Table 3 Barriers, facilitators, and implementation strategies for the implementation of psychosocial care in orthopedic settings

 Inner setting/culture

Barrier

Value of maximizing clinic efficiency above all else and lack of acceptability of any innovation that might disrupt clinical flow

Streamline referral process to minimize disruption to clinical flow; capitalize on existing wait time in clinical flow; Educate on how psychosocial care might reduce patient follow-up needs (e.g., post-surgery calls and visits); solicit feedback from providers regarding integration within clinic flow

Tailor strategies*

Conduct educational meetings*

Create a learning collaborative*

“Medicine has turned into this, you know, turn and burn. You only get paid per click, you ‘gotta get him in and out… It’s just that our time constraints are narrowed down so much that it tends to fall down the list of priorities, right?” — Surgeon, site A

Facilitator

Emphasis on values-based care; desire to maximize patients’ wellbeing

Capitalize on the desire by providing education about the positive impact of psychosocial interventions and building collaborative alliances

Identify and prepare champions*

Recruit, designate and train for leadership*

“We’re not money driven. Our goal is not to do more surgeries. We like to treat the patient as a whole.” — Medical Assistant, site A

 Inner setting/implementation climate

Barrier

Resistance to innovation in clinic; low receptivity, and no expectation that use of the innovation will be rewarded, supported, or expected

Provide relevant incentives that are tailored for the specific type of stakeholders (e.g., evidence of treatment efficacy for surgeons or provision of support from leadership for other health professionals)

Conduct local needs assessment*

Alter incentive/allowance structures*

“For me it’s always difficult doing it. Change is always difficult. There’s no stimulus to do it unless you feel is a definite effect, so if it’s unlikely how much of an effect in this lot of work that is going to happen…” — Surgeon, site C

Facilitator

Openness to innovation in clinic

Invest in and seek support from health professionals who are express openness

Identify early adopters*

“I’m all for it. I’m big on improvement and, kind of, you know, evolving my practice. So, I’m looking forward to it.” — Surgeon, site B

 Inner setting/access to information and knowledge

Barrier

Providers’ lack of knowledge of the importance of psychosocial factors in patient recovery

Provide data-driven and concise education/resources (electronic resources, videos, or in-person communication preferred) to highlight existing empirical evidence

Develop educational materials*

Distribute educational materials*

“And a lot of the times providers don’t really take mental health all that seriously if that makes sense. Like, sometimes they’re … ‘Oh he’s just crazy.’” — Medical Assistant, site A

Barrier

Providers recognize they have a rudimentary knowledge of mental health; systemic education barrier

Provide data-driven and concise education/resources (electronic resources, videos, or in-person communication preferred) on managing with psychosocial factors

Conduct educational meetings*

Conduct ongoing training*

“Sometimes [patients] also have a psychiatrist and they will explain to me that they’ve been put on different medication and how they’re feeling, but that’s the extent of my conversation with them. You know, I have very rudimentary knowledge of psychiatry from medical school and that’s all I resort to.” — Surgeon, site C

Barrier

Lack of acceptability of lengthy/time-consuming communications and trainings

Ensure communication is concise, to-the-point; Take advantage of captive time (e.g., grand rounds, scheduled meetings)

Develop educational materials*

Distribute educational materials*

“Medicine is very evidence-based, and—especially surgeons are—I think being concise, and to-the-point is very important. If it’s, you know, a very long email or a very long flyer, it can easily get thrown by the wayside, so being concise and data-driven I think are the biggest things.” — Resident, site A

 Characteristics of individuals/knowledge and beliefs about intervention

Barrier

Personal negative bias against mental health factors (i.e., stigma)

Provide tailored psychoeducation according to the providers level of knowledge and source of bias

Conduct educational meetings*

Develop educational materials*

“I’ll admit this upfront. You know, 20 years of military service when you talk about mental health, psychological, even though I incorporate into my treatment plan, actually I have a strong, negative, unconscious bias towards it.” — Surgeon, site A

