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Implementation Strategies & Outcomes: Advancing the Science

  1. Enola  Proctor   Johns  Hopkins   February  24,  2014   1   Implementa)on     Strategies  &  Outcomes:     Advancing  the  science  
  2. Session  overview:   1. Implementa?on  science:     What  is  it?     2. Implementa?on  outcomes  &   strategies:    conceptual  &   methodological  challenges   3.    Where  are  we  going?             2  
  3. I.    What  is  it?   NIH  Defini?ons*   Dissemina?on  Research:     –  study  of  how  &  when  research  evidence  spreads   throughout  agencies,  organiza?ons,  and  front  line   workers.   Implementa?on  Research:     –  scien?fic  study  of  how  to  move  evidence-­‐based   interven?ons  into  healthcare  prac?ce  and  policy   **PAR13-­‐055   3  
  4. What  is  implementa?on  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   4  
  5. Implementa)on  research:   What  does  it  take?       Quality  gaps  to  address     Evidence-­‐based  interven?ons   The  “how:”  Implementa?on  strategies   The  “where:”    Context   Theory   Partnerships   Research  Methods  &  tools   5  
  6. Implementa?on  is  about  improving   care   The  care  that  “could  be”   vs   The  care  that  “is”   What  quality  gaps  are  of  concern?   6  
  7. Quality  gaps     •     
  8. 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.  popula?on   with  a  serious  mental  disorder  receives   adequate  care  (Kessler  et  al,  2005)   Racial  dispari?es  in  care     8  
  9. Evidence  Based  interven?ons   Are  interven?ons  ready  for  D&I?   Balancing  Tx  discovery  v  Tx  roll  out     9  
  10. When  we  have  effec?ve  interven?ons,   it’s  ?me  to  delivery  them   Professional  Associa?ons   10  
  11. Implementa)on   Outcomes   Feasibility   Fidelity   Penetra?on   Acceptability   Sustainability   Uptake   Costs   *IOM  Standards  of  Care   Conceptual  Model  for  Implementa)on  Research   What?   QIs   ESTs   How?   Implementa?on   Strategies   Implementa?on  Research  Methods   Service   Outcomes*   Efficiency   Safety   Effec?veness   Equity   Pa?ent-­‐   centeredness   Timeliness   Pa)ent  Outcomes   Clinical/health   status   Symptoms   Func?on   Sa?sfac?on   Proctor  et  al  2009  Admin.  &  Pol.  in  Mental  Health  Services   CONTEXT   CONTEXT   CONTEXT   CONTEXT   The  Usual   The  Core  of   Implementa)on   Science   11  
  12. Implementa?on  research  studies…   Key  variables:        behavior  of  healthcare  professionals  and  support  staff      healthcare  organiza?ons  (culture/  context)      healthcare  consumers  and  family  members      policymakers  in  context  as  key  variables     Key  outcomes:      sustainable  adop?on,  implementa?on  and  uptake  of   evidence-­‐based  interven?ons     12  
  13. Theories   Now:    Many  models!!!     109  iden?fied  models    How  to  choose?   Tabak,  Khoong,  Chambers,  &  Brownson  (2012),  Bridging  Research  and  Prac?ce:     Models  for  Dissemina?on  and  Implementa?on   Research,  J  Prev  Med,  43(3):337–350   13  
  14. Implementation Strategies: Definition Systematic intervention process to adopt and integrate evidence-based healthcare innovations into usual care * Active ingredient in processes for moving EST’s and QI’s into usual care *Powell, McMillen, Proctor et al., Medical Care Research and Review, 2012 14
  15. Implementa?on  Strategies   …………the  ‘how  to’  component  of   changing  healthcare  prac?ce.     ……….Key:        How  to  make  the  “right  thing  to  do”      the  “easy  thing  to  do…Carolyn  Clancy   15  
