A randomized clinical trial testing two implementation strategies to promote the treatment of tobacco dependence in community mental healthcare.

INTRODUCTION: People with serious mental illness (SMI) are more likely to smoke and less likely to receive tobacco treatment. Implementation strategies may address clinician and organizational barriers to treating tobacco in mental healthcare. METHODS: A cluster-randomized trial (Clinic N=13, Client N=610, Staff N=222) tested two models to promote tobacco treatment in community mental healthcare: standard didactic training vs. Addressing Tobacco Through Organizational Change (ATTOC), an organizational model that provides clinician and leadership training and addresses system barriers to tobacco treatment. Primary outcomes were changes in tobacco treatment from clients, staff, and medical records. Secondary outcomes were changes in smoking, mental health, and quality of life (QOL), and staff skills and barriers to treat tobacco. RESULTS: Clients at ATTOC sites reported a significant increase in receiving tobacco treatment from clinician at weeks 12 and 24 (ps<0.05) and tobacco treatments and policies from clinics at weeks 12, 24, 36, and 52 (ps<0.05), vs. standard sites. ATTOC staff reported a significant increase in skills to treat tobacco at week 36 (p=0.05), vs. standard sites. For both models, tobacco use medications, from clients (week 52) and medical records (week 36), increased (ps<0.05), while perceived barriers decreased at weeks 24 and 52 (ps<0.05); 4.3% of clients quit smoking which was not associated with model. QOL and mental health improved over 24 weeks for both models (ps<0.05). CONCLUSIONS: Standard training and ATTOC improve use of evidence-based tobacco treatments in community mental healthcare without worsening mental health, but ATTOC may more effectively address this practice gap.

Handoffs and transitions in critical care-understanding scalability: study protocol for a multicenter stepped wedge type 2 hybrid effectiveness-implementation trial.

BACKGROUND: The implementation of evidence-based practices in critical care faces specific challenges, including intense time pressure and patient acuity. These challenges result in evidence-to-practice gaps that diminish the impact of proven-effective interventions for patients requiring intensive care unit support. Research is needed to understand and address implementation determinants in critical care settings. METHODS: The Handoffs and Transitions in Critical Care-Understanding Scalability (HATRICC-US) study is a Type 2 hybrid effectiveness-implementation trial of standardized operating room (OR) to intensive care unit (ICU) handoffs. This mixed methods study will use a stepped wedge design with randomized roll out to test the effectiveness of a customized protocol for structuring communication between clinicians in the OR and the ICU. The study will be conducted in twelve ICUs (10 adult, 2 pediatric) based in five United States academic health systems. Contextual inquiry incorporating implementation science, systems engineering, and human factors engineering approaches will guide both protocol customization and identification of protocol implementation determinants. Implementation mapping will be used to select appropriate implementation strategies for each setting. Human-centered design will be used to create a digital toolkit for dissemination of study findings. The primary implementation outcome will be fidelity to the customized handoff protocol (unit of analysis: handoff). The primary effectiveness outcome will be a composite measure of new-onset organ failure cases (unit of analysis: ICU). DISCUSSION: The HATRICC-US study will customize, implement, and evaluate standardized procedures for OR to ICU handoffs in a heterogenous group of United States academic medical center intensive care units. Findings from this study have the potential to improve postsurgical communication, decrease adverse clinical outcomes, and inform the implementation of other evidence-based practices in critical care settings. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT04571749 . Date of registration: October 1, 2020.

Is the end in sight? A study of how and why services are decommissioned in the English National Health Service.

The decommissioning of a health-care service is invariably a highly complex and contentious process which faces many implementation challenges. There has been little specific theorisation of this phenomena, although insights can be transferred from wider literatures on policy implementation and change processes. In this paper, we present findings from empirical case studies of three decommissioning processes initiated in the English National Health Service. We apply Levine's (1979, Public Administration Review, 39(2), 179-183) typology of decommissioning drivers and insights from the empirical literature on pluralistic health-care contexts, complex change processes and institutional constraints. Data include interviews, non-participant observation and documents analysis. Alongside familiar patterns of pluralism and political partisanship, our results suggest the important role played by institutional factors in determining the outcome of decommissioning processes and in particular the prior requirement of political vulnerability for services to be successfully closed. Factors linked to the extent of such vulnerability include the scale of the proposed changes and extent to which they are supported at the macrolevel.

