Yale Psychiatry Grand Rounds: October 7, 2022

October 07, 2022

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"From Evidence to Implementation: Four Strategies and a Mantram to Increase Uptake of Mental Health and Substance Use Treatments in Community Settings"

A. Rani Elwy, PhD, Professor of Psychiatry and Human Behavior, Professor of Behavioral and Social Sciences, Brown University

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00:00Thank you so much, Doctor.
00:03Thank you so much Doctor O'Malley.
00:04I really appreciate you inviting me to
00:08this and to seeing all of you here,
00:10and really excited to start spreading
00:12the word even more about the
00:15importance of implementation science.
00:21So we all know this quote that on average
00:25it takes 17 years for just 14% of original
00:29research to make its way into practice.
00:32And so this really shows that we
00:34really don't have an evidence
00:35problem when it comes to research,
00:37but we have an implementation problem.
00:39And this is where the field of implementation
00:42science really comes into play,
00:44that we really need to be
00:46thinking and and training.
00:48People to think about the relevance of their
00:51research and the impulse impactful Ness
00:53that they can have from a very early stage.
00:56We really need to be working
00:58with a range of stakeholders,
01:00healthcare leaders, staff,
01:01people in the Community,
01:03patients and families in order
01:05to break down this research to
01:07practice gap and increase the public
01:10health impact of our work.
01:11And we also need to be thinking about
01:14the different study designs that we
01:16use in order to speed that development,
01:18as doctor Melley mentioned,
01:20so that we don't have to wait 17 years
01:23and that we can have more than 14% of
01:26the research make its way into routine care.
01:30People have been spending a lot of
01:32time thinking about why we waste
01:34so much of our research funding
01:36and they don't necessarily focus on
01:38implementation science when they do this.
01:40But some of the things that they
01:43really highlight that we need to
01:45be doing more of are very relevant
01:47implementation science.
01:48So in,
01:49you know,
01:50work that's been happening since 2009,
01:53Chalmers and colleagues have been
01:55focusing on this,
01:56this number of 85% of waste in reporting.
01:59The use of research evidence,
02:01which I'm sure you've also heard about,
02:03and it's just staggering because if you
02:06look at numbers from 2010 where there
02:09was $200 billion of research funding,
02:11that means that about $170
02:13billion never of research,
02:16never really made it into publication,
02:19into practice, into dissemination.
02:21And so lots of people spend time thinking,
02:24why is that?
02:25And so they these are some of the questions
02:28that they're saying that we need to.
02:30To focus on more in our research,
02:32you know,
02:32are our research decisions that
02:34we're making based on questions
02:36that are relevant to users?
02:38Are we using appropriate research designs,
02:40methods and analysis?
02:42If not,
02:43really going to get into research
02:45regulation and management here,
02:46but that is certainly an issue.
02:49Do we make our research findings
02:52accessible and our our reports unbiased?
02:55And importantly,
02:56are they usable to the people who need them?
02:59So I'm going to be thinking about.
03:00These questions,
03:01along with other things that are
03:04related to implementation science
03:05throughout this talk to really think
03:08about how we can reduce this gap
03:11from evidence into implementation.
03:13I love this screenshot because it's
03:15the editorial from the very first
03:18issue of the journal implementation
03:21Science back in 2006 by Martin Eccles
03:24in the UK and Brian Mittman in the US.
03:27I've been very fortunate to have
03:29Brian as a mentor and implementation
03:31science for the last 15 years.
03:33And what I love about this is that
03:35even though implementation science
03:37had been around prior to 2006,
03:39we didn't really have a
03:40specific journal for it.
03:41And so now, I mean you will
03:43find implementation science
03:44articles in many journals,
03:45but this is considered our flagship.
03:47And in this they defined what
03:49implementation research is,
03:50which is the scientific study of methods
03:53to promote the systematic uptake of
03:55research findings and other evidence
03:57based practices into routine practice,
03:59routine care and hence to improve the
04:01quality and effectiveness of health services.
04:04And care.
04:04And so this is really where I'm
04:07coming from when I talk to you
04:09today about implementation science
04:11and implementation research.
04:13No one has ever told me these
04:14are the three unique aspects
04:16of implementation science,
04:17but they are what I think are
04:19the three unique aspects.
04:20We have implementation strategies that
04:22we've developed and I'll say more about
04:25each of these throughout this talk.
04:27We have these implementation strategies
04:28that we need to use and test to make
04:31sure that our evidence gets into practice.
04:33We've developed our own type of study design,
04:36which is this hybrid effectiveness
04:38implementation trial design,
04:40and we also really need to focus on
04:42the pragmatic aspects of our research.
04:45So first, the strategies.
04:46This paper was a seminal paper from 2015
04:50by Byron Powell and colleagues really.
04:52And they used a modified
04:54Delphi consensus approach.
04:55I was one of many,
04:57many people who participated in this
04:59work to really think about what are
05:02the strategies that we need to use
05:04to get our research into practice,
05:06and they define implementation
05:08strategies as methods or techniques
05:11used to enhance the adoption,
05:13implementation and sustainability.
05:14Of a clinical programmer practice,
05:17they list 73 strategies in this
05:19paper and that's very overwhelming.
05:22And I would say that you know
05:24this papers from 2015,
05:25there are many more identified
05:27and developed since then.
05:29So I think it's really more helpful
05:30to think about the buckets or
05:32the categories of implementation
05:33strategies that we can use.
05:35And this is actually from an
05:36earlier paper by the same group.
05:38And so here are these nine buckets
05:41of implementation strategies.
05:42I would say that the ones I
05:43use the most are bucket.
05:453 adapting and tailoring to the context.
05:48Bucket 4 developing
05:50stakeholder relationships.
05:52Bucket 5 training and educating stakeholders,
05:56and six supporting clinicians.
05:57We've also tried to do a little
06:00bit around changing infrastructure.
06:02That's a little bit harder,
06:03but all of these are things that you can
06:05think about when you're thinking about,
06:07well, how?
06:08What are the methods, techniques,
06:09and tools I need to use,
06:11identify, use, develop, and test?
06:15To get evidence into practice.
06:19And then our hybrid designs,
06:20which are really just the
06:22most important part,
06:24I was one of the most important
06:26parts of implementation science
06:27that I would say and this is really
06:29trying to help speed that that
06:32evidence to implementation process.
06:33So there are three types,
06:35hybrid type one, Type 2 and Type 3.
06:38And I'm going to make the argument
06:40that any randomized control trial
06:42needs to be a hybrid type one.
06:44And I'll be saying that more and more,
06:46but this is what we would
06:47consider a traditional.
06:48Randomized controlled trial of effectiveness.
06:51But more and more people are
06:52using this in efficacy too.
06:53And I'll say more about that too.
06:54But this is where we have our
06:56primary goals of effectiveness.
06:58And then we usually have our aim.
06:59Three, to understand more about
07:01the implementation context.
07:03You know,
07:03what is it that we are learning
07:05about from this particular trial
07:07that can help us move evidence
07:10into practice sooner and apply that
07:13information into the next study.
