Time and Organizational Cost for Facilitating Implementation of Primary Care Mental Health Integration.

BACKGROUND: Integrating mental health services into primary care settings is complex and challenging. Although facilitation strategies have successfully supported implementation of primary care mental health integration and other complex innovations, we know little about the time required or its cost. OBJECTIVE: To examine the time and organizational cost of facilitating implementation of primary care mental health integration. DESIGN: Descriptive analysis. PARTICIPANTS: One expert external facilitator and two internal regional facilitators who helped healthcare system stakeholders, e.g., leaders, managers, clinicians, and non-clinical staff, implement primary care mental health integration at eight clinics. INTERVENTION: Implementation facilitation tailored to the needs and resources of the setting and its stakeholders. MAIN MEASURES: We documented facilitators' and stakeholders' time and types of activities using a structured spreadsheet collected from facilitators on a weekly basis. We obtained travel costs and salary information. We conducted descriptive analysis of time data and estimated organizational cost. KEY RESULTS: The external facilitator devoted 263 h (0.09 FTE), including travel, across all 8 clinics over 28 months. Internal facilitator time varied across networks (1792 h versus 1169 h), as well as clinics. Stakeholder participation time was similar across networks (1280.6 versus 1363.4 person hours) but the number of stakeholders varied (133 versus 199 stakeholders). The organizational cost of providing implementation facilitation also varied across networks ($263,490 versus $258,127). Stakeholder participation accounted for 35% of the cost of facilitation activities in one network and 47% of the cost in the other. CONCLUSIONS: Although facilitation can improve implementation of primary care mental health integration, it requires substantial organizational investments that may vary by site and implementation effort. Furthermore, the cost of using an external expert to transfer facilitation skills and build capacity for implementation efforts appears to be minimal.

Establishing Measurement-based Care in Integrated Primary Care: Monitoring Clinical Outcomes Over Time.

Full implementation of the patient-centered medical home requires the identification and treatment of patients with behavioral health concerns, leading to improved patient outcomes and reduced health care costs. Measurement-based care (MBC) for mental health conditions is an essential step in achieving these goals. Integrated primary care (IPC) administrators and providers are key leaders in MBC that spans initial screening for conditions to monitoring clinical outcomes over time. The purpose of this article is to assist IPC leaders, in partnership with their primary care team, in developing standard operating procedures for screening and follow up evaluations in order to lay a foundation for assessing program outcomes and improving quality of care in their unique settings.

Moving toward integrated behavioral intervention for treating multimorbidity among chronic pain, depression, and substance-use disorders in primary care.

INTRODUCTION: The importance of using integrated treatment for multimorbidity has been increasingly recognized. One prevalent cluster of health conditions is multimorbidity of chronic pain, depression, and substance-use disorders, a common triad of illnesses among primary care patients. This brief report brings attention to an emerging treatment method of an integrated behavioral approach to improve health outcomes for individuals with these 3 conditions in the outpatient setting, particularly primary care. METHODS: A multidatabase search was conducted to identify studies of behavioral interventions targeting co-occurrence or multimorbidity among the 3 health conditions in the adult outpatient setting. An independent screening of the articles was accomplished by all authors with consensus on the final inclusion for review. RESULTS: Three studies met formal inclusion criteria for this review. The included studies evaluated cognitive behavioral therapy or combined motivational interviewing with cognitive behavioral therapy. Key findings from other reviews and additional studies are also included in this review to further inform the development of a common approach for treating this triad of conditions in primary care. CONCLUSIONS: Although there has been increased recognition for more effective and practical behavioral treatments for patients with multiple chronic health conditions, the evidence-base to inform practice remains limited. The findings from this review suggest that a common approach, rather than a distinct intervention for chronic pain, depression, or substance-use disorders, is indicated and that best care can be provided within the context of a coordinated, interdisciplinary, and patient-centered primary care team.

Implementing evidence-based telephone coaching for health behavior program enrollment: A quality improvement project.

INTRODUCTION: This program evaluation describes the use of implementation facilitation to support uptake of a telephone-based engagement coaching intervention, ACTIVATE, using paraprofessional staff, to support health behavior program enrollment. METHOD: The RE-AIM (reach, effectiveness, adoption, implementation, maintenance) framework guided the formative evaluation. A mixed-methods approach was used to integrate qualitative (i.e., rapid analysis approach) and quantitative (i.e., descriptive statistics, chi-square test of independence, logistic regression) analyses for each outcome. RESULTS: Most patients (95%; 319 of 335) were offered ACTIVATE, and 82 patients completed ACTIVATE. Delivery with paraprofessional staff was feasible with adaptations for translation from research to a clinical setting, which are described. External facilitation (a form of implementation facilitation) was associated with higher reach. DISCUSSION: Delivery of telephone-based coaching by paraprofessional staff to support health behavior program enrollment was feasible. External facilitation was important to the translation of ACTIVATE from research to clinical practice. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Development and Preliminary Evaluation of an Implementation Facilitation Training Program.

