Partnering with Health Systems Leadership to Develop a Randomized, Controlled Implementation Trial Mark S. Bauer, MD VA Center for Healthcare Organization & Implementation Research (CHOIR) & the VA QUERI for Team-Based Behavioral Health
Behavioral Health Interdisciplinary Program Teams (BHIP) Overview / Aims • Office of Mental Health Operations operational initiative • Goal: Establish team-based care in all general MH clinics in VA • 2015: OMHO adopted the Collaborative Chronic Care Model ( CCM — see next slide) as the model for BHIPs • QUERI project: Randomized controlled trial of “blended facilitation” to help this happen (9 sites)
CCM Elements CCM Goal: Anticipatory, Continuous, Evidence- Based, Collaborative Care via… CCM-3: CCM-4: CCM-2: Veteran CCM-5: CCM-6: Provider Work Role Self- Information Communit Decision Redesign Management Management y Linkages Support Support • Care • Focus on the • Provider • Additional Population : • Registry management individual’s education resources • Need-driven • Practice • Peer- values and skills • Shared decision- access guidelines Provider: based • Activated • Specialty • Outcome making support • Self-mgt skills follow-up consultation tracking • Recovery- • Feedback orientation CCM-1: Organizational Leadership and Support 3
BHIP Overview / Aims Hypotheses: • Facilitation CCM-ness improved outcomes: • Veteran health status, perceptions of care • Provider perceptions of CCM-ness • Administrative measures of fidelity to BHIP/CCM
BHIP Overview / Aims Study Design: • “ S tepped wedge” design (see next slide) • Add blended facilitation to enhanced technical assistance • External Facilitator [study staff] partners with Internal Facilitator [facility staff] • 1.5-day site visit • Regular phone/video meetings for 12 months: team-building & process redesign • Workbook-guided: BHIP-CCM Build-Out Guide
Stepped Wedge Design
Partnering…where the rubber meets the road Design Element Operational Considerations Researcher Considerations Sites and Population • • The BHIP Need results to inform Sells the project to facilities • operational ongoing process Increases sustainability • • initiative has Can capitalize on momentum Stepped wedge addresses already begun of the system to engage sites secular trends
Partnering…where the rubber meets the road Design Element Operational Considerations Researcher Considerations Sites and Population • • The BHIP Need results to inform Sells the project to facilities • operational ongoing process Increases sustainability • • initiative has Can capitalize on momentum Stepped wedge addresses already begun of the system to engage sites secular trends • Avoid ceiling effects (high Identifying the • Slower-to-adopt facilities are performers) and insufficient population of focus commitment to change facilities to target (laggards)
Partnering…where the rubber meets the road Design Element Operational Considerations Researcher Considerations Sites and Population • • The BHIP Need results to inform Sells the project to facilities • operational ongoing process Increases sustainability • • initiative has Can capitalize on momentum Stepped wedge addresses already begun of the system to engage sites secular trends • Avoid ceiling effects (high Identifying the • Slower-to-adopt facilities are performers) and insufficient population of focus commitment to change facilities to target (laggards) • National & regional • Provides access beyond “usual communications structure suspect” and “friends of Site recruiting enhances facility friends” facilities to enhance identification and endorses external validity the project
Partnering…where the rubber meets the road Design Element Operational Considerations Researcher Considerations Intervention & Design • Stepped wedge • All sites to receive Justifies the project on policy accommodates this implementation level • Design supports formative • support Can be a site recruiting tool evaluation
Partnering…where the rubber meets the road Design Element Operational Considerations Researcher Considerations Intervention & Design • Stepped wedge • All sites to receive Justifies the project on policy accommodates this implementation level • Design supports formative • support Can be a site recruiting tool evaluation • • Experience-based expertise Sophisticated algorithm for Balance in contributes identifying balancing ( see Bob Lew’s talk randomization characteristics of success here at ARM)
Partnering…where the rubber meets the road Design Element Operational Considerations Researcher Considerations Intervention & Design • Stepped wedge • All sites to receive Justifies the project on policy accommodates this implementation level • Design supports formative • support Can be a site recruiting tool evaluation • • Experience-based expertise Sophisticated algorithm for Balance in contributes identifying balancing ( see Bob Lew’s talk randomization characteristics of success here at ARM, 3pm Monday) • Researchers need a credible Control condition • Sites seek as much support as contrast condition possible, as soon as possible • Need to engage later sites
Partnering…where the rubber meets the road Design Element Operational Considerations Researcher Considerations Intervention & Design • Stepped wedge • All sites to receive Justifies the project on policy accommodates this implementation level • Design supports formative • support Can be a site recruiting tool evaluation • • Experience-based expertise Sophisticated algorithm for Balance in contributes identifying balancing ( see Bob Lew’s talk randomization characteristics of success here at ARM, 3pm Monday) • Researchers need a credible Control condition • Sites seek as much support as contrast condition possible, as soon as possible • Need to engage later sites Length of • • Experience-based expertise Timeliness requires steps in implementation suggests one year needed wedge of four months support
Partnering…where the rubber meets the road Design Element Operational Considerations Researcher Considerations Intervention & Design (cont) • Use existing VAMC Sustainability more likely • No additional clinical or • staff without Distinct scientific contribution administrative staff external support beyond RCTs
Partnering…where the rubber meets the road Design Element Operational Considerations Researcher Considerations Intervention & Design (cont) • Use existing VAMC Sustainability more likely • No additional clinical or • staff without Distinct scientific contribution administrative staff external support beyond RCTs • Providers can choose not to • A facility’s participation in this participate in qualitative Quality implementation project is interviews. • improvement vs. optional Patients can choose not to • research Staff participation in their participate in health status facility’s BHIP is not optional and perception of care assessments.
Partnering…where the rubber meets the road Design Element Operational Considerations Researcher Considerations Intervention & Design (cont) • Use existing VAMC Sustainability more likely • No additional clinical or • staff without Distinct scientific contribution administrative staff external support beyond RCTs • Providers can choose not to • A facility’s participation in this participate in qualitative Quality implementation project is interviews. • improvement vs. optional Patients can choose not to • research Staff participation in their participate in health status facility’s BHIP is not optional and perception of care assessments. Videoconference • • Budget will not support Provides greater likelihood of and telephone for frequent site visits by external spread of intervention external facilitators strategy facilitation
Partnering…where the rubber meets the road Design Element Operational Considerations Researcher Considerations Outcome Assessment & Analysis • Both quality and Priorities: (a) whether CCM can • Hybrid Type III designs health status be implemented and (b) address implementation & impacts are whether CCM-guided BHIP health status outcomes important teams have impact
Partnering…where the rubber meets the road Design Element Operational Considerations Researcher Considerations Outcome Assessment & Analysis • Both quality and Priorities: (a) whether CCM can • Hybrid Type III designs health status be implemented and (b) address implementation & impacts are whether CCM-guided BHIP health status outcomes important teams have impact • Outcome Program fidelity measures must • Patient-level measures must domains and be streamlined and be psychometrically valid and appropriate benchmarked against national feasible instruments data
Recommend
More recommend
