What Gets Measured Gets Done: How Mental Health Agencies can Leverage Measurement-Based Care for Better Patient Care, Clinician Supports, and Organizational Goals.

Mental health clinicians and administrators are increasingly asked to collect and report treatment outcome data despite numerous challenges to select and use instruments in routine practice. Measurement-based care (MBC) is an evidence-based practice for improving patient care. We propose that data collected from MBC processes with patients can be strategically leveraged by agencies to also support clinicians and respond to accountability requirements. MBC data elements are outlined using the Precision Mental Health Framework (Bickman et al. in Adm Policy Mental Health Mental Health Serv Res 43:271-276, 2016), practical guidance is provided for agency administrators, and conceptual examples illustrate strategic applications of one or more instruments to meet various needs throughout the organization.

Sexual minority men want provider behavior consistent with attitudes and norms during patient-provider interactions regarding HIV prevention.

HIV is a health problem for sexual minority men in the United States. One factor among many that contributes to this HIV disparity is poor patient-provider interactions. We focused on specific provider behavior preferred by sexual minority men during patient-provider interactions about HIV prevention. We interviewed 20 HIV-negative sexual minority men who endorsed 1+ psychosocial HIV risk factor. We used follow up interviews and conventional content analysis. Among our sample, 55% identified as White; 50% as bisexual, (Mage = 28.45). Findings suggested even some providers knowledgeable about sexual minority health provided unhelpful care to sexual minority men (knowledge-behavior discrepancy). Some knowledgeable providers engaged in affirmative, tailored treatment (knowledge-behavior consistency). Specific behaviors of preferred patient-provider interactions regarding HIV prevention are reported. Our recommendations are based on patient perceptions, which is a limit and strength. We identified an important type of unhelpful patient-provider interaction for HIV-negative sexual minority men beyond discriminatory experiences. Patient-provider interaction efforts need to go beyond education to help providers practice skills. With increased focus on cultural competency for sexual minority patients, more providers may advertise their practice as affirmative, yet interactions will likely vary, may require lifelong practice of cultural humility, and impact HIV prevention.

Testing and Exploring the Limits of Traditional Notions of Fidelity and Adaptation in Implementation of Preventive Interventions.

This commentary reflects on key challenges raised across the articles of this special issue, notably the tension between fidelity and adaptation, the importance of articulating core components and principles of evidence-based programs, the need for pragmatic measures, and the challenges associated with articulating and testing mechanisms of implementation strategies. These challenges are amplified in the context of prevention research where task shifting, or revising professional roles, is especially common. Synergies with work emerging from the Society for Implementation Research Collaboration are highlighted throughout.

It Takes a Village: A Mixed Method Analysis of Inner Setting Variables and Dialectical Behavior Therapy Implementation.

Guided by the Consolidated Framework for Implementation Research, this mixed method study explored the relationship between inner setting variables and dialectical behavior therapy (DBT) implementation. Intensively trained DBT clinicians completed an online quantitative survey (n = 79) and a subset were sequentially interviewed using qualitative methods (n = 20) to identify relationships between inner setting variables and DBT implementation. Four interpersonal variables-team cohesion, team communication, team climate, and supervision-were correlated with the quantity of DBT elements implemented. Qualitative themes corroborated these findings. Additional variables were connected to implementation by either quantitative or qualitative findings, but not both.

Recruitment tools for transgender and gender diverse veterans in health care research.

