Assessing Implementation Strategies for the Uptake of Bundled Interventions to Improve Culturally Relevant Care for Black women with HIV

Andrea Dakin, PhD, MA
AIDS Foundation Chicago

Serena Rajabiun, PhD
University of Massachusetts Lowell

Alicia Downes, LMSW
AIDS United

Corliss Heath, PhD
US Department of Health and Human Services

ABSTRACT:
The Health Resources and Services Administration (HRSA), HIV/AIDS Bureau(HAB), Ryan White HIV/AIDS Program (RWHAP), Part F- Special Projects of National Significance initiative entitled Improving Care and Treatment Coordination for Black women with HIV funded 12 clinical and community-based organizations and one evaluation center to adapt, implement, and assess the uptake of evidence based/informed (EB/EI) bundled interventions to improve health outcomes and well-being for Black women with HIV. This study examines the successes, challenges, and adaptations to implementation strategies to support intervention uptake and cultural responsiveness for Black women with HIV.

Guided by the Expert Recommendations for Implementing Change (ERIC) compilation, the Evaluation and Technical Assistance Center working in partnership with the demonstration sites selected five implementation strategies for intervention uptake: tailoring interventions to local context; train/educate stakeholders; evaluation and iterative strategies; engaging consumers; and changing infrastructure. Tracking implementation strategies and adaptations across sites required multiple approaches to data collection, as each of the twelve sites bundled two-four EB/EIs. Modifications to strategies during the pre-implementation and implementation phases were documented using FRAME-IS core modules gathered through monthly coaching calls with sites and annual site visits with evaluation center coaches and site implementation teams. This presentation will outline the data collection and analysis methods employed by the evaluation center, as well as present a case study from one of the demonstration sites.

Supercharging implementation science with insights from behavioral economics

Rinad Beidas, MA, PhD
Northwestern University

ABSTRACT:
This presentation will describe efforts to apply the tools and insights from behavioral economics to improve upon implementation of evidence-based practices.

Building an Implementation Blueprint to Support Evidence-Based Intervention Scale-Up

Kelli Scott, PhD
Northwestern University

ABSTRACT:
A key first step in implementing an evidence-based practice in a novel setting is to identify the determinants of practice (i.e., barriers and facilitators) that may impact successful implementation and sustainment. In addition to collecting these important data on determinants of practice, systematic methods are needed to pair research-supported implementation strategies to identified barriers and facilitators and develop an implementation blueprint. In this talk we provide an overview of the key steps to develop an implementation blueprint in collaboration with key community partner stakeholders. These steps include conducting a mixed methods needs assessment, identifying and prioritizing implementation barriers, engaging in collaborative strategy selection, matching barriers and strategies, formation of an implementation team, and implementation blueprint creation. We will also provide an exemplar of how each of these steps can be deployed in the context of a Cognitive Behavioral Therapy implementation effort in adolescent residential treatment facilities.

Reducing Opioid Use Disorder and Overdose in the United States: Model Development and Policy Analysis

Mohammad Jalali, PhD
Harvard University

Wayne Wakeland, PhD
Portland State University

ABSTRACT:
The opioid crisis is one of the most pressing public health issues in the U.S. today. Opioid overdoses are the proverbial “tip of the iceberg,” arising within a complex adaptive system characterized by rapidly changing dynamics combined with significant time lags and large uncertainties in the data. System dynamics modeling is a critical tool to guide policymaking and avoid unintended consequences. We developed a simulation model of the opioid system, spanning from medical use of prescription opioids to opioid misuse and heroin use, use disorder, treatment, and remission. The model aims to help policymakers address the crisis by aiding in policy analysis and decision-making under uncertainty. We project the effects of several policies to reduce opioid use disorder and overdose, and analyze intended and unintended effects of the policies over the next 10 years. Model simulations suggest most policies implemented on their own will achieve only modest reduction in either fatal overdoses or prevalence of OUD.

