Evaluation of Implementing FLOW

Not Applicable

Completed

Conditions: Mental Health

Interventions: Other: FLOW intervention

Registration Number: NCT04193033

Lead Sponsor: VA Office of Research and Development

Brief Summary: Adequate access to mental health is one of the most important problems facing the VA and VISN 19. Mental health patients who are stabilized and recovered should be transitioned back to primary care to increase availability in mental health for new patients, and to signal to recovered patients that they are successfully recovered. Because there are currently no methods to identify who is recovered or tools and processes to assist in transitions, few patients 'graduate' mental health. The FLOW program consists of an algorithm to identify patients who are potentially appropriate for transition, a user-friendly online report to communicate this information to providers, materials to explain this process to patients and providers, and an electronic medical record (EMR) note template to document the transition. The investigators are partnering with VISN 19 to evaluate this program using a stepped wedge design with 9 sites randomly allocated into 3 steps in the wedge. Sites will receive an evidence-based implementation facilitation approach. The investigators will evaluate the number of patients transitioned, success of those transitions, and patient and provider satisfaction.

Detailed Description: Our study sites requested that we pause implementation due to clinical efforts and site disruption related to COVID-19. Date of study resumption is unclear.

Adequate access to mental health is one of the most important problems facing the VA and VISN 19. Mental health patients who are stabilized and recovered should be transitioned back to primary care to increase availability in mental health for new patients, and to signal to recovered patients that they are successfully recovered. Because there are currently no methods to identify who is recovered or tools and processes to assist in transitions, few patients 'graduate' mental health. The FLOW program consists of an algorithm to identify patients who are potentially appropriate for transition, a user-friendly online report to communicate this information to providers, materials to explain this process to patients and providers, and an electronic medical record (EMR) note template to document the transition. The investigators are partnering with VISN 19 to evaluate this program using a stepped wedge design with 9 sites randomly allocated into 3 steps in the wedge. Sites will receive an evidence-based implementation facilitation approach. The investigators will evaluate the number of patients transitioned, success of those transitions, and patient and provider satisfaction.

Specific aims for this proposal are:

1. To evaluate the impact of FLOW, using the evaluation framework RE-AIM, including:

1. Reach of the program: % of clinic patients transitioned to PC using FLOW

2. Effectiveness: successful transition to primary care and impact on clinic access for future patients

3. Adoption: percent of providers in the selected clinics transitioning patients to primary care

4. Implementation: use of all FLOW components

5. Maintenance: sustainment of FLOW after withdrawal of external facilitation

2. To evaluate structural and process implementation factors, including organizational readiness to change, staffing levels, interservice agreements about care, leadership support, and internal facilitation.

Recruitment & Eligibility

Status: COMPLETED

Sex: All

Target Recruitment: 9

Inclusion Criteria

This study uses site-level randomization
Sites must be VA sites with substantial numbers of mental health patients
- VA medical centers or large or very large community based outpatient clinics

Exclusion Criteria

Non-VA sites and CBOCs smaller than large

Study & Design

Study Type: INTERVENTIONAL

Study Design: CROSSOVER

Arm && Interventions

Group	Intervention	Description
FLOW intervention	FLOW intervention	Sites receive the FLOW program, including internal and external facilitation, use of the FLOW online report to identify patients, patient and provider education materials, a medical record template, and regular data tracking and feedback about the process.

Primary Outcome Measures

Name	Time	Method
Reach: Percent of Specialty Mental Health Patients Transitioned to Primary Care	Change from baseline to 12 months	Percent of mental health patients in each of the participating clinics who are transitioned to primary care through use of the FLOW intervention, based upon electronic medical record data documenting this transition
Effectiveness of Intervention's Impact on Clinic Access	Change from baseline to 12 months	Appointments freed up by FLOW consistent discharges from mental health clinics, by site
Implementation Fidelity to the Protocol	12 months	Percent of all FLOW components implemented as designed, based upon the items in the FLOW implementation checklist
Adoption: Percent of Mental Health Providers Who Use FLOW Intervention	12 months	Percent of mental health providers who use the FLOW intervention for at least 3 patients, compared to the total number of mental health providers in the participating clinics

Secondary Outcome Measures

Name	Time	Method
Maintenance of Reach: Percentage of Specialty Mental Health Patients Transitioned to Primary Care	from 12-24 months	Percent of mental health patients in each of the participating clinics who are transitioned to primary care through use of the FLOW intervention, based upon electronic medical record data documenting this transition, during the maintenance period
Maintenance of Effectiveness of Intervention's Impact on Clinic Access	12-18 months	Encounter slots 'freed up' by FLOW discharges
Maintenance of Implementation Fidelity to the Protocol	12-24 months	Percent of all FLOW components implemented as designed, based upon the items in the FLOW implementation checklist, from 12 to 24 months