Sustainability of depression care improvements: success of a practice change improvement collaborative.

BACKGROUND: Long-term sustainment of improvements in care continues to challenge primary care practices. During the 2 years after of our Improving Depression Care collaborative, we examined how well practices were sustaining their depression care improvements. METHODS: Our study design used a qualitative interview follow-up of a modified learning collaborative intervention. We conducted telephone interviews with practice champions from 15 of the original 16 practices. Interviews were conducted during a 3-month period in 2008, and were recorded and professionally transcribed. Data on each of the depression care improvements and the change management strategy emphasized during the learning collaborative were summarized after review of the primary data and a consensus process to resolve differing interpretations. RESULTS: During the period from 15 months to 3 years since our project began, depression screening or case finding was sustained in 14 of 15 practices. Thirteen practices sustained use of the 9-item Patient Health Questionnaire for depression monitoring, and one additional practice initiated it. Seven practices initiated self-management support and 2 of 3 practices sustained it. In contrast, tracking and case management proved difficult to sustain, with only 4 of 8 practices continuing this activity. Diffusion of use of the 9-item Patient Health Questionnaire to other clinicians in the practice was maintained in all but 3 practices and expanded in one practice. Six of the practices continued to use the change management strategy, including all 4 of the practices that sustained tracking. CONCLUSIONS: Practices demonstrated long-term sustained improvement in depression care with the exception of tracking and care management, which may be a more challenging innovation to sustain. We hypothesize that sustaining complex depression care innovations may require active management by the practice.

It takes two: using coleaders to champion improvements in small primary care practices.

BACKGROUND: Making the kind of improvement changes necessary to move toward a patient-centered medical home will continue to challenge small, independent primary care practices. Here we describe further analysis of a successful program to understand the roles of coleaders of a change management process. METHODS: Through an improvement collaborative we trained 2 coleaders (a physician and a non-physician) from 16 small primary care practices to institute depression care improvements. These coleaders participated in 3 learning sessions that provided depression care content as well as skills to implement a change management strategy. Qualitative data were collected by observation during the learning sessions and through in-depth interviews conducted at baseline, between each learning session, at the end of the project, 6 months after the project ended, and, finally, 26 months after the project's end. RESULTS: Interview results with the coleaders affirmed that a team approach is a viable strategy for practice improvement. The 2 coleaders used their complementary skills, relationships, and credibility among the practice staff to implement and sustain practice improvements. In their differing roles, they varied in how they perceived barriers to change and how they assessed their team's progress. CONCLUSIONS: Involving both a physician and a non-physician as coleaders enables improvement teams in small primary care practices to make progress both in the clinical content of their work and in the critical change management activities involved with creating a team, managing meetings, and coordinating work between meetings. Using a coleader structure enriches the improvement process, broadens participation in the change process, and helps to sustain these efforts over time.

Integrating practices' change processes into improving quality of depression care.

BACKGROUND: Primary care practices would benefit from improved understanding of how to make and sustain fundamental changes in their delivery systems. An improvement collaborative project was conducted in 2005 to not only improve the quality of depression care but help participating practices adopt and adapt more effective change processes to implement improved depression care. In a follow-up to an article on the project's impact in terms of measurable, sustained improvements in depression care, an exploratory qualitative study was conducted to examine primary care practices' adoption of effective change processes. METHODS: Qualitative data were collected from 16 primary care practices participating in the National Depression Management Leadership Initiative's Improving Depression Care project. A multistep process of qualitative analysis was used to identify exemplar practices, and a constant comparative method was applied to identify salient features that influenced adoption of change processes associated with improvements in depression care during the course of the 18-month project. RESULTS: The participating practices showed considerable variability in terms of the improvements they made in depression care and corresponding adoption of change processes to help make these and other improvements. Nearly all practices that showed the greatest improvements in depression care also adopted more effective processes for change, with several features associated with exemplar practices able to improve depression care and change processes. DISCUSSION: These findings support the thesis that successful quality improvement efforts should address both clinical content and change processes. They also add to the literature on the impact of improvement collaborative projects, which to date have demonstrated mixed effects in a variety of chronic diseases, including depression.

Inducing sustainable improvement in depression care in primary care practices.

