BACKGROUND: Technology-enabled services (TESs) have the potential to increase access to mental healthcare. However, little research has focused on how TESs can be integrated into publicly funded service settings. As part of the state-wide Help@Hand project, Marin County conducted a pilot implementation of myStrength, a digital cognitive behavioral therapy platform, to explore its potential to reduce loneliness among isolated older adults. We evaluated the pilot impact using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. METHOD: A single-site 6-month pilot implementation recruited English (n = 15) and Spanish-speaking (n = 15) isolated older adults who received a digital literacy course followed by 8 weeks of myStrength access and human support. We evaluated factors related to reach, effectiveness, adoption, and implementation using the perspectives of users and County staff. Descriptive statistics were used to examine reach, adoption, and implementation. Nonparametric tests, including Friedman and Wilcoxon signed-rank, were used to examine effectiveness. RESULTS: Reach: Compared to overall county demographics, platform users were majority female (93.1% vs. 50.5%), ethnoracialized (62.1% vs. 24.2%), and of lower socioeconomic status (Mdn = $35,000 vs. $131,008). Effectiveness: Users reported a significant (z = -2.62, p < .001) decrease in loneliness. Adoption: Users logged into myStrength an average of 10 times and completed 33 activities during the 8 weeks of myStrength use. Implementation: Each pilot staff (N = 20) spent an average of 19.8 hr (SD = 16.51) supporting users use of myStrength during the pilot. Pilot staff reported several adaptations to meet the needs of users. CONCLUSIONS: Successes included reaching the target population, reducing loneliness, and user adoption. However, pilot staff invested significant time to support those with lower digital literacy skills. As such, although TESs may address unmet needs, their use with underserved populations may require upfront and ongoing support provided by the settings where they are implemented. PLAIN LANGUAGE SUMMARY TITLE: Testing a New Digital Therapy Tool for Isolated Older Adults in County Mental Health Services.

Background

Digital mental health interventions (DMHIs) represent a promising solution to address the growing unmet mental health needs and increase access to care. Integrating DMHIs into clinical and community settings is challenging and complex. Frameworks that explore a wide range of factors, such as the Exploration, Preparation, Implementation, Sustainment (EPIS) framework, can be useful for examining multilevel factors related to DMHI implementation efforts.

Objective

This paper aimed to identify the barriers to, facilitators of, and best practice recommendations for implementing DMHIs across similar organizational settings, according to the EPIS domains of inner context, outer context, innovation factors, and bridging factors.

Methods

This study stems from a large state-funded project in which 6 county behavioral health departments in California explored the use of DMHIs as part of county mental health services. Our team conducted interviews with clinical staff, peer support specialists, county leaders, project leaders, and clinic leaders using a semistructured interview guide. The development of the semistructured interview guide was informed by expert input regarding relevant inner context, outer context, innovation factors, and bridging factors in the exploration, preparation, and implementation phases of the EPIS framework. We followed a recursive 6-step process to conduct qualitative analyses using inductive and deductive components guided by the EPIS framework.

Results

On the basis of 69 interviews, we identified 3 main themes that aligned with the EPIS framework: readiness of individuals, readiness of innovations, and readiness of organizations and systems. Individual-level readiness referred to the extent to which clients had the necessary technological tools (eg, smartphones) and knowledge (digital literacy) to support the DMHI. Innovation-level readiness pertained to the accessibility, usefulness, safety, and fit of the DMHI. Organization- and system-level readiness concerned the extent to which providers and leadership collectively held positive views about DMHIs as well as the extent to which infrastructure (eg, staffing and payment model) was appropriate.

Conclusions

The successful implementation of DMHIs requires readiness at the individual, innovation, and organization and system levels. To improve individual-level readiness, we recommend equitable device distribution and digital literacy training. To improve innovation readiness, we recommend making DMHIs easier to use and introduce, clinically useful, and safe and adapting them to fit into the existing client needs and clinical workflow. To improve organization- and system-level readiness, we recommend supporting providers and local behavioral health departments with adequate technology and training and exploring potential system transformations (eg, integrated care model). Conceptualizing DMHIs as services allows the consideration of both the innovation characteristics of DMHIs (eg, efficacy, safety, and clinical usefulness) and the ecosystem around DMHIs, such as individual and organizational characteristics (inner context), purveyors and intermediaries (bridging factor), client characteristics (outer context), as well as the fit between the innovation and implementation settings (innovation factor).