Implementation Strategies to Promote Measurement-Based Care in Schools: Evidence from Mental Health Experts Across the United States

Background: Despite an established, comprehensive taxonomy of implementation strategies, minimal guidance exists for how to select and adapt strategies to specific services and contexts. We employed a replicable method to identify the most feasible and important implementation strategies to increase mental health providers’ use of measurement-based care (MBC) in schools. MBC is the routine use of patient-reported progress measures throughout treatment to inform patient-centered, data-driven treatment adjustments. Methods: A national sample of 52 school mental health providers and researchers completed two rounds of modified Delphi surveys to rate the relevance, importance, and feasibility of 33 implementation strategies identified for school settings. Strategies were reduced and definitions refined using a multimethod approach. Final importance and feasibility ratings were plotted on “go-zone” graphs and compared across providers and researchers to identify top-rated strategies. Results: The initial 33 strategies were rated as “relevant” or “relevant with changes” to MBC in schools. Importance and feasibility ratings were high overall for both survey rounds; importance ratings (3.61 - 4.48) were higher than feasibility ratings (2.55 – 4.06) on average. Survey 1 responses resulted in a reduced, refined set of 21 strategies, and six were rated most important and feasible on Survey 2: 1) assess for readiness and identify barriers and facilitators; 2) identify and prepare champions; 3) develop a usable implementation plan; 4) offer a provider-informed menu of free, brief measures; 5) develop and provide access to training materials; and 6) make implementation easier by removing burdensome documentation tasks. Provider and researcher ratings were not significantly different, with a few exceptions: providers reported higher feasibility and importance of removing burdensome paperwork than researchers, and providers reported higher feasibility of train-the trainer approaches than researchers; researchers reported higher importance of monitoring fidelity than providers. Conclusions: The education sector is the most common setting for child and adolescent mental health service delivery in the United States. Effective MBC implementation in schools has the potential to elevate the quality of care received by many children, adolescents and their families. This empirically-derived, targeted list of six implementation strategies offers potential efficiencies for future testing of MBC implementation in schools.

Communication strategies to facilitate the implementation of new clinical practices: a qualitative study of community mental health therapists

Lay Summary There has been a great deal of attention recently to the study of implementation, or how something (e.g., a new clinical practice or initiative) is actually put into effect. Many studies have found a number of barriers to and facilitators of the implementation process. But despite this increased attention, the field of implementation science may not have paid enough attention to the role of communication. Although communication is generally acknowledged as important, precisely how it impacts implementation—and, importantly, the ways it might be improved—is typically unexplored. This study conducted focus groups with mental health therapists in 12 clinics which were about to implement a new clinical practice: measurement-based care for depressed adults receiving psychotherapy. What these therapists shared about their perspectives and experiences suggest that there are at least five ways to facilitate effective communication when introducing a new clinical practice: communicating a clear rationale for the new practice, providing necessary procedural knowledge, using multiple methods to communicate about the change, giving sufficient lead time to prepare for the change, and providing the opportunity for bidirectional engagement.

The Results of Clinician-Focused Implementation Strategies on Uptake and Outcome of Measurement-Based Care in General Mental Health Care

BACKGROUND: Measurement-Based Care (MBC) is a promising way to improve outcomes in clinical practice, but the implementation of MBC is often problematic and the uptake by clinicians is low.METHODS: We used an effectiveness-implementation hybrid design based on Grol and Wensing’s implementation framework to examine the results of clinician-focused implementation strategies on both clinicians’ uptake of MBC and outcomes of MBC for clients in general mental health care. Primary outcomes were questionnaire completion rate and discussion of feedback. Secondary outcomes were treatment outcome, treatment length, and satisfaction with treatment. RESULTS: There was a significant medium effect of the MBC implementation strategies on questionnaire completion rate (one part of the clinicians’ uptake), but no significant effect on the amount of discussion of the feedback (the other part of the clinicians’ uptake). Neither was there a significant effect on clients’ outcomes (treatment outcome, treatment length, satisfaction with treatment).CONCLUSIONS: Establishing and sustaining MBC in real world general mental health care is very complex. Our study helps to disentangle the effects of MBC implementation strategies on differential clinician uptake, but the effects of MBC implementation strategies on client outcomes need further examination.

The effectiveness of enhanced evidence-based care for depressive disorders: a meta-analysis of randomized controlled trials

Several care models have been developed to improve treatment for depression, all of which provide “enhanced” evidence-based care (EEC). The essential component of these approaches is Measurement-Based Care (MBC). Specifically, Collaborative Care (CC), and Algorithm-guided Treatment (AGT), and Integrated Care (IC) all use varying forms of rigorous MBC assessment, care management, and/or treatment algorithms as key instruments to optimize treatment delivery and outcomes for depression. This meta-analysis systematically examined the effectiveness of EEC versus usual care for depressive disorders based on cluster-randomized studies or randomized controlled trials (RCTs). PubMed, the Cochrane Library, and PsycInfo, EMBASE, up to January 6th, 2020 were searched for this meta-analysis. The electronic search was supplemented by a manual search. Standardized mean difference (SMD), risk ratio (RR), and their 95% confidence intervals (CIs) were calculated and analyzed. A total of 29 studies with 15,255 participants were analyzed. EEC showed better effectiveness with the pooled RR for response of 1.30 (95%CI: 1.13–1.50, I2 = 81.9%, P < 0.001, 18 studies), remission of 1.35 (95%CI: 1.11–1.64, I2 = 85.5%, P < 0.001, 18 studies) and symptom reduction with a pooled SMD of −0.42 (95%CI: −0.61–(−0.23), I2 = 94.3%, P < 0.001, 19 studies). All-cause discontinuations were similar between EEC and usual care with the pooled RR of 1.08 (95%CI: 0.94–1.23, I2 = 68.0%, P = 0.303, 27 studies). This meta-analysis supported EEC as an evidence-based framework to improve the treatment outcome of depressive disorders.Review registration: PROSPERO: CRD42020163668

Addressing Burgeoning Unmet Needs in College Mental Health (Preprint)

UNSTRUCTURED If we can measure the psychosocial impact of mental health challenges for college students, we can triage precious mental health resources through personalized measurement-based care, treatment matching, and a peer-support network. Thus, digitally derived measurement-based self-care, peer care, and clinician-delivered care can be deployed in a way that is meaningful to a student’s needs, preferences, and acceptability, and translated back for daily use and decision making. Indeed, if students can utilize a deeper understanding of behaviors to adopt or change, they can also make decisions about when to seek treatment. This ecological approach to the experience of students is advantageous not only for health promotion, but also better contextualizes symptoms to social determinants of health, early life stress exposure, adversity, and life events. While preliminary mental health digital applications and their uptake are encouraging, we have yet to tap the full potential of a more integrated approach to optimize mental health for all college students. Establishing the foundations of this path forward have never been more imperative.