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Using NIATx strategies to implement integrated services in routine care: a study protocol.

ABSTRACT: BACKGROUND:Access to integrated services for individuals with co-occurring substance use and mental health disorders is a long-standing public health issue. Receiving integrated treatment services are both more effective and preferred by patients and families versus parallel or fragmented care. National policy statements and expert consensus guidelines underscore the benefits of integrated treatment. Despite decades of awareness, adequate treatment for individuals with co-occurring substance use and mental health disorders occurs infrequently. The underlying disease burden associated with alcohol, illicit and prescription drug problems, as well as mental health disorders, such as depression, posttraumatic stress disorder and schizophrenia, is substantial. METHODS:This cluster randomized controlled trial (RCT) is designed to determine if the multi-component Network for the Improvement of Addiction Treatment (NIATx) strategies are effective in implementing integrated services for persons with co-occurring substance use and mental health disorders. In this study, 50 behavioral health programs in Washington State will be recruited and then randomized into one of two intervention arms: 1) NIATx implementation strategies, including coaching and learning sessions over a 12-month intervention period to implement changes targeting integrated treatment services; or 2) wait-list control. Primary outcome measures include: 1) fidelity - a standardized organizational assessment of integrated services (Dual Diagnosis in Addiction Treatment [DDCAT] Index); and 2) penetration - proportion of patients screened and diagnosed with co-occurring disorders, proportion of eligible patients receiving substance use and mental health services, and psychotropic or substance use disorder medications. Barriers and facilitators, as determinants of implementation outcomes, will be assessed using the Consolidated Framework for Implementation Research (CFIR) Index. Fidelity to and participation in NIATx strategies will be assessed utilizing the NIATx Fidelity Scale and Stages of Implementation Completion (SIC). DISCUSSION:This study addresses an issue of substantial public health significance: the gap in access to an evidence-based practice for integrated treatment for individuals with co-occurring mental health and substance use disorders. The study utilizes rigorous and reproducible quantitative approaches to measuring implementation determinants and strategies, and may address a longstanding gap in the quality of care for persons with co-occurring disorders. TRIAL REGISTRATION:ClinicalTrials.gov NCT03007940 . Registered 02 January 2017 - Retrospectively Registered.

SUBMITTER: Ford JH

PROVIDER: S-EPMC5994046 | biostudies-literature | 2018 Jun

REPOSITORIES: biostudies-literature

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Using NIATx strategies to implement integrated services in routine care: a study protocol.

Ford James H JH Osborne Eric L EL Assefa Mehret T MT McIlvaine Amy M AM King Ahney M AM Campbell Kevin K McGovern Mark P MP

BMC health services research 20180608 1

<h4>Background</h4>Access to integrated services for individuals with co-occurring substance use and mental health disorders is a long-standing public health issue. Receiving integrated treatment services are both more effective and preferred by patients and families versus parallel or fragmented care. National policy statements and expert consensus guidelines underscore the benefits of integrated treatment. Despite decades of awareness, adequate treatment for individuals with co-occurring subst ...[more]

PMID: 29884164

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Project description:BackgroundAlthough the COVID-19 pandemic has significantly boosted the implementation of digital services worldwide, it has become increasingly important to understand how these solutions are integrated into professionals' routine work. Professionals who are using the services are key influencers in the success of implementations. To ensure successful implementations, it is important to understand the multiprofessional perspective, especially because implementations are likely to increase even more.ObjectiveThe aim of this study is to examine health and social care professionals' experiences of digital service implementations and to identify factors that support successful implementations and should be considered in the future to ensure that the services are integrated into professionals' routine work.MethodsA qualitative approach was used, in which 8 focus group interviews were conducted with 30 health and social care professionals from 4 different health centers in Finland. Data were analyzed using qualitative content analysis. The resulting categories were organized under the components of normalization process theory.ResultsOur results suggested 14 practices that should be considered when implementing new digital services into routine work. To get professionals to understand and make sense of the new service, (1) the communication related to the implementation should be comprehensive and continuous and (2) the implementation process should be consistent. (3) A justification for the service being implemented should also be given. The best way to engage the professionals with the service is (4) to give them opportunities to influence and (5) to make sure that they have a positive attitude toward the service. To enact the new service into professionals' routine work, it is important that (6) the organization take a supportive approach by providing support from several easy and efficient sources. The professionals should also have (7) enough time to become familiar with the service, and they should have (8) enough know-how about the service. The training should be (9) targeted individually according to skills and work tasks, and (10) it should be diverse. The impact of the implementation on the professionals' work should be evaluated. The service (11) should be easy to use, and (12) usage monitoring should happen. An opportunity (13) to give feedback on the service should also be offered. Moreover, (14) the service should support professionals' work tasks.ConclusionsWe introduce 14 practices for organizations and service providers on how to ensure sustainable implementation of new digital services and the smooth integration into routine work. It is important to pay more attention to comprehensive and continuing communication. Organizations should conduct a competence assessment before training in order to ensure proper alignment. Follow-ups to the implementation process should be performed to guarantee sustainability of the service. Our findings from a forerunner country of digitalization can be useful for countries that are beginning their service digitalization or further developing their digital services.

