Impact of Primary Care-Mental Health Care Integration on Mental Health Care Engagement Across Racial and Ethnic Groups.

OBJECTIVE: Receiving mental health services as part of primary care in the Veterans Health Administration (VHA) might increase engagement in specialty mental health care. The authors reexamined the association between primary care-mental health integration (PCMHI) and continued engagement in specialty mental health care for VHA patients and assessed differences by race and ethnicity. METHODS: The study included 437,051 primary care patients with a first in-person specialty mental health encounter in 2015-2016 (no specialty mental health encounters in prior 12 months), including 46,417 patients with new PCMHI encounters in the year before the first specialty mental health encounter. Multivariable logistic regression assessed odds of follow-up specialty mental health care within 3 months of the first specialty mental health encounter. The dependent variable was care engagement (attending a second specialty mental health appointment); independent variables were whether patients were seen by PCMHI on the same day as the primary care appointment ("same-day access"), the time between PCMHI and first specialty mental health appointments, and race and ethnicity. RESULTS: PCMHI was associated with increased engagement in specialty mental health care for all patients, with a greater likelihood of engagement among non-Hispanic White patients. Same-day access to PCMHI was positively associated with care engagement, with no significant differences by race or ethnicity. PCMHI care within 3 months before a first specialty mental health encounter was associated with greater care engagement. CONCLUSIONS: PCMHI, especially same-day access to PCMHI care, may boost engagement in mental health care, although the study design precluded conclusions regarding causal relationships.

Challenges and promising solutions to engaging patients in healthcare implementation in the United States: an environmental scan.

BACKGROUND: One practice in healthcare implementation is patient engagement in quality improvement and systems redesign. Implementers in healthcare systems include clinical leadership, middle managers, quality improvement personnel, and others facilitating changes or adoption of new interventions. Patients provide input into different aspects of health research. However, there is little attention to involve patients in implementing interventions, especially in the United States (U.S.), and this might be essential to reduce inequities. Implementers need clear strategies to overcome challenges, and might be able to learn from countries outside the U.S. METHODS: We wanted to understand existing work about how patients are being included in implementation activities in real world U.S. healthcare settings. We conducted an environmental scan of three data sources: webinars, published articles, and interviews with implementers who engaged patients in implementation activities in U.S. healthcare settings. We extracted, categorized, and triangulated from data sources the key activities, recurring challenges, and promising solutions using a coding template. RESULTS: We found 27 examples of patient engagement in U.S. healthcare implementation across four webinars, 11 published articles, and seven interviews, mostly arranging patient engagement through groups and arranging processes for patients that changed how engaged they were able to be. Participants rarely specified if they were engaging a population experiencing healthcare inequities. Participants described eight recurring challenges; the two most frequently identified were: (1) recruiting patients representative of those served in the healthcare system; and (2) ensuring processes for equitable communication among all. We matched recurring challenges to promising solutions, such as logistic solutions on how to arrange meetings to enhance engagement or training in inclusivity and power-sharing. CONCLUSION: We clarified how some U.S. implementers are engaging patients in healthcare implementation activities using less and more intensive engagement. It was unclear whether reducing inequities was a goal. Patient engagement in redesigning U.S. healthcare service delivery appears similar to or less intense than in countries with more robust infrastructure for this, such as Canada and the United Kingdom. Challenges were common across jurisdictions, including retaining patients in the design/delivery of implementation activities. Implementers in any region can learn from those in other places.

Increasing consumer engagement: tools to engage service users in quality improvement or implementation efforts.

