improving practice: the promise of implementation research enola proctor community academic...
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Improving Practice:The promise of
Implementation Research
Enola ProctorCommunity Academic Partnerships on Addiction
Brown SchoolJanuary 27, 2014
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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
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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
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II. Implementation:What does it take?
Quality gaps to address Evidence-based interventionsThe “how:” Implementation strategiesThe “where:” ContextPartnerships
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Implementation is about improving care
The care that “could be”vs
The care that “is”
What quality gaps are of concern?
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The care “that is…”
What services are we delivering?
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The care “could be…”
What services should we be delivering?
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Quality gaps The quality chasm reflected by:
%
%
What is the quality of social work services?
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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
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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
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Evidence Based interventions
Are interventions ready for D&I?Balancing Tx discovery v Tx roll out
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Evidence-based interventions
• What is the supply of EB interventions?• How strong is the evidence?• How relevant is the evidence?
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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”)
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When we have effective interventions, it’s time to delivery them
Professional Associations
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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
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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
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A Compilation or “menu”68 strategies grouped by six key processes*
*Powell, McMillen, Proctor et al., Medical Care Research and Review, 2012
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Plan Strategies
• Gather information• Select strategies• Build buy-in• Initiate leadership• Develop
relationships
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Educate Strategies
• Develop materials• Provider training• Inform and
influence stakeholders
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Finance Strategies
• Modify incentives for clinicians, consumers, reduce disincentives
• Facilitate financial support: place on formularies
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Restructure strategies
• Revise roles• Create new teams• Change sites• Change record
systems• Structure
communication protocols
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Quality Management Strategies
• Audit and provide feedback
• Clinician reminders• Develop T.A.
systems
• Conduct cyclical small tests of change
• Checklists
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Policy Strategies
Licensure AccreditationCertificationLiability
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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
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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
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Implementation Outcomes
Distinct from clinical outcomes Could have an effective
intervention, poorly implemented Could have an ineffective
treatment, successfully implemented
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Implementation Outcomes: Key Concepts
• Acceptability• Adoption• Appropriateness• Feasibility• Fidelity• Implementation cost• Penetration• Sustainability
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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
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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
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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?
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Implementation = partnered
Multiple stakeholders• service consumers • families• providers• administrators• funders• legislators
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Where are we going?
Challenges and opportunities in
implementation science
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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?
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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
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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
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Treatment Evidence Continues to Grow
What strategies can enable providers & organizations to implement evolving evidence?
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Priority area III:Implementation Outcomes
Priority outcomes:•incremental cost•scale up & spread•sustainability
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Program Sustainability Assessment Tool
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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?
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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
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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