Practice-based Implementation Research Articles

Practice-Based Implementation Network: Behavioral Health Technician Optimization Pilot Lessons Learned.

Between June 2021 and December 2022, the Practice-Based Implementation (PBI) Network conducted a pilot to study the optimization of behavioral health technicians (BHTs) within military behavioral health (BH) care system specialty BH clinics. Behavioral health technicians are paraprofessionals found in all branches of the military, and with training across a variety of clinic functions. Behavioral health technicians support BH specialty providers in many clinic functions (i.e., administrative, case management, clinical, and outreach). The primary aim of the BHT optimization pilot was to increase BHTs' involvement in clinical care. Four military BH outpatient clinics participated in the BHT optimization pilot. Participants from the 4 clinics included 12 BHTs, 3 providers, 3 internal facilitators, and 3 dual-role providers/internal facilitators. The pilot asked each clinic to assess their BHT utilization needs, and then barriers and facilitators to BHT optimization were addressed by creating site-specific BHT optimization plans. The degree to which clinic optimization of BHTs impacts provider workload, clinic capability or capacity, and patient access to evidence-based care could not be determined during the BHT optimization pilot. However, individualized clinic BHT optimization plans and strategies appeared to be feasible and acceptable methods for military health system BH clinics to optimize BHTs' clinical skills. Lessons learned from this pilot included that: (1) clinics should consider establishing and maintaining action plans with specific, actionable goals for use of BHTs, and (2) BHT supervision, training, and clinic processes supporting optimization should be prioritized despite time constraints. Overall, individualized clinic BHT optimization plans and strategies appear to be feasible and acceptable methods for military health system BH clinics to optimize BHTs' clinical skills.

Conducting research with Indigenous Peoples in Canada: ethical and policy considerations.

The international context of Indigenous mental health and wellbeing has been shaped by a number of key works recognizing Indigenous rights. Despite international recognitions, the mental health and wellness of Indigenous Peoples continues to be negatively affected by policies that ignore Indigenous rights, that frame colonization as historical rather than ongoing, or that minimize the impact of assimilation. Research institutions have a responsibility to conduct ethical research; yet institutional guidelines, principles, and policies often serve Indigenous Peoples poorly by enveloping them into Western knowledge production. To counter epistemological domination, Indigenous Peoples assert their research sovereignty, which for the purposes of this paper we define as autonomous control over research conducted on Indigenous territory or involving Indigenous Peoples. Indigenous sovereignty might also be applied to research impacting the landscape and the web of animal and spiritual lives evoked in a phrase such as "all my relations." This narrative review of material developed in the Canadian context examines the alignment with similar work in the international context to offer suggestions and a practice-based implementation tool to support Indigenous sovereignty in research related to wellness, mental health, and substance use. The compilation of key guidelines and principles in this article is only a start; addressing deeper issues requires a research paradigm shift.

Are we being equitable enough? Lessons learned from sites lost in an implementation trial.

There is a growing interest in practice-based implementation research, yet too often research prioritizes and is most successful in academic settings. During a national implementation trial to evaluate the effectiveness of Collaborative Care for co-occurring opioid use and mental health disorders, we lost three of our 11 participating implementation sites, all representing community sites. To better understand needed supports for implementation trial participation, we conducted exit interviews (n = 5) with key staff at these community sites. Interview transcripts were double-coded and analyzed using Rapid Assessment Process. Qualitative themes were iteratively reviewed by the study team. Three themes emerged characterizing challenges for community sites, including that: (1) research threatens sites' most precious resource-staff; (2) staff lack comfort with and skills for research; and (3) research participation in its current form does not offer a clear return on investment. Learnings from this work illuminate some of the barriers community sites face when trying to participate in multisite implementation research. An undercurrent of participant perspectives was the belief that community sites like theirs are just not set up to successfully participate in clinical trial research, including population-based implementation trials. Future implementation trials should consider strategies that disrupt traditional approaches, increasing the equitable inclusion of diverse practice settings in implementation research.

