Abstract
People with serious mental illnesses (SMIs) experience excess mortality, driven in large part by high rates of cardiovascular disease (CVD), with all cardiovascular disease risk factors elevated. Interventions designed to improve the cardiovascular health of people with SMI have been shown to lead to clinically significant improvements in clinical trials; however, the uptake of these interventions into real-life clinical settings remains limited. Implementation strategies, which constitute the “how to” component of changing healthcare practice, are critical to supporting the scale-up of evidence-based interventions that can improve the cardiovascular health of people with SMI. And yet, implementation strategies are often poorly described and rarely justified theoretically in the literature, limiting the ability of researchers and practitioners to tease apart why, what, how, and when implementation strategies lead to improvement. In this Perspective, we describe the implementation strategies that the Johns Hopkins ALACRITY Center for Health and Longevity in Mental Illness is using to scale-up three evidenced-based interventions related to: (1) weight loss; (2) tobacco smoking cessation treatment; and (3) hypertension, dyslipidemia, and diabetes care for people with SMI. Building on concepts from the literature on complex health interventions, we focus on considerations related to the core function of an intervention (i.e., or basic purposes of the change process that the health intervention seeks to facilitate) vs. the form (i.e., implementation strategies or specific activities taken to carry out core functions that are customized to local contexts). By clearly delineating how implementation strategies are operationalized to support the interventions' core functions across these three studies, we aim to build and improve the future evidence base of how to adapt, implement, and evaluate interventions to improve the cardiovascular health of people with SMI.
Highlights
Cardiovascular disease (CVD) is the primary cause of preventable death for people with serious mental illnesses (SMIs) [1], due in large part to elevated rates of cardiovascular disease (CVD) risk factors and risk behaviors that are 1.5–3 times higher in people with SMI than in the overall population [2,3,4,5]
We describe the implementation strategies being leveraged by the Johns Hopkins ALACRITY Center for Health and Longevity in Mental Illness, a research-practice translation center funded by the National Institute of Mental Health (NIMH) that aims to reduce premature mortality among people with SMI [26]
We describe the forms, or implementation strategies used to carry out the core functions, using Proctor et al.’s recommendations for specifying and reporting implementation strategies [21]
Summary
Cardiovascular disease (CVD) is the primary cause of preventable death for people with serious mental illnesses (SMIs) [1], due in large part to elevated rates of CVD risk factors (obesity, hypertension, dyslipidemia, and diabetes mellitus) and risk behaviors (tobacco smoking, physical inactivity, and unhealthy diet) that are 1.5–3 times higher in people with SMI than in the overall population [2,3,4,5]. The bundle includes two overarching components: [1] clinical care processes (e.g., annual dilated eye exam for patients with diabetes), and [2] care coordination and management processes (e.g., using a brief form to facilitate communication between a primary care provider and behavioral health home team at the time of a routinely scheduled visit) These evidence-based practices will be implemented using an adapted version of the Comprehensive Unit Safety Program (CUSP) strategy, which seeks to foster a team-based quality improvement culture and reduce preventable harm [31]. Since all of the interventions are being implemented by mental health program staff—not research staff—another core function is to educate clinicians and staff to be able to deliver the interventions’ components with fidelity and to use skills in motivational interviewing (i.e., an evidence-based and patient-centered communication method) to more effectively engage with clients in conversations around the targeted behaviors. By training providers and putting standard processes to implement evidence-based care in place, the CUSP implementation strategy is designed to improve the organization’s culture as well as providers’ self-efficacy to deliver guideline-concordant care
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