The Intersection of Adolescent Development and Anti-Black Racism

Joanna Williams, PhD
Rutgers University

Andrew Fuligni, PhD
University of California, Los Angeles

ABSTRACT:
Adolescence—beginning around 10 years of age and ending in the early 20s—represents a particularly important period of experience and opportunity during which youth explore the world, develop a sense of agency, and define their identity. These years are also a key window during which the effects of racism are amplified and deeply felt. Experiences with racism within common contexts and spaces create different experiences for youth along racial lines. We cannot fully support the formation of identity and belonging and increasing agency and exploration for Black youth without considering the impact that anti-Black racism has on these developmental milestones.

 In this presentation, report lead Joanna Lee WillIiams, PhD, and co-author Andrew Fuligni, PhD, will discuss insights from developmental science on how racism and related inequities impact key developmental milestones of adolescence and review research-based recommendations to support Black youth within key social contexts of the middle and high school years.

A Social Networked Approach to Implementation: Questions, Methods, and Interventions

Alicia Bunger, MSW, PhD
The Ohio State University

Reza Yousefi-Nooraie, PhD
University of Rochester

ABSTRACT:
Social networks are channels for transmitting knowledge, influence, and resources among patients, professionals, and organizations. These relationships are at the heart of all dissemination and implementation efforts. Examining implementation from a social network perspective has potential to help us better understand the complex social contexts of implementation, their dynamic evolution over time, and implementation success. Networks can also be altered or leveraged deliberately to facilitate and sustain implementation. In this talk, we will introduce terminology and assumptions underlying social network analysis and illustrate how social network analysis can be used to address a range of implementation research questions. We will also introduce a new typology of network interventions (interventions that deliberately alter network structures) that have potential to be used as implementation strategies.

To request powerpoint slides, please email psmg@northwestern.edu

The Implementation and Sustainment Facilitation (ISF) Strategy A promising strategy for improving implementation climate, implementation effectiveness, and intervention effectiveness.

Bryan Garner, Ph.D.
RTI International

ABSTRACT:
Over at least the past 15 years, implementation research has been defined as the scientific study of the use of strategies to adopt and integrate evidence-based health interventions into clinical and community settings in order to improve patient outcomes and benefit population health. Notwithstanding the significant progress that has been made to date, there remains a significant need for implementation research to identify effective and cost-effective strategies for improving the implementation and sustainment of evidence-based health interventions into clinical and community settings. In 2014, the National Institute on Drug Abuse funded a dual-randomized type 2 hybrid trial that focused on experimentally testing the Implementation and Sustainment Facilitation (ISF) Strategy as an adjunct to a staff-focused Addiction Technology Transfer Center (ATTC) Strategy. After providing a brief overview of the ATTC Strategy, this presentation will focus on describing the ISF Strategy, with emphasis on: (a) its guiding theory, framework, and principles, (b) its standardized tools/exercise, (c) study results that support its effectiveness and cost-effectiveness as an adjunct to the ATTC strategy, and (d) how it is currently being tested as part of several on-going implementation research experiments.

Wingman-Connect Program: A Network-Health Suicide and Depression Prevention Program for Air Force Trainees

Peter Wyman, Ph.D.
University of Rochester School of Medicine

Anthony R. Pisani, Ph.D.
University of Rochester School of Medicine

Bryan Yates, BA
University of Rochester School of Medicine

C. Hendricks Brown, Ph.D.
Northwestern University

ABSTRACT:
Suicide has been a leading manner of death for military members in recent years. In this talk, we will describe a Dept of Defense-funded initiative to develop and test a universal prevention program for Airmen in training. The Wingman-Connect Program applies a network health approach to enhance protective group processes in natural organizational units including cohesion and diffusion of healthy norms among members. We report results from a cluster- randomized clinical trial testing impact on airmen through a 6-month follow-up period.

Treatment for opioid use disorder in the Florida Medicaid population: A cascade of care approach to assessing quality.

Kimberly Johnson, Ph.D.
University of South Florida

ABSTRACT:
Despite increased funding, opioid overdose rates remain high. Understanding at what stage of the process and for whom the system is failing is critical to improving care. A cascade of care (CoC) model may improve understanding of gaps in addiction treatment availability and quality over current single measure methods. Using a CoC framework, we assessed treatment quality and outcomes for opioid use disorder for the Florida Medicaid population in 2017/2018 by demographics.

