Practical Use of Process Mapping to Guide Implementation of a Care Coordination Program for Rural Veterans

An implementation strategy postmortem method developed in the VA rural Transitions Nurse Program to inform spread and scale-up

BACKGROUND

High-quality implementation evaluations report on intervention fidelity and adaptations made, but a practical process for evaluating implementation strategies is needed. A retrospective method for evaluating implementation strategies is also required as prospective methods can be resource intensive. This study aimed to establish an implementation strategy postmortem method to identify the implementation strategies used, when, and their perceived importance. We used the rural Transitions Nurse Program (TNP) as a case study, a national care coordination intervention implemented at 11 hospitals over three years.

METHODS

The postmortem used a retrospective, mixed method, phased approach. Implementation team and front-line staff characterized the implementation strategies used, their timing, frequency, ease of use, and their importance to implementation success. The Expert Recommendations for Implementing Change (ERIC) compilation, the Quality Enhancement Research Initiative phases, and Proctor and colleagues' guidance were used to operationalize the strategies. Survey data were analyzed descriptively, and qualitative data were analyzed using matrix content analysis.

RESULTS

The postmortem method identified 45 of 73 ERIC strategies introduced, including 41 during pre-implementation, 37 during implementation, and 27 during sustainment. External facilitation, centralized technical assistance, and clinical supervision were ranked as the most important and frequently used strategies. Implementation strategies were more intensively applied in the beginning of the study and tapered over time.

CONCLUSIONS

The postmortem method identified that more strategies were used in TNP than planned and identified the most important strategies from the perspective of the implementation team and front-line staff. The findings can inform other implementation studies as well as dissemination of the TNP intervention.

Tools, frameworks and resources to guide global action on strengthening rural health systems: a mapping review

BACKGROUND

Inequities of health outcomes persist in rural populations globally. This is strongly associated with there being less health coverage in rural and underserviced areas. Increasing health care coverage in rural area requires rural health system strengthening, which subsequently necessitates having tools to guide action.

OBJECTIVE

This mapping review aimed to describe the range of tools, frameworks and resources (hereafter called tools) available globally for rural health system capacity building.

METHODS

This study collected peer-reviewed materials published in 15-year period (2005-2020). A systematic mapping review process identified 149 articles for inclusion, related to 144 tools that had been developed, implemented, and/or evaluated (some tools reported over multiple articles) which were mapped against the World Health Organization's (WHO's) six health system building blocks (agreed as the elements that need to be addressed to strengthen health systems).

RESULTS

The majority of tools were from high- and middle-income countries (n = 85, 59% and n = 43, 29%, respectively), and only 17 tools (12%) from low-income countries. Most tools related to the health service building block (n = 57, 39%), or workforce (n = 33, 23%). There were a few tools related to information and leadership and governance (n = 8, 5% each). Very few tools related to infrastructure (n = 3, 2%) and financing (n = 4, 3%). This mapping review also provided broad quality appraisal, showing that the majority of the tools had been evaluated or validated, or both (n = 106, 74%).

CONCLUSION

This mapping review provides evidence that there is a breadth of tools available for health system strengthening globally along with some gaps where no tools were identified for specific health system building blocks. Furthermore, most tools were developed and applied in HIC/MIC and it is important to consider factors that influence their utility in LMIC settings. It may be important to develop new tools related to infrastructure and financing. Tools that have been positively evaluated should be made available to all rural communities, to ensure comprehensive global action on rural health system strengthening.

Optimizing process flow diagrams to guide implementation of a colorectal cancer screening intervention in new settings

PURPOSE

The goal of this study was to assess acceptability of using process flow diagrams (or process maps) depicting a previously implemented evidence-based intervention (EBI) to inform the implementation of similar interventions in new settings.

METHODS

We developed three different versions of process maps, each visualizing the implementation of the same multicomponent colorectal cancer (CRC) screening EBI in community health centers but including varying levels of detail about how it was implemented. Interviews with community health professionals and practitioners at other sites not affiliated with this intervention were conducted. We assessed their preferences related to the map designs, their potential utility for guiding EBI implementation, and the feasibility of implementing a similar intervention in their local setting given the information available in the process maps.