An iterative approach to developing a multifaceted implementation strategy for a complex eHealth intervention within clinical practice

BackgroundThe number of complex eHealth interventions has increased considerably. Despite available implementation theory outlining well-designed strategies, implementing complex interventions within practice proves challenging and often does not lead to sustainable use. To improve sustainability, theory and practice should be addressed during the development of an implementation strategy. By subsequently transparently reporting the executed theory-based steps and their corresponding practice findings, others can learn from these valuable lessons learned. This study outlines the iterative approach by which a multifaceted implementation strategy for a complex eHealth intervention in clinical practice was developed, tested and refined.MethodsWe implemented the BENEFIT program, an advanced eHealth platform with Personal Health Portal facilitating healthy living in cardiac patients. In six iterative phases alternating between theory and practice, the implementation strategy was developed, tested and refined. The initial implementation strategy (phase 1) was drawn up using the Implementation model and RE-AIM. Subsequently, this strategy was further updated in brainstorming sessions and group discussions with twenty key stakeholders from three cardiac care centres and then evaluated in a pilot (phases 2 and 3).ResultsThe pilot of the program led to the identification of (context-specific) key challenges in practice (phase 4), which were subsequently connected back to broader theory (phase 5) using the Consolidated Framework of Implementation Research (CFIR). In the final phase, practice recommendations tackling the key challenges were formulated (phase 6) based on CFIR theory, the CFIR-ERIC Matching Tool, and stakeholders’ input and feedback. These recommendations were then added to the refined strategy. Thus, executing this approach led to the realisation and use of a multifaceted theory-informed practice-based implementation strategy.ConclusionThis case study gives an in-depth description of an iterative approach to developing an evidence-based, practice-tailored strategy for implementing a complex eHealth intervention in cardiac care. As such, this study may serve as a blueprint for other researchers aspiring to implement complex eHealth interventions within clinical practice sustainably.

Sample Size Calculations for Stepped Wedge Designs with Treatment Effects that May Change with the Duration of Time under Intervention

The stepped wedge design is often used to evaluate interventions as they are rolled out across schools, health clinics, communities, or other clusters. Most models used in the design and analysis of stepped wedge trials assume that the intervention effect is immediate and constant over time following implementation of the intervention (the “exposure time”). This is known as the IT (immediate treatment effect) assumption. However, recent research has shown that using methods based on the IT assumption when the treatment effect varies over exposure time can give extremely misleading results. In this manuscript, we discuss the need to carefully specify an appropriate measure of the treatment effect when the IT assumption is violated and we show how a stepped wedge trial can be powered when it is anticipated that the treatment effect will vary as a function of the exposure time. Specifically, we describe how to power a trial when the exposure time indicator (ETI) model of Kenny et al. (Statistics in Medicine, 41, 4311–4339, 2022) is used and the estimand of interest is a weighted average of the time-varying treatment effects. We apply these methods to the ADDRESS-BP trial, a type 3 hybrid implementation study designed to address racial disparities in health care by evaluating a practice-based implementation strategy to reduce hypertension in African American communities.

Pilot outcomes of cognitive processing therapy implementation in military health system outpatient behavioral health clinics.

Enterprise data indicates that U.S. service members (SMs) with posttraumatic stress disorder (PTSD) may not receive an evidence-based treatment (EBT) or may receive an EBT with low fidelity to the core components. Successful delivery of EBTs requires provider training and ongoing supervision/consultation, adjustment of clinic processes and structure, and leadership support. The Department of Defense (DoD) Practice-Based Implementation (PBI) Network is a dedicated team of implementation science specialists that support the integration of EBTs into clinical practice in the Military Health System (MHS). The PBI Network conducted a Cognitive Processing Therapy (CPT) pilot to investigate the acceptability and feasibility of a novel trauma specialist implementation approach proposed by South Texas Research Organizational Network Guiding Studies on Trauma and Resilience (STRONG STAR). This approach, CPT Trauma Specialist (CPT-TS), called for training designated behavioral health (BH) therapists as the primary CPT providers in their clinics. In collaboration with the Uniformed Services University Center for Deployment Psychology, the PBI Network provided training and consultation to 26 providers across 13 MHS BH clinics and supported ongoing facilitation. Despite provider interest and clinic leadership support, less than half of the pilot provider participants were able to meet the consultation and CPT delivery requirements for designation as a CPT trauma trained specialist. Prevalent implementation barriers included lack of adequate clinic resources, provider challenges balancing clinical and military-related duties, the need to focus on high-risk patients, and other military system-related constraints. These findings highlight the need for implementation scientists to examine alternatives to traditional training models and identify fidelity-consistent adaptations that allow for delivery of evidence-based care within highly constrained systems of care. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

