Points of Impact: Amy Kilbourne, Ph.D., M.P.H.

Here, Dr. Kilbourne discusses how implementation scientists partner with providers and other researchers to integrate new evidence throughout routine healthcare practice and more rapidly respond to current health policy challenges.

What does implementation science mean, exactly?

Within healthcare, implementation science examines how providers can apply research evidence more effectively in routine clinical practice. I think of it as the study of provider behavior change within a context of organizational constraints (such as limited resources, for example).

The field is relatively new and still evolving, with roots in behavioral health sciences such as psychology, the dissemination sciences that so effectively promote public health campaigns, and business management and leadership training, including some of the process improvement models such as Lean. In day-to-day healthcare practice, it's rare that effective treatments or research get completely diffused and used in real-world settings.

That’s in part because healthcare settings often have a lot of organizational barriers to the adoption of these practices, however small the changes may seem, as well as some psychological barriers, especially when people may feel imposed upon if asked to introduce a new way of doing something they perceive may consume major time and resources.

When providers are already trying to juggle five different things on their plate, and you’re asking them to implement a new practice, they need to know how it’s going to improve their patient care, and they also need to have the evidence demonstrating how that change is likely to offer long-term benefits that would outweigh short-term costs. Depending on the setting, they may also need training in skills to convince organizational leadership that a new practice makes good business sense.

How can implementation science benefit patients?

Implementation science can help shrink the gap between what research has proven effective and what actually happens in healthcare practice, to help patients get better access to evidence-based treatments, and avoid care that may be of little benefit or even harmful.

What are some common implementation strategies?

Replicating Effective Programs, or REP, engages providers to customize an intervention so that it’s palatable for them to use in their real-world setting. Originally developed by the Centers for Disease Control and Prevention (CDC), REP focuses on “packaging” an effective practice into a user-friendly toolkit, and specifies steps including provider training, technical support, and ongoing monitoring of their success with scaling up and spreading the effective practice.

Another strategy (Facilitation) involves training providers on strategic thinking so that they can make the business case of why it’s so vital to have an evidence-based clinical treatment or intervention used across different settings.

These “transformational” skills are fairly common sense, yet at the same time really hard to teach. It's not just about training yourself to be the best deliverer of the intervention, but also essentially motivating leadership and other providers to adopt the intervention, notably by taking their perspective of what their needs are and what the intervention could do for them.

How does implementation happen across very different settings, and what does it look like?

Some great examples of this come from the Michigan Mental Health Integration Partnership, or MIP, which I direct. MIP, which is a public-private matching program funded in part by the Centers for Medicare and Medicaid Services (CMS) and administered through the State, works to implement and evaluate innovative programs to address unmet mental health needs in Michigan.  Michigan Child Collaborative Care, or MC3, is one such program.

Primary care providers around the state, and particularly in remote and underserved areas, can connect with psychiatrists through tele-medicine for expert consultation on child and adolescent patients with moderate to severe behavioral health issues.

Not only are primary care providers receiving a consultative service, but they’re being trained in implementing more effective treatments and making them sustainable within their practices. The program has now expanded to nearly every county in the state.

Another example is the TRAILS (Transforming Research into Action to Improve the Lives of Students) program, which trains school professionals in evidence-based mental health care approaches, such as Cognitive Behavioral Therapy (CBT), and then connects them with community mental health providers who provide follow-up training. In an NIMH-funded R01 trial (R01 MH 114203), we’re evaluating how well CBT is being delivered in the schools through TRAILS as well as changes in students’ mental health outcomes.

MIP provides matched Medicaid funding to more than 20 projects, and this year we're developing a comprehensive implementation strategy package that our investigators can use for everything from implementing a brief intervention for PTSD among primary care providers to helping emergency room providers carry out violence prevention programs. We’re boiling down the common characteristics of what makes an implementation process successful, focusing on the best ways of training and coaching providers, as well as how to get best practices imbedded in the systems or communities so that they’re sustainable.

What’s involved in using implementation strategies in promoting practice adoption at the national level?

I am also the Director of the VA’s Quality Enhancement Research Initiative (VA QUERI), a national program devoted to improving Veteran health through the more rapid implementation of research evidence into practice. QUERI funds a national network of VA centers, which in 2017 alone implemented more than 50 complex evidence-based interventions nationally, using implementation strategies such as Facilitation and REP.

Currently, QUERI is establishing an Implementation Training Network for VA leaders and providers to learn essential implementation skills that can be applied to scale up and spread effective interventions for major VA priorities, including enhancing access to care, quality and safety, and suicide prevention.

A unique program that embeds researchers in routine clinical practice, QUERI is also home to several national evaluations of major VA programs and policies to ensure they work at the clinic level, including the VA’s Caregiver Support Program and the initial Veterans Choice Act, which enables Veterans to seek care outside the VA. The process of applying implementation strategies at the national level can be complex.

Prior to my QUERI Director role, the VA asked us to implement a program of brief care management to identify Veterans with serious mental illness who were lost to care. This is a vulnerable population with lots of physical comorbidities who had not been seen by VA care providers in over a year. We created a program called Re-Engage to identify these Veterans and have frontline mental health providers try to bring them back into care, and we found it led to reduced mortality and better engagement by Veterans.

The VA Under Secretary at the time wanted to implement Re-Engage nationally, so we did a randomized program evaluation of REP versus REP + Facilitation implementation strategies, and found that provider uptake increased significantly among the sites that received added facilitation.

A key ingredient in Facilitation was the use of strategic thinking by the frontline mental health provider and their increased communication with their leadership at their facility about getting resources to make Re-Engage feasible to implement, as well as ways in which they could engage with their own colleagues to make Re-Engage imbedded in the routine care system, and ultimately, a national policy.

Based on this experience with Re-Engage and through VA QUERI, we've encouraged other investigators to develop and utilize implementation strategies to scale up and spread evidence-based policies as well as clinical interventions at the national level. QUERI is helping support four ongoing national randomized evaluations on opioid abuse, suicide prevention, the scale up and spread of tele-health services, and home-based geriatric services.

This work is all based on this notion that you can make the difference. It’s not enough just to publish a policy and expect people to adopt it. But you can make a big difference if you really apply the right types of implementation strategies, and provide the clinicians in a field with training as well as the strategic skills and moral support to help them realize change that ultimately improves patient care.