Using NIATx Strategies to Implement Integrated Services in Routine Care

描述（由申请人提供）：拟议的实施研究解决了行为卫生保健中一个长期存在且令人烦恼的问题：为同时发生物质使用和精神健康障碍的人提供综合服务。尽管人们几十年来一直意识到这一问题，但目前只有不到10%的合并症患者接受循证综合服务。实施科学是解决这一持续存在的差距的关键。本研究统一并操作化了三个主要的实施研究分类：实施研究的综合框架，实施完成的阶段，以及普罗克特等人（2011）的实施结果分类。由工业工程师开发的多方面实施策略NIATx已被证明在实施和维持行为医疗保健服务的简单干预方面是有效的。该项目的总体目标是测试NIATx策略是否有效地实施了一项复杂的循证干预措施：为合并疾病的患者提供综合服务。有希望的试点数据表明，NIATx实际上可以整合服务，但需要更严格的研究。我们现在采取这一步骤，并在此提出了一个集群随机等待名单对照组设计，其中一个队列的23个机构收到积极的NIATx方法，而其他队列的23个机构的等待名单。在第二阶段，由23个机构组成的等待小组参加NIATx，第一组进入维持阶段。假设安装和维持综合服务，NIATx检查两个核心实施成果的有效性：保真度和渗透，以及病人护理成果（精神和物质使用症状减少）。NIATx战略交付的程度和保真度的变化使用NIATx保真度量表进行评估，该量表嵌入了实施完成阶段的衡量标准。在实施前、实施后和维持后续阶段评估主要成果。定性和经济分析增加了定量数据，并增加了对组织和社会动态以及资源成本的解释。我们组建了一个多学科的研究团队，拥有相当多的互补专业知识和经验。该研究利用了整个州护理系统（华盛顿）技术上先进的临床管理信息能力，在20个县开展了具有代表性的门诊项目。与美国的数据一致，参与机构及其主要利益相关者都非常积极地改善对合并疾病患者的服务。实际的实施策略，包括其相关成本，以及对服务和患者结果的可衡量影响，将是确定的研究产品。这项强有力的研究结果立即适用于改善临床服务，推进实施研究，并最终指导未来与其他行为健康系统和环境的实施。

DESCRIPTION (provided by applicant): The proposed implementation research addresses a longstanding and vexing problem in behavioral health care: Access to integrated services for persons with co-occurring substance use and mental health disorders. Despite decades of awareness of this problem, at present, less than 10% of treated patients with co-occurring disorders receive evidence-based integrated services. Implementation science holds to key to addressing this persistent gap. The present study unifies and operationalizes three major implementation research heuristics: the Consolidated Framework for Implementation Research, the Stages of Implementation Completion, and the Proctor et al (2011) taxonomy of implementation outcomes. Developed by industrial engineers, a multi-faceted implementation strategy, NIATx, has proven to be effective in implementing and sustaining simple interventions in behavioral health care services. The overarching goal of this project is to test whether NIATx strategies are effective in implementing a complex evidence-based intervention: Integrated services for persons with co-occurring disorders. Promising pilot data suggest that NIATx actually can integrate services, but a more rigorous study is needed. We now take this step and herein propose a cluster randomized wait-list control group design, in which a cohort of 23 agencies receive the active NIATx approach while the other cohort of 23 agencies are waitlisted. In the second phase, the wait-list group of 23 agencies participates in NIATx and the initial group enters a sustainment phase. Hypothesized to install and sustain integrated services, NIATx is examined for effectiveness on two core implementation outcomes: fidelity and penetration, as well as patient care outcomes (psychiatric and substance use symptom reduction). Variation in the extent of and fidelity to which NIATx strategies are delivered are evaluated using the NIATx Fidelity Scale, which embeds the Stages of Implementation Completion measure. Primary outcomes are assessed at pre- implementation, post-implementation and at sustainment follow-up periods. Qualitative and economic analyses augment the quantitative data, and add to the interpretation of organizational and social dynamics, as well as resource costs. We assemble a multi-disciplinary research team with considerable and complementary expertise and experience. Capitalizing on a technically sophisticated clinical management information capacity across a state system of care (Washington), the study engages representative outpatient programs across 20 counties. Consistent with US data, the participating agencies and their key stakeholders are highly motivated to improve services for patients with co-occurring disorders. Practical implementation strategies, including their associated costs, and the measurable impact on services and patient outcomes, will be definitive research products. Findings from this robust study are immediately applicable to improve clinical services, to advance implementation research, and ultimately, to guide future implementations with other behavioral health systems and settings.