Transgender and gender diverse (TGD) veterans in the Veterans Health Administration experience health and health care disparities, and research with this population is needed to improve gender-affirming care in Veterans Health Administration. However, TGD veterans may experience hesitancy to participate in research. We must address barriers to participation through feasible and acceptable methods. Opt-out letters are an effective tool used to recruit veterans in mental health research. The present study examined the feasibility and acceptability of opt-out letters modified for TGD veterans. Opt-out letters were sent to 54 potential TGD participants at three sites. The letters stated the research team would begin contacting veterans by phone in 2 weeks if they did not opt out of being contacted. Feasibility was measured through response rate. Acceptability was assessed through qualitative template analysis of interview data. Of the 54 potential participants, two opted out, three letters were undeliverable, and eight veterans called to opt in. Veterans reported that they found the letters to be clear and useful. The responses to the opt-out letters resulted in completing recruitment for two of the three sites. The research team then called the veterans who received the letter at the third site (three veterans) and recruited one additional veteran, for a total of nine TGD veterans. Opt-out letters may be a helpful tool to recruit TGD veterans to participate in research. Although these letters were designed to opt out, 89% of participants called the research team to opt in. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Getting to Fidelity: Consensus Development Process to Identify Core Activities of Implementation Facilitation.

Transferring successful implementation strategies from research to practice requires approaches for assessing fidelity to the strategy's core components. Implementation facilitation (IF) is a strategy involving an interactive process of problem-solving, enabling, and supporting individuals in efforts to implement clinical innovations that occurs in the context of a recognized need for improvement and supportive interpersonal relationships. Because IF is a dynamic strategy involving numerous activities, our objective was to conduct a rigorous consensus development process to identify core activities for monitoring fidelity to IF when applied in clinical settings. We first conducted a scoping literature review to identify the range of activities used when IF has been applied in clinical settings, searching multiple citation databases for English-language articles including "facilitation" or other commonly-used terms for the strategy published from 1996-2015. Through multi-stage screening, 135 articles (from 94 studies) were identified for data extraction on IF activities, frequency with which IF activities were identified as 'core' by study authors, and study outcomes. From the literature review, we identified 32 distinct IF activities and developed definitions/examples for each. Next, we conducted a 3-stage, modified-Delphi expert panel consensus development process to identify core IF activities across three implementation phases (i.e., Pre-Implementation, Implementation, Sustainment). The expert panel identified 8 core activities for the Pre-Implementation Phase, 8 core activities for the Implementation Phase, and 4 core activities for the Sustainment Phase. This work provides an important foundation for developing measures/tools to assess use of core IF activities to ensure the strategy is delivered with fidelity.

Caring Letters Sent by a Clinician or Peer to At-Risk Veterans: A Randomized Clinical Trial.

Importance: Caring letters is an evidence-based suicide prevention intervention in acute care settings, but its outcomes among individuals who contact a national crisis line have not previously been evaluated. Objective: To examine the outcomes of the Veterans Crisis Line (VCL) caring letters intervention and determine whether there are differences in outcomes by signatory. Design, Setting, and Participants: This parallel randomized clinical trial compared signatories of caring letters and used an observational design to compare no receipt of caring letters with any caring letters receipt. Participants included veterans who contacted the VCL. Enrollment occurred between June 11, 2020, and June 10, 2021, with 1 year of follow-up. Analyses were completed between July 2022 and August 2023. Intervention: Veterans were randomized to receive 9 caring letters for 1 year from either a clinician or peer veteran signatory. Main Outcomes and Measures: The primary outcome measure was suicide attempt incidence in the 12 months following the index VCL contact. Incidence of Veterans Health Administration (VHA) inpatient, outpatient, and emergency health care use were secondary outcomes. All-cause mortality was an exploratory outcome. Wilcoxon rank-sum tests and χ2 tests were used to assess the differences in outcomes among the treatment and comparison groups. Results: A total of 102 709 veterans (86 942 males [84.65%]; 15 737 females [15.32%]; mean [SD] age, 53.82 [17.35] years) contacted the VCL and were randomized. No association was found among signatory and suicide attempts, secondary outcomes, or all-cause mortality. In the analysis of any receipt of caring letters, there was no evidence of an association between caring letters receipt and suicide attempt incidence. Caring letters receipt was associated with increased VHA health care use (any outpatient: hazard ratio [HR], 1.10; 95% CI, 1.08-1.13; outpatient mental health: HR, 1.19; 95% CI, 1.17-1.22; any inpatient: HR, 1.13; 95% CI, 1.08-1.18; inpatient mental health: HR, 1.14; 95% CI, 1.07-1.21). Caring letters receipt was not associated with all-cause mortality. Conclusions and Relevance: Among VHA patients who contacted the VCL, caring letters were not associated with suicide attempts, but were associated with a higher probability of health care use. No differences in outcomes were identified by signatory. Trial Registration: isrctn.org Identifier: ISRCTN27551361.