  16. Implementa?on  Strategies:   Complexity*   Discrete   •  involve  one  process  or  ac?on,  such  as  “mee?ngs,”   “reminders”   Mul)faceted**   •  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   16  
  17. A  Compila?on  or  “menu”   68  strategies  grouped  by  six  key   processes*   *Powell,  McMillen,  Proctor  et  al.,  Medical  Care  Research  and   Review,  2012   17  
  18. Plan  Strategies   •  Gather  informa?on   •  Select  strategies   •  Build  buy-­‐in   •  Ini?ate  leadership   •  Develop   rela?onships  
  19. Educate  Strategies   •  Develop  materials   •  Provider  training   •  Inform  and   influence   stakeholders  
  20. Finance  Strategies   •  Modify  incen?ves   for  clinicians,   consumers,  reduce   disincen?ves   •  Facilitate  financial   support:  place  on   formularies  
  21. Restructure  strategies   •  Revise  roles   •  Create  new  teams   •  Change  sites   •  Change  record   systems   •  Structure   communica?on   protocols  
  22. Quality  Management  Strategies   •  Audit  and  provide   feedback   •  Clinician  reminders   •  Develop  T.A.   systems   •  Conduct  cyclical   small  tests  of   change   •  Checklists  
  23. Policy  Strategies     Licensure   Accredita?on   Cer?fica?on   Liability  
  24. Strategies:    What  do  we  know?   •  Passive  dissemina?on  is  ineffec?ve     – E.g.  publishing  ar?cles,  issuing  a  memo,  “edict”   •  Training  is  most  frequently  used   strategy   •  Mul?-­‐component,  mul?level  are   more  effec?ve   24  
  25. Implementa?on  Strategies:      What  do  we  know?   Discrete:    checklists,  data  feedback,  reminders   Bundled  or  complex:    Organiza?onal  change  strategies:   –  teamwork,  culture,  communica?on   –  Ex:    ARC    Technological  strategies?    Training  strategies:    Provider  educa?on,  coaching    Support  strategies:          Supervision,  Site  level  support  and  monitoring   25  
  26. Implementa?on  Outcomes   Dis?nct  from  clinical  outcomes        Could  have  an  effec?ve                  interven?on,  poorly  implemented        Could  have  an  ineffec?ve      treatment,  successfully    implemented   26  
  27. Implementa?on  Outcomes:     Key  Concepts   •  Acceptability   •  Adop?on   •  Appropriateness   •  Feasibility   •  Fidelity   •  Implementa?on  cost   •  Penetra?on   •  Sustainability   27  
  28. Implementa)on  Outcomes   Mul?ple  stakeholders  &  mul?ple  perspec?ves   •  Service  consumers,  families,  providers,   administrators,  funders,  legislators   •  Which  outcomes  mater  most  to  whom?   How  are  outcomes  related?       •  This  informs  modeling  of  change   •  IO  ↔  IO   •  IO  →service  system  and  clinical  outcomes   28  
  29. Measuring  Constructs   Developing  field     – Standard  measures  lacking   Common,  overlapping  constructs   Meta-­‐analysis  to  enhance  D&I  measures   inhibited  by:     – Weaknesses  in  informa?on  about  outcomes   – Use  of  dichotomous  measures   – Unit  of  analysis   29  
  30. Measurement:  Toward  Standardiza?on   &  Harmoniza?on   •  Seatle  Implementa?on  Research  Conference   Measures  Project   – htp://www.seatleimplementa?­‐ projects/sirc-­‐measures-­‐project/     •  Grid-­‐Enabled  Measures  developed  by  the   Na?onal  Cancer  Ins?tute   – htp://     30  
  31. Implementa?on  Outcomes   Ques?on  from  the  field:  How  much  will  this   cost  and  what  kind  of  havoc  will  it  wreak?   Priority  outcomes:   •   incremental  cost   •   scale  up  &  spread   •   sustainability   31  