07:15Hybrid Type 2 is when we have dual aims
07:17of effectiveness and implementation.
07:19Trying to understand it what not only
07:21is our intervention effective but our
07:24our implementation strategies effective.
07:26And hybrid Type 3 is when we
07:27flip things on their head.
07:29And our primary aim is we know
07:31that our intervention works.
07:33We've tested this,
07:34we know this,
07:35we've tested it in multiple settings.
07:36Now we need to know what are the
07:38most effective strategies and so we
07:40randomize on strategies and that's
07:41really exciting and I'll I'll talk
07:43about some work that we're doing there too.
07:46And then the pragmatic aspect of our work,
07:49you may already know about the
07:52pragmatic explanatory continuum
07:53indicator summary or the precise.
07:54And this is the second version of it.
07:56And these are the types of
07:58things that we can think about.
07:59All randomized controlled trials are on a
08:03spectrum from explanatory to pragmatic.
08:06the Super tight controlled efficacy trials,
08:09especially things like drug trials,
08:10they're going to be at the one
08:13level here really controlled highly.
08:15Restricted, very rigid and you know,
08:18especially in the world of drug trials,
08:20that's important.
08:21But we're really talking about
08:23behavioral interventions here.
08:24And so these can be much more
08:26pragmatic moving up the scale from
08:28one to five in terms of what are
08:30the outcomes that we're assessing.
08:32We need to make sure that these are
08:34relevant to the people involved.
08:35You know,
08:36if you are talking to your
08:38stakeholders early,
08:39you'll find out that maybe one
08:40of the things that patients and
08:41families want to know about is
08:43like how can my loved one get back
08:45to work or how can my loved one.
08:46Have enough energy to play with their
08:48grandchildren or something like that.
08:50And so those aren't necessarily the things
08:52that we assess in a in an efficacy trial,
08:54but these are the things that
08:55matter to the people who are
08:57going to be using our research.
08:58Eligibility is a big thing in our.
09:03Try.
09:06And. Controlled trial,
09:09the expanded exclusive and often
09:11we exclude the people who are going
09:13to benefit most from our work
09:15and that is really true in mental
09:17health and substance use research.
09:19And a pragmatic trial would say be more
09:22inclusive, open it up to more people.
09:24Those are the people that we're really
09:25going to be able to affect in the
09:27future and we need to know if our work,
09:29if our research works for them now.
09:31And that's part of the problem of
09:33the research to of the evidence to
09:35implementation gap is that we didn't
09:37involve these people in the beginning.
09:39We excluded them and then when we
09:41move into Community settings we
09:43find that it's not working for them.
09:45And this gets to the setting piece,
09:46where is the trial being done?
09:48Often our work is being done
09:49in hospital settings,
09:50what we call the ivory tower,
09:52and we're not reaching the people
09:53for whom that is not the place
09:55where they're getting their care.
09:57And so again,
09:58another push for talking to stakeholders,
10:00moving our research out into
10:02the Community faster,
10:03doing more hybrid trials so that we
10:05can understand how our intervention
10:06is going to work in the place that
10:09we want to eventually see it in.
10:11And then the delivery and you know
10:12and this is really hard when with
10:15very highly protocolized renal
10:16randomized controlled trials,
10:17I understand.
10:18But there are things that we can do to
10:20think more about the flexible delivery
10:21and I'm going to give you an example
10:23of what we've done in one of those.
10:26So recently people have been trying to
10:29think about with what are the really
10:31key things we need to be doing to
10:33move evidence into implementation.
10:35And this is a paper that I did with
10:38colleagues Sarah Becker and Kelly Scott,
10:40who were Brown and now at
10:43Northwestern University,
10:43where we really thought about what
10:46are the guiding principles that
10:48anyone should use in terms of moving
10:51their research into implementation.
10:53And so there we came up with
10:55five guiding principles.
10:56For that,
10:56this paper just actually came
10:58out a few days ago in print.
11:00And then another paper that actually
11:03Doctor O'Malley shared with me came
11:05out in August in in Jamaica psychiatry
11:08by Beth McGinty and Matthew Eisenberg.
11:10Really thinking about exactly what
11:12we're talking about here that we have.
11:15We don't have an evidence problem.
11:16We have an implementation problem.
11:18And in this paper they talked about
11:20four different strategies that
11:22any researcher should use to to
11:24address that implementation problem.
11:26And that's so I've been thinking
11:27about this for a while and I spend a
11:30lot of time trying to build capacity
11:32for implementation science among,
11:34you know everyone from PhD students,
11:36postdocs, early career,
11:38up to full professors.
11:39And even though I've been part of this work,
11:42I really think when I compare like
11:45what Doctor Becker's got and I
11:47did and what Doctor McGinty and
11:48Doctor Eisenberg did,
11:49I really think that you can combine
11:51them into 4 strategies to increase the
11:54uptake of behavioral interventions and.
11:56I would say that first of all when
11:57I use the word strategies here,
11:59I'm not talking about an implementation
12:01strategy as we just mentioned,
12:02but just what are the ways that we can
12:05reduce the 17 year gap and what are
12:08the ways that we can make research
12:10less wasteful, more impactful.
12:12And so I would say these strategies
12:14are we need to conduct more hybrid
12:17effectiveness implementation trials
12:18and that was mentioned in our
12:20paper and also the McKinsey paper
12:23let's theory be your guide,
12:25I always say to people.
12:26Here is your friend Siri tells you exactly
12:29what it is that you need to be addressing,
12:31that you need to be measuring,
12:33and can help you plan your work.
12:34And we also talked about this in our paper.
12:37You need to get to know your stakeholders
12:39and that is just essential you.
12:41I'm not an intervention developer,
12:44treatment developer,
12:44but I talked to people who are all
12:47the time and I feel it at that stage.
12:49We need to be talking to stakeholders.
12:51Why develop something that
12:52isn't going to work?
12:53You can find that out from the beginning.
12:55Even if you conducted a really strong,
12:58highly controlled,
12:58randomized controlled trial
13:00and you did find effective or
13:02efficacy for your intervention,
13:03if it's not acceptable to people,
13:05it's not going to make it into the.
13:07Community based settings in which we
13:09want it to and so involve stakeholders
13:11right from the beginning and something
13:13that is unique and wasn't mentioned
13:15in those two previous papers that I
13:17just talked to you about is I think
13:19we really need to tell your tailor
13:20our dissemination efforts more.
13:22This is a big,
13:24there are a lot of people who focus on this,
13:25Ross Brownson at Washington
13:27University in Saint Louis.
13:28But I've been involved now in a quarry
13:32project where we really are needing
13:35to move our work out into wider.
13:38Widespread use and this tailoring
13:40is just really hit me over the
13:44head with how essential this is.
13:46And then of course I said 4
13:48strategies in a month term and
13:49you're going what is the mantra?
13:50And so mantra is fun for me to think about.
13:53I'm actually somebody who
13:55studies mantram meditation.
