Implementation cost analysis of collaborative care for perinatal mental health in community health centers

Implementation cost analysis of collaborative care for perinatal mental health in community health centers | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Implementation cost analysis of collaborative care for perinatal mental health in community health centers Tess Grover, Ian M Bennett, Mark Campbell, Melinda Vredevoogd, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5256122/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Although costs are of key importance to clinic leadership when considering adoption of new programs, few studies examine real-world resource needs associated with implementing complex interventions for chronic conditions in primary care. This analysis sought to identify the costs necessary to implement the evidence-based collaborative care model (CoCM), an integrated behavioral health program for common mental disorders in primary care. Methods Ten federally qualified health centers (FQHCs) adopted CoCM as part of a larger national randomized trial evaluating implementation strategies for CoCM when adapted for perinatal mental health. The Cost of Implementing New Strategies (COINS) tool was used to assess implementation costs associated with activities completed by sites as they progressed through the implementation process. National wage norms were used to calculate cost estimates for staff time. Results On average, clinics spent $ 40,778 (SD= $ 30,611) on implementation, with clinics ranging widely from $ 4,502 to $ 103,156. Three out of 10 participating clinics achieved competency in the intervention during the 2-year implementation period. Costs among competent clinics ranged from $ 20,944 to $ 65,415 (mean= $ 41,788). Clinics that did not achieve competency were more varied, with both the lowest and highest resource use. Significant staff effort was required to complete all implementation stages; clinical staff and program champions showed greatest effort. Conclusions Site implementation costs for this complex behavioral health intervention were substantial and varied dramatically, particularly among sites who did not achieve competence. Additional work is needed to identify optimal site resource investment related to implementation success for CoCM. Trial registration: ClinicalTrials.gov.NCT02976025. Registered on November 23, 2016. perinatal depression collaborative care implementation costs integrated behavioral health Contributions to the literature Although cost is a key consideration for clinic leadership when planning adoption of a new program, few studies look at the actual resource needs associated with implementing complex interventions, such as the collaborative care model (CoCM), in primary care. Our study found evidence that clinics who did not successfully adopt CoCM for perinatal depression incurred costs that were either considerably higher or lower than sites that did successfully adopt the model, indicating efficiency of resource use as a factor in successful implementation. These findings contribute to gaps in the literature around successful adoption of CoCM, including the importance of optimal site resource investment as a consideration for implementation planning. Background Perinatal mood and anxiety disorders (PMAD) are common, undertreated, and affect both parents and their infants during pregnancy and the first year after childbirth [ 1 – 3 ]. People who are pregnant or postpartum are at risk for major depressive disorder or dysthymia, with up to 16% experiencing symptoms of depression during pregnancy [ 4 ] and up to 14% experiencing symptoms of anxiety [ 5 ]. Perinatal depression is more than twice as prevalent in patients who are low-income than other patients [ 6 ]. Suicide, most often among patients with depression, is a leading cause of maternal mortality [ 7 , 8 ], and mental health conditions are linked to 11% of pregnancy-related deaths [ 9 ]. Despite these significant deleterious outcomes, patients from low income or racial and/or ethnic minority backgrounds are less likely to be identified and treated for PMAD than other patients [ 10 , 11 ]. Systematic efforts to address the mental health needs of parents during the perinatal period in general, and within these high-risk populations specifically, are not widely implemented [ 10 , 11 ]. Federally qualified health centers (FQHCs), are federally supported safety net sites serving disproportionately high numbers of low income and race/ethnic minority populations that have historically been underserved. These sites provide multi-disciplinary maternal-child and primary care allowing for opportunities to address PMAD through continuity across the pre/inter-pregnancy, prenatal, and postpartum transitions [ 12 ]. Yet, few evidence-based interventions focused on perinatal mental health are employed within primary care settings. The collaborative care model (CoCM) is an evidence-based, behavioral health integration intervention to support the treatment of common behavioral health conditions in primary care settings [ 13 ]. CoCM leverages existing behavioral health professionals working in primary care clinics and additional specialty mental health consultants (typically psychiatrists or psychiatric nurse practitioners) to support the patient through team-based care [ 13 – 15 ]. CoCM has been tested in more than 80 randomized controlled trials in the US and internationally, and meta-analyses of these studies indicate that it consistently improves on care as usual, including in perinatal populations [ 16 – 22 ]. Because of the high level of evidence, the Center for Medicare and Medicaid Services (CMS) has promulgated billing codes to support activities related to CoCM [ 23 – 25 ]. Despite these reimbursement opportunities and demonstrated improved outcomes in patients with perinatal depression, CoCM is not yet widely implemented within clinics that serve this population [ 20 ]. One barrier to the implementation of new interventions is the perceived resource needs associated with implementation, including training, change management, and salary costs for time spent on this work [ 26 ]. This is particularly true for complex interventions such as CoCM that involve coordination across multiple providers, managers, and diverse support staff.[ 27 ] Previous studies examining cost associated with CoCM primarily examined cost effectiveness of the intervention, finding improved clinical outcomes at no greater cost than usual care [ 28 , 29 ]. Cost-benefit analyses have shown that every dollar spent on CoCM for geriatric depression resulted in $ 6 long-term healthcare costs saved per patient [ 30 ]. Other studies have found that CoCM produces lower annualized total healthcare costs per patient than usual care [ 31 ] and less outpatient health services costs than usual care [ 32 ]. While helpful for public policy financing decisions, these analyses do not address the implementation cost for integrating the intervention into clinics, which is critical to individual site choices regarding the adoption of clinical innovations. Despite the positive cost outcomes of CoCM in rigorous trials for treating depression, the unknown real-world implementation costs—including the costs of building the infrastructure and environment needed to successfully deliver CoCM—pose a barrier to adoption. By understanding the implementation costs of CoCM for perinatal depression, appropriate planning and support can be provided for clinics serving patients at risk for PMAD. In the current study, we wished to capture the real-world costs associated with implementing CoCM for perinatal depression in health centers serving patients in pregnancy and the year postpartum from historically underserved populations and at high risk of PMAD. Those costs include staffing based on the amount of time various clinic team members spent on implementation activities, practice facilitation, coaching, and training. Methods Participants: The Maternal Infant Dyad Implementation (MInD-I) study was designed to evaluate strategies for helping sites implement CoCM for perinatal depression and anxiety (NCT02976025: PI Bennett). The study was reviewed and approved by the University of Washington Institutional Review Board (IRB). Sites were recruited from the OCHIN national primary care informatics network comprised primarily of Federally Qualified Health Centers (FQHCs) and FQHC look-alikes [ 12 ]. OCHIN sites are part of a national collaborative of over 500 primary care clinics in 47 states that share an iteration of the Epic© electronic health record. Clinics were enrolled in the study based on two criteria: 1) use of the shared Epic© electronic medical record for perinatal care and 2) a minimum of 50 perinatal patients served annually. Ten FQHCs agreed to participate in the first cohort of the project from April 2016 to April 2020, including 4 sites in California, 2 sites in Massachusetts, 1 site in Indiana, 1 in Texas, 1 in Wisconsin, and 1 in Oregon. Sites ranged in size, serving 59–1,245 unique perinatal patients annually, with a mean of 406 perinatal patients served per year. On average, 72% of patients served by the sites identified as racial and/or ethnic minority patients (as reported in annual health center data) and 89% were at or below 200% of the federal poverty guideline (Table 1 ). Table 1 MInD-I site baseline characteristics a Site State Unique patients per year Unique perinatal patients per year Racial and/or ethnic minority patients Patients at or below 200% of federal poverty level A CA 12,144 188 70% 96% B CA 11,400 323 95% 99% C CA 15,145 469 84% 80% D TX 12,032 1345 97% 98% E CA 55,159 637 19% 76% F WI 11,408 256 93% 96% G OR 3359 59 3% 63% H IN 10,000 430 90% 98% I MA 13,271 180 78% 87% J MA 12,410 175 95% 100% Mean --- 15,633 406 72% 89% a Source: US Health Resources and Services Administration Data Warehouse (2016 data) Implementation Strategies Participating clinics received implementation support and registry training from experts in practice facilitation based at OCHIN and clinical training and expert consultation from CoCM trainers and consultants employed by the Advancing Integrated Mental Health Solutions (AIMS) Center at the University of Washington. Practice facilitation