Barriers and Facilitators to Implementing a Technology-enhanced Psychiatric Collaborative Care Model among Rural Primary Care Sites. Sponsored by ACLP's Telepsychiatry SIG.

Abstract: Background/Significance

Psychiatric collaborative care management (CoCM) has potential to mitigate the challenges rural communities face accessing behavioral health (BH) services. However, implementation of CoCM in rural clinics has proved difficult and may take a tailored approach. This study examines implementation of a telehealth-enabled CoCM program in four rural South Carolina clinics guided by the Dynamic Adaptation Process (DAP), with particular focus on identifying barriers, facilitators, and strategies to support implementation.

Methods

This study used a mixed methods, embedded, chronological case study approach, integrating several data sources collected across implementation. Data sources included pre-implementation surveys and focus groups with clinic staff, post-implementation surveys with clinic staff, key informant interviews with CoCM care team members, and several administrative data sources. Data were integrated using a weaving approach to develop summaries of each of the DAP phases of program implementation (Exploration, Preparation, Implementation, Sustainment).

Results

Initial Exploration implementation activities included workflow development, telehealth platform configuration, building the CoCM care team, and conducting an assessment among the four clinics. Scarcity of BH resources was the primary barrier to rural BH treatment. These data informed activities and adaptations in subsequent phases. During the Preparation phase, the CoCM team was trained and site visits were conducted to clinics by the remote care manager to support rapport building. In the Implementation phase, providers began referring resulting in 296 referrals and 99 patient enrollments in the first eight months. Post-implementation feedback showed strong provider satisfaction. Patient need, patient interest, and provider engagement with the care manager were identified as the primary facilitators for referral. 68% of patients reported a reduction in depression symptoms after 8 weeks (PHQ-9), and 58% reported reduction in anxiety symptoms (GAD-7). Providers reported 100% interest in the pilot programming continuing. During the Sustainment phase, workflow, technology, and auditing process improvements took focus as did planning for expansion of the program to additional sites.

Discussion

By providing in-depth case summaries of the implementation activities, contextual factors, and adaptations made during each phase of the DAP, we demonstrate the utility of this framework in supporting implementation and elucidate key barriers, facilitators, and implementation strategies that may influence adoption of CoCM programs in rural communities.

The DAP model was a particularly helpful tool for our Implementation Resource Team, whose members were outsiders to these rural clinic settings. Leveraging the use of a remote CoCM care team was a critical enabler of this model, especially given the already strained BH infrastructure of these communities. Not requiring collocation of the BHCM at sites gave us a statewide pool of BHCM candidates to hire from. Supporting multiple practices at once, we were able to reach a higher BHCM caseload more quickly and support practices with only one PCP which likely would not have been tenable otherwise.

Conclusions/Implications

The DAP shows great utility for tailoring implementation of CoCM to specific rural settings by providing a roadmap for identifying contextual barriers and facilitators that can be addressed through adaptation and other implementation strategies.