13:56And mantram in that context is
13:59usually a spiritual word or phrase
14:01that has a spiritual meaning or a
14:04higher level meaning and can help
14:07us bring focused attention to what
14:09it is that we need to be working on.
14:11It can help us also block out the noise.
14:14It can bring awareness to the issue and.
14:17A slow down and process and and so
14:19you'll see why I've been interested
14:20in this in the in the mental
14:22health space in a minute.
14:24But here I think the mantra now is
14:27that we really need to integrate
14:30HealthEquity with implementation science.
14:33This is not a new thing.
14:35It's quite a long you know a call
14:38to action that is long overdue.
14:40But you know we are now seeing
14:42more and more implementation
14:44scientists and more and more funding.
14:47Opportunities really focusing
14:48on how not only are we going to
14:51bring our evidence into practice,
14:53but how are we going to do
14:54this in an equitable way.
14:55And so just to make sure
14:56we're on the same page,
14:57I like to use this definition that
14:59was in a blog post in the journal
15:02Health Affairs that HealthEquity
15:03refers to providing a fair and
15:05just opportunity to be healthy by
15:07reducing and ultimately eliminating
15:09disparities in health and its
15:11determinants that adversely affect
15:13excluded or marginalized groups.
15:15So or seeing.
15:16All of the work here today is that we
15:19need to be integrating HealthEquity
15:22with implementation science.
15:23So let's go back to this first
15:26strategy of using hybrid trials.
15:28When I've talked to Jeff Kern
15:30and Brian Mittman,
15:30authors of the Seminole Paper
15:33on hybrid designs from 2012,
15:35they wish they would have emphasized
15:36more in that paper that every
15:38randomized control trial should
15:39be a hybrid type one trial.
15:41As I mentioned, you can do a really rigorous,
15:45unbiased trial of effectiveness,
15:47and some people are now doing
15:49it in efficacy work while also
15:52collecting implementation context.
15:53Along the way,
15:54and this is the information that's
15:56going to help you understand
15:57what it is that you still need
15:59to do to increase this uptake of
16:01evidence into practice.
16:02If we do hybrid trials that have
16:04a focus on effectiveness we need,
16:07we can then also hopefully not need to do
16:12as much adaptation of our intervention
16:15or our strategies in the future.
16:17So we always talk about interventions have
16:19core components and those are essential.
16:21We can't change those.
16:23There are essential things about,
16:25you know,
16:26cognitive behavioral therapy
16:27that have to happen.
16:29But we can talk about cultural adaptations,
16:31we can talk about setting adaptations.
16:34Targeted audience adaptations,
16:35the people who deliver them.
16:37Adaptations that will not change the core
16:40components of cognitive behavioral therapy,
16:43but will increase the uptake
16:44of its use in practice.
16:46And if we start there,
16:48as opposed to a really highly
16:50controlled efficacy trial,
16:51we might actually be able to build
16:53those things in and not need to do so
16:55much adaptation work in the future.
16:57We also need to be as Chalmers
16:59and colleague mentioned earlier
17:00that really need to think about
17:02what are the research questions
17:03that are relevant to the end users
17:05that could be the providers who
17:07are going to be delivering them,
17:08the patients,
17:08families who are going to be receiving them,
17:11participating in them.
17:11So think about that early on and we
17:14can do that in a hybrid trial and also
17:16then focus on that pragmatic issues,
17:18you know,
17:18making sure that the outcomes that
17:20we're measuring are relevant to
17:22participants that that we're not
17:23as rigid in who can participate
17:25in our trials and that helps
17:27with. Increasing HealthEquity and then also
17:30expanding our recruitment efforts as well.
17:34So my colleagues Megan landfall,
17:36Jeff Kern and Renat Badas created
17:38this what I love this really cool
17:41subway map of implementation research.
17:43And so you can really identify
17:45yourself along this line.
17:46So where are you in terms of
17:48your practice of interest?
17:50You know, what is it that you want to
17:52see implemented in real world settings?
17:54And then you can follow along,
17:55where are you?
17:56And so if you feel that you really
17:59still need more efficacy research, done.
18:02And you can still design for implementation
18:05and that's why a hybrid designs are
18:08now moving into the efficacy space.
18:10You can still do the,
18:12you can still do efficacy research,
18:14really rigorous control things
18:16and obviously of course in drug
18:18medication trials this is essential.
18:21But you can still be collecting information
18:23on what are the perceived benefits of this,
18:26what are the challenges to doing
18:27this so that you are prepared for
18:29moving this forward and in fact
18:31if you are aware of the VA's.
18:33Cooperative studies program where
18:35trials are funded at like $35 million.
18:38They now have a policy that everyone
18:42of those very large 5 to 7 year
18:45trials must be a hybrid type 1.
18:48So you even if you're doing efficacy
18:50research think about a hybrid type
18:52one or maybe you feel that you
18:54still need to do effectiveness.
18:55You you have efficacy you can move
18:59into effectiveness but you know this
19:01is where the comment from current and
19:03mitman come in that even an effectiveness
19:05research trial should be a hybrid one.
19:07Think you should be thinking about how
19:09you can get yourself onto that green line.
19:12I don't know if you you know in
19:13Boston we just call our subway lines
19:15by colors red line, yellow line,
19:17green line, the red line right now.
19:19It's not so great in the subway
19:21world in Boston.
19:22The Orange Line,
19:23which we don't have here is horrific.
19:25The green line is OK.
19:27Hopefully the green line here
19:28for implementation research is
19:29a little bit better.
19:31But I feel like,
19:32you know,
19:33you can do a hybrid trial at any
19:35point and you can also be doing
19:37these mixed method studies,
19:38designing and testing your
19:41implementation strategies.
19:42So in this trial which I will tell
19:44you started out as more of a clinical
19:46trial and I am not a clinical trialist.
19:48I partnered with my colleague Jill
19:50Bornman at VA San Diego to do a
19:53trial testing mantram repetition or
19:54mantra meditation as a treatment for
19:57post traumatic stress disorder among
19:59veterans who had been in combat.
20:02And our our funder which was VA
20:04clinical services research and
20:06development really wanted more
20:07efficacy trials but we did some
20:10pre work talked to a lot of.
20:12Stakeholders,
20:12because of our implementation
20:14science background and found that
20:16what we intended to do in this
20:18trial was not going to work.
20:20Maybe it could have worked
20:21in the trial itself,
20:22but it wasn't going to work long term.
20:23So for example, one of the
20:25things that we wanted to do was
20:26do this as a group treatment.
20:27We wanted to do group based monitoring,
20:29repetition. Jill had done lots of
20:32work already with mantram repetition.
20:34In this case, she had been looking to
20:37see how it could increase adherence
20:39to HIV treatment and she wanted
20:40to now move it into this PTSD.
20:42Space and we talked to veterans of
20:44all genders and found that they had
20:47absolutely no intention of doing
20:48this in a group based setting,
20:50but they were very happy to participate
20:53this in individual treatment.
