The DIAMOND Initiative: Implementing Collaborative Care for Depression in 75 Primary Care Clinics

Background: The many randomized trials of the collaborative care model for improving depression in primary care have not described the implementation and maintenance of this model. This paper reports how and the degree to which collaborative care process changes were implemented and maintained for the 75 primary care clinics participating in the DIAMOND Initiative (Depression Improvement Across Minnesota–Offering a New Direction). Methods: Each clinic was trained to implement seven components of the model and participated in ongoing evaluation and facilitation activities. For this study, assessment of clinical process implementation was accomplished via completion of surveys by the physician leader and clinic manager of each clinic site at three points in time. The physician leader of each clinic completed a survey measure of the presence of various practice systems prior to and one and two years after implementation. Clinic managers also completed a survey of organizational readiness and the strategies used for implementation. Results: Survey response rates were 96% to 100%. The systems survey confirmed a very high degree of implementation (with large variation) of DIAMOND depression practice systems (mean of 24.4 ± 14.6%) present at baseline, 57.0 ± 21.0% at one year (P = \u3c0.0001), and 55.9 ± 21.3% at two years. There was a similarly large increase (and variation) in the use of various quality improvement strategies for depression (mean of 29.6 ± 28.1% at baseline, 75.1 ± 22.3% at one year (P = \u3c0.0001), and 74.6 ± 23.0% at two years. Conclusions: This study demonstrates that under the right circumstances, primary care clinics that are prepared to implement evidence-based care can do so if financial barriers are reduced, effective training and facilitation are provided, and the new design introduces the specific mental models, new care processes, and workers and expertise that are needed. Implementation was associated with a marked increase in the number of improvement strategies used, but actual care and outcomes data are needed to associate these changes with patient outcomes and patient-reported care

Logopädische Therapie bei schwerhörigen Kindern mit CI: Begleitung, Integration, Diagnostik und Therapie

Hören und Sprechen sind in der Sprachentwicklung eng miteinander verbunden. Jegliche Einschränkung des Hörvermögens reduziert die Möglichkeiten des Lautspracherwerbs. Kinder mit einer hochgradigen Hörschädigung benötigen nebst einer guten Versorgung mit Hörhilfen eine logopädische Therapie, um die Lautsprache bestmöglich erwerben zu können

A Stepped-Wedge Evaluation of an Initiative to Spread the Collaborative Care Model for Depression in Primary Care

PURPOSE: Scale-up and spread of evidence-based practices is one of the most important challenges facing health care. We tested whether a statewide initiative, Depression Improvement Across Minnesota–Offering a New Direction (DIAMOND), to implement the collaborative care model for depression in 75 primary care clinics resulted in patient outcome improvements corresponding to those reported in randomized controlled trials. METHODS: Health plans provided a new monthly payment to participating clinics after a 6-month intensive training program with ongoing data submission, networking, and consultation. Implementation was staggered, with 5 sequences of 10 to 40 clinics every 6 months. Payers provided weekly contact information for members from participating clinics who were filling antidepressant prescriptions, and we conducted baseline and 6-month surveys of 1,578 patients about their care and outcomes. RESULTS: There were 466 patients in DIAMOND clinics who received usual care before implementation (UCB), 559 who received usual care in DIAMOND clinics after implementation (UCA), 245 who received DIAMOND care after implementation (DCA), and 308 who received usual care in comparison clinics (UC). Patients who received DIAMOND care after implementation reported more collaborative care depression services than the 3 comparison groups (10.9 vs 6.4–6.7, on a scale of 0 of 14, where higher numbers indicate more services; P \u3c.001) and more satisfaction with their care (4.0 vs 3.4 on a scale 1 to 5, in which higher scores indicate higher satisfaction; P ≤.001). Depression remission rates, however, were not significantly different among the 4 groups (36.4% DCA vs 35.8% UCB, 35.0% UCA, 33.9% UC; P = .94). CONCLUSIONS: Despite the incentive of a supporting payment change and intensive training and support for clinics volunteering to participate, no difference in depression outcomes was documented. Specific unmeasured actions present in trials but not present in these clinics may be critical for successful outcome improvement

Effective Implementation of Collaborative Care for Depression: What Is Needed?

Objectives: To identify the care model factors that were key for successful implementation of collaborative depression care in a statewide Minnesota primary care initiative. Study Design: We used a mixed-methods design incorporating both qualitative data from clinic site visits and quantitative measures of patient activation and 6-month remission rates. Methods: Care model factors identified from the site visits were tested for association with rates of activation into the program and remission rates. Results: Nine factors were identified as important for successful implementation of collaborative care by the consultants who had trained and interviewed participating clinic teams, and rated according to a Likert Scale. Factors correlated with higher patient activation rates were: strong leadership support (0.63), well-defined and -implemented care manager roles (0.62), a strong primary care physician champion (0.60), and an on-site and accessible care manager (0.59). However, remission rates at 6 months were correlated with: an engaged psychiatrist (0.62), not seeing operating costs as a barrier to participation (0.56), and face-to-face communication (warm handoffs) between the care manager and primary care physician for new patients (0.54). Conclusions: Care model factors most important for successful program implementation differ for patient activation into the program versus remission at 6 months. Knowing which implementation factors are most important for successful activation will be useful for those interested in adopting this evidence-based approach to improving primary care for patients with depression

Conformal Ultrathin Film Metal–Organic Framework Analogues: Characterization of Growth, Porosity, and Electronic Transport

Thin-film formation and transport properties of two copper-paddlewheel metal-organic framework (MOF) -based systems (MOF-14 and MOF-399) are investigated for their potential integration into electrochemical device architectures. Thin-film analogs of these two systems are fabricated by the sequential, alternating, solution-phase deposition of the inorganic and organic ligand precursors that result in conformal films via van der Merwe-like growth. Atomic force microscopy reveals smooth film morphologies with surface roughnesses determined by the underlying substrates and linear film growth of 1.4 and 2.2 nm per layer for the MOF-14 and MOF-399 systems, respectively. Electrochemical impedance spectroscopy is used to evaluate the electronic transport properties of the thin films, finding that the MOF-14 analog films demonstrate low electronic conductivity, while MOF-399 analog films are electronically insulating. The intrinsic porosities of these ultrathin MOF analog films are confirmed by cyclic voltammetry redox probe characterization using ferrocene. Larger peak currents are observed for MOF-399 analog films compared to MOF-14 analog films, which is consistent with the larger pores of MOF-399. The layer-by-layer deposition of these systems provides a promising route to incorporate MOFs as thin films with nanoscale thickness control and low surface roughness for electrochemical devices