Thread by @rnsoicher

#SIRC2019 Next session: Building Roads: Exploring
Implementation Outcomes Across Diverse Contexts

First up - Dr. Lisa Rogers Making Sense of Context: A Systematic Review; Dr. Rogers became interested in #ImplementationScience from her on-the-ground experience on nursing wards #SIRC2019

Outline: Background, review methods, results, implications #SIRC2019

Context is among the strongest influences on implementation success (May et al., 2016; Pfadenhauer et al., 2017; Ovretveit et al., 2018). Poorly understood and reported (Nilsen, 2015) #SIRC2019

Williams (2004) states that context is a "catch-all" for anything relevant to a situation but hasn't been identified/measured/etc. #SIRC2019

Purpose of present project: investigate how context is defined, improve consistency for the word, see what methods exist to measure context. #SIRC2019

Inclusion criteria: peer-reviewed, English language, published in last 10 years, context was a key focus during implementation of a health care initiative, had definition and assessment of "context" #SIRC2019

Total of 64 studies included in qualitative synthesis. Many from US, UK, and Canada. Most published 2015-2018. 34/64 qualitative, 18 quantitative, 12 mixed-methods. #SIRC2019

Variety of definitions to describe context - list contextual factors or sub-elements of a framework that includes context; 15% had both subelements of a framework and meaningful def, 8% meaningful def of an element of context, 17% meaningful definition of context as a whole

78% of studies used context measure to guide data collection, analysis, and the association between context and implementation success. #SIRC2019

Only 4 papers were consistent with their approach by listing factors and the relevant system level in their definition and analyzed data accordingly. Most studies used individual level of analysis, but only 10 used an individual-level factor in their def of context. #SIRC2019

Context is a multi-dimensional construct encompassing micro, meso, and macro-level determinants that are pre-existing, dynamic, and emergent throughout the implementation process. These factors are inextricably intertwined, incorporating multi-level constructs like culture...

Need for researchers to define and analyze context coherently and consistently in order to advance implementation science. #SIRC2019

Next steps: develop context coding framework and apply that to evaluate how context influences the implementation of a healthcare initiative. #SIRC2019

All from @LisaRogers93 !!

@LisaRogers93 Next up in this session: Brittany Rudd, PhD - Implementing Mental Health Assessment in a Juvenile Detention Behavioral Health Unit: Lessons Learned from a Community-Academic Partnership. #SIRC2019

@LisaRogers93 Outline: Review of youth in juvenile justice, review of setting, review of process, lessons learned. #SIRC2019

@LisaRogers93 Youth in juvenile justice system more likely to have mental health issues and suicide is the 2nd leading cause of death among adolescents in US and juveniles in justice system 4x more likely to have suicidal ideation #SIRC2019

@LisaRogers93 Extremely high-risk group of individuals. Despite the plethora of guidelines for preventing suicide in this setting, there is little known about how to use them. #SIRC2019

@LisaRogers93 Present study examined juvenile detention center in Philadelphia; 150 beds, avg length of stay 14 days; behavioral health unit has two therapists, one pt psychiatrist, one pt supervisor of the therapies. #SIRC2019

@LisaRogers93 The clinicians asked how they could improve their EBPs!!! #SIRC2019

@LisaRogers93 PDSA cycle for quality improvement; Plan, Do, Study, Act framework. Plan: objective + predictions + operationalized plan to achieve and collect data; Do: carry out the plan; Study: analyze, compare, summarize; Act: Make changes and start over #SIRC2019

@LisaRogers93 Quality Improvement Team: all clinicians in the center, research assistant (MPH student). 3/1/18 - initial meeting for SWOT analysis. Motivated staff, interested in EBPs, trained in TF-CBT. Weakness - difficult to prioritize youth and select most appropriate EBP. #SIRC2019

@LisaRogers93 Opportunity - Redesign of intake process to match youth to EBP and enhance clinician ability to triage and disposition plan. #SIRC2019

@LisaRogers93 9/1-9/27 explored context by watching sessions, reviewing charts, spoke to staff regarding pros and cons of current process, reviewed literature about screening in juvenile detention. Proposed evidence-based screeners and received feedback from clinicians. #SIRC2019

@LisaRogers93 9/27-11/26: Develop infrastructure to support EBP - workflow checklists, nudges in intake forms (added places to insert scores, added triage reminders) and trained staff to use new measures. #SIRC2019

@LisaRogers93 10/28-2/14: weekly pilots where staff used forms, took notes about problems, gave feedback, revised the process based on feedback. A host of inconsistently used screenings for anxiety, depression, substance use, trauma, mood, and functioning. #SIRC2019

@LisaRogers93 Afterward, universal use of 6 measures and follow-up depending on initial intake. PTSD, suicidality, psychosis, etc. depending on what was needed. Since 12/2018 this is happening systematically. #SIRC2019

@LisaRogers93 Lessons Learned: Importance of TRUE community partnership. "What keeps you up at night" is the best question to work from. Clinicians reached out, relationship facilitated trust, ability to match EBP to needs of providers #SIRC2019

@LisaRogers93 Quality Improvement processes may be useful in juvenile justice contexts but there are inherent challenges. Which version of the screen do you evaluate? When do you evaluate if the process is continuously changing? #SIRC2019

@LisaRogers93 A number of challenges with actual research in vulnerable populations and also with leadership at center. #SIRC2019

@LisaRogers93 Perspective from Clinicians: outside consultation improved team cohesion. Shared instruments provided shared language. Systematically using suicide screening facilitated triaging of youth. Have questions? [e-mail] #SIRC2019

@LisaRogers93 Next up: Sean Wright on DIY Implementation: Lessons from a practitioner-led implementation of an EBP. #SIRC2019

@LisaRogers93 Co-presenter Sonia Combs had previously attended SIRC and championed the research aspect. Sean, working as a clinician, was being asked to scale up and use ACT #SIRC2019

@LisaRogers93 Very moving personal motivation for the DIY implementation. "DIY" means exploratory, bottom-up, provider-led, provider-evaluated. 100% voluntary, no expectation of use or participation, not incentivized, minimal budget #SIRC2019

@LisaRogers93 (ahem: edu researchers, our classrooms aren't any messier than this).