RESULTS

Eleven community health representatives were interviewed. Participants were able to understand how the intervention was implemented and engage in discussions around the feasibility of implementing this type of complex intervention in their local system. Potential uses of the maps for supporting implementation included staff training, role delineation, monitoring and quality control, and adapting the components and implementation activities of the existing intervention.

CONCLUSION

Process maps can potentially support decision-making about the adoption, implementation, and adaptation of existing EBIs in new contexts. Given the complexities involved in deciding whether and how to implement EBIs, these diagrams serve as visual, easily understood tools to inform potential future adopters of the EBI about the activities, resources, and staffing needed for implementation.

Jumping Through Hoops: Community Care Clinician and Staff Experiences Providing Primary Care to Rural Veterans

BACKGROUND

The 2019 VA Maintaining Systems and Strengthening Integrated Outside Networks Act, or MISSION Act, aimed to improve rural veteran access to care by expanding coverage for services in the community. Increased access to clinicians outside the US Department of Veterans Affairs (VA) could benefit rural veterans, who often face obstacles obtaining VA care. This solution, however, relies on clinics willing to navigate VA administrative processes.

OBJECTIVE

To investigate the experiences rural, non-VA clinicians and staff have while providing care to rural veterans and inform challenges and opportunities for high-quality, equitable care access and delivery.

DESIGN

Phenomenological qualitative study.

PARTICIPANTS

Non-VA-affiliated primary care clinicians and staff in the Pacific Northwest.

APPROACH

Semi-structured interviews with a purposive sample of eligible clinicians and staff between May and August 2020; data analyzed using thematic analysis.

KEY RESULTS

We interviewed 13 clinicians and staff and identified four themes and multiple challenges related to providing care for rural veterans: (1) Confusion, variability and delays for VA administrative processes, (2) clarifying responsibility for dual-user veteran care, (3) accessing and sharing medical records outside the VA, and (4) negotiating communication pathways between systems and clinicians. Informants reported using workarounds to combat challenges, including using trial and error to gain expertise in VA system navigation, relying on veterans to act as intermediaries to coordinate their care, and depending on individual VA employees to support provider-to-provider communication and share system knowledge. Informants expressed concerns that dual-user veterans were more likely to have duplication or gaps in services.

CONCLUSIONS

Findings highlight the need to reduce the bureaucratic burden of interacting with the VA. Further work is needed to tailor structures to address challenges rural community providers experience and to identify strategies to reduce care fragmentation across VA and non-VA providers and encourage long-term commitment to care for veterans.

Research-practice partnerships: Adapting a care coordination intervention for rural Veterans over 3 years at multiple sites

PURPOSE

Rural Veterans are more likely than urban Veterans to qualify for community care (Veterans Health Administration [VHA]-paid care delivered outside of VHA) due to wait times ≥30 days and longer travel times for VHA care. For rural Veterans receiving both VHA and community care, suboptimal care coordination between VHA and community providers can result in poor follow-up and care fragmentation. We developed Telehealth-based Coordination of Non-VHA Care (TECNO Care) to address this problem.

METHODS

We iteratively developed and adapted TECNO Care with partners from the VHA Office of Rural Health and site-based Home Telehealth Care in the Community programs. Using templated electronic health record notes, Home Telehealth nurses contacted Veterans monthly to facilitate communication with VHA/community providers, coordinate referrals, reconcile medications, and follow up on acute episodes. We evaluated TECNO Care using a patient-level, pre-post effectiveness assessment and rapid qualitative analysis with individual interviews of Veterans and VHA collaborators. Our primary effectiveness outcome was a validated care coordination quality measure. We calculated mean change scores for each care continuity domain.

FINDINGS

Between March 2019 and October 2021, 83 Veterans received TECNO Care. Veterans were predominately White (86.4%) and male (88.6%) with mean age 71.4 years (SD 10.4). Quantitative data demonstrated improvements in perceived care coordination following TECNO Care in 7 categories. Qualitative interviews indicated that Veterans and Home Telehealth nurses perceived TECNO Care as beneficial and addressing an area of high need.

