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Development of an Implementation Facilitation Strategy to Link Mental Health Screening and eHealth Intervention for Clients in Ryan White–Funded Clinics in Chicago

Stump, Tammy K. PhD, MSa; Ethier, Kristen PhD, LCSWc; Hirschhorn, Lisa R. MD, MPHb; Dakin, Andrea PhD, MAd; Bouacha, Nora MPPd; Freeman, Angela MPHb; Bannon, Jacqueline PhD, RNb; Gómez, Walter PhD, MSW, MAe; Moskowitz, Judith T. PhD, MPHb; Bouris, Alida PhD, MSWc,f

Author Information
JAIDS Journal of Acquired Immune Deficiency Syndromes: July 1, 2022 - Volume 90 - Issue S1 - p S197-S205
doi: 10.1097/QAI.0000000000002980

Abstract

INTRODUCTION

Depression is highly prevalent among people living with HIV (PLWH)1,2 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.3–6 Optimizing Resilience and Coping with HIV through Internet Delivery (ORCHID) is an evidence-based intervention that lowers symptoms of depression by teaching skills that help individuals experience positive emotions, even during stressful times.7 Although prior research found that ORCHID is effective at reducing depression symptoms and decreasing viral load,7–9 it has not been evaluated in a clinic setting. To leverage ORCHID to effectively address depression among PLWH and help realize the goals of the National Ending the HIV Epidemic Plan,10 we are conducting research to guide, and later evaluate, its implementation in the context of a hybrid, type-2, stepped, wedge cluster randomized trial. In partnership with AIDS Foundation Chicago (AFC), we will roll-out ORCHID in Ryan White Medical Case Management (RWMCM)11 sites in the Chicagoland area in tandem with their launch of a behavior health screener (BHS; ie, mental health and substance use), through which clients with elevated depression symptoms will be referred to ORCHID.

The BHS developed by AFC includes standardized assessments on: depression (PHQ-912), anxiety (GAD-713), posttraumatic stress symptoms (PCL-C14), alcohol use (AUDIT15), and substance use (DAST-1016). The BHS was designed to be administered by medical case managers (MCMs), that is, trained staff who provide patient-centered services to eliminate barriers and promote engagement with HIV-related medical care.17–19 In early 2019, AFC launched a pilot to better understand the behavioral health needs of clients receiving RWMCM services. Six subcontracted agencies piloted the BHS; of 777 eligible clients, 374 (48.1%) were offered the screener. Of the 282 who completed the PHQ-9, 33.3% (n = 94) had scores of ≥5, indicating clinically significant depressive symptomatology. Qualitative data collected during the pilot indicated that staff were concerned that available mental health services were not sufficient (eg, were too costly, had long wait times) to meet client needs identified through the screener.19

By virtue of its online, self-guided format, ORCHID addresses several barriers to receiving mental health services. ORCHID is an evidence-based intervention that consists of 8 empirically supported skills that increase positive affect (ie, positively valenced feelings, eg, calm, satisfied, excited, thrilled), even in the face of stress 20–26: (1) noting daily positive events; (2) savoring positive events; (3) gratitude; (4) mindfulness; (5) positive reappraisal; (6) focusing on personal strengths; (7) setting and working toward attainable goals; and (8) self-compassion.27 Among PLWH, positive effect has been linked to a number of benefits, including lower depression levels,28 slower disease progression,29,30 higher likelihood of viral suppression,31 and lower risk of mortality.27 The intervention has demonstrated feasibility, acceptability, and efficacy in pilot tests and randomized controlled trials among multiple clinical samples, including people with depression and PLWH.7–9,27 Specifically, randomized controlled trials conducted among PLWH have found that participants in the in-person version of ORCHID reported higher levels of past day positive effect, were less likely to use antidepressants, and were more likely to be virally suppressed.8,9 A pilot of the online self-guided version of ORCHID showed increased positive emotions and decreased depressive mood in PLWH.7

In the present trial, MCMs will refer all clients with PHQ-9 scores of ≥5 to ORCHID through a brief interest form and/or distribution recruitment materials (eg, online flyer). In the preimplementation work reported here, we conducted a needs assessment to identify facilitators and barriers that could be used to guide implementation strategies to support the implementation of the BHS + ORCHID in the RWMCM system.

