Collaborative chronic care model implementation within outpatient behavioral health care teams: qualitative results from a multisite trial using implementation facilitation

Abstract

Background: This paper reports on a qualitative evaluation of a hybrid type II stepped-wedge, cluster randomized trial using implementation facilitation to implement team-based care in the form of the collaborative chronic care model (CCM) in interdisciplinary outpatient mental health teams. The objective of this analysis is to compare the alignment of sites' clinical processes with the CCM elements at baseline (time 1) and after 12 months of implementation facilitation (time 2) from the perspective of providers.

Methods: We conducted semi-structured interviews to assess the extent to which six CCM elements were in place: work role redesign, patient self-management support, provider decision support, clinical information systems, linkages to community resources, and organizational/leadership support. Interviews were transcribed and a priori CCM elements were coded using a directed content analysis approach at times 1 and 2. We sought consensus on, and compared, the extent to which each CCM element was in place at times 1 and 2.

Results: We conducted 27 and 31 telephone interviews at times 1 and 2, respectively, with outpatient mental health providers at nine participating sites. At time 1 and time 2, three CCM elements were most frequently present across the sites: work role redesign, patient self-management support, and provider decision support. The CCM elements with increased implementation from time 1 to time 2 were work role redesign, patient self-management support, and clinical information systems. For two CCM elements, linkages to community resources and organizational/leadership support, some sites had increased implementation at time 2 compared to time 1, while others had reductions. For the provider decision support element, we saw little change in the extent of its implementation.

Conclusions: Sites increased the extent of implementation on several CCM elements. The most progress was made in the CCM elements where sites had CCM-aligned processes in place at time 1. Teams made progress on elements they could more easily control, such as work role redesign. Our results suggest that maximizing the benefits of CCM-based outpatient mental health care may require targeting resources and training toward specific CCM elements-especially in the use of clinical information systems and linking with community resources.

Trial registration: Clinical Trials NCT02543840 .

Keywords: Chronic care; Mental health; Qualitative research.

Conflict of interest statement

Dr Bauer reported receiving royalties from Springer Publishing and New Harbinger Publishing for books related to the CCM during the conduct of the study. Dr Miller reported grants from US Department of Veterans Affairs, Health Services Research and Development Service during the conduct of the study. Dr Elwy reported grants from Department of Veterans Affairs, Health Services Research and Development Service, Quality Enhancement Research Initiative during the conduct of the study. Dr. Sullivan reported grants from Department of Veterans Affairs, Health Services Research and Development Service, Quality Enhancement Research Initiative during the conduct of the study. No other disclosures were reported.

Figures

Fig. 1

Work flow for data analysis: time 1 and time 2