A Method for Tracking Implementation Strategies: An Exemplar Implementing Measurement-Based Care in Community Behavioral Health Clinics

Implementation experts suggest tailoring strategies to the intended context may enhance outcomes. However, it remains unclear which strategies are best suited to address specific barriers to implementation, in part because few measurement methods exist that adhere to recommendations for reporting. In the context of a dynamic cluster randomized trial comparing a standardized to tailored approach to implementing measurement-based care (MBC), this study aimed to (a) describe a method for tracking implementation strategies, (b) demonstrate the method by tracking strategies generated by teams tasked with implementing MBC at their clinics in the tailored condition, and (c) conduct preliminary examinations of the relation between strategy use and implementation outcomes (i.e., self-reported fidelity to MBC). The method consisted of a coding form based on Proctor, Powell, and McMillen (2013) implementation strategy reporting guidelines and Powell et al.’s (2012) taxonomy to facilitate specification of the strategies. A trained research specialist coded digitally recorded implementation team meetings. The method allowed for the following characterization of strategy use. Each site generated 39 unique strategies across an average of six meetings in five months. There was little variability in the use of types of implementation strategies across sites with the following order of prevalence: quality management (50.00%), restructuring (16.53%), communication (15.68%), education (8.90%), planning (7.20%), and financing (1.69%). We identified a new category of strategies not captured by the existing taxonomy, labeled “communication.” There was no evidence that number of implementation strategies enacted was statistically significantly associated with changes in self-reported fidelity to MBC—however, financing strategies were associated with increased fidelity. This method has the capacity to yield rich data that will inform investigations into tailored implementation approaches.     

Mental health measurement among women veterans receiving co-located,collaborative care services

Routine use of measurement to identify patient concerns and track treatment progress is critical to high quality patient care. This is particularly relevant to the Primary Care Behavioral Health model, where rapid symptom assessment and effective referral management are critical to sustaining population-based care. However, research suggests that women who receive treatment in co-located collaborative care settings utilizing the PCBH model are less likely to be assessed with standard measures than men in these settings. The current study utilized regional retrospective data obtained from the Veterans Health Administration’s electronic medical record system to: (1) explore rates of mental health measurement for women receiving co-located collaborative care services (N = 1008); and (2) to identify predictors of mental health measurement in women veterans in these settings. Overall, only 8% of women had documentation of standard mental health measures. Measurement was predicted by diagnosis, facility size, length of care episode and care setting. Specifically, women diagnosed with depression were less likely than those with anxiety disorders to have standard mental health measurement documented. Several suggestions are offered to increase the quality of mental health care for women through regular use of measurement in integrated care settings.     

Patient experiences with treatment in private practice compared with public mental health services

The study compared patient experiences with psychiatric treatment provided by private practitioners and public outpatient clinics. Questionnaires were completed by 642 outpatients in private practice and 6,677 outpatients in public clinics. The questionnaire included a measure of patient experiences comprising six items: treatment outcome, enough time for contact and dialogue with clinician, clinicians' understanding of patient's situation, suitability of therapy and treatment, clinician follow-up of planned actions, and influence on treatment. Patients in private practice had generally better experiences than patients in public outpatient treatment. The difference between private and public patients was largest for patients with poor self-evaluated mental health or those who had just one consultation in the previous three months. Private practitioners appear to have an important role in mental health services delivery, and patients have relatively good experiences with services. Further studies that assess the patient - clinician interaction in different mental health services may give further insights into potential service improvements.     

Can CORE assessment data identify those clients less likely to benefit from brief counselling in primary care?

Studies show that counsellors in primary care see many clients with difficulties of a severity similar to those found in secondary care services. Evidence from both RCTs and studies of routinely collected data indicates that many of these ‘clinical’ clients benefit from brief counselling intervention. However, little is known about why some benefit while others fail to do so despite completing their counselling contract. This paper considers client characteristics recorded at assessment and aims, using logistic regression analysis, to identify those characteristics predictive of a poor outcome. Results indicate that a number of characteristics are associated with poor outcome; the most important predictors are economic inactivity and aspects of the patient's condition, particularly continuous/recurrent depression, with some differences between genders. However, the models produced were not acceptable in their predictive power. This may be partly due to data quality issues or important characteristics not being available in the data. The paper concludes that being unemployed or on state benefits may be a proxy measure of severity that has an important impact on outcome for all patients, and particularly for males. Some reasons are suggested and areas of future research are identified.     