@LisaRogers93 Strengths: guided by provider voice, flexible use based on changing needs, ecologically valid, minimizes impact of incentives/expectations. Limitations: limited conclusions, limited sources of data, long implementation period implies results affected by inner/outer context

@LisaRogers93 The Intervention: Acceptance & Commitment Therapy Methods: anonymous online survey to identify facilitators/barriers to implementation (adapted from Long 2015). #SIRC2019

@LisaRogers93 Piloted monthly training; Follow-up after 4 months to assess changes in attitudes, knowledge, experience, acceptability of ACT in an agency context; Implementation was scaled up based on need/opportunity; Penetration was measured using a month of EHR data #SIRC2019

@LisaRogers93 Some survey results: 15 (/40) pre-post pairs of survey measures for clinicians. Avg dose was 2.2 hours of ACT training. #SIRC2019

@LisaRogers93 Baseline - 0 therapists using ACT (not a reportable EBP in WA), 49 months since beginning, 7.9% of progress notes identify ACT and 32% of eligible outpatient therapists documented use of ACT #SIRC2019

@LisaRogers93 Very rich set of qualitative data on use of different implementation strategies: educating clinicians, developing stakeholder relationships, evaluative and iterative strategies; financial strategies [successfully advocated for ACT to be added to WA list of EBPs!] #SIRC2019

@LisaRogers93 Neal & Neal (2019) - Implementation capital: Merging frameworks of implementation outcomes and social capital to support the use of EBPs

There is now an Implementation Research Group at the agency, from the bottom-up and true to on-the-ground conditions. #SIRC2019

@LisaRogers93 Last up: Dr. Lisa Sanetti - Implementation of an Educator Participatory Program for Improving Teacher Well-Being #SIRC2019

@LisaRogers93 Side note: (not too many teachers at ImpSci conference, but growing) I agree! #SIRC2019

@LisaRogers93 Teachers have the hardest job. But teachers in two schools within the same district still experience different contexts. Teacher well-being is a notion being brought to the fore-front. We are seeing "packaged" wellness programs #SIRC2019

@LisaRogers93 These are not sufficient to improve teacher well-being. In comes Healthy Workplace Participatory Program (HWPP) - evidence-based total worker health approach. Developed in occupational health. Aligned with ImpSci processes. #SIRC2019

@LisaRogers93 Scale-out pilot study with two 3rd-5th grade Title 1 schools in a large suburban district #SIRC2019

@LisaRogers93 The superintendent was very interested in this work. This is not necessarily the case in other districts. #SIRC2019

@LisaRogers93 Mindset and context is important for getting these interventions moving. #SIRC2019

@LisaRogers93 HWPP has two committees: design team and steering committee that work with a facilitator to do participatory work. Design team is front-line teachers. Steering is decision-makers on campus. 7-step process - identify concerns, set objectives, apply performance indicators

@LisaRogers93 evaluate interventions, recommend interventions (all teacher). Next steps are plan and implement interventions, monitor and evaluate interventions on the steering committee. [I may have misunderstood this part] #SIRC2019

@LisaRogers93 Pick ONE health/wellness concern at a time. Go through this iterative process for each concern identified. Used the EPIS phase model for the process. ex: need evaluation happens during exploration phase. #SIRC2019

@LisaRogers93 All-employee survey (free tool available online) that measures workplace health/wellness. 85% of teachers indicated job was highly stressful. 90% experience emotional exhaustion. 95% felt low level of personal accomplishment. 50% experienced depersonalization. #SIRC2019

@LisaRogers93 Take home: clearly there is a NEED for this work. HWPP has a readiness measure and both schools passed :) #SIRC2019

@LisaRogers93 Focus groups elicited themes such as leadership, voice, mental health, changing expectations, low levels of support, poor communication #SIRC2019

@LisaRogers93 From survey, created a data packet to give to design teams, design teams discussed major concerns and picked top 3. In the end, primary issue was peer-to-peer and adminstration-teacher communication. Root cause analysis looks at malleable causes of poor communication #SIRC2019

@LisaRogers93 Improved communication and workplace climate (school 1) and wellbeing & climate (school 2). Both schools had about 8 solutions. At school 1, all were structural root causes (not behavioral). At school 2, some were looking for stress management strategies (behavioral) #SIRC2019

@LisaRogers93 Specific, contextually based strategies. Acceptability was high across both schools for strategies. Adoption was at about 50%, all low-cost. Feasibility was challenging because principals tried to oversee implementation (which was too much). Reach was questionable. #SIRC2019

@LisaRogers93 post-test data didn't look much better than pre-test, but the culture around change has shifted. Teachers expressing more hope and program is renewed another year. Working toward sustainment. #SIRC2019

@LisaRogers93 @DrSanetti [e-mail] if you want more informtion #SIRC2019

@LisaRogers93 @DrSanetti Short break and then onto Driving the School Bus:
Exploring Applications of Implementation Science in School and Community Settings, which is the closest I'm going to get to ImpSci relevant to #HigherEd and I aim to glean as much as I can from it. #Dissertating

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