Dr. Amy M. Kilbourne, PhD, MPH is Director of the VA Quality Enhancement Research Initiative (QUERI) and Professor of Psychiatry at the University of Michigan (UM) Medical School. She is also Associate Director for Implementation and Policy for the UM Depression Center and the Director of the Michigan Mental Health Integration Partnership (MIP) whose goal is to improve the lives of Michigan residents with behavioral health care needs through public-private partnerships. To learn more, download Dr. Kilbourne's ROCC Star Profile and view a webinar highlighting her work.
Please briefly describe your study of the implementation of the Re-Engage program?
Re-Engage is VA’s national outreach program to help improve access and timely care for high-risk veterans with serious mental illness who had not been seen in VA care for at least 12 months. Evidence suggests that persons with serious mental illness die on average 8-25 years younger than the general population, primarily due to general medical conditions that go untreated. In 2012, VA launched a national initiative to implement Re-Engage nationally across VA sites and our study focused on determining the best implementation strategies to improve the Re-Engage program among providers at sites not initially adopting Re-Engage
What techniques should researchers consider adopting when researching or deploying implementation strategies in areas with limited resources?
Any implementation study requires a “double-major” - the ability to conduct rigorous evaluation methods and expertise in academic-real-world partnership development. Implementation strategies used to deploy Re-Engage (Facilitation and Replicating Effective Programs), are the “how-to” of achieving quality improvement and focus on garnering input from frontline providers on tailoring Re-Engage, using data to track progress, and adopting strategic thinking skills to obtain leadership support for Re-Engage at their sites. These strategies do not need to be expensive so they can be deployed to lower-resourced sites (e.g., facilitation was provided by a doctoral-level clinical expert who spent on average less than 8 hours per site on regular calls to the frontline providers for 6 months).
What suggestions do you have for researchers and health systems in the evaluation of implementation models?
There are a number of advantages to conducting implementation studies in VA that are also found in other highly-integrated health care systems, notably our national electronic medical records system for measuring outcomes, as well as a national network of providers to involve in the implementation strategies. However, for investigators to propose implementation studies in large healthcare systems, they need to select an effective practice that addresses a high-priority area for the healthcare leadership (Re-Engage for example was supported by a VHA national directive), determine where the gaps in implementation of the effective practice might be (e.g., “later-majority” sites), and work with frontline providers to adapt the effective practice before coming up with an implementation strategy, so there is ownership on the part of the end-users. A number of implementation strategies exist but many have not been rigorously compared to each other, which then provides an opportunity for a piggy-back scientific study of a regional or national deployment of effective practice across different sites.
Given you experience leading QUERI, what are the most difficult challenges in the implementation of a learning health system?
I think the first challenge is understanding that technology advances alone (e.g., EHRs, m-health) will not automatically lead to implementation of effective practices or ultimately, quality improvement. Implementation is the process of changing provider behavior within the context of organizational constraints so understanding and facilitating provider buy-in will be key. A second challenge is determining what to implement and when, in light of competing priorities under leadership, and how to implement across different settings. The quality improvement field is masterful at helping to improve overall practice function; I see the field of implementation science as working to sustain those improvements by focusing on alleviating barriers especially in lower-resourced, later-adopter settings. Finally, there aren’t enough trained implementation scientists who truly bridge research and clinical practice so further investment in implementation strategy deployment will be essential to the learning healthcare system core competencies.