CONCLUSIONS

TECNO Care appeared to improve the coordination of VHA and community care and was valued by Veterans.

Study protocol: Type III hybrid effectiveness-implementation study implementing Age-Friendly evidence-based practices in the VA to improve outcomes in older adults

BACKGROUND

Unmet care needs among older adults accelerate cognitive and functional decline and increase medical harms, leading to poorer quality of life, more frequent hospitalizations, and premature nursing home admission. The Department of Veterans Affairs (VA) is invested in becoming an "Age-Friendly Health System" to better address four tenets associated with reduced harm and improved outcomes among the 4 million Veterans aged 65 and over receiving VA care. These four tenets focus on "4Ms" that are fundamental to the care of older adults, including (1) what Matters (ensuring that care is consistent with each person's goals and preferences); (2) Medications (only using necessary medications and ensuring that they do not interfere with what matters, mobility, or mentation); (3) Mentation (preventing, identifying, treating, and managing dementia, depression, and delirium); and (4) Mobility (promoting safe movement to maintain function and independence). The Safer Aging through Geriatrics-Informed Evidence-Based Practices (SAGE) Quality Enhancement Research Initiative (QUERI) seeks to implement four evidence-based practices (EBPs) that have shown efficacy in addressing these core tenets of an "Age-Friendly Health System," leading to reduced harm and improved outcomes in older adults.

METHODS

We will implement four EBPs in 9 VA medical centers and associated outpatient clinics using a type III hybrid effectiveness-implementation stepped-wedge trial design. We selected four EBPs that align with Age-Friendly Health System principles: Surgical Pause, EMPOWER (Eliminating Medications Through Patient Ownership of End Results), TAP (Tailored Activities Program), and CAPABLE (Community Aging in Place - Advancing Better Living for Elders). Guided by the Pragmatic Robust Implementation and Sustainability Model (PRISM), we are comparing implementation as usual vs. active facilitation. Reach is our primary implementation outcome, while "facility-free days" is our primary effectiveness outcome across evidence-based practice interventions.

DISCUSSION

To our knowledge, this is the first large-scale randomized effort to implement "Age-Friendly" aligned evidence-based practices. Understanding the barriers and facilitators to implementing these evidence-based practices is essential to successfully help shift current healthcare systems to become Age-Friendly. Effective implementation of this project will improve the care and outcomes of older Veterans and help them age safely within their communities.

TRIAL REGISTRATION

Registered 05 May 2021, at ISRCTN #60,657,985.

REPORTING GUIDELINES

Standards for Reporting Implementation Studies (see attached).

Effects of a Multimodal Transitional Care Intervention in Patients at High Risk of Readmission: The TARGET-READ Randomized Clinical Trial

Importance

Hospital readmissions are frequent, costly, and sometimes preventable. Although these issues have been well publicized and incentives to reduce them introduced, the best interventions for reducing readmissions remain unclear.

Objectives

To evaluate the effects of a multimodal transitional care intervention targeting patients at high risk of hospital readmission on the composite outcome of 30-day unplanned readmission or death.

Design, Setting, and Participants

A single-blinded, multicenter randomized clinical trial was conducted from April 2018 to January 2020, with a 30-day follow-up in 4 medium-to-large-sized teaching hospitals in Switzerland. Participants were consecutive patients discharged from general internal medicine wards and at higher risk of unplanned readmission based on their simplified HOSPITAL score (≥4 points). Data were analyzed between April and September 2022.

Interventions

The intervention group underwent systematic medication reconciliation, a 15-minute patient education session with teach-back, a planned first follow-up visit with their primary care physician, and postdischarge follow-up telephone calls from the study team at 3 and 14 days. The control group received usual care from their hospitalist, plus a 1-page standard study information sheet.

Main Outcomes and Measures

Thirty-day postdischarge unplanned readmission or death.

