Literature Collection

AIM: Our objective was to integrate lessons learned from perinatal collaborative care programs across the United States, recognizing the diversity of practice settings and patient populations, to provide guidance on successful implementation. BACKGROUND: Collaborative care is a health services delivery system that integrates behavioral health care into primary care. While efficacious, effectiveness requires rigorous attention to implementation to ensure adherence to the core evidence base. METHODS: Implementation strategies are divided into three pragmatic stages: preparation, program launch, and program growth and sustainment; however, these steps are non-linear and dynamic. FINDINGS: The discussion that follows is not meant to be prescriptive; rather, all implementation tasks should be thoughtfully tailored to the unique needs and setting of the obstetric community and patient population. In particular, we are aware that implementation on the level described here assumes commitment of both effort and money on the part of clinicians, administrators, and the health system, and that such financial resources are not always available. We conclude with synthesis of a survey of existing collaborative care programs to identify implementation practices of existing programs.

OBJECTIVE: A process evaluation of the Children and Young People's Health Partnership (CYPHP) model of integrated care for the interpretation of trial findings and building evidence on the implementation of integrated care for children. DESIGN: A mixed-methods process evaluation. SETTING: CYPHP was implemented at scale across two inner-city London boroughs in South London, England, as a pragmatic cluster-randomised controlled trial involving nearly 98 000 children, with a nested process evaluation. PARTICIPANTS: Linked data were available from 73 000 participants. Qualitative data collection was through 102 interviews (group and 1:1) and observations. INTERVENTIONS: Local child health clinics delivered by paediatricians and general practitioners and a nurse-led early intervention service for children with tracer conditions (asthma, eczema and constipation), decision support, a primary care hotline, self-management support and health promotion. MAIN OUTCOME MEASURES: Five domains of the RE-AIM implementation framework: Reach, Effectiveness, Adoption, Implementation and Maintenance. RESULTS: Implementation varied depending on resource availability, competing priorities and natural changes over time. Successful implementation drivers included cohesive interprofessional and partnership collaboration. CONCLUSIONS: Integrated care for children can be implemented at scale, but variability, particularly low reach, may limit measurable impact at the population level. Significant health system strengthening, implementation plasticity and contextual tailoring are crucial for ensuring the efficacy and sustainability of impactful integrated care for children. TRIAL REGISTRATION NUMBER: NCT03461848.

INTRODUCTION: The Centers for Disease Control and Prevention Clinical Practice Guideline for Prescribing Opioids for Pain - United States, 2022 emphasizes the need to establish referral options for patients with opioid use disorder. The purpose of this quality improvement (QI) project was to determine the effectiveness of the integration of Webster and Webster's Opioid Risk Tool (ORT) into current opioid prescribing practices to improve identification of patients at risk for opioid use disorder for appropriate referrals and pain treatment. METHODS: A QI design was used to compare referral rates to pain management, behavioral health, and substance use disorder treatment facilities before and after the implementation of the ORT among patients with chronic noncancer pain in an integrated primary care clinic in a rural region of Arizona. This article is a report of the project and compares pre- and postimplementation data to assess outcomes of a practice change. RESULTS: There were 375 participants in the project, including 212 in the preimplementation group and 163 in the postimplementation group. There were 46 referrals (22%) in the preimplementation group compared with 55 referrals (34%) in the postimplementation group. CONCLUSION: In this project, referral rates to pain management, behavioral health, and substance use disorder treatment facilities increased after integration of the ORT. Providers can use the ORT to identify at-risk patients and provide a network of treatment options.