Impact of Implementation Facilitation on the REACH VET Clinical Program for Veterans at Risk for Suicide.

OBJECTIVE: In 2017, the Veterans Health Administration (VHA) implemented a national suicide prevention program, called Recovery Engagement and Coordination for Health-Veterans Enhanced Treatment (REACH VET), that uses a predictive algorithm to identify, attempt to reach, assess, and care for patients at the highest risk for suicide. The authors aimed to evaluate whether facilitation enhanced implementation of REACH VET at VHA facilities not meeting target completion rates. METHODS: In this hybrid effectiveness-implementation type 2 program evaluation, a quasi-experimental pre-post design was used to assess changes in implementation outcome measures evaluated 6 months before and 6 months after onset of facilitation of REACH VET implementation at 23 VHA facilities. Measures included percentages of patients with documented coordinator and provider acknowledgment of receipt, care evaluation, and outreach attempt. Generalized estimating equations were used to compare differences in REACH VET outcome measures before and after facilitation. Qualitative interviews were conducted with personnel and were explored via template analysis. RESULTS: Time had a significant effect in all outcomes models (p<0.001). An effect of facilitation was significant only for the outcome of attempted outreach. Patients identified by REACH VET had significantly higher odds of having a documented outreach attempt after facilitation of REACH VET implementation, compared with before facilitation. Site personnel felt supported and reported that the external facilitators were helpful and responsive. CONCLUSIONS: Facilitation of REACH VET implementation was associated with an improvement in outreach attempts to veterans identified as being at increased risk for suicide. Outreach is critical for engaging veterans in care.

Treating complex trauma among veterans: three stage-based treatment models.

This article addresses the issue of complex trauma in veterans and treatments for symptom presentations resulting from complex trauma exposure. While various definitions have been proposed for complex trauma, the clinical issues related to it are relevant for veterans as they are at risk for cumulative trauma exposures such as multiple combat deployments and military sexual trauma. Several treatments were either developed to address and/or implemented with complex trauma. This article discusses three of these treatments that share a stage-based approach, focusing on the present (e.g., skills training and psychoeducation), which can then be followed, if needed, with a past-focused (e.g., exposure-based) treatment: Dialectical Behavior Therapy (Linehan, 1993), Seeking Safety (Najavits, 2002), Skills Training in Affective and Interpersonal Regulation (STAIR) Narrative Therapy (Cloitre, Cohen, & Koenen, 2006). This article also discusses what is currently being done to address symptom presentations resulting from complex trauma exposure and challenges and possible solutions to implementing this care.

Barriers and Facilitators to Dialectical Behavior Therapy Skills Groups in the Veterans Health Administration.

