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Examining Implementation of a Patient Activation and Self-management Intervention Within the Context of an Effectiveness Trial

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Administration and Policy in Mental Health and Mental Health Services Research Aims and scope Submit manuscript

Abstract

This qualitative study examines factors important for delivering a patient activation/self-management intervention in 13 mental health clinics within the context of an effectiveness trial to inform understanding of real-world implementation. Eighteen key personnel were interviewed about the following factors relative to the intervention and its delivery: alignment with organization values/patient needs; buy-in/support from leaders and providers; roles played by leaders and key personnel; and availability of organizational resources. Where supportive, these factors facilitated the delivery of the intervention; elsewhere, they presented as impediments. Findings from this study could help anticipate challenges to implementation that could be examined in a full-scale implementation study.

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Notes

  1. The parent effectiveness trial is referred to as a blended efficacy-effectiveness study in other manuscripts reporting findings from the parent study (Alegría et al., Under Review; Carson et al., Under Review) due to the research team’s attempts to control several aspects of the effectiveness trial.

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Acknowledgments

This study was supported by NIH Research Grant No. P60 MD002261-03 funded by the National Institute of Minority Health and Health Disparities. The DECIDE intervention is based upon the educational strategy developed by the non-profit organization, the Right Question™ Institute (formerly, the Right Question Project). Since 1991, the Right Question Institute (www.rightquestion.org) has been developing and refining its innovative strategy for teaching question formulation and decision skills by learning from people in low-income communities around the country as they learned to advocate for their children’s education, and advocated for themselves and their families in their ordinary encounters with social services, health care, housing agencies, job training and other programs. RIGHT QUESTION™, QUESTION FORMULATION TECHNIQUE™ and FRAMEWORK FOR ACCOUNTABLE DECISION-MAKING™ are trademarks owned by the Right Question Institute and are being used by the Cambridge Health Alliance with the Right Question Institute’s permission. The Right Question Institute neither endorses nor is affiliated with this material and the associated research. The first author was also supported by a National Institute of Mental Health NRSA Post-doctoral Training Grant Award (NIMH Grant No. T32MH019733). The authors would like to thank Alejandro Interian, Dharma Cortes, and Enola Proctor for reviewing earlier versions of the manuscript and providing helpful comments. The authors would also like to thank Nicholas Carson, Darcie DeAngelo, Michael Flores, Julia Lin, Amy Russell, and Anna Lessios for their support with the study and paper.

Disclosures

The first author’s role was confined to the hybrid implementation study. The first author had no input into the design of the parent research study, no involvement in hiring the Site Investigators or Care Managers, and no involvement in the day-to-day activities of executing the parent research study. The second author of the paper was a Site Investigator for the parent research study and helped code interviews for the hybrid implementation study (minus any interviews from her clinic). A third coder was brought into code interviews from the second author’s clinic. The third coder was previously a project coordinator of the parent research study. The first author ensured that any identifying information was removed from all interviews.

Author information

Authors and Affiliations

  1. Center for Multicultural Mental Health Research, Cambridge Health Alliance, 120 Beach Street, 4th Floor, Somerville, MA, 02143, USA

    Andrea Ault-Brutus & Margarita Alegría

  2. Department of Psychiatry & Human Behavior, Brown Medical School, Providence, RI, USA

    Catherine Lee

  3. Department of Health Policy and Management, Harvard School of Public Health, Boston, MA, USA

    Sara Singer

  4. Family Medicine and Community Health, University of Minnesota, Minneapolis, MN, USA

    Michele Allen

  5. Department of Psychiatry, Harvard Medical School, Boston, MA, USA

    Margarita Alegría

Authors
  1. Andrea Ault-Brutus
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  2. Catherine Lee
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  3. Sara Singer
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  4. Michele Allen
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  5. Margarita Alegría
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Corresponding author

Correspondence to Andrea Ault-Brutus.

Additional information

Paper was presented as a poster presentation at the 5th Annual NIH Dissemination and Implementation Conference, Bethesda, MD, March 19, 2012.

Paper will be presented as an oral presentation at the 141st American Public Health Association Annual Meeting on November 5, 2013.

Appendix: Interview Guide for Evaluating the Implementation of DECIDE

Appendix: Interview Guide for Evaluating the Implementation of DECIDE

  1. 1.

    Description of DECIDE & Alignment with Clinic Values and Needs

    • How would you describe the DECIDE intervention?

