Collaborative chronic care model implementation within outpatient behavioral health care teams: qualitative results from a multisite trial using implementation facilitation

Abstract

Background This paper reports on a qualitative evaluation of a hybrid type II stepped-wedge, cluster randomized trial using implementation facilitation to implement team-based care in the form of the collaborative chronic care model (CCM) in interdisciplinary outpatient mental health teams. The objective of this analysis is to compare the alignment of sites’ clinical processes with the CCM elements at baseline (time 1) and after 12 months of implementation facilitation (time 2) from the perspective of providers. Methods We conducted semi-structured interviews to assess the extent to which six CCM elements were in place: work role redesign, patient self-management support, provider decision support, clinical information systems, linkages to community resources, and organizational/leadership support. Interviews were transcribed and a priori CCM elements were coded using a directed content analysis approach at times 1 and 2. We sought consensus on, and compared, the extent to which each CCM element was in place at times 1 and 2. Results We conducted 27 and 31 telephone interviews at times 1 and 2, respectively, with outpatient mental health providers at nine participating sites. At time 1 and time 2, three CCM elements were most frequently present across the sites: work role redesign, patient self-management support, and provider decision support. The CCM elements with increased implementation from time 1 to time 2 were work role redesign, patient self-management support, and clinical information systems. For two CCM elements, linkages to community resources and organizational/leadership support, some sites had increased implementation at time 2 compared to time 1, while others had reductions. For the provider decision support element, we saw little change in the extent of its implementation. Conclusions Sites increased the extent of implementation on several CCM elements. The most progress was made in the CCM elements where sites had CCM-aligned processes in place at time 1. Teams made progress on elements they could more easily control, such as work role redesign. Our results suggest that maximizing the benefits of CCM-based outpatient mental health care may require targeting resources and training toward specific CCM elements—especially in the use of clinical information systems and linking with community resources. Trial registration Clinical Trials NCT02543840.

Primary aim results of a clustered SMART for developing a school-level, adaptive implementation strategy to support CBT delivery at high schools in Michigan

“…For organizational barriers, Facilitation-based on the integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) [39] frameworkprovides schools with ongoing consultation from an expert in strategic thinking and EBP implementation to garner administrative support, solve logistical challenges, and build community buy-in. In several communitybased cluster-randomized trials, Facilitation has been shown to improve mental health EBP uptake [30,34,[40][41][42][43][44][45] and to be highly cost-effective [46,47].…”

Development of a qualitative data analysis codebook informed by the i-PARIHS framework

“…They then summarized coded text by relevant subcodes for the four i-PARIHS constructs in a Word document. Because they had previously coded the same dataset by collaborative care model elements [ 42 ], they also examined the cross-coding between the collaborative care model and i-PARIHS codes/subcodes. The analysis team included JLS, KLD, and another BH QUERI investigator who had served on the expert panel.…”

Sustainability of the Collaborative Chronic Care Model in Outpatient Mental Health Teams Three Years Post-Implementation: A Qualitative Analysis

“…Consistent with other qualitative work (Hamilton & Finley, 2019;Miller et al, 2019;Sullivan et al, 2021), we aimed to recruit about three to four staff at each of the nine VA medical centers, including a multidisciplinary mix of mental health leaders and frontline BHIP staff. Whenever possible, for each site we aimed to recruit at least one BHIP clinician who had been present during the original BHIP-CCM Enhancement Project (i.e., had participated in implementation facilitation between 2016 and 2018).…”

“…We developed the interview guide collaboratively as a project team, based on the following: (a) the six CCM elements, (b) core constructs of the i-PARIHS implementation framework (Harvey & Kitson, 2015;Ritchie et al, 2022), (c) the current project's focus on sustainability, and (d) the interview guides used in previous studies of BHIP-CCM implementation (Miller et al, 2019;Sullivan et al, 2021;see Supplemental File). Interview questions asked about the extent to which care processes within the BHIP team remained aligned with the 6 CCM elements described above.…”