20:54So we had to request a modification
20:56and move into individual treatment
20:57and that was our first step in
20:59that pragmatic space of thinking
21:01about that flexible delivery.
21:03We cannot do how this had initially
21:05been planned because we knew
21:06even if it worked in this trial,
21:08it wasn't going to work in the real world.
21:10The other thing we did is we
21:11really thought about who would
21:12be delivering these services and
21:14that's another pragmatic issue.
21:15We didn't want to hire PhD level
21:17people who were going to disappear
21:19after the study and we're only
21:21going to be interventionist.
21:23And so we talked to the clinicians.
21:26Masters degree level clinicians at each
21:28of our sites to see who would want
21:30to become involved in this project
21:32and so we really didn't involve the people,
21:35a lot of social workers for example,
21:37who would be involved in delivering
21:39mantra repetition in the future.
21:41So that was a great,
21:42great first step towards becoming
21:44more of a pragmatic design.
21:46Mantram repetition Mantra Meditation
21:48was developed by Eknath Ishwaran,
21:51who developed the Blue Mountain
21:53Retreat Center Meditation Retreat
21:55Center in San Diego.
21:57And you know,
21:58Mantram is just it's it's so simple,
22:02which is actually essential
22:04for implementation.
22:05It's not complex at all,
22:06and these are a couple of the books
22:08available at that website there.
22:10But really, mantram is a way of slowing down,
22:15having focused attention.
22:16Trying to make sure that you can
22:19block out a lot of the challenges,
22:21especially the kinds of things that
22:23happen in post traumatic stress disorder,
22:25nightmares incurring.
22:26So you the person starts,
22:28the first thing that you have to
22:30do is actually pick a montrem
22:31if you're in this group.
22:32And so the mantram has to be
22:34a spiritual word or phrase.
22:36It doesn't.
22:36You don't have to be a religious person,
22:38but you need to have a sense of
22:41higher order and can come from
22:43any religion and if any of these
22:46religious or spiritual words.
22:48Don't seem to fit for someone.
22:49They can pick something else.
22:52And so we would say if none of these work,
22:54you can just use the word one.
22:56You could not use anything vulgar,
22:58you couldn't use a swear word,
22:59etcetera, had to have a higher order.
23:01And we often say to people that
23:03your mantra will pick you.
23:05So for example, I went through the
23:07training myself because I thought, well,
23:08if I'm going to be trying to do this trial,
23:09I need to practice mantra meditation
23:11and see what this is like.
23:13And I really wanted the word.
23:15I really wanted the phrase Om Namah shivaya.
23:18It sounds so beautiful, you know,
23:20and a lot of these words come from
23:23Sanskrit or are, you know, maybe Hindi.
23:26Some of these words are from Buddhism,
23:29others are from Judaism,
23:32Christianity, etcetera.
23:33I really wanted Onama shivaya
23:35invocation to beauty and fearlessness.
23:38But as I went through the training and
23:40you need to learn how to invoke the mantra
23:42when you need it, like on the spot,
23:44I couldn't remember my mantra and
23:46so then I understood why the mantra.
23:48Makes you the one word that I
23:50could remember always was Rama,
23:51Eternal joy within.
23:52So that became my mantra.
23:54So I would silently say it to myself.
23:57I would write it down.
23:58Those are the kinds of things that we
24:01ask people to do when they need it.
24:03First you learn how to use the
24:04mantra when you don't need it,
24:05and then you move to using
24:07it when you need it.
24:09And we compared this to a very active
24:11treatment arm of present centered therapy,
24:14which through Polish,
24:16schnurr and others has really
24:19established very strong.
24:21Effectiveness and efficacy work.
24:23It's really helping people to
24:25alter their present maladaptive
24:27reactions and patterns and providing
24:30some sorry cycle education.
24:32And importantly,
24:33there's no meditation at all
24:34and no mantra meditation.
24:36And so it was a really good
24:38comparison arm and again,
24:38we had masters level people
24:41who were using this.
24:42And importantly,
24:43in both of our mental health settings,
24:46neither one of these treatments
24:48was available as routine and so
24:50it was considered something new.
24:51Any veteran participating?
24:52And so we use the caps,
24:55which is I will admit is not
24:56exactly the outcome that matters
24:58to the people who are using.
25:00It is very difficult to both
25:02administer and participate in.
25:04But you know,
25:05we had 89 people in our monitoring
25:07group and 84 in our present centered
25:10group and the Montreal Group improved
25:13tremendously on that measure over time.
25:15And so the present centered
25:17group also improved,
25:18but not as much as the mantra in
25:20terms of the Caps scoring and
25:22we also wanted to know.
25:23What was driving PTSD and so we
25:25thought that we could maybe find out
25:28if insomnia had anything to do with this.
25:30And so we asked about the using
25:33the Insomnia Severity Index and
25:35found that the present centered
25:37therapy group really didn't change
25:38in terms of insomnia over time.
25:40But the sorry the the mantra group
25:43did that their insomnia improved a
25:46little bit and kept going down but
25:48didn't get to the point where it
25:51it wasn't clinically meaningful.
25:52Both things both groups still
25:53had clinically meaningful.
25:55Some symptoms.
25:57And so this is where we were like we need
25:59to know about how,
26:00how is this actually going to work?
26:01We saw that it works in this group of
26:04veterans with post Traumatic stress
26:07disorder resulting from combat.
26:09But what was it going to take
26:11to make this work in real life?
26:13And so this is where a
26:14process evaluation comes in.
26:15After the recruitment was done,
26:18after providers were no longer
26:20referring patients to us and providers
26:22were such an essential part of this.
26:25So they really needed to have.
26:27Buy in, they needed to believe
26:28that we were doing something unique
26:30and helpful for the veterans
26:32that they were serving.
26:33We wanted to find out from them what
26:35were are some potential barriers
26:37and facilitators to implementation
26:38that we can think about now so
26:40that we can address in the future.
26:42And so this gets into strategy #2 already,
26:45which is the that we were guided by
26:47theory with this and we chose the
26:49theory of diffusion of innovation
26:51which actually was not developed
26:53in healthcare at all,
26:54really developed in the agricultural space.
26:57And really says that there are
26:59key features of any innovation,
27:02any adoption of innovation.
27:03And that is that a user will see it
27:06as a perceived relative advantage
27:07compared to anything else that they're doing,
27:10that it's compatible with their
27:12perceived needs, values, norms,
27:14low complexity,
27:15sure.
27:16Yet that's essential and have the
27:18best intervention in the world.
27:19But if it's seen as too complex,
27:21it won't be adopted.
27:22And so these are the kinds of things
27:24that we needed to assess in our
27:26process evaluation with our providers.
27:28Did they see this as a relative advantage
27:30for themselves and their veterans?
27:31Did they see it compatible
27:32with their perceived needs,
27:33values and norms and their veterans?
27:36And was it low in complexity to
27:38them and also to their veterans?
