Factors associated with successful FLOW implementation to improve mental health access: a mixed-methods study

The FLOW program assists mental health providers in transitioning recovered and stabilized specialty mental health (SMH) patients to primary care to increase access to SMH care. In a recent cluster-randomized stepped-wedge trial, nine VA sites implemented the FLOW program with wide variation in implementation success. The goal of this study is to identify site-level factors associated with successful implementation of the FLOW program, guided by the Consolidated Framework for Implementation Research (CFIR). We used the Matrixed Multiple Case Study method, a mixed-methods approach, to compare key metrics hypothesized to impact implementation that were aligned with CFIR. Based upon the number of veterans transitioned at each site, we categorized two sites as higher implementation success, three as medium, and four as lower implementation success. Themes associated with more successful implementation included perceptions of the intervention itself (CFIR domain Innovation), having a culture of recovery-oriented care and prioritizing implementation over competing demands (CFIR domain Inner Setting), had lower mental health provider turnover, and had an internal facilitator who was well-positioned for FLOW implementation, such as having a leadership role or connections across several clinics (CFIR domain Characteristics of Individuals). Other variables, including staffing levels, leadership support, and organizational readiness to change did not have a consistent relationship to implementation success. These data may assist in identifying sites that are likely to need additional implementation support to succeed at implementing FLOW. Successful implementation of this mental health access program was associated with staff having positive perceptions of the intervention, having a culture of recovery-oriented care, prioritizing implementation over competing demands, and having a local provider in charge of implementation who was well-positioned for implementation. The FLOW program helps mental health providers transition recovered mental health patients to primary care, which can free up appointments for other mental health patients. In a recent study, nine VA sites were asked to implement the FLOW program. Their success varied widely, and thus the current study examines potential reasons why some sites were more successful than others. We used a mixed-methods approach to compare factors that may affect implementation. Two sites were more successful at using FLOW, three were medium, and four were relatively unsuccessful. Sites with more successful implementation had positive perceptions of the FLOW intervention itself, had a culture of recovery-oriented care, prioritized implementation over competing demands, had a local provider in charge of implementation who was well-positioned for FLOW implementation, and had lower staff turnover. Other things, including staffing levels, leadership support, and organizational readiness to change did not appear to predict success. This research may help us understand how best to implement FLOW in the future.