Results

A total of 1386 patients were included with a mean (SD) age of 72 (14) years; 712 (51%) were male. The composite outcome of 30-day unplanned readmission or death was 21% (95% CI, 18% to 24%) in the intervention group and 19% (95% CI, 17% to 22%) in the control group. The intention-to-treat analysis risk difference was 1.7% (95% CI, -2.5% to 5.9%; P = .44). There was no evidence of any intervention effects on time to unplanned readmission or death, postdischarge health care use, patient satisfaction with the quality of their care transition, or readmission costs.

Conclusions and Relevance

In this randomized clinical trial, use of a standardized multimodal care transition intervention targeting higher-risk patients did not significantly decrease the risks of 30-day postdischarge unplanned readmission or death; it demonstrated the difficulties in preventing hospital readmissions, even when multimodal interventions specifically target higher-risk patients.

Trial Registration

ClinicalTrials.gov Identifier: NCT03496896.

The Influence of the Rural Transitions Nurse Program for Veterans on Healthcare Utilization Costs

BACKGROUND

The Veterans Affairs (VA) Healthcare System Rural Transitions Nurse Program (TNP) addresses barriers veterans face when transitioning from urban tertiary VA hospitals to home. Previous clinical evaluations of TNP have shown that enrolled veterans were more likely to follow up with their primary care provider within 14 days of discharge and experience a significant reduction in mortality within 30 days compared to propensity-score matched controls.

OBJECTIVE

Examine changes from pre- to post-hospitalization in total, inpatient, and outpatient 30-day healthcare utilization costs for TNP enrollees compared to controls.

DESIGN

Quantitative analyses modeling the changes in cost via multivariable linear mixed-effects models to determine the association between TNP enrollment and changes in these costs.

PARTICIPANTS

Veterans meeting TNP eligibility criteria who were discharged home following an inpatient hospitalization at one of the 11 implementation sites from April 2017 to September 2019.

INTERVENTION

The four-step TNP transitional care intervention.

MAIN MEASURES

Changes in 30-day total, inpatient, and outpatient healthcare utilization costs were calculated for TNP enrollees and controls.

KEY RESULTS

Among 3001 TNP enrollees and 6002 controls, no statistically significant difference in the change in total costs (p = 0.65, 95% CI: (- $675, $350)) was identified. However, on average, the increase in inpatient costs from pre- to post-hospitalization was approximately $549 less for TNP enrollees (p = 0.02, 95% CI: (- $856, - $246)). The average increase in outpatient costs from pre- to post-hospitalization was approximately $421 more for TNP enrollees compared to controls (p = 0.003, 95% CI: ($109, $671)).

CONCLUSIONS

Although we found no difference in change in total costs between veterans enrolled in TNP and controls, TNP was associated with a smaller increase in direct inpatient medical costs and a larger increase in direct outpatient medical costs. This suggests a shifting of costs from the inpatient to outpatient setting.

Development of a workflow process mapping protocol to inform the implementation of regional patient navigation programs in breast oncology

BACKGROUND

Implementing city-wide patient navigation processes that support patients across the continuum of cancer care is impeded by a lack of standardized tools to integrate workflows and reduce gaps in care. The authors present an actionable workflow process mapping protocol for navigation process planning and improvement based on methods developed for the Translating Research Into Practice study.

METHODS

Key stakeholders at each study site were identified through existing community partnerships, and data on each site's navigation processes were collected using mixed methods through a series of team meetings. The authors used Health Quality Ontario's Quality Improvement Guide, service design principles, and key stakeholder input to map the collected data onto a template structured according to the case-management model.

RESULTS

Data collection and process mapping exercises resulted in a 10-step protocol that includes: 1) workflow mapping procedures to guide data collection on the series of activities performed by health care personnel that comprise a patient's navigation experience, 2) a site survey to assess program characteristics, 3) a semistructured interview guide to assess care coordination workflows, 4) a site-level swim lane workflow process mapping template, and 5) a regional high-level process mapping template to aggregate data from multiple site-level process maps.