27:41And what the theory of diffusion
27:43of innovation says is when we
27:44start to have conversations,
27:46peer-to-peer conversations with others
27:47that we work with who are in our networks,
27:50in our communities,
27:51and we hear what they think
27:54about that innovation,
27:55then we start to consider change
27:57and we start to consider adoption.
27:59And we do this because we have
28:01a sense of trust.
28:02We believe in the person
28:03that we're talking to.
28:04And although we may not have seen
28:07this benefit yet of this innovation,
28:09we start to trust them.
28:11Because they are already somebody
28:13who we consider credible,
28:15and if they're telling us that it works,
28:17we're going to try it out too.
28:20And so we did a survey with 69 of
28:22the providers who participated in
28:24this trial in terms of referring
28:26patients to us and then we did a 12
28:30interviews with a subset of those just
28:32to get a little bit more deeper dive.
28:34And from the survey and the interviews
28:36we really had three main themes
28:38that came out that were can really
28:40inform implementation of this
28:42mantra meditation in the future.
28:44We the first two are things
28:45that have been talked
28:46about in the literature already that you know
28:48believing in one's own clinical judgment.
28:49Often Trump's the actual evidence based
28:52treatment because we just don't see
28:54that as being relevant for our patient.
28:57And then there are some other factors.
28:59But what was new in our work
29:01was that people, clinicians,
29:03providers were doing just extraordinary
29:06things to deliberately manufacture time,
29:09to have conversations with
29:10trusted others in their clinic,
29:12to learn more about Mantra meditation,
29:15to learn more about other evidence based
29:18treatments for PTSD and so for example.
29:21Things that they told us was that,
29:22you know, they wanted to have
29:24lunch to talk about these things,
29:26and they knew that having lunch
29:28would mean that they'll have to stay
29:30late to write their clinical notes.
29:31But doing this once a month or so
29:33is worth it because it was at this
29:36lunchtime conversation that they
29:37learned important aspects of treatment.
29:39That they really went to great effort
29:41to talk to colleagues outside of work
29:43and even walking to a colleague's car
29:45after work in order to have 10 minutes
29:48outside of the car was how they snuck
29:50time they were sneaking time to have
29:52these conversations with just really
29:54resonated as just like a way of trying
29:57to learn whatever they could and really
30:00emphasize to us how conversations
30:02about evidence based practices,
30:04mantra,
30:04meditation,
30:05anything are really not interwoven
30:07into the system yet and.
30:10In a way that is helpful for change.
30:12So here we're not talking about
30:14anything really related to the
30:16meditation trial in terms of the
30:18meditation as an intervention.
30:20We're talking about all of the organizational
30:22and cultural things that are happening
30:24in settings that we need to address.
30:26And we took this information and said
30:28this is the implementation strategy
30:30that we need to use in future work.
30:33We need to think about how do
30:35you promote network weaving and
30:36that is identifying and building
30:38out existing high quality working
30:40relationships within an organization.
30:42To promote information sharing,
30:44collaborative problem solving,
30:45shared goals related to an implementation.
30:48This is one of those 73 implementation
30:50strategies that's listed in
30:52Byron Powell's 2015 paper.
30:53But this really showed us that
30:55what we were learning from our
30:57providers was what we needed to do.
30:58And so we have since developed a social
31:01network survey of three questions asking
31:03people who do they talk to at work?
31:05Who do they seek advice from,
31:07who do they go to when there's a difficult
31:10clinical problem that they have,
31:11and answers to these questions.
31:13Help us identify who those champions are
31:15at each other's sites and who we can
31:18involve in our implementation efforts
31:20and how we can promote network weaving.
31:22How can we get that champion,
31:24that trusted person,
31:25to start talking to other people
31:27about the implementation effort.
31:29And that's really essential.
31:30And so without having done a hybrid type
31:33one and adding this process evaluation,
31:35we would never have known this.
31:38And so this moves us into Strategy 2,
31:40which is let theory be your guide.
31:41And I know you know that.
31:43You've all seen this quote from Kurt Lewin.
31:44Nothing is more practical than a good theory.
31:47And one of the things that this
31:49addresses in the Chalmers that all
31:51research waste issue is that theory
31:53can help us develop appropriate
31:55research design methods and analysis.
31:57And hopefully that will help us speed
32:00that public health impact translation.
32:02I always tell people that
32:03theory is your friend.
32:04It tells you what you need to measure.
32:06It tells you how frequently.
32:09Perhaps you need to do this.
32:10What are the kinds of concerns that that
32:12might occur that you haven't thought about?
32:14And also, we won't waste research
32:16dollars if we're collecting data
32:18that we're not intending to use.
32:20Theory helps us figure that out,
32:22and this is a wonderful website
32:24that is a collaboration between
32:25the University of Colorado and
32:27Washington University in Saint Louis.
32:29You can go to the website here.
32:30It's free to use.
32:31There are lots and lots of
32:33different theories, models,
32:34and frameworks to look at that are used
32:37in the implementation science space.
32:39In a paper in 2018 by Sharon
32:42Strauss and colleagues in Toronto,
32:44they identified at least 159 theories,
32:47models and frameworks.
32:48So we don't need any more
32:50development of these theories,
32:51models and frameworks.
32:52We just need to figure out
32:54which ones work for us.
32:56So in my work that I'm doing
32:58in the VA with my colleagues,
33:00Umm Keith McGuinness,
33:01Amanda Midboe, David Snelson,
33:03we have something called the bridge.
33:05Prairie Bridge is a short name
33:07for bridging the care continuum
33:09for vulnerable veterans in VA
33:11and community care settings.
33:13And we're really focusing on how to
33:15increase the uptake of three different
33:18evidence based practices related
33:19to mental health and substance use.
33:22We're in each of these projects.
33:24Each one is a hybrid Type 3 design.
33:25Being implemented in at least
33:27six sites around the country.
33:29Some of these are VA sites,
33:30some of these are community based sites.
33:32So for example,
33:33the top one veterans with opioid
33:35use disorder,
33:36this is the homeless overdose
33:39prevention expansion program
33:41that's being led by Amanda Midvale.
33:43And the one on the bottom right is on
33:46veterans released from incarceration.
33:49This is the pie program.
33:51This is called the post Incarceration
33:53engagement program and the.
33:55Now on the bottom left is the
33:59mission CJ program,
34:00and this is the maintaining independence
34:03and sobriety through systems integration,
34:05outreach and networking.
34:07Criminal justice,
34:08which is why I had to look at my notes
34:09because I can never remember that.
34:11But in each of these there are there's
34:13lots of evidence for this treatment.
34:16We are trying to, in some cases,
34:19use peers.
34:19So having a flexible delivery
34:21model and also thinking about who
34:23can deliver these interventions,
34:24we're using peer specialists.
34:26And we're trying to do this in what
34:28we're doing this in a hybrid Type 3,
34:31which means that our focus is on
34:33the implementation strategies.
34:34So I'll say more about that.
