JULIANNE MANCHESTER, PhD, LSSBB
This third issue brief, in a series focused on planning, implementing, and evaluating integrated behavioral health initiatives, discusses logic models and their use as monitoring and evaluation tools. Further, nested logic models with simultaneous, community-based activities can sustain stakeholder engagement and result in comprehensive planning across the spectrum of care.
As discussed in the second issue brief, Improving Community Based Behavioral Health Initiatives Through Participatory Implementation and Evaluation, integrated behavioral health activities can impact multiple areas of the Social Determinants of Health (SDoH) within a similar timeframe. A nested logic model built from stakeholder observation, along with pertinent behavioral health frameworks such as care coordination to improve care pathways, can visually delineate simultaneous efforts and enhance understanding of salient actions leading to anticipated changes (improved clinical and non-clinical outcomes).
- Logic Models and Their Role in Stakeholder Engagement
Logic models are visual illustrations to convey a program, activity, or intervention’s notions of change to stakeholders1. Figure 1 below provides a basic structure, where Activities (critical action steps) produce tangible Outputs (numbers and counts, often referred to as performance measures) prior to any Outcomes (Changes) emerging. Logic models tend to be linear, with notions of cause and effect to quickly identify which Outputs will be measured and tracked once implementation of Activities begin, or which Inputs are necessary to support Activities.
Figure 1. Basic Logic Model
An integrated behavioral team may use grant funds and other operational resources (Inputs) to support stakeholder meetings, crisis planning, case management, patient education, outreach, and provider training (Activities) with a measurable number of recipients, attendees, providers, and materials (Outputs, or performance metrics). Outcomes, or changes, may include decreased wait times (Short-Term) for patients, increased patient adherence to care plans (Intermediate), and lowered addiction rates (Long-Term).
As part of their sustained engagement in integrated behavioral health program planning, multi-sector stakeholders can collaboratively identify and map reasonable and expected Outcomes during their regular planning meetings, an early step in creating the logic model. Anecdotal observations and case study information are valid sources of information in participatory implementation and evaluation. Stakeholders can provide insight on contextual factors that may interact with the main Activities. These factors are vital to capture and address early in the project, as they may serve as either facilitators or barriers to achieving Outcomes. These factors originate with recipients themselves (cultural, linguistic), in program delivery (on-line, in-person, clinical, non-clinical), and in the environment (geographic, socio-economic, neighborhood).
- Nested Logic Modeling in an Integrated Behavioral Health Context
Social Determinants of Health (SDoH) affect functioning across life systems of work, play, home, and worship, among many others2. Many of the contextual factors discussed above reside or originate in one or more of the five SDoH domains. This requires stakeholders to not only represent these domains in an integrated behavioral health initiative, but to integrate their knowledge of them in implementation, monitoring, and evaluation planning. Figure 2 builds on the previous discussion of the basic logic model structure to identify Activity groupings across non-clinical (education, housing, corrections) and clinical (health, behavioral health) sectors.
The nested logic model example (Figure 2) is not prescriptive or exhaustive of elements that could be at play in this context. Here, the model implies that the Activities of ‘Screenings, Assessment, and Diagnosis’ interact with ‘Care Planning’ and ‘Outpatient Services.’ For example, the quality of information collected from standardized and valid instruments during grouping 2A influences the effectiveness of comprehensive care planning. All conducted Activities will produce Outputs, or Performance Measures, which tend to be of high interest to funders (perhaps required to show progress toward goals) and other stakeholders (monthly reports; program updates). The appropriateness of chosen ‘Outpatient Services,’ 3C (based on 3A-3B diagnostic and care plan specifications) should influence whether behavioral health consumers show changes (demonstrate Outcomes) in 4A (Short-Term) through 4C (Long-Term).
Figure 2. Nested Logic Model- Integrated Behavioral Health Initiative
As stated, contextual factors from across the SDoH can facilitate and/or prevent Outcomes demonstrations in 4A-4c, as discussed below:
◦ Behavioral health and health issues limit one’s Economic Stability, particularly in securing and maintaining employment. Exposure to coordinated care to address depression, addiction, and/or chronic disease such as diabetes can improve employability.
◦ Vulnerable adolescents and young adults with depression and addiction are less likely to graduate high school, attend college, or learn vocational skills, limiting Education Access & Quality. Linkages between school, home, and integrated behavioral healthcare (three systems in which individuals spend time) through care coordination can improve the odds of educational attainment.
◦ Team-based care options in one’s community improves Healthcare Access & Quality through increasing access to risk screens and psychosocial interventions that can reduce incarceration or unemployment, reducing rates of emergency room visits, and opening preventive care pathways.
◦ Integrated behavioral health approaches that involve stakeholders in the position to increase opportunities for recreation, improve safety of neighborhood parks, or reduce environmental toxins such as lead and smoke are working to improve the Neighborhood and Built Environment, an important factor in sustaining wellness and resiliency over time.
◦ Finally, care coordination improves the Social and Community Context for the consumer, fostering greater communication between family members, peers, and influential systems (school, work, health) through its interdisciplinary and multi-sector nature.
References
- Wholey, J.S., Hatrey, H.P., & Newcomer, K.E. (ed.) (2010). “Handbook of Practical Program Evaluation (3rd ed.),” San Francisco: Jossey-Bass.
- Healthy People 2030, U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Retrieved from https://health.gov/healthypeople/objectives-and-data/social-determinants-health
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