METHODS

We conducted a sequential mixed-methods study with MCMs and supervisors in the RWMCM system in Chicago. Surveys and interviews were guided by the Consolidated Framework for Implementation Research (CFIR),32 a meta-theoretical framework focused on 5 domains important for implementing a new practice/intervention. We synthesized these data in an Implementation Research Logic Model (IRLM), a semistructured tool designed to increase rigor and reproducibility by mapping the relationships between implementation determinants, strategies, mechanisms of influence, and outcomes.33

Participants

Survey and interview participants were MCMs and MCM supervisors at 16 RWMCM sites in the Chicagoland area. Eligibility criteria were (1) current employment as a MCM or Supervisor, (2) age 18 or older, and (3) ability to read or write in English.

Survey

Recruitment and Data Collection

All current MCMs and supervisors from the 16 RWMCM sites with colocated clinical services were emailed an invitation to participate in a survey about implementing the BHS + ORCHID. After completing an online consent form, participants were linked to a REDCap survey.34 All participants received a $20 egift card as compensation.

Measures

Survey items were selected and adapted from existing research35 (eg, the Practice Adaptive Reserve Scale,36 ARTAS implementation evaluation37) and supplemented with several items written specifically for this project. CFIR constructs included in the survey were selected by the interdisciplinary study team (which included AFC staff and social/health psychology, social work, nursing, implementation science, and public health researchers) based on findings from the BHS pilot and prior experiences working with MCMs and PLWH. Unless noted, all items were scored from 1 = strongly disagree to 5 = strongly agree.35–37Tables 1 and 2 show specific items and internal consistency of included scales.

TABLE 1. - Outer and Inner Setting Characteristics of 16 Ryan White HIV Clinics as Reported in a Survey of Medical Case Management Staff
Domain Endorsement
Outer setting, ie, factors exogenous to the implementation setting
 Behavioral health needs: how many of your clients do you think struggle with: [1 = none to 5 = all] Mean (SD)
  Depression 3.69 (0.82)
  Anxiety 3.66 (0.89)
  Substance use 3.12 (0.82)
  None 2.00 (0.85)
 Daily technology access (estimate of % clients with each resource)
  Smartphone (n = 54) 62.59
  Tablet (n = 53) 22.08
  Computer (n = 53) 29.62
  None (n = 52) 17.69
 Reporting requirements (n = 15, supervisors only): is your clinic required to report any of the following to an outside organization (eg, CDPH, IDPH, HRSA)? [% yes]
  Doing behavioral health screener 60.00
  Results of behavioral health screener 40.00
  Referrals to behavioral health services 66.70
  Outcomes of quality improvement projects 66.70
 Incentives present (n = 15, supervisors only) 3
  Public recognition 26.70
  Payment 6.70
  Positive end-of-year score 46.70
Inner setting, ie, factors within the setting of intervention implementation
 Available resources: would be problematic because we do not have effective referrals or other supportive care resources to care for any more PLWH with behavioral health needs (Rev) 3.16 (1.21)
 Responsiveness to client needs 36 : 7 items; α = 0.81, eg, this team does a good job assessing client needs and expectations 3.92 (0.60)
 Overall culture 36 : 9 items; α = 0.89, eg, people at all levels openly talk about what is and is not working 3.80 (0.60)
 Culture stress 36 : 4 items; α = 0.85, eg, I am under too many pressures to do my job effectively (Rev) 3.06 (0.85)
 Learning climate 36 : 4 items; α = 0.85, eg, we regularly take time to consider ways to improve how we do things 36 3.87 (0.68)
Implementation readiness (leaders) 36 : 4 items; α = 0.92, eg, leadership strongly supports change efforts 36 3.83 (0.79)
 Compatibility 1: BHS is compatible and consistent with the behavioral health needs of my clients 37 3.97 (0.46)
 Compatibility 2: ORCHID is compatible and consistent with the behavioral health needs of my clients 37 3.69 (0.73)
 Compatibility 3: ORCHID is compatible and consistent with the behavioral health needs of my clients with depression 37 3.71 (0.70)
n = 58 unless otherwise noted. For incentives and reporting requirements, percentages reports are the percentage of supervisors who replied “yes.” All other variables rated on 1–5 scales; higher values indicate a more positive environment for implementation. Items without a citation were written by study authors.
CDPH, Chicago Department of Public Health; HRSA, Health Resources and Services Administration; IDPH, Illinois Department of Public Health; Rev, reverse scored; higher scores indicate a more positive environment for implementation (eg, less stressful work culture).