Assessing barriers to providing tobacco use disorder treatment in community mental health settings with a revised version of the Smoking Knowledge, Attitudes, and Practices (S-KAP) instrument.

BACKGROUND: Tobacco use disorder (TUD) rates are 2-3 times higher among people with serious mental illness (SMI) than the general population. Clinicians working in outpatient community mental health clinics are well positioned to provide TUD treatment to this group, but rates of treatment provision are very low. Understanding factors associated with the provision of TUD treatment by mental health clinicians is a priority. METHODS: This study used baseline data from an ongoing cluster-randomized clinical trial evaluating two approaches to training clinicians to increase TUD treatment. Following a psychometric assessment of our assessment tool, the Smoking Knowledge, Attitudes, and Practices (S-KAP) instrument, a new factor structure was evaluated utilizing confirmatory factor analysis. Structural equation modeling was then used to examine the associations between TUD treatment practices and clinician, setting, and patient characteristics in a sample of 182 mental health clinicians across 10 mental health clinics. RESULTS: Clinician but not setting or patient characteristics emerged as significant correlates of providing TUD treatment. Specifically, clinicians' general ethical commitment to providing TUD services and perceptions of their skills in providing this type of care were associated with providing TUD treatment. In contrast, clinician perceptions of patient motivation, anticipated quit rates, or available setting resources were not significantly associated with providing TUD treatment. CONCLUSIONS: Enhancing community mental health clinician TUD treatment skills and commitment to providing such services may reduce TUD rates among people with SMI. Future studies should evaluate interventions that target these factors.

Does implementing a new intervention disrupt use of existing evidence-based autism interventions?

LAY ABSTRACT: Interventions for children with autism spectrum disorder are complex and often are not implemented successfully within schools. When new practices are introduced in schools, they often are layered on top of existing practices, with little attention paid to how introducing new practices affects the use of existing practices. This study evaluated how introducing a computer-assisted intervention, called TeachTown:Basics, affected the use of other evidence-based practices in autism support classrooms. We compared how often teachers reported using a set of evidence-based practices in classrooms that either had access to TeachTown:Basics or did not have the program. We found that teachers who had access to the computer-assisted intervention reported using the other evidence-based practices less often as the school year progressed. Teachers also reported that they liked the computer-assisted intervention, found it easy to use, and that it helped overcome challenges to implementing other evidence-based practices. This is important because the computer-assisted intervention did not improve child outcomes in a previous study and indicates that teachers may use interventions that are appealing and easier to implement, even when they do not have evidence to support their effectiveness. These findings support the idea of interventions' complexity and how well the intervention fits within the classroom affect how teachers use it and highlight the need to develop school-based interventions that both appeal to the practitioner and improve child outcomes.

History and Correlates of Smoking Cessation Behaviors Among Smokers With Serious Mental Illness.

INTRODUCTION: Individuals with serious mental illness (SMI) smoke at rates two to three times greater than the general population but are less likely to receive treatment. Increasing our understanding of correlates of smoking cessation behaviors in this group can guide intervention development. AIMS AND METHODS: Baseline data from an ongoing trial involving smokers with SMI (N = 482) were used to describe smoking cessation behaviors (ie, quit attempts, quit motivation, and smoking cessation treatment) and correlates of these behaviors (ie, demographics, attitudinal and systems-related variables). RESULTS: Forty-three percent of the sample did not report making a quit attempt in the last year, but 44% reported making one to six quit attempts; 43% and 20%, respectively, reported wanting to quit within the next 6 months or the next 30 days. Sixty-one percent used a smoking cessation medication during their quit attempt, while 13% utilized counseling. More quit attempts were associated with lower nicotine dependence and carbon monoxide and greater beliefs about the harms of smoking. Greater quit motivation was associated with lower carbon monoxide, minority race, benefits of cessation counseling, and importance of counseling within the clinic. A greater likelihood of using smoking cessation medications was associated with being female, smoking more cigarettes, and receiving smoking cessation advice. A greater likelihood of using smoking cessation counseling was associated with being male, greater academic achievement, and receiving smoking cessation advice. CONCLUSIONS: Many smokers with SMI are engaged in efforts to quit smoking. Measures of smoking cessation behavior are associated with tobacco use indicators, beliefs about smoking, race and gender, and receiving cessation advice. IMPLICATIONS: Consideration of factors related to cessation behaviors among smokers with SMI continues to be warranted, due to their high smoking rates compared to the general population. Increasing our understanding of these predictive characteristics can help promote higher engagement in evidence-based smoking cessation treatments among this subpopulation.