34:36And so here are the projects and
34:38I lead the implementation core,
34:40which is responsible for overseeing
34:43the tracking of the implementation
34:45strategies that we're using,
34:47focusing on how we can increase
34:49the spread and sustainability and
34:51making sure that each of the projects
34:53is collecting the same outcomes,
34:54implementation outcomes and
34:56effectiveness outcomes.
34:57So that we can make some comparisons
34:59across these 18 sites that are involved.
35:02Even though there are three different
35:04evidence based practices happening,
35:06a hybrid Type 3 focus is really on.
35:09That's the last hybrid step before
35:12truly trying to sustain something
35:15in in routine care.
35:17And so as a result of that,
35:18we decided to use the dynamic
35:21sustainability framework as our way
35:23of focusing on not just implementation
35:26of sustainability and the DSF,
35:28which was developed by David Chambers,
35:30Russ Glasgow Heart stage Dangy is
35:33that we need to constantly assess
35:35not just one time,
35:37but over time how the intervention
35:40fits with the practice setting and
35:42fits within the ecological system.
35:44So oftentimes we only assess
35:46these things once.
35:47But we really need to do this overtime.
35:49And so we have developed a system
35:51of looking at pre implementation,
35:52implementation and sustainability
35:54across these three hybrid type threes.
35:56So we're always learning about what's
35:58happening with the intervention,
36:00what needed to be adapted,
36:02how are things working in that
36:03particular practice setting,
36:04because sometimes we are in jail
36:06settings that are outside the VA,
36:08sometimes we are in outpatient settings.
36:10So we need to figure out you know what
36:12the organizational climate is like,
36:14what's the staffing,
36:14what kind of training and supervision
36:16is needing and then.
36:17Certainly the ecological system which
36:19is our real world factors like what's
36:22happening in the world of policy
36:24and regulation and market forces.
36:25So a perfect example is that we
36:28intended to have these sites,
36:30the 12 of the sites that are using peers,
36:33higher peers at certain times.
36:35So that we could use a cluster
36:38randomized stepped wedge design
36:40to roll out our evidence based
36:42practices to sites at a time.
36:44And then COVID hit this actually this
36:46grant got funded on October 2020,
36:49so we were in the midst of COVID and then
36:52the American Rescue Plan Act got funded.
36:55The ARPA in VA got lots of
36:58money to hire peers.
36:59And so even though we had staggered our
37:02hiring at peers at these sites to meet
37:05with our cluster stepped wedge design,
37:08we could no longer have a
37:10stepped wedge design because our
37:12sites got peers immediately so.
37:14In terms of flexible adaptation,
37:17we had to switch from a stepped wedge
37:20design to more of an adaptive design,
37:23and that was a really hard switch
37:25in the middle of our planning,
37:27but was essential because of
37:29the ecological system changes.
37:32And one of the things that I'm overseeing
37:34is that we are randomizing sites in
37:36now are now adaptive designs to either
37:39receive high intensity strategies
37:41which we're calling implementation
37:43facilitation or low intensity
37:45strategies of education,
37:47outreach and academic detailing.
37:48And both of these have very clear
37:51definitions of what they are and we
37:53are tracking and in a hybrid type 3,
37:56the research groups do not do
37:58the implementation strategy work,
38:00we train people on the sites.
38:02Appears that we've hired or in the
38:04case of the Hope project we train a
38:06lot of the social workers who are
38:08involved to actually do the training
38:10of the intervention at that site.
38:12And so they we are using our
38:14implementation strategies with those
38:16those people and then they in turn
38:19are delivering the intervention.
38:20And so I you know often talk about
38:23implementation science being
38:24just gigantic tracking effort.
38:26We track a lot of things.
38:28We have calls often with the
38:29sites to learn what they're doing
38:30and talk to the point of.
38:32Contact to learn more about what's happening.
38:35We've created dashboard to look at the
38:37different outcomes that we are assessing.
38:39This is just a fake version just
38:41for presentation to show that we're
38:43trying to learn about acceptability,
38:45appropriateness, feasibility and
38:47trying to see if organizational change,
38:50readiness for implementing change
38:53changes increases, gets worse etcetera.
38:56Over the time of the of the project,
38:58people will be hired,
39:00people will leave at cultural changes
39:02will happen.
39:03So we're just trying to track all of that
39:05and see how that impacts sustainability.
39:07We are actually presenting this
39:09work as part of a symposium at
39:12the DI Conference in in December
39:14if people attend that conference.
39:17And the other thing that we're
39:18doing is we're also keeping track
39:20of the qualitative work that we're
39:22collecting according to the Dynamic
39:24sustainability framework pieces
39:25and to see what we can learn from
39:27that in order to adapt any of
39:29our strategies if needed.
39:30And we're also presenting
39:32that work at the conference.
39:33So the third strategy is that we need to
39:35get to know your stakeholders and this is.
39:37To go back to the Chalmers piece,
39:39we need to be have research that's
39:40relevant to the users of the
39:42research and we need to provide fully
39:44accessible research information.
39:45And we can do this if we build these
39:47partnerships and these relationships
39:49with our stakeholders from the beginning.
39:51And so a project that I've done with
39:53colleagues and Pittsburgh funded by pecori,
39:55this is the heel study.
39:57Heel was developed long before the
39:59night of heel and in this case
40:01heel stands for healing encounters
40:03and attitudes list.
40:04It's a set of 6 self report questionnaires
40:07built on the promise methodology.
40:10Really generalizable to any treatment,
40:11but we're trying to use them
40:13to see what we can,
40:14how these measures might be used to reduce
40:17opioid use in community based pain clinics.
40:21And so these are our measures of treatment,
40:23expectancy,
40:23patient provider connection,
40:25healthcare environment,
40:27positive outlook,
40:28spirituality added towards
40:29towards complementing restorative
40:31medicine through spirit.
40:33Through our formative evaluation work.
40:35We actually decided not to focus
40:37on spirituality and attitudes
40:38and only use healthcare
40:40environment a little bit.
40:41So most of the project focuses on treatment,
40:43expectancy, patient provider,
40:45connection and positive outlook and we
40:48partnered every Pecori project has to
40:50have stakeholders involved anyway and so.
40:51We partnered with the UPMC Pain
40:54Medicine Chair, Vice Chair,
40:55and even though UPMC is
40:57central in Pittsburgh,
40:58a lot of their satellite clinics are
41:00suburban and some are even considered
41:02rural because they read they're
41:04like 2 hours away from Pittsburgh.
41:06And so it was a really great place to
41:08try to do a true implementation project.
41:11Carol Greco,
41:12who led the project with Ajay Wassan,
41:14had already done so much work to show
41:16that there was a strong relationship
41:18between responses to treatment expectancy,
41:20positive outlook.
41:21Patient provider relationship and
41:23promise measures of pain severity,
41:25promise measures of global
41:27functioning etcetera.
41:28We just wanted now to see can we put
41:30these measures into what was already
41:32happening in the clinic and the clinic
41:35was already using the choir platform,
41:37the collaborative Health Outcomes
41:39Information Registry and open source
41:41web-based patient reported outcome
41:43application where patients are sent
41:45an e-mail link and or they can
41:47complete the survey questions on
41:48a clinic pad and the survey is of.