Facilitator

Understanding of the emotional toll of traumatic injuries; empathy for patients’ psychological needs

Identify and develop early collaborations with stakeholders who show enthusiasm and could potentially serve as champions

Assess for readiness and identify facilitators*

“You just happened to get a couple of people on the line tonight who were kind of in tune to some psychosocial aspects of patients…I’m only attuned to it really, quite frankly… I wasn’t very sensitive to the psychosocial aspects of being a fracture patient until I was in fact myself a fracture patient.” — Surgeon, site B

Facilitator

Previous experience in psychology or good training in medical school and residency to see/treat the whole patient rather than the bone or injury

Consider starting from more advance stages of implementation and the potential for serving as champions.

Stage implementation scale up*

Identify and prepare champions*

“We are sensitive providers, you know. I think we think of the whole patient… I don’t think it happened in residency, dependent on mentor, but in Med school, you’ve got to think of the whole patient, you can’t just think of the bone. You meet that injury, you’ve got to think about everything, and I keep getting reminded. I had pretty good mentors in residency who reminded me of that too.” — Surgeon, site B

 Characteristics of Individuals/self-efficacy

Barrier

Heterogeneity of providers' comfort level discussing mental health factors and perceived importance of mental health factors

Provide individualized education to providers regarding bringing up mental health concerns to patients; Take advantage of captive time (e.g., grand rounds, scheduled meetings)

Conduct ongoing dynamic training/consultation*

Model and simulate change*

Shadow other experts*

“People are going to come at it with different levels of, you know, how much they think mental health measures, you know, are important in incorporating recovery …it’s not something that was traditionally part of people’s training, and so I think people will just come at it from different perspectives.” — Resident, site A

 Implementation process/engaging/opinion leaders

Facilitator

Influence of leadership on perspectives of acceptability of innovations for providers

Engage formal leadership and opinion leaders to facilitate buy-in

Involve executive boards*

Obtain formal commitments*

Inform local opinion leaders*

“I think if you have leadership within the orthopedic trauma department to say, “This is a priority. We want you guys to start implementing this into your patient visits,” … That’s probably path to success.” — Research Personnel, site B

 Intervention characteristics/adaptability

Barrier

Heterogeneity in patients’ social/cultural contexts

Flexibly attune to patients’ social/cultural identities in treatment content using a culturally-informed approach (e.g., tailor examples of pleasurable activities, consider appropriateness of mindfulness for trauma-exposed patients)

Capture and share local knowledge*

Tailor strategies*

Conduct local consensus discussions*

“If there’s homework in the therapy sessions, be mindful of what they are. So, an example can be, you know, “Go out and take a walk in your neighborhood” … and be aware of what the person’s environment is and know what would be an appropriate intervention, culturally, and then what’s going on with the patients.” — Physical Therapist, site A

Barrier

Communication barrier with non-English-speaking populations (e.g., Spanish-speaking, Arabic-speaking)

Provide resources available in multiple languages, translation services available, and racially/ethnically diverse mental health service providers

Conduct local needs assessment*

Promote adaptability*

“If you’re going to work on serving patients who speak other languages or more diverse population, having materials translated is really important. I know from my experience, there are times where I’ve had to translate materials and sometimes that can be really challenging for the provider.” — Social Worker, site A

 Intervention characteristics/evidence strength or quality

Barrier

Skepticism about priority/ relevancy of psychosocial interventions for orthopedic patients

Provide education to medical providers on evidence base for psychosocial interventions

Conduct educational meetings*

Inform local opinion leaders*

Conduct educational outreach visits*

Distribute educational materials*

“My role is to make sure everything is right in terms of classical medicine…while appreciate the patient perception, I should first make sure that everything is right …then reassure them that what I do [in terms of medical treatment] is right…I am not going to introduce them to a nonclassical medicine route.” — Surgeon, site C

Barrier

Skepticism treating non-specific psychiatric disease (i.e., treating general emotional distress)

Ensure individualized services available; Provide education to medical providers on evidence base for transdiagnostic psychosocial interventions