began roughly 3 months prior to launching care and was intended to orient sites to CoCM, help identify staff for collaborative care team roles, and develop team readiness and clinical workflows. Core team members, including care managers, psychiatric consultants, PCP (primary care provider) champions, project leads, and the Epic© site specialist from each clinic attended a 2-day in-person CoCM training prior to program launch. The core care team received 1 hour of practice facilitation support monthly. Care managers met once a month for training webinars, and psychiatric consultants met quarterly for calls with an expert CoCM psychiatrist trainer. Clinics were provided with online training resources via an online learning management system (LMS), but use of these resources varied among clinics and roles. Clinics were permitted to configure the CoCM team for their clinical context, as long as key components were maintained, resulting in variation in the types and quantities of staff participating in the implementation of MInD-I at each site. Four of the sites received additional support over the first 12 months after launching services in the form of Longitudinal Remote Coaching (LRC) by an experienced psychiatric consultant who observed the work of the local teams during select systematic case reviews and provided feedback [ 33 ]. Measures The Cost of Implementing New Strategies (COINS) approach is a method for mapping resources needed for implementation efforts of sites (clinics/agencies/systems) adopting new interventions or practices [ 34 , 35 ]. Implementation costs are mapped onto activities operationalized within the Stages of Implementation Completion (SIC©) [ 36 , 37 ]. The SIC is a measure of implementation process that defines, captures, and tracks necessary implementation activities by newly adopting sites across eight stages, from Engagement (Stage 1) to Competency (Stage 8). Each of these stages falls within three well-established phases of implementation: Pre-implementation, Implementation, and Sustainment [ 38 ]. The SIC has been rigorously evaluated and developed for use for the implementation of evidence-based practices (EBPs) [ 37 , 39 , 40 ]. Although the 8 implementation stages are standard across practices, activities within the stages are tailored or customized to the practice being monitored. The SIC previously has been adapted for CoCM [ 36 ], which in turn was customized further for the MInD-I implementation strategies that were integrated within CoCM. During the course of the MInD-I implementation, sites incurred resources and costs as they progressed through the implementation process, including assessment of feasibility (SIC Stage 2), readiness planning (SIC Stage 3), hiring and training of staff (SIC Stage 4), delivering the program with fidelity (SIC Stages 5–7), and ultimately achieving competency to sustain the program (SIC Stage 8). The COINS tool provides a validated approach to collect the costs and resources involved in completing the implementation strategies associated with each of these stages. The COINS tool is web-based, allowing for easier real-time data entry and management. To prepare for programming of the MInD-I COINS, implementation activities were identified on the MInD-I SIC where resource use might occur. The type of positions and/or roles that might be involved in completing each activity were defined and programmed to capture which roles were involved for each site. The COINS system prompted the data collector to capture human resources (i.e., amount of time and position), and fixed expenditures (e.g., rent, computers, advertising) that were required to implement MInD-I. The majority of the costs in the Pre-Implementation Phase resulted from labor resources on the unique activities, with none of the sites incurring associated fixed, infrastructure or assigned FTE (full-time equivalent) costs. Implementation Phase costs primarily resulted from clinical staff FTE assigned to the implementation, in addition to the direct resources spent on each activity at the site. Data Collection Data were collected by a member of the research team (the first author) from each of the 10 participating sites during the site support period from April 2016 to April 2020. COINS data were collected through remote conversations among the data collector, implementation facilitators, and the sites. Additionally, site and purveyor organization travel costs were collected via project invoices. Data regarding the number of patients served by the MInD-I program came from ADVANCE (Accelerating Data Value Across a National Community Health Center Network), a PCORnet clinical trials network that includes data from community health centers. Results Site Costs: The COINS method described above produces several different results that can be compiled to generate the total cost of implementation: 1) fixed expenses associated with the implementation, 2) staff hours associated with the discrete implementation activities described in the SIC, and 3) MInD-I FTE allocation during the implementation process. Fixed expenses in this context refers to rent/office space, computers, office supplies, and other non-employee based expenses incurred to support the intervention. Because MInD-I was incorporated into existing clinic settings for the project, no additional fixed expenses were reported. Thus, all resource costs to implement MInD-I within the participating clinics were strictly incurred by staff hours. Table 2 shows the start and end dates for the MInD-I implementation at the 10 different sites, the duration of time spent from the beginning of the implementation to completion (i.e., achievement of competency or discontinuation) of the site, the highest SIC stage the site reached during implementation, and whether or not the site was deemed competent in the MInD-I intervention. To address study timeline limitations, sites were given a fixed contract time period of 2 years to complete the implementation. As shown, three sites achieved “Competent” delivery of MInD-I within that timeframe. Table 2 MInD-I implementing site characteristics Site Duration (months) Highest SIC© stage Competent Number of CoCM patients A 14.7 8 Yes 45 B 25.5 8 No 14 C 23.7 8 No 43 D 20.6 8 No 27 E 33.1 8 Yes 172 F 26.5 8 No 72 G 17.5 8 Yes 15 H 20.3 8 No 21 I 19.6 7 No 36 J 10.9 6 No 0 Table 3 shows the provider and staff roles at each clinic that were identified as having participated in implementation activities operationalized on the MInD-I SIC. As shown, the average hours spent on MInD-I implementation activities varied by position type across the implementation stages. The majority of leadership and staff hours spent toward the implementation were during Stage 3 (Readiness) through Stage 7 (Ongoing Service Delivery and Fidelity Monitoring), including activities related to setting up infrastructure, completing fidelity monitoring protocols, and establishing MInD-I within the clinic. All 10 sites endorsed using clinical staff, a program champion, and support staff, with the majority of implementation activity hours being completed by these three positions. The COINS also assesses the FTE assignment of each position. The Bureau of Labor Statistics (BLS) national median hourly wage information was mapped onto each position to obtain a quantifiable estimate of the resources involved. The BLS wages allowed for an average national estimate for the different positions, reducing the potential to over- or underestimate between-site costs due to wage discrepancies between site locations’ local wages. Table 3 Mean hours spent on implementation tasks by site role a Role type Count Stage 1 (N = 10) Stage 2 (N = 10) Stage 3 (N = 10) Stage 4 (N = 10) Stage 5 (N = 10) Stage 6 (N = 10) Stage 7 (N = 6) Stage 8 (N = 2) Total hours Admin support b 1 0 0 2 0 0 0 0 0 2 CEO/director 6 1 1 2 0 0 0 0 0 4 Clinical staff 10 1 1 19 39 25 3 25 6 119 Executives 8 1 0 2 2 0 1 6 0 12 Finance 4 0 0 4 1 0 0 1 0 6 Financial officer 3 0 0 4 0 0 0 0 0 4 Middle management 5 2 1 5 3 0 0 1 0 12 Program champion 10 2 1 21 3 9 1 12 1 50 Support staff 10 0 1 5 0 20 1 5 0 32 Total stage hours --- 7 5 64 48 54 6 50 7 241 a The table represents the average (mean) resources reported per position per site. Parentheses indicate the number of sites reporting resource use for a listed position, or the number of sites represented per stage. b Includes clerical staff, administrative assistants, and public relations staff. Table 4 quantifies the implementation activity costs for MInD-I throughout the implementation process by combining reported hours and BLS wage data for identified positions involved in implementation. Minimal staffing resources were identified in Stages 1 (Engagement) and 2 (Feasibility Assessment), with resource use increasing in Stage 3 (Readiness). The cumulative total prior to Stage 4 represents costs incurred during the Pre-Implementation Phase (Stages 1–3). Costs ranged from $ 1,594 – $ 7,810 across sites for this phase. Costs for the sites began to diverge more during the Implementation Phase (Stages 4–7). As depicted in Table 2 , this is due to variation in the duration of the implementation among sites. Site A, for example, achieved competency in 14.7 months at an observed cost of $ 20,944, whereas Site C spent 23.7 months (without reaching competency) at a cost of $ 73,580. Table 4 Total implementation cost by stage Site Activity Total FTE Total Cumulative Total A $ 5,557 $ 15,387 $ 20,944 B $ 3,389 $ 1,114 $ 4,502 C $ 4,618 $ 68,962 $ 73,580 D $ 3,903 $ 16,674 $ 20,577 E $ 4,237 $ 34,769 $ 39,006 F $ 2,820 $ 100,336 $ 103,156 G $ 7,625 $ 57,790 $ 65,415 H $ 7,902 $ 30,418 $ 38,320 I $ 4,571 $ 19,622 $ 24,089 J $ 3,447 $ 16,017 $ 19,464 Site average $ 4,807 $ 36,109 $ 40,778 The total cost to implement MInD-I was, on average, $ 40,778 (SD= $ 30,611) per site with a wide range from $ 4,502 – $ 103,156 across sites. Implementation Training and Facilitation Costs Costs associated with expert consultation and training provided to the sites are shown in Table 5 . The total charges for training and practice facilitation were $ 444,251, resulting in a cost of $ 44,425 for each site across the cohort. Combining the average staffing cost of $ 40,778 per MInD-I clinic with the $ 44,425 paid by the grant for