Implementing eScreening for suicide prevention in VA post-9/11 transition programs using a stepped-wedge, mixed-method, hybrid type-II implementation trial: a study protocol

James O E Pittman, Laurie Lindamer, Niloofar Afari, Colin Depp, Miguel Villodas, Alison Hamilton, Bo Kim, Maria K Mor, Erin Almklov, John Gault, Borsika Rabin, James O E Pittman, Laurie Lindamer, Niloofar Afari, Colin Depp, Miguel Villodas, Alison Hamilton, Bo Kim, Maria K Mor, Erin Almklov, John Gault, Borsika Rabin

Abstract

Background: Post-9/11 veterans who enroll in VA health care frequently present with suicidal ideation and/or recent suicidal behavior. Most of these veterans are not screened on their day of enrollment and their risk goes undetected. Screening for suicide risk, and associated mental health factors, can lead to early detection and referral to effective treatment, thereby decreasing suicide risk. eScreening is an innovative Gold Standard Practice with evidence to support its effectiveness and implementation potential in transition and care management (TCM) programs. We will evaluate the impact of eScreening to improve the rate and speed of suicide risk screening and referral to mental health care compared to current screening methods used by transition care managers. We will also evaluate the impact of an innovative, multicomponent implementation strategy (MCIS) on the reach, adoption, implementation, and sustained use of eScreening.

Methods: This is an eight-site 4-year, stepped-wedge, mixed-method, hybrid type-II implementation trial comparing eScreening to screening as usual while also evaluating the potential impact of the MCIS focusing on external facilitation and Lean/SixSigma rapid process improvement workshops in TCM. The aims will address: 1) whether using eScreening compared to oral and/or paper-based methods in TCM programs is associated with improved rates and speed of PTSD, depression, alcohol, and suicide screening & evaluation, and increased referral to mental health treatment; 2) whether and to what degree our MCIS is feasible, acceptable, and has the potential to impact adoption, implementation, and maintenance of eScreening; and 3) how contextual factors influence the implementation of eScreening between high- and low-eScreening adopting sites. We will use a mixed methods approach guided by the RE-AIM outcomes of the Practical Robust Implementation and Sustainability Model (PRISM). Data to address Aim 1 will be collected via medical record query while data for Aims 2 and 3 will be collected from TCM staff questionnaires and qualitative interviews.

Discussion: The results of this study will help identify best practices for screening in suicide prevention for Post-9/11 veterans enrolling in VA health care and will provide information on how best to implement technology-based screening into real-world clinical care programs.

Trial registration: ClinicalTrials.gov : NCT04506164; date registered: August 20, 2020; retrospectively registered.

Keywords: Facilitation; Implementation; PRISM; RE-AIM; Suicide; Veterans; eScreening.

Conflict of interest statement

Authors JP & NA are working with the VA Technology Transfer Program to facilitate the commercialization of the VA eScreening program to benefit veterans and the American public, which includes a patent pending. All other authors declare that they have no competing interests. The views expressed in this paper are those of the authors and do not reflect the official policy or position of the Department of Veteran Affairs or any of the institutions with which the authors are affiliated.

Figures

Fig. 1
Fig. 1
Practical Robust Implementation and Sustainability Model adapted for eScreening
Fig. 2
Fig. 2
Project overview (N=8 sites; 45 staff; 27,600 Veterans)

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