心理治疗的循证实践与循效施治

循证实践与循效施治是当前国外心理治疗的两种相互补充的模式,二者在理论假设、获取证据的来源、操作流程等方面存在着明显不同。从影响来看,循证实践的影响力超过了循效施治,它被美国提升推广为一种心理学运动,它的倡导昭示着目前临床心理治疗的一个关键性改革。然而,在心理治疗中要真正实施循证实践存在着很多困难和挑战,循效施治是解决这些困难和问题的方法之一。我国心理治疗的专业化水平不高,藉美国心理治疗循证实践提供的理念和方法去思考中国心理治疗的问题,我们亦可获得有益于中国心理治疗发展的思路。     

The Impact of Experience with the Aged upon the Time Perspective of Young Adults

With the use of questionnaire returns from 214 male and 286 female upper-year high school students, a model of adolescent drug use is proposed. The model hypothesizes that the parents' child-rearing practices produce within the child a personality which shapes his attitudes toward the use of drugs, which in turn affect the child's use of marijuana, alcohol, and tobacco. The personality dimension in the model is Authoritarianism. The model proved more successful in predicting illicit than licit drug use. Further, love on the part of the mother and positive control on the part of the father were the most salient dimensions within the model with regard to child-rearing practices.     

Who drops-out? Do measures of risk to self and to others predict unplanned endings in primary care counselling?

Aims: Unplanned endings, where clients unilaterally end therapy, are of concern for psychological therapy services generally as they raise questions about the appropriateness of the treatment and it's delivery for some clients. Limited available data indicates that those who drop-out often have more severe symptoms at entry, and have poorer clinical outcomes. This raises further questions about risk to self and others for those clients who leave therapy prematurely and how these clients might be identified and kept engaged. Method: This paper uses a large dataset of CORE data collected routinely in a primary care counselling service between 2000 and 2003. Logistic regression was utilised to consider different measures of risk and other client characteristics recorded at assessment to predict drop-out from the service. Results: These indicate that younger age, greater psychological distress at assessment, an addiction problem and greater risk to others, are associated with an unplanned ending. However, no reliable logistic regression model could be produced. This may be partly due to data quality issues or important characteristics not being available in the data. Implications for practice: The paper concludes that counsellors should actively seek to minimise unplanned endings, as amongst them may be represented the more distressed and risky clients referred to primary care counselling.     

The Difficulty of Making Psychology Research and Clinical Practice Relevant to Medicine: Experiences and Observations

Psychology and medicine research and practice have demonstrated substantial and unique bodies of knowledge designed to both improve patient care and respond to contemporary health care needs for use of evidence and cost consciousness. At their full potential they represent a significant paradigm shift in healthcare. Despite impressive successes, it is clear that we are just on the cusp of such a change. These findings have had limited impact and penetration into medical practice, particularly outside of academic medicine and large, organized systems of health care, and there are multiple examples of such limitations in various arenas of health care. There also appear to be common themes to such examples which provide us opportunities to consider how psychologists might move things ahead. They also suggest how our unique position in academic medicine can both limit our impact and provide ways of creating continued shifts in the healthcare paradigm. This paper is based in part on the author’s presentation at the Association of Psychologists in Academic Health Centers 3rd National Conference in Minneapolis, Minnesota, May 2007.     

The Australian Psychology Workforce 4: An analysis of psychologists in private practice providing Medicare‐funded services

There have always been independent private psychology practitioners in Australia, yet in the past payment of their services was largely by a user‐pays model. The introduction of Medicare Benefits for patients, under the Enhanced Primary Care program in 1999, and Better Access in Mental Health Care in 2006, along with Government‐funded mental health initiatives such as Better Outcomes in Mental Health Care introduced in 2001, has provided an alternative funding model for independent private psychological services. Introduction of these and other Government‐funded programs has raised questions about the responsiveness of the psychology workforce to meet the changing demands for psychological services created by these reforms. This study aimed to profile the characteristics of 3,587 independent private psychologists who provide services to clients under these schemes by analysing their responses to the Australian Psychology Workforce Survey. Of the 44% of psychologists completing the survey who indicated that they had a Medicare Provider Number, only 61% were in private practice as their main job. The remainder conducted services for Medicare‐funded clients as part of a private practice in a second job. The demographic characteristics, work roles, client groups and income of psychologists with Medicare provider numbers are reported.     

The silent voices of research: What can we do to help them speak?1

The authors challenge the legitimacy of making commissioning decisions based solely upon the current outcome research for the psychological treatments. They argue that this outcome data does not represent the treatment needs of the patient who fails to complete a therapy. They call for a shift in the focus of research in order to right this oversight.