O3-1 Key factors for sustainable implementation of community-based physical activity promotion with a focus on individuals with social disadvantages: a systematic review with narrative synthesis

Abstract Background According to the German prevention law (§ 20a SGB V) of 2016, statutory health insurances are legally bound to integrate sustainable setting-based health promotion in their activities. This includes the development of sustainable concepts for community-based physical activity promotion (cbPAP) with a focus on socially disadvantaged individuals (SDI) (e.g. individuals with low income, low social status) to improve health equity. The aim of the systematic review with a narrative synthesis is to identify context-specific factors for the sustainable implementation of cbPAP and further, to inform the project KOMBINE (German acronym for ‘Community-Based PA Promotion to Implement National Recommendations’) for a scientific and practice-based implementation of the National Recommendations for Physical Activity and Physical Activity Promotion in communities. Methods A systematic review with narrative synthesis was conducted. The search was carried out in the databases PubMed, Scopus, CINAHL, PsycINFO/SportDiscus, and WebofScience. Searches were limited to only include studies published up until 04/2020, in English and German. Altogether, qualitative, quantitative, “mixed-method” studies, reports and reviews were considered. Articles referring to factors of sustainable implementation of community-based physical activity promotion with a whole-system approach were included. Although this was not an inclusion criterion, articles addressing accessibility for SDI were specifically taken into account. The framework by Schell et al. (2013) was used for data extraction and analysis, while the four main elements from Popay et al. (2006) were applied in the narrative synthesis process. Results 29 studies (13 qualitative, 1 quantitative, 9 “mixed-method” studies, 3 reviews, 3 reports) were included in the review. 137 references to sustainability factors were identified. According to the framework by Schell et al. (2013), factors were most frequently reported in domains of organizational levels (21), partnerships (18) and financial stability (16). Additional factors in the domains of accessibilities for SDI (11), infrastructure (7), participation (9), and cultural context (10) were identified by the authors. The relationship between the factors and the context of the programs are considered as well. Conclusions The identified factors for sustainability should be systematically addressed at an early stage in the conception of cbPAP measures for SDI to ensure sustainability after implementation.

A culturally grounded autism parent training program with Black parents

Parent training programs have been well-studied in Autism Spectrum Disorders and shown to increase a parent's feeling of empowerment, advocacy skills, and treatment enrollment for their child. The majority of parent training interventions have been developed without considering the unique needs of under-represented communities, such as the Black community. Black children with autism are not only misdiagnosed or not diagnosed at all, but are not accessing services equally compared to their White peers. There is an urgent need for culturally adapted interventions in order to decrease the disparity gap. The Color of Autism Foundation developed and ran a parent training program for Black parents of children with autism. The program was grounded in two key features: (1) creating a circle of support for parents to connect and heal from ongoing and historical racial trauma and (2) using parents of Black children with autism as the main facilitators. We believe this increased parent's ability to engage in the educational aspects of the training. Overall, parents reported high levels of satisfaction with the training were highly engaged (attended an average of five of six sessions) and reported high levels of empowerment. Parents also reported continued mistrust in the medical and research community and a need for more Black providers. Further work should examine the relationship of the parent and provider in autism treatment and study the impact of circles of healing for Black families.

Creating a Practice-Based Implementation Network: Facilitating Practice Change Across Health Care Systems.

