Association of organizational culture and climate with variation in the clinical outcomes of collaborative care for maternal depression in community health centers.

Background: Organizational factors may help explain variation in the effectiveness of evidence-based clinical innovations through implementation and sustainment. This study tested the relationship between organizational culture and climate and variation in clinical outcomes of the Collaborative Care Model (CoCM) for treatment of maternal depression implemented in community health centers. Method: Organizational cultures and climates of 10 community health centers providing CoCM for depression among low-income women pregnant or parenting were assessed using the organizational social context (OSC) measure. Three-level hierarchical linear models tested whether variation in culture and climate predicted variation in improvement in depression symptoms from baseline to 6.5-month post-baseline for N = 468 women with care ±1 year of OSC assessment. Depression symptomology was measured using the Patient Health Questionnaire (PHQ-9). Results: After controlling for patient characteristics, case mix, center size, and implementation support, patients served by centers with more proficient cultures improved significantly more from baseline to 6.5-month post-baseline than patients in centers with less proficient cultures (mean improvement = 5.08 vs. 0.14, respectively, p = .020), resulting in a large adjusted effect size of dadj = 0.78. A similar effect was observed for patients served by centers with more functional climates (mean improvement = 5.25 vs. 1.12, p < .044, dadj = 0.65). Growth models indicated that patients from all centers recovered on average after 4 months of care. However, those with more proficient cultures remained stabilized whereas patients served by centers with less proficient cultures deteriorated by 6.5-month post-baseline. A similar pattern was observed for functional climate. Conclusions: Variation in clinical outcomes for women from historically underserved populations receiving Collaborative Care for maternal depression was associated with the organizational cultures and climates of community health centers. Implementation strategies targeting culture and climate may improve the implementation and effectiveness of integrated behavioral health care for depression.

While many implementation theories espouse the importance of organizational culture and climate for the successful implementation of evidence-based practices in primary care, there is little research that tests this hypothesis. Since there are interventions which can improve organizational culture and climate, having more evidence that these factors are associated with implementation would support efforts to modify these aspects of a community health center as a means of improving implementation. This study showed that the extent to which patients clinically benefitted from the evidence-based Collaborative Care Model for maternal depression was related to the prevailing culture and climate of community health centers where they received treatment. Specifically, women seen at centers in which the staff and providers indicated that their organizations prioritize responsiveness to patients' needs over competing organizational goals and maintain competence in up-to-date treatment models (referred to as proficient culture), and understand their role in the organization and receive the cooperation and support they need from colleagues and supervisors to perform their job well (functional climate) were associated with sustained improvements in depression symptoms. This benefit was independent of other factors already known to be associated with these outcomes. Implementation strategies that target organizational culture (i.e., priorities and expectations for staff) and climate (i.e., quality of working environment) may improve the clinical outcomes of integrated collaborative care models for depression and reduce the commonly seen variation in outcomes across health centers.

Rural clinics implementing collaborative care for low-income patients can achieve comparable or better depression outcomes.

INTRODUCTION: The gap between depression treatment needs and the available mental health workforce is particularly large in rural areas. Collaborative care (CoCM) is an evidence-based approach that leverages limited mental health specialists for maximum population effect. This study evaluates depression treatment outcomes, clinical processes of care, and primary care provider experiences for CoCM implementation in 8 rural clinics treating low-income patients. METHOD: We used CoCM registry data to analyze depression response and remission then used logistic regression to model variance in depression outcomes. Primary care providers reported their experiences with this practice change 18 months following program launch. RESULTS: Participating clinics enrolled 5,187 adult patients, approximately 15% of the adult patient population. Mean PHQ-9 depression score was 16.1 at baseline and 10.9 at last individual measurement, a statistically and clinically significant improvement (SD6.7; 95% CI [4.9, 5.3]). Suicidal ideation also reduced significantly. Multivariate logistic regression predicted the probability of depression response and remission after controlling for several demographic attributes and processes of care, showing a significant amount of variance in outcomes could be explained by clinic, length of time in treatment, and age. Primary care providers reported positive experiences overall. DISCUSSION: Three quarters of participating primary care clinics, adapting CoCM for limited resource settings, exceeded depression response outcomes reported in a controlled research trial and mirrored results of large-scale quality improvement implementations. Future research should examine quality improvement strategies to address clinic-level variation and sustain improvements in clinical outcomes achieved. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Scaling Implementation of Collaborative Care for Depression: Adaptation of the Stages of Implementation Completion (SIC).

Tools to monitor implementation progress could facilitate scale-up of effective treatments. Most treatment for depression, a common and disabling condition, is provided in primary care settings. Collaborative Care Management (CoCM) is an evidence-based model for treating common mental health conditions, including depression, in this setting; yet, it is not widely implemented. The Stages of Implementation Completion (SIC) was adapted for CoCM and piloted in eight rural primary care clinics serving adults challenged by low-income status. The CoCM-SIC accurately assessed implementation effectiveness and detected site variations in performance, suggesting key implementation activities to aid future scale-ups of CoCM for diverse populations.

Acceptability of mHealth augmentation of Collaborative Care: A mixed methods pilot study.

OBJECTIVE: To assess the feasibility and acceptability of a mobile health platform supporting Collaborative Care. METHOD: Collaborative Care patients (n=17) used a smartphone app to transmit PHQ-9 and GAD-7 scores and sensor data to a dashboard used by one care manager. Patients completed usability and satisfaction surveys and qualitative interviews at 4weeks and the care manager completed a qualitative interview. Mobile metadata on app usage was obtained. RESULTS: All patients used the app for 4weeks, but only 35% (n=6) sustained use at 8weeks. Prior to discontinuing use, 88% (n=15) completed all PHQ-9 and GAD-7 measures, with lower response rates for daily measures. Four themes emerged from interviews: understanding the purpose; care manager's role in supporting use; benefits of daily monitoring; and privacy / security concerns. Two themes were user-specific: patients' desire for personalization; and care manager burden. CONCLUSIONS: The feasibility and acceptability of the mobile platform is supported by the high early response rate, however attrition was steep. Our qualitative findings revealed nuanced participant experiences and uncovered some concerns about mobile health. To encourage retention, attention may need to be directed toward promoting patient understanding and provider engagement, and offering personalized patient experiences.