Practice change, whether individual or organizational, can be challenging. The IMPACT Implementation Center has helped numerous, diverse organizations successfully adapt and implement IMPACT. We continue learning the most effective ways to plan this type of quality improvement program and are available to help you plan your implementation.

Needs Assessment

Quality Indicators and Fidelity

Traditional fidelity measures evaluate how faithfully an implementation is to the original research protocol. It is based on the assumption that the more an implementation strays from the original program the greater the likelihood that it will lose its effectiveness. This does not have to be the case, as demonstrated by a program evaluation of an IMPACT adaptation done at Kaiser Permanente.

Rather than advocate implementations of IMPACT that exactly match the randomized study, we understand that providers and organizations may want to adapt the program to meet the unique needs of their setting. We believe that this can increase the likelihood that the program can be sustained and spread.

In addition to implementing the key components, we encourage providers and organizations implementing or adapting IMPACT to measure the effectiveness of their program to convince themselves that they are achieving their goals. Below are the quality indicators that we recommend. The goal for indicators 1-5 should be to implement them with at least 75% of eligible patients. The goal for indicator 6 should be to achieve this with at least 50% of eligible patients.

1. Depression Screening: % of patients with documentation of annual screening for depression with the PHQ-2 or similar screening measure
2. Diagnosis: % of patients with a positive screen who receive a structured depression assessment (e.g. PHQ-9) to help confirm a diagnosis of depression within 4 weeks of screening
3. Initiation of Treatment: % of primary care patients diagnosed with depression who initiated treatment (antidepressant medication, psychotherapy, or ECT) or attended a mental health specialty visit within 4 weeks of initial diagnosis
4. Measurement of Treatment Outcomes: % of primary care patients treated for depression who receive a structured clinical assessment (i.e., PHQ-9) of depression severity at:
   baseline: within 2 weeks prior or subsequent to treatment initiation
   follow-up: within 8 to 12 weeks following treatment initiation
   continuation: within 3 to 6 months following treatment initiation
5. Adjustment of Treatment Based on Outcomes: % of primary care patients treated for depression with a PHQ-9 score of >= 10 at follow up who receive an adjustment to their depression treatment (e.g. change in antidepressant medication or psychotherapy) or attend a mental health specialty consult within 8-12 weeks of initiating treatment
6. Symptom Reduction: % of patients treated for depression who have a decrease > 50% in depression symptom levels from baseline as measured by the PHQ-9 or similar quantifiable measure and a PHQ-9 score < 10 within 6 months of initiating treatment

Fidelity Measure

Organizational Change

Practice change is more complex and challenging when an entire organization is adopting an evidence-based practice like IMPACT. An Institute of Medicine report states that it typically takes 17 years until healthcare innovations reach the average patient. There are many factors involved in that lag. Researchers are increasingly studying the process of moving evidence-based practices from research to the ‘real world.’ This includes studying factors that facilitate or hinder the process. The IMPACT Implementation Center uses this literature to better understand how to help organizations adopting IMPACT.