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

优化儿科协作护理的护理团队和实践水平实施策略：整群随机试验

• 批准号: 10531931
• 负责人: DAVID KOLKO
• 金额: $ 80.97万
• 依托单位: UNIVERSITY OF PITTSBURGH AT PITTSBURGH
• 依托单位国家: 美国
• 财政年份: 2021
• 资助国家: 美国
• 起止时间: 2021-01-18 至 2025-11-30
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10531931
• 关键词: Academy; Acceleration; Address; Adopted; Adult; American; Attention deficit hyperactivity disorder; Attitude; Caregivers; Caring; Case Manager; Child; Child Behavior; Childhood; Clinical; Clinical Trials; Cluster randomized trial; Collection; Competence; Data; Diagnosis; Evidence based practice; Face; Family; Health Personnel; Home; Hybrids; Intervention; Knowledge; Leadership; Learning; Manuals; Measures; Mediating; Mediation; Mediator; Medical; Mental Health; Meta-Analysis; Minority; Modeling; National Institute of Mental Health; Outcome; Patient-Focused Outcomes; Pediatrics; Pennsylvania; Prevalence; Primary Care; Primary Care Physician; Problem Solving; Problem behavior; Protocols documentation; Provider; Psychiatrist; Public Health; Quality of life; Randomized; Replicating Effective Programs; Research; Resources; Sampling; Schedule; Science; Services; Severities; Strategic Planning; Symptoms; System; Teenagers; Testing; Training; Training Programs; Work; behavioral health; behavioral impairment; care providers; chronic care model; collaborative care; comorbidity; design; effectiveness outcome; effectiveness/implementation trial; evidence base; health record; implementation barriers; implementation intervention; implementation outcomes; implementation science; implementation strategy; improved; multidisciplinary; novel; patient centered medical home; pediatric patients; primary care practice; programs; response; scale up; supportive environment; theories; uptake; videoconference

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.

项目概要/摘要 由多学科提供者团队提供循证实践 (EBP) 的慢性病护理模型 (CCM) 初级保健医生 (PCP) 和行为健康 (BH) 提供者（作为护理管理者，CM） 改善了成人1-3和儿童/青少年的 BH 结果，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 的简化交叉诊断 CCM 协议（Doctor Office Collaborative 关心; DOCC； MH064372），但 DOCC 需要有针对性的实施支持，以提高采用率和 解决护理团队的实际障碍（例如，协调性低）和实践/领导水平（例如，低） 优先事项）。此外，荟萃分析表明，科学对于如何克服这种问题几乎没有提供答案。 由于试验尚未测试扩大儿科 CCM 的实施策略，因此存在障碍。作为一个以理论为基础的 实施干预、由外部专家与提供商/团队（外部）提供的协助或 实践经理/领导者（内部）增强了提供者提供 EBP 和领导力的能力或 组织层面对 EBP 实施的承诺。应用于护理团队的外部促进策略 （团队）可能会涉及经过验证的目标（即团队运作），而内部促进策略适用于 领导者 (LEAD) 可以制定实践层面的目标（即实施支持）来提高采用率。他们可能 相互作用以增强 EBP 的吸收和患者的治疗效果。该 R01 应用提出了一种随机、混合 类型 3 有效性实施试验：1) 测试 TEAM 和 LEAD 的主要效果和交互效果 促进提供者实施和临床结果的增强，2) 测试目标参与度和 在团队和领导层进行调解，以及 3) 检查选定的实践、提供者和家庭 实施的主持人。全州样本包括来自医疗机构的 24 个初级保健实践 美国儿科学会宾夕法尼亚分会的家庭计划。经过标准培训后 DOCC EBP，所有练习将随机分配到以下四种情况之一：1) 无团队或领导； 2) 仅限团队； 3） 仅领导，以及 4) 团队+领导。团队和领导的协助将通过视频会议进行 超过 18 个月的分级时间表。护理团队将为 25 名符合临床截止时间的儿童提供 DOCC （第 75 个百分点）儿科症状检查表 17 外化量表及其护理人员。我们将收集 175 名执业工作人员（0、6、12、18、24 个月）和 600 名护理人员（即 0、3、6、 12 个月）来支持所有分析。收集常规儿科实践的通用数据将产生新的结果 关于 CCM 实施的影响、调解因素和调节因素的知识。在第一个大规模的 旨在实现这些目标并响应 RFA-MH-18-701 和 NIMH 的战略计划 (4.2)，该试验将推进完善所需的实施科学知识 加速儿科医疗之家 DOCC 的交付和规模化的有前景的策略。