Provider perceptions of the anticipated benefits, barriers, and facilitators associated with implementing a stepped care model for the delivery of addiction and mental health services in New Brunswick: a mixed-methods observational implementation study.

BACKGROUND: Providers who work within addiction and mental health (A&MH) services in New Brunswick (NB), Canada completed training in Stepped Care 2.0 and One-at-a-Time (OAAT) therapy as part of a provincial practice change initiative to implement a provincial stepped care model. The present study aimed to identify: (1) the perceived acceptability and feasibility of the SC2.0 model; (2) the perceived benefits, barriers, and facilitators to implement SC2.0 in practice; and (3) perceived impacts on clinical practice. METHODS: This is a mixed-methods observational implementation study. Quantitative surveys were completed after training courses. Open-ended responses were collected after completion of SC2.0 training. A subset of providers who completed surveys were asked to participate in semi-structured interviews. Descriptive statistics were used to describe results from surveys. Open-ended responses and semi-structured interviews were compiled and thematically synthesized in an iterative process using a grounded theory framework. Quantitative and qualitative data were triangulated to build an in-depth understanding of provider perceptions. RESULTS: 316 providers completed surveys and responded to open-ended prompts. Interviews were completed with 28 of those providers. SC2.0 was deemed to be acceptable, a suitable fit, and feasible to implement. Perceived benefits included: (1) timely access to services; (2) increased practice efficiency; and (3) increased availability of services. Perceived barriers included: (1) insufficient availability of resources to populate a SC2.0 continuum of care; (2) provider complacency with their current practice; and (3) difficulty for clients to accept and adjust to change. CONCLUSIONS: Identifying the perceived benefits, facilitators, and barriers to adopting stepped care in practice can lead to targeted implementation strategies and the collection of data that can inform continuous improvement cycles.

Implementing One-at-a-Time Therapy in community addiction and mental health centres: a retrospective exploration of the implementation process and initial outcomes.

BACKGROUND: The Department of Health of the Government of New Brunswick and Regional Health Authorities elected to implement Stepped Care 2.0 (SC2.0) in 2021, and began with One-at-a-Time (OAAT) therapy in Community Addiction and Mental Health Centres (CAMHCs) to facilitate rapid access to addiction and mental healthcare. This study: 1) explicated the process of implementing OAAT therapy as it aligned to evidence-based implementation frameworks and strategies; 2) assessed readiness for change among providers during the implementation; and 3) evaluated initial client and system outcomes. METHODS: The process of implementing OAAT therapy within CAMHCs was documented and retrospectively aligned with the Active Implementation Frameworks-Stages of Implementation, Consolidated Framework for Implementation Research, and incorporated strategies endorsed by the Expert Recommendations for Implementing Change. Providers working in CAMHCs completed online asynchronous courses in OAAT therapy and SC2.0, and were recruited to participate in research on perceptions of organizational readiness. Initial outcomes of the implementation were evaluated through client satisfaction surveys administered in CAMHCs and system performance indicators. RESULTS: Aligning with implementation stages, key strategies included: 1) continuously monitoring readiness and soliciting stakeholder feedback for iterative improvement; 2) building a representative implementation team with engaged leaders; 3) creating a comprehensive implementation plan on staff training, communication, and system changes; and 4) supporting sustainability. Providers who participated in research (N = 170, ~ 50% response rate) agreed that their organization was ready for implementation, and that OAAT therapy delivered within a SC2.0 framework was acceptable, appropriate, and feasible. More than 3,600 OAAT therapy sessions were delivered during the initial implementation stage, and waitlists were reduced by 64.1%. The majority of clients who completed surveys (N = 1240, ~ 35% response rate) reported that their OAAT therapy session was helpful, with a minority reporting that additional intervention was needed. CONCLUSIONS: Thoughtful planning and execution, aligned with evidence-based implementation frameworks and strategies, played an important role in this provincial change initiative. Implementation steps outlined can help inform others looking to enact large-scale change.