41:52The promised measures had started
41:53in 2016 and we wanted to roll into
41:56this the treatment expectancy,
41:58patient provider out,
41:59patient provider relationship
42:01and positive outlook questions.
42:03So this is the kind of report on
42:05the promise measures that clinicians
42:06in the pain clinics would get
42:08before they saw their patients.
42:10And so we would be adding in these
42:12treatment expectancy questions for example,
42:14so that they could look at them.
42:15And the whole goal was to try to
42:18increase greater conversation about
42:20pain treatment between the provider
42:22and the patient and reduce opioids
42:25hopefully and then refer to other
42:27non pharmacological treatments.
42:28And so we had a lot of,
42:31we did formative evaluation work,
42:33we did process evaluation and
42:35summative evaluation.
42:35But really the intervention here
42:37was putting these heel measures
42:39into the choir platform,
42:40so involved the IT group and then
42:43trying to use our strategies to get.
42:46Clinic staff to talk to this
42:47about with their with their people
42:49who check in for the clinic,
42:51trying to talk to the providers about it,
42:53reminding them that these aren't.
42:56Measuring.
42:57A.
43:01There's evaluation work,
43:02and the other work is forthcoming.
43:05And here are some examples
43:07of treatment expectancy.
43:09So Umm, you know,
43:10not surprising to any of you,
43:13but I'm confident in this treatment,
43:15this treatment will be successful.
43:16I feel good about this treatment, etcetera.
43:18And so our formative work was really to
43:20talk to patients and providers and staff
43:22to find out what they thought about it.
43:24And again, we drew on the theory
43:26of diffusion of innovation.
43:27So we wanted to know what
43:29did they think about it.
43:30And we were able to figure out what was the
43:32relative advantage of this considered higher,
43:34low and so some patients.
43:36Said that it was high that, you know,
43:38when they go to the pain center,
43:39they don't expect to leave pain free.
43:41They want their pain just to
43:43be manageable or tolerable.
43:45They think that their doctor feels that
43:47the opioid problem is people not wanting
43:48to have pain and but really what they
43:50want is just to be able to manage it.
43:52And so they felt it would be great
43:54to answer these treatment expectancy
43:56questions and then to have a conversation
43:58with their provider about it.
44:00Some providers thought it would be
44:02a great idea because they are very
44:04interested in treatment expectancy.
44:05They know how it affects.
44:06Pain perception.
44:07And then some patients
44:09and providers thought oh,
44:10these,
44:10you know,
44:11these questions are really repetitive
44:13and people aren't going to want to
44:15listen to this or people aren't going
44:17to want to complete these items.
44:19And so they were really doubtful about it.
44:20And then this gave us some information
44:24to develop implementation strategies.
44:26And so for patients,
44:28we did these FAQ sheets where we
44:31look specifically at, you know,
44:34these questions seem repetitive.
44:35Do I really need to answer these,
44:36you know, will my doctor talk to me about?
44:38These will these affect my treatment.
44:39Those are the kinds of things that
44:41we were hearing from patients and
44:43our interviews and so we created some
44:45educational strategies to address that.
44:47For providers,
44:47we went a little bit more actively
44:50and we created these six videos
44:52with our stakeholder champion,
44:55the clinic lead about the different
44:57types of measures that we were
45:00using and really sharing with
45:02providers what was important.
45:04So they were short,
45:06you know two-minute videos
45:07that we sent to clinics.
45:09The clinics would then do a little red
45:11CAP survey to to say that they'd watched
45:12it and then you know the Clinton,
45:14we had a little competition going,
45:16clinics who watched more of the survey,
45:20more of the videos,
45:22got coffee and Donuts for that week.
45:24So just trying to get the word out in
45:27an educational strategy and sort of
45:29engaging way about why it's important
45:31to do this because this project was
45:34a true implementation project.
45:36It was not a hybrid type three.
45:37We did not have any research.
45:39Staff in the clinics,
45:40we were just trying to remotely
45:42convince people at these clinics
45:43that this is what they needed to do,
45:46and so a real true test of behavior change.
45:50And so we're still working on the results.
45:52The project has ended in April,
45:55but you know over we have these
45:56different nine month periods that
45:58we looked at and there were a lot of
46:00unique patients at these clinics,
46:01a lot of patient appointments and
46:04we looked at initially did patients
46:06complete the surveys and did staff
46:08complete looking at those reports
46:10because we really didn't have any
46:12other way of seeing how engaged
46:14they were with these results.
46:16So pre implementation of
46:18these measures which was 2018.
46:21These were sort of our baseline when it
46:23was just the patient reported outcomes,
46:25just the promise measures in the
46:26system surveys were being completed,
46:28about 72% of the patients,
46:30about 79% of the staff were looking at these.
46:32These are pretty high numbers and
46:34we didn't know if we'd be able
46:36to improve upon that post heal,
46:38but still pre COVID around 2019,
46:41so post heal implementation,
46:43so now the heel measures of treatment
46:46expectancy etcetera are in the system
46:48are more people completing the surveys.
46:51Not really.
46:52Our more staff reviewing their reports.
46:54No, it's totally the same.
46:56And so we had to like up our
46:59implementation strategies.
46:59We did further educational efforts,
47:02we did a retreat.
47:03We did started doing journal clubs,
47:04we did lunch and learns,
47:06then COVID hits and everything
47:09went remote and interestingly.
47:11As a result of telemedicine,
47:13when people could not see their patients
47:15and patients could not see their
47:17doctors in real life everything was virtual.
47:19We had a higher survey completion rates.
47:22And we had a higher rate of clinicians
47:24and staff looking at those reports and
47:27so really indicated that there was
47:30a real need for understanding more
47:32about how people were feeling about
47:34their treatments in this telemedicine space.
47:37And when we looked at changes over time
47:40in terms of what was happening with,
47:43you know, and we and it's not
47:45a controlled trial at all,
47:460 control on this.
47:47We're making a lot of assumptions and of
47:49course there are a lot of limitations here.
47:51But we can see that from 2018 until now,
47:55there's been a big increase in
47:57referrals to integrative medicine,
47:5950%.
48:00And there's been an increase of 19%
48:03in referrals to psychiatric and
48:05psychological services and maybe.
48:08This is a result of having a decrease
48:10in prescriptions for opioids,
48:11which are down 8 to 14%.
48:13Orders for injections are down
48:15a little bit and interestingly,
48:17orders for physical therapy
48:18and occupational also down,
48:19and we think it might be because they're
48:21referring more to integrative medicine.
48:23We also saw a decrease in the
48:25number of ER visits and urgent care
48:28visits per pain patient.
48:30That doesn't mean these visits were
48:32not necessarily related to a pain
48:34issue that they were experiencing.
48:36And so it's just an observation.
48:38That we've made.
48:39But this is a true implementation project.
48:42This is, there's nothing controlled here,
48:44there's no research staff.