Moving organizational theory in health care forward: A discussion with suggestions for critical advancements.

In May 2019, scholars in management and organization of health care organizations and systems met. The opening plenary was a moderated discussion with five distinguished scholars who have exemplified pushing the frontier of organizational theory and practice throughout their careers: Ann Barry Flood of Dartmouth College, John Kimberly of the University of Pennsylvania, Anthony (Tony) Kovner of New York University, Stephen (Steve) Shortell of University of California at Berkeley, and Jacqueline (Jackie) Zinn of Temple University. The discussion was moderated by Ingrid Nembhard of the University of Pennsylvania. The goal of the plenary was to provide an opportunity to hear from senior members of the health care management community how they think about organizational behavior and theory, changes that they have observed, research gaps that they see, and lessons for research and practice that they have learned. This article is the transcript of that plenary discussion. It is shared to capture the intellectual history of the field and help surface the critical advancements still needed in organizational theory and practice in health care. The closing remarks of the panelists summarize recommendations for both practice and scholarship in health care organization management.

A Cluster-Randomized Clinical Trial Testing the Effectiveness of the Addressing Tobacco Through Organizational Change Model for Improving the Treatment of Tobacco Use in Community Mental Health Care: Preliminary Study Feasibility and Baseline Findings.

INTRODUCTION: People with mental illness are more likely to smoke and less likely to receive tobacco treatment than the general population. The Addressing Tobacco Through Organizational Change (ATTOC) approach supports organizational change to increase tobacco treatment in this population. We describe preliminary study feasibility and baseline behaviors and attitudes among clients and staff regarding tobacco treatment, and assesse correlates of treatment of smoking. METHODS: Preliminary accrual, engagement, and baseline data are reported from a cluster-randomized trial comparing ATTOC to usual care. Feasibility, thus far, was the rate of site and participant accrual and engagement (eg, participants remaining in the trial). Correlates of assessing smoking, advising cessation, and providing treatment were assessed. RESULTS: Site and participant accrual is 80% (8/10) and 86% (456/533), and engagement is 100% and 82%. "Staff asking about smoking" was reported by 63% of clients and 38% of staff; "staff advising cessation" was reported by 57% of clients and 46% of staff; staff report "assisting clients with any medication" at most 22% of the time, whereas at most 18% of clients report receiving a cessation medication; 59% of clients want tobacco treatment, but 36% of staff think that it is part of their job. "Staff assisting with medications" is related to more training, believing treating smoking is part of their job, and believing patients are concerned about smoking (ps < .05). CONCLUSIONS: This trial of training in tobacco treatment within mental health care is feasible thus far; self-reported rates of tobacco treatment are low and associated with clinician attitudes and barriers. IMPLICATIONS: Evaluation of ways to help address tobacco use treatment in community mental health care is feasible and needed, including the use of technical assistance and training guided by an organizational change approach.

Study protocol: implementation of a computer-assisted intervention for autism in schools: a hybrid type II cluster randomized effectiveness-implementation trial.

BACKGROUND: The number of children diagnosed with autism has rapidly outpaced the capacities of many public school systems to serve them, especially under-resourced, urban school districts. The intensive nature of evidence-based autism interventions, which rely heavily on one-to-one delivery, has caused schools to turn to computer-assisted interventions (CAI). There is little evidence regarding the feasibility, effectiveness, and implementation of CAI in public schools. While CAI has the potential to increase instructional time for students with autism, it may also result in unintended consequences such as reduction in the amount of interpersonal (as opposed to computerized) instruction students receive. The purpose of this study is to test the effectiveness of one such CAI-TeachTown-its implementation, and its effects on teachers' use of other evidence-based practices. METHODS: This study protocol describes a type II hybrid cluster randomized effectiveness-implementation trial. We will train and coach 70 teachers in autism support classrooms in one large school district in the use of evidence-based practices for students with autism. Half of the teachers then will be randomly selected to receive training and access to TeachTown: Basics, a CAI for students with autism, for the students in their classrooms. The study examines: (1) the effectiveness of TeachTown for students with autism; (2) the extent to which teachers implement TeachTown the way it was designed (i.e., fidelity); and (3) whether its uptake increases or reduces the use of other evidence-based practices. DISCUSSION: This study will examine the implementation of new technology for children with ASD in public schools and will be the first to measure the effectiveness of CAI. As importantly, the study will investigate whether adding a new technology on top of existing practices increases or decreases their use. This study presents a unique method to studying both the implementation and exnovation of evidence-based practices for children with autism in school settings. TRIAL REGISTRATION: NCT02695693 . Retrospectively registered on July 8, 2016.

