Mediators of measurement-based care implementation in community mental health settings: results from a mixed-methods evaluation

Abstract

Background Tailored implementation approaches are touted as superior to standardized ones with the reasoning that tailored approaches afford opportunities to select strategies to resolve determinants of the local context. However, results from implementation trials on this topic are equivocal. Therefore, it is important to explore relevant contextual factors that function as determinants to evaluate if they are improved by tailoring and subsequently associated with changes in implementation outcomes (i.e., via statistical mediation) to better understand how tailoring achieves (or does not achieve) its effects. The present study examined the association between a tailored and standardized implementation approach, contextual factors that might mediate change, and a target implementation outcome in an initiative to implement measurement-based care (specifically the clinical integration of the Patient Health Questionnaire [PHQ-9] for depression) in a community mental health organization. Methods Using a cluster randomized control design, twelve community-based mental health clinics were assigned to a tailored or standardized implementation group. Clinicians completed a self-report battery assessing contextual factors that served as candidate mediators informed by the Framework for Dissemination at three time points: baseline, 5 months after active implementation support, and 10 months after sustainment monitoring. A subset of clinicians also participated in focus groups at 5 months. The routine use of the PHQ-9 (implementation outcome) was monitored during the 10-month sustainment period. Multi-level mediation analyses assessed the association between the implementation group and contextual factors and the association between contextual factors and PHQ-9 completion. Quantitative results were then elaborated by analyzing qualitative data from exemplar sites. Results Although tailored clinics outperformed standard clinics in terms of PHQ-9 completion at the end of active implementation, these group differences disappeared post sustainment monitoring. Perhaps related to this, no significant mediators emerged from our quantitative analyses. Exploratory qualitative analyses of focus group content emphasized the importance of support from colleagues, supervisors, and leadership when implementing clinical innovations in practice. Conclusions Although rates of PHQ-9 completion improved across the study, their sustained levels were roughly equivalent across groups and low overall. No mediators were established using quantitative methods; however, several partial quantitative pathways, as well as themes from the qualitative data, reveal fruitful areas for future research. Trial registration Standardized versus tailored implementation of measurement-based care for depression. ClinicalTrials.gov NCT02266134, first posted on October 16, 2014

Improving measurement-based care implementation in youth mental health through organizational leadership and climate: a mechanistic analysis within a randomized trial

“…In this trial, increases in first-level leaders’ use of implementation leadership by 4-month post-baseline explained 82% of LOCI’s effect on improvement in clinic implementation climate by 12-month post-baseline. This finding aligns with qualitative data from another recent trial of MBC implementation in community mental health [ 93 ], which also found that leader and clinical supervisor support for MBC were perceived as key implementation mechanisms. The linkage of implementation leadership to improvement in clinic implementation climate suggests implementation leadership behaviors are important targets for implementation success.…”

Study protocol: Novel Methods for Implementing Measurement-Based Care with youth in Low-Resource Environments (NIMBLE)

“…Research has shown that tailoring implementation strategies to address high-priority implementation barriers can increase MBC fidelity, at least with respect to one element: routine administration of measures symptoms, outcomes, and processes before therapy sessions [ 11 – 13 ]. Our experience suggests, however, that for tailored implementation to realize its full potential, new methods are needed for identifying and prioritizing implementation barriers and matching strategies to high-priority barriers [ 14 ].…”