Conduct educational meetings*

Inform local opinion leaders*

Conduct educational outreach visits*

Distribute educational materials*

“You must realize that that goes against every aspect of medical care that we’ve been trained to do… just everybody who might not be feeling great that day is far too vague than dealing with any specific problem… grouping them together just doesn’t make any sense at all… Just strikes me as completely insane.” — Surgeon, site C

Facilitator

Data-driven value of providers coupled with provider interest in patient functional outcomes

Capitalize on providers data-driven values by providing direct evidence on improvement in outcome following psychosocial interventions

Develop academic partnerships*

“We’re in the age of evidence-based medicine, and if you have evidence to prove it that would work. … Orthopedic trauma itself is a very vast field with so many different personalities and characteristics, but no one can refute evidence.” — Surgeon, Site B

 Intervention characteristics/complexity

Barrier

Concern for appropriateness of intervention for persons with low levels of education/literacy

Use simplified language or “lay” language; Incorporate figures and illustrations into educational materials

Capture and share local knowledge*

Develop a formal implementation blueprint*

Model and simulate change*

“But you can’t—you can’t use big words—you can’t—I mean, you laugh—but, it’s—it’s the truth, like, you’re going to lose people—you can’t use big words… you can’t forget your population.” — Resident, site B

 Outer setting/patient needs and resources

Barrier

Patients who do not have basic needs met (e.g., are experiencing homelessness, substance use, do not have access to food/safe space/transportation) or may not have ability/willingness to engage in psychosocial services

Enable flexibility in treatment pacing, duration, and content based on individualized needs to build rapport and “meet patients where they’re at”

Conduct local needs assessment*

Involve patients/consumers and family members*

Obtain and use patients/consumers and family feedback*

“I think one thing I noticed on my psych rotation is that a lot of these folks are living a very teetering life where one unfortunate circumstance can have their life spin out of balance …. So, getting appropriate resources for them is really important.” — Resident, site B

Barrier

Orthopedic team’s not prioritizing addressing psychosocial care within orthopedic care

Seek support from leadership for system change through provision of incentives and educational opportunities

Assess for readiness and identify barriers and facilitators*

Use advisory boards and workgroups*

“Our healthcare system is so fragmented, so I think, as a specialty practice, we don’t do as good of a job at addressing those needs… I think we have this view—it’s like, ‘Well, we’re orthopedics, we’re just treating that fracture, or that injury,’ and if the patient does have psych needs, it’s, you know, often kind of a culture as ‘Well, that’s for the PCP to, sort of, deal with, or that’s for the psychologist, or the psychiatrist.’” — Nurse, site C

Barrier

Difficulty of determining which patients would benefit from integrated psychosocial care versus outside specialty providers

Exploring the specific characteristics of the setting and patient population to develop system of decision making, and referral tailored for individual patient.

Conduct local needs assessment*

Involve patients/consumers and family members*

“We see an ever-increasing number of patients. So, that brings up an interesting point—how do you refer people with psychological needs outside of the system and maintain some sort of working relationship? And then, how do you figure out which patients are going to benefit from staying within an interdisciplinary system versus getting their needs met from an outside referral?” — Physical Therapist, site A

Barrier

Perception of lack of clear pathways to getting appointments to patients who express a mental health need

Collaborative clarification of the available resources and road map for referrals

Conduct local consensus discussions*

“To just have the name if we needed somebody, like a local person to send people to… that might be helpful. I just feel like we have little partnerships with doctors around [the area] but we don’t really have a psychiatrist or anything like that already.” — Medical Assistant, site A

Barrier

Lack of knowledge on how to engage patients to follow with outpatient services and goals (e.g., physical therapy, meds)

Enable treatment strategies to improve patients’ insight and motivation for engagement with care related practices.

