improving practice: the promise of i mplementation research
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Improving Practice: The promise of I mplementation Research. Enola Proctor Community Academic Partnerships o n 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.” - PowerPoint PPT PresentationTRANSCRIPT
Improving Practice:The promise of
Implementation Research
Enola ProctorCommunity Academic Partnerships on Addiction
Brown SchoolJanuary 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 interventionsThe “how:” Implementation strategiesThe “where:” ContextPartnerships
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 The quality chasm reflected by:
%
%
What is the quality of social work services?
Quality of mental health careUS 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 AccreditationCertificationLiability
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, remindersBundled or complex:
Organizational change strategies:– teamwork, culture, communication– Ex: ARC
Technological strategies?Training strategies: Provider education, coachingSupport 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
ContextPractice 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 strategiesUnderstanding what strategies work, for which
EST’s, in which settingsDeveloping 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’sEvidence evolves → Continually adoptLimited absorptive capacity → Must de-adoptFit to local context → AdaptationStaff 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 & teamsImplementing 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 MH068579R25 MH080916P30 DK092950 U54 CA155496UL1 RR024992 (Clinical and Translational Science Award, CTSA)
Washington University Institute for Public HealthBrown School of Social Work
Conflicts: none