Implementation science provides frameworks, theories, models, strategies, and mechanisms to support researchers and practitioners in translating evidence-based interventions into practice and improving the effectiveness of these interventions. However, until recently most implementation science studies did not attend to factors related to health equity. Arguably, the fields of implementation science and health equity research and practice often seek to meet similar outcomes including widespread access to services and resources, improved quality of services delivered, and generalizable benefits from evidence-based intervention implementation.

This dissertation evaluates equitable implementation and sustainment of California’s Whole Person Care initiative, which tested whether provision of care coordination, housing assistance, and other social services could improve cost and outcomes of care for high-risk, high-need Medicaid enrollees. Health systems increasingly use case management programs to integrate social and medical services to support health equity for high-risk, high-need patients. Limited evidence exists about key components of integrated case management program implementation and sustainability, especially from a health equity perspective.

Chapter 1 is a thematic analysis exploring how a single WPC pilot integrating medical and social services for high-risk, high-need patients addressed health equity through pilot design and implementation. Chapter 2 applies a mixed methods approach to identify key individual, interpersonal, and organizational factors associated with case manager job satisfaction and intention to leave their role among a sample of Whole Person Care frontline case management staff. Chapter 3 applies a thematic analysis approach to identify multi-level factors hindering or supporting equitable sustainability of Whole Person Care pilot components beyond the pilot phase. Combined, these analyses provide a blueprint for assessing equity research and practice leveraging the strengths of implementation science, while also offering pragmatic findings to inform future efforts to design, implement, and evaluate integrated case management models broadly.

Individuals with decompensated cirrhosis (DC) in the United States (U.S.) receive costly, burdensome care at the end of life that may not be concordant with their goals and preferences. With a growing prevalence of individuals affected by liver disease over the past decade and limited capacity for performing liver transplantation (LT), solutions are critically needed. Advance care planning (ACP), a process that supports adults in understanding and sharing their personal values, life goals, and preferences regarding future medical care, is beneficial in helping patients with serious, life-limiting illnesses and their caregivers cope with the realities of their disease. Use of ACP has been associated with improved end of life outcomes, such as lower healthcare utilization and care consistent with goals. However, little is known about how often ACP occurs in patients with DC.

This dissertation explores the experience of ACP in patients with DC at LT centers. Semi-structured interviews were conducted with 42 patients with DC and 46 LT providers at three major LT centers in Los Angeles. Analyses focused on understanding the extent to which

LT providers currently engage in ACP with patients with DC (Study 1), the experience of ACP from the perspectives of patients (Study 2), and barriers to ACP experienced by LT providers (Study 3). Results show that although most LT providers find early engagement in ACP acceptable, few providers engage in ACP in patients with DC at LT centers, and if goals of care discussions occur, they happen at the very end of life. Patients with DC similarly report limited conversations with providers at LT centers, but are mostly ready to have these conversations. The most common barriers faced by providers in performing ACP include an organizational culture that prioritizes transplants over other care (“transplant culture”), competing demands for provider time, role ambiguity, language barriers, and limited cultural competence. In light of these findings, we advocate for future research efforts to focus on identifying provider knowledge gaps and creating models of care that incorporate palliative care, as well as changes in policy. We believe this dissertation provides an important framework for understanding the current state of ACP in patients with DC and can direct the development of interventions that ultimately promote provision of goal-concordant care in this population.

