Improving Practice: The promise of Implementation Research Enola Proctor Community Academic Partnerships on Addiction Brown School January 27, 2014

What is implementation research? “Research to inform how to make the right thing to do the easy thing to do.” -Carolyn Clancy, Agency for Healthcare Research and Quality

I. What is it? NIH Definitions * Dissemination Research: – study of how research evidence spreads through agencies, organizations, and front line workers. Implementation Research: – scientific study of how to move evidence-based interventions into practice and policy **PAR13-055

II. Implementation: What does it take? Quality gaps to address Evidence-based interventions The “how:” Implementation strategies The “where:” Context Partnerships

Implementation is about improving care The care that “could be” vs The care that “is” What quality gaps are of concern?

The care “that is…” What services are we delivering?

The care “could be…” What services should we be delivering?

Quality gaps

Quality of mental health care US mental health care: “D grade” (NAMI) AHRQ: Physical healthcare is improving, but no improvement in depression care (AHRQ’s 2010 Health Care Quality Report) Household data: <10% of the U.S. population with a serious mental disorder receives adequate care (Kessler et al, 2005) Racial disparities in care

Quality of SW services Parent training * – 11% of services offered = “well-established empirically supported interventions (ESI’s)” – 20% contained some hallmarks of ESI’s School mental health** – 19.3% of school mental health professionals use “any” EB programs Substance prevention programs – 36.8% use any EB programs

Evidence Based interventions Are interventions ready for D&I? Balancing Tx discovery v Tx roll out

Evidence-based interventions What is the supply of EB interventions? How strong is the evidence? How relevant is the evidence?

Sources of evidence reviews The Cochrane Collaboration (standard setter) National Registry of Evidence-based Programs & Practices (SAMHSA rating & classification system) AHRQ Evidence-based Practice Centers California Evidence-Based Clearing House for Child Welfare US Preventive Services Task Force (clinical) The Community Preventive Services Task Force (community “guides”)

When we have effective interventions, it’s time to delivery them Professional Associations

Implementation Strategies ………… the ‘how to’ component of changing healthcare practice. ……….Key: How to make the “right thing to do” the “easy thing to do …Carolyn Clancy

Implementation Strategies: Complexity* Discrete involve one process or action, such as “meetings,” “reminders” Multifaceted** uses two or more discrete strategies, such as “training + technical assistance” Blended several discrete strategies are interwoven & packaged as protocolized or branded strategies, such as “ARC,” IHI Framework fro Spread” *Powell, McMillen, Proctor et al., 2012 ** Grimshaw et al., 2001, Grol & Grimshaw, 2003

A Compilation or “menu” 68 strategies grouped by six key processes* *Powell, McMillen, Proctor et al., Medical Care Research and Review, 2012

Plan Strategies Gather information Select strategies Build buy-in Initiate leadership Develop relationships

Educate Strategies Develop materials Provider training Inform and influence stakeholders

Finance Strategies Modify incentives for clinicians, consumers, reduce disincentives Facilitate financial support: place on formularies

Restructure strategies Revise roles Create new teams Change sites Change record systems Structure communication protocols

Quality Management Strategies Audit and provide feedback Clinician reminders Develop T.A. systems Conduct cyclical small tests of change Checklists

Policy Strategies Licensure Accreditation Certification Liability

Strategies: What do we know? Passive dissemination is ineffective – E.g. publishing articles, issuing a memo, “edict” Training is most frequently used strategy Multi-component, multilevel are more effective

Implementation Strategies for social work: What do we know? Discrete: checklists, data feedback, reminders Bundled or complex: Organizational change strategies: – teamwork, culture, communication – Ex: ARC Technological strategies? Training strategies: Provider education, coaching Support strategies: Supervision, Site level support and monitoring

Implementation Outcomes Distinct from clinical outcomes  Could have an effective intervention, poorly implemented  Could have an ineffective treatment, successfully implemented

Implementation Outcomes: Key Concepts Acceptability Adoption Appropriateness Feasibility Fidelity Implementation cost Penetration Sustainability

Implementation outcomes: what do we know? Fidelity = most frequently measured outcome Provider attitudes frequently assessed Implementation outcomes are interactive: – Effectiveness greater acceptability – Cost feasibility We don’t know much about: – Sustainability – Scale up and spread

Context Practice change needs to aligned with  Priorities and trends in policy ecology*  Agency infrastructure, system antecedents ** Practice change requires  Leadership  Culture of a “learning organization” *Raghavan, 2009 ** Emmons, 2013

Context: Need for an implementation imperative Which stakeholders care about, demand EB services? Payers, Policy makers Administrators Researchers Clients/ Patients, Families Providers (clinicians, counselors, M.D.’s, nurses, OT, PT, SW) Support staff (units, labs, medical records) Supervisors, training teams How invested, and how powerful? What is the imperative to improve outcomes?

Implementation = partnered Multiple stakeholders service consumers families providers administrators funders legislators

Where are we going? Challenges and opportunities in implementation science

Priority area #1: Implementation Strategies Identify effective implementation strategies Understanding what strategies work, for which EST’s, in which settings Developing more parsimonious strategies: which components have which effects? Which strategies for which implementation outcomes?

Implementation Strategies: How to select? Context assessment: – Barrier identification – System antecedents * – Root cause analysis Target to context Stakeholder engagement *Emmons, K. M., Weiner, B., Fernandez, M.E., & Tu, S. (2012), Systems Antecedents for Dissemination and Implementation : A Review and Analysis of Measures, Health Educ Behav 39: 87 ** Flottorp, S.A., Oxman, A.D., Krause, J. et al., (2013), A checklist for identifying determinants of practice: A systematic review and synthesis of frameworks and taxonomies of factors that prevent or enable improvements in healthcare professional practice, Implementation Science, 8:35

Priority area II: Informing complex implementation Reality of most service delivery: Co-occurring conditions → Multiple EBI’s Evidence evolves → Continually adopt Limited absorptive capacity → Must de- adopt Fit to local context → Adaptation Staff turnover→ Continual training 35

Treatment Evidence Continues to Grow What strategies can enable providers & organizations to implement evolving evidence? 36

Priority area III: Implementation Outcomes Priority outcomes: incremental cost scale up & spread sustainability

Program Sustainability Assessment Tool

Priority Area IV: How to implement in different agency contexts? Understanding leadership for implementation Implementing EB services in resource-limited settings What strategies work for what kinds of context?

Projects & teams Implementing multiple EB interventions EB eating disorder Tx in college MH Cultural adaptation of TX for Implementation RCT of ARC in child mental health Sustainability of EB programs Dissemination & policy implementation

Support: National Institute of Mental Health P30 MH R25 MH P30 DK U54 CA UL1 RR (Clinical and Translational Science Award, CTSA) Washington University Institute for Public Health Brown School of Social Work Conflicts: none

Questions… ….???????? Enola Proctor