Table 4.

Adaptation of multi-component iHeart DepCare implementation strategy to fit local context

Actor	Preliminary implementation strategy	Reasons for adaptation	Final implementation strategy
System/Staff	- Ongoing problem-solving meetings by implementation/research team	- Need for more formal, data-driven process for addressing implementation needs - Need to keep physician champions and mental health providers engaged in implementation process given rapid contextual changes during COVID19 pandemic - Continued concerned about lack of access to mental health providers, particularly those educated to treat CHD patients	- Expanded problem-solving meetings to include physical and mental health providers to address contextual determinants of implementation (e.g., brainstorm how to maximize limited resources, address wait times, incorporate behavioral activation into mental health treatment for CHD patients, update referral lists, disseminate screening quality videos to staff) - Aligned with existing Learning Mental Health Collaborative to ensure data-driven approach
Provider	- In Person Grand Rounds presentation on depression and heart disease	- Shifts to remote work during COVID19 pandemic/Concerns for low meeting attendance rates - Concerns regarding lack of low fidelity/provider adherence to educational strategy (e.g., due to lack of time, length of material) -Need for clear, brief, action- oriented language (e.g., pneumonic)	- Developed online formats (video and newsletter) for distribution of educational content - Content limited to essential, “need to know” information and task oriented (e.g., referral and treatment optimization) - Incorporated essential content within body of email/newsletter in case providers don’t click on links - Have clinic directors deliver the video/survey to improve fidelity to strategy
	- Built in prompts/cues/dashboard for referral feedback in EHR	- Concerns regarding acceptability of automated alerts via Epic, often ignored due to alert-fatigue among providers; could be viewed as overly intrusive - Lack of feasibility of creating dashboard for individual providers given competing clinic priorities during COVID19 - Concerns for overwhelming limited mental health system	- Developed “iHeart” smartphrase (i.e., “dot phrases,” that allow commonly used chunks of text to easily be inserted into patient notes”) -Email notification of feedback on clinic level referral rates, also presented during problem solving meetings
	- Summary report from eSDM tool on patient treatment preferences and optimization recommendations printed and delivered to provider during visit	-Restrictions to waiting room projects 2/2 to COVID19 -Too long/detailed, not enough information on actionable next steps for busy providers	- Adapted, shortened summary report with “recommended action” on top - Summary report delivered via email and Epic - Included cardiac health profile with feedback on health behaviors to improve usefulness and acceptability
Patient	eSDM tool with depression screening, psychoeducation (via patient and provider videos), treatment decision support with pros/cons, and review of barriers to treatment -Delivered by implementation team in waiting room via iPad	Mode of Delivery - COVID-19 pandemic required flexible delivery approach outside waiting rooms	- Shifted from focus on iPad to supporting web-based application (accessible via phone, tablet, or computer)
		Workflow - Concerns by patients that making primary care providers or cardiologists address depression, which might undermine their medical concerns - Concerns by stakeholders that bypassing providers and automatically referring patients would overwhelm the limited mental health system - Need to align with clinic-level screening efforts - Digital Literacy considerations	- Delivery of tool results to mental health navigators/ providers (in addition to primary care providers/cardiologists) and alerting patients that their results would be delivered to their physicians - Tool bypasses screening if already done by system - Included paper copy of tool for all patients; multi-modal delivery of tool components (e.g., email pdf or video)
		Content - Concern for increasing stress/anxiety by broaching heart attack - Need more education on heart disease to better engage patients - Concern that patient video about mental health may be less acceptable to mostly male CHD patients - Need for contingency plan in the case that clinicians ignore prompts/summary report	- Removed “heart attack” signs/language - Prioritized depression treatment/maintenance/outcomes vs. education on the heart disease. - Added content hub at end of tool on heart disease and depression - Created animation of CHD patient, kept authoritative provider video - Included links on how to find a counselor/therapy/cardiac rehabilitation in community (e.g., based on zip code/insurance) - Option not to address depression

Abbreviations: CHD Coronary Heart Disease; EHR electronic health record; eSDM electronic shared decision-making tool.