travel, training, and expert consultation, the total cost per site would have been $ 85,203 if the grant had not covered the aforementioned training components. Table 5 OCHIN & AIMS consultation and training costs Type of cost 2017 2018 2019 2020 Total cost OCHIN & AIMS FTE $ 113,446 $ 133,326 $ 44,441 $ 2,027 $ 293,241 Travel $ 9,250 $ 23,092 $ 386 --- $ 32,728 Other (catering, supplies, etc.) $ 389 $ 1,193 $ 117 --- $ 1,699 PST training --- --- $ 1,900 --- $ 1,900 Overhead (35%) $ 43,080 $ 55,164 $ 15,731 $ 710 $ 114,684 Total cost $ 166,165 $ 212,774 $ 62,575 $ 2,737 $ 444,252 Discussion Implementation costs can be difficult to capture but if left undefined can lead to uninformed decisions regarding whether or not to implement a new program and where to direct resources. Evidence from the first 10 clinics recruited to implement the evidence-based CoCM intervention for team-based integrated perinatal mental health care suggested that successful programs were relatively efficient (utilizing neither too many nor too little resources) in their implementation approach. Site implementation costs for this complex behavioral health intervention were substantial and varied dramatically, particularly among sites that did not achieve competence— those sites incurred costs that were either considerably higher or lower than sites that did achieve competence, indicating inefficient use of resources or lack of dedication to the implementation. Of note, one site (site J) discontinued relatively quickly (10.9 months), spending less ( $ 19,464) than the overall average implementation costs, reflecting the relative savings associated with the decision to end implementation rather than continue with little likelihood of success. Further, our study demonstrated that the COINS method can successfully assess cost and resource variations across clinics implementing a complex, multicomponent implementation strategy and that successful and cost viable implementation of CoCM is possible within 2 years. One limitation of this study is that it did not directly track ways in which sites could have recouped implementation costs. Currently, 16 states allow for Medicaid billing for the select Current Procedural Terminology (CPT) codes associated with CoCM [ 41 ]. Billing for CoCM also requires complex tracking procedures novel to most sites such as tracking the number of minutes spent on care coordination over the course of a month, with a requirement that the first month must have at least 36 minutes of billable activity and subsequent months must have at least 31 minutes in order to bill for services. Although it would have been possible for a site participating in MInD-I to recoup the implementation costs of CoCM within the two-year project window, it is more likely that it would take longer. Further research is needed to determine real-world ability of sites to recoup implementation costs through billing practices for newly implemented CoCM services. Additionally, we recommend more research to better pinpoint which site resource investments contribute most to the successful implementation of CoCM. Knowing more about where sites should invest their time and effort would allow CoCM practice facilitators to strategically coach sites on how best to utilize their resources to more efficiently implement with a higher rate of competence. Cost information can thereby support efforts to expand evidence-based models of care to more patients in need with less financial burden on sites. Conclusions Site leadership must consider implementation costs for complex behavioral health interventions such as CoCM to plan appropriately for implementing these interventions. Sites that failed to successfully implement CoCM for the perinatal population within a 2-year period tended to utilize resources inefficiently, incurring either much higher or much lower costs than sites that achieved competence in this model of care. Further understanding of optimal site resource investment is needed to help support sites seeking to improve behavioral health services through evidence-based practice change. Abbreviations federally qualified health centers (FQHCs), collaborative care model (CoCM), Cost of Implementing New Strategies (COINS), perinatal mood and anxiety disorders (PMAD), Center for Medicare and Medicaid Services (CMS), Maternal Infant Dyad Implementation (MInD-I), primary care provider (PCP), Stages of Implementation Completion (SIC), evidence-based practices (EBPs), full-time equivalent (FTE), Accelerating Data Value Across a National Community Health Center Network (ADVANCE), National Patient-Centered Clinical Research Network (PCORnet), Current Procedural Terminology (CPT) Declarations Ethics approval and consent to participate: This study was reviewed and approved by the University of Washington Institutional Review Board (IRB) STUDY00001294. Consent for publication: Not applicable. Availability of data and materials: The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests: LS is the primary developer of the Stages of Implementation Completion (SIC) and holds a license agreement with Oregon Social Learning Center to access, utilize, and grant permission to use the SIC repository and its associated data. As such, Dr. Saldana is not involved in the data collection, entry, management, manipulation, or analysis for this or other manuscripts. Funding: This study was supported by the National Institutes of Health (NIH) grant 1R01MH108548-01 and by the California Health Care Foundation (CHCF) grant 19713. Development of the adapted CoCM SIC was supported by the Implementation Research Institute (IRI), at the George Warren Brown School of Social Work, Washington University in St. Louis; through an award from the National Institute of Mental Health (R25 MH080916- 01A2) and the Department of Veterans Affairs, Health Services Research & Development Service, Quality Enhancement Research Initiative (QUERI); funding from the National Institute of Health (R01 MH097748; R01 DA044745; R01 MH108548); and through an award from The John A. Hartford Foundation (2012-0213) that includes support from the Corporation for National and Community Service Social Innovation Fund. Authors' contributions: TG oversaw the paper and cost data collection for the project and contributed to writing. IB led the conception and design of the study and contributed to writing. MC provided the cost data analysis and contributed to writing. MV reviewed and edited the manuscript. LS reviewed and edited the manuscript and supported interpretation of results. Acknowledgements: This work was conducted with the Accelerating Data Value Across a National Community Health Center Network (ADVANCE) Clinical Research Network (CRN). OCHIN leads the ADVANCE network in partnership with Health Choice Network, Fenway Health, and Oregon Health & Science University. ADVANCE is funded through the Patient-Centered Outcomes Research Institute (PCORI), contract number RI-CRN-2020-001. The authors would also like to acknowledge the contributions of Rachel Gold, PhD, MPH (OCHIN, Inc. and Kaiser Permanente) and April Lee, MPH (OCHIN, Inc.). References Gavin NI, Gaynes BN, Lohr KN, Meltzer-Brody S, Gartlehner G, Swinson T. Perinatal depression: a systematic review of prevalence and incidence. Obstet. Gynecol. 2005;106:1071–83. Fedock GL, Alvarez C. 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Scaling implementation of collaborative care for depression: adaptation of the Stages of Implementation Completion (SIC). Adm Policy Ment Health Ment Health Serv Res. 2020;47:188–96. Saldana L. The stages of implementation completion for evidence-based practice: protocol for a mixed methods study. Implement. Sci. IS 2014;9:43. Chamberlain P, Brown CH, Saldana L. Observational measure of implementation progress in community based settings: the Stages of implementation completion (SIC). Implement. Sci. 2011;6:116. Watson DP, Snow-Hill N, Saldana L, Walden AL, Staton M, Kong A, et al. A longitudinal mixed method approach for assessing implementation context and process factors: comparison of three sites from a Housing First implementation strategy pilot. Implement. Res. Pract. 2020;1:2633489520974974. HE Frank, Saldana L, Kendell P, Schaper H, Norris L. Bringing evidence-based interventions into the schools: an examination of organizational factors and implementation outcomes. Child Youth Serv. 2021;0:1-20 Best Practices for Reimbursing the Collaborative Care Model in Medicaid. Washington, DC, American Psychiatric Association, 2020 . Supplementary Files CHEERSChecklistCOINSMiNDI.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5256122","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":376304083,"identity":"8c8a0a3f-e05a-4801-aa48-3d53e90d4285","order_by":0,"name":"Tess Grover","email":"","orcid":"","institution":"University of Washington Seattle Campus: University of Washington","correspondingAuthor":false,"prefix":"","firstName":"Tess","middleName":"","lastName":"Grover","suffix":""},{"id":376304084,"identity":"b274d998-eaed-4931-afa5-9164a30e39d2","order_by":1,"name":"Ian M Bennett","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAArUlEQVRIiWNgGAWjYBACNgkogx/CJV6LgYRkA7FaGGBaDA4Qq4VPuvnY44KKP3XGN3IMGD6UHSbCYTLH0o1nnDGQMANqYZxxjhgtEjlm0rxtIC25G5h524jSkv9NmvefgYTxDKCWv8RpyWGT5m0Ael8CqIWRKC0yx8ykeY4ZS8448/7DwZ5z6YS1yM9ufibNUyPHz9+elvjgR5k1YS0o4ACJ6kfBKBgFo2AU4AIAV00yW3ylJrAAAAAASUVORK5CYII=","orcid":"https://orcid.org/0000-0002-7139-9456","institution":"University of Washington Seattle Campus: University of Washington","correspondingAuthor":true,"prefix":"","firstName":"Ian","middleName":"M","lastName":"Bennett","suffix":""},{"id":376304085,"identity":"7c69ea22-664d-4680-a11f-19f6ac0b359d","order_by":2,"name":"Mark Campbell","email":"","orcid":"","institution":"Chestnut Health Systems Inc","correspondingAuthor":false,"prefix":"","firstName":"Mark","middleName":"","lastName":"Campbell","suffix":""},{"id":376304086,"identity":"d97f7b47-8c6c-476a-9351-fb6e77eb75cd","order_by":3,"name":"Melinda Vredevoogd","email":"","orcid":"","institution":"University of Washington Seattle Campus: University of Washington","correspondingAuthor":false,"prefix":"","firstName":"Melinda","middleName":"","lastName":"Vredevoogd","suffix":""},{"id":376304087,"identity":"757548b4-daba-4423-b43f-a213dc3a44a6","order_by":4,"name":"Lisa