The Role of Organizational Context in the Implementation of Mental Health Services in Pediatric Primary Care: Concepts, Mechanisms, and Intervention

Mental health is the most common concern that families bring to pediatric primary care providers (Blanchard, Gurka, & Blackman, 2006) and the leading cause of childhood disability (Halfon, Houtrow, Larson, & Newacheck, 2012) in the United States (Stein et al., 2015). While pediatric staff are in a unique position to coordinate mental health care (Coker, Thomas, & Chung, 2013), there has been little to no change in screening, diagnosis, and treatment practices over the past decade (Stein et al., 2015). This dissertation focuses on a factor that may play a key role in the successful implementation of mental health services in primary care: organizational context. While the concept is common to many implementation science frameworks, there is little consensus on how it is defined and measured through surveys in child health care. It is also unclear what aspects matter to mental health implementation in pediatrics; the mechanisms by which they support or hinder mental health promotion; and the efficacy of complex interventions addressing both individual and organizational determinants of practice change. This mixed-methods research involved primary collection and analysis of data from the Ohio Building Mental Wellness Wave III Learning Collaborative, in which 29 pediatric primary care and family medicine practices were engaged to enhance mental health care delivery. Methods involved a systematic review of the organizational context literature and psychometric testing of a revised survey tool; in-depth qualitative interviews and statistical and qualitative configurative analysis of survey data to explore and test the role of organizational context in practice change; and quasi-experimental pre-post analysis of the effects of the complex intervention on implementation, service, and client outcomes. Taken together, mixed-method findings demonstrate how facets of inner context, including culture, structure/processes, climate and technologies, and outer/fixed context, such as payer mix, co-location, and electronic medical record use, come together in unique ways to moderate the success of mental health service implementation. Findings provided initial evidence that a complex intervention can bring about changes in clinician attitudes and confidence; mental health screening, diagnosis and prescribing patterns; and child mental health outcomes. We conclude that organizational context is critical to successful mental health service implementation and provide practical recommendations for enhancing the organizational context of pediatric primary care to be more supportive of mental health. The “Pediatric Primary Care Office Inventory” survey will be further refined and made freely available to providers as a reliable/valid tool for assessing their organizational context for mental health and identifying strengths and areas for improvement