Sustaining Practice Change: How to Prevent Organizational Relapse

Implementation of a high-quality collaborative care program can be challenging but sustaining that program can be even more difficult. In this month’s column, Diane Powers, M.B.A., M.A., writes about lessons learned from developing a sustainment intervention as part of a collaborative care implementation in the rural West. —Jürgen Unützer, M.D., M.P.H.

Over the past 15 years, the University of Washington AIMS Center has learned a lot about what it takes to implement a multicomponent health care innovation. One of the key lessons learned from efforts to implement the Collaborative Care Model (CoCM)—an approach that integrates behavioral health care and primary care—is that it can be more difficult to sustain practice change than to implement it.

Sustaining innovative health care programs can be particularly challenging in rural areas, where there are fewer health care providers as well as technological limitations, such as a lack of high-speed internet.

A few years ago, the AIMS Center provided CoCM training, practice coaching, and program evaluation for primary care clinics serving low-income individuals living in health care provider shortage areas and/or medically underserved areas of the rural West. Through conversations with employees at these clinics, several best practices for sustaining practice change emerged:

Sustainment Starts Before Implementation

• Develop a clear vision and goals for the practice change. The first step in implementing a practice change is to develop a clear rationale for the practice change being implemented and clear, concrete goals. Engaging all stakeholders, including clinicians, support staff, clinic leadership, board of directors, and patients, in developing the vision and goals increases the likelihood of employee alignment with the practice change and strengthens shared accountability to patients and other stakeholders.

  The goals established during the planning stage are intended as a starting point that clinic leadership can use to measure progress toward achieving their behavioral health integration goals. These goals should evolve over time.

• Develop a business case for integrating behavioral health care. Financing is often the biggest barrier to sustainment. Available financing strategies include external start-up funding, Centers for Medicare and Medicaid Services billing codes, and support from commercial payers. Regardless of the funding sources, it is crucial that clinics develop a business case for integrating behavioral health care and primary care that is at least revenue neutral.

  “[T]he biggest [revenue] hurdle to overcome is that the care manager can’t bill, so they’re not an income-generating position,” explained an employee at one of the clinics participating in the CoCM program. “We can look at other programs in our organization that are generating revenue to help us out, but I would say [billing is] the biggest hurdle.”

Sustainment Is a Process

• Establish measurable treatment targets. Perhaps the most important component of CoCM is measurement-based treatment to target. This means measuring patient-level clinical outcomes and using this information to make proactive changes in treatment when patients are not improving. While we usually think of this in the context of individual patient care, it also applies to organizational sustainment. That is, the organization should measure aggregate clinical outcomes and evidence-based processes of care (for example, proportion of patients discussed with psychiatric consultant) and make program adjustments if organizational goals are not being met.

• Be prepared for staff turnover. One of the biggest threats to sustainment is staff turnover, especially in rural areas where workforce shortages are most acute. “You have a time when everything is running smoothly, and … then the medical team changes due to attrition and you have to start the process all over again,” said an employee at one of the clinics participating in the CoCM program.

  To address this issue, staff at this clinic built trainings on CoCM into the onboarding process for new medical providers in all three roles—care managers, primary care providers, and psychiatric consultants.

• Establish a process for continuous quality improvement. For practice change to become institutionalized, a continuous quality improvement process is necessary. This involves regularly reviewing process and outcome metrics, identifying areas for improvement, implementing interventions to make those improvements, and evaluating the outcomes.

  “It’s particularly useful to have … very clear standards, expectations, and trackable data. When [processes] aren’t working, there needs to be troubleshooting [to pinpoint the problem area],” said leaders at one of the clinics participating in the CoCM program. Continuous quality improvement has “forced examination of policies and procedures everywhere [from] clinical flow to human resources. It’s been a very useful driver of overall, organizational improvement.”

Clinics implementing CoCM often assume that effective implementation seamlessly translates to effective sustainment. But preventing organizational relapse requires planning for sustainment during the implementation planning phase and ongoing review of processes and outcomes after implementation. ■