Systemic challenges and resiliency in rural family practice.

Introduction: The objective of our study was to understand how Canadian rural family physicians (RFPs) define and use resilience strategies to maintain their roles as generalists and resist burnout, while also understanding how organisational supports and systems may play a role. Methods: This was a qualitative study of RFPs with at least 1 year of experience working in rural Canada. Data were collected via semi-structured, in-depth interviews using a grounded theory approach. The participant recruitment process involved purposive and theoretical sampling, and was stopped when theoretical saturation was reached. Results: RFPs identified the following five themes related to resilience: (1) powerlessness, (2) strained work/life balance, (3) colleagues as supportive or straining, (4) living under the microscope and (5) compassion fatigue or empathy. Strategies to enhance resilience were identified at personal, community and organisational levels by participants. Conclusion: Enhancing RFPs' awareness of the specific individual and organisational strategies, as well as system-oriented solutions to maintain resilience, is of benefit to RFPs and rural and remote communities across Canada.

RésuméIntroduction: Notre étude avait pour objectif de comprendre comment les médecins de famille en milieu rural canadien définissent et utilisent les stratégies de résilience afin de maintenir leur rôle de généraliste, et de résister à l'épuisement professionnel, tout en comprenant le rôle des systèmes de soutien et organisationnels. Méthodes: Il s'agissait d'une étude qualitative menée auprès de médecins de famille en milieu rural ayant au moins une année d'expérience dans les régions rurales du Canada. Les données ont été recueillies dans le cadre d'entrevues approfondies semi-structurées à l'aide de l'approche fondée de théorisation ancrée.. Le recrutement des participants comprenait un échantillonnage dirigé et théorique, et a pris fin lorsque la saturation théorique a été atteinte. Résultats: Les médecins de famille ruraux ont identifié les 5 thèmes suivants reliés à la résilience: 1. Impuissance, 2. Équilibre tendu entre la vie professionnelle et la vie personnelle, 3. Collègues qui soutiennent ou causent du stress, 4. Une vie à la loupe, 5. Fatigue de compassion empathie. Les stratégies visant à rehausser la résilience ont été identifiées comme personnelles, communautaires et organisationnelles par les participants. Conclusion: Il est bénéfique aux médecins de famille en régions rurales et dans les communautés éloignées du Canada de rehausser leur prise de conscience quant aux stratégies individuelles et organisationnelles, et aux solutions axées sur le système pour maintenir la résilience. Mots-clés: Résilience, généraliste, épuisement professionnel, pratique familiale rurale.

Scoping review of stepped care interventions for mental health and substance use service delivery to youth and young adults.

AIMS: Many young people with mental health and/or substance use concerns do not have access to timely, appropriate, and effective services. Within this context, stepped care models (SCMs) have emerged as a guiding framework for care delivery, inspiring service innovations across the globe. However, substantial gaps remain in the evidence for SCMs as a strategy to address the current systemic challenges in delivering services for young people. This scoping review aims to identify where these gaps in evidence exist, and the next steps for addressing them. METHODS: A scoping review was conducted involving both peer-reviewed and grey literature. Eligible studies explored SCMs implemented in the various health care settings accessed by young people aged 12-24 seeking treatment for mental health and substance use challenges. After screening titles and abstracts, two reviewers examined full-text articles and extracted data to create a descriptive summary of the models. RESULTS: Of the 656 studies that were retrieved, 51 studies were included and grouped by study team for a final yield of 43 studies. Almost half of the studies were focused on the adult population (i.e., 18 and over), and most did not specify interventions for young people. Among the SCMs, substantial variability was found in almost every aspect of the models. CONCLUSIONS: Considering the current body of evidence, there is an urgent need for a consensus position on the definition, implementation, and outcome measures required for rigorously assessing the utility of SCMs for young people.