Introduction: Engaging service users or consumers in quality improvement or implementing a new service is important across settings and may reduce health inequities. Implementation strategies leveraging consumer engagement are neither commonly used nor robustly operationalized in implementation science. Implementers (e.g., middle managers, facilitators) want to involve consumers in implementation activities, but do not always feel confident in how to proceed. We developed a compendium of tools called Consumer Voice to guide others how to engage consumers in design/delivery of implementation strategies. Although generalizable to other settings, we developed Consumer Voice within the context of implementing suicide prevention treatments in healthcare to reach rural U.S. military veterans, as there are suicide inequities for people in rural areas. Methods: We developed Consumer Voice using a multistep process and human-centered design methods. In between steps, a design team met to generate insights from data, and decide which prototypes to create/refine. In preliminary work, we conducted a scan of examples in healthcare of patient engagement in implementation activities and interviewed two implementation experts about preferred learning styles. In Step 1, we interviewed 26 participants with experience in community engagement, implementation, or lived experience as a rural U.S. veteran with suicidal thoughts/behavior. In Step 2, 11 implementers beta tested prototypes then share feedback in focus groups. In Step 3, we reconvened participants from prior steps to review tools and, using nominal group technique, prioritized remaining recommendations. Results: Consumer Voice is online, modular, and nonlinear for self-guided learning tailored to beginner, intermediate, or advanced experience with consumer engagement. Tools consist of slides, audiovisual content with written text, and templates. Findings indicated there is not one "right" way to engage consumers in implementation activities, rather that implementers wanted tools showcasing core principles for consumer engagement and practical ideas. Discussion: Consumer Voice can be used by implementers to reflect and decide on how to apply consumer engagement implementation strategies to improve equitable dissemination and uptake of evidence-based practices. Most insights generated by user data were explicitly to build trust between consumers and professionals representing institutions, which may be one component to reducing healthcare inequities.

Pre-implementation adaptation of suicide safety planning intervention using peer support in rural areas.

Introduction: Currently, seventeen veterans die by suicide daily in the United States (U.S.). There are disparities in suicide behavior and access to preventative treatment. One disparity is the suicide rate in rural areas, including the state of Arkansas-suicide deaths among rural veterans increased 48% in the last 2 decades, double that of urban veterans. One major challenge for veterans in rural areas is the lack of healthcare providers to provide Safety Planning Intervention, which is an effective intervention to reduce suicide attempts in the general adult population and among veterans. One solution is more broadly implementing Safety Planning Intervention, by using peers to deliver the intervention in rural communities. Before implementation, the intervention needs to be adapted for peer-to-peer delivery, and barriers and facilitators identified. Methods: Since January 2021, using community-based participatory research, we collaboratively developed and executed a 1 year study to adapt Safety Planning Intervention for peer-to-peer delivery in rural communities and identified implementation barriers and facilitators prior to spread. From July 2022 to February 2023, we conducted group interviews with 12 participants: rural veterans with prior suicidal thoughts or attempts in one U.S. state, their support persons, and healthcare professionals with expertise in veteran suicide prevention, Safety Planning Intervention, and/or peer delivery. We collected qualitative data through interviews during nine, 2 h meetings, and quantitative data from one anonymous survey and real-time anonymous voting-all on the topic of core and adaptable components of Safety Planning Intervention and implementation barriers and facilitators for peer delivery in rural communities. Questions about adaptation were designed according to processes in the ENGAGED for CHANGE community-engaged intervention framework and questions about facilitators and barriers were designed according to the Health Equity Implementation Framework. Participants categorized which Safety Planning Intervention components were core or adaptable, and how freely they could be adapted, using the metaphor of a traffic light in red (do not change), yellow (change with caution), and green (change freely) categories. Results: Participants made few actual adaptations (categorized according to the FRAME modification system), but strongly recommended robust training for peers. Participants identified 27 implementation facilitators and 47 barriers, organized using the Health Equity Implementation Framework. Two example facilitators were (1) peer-to-peer safety planning intervention was highly acceptable to rural veterans; and (2) some state counties already had veteran crisis programs that could embed this intervention for spread. Two example barriers were (1) some community organizations that might spread the intervention have been motivated initially, wanting to help right away, yet not able to sustain interventions; and (2) uncertainty about how to reach veterans at moderate suicide risk, as many crisis programs identified them when suicide risk was higher. Discussion: Our results provide one of the more comprehensive pre-implementation assessments to date for Safety Planning Intervention in any setting, especially for peer delivery (also referred to as task shifting) outside healthcare or clinical settings. One important next step will be mapping these barriers and facilitators to implementation strategies for peer-to-peer delivery. One finding surprised our research team-despite worse societal context in rural communities leading to disproportionate suicide deaths-participants identified several positive facilitators specifically about rural communities that can be leveraged during implementation.

