Depression is a common and serious disorder among pregnant women but few from low income groups receive effective treatment. The highly evidence based collaborative care (CC) model for depression has been shown to work for women in pregnancy but has not been widely implemented. In cases where large scale pragmatic implementation of this innovation has been attempted there has been great variation in the success at individual health centers. A major obstacle to achieving the same success in large scale efforts to implement this care innovation as is seen in more controlled effectiveness trials is the limit of resources available to support the staff members carrying out this care. Although ongoing support in the form of training, technical assistance, quality improvement, and tools has been found to improve implementation and patient outcomes through longitudinal consultation by content experts in the health innovation being implemented most implementation efforts rely primarily on brief intensive training for staff. These content experts are complementary but distinct from general practice facilitators that address general processes that are applicable to implementation of any innovation. In order to achieve the potential public health benefits of CC an efficient and scalable model of longitudinal consultation may be needed to facilitate its effective implementation. We propose a pragmatic cluster randomized trial of longitudinal remote consultation (LRC) utilizing video conferencing to efficiently link providers to consultants who provide timely feedback and training. We plan to use a Hybrid Type III implementation design with a focus on implementation outcomes but also clinical outcomes. The proposed study will involve twenty federally qualified health centers (FQHCs) providing prenatal care and which are part of the national OCHIN Network with a shared electronic health record. All sites will receive a standard multifaceted approach to implementation used in many current broad implementation efforts. After pre-implementation training ten of the sites will be randomly selected to receive the LRC. Implementation and clinical outcomes as well as costs will be compared between the study conditions after a 12 month implementation period and a 13-21 month sustainment period. The results of the proposed study will provide critical generalizable knowledge regarding the benefits of ongoing consultation for implementation of complex interventions like collaborative care.
We plan to carry out a rigorous pragmatic evaluation of the Longitudinal Remote Consultation (LRC) implementation strategy to improve implementation and patient outcomes from team based collaborative care for perinatal depression in federally qualified health centers (FQHCs). LRC improves implementation of evidence based practices for mental health care provided by individual providers but has not been assessed for complex interventions such as collaborative care. Because of the negative impact of perinatal depression, particularly on low income women and their families seen in FQHCs, this promising strategy has great potential for public health impact nationally.