Making value a priority: how this paradigm shift is changing the landscape in health care.

The world of health care is changing dramatically, as reflected in the number, magnitude, and scope of innovative new approaches-to how illness is treated and how better health is promoted-that are being implemented around the globe. The changes triggered by these initiatives affect both how care is organized, managed, and paid for and the kinds of approaches that are being developed to keep people healthy. Underlying these changes is a more fundamental paradigm shift, a shift in the priority given to "value" in the formulation of policy and management practice. This brief essay highlights five trends that are central in this shift: increasing emphasis on health promotion, movement toward value-based payment, advances in digital/mobile technology, exploitation of big data, and changes in support for biomedical research. Each of these has its own value controversies, and the individual impact of each is impossible to predict. Collectively, however, their impact is likely to be significant.

Managing customization in health care: a framework derived from the services sector literature.

Organizations that provide health services are increasingly in need of systems and approaches that will enable them to be more responsive to the needs and wishes of their clients. Two recent trends, namely, patient-centered care (PCC) and personalized medicine, are first steps in the customization of care. PCC shifts the focus away from the disease to the patient. Personalized medicine, which relies heavily on genetics, promises significant improvements in the quality of healthcare through the development of tailored and targeted drugs. We need to understand how these two trends can be related to customization in healthcare delivery and, because customization often entails extra costs, to define new business models. This article analyze how customization of the care process can be developed and managed in healthcare. Drawing on relevant literature from various services sectors, we have developed a framework for the implementation of customization by the hospital managers and caregivers involved in care pathways.

The sustainability of new programs and innovations: a review of the empirical literature and recommendations for future research.

BACKGROUND: The introduction of evidence-based programs and practices into healthcare settings has been the subject of an increasing amount of research in recent years. While a number of studies have examined initial implementation efforts, less research has been conducted to determine what happens beyond that point. There is increasing recognition that the extent to which new programs are sustained is influenced by many different factors and that more needs to be known about just what these factors are and how they interact. To understand the current state of the research literature on sustainability, our team took stock of what is currently known in this area and identified areas in which further research would be particularly helpful. This paper reviews the methods that have been used, the types of outcomes that have been measured and reported, findings from studies that reported long-term implementation outcomes, and factors that have been identified as potential influences on the sustained use of new practices, programs, or interventions. We conclude with recommendations and considerations for future research. METHODS: Two coders identified 125 studies on sustainability that met eligibility criteria. An initial coding scheme was developed based on constructs identified in previous literature on implementation. Additional codes were generated deductively. Related constructs among factors were identified by consensus and collapsed under the general categories. Studies that described the extent to which programs or innovations were sustained were also categorized and summarized. RESULTS: Although "sustainability" was the term most commonly used in the literature to refer to what happened after initial implementation, not all the studies that were reviewed actually presented working definitions of the term. Most study designs were retrospective and naturalistic. Approximately half of the studies relied on self-reports to assess sustainability or elements that influence sustainability. Approximately half employed quantitative methodologies, and the remainder employed qualitative or mixed methodologies. Few studies that investigated sustainability outcomes employed rigorous methods of evaluation (e.g., objective evaluation, judgement of implementation quality or fidelity). Among those that did, a small number reported full sustainment or high fidelity. Very little research has examined the extent, nature, or impact of adaptations to the interventions or programs once implemented. Influences on sustainability included organizational context, capacity, processes, and factors related to the new program or practice themselves. CONCLUSIONS: Clearer definitions and research that is guided by the conceptual literature on sustainability are critical to the development of the research in the area. Further efforts to characterize the phenomenon and the factors that influence it will enhance the quality of future research. Careful consideration must also be given to interactions among influences at multiple levels, as well as issues such as fidelity, modification, and changes in implementation over time. While prospective and experimental designs are needed, there is also an important role for qualitative research in efforts to understand the phenomenon, refine hypotheses, and develop strategies to promote sustainment.

Analyzing performance in addiction treatment: an application of data envelopment analysis to the state of Maryland system.