CONCLUSIONS

This iterative, participatory approach to data collection and process mapping can be used by improvement teams to streamline care coordination, ultimately improving the design and delivery of an evidence-based navigation model that spans multiple treatment modalities and multiple health systems in a metropolitan area. This protocol is presented as an actionable toolkit so the work may be replicated to support other quality-improvement initiatives and efforts to design truly patient-centered breast cancer treatment experiences.

LAY SUMMARY

Evidence-based patient navigation in breast cancer care requires the integration of services through each phase of cancer treatment. The Translating Research Into Practice study aims to implement patient navigation for patients with breast cancer who are at risk for delays and are seeking care across 6 health systems in Boston, Massachusetts. The authors designed a 10-step protocol outlining procedures and tools that support a systematic assessment for health systems that want to implement breast cancer patient navigation services for patients who are at risk for treatment delays.

Effectiveness of the rural transitions nurse program for Veterans: A multicenter implementation study

BACKGROUND

Veterans are often transferred from rural areas to urban VA Medical Centers for care. The transition from hospital to home is vulnerable to postdischarge adverse events.

OBJECTIVE

To evaluate the effectiveness of the rural Transitions Nurse Program (TNP).

DESIGN, SETTING, AND PARTICIPANTS

National hybrid-effectiveness-implementation study, within site propensity-matched cohort in 11 urban VA hospitals. 3001 Veterans were enrolled in TNP from April 2017 to September 2019, and 6002 matched controls.

INTERVENTION AND OUTCOMES

The intervention was led by a transitions nurse who assessed discharge readiness, provided postdischarge communication with primary care providers (PCPs), and called the Veteran within 72 h of discharge home to assess needs, and encourage follow-up appointment attendance. Controls received usual care. The primary outcomes were PCP visits within 14 days of discharge and all-cause 30-day readmissions. Secondary outcomes were 30-day emergency department (ED) visits and 30-day mortality. Patients were matched by length of stay, prior hospitalizations and PCP visits, urban/rural status, and 32 Elixhauser comorbidities.

RESULTS

The 3001 Veterans enrolled in TNP were more likely to see their PCP within 14 days of discharge than 6002 matched controls (odds ratio = 2.24, 95% confidence interval [CI] = 2.05-2.45). TNP enrollment was not associated with reduced 30-day ED visits or readmissions but was associated with reduced 30-day mortality (hazard ratio = 0.33, 95% CI = 0.21-0.53). PCP and ED visits did not have a significant mediating effect on outcomes. The observational design, potential selection bias, and unmeasurable confounders limit causal inference.

CONCLUSIONS

TNP was associated with increased postdischarge follow-up and a mortality reduction. Further investigation to understand the reduction in mortality is needed.

Sustainment stories: a qualitative analysis of barriers to sustainment of the National Rural Transitions of Care Nurse Program

Background

Understanding how to successfully sustain evidence-based care coordination interventions across diverse settings is critical to ensure that patients continue to receive high quality care even after grant funding ends. The Transitions Nurse Program (TNP) is a national intervention in the Veterans Administration (VA) that coordinates care for high risk veterans transitioning from acute care VA medical centers (VAMCs) to home. As part of TNP, a VA facility receives funding for a full-time nurse to implement TNP, however, this funding ends after implementation. In this qualitative study we describe which elements of TNP sites planned to sustain as funding concluded, as well as perceived barriers to sustainment.

Methods

TNP was implemented between 2016 and 2020 at eleven VA medical centers. Three years of funding was provided to each site to support hiring of staff, implementation and evaluation of the program. At the conclusion of funding, each site determined if they would sustain components or the entirety of the program. Prior to the end of funding at each site, we conducted midline and exit interviews with Transitions nurses and site champions to assess plans for sustainment and perceived barriers to sustainment. Interviews were analyzed using iterative, team-based inductive deductive content analysis to identify themes related to planned sustainment and perceived barriers to sustainment.

Results

None of the 11 sites planned to sustain TNP in its original format, though many of the medical centers anticipated offering components of the program, such as follow up calls after discharge to rural areas, documented warm hand off to PACT team, and designating a team member as responsible for patient rural discharge follow up. We identified three themes related to perceived sustainability. These included: 1) Program outcomes that address leadership priorities are necessary for sustainment.; 2) Local perceptions of the need for TNP or redundancy of TNP impacted perceived sustainability; and 3) Lack of leadership buy-in, changing leadership priorities, and leadership turnover are perceived barriers to sustainment.