Prepare patients/consumers to be active participants*

Intervene with patients to enhance uptake and adherence*

“We talk about non-compliance… So, it may seem really easy to say, ‘Take your meds, exercise, do these exercises and practice mindfulness,’ you know, that sounds like those are very smart goals and you can do those, but really understanding what their situation is and just being really intentional of how to help.” — Physical Therapist, site A

Facilitator

Perception that psychosocial needs in patients are vast and under addressed

Consider as an avenue for developing constructive collaboration with the providers to address these needs

Build a coalition*

“These people aren’t hiding, like, they are in plain sight. You see them in the trauma clinic, and you’re like ‘That is someone who is not coping well.’ … These are people who are struggling. I think they want help.” — Resident, site A

 Outer setting/external policy and incentives

Facilitator

Telehealth as increasing accessibility of care

Capitalize on the increased accessibility to further disseminate the psychosocial interventions

Change structure and equipment*

“I think prior to COVID I was like ‘Oh I don’t know about the videos’ but now, ever since COVID started and we had to do a lot more Zoom, I feel like patients are liking like these videos.” — Medical Assistant, site A

 Inner setting/structural characteristics

Barrier

High patient volume and fast-paced clinic flow make implementation of innovations difficult

Streamline process for providers referring patients to psychosocial care; Solicit feedback from providers regarding integration within clinic flow

Assess for readiness and identify barriers and facilitators*

Change structure and equipment*

Conduct cyclical small tests of change*

“You’ve tapped a trauma surgeon that is very busy on the bell curve, they’re top five percent as far as volume…You got to understand what goes along with that in a private practice and make sure that the metrics you’re looking for are well-defined, and you don’t vacillate from it.” — Surgeon, site A

Facilitator

Multidisciplinary nature of department (e.g., embedded physical therapists, dieticians etc.); interest in being a “one stop shop”

Use as an opportunity to promote multidisciplinary collaboration

Identify early adopters*

Promote network weaving*

Build a coalition*

“Another thing that’s different about [our site] is we not only have a primary surgeon, but we have our NPs and PAs. We also have a physical therapist, we have dietitians and social work, so there can be one patient who’s there for four hours, but they meet the surgeon, they meet the dietitian … We try to do like a one stop shop here for the patient so they can get everything as much as possible in one visit.” — Medical Assistant, site A

 Inner setting/compatibility

Barrier

Concern regarding interference with surgeons’ clinical flow and workflow

Develop adaptive ways for integration of psychosocial referrals into the surgeons’ workflow by soliciting feedback from the providers

Promote adaptability*

Conduct local consensus discussions*

Purposely reexamine the implementation*

“I think that success is going to come from being as non-obtrusive in your implementation as possible.” — Resident, site B

Facilitator

Perceived relevance of psychosocial care for patients’ needs and acknowledgment that psychosocial care would reduce burden on surgeons to have mental health-related conversations with patients

Capitalize on this insight and seek avenues to facilitate implementation through building fruitful collaborations, preparing champions, etc.

Assess for readiness and identify facilitators*

Identify and prepare champions*

Facilitation*

“In a perfect world, it would be wonderful if we had a psych team that was designated just for, like, trauma, that we could call, and they could see the patient and, you know, they’ve specialized in patients who have the mental health history, and then, on top of that, now they’re experiencing a traumatic injury, and, just, too, for the person who doesn’t have the psych history and experiences a trauma….I know that would generally benefit our providers, our patients, their outcomes, patient satisfaction—all of it—provider satisfaction, it would just be huge.” — Nurse, site C

Facilitator

Providers’ desire for additional support in encouraging patients to develop resilience to pain and engage in activity despite pain

Ensure message of psychosocial services align with recovery messages of clinic providers through communication/education

Build a coalition*

“I think the huge thing was safely getting involved in activity despite pain. Patients are afraid. A lot of times, if something hurts, they think that they’re, you know, damaging themselves, or they’re going to re-break something, or mess up their fixation, but I think the biggest thing is getting these patients up and out of bed, and being able to mobilize them, and any kind of, fight through to prevent them having contractures, or, you know, continued pain. I think that’s huge.” — Resident, site B

 Intervention characteristics/cost

Barrier

Patients’ insurance might have limited coverage for psychosocial care

Seek potential avenues to reduce cost in collaboration with local and regional stakeholders

