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Article Title

Cluster Randomized Trial of Enhanced Versus Standard Implementation Strategy to Improve Collaborative Care Uptake and Patient-Level Utilization Outcomes

Publication Date

4-30-2015

Keywords

implementation strategies, patient-level outcomes utilization

Abstract

Background/Aims: Implementation strategies are increasingly being used to promote the uptake of evidence-based practices, yet few studies have demonstrated their impact on the efficiency of patient-level utilization. This cluster randomized controlled study determined whether an enhanced versus standard version of the Replicating Effective Programs (REP) implementation strategy, designed to promote the uptake of an evidence-based collaborative care program, impacted emergency department (ED) utilization outcomes among patients with bipolar disorder. We hypothesized that the enhanced version would lead to decreased ED use compared to the standard.

Methods: Seven community-based clinics in Michigan and Colorado were randomized to receive either standard (REP) or enhanced REP (E-REP) to improve the uptake of Life Goals Collaborative Care (LG-CC). Providers at sites randomized to REP received the LG-CC toolkit (manual, implementation guide), LG-CC training and, as needed, technical assistance. Providers at sites receiving E-REP were given support to customize LG-CC manuals and training and ongoing facilitation for 6 months, where organizational barriers to LG-CC uptake were addressed through provider coaching to support integration of LG-CC into routine care. Providers were responsible for implementing four weekly LG-CC group sessions and monthly care management calls over 6 months with patients with a diagnosis of bipolar disorder seen at their clinics. Prior to attending LG-CC sessions, patients were consented and completed baseline and follow-up assessments at 6 and 12 months. Primary utilization outcomes included self-reported ED visits.

Results: Within 12 months, patients (N=246) at sites randomized to E-REP (n=146) compared to REP sites (n=100) had a smaller self-reported number of ED visits (0.14 for E-REP sites vs. 0.36 for REP; odds ratio: 0.24, P=0.004) adjusted for patient-level demographics (sex, race, age, education, homelessness, employment), clinical factors (psychiatric symptoms, medical diagnoses), ED utilization measured in the baseline survey and number of LG-CC contacts. LG-CC uptake, particularly having at least 4 care management contacts, appeared to mediate the effect of the E-REP implementation strategy and decreased ED use.

Discussion: Implementation strategies such as enhanced REP that provide customization and coaching in the use of a collaborative care model may reduce ED use, primarily by improving overall uptake and increasing care management contacts.

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