TABLE 2. - Intervention Characteristics and Characteristics of Individuals as Reported in a Survey of Medical Case Management Staff at 16 Chicagoland Ryan White HIV Clinics
Domain Mean (SD)
Intervention characteristics
 BHS
  Adaptability: could be administered in a way that is easily adapted to fit the needs of the team. 37 3.84 (0.67)
  Complexity 1: would be easy to understand and use after training. 37 4.00 (0.62)
  Complexity 2: is too complex. 37 (Rev) 3.47 (0.88)
  Cost 1: would take too much time and effort. 37 (Rev) 3.07 (1.06)
  Cost 2: is something I would only be interested in adopting in the future if funding was provided for it. 37 (Rev) 2.71 (0.99)
  Relative advantage 1: would be successful in linking clients living with HIV and behavioral health needs to services. 37 3.71 (0.84)
  Relative advantage 2: is unnecessary because my clinic already screens for behavioral health issues. (Rev) 3.17 (0.96)
 ORCHID
  Adaptability: would be difficult to adapt to meet the needs of different PLHV populations with behavioral health needs. 37 (Rev) 3.41 (0.80)
  Cost: would take too much time and effort. 37 3.33 (0.85)
  Relative advantage: would be more effective than methods we are currently using to address the behavioral health needs of clients living with HIV. 37 3.09 (0.78)
Characteristics of individuals (knowledge/beliefs about intervention benefits)
 BHS
  Wouldn't really work for my clients, even though it was shown to be effective in other agencies. 37 (Rev) 3.64 (0.87)
  Would be difficult to administer because it is uncomfortable to ask questions about substance use or mental health. 37 (Rev) 3.91 (0.88)
  Would have a visible and substantial impact on the health status of my clients. 37 3.71 (0.70)
  Is something that would benefit clients living with HIV. 37 4.12 (0.60)
  Is problematic because asking about suicidality or depression could trigger these symptoms. 37 (Rev) 4.05 (0.83)
 ORCHID
  Wouldn't really work for my clients, even though it was shown to be effective in research trials. 37 (Rev) 3.55 (0.77)
  Would be less effective at addressing behavioral health needs and improving viral suppression among my clients than it was in the original research studies. 37 (Rev) 3.56 (0.73)
  Would have a visible and substantial impact on the health status of my clients. 37 3.62 (0.64)
  Is something that would benefit clients living with HIV. 37 3.97 (0.53)
Items were rated on 1–5 scales with higher values indicating a more positive environment for implementation. Items without a citation were written by study authors. All knowledge/belief items were scored such that higher values indicated more favorable views of the intervention.
Rev, reverse-scored item.

Quantitative Analysis

Subscales for each construct were created and descriptive statistics (mean, SD, range) were computed, both overall and for each clinic. All items and subscales were scored such that higher values indicated a more positive environment for implementation.