INTRODUCTION: Dialectical behavior therapy (DBT) is a multimodal evidence-based suicide prevention psychotherapy with barriers to full implementation. This study qualitatively examined barriers and facilitators to the DBT skills group treatment mode, which can be implemented as a stand-alone intervention. Using data from a national mixed-methods program evaluation of DBT in the Veterans Health Administration (VHA), this is the first article to examine barriers and facilitators to DBT skills groups implemented with a DBT consultation team or as a stand-alone intervention. MATERIALS AND METHODS: A subset of data from semi-structured telephone interviews of six clinicians and three administrators (n = 9 respondents) was analyzed to provide complementarity and expansion on prior quantitative findings. The data were coded using an iterative process based on content analysis and a codebook based on the Promoting Action on Research Implementation in Health Services framework. The study was approved by the institutional review board for the Palo Alto VA Health Care System. RESULTS: Barriers and facilitators were organized by Promoting Action on Research Implementation in Health Services domains of evidence, context, and facilitation. Results showed how reduced leadership support and low receptivity to providing DBT skills groups functioned as barriers and also identified a barrier not described earlier in the literature: the perception that this group could conflict with expanding access to care for more veterans. The results showed how leadership supported implementation, including by mapping clinic grids and supporting training, and also revealed how a supportive culture among providers facilitated division of labor between skills group providers, and how offering a treatment that filled a gap in services supported the group. At some sites, a provider with prior DBT experience was instrumental in starting DBT skills groups or developing ongoing training. CONCLUSIONS: Qualitatively analyzed barriers and facilitators to a group-delivered suicide prevention intervention, DBT skills groups, expanded on quantitative findings on the importance of leadership support, culture, and training as facilitators. Future work implementing DBT skills group as a stand-alone treatment will need to address the barrier of receptivity and perceived barriers about access to care.

Rural Community Pharmacists' Perceptions of Implementing Mental Health Interventions to Reach Underserved Populations.

Mental illness and suicide are significant public health problems. Limited resources put individuals at greater risk, particularly in rural areas with fewer health providers. Community pharmacists are the most accessible health professionals in rural communities and are interested in addressing mental health concerns. Research is limited on how to implement mental health interventions in community pharmacy settings. The objectives of this study were to assess community pharmacists' perceptions of mental health interventions and barriers and facilitators to implementation and prioritize interventions to be pilot tested. Qualitative interviews were conducted with community pharmacists (N=17). Interviews focused on perceptions of mental health interventions in pharmacy settings. Data were analyzed using template analysis. A stakeholder meeting reviewed data and prioritized interventions to be pilot tested. Pharmacists viewed implementing mental health interventions positively. Barriers included lack of mental health knowledge, time, diagnosis, and concerns about workflow. Facilitators included accessible settings, knowing the community, and seeing patients frequently. The most common needs for implementation were education and payment. Pharmacists preferred progress monitoring in collaboration with a prescriber and mental health first aid training. Further research is needed to gather feedback from prescribers to inform implementation.

Effectiveness of a Self-Administered Computerized Mental Health Screening Tool in the Emergency Department.

OBJECTIVE: The authors sought to determine the effectiveness of a self-administered computerized mental health screening tool in a general acute care emergency department (ED). METHODS: Changes in patient care (diagnosis of a past-year psychiatric disorder, request for psychiatric consultation, psychiatric referral at discharge, or transfer to psychiatric facility) and patient ED return visits (3 months after discharge vs. 3 months before) were assessed among ED physicians (N=451) who received patients' computerized screening reports (N=207) and those who did not (N=244). All patients received copies of screening results. RESULTS: The computerized mental health screening tool identified previously undiagnosed psychiatric problems. However, no statistically significant differences were found in physician care or patient ED return visits. CONCLUSIONS: Computerized mental health screening did not result in further psychiatric diagnoses or treatment; it also did not significantly reduce patient ED return visits. Collaboration among EDs and mental health treatment agencies, organizations, and researchers is needed to facilitate appropriate treatment referrals and linkage.

Cost comparison of in-person and telehealth modalities for a suicide safety planning group intervention: interim results from the "Project Life Force" randomized clinical trial.