Alter patient/consumer fees*

Access new funding*

Use other payment schemes*

“I was going to say cost [as a barrier], and what their insurance covers.” — Resident, site A

Barrier

Perception of need for large amount of funding by organization to implement any type of psychosocial care

Show data on how psychosocial care might be cost saving for organization

Develop resource sharing agreements*

Fund and contract for clinical innovation*

Place innovation on fee for service lists/formularies*

Involve executive boards*

“I’d be pretty open to it, but, again, it comes to funding. Like, who’s going to pay for the psychologist? You know, if this is an ortho-trauma provider, you know, that’s what our boss is going to look at, you know, they’re going to look at the bottom—bottom dollar, you know.” — Surgeon, site B

 Inner setting/networks and communication

Barrier

Challenge to maintain communication regarding patient needs among multidisciplinary providers

Frequent reminders

Organize clinician implementation team meetings*

Promote network weaving*

“I mean, so this is a problem in being in an interdisciplinary environment, is there are so many people considering different pieces of one puzzle, and then we’re kind of relying on our interoffice communication to put it together.” — Physical Therapist, site A

Facilitator

Use of screeners that can funnel patients into appropriate services in conjunction with orthopedic care after visits

Enable centralized center-wide screening methods for early identification of the need for psychosocial care

Centralize technical assistance*

“We do have screening that occurs from a PROs perspective, before they come in… I’m thinking of a particular patient that I have—who, 2-3 visits in, it was clear to me that I was not going to be able to address this on my own, and I asked if she would be interested in talking to social work, and so she agreed and so then I requested social work involvement.” — Physical Therapist, site A

Facilitator

Trust between doctors and clinical staff; Horizontal staff structure in which staff are encouraged to communicate observations to higher-ups

Encourage and develop a system of knowledge sharing and communication in the service of patients’ needs

Capture and share local knowledge*

Create a learning collaborative*

“We’re definitely comfortable speaking with each other and especially about patients. It’s a high priority to us… like I said, we do those questionnaires for anxiety and depression, you know, even if those look normal and I just get a weird vibe with maybe a patient mentioned something concerning, I have no problem bringing it up to the provider and saying ‘Hey, you might want to ask them about this because they said something about this.’” — Medical Assistant, site A

 Inner setting/available resources

Barrier

Perception of lack of human resources to support integration of psychosocial care

Ensure adequate staff to facilitate referral process for psychosocial care and provision of psychosocial care; educate and collaborate with all types of providers in orthopedic department; ensure clear division of responsibilities

Fund and contract for clinical innovation*

Develop resource sharing agreements*

“Adding another job responsibility on to the trauma clinics—maybe some of the other clinics—but in the trauma clinic specifically it’s extremely hard already trying to do the job at hand.” — Medical Assistant, site A

Barrier

Perceived lack of time in clinic flow to implement innovations (e.g., time for referral process or time to have “heart to heart” with patients)

Streamline process for providers referring patients to psychosocial care; Solicit feedback from providers regarding integration within clinic flow

Capture and share local knowledge*

Change structure*

Develop resource sharing agreements*

“They would probably do well with like a 15-minute, you know, kind of heart-to-heart with the doctor. But when we see 35 people, you don’t have the time to do that with every single person…So, part of the problem is you just don’t have the time to make them feel better, which sounds really insensitive.” — Medial Assistant, site A

 Inner setting/tension for change

Barrier

Despite the belief that psychosocial care is needed for orthopedic patients, the current situation does not seem as intolerable to the stakeholders

Provide evidence regarding the short term and long-term costs of delaying the implementation of psychosocial care model

Facilitate relay of clinical data to providers*

Inform local opinion leaders*

“How could we consider the addition of a new tool or something, even though we all acknowledge that it’s really a big deal, but we haven’t been able to break the inertia that it takes to incorporate certain things.” — Surgeon, site A

