Advancing Implementation Science Process Outcome Conceptual Framework Enola

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Advancing Implementation Science: Process & Outcome Conceptual Framework Enola Proctor George Warren Brown School

Advancing Implementation Science: Process & Outcome Conceptual Framework Enola Proctor George Warren Brown School of Social Work Washington University in St. Louis Improving Implementation Research Methods for Behavioral and Social Science Meeting Silver Spring, MD September 20, 2010

Definitions drive conceptual framework Implementation science= Scientific study of the process of moving new

Definitions drive conceptual framework Implementation science= Scientific study of the process of moving new practices into routine care

Key components for focus in IR Implementation Research concepts What? QI’s/ EST’s Where? Setting

Key components for focus in IR Implementation Research concepts What? QI’s/ EST’s Where? Setting (multi-level) Who? Stakeholders How? Implementation strategies* Why? Outcomes: * Implementation outcomes Service system outcomes Health status outcomes * Strategies & Outcomes = focus of presentation

The “What” (is being implemented? ) Ø Treatment guidelines Ø Evidence-based treatments Ø Empirically

The “What” (is being implemented? ) Ø Treatment guidelines Ø Evidence-based treatments Ø Empirically supported programs Ø Quality improvement processes that have been shown effective Product of nation’s investment of $$ billions in basic, clinical efficacy, effectiveness and CER

“Where” Real-world care = target of implementation science Health, behavioral health, and social service

“Where” Real-world care = target of implementation science Health, behavioral health, and social service delivery systems Complex organizations Varying infrastructures “Who” “WHERE” THE Array of providers, with variable training in EBP

Why? • To what effect? producing change in usual care provision of evidence-based treatment

Why? • To what effect? producing change in usual care provision of evidence-based treatment Outcomes: clinical, service system, implementation

Conceptual Model for Implementation Research What? How? QIs ESTs Implementation Strategies Implementation Outcomes Acceptability

Conceptual Model for Implementation Research What? How? QIs ESTs Implementation Strategies Implementation Outcomes Acceptability Adoption Appropriateness Feasibility Fidelity I Costs Penetration Sustainability Service Outcomes* Efficiency Safety Effectiveness Equity. Patientcenteredness Timeliness *IOM Standards of Care Implementation Research Methods Proctor et al 2009 Admin. & Pol. in Mental Health Services Patient Outcomes Satisfaction Function Health status/ symptoms

Emphasis of conceptual model • Distinguishes processes from outcomes • Emphasizes two process technologies:

Emphasis of conceptual model • Distinguishes processes from outcomes • Emphasizes two process technologies: – QI’s/ EST’s – Implementation strategies • Outcome distinctions – Implementation outcomes versus service & client outcomes – Types of implementation outcomes

Key components for focus in IR: Implementation Strategies systematic intervention processes to adopt and

Key components for focus in IR: Implementation Strategies systematic intervention processes to adopt and integrate evidence-based health interventions; impact organizational structure, climate, & culture; and change practice patterns within specific settings, thus enabling the …implementation of effective clinical interventions* *consistent with NIH PAR-10 -0380

Implementation requires strategic interventions • Won’t happen by admonition, or order • Requires deliberate

Implementation requires strategic interventions • Won’t happen by admonition, or order • Requires deliberate and targeted action – Thus need for empirically tested implementation strategies

Implementation strategies • Preponderance of descriptive research: Identifying barriers to implementation Observations of “usual”

Implementation strategies • Preponderance of descriptive research: Identifying barriers to implementation Observations of “usual” care in changing practice (naturalistic spread, implementation) • Need to derive strategies from theory, from descriptive studies • Context of implementation demands strategies for multiple levels Ø Ø Policy Organizational Provider Patient/consumer

Taxonomies of implementation strategies • Leeman et al. , 2006, Journal of Advanced Nursing

Taxonomies of implementation strategies • Leeman et al. , 2006, Journal of Advanced Nursing – 14 methods in 5 categories: increasing coordination; raising awareness; persuasion via interpersonal channels; persuasion via reinforcing belief that behavior will lead to desirable results and increasing behavioral control • EPOC, Cochrane Collaboration – 4 categories: Professional, financial, organizational, regulatory • AHRQ critical analysis of QI strategies – 5 categories: Provider, information systems, financial, org change, patient education & reminders

Organizational implementation strategies: Examples: • Organizational interventions: – Revision of professional roles (boundary shifting,

Organizational implementation strategies: Examples: • Organizational interventions: – Revision of professional roles (boundary shifting, expansion of roles) – Team building, including clinical multidisciplinary teams – Improving organizational climate and culture* – Electronic data and decision support tools – Co-location of care • * Glisson, ARC model

Provider/ professional implementation strategies: Examples: • Provider/ professional interventions: – Educational materials and meetings

Provider/ professional implementation strategies: Examples: • Provider/ professional interventions: – Educational materials and meetings – Local consensus processes – Academic detailing (information to providers) – Local opinion leaders – Client-mediated interventions (score feedback to providers) – Audit and feedback (summary of clinical performance) – Reminders – Marketing • *EPOC, also Gilbody et al, JAMA, 2003

Implementation strategies: 30, 000 ft. perspective Top down versus bottom up “Package” or “bundled