A proof-of-concept practice-based implementation network was developed in the US Departments of Veteran Affairs (VA) and Defense to increase the speed of implementation of mental health practices, derive lessons learned prior to larger-scale implementation, and facilitate organizational learning. One hundred thirty-four clinicians in 18 VA clinics received brief training in the use of the PTSD checklist (PCL) in clinical care. Two implementation strategies, external facilitation and technical assistance, were used to encourage the use of outcomes data to inform treatment decisions and increase discussion of results with patients. There were mixed results for changes in the frequency of PCL administration, but consistent increases in clinician use of data and incorporation into the treatment process via discussion. Programs and clinicians were successfully recruited to participate in a 2-year initiative, suggesting the feasibility of using this organizational structure to facilitate the implementation of new practices in treatment systems.

The Practice-Based Implementation (PBI) Network: Technology (Tech) into Care pilot.

Technology can support the use of evidence-based behavioral health treatments, as well as serve as a link to care to improve patient engagement and adherence to treatment. While research suggests that mobile applications (apps) specifically have the potential to enhance the delivery of behavioral health treatment, little guidance exists on how clinicians can effectively and safely integrate mobile apps into their clinical practice. The purpose of this paper is to describe the Department of Defense Practice-Based Implementation (PBI) Network's approach to implementation and present the results of the Technology (Tech) into Care pilot. The PBI Network conducted this pilot to address providers' knowledge gaps regarding the integration of mobile apps into behavioral health care within the Military Health System (MHS) and examine the feasibility of widespread dissemination of the practice change in the MHS. A mixed-method design guided by the Promoting Action on Research Implementation in Health Services framework was used to evaluate the approach and identify facilitators and barriers to practice change. Positive preliminary support for the feasibility of the Tech into Care approach was demonstrated in improvements in providers' knowledge, comfort, and perceived level of preparation to integrate mobile apps into care. Organizational challenges including time constraints and staff turnover negatively impacted implementation success. The PBI Network Tech into Care implementation approach is a feasible method to address knowledge gaps related to the integration of mobile apps into clinical practice within the MHS. Contextual factors, such as competing time demands, often impede providers' ability to effectively integrate mobile apps into care.

Development and Guiding Principles of the Icelandic Model for Preventing Adolescent Substance Use.

Adolescent substance use—the consumption of alcohol, tobacco, and other harmful drugs—remains a persistent global problem and has presented ongoing challenges for public health authorities and society. In response to the high rates of adolescent substance use during the 1990s, Iceland has pioneered in the development of the Icelandic Model for Primary Prevention of Substance Use—a theory-based approach that has demonstrated effectiveness in reducing substance use in Iceland over the past 20 years. In an effort to document our approach and inform potentially replicable practice-based processes for implementation in other country settings, we outline in a two-part series of articles the background and theory, guiding principles of the approach, and the core steps used in the successful implementation of the model. In this article, we describe the background context, theoretical orientation, and development of the approach and briefly review published evaluation findings. In addition, we present the five guiding principles that underlie the Icelandic Prevention Model’s approach to adolescent substance use prevention and discuss the accumulated evidence that supports effectiveness of the model. In a subsequent Part 2 article, we will identify and describe key processes and the 10 core steps of effective practice-based implementation of the model.

Accelerating Psychological Health Research Findings into Clinical Practice Through the Practice-Based Implementation Network Model.

The benefits of new clinical research developments often take years to reach patients. As such, the Departments of Defense (DoD) and Veterans Affairs built the Practice-Based Implementation (PBI) Network as an infrastructure to facilitate more rapid translation of psychological health (PH) research into clinical practice changes to improve the quality of care for military and Veteran patients. To regularly identify research findings appropriate for enterprise implementation, the DoD PBI Network developed a model aligned with the Consolidated Framework for Implementation Research to select and pilot PH practice change. Within this model, practice change pilots were selected following a survey of field clinicians, a public call for proposals, annual meeting of implementation science subject matter experts, and final pilot selection by PH strategic leaders. These components facilitated commitment and engagement from Military Health System PH leadership, as well as clinicians, leading to increased stakeholder buy-in and efficiency with selecting and piloting PH practice change. The DoD PBI Network model has been refined for future PH research translation pilots. It serves as a first operational model for annual implementation of PH research findings in the DoD and may be of use to other entities engaged in practice change implementation.

