■只有7%的同时患有心理健康和物质使用障碍(COD)的人获得了这两种情况的服务。我们通过系统集成实施和评估保持独立性和清醒,外展和网络-退伍军人版(任务-兽医),对患有COD的退伍军人进行基于证据的手动心理社会干预。本文确定了解释“如何,为谁,以及在什么条件下“任务-兽医收养”,实施,和保真度工作时,应用于具有促进支持的复杂自适应系统。
■在两个VA医疗保健系统(站点A和B)中,一项混合III试验测试了实施MISSION-Vet的促进作用.我们根据42个半结构化实施研究综合框架(CFIR)对现场领导进行了指导访谈,进行了两个现场案例研究。实施者(社会工作者,同行专家),和团队成员(主持人,现场线索)。对访谈进行了编码,并使用了CFIR构造来生成“上下文机制=结果”配置,以了解MISSION-Vet采用的条件,实施,和忠诚。
■站点A很低,站点B的采用率很高,实施,和忠诚。采用犹豫/渴望(结果)是由“外部政策”(上下文)抑制/鼓励“变革紧张”(机制)的相互作用引起的。实施强度(结果)是基于“同伴压力”或实践文化(背景)如何激活员工“自我效能”(机制)与MISSION-Vet互动并评估其“相对优势”。当前的实践(机制)。富达依靠“人员配置结构和可用性”(上下文)如何激活/减弱“促进”(机制)来实现战略和干预适应(结果)。
■我们描述了特定环境如何激活某些机制,以推动实施多方面COD处理干预措施的不同阶段。
■ClinicalTrials.gov,NCT02942979。
■实施本质上是动态的,并且受到个体之间相互依赖的因素的影响,组织,和系统级别。对于解决并存的心理健康和物质使用障碍的复杂干预措施尤其如此,因为此类干预措施涉及同时提供的多种治疗方式。在繁忙的练习设置中,具有挑战性的人口。本文将合并的实施研究框架(CFIR)构造与现实主义评估相结合,以生成对采用重要的配置,实施,以及高度复杂的干预措施的适应阶段,以解决弱势群体的行为健康和住房需求。每个配置都描述了上下文因素如何触发机制来生成实施结果和答案“什么对谁有用,在什么情况下,在什么方面,这些发现进一步加深了我们对可能的变化机制的理解,并推动我们更精确地识别结构之间的因果关系,这些因果关系有助于成功实施复杂的干预措施。这项工作也促使我们从理论上和方法上进行更有活力的思考,从而导致更具响应性的实施实践。
UNASSIGNED: Only 7% of individuals with co-occurring mental health and substance use disorder (COD) receive services for both conditions. We implemented and evaluated maintaining independence and sobriety through systems integration, outreach and networking-Veteran\'s edition (MISSION-Vet), an evidence-based manualized psychosocial intervention for Veterans with CODs. This paper identifies the generative mechanisms that explain \"how, for whom, and under what conditions\" MISSION-Vet adoption, implementation, and fidelity work when applied in a complex adaptive system with facilitation support.
UNASSIGNED: Within two VA healthcare systems (Sites A and B), a hybrid III trial tested facilitation to implement MISSION-Vet. We conducted a two-site
case study based on 42 semi-structured consolidated framework for implementation research (CFIR) guided interviews with site leadership, implementers (social workers, peer specialists), and team members (facilitators, site leads). Interviews were coded and CFIR constructs used to generate \"Context + Mechanism = Outcome\" configurations to understand the conditions of MISSION-Vet adoption, implementation, and fidelity.
UNASSIGNED: Site A was low, and Site B was high in adoption, implementation, and fidelity. Adoption hesitancy/eagerness (outcome) resulted from the interaction of \"external policy\" (context) dampening/encouraging a \"tension for change\" (mechanism). Implementation intensity (outcome) was based on how \"peer pressure\" or practice culture (context) activated staff \"self-efficacy\" (mechanism) to engage with MISSION-Vet and appraise its \"relative advantage\" over current practices (mechanism). Fidelity relied on how \"staffing structure and availability\" (context) activated/muted \"facilitation\" (mechanism) to result in strategy and intervention adaptation (outcome).
UNASSIGNED: We delineated how specific contexts activated certain mechanisms to drive the different stages of implementation of a multi-faceted COD treatment intervention.
UNASSIGNED: ClinicalTrials.gov, NCT02942979.
UNASSIGNED: Implementation is inherently dynamic and influenced by interdependent factors operating at the individual, organizational, and system levels. This is especially true for complex interventions addressing co-occurring mental health and substance use disorders because such interventions involve multiple treatment modalities delivered simultaneously, in busy practice settings, with challenging populations. This paper pairs consolidated framework for implementation research (CFIR) constructs with a realist evaluation approached to generate configurations important to the adoption, implementation, and adaptation stages of a highly complex intervention addressing the behavioural health and housing needs of a vulnerable population. Each configuration describes how contextual factors trigger mechanisms to generate implementation outcomes and answers \"what works for whom, in what circumstances and in what respects, and how?\" These findings further our understanding of possible mechanisms of change and push us to be more precise about identifying causal relationships among constructs that contribute to the success of implementing complex interventions. This work also moves us to think theoretically and methodologically in a more dynamic fashion, thereby leading to more responsive implementation practice.