VA Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, 2200 Fort Roots Drive, North Little Rock, AR, USA.
Department of Psychiatry, University of Arkansas for Medical Sciences, 4301 West Markham, Little Rock, AR, USA.
Implement Sci. 2019 Mar 21;14(1):33. doi: 10.1186/s13012-019-0875-5.
Integrating mental health providers into primary care clinics improves access to and outcomes of mental health care. In the Veterans Health Administration (VA) Primary Care Mental Health Integration (PCMHI) program, mental health providers are co-located in primary care clinics, but the implementation of this model is challenging outside large VA medical centers, especially for rural clinics without full mental health staffing. Long wait times for mental health care, little collaboration between mental health and primary care providers, and sub-optimal outcomes for rural veterans could result. Telehealth could be used to provide PCMHI to rural clinics; however, the clinical effectiveness of the tele-PCMHI model has not been tested. Based on evidence that implementation facilitation is an effective implementation strategy to increase uptake of PCMHI when delivered on-site at larger VA clinics, it is hypothesized that this strategy may also be effective with regard to ensuring adequate uptake of the tele-PCMHI model at rural VA clinics.
This study is a hybrid type 2 pragmatic effectiveness-implementation trial of tele-PCMHI in six sites over 24 months. Tele-PCMHI, which will be delivered by clinical staff available in routine care settings, will be compared to usual care. Fidelity to the care model will be monitored but not controlled. We will use the Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) framework to evaluate the patient-level clinical effectiveness of tele-PCMHI in rural VA clinics and also to evaluate the fidelity to and outcomes of the implementation strategy, implementation facilitation. The proposed study will employ a stepped-wedge design in which study sites sequentially begin implementation in three steps at 6-month intervals. Each step will include (1) a 6-month period of implementation planning, followed by (2) a 6-month period of active implementation, and (3) a final period of stepped-down implementation facilitation.
This study will evaluate the effectiveness of PCMHI in a novel setting and via a novel method (clinical video telehealth). We will test the feasibility of using implementation facilitation as an implementation strategy to deploy tele-PCMHI in rural VA clinics.
ClinicalTrials.gov registration number NCT02713217 . Registered on 18 March 2016.
将心理健康提供者整合到初级保健诊所中，可以改善心理健康护理的可及性和效果。在退伍军人健康管理局（VA）的初级保健心理健康整合（PCMHI）计划中，心理健康提供者与初级保健诊所共同设置，但在大型 VA 医疗中心之外，这种模式的实施具有挑战性，特别是对于没有全职心理健康人员的农村诊所。这可能导致心理健康护理的等待时间延长、心理健康和初级保健提供者之间的合作很少，以及农村退伍军人的结果不理想。远程医疗可用于向农村诊所提供 PCMHI；然而，远程 PCMHI 模式的临床效果尚未得到检验。基于在较大的 VA 诊所提供现场实施促进措施可有效增加 PCMHI 的采用这一证据，假设该策略对于确保在农村 VA 诊所充分采用远程 PCMHI 模式也可能是有效的。
本研究是一项为期 24 个月的 6 个地点的混合 2 型实用有效性-实施试验，对远程 PCMHI 进行测试。远程 PCMHI 将由常规护理环境中现有的临床工作人员提供，与常规护理进行比较。将监测对护理模式的保真度，但不进行控制。我们将使用 Reach Effectiveness Adoption Implementation Maintenance（RE-AIM）框架来评估农村 VA 诊所远程 PCMHI 的患者级临床效果，还将评估实施策略（实施促进）的保真度和结果。拟议的研究将采用逐步楔形设计，研究地点将以 6 个月的间隔分三个步骤顺序开始实施。每个步骤将包括（1）6 个月的实施计划期，然后是（2）6 个月的积极实施期，以及（3）最后是逐步减少实施促进期。
本研究将在新环境中通过新方法（临床视频远程医疗）评估 PCMHI 的有效性。我们将测试使用实施促进作为在农村 VA 诊所部署远程 PCMHI 的实施策略的可行性。
ClinicalTrials.gov 注册号 NCT02713217。于 2016 年 3 月 18 日注册。