Key Informant Interviews

Recruitment and Data Collection

After analyzing survey data, MCMs and supervisors, that is, key informants, were purposively sampled to ensure roughly equal representation of (1) clinics with low and high means on CFIR constructs and (2) length of employment in case management (below and more than 5 years). Staff selected for inclusion (n = 24) were emailed an invitation, if interested, were linked to an online consent form, and scheduled for an interview. All interviews were conducted and recorded via a video conferencing service (ie, Zoom). Interviews lasted about 75 minutes (range: 36–100 minutes; the shortest interview was with a seasoned supervisor who gave succinct answers), and each participant received a $50 egift card as compensation.

The team developed separate MCM and supervisor interview guides that explored the following: (1) implementing the BHS, (2) implementing the referral to ORCHID, and (3) the overall implementation process. Questions were drawn from all 5 CFIR domains32 and selected to elicit details on key survey findings, for example, perspectives on the relative advantage of the BHS + ORCHID. Before each section, interviewers provided descriptive information about the BHS and ORCHID. The guides were further refined after pilot interviews with 2 AFC staff who were former MCMs and supervisors (see Supplementary Table 1, Supplemental Digital Content 1, https://links.lww.com/QAI/B880 for sample questions). After each interview, interviewers completed a field note to capture relevant themes and follow-up areas.38

Qualitative Analysis

After interviews were professionally transcribed, 5 coders analyzed the data using a 4-step Rapid Qualitative Analysis approach.39 First, we developed a structured template mapping the relationships between major analytic domains, interview questions, and CFIR constructs. After piloting the template with a single interview to refine usability and interrater reliability, each coder independently analyzed 3–4 transcripts. The team then met to discuss key findings and to develop an analytic matrix of deductively derived codes, at which point coders independently synthesized key barriers, facilitators, and quotes, along with relevant CFIR constructs and potential implementation strategies. This approach was supplemented with open coding40 to capture themes not included in the matrix. The analysts met a final time to evaluate overall agreement in coding, with coding differences resolved via discussion.

All procedures were reviewed by the Institutional Review Board at the Northwestern University, which deemed the study as not human subjects research.

Synthesis and Application Using Implementation Research Logic Model

Survey and interview responses were converted to CFIR ratings using the following schema: mean 1–1.499 = −2 (strong barrier); mean 1.5–2.499 = −1 (moderate barrier); mean 2.5–3.499 = 0 (neutral); mean 3.5–4.499 = +1 (moderate facilitator); mean 4.5–5 = +2 (strong facilitator); “mixed” (+/−) if >2 sites had an opposite-valenced responses to the modal response. When key informants addressed constructs not captured in the surveys, the team devised a rating through discussion. In an iterative discussion-based process, our interdisciplinary team used these findings to select relevant implementation strategies. To support broader efforts to systematize implementation strategies, we also mapped our strategies on to those identified in the Expert Recommendations for Implementing Change.41 We then developed an initial IRLM that included CFIR ratings of relevant contextual determinants, implementation strategies, and potential mechanisms of influence important for understanding the planned implementation and effectiveness outcomes (Fig. 1).

F1
FIGURE 1.:
Implementation research logic model for BHS + ORCHID. *No CFIR ratings provided for process variables, which were not explicitly evaluated during this preimplementation phase. Notes. CFIR ratings ranged from −2 (strong barrier) to +2 (strong facilitator), with “0” indicating “neutral” and +/− denoting mixed responses. Hypothesized pathways through with the implementation strategies and influence mechanism and outcomes are denoted by superscripts. The outcomes presented in the rightmost column were selected by the team in advance of the present preimplementation work.

RESULTS

Participants

In total, n = 58 MCMs and supervisors from all 16 clinics completed the survey (70% response rate), and of 24 invited, n = 9 MCMs and n = 6 supervisors (n = 15; 62.5% response rate) from 11 clinics completed an interview. Mean years in case management was 4.7 for MCMs and 7.4 for supervisors. About half (43%) of respondents reported education beyond a bachelor's degree and 11% of respondents reported participation in the BHS pilot.

