A fidelity measure for integrated management of depression in primary care.
ABSTRACT Integrated models of primary care depression management improve outcomes. Subsequent dissemination efforts and their evaluation need a fidelity measure.
We sought to develop and validate a fidelity measure using data gathered during routine clinical application of the clinical model.
Longitudinal outcome data on depression severity were obtained from 224 subjects experiencing major depression or dysthymia and assigned to a 3-component model (3CM) intervention. Data on 10 essential 3CM process-of-care components were obtained from telephone logs maintained by care managers administering 3CM care. Stakeholders (n = 23), including researchers, health care administrators, and care managers, independently rated the importance of the 10 elements distributing 100 points among the elements. Mean ratings were used as weights to construct a fidelity score. Predictive validity was assessed using logistic regression for patient response and remission at 3 and 6 months.
3CM fidelity was high, with a mean of 74.1 at 3 months and 75.9 at 6 months. Given a large gap in the scores' distribution, subjects were classified into zero, low-, and high-fidelity groups. Logistic regressions adjusting for baseline depression found a distinct continuum. Patients that were provided high fidelity 3CM were significantly more likely to achieve treatment response and remission at 3 months. At 6 months, high-fidelity care was again significantly more likely to produce a response, but remission rate did not differ from patients provided low fidelity.
Most patients received a substantially implemented "3CM dose." Even within this high implementation, however, a higher fidelity score was associated with better outcomes. The easily applied measure is a promising tool for monitoring the quality of implementation of integrated care.
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ABSTRACT: Background: The National Evidence-Based Practices (EBPs) Project developed and tested a model for facilitating the implementation of five psychosocial EBPs for adults with severe mental illness in the United States. Methods: The implementation model was tested in 53 sites in 8 states. In each site, one of the five EBPs was adopted for implementation and then studied for a 2-year period using a combination of qualitative and quantitative methods. Findings: At baseline, none of the sites had programs attaining high fidelity. Four factors were identified as influencing fidelity: (a) EBP-specific factors, (b) governmental factors, (c) leadership factors, and (d) fidelity review factors. Conclusion: A multipronged implementation strategy was effective in achieving high fidelity in over half of the sites seeking to implement a new EBP.Research on Social Work Practice 08/2009; 19(5):569-581. DOI:10.1177/1049731509335531 · 1.53 Impact Factor
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ABSTRACT: As the U.S. population ages and chronic illness prevalence increases, new approaches to care are needed. Although large health systems have begun to respond to this challenge, most Americans seek care from practitioners functioning in small office settings. Implementing systematic sustainable changes for quality improvement in this setting remains an unresolved challenge. In this study, trained Nurse Coaches (NCs) were employed to assist practices in adopting a new model of patient care called Virtual Integrated Practice (VIP). The feasibility and treatment fidelity of this approach were assessed through process measures and interviews in three practices. Findings document high acceptance of the NC approach and consistent delivery of the intervention. Enactment of the VIP model took place across practices, although to a variable degree. The study suggests that NCs may be an effective delivery method for quality and organizational improvements in small primary care practices.Western Journal of Nursing Research 03/2008; 30(6):690-703. DOI:10.1177/0193945907311321 · 1.38 Impact Factor
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