Suicide prevention is a clinical priority for the US Veterans Health Administration. Evidence-based interventions, including developing a suicide safety plan, are recommended practices and are becoming more widespread. Adaptations to further augment safety planning include a manualized group intervention (Project Life Force, PLF) that combines safety planning with the teaching of skills to maximize use of the plan. A multi-year randomized controlled trial to test efficacy of PLF compared to treatment as usual is currently in progress. However, approximately a year into the study, in-person groups were converted to telehealth groups due to the COVID-19 pandemic. This study compares the per-veteran cost of PLF when delivered in-person versus by telehealth using preliminary trial data from the first 2.5 years of the trial. Cost to deliver PLF was obtained from the Veterans Health Administration's Managerial Cost Accounting data, which relies on activity-based costing. We found no significant differences in the average number of sessions or average group size between in-person and telehealth. However, the cost per group session was lower for the telehealth modality and this led to significant overall per-veteran savings. While efficacy data comparing from the two arms is still underway and we await the ongoing RCT results, our interim cost analysis highlights potential savings with the telehealth modality.

Prospective Predictors of Work Limitations in Young Adult Lesbian and Bisexual Women: An Examination of Minority Stress, Trauma Exposure, and Mental Health.

Trauma exposure and mental health problems adversely affect work functioning. Sexual minority women are at increased risk for trauma exposure, depression, and PTSD. Sexual minority women also experience unique stressors related to their sexual orientation, which can directly impact work functioning. However, little research to date has examined the impact of trauma exposure and mental health problems among sexual minority women on their occupational outcomes. The goal of the current study was to examine whether trauma exposure, mental health problems, and minority stressors were associated with occupational functioning one year later in a large sample of young adult lesbian and bisexual women. The study utilized a subset of data (N = 304) from a larger longitudinal study on health risk behaviors among young adult lesbian and bisexual women. Results indicated that trauma exposure, posttraumatic stress, depression, and perceived heterosexism were each associated with subsequent work limitations, but after accounting for shared variance between predictors, only perceived heterosexism and depression were uniquely associated with subsequent work functioning. These findings highlight the roles of mental health and sexual orientation-related stress in the challenges that lesbian and bisexual women experience at work and point to a need for additional research to better understand risk and protective factors related to negative employment outcomes among lesbian and bisexual women.

Implementation of LGBTQ+ affirming care policies in the Veterans Health Administration: preliminary findings on barriers and facilitators in the southern United States.

Background: In the United States Department of Veterans Affairs (VA), veterans who are lesbian, gay, bisexual, transgender, queer, and similar gender and sexual minoritized people (LGBTQ+) experience health disparities compared to cisgender, heterosexual veterans. VA's LGBTQ+ Health Program created two healthcare policies on providing LGBTQ+ affirming care (healthcare that is inclusive, validating, and understanding of the LGBTQ+ population). The current project examines providers' barriers and facilitators to providing LGBTQ+ affirming care and LGBTQ+ veterans' barriers and facilitators to receiving LGBTQ+ affirming care. Methods: Data collection and analysis were informed by the Consolidated Framework for Implementation Research, which was adapted to include three health equity domains. Data collection involved telephone interviews conducted with 11 VA providers and 12 LGBTQ+ veterans at one rural and one urban VA medical center, and one rural VA community clinic. Qualitative data were rapidly analyzed using template analysis, a data reduction technique. Results: Providers described limited education, limited time, lack of experience with the population, and a lack of awareness of resources as barriers. Providers discussed comfort with consulting trusted peers, interest in learning more about providing LGBTQ+ affirming care, and openness and acceptance of the LGBTQ+ community as facilitators. LGBTQ+ veterans described a lack of provider awareness of their needs, concerns related to safety and discrimination, and structural discrimination as barriers. LGBTQ+ veterans described positive relationships with providers, knowledge of their own healthcare needs, and ability to advocate for their healthcare needs as facilitators. Although VA's LGBTQ+ affirming care policies are in place, providers and veterans noted a lack of awareness regarding specific healthcare processes. Conclusion: Allowing more time and capacity for education and engaging LGBTQ+ veterans in determining how to improve their healthcare may be the path forward to increase adherence to LGBTQ+ affirming care policies. Engaging patients, especially those from marginalized backgrounds, in strategies focused on the uptake of policy may be a path to improve policy implementation. It is possible that creating truly collaborative structures in which patients, staff, providers, leadership, and policymakers can work together towards policy implementation may be a useful strategy. In turn, improved policy implementation would result in increased physical and mental health for LGBTQ+ veterans.