BACKGROUND: Improving primary care depression care is costly and challenging to sustain. The feasibility and potential success ofa modified improvement collaborative model to create sustained improvements in depression care was assessed. METHODS: Sixteen practices from the American Academy of Family Physicians National Research Network and the American College of Physicians Practice-based Research Network completed a nine-month program. Two practice champions (PCs) from each practice attended three two-day learning sessions, where practice change strategies and key depression care elements were discussed. The nine-item Patient Health Questionnaire (PHQ-9) was used for screening, diagnosis, surveillance, tracking and care management, and self-management support. Pre- and postintervention depression care survey data were gathered from all practice clinicians, and qualitative data were collected via interviews with PCs and field notes from learning sessions. RESULTS: On the basis of PC reports at nine months, 16 practices had implemented the PHQ-9 for depression case-finding and 13 for monitoring severity; 5 practices had implemented tracking and care management and 1, self-management support. At the 15-month follow-up, nearly all changes had been sustained, and additional practices had implemented tracking/care management and self-management support. Significant pre-post improvements were reported on several subscales of the clinician survey, demonstrating substantial diffusion from the PC to other clinicians in the practice. DISCUSSION: The program led to measurable improvements in implementation of office procedures and systems known to improve depression care. The improvements were both sustained beyond the end of the program and substantially diffused to the other clinicians in the practice.

Care management for depression in primary care practice: findings from the RESPECT-Depression trial.

PURPOSE: This qualitative study examined the barriers to adopting depression care management among 42 primary care clinicians in 30 practices. METHODS: The RESPECT-Depression trial worked collaboratively with 5 large health care organizations (and 60 primary care practices) to implement and disseminate an evidence-based intervention. This study used semistructured interviews with 42 primary care clinicians from 30 practice sites, 18 care managers, and 7 mental health professionals to explore experience and perceptions with depression care management for patients. Subject selection in 4 waves of interviews was driven by themes emerging from ongoing data analysis. RESULTS: Primary care clinicians reported broad appreciation of the benefits of depression care management for their patients. Lack of reimbursement and the competing demands of primary care were often cited as barriers. These clinicians at many levels of initial enthusiasm for care management increased their enthusiasm after experiencing care management through the project. Psychiatric oversight of the care manager with suggestions for the clinicians was widely seen as important and appropriate by clinicians, care managers, and psychiatrists. Clinicians and care managers emphasized the importance of establishing effective communication among themselves, as well as maintaining a consistent and continuous relationship with the patients. The clinicians were selective in which patients they referred for care management, and there was wide variation in opinion about which patients were optimal candidates. Care managers were able to operate both from within a practice and more centrally when specific attention was given to negotiating communication strategies with a clinician. CONCLUSIONS: Care management for depression is an attractive option for most primary care clinicians. Lack of reimbursement remains the single greatest obstacle to more widespread adoption.

Implementing a depression improvement intervention in five health care organizations: experience from the RESPECT-Depression trial.

A growing body of research provides strong evidence for the effectiveness of programs to improve the primary care of depression based on the chronic care model. At the same time these changes are difficult to sustain in their original research settings and more difficult to widely disseminate in primary care practice. The RESPECT-Depression trial tested an implementation and dissemination strategy by working through five community-based health care organizations (HCOs) to implement the Three Component Model (TCM) for improving depression care. This report describes the results of extensive interviews of project principals, health care program managers, depression care managers, and practicing primary care clinicians to understand the characteristics of organizations and the intervention components that were associated with implementation and dissemination of the TCM. In two of the organizations all 29 participating practices continued the TCM, while all 31 practices from the other three organizations did not. Successful continuation and dissemination appeared to be related to a broadly shared vision and commitment among all levels of the organization, clearly articulated by clinical leadership, for pursuing a systematic change strategy to improve chronic care that included, but extended beyond, depression, independent of clear evidence for cost-effectiveness of expanding depression management. Factors associated with inability to sustain the TCM included lack of a shared change strategy throughout the organization and inability to rationalize an economic model of depression care.

Selecting, implementing, and evaluating teen pregnancy prevention interventions: lessons from the CDC's Community Coalition Partnership Programs for the Prevention of Teen Pregnancy.