The pressure is on to measure performance and to increase accountability in health care in general and in addiction treatment in particular. The pressure in the world of addiction treatment comes in large measure from the limited resources that are available in relation to the very large numbers of potential patients. Using data on 161 clinics in the state of Maryland, this article illustrates how data envelopment analysis (DEA), a methodology used widely in other settings, can be used to measure the performance of addiction treatment clinics and can help to identify appropriate benchmarks for clinics wishing to improve their performance. The potential utility of DEA is not only limited to the analysis of state networks but extends to analyses of organizations that have a number of treatment locations. However, its full potential at the national and state levels will only be realized when state-level uniform data sets become available.

Improving consistency and quality of service delivery: implications for the addiction treatment field.

Addiction treatment providers face serious problems in delivering consistent, high-quality services over time. Among those providers with multiple treatment sites, there is also intersite variability. This is a serious problem in the addiction field, likely to be made worse as new technologies are introduced and/or as there is industry consolidation (Corredoira, R., Kimberly, J. (2006) Industry evolution through consolidation: Implications for addiction treatment. Journal of Substance Abuse Treatment 31, 255-265.). Although serious, these problems in managing and monitoring to assure consistent service quality have been faced by many other industries. Here, we review evidence from research in other industries regarding three different forms of management (vertical integration, franchising, and licensing) across a chain of individual service providers. We show how each management form affects the level, consistency, and improvement of service delivery over time. In addition, we discuss how such performance advantages affect customer demand as well as regulatory endorsement of the consolidated firm and its approach.

Organizational measurement and the implementation of innovations in mental health services.

This paper presents a brief review of organizational measures related to implementation of new practices and technologies in sectors other than mental health, and discusses potential application of these measures to mental health implementation research. A few standardized organizational measures are presented along with considerations regarding the appropriateness of adapting existing measures rather than creating novel ones or using additional methodologies. Challenges and opportunities for researchers in measuring key organizational constructs related to implementation in mental health settings are discussed.

The adoption of innovations by provider organizations in health care.

Innovations in health care account for some of the most dramatic improvements in population health outcomes in the developed world as well as for a nontrivial proportion of growth in expenditures. Provider organizations are the adopters of many of these innovations, and understanding the factors that inhibit or facilitate their diffusion to and possible disengagement from these organizations is important in addressing cost, quality, and access issues. Given the importance of these issues, the purpose of this article is to (1) create a comprehensive census of studies examining the adoption of and disengagement from innovations in health care provider organizations; (2) organize these studies into an inductively derived classification scheme; (3) assess the studies' strengths and weaknesses; and (4) reflect on the implications of our review for future research.

The business of addiction treatment: A research agenda.

The social and economic costs of addiction are substantial and of great concern to society. Research in the past decade has led to promising therapies that appear to be highly effective but not widely diffused. This leads one to wonder if there is something about the structure, dynamics, or structure and dynamics of the addiction treatment industry that is getting in the way. However, there has been very little research in the areas of organization, finance, or management practices within the substance abuse treatment field-the kinds of issues that reduce the potential impact of addiction treatment industrywide. With this as background, this article introduces the Center for Organization and Management in Addiction Treatment (COMAT) and a special section on research in the "business of addiction treatment." Many other industries have experienced significant problems that are similar, in many respects, to those seen in substance abuse treatment, but research in leadership, innovation, investment, organization, and consolidation strategies has helped to overcome those problems. COMAT is dedicated to implementing and testing evidence-based methods from other industries to improve the outcomes performance and, ultimately, the clinical effectiveness of service providers in the addiction treatment field.

Industry evolution through consolidation: Implications for addiction treatment.

Drawing on experiences in other industries, this article argues that the business of addiction treatment is likely to be transformed by the advent of a period of consolidation, in which a number of small independent programs will be acquired by larger, better capitalized, and managerially more sophisticated enterprises. Consolidation will be driven by opportunities to leverage new technologies, to exploit new regulatory initiatives, and to introduce economies of scale and scope into an industry that is currently highly fragmented. The process is likely to result in segmentation of the market, with the coexistence of large, generalist, highly standardized firms and a number of small highly specialized firms. When an industry consolidates, the types and quality of services provided can improve through the adoption of best practices and through increased competition among larger providers. If these larger providers are publicly traded, however, efforts to improve will inevitably be influenced by pressures to maintain or increase quarter-to-quarter earnings and share prices, leaving open the long-term impact on service quality.