Literature Collection

Increases in stimulant drug use (such as methamphetamine) and related deaths creates an imperative for community settings to adopt evidence-based practices to help people who use stimulants. Contingency management (CM) is a behavioral intervention with decades of research demonstrating efficacy for the treatment of stimulant use disorder, but real-world adoption has been slow, due to well-known implementation barriers, including difficulty funding reinforcers, and stigma. This paper describes the training and technical assistance (TTA) efforts and lessons learned for two state-wide stimulant-focused CM implementation projects in the Northwestern United States (Montana and Washington). A total of 154 providers from 35 community-based service sites received didactic training in CM beginning in 2021. Seventeen of these sites, ten of eleven in Montana (90.9%) and seven of 24 in Washington (29.2%), went on to implement contingency management programs adherent to their state's established CM protocol and received ongoing TTA in the form of implementation coaching calls. These findings illustrate that site-specific barriers such as logistical fit precluded implementation in more than 50% of the trained sites; however, strategies for site-specific tailoring within the required protocol aided implementation, resulting in successful CM program launch in a diverse cross-section of service sites across the states. The lessons learned add to the body of literature describing CM implementation barriers and solutions.

There is inadequate availability and access to behavioral health services to meet demand, and this issue amplified during the pandemic, creating a mental health crisis. Group therapy is an effective way to meet this need. The rapid implementation of telehealth group psychotherapy as part of a Primary Care Behavioral Health Integration program in a U.S. safety-net health care setting is described. Implementation lessons are summarized as barriers or facilitators, using thematic analysis of qualitative data from meeting notes. Major facilitators identified include having key staff serve as technology champions, dedicated administrative leadership to operationalize workflows, and communication and collaboration across teams and layers of infrastructure. Major barriers include uncertainty about operational workflows and technological challenges. While group visit volume initially waned, it began to rebound and quantitative analysis of demographic data shows that important underserved populations were reached. Frequent communication, collaboration, and adaptation among teams are critical elements for improving the likelihood of successful telehealth group therapy. It is feasible to expeditiously implement telehealth group psychotherapy in safety-net health care systems with limited resources.

Uncontrolled hypertension is common and frequently related to inadequate adherence to prescribed medications, resulting in suboptimal blood pressure control and increased healthcare utilization. Although healthcare providers have the opportunity to improve medication adherence, they may lack the tools to address adherence at the point of care. This study aims to assess the usability of a digital tool designed to improve medication adherence and blood pressure control among patients with hypertension who are not adherent to therapy. By evaluating usability, the study seeks to refine the tool's design, underscore the role of technology in managing hypertension, and provide insights to inform clinical decisions.We performed qualitative usability testing of an electronic health record (EHR)-integrated intervention with medical assistants (MAs) and primary care providers (PCPs) from a large integrated health system. Usability was assessed with these end-users using the "think aloud" and "near live" approaches. This evaluation was guided by two frameworks: the End-User Computing Satisfaction Index (EUCSI) and the Technology Acceptance Model (TAM). Interviews were analyzed using a thematic analysis approach.Thematic saturation was reached after usability testing was performed with 10 participants, comprising 5 PCPs and 5 MAs. The study identified several strengths within the content, format, ease of use, timeliness, accuracy, and usefulness of the tool, including the user-friendly content presentation, the usefulness of adherence information, and timely alerts that fit into the workflow. Challenges centered around alert visibility and specificity of information.Leveraging the two conceptual frameworks (TAM and EUCSI) to test the usability of the medication adherence tool was helpful. The tool's several strengths and opportunities for improvement were found. The resulting suggestions will be used to support the enhancement of the design for optimal implementation in a clinical trial.

This column describes Project ECHO (Extension for Community Healthcare Outcomes), a teleconsultation, tele-education, telementoring model for enhancing primary care treatment of underserved patients with complex medical conditions. Numerous centers have adapted ECHO to support primary care treatment of behavioral health disorders. Preliminary evidence for behavioral health ECHO programs suggests positive impacts on providers, treatment planning, and emergency department costs. ECHO has the potential to improve access to effective and cost-effective behavioral health care by virtually integrating behavioral health knowledge and support in sites where specialty providers are not available. Patient-level outcomes research is critical.

Individuals with serious mental illness (SMI) have poorer oral health than the general population for various reasons, including poor oral hygiene, adverse effects of psychotropic medicines, stigma, fear, cognitive impairment, lack of insur¬ance coverage, and a shortage of professionals qualified to manage the oral health needs of this population. Oral health deteriorates further when care is postponed, resulting in greater treatment needs when the patient visits the dental office. This retrospective study aimed to determine differ¬ences in service return rate and frequency of visits for each of 12 American Dental Association (ADA) oral procedures in patients with and without SMI who were treated in a predoctoral dental clinic at a northeastern US dental school. This retrospective study used the dental electronic health records of 12,138 adult patients aged 18 years and over (total of 19,096 unique patient encounters) who received at least 1 comprehensive oral evaluation between January 1, 2017, and August 31, 2021. Three data processing methods were implemented to retrieve periodontal diagnoses in accordance with American Academy of Periodontology guidelines and to extract medical histories and behavioral factors from free text. Chi-square tests determined that there were statistically significant differences between the 2 groups for 4 of 12 ADA procedures, while t tests deter¬mined that the SMI group had a higher frequency of visits for 6 procedure categories. Logistic regression analysis showed that patients with an SMI had a significantly higher odds ratio of receiving 2 procedure categories (remov¬able prosthodontics and adjunctive general services). A negative binomial regression analysis was then conducted to predict the frequency of visits; patients with an SMI had a higher incidence rate ratio of receiving 4 ADA procedure categories (preventive, removable prosthodontics, oral and maxillofacial surgery, and adjunctive general services). This study identified the existence of oral healthcare disparities in a population with SMI in relation to specific ADA dental procedure categories. Improving integrated care models, interprofessional collaboration, and education of predoc¬toral dental students and licensed professionals may help alleviate some of the existing disparities.

OBJECTIVE: The primary objective was to evaluate the impact of clinical decision support (CDS) tool integration into primary care visits on depression screening and follow-up rates and to assess whether CDS use improves adherence to Health Resources and Services Administration (HRSA) guidelines for depression screening and follow-up. DESIGN: This quality improvement evaluation study employed quantitative and qualitative components conducted in parallel to provide complementary insights. Modified Poisson regression with generalised estimating equation (GEE) was used to assess the association between CDS tool use and meeting HRSA criteria for depression screening and follow-up. In addition, semi-structured interviews explored perspectives on the implementation and utility of CDS tools. SETTING: This study was conducted at a federally qualified health centre in Minnesota. PARTICIPANT: The dataset included 12 338 patient encounters attributed to 8647 unique patients, covering 2 years of data. Five care providers were recruited through purposive sampling for the semi-structured interviews. RESULT: CDS use was significantly associated with an increased likelihood of meeting HRSA depression screening and follow-up criteria (relative risk 1.44, 95% CI 1.34 to 1.55; p<0.001). Qualitative findings suggested that while providers found CDS tools useful, workflow challenges and human-centred practices shaped their effectiveness. CONCLUSION: Integrating CDS tools into primary care workflows can enhance adherence to depression screening and follow-up guidelines. However, their effectiveness relies on supportive person-centred approaches, including collaboration and previsit preparation. These findings highlight the need for a balanced approach that integrates technological interventions with human interaction to enhance clinical practices. Future research should investigate how CDS tools are used in practice, address barriers to their adoption and develop strategies to promote their broader use while fostering continued learning among providers.