Assessing researchers' capabilities, opportunities, and motivation to conduct equity-oriented dissemination and implementation research, an exploratory cross-sectional study.

BACKGROUND: A recent paradigm shift has led to an explicit focus on enhancing health equity through equity-oriented dissemination and implementation (D&I) research. However, the integration and bidirectional learning across these two fields is still in its infancy and siloed. This exploratory study aimed to examine participants' perceived capabilities, opportunities, and motivations to conduct equity-oriented D&I research. METHODS: We conducted an exploratory cross-sectional survey distributed online from December 2020 to April 2021. Participants were recruited at either D&I or health disparities-oriented conferences, meetings, through social media, or personal outreach via emails. Informed by the Capability, Opportunity, and Motivation Model (COM-B), the survey queried respondents about different aspects of engaging in and conducting equity-oriented D&I research. All analyses were conducted in SPSS Version 27.0. RESULTS: A total of 180 participants responded to the survey. Most participants were women (81.7%), white (66.1%), academics (78.9%), and faculty members (53.9%). Many reported they were advanced (36.7%) or advanced beginners (27.8%) in the D&I field, and a substantial proportion (37.8%) reported being novice in D&I research that focused on health equity. Participants reported high motivation (e.g., 62.8% were motivated to apply theories, models, frameworks for promoting health equity in D&I research), but low capability to conduct equity-oriented D&I research (e.g., 5% had the information needed for promoting health equity in D&I research). Most participants (62.2%) reported not having used measures to examine equity in their D&I projects, and for those who did use measures, they mainly used individual-level measures (vs. organizational- or structural-level measures). When asked about factors that could influence their ability to conduct equity-oriented D&I research, 44.4% reported not having the skills necessary, and 32.2% stated difficulties in receiving funding for equity-oriented D&I research. CONCLUSIONS: Study findings provide empirical insight into the perspectives of researchers from different backgrounds on what is needed to conduct equity-oriented D&I research. These data suggest the need for a multi-pronged approach to enhance the capability and opportunities for conducting equity-oriented D&I work, such as: training specifically in equity-oriented D&I, collaboration between D&I researchers with individuals with expertise and lived experience with health equity research, funding for equity-oriented D&I research, and recognition of the value of community engaged research in promotion packages.

Determining feasibility of incorporating consumer engagement into implementation activities: study protocol of a hybrid effectiveness-implementation type II pilot.

INTRODUCTION: Implementation researchers could draw from participatory research to engage patients (consumers of healthcare) in implementation processes and possibly reduce healthcare disparities. There is a little consumer involvement in healthcare implementation, partially because no formal guidance exists. We will create and pilot a toolkit of methods to engage consumers from the US' Veterans Health Administration (VHA) in selecting and tailoring implementation strategies. This toolkit, Consumer Voice, will provide guidance on what, when, where, how and why an implementer might engage consumers in implementing treatments. We will pilot the toolkit by implementing Safety Planning Intervention for suicide prevention with rural veterans, a population with suicide disparities. Safety Planning Intervention is effective for reducing suicidal behaviours. METHODS AND ANALYSIS: In Aim 1, we will use participatory approaches and user-centred design to develop Consumer Voice and its methods. In Aim 2, we will pilot Consumer Voice by implementing the Safety Planning Intervention in two clinics serving rural VHA patients. One site will receive a current implementation strategy (Implementation Facilitation) only; the second will receive Implementation Facilitation plus Consumer Voice. We will use mixed methods to assess feasibility and acceptability of Consumer Voice. We will compare sites on preliminary implementation (reach, adoption, fidelity) and clinical outcomes (depression severity, suicidal ideation, suicidal behaviour). In Aim 3, we will evaluate Aim 2 outcomes at 20 months to assess sustained impact. We will gather qualitative data on sustainability of the Safety Planning Intervention. ETHICS AND DISSEMINATION: These studies are overseen by the Institutional Review Board at the Central Arkansas Veterans Healthcare System. We plan to use traditional academic modalities of dissemination (eg, conferences, publications). We plan to disseminate findings through meetings with other trainers in implementation practice so they may adopt Consumer Voice. We plan to share results with local community boards.

