Developing an implementation facilitation strategy to link behavioral health screening to an eHealth intervention for clients in Ryan White-funded clinics in Chicago: Mixed-methods findings from pre-implementation research with Medical Case Managers and Supervisors
Alida Bouris, PhD
The University of Chicago
Andrea Dakin, PhD
AIDS Foundation of Chicago
ABSTRACT:
Background: Depression is highly prevalent among people living with HIV (PLWH) and is associated not only with a lower quality of life but also with HIV progression, lower retention in care, and a lower likelihood of viral suppression. In 2019, AIDS Foundation Chicago piloted an evidence-based Behavioral Health Screener (BHS) to assess the mental health and substance use needs of a subset of clients within the Ryan White Medical Case Management (RWMCM) system. Pilot results indicated a need for staff training and support to implement the screener with high fidelity, and a referral gap in readily available behavioral health services for clients with behavioral health needs. In this presentation, we present findings from a sequential explanatory mixed-methods study conducted in preparation for a Hybrid Type II trial that will examine the effectiveness and implementation of a BHS and referral to ORCHID (Optimizing Resilience and Coping with HIV through Internet Delivery), an eHealth intervention to address depression and Continuum of Care outcomes among PLWH.
Methods: To prepare for implementing the BHS and for referring clients with elevated depression symptoms to ORCHID, we conducted a sequential explanatory mixed-methods study with Medical Case Managers (MCM) and Supervisors across Ryan White Clinics in Chicagoland. Pre-implementation surveys informed by the Consolidated Framework for Implementation Research (CFIR) were conducted with n=58 staff to identify site-specific and system-wide determinants. Survey data was analyzed in SPSS and survey findings were used to inform a protocol for in-depth interviews with n=15 MCMs and Supervisors. Interview data was analyzed by rapid qualitative analysis. Both survey and interview data were then used to identify and rate implementation barriers and facilitators, identify and operationalize implementation strategies, and generate an Implementation Research Logic Model to guide implementation evaluation efforts.
Findings: On average, survey respondents slightly agreed with positive views of team culture, learning climate, and implementation readiness. Potential barriers included intervention complexity, needed human resources, and only slight agreement that the BHS presented a relative advantage over existing screening/referral systems. Qualitative results identified low advantage for clinics with robust internal behavioral health systems but strong advantage in clinics without these services. Respondents also identified system-wide training and monitoring strategies to facilitate implementation, as well as structural barriers that may hinder it.
Conclusions: We developed implementation strategies designed to impact clinic-and individual-level outcomes, including electronic prompts (reduce complexity), training on ORCHID as a complement to other behavioral health services (increase relative advantage), and feedback during implementation (strengthen rewards/incentives). The team also is pursuing additional strategies to address larger health equity issues.
