Evaluating the implementation of measurement-based care in child and adolescent mental health services as part of a learning health system

Background Mental health conditions affect one in seven young people and research suggests that current mental health services are not meeting the needs of many children and youth. Learning health systems are an approach to enhancing mental health services through rapid, routinized cycles of continuous learning and improvement. Patient-reported outcome measures (PROMs) provide a key data source for learning health systems. PROMs also improve outcomes for patients when integrated into routine clinical care - an approach often referred to as measurement-based care (MBC) in mental health services. However, implementing MBC into health systems is challenging. The purpose of this study was to evaluate the implementation of MBC in a child and adolescent mental health centre in Calgary, Canada. Our specific objectives were to assess implementation outcomes, and identify barriers and facilitators to implementation. Methods This study is a mixed-methods, formative evaluation using the Consolidated Framework for Implementation Research. The child and adolescent mental health centre has three services: single session Walk-in service, Day Hospital and Intensive Community Treatment Services. Participants included managers, clinicians, administrative support, embedded researchers at the centre, and youth and caregivers who have accessed the centre’s services. Surveys, PROM and administrative data, as well as semi-structured interview data were analyzed to evaluate implementation outcomes (acceptability, appropriateness, penetration, fidelity), as well as assess barriers and facilitators to implementation of MBC. Results Clinicians (n = 14), managers (n = 3), administrative support (n = 6), and embedded research team members (n = 4) participated. Acceptability of MBC was high, perceptions of appropriateness varied by service. Penetration and fidelity metrics were high in intensive community treatment services, mixed in Day Hospital and low in the Walk-in service. Key facilitators identified include leadership support, a culture of innovation, the design of MBC, and clinician self-efficacy with standardized assessment tools. Key barriers included the platform for administering MBC, inconsistent engagement with clinical staff, and the policies of the large health services provider operating the centre. Conclusion This study described implementation outcomes and identified determinants of successful implementation of MBC in child and adolescent mental health services. The findings will be useful in designing implementation strategies in similar settings.