Team-based care can be associated with improved care quality, but simply being on a team is not sufficient for achieving the “quadruple aim” of enhancing patient care experiences, improving population health, reducing healthcare costs and improving provider experience. Rather, implementation of healthcare teams varies greatly across and within organizations, and there is a growing body of contradictory evidence on how implementing team models can impact the well-being of team members. This dissertation examines how healthcare organizations may take steps to improve team functioning and team member well-being in primary care settings.Our first study addresses this question by contributing empirical evidence to guide practices on how to optimize team functioning. We examined how the implementation strategy, evidence-based quality improvement (EBQI), was used to change PC team processes at two VA medical centers (Sites A and B) over a two year period. We used a comparative case study, analyzing multiple qualitative data sources collected from those sites: baseline and follow-up interviews with key stakeholders and provider team (“teamlet”) members (n=64), and EBQI meeting notes, reports, and supporting materials. Our analysis showed that the sites developed unique innovations upon participating in EBQI, with each project tailored to their site’s respective needs, context and capacity: Site A’s QI project entailed engaging in structured daily huddles using a huddle checklist and developing a protocol clarifying team member roles and responsibilities; and Site B initiated weekly virtual team meetings that spanned two practice locations. Respondents from both sites perceived these projects as improving team structure and staffing, team communications, role clarity, staff voice and personhood, accountability, and ultimately, overall team functioning over time. Our second study examines the association between team processes and team members’ well-being, as well as the practices that optimize their team experiences in those areas. We used a sequential explanatory mixed methods approach and examined: cross-sectional survey data (n=244) to explore the relationship between team processes such as communication and participation in decision-making with job satisfaction, as well as the more distal outcome of turnover intent; and interview data (n=73) to conduct a thematic analysis of how various practices and mechanisms impacted team members’ experiences with those team processes. Additionally, we explored whether team members varied in their reported well-being and team experiences by role. We found a strong and significant association between team member processes (e.g., communication and participation in decision-making) with team members’ reported rate of job satisfaction and, to a lesser degree, their intent to remain in their positions. Job satisfaction and intent to continue were generally high among care teams, but clinical associates were less likely to be satisfied with their jobs, and clerical associates were less likely to report an intent to stay in their current positions. Qualitative analysis found some clerical and clinical staff still experiencing an imbalance in voice and participation within their teams. The qualitative analysis affirmed the importance of the proximity, availability and attributes of providers and staff in how their team members experienced team processes.

In medicine, computers are increasingly used not only to document patient care, but to support clinical decisions with relevant medical knowledge and patient information. This function is referred to as clinical decision support (CDS). Decades of scholarship have focused on evaluating CDS effectiveness, with promising but highly variable results. Having established that CDS can be useful, many have turned to more complex questions: what factors make CDS more effective and better-received by its users? How does CDS fit in with other strategies meant to ensure that clinical decisions are informed by current medical knowledge? When CDS works well, why and how does it do so? These are particularly important questions within the Department of Veterans Affairs (VA), which has a long history of using CDS, and has a massive scale that can enable CDS improvements to affect millions of patients. In this dissertation, I explore the use of CDS in VA primary care clinics. In study 1, I use VA-wide survey data to evaluate "user-centered design" strategies intended to make CDS easier to use and more effective. In study 2, I link that survey data with administrative records on colorectal cancer screening to examine CDS as one of several strategies for implementing evidence-based practices. In study 3, I use data from semi-structured interviews with primary care providers at VA clinics around Los Angeles to understand how CDS works for a specific clinical decision (prostate cancer screening).

I find that “analysis of impact on performance improvement” is positively associated with perceived utility of CDS, but no association is evident for the other three user-centered design strategies examined. In assessing CDS efficacy alongside other strategies to support colorectal cancer screening, I find that neither CDS, nor any other implementation strategy examined, is associated with screening. In the qualitative study, I identify key factors in the effectiveness and acceptability of CDS for prostate cancer screening, including: workflow compatibility, the use of a trusted clinical guideline, and consultation with the intended users of CDS as part of its implementation.

Conclusion: Judicious implementation and governance of CDS are important determinants of its usefulness.

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Complementary and Integrative Health (CIH) approaches to medical care include trained medical providers working closely with patients to incorporate both alternative (e.g., acupuncture, yoga, meditation, etc.) and conventional medicine into standard medical care. While the effectiveness of CIH therapies is a well-studied topic, less is known about their use and adoption within large health care systems. As with other therapeutic modalities, use and adoption of CIH therapies is impacted by a myriad of interacting factors at the patient, provider, and organizational levels. This three-paper dissertation explored some of these factors through a service delivery and policy lens, with an aim to provide policy makers and other health systems with data on whether and how novel, non-pharmaceutical therapeutics are being integrated into the conventional health system. In Chapter 2 (Study 1), I used a longitudinal design to measure use of CIH therapies funded by the Department of Veterans Affairs (VA) for a defined cohort of Veterans over a three-year period. I compared the proportion of users in Flagship and non-Flagship VA medical centers (VAMCs) pre-and mid-implementation of a three-year pilot aimed at expanding provision of CIH therapies. Flagship VAMCs received considerable financial and implementation support from central VA administration to assist with expanding availability and accessibility to CIH therapies and other Whole Health System services. Non-Flagship VAMCs were expected to also expand access to the eight mandated CIH therapies, but without the additional financial or technical support provided to Flagship VAMCs. From pre-implementation to two years post-implementation of the three-year pilot, the percent of users increased by an absolute value of 3.1% system-wide for this population (from 10.2% to 13.3%). Increases were observed for Veterans in both Flagship and non-Flagship VAMCs, but were significantly greater at Flagship VAMCs, particularly in the final study year. In Chapter 3 (Study 2), I used a cross-sectional design to examine organizational characteristics associated with use of VA-funded CIH therapies. VAMCs are required to provide access to eight CIH therapies for Veterans, but can choose whether to provide these services directly or via referral to community-based providers. Direct provision of CIH therapies within VAMCs is resource intensive, as it requires program development, hiring and training of staff, and system level changes that support incorporation into standard medical care. However, overreliance on VA-funded community care increases risk of care fragmentation and negatively impacts resources available for internal VAMC use. This study found that rurality, Flagship status, and receipt of targeted Whole Health System grants were not associated with provision of more VA-funded CIH therapies. I also found that VAMCs with fewer VA-based CIH therapies available provided as many or more total CIH visits on average as VAMCs with more VA-based CIH therapies, due to greater reliance on VA-funded community care. Chapter 4 (Study 3) was a qualitative study that assessed Veteran and provide knowledge and attitudes towards CIH therapies, as well as perceived barriers to CIH uptake. Data included interviews with 17 Veterans with chronic pain and opioid use disorder (OUD) and 45 providers from five VAMCs in the southwestern US. It found that Veterans and providers had good knowledge of CIH therapies as effective and important treatment options based on personal experience and recognition of need for multi-modal treatments that include NPIs, particularly for Veterans with chronic pain. As a result, they were generally enthusiastic about integrating CIH therapies into treatment plans as an NPI option for chronic pain. However, providers had more mixed attitudes towards using CIH therapies for Veterans with OUD because they noted this population is more resistant to using CIH therapies and is more unstable. Veterans interviewed for this study did not express those fears and largely wanted access to these therapies. Providers also noted several system-level challenges impacting use of CIH therapies through the VA, including lack of availability, the absence of central directory showing availability of CIH therapies within VAMCs, and the bureaucratic community care referral system.

Despite evidence that care management practices (CMPs) are helpful in managing chronic illness, uneven adoption by physician organizations persists. This dissertation used an explanatory sequential mixed methods design to examine factors influencing physician organizations’ adoption of evidence-based CMPs for chronic conditions. Data were drawn from the third wave of the National Survey of Physician Organizations (NSPO3). Three distinct studies were conducted.

The first study utilized item response theory to explore whether physician organizations’ CMP adoption choices were linked, and whether adoption choices could be ordered by disease focus or CMP type. Scales for CMP type consistently ranked diabetes CMPs as the most adoptable, and depression CMPs as the least adoptable. Scales for disease focus consistently ranked patient reminders as the most adoptable CMP and clinician feedback and patient education as the least adoptable CMPs.

The second study examined contextual and organizational factors associated with CMP adoption. Results of a logistic regression conducted on the full NSPO3 sample (N=1,398) indicated that interest in patient-centered medical home accreditation or participation in an accountable care organization were among the factors associated with adoption of at least one CMP. Zero-truncated negative binomial regression conducted on the sample of organizations adopting at least one CMP (n=1,263) found that in addition to these variables, use of quality improvement systems and support of CMPs by external entities were also associated with number of CMPs adopted.

The third study explored different strategies that may be required to support uptake of diabetes CMPs in late- and non-adopting organizations, which are quite different from the early adopters typically described in the literature. Quantitative analyses were used to identify “positive deviants,” i.e., organizations that had adopted at least one diabetes CMP despite having organizational characteristics associated with non-adoption. Comparative case studies of two non-adopting and two positive deviant organizations revealed that positive deviants identified organizational priorities aligned with diabetes management and leveraged external support for CMP uptake.

Implications/Conclusion. Lessons learned from adoption patterns and positive deviants in real-world practice environments of physician organizations may be key in building strategies to promote uptake of evidence-based practices and combat variations in care.

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