Saldana","email":"","orcid":"","institution":"Chestnut Health Systems Inc","correspondingAuthor":false,"prefix":"","firstName":"Lisa","middleName":"","lastName":"Saldana","suffix":""}],"badges":[],"createdAt":"2024-10-13 15:54:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5256122/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5256122/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":73415556,"identity":"f9ea0940-a8fd-4a30-9771-54ab321a3e11","added_by":"auto","created_at":"2025-01-09 16:59:57","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":840388,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5256122/v1/9100b3c6-d2bb-4d67-9f77-fb0b40765035.pdf"},{"id":69971938,"identity":"3c07d322-59a6-4871-9a29-1e63d0c2a3b2","added_by":"auto","created_at":"2024-11-27 06:24:12","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":26278,"visible":true,"origin":"","legend":"","description":"","filename":"CHEERSChecklistCOINSMiNDI.docx","url":"https://assets-eu.researchsquare.com/files/rs-5256122/v1/df6444ba87072763753c175f.docx"}],"financialInterests":"","formattedTitle":"Implementation cost analysis of collaborative care for perinatal mental health in community health centers","fulltext":[{"header":"Contributions to the literature","content":"\u003cul\u003e\n \u003cli\u003eAlthough cost is a key consideration for clinic leadership when planning adoption of a new program, few studies look at the actual resource needs associated with implementing complex interventions, such as the collaborative care model (CoCM), in primary care.\u003c/li\u003e\n \u003cli\u003eOur study found evidence that clinics who did not successfully adopt CoCM for perinatal depression incurred costs that were either considerably higher or lower than sites that did successfully adopt the model, indicating efficiency of resource use as a factor in successful implementation.\u003c/li\u003e\n \u003cli\u003eThese findings contribute to gaps in the literature around successful adoption of CoCM, including the importance of optimal site resource investment as a consideration for implementation planning.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Background","content":"\u003cp\u003ePerinatal mood and anxiety disorders (PMAD) are common, undertreated, and affect both parents and their infants during pregnancy and the first year after childbirth [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. People who are pregnant or postpartum are at risk for major depressive disorder or dysthymia, with up to 16% experiencing symptoms of depression during pregnancy [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] and up to 14% experiencing symptoms of anxiety [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Perinatal depression is more than twice as prevalent in patients who are low-income than other patients [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Suicide, most often among patients with depression, is a leading cause of maternal mortality [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], and mental health conditions are linked to 11% of pregnancy-related deaths [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Despite these significant deleterious outcomes, patients from low income or racial and/or ethnic minority backgrounds are less likely to be identified and treated for PMAD than other patients [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Systematic efforts to address the mental health needs of parents during the perinatal period in general, and within these high-risk populations specifically, are not widely implemented [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFederally qualified health centers (FQHCs), are federally supported safety net sites serving disproportionately high numbers of low income and race/ethnic minority populations that have historically been underserved. These sites provide multi-disciplinary maternal-child and primary care allowing for opportunities to address PMAD through continuity across the pre/inter-pregnancy, prenatal, and postpartum transitions [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Yet, few evidence-based interventions focused on perinatal mental health are employed within primary care settings. The collaborative care model (CoCM) is an evidence-based, behavioral health integration intervention to support the treatment of common behavioral health conditions in primary care settings [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. CoCM leverages existing behavioral health professionals working in primary care clinics and additional specialty mental health consultants (typically psychiatrists or psychiatric nurse practitioners) to support the patient through team-based care [\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. CoCM has been tested in more than 80 randomized controlled trials in the US and internationally, and meta-analyses of these studies indicate that it consistently improves on care as usual, including in perinatal populations [\u003cspan additionalcitationids=\"CR17 CR18 CR19 CR20 CR21\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Because of the high level of evidence, the Center for Medicare and Medicaid Services (CMS) has promulgated billing codes to support activities related to CoCM [\u003cspan additionalcitationids=\"CR24\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Despite these reimbursement opportunities and demonstrated improved outcomes in patients with perinatal depression, CoCM is not yet widely implemented within clinics that serve this population [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOne barrier to the implementation of new interventions is the perceived resource needs associated with implementation, including training, change management, and salary costs for time spent on this work [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. This is particularly true for complex interventions such as CoCM that involve coordination across multiple providers, managers, and diverse support staff.[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] Previous studies examining cost associated with CoCM primarily examined cost effectiveness of the intervention, finding improved clinical outcomes at no greater cost than usual care [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Cost-benefit analyses have shown that every dollar spent on CoCM for geriatric depression resulted in \u003cspan\u003e$\u003c/span\u003e6 long-term healthcare costs saved per patient [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Other studies have found that CoCM produces lower annualized total healthcare costs per patient than usual care [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] and less outpatient health services costs than usual care [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. While helpful for public policy financing decisions, these analyses do not address the implementation cost for integrating the intervention into clinics, which is critical to individual site choices regarding the adoption of clinical innovations. Despite the positive cost outcomes of CoCM in rigorous trials for treating depression, the unknown real-world implementation costs\u0026mdash;including the costs of building the infrastructure and environment needed to successfully deliver CoCM\u0026mdash;pose a barrier to adoption. By understanding the implementation costs of CoCM for perinatal depression, appropriate planning and support can be provided for clinics serving patients at risk for PMAD. In the current study, we wished to capture the real-world costs associated with implementing CoCM for perinatal depression in health centers serving patients in pregnancy and the year postpartum from historically underserved populations and at high risk of PMAD. Those costs include staffing based on the amount of time various clinic team members spent on implementation activities, practice facilitation, coaching, and training.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eParticipants:\u003c/h2\u003e \u003cp\u003eThe Maternal Infant Dyad Implementation (MInD-I) study was designed to evaluate strategies for helping sites implement CoCM for perinatal depression and anxiety (NCT02976025: PI Bennett). The study was reviewed and approved by the University of Washington Institutional Review Board (IRB). Sites were recruited from the OCHIN national primary care informatics network comprised primarily of Federally Qualified Health Centers (FQHCs) and FQHC look-alikes [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. OCHIN sites are part of a national collaborative of over 500 primary care clinics in 47 states that share an iteration of the Epic\u0026copy; electronic health record. Clinics were enrolled in the study based on two criteria: 1) use of the shared Epic\u0026copy; electronic medical record for perinatal care and 2) a minimum of 50 perinatal patients served annually.