48:45This is just the use of strategies to try
48:49to increase the uptake of something that
48:51we think will work to change practice
48:54behavior and change prescribing behavior.
48:56And all built on the formative evaluations
48:59and process evaluations that we're
49:01doing to learn what's working and
49:04what's not working in the clinics.
49:06And so the final strategy is that we need
49:10to tailor our dissemination efforts more.
49:11And this will really help address the
49:14Chalmers comment of having unbiased
49:16and usable research reports like
49:17what can we create for the different
49:20audiences and the different groups who
49:23need to know more about our efforts
49:25to decide that they also want to
49:28adopt it and invest in this.
49:30And I just will say that Yale
49:33has a terrific dissemination.
49:34I don't know what you call it,
49:37a report, a report on strategies,
49:41but I use this all the time.
49:43I share it with lots of people.
49:45If you aren't familiar with this,
49:46it's it's the link is there
49:48and I will share these slides.
49:49But really talking about these key
49:51characteristics of an effective
49:52dissemination plan and that number one,
49:54is super important to orienting towards the
49:56needs of the audience using appropriate
49:59language and information levels.
50:00And when we are thinking about this,
50:02a quarry project that we just completed
50:04and how can we start to convince people
50:07that they can add these questions,
50:09these treatment expectancy, excuse me,
50:11expectancy, positive outlook,
50:14patient provider relationship
50:16questions in a way that may inform
50:19the conversations that providers and
50:22patients are having and may inform future
50:25treatments moving away from opioid use,
50:27moving into non pharmacological
50:28treatments we think well what is it?
50:30That a clinic needs to know what is
50:32it that leadership needs to know
50:34and we're talking to, you know,
50:36small, you know,
50:37small clinics around the country.
50:38We're talking to larger hospital based.
50:41What do they need to know?
50:43And honestly what they need to know is
50:46what are the costs of implementing this.
50:49And luckily,
50:50Lisa Saldana,
50:50who's at the Oregon Social Learning Center,
50:53has worked done a lot of work on
50:55something called the stages of
50:57implementation completion checklist,
50:59which she has also shown can be
51:01a way of tracking the costs of
51:04implementing these strategies.
51:05And these are the eight steps in an
51:08implementation pipeline if you will.
51:10First,
51:10there's a pre implementation phase of
51:13engagement understanding, feasibility,
51:15readiness planning with a site.
51:18So those are considered.
51:19The first three steps are pre
51:21implementation work and then so besides
51:23done all that and they're ready to implement,
51:26you can move to the implementation
51:27phase which is we hire staff and train
51:29them or we don't need to hire staff
51:31but we move staff into certain roles,
51:33we do some fidelity monitoring we.
51:36Maybe the research team provides some
51:37consultation to get started up and
51:39maybe at that point then someone at
51:40the site takes over that consultation,
51:42working with the different groups of the
51:44clinic on that implementation effort.
51:46There's going to be some ongoing
51:47monitoring of what's going on.
51:49That's the implementation phase.
51:50And then obviously we need to
51:52understand has true competency been
51:54achieved which can lead to sustainment.
51:56Each of these eight steps requires the
51:59research team to do a lot of tracking
52:02of the different efforts involved in
52:04every implementation to understand
52:06what does engagement mean for me?
52:08What does feasibility mean for me?
52:10Who's involved with that?
52:11But through this meticulous tracking,
52:13and especially if you're working
52:15with a champion like we were with
52:17the head of the Pain Medicine Group,
52:19we could start to identify what does
52:20that mean in terms of minutes and what
52:23does that mean in terms of costs for
52:25the people who are working on this.
52:27And so through a lot of work we did a cost,
52:30we got an extension for Macquarie to do
52:31a cost of implementation enhancement.
52:33We tracked costs from March 1st
52:35to November 30th of 2021.
52:37We found that at this point
52:39there were 24,000 patients.
52:41This involved 74 clinic personnel.
52:43We could figure out when people
52:45moved from a pre implementation to
52:47an implementation to a sustainment
52:49phase in each of these clinics.
52:51And then we also could figure out
52:53who at each of the clinics was
52:55working on this and so in general.
52:57We collected costs that are going
52:59to help a future clinic decide
53:01do they want to invest in this,
53:03what is this going to mean for
53:05us at what's the bottom line.
53:07And so looking at attending physicians,
53:09mid level providers, nurse managers,
53:11nurses etcetera,
53:12including front desk staff
53:14because they're very important.
53:15We found that one hour of heal
53:19implementation of tracking,
53:21you know the input,
53:22you know for everything from encouraging
53:25people to complete the surveys sending out.
53:28Survey links reminding them
53:30downloading reports, looking at them,
53:33having conversations, etcetera.
53:34But that was about $572 per hour.
53:39Per clinic and a 10 minute increment for
53:42all clinic staff is about $95 because
53:44not everything happens in an hour time,
53:46sometimes just little bits and pieces,
53:48which means that a total implementation
53:51cost for heal is about $28,000.
53:53And so this is now something that we
53:56can disseminate to clinics to think
53:59about is this worth your investment
54:02and if people think about what having?
54:05Patients use opioids has led to and
54:08what that crisis is like and what
54:10they might be saving elsewhere.
54:12This is the kind of decision making
54:14that can happen in terms of deciding
54:16whether or not to adopt or not
54:17adopt an innovation or in this
54:19case an evidence based practice.
54:21So in summary,
54:22we've talked about a lot of things that
54:24can address the implementation gap and
54:26reduce waste and research by increasing
54:28uptake of evidence into the community.
54:30We talked about using hybrid study designs,
54:33be guided by theory,
54:34get to know your stakeholders and
54:36tailor your dissemination efforts.
54:38And throughout it all,
54:40we hope that HealthEquity can be achieved
54:42through using pragmatic real-world research.
54:45Few, if any exclusions, we take all comers.
54:49Research is meaningful to the end users.
54:51Adaptation needs are considered
54:53at the beginning so that we're
54:55not implementing something that
54:56isn't going to work in real world.
54:59And we also can start to
55:00incorporate new ways of thinking,
55:01and I didn't really talk about this yet,
55:02but this is what is going on right now
55:04in the HealthEquity space is how can
55:06we take the existing theories that
55:07we have and just and just incorporate
55:09new ways of thinking into them.
55:11So if we're thinking about did we reach
55:13people we can think about or who's adopting,
55:16we can answer ask questions that have
55:19a HealthEquity perspective to them.
55:21So did all settings equitably
55:22adopt the intervention?
55:24Are the health impacts that we
55:25see equitable across all groups?
55:27Are all populations?
55:28Equitably reached by this intervention.
55:31So just taking our theory but thinking
55:33about them in new ways in which we
55:35can achieve HealthEquity and that's
55:37definitely something a goal for me.
55:39I'm not yet there trying to do that
55:41with like current projects and hope it
55:44becomes something that we do all the time.
55:47And with that, I'll stop.
55:48Thank you very much.
55:50Thank you so much.
55:52Really enjoyed your presentation.