VISN 4 Mental Illness Research, Education and Clinical Center, VA Pittsburgh, Pittsburgh, PA, USA.
Center for Health Equity Research and Promotion, VA Pittsburgh, Pittsburgh, PA, USA.
Implement Sci. 2021 Jun 7;16(1):60. doi: 10.1186/s13012-021-01130-2.
Over 1100 veterans work in the Veterans Health Administration (VHA) as peer specialists (PSs)-those with formal training who support other veterans with similar diagnoses. A White House Executive Action mandated the pilot reassignment of VHA PSs from their usual placement in mental health to 25 primary care Patient Aligned Care Teams (PACTs) in order to broaden the provision of wellness services that can address many chronic illnesses. An evaluation of this initiative was undertaken to assess the impact of outside assistance on the deployment of PSs in PACTs, as implementation support is often needed to prevent challenges commonly experienced when first deploying PSs in new settings.
This study was a cluster-randomized hybrid II effectiveness-implementation trial to test the impact of minimal implementation support vs. facilitated implementation on the deployment of VHA PSs in PACT over 2 years. Twenty-five Veterans Affairs Medical Centers (VAMCs) were recruited to reassign mental health PSs to provide wellness-oriented care in PACT. Sites in three successive cohorts (n = 7, 10, 8) over 6-month blocks were matched and randomized to each study condition. In facilitated implementation, an outside expert worked with site stakeholders through a site visit and regular calls, and provided performance data to guide the planning and address challenges. Minimal implementation sites received a webinar and access to the VHA Office of Mental Health Services work group. The two conditions were compared on PS workload data and veteran measures of activation, satisfaction, and functioning. Qualitative interviews collected information on perceived usefulness of the PS services.
In the first year, sites that received facilitation had higher numbers of unique veterans served and a higher number of PS visits, although the groups did not differ after the second year. Also, sites receiving external facilitation started delivering PS services more quickly than minimal support sites. All sites in the external facilitation condition continued in the pilot into the second year, whereas two of the sites in the minimal assistance condition dropped out after the first year. There were no differences between groups on veterans' outcomes-activation, satisfaction, and functioning. Most veterans were very positive about the help they received as evidenced in the qualitative interviews.
These findings demonstrate that external facilitation can be effective in supporting the implementation of PSs in primary care settings. The lack of significant differences across conditions after the second year highlights the positive outcomes associated with active facilitation, while also raising the important question of whether longer-term success may require some level of ongoing facilitation and implementation support.
This project is registered at ClinicalTrials.gov with number NCT02732600 (URL: https://clinicaltrials.gov/ct2/show/NCT02732600 ).
超过 1100 名退伍军人在退伍军人健康管理局（VHA）担任同伴专家（PS）——他们接受过正规培训，为其他患有类似疾病的退伍军人提供支持。白宫的一项行政命令授权试点将 VHA 的 PS 从他们通常在心理健康部门的岗位重新分配到 25 个基层医疗患者协作护理团队（PACT）中，以扩大提供可以解决许多慢性疾病的健康服务。这项计划的评估旨在评估外部援助对 PACT 中 PS 部署的影响，因为在新环境中首次部署 PS 时，通常需要实施支持来防止常见的挑战。
本研究是一项集群随机混合 II 有效性-实施试验，旨在测试最小实施支持与促进实施对 VHA PS 在 PACT 中部署的影响，为期 2 年。招募了 25 家退伍军人事务医疗中心（VAMC）将心理健康 PS 重新分配到 PACT 中提供以健康为导向的护理。在 6 个月的时间里，三个连续队列（n = 7、10、8）的站点进行匹配和随机分配到每个研究条件。在促进实施中，一名外部专家通过现场访问和定期电话与现场利益相关者合作，并提供绩效数据来指导规划和解决挑战。最小实施站点收到了网络研讨会和访问 VHA 心理健康服务办公室工作组的机会。在 PS 工作量数据和退伍军人的激活、满意度和功能方面，比较了两种情况。定性访谈收集了有关 PS 服务有用性的信息。
在第一年，接受促进的站点服务的独特退伍军人人数和 PS 访问次数更高，尽管第二年两组之间没有差异。此外，接受外部促进的站点比接受最小支持的站点更快地开始提供 PS 服务。外部促进条件下的所有站点都在第二年继续进行试点，而最小辅助条件下的两个站点在第一年之后退出。退伍军人的结果——激活、满意度和功能方面，两组之间没有差异。大多数退伍军人在定性访谈中非常积极地评价了他们所得到的帮助。
这些发现表明，外部促进可以有效地支持 PS 在基层医疗环境中的实施。第二年之后，条件之间没有显著差异，突出了积极促进带来的积极结果，同时也提出了一个重要问题，即长期成功是否需要某种水平的持续促进和实施支持。
该项目在 ClinicalTrials.gov 注册，编号为 NCT02732600（网址：https://clinicaltrials.gov/ct2/show/NCT02732600）。