\u003c/p\u003e \u003cp\u003eTen FQHCs agreed to participate in the first cohort of the project from April 2016 to April 2020, including 4 sites in California, 2 sites in Massachusetts, 1 site in Indiana, 1 in Texas, 1 in Wisconsin, and 1 in Oregon. Sites ranged in size, serving 59\u0026ndash;1,245 unique perinatal patients annually, with a mean of 406 perinatal patients served per year. On average, 72% of patients served by the sites identified as racial and/or ethnic minority patients (as reported in annual health center data) and 89% were at or below 200% of the federal poverty guideline (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMInD-I site baseline characteristics\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSite\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eState\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUnique patients per year\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUnique perinatal patients per year\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRacial and/or ethnic minority patients\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePatients at or below 200% of federal poverty level\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12,144\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e188\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e70%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e96%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11,400\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e323\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e95%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e99%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15,145\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e469\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e84%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e80%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12,032\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1345\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e97%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e98%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e55,159\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e637\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e76%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11,408\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e256\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e93%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e96%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3359\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e63%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e430\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e90%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e98%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13,271\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e180\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e78%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e87%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12,410\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e175\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e95%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e100%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15,633\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e406\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e72%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e89%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003csup\u003ea\u003c/sup\u003eSource: US Health Resources and Services Administration Data Warehouse (2016 data)\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eImplementation Strategies\u003c/h3\u003e\n\u003cp\u003eParticipating clinics received implementation support and registry training from experts in practice facilitation based at OCHIN and clinical training and expert consultation from CoCM trainers and consultants employed by the Advancing Integrated Mental Health Solutions (AIMS) Center at the University of Washington. Practice facilitation began roughly 3 months prior to launching care and was intended to orient sites to CoCM, help identify staff for collaborative care team roles, and develop team readiness and clinical workflows. Core team members, including care managers, psychiatric consultants, PCP (primary care provider) champions, project leads, and the Epic\u0026copy; site specialist from each clinic attended a 2-day in-person CoCM training prior to program launch. The core care team received 1 hour of practice facilitation support monthly. Care managers met once a month for training webinars, and psychiatric consultants met quarterly for calls with an expert CoCM psychiatrist trainer. Clinics were provided with online training resources via an online learning management system (LMS), but use of these resources varied among clinics and roles. Clinics were permitted to configure the CoCM team for their clinical context, as long as key components were maintained, resulting in variation in the types and quantities of staff participating in the implementation of MInD-I at each site. Four of the sites received additional support over the first 12 months after launching services in the form of Longitudinal Remote Coaching (LRC) by an experienced psychiatric consultant who observed the work of the local teams during select systematic case reviews and provided feedback [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eMeasures\u003c/h3\u003e\n\u003cp\u003eThe Cost of Implementing New Strategies (COINS) approach is a method for mapping resources needed for implementation efforts of sites (clinics/agencies/systems) adopting new interventions or practices [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Implementation costs are mapped onto activities operationalized within the Stages of Implementation Completion (SIC\u0026copy;) [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. The SIC is a measure of implementation process that defines, captures, and tracks necessary implementation activities by newly adopting sites across eight stages, from Engagement (Stage 1) to Competency (Stage 8). Each of these stages falls within three well-established phases of implementation: Pre-implementation, Implementation, and Sustainment [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe SIC has been rigorously evaluated and developed for use for the implementation of evidence-based practices (EBPs) [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Although the 8 implementation stages are standard across practices, activities within the stages are tailored or customized to the practice being monitored. The SIC previously has been adapted for CoCM [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e], which in turn was customized further for the MInD-I implementation strategies that were integrated within CoCM. During the course of the MInD-I implementation, sites incurred resources and costs as they progressed through the implementation process, including assessment of feasibility (SIC Stage 2), readiness planning (SIC Stage 3), hiring and training of staff (SIC Stage 4), delivering the program with fidelity (SIC Stages 5\u0026ndash;7), and ultimately achieving competency to sustain the program (SIC Stage 8). The COINS tool provides a validated approach to collect the costs and resources involved in completing the implementation strategies associated with each of these stages.\u003c/p\u003e \u003cp\u003eThe COINS tool is web-based, allowing for easier real-time data entry and management. To prepare for programming of the MInD-I COINS, implementation activities were identified on the MInD-I SIC where resource use might occur. The type of positions and/or roles that might be involved in completing each activity were defined and programmed to capture which roles were involved for each site. The COINS system prompted the data collector to capture human resources (i.e., amount of time and position), and fixed expenditures (e.g., rent, computers, advertising) that were required to implement MInD-I. The majority of the costs in the Pre-Implementation Phase resulted from labor resources on the unique activities, with none of the sites incurring associated fixed, infrastructure or assigned FTE (full-time equivalent) costs. Implementation Phase costs primarily resulted from clinical staff FTE assigned to the implementation, in addition to the direct resources spent on each activity at the site.\u003c/p\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003eData were collected by a member of the research team (the first author) from each of the 10 participating sites during the site support period from April 2016 to April 2020. COINS data were collected through remote conversations among the data collector, implementation facilitators, and the sites. Additionally, site and purveyor organization travel costs were collected via project invoices. Data regarding the number of patients served by the MInD-I program came from ADVANCE (Accelerating Data Value Across a National Community Health Center Network), a PCORnet clinical trials network that includes data from community health centers.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eSite Costs:\u003c/h2\u003e \u003cp\u003eThe COINS method described above produces several different results that can be compiled to generate the total cost of implementation: 1) fixed expenses associated with the implementation, 2) staff hours associated with the discrete implementation activities described in the SIC, and 3) MInD-I FTE allocation during the implementation process. Fixed expenses in this context refers to rent/office space, computers, office supplies, and other non-employee based expenses incurred to support the intervention. Because MInD-I was incorporated into existing clinic settings for the project, no additional fixed expenses were reported. Thus, all resource costs to implement MInD-I within the participating clinics were strictly incurred by staff hours.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows the start and end dates for the MInD-I implementation at the 10 different sites, the duration of time spent from the beginning of the implementation to completion (i.e., achievement of competency or discontinuation) of the site, the highest SIC stage the site reached during implementation, and whether or not the site was deemed competent in the MInD-I intervention. To address study timeline limitations, sites were given a fixed contract time period of 2 years to complete the implementation. As shown, three sites achieved \u0026ldquo;Competent\u0026rdquo; delivery of MInD-I within that timeframe.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMInD-I implementing site characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSite\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDuration (months)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHighest SIC\u0026copy; stage\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCompetent\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNumber of CoCM patients\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e23.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e20.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e33.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e172\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e26.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e72\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e20.