PURPOSE: To summarize 13 communities' experiences with selecting, implementing, and evaluating teen pregnancy prevention interventions within the CDC Community Coalition Partnership Programs for the Prevention of Teen Pregnancy. The study focuses on decision-making processes and barriers encountered in five categories of interventions: reproductive health services, reproductive health education, parent-child communication, male involvement, and programs for pregnant and parenting teens. METHODS: Telephone interviews were conducted with program directors, lead evaluators, and community coalition chairpersons in each of the 13 communities. The descriptive analysis explored factors that influenced community decisions to develop or not to develop interventions. These factors were analyzed by type of intervention. RESULTS: Each community implemented an average of six interventions and operated them with a variety of funding sources. Interventions were selected on the basis of need, and the community needs and assets assessment process was "very important" for most reported interventions. Decision-making was influenced most often by project staff, the coalition, or related work groups. Teens were infrequently viewed as primary decision-makers in the selection of interventions. Communities with family planning services as hub agencies were more likely to address reproductive services and reproductive health education. Communities with child advocacy or youth-serving agencies were more likely to focus on other intervention categories. About two-thirds of the interventions were evaluated by either process or outcome measures, or by both. CONCLUSIONS: This study highlights important lessons learned that should be considered in examinations of the overall effectiveness of this community coalition approach to the prevention of teen pregnancy.

Challenges in data collection, analysis, and distribution of information in community coalition demonstration projects.

PURPOSE: This article summarizes the experiences of 13 grantees funded by the Centers for Disease Control and Prevention under the Community Coalition Partnership for the Prevention of Teenage Pregnancy in collecting, analyzing, and disseminating data as required under the requirements of this community-based demonstration project. While describing the challenges associated with these activities, this article suggests how future demonstration projects can better support both centralized and locally based data collection and analysis and enhance their usefulness for various audiences. METHODS: A multi-method data collection approach was employed that included: (a) a systematic review of semiannual progress reports submitted by the grantees to CDC between 1998 and 2002, (b) telephone interviews with program directors and evaluators and (c) site visits to four of the 13 grantee locations. In all, 46 individuals were interviewed, for an average of 3.5 respondents per grantee site. Data collected for this article focused on three data collection/analysis activities required as part of the Partnership: needs assessments conducted during the planning phase of the project, the collection of cross-site indicator data and project-specific studies. RESULTS: Grantees from the 13 Partnership communities indicated that two of the data collection/analysis requirements (the needs and assets assessments and project-specific studies) were useful and should be included in future demonstration projects. The collection of cross-site indicator data was found to be more challenging. Across all areas of data collection/analysis, the grantees' efforts were complicated by data collection challenges, difficulties conducting studies of local programs, and uncertainties about how local efforts fit with national goals for the demonstration projects. CONCLUSION: The data collection/analysis activities within the Partnership were viewed by the grantees as being both supportive of project efforts, but also challenging. On the positive side, the presence of community-based evaluators helped the grantees to profile community needs, identify program interventions, provide participant feedback, and track community mobilization efforts. Collection of the cross-site indicator data was difficult for many of the grantees and not always connected to locally determined objectives. The value of these activities can be enhanced in the future if greater attention is given to creating more clearly defined goals at the demonstration project level and to providing guidance on scientifically valid data collection and analysis techniques to maximize the usefulness of local efforts.

Implementation of youth development programs: promise and challenges.

PURPOSE: The Community Coalition Partnership Program for the Prevention of Teen Pregnancy provided a unique laboratory for observing how youth development projects were implemented in 13 community-based settings. This article focuses on the scope of these efforts, the content of the projects, and their expected outcomes. METHODS: The investigators inventoried all youth development activities created within the grantee communities between 1997 and 2000 and then surveyed 28 site representatives by telephone. The scope and content of the identified youth development programs were compared with national registries of other such programs. RESULTS: The youth development efforts implemented by the 13 grantees were diverse, multi-faceted, and broad in scope. Most were short-term, but reflected a broad base of support for youth development principles among various community partners. Of the array of youth development efforts developed, more than two-thirds targeted three program areas: community services/outreach, education/training programs, or mentoring programs-a pattern found among youth development programs throughout the country. CONCLUSIONS: Within this partnership, youth development was a better-received framework for mobilizing community partners than were more traditional pregnancy prevention approaches. Communities were successful in creating diverse programs that may have benefits for individual youth, service agencies, and the community at large.