Background: Implementation scientists are identifying evidence-based implementation strategies that support the uptake of evidence-based practices and other clinical innovations. However, there is limited information regarding the development of training methods to educate implementation practitioners on the use of implementation strategies and help them sustain these competencies. Methods: To address this need, we developed, implemented, and evaluated a training program for one strategy, implementation facilitation (IF), that was designed to maximize applicability in diverse clinical settings. Trainees included implementation practitioners, clinical managers, and researchers. From May 2017 to July 2019, we sent trainees an electronic survey via email and asked them to complete the survey at three-time points: approximately 2 weeks before and 2 weeks and 6 months after each training. Participants ranked their knowledge of and confidence in applying IF skills using a 4-point Likert scale. We compared scores at baseline to post-training and at 6 months, as well as post-training to 6 months post-training (nonparametric Wilcoxon signed-rank tests). Results: Of the 102 participants (76 in-person, 26 virtual), there was an increase in perceived knowledge and confidence in applying IF skills across all learning objectives from pre- to post-training (95% response rate) and pre- to 6-month (35% response rate) follow-up. There was no significant difference in results between virtual and in-person trainees. When comparing post-training to 6 months (30% response rate), perceptions of knowledge increase remained unchanged, although participants reported reduced perceived confidence in applying IF skills for half of the learning objectives at 6 months. Conclusions: Findings indicated that we have developed a promising IF training program. Lack of differences in results between virtual and in-person participants indicated the training can be provided to a remote site without loss of knowledge/skills transfer but ongoing support may be needed to help sustain perceived confidence in applying these skills. Plain Language Summary: While implementation scientists are documenting an increasing number of implementation strategies that support the uptake of evidence-based practices and other clinical innovations, little is known about how to transfer this knowledge to those who conduct implementation efforts in the frontline clinical practice settings. We developed, implemented, and conducted a preliminary evaluation of a training program for one strategy, implementation facilitation (IF). The training program targets facilitation practitioners, clinical managers, and researchers. This paper describes the development of the training program, the program components, and the results from an evaluation of IF knowledge and skills reported by a subset of people who participated in the training. Findings from the evaluation indicate that this training program significantly increased trainees' perceived knowledge of and confidence in applying IF skills. Further research is needed to examine whether ongoing mentoring helps trainees retain confidence in applying some IF skills over the longer term.

The effects of priming on a public health campaign targeting cardiovascular risks.

Public health interventions are cost-effective methods to reduce heart disease. The present study investigated the impact of a low-cost priming technique on a public health campaign targeting cardiovascular risk. Participants were 415 individuals (66% female) ages 18 and older recruited through clinics and churches. The study consisted of three phases. In Phase I, participants completed a brief survey to assess knowledge of the cardiovascular health indicators. The survey served as the prime (intervention) for the study. At Phase II, participants were provided with access to a public health campaign consisting of an education brochure on cardiovascular health. Following the educational campaign, all participants completed a post-campaign survey in Phase III of the study. Participants who completed the surveys in both Phase I and III were placed in the intervention condition (26%) and those who only completed the Phase III survey were placed in the control condition (74%). Participants who were primed reported greater awareness of the public health campaign. Additionally, more intervention participants reported they had knowledge of their own and the normal ranges for cholesterol, glucose, and body mass index. For participants who were aware of the health promotion campaign, more participants in the primed group indicated they had knowledge of their own cholesterol and glucose levels and had made positive lifestyle changes as a result of the campaign. Results suggest the presence of a priming effect. Public health campaigns may benefit from the inclusion of a low-cost prime prior to intervention.

Patients' perspectives of brief cognitive behavioral therapy for chronic pain: Treatment satisfaction, perceived utility, and global assessment of change.

