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

Questions…….????????

Enola Proctorekp@wustl.edu