The DoD practice-based implementation (PBI) Network: estimating return on investment

The Department of Defense (DoD) and veterans affairs (VA) built the practice-based implementation (PBI) Network in 2013 to facilitate more rapid translation of psychological health (PH) research findings into clinical practice. DoD PBI Network operations include centrally located facilitators, a military treatment facility PH clinic network, liaison site champions, and enterprise governance. The PBI Network works to identify new research findings for enterprise-wide practice change implementation; pilots identified practice changes; evaluates implementation; and provides enterprise feedback to inform policy and practice decisions. Infrastructure establishment yielded two major benefits: increased speed of selecting, piloting, and adopting sustained practice change, and increased stakeholder buy-in during implementation. The PBI Network grant final report required evaluation of return-on-investment (ROI) (DoD 2016). The DoD health care system did not produce data necessary to conduct a traditional ROI, or to assess cost effectiveness using normally qualifying concept categories; the complex framework of the PBI Network includes many intrinsic factors not normally qualifying for a traditional ROI analysis. Instead, we developed a new alternative model and methodology, identified data requirements and limitations, and tested the model. This manuscript describes the theoretical basis for the model and methodology, and explores further potential applications of the model.

Perceptions of Health Care Transition Care Coordination in Patients With Chronic Illness.

Expert consensus jointly authored in 2011 by the American Academy of Pediatrics, American Academy of Family Physicians, and American College of Physicians supports the use of health care transition (HCT) care coordination (CC). Although gaps in care are addressed in these practice-based implementation recommendations, such recommendations have never undergone rigorous assessment. We assessed the effectiveness of implementation on quality of chronic illness care and CC during HCT for adolescents and young adults. Adolescents and young adults with special health care needs were enrolled in a randomized HCT CC intervention. Intervention participants received HCT CC as outlined in the 2011 clinical report. Perceptions of chronic illness care quality and CC were assessed at 0, 6, and 12 months. Intervention participants had a Patient Assessment of Chronic Illness Care score at 12 months of 3.6 vs 3.3 compared with participants in the control group (P = .01). Intervention participants had higher average scores for patient activation (3.7 vs 3.4; P = .01), problem solving (3.8 vs 3.4; P = .02), and coordination/follow-up (3.0 vs 2.5; P < .01). The Client Perceptions of Coordination Questionnaire revealed that intervention participants had 2.5 times increased odds to endorse mostly or always receiving the services they thought they needed and had 2.4 times increased odds to have talked to their provider about future care (P < .01). Implementing recommended HCT CC practices improved patient or patient caregiver perception of quality of chronic illness care and CC especially among the most complex patients.

Identifying a practice-based implementation framework for sustainable interventions for improving the evolving working environment: Hitting the Moving Target Framework

Our aim was to identify implementation components for sustainable working environment interventions in the nursing assistant sector to generate a framework to optimize the implementation of workplace improvement initiatives. The implementation framework was informed by: 1) an industry advisory group, 2) interviews with key stakeholder, 3) concept mapping workshops, and 4) an e-mail survey. Thirty five stakeholders were interviewed and contributed in the concept mapping workshops. Eleven implementation components were derived across four domains: 1) A supportive organizational platform, 2) An engaged workplace with mutual goals, 3) The intervention is sustainably fitted to the workplace, and 4) the intervention is an attractive choice. The highest rated component was “Engaged and Active Management” (mean 4.1) and the lowest rated was “Delivered in an Attractive Form” (mean 2.8). The framework provides new insights into implementation in an evolving working environment and is aiming to assist with addressing gaps in effectiveness of workplace interventions and implementation success.