Introduction: Brief Cognitive Behavioral Therapy for Chronic Pain (Brief CBT-CP) is a biopsychosocial treatment designed to improve access to nonpharmacological pain care in primary care. Results from a clinical demonstration project in Veterans Health Administration (VHA) clinics showed rapid improvement in pain outcomes following Brief CBT-CP treatment in Primary Care Behavioral Health (PCBH). As part of this larger project, the current work aimed to understand patients' perspectives of Brief CBT-CP via a self-report survey completed posttreatment. Method: Thirty-four primary care patients received Brief CBT-CP as part of their usual VHA care and subsequently completed an anonymous survey that included questions regarding treatment modality, intervention content, utility, and satisfaction, as well as global assessment of change in pain-related functioning. Results: Participants reported that Brief CBT-CP content was useful (91%) and that they were satisfied with the intervention overall (89%), including appointment length, frequency of encounters, and comprehensibility of content. On average (M = 4.50, SD = 1.71), participants reported "somewhat better" to "moderately better" pain-related functioning following treatment. Exploratory descriptive analysis indicated that self-reported change in function following treatment may vary by patient characteristics, including gender and opioid use history. Discussion: Patients were receptive to Brief CBT-CP, were satisfied with their experience during treatment, and reported benefit in pain-related functioning after treatment. Further development and evaluation of Brief CBT-CP as a feasible biopsychosocial treatment option for pain in primary care clinics using the PCBH model of integration is warranted. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Steps for implementing measurement-based care: Implementation planning guide development and use in quality improvement.

Although the benefits of measurement-based care (MBC) are widely noted, MBC remains underutilized in mental health services. In 2016, the Department of Veterans Affairs, Veterans Health Administration began the MBC in Mental Health Initiative to implement MBC as a standard of care across VHA mental health services. Subsequently, in January 2018 The Joint Commission (TJC) revised their behavioral health care standards to require implementation of MBC. Based on key informant interviews with early adopters across VHA, we developed an MBC Implementation Planning Guide to support implementation of MBC in diverse mental health settings. In this article, we present the MBC Implementation Planning Guide, describe how it was developed, and suggest a process for its use by implementation teams within an overall quality improvement framework to support implementation of MBC consistent with local context and TJC requirements. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Protocol: examining the effectiveness of an adaptive implementation intervention to improve uptake of the VA suicide risk identification strategy: a sequential multiple assignment randomized trial.

BACKGROUND: In 2018, the Veterans Health Administration (VHA) mandated implementation of a national suicide risk identification strategy (Risk ID). The goal of Risk ID is to improve the detection and management of suicide risk by standardizing suicide risk screening and evaluation enterprise-wide. In order to ensure continuous quality improvement (QI), ongoing evaluation and targeted interventions to improve implementation of Risk ID are needed. Moreover, given that facilities will vary with respect to implementation needs and barriers, the dose and type of intervention needed may vary across facilities. Thus, the objective of this study is to examine the effectiveness of an adaptive implementation strategy to improve the uptake of suicide risk screening and evaluation in VHA ambulatory care settings. In addition, this study will examine specific factors that may impact the uptake of suicide risk screening and evaluation and the adoption of different implementation strategies. This protocol describes the stepped implementation approach and proposed evaluation plan. METHODS: Using a sequential multiple assignment randomized trial (SMART) design, two evidence-based implementation strategies will be evaluated: (1) audit and feedback (A&F); (2) A&F plus external facilitation (A&F + EF). Implementation outcomes of interest include uptake of secondary suicide risk screening and uptake of comprehensive suicide risk evaluation (stages 2 and 3 of Risk ID). Secondary outcomes include rates of other clinical outcomes (i.e., safety planning) and organizational factors that may impact Risk ID implementation (i.e., leadership climate and leadership support). DISCUSSION: This national QI study will use a SMART design to evaluate whether an adaptive implementation strategy is effective in improving uptake of a mandated VHA-wide suicide risk screening and evaluation initiative. If this study finds that the proposed stepped implementation strategy is effective at increasing uptake and maintaining performance improvements, this approach may be used as an overarching QI strategy for other national suicide prevention programs. TRIAL REGISTRATION: ClinicalTrials.gov NCT04243330 . Registered 28 January 2020.

Spousal and alcohol-related predictors of smoking cessation: a longitudinal study in a community sample of married couples.

We investigated the longitudinal influence of spousal and individual heavy drinking and heavy smoking on smoking cessation among married couples. Couples' (N = 634) past-year smoking, alcohol problems, and heavy drinking were assessed. We used an event history analysis and found that spousal and one's own heavy smoking and one's own heavy drinking decreased the likelihood of smoking cessation. Heavy drinking and spousal behavior should be considered when developing public health interventions and policies for smoking cessation.