Outer Setting

In surveys (Table 1), depression was identified as the most common behavioral health concern. Most staff perceived that clients had daily internet access, with the most common device being a smartphone. Most clinics had some incentives and reporting requirements related to behavioral health screening, but less than half were required to report the results of these screenings.

Elaborating on survey findings, MCMs described serving clients with posttraumatic stress disorder, psychosis, homelessness, and high levels of resource instability, in addition to depression and anxiety. All informants were frustrated by the lack of behavioral health services in the community, and access to care was especially limited for non–English-speaking clients (row 1, Table 3 and see Supplementary Table 2, Supplemental Digital Content 2, https://links.lww.com/QAI/B881). MCMs feared that stigma could negatively influence clients' willingness to provide truthful answers to the BHS or that clients would be frustrated by responding to BHS questions when their primary need was resource counseling. Staff also were concerned that high mental health acuity could be a barrier to using ORCHID—a concern heightened by the pandemic. In contrast to survey findings, MCMs perceived that client access to technology could be a significant barrier to using ORCHID. In addition, some staff indicated that their clients might not be motivated to use ORCHID, especially if their primary presenting problem was housing or food insecurity (row 2, Table 3 see Supplementary Table 2, Supplemental Digital Content 2, https://links.lww.com/QAI/B881).

TABLE 3. - Illustrative Quotes From In-Depth Interviews With MCMs (n = 9) and SUPs (n = 6), Chicagoland Ryan White Medical Case Management System
Theme Select Quotations
High BH needs and low availability of services MCM: “… you do encounter waitlists … you've no idea how much longer it'll be between now and them being able to receive the treatment they deserve.”
MCM: “… it's harder for our Latino population because there's not a lot of people out there that speak Spanish ….”
SUP: “We'll be referring people to our case managers and right now … every single therapist that we work with is full ….”
Client barriers to accessing ORCHID MCM: “… a lot of my clients, they have a phone, they don't have a phone, they have service, they don't have service. Some … are currently jobless … or houseless, because of the pandemic … or even other reasons outside of their control ….”
MCM: “Some people might take it as an offense. It can be really offensive. ‘Why do you offer this to me? I've never asked you. Did I tell you that I need the service? Do I look like I'm crazy?’”
MCM: “The barriers with language, will it be in Spanish and English and Russian and Aramaic…? How will that be solved?”
Team culture MCM: “We've gotten hit with so many new things within this past year alone that we can just handle it no problem. We try to be as resourceful as we can be. That's a really big value to us … being resourceful, empathetic ….”
MCM: “We're a really tight team … if we find a problem, we'll talk about it, and then we always reach out to each other, we reach out to our supervisor. I don't think we've seen anything that we're like ‘Oh no, we can't do that’ ….”
Variability in BH screening across clinics MCM: “We don't have a set screening right now, so it's really just in conversation.”
MCM: “I offer those resources to them in house here at my clinic. We have a mental health specialist. She and I have been working together. Oftentimes, with client permission, we may do our assessments together initially ….”
Relative advantage of BHS MCM: “… it seems like it'll give me a wider scope to talk about the different types of assessments, … even though I'm not a mental health specialist, this might help me really refine my referrals.”
MCM: “I think it would just formalize the process. Right now, it's very informal.”
SUP: “From an agency standpoint, leadership may say, ‘Well, why do we need to do that if we already have a screener …?’”
Flexible and adaptable implementation MCM: “They're going to react differently …. Some people don't care and some … might get kind of insulted … if people have taken it 3 times, maybe we can go to once a year.”
Enthusiasm for ORCHID MCM: “Well, 1, it's self-empowering, so it's… they'll make time for themselves as opposed to having somebody else make time for them … I think that it's very, like I said, empowering people to see what resources they have within themselves to address whatever issues and concerns they have, and needs that they have. I think in that regard, it would definitely be beneficial that they would have that on their own scheduling.”
MCM role compatibility MCM: “We have doctors who are there for years and they know patients for years so of course, they know more about them … they know better than us.”
MCM: “A lot of times we hear a lot of positive feedback from our clients saying, ‘Oh wow, even my therapist is not doing this job this good.’”
Perceptions of “ideal” clients MCM: “I wouldn't refer somebody to [ORCHID] that didn't really have the mental health need. If somebody is in need of these more intense services … with these skills, I feel like the interest would be there.”
Implementation expectations and boundaries MCM: “[A] lot of my clients are latino and they do have technology issues, but if I see that it's something that's going to help them … I could always help them.”
SUP: “I will set up time to meet with each of my staff individually to review it after they…practice it. I would actually mandate that they set a specific time, like an hour where they're actually going to sit down and review it
Training needs MCM: “First, [training on] how to initiate these conversations … with our clients, and how to encourage our clients … how to make it simple for them.”
MCM: “I think more of the background on how [ORCHID] was developed and the fact that it is based in real science, and that there are a lot of other online tools that work for people. This is just going to be another 1 that, hopefully, probably, will also work.”
Recommended strategies MCM: “Hopefully, there's, like, a support service or something. You know, like, we have problems with AFC, we call AFC. We have a problem with something, we could email you.”
SUP: “Training for the case managers on start to finish, from screener to all the things involved with ORCHID. And then, release good marketing materials, so the case managers have language around why it would benefit their clients.”
SUP: “… for my team, I think they find value in when we run our monthly reports and we look at the dashboards and people see—I color code them with green for current and yellow for due and orange for overdue … I think they love to see all the green pop up on their screens.”
BH, behavioral health; SUP, supervisor.

