Implementation of evidence based practices and programs (EBPs) is complex, challenging, and rarely sustained. There is evidence that ongoing facilitation can foster EBP implementation. We previously developed an external/internal facilitation strategy that combines an external facilitator, an expert in implementation methods and specific EBPs, with a network-level internal facilitator who is familiar with clinic-level structures, climates, and practices and who, with mentoring, develops expertise in implementation facilitation. The Blended Facilitation study implemented and rigorously evaluated this strategy within the context of VA's Uniform Mental Health Services Handbook requirements for primary care-mental health integration (PC-MHI). Using external/internal facilitation can enable VA to foster the sustainable organizational change that new policy and associated implementation of system wide QI initiatives require.
This project sought to 1) test effectiveness of the facilitation strategy versus standard national support on extent of clinic-level outcomes, provider behavior change, and changes in Veterans' service utilization; 2) assess organizational context, perceptions and attitudes regarding evidence for PC-MHI programs, and the facilitation process within the context of those findings; 3) collect data on facilitation time/activities for use in a future cost proposal; and 4) document activities and time required to transfer external/internal facilitation to VA Operations personnel.
We used a multi-site, quasi-experimental design with non-equivalent comparison groups. Eight PC clinics from two VA networks received external/internal facilitation. We compared clinics to eight matched clinics in two matched networks. We excluded one matched clinic pair from administrative data analysis due to the facilitation site's failure to complete the program design phase. Using quantitative and qualitative methods we evaluated the facilitation strategy on RE-AIM framework dimensions of reach, effectiveness, adoption, implementation, and maintenance. We collected data during late phase PC-MHI implementation and one year later. We compared clinics on percentage of PC patients with a PC-MHI encounter, a first MH specialty care visit, and PC-MHI referral/same day encounter; percentage of PC providers referring at least one patient and providers' patients that were referred to PC-MHI. We also assessed PC-MHI program components and obtained expert ratings of clinics' program quality. We conducted 83 interviews with study facilitators to document their activities and collected time data for facilitation activities. We also conducted organizational context surveys early in the implementation process. At four selected facilitation sites, we assessed key stakeholder perceptions about facilitation and its value. To document efforts to transfer this strategy to VA Operations, we conducted 45 interviews with facilitators and collected time data for their activities.
Aim 1: In assessing late phase implementation, compared to non-facilitation sites, facilitation sites achieved statistically significant (p<0.05) higher rates of PC-MHI engagement (4.1%, 1.7%), providers referring at least one patient (86.8%, 72.9%), providers' patients referred to PC-MHI (1.72%, 0.25%), and patients receiving same day access to PC-MHI compared to non-facilitation sites (32.0%, 9.2%). In assessing implementation maintenance phase, facilitation sites maintained statistically significant higher rates of engagement (4.8%, 2.3%), provider median referral rate (2.69%, 1.48%) and same day access (29.1%, 22.6%). Facilitation sites also maintained a greater proportion of providers referring to PC-MHI (94.4%, 87.0%) however; the difference was not statistically significant. Although the median rate for initial MHSC encounters at facilitation sites was lower than that of non-facilitation sites at both study periods (42% - 54%, 40% - 49% respectively) the differences were not significant. Upon examination of qualitative data it was discovered that two non-facilitation sites were recording PC-MHI encounters without a PC-MHI program. An additional analysis excluding these encounters strengthened our original findings. In addition, the proportion of providers referring to PC-MHI in facilitation sites during the maintenance phase was statistically significant (94.4%, 69.8% respectively). These findings suggest that sites receiving facilitation implement PC-MHI more robustly and maintain their gains over time. Supporting these findings, our qualitative assessment of late phase implementation revealed that seven facilitation but only five comparison sites had implemented PC-MHI programs. During the maintenance phase, all facilitation but still only five comparison sites had programs. Experts rated all but one of the facilitation site programs higher than their matched comparison sites.
Aim 2: We examined the interplay between facilitation and organizational context and found that facilitation helps overcome organizational barriers. We also conducted a detail analysis of the facilitation process. Concordant with the literature, we found that facilitators both "do" things for stakeholders and "enable" stakeholders to do things for themselves. One particular activity type (e.g., education), however, can involve both "doing" (e.g., providing education) and enabling (e.g., fostering attendance). We also assessed change over time. Although certain activities cluster during particular implementation periods, we found organizational context and stakeholders' needs play a substantial role in what facilitators do and when they do it. We also observed systematic regional differences in the process, possibly due to organizational or facilitator characteristics. Finally, stakeholders and facilitators believed that facilitators ideally possess certain characteristics and skills. It is possible that coaching and mentoring may help those who do not possess these to obtain them.
Aim 3: Analysis of time data revealed that during the study, 3 facilitators spent 3,955 person hours helping clinics implement PC-MHI. Facilitators' top three activities in terms of person hours were preparation and planning, stakeholder engagement, and education. VHA stakeholders (n=399) from all levels participated in facilitation activities for 3,042 person hours.
Aim 4: In transferring the facilitation strategy to OMHO, it was important to be flexible and respond to their changing agenda and balance quality improvement and scientific rigor. Consultants provided 590 person hours, during half of which they conducted preparation/planning and mentoring.
This project has cemented partnerships with operational leaders, continues to have significant impacts on VA's efforts to implement the Uniform Mental Health Services Handbook to ensure that all Veterans have access to needed mental health services, has informed national policy and planning task forces and other research studies and has contributed to implementation of two PC-MHI 'best practices."
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