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows the provider and staff roles at each clinic that were identified as having participated in implementation activities operationalized on the MInD-I SIC. As shown, the average hours spent on MInD-I implementation activities varied by position type across the implementation stages. The majority of leadership and staff hours spent toward the implementation were during Stage 3 (Readiness) through Stage 7 (Ongoing Service Delivery and Fidelity Monitoring), including activities related to setting up infrastructure, completing fidelity monitoring protocols, and establishing MInD-I within the clinic. All 10 sites endorsed using clinical staff, a program champion, and support staff, with the majority of implementation activity hours being completed by these three positions. The COINS also assesses the FTE assignment of each position. The Bureau of Labor Statistics (BLS) national median hourly wage information was mapped onto each position to obtain a quantifiable estimate of the resources involved. The BLS wages allowed for an average national estimate for the different positions, reducing the potential to over- or underestimate between-site costs due to wage discrepancies between site locations\u0026rsquo; local wages.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMean hours spent on implementation tasks by site role\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"11\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRole type\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCount\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStage 1\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;10)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStage 2\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;10)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStage 3\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;10)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eStage 4\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;10)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eStage 5\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;10)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eStage 6\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;10)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eStage 7\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;6)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eStage 8\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;2)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003eTotal hours\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdmin support\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCEO/director\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical staff\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e119\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExecutives\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFinance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFinancial officer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMiddle management\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProgram champion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSupport staff\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal stage hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e241\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"11\"\u003e\u003csup\u003ea\u003c/sup\u003eThe table represents the average (mean) resources reported per position per site. Parentheses indicate the number of sites reporting resource use for a listed position, or the number of sites represented per stage.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"11\"\u003e\u003csup\u003eb\u003c/sup\u003eIncludes clerical staff, administrative assistants, and public relations staff.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e quantifies the implementation activity costs for MInD-I throughout the implementation process by combining reported hours and BLS wage data for identified positions involved in implementation. Minimal staffing resources were identified in Stages 1 (Engagement) and 2 (Feasibility Assessment), with resource use increasing in Stage 3 (Readiness). The cumulative total prior to Stage 4 represents costs incurred during the Pre-Implementation Phase (Stages 1\u0026ndash;3). Costs ranged from \u003cspan\u003e$\u003c/span\u003e1,594 \u0026ndash; \u003cspan\u003e$\u003c/span\u003e7,810 across sites for this phase. Costs for the sites began to diverge more during the Implementation Phase (Stages 4\u0026ndash;7). As depicted in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, this is due to variation in the duration of the implementation among sites. Site A, for example, achieved competency in 14.7 months at an observed cost of \u003cspan\u003e$\u003c/span\u003e20,944, whereas Site C spent 23.7 months (without reaching competency) at a cost of \u003cspan\u003e$\u003c/span\u003e73,580.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTotal implementation cost by stage\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSite\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eActivity Total\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFTE Total\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCumulative Total\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e5,557\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e15,387\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e20,944\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e3,389\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e1,114\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e4,502\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e4,618\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e68,962\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e73,580\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e3,903\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e16,674\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e20,577\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e4,237\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e34,769\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e39,006\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e2,820\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e100,336\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e103,156\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e7,625\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e57,790\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e65,415\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e7,902\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e30,418\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e38,320\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e4,571\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e19,622\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e24,089\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e3,447\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e16,017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e19,464\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSite average\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e4,807\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e36,109\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e40,778\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe total cost to implement MInD-I was, on average, \u003cspan\u003e$\u003c/span\u003e40,778 (SD=\u003cspan\u003e$\u003c/span\u003e30,611) per site with a wide range from \u003cspan\u003e$\u003c/span\u003e4,502 \u0026ndash; \u003cspan\u003e$\u003c/span\u003e103,156 across sites.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eImplementation Training and Facilitation Costs\u003c/h3\u003e\n\u003cp\u003eCosts associated with expert consultation and training provided to the sites are shown in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e. The total charges for training and practice facilitation were \u003cspan\u003e$\u003c/span\u003e444,251, resulting in a cost of \u003cspan\u003e$\u003c/span\u003e44,425 for each site across the cohort. Combining the average staffing cost of \u003cspan\u003e$\u003c/span\u003e40,778 per MInD-I clinic with the \u003cspan\u003e$\u003c/span\u003e44,425 paid by the grant for travel, training, and expert consultation, the total cost per site would have been \u003cspan\u003e$\u003c/span\u003e85,203 if the grant had not covered the aforementioned training components.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOCHIN \u0026amp; AIMS consultation and training costs\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType of cost\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2017\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2018\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2019\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2020\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eTotal cost\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOCHIN \u0026amp; AIMS FTE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e113,446\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e133,326\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e44,441\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e2,027\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e293,241\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTravel\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e9,250\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e23,092\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e386\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e32,728\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther (catering, supplies, etc.)