Inner Setting

Survey responses (see Table 1) indicated that teams were perceived as being responsive to client needs, with a supportive culture, learning climate, and leadership that exhibited implementation readiness (eg, supports change efforts). However, respondents also expressed moderate agreement that a stressful culture existed within teams, and low rates of effective referrals and supportive care resources to serve clients.

Consistent with survey findings, almost every key informant described having a strong team culture characterized by high levels of communication, a commitment to supporting client well-being, and a willingness to try new things (row 3, Table 2 and see Supplementary Table 2, Supplemental Digital Content 2, https://links.lww.com/QAI/B881). However, there was significant variability in how clinics screened for behavioral health, pointing to variable compatibility and tension for change across the system (row 4, Table 2 and see Supplementary Table 2, Supplemental Digital Content 2, https://links.lww.com/QAI/B881). For example, some staff described having robust screening systems, close communication and collaboration with behavioral health staff, and in-house behavioral health services. In these clinics, staff were concerned about how the BHS + ORCHID would affect their current workflow. In contrast, others described being in clinics with less systematic screening approaches and less communication with behavioral health teams. Staff in these clinics reported less difficulty with integrating the BHS into their workflow (row 4, Table 2 and see Supplementary Table 2, Supplemental Digital Content 2, https://links.lww.com/QAI/B881). Additional facilitators in the inner setting included access to private space, having engaged clinic leaders, and incentives in the form of public recognition at both clinic and system-wide meetings—resources not currently present in all clinics.

Intervention Characteristics

As shown in Table 2, both the BHS and ORCHID were viewed as adaptable. However, they were also viewed as being somewhat complex and costly, with only slight agreement that the BHS + ORCHID had a relative advantage compared with existing systems for screening and referrals for mental health treatment. Qualitative data revealed that staff in clinics with weaker screening systems believed that the BHS would help them to better understand, refer, and support their clients, but those in clinics with robust systems were uncertain about what the BHS would add (row 5, Table 3 and see Supplementary Table 2, Supplemental Digital Content 2, https://links.lww.com/QAI/B881). Staff emphasized the need for a flexible implementation process that would allow them to deliver client-centered services and offered suggestions such as screening after the initial intake visit, less frequent screening, or collaborating with on-site behavioral health teams (row 7, Table 3 and see Supplementary Table 2, Supplemental Digital Content 2, https://links.lww.com/QAI/B881). Across interviews, the referral to ORCHID was viewed as similar to making other referrals, suggesting low complexity and good compatibility. Overall, there was high enthusiasm for incorporating ORCHID as a referral option, with many staff noting that an online intervention could help to address the lack of community-based behavioral health services (row 6, Table 3 and see Supplemental Table 2, Supplemental Digital Content 2, https://links.lww.com/QAI/B881).

