A theory-informed, rapid cycle approach to identifying and adapting sustainability strategies: Optimizing depression treatment in primary care clinics seeking to sustain collaborative/integrated care (The Transform DepCare Study)”

Abstract Background: Few if any examples exist of how best to select and adapt sustainability strategies. We used a collaborative/integrated care use case to describe a novel, theory-informed, stakeholder engaged process for operationalizing sustainability strategies. Methods: Informed by the Behavior Change Wheel, we used mixed methods to identify key sustainability behaviors and determinants of sustainability before conducting a “sustainability mapping” phase to identify acceptable and equitable intervention functions and behavioral change techniques. Drawing on user centered design principles, we enlisted 22 national and local stakeholders to operationalize and adapt (e.g., content, functionality, workflow) a multi-level sustainability strategy to maximally target behavioral determinants of sustainability. Results: We identified ongoing provider treatment optimization and patient initiation as key sustainability behaviors in settings receiving external facilitation and fiscal implementation strategies. The most acceptable, equitable and feasible intervention functions included environmental restructuring, education, training, modeling, persuasion, and enablement. We determined that a waiting room delivered shared decision making and psychoeducation patient tool (DepCare) the results of which are delivered to providers as well as ongoing problem-solving/implementation team meetings with care managers would be the most acceptable and equitable multi-level strategy in diverse settings seeking to sustain CC programs. Key adaptations in response to contextual factors included expanding the DepCare tool to incorporate anxiety/suicide screening, triage support, multi-modal delivery, and patient activation (vs. shared decision making); pairing preference reports with decisional support as well as yearly onboarding/motivational provider and staff educational videos; shifting problem solving meetings from billing support to triage/reducing inappropriate referrals. Conclusion: We provide a roadmap for designing theory-informed, sustainability strategies and employing user centered design principles to adapt strategies to changing mental health landscapes.