Conclusions

Understanding perceived sustainability is critical to continuing high quality care coordination interventions after funding ends. Our findings suggest that sustainment of care coordination interventions requires an in-depth understanding of the facility needs and local leadership priorities, and that building adaptable programs that continually engage key stakeholders is essential.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07420-1.

Association of Social and Behavioral Risk Factors With Mortality Among US Veterans With COVID-19

IMPORTANCE

The US Department of Veterans Affairs (VA) offers programs that reduce barriers to care for veterans and those with housing instability, poverty, and substance use disorder. In this setting, however, the role that social and behavioral risk factors play in COVID-19 outcomes is unclear.

OBJECTIVE

To examine whether social and behavioral risk factors were associated with mortality among US veterans with COVID-19 and whether this association might be modified by race/ethnicity.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study obtained data from the VA Corporate Data Warehouse to form a cohort of veterans who received a positive COVID-19 test result between March 2 and September 30, 2020, in a VA health care facility. All veterans who met the inclusion criteria were eligible to participate in the study, and participants were followed up for 30 days after the first SARS-CoV-2 or COVID-19 diagnosis. The final follow-up date was October 31, 2020.

EXPOSURES

Social risk factors included housing problems and financial hardship. Behavioral risk factors included current tobacco use, alcohol use, and substance use.

MAIN OUTCOMES AND MEASURES

The primary outcome was all-cause mortality in the 30-day period after the SARS-CoV-2 or COVID-19 diagnosis date. Multivariable logistic regression was used to estimate odds ratios, clustering for health care facilities and adjusting for age, sex, race, ethnicity, marital status, clinical factors, and month of COVID-19 diagnosis.

RESULTS

Among 27 640 veterans with COVID-19 who were included in the analysis, 24 496 were men (88.6%) and the mean (SD) age was 57.2 (16.6) years. A total of 3090 veterans (11.2%) had housing problems, 4450 (16.1%) had financial hardship, 5358 (19.4%) used alcohol, and 3569 (12.9%) reported substance use. Hospitalization occurred in 7663 veterans (27.7%), and 1230 veterans (4.5%) died. Housing problems (adjusted odds ratio [AOR], 0.96; 95% CI, 0.77-1.19; P = .70), financial hardship (AOR, 1.13; 95% CI, 0.97-1.31; P = .11), alcohol use (AOR, 0.82; 95% CI, 0.68-1.01; P = .06), current tobacco use (AOR, 0.85; 95% CI, 0.68-1.06; P = .14), and substance use (AOR, 0.90; 95% CI, 0.71-1.15; P = .41) were not associated with higher mortality. Interaction analyses by race/ethnicity did not find associations between mortality and social and behavioral risk factors.

CONCLUSIONS AND RELEVANCE

Results of this study showed that, in an integrated health system such as the VA, social and behavioral risk factors were not associated with mortality from COVID-19. Further research is needed to substantiate the potential of an integrated health system to be a model of support services for households with COVID-19 and populations who are at risk for the disease.

Process mapping in healthcare: a systematic review

INTRODUCTION

Process mapping (PM) supports better understanding of complex systems and adaptation of improvement interventions to their local context. However, there is little research on its use in healthcare. This study (i) proposes a conceptual framework outlining quality criteria to guide the effective implementation, evaluation and reporting of PM in healthcare; (ii) reviews published PM cases to identify context and quality of PM application, and the reported benefits of using PM in healthcare.

METHODS

We developed the conceptual framework by reviewing methodological guidance on PM and empirical literature on its use in healthcare improvement interventions. We conducted a systematic review of empirical literature using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) methodology. Inclusion criteria were: full text empirical study; describing the process through which PM has been applied in a healthcare setting; published in English. Databases searched are: Medline, Embase, HMIC-Health Management Information Consortium, CINAHL-Cumulative Index to Nursing and Allied Health Literature, Scopus. Two independent reviewers extracted and analysed data. Each manuscript underwent line by line coding. The conceptual framework was used to evaluate adherence of empirical studies to the identified PM quality criteria. Context in which PM is used and benefits of using PM were coded using an inductive thematic analysis approach.