Brief Cognitive Behavioral Therapy For Chronic Pain: Results From a Clinical Demonstration Project in Primary Care Behavioral Health.

OBJECTIVES: Although cognitive behavioral therapy is an effective intervention for chronic pain, it is a lengthy treatment typically applied only in specialty care settings. The aim of this project was to collect preliminary effectiveness data for Brief Cognitive Behavioral Therapy for Chronic Pain (Brief CBT-CP), an abbreviated, modular form of treatment designed for use in primary care. METHODS: A clinical demonstration project was conducted in which Brief CBT-CP was delivered to primary care patients by 22 integrated care providers practicing in the Primary Care Behavioral Health model of Veterans Health Administration primary care clinics. Brief measures were used at each appointment to collect patient-reported clinical outcomes. RESULTS: One hundred eighteen patients provided sufficient data for analysis (male, 75%; mean age, 51.4 y). Multilevel modeling suggested that a composite measure of pain intensity and functional limitations showed statistically significant improvements by the third appointment (Cohen's d=0.65). Pain-related self-efficacy outcomes showed a similar pattern of results but of smaller effect size (Cohen's d=0.22). The exploratory analysis identified that Brief CBT-CP modules addressing psychoeducation and goal setting, pacing, and relaxation training were associated with the most significant gains in treatment outcomes. DISCUSSION: These findings provide early support for the effectiveness of Brief CBT-CP when delivered by providers in every day Primary Care Behavioral Health settings. Results are discussed in relation to the need for additional research regarding the potential value of employing safe, population-based, nonpharmacological approaches to pain management in primary care.

Cigar/cigarillo surveillance: limitations of the U.S. Department of Agriculture system.

BACKGROUND: The U.S. Department of Agriculture (USDA) reports data on cigar sales in two categories: little cigars (weighing less than 3 lbs. per thousand) and large cigars and cigarillos (weighing more than 10 lbs. per thousand). A rise in the sales of little cigars in recent years is a cause for concern. The capacious second category could be obscuring the growth of sales in cigarillos. METHODS: Trends in cigar use were analyzed in May 2007 using (1) the standard USDA two-level system and (2) data from the Maxwell Report that provides information on cigarillos as a separate category. The intercorrelations among cigar use trends in the three areas were also explored. RESULTS: From 1993 to 2006, unit sales of little cigars increased from 37% to 47% of the cigar market, cigarillos increased from 25% to 32%, and large cigars dropped from 37% to 22%. From 1976 to 2006, cigarillo sales were strongly related to sales of little cigars (r=0.93; 95% CI=0.86-0.97), while sales of large cigars and cigarillos were modestly related (r=0.42; 95% CI=0.08-0.57). CONCLUSIONS: Analyses show strong correlations between cigarillo and little cigar sales and argue for more detailed reporting of cigar sales as a function of cigar size. Tobacco surveillance should at minimum be watching the same trends as the tobacco industry. The sales of little cigars, cigarillos, and large cigars should be monitored, and the measuring of cigarillo sales in 3-5 subcategories according to size is encouraged.

The relationship of character strengths to sexual behaviors and related risks among African American adolescents.

BACKGROUND: Relatively few studies have examined positive character traits that are associated with lower HIV/STD risks. PURPOSE: In the present study, the relationships of character strengths with sexual behaviors and attitudes were assessed among 383 African-American adolescents. METHOD: Character strengths were measured using the Values in Action Inventory of Strengths. Because the strengths were highly inter-correlated, stepwise discriminant function analyses were utilized to assess their independent associations with sexual behaviors and attitudes. RESULTS: Greater Love of Learning was related to self-reported abstinence from sexual intercourse for boys and self-reported abstinence from drug use for boys and girls. Greater Love of Learning and Curiosity were related to the belief in no premarital sex for boys, whereas only Curiosity was significant for girls. Prudence was related to reported abstinence from sexual intimacy (e.g., touching or kissing). Judgment was related to sexual initiation efficacy for girls and boys, whereas Leadership was only significant for girls. CONCLUSIONS: The findings suggest that character strengths may be associated with lower levels of sexual behaviors and sex-related beliefs among a sample of African-American adolescents.

Achieving same-day access in integrated primary care.

