Factors associated with successful FLOW implementation to improve mental health access: a mixed-methods study

Area of Science:

• Health Services Research
• Implementation Science
• Mental Health Services

Background:

• The FLOW program aims to improve access to specialty mental health (SMH) care by transitioning stabilized patients to primary care.
• Implementation of the FLOW program across nine VA sites showed significant variation in success.
• Understanding site-level factors influencing implementation is crucial for program optimization.

Purpose of the Study:

• To identify site-level factors associated with successful implementation of the FLOW program.
• To guide future implementation efforts by highlighting key facilitators and barriers.
• To inform strategies for enhancing the reach and effectiveness of mental health service transitions.

Main Methods:

• A cluster-randomized stepped-wedge trial involving nine VA sites.
• A mixed-methods approach using the Matrixed Multiple Case Study method.
• Analysis guided by the Consolidated Framework for Implementation Research (CFIR) to compare implementation metrics.

Main Results:

• Sites with higher implementation success (measured by veteran transitions) demonstrated positive perceptions of the FLOW intervention (CFIR domain: Innovation).
• A recovery-oriented care culture, prioritizing implementation, and lower mental health provider turnover were associated with greater success (CFIR domain: Inner Setting).
• Well-positioned internal facilitators with leadership roles or cross-clinic connections positively impacted implementation (CFIR domain: Characteristics of Individuals).

Conclusions:

• Perceptions of the intervention, organizational culture, provider stability, and facilitator positioning are critical for successful FLOW program implementation.
• Factors like staffing levels, leadership support, and organizational readiness did not show a consistent relationship with implementation success.
• Identifying these key factors can help target additional support to sites needing assistance for successful program adoption.