Methods: Data from Florida Medicaid claims for 2017 and 2018 were used to calculate the number of enrollees who were diagnosed, began medication, were retained on medication for a minimum of 180 days, and who died.

Results: Only 28% of those newly diagnosed with OUD in 2017 began treatment with an FDA approved medication. Once on medication, 38% of newly diagnosed enrollees were retained in treatment for at least 180 days. Those who remained in treatment for 180 days had a hazard ratio of death of 0.226 (95% CI = 0.174 to 0.294) compared to those that did not initiate treatment, a reduction in mortality from 10% without care to 2% with care.

Conclusions: Initiating medication after diagnosis is the process most in need of improvement, though there is much room for improvement in treatment retention as well. The CoC is an appropriate method of measuring the quality of the functioning of the treatment system at the state level.

Advancing Research on Sustainability within Implementation Science

Rachel Shelton, ScD, MPH
Columbia University

ABSTRACT:
This webinar will focus on opportunities within implementation science to advance research on sustainability. Sustainability relates to the continued delivery of program components for the sustained achievement of desirable program goals and health outcomes.

Bridging the Gap: Implementation Science as an Implementation Strategy for EHE

Sarit Golub, PhD, MPH
Hunter College

ABSTRACT:
This talk will discuss the role of implementation science in Ending the HIV Epidemic (EHE) goals at both the national and local levels. Not only can implementation science inform EHE investments, its tools, models and frameworks are critical to supporting and enhancing successful EHE programs and strategies. Practice-driven, collaborative implementation science research that focuses on mechanisms, intervention specification, and all four levels of strategies and outcomes will have the greatest impact.

Implementation Research Logic Model: A Method for Planning, Executing, Reporting and Synthesizing Implementation Projects

JD Smith, PhD
University of Utah School of Medicine

Dennis Li, PhD, MPH
Northwestern University

Miriam Rafferty, PT, DPT, PhD
Northwestern University

ABSTRACT:
Background: Numerous models, frameworks, and theories exist for specific aspects of implementation research, including for determinants, strategies, and outcomes. However, implementation research projects often fail to provide a coherent rationale or justification for how these aspects are selected and tested in relation to one another. Despite this need to better specify the conceptual linkages between the core elements involved in projects, few tools or methods have been developed to aid in this task. The Implementation Research Logic Model (IRLM) was created for this purpose and to enhance the rigor and transparency of describing the often-complex processes of improving the adoption of evidence-based practices in healthcare delivery systems.

Methods: The IRLM structure and guiding principles were developed through a series of preliminary activities with multiple investigators representing diverse implementation research projects in terms of contexts, research designs, and implementation strategies being evaluated. The utility of the IRLM was evaluated in the course of a two-day training to over 130 implementation researchers and healthcare delivery system partners.

Results: Preliminary work with the IRLM produced a core structure and multiple variations for common implementation research designs and situations, as well as guiding principles and suggestions for use. Results of the survey indicated high utility of the IRLM for multiple purposes, such as improving rigor and reproducibility of projects; serving as a “roadmap” for how the project is to be carried out; clearly reporting and specifying how the project is to be conducted; and understanding the connections between determinants, strategies, mechanisms, and outcomes for their project. 

Conclusions: The IRLM is a semi-structured, principles-guided tool designed to improve the specification, rigor, reproducibility, and testable causal pathways involved in implementation research projects. The IRLM can also aid implementation researchers and implementation partners in the planning and execution of practice change initiatives. Adaptation and refinement of the IRLM is ongoing, as is the development of resources for use and applications to diverse projects, to address the challenges of this complex scientific field. This presentation will cover the primary elements and use of the IRLM, review evidence of its utility, and present multiple completed examples.

