BACKGROUND/RATIONALE:
Although studies have shown that the collaborative care model for depression management improves care quality and outcomes, it has not been widely adopted. Further, not all practices that utilize the model adopt all of its essential elements. This problem is not unique to collaborative care; translating research into practice is often difficult.
OBJECTIVE(S):
We sought to identify facilitators of and barriers to the successful translation of research into practice. Towards this end, we first examined key stakeholders’ assessments of a VHA collaborative care initiative (TIDES) and perceptions about how to implement and sustain such initiatives. Second, we examined TIDES design, implementation, and maintenance costs and effects on system cost. Finally, we sought to develop tools to assess readiness to adopt the model and to identify the best evidence-based design choices for a particular practice.
METHODS:
We assessed key stakeholder groups’ perceptions in five primary care practices across three VISNs. We conducted semi-structured qualitative interviews at the VISN, VAMC and clinic levels and conducted a content analysis of the resulting verbatim interview transcripts. We also conducted a cost analysis on the design and implementation of TIDES at seven clinics, as well as its effects on system costs.
FINDINGS/RESULTS:
Stakeholders believed that it is important to include staff members from all organizational levels in QI program implementation and described unique roles for individuals at each level. Although informants also believed that local customization was essential, many recognized the importance of adhering to evidence and providing consistent care across facilities. Thus, it is important to create a dialogue between frontline staff members and experts. Stakeholders offered suggestions for structuring such a dialogue and argued that frontline staff members have protected time to participate in it. Additionally, stakeholders emphasized the value of local champions. They suggested that a group of individuals could share champion duties so as to make best use of particular talents and reduce burden. With respect to the TIDES model, stakeholder groups placed different relative value on the model’s components. We determined that the length of time required for TIDES adaptation decreased with the order of participation. We also determined that research team contributed more person hours and costs than did clinical partners. We did not find significant shifts in provider staffing level between primary care and mental health care clinics after the implementation or significant differences in changes in utilization patterns between the intervention and control groups. Although we did find that the patients in the high penetration intervention sites had significantly more primary care, primary care depression, and mental health visits than control patients, there were no significant differences in utilization measures between the two groups.
IMPACT:
We provide substantial insight into the perspectives of VHA stakeholders regarding quality improvement implementation, especially for evidence based practices. Stakeholders provided clear and practical suggestions for fostering adoption and sustainability of new initiatives. We also offer detailed information regarding the costs of implementing one such initiative, depression collaborative care, and offer these as a basic framework to account for research translation costs in VHA. Finally, we have developed tools to facilitate implementation.
PUBLICATIONS:
Journal Articles
- Fickel JJ, Parker LE, Yano EM, Kirchner JE. Primary care - mental health collaboration: an example of assessing usual practice and potential barriers. Journal of Interprofessional Care. 2007; 21(2): 207-16.