Project description:BACKGROUND:An estimated 8.2 million adults in the United States live with co-occurring mental health and substance use disorders. Although the benefits of integrated treatment services for persons with co-occurring disorders has been well-established, gaps in access to integrated care persist. Implementation research can address this gap. We evaluated if the Network for the Improvement of Addiction Treatment (NIATx) implementation strategy was effective in increasing integrated services capacity among organizations treating persons with co-occurring disorders. METHODS:This study employed a cluster randomized waitlist control group design. Forty-nine addiction treatment organizations from the State of Washington were randomized into one of two study arms: (1) NIATx strategy (active implementation strategy), or (2) waitlist (control). The primary outcome was a standardized organizational measure of integrated service capability: the Dual Diagnosis in Addiction Treatment (DDCAT) Index. Intent-to-treat analyses and per-protocol analyses were conducted to address the following questions: (1) Is NIATx effective in increasing integrated service capacity? and (2) Are there differences in organizations that actually use NIATx per-protocol versus those that do not? RESULTS:From baseline to one-year post active implementation, both the NIATx strategy and waitlist arms demonstrated improvements over time in DDCAT Index total and DDCAT dimension scores. In intent-to-treat analyses, a moderate but statistically significant difference in improvement between study arms was seen only in the Program Milieu dimension (p =?0.020, Cohen's d?=?0.54). In per-protocol analyses, moderate-to-large effects in Program Milieu (p =?0.002, Cohen's d?=?0.91) and Continuity of Care (p =?0.026, Cohen's d?=?0.63) dimensions, and in total DDCAT Index (p =?0.046, Cohen's d?=?0.51) were found. CONCLUSIONS:Overall, organizations in both study arms improved DDCAT Index scores over time. Organizations in the NIATx strategy arm with full adherence to the NIATx protocol had significantly greater improvements in the primary outcome measure of integrated service capacity for persons with co-occurring disorders. TRAIL REGISTRATION:ClinicalTrials.gov, NCT03007940 . Retrospectively registered January 2017.

Project description:BackgroundBlunt chest injury can lead to significant morbidity and mortality if not treated appropriately. A blunt chest injury care bundle was to be implemented at two sites to guide care.AimTo identify facilitators and barriers to the implementation of a blunt chest injury care bundle and design strategies tailored to promote future implementation.Methods1) A mixed-method survey based on the theoretical domains framework (TDF) was used to identify barriers and facilitators to the implementation of a blunt chest injury care bundle. This survey was distributed to 441 staff from 12 departments across two hospitals. Quantitative data were analysed using SPSS and qualitative using inductive content analysis. 2) The quantitative and qualitative results from the survey were integrated and mapped to each of the TDF domains. 3) The facilitators and barriers were evaluated using the Behaviour Change Wheel to extract specific intervention functions, policies, behaviour change techniques and implementation strategies. Each phase was assessed against the Affordability, Practicability, Effectiveness and cost-effectiveness, Acceptability, Side-effects or safety and Equity (APEASE) criteria.ResultsOne hundred ninety eight staff completed the survey. All departments surveyed were represented. Nine facilitators and six barriers were identified from eight domains of the TDF. Facilitators (TDF domains) were: understanding evidence-informed patient care and understanding risk factors (Knowledge); patient assessment skills and blunt chest injury management skills (Physical skills); identification with professional role (Professional role and identity); belief of consequences of care bundle (Belief about consequences); provision of training and protocol design (Environmental context and resources); and social supports (Social influences). Barriers were: not understanding the term 'care bundle' (Knowledge); lacking regional analgesia skills (Physical skills); not remembering to follow protocol (Memory, attention, and decision processes); negative emotions relating to new protocols (Emotions); equipment and protocol access (Environmental context and resources). Implementation strategies were videos, education sessions, visual prompt for electronic medical records and change champions.ConclusionsMultiple facilitators and barriers were identified that may affect the implementation of a blunt chest injury care bundle. Implementation strategies developed through this process have been included in a plan for implementation in the emergency departments of two hospitals. Evaluation of the implementation is underway.