  32. Implementa?on  outcomes:   what  do  we  know?   •  Fidelity  =  most  frequently  measured  outcome   •  Provider  aytudes  frequently  assessed   •  Implementa?on  outcomes  are  interac?ve:   – Effec?veness        greater  acceptability     – Cost                        feasibility   •  We  don’t  know  much  about:   – Sustainability   – Scale  up  and  spread   32  
  33. Which  implementa?on  outcomes  are   most  important  to  pursue?   Stakeholder  assessment   Who  are  they?     –   Payers,  Policy  makers   –  Administrators   –  Researchers   –  Clients/  Pa?ents  ,  Families   –  Providers  (clinicians,  counselors,  M.D.’s,  nurses,  OT,  PT,  SW)   –  Support  staff  (units,  labs,  medical  records)   –  Supervisors,  training  teams     Where  are  they  re:  the  implementa?on?     33  
  34. Which  implementa?on  outcomes  are   most  important  to  pursue?   Push  &  pull        Is  there  a  demand  to  implement?        Is  there  a  push?        Is  there  a  pull?   34  
  35. Which  implementa?on  outcomes  are   most  important  to  pursue?   Contextual  assessment:       Barrier  assessment:   Prac?ce  change  needs  to  aligned  with      Priori?es  and  trends  in  policy  ecology*      Agency  infrastructure,  system  antecedents  **    Capacity     *Raghavan,  2009   **  Emmons,  2013   35  
  36. Context:  Consolidated  Framework  for   Implementa?on  Research  (CFIR)   •  Composed  of  5  major   domains:     –  Interven?on   characteris?cs   –  Outer  seyng   –  Inner  seyng   –  Characteris?cs  of  the   individuals  involved   –  Process  of   implementa?on   Damschroder  L,  Aron  D,  Keith  R,  Kirsh  S,  Alexander  J,  Lowery  J.:  Fostering  implementa?on  of  health  services  research  findings  into  prac?ce:  a   consolidated  framework  for  advancing  implementa?on  science.  Implement  Sci  2009,  4(1):50.   36  
  37. Implementa?on  Context   Advancing  measurement  for  contextual  constructs   •  Measures  exist  for  several  of  CFIR’s  constructs   •  More  informa?on  on  the  Wiki:     htp://   Understanding  how  to  fit  changing  EB   interven)ons  into  changing  context*   *  Dynamic  sustainability  framework,  Chambers  et  al.,   Implementa?on    Science,  2013   37  
  38. Implementa)on  Strategies:      How  to  select?   Evidence  of  effec)veness  and  fit     Under  construc?on   Informed  by  context  assessment       Inner  seyng     Outer  seyng     Interven?on  features     Barriers  assessment     Flotorp,  S.A  (2013)  A  checklist  for  iden?fying  determinants  of   prac?ce:  A  systema?c  review  and  synthesis  of  frameworks  and   taxonomies  of  factors  that  prevent  or  enable  improvements  in   healthcare  professional  prac?ce.  ImplementaDon  Science  8:35     38  
  39. Where  are  we  going?   Challenges  and   opportuniDes  in   implementaDon  science   39  
  40. Priority  area  #1:     Implementa)on  Strategies   Build  the  evidence   Empirical  tests  of  strategies    CER    Cost  effec?veness   Understanding  what  strategies  work,  for  which   EST’s,  in  which  seyngs   Developing  more  parsimonious  strategies:    which  components  have  which  effects?   Which  strategies  for  which  implementa?on   outcomes?   40  