Economic analyses of behavioral health intervention implementation: Perspective on stakeholder engagement.

To provide full potential benefits to patients, behavioral health interventions often require comprehensive and systematic implementation efforts. The costs of these efforts should therefore be included when organizations decide to fund or adopt a new intervention. However, existing guidelines for conducting economic analyses like cost-effectiveness analyses and budget impact analyses are not well-suited to the complexity of the behavioral healthcare pathway and its many stakeholders. Stakeholder engagement, when used effectively with recent innovations in economic analysis, advance more equitable access to interventions for individuals living with behavioral health conditions. But early and ongoing stakeholder engagement has not yet been incorporated into best-practice guidelines for economic evaluation. We discuss our perspective, as researchers and clinicians in a large integrated health system, on how the integration of stakeholder engagement with existing economic analysis methods could improve decision-making about implementation of behavioral health interventions.

A more practical guide to incorporating health equity domains in implementation determinant frameworks.

BACKGROUND: Due to striking disparities in the implementation of healthcare innovations, it is imperative that researchers and practitioners can meaningfully use implementation determinant frameworks to understand why disparities exist in access, receipt, use, quality, or outcomes of healthcare. Our prior work documented and piloted the first published adaptation of an existing implementation determinant framework with health equity domains to create the Health Equity Implementation Framework. We recommended integrating these three health equity domains to existing implementation determinant frameworks: (1) culturally relevant factors of recipients, (2) clinical encounter or patient-provider interaction, and (3) societal context (including but not limited to social determinants of health). This framework was developed for healthcare and clinical practice settings. Some implementation teams have begun using the Health Equity Implementation Framework in their evaluations and asked for more guidance. METHODS: We completed a consensus process with our authorship team to clarify steps to incorporate a health equity lens into an implementation determinant framework. RESULTS: We describe steps to integrate health equity domains into implementation determinant frameworks for implementation research and practice. For each step, we compiled examples or practical tools to assist implementation researchers and practitioners in applying those steps. For each domain, we compiled definitions with supporting literature, showcased an illustrative example, and suggested sample quantitative and qualitative measures. CONCLUSION: Incorporating health equity domains within implementation determinant frameworks may optimize the scientific yield and equity of implementation efforts by assessing and ideally addressing implementation and equity barriers simultaneously. These practical guidance and tools provided can assist implementation researchers and practitioners to concretely capture and understand barriers and facilitators to implementation disparities.

The health equity implementation framework: proposal and preliminary study of hepatitis C virus treatment.

