Lead/Presenter: Bo Kim, COIN - Bedford/Boston
All Authors: Kim B (Center for Healthcare Organization and Implementation Research, Harvard Medical School), Sullivan JL (Long-Term Services and Supports Center of Innovation, Brown University School of Public Health) Brown ME (Center for Healthcare Organization and Implementation Research) Connolly SL (Center for Healthcare Organization and Implementation Research, Harvard Medical School) Spitzer EG (Center for Healthcare Organization and Implementation Research, Harvard Medical School) Bailey HM (Center for Healthcare Organization and Implementation Research) Sippel L (Northeast Program Evaluation Center, Geisel School of Medicine at Dartmouth) Weaver K (Office of Mental Health and Suicide Prevention) Miller CJ (Center for Healthcare Organization and Implementation Research, Harvard Medical School)
Sustaining evidence-based practices (EBPs) is crucial to ensuring care quality and addressing health disparities. Approaches to identifying pertinent factors affecting (i.e., circumstances or influences contributing to) sustainability are sorely needed. One such approach is Matrixed Multiple Case Study (MMCS), which identifies factors and their combinations that matter for implementation. We applied MMCS to identify factors related to sustainability of the evidence-based Collaborative Chronic Care Model (CCM) for delivering interdisciplinary outpatient mental health care [Behavioral Health Interdisciplinary Program (BHIP)] at nine VA medical centers, 3-4 years after implementation support had concluded. The CCM is (i) designated by the VA Office of Mental Health and Suicide Prevention as BHIPâ€™s guiding framework and (ii) increasingly implemented in real-world settings within and outside VA.
We conducted directed content analysis of thirty provider interviews, using six CCM elements and four Integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) domains as codes. Based on CCM code summaries, we designated each site as high/medium/low sustainability. We used i-PARIHS code summaries to identify relevant factors per site, the extent of their presence, and the type of influence they had on sustainability (enabling/neutral/hindering/unclear). We organized these data into a sortable matrix and assessed cross-site trends affecting sustainability.
CCM sustainability status was distributed among the sites, with three sites each being high, medium, and low. Twenty-six factors were identified from the i-PARIHS code summaries, of which three exhibited strong trends by sustainability status (relevant i-PARIHS domain in square brackets): â€œStaff/Leadership turnover [Recipient],â€ â€œCollaborativeness/Teamwork [Recipient],â€ and â€œHaving a consistent/strong internal facilitator [Facilitation]â€ during and after active implementation. Four factors were identified at most high-sustainability sites but not at most medium- or low-sustainability sites: â€œHaving a knowledgeable/helpful external facilitator [Facilitation]â€ enabled sustainability, while â€œClarity about what CCM comprises [Innovation],â€ â€œInterdisciplinary coordination [Recipient],â€ and â€œAdequate clinic space for CCM team members [Context]â€ were somewhat or less present with mixed influences on sustainability. Two factors were identified at most medium- or low-sustainability sites but not at most high-sustainability sites: â€œAbility to continue patient care during COVID [Context]â€ was enabling when present and hindering when not, while not having â€œAdequate resources/capacity to deliver CCM-consistent care [Context]â€ hindered sustainability.
MMCS revealed that CCM sustainability in outpatient mental health clinics may be affected most strongly by knowledge retention during staff/leadership transitions, provider collaboration, and availability of skilled internal facilitators. Factors identified at high-sustainability sites demonstrate the importance of CCM-based care being coordinated, co-located, and clear to staff regarding its guiding principles and representative processes. Factors identified at medium- or low-sustainability sites call for ensuring continuity in and capacity for delivering care in the face of adversity or change, to make CCM-based care possible. CCM implementation efforts targeting sustainability may benefit from accounting for these factors in operationalizing their implementation strategies.
These findings inform a subsequent VA CCM implementation trial that prospectively examines whether enhancing the above-mentioned factors within implementation facilitation improves sustainability. As a systematic approach to multi-site examination, MMCS can help investigate sustainability-related factors applicable to EBPs beyond the realms of CCMs and VA.