Care Team and Practice Level Implementation Strategies to Optimize Pediatric Collaborative Care: A Cluster-Randomized Trial

项目摘要/摘要 由多学科提供者团队提供循证实践(EBP)的慢性护理模式(CCM) 初级保健医生(PCP)和行为健康(BH)提供者(作为护理经理，CM)有 改善成人1-3岁和儿童/青少年的BH结局，但其广泛应用受到以下因素的阻碍 多个层面的实施障碍。例如，我们的临床试验记录了 针对儿童行为问题和ADHD(医生办公室协作)的简化交叉诊断CCM方案 CARE；DOCC；MH064372)，但DOCC需要有针对性的实施支持，以增强接受和 解决护理团队和实践/领导层面的实际障碍(例如，低协调)和实践/领导级别(例如，低 优先级)。此外，元分析表明，科学对如何克服这些问题提供的答案很少。 障碍，因为试验尚未测试扩大儿科CCM的实施战略。作为一种基于理论的 实施干预、由外部专家与提供商/团队(外部)或 实践经理/领导者(内部)增强了提供商的能力，以交付EBP和领导力或 组织层面对EBP实施的承诺。适用于护理团队的外部促进策略 (团队)可以使用经过验证的目标(即团队运作)，而内部促进战略适用于 领导者(领导者)可以利用实践层面的目标(即实施支持)来加强理解。他们可能会 相互作用，以提高EBP摄取率和患者预后。这个R01应用程序提出了一种随机的、混合的 类型3有效性-实施试验：1)测试团队和领导的主要和交互影响 促进提供商实施和临床结果，2)测试目标参与度和 团队和领导层的调解，以及3)检查选定的实践、提供者和家庭 执行的主持人。全州范围内的样本包括24家初级保健诊所，来自 美国儿科学会宾夕法尼亚州分会的家庭计划。在经过标准的培训后， Docc EBP，所有练习将随机分为以下四种情况之一：1)没有团队或领导；2)仅团队；3) 仅领导，4)团队+领导。团队和领导培训将通过视频会议在 超过18个月的分级时间表。护理团队将为25名达到临床截止日期的儿童提供DOCC (第75百分位)在儿科症状自评量表-17外化量表和他们的照顾者。我们会收集 实践/提供者测量来自175名实践工作人员(0、6、12、18、24个月)和600名照顾者(即0、3、6、 12个月)，以支持所有分析。收集可推广到常规儿科实践的数据将产生新的 关于CCM实施的影响、调解人和主持人的知识。这是第一批大规模的 服务系统干预的儿科试验以实现这些目标并响应RFA-MH-18-701和 NIMH的战略计划(4.2)，这项试验将推进完善所需的实施科学知识 在儿科医疗之家加速DOCC的交付和扩大的有希望的策略。

PROJECT SUMMARY/ABSTRACT Chronic care models (CCM) that deliver evidence-based practices (EBP) by multidisciplinary provider teams with primary care physicians (PCP) and behavioral health (BH) providers (as care managers, CM) have improved BH outcomes in adults1-3 and children/teens, but their widespread application is impeded by implementation barriers at multiple levels. As an example, our clinical trials document the benefits of a simplified cross-diagnosis CCM protocol for child behavior problems and ADHD (Doctor Office Collaborative Care; DOCC; MH064372), but DOCC requires targeted implementation support to enhance uptake and address practical barriers at the care team (e.g., low coordination) and practice/leadership levels (e.g., low priority). Further, meta-analyses suggest that science provides few answers for how to overcome such obstacles as trials have not tested implementation strategies to scale-up a pediatric CCM. As a theory-based implementation intervention, Facilitation delivered by an outside expert with providers/teams (external) or practice manager/leaders (internal) has enhanced provider competency to deliver an EBP and leadership or organizational-level commitment to EBP implementation. External facilitation strategies applied to a care team (TEAM) may engage validated targets (i.e., team functioning), whereas internal facilitation strategies applied to leaders (LEAD) may engage practice-level targets (i.e., implementation support) to enhance uptake. They may interact to enhance EBP uptake and patient outcomes. This R01 application proposes a randomized, hybrid type 3 effectiveness-implementation trial to: 1) test the main and interactive effects of TEAM and LEAD facilitation augmentation on provider implementation and clinical outcomes, 2) test for target engagement and mediation at the team and leadership levels, and 3) examine selected practice, provider, and family moderators of implementation. The state-wide sample includes 24 primary care practices from the medical home program of the American Academy of Pediatrics-Pennsylvania Chapter. After standard training in the DOCC EBP, all practices will be randomized to one of four conditions: 1) No TEAM or LEAD; 2) TEAM only; 3) LEAD only, and 4) TEAM+LEAD. TEAM and LEAD facilitation will be delivered via videoconference on a graded schedule over 18 months. Care teams will deliver DOCC to 25 children who meet the clinical cutoff (75th percentile) on the Pediatric Symptom Checklist-17 Externalizing scale and their caregivers. We will collect practice/provider measures from 175 practice staff (0, 6, 12, 18, 24 months) and 600 caregivers (i.e., 0, 3, 6, 12 months) to support all analyses. Collection of generalizable data to routine pediatric practice will yield new knowledge about the impact, mediators, and moderators of CCM implementation. In one of the first large-scale pediatric trials of a service system intervention to address these aims and respond to RFA-MH-18-701 and the NIMH’s Strategic Plan (4.2), this trial will advance the implementation science knowledge needed to refine promising strategies for accelerating the delivery and scale-up of DOCC in a pediatric medical home.