OBJECTIVE: Screening questionnaires are one option for identification of at-risk substance use and substance use disorder (SUD) during pregnancy. We report the experience of a single institution following universal implementation of a brief screening tool for self-reported substance use at the first prenatal encounter. STUDY DESIGN: This is a prospective implementation study evaluating screening for substance use in pregnancy in a large safety net healthcare system. Universal screening with the National Institute of Drug Abuse (NIDA) Quick Screen V1.0 was integrated into the electronic medical record (EMR) and administered at the first point of contact with the healthcare system. SUD was identified initially with diagnosis within the EMR by a healthcare provider and was confirmed with toxicology (maternal or neonatal) results corroborating a pattern of substance use and maternal and neonatal ICD-10 codes for SUD. Patients identified with SUD were then classified as moderate or severe SUD based on criteria established by the Diagnostic and Statistical Manual of Mental Disorders, 5th edition. We measured rates of NIDA implementation across different healthcare settings, evaluated NIDA concordance with ascertainment of SUD, and compared adverse pregnancy outcomes associated with moderate and severe SUD. RESULTS: From July 28, 2021, through June 25, 2022, 14,634 unique pregnant individuals accessed care at ambulatory and acute care sites. Universal implementation of the NIDA Quick Screen identified at-risk substance use in 2146 (14.7%) of those who accessed our system, or 17.1% of 12,550 screened across the system, with greater screen completion in ambulatory over acute care settings. SUD was identified in 256 (1.7%) of 14,634 individuals and moderate or severe SUD was identified in 184 (1.3%). Among those with moderate or severe SUD, 90 (48.9%) were NIDA positive, 22 (12.0%) NIDA negative, and 72 (39.1%) unscreened. Of 94 individuals with NIDA discordance or who were unscreened 76 (81%) accessed initial care through an acute care setting. Of 96 individuals with opioid use disorder, 68 (70.8%) were treated with medication-assisted therapy, and 56 (58.3%) were screened with the NIDA Quick Screen. Among delivered individuals with available outcomes, those with moderate or severe SUD were less likely to seek prenatal care (71 (76%) vs 9852 (98%), <0.001)) and more likely to deliver before 37 weeks, (18 (20%) vs 909 (9%), RR (95% CI) 2.13 (1.40, 3.24)) compared to individuals without SUD. Neonates exposed to moderate or severe SUD were more likely to have birth weight <10th centile for gestational age (20 (22%) vs 1147 (12%), RR (95% CI) 1.92 (1.29, 2.85)) and require admission to the neonatal intensive care unit (NICU) (19 (21%) vs 964 (10%), RR (95%) 1.95 (1.30, 2.93)). CONCLUSION: Universal screening was implemented across a large public healthcare system at a high rate, with higher rates of implementation in ambulatory settings. NIDA successfully identified at-risk substance use in 17% of the SUD cohort but failed to identify more than 50% of patients with moderate or severe SUD. Patients with moderate and severe SUD accessed care primarily through the emergency department and experienced higher rates of adverse obstetric and neonatal outcomes. Future efforts to identify, engage, and retain this highest-risk group are needed.

BACKGROUND: Mental disorders are a leading cause of global disability, driven primarily by depression and anxiety. Most of the disease burden is in Low and Middle Income Countries (LMICs), where 75% of adults with mental disorders have no service access. Our research team has worked in western Kenya for nearly ten years. Primary care populations in Kenya have high prevalence of Major Depressive Disorder (MDD) and Posttraumatic Stress Disorder (PTSD). To address these treatment needs with a sustainable, scalable mental health care strategy, we are partnering with local and national mental health stakeholders in Kenya and Uganda to identify 1) evidence-based strategies for first-line and second-line treatment delivered by non-specialists integrated with primary care, 2) investigate presumed mediators of treatment outcome and 3) determine patient-level moderators of treatment effect to inform personalized, resource-efficient, non-specialist treatments and sequencing, with costing analyses. Our implementation approach is guided by the Exploration, Preparation, Implementation, Sustainment (EPIS) framework. METHODS/DESIGN: We will use a Sequential, Multiple Assignment Randomized Trial (SMART) to randomize 2710 patients from the outpatient clinics at Kisumu County Hospital (KCH) who have MDD, PTSD or both to either 12 weekly sessions of non-specialist-delivered Interpersonal Psychotherapy (IPT) or to 6 months of fluoxetine prescribed by a nurse or clinical officer. Participants who are not in remission at the conclusion of treatment will be re-randomized to receive the other treatment (IPT receives fluoxetine and vice versa) or to combination treatment (IPT and fluoxetine). The SMART-DAPPER Implementation Resource Team, (IRT) will drive the application of the EPIS model and adaptations during the course of the study to optimize the relevance of the data for generalizability and scale -up. DISCUSSION: The results of this research will be significant in three ways: 1) they will determine the effectiveness of non-specialist delivered first- and second-line treatment for MDD and/or PTSD, 2) they will investigate key mechanisms of action for each treatment and 3) they will produce tailored adaptive treatment strategies essential for optimal sequencing of treatment for MDD and/or PTSD in low resource settings with associated cost information - a critical gap for addressing a leading global cause of disability. TRIAL REGISTRATION: ClinicalTrials.gov NCT03466346, registered March 15, 2018.