  41. Implementa?on  Strategies:   How  to  select?   •  Context  assessment:   –  Barrier  iden?fica?on   –  System  antecedents  *   –  Root  cause  analysis   •  Target  to  context   •  Stakeholder  engagement   *Emmons,  K.  M.,  Weiner,  B.,  Fernandez  ,  M.E.,  &  Tu,  S.  (2012),    Systems  Antecedents   for  Dissemina?on  and  Implementa?on  :  A  Review  and  Analysis  of  Measures,  Health   Educ  Behav  39:  87   **  Flotorp,  S.A.,  Oxman,  A.D.,  Krause,  J.  et  al.,  (2013),  A  checklist  for  iden?fying   determinants  of  prac?ce:  A  systema?c  review  and  synthesis  of  frameworks  and   taxonomies  of  factors  that  prevent  or  enable  improvements  in  healthcare  professional   prac?ce,  Implementa?on  Science,  8:35   41  
  42. Implementa?on  Strategies:   Specifica?on  &  repor?ng*   Implementa)on  strategies  carry  same  demands  as   interven)ons   •  Opera?onal  defini?ons     •  Protocols  &  manuals   •  Fidelity   Define  strategies  conceptually,  opera)onally   42   DEBATE Open Access Implementation strategies: recommendations for specifying and reporting Enola K Proctor1* , Byron J Powell1 and J Curtis McMillen2 Abstract Implementation strategies have unparalleled importance in implementation science, as they constitute the ‘how to’ Implementation Science Proctor et al. Implementation Science 2013, 8:139
  43. Priority  area  II:   Implementa)on  Outcomes   Mul)ple  stakeholders  &  mul)ple  perspec)ves   •  Which  outcomes  mater  most  to  whom?   •  Ques?on  from  the  field:  How  much  will  this   cost  and  what  kind  of  havoc  will  it  wreak?   Priority  outcomes:   •   incremental  cost   •   scale  up  &  spread   •   sustainability   43  
  44. Priori?es  for  Sustainability  Research   •  Sustainability  of  EBPs  when  contexts   change   •  Adaptability/Evolu?on  of  EBPs  over  ?me   •  Scaling  up  prac?ces  across  health  plans,   systems,  and  networks   •  Studying  De-­‐Implementa?on   44  
  45. Program  Sustainability  Assessment  Tool   45  
  46. Priority  area  III:   Capturing  complex  implementa)on     Reality  of  most  service  delivery:   Co-­‐occurring  condi)ons  →  Mul)ple  EBI’s   Evidence  evolves  →  con)nually  adopt   Limited  capacity  →  must  de-­‐adopt   Fit  to  local  context  →  adapta)on   Staff  turnover→    con)nual  training     46  
  47. Treatment  Evidence  Con)nues  to  Grow   What  strategies  can  enable   providers  &  organizaDons  to   implement  evolving  evidence?       47  
  48. Training:   Implementa)on  Research  Ins)tute   (IRI)   •  Na?onal  faculty  &  scholars   •  2  yr.  program  for  IR  in  mental  health   •  Funded  by  an  NIMH  R25  grant  (NIMH  -­‐  R25   MH080916-­‐03);  VA  &  NIDA  supplements   •  Held  at  Brown  School    Washington  University  in   St.  Louis   48  
  49. Training:   IRI  fellows  at  Hopkins   49  
  50. Training:     Mentored  Training  for  Dissemina?on  &   Implementa?on  Research  in  Cancer   (MT-­‐DIRC)   Na?onal  faculty  &  fellows   2  yr.  program  of  summer  ins?tutes   Based  at  Washington  University   NCI  supported   12  fellows  per  year     Applica?ons  for  summer  2014  due  this  winter   Contact:   50  
  51. Training:   Training  Ins?tute  for  Dissemina?on  &   Implementa?on  Research  in  Health   TIDIRH  NIH  wide   Housed:    UNC,  UCSF,  Washington  U,  Harvard   htp://­‐training-­‐ins?tute-­‐ dissemina?on-­‐and-­‐implementa?on-­‐research-­‐health-­‐?dirh   •  Applica?ons  for  2014  due  this  winter   51  
  52. Support:       Na)onal  Ins)tute  of  Mental  Health    P30  MH068579    R25  MH080916    P30  DK092950      U54  CA155496    UL1  RR024992  (Clinical  and            Transla?onal  Science  Award,  CTSA)   Washington  University        Ins?tute  for  Public  Health    Brown  School  of  Social  Work   Conflicts:      none   52  
  53. 53  
  54. QuesDons…   ….????????   Enola  Proctor   54