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

项目总结/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） 改善成人1 -3岁和儿童/青少年的BH结果，但其广泛应用受到以下因素的阻碍： 多层次的实施障碍。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 护理; DOCC; MH 064372），但DOCC需要有针对性的实施支持，以提高吸收率， 解决护理团队的实际障碍（例如，低协调性）和实践/领导水平（例如，低 优先）。此外，荟萃分析表明，科学提供了如何克服这种问题的答案很少。 由于试验尚未测试扩大儿科CCM的实施策略，因此存在障碍。作为一个理论基础 实施干预，由外部专家与提供者/团队（外部）一起提供便利，或 业务经理/领导（内部）已增强提供商提供EBP和领导能力的能力，或 组织一级对EBP实施的承诺。应用于护理团队的外部促进策略 （TEAM）可以与经验证的目标（即，团队运作），而内部促进策略适用于 领导者（LEAD）可以参与实践级目标（即，执行支助），以提高采用率。他们可能 相互作用，以提高EBP的吸收和患者的结果。该R 01申请提出了一种随机化、混合 第3类有效性-实施试验：1）测试TEAM和LEAD的主要和交互作用 对提供者实施和临床结果的促进增强，2）测试目标参与度， 在团队和领导层面进行调解，3）检查选定的实践，提供者和家庭 执行的主持人。全州范围的样本包括24个初级保健实践， 美国儿科学会宾夕法尼亚分会的家庭项目。经过标准的培训， DOCC EBP，所有实践将被随机分配到以下四种情况之一：1）无团队或电极导线; 2）仅团队; 3） 4）团队+领导。评估小组和牵头机构将通过视频会议提供协助， 18个月的时间表。护理团队将为25名符合临床截止日期的儿童提供DOCC (75th百分位）的儿科症状自评量表-17外化规模和他们的照顾者。我们将收集 来自175名执业人员（0、6、12、18、24个月）和600名护理人员（即，0，3，6， 12个月），以支持所有分析。收集常规儿科实践的可推广数据将产生新的 了解CCM实施的影响、调解人和主持人。在第一次大规模的 一项服务系统干预的儿科试验，以解决这些目标并响应RFA-MH-18-701和 NIMH的战略计划（4.2），这项试验将推进实施所需的科学知识， 有前途的战略，加速交付和规模扩大DOCC在儿科医疗之家。

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.