Consensus on strategies for implementing high priority mental health care practices within the US Department of Veterans Affairs

Abstract

Background: Identifying feasible and effective implementation strategies remains a significant challenge. At present, there is a gap between the number of strategies prospectively included in implementation trials, typically four or fewer, and the number of strategies utilized retrospectively, often 20 or more. This gap points to the need for developing a better understanding of the range of implementation strategies that should be considered in implementation science and practice.

Methods: This study elicited expert recommendations to identify which of 73 discrete implementation strategies were considered essential for implementing three mental health care high priority practices (HPPs) in the US Department of Veterans Affairs: depression outcome monitoring in primary care mental health (n = 20), prolonged exposure therapy for treating posttraumatic stress disorder (n = 22), and metabolic safety monitoring for patients taking antipsychotic medications (n = 20). Participants had expertise in implementation science, the specific HPP, or both. A highly structured recommendation process was used to obtain recommendations for each HPP.

Results: Majority consensus was identified for 26 or more strategies as absolutely essential; 53 or more strategies were identified as either likely essential or absolutely essential across the three HPPs.

Conclusions: The large number of strategies identified as essential starkly contrasts with existing research that largely focuses on application of single strategies to support implementation. Systematic investigation and documentation of multi-strategy implementation initiatives is needed.

Plain language summary: Most implementation studies focus on the impact of a relatively small number of discrete implementation strategies on the uptake of a practice. However, studies that systematically survey providers find that dozens or more discrete implementation strategies can be identified in the context of the implementation initiative. This study engaged experts in implementation science and clinical practice in a structured recommendation process to identify which of the 73 Expert Recommendations for Implementing Change (ERIC) implementation strategies were considered absolutely essential, likely essential, likely inessential, and absolutely inessential for each of the three distinct mental health care practices: depression outcome monitoring in primary care, prolonged exposure therapy for posttraumatic stress disorder, and metabolic safety monitoring for patients taking antipsychotic medications. The results highlight that experts consider a large number of strategies as absolutely or likely essential for supporting the implementation of mental health care practices. For example, 26 strategies were identified as absolutely essential for all three mental health care practices. Another 27 strategies were identified as either absolutely or likely essential across all three practices. This study points to the need for future studies to document the decision-making process an initiative undergoes to identify which strategies to include and exclude in an implementation effort. In particular, a structured approach to this documentation may be necessary to identify strategies that may be endogenous to a care setting and that may not be otherwise be identified as being "deliberately" used to support a practice or intervention.

Keywords: Expert consensus; US Department of Veterans Affairs; antipsychotic; depression; implementation strategies; measurement-based care; mental health; metabolic; posttraumatic stress disorder; prolonged exposure.

Figure 1.

Summary of recommendations. Composite ratings are provided for each strategy where the six-pointed blue star reflects ⩾50% endorsements for a strategy as absolutely essential. Some blue stars are underlined to highlight strategies receiving absolutely essential ratings across all three HPPs. The five-pointed green star reflects ⩾50% endorsements for a strategy as likely essential (inclusive of absolutely essential ratings <50%). The three-pointed yellow symbol reflects ⩾50% endorsements for a strategy as likely inessential (inclusive of higher ratings <50%). The orange bar reflects ⩾50% endorsements for a strategy as absolutely inessential. These composite recommendations were derived by aggregating recommendations by taking the highest endorsement each expert provided across the nine assessment points (three scenarios by three phases) for each HPP.