A Method for Tracking Implementation Strategies: An Exemplar Implementing Measurement-Based Care in Community Behavioral Health Clinics

A Pilot Project to Integrate Individualized Measurement Into Measurement-Based Care in a Child Partial Hospitalization Program

Measurement-based care (MBC), or the regular use of progress measures to inform clinical decision-making, improves quality of care and clinical outcomes. MBC typically focuses on standardized rather than individualized outcome measurement. In this pilot study, we examined the clinical utility of integrating individualized measurement with existing standardized outcome monitoring in a children's partial hospitalization program. Participants were 48 youth (M age 10.13 ± 1.39; 54.2% male, 41.7% female, 4.2% transgender or nonbinary). Comorbidity was common; 83.4% of youth had more than one diagnosis at intake. Using the Youth Top Problems for individualized outcome measurement, we examined Top Problem content and clinical improvement over time. Finally, we examined completion rates and describe implementation issues. Top Problems were heterogeneous and sensitive to change. Of the 144 problems, 107 (74%) had a focus consistent with measures used in program, while 37 (26%) were not captured by standardized measures used in program. Effect sizes from admission to final measurement ranged from Cohen's d = .75 - 1.00. Initial adoption of the MBC was strong, but sustained use of the system over the treatment course was challenging. Individualized outcome measurement in children's partial hospitalization programs is feasible to administer and sensitive to clinical change that is unique from change captured in standardized measures. Parents were able to self-identify clinically meaningful, highly individualized Top Problems. Challenges of implementation and clinical assessment in acute settings and potