Lagniappes: "A Little Something Extra" or Unintended Positive Consequences of Implementation Facilitation.

OBJECTIVE: Implementation facilitation is an effective strategy that increases uptake of behavioral health interventions. Facilitation is grounded in partnerships with leadership and clinical stakeholders. Researchers have documented some negative consequences of facilitation-time, financial, and opportunity costs. Clinical leaders often agree to facilitation with the promise of increased implementation of an intervention. This study examined whether unintended positive consequences of facilitation might offset known costs. METHODS: This study was part of a stepped-wedge, hybrid type 2, pragmatic trial that used implementation facilitation to implement primary care mental health integration (PCMHI) via telehealth technology in six satellite Veterans Health Administration (VHA) clinics. Two facilitators provided facilitation for at least 6 months. This study included a focused analysis of an emerging phenomenon captured through weekly debriefing interviews with facilitators: unintended positive consequences of implementation facilitation, termed "lagniappes" here. A rapid content analysis was conducted to identify and categorize these consequences. RESULTS: The authors documented unintended positive consequences of the facilitation across the six VHA sites and categorized them into three clinically relevant domains: supporting PCMHI outreach at other clinics not in the original catchment area (e.g., providing tools to other sites), strengthening patient access (e.g., resolving unnecessary patient travel), and improving or modifying work processes (e.g., clarifying suicide assessment protocols). The positive consequences benefited sites and strengthened ongoing partnerships. CONCLUSIONS: Documenting unintended positive consequences of implementation facilitation may increase leadership engagement. Facilitators should consider leveraging unintended positive consequences as advantages for the site that may add efficiency to facility processes and workflows.

Using implementation facilitation to implement primary care mental health integration via clinical video telehealth in rural clinics: protocol for a hybrid type 2 cluster randomized stepped-wedge design.

BACKGROUND: Integrating mental health providers into primary care clinics improves access to and outcomes of mental health care. In the Veterans Health Administration (VA) Primary Care Mental Health Integration (PCMHI) program, mental health providers are co-located in primary care clinics, but the implementation of this model is challenging outside large VA medical centers, especially for rural clinics without full mental health staffing. Long wait times for mental health care, little collaboration between mental health and primary care providers, and sub-optimal outcomes for rural veterans could result. Telehealth could be used to provide PCMHI to rural clinics; however, the clinical effectiveness of the tele-PCMHI model has not been tested. Based on evidence that implementation facilitation is an effective implementation strategy to increase uptake of PCMHI when delivered on-site at larger VA clinics, it is hypothesized that this strategy may also be effective with regard to ensuring adequate uptake of the tele-PCMHI model at rural VA clinics. METHODS: This study is a hybrid type 2 pragmatic effectiveness-implementation trial of tele-PCMHI in six sites over 24 months. Tele-PCMHI, which will be delivered by clinical staff available in routine care settings, will be compared to usual care. Fidelity to the care model will be monitored but not controlled. We will use the Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) framework to evaluate the patient-level clinical effectiveness of tele-PCMHI in rural VA clinics and also to evaluate the fidelity to and outcomes of the implementation strategy, implementation facilitation. The proposed study will employ a stepped-wedge design in which study sites sequentially begin implementation in three steps at 6-month intervals. Each step will include (1) a 6-month period of implementation planning, followed by (2) a 6-month period of active implementation, and (3) a final period of stepped-down implementation facilitation. DISCUSSION: This study will evaluate the effectiveness of PCMHI in a novel setting and via a novel method (clinical video telehealth). We will test the feasibility of using implementation facilitation as an implementation strategy to deploy tele-PCMHI in rural VA clinics. TRIAL REGISTRATION: ClinicalTrials.gov registration number NCT02713217 . Registered on 18 March 2016.

Modeling stigma, help-seeking attitudes, and intentions to seek behavioral healthcare in a clinical military sample.

OBJECTIVE: This study examined the relationship between public and self-stigma of seeking behavioral health services, and help-seeking attitudes and intent in a sample of active duty military personnel currently being assessed for traumatic brain injuries in a military health center. Although it has been suggested that many military personnel in need of care do not seek services due to concerns with stigma it is not fully clear what role different types of stigma play in the process. METHOD: Using previously collected data from a clinical sample of 97 military personnel, we conducted path analyses to test the mediation effects of self-stigma on the relationship between public stigma and attitudes toward and intentions to seek behavioral health care. RESULTS: In contrast to a model of military stigma but in line with research with civilian samples, results from this study indicate that self-stigma fully mediates the relationship between public stigma and help-seeking attitudes and intentions. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: These results indicate that programming aimed at increasing mental health care use in the military might best focus on reducing self-stigma associated with seeking mental health services.

Personality Profiles of Incoming Male and Female Medical Students: Results of a Multi-Site 9-Year Study.

PURPOSE: This study conveys findings of a 9-year multi-site study of personality traits among incoming medical students. The purpose of the study was twofold. First, it assessed gender differences by exploring personality traits of incoming male and female medical students. Second, it sought to illuminate personality factors associated with those who choose a career in medicine by comparing personality characteristics of medical students to those of the general population. METHODS: The Sixteen Personality Factor Questionnaire (16PF) was administered at four medical schools to two thousand one hundred seventy seven first-year medical students (1021 females; 1156 males). RESULTS: Study findings revealed significant personality differences between male and female medical students on 11 of 16 personality factors as well as substantial differences in personality functioning between medical students and the general population. Findings are described and future directions for analyses are presented.

Assessing medical students' personalities: a parallel comparison of normed and perception-based metrics.

Various methodologies have been applied in the study of physicians' and medical students' personalities. Little, however, has been reported on distinguishing medical students' self-perceptions from their objectively measured personality traits. 687 first-year medical students at three U.S. medical schools were administered the 16PF and a parallel, author-generated, self-rating form. Paired sample t tests yielded significant differences between students' perceived personality traits vs normed measures of these traits on 14 of 16 personality factor dimensions. Students self-attributed greater magnitudes of socially acceptable traits than their objective scores indicated, as well as less domineering, suspicious, and self-doubting. Implications for admissions and career counseling are discussed.

Techniques for reducing anesthetic injection pain: an interdisciplinary survey of knowledge and application.

BACKGROUND: The authors conducted a study that considered family physicians' and dentists' knowledge and application of techniques to reduce the pain associated with anesthetic injections. They also assessed practitioners' discomfort with patients' injection pain and needle anxiety/phobia. METHODS: The authors designed a questionnaire about awareness and use of 10 techniques for reducing pain of anesthetic injection and mailed it to 2,000 randomly selected family physicians and general dentists. They analyzed the data to examine differences between disciplines regarding awareness and use of techniques, reasons for not using techniques, number of injections given per week, and predictive value of certain demographic variables on reported use of individual techniques and on practitioner reactions to patients' pain and anxiety. RESULTS: The response rate was 35 percent. The authors used the chi2 test for differences between disciplines' awareness of and use or nonuse of techniques, Wilcoxon testing to assess differences between disciplines' median values of number of weekly injections and logistic regression to study demographic variables' predictive values (P = .01). General dentists give more injections than do family physicians. Differences existed between disciplines' awareness and use of eight of 10 techniques. Disciplines reported cost and time issues as reasons for not using some techniques. Number of years in practice and age were associated with use of six techniques. Dentists reported feeling greater personal effects of patients' pain and needle anxiety/phobia than did family physicians. CONCLUSIONS: Those not using pain-lessening techniques inaccurately identified time and cost as problems, suggesting that respondents may be less familiar with these techniques than otherwise reported. Further study is recommended. CLINICAL IMPLICATIONS: Pain reduction techniques for anesthetic injection cost little to implement, are not time liabilities, and can lessen avoidable pain and reduce the incidence of needle phobia.

Doctor-patient communications: using concept cards to instruct.

Less teaching time is available for many faculty, so innovation is needed if educators are to properly serve doctors in training and their patients. In this context, an offer of 1 hour to teach doctor-patient communications generated a simple yet effective teaching method--"concept cards." More than 100 third-year medical students have participated in an exercise where concept cards convey knowledge relevant to the practice of ambulatory primary care medicine. Student ratings establish the utility of the teaching method. Even in an hour, teaching designed for the adult learner can engage medical students and have a positive impact on learning.