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e389\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e1,193\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e117\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e1,699\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePST training\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e1,900\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e1,900\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverhead (35%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e43,080\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e55,164\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e15,731\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e710\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e114,684\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal cost\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e166,165\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e212,774\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e62,575\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e2,737\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e444,252\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eImplementation costs can be difficult to capture but if left undefined can lead to uninformed decisions regarding whether or not to implement a new program and where to direct resources. Evidence from the first 10 clinics recruited to implement the evidence-based CoCM intervention for team-based integrated perinatal mental health care suggested that successful programs were relatively efficient (utilizing neither too many nor too little resources) in their implementation approach. Site implementation costs for this complex behavioral health intervention were substantial and varied dramatically, particularly among sites that did not achieve competence\u0026mdash; those sites incurred costs that were either considerably higher or lower than sites that did achieve competence, indicating inefficient use of resources or lack of dedication to the implementation. Of note, one site (site J) discontinued relatively quickly (10.9 months), spending less (\u003cspan\u003e$\u003c/span\u003e19,464) than the overall average implementation costs, reflecting the relative savings associated with the decision to end implementation rather than continue with little likelihood of success. Further, our study demonstrated that the COINS method can successfully assess cost and resource variations across clinics implementing a complex, multicomponent implementation strategy and that successful and cost viable implementation of CoCM is possible within 2 years.\u003c/p\u003e \u003cp\u003eOne limitation of this study is that it did not directly track ways in which sites could have recouped implementation costs. Currently, 16 states allow for Medicaid billing for the select Current Procedural Terminology (CPT) codes associated with CoCM [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Billing for CoCM also requires complex tracking procedures novel to most sites such as tracking the number of minutes spent on care coordination over the course of a month, with a requirement that the first month must have at least 36 minutes of billable activity and subsequent months must have at least 31 minutes in order to bill for services. Although it would have been possible for a site participating in MInD-I to recoup the implementation costs of CoCM within the two-year project window, it is more likely that it would take longer. Further research is needed to determine real-world ability of sites to recoup implementation costs through billing practices for newly implemented CoCM services.\u003c/p\u003e \u003cp\u003eAdditionally, we recommend more research to better pinpoint which site resource investments contribute most to the successful implementation of CoCM. Knowing more about where sites should invest their time and effort would allow CoCM practice facilitators to strategically coach sites on how best to utilize their resources to more efficiently implement with a higher rate of competence. Cost information can thereby support efforts to expand evidence-based models of care to more patients in need with less financial burden on sites.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eSite leadership must consider implementation costs for complex behavioral health interventions such as CoCM to plan appropriately for implementing these interventions. Sites that failed to successfully implement CoCM for the perinatal population within a 2-year period tended to utilize resources inefficiently, incurring either much higher or much lower costs than sites that achieved competence in this model of care. Further understanding of optimal site resource investment is needed to help support sites seeking to improve behavioral health services through evidence-based practice change.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003efederally qualified health centers (FQHCs), collaborative care model (CoCM), Cost of Implementing New Strategies (COINS), perinatal mood and anxiety disorders (PMAD), Center for Medicare and Medicaid Services (CMS), Maternal Infant Dyad Implementation (MInD-I), primary care provider (PCP), Stages of Implementation Completion (SIC), evidence-based practices (EBPs), full-time equivalent (FTE), Accelerating Data Value Across a National Community Health Center Network (ADVANCE), National Patient-Centered Clinical Research Network (PCORnet), Current Procedural Terminology (CPT)\u003c/p\u003e\n"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/em\u003eThis study was reviewed and approved by the University of Washington Institutional Review Board (IRB) STUDY00001294.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eConsent for publication:\u0026nbsp;\u003c/em\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAvailability of data and materials:\u0026nbsp;\u003c/em\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eCompeting interests:\u0026nbsp;\u003c/em\u003eLS is the primary developer of the Stages of Implementation Completion (SIC) and holds a license agreement with Oregon Social Learning Center to access, utilize, and grant permission to use the SIC repository and its associated data. As such, Dr. Saldana is not involved in the data collection, entry, management, manipulation, or analysis for this or other manuscripts.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eFunding:\u0026nbsp;\u003c/em\u003eThis study was supported by the National Institutes of Health (NIH) grant 1R01MH108548-01 and by the California Health Care Foundation (CHCF) grant 19713. Development of the adapted CoCM SIC was supported by the Implementation Research Institute (IRI), at the George Warren Brown School of Social Work, Washington University in St. Louis; through an award from the National Institute of Mental Health (R25 MH080916- 01A2) and the Department of Veterans Affairs, Health Services Research \u0026amp; Development Service, Quality Enhancement Research Initiative (QUERI); funding from the National Institute of Health (R01 MH097748; R01 DA044745; R01 MH108548); and through an award from The John A. Hartford Foundation (2012-0213) that includes support from the Corporation for National and Community Service Social Innovation Fund.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAuthors\u0026apos; contributions:\u0026nbsp;\u003c/em\u003eTG oversaw the paper and cost data collection for the project and contributed to writing. IB led the conception and design of the study and contributed to writing. MC provided the cost data analysis and contributed to writing. MV reviewed and edited the manuscript. LS reviewed and edited the manuscript and supported interpretation of results.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eAcknowledgements:\u0026nbsp;\u003c/em\u003eThis work was conducted with the Accelerating Data Value Across a National Community Health Center Network (ADVANCE) Clinical Research Network (CRN). OCHIN leads the ADVANCE network in partnership with Health Choice Network, Fenway Health, and Oregon Health \u0026amp; Science University. ADVANCE is funded through the Patient-Centered Outcomes Research Institute (PCORI), contract number RI-CRN-2020-001. The authors would also like to acknowledge the contributions of Rachel Gold, PhD, MPH (OCHIN, Inc. and Kaiser Permanente) and April Lee, MPH (OCHIN, Inc.).\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eGavin NI, Gaynes BN, Lohr KN, Meltzer-Brody S, Gartlehner G, Swinson T. Perinatal depression: a systematic review of prevalence and incidence. Obstet. Gynecol. 2005;106:1071\u0026ndash;83.\u003c/li\u003e\n\u003cli\u003eFedock GL, Alvarez C. Differences in screening and treatment for antepartum versus postpartum patients: are providers implementing the guidelines of care for perinatal depression? J. Womens Health. 2018;27:1104\u0026ndash;13.\u003c/li\u003e\n\u003cli\u003eFlynn HA, McBride N, Cely A, Wang Y, DeCesare J. Relationship of prenatal depression and comorbidities to infant outcomes. CNS Spectr. 2015;20:20\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eDunkel Schetter C, Tanner L. Anxiety, depression and stress in pregnancy: implications for mothers, children, research, and practice. Curr. Opin. Psychiatry. 2012;25:141\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eHenderson J, Redshaw M. Anxiety in the perinatal period: antenatal and postnatal influences and women\u0026rsquo;s experience of care. J. Reprod. Infant Psychol. 2013;31:465\u0026ndash;78.\u003c/li\u003e\n\u003cli\u003eTandon SD, Leis JA, Mendelson T, Perry DF, Kemp K. Six-month outcomes from a randomized controlled trial to prevent perinatal depression in low-income home visiting clients. Matern. Child Health J. 2014;18:873\u0026ndash;81.\u003c/li\u003e\n\u003cli\u003eThe California Pregnancy-Associated Mortality Review Report: Pregnancy-Associated Suicide, 2002-2012. Sacramento: California Department of Public Health, Maternal, Child and Adolescent Health Division; 2019.\u003c/li\u003e\n\u003cli\u003eDavis NL, Smoots AN, Goodman DA. Pregnancy-Related Deaths: Data from 14 U.S. Maternal Mortality Review Committees, 2008-2017. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Department of Health and Human Services; 2019.\u003c/li\u003e\n\u003cli\u003eTrost SL, Beauregard JL, Smoots AN, Ko JY, Haight SC, Moore Simas TA, et al. Preventing pregnancy-related mental health deaths: insights from 14 US maternal mortality review committees, 2008-17. Health Aff. 2021;40:1551\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eBennett IM, Marcus SC, Palmer SC, Coyne JC. Pregnancy-related discontinuation of antidepressants and depression care visits among Medicaid recipients. Psychiatr Serv. 2010;61:386\u0026ndash;91.\u003c/li\u003e\n\u003cli\u003eMeunier MR, Bennett IM, Coco AS. Use of antidepressant medication in the United States during pregnancy, 2002-2010. Psychiatr Serv. 2013;64:1157\u0026ndash;60.