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Despite high depression rates among people with HIV (PWH), there are uneven mental health screening and referral systems across the Ryan White Medical Case Management (RWMCM) system, which serves >50% of PWH. We conducted a Hybrid type II stepped wedge cluster randomized controlled trial testing the system-wide implementation of a behavioral health screener and referral to ORCHID, an online, evidence-based positive affect intervention in the Chicago RWMCM system.
Methods
As part of the hybrid type II trial, we conducted a multi-method implementation evaluation of the screener and referral process in each wedge of the trial. Quality improvement data informed an interview protocol for Medical Case Managers (MCMs) and supervisors. Interview questions, based on the Consolidated Framework for Implementation Research (CFIR), explored implementation determinants in the inner and outer settings, at the innovation and process levels, and individual characteristics of implementers. We conducted semi-structured interviews with 23 MCMs and supervisors (58% of those invited to participate) from 9 clinics (88% of clinics) in Wedges 1 and 2. Interviews were audio recorded and transcribed. Teams of independent coders analyzed the transcripts using Rapid Qualitative Analysis to identify relevant determinants and to adapt or add implementation strategies for the final Wedge of the trial.
Results
Across wedges, 46% of eligible clients were screened. Of these, 20% had PHQ-9 scores >5, making them eligible for ORCHID, and 6% of those eligible were referred. Qualitative findings indicated that many MCMs and supervisors found it difficult to integrate the screener into their workflows. Integration facilitators included adapting workflows to align the screener with required assessments and the introduction of self-administered and Spanish versions of the screener. However, we also find that many MCMs invoked selective heuristics about which clients needed screening and referral in light of the perceived relative priority, compatibility, and advantage of the behavioral health screening and ORCHID for clients with elevated depression. For example, many MCMs reported not offering ORCHID referrals to older clients with elevated depression scores due to perceived low compatibility or to clients who they perceived would benefit more from psychotherapy. In Wedge 1, many MCMs reported an inaccurate understanding of ORCHID. Despite strengthening of training between wedges, Wedge 2 MCMs
and supervisors reported low buy-in on the compatibility of ORCHID for meeting their client’s behavioral health needs. MCMs continued to identify low acuity, younger, and tech savvy clients as those most appropriate for ORCHID, whereas they were less likely to refer clients who did not meet those criteria.
Conclusions Findings highlight challenges with implementing a universal screener and referral process to an online positive affect intervention in a large, multi-site system that relies on the discretionary authority and skills of direct service workers. In the absence of an implementation strategy that mandates screening and referral, RWMCM staff invoke selective heuristics and gatekeeping. Ground-up approaches to implementation, including providing resources and training that leverage the discretion
of direct service workers, are necessary for the long-term systemic change needed to facilitate equitable mental health screening and access among PWH.