Implementation strategies: 30, 000 ft. perspective Top down versus bottom up “Package” or “bundled approaches, with overlap Little empirical evidence for components Few tests of comparative effectiveness

Research priorities: Implementation Strategies 1) Develop taxonomies of distinct implementation strategies for each level

Research priorities: Implementation Strategies 1) Develop taxonomies of distinct implementation strategies for each level of change initial “measurement” work = nominal definition, conceptual distinctions, internal consistency within categories 2) Discover “breakthroughs” to the barriers to the delivery of evidence-based health care 3) Shape implementation strategies with use in mind; around stakeholder preferences 4) Map pathways (non-linear) to uptake and sustainability

Research Priorities, cont’d. 5) Test the comparative effectiveness of implementation strategies 6) Test relationships

Research Priorities, cont’d. 5) Test the comparative effectiveness of implementation strategies 6) Test relationships between EST’s and Implementation strategies: Are implementation strategies effective across different EST’s? Drill down: Core components of implementation strategies, unique contribution (for parsimony) 7) Test generalizability of strategies across settings

Key components for focus in IR: Implementation Outcomes = the effects of deliberate and

Key components for focus in IR: Implementation Outcomes = the effects of deliberate and purposive actions to implement new treatments, practices, and services Provides way to conceptualize and measure success of implementation processes

Implementation outcomes Serve as intermediate outcomes, or proximal reflections of, efforts to change clinical

Implementation outcomes Serve as intermediate outcomes, or proximal reflections of, efforts to change clinical outcomes Implementation outcomes are distinct from clinical outcomes – Could have an effective intervention, poorly implemented – Could have an ineffective treatment, successfully implemented

Conceptual Model for Implementation Research What? How? QIs ESTs Implementation Strategies Implementation Outcomes Acceptability

Conceptual Model for Implementation Research What? How? QIs ESTs Implementation Strategies Implementation Outcomes Acceptability Adoption Appropriateness Feasibility Fidelity I Costs Penetration Sustainability Service Outcomes* Efficiency Safety Effectiveness Equity. Patientcenteredness Timeliness *IOM Standards of Care Implementation Research Methods Proctor et al 2008 Admin. & Pol. in Mental Health Services Patient Outcomes Satisfaction Function Health status/ symptoms

Implementation outcomes: state of art: 30, 000 ft perspective • Overlapping concepts • Inconsistent

Implementation outcomes: state of art: 30, 000 ft perspective • Overlapping concepts • Inconsistent terminology • Literature: Scattered across health and behavioral health fields

Implementation Outcomes: Research agenda 1) Advancing consistency of terminology 2) Advancing measurement 3) Mapping

Implementation Outcomes: Research agenda 1) Advancing consistency of terminology 2) Advancing measurement 3) Mapping inter-relationships (non-linear) among implementation outcomes 4) Testing salience to stakeholders 5) Testing salience over implementation process 6) As outcomes for tests of implementation strategies

Key components for focus in IR: Multiple stakeholders • • • service consumers families

Key components for focus in IR: Multiple stakeholders • • • service consumers families providers administrators funders legislators

Multiple stakeholders have different priorities • Shumway research: – Stakeholder groups value and prioritize

Multiple stakeholders have different priorities • Shumway research: – Stakeholder groups value and prioritize different clinical outcomes • We expect that different stakeholders differ regarding implementation strategies and outcomes: • Rationale • Preferences • Priorities

Implementation research is team science Transdisciplinary: Ø economics, policy, organizational researchers Ø psychologists, social

Implementation research is team science Transdisciplinary: Ø economics, policy, organizational researchers Ø psychologists, social workers, MD’s, anthropologists, Convergence of research perspectives: Ø Ø Ø mixed methods treatment researchers service systems researchers research design specialists measurement specialists

Implementation research is transdisciplinary, team science • Transcends “disease states” and funding streams •

Implementation research is transdisciplinary, team science • Transcends “disease states” and funding streams • “Field” of D&I must be built – Training needs paramount – Implementation Research Institute • R 25 supported 2 year institute in mental health) – Dissemination and Implementation Research Cores, providing technical assistance to researchers: • In research centers • Through CTSA’s

Acknowledgements Paper Co-authors: Greg Aarons, David Chambers, Charles Glisson, John Landsverk, Brian Mittman Adm.

Acknowledgements Paper Co-authors: Greg Aarons, David Chambers, Charles Glisson, John Landsverk, Brian Mittman Adm. Policy Mental Health (2009) 36: 24– 34 Funding support: Ø Center for Mental Health Services Research, NIMH “Advanced” Center with focus on implementation science, 5 P 30 MH 068579 Ø Institute for Clinical and Translational Science, ICTS 5 UL 1 RR 024992 Ø Implementation Research Institute in Mental Health, R 25 MH 080916 & Veterans Administration Contract

 Contact & Disclosure: Enola Proctor, Director, CMHSR 314 -935 -6660 ekp@wustl. edu iri@brownschool.

Contact & Disclosure: Enola Proctor, Director, CMHSR 314 -935 -6660 ekp@wustl. edu iri@brownschool. wustl. edu No relevant financial interests to disclose