Localized Economic Modeling to Support Implementation of the “Ending the HIV Epidemic in America” Initiative

Bohdan Nosyk, PhD, MA
Simon Fraser University

ABSTRACT:
Rather than a homogeneous national epidemic, the HIV epidemic in the US is a collection of diverse local microepidemics concentrated primarily in the South, hotspot counties, and large urban centers, with fundamental differences in health system infrastructure, funding and HIV-related laws and policies. Recognizing these facts, the US launched the ambitious ‘Ending the HIV Epidemic (EHE) initiative in February 2019. The plan called for an initial focus on 48 of the most-affected counties plus Washington, DC, San Juan, Puerto Rico and seven southern states to reduce new infections by 75% within 5 years and by 90% within 10 years. These goals are now challenged by the onset of the global COVID-19 pandemic, which may have severe consequences for people living with HIV and on HIV microepidemics across the US. A value-based approach, accounting for the pervasive racial/ethnic inequities in healthcare access and explicating key elements of the implementation process are now more critical than ever in reaching the ambitious targets of the EHE initiative.

In 2016 our investigative team began a project aiming to identify optimal combination implementation strategies to reduce the public health burden of HIV/AIDS in six US cities (NIH-DA-041747). These six cities, all subsequently included in the EHE initiative, comprised 12 of 48 EHE-targeted counties and 24.1% of people living with HIV/AIDS in the nation. Considering the impact of 16 evidence-based interventions to Diagnose, Treat and Protect against HIV/AIDS, we found unique combination implementation strategies provided the greatest health benefits in each city; no two cities featured the same mix of interventions in their ‘optimal’ strategy. Moreover, we found the EHE goals were attainable in three of six cities. The biomedical interventions we considered would however have to be delivered at ideal levels of implementation, which would require additional efforts to reduce barriers in access to care and explicitly focus on reducing disparities in healthcare access among Black and Hispanic communities. We argue that promoting health equity is key to bridging this implementation gap and propose an approach to establish an equitable distribution of resources to maximize the impact of the EHE initiative.

Mixed Up: Modeling for Context

Hendricks Brown, PhD
Northwestern University Feinberg School of Medicine

Daniel Almirall, PhD
University of Michigan

Robert Gibbons, PhD
University of Chicago

Don Hedeker, PhD
University of Chicago, Public Health Sciences

Carlos Gallo, PhD
Northwestern University Feinberg School of Medicine

Naihua Duan, PhD
Columbia University

ABSTRACT:
This presentation provides a background into design and analysis of interventions or implementation strategies that are initially randomized, then afterwards are conducted in group or network settings where the units randomized can no longer be treated as independent. Such designs include individually randomized group assigned trials, where the group context is an active ingredient in delivering one arm of the trial. Also included are implementation trials that involve formal learning collaboratives where the sites interact with one another. A wide variation of such designs occur, including trials with rolling entrances and exits to groups, network based interventions, and so-called rollout trials. It is important to take into account such non-independence in analysis, because otherwise the critical values ordinarily used in test statistics are too small and therefore erroneously finding significance more often than they should. Examples are given in multiple contexts, and appropriate statistical procedures are given. To increase appropriate statistical testing, we provide tools to conduct such analyses across different statistical platforms. A shiny R program that accounts for some of these procedures is demonstrated.

Optimization of implementation strategies to maximize impact and learning

Predrag Klasnja, PhD
University of Michigan

ABSTRACT:
In recent years, behavioral science has been moving toward systematic optimization of interventions prior to their confirmatory evaluation. Intervention optimization refers to studies that are explicitly intended to improve the intervention package by assessing whether and how individual components within the package work, so that the package can be constructed only from those components that are both efficacious and that satisfy other key optimization criteria such as cost constraints. My colleagues and I have been drawing on methods from intervention optimization, as well as on Agile Science, to enable rigorous development of implementation strategies in order to more effectively target intended mechanisms of action as well as to create “usable evidence” about how and under what conditions implementation strategies are effective. In this talk I will give an overview of our approach and argue that its use in implementation science can contribute evidence about the functioning of implementation strategies that allows effective knowledge accumulation and reuse. 