BACKGROUND: Researchers could benefit from methodological advancements to advance uptake of new treatments while also reducing healthcare disparities. A comprehensive determinants framework for healthcare disparity implementation challenges is essential to accurately understand an implementation problem and select implementation strategies. METHODS: We integrated and modified two conceptual frameworks-one from implementation science and one from healthcare disparities research to develop the Health Equity Implementation Framework. We applied the Health Equity Implementation Framework to a historical healthcare disparity challenge-hepatitis C virus (HCV) and its treatment among Black patients seeking care in the US Department of Veterans Affairs (VA). A specific implementation assessment at the patient level was needed to understand any barriers to increasing uptake of HCV treatment, independent of cost. We conducted a preliminary study to assess how feasible it was for researchers to use the Health Equity Implementation Framework. We applied the framework to design the qualitative interview guide and interpret results. Using quantitative data to screen potential participants, this preliminary study consisted of semi-structured interviews with a purposively selected sample of Black, rural-dwelling, older adult VA patients (N = 12), living with HCV, from VA medical clinics in the Southern part of the USA. RESULTS: The Health Equity Implementation Framework was feasible for implementation researchers. Barriers and facilitators were identified at all levels including the patient, provider (recipients), patient-provider interaction (clinical encounter), characteristics of treatment (innovation), and healthcare system (inner and outer context). Some barriers reflected general implementation issues (e.g., poor care coordination after testing positive for HCV). Other barriers were related to healthcare disparities and likely unique to racial minority patients (e.g., testimonials from Black peers about racial discrimination at VA). We identified several facilitators, including patient enthusiasm to obtain treatment because of its high cure rates, and VA clinics that offset HCV stigma by protecting patient confidentiality. CONCLUSION: The Health Equity Implementation Framework showcases one way to modify an implementation framework to better assess health equity determinants as well. Researchers may be able to optimize the scientific yield of research inquiries by identifying and addressing factors that promote or impede implementation of novel treatments in addition to eliminating healthcare disparities.

Positive social interaction offsets impact of low socioeconomic status on stress.

BACKGROUND: Stress is associated with unhealthy behaviors and premature morbidity and mortality, especially among those of low socioeconomic status (SES). Clarifying the roles of stress-related risk and protective factors can guide interventions designed to reduce stress and improve health among socioeconomically disadvantaged populations. PURPOSE: (1) Replicate prior research showing that lower SES is associated with higher stress in a predominantly racial minority, socioeconomically disadvantaged sample, and (2) test the hypothesis that different types of social support (a protective factor) mitigate the deleterious effects of SES on self-reported perceived stress. METHODS: Low-income patients (N = 508, 54% male, 68% African American, Mage = 28) from a publicly-funded clinic provided demographic information and then completed measures of perceived stress and social support. Four types of social support were assessed (viz., affectionate, emotional/informational, positive social interaction, and tangible). Structural equation modeling tested the hypothesized associations among SES, social support, and stress. RESULTS: Individuals of lower SES, ß = -0.27 (0.08), p < 0.01, and lower overall social support, ß = -0.47 (0.05), p < 0.001, reported higher stress. Social support moderated associations between SES and stress, with participants with lower SES benefitting the most from social support. Of the four types of social support that were measured, positive social interaction was the strongest moderator, ß = 0.20 (0.08), p = 0.01. CONCLUSIONS: The associations among SES, stress, and social support corroborate prior research. Positive social interaction was particularly important for decreasing stress among socioeconomically disadvantaged persons.

Harnessing Implementation Science to Increase the Impact of Health Equity Research.

BACKGROUND: Health disparities are differences in health or health care between groups based on social, economic, and/or environmental disadvantage. Disparity research often follows 3 steps: detecting (phase 1), understanding (phase 2), and reducing (phase 3), disparities. Although disparities have narrowed over time, many remain. OBJECTIVES: We argue that implementation science could enhance disparities research by broadening the scope of phase 2 studies and offering rigorous methods to test disparity-reducing implementation strategies in phase 3 studies. METHODS: We briefly review the focus of phase 2 and phase 3 disparities research. We then provide a decision tree and case examples to illustrate how implementation science frameworks and research designs could further enhance disparity research. RESULTS: Most health disparities research emphasizes patient and provider factors as predominant mechanisms underlying disparities. Applying implementation science frameworks like the Consolidated Framework for Implementation Research could help disparities research widen its scope in phase 2 studies and, in turn, develop broader disparities-reducing implementation strategies in phase 3 studies. Many phase 3 studies of disparity-reducing implementation strategies are similar to case studies, whose designs are not able to fully test causality. Implementation science research designs offer rigorous methods that could accelerate the pace at which equity is achieved in real-world practice. CONCLUSIONS: Disparities can be considered a "special case" of implementation challenges-when evidence-based clinical interventions are delivered to, and received by, vulnerable populations at lower rates. Bringing together health disparities research and implementation science could advance equity more than either could achieve on their own.