Evaluation of Implementing FLOW in VISN 19: Transitioning Stabilized Mental Health Patients to Management in Primary Care

充分获得心理健康治疗是退伍军人健康面临的最优先问题之一 管理（VHA）和VISN 19。长期的人员短缺和一些临床实践联合收割机， 获得心理健康治疗。难以获得护理可能导致自杀和残疾，以及长期等待 时间导致患者不满意和脱离护理。常见的心理健康状况有 预计在许多情况下会缓解或通过循证处方得到实质性改善， 心理治疗，使病人不再需要密集的专业精神卫生服务。国际 临床指南鼓励使用分级护理，即患者应接受最低强度的治疗 适合其病情的护理水平。虽然退伍军人事务部已经接受了阶梯式护理， 连续护理模式，VA手册未提供关于哪些患者适合 过渡到初级保健或如何过渡应该发生。在没有指导的情况下， 患者得到适当的过渡，专业心理健康小组仍然满员， 问题FLOW程序通过一种算法来解决这些问题， 可能适合于过渡，用户友好的在线报告，以将此信息传达给供应商， 向患者和提供者解释此过程的材料，以及电子病历（EMR）说明 模板来记录转换。在提供者认为持续专业精神健康的情况下， 治疗是必要的，或病人反对过渡，病人可以继续在专科精神卫生。这 这种方法对缓解患者也有很高的可接受性，因为他们认为这种方法减少了耻辱感， 当他们的护理是在初级保健管理预约负担。VISN 16和17的初步数据 表明FLOW可以有效地将康复患者过渡到初级保健，并增加新的 心理健康患者。在最初的试点地点，实施成功率差异很大，但数据 收集到的数据没有对此作出解释，也没有允许审查与以下方面有关的执行因素： 成功为了准备在全国范围内推出FLOW，我们正在与VISN 19合作，评估其影响 使用阶梯楔形设计，将7-9个部位随机分配到楔形的3个阶梯中。一个 将在每个地点采用循证执行便利办法。评估的结果将包括 计划的有效性以及与跨站点实施成功相关的因素。程序 将根据RE-AIM模型检查有效性结局，具体结局为达到（%） 转换的诊所患者的百分比）、有效性（成功转换并对未来诊所产生影响的百分比 访问）、采用（使用FLOW的供应商的百分比）、实施（按计划对模型的忠实度），以及 在撤销执行便利后的一段时间内予以维持。我们还将评估执行情况 在执行情况研究综合框架的指导下， 各地点的成功，包括组织对变革的准备、人员配备水平、军种间协议 关心、领导力支持和内部促进。

Adequate access to mental health treatment is one of the highest priority problems facing the Veterans Health Administration (VHA) and VISN 19. Chronic staffing shortages and some clinical practices combine to reduce access to mental health treatment. Poor access to care can contribute to suicide and disability, and long wait times contribute to patient dissatisfaction and disengagement from care. Common mental health conditions are expected to remit in many cases or to be substantially improved with evidence-based prescribing and psychotherapy such that patients no longer need intensive specialty mental health services. International clinical guidelines encourage the use of stepped care, in which patients should be treated at the least intensive level of care that is appropriate to their condition. Although VA has embraced stepped care with the recent VA Continuum of Care model, VA manuals do not provide clear guidance on which patients are appropriate for transition back to primary care or how the transition should take place. In the absence of guidance, few patients are appropriately transitioned and specialty mental health panels remain full, contributing to access problems. The FLOW program addresses these problems with an algorithm to identify patients who are potentially appropriate for transition, a user-friendly online report to communicate this information to providers, materials to explain this process to patients and providers, and an electronic medical record (EMR) note template to document the transition. In cases where providers believe continued specialty mental health treatment is warranted or patients object to the transition, patients can remain in specialty mental health. This approach also has high acceptability to remitted patients because of perception of less stigma and reduction in appointment burden when their care is managed in primary care. Preliminary data from VISNs 16 and 17 indicates that FLOW can effectively transition recovered patients to primary care and increase access for new mental health patients. Implementation success differed dramatically across the original pilot sites but data collected did not offer an explanation for this or allow examination of implementation factors associated with success. In preparation for a national rollout of FLOW, we are partnering with VISN 19 to evaluate the impact of FLOW using a stepped wedge design with 7-9 sites randomly allocated into 3 steps in the wedge. An evidence-based implementation facilitation approach will be used at each site. Outcomes assessed will include program effectiveness and the factors that are associated with implementation success across sites. Program effectiveness outcomes will be examined according to the RE-AIM model, with specific outcomes for reach (% of clinic patients transitioned), effectiveness (% of transitions that are successful and impact on future clinic access), adoption (% of providers using FLOW), implementation (fidelity to the model as planned), and maintenance over time after withdrawal of implementation facilitation. We will also evaluate implementation factors, guided by the Consolidated Framework for Implementation Research, related to implementation success across sites, including organizational readiness to change, staffing levels, interservice agreements about care, leadership support, and internal facilitation.