Using Systems Consultation to Improve Opioid Prescribing in Primary Care: Protocol for a Sequential, Multiple-Assignment Randomized Trial (SMART)

Andrew Quanbeck, PhD
Department of Family Medicine and Community Health
University of Wisconsin
School of Medicine and Public Health

ABSTRACT:
Background (context and purpose of the study) Health care systems are notoriously slow to adopt clinical guidelines and other evidence-based practices, in part because the literature offers little help about which implementation strategies work best in different clinical settings and how strategies could be tailored to maximize their effectiveness in different contexts. This study tests a blended implementation strategy called systems consultation to improve concordance with clinical guideline for opioid prescribing in primary care. Systems consultation consists of the following theoretically and empirically proven strategies: (1) an educational meeting followed by audit and feedback, (2) practice facilitation, and (3) physician peer consulting. The study aims to discover the most cost-effective sequence and combination of strategies for improving opioid prescribing practices in diverse primary care clinics.

Methods (how the study will be performed) The study is a hybrid type 3 cluster-randomized sequential multiple-assignment randomized trial (SMART) that randomizes clinics at two timepoints, months 3 and 6 of an 18-month intervention period. The study will compare the effect on morphine-milligram equivalent dose of the elements of systems consultation. Four combinations of implementation strategies will be assessed: an educational meeting and audit and feedback alone (AF), AF plus practice facilitation (PF), AF + PF plus physician peer consulting (PPC), and AF + PPC. In addition, an assessment of system-, clinic-, and prescriber-level contextual factors will be developed and tested to build a tool for tailoring strategies to different clinics, and a cost estimate will be conducted of the strategies that make up systems consultation. The study aims to enroll up to 38 clinics from three health systems. Mixed methods will be used to evaluate systems consultation using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework. Clinics will be the primary unit of analysis.

Discussion (summary and potential implications) Systems consultation is a practical blend of evidence-based strategies, in this case used to improve opioid prescribing practices in primary care. The blend offers a range of strategies from minimally to substantially intensive to make available the most cost-effective strategy(ies) for specific clinical contexts. Systems consultation and the adaptive approach used to deliver the strategy may generalize to the adoption of other evidence-based practices as well.

The SUpporting Primary care Providers in Opioid Risk reduction and Treatment (SUPPORT) center to increase identification and treatment of opioid use disorder in VA primary care: An operationally-partnered internal facilitation implementation effort

Emily C. Williams, PhD, MPH
Department of Health Services
University of Washington

Eric J. Hawkins, PhD
Addiction Medicine
VA Puget Sound Health Care System

ABSTRACT:
Opioid use disorders (OUD) are increasingly common and dangerous. Though medication treatment of OUD is effective, recommended, and can be offered in primary care settings where patients with OUD are frequently seen, it is substantially underused with multiple barriers to its provision. The SUpporting Primary care Providers in Opioid Risk reduction and Treatment (SUPPORT) Center is a partnership between researchers and clinical leaders to assist VA primary care clinics in identifying and treating OUD. We will describe our operationally-partnered implementation efforts using internal facilitation and use of rapid mixed-methods formative evaluation to refine our implementation strategies, and we will present up-to-date evaluation results.

Health Economic Research Supporting the U.S. Response to the Opioid Crisis: Defining Cost Effective Interventions and Implementation Strategies

Kathryn McCollister, Phd
University of Miami, Miller School of Medicine

ABSTRACT:
As the U.S. continues to grapple with the opioid epidemic, the National Institutes of Health, in collaboration with the Substance Abuse and Mental Health Services Administration, has recently launched several funding initiatives tasked with identifying, testing, and implementing evidence-based strategies to significantly reduce overdose fatalities and other negative consequences associated with opioid use disorders (OUD). Health economics research is highlighted as an important component to these new studies; specifically, the need for economic data informing resource allocation, cost effectiveness, and financing mechanisms that support the feasibility and sustainability of recommended strategies. This talk will describe the current state of knowledge on the cost effectiveness of treatment interventions and other strategies for OUD as well as relatively new questions relating to the economics of implementation at a broader community- or systems-level.

