for HIV-infected men who have sex with men. J Assoc Nurses AIDS Care 2012; 23:388-96. [PMID: 22209470 PMCID: PMC3319472 DOI: 10.1016/j.jana.2011.09.004] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2011] [Accepted: 09/13/2011] [Indexed: 11/26/2022]
Abstract
Combinations of medications that control HIV viral replication are called antiretroviral therapy (ART). Regimens can be complex, so medication adherence is often suboptimal, although high rates of adherence are necessary for ART to be effective. Social support, which has been directly and indirectly associated with better treatment adherence in HIV-infected individuals, influences negative affect, including depression and anxiety. Our study assessed whether current anxious and depressive symptoms mediated the relationship between general social support and recent self-reported medication adherence in HIV-infected men who have sex with men (N= 136; 65% White, 15% Black/African American). Results revealed no direct effect, but an indirect effect of depressive (95% CI [-.011, -.0011]) and anxious symptoms (95% CI [-.0097, -.0009]), between social support and medication adherence. Greater levels of social support were associated with lower levels of depression and anxiety, which in turn were associated with lower ART adherence.
Collapse
Affiliation(s)
- Eva N Woodward
- Clinical Psychology, Suffolk University, Boston, Massachusetts, USA
| | | |
Collapse
|
24
|
Bloom JM, Woodward EN, Susmaras T, Pantalone DW. Use of dialectical behavior therapy in inpatient treatment of borderline personality disorder: a systematic review. Psychiatr Serv 2012; 63:881-8. [PMID: 22751905 DOI: 10.1176/appi.ps.201100311] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Dialectical behavior therapy (DBT) is an empirically supported treatment for outpatients with borderline personality disorder. However, the utility of DBT strategies for inpatients with the disorder is unclear. This review summarizes and synthesizes findings from trials of DBT in inpatient settings. METHODS Multiple research databases were searched for articles published through June 2011 that reported on any implementation of DBT in an inpatient setting to address symptoms related to borderline personality disorder, including suicidal and self-injurious behavior. RESULTS Eleven studies that reported pre- and posttreatment symptoms related to borderline personality disorder were evaluated. Studies indicated that many variations of standard DBT have been used in inpatient settings, including approaches that do not include phone consultation, that include group therapy only, and that vary in treatment duration (from two weeks to three months). Most studies reported reductions in suicidal ideation, self-injurious behaviors, and symptoms of depression and anxiety, whereas results for reducing anger and violent behaviors were mixed. Follow-up data indicated that symptom reduction was often maintained between one and 21 months posttreatment. On the basis of the evidence, the authors identify essential components of an inpatient DBT package and discuss its potential function as an "intensive orientation" to outpatient DBT services. CONCLUSIONS There is considerable variation in the configuration and duration of DBT implementation for inpatients with borderline personality disorder. However, findings suggest that DBT may be effective in reducing symptoms related to borderline personality disorder in inpatient settings. Future research should standardize and systematically test inpatient DBT. (Psychiatric Services 63:881-888, 2012; doi: 10.1176/appi.ps.201100311).
Collapse
Affiliation(s)
- Jill Myerow Bloom
- Department of Psychology, Suffolk University, 41 Temple St., 6th Floor, Boston, MA 02114, USA.
| | | | | | | |
Collapse
|