    • Does DECIDE align with the values of your organization? How so? In what ways is DECIDE not aligned with the organization’s values?

    • Does DECIDE address the patient population needs of your organization or not? How so?

  2. 2.

    Buy-In

    • How did the clinic leaders, providers, and staff members feel about the idea of implementing the DECIDE study in the beginning?

      (PROBE: Value in implementing DECIDE; Enthusiasm for DECIDE; Time to implement DECIDE)

    • Do you think buy-in occurred for the implementation of the DECIDE study (among the related personnel in the organization)?

      • If Yes - Why do you think buy-in occurred? Was it for most, some, or a few of the personnel?

      • If No - Why do you think buy-in did not occur?

    • How do clinic leaders feel about the DECIDE study now?

    • How do providers feel about the DECIDE study now?

    • How do staff members feel about the DECIDE study now?

      For Site Investigators Only

    • What specific strategies did you use to get buy-in to implement the DECIDE study? Did they work?

  3. 3.

    Implementation—Overall

    • How involved were you (are you) in implementing DECIDE?

    • How do you think the implementation of the DECIDE study went in your clinic?

    • On a scale of 1–5, with 1 worse than you expected and 5 better than you expected, how would you rate the overall implementation of the DECIDE study in your clinic?

    • Why did you rate it this way?

    • (If < 5) What could have been done differently to bring your rating up to a 5?

  4. 4.

    Organizational Leadership

    Now I am going to ask you some questions about the leadership at this clinic and their role in DECIDE project (not leadership from within the Research Team).

    • Who played a leading role in implementing DECIDE at this clinic?

      • What is the person’s role in the organization? (For each person identified)

      • Why do you consider that person to be a leader in implementing DECIDE? /What did that person do? (For each person identified)

    • How much of a leading role did you play in the implementation of DECIDE?

    • What was expected from leadership in implementing DECIDE?

    • What did the leader(s) do well in implementing DECIDE?

    • What could the leader(s) have done better in implementing DECIDE?

  5. 5.

    Workforce

    Now I am going to ask you some questions about the workforce. Workforce can include, but is not limited to, the site investigator, the care manager, the director of the clinic, clinicians, and the administrative staff. I may sometimes refer to the workforce as staff members.

    • Were there any workforce issues your organization had to deal with in implementing DECIDE? (PROBE: Staff turnover; under-resourced; burn-out; resistance)

      • How did these issues affect implementation?

      • Were these issues resolved?

        • If yes, what strategies helped your organization overcome these challenges?

        • If no, what could have been done to overcome these challenges?

    • What did staff members do well in implementing DECIDE? (Please identify staff member)

    • What did staff members not do well in implementing DECIDE? (Please identify staff member)

  6. 6.

    Remaining Implementation Questions

    • Was there a change in the implementation of DECIDE over time? If yes, how so?

    • What helped facilitate the implementation of the DECIDE effectiveness study?

    • What were some barriers/challenges to implementing the DECIDE effectiveness study?

      • Were these challenges resolved?

        • If yes, what strategies helped your organization overcome these challenges?

        • If no, what could have been done to overcome these challenges?

      (Probes for Site Investigator who were fully involved in the study or Care Managers)

      PROBE: Infrastructure (e.g., clinical record keeping; information systems); Polices and Practices (e.g., financing; approaching patients; handing new patients; referral practices); Bureaucratic/Administrative Challenges (e.g., Clinical Director)

    • Has your clinic implemented other interventions similar to the DECIDE intervention? If so, how would you describe your experience with implementing DECIDE in comparison to implementing other interventions at your clinic?

    • If the DECIDE intervention is found to be effective, hypothetically, what criteria would be used by the clinic in deciding whether to adopt and sustain the intervention?

    • If you could predict the likelihood of DECIDE being adopted and sustained in your site after the study is over, what probability would you give it? Why?

      Unlikely    Somewhat Likely    Likely

    • If a health care organization decided to implement the DECIDE intervention (outside the context of a research study), what advice would you give them in implementing the intervention?

    • Is there anything else you would like to add that would be helpful for us to know?

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Ault-Brutus, A., Lee, C., Singer, S. et al. Examining Implementation of a Patient Activation and Self-management Intervention Within the Context of an Effectiveness Trial. Adm Policy Ment Health 41, 777–787 (2014). https://doi.org/10.1007/s10488-013-0527-z

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