Characteristics of Individuals

Survey data indicated that MCMs and Supervisors agreed that both the BHS and ORCHID would be effective (Table 2). Across interviews, most MCMs recognized that they were in a unique position to implement a BHS, as they had close relationships with clients. However, some MCMs perceived that it was outside their role to conduct a BHS and believed that medical/behavioral health clinicians were better qualified, suggesting mixed levels of self-efficacy (row 8, Table 3 and see Supplementary Table 2, Supplemental Digital Content 2, https://links.lww.com/QAI/B881). Some MCMs also had a mental image of an “ideal” client for ORCHID, for example, someone who did not have high levels of mental health distress. MCMs also were disappointed to learn that ORCHID was only available in English (row 9, Table 3 and see Supplementary Table 2, Supplemental Digital Content 2, https://links.lww.com/QAI/B881). Whereas some MCMs were concerned about guiding clients through the uptake and completion of ORCHID, others were eager to help clients access and complete ORCHID, even offering to sit with their clients and translate the material into Spanish (row 10, Table 3 and see Supplementary Table 2, Supplemental Digital Content 2, https://links.lww.com/QAI/B881).

Process

Key informants had several suggestions for ensuring a successful implementation process (survey items did not assess this domain). All identified interactive trainings with opportunities to ask questions and practice with one another as critical for preparing them to screen and respond appropriately, especially for addressing potential stigma and/or reluctance to engage with mental health services. Importantly, all informants noted that AFC had a strong history of providing engaging training and effective technical support. Both MCMs and supervisors thought that it was important to share high-quality marketing materials across platforms, for example, pamphlets/brochures distributed at meetings, email, and social media (row 11, Table 3 and Supplementary Table 2, Supplemental Digital Content 2, https://links.lww.com/QAI/B881). Given variability in screening and referral systems across the RWMCM system, staff also recommended engaging both clinic and behavioral health leaders in the implementation process. Reflecting and evaluating during the implementation process was identified as vital: supervisors recommended folding this into regular team meetings, with data support from AFC, and both groups recommended using a dashboard system to provide direct feedback on BHS reach and fidelity. During implementation, informants also wanted to learn from their colleagues and to share feedback with AFC leaders and the research team (row 12, Table 3 and see Supplementary Table 2, Supplemental Digital Content 2, https://links.lww.com/QAI/B881).

DISCUSSION

Implementation research is critical for supporting the adoption, scale-up, and sustainment of evidence-based interventions in clinical care settings serving PLWH.42,43 Through quantitative and qualitative data, we identified a number of important determinants that will guide the implementation of the BHS + ORCHID. MCMs and supervisors perceived a strong need for additional client services, and the BHS was viewed as a valid tool to screen for clients' behavioral health needs (ie, high compatibility). Yet MCMs also described potential barriers in the inner and outer settings, including redundancy with some clinic's existing workflows (ie, low relative advantage and compatibility), limited time and resources to conduct the screening and any needed follow-up (ie, high human resource costs), and a need to address mental health stigma and clients' immediate resource needs. Whereas ORCHID was viewed as a way to address the lack of immediately accessible referral options, some informants were concerned about access for clients with technological or linguistic barriers. Nevertheless, staff highlighted strong team cultures as well as training and leadership from AFC on prior initiatives as key predictors of implementation success; they also recommended several strategies to support implementation.