Facilitator

Perceived urgency to address psychosocial needs in patients

Use these opportunities to capitalize on providers need and promote/move forward with the implementation of psychosocial care model

Identify and prepare champions*

“Particularly in the pandemic, the needs are higher, and so I’ve heard from social workers that it’s really heavy and difficult to hear the trauma stories, process, problem solve—it feels a little bit heavier than before because of the difficulties of the pandemic.” — Social Worker, site A

 Implementation process/engaging

Barrier

Individual nature of buy-in by providers (i.e., difficult to engage all providers)

Education should be engaging and motivational to increase chance of buy-in; engage formal leadership and opinion leaders to facilitate buy-in; build rapport/relationships with providers

Make training dynamic*

Facilitate relay of clinical data to providers*

Inform local opinion leaders*

“Identify which surgeons on the trauma service want to participate…and then—and—and then—I don’t know if you could try to focus on those clinics—but that might be the best way to go.” — Nurse, site C

Barrier

Stigma associated with mental health may impede patient uptake of services

Have doctors refer patients to services; Emphasize importance of psychosocial services for pain, recovery, and overall health; Hire providers who sound/talk like patients; Ensure patient privacy/confidentiality related to mental health discussions (i.e., do not introduce in front of family members)

Intervene with patients to enhance uptake and adherence*

Involve patients*

Identify and prepare champions*

Tailor strategies*

“We definitely have long conversations over avoiding the word ‘depression,’ you know, using the word like ‘feeling blue’ or ‘sad.’ I think people, when they see the words ‘anxiety’ and ‘depression,’ ‘mental health,’ they get scared and they think ‘Oh that’s, you’re getting too private now.’” — Medical Assistant, site A

Barrier

Patients may have negative reaction to hearing psychosocial factors are a contributor to their pain; Patients may get message that pain is “all in their head”

Emphasize importance of psychosocial services for pain, recovery, and overall health with a focus on a mind-body framework

Intervene with patients to enhance uptake and adherence*

Involve patients and family members*

“Well, you know, we still live in a world where, you know, unfortunately, psychosocial issues are still considered taboo, and so I would say that when you start to say anything about treatments that involve anything related to the mental capacity, mental space, they assume you mean that you think they’re crazy and they’re not going to get—you know, that it’s all in their head.” — Nurse Practitioner, site A

Barrier

Fast-paced nature of clinic makes it challenging for patients to open up about thoughts and feelings

Give psychosocial factors attention deserved by “owning” time during clinic flow when talking to patients

Change structure and equipment*

Promote adaptability*

“I think making sure to like, slow the process down, maybe, however you implement yourself into the process, because I think if you rush patients, they’re probably not going to be as open.” — Research Personnel, site B

Facilitator

Patient interest in pain and doing anything to alleviate pain

Emphasize/educate patients that psychosocial factors are a primary contributor to pain

Intervene with patients to enhance uptake and adherence*

Obtain and use patients and family feedback*

Prepare patients to be active participants*

“All of my patients care about their pain and their pain control, and honestly, when can they get their next pain medication refill, and so anything that, up front says that we have proven that, you know, these techniques are going to help, you know… ‘We believe that this is going to help your pain,’ honestly, that’s the big selling point that my patients need to hear.” — Nurse Practitioner, site A

Facilitator

Buy-in from providers can help convince patients that psychosocial care is important

Engage formal leadership and opinion leaders to facilitate buy-in; have doctors refer patients to services

Conduct educational meetings*

Inform local opinion leaders*

Make training dynamic*

“And so, I think having—having the surgeon—kind of, providing them with the tools to at least, you know, bring up the topic and endorse the problem itself, directly and deliberately, will be an important part of patient enrollment and compliance.” — Resident, site A

Facilitator

Residents are available who are more malleable than attendings

Enable engaging scientific discussions to highlight the need for psychosocial care

Conduct educational outreach visits*

“So, I mean, I think you guys are doing a good thing and trying to target academic institutions, especially where residents are involved, because if you can change behavior in residence, then that’ll be a big impact.” — Research Personnel, site B