RESULTS

The framework outlines quality criteria for each PM phase: (i) preparation, planning and process identification, (ii) data and information gathering, (iii) process map generation, (iv) analysis, (v) taking it forward. PM is used in a variety of settings and approaches to improvement. None of the reviewed studies (N = 105) met all ten quality criteria; 7% were compliant with 8/10 or 9/10 criteria. 45% of studies reported that PM was generated through multi-professional meetings and 15% reported patient involvement. Studies highlighted the value of PM in navigating the complexity characterising healthcare improvement interventions.

CONCLUSION

The full potential of PM is inhibited by variance in reporting and poor adherence to underpinning principles. Greater rigour in the application of the method is required. We encourage the use and further development of the proposed framework to support training, application and reporting of PM.

TRIAL REGISTRATION

Prospero ID: CRD42017082140.

Training registered nurses to conduct pre-implementation assessment to inform program scale-up: an example from the rural Transitions Nurse Program

OBJECTIVES

Adapting evidence-based practices to local settings is critical for successful implementation and dissemination. A pre-implementation assessment evaluates local context to inform implementation, but there is little published guidance for clinician-implementers. The rural Transitions Nurse Program (TNP) is a care coordination intervention that facilitates care transitions for rural veterans. In year 1 of TNP, pre-implementation assessments were conducted by a centralized project team through multi-day visits at five sites nationwide. In year 2, we tested if local site TNP nurses could conduct pre-implementation assessments using evidence-based tools and coaching from the TNP team. This required developing a multicomponent pre-implementation strategy bundle to guide data collection and synthesis. We hypothesized that (1) nurses would find the pre-implementation assessment useful for tailoring TNP to local contexts and (2) nurses would identify similar barriers and facilitators to those identified at first year sites.

METHODS

The bundle included guides for conducting key informant interviews, brainwriting, process mapping, and reflective journaling. We evaluated TNP nurse satisfaction and perceived utility of the structure and process of the training and bundle through pre-post surveys. To assess the outcome of data collection efforts, we interviewed nurses 4 months after completion of the pre-implementation assessment to determine if and how they used pre-implementation findings to tailor implementation of TNP to local contexts. To further assess outcomes, all data that the nurses collected were analyzed thematically. Themes related to barriers and facilitators were compared across years.

FINDINGS

Five nurses at different VA medical centers used the pre-implementation strategy bundle to collect site-level data and completed pre-post surveys. Findings indicated that the pre-implementation assessment was highly recommended, and the bundle provided adequate training. Nurses felt that pre-implementation work oriented them to the local context and illustrated how to integrate TNP into existing processes. Barriers and facilitators identified by nurses were similar to those collected in year 1 by the TNP research team, including communication challenges, need for buy-in, and logistical concerns.

CONCLUSIONS

This proof-of-concept study suggests that evidence-based tools can effectively guide clinician-implementers through the process of conducting a pre-implementation assessment. This approach positively informed TNP implementation and oriented nurses to their local context prior to implementation.

Differences in transitional care processes among high-performing and low-performing hospital-SNF pairs: a rapid ethnographic approach

BACKGROUND

Despite the increased focus on improving patient's postacute care outcomes, best practices for reducing readmissions from skilled nursing facilities (SNFs) are unclear. The objective of this study was to observe processes used to prepare patients for postacute care in SNFs, and to explore differences between hospital-SNF pairs with high or low 30-day readmission rates.

DESIGN

We used a rapid ethnographic approach with intensive multiday observations and key informant interviews at high-performing and low-performing hospitals, and their most commonly used SNF. We used flow maps and thematic analysis to describe the process of hospitals discharging patients to SNFs and to identify differences in subprocesses used by high-performing and low-performing hospitals.