The identified barriers and facilitators are consistent with prior research on the implementation of behavioral health screenings and mHealth interventions in diverse care settings, including primary care clinics,44 federally qualified health centers,45 and clinics serving people with chronic health conditions. Within the CFIR, implementation readiness is a multidimensional construct that refers to the “tangible and immediate” indicators of an organization's commitment to the decision to implement a new intervention.32 Both survey and interview data pointed to a strong history of AFC leadership engagement, support, training, and technical assistance to implement new programs and initiatives within the RWMCM, strategies correlated with implementation readiness in prior research.32,46,47

To address relevant barriers and to strengthen implementation readiness and other facilitators, we selected an initial set of strategies to increase MCM awareness, knowledge, and self-efficacy and to support identified implementation outcomes (see IRLM in Fig. 1). During the preimplementation phase, we will release educational materials in multiple modalities and conduct a series of dynamic trainings. Trainings will include content on behavioral health among PLWH and information on screening and referral procedures. Given identified stigma concerns, trainings also will provide practice opportunities to increase MCM self-efficacy to address client reticence to discuss mental health. We also will identify clinic and system-wide champions who can share their positive experiences during meetings and trainings. Finally, trainings and materials will highlight ORCHID as a complement that may support clients as they wait for other services. Trainings will be provided before and during implementation. During implementation, we will refine and implement quality monitoring tools and systems. These strategies will enable the team to audit and provide feedback on the BHS + ORCHID to each clinic. Following staff recommendations, feedback will be given via a dashboard system that also provides electronic prompts. Technical assistance will be provided, with AFC supporting the BHS and the research team supporting ORCHID. As implementation proceeds in each clinic, the research team will conduct additional mixed-methods research to identify actual barriers and facilitators and to evaluate and adapt strategies as needed.48Figure 1 and Supplementary Table 3 (see Supplemental Digital Content 3, https://links.lww.com/QAI/B882) provide a complete list of planned implementation strategies, mapped to Expert Recommendations for Implementing Change strategies.

Strengths and Limitations

Study strengths include the use of the CFIR to guide data collection and analysis,32,49 use of validated CFIR measures,35,36 strong sampling methods, and the sequential mixed-methods study design. However, the study is not without limitations. The scales used to measure CFIR constructs assessed the extent of agreement that specific potential barriers and facilitators (eg, implementation climate) were present35–37 but not whether these factors were perceived as being barriers, facilitators, or as not relevant (neutral) to implementing BHS + ORCHID. A different measurement strategy may have yielded different insights into perceived barriers or facilitators. Future mixed-methods research during the trial will provide additional data on how and whether these determinants operate as actual barriers or facilitators. Although MCMs and supervisors were recruited from across the RWMCM system, not all invitees opted to participate and few provided a reason for declining. It is possible that staff with the most burdensome schedules and/or least interest chose not to participate. Nevertheless, we obtained survey responses from all eligible clinic sites and reached coding saturation after 15 interviews. Finally, data collection took place between November 2020 and March 2021—a time period when the COVID-19 pandemic likely resulted in changes to practice with long-term implications of these plans being unknown.

We additionally acknowledge that our implementation plans will not ameliorate all barriers for PLWH who could benefit from ORCHID, for example, structural inequalities, dearth of community-based behavioral health services, technology access, and access for non–English-speaking clients. Although we partially address technology access by optimizing ORCHID for mobile device delivery and by suggesting community resources through which clients can regularly access the internet, additional research is needed to adapt ORCHID for non–English-speaking persons. Spanish-speaking versions of positive affect interventions have been developed, and translation is a high priority for future iterations of ORCHID.50 We also do not explicitly intervene at the outer setting level, as would be ideal, because of limitations in project scope and resources. Future research should incorporate health equity frameworks in implementation science research on the outer setting, which may help to improve intervention reach.51,52 We will track variation in outcomes by demographic categories, reasons for unsuccessful screenings of interested study participants, and reasons eligible participants cannot access ORCHID. These data will help to better understand outer setting barriers and may suggest the selection of future implementation strategies to address these barriers.

CONCLUSIONS

RWMCM sites are a generally favorable context for implementation of interventions. Identified barriers will be addressed through deploying implementation strategies proposed 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).

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Keywords:

HIV; positive affect; depression; screening; implementation

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