Project description:BACKGROUND:Overtreatment and overtesting expose patients to unnecessary, wasteful, and potentially harmful care. Reducing overtreatment or overtesting that has become ingrained in current clinical practices and is being delivered on a routine basis will require solutions that incorporate a deep understanding of multiple perspectives, particularly those on the front lines of clinical care: patients and their clinicians. Design approaches are a promising and innovative way to incorporate stakeholder needs, desires, and challenges to develop solutions to complex problems. OBJECTIVE:This study aimed (1) to engage patients in a design process to develop high-level deintensification strategies for primary care (ie, strategies for scaling back or stopping routine medical services that more recent evidence reveals are not beneficial) and (2) to engage both patients and primary care providers in further co-design to develop and refine the broad deintensification strategies identified in phase 1. METHODS:We engaged stakeholders in design charrettes-intensive workshops in which key stakeholders are brought together to develop creative solutions to a specific problem-focused on deintensification of routine overuse in primary care. We conducted the study in 2 phases: a 6.5-hour design charrette with 2 different groups of patients (phase 1) and a subsequent 4-hour charrette with clinicians and a subgroup of phase 1 patients (phase 2). Both phases included surveys and educational presentations related to deintensification. Phase 1 involved several design activities (mind mapping, business origami, and empathy mapping) to help patients gain a deeper understanding of the individuals involved in deintensification. Following that, we asked participants to review hypothetical scenarios where patients, clinicians, or the broader health system context posed a barrier to deintensification and then to brainstorm solutions. The deintensification themes identified in phase 1 were used to guide phase 2. This second phase primarily involved 1 design activity (WhoDo). In this activity, patients and clinicians worked together to develop concrete actions that specific stakeholders could take to support deintensification efforts. This activity included identifying barriers to the actions and approaches to overcoming those barriers. RESULTS:A total of 35 patients participated in phase 1, and 9 patients and 7 clinicians participated in phase 2. The analysis of the deintensification strategies and survey data is currently underway. The results are expected to be submitted for publication in early 2020. CONCLUSIONS:Health care interventions are frequently developed without input from the people who are most affected. The exclusion of these stakeholders in the design process often influences and limits the impact of the intervention. This study employed design charrettes, guided by a flexible user-centered design model, to bring clinicians and patients with differing backgrounds and with different expectations together to cocreate real-world solutions to the complex issue of deintensifying medical services. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID):RR1-10.2196/15618.

Project description:BackgroundThe prescription of physical activity (PA) in clinical care has been advocated worldwide. This "exercise is medicine" (E=M) concept can be used to prevent, manage, and cure various lifestyle-related chronic diseases. Due to several challenges, E=M is not yet routinely implemented in clinical care.ObjectiveThis paper describes the rationale and design of the Physicians Implement Exercise = Medicine (PIE=M) study, which aims to facilitate the implementation of E=M in hospital care.MethodsPIE=M consists of 3 interrelated work packages. First, levels and determinants of PA in different patient and healthy populations will be investigated using existing cohort data. The current implementation status, facilitators, and barriers of E=M will also be investigated using a mixed-methods approach among clinicians of participating departments from 2 diverse university medical centers (both located in a city, but one serving an urban population and one serving a more rural population). Implementation strategies will be connected to these barriers and facilitators using a systematic implementation mapping approach. Second, a generic E=M tool will be developed that will provide tailored PA prescription and referral. Requirements for this tool will be investigated among clinicians and department managers. The tool will be developed using an iterative design process in which all stakeholders reflect on the design of the E=M tool. Third, we will pilot-implement the set of implementation strategies, including the E=M tool, to test its feasibility in routine care of clinicians in these 2 university medical centers. An extensive learning process evaluation will be performed among clinicians, department managers, lifestyle coaches, and patients using a mixed-methods design based on the RE-AIM framework.ResultsThis project was approved and funded by the Dutch grant provider ZonMW in April 2018. The project started in September 2018 and continues until December 2020 (depending on the course of the COVID-19 crisis). All data from the first work package have been collected and analyzed and are expected to be published in 2021. Results of the second work package are described. The manuscript is expected to be published in 2021. The third work package is currently being conducted in clinical practice in 4 departments of 2 university medical hospitals among clinicians, lifestyle coaches, hospital managers, and patients. Results are expected to be published in 2021.ConclusionsThe PIE=M project addresses the potential of providing patients with PA advice to prevent and manage chronic disease, improve recovery, and enable healthy ageing by developing E=M implementation strategies, including an E=M tool, in routine clinical care. The PIE=M project will result in a blueprint of implementation strategies, including an E=M screening and referral tool, which aims to improve E=M referral by clinicians to improve patients' health, while minimizing the burden on clinicians.