SETTING AND PARTICIPANTS

Hospitals were classified as high or low performers based on their 30-day readmission rates from SNFs. The final sample included 148 hours of observations with 30 clinicians across four hospitals (n=2 high performing, n=2 low performing) and corresponding SNFs (n=5).

FINDINGS

We identified variation in five major processes prior to SNF discharge that could affect care transitions: recognising need for postacute care, deciding level of care, selecting an SNF, negotiating patient fit and coordinating care with SNF. During each stage, high-performing sites differed from low-performing sites by focusing on: (1) earlier, ongoing, systematic identification of high-risk patients; (2) discussing the decision to go to an SNF as an iterative team-based process and (3) anticipating barriers with knowledge of transitional and SNF care processes.

CONCLUSION

Identifying variations in processes used to prepare patients for SNF provides critical insight into the best practices for transitioning patients to SNFs and areas to target for improving care of high-risk patients.

Implementation Science to Respond to the COVID-19 Pandemic

The COVID-19 pandemic continues to expand globally, requiring massive public health responses from national and local governments. These bodies have taken heterogeneous approaches to their responses, including when and how to introduce and enforce evidence-based interventions—such as social distancing, hand-washing, personal protective equipment (PPE), and testing. In this commentary, we reflect on opportunities for implementation science to contribute meaningfully to the COVID-19 pandemic response. We reflect backwards on missed opportunities in emergency preparedness planning, using the example of PPE stockpiling and supply management; this planning could have been strengthened through process mapping with consensus-building, microplanning with simulation, and stakeholder engagement. We propose current opportunities for action, focusing on enhancing the adoption, fidelity, and sustainment of hand washing and social distancing; we can combine qualitative data, policy analysis, and dissemination science to inform agile and rapid adjustment to social marketing strategies to enhance their penetration. We look to future opportunities to enhance the integration of new evidence in decision-making, focusing on serologic and virologic testing systems; we can leverage simulation and other systems engineering modeling to identify ideal system structures. Finally, we discuss the ways in which the COVID-19 pandemic challenges implementation science to become more rapid, rigorous, and nimble in its approach, and integrate with public health practice. In summary, we articulate the ways in which implementation science can inform, and be informed by, the COVID-19 pandemic, looking backwards, proposing actions for the moment, and approaches for the future.

Establishing a Geriatric Hip Fracture Program at a Level 1 Community Trauma Center

BACKGROUND

Traditional care of patients with geriatric hip fracture has been fragmented with patients admitted under various specialty services and to different units within a hospital. This produces inconsistent care and leads to varying outcomes that can be associated with increased length of stay, delays in time from admission to surgery, and higher readmission rates.

PURPOSE

The purpose of this article is to describe the process taken to establish a successful geriatric hip fracture program (GFP) and the initial results observed in a single institution after its implementation.

METHODS

All patients 60 years or older, with an osteoporotic hip fracture sustained from a low energy mechanism (defined as a fall from 3-ft height or less), were included in our program. Fracture patterns include femoral neck, intertrochanteric, pertrochanteric, and subtrochanteric femur fractures including displaced, nondisplaced, and periprosthetic fractures. Preprogram data included all patients admitted from January 1, 2012, through December 31, 2014; postprogram data were collected on patients admitted between May 1, 2016, and May 1, 2018.

RESULTS

Demographic characteristics of the populations were similar. After the GFP was implemented, the proportion of patients who were treated surgically within 24 and 48 hours increased. The average number of hours between admission and surgery significantly reduced from 35.2 to 23.2 hours. Overall length of stay was decreased by 1.8 days and readmission within 30 days of discharge was lower. Reasons for readmission were similar in both timeframes. The rate of inpatient death was similar in the two groups. Mortality within 30 days of surgery appeared somewhat higher in the post-GFP period.

CONCLUSION

Our program found that, with the utilization of a multidisciplinary approach, we could positively influence the care of patients with geriatric hip fracture through the implementation of evidence-based practice guidelines. In the first 2 years after initiation of the GFP, our institution saw a decrease in time from admission to surgery, length of stay, and blood transfusion requirements.