What Would It Take? Stakeholders' Preferences for Implementing Health Care Manager Programs in Public Mental Health Clinics Under Health Care Reform

Introduction. Adults with serious mental illness (SMI) die at an early age due to chronic medical conditions and poor medical care.  Health care manager interventions can improve the physical health of people with SMI and are a central element of medical homes under health care reform in the U.S.  Yet these interventions are not widely used in the community.  In this federally funded study, we used concepts from the theory of diffusion of innovations, the consolidated framework for implementation research, and a taxonomy of implementation strategies to examine stakeholders’ views of a promising health care manager intervention (Primary Care, Access, Referral and Evaluation [PCARE] program) and their recommendations for implementing this intervention in public mental health clinics serving Hispanics with SMI.

Methods. A purposive sample of 20 stakeholders was recruited from mental health agencies, primary care clinics, and consumer advocacy organizations in New York.  We presented participants a vignette describing PCARE and then used semi-structured qualitative interviews to examine their views about the program and their preferences and recommendations for implementing this program.  Interviews were recorded and professionally transcribed.  We used directed content analysis to inform our qualitative analysis. This is a deductive analytical strategy that employs existing theories and constructs to inform the coding process and allows for the validation, expansion, and refutation of frameworks and theories.   The following strategies were used to ensure the trustworthiness of our analysis: generation of an audit trail, peer debriefing meetings, and member-checking presentations to the project’s community advisory board

Results. Our sample was composed of 5 mental health providers, 5 primary care doctors, 5 clinic administrators, and 5 consumer advocates.  We found that stakeholders viewed PCARE positively as it addressed the health care needs of the patient population.  The following intervention characteristics were central in shaping stakeholders’ opinions of PCARE: relative advantage, cost, compatibility to the organization, and compatibility to Hispanics.  Stakeholders’ concerns about PCARE centered on how to best integrate this complex intervention into routine practice by demonstrating its local relative advantage over existing services, addressing cost concerns (e.g., how to pay for PCARE services), and enhancing the compatibility of the intervention to the organization and the client population.  Stakeholders’ discussions on how to implement PCARE indicated that a blend of implementation strategies (e.g., financial, quality management) was needed to move this intervention into practice.