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.

Qualitative Evaluation of a Caring Letters Suicide Prevention Intervention for the Veterans Crisis Line.

OBJECTIVE: Suicide is a leading cause of death in the United States. This has prompted the U.S. surgeon general to issue a report describing actionable items to reduce suicide rates, including a recommendation to increase the use of the caring letters intervention. This intervention involves mailing brief, nondemanding messages of care. As part of the Department of Veterans Affairs' (VA's) efforts to reduce suicide rates among veterans, a caring letters project was developed for veterans who contact the Veterans Crisis Line (VCL). This article describes the results of qualitative interviews conducted to better understand the experiences of veterans who received caring letters. METHODS: Beginning in 2020, all identifiable veterans who used Veterans Health Administration services and contacted the VCL received nine letters over 1 year, along with a list of mental health resources. Semistructured interviews (N=23) were conducted, and content analysis was used to identify veterans' perspectives and suggestions for improving the intervention. RESULTS: Sixteen men and seven women participated (mean age=53 years). Feedback varied, with most participants reporting that receiving caring letters had a positive impact and others noting aspects that could be improved to enhance the intervention's caring intent. Some also reported that the letters helped them engage with community resources and made them more likely to seek VA care. CONCLUSIONS: The caring letters intervention, received after contact with the VCL, was well received by participants. They described feeling appreciated, cared for, encouraged, and connected. The results of this study will inform future evaluation examining veteran outcomes.

Evidence-Based Quality Improvement (EBQI) in the pre-implementation phase: key steps and activities.

Background: Evidence-Based Quality Improvement (EBQI) involves researchers and local partners working collaboratively to support the uptake of an evidence-based intervention (EBI). To date, EBQI has not been consistently included in community-engaged dissemination and implementation literature. The purpose of this paper is to illustrate the steps, activities, and outputs of EBQI in the pre-implementation phase. Methods: The research team applied comparative case study methods to describe key steps, activities, and outputs of EBQI across seven projects. Our approach included: (1) specification of research questions, (2) selection of cases, (3) construction of a case codebook, (4) coding of cases using the codebook, and (5) comparison of cases. Results: The cases selected included five distinct settings (e.g., correction facilities, community pharmacies), seven EBIs (e.g., nutrition promotion curriculum, cognitive processing therapy) and five unique lead authors. Case examples include both community-embedded and clinically-oriented projects. Key steps in the EBQI process included: (1) forming a local team of partners and experts, (2) prioritizing implementation determinants based on existing literature/data, (3) selecting strategies and/or adaptations in the context of key determinants, (4) specifying selected strategies/adaptations, and (5) refining strategies/adaptations. Examples of activities are included to illustrate how each step was achieved. Outputs included prioritized determinants, EBI adaptations, and implementation strategies. Conclusions: A primary contribution of our comparative case study is the delineation of various steps and activities of EBQI, which may contribute to the replicability of the EBQI process across other implementation research projects.

The Veterans Health Administration REACH VET Program: Suicide Predictive Modeling in Practice.

The U.S. Veterans Health Administration developed a suicide prediction statistical model and implemented a novel clinical program, Recovery Engagement and Coordination for Health-Veterans Enhanced Treatment (REACH VET). This high-value suicide prevention program aims to efficiently identify patients at risk and connect them with care. Starting in April 2017, national REACH VET metric data were collected from electronic health records to evaluate required task completion. By October 2020, 98% of veterans identified (N=6,579) were contacted by providers and had their care evaluated. In the nation's largest health care system, it was feasible to implement a clinical program based on a suicide prediction model.