Same-day access to behavioral health services is a critical feature of integrated primary care. Despite the benefits of same-day access, implementing and sustaining this key feature has been a challenge for multiple health care settings. Further, there is relatively little practical guidance on how to implement this practice management feature. Diverse program design solutions for same-day access are implemented in clinics across the Veterans Health Administration. The authors identified innovative approaches, developed in local facilities, with demonstrated success in same-day access that can be implemented in any setting. The purpose of this article is to describe five approaches for providing same-day access within integrated care. The authors discuss key considerations (staffing, space, program maturity), potential challenges and facilitators, and provide practical recommendations for implementation. (PsycINFO Database Record

Envisioning Transformation in VA Mental Health Services Through Collaborative Site Visits.

This column reviews the unique contributions of multiple partners in establishing a standardized site visit process to promote quality improvement in mental health care at the Veterans Health Administration. Working as a team, leaders in policy and operations, staff of research centers, and regional- and facility-level mental health leaders developed a standardized protocol for evaluating mental health services at each site and using the data to help implement policy goals. The authors discuss the challenges experienced and lessons learned in this systemwide process and how this information can be part of a framework for improving mental health services on a national level.

Advice on using over-the-counter nicotine replacement therapy-patch, gum, or lozenge-to quit smoking.

Although the use of over the counter (OTC) nicotine replacement therapy (NRT) is effective for smoking cessation, many concerns and misunderstandings persist that may reduce the effectiveness of NRT. Clinical practice and public health experts responded to a questionnaire that explored challenges associated with promoting proper NRT use and gathered recommendations on overcoming these challenges. Two predominant themes emerged including the identification of policies and practices that hinder NRT use, and smokers' views regarding NRT use. To address these needs, a two-part consensus statement about the use of OTC NRT to quit smoking was developed. The first part of the consensus statement identifies policy issues. The second part of the consensus statement was developed for smokers to reduce misperceptions and concerns about NRT by providing information on safety and the most effective use of NRT. The statement integrates state of the art clinical practice guidelines in a patient-centered format and presents information for policy makers to effectively support quit attempts.

Research and services partnerships: Responding to needs of clinical operations partners: transferring implementation facilitation knowledge and skills.

This column describes a facilitation strategy that incorporates evidence-based implementation knowledge and practice-based wisdom. The authors also describe a partnership between research and clinical operations leaders in the U.S. Department of Veterans Affairs to bridge the gap between implementation knowledge and its use. The initial product of the partnership, the Implementation Facilitation Training Manual: Using External and Internal Facilitation to Improve Care in the Veterans Health Administration, is a resource that can be used by others to guide implementation efforts.

Research & services partnerships: lessons learned through a national partnership between clinical leaders and researchers.

This column describes lessons learned by U.S. Department of Veterans Affairs (VA) researchers and clinical operations managers while they were engaged in a unique partnership. In this partnership, researchers turned generalizable lessons from implementation research into actionable guidance for use by clinical managers in implementing health care system change. The lessons learned are reflections about the necessary foundations for partnering, the importance of relationships, the need for regular communication, and the need to recognize and adapt to partners' timelines and time constraints.

Psychometric assessment of the Primary Care Behavioral Health Provider Adherence Questionnaire (PPAQ).

Adherence to protocol among behavioral health providers working in co-located, collaborative care or Primary Care Behavioral Health settings has rarely been assessed due to limited measurement options. Development of psychometrically sound measures of provider fidelity may improve the translation of these service delivery models into every day practice. One hundred seventy-three integrated behavioral health providers in VA primary care clinics responded to an online questionnaire to assess the reliability and validity of the Primary Care Behavioral Health Provider Adherence Questionnaire (PPAQ). Psychometric assessment resulted in a reliable 48-item measure with two subscales that specified essential and prohibited provider behaviors. The PPAQ demonstrated strong convergent and divergent validity when compared to another measure of health care integration. Known-group comparisons provided partial support for criterion validity. The PPAQ is a reliable and valid self-report of behavioral health provider fidelity with implications for improving provider training, program monitoring, and clinical research.

Commentary: Understanding the origins of anger, contempt, and disgust in public health policy disputes: applying moral psychology to harm reduction debates.

Scientific disputes about public health issues can become emotional battlefields marked by strong emotions like anger, contempt, and disgust. Contemporary work in moral psychology demonstrates that each of these emotions is a reaction to a specific type of moral violation. Applying this work to harm reduction debates, specifically the use of smokeless tobacco to reduce harm from tobacco use, we attempt to explain why some public health disputes have been so heated. Public health ethics tend to emphasize social justice concerns to the exclusion of other moral perspectives that value scientific authority, professional loyalty, and bodily purity. An awareness of their different emotional reactions and underlying moral motivations might help public health professionals better understand each others' viewpoints, ultimately leading to more productive dialogue.