\u003c/li\u003e\n\u003cli\u003eFederally Qualified Health Centers. Washington, DC, U.S. Health Resources \u0026amp; Services Administration, 2018. https://www.hrsa.gov/opa/eligibility-and-registration/health-centers/fqhc/index.html. Accessed 6 Feb 2022.\u003c/li\u003e\n\u003cli\u003eUnutzer J, Katon W, Callahan CM, Williams JW Jr, Hunkeler E, Harpole L, et al. Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial. JAMA. 2002;288:2836\u0026ndash;45.\u003c/li\u003e\n\u003cli\u003eThielke S, Vannoy S, Unutzer J. Integrating mental health and primary care. Prim. Care Clin. Off. Pract. 2007;34:571\u0026ndash;92, vii.\u003c/li\u003e\n\u003cli\u003eUnutzer J, Park M. Strategies to improve the management of depression in primary care. Prim. Care Clin. Off. Pract. 2012;39:415\u0026ndash;31.\u003c/li\u003e\n\u003cli\u003eArcher J, Bower P, Gilbody S, Lovell K, Richards D, Gask L, et al. Collaborative care for depression and anxiety problems. Cochrane Database Syst. Rev. 2012;10:CD006525.\u003c/li\u003e\n\u003cli\u003eGilbody S, Bower P, Fletcher J, Richards D, Sutton AJ. Collaborative care for depression: a cumulative meta-analysis and review of longer-term outcomes. Arch. Intern. Med. 2006;166:2314\u0026ndash;21.\u003c/li\u003e\n\u003cli\u003eThota AB, Sipe TA, Byard GJ, Zometa CS, Hahn RA, McKnight-Eily LR, et al. Collaborative care to improve the management of depressive disorders: a community guide systematic review and meta-analysis. Am. J. Prev. Med. 2012;42:525\u0026ndash;38.\u003c/li\u003e\n\u003cli\u003eMelville JL, Reed SD, Russo J, Croicu CA, Ludman E, LaRocco-Cockburn A, et al. Improving care for depression in obstetrics and gynecology: a randomized controlled trial. Obstet. Gynecol. 2014;123:1237\u0026ndash;46.\u003c/li\u003e\n\u003cli\u003eGrote NK, Katon WJ, Russo JE, Lohr MJ, Curran M, Galvin E, et al. Collaborative care for perinatal depression in socio-economically disadvantaged women: a randomized trial. Depress Anxiety. 2015;32:821\u0026ndash;34.\u003c/li\u003e\n\u003cli\u003eAraya R, Rojas G, Fritsch R, Gaete J, Rojas M, Simon G, et al. Treating depression in primary care in low-income women in Santiago, Chile: a randomised controlled trial. Lancet. 2003;361:995\u0026ndash;1000.\u003c/li\u003e\n\u003cli\u003eRojas G, Fritsch R, Solis J, Jadresic E, Castillo C, Gonz\u0026aacute;lez M, et al. Treatment of postnatal depression in low-income mothers in primary-care clinics in Santiago, Chile: a randomised controlled trial. Lancet. 2007;370:1629\u0026ndash;37.\u003c/li\u003e\n\u003cli\u003eLiao JM, Navathe AS, Press MJ. Medicare\u0026rsquo;s approach to paying for services that promote coordinated care. JAMA. 2019;321:147\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003ePress MJ, Howe R, Schoenbaum M, Cavanaugh S, Marshall A, Baldwin L, et al. Medicare payment for behavioral health integration. N Engl J Med. 2017;376:405\u0026ndash;7.\u003c/li\u003e\n\u003cli\u003eCarlo AD, Corage Baden A, McCarty RL, Ratzliff ADH. Early health system experiences with collaborative care (CoCM) billing codes: a qualitative study of leadership and support staff. J Gen Intern Med. 2019;34:2150\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eCidav Z, Mandell D, Pyne J, Beidas R, Curran G, Marcus S. A pragmatic method for costing implementation strategies using time-driven activity-based costing. Implement. Sci. 2020;15:28.\u003c/li\u003e\n\u003cli\u003eSeckler E, Regauer V, Rotter T, Bauer P, M\u0026uuml;ller M. Barriers to and facilitators of the implementation of multi-disciplinary care pathways in primary care: a systematic review. BMC Fam. Pract. 2020;21:113.\u003c/li\u003e\n\u003cli\u003eKaton W, Unutzer J, Fan MY, Williams JW Jr, Schoenbaum M, Lin EH, et al. Cost-effectiveness and net benefit of enhanced treatment of depression for older adults with diabetes and depression. Diabetes Care. 2006;29:265\u0026ndash;70.\u003c/li\u003e\n\u003cli\u003eKaton WJ, Russo JE, Von Korff M, Lin EH, Ludman E, Ciechanowski PS. Long-term effects on medical costs of improving depression outcomes in patients with depression and diabetes. Diabetes Care 2008;31:1155\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eUnutzer J, Katon WJ, Fan MY, Schoenbaum MC, Lin EHB, Della Penna RD, et al. Long-term cost effects of collaborative care for late-life depression. Am. J. Manag. Care. 2008;14:95\u0026ndash;100.\u003c/li\u003e\n\u003cli\u003eGrypma L, Haverkamp R, Little S, Unutzer J. Taking an evidence-based model of depression care from research to practice: making lemonade out of depression. Gen Hosp Psychiatry. 2006;28:101\u0026ndash;7.\u003c/li\u003e\n\u003cli\u003eSimon GE, Katon WJ, Lin EH, Rutter C, Manning WG, Von Korff M, et al. Cost-effectiveness of systematic depression treatment among people with diabetes mellitus. Arch Gen Psychiatry. 2007;64:65\u0026ndash;72.\u003c/li\u003e\n\u003cli\u003eBhat A, Bennett IM, Bauer AM, Beidas RS, Eriksen W, Barg FK, et al. Longitudinal remote coaching for implementation of perinatal collaborative care: a mixed methods analysis. Psychiatr Serv. 2020;71:518\u0026ndash;21.\u003c/li\u003e\n\u003cli\u003eSaldana L, Chamberlain P, Bradford WD, Campbell M, Landsverk J. he Cost of Implementing New Strategies (COINS): a method for mapping implementation resources using the stages of implementation completion. Child Youth Serv Rev. 2014;39:177\u0026ndash;82.\u003c/li\u003e\n\u003cli\u003eEisman AB, Kilbourne AM, Dopp AR, Saldana L, Eisenberg D. Economic evaluation in implementation science: making the business case for implementation strategies. Psychiatry Res. 2020;283:112433.\u003c/li\u003e\n\u003cli\u003eSaldana L, Bennett I, Powers D, Vredevoogd M, Grover T, Schaper H, et al. Scaling implementation of collaborative care for depression: adaptation of the Stages of Implementation Completion (SIC). Adm Policy Ment Health Ment Health Serv Res. 2020;47:188\u0026ndash;96.\u003c/li\u003e\n\u003cli\u003eSaldana L. The stages of implementation completion for evidence-based practice: protocol for a mixed methods study. Implement. Sci. IS 2014;9:43.\u003c/li\u003e\n\u003cli\u003eChamberlain P, Brown CH, Saldana L. Observational measure of implementation progress in community based settings: the Stages of implementation completion (SIC). Implement. Sci. 2011;6:116.\u003c/li\u003e\n\u003cli\u003eWatson DP, Snow-Hill N, Saldana L, Walden AL, Staton M, Kong A, et al. A longitudinal mixed method approach for assessing implementation context and process factors: comparison of three sites from a Housing First implementation strategy pilot. Implement. Res. Pract. 2020;1:2633489520974974.\u003c/li\u003e\n\u003cli\u003eHE Frank, Saldana L, Kendell P, Schaper H, Norris L. Bringing evidence-based interventions into the schools: an examination of organizational factors and implementation outcomes. Child Youth Serv. 2021;0:1-20\u003c/li\u003e\n\u003cli\u003eBest Practices for Reimbursing the Collaborative Care Model in Medicaid. Washington, DC, American Psychiatric Association, 2020\u003cstrong\u003e.\u003c/strong\u003e\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"perinatal depression, collaborative care, implementation costs, integrated behavioral health","lastPublishedDoi":"10.21203/rs.3.rs-5256122/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5256122/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eAlthough costs are of key importance to clinic leadership when considering adoption of new programs, few studies examine real-world resource needs associated with implementing complex interventions for chronic conditions in primary care. This analysis sought to identify the costs necessary to implement the evidence-based collaborative care model (CoCM), an integrated behavioral health program for common mental disorders in primary care.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eTen federally qualified health centers (FQHCs) adopted CoCM as part of a larger national randomized trial evaluating implementation strategies for CoCM when adapted for perinatal mental health. The Cost of Implementing New Strategies (COINS) tool was used to assess implementation costs associated with activities completed by sites as they progressed through the implementation process. National wage norms were used to calculate cost estimates for staff time.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOn average, clinics spent \u003cspan\u003e$\u003c/span\u003e40,778 (SD=\u003cspan\u003e$\u003c/span\u003e30,611) on implementation, with clinics ranging widely from \u003cspan\u003e$\u003c/span\u003e4,502 to \u003cspan\u003e$\u003c/span\u003e103,156. Three out of 10 participating clinics achieved competency in the intervention during the 2-year implementation period. Costs among competent clinics ranged from \u003cspan\u003e$\u003c/span\u003e20,944 to \u003cspan\u003e$\u003c/span\u003e65,415 (mean=\u003cspan\u003e$\u003c/span\u003e41,788). Clinics that did not achieve competency were more varied, with both the lowest and highest resource use. Significant staff effort was required to complete all implementation stages; clinical staff and program champions showed greatest effort.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eSite implementation costs for this complex behavioral health intervention were substantial and varied dramatically, particularly among sites who did not achieve competence. Additional work is needed to identify optimal site resource investment related to implementation success for CoCM.\u003c/p\u003e\u003ch2\u003eTrial registration:\u003c/h2\u003e \u003cp\u003eClinicalTrials.gov.NCT02976025. Registered on November 23, 2016.\u003c/p\u003e","manuscriptTitle":"Implementation cost analysis of collaborative care for perinatal mental health in community health centers","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-27 06:24:05","doi":"10.21203/rs.3.rs-5256122/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3d6dc2a6-50e5-4cb4-b88d-61e76af4c3c2","owner":[],"postedDate":"November 27th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-01-28T07:08:23+00:00","versionOfRecord":[],"versionCreatedAt":"2024-11-27 06:24:05","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5256122","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5256122","identity":"rs-5256122","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}