Feasibility of Assessing Parental ACEs in Pediatric Primary Care: Implications for Practice-Based Implementation

To determine the feasibility and provider acceptability of implementing assessments for parental ACEs within the context of an outpatient pediatric clinic, and to compare parental ACE detection rates between an item-level response tool and an aggregate-level response tool. A convenience sample of parents completed one of two assessment tools during their child’s four month well visit. Detection of ACE scores ≥4 was compared between the two tools. Providers conducting the assessments completed a qualitative survey describing their experiences. Detection rates were significantly higher with the use of an aggregate-level reporting tool compared to item-level tool (11.2% versus 8.1%, p = 0.013). Provider feedback on the assessment process was positive; providers reported improved clinic visits without undue burden in terms of time constraints or parental resistance to ACE assessments. Implementing parental ACE assessments is feasible with limited resources in an outpatient setting. Providers and parents appear receptive to the conversations about past trauma, and find value in including this information in their counseling during well visits. Parents appear to be more likely to disclose ACEs when a degree of privacy is given through aggregate-level versus item-level reporting.

Practice-Based Implementation Research on the National Scale-Up of Micronutrient Powders in Bolivia

Practice-Based Implementation Research on the National Scale-Up of Micronutrient Powders in Bolivia

The Counseling African Americans to Control Hypertension Study and Ways to Enhance the Next Wave of Behavioral Interventions

The Counseling African Americans to Control Hypertension (CAATCH) study by Ogedegbe et al in this issue of Circulation represents a carefully done study which had many strengths. It recognized that African Americans have the highest prevalence of hypertension (HTN)1 and that poor hypertension-related outcomes explain most of the racial gap in mortality between African Americans and whites.2 It represents the largest practice-based implementation trial to date of a multilevel evidence-based intervention targeted at blood pressure control in hypertensive African Americans in community health centers (CHCs), where many low income Americans receive their care. In addition, although the individual components of CAATCH (patient education, home BP monitoring, CME, physician chart audit and feedback) have proven efficacious and effective for improving BP control,3 the effectiveness of a combined approach in CHCs has not been rigorously evaluated. The study was adequately powered to detect a difference of at least 4 mmHg for systolic BP and 3 mm Hg for diastolic BP at 12 months between intervention and control arms assuming a 15% attrition rate.

Institutional Review Board Barriers and Solutions Encountered in the Collaboration Among Pharmacists and Physicians to Improve Outcomes Now Study: A National Multicenter Practice-Based Implementation Trial

To categorize institutional review board (IRB) challenges and solutions encountered in a multicenter practice-based research network (PBRN) study and to assess the impact of IRB requirements on the willingness of individual principal investigators (PIs) to participate in future PBRN studies. Descriptive analysis of IRB challenges and solutions encountered in the Collaboration Among Pharmacists and Physicians to Improve Outcomes Now (CAPTION) trial, a multicenter prospective cluster-randomized study conducted by the National Interdisciplinary Primary Care PBRN, and a correlational analysis from a survey of individual site PIs. IRB barriers encountered and solutions were categorized for study sites. A survey of study-site PIs was conducted with a correlational analysis assessing the impact of various IRB requirements and the willingness of individual PIs to participate in future PBRN studies; of 31 study sites participating in the CAPTION study, 28 study-site PIs were surveyed. IRBs posed a number of challenges including bias regarding the source of the application, issues regarding study design, study instruments, access to patient records, study procedures, Spanish-only speaking subjects, role of clinic physicians, interdepartmental concerns, and updates at continuing review. Responses from the PI survey (21 of 28 PIs surveyed [75% response rate]) indicated that the willingness of an individual to serve as a PI in the future was inversely related to the perceived difficulty of obtaining initial (rS =-0.599, p=0.004) and continuing (rS =-0.464, p=0.034) IRB approval. Significant time and resources were required to address various challenges associated with IRB approval, which had a negative impact on an individual PI's willingness to participate in future PBRN projects. A revision of current rules and regulations regarding the protection of human subjects for practice-based studies, improvement in IRB processes, and support from coordinating centers may decrease the burden associated with IRB approval and increase participation in practice-based research.

Institutional Review Board Barriers and Solutions Encountered in the Collaboration Among Pharmacists and Physicians to Improve Outcomes Now Study: A National Multicenter Practice-Based Implementation Trial

Institutional Review Board Barriers and Solutions Encountered in the Collaboration Among Pharmacists and Physicians to Improve Outcomes Now Study: A National Multicenter Practice-Based Implementation Trial