Project description:BackgroundIntegrated care is recognised as an important enabler to healthy ageing, yet few countries have managed to sustainably deliver integrated care for older people. We aimed to gather global consensus on the key actions required to realign health and long-term systems and integrate services to implement the World Health Organization (WHO) Integrated Care for Older People (ICOPE) approach.MethodsA two-round eDelphi study, including a global consultation meeting, was undertaken to identify, refine and generate consensus on the actions required across high-, middle- and low-income countries to implement the WHO ICOPE approach. In round 1, a framework of 31 actions, empirically derived from previous WHO evidence reviews was presented to panellists to judge the relative importance of each action (numeric rating scale; range:1-9) and provide free-text comments concerning the scope of the actions. These outcomes were discussed and debated at the global consultation meeting. In round 2, a revised framework of 19 actions was presented to panellists to measure their extent of agreement and identify 'essential' actions (five-point Likert scale; range: strongly agree to strongly disagree). A threshold of ≥80% for agree/strongly agree was set a priori for consensus.ResultsAfter round 1 (n = 80 panellists), median scores across 31 actions ranged from 6 to 9. Based on pre-defined category thresholds for median scores, panellists considered 28 actions (90·3%) as 'important' and three (9·7%) as 'uncertain'. Fifteen additional actions were suggested for inclusion based on free-text comments, creating 46 for consideration at the global consultation meeting. In round 2 (n = 84 panellists), agreement (agree or strongly agree) ranged from 84·6-97·6%, suggesting consensus. Fourteen (73·7%) actions were rated as essential.ConclusionFourteen essential actions and five important actions are necessary at system (macro; n = 10) and service (meso; n = 9) levels to implement community-based integrated care for older people.

Project description:BackgroundIncreased awareness of the world's problematic growing health care expenditure and health care shortages requires sustainable use of available resources. To promote cultural changes in medical mindsets, societies representing medical specialties have developed new Choosing Wisely strategies. The Valais Medical Society and the Valais Pharmacy Association have developed an interprofessional collaboration project entitled "Less-is-more Together-PPI" to analyze and optimize change management practices focusing on the prescription and deprescription of proton pump inhibitors (PPIs).ObjectiveThis study aims to enhance interprofessional collaboration between physicians, pharmacists, and patients to optimize PPI use, avoid unnecessary treatments and improve therapeutic adherence to indicated therapies, and to analyze hindrances and facilitators to implementing interprofessional Less-is-more strategies in the field.MethodsHome-dwelling adults domiciled in Valais and prescribed PPIs in the last 6 months will be invited to participate in this observational study. The studied subpopulation will be constituted of consenting patients whose physicians and pharmacists also voluntarily agree to participate. The process of collecting, pooling, transmitting, evaluating, and protecting data has been validated by the Human Research Ethics Committee of the Canton Vaud.ResultsThe Primary Triple Aim outcome measures will be (1) population health: patient's assessment of their own health, functional status, and disease burden using a monthly questionnaire for 6 months; Behavioral/physiological factors will be investigated using a final questionnaire at 6 months, (2) experience of care: assessment using a final questionnaire for participating patients, pharmacists and physicians, and an analysis of negative/positive experiences via 6 follow-up questionnaires, and (3) Per capita cost: participants' fluctuating or decreasing PPI intake (number of pills/dosage) and an analysis of participants' different categories following their medical prescription, in relation to possible bias effects on the overall drug intake of the population studied. Secondary outcomes will be participation rates; patient, physician, and pharmacist follow-up; and evaluations of participants' experiences and their perceived benefits, as well as whether the interprofessional process can be improved.ConclusionsThis project seeks a deeper understanding of how Less-is-more and smarter-medicine strategies are perceived by patients and health care providers in their daily lives in a very specific context. It will reveal some of the hindrances to and facilitators for efficient cultural change toward a more sustainable health care system. The results will be useful to optimize and scale up further Choosing Wisely approaches.International registered report identifier (irrid)DERR1-10.2196/13896.

Dataset Information

Using NIATx strategies to implement integrated services in routine care: a study protocol.

Publications

Using NIATx strategies to implement integrated services in routine care: a study protocol.

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