House on Fire: Addressing Opioid Overdose as an Epidemic

Kimberly Johnson, PhD, MBA
Research Associate Professor, University of South Florida

ABSTRACT:
There are standard public health models of addressing epidemics of contagious disease. This presentation will argue that if we use standard protocols that have been developed to address other epidemics, we would make greater progress in reducing the rate of drug overdose deaths in the United States. The presentation will remind participants of how smallpox was eradicated and what was learned about epidemic control in that effort as well as what is being learned in international efforts to eradicate the spread of HIV. The presentation will conclude with a discussion of the strengths and weaknesses of the current response to the opioid epidemic from a public health epidemic control perspective.

Mothers and Babies: Scaling an Evidence-Based Intervention Nationally to Improve Perinatal Mental Health

Shiv Darius Tandon, PhD
Institute for Public Health and Medicine
Northwestern University, Feinberg School of Medicine

ABSTRACT:
An estimated 1 in 7 women are affected by postpartum depression. Experiencing postpartum depression makes it more likely that someone will have recurring depression in the future, poor attachment with her baby, relationship problems with her partner, and diminished economic stability. Mothers and Babies (MB) is a manualized intervention that has demonstrated efficacy via multiple RCTs in preventing onset of postpartum depression and reducing depressive symptoms. Recently, MB was highlighted as one of the two most efficacious perinatal depression preventive interventions by the United States Preventive Services Task Force. With increased national attention, our research lab has received a growing number of inquiries from healthcare systems, community-based organizations, and city and state health departments to train their providers to deliver MB. This presentation will describe our model for scaling MB via training and technical assistance. It will also share results from research studies we have conducted examining the implementation and sustainment of MB.

Project MIMIC (Maximizing Implementation of Motivational Incentives in Clinics): A type 3 effectiveness-implementation hybrid trial

Bryan Garner, Ph.D.
Research Triangle Institute (RTI)

Sara Becker, Ph.D.
Department for Behavioral and Social Sciences, Brown University School of Public Health

ABSTRACT:
There is an urgent public health need to improve the outcomes of individuals with opioid use disorders (OUDs). There are currently five approved medication formulations, which relative to placebo have demonstrated effectiveness in helping patients attain abstinence from opioids. Nonetheless, patients’ opioid abstinence rates are sub-optimal: even when treated with the newest extended-release formulations only about 40% of patients maintain abstinence during the first 6-months of treatment. Contingency Management (CM) is one of the only behavioral treatment shown to improve OUD pharmacotherapy outcomes, yet implementation of CM within OUD treatment centers remains quite low. Project MIMIC is a type 3 effectiveness-implementation hybrid trial to test the effectiveness of an enhanced-version of the Addiction Technology Transfer Center’s current multifaceted implementation strategy on both implementation outcomes (primary aim) and patient outcomes (secondary aim). For this PSMG web-presentation, Drs. Becker and Garner (Project MIMIC’s principal investigators) will teach others about the project and its protocol, with special emphasis on helping the audience learn more about the project’s two implementation conditions, key challenges, and key lessons learned.

Stimulant Use Disorders: Epidemiology, Clinical Challenges, and Review of Treatments

Richard Rawson, PhD
Department of Psychiarty, UCLA

ABSTRACT:
Methamphetamine and cocaine use rates and overdose deaths are rapidly increasing in much of the US.  The presentation will review the clinical challenges presented by individuals who use stimulants and current protocols for addressing acute medical/psychiatric conditions.  Evidence-based behavioral/psychosocial strategies are presented, along with pharmacotherapies currently considered promising.

Leveraging Treatment & Recovery Services to Address the Opioid Crisis

Todd Molfenter, PhD
University of Wisconsin - Madison, Center for Health Enhancement Systems Studies

Abstract: Dr. Molfenter will provide an overview of the “Opioid Crisis” in the United States and how it is impacting research opportunities in the addiction treatment and Implementation Science fields.  Causes and impact of the epidemic will initially be discussed. Then, opioid use disorder treatment evidence-based practices will be described. Followed by the gaps and challenges being experience in getting these practices implemented and research we have conducted to better understand how to get these practices implemented (or scaled-up) into broader practice.