Engaging Community Networks to Improve Depression Services: A Cluster-Randomized Trial of a Community Engagement and Planning Intervention.

This paper explores the effects of a group-randomized controlled trial, Community Partners in Care (CPIC), on the development of interagency networks for collaborative depression care improvement between a community engagement and planning (CEP) intervention and a resources for services (RS) intervention that provided the same content solely via technical assistance to individual programs. Both interventions consisted of a diverse set of service agencies, including health, mental health, substance abuse treatment, social services, and community-trusted organizations such as churches and parks and recreation centers. Participants in the community councils for the CEP intervention reflected a range of agency leaders, staff, and other stakeholders. Network analysis of partnerships among agencies in the CEP versus RS condition, and qualitative analysis of perspectives on interagency network changes from multiple sources, suggested that agencies in the CEP intervention exhibited greater growth in partnership capacity among themselves than did RS agencies. CEP participants also viewed the coalition development intervention both as promoting collaboration in depression services and as a meaningful community capacity building activity. These descriptive results help to identify plausible mechanisms of action for the CPIC interventions and can be used to guide development of future community engagement interventions and evaluations in under-resourced communities.

Participatory Technology Development to Enhance Community Resilience.

Objective: To assess the feasibility of a novel, partnered technology development process to co-create mobile health applications (apps) addressing community health priorities, using psychoeducation of cognitive behavioral therapy (CBT) principles for enhancing resilience as an example. Design: Stakeholder engagement, workgroups, pilot feasibility study using mixed methods during October 2013 through January 2016 over three phases: 1) defining the vision of the project and increasing technical capacity, 2) co-development and pilot testing of the app, and 3) planning for sustainability. Setting: An academic-community partnership in South Los Angeles, California. Participants: Eight stakeholders; 30 pilot participants from the community. Main Outcome Measures: Qualitative analysis of audio-recordings of the app development process and stakeholder interviews, surveys of stakeholders' perception of the development process, app use data, and feedback from pilot participants. Results: The participatory technology development process resulted in creation and pilot-testing of a resiliency-focused text messaging app. Of the 1,107 messages sent, 23 out of 30 (77%) app users responded to explore interactive content. Stakeholders reported increased perceived competency in creating mobile apps and that the process fostered a culture of co-leadership. There was also sustained engagement in mobile app development by stakeholders beyond the initial project period. Conclusions: This is the first study, to our knowledge, to demonstrate the feasibility of participatory technology development, an approach involving direct participation in the development, tailoring and maintenance of a mobile app by a broad set of stakeholders with high representation from racial/ethnic minorities from an under-resourced community. Participatory technology development is a promising approach for creating sustainable, relevant and engaging health technologies across different technological, clinical and community settings.

Resident Workflow and Psychiatric Emergency Consultation: Identifying Factors for Quality Improvement in a Training Environment.

OBJECTIVE: Quality improvement to optimize workflow has the potential to mitigate resident burnout and enhance patient care. This study applied mixed methods to identify factors that enhance or impede workflow for residents performing emergency psychiatric consultations. METHODS: The study population consisted of all psychiatry program residents (55 eligible, 42 participating) at the Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles. The authors developed a survey through iterative piloting, surveyed all residents, and then conducted a focus group. The survey included elements hypothesized to enhance or impede workflow, and measures pertaining to self-rated efficiency and stress. Distributional and bivariate analyses were performed. Survey findings were clarified in focus group discussion. RESULTS: This study identified several factors subjectively associated with enhanced or impeded workflow, including difficulty with documentation, the value of personal organization systems, and struggles to communicate with patients' families. CONCLUSION: Implications for resident education are discussed.

Patient and Provider Cocreation of Mobile Texting Apps to Support Behavioral Health: Usability Study.

BACKGROUND: Mobile technologies hold potential for improving the quality of care and engagement of patients. However, there are considerable challenges in ensuring that technologies are relevant, useful, and engaging. While end users such as patients and providers are increasingly involved in the design of health technologies, there are limited examples of their involvement in directly creating technologies for their personal use. OBJECTIVE: We aim to evaluate the feasibility and acceptability of patients and providers creating mobile texting apps to support treatment goals. METHODS: In an 11-month usability study, we enrolled 4 providers and 28 patients in an intensive outpatient program for obsessive-compulsive disorder. Patients and providers created their own mobile texting apps using a visual app development platform. A subsample of 10 patients and 4 providers completed a usability measure. RESULTS: Participants created a total of 360 unique mobile text messages (1787 total messages sent). There were 4 types of messages identified, including personalized reminders, clinical exposures, interactive prompts, and encouraging/informational messages. A total of 9 out of 10 (90%) patients agreed that the messages were relevant to their recovery, and 8 out of 10 (80%) agreed that the messages were effective at helping complete treatment plans. CONCLUSIONS: Enabling patients and providers to cocreate apps for their own use by using a visual application platform is feasible and holds potential for increasing the relevance, sustainability, and effectiveness of digital health technologies.

Turning readmission reduction policies into results: some lessons from a multistate initiative to reduce readmissions.

Efforts are under way nationally to reduce avoidable hospital readmissions by changing payments to hospitals, but it is unclear how well or how quickly these policy changes will produce widespread reductions in hospital readmissions. To examine some of the challenges to implementing such approaches, the authors analyzed the early experiences of 3 statewide programs to reduce preventable readmissions that began in 2009. Based on interviews with program participants in 2011, the authors identified 3 key obstacles to progress: the difficulty of developing collaborative relationships across care settings, gaps in evidence for effective interventions, and deficits in quality improvement capabilities among some organizations. These findings underscore the uncertainty of success of current readmissions policies and suggest that immediate improvement in readmission rates through a change in reimbursement may be unlikely unless these other obstacles are addressed expeditiously. In particular, cultivation of productive collaboration across care settings will be critical because these kinds of relationships are not well established or naturally occurring in most communities.

Barriers and strategies to align stakeholders in healthcare alliances.

OBJECTIVE: To identify barriers to stakeholder alignment and strategies used by 14 multi-stakeholder alliances participating in the Aligning Forces for Quality initiative to overcome these barriers. STUDY DESIGN: The study used a mixed method, comparative case study design. METHODS: Alliances were categorized as more or less highly aligned based on an alignment index constructed from survey responses. Six alliances (top and bottom quartile) were selected for more in-depth qualitative analysis. Semi-structured interviews of key informants were used to identify factors that distinguished more highly aligned alliances from less highly aligned alliances. RESULTS: Market context was one of the most important factors differentiating alliances. More highly aligned alliances had more extensive histories of collaboration, established more credibility in the local community, and were more effective at balancing collaborative initiatives against competitive interests. More highly aligned alliances also took more active approaches to build consensus among stakeholders regarding alliance initiatives, and were able to successfully utilize small decision-making bodies to foster this consensus. In contrast, leadership credibility, leadership stability, and trust were important facilitators of alignment for all alliances, regardless of the level of alignment. These factors intersect and overlap in a multitude of ways to influence stakeholder alignment. CONCLUSIONS: Alignment in an alliance context is critical for leveraging the unique knowledge, skills, and abilities of stakeholders in ways that can build capacity to improve the health of the community in ways that cannot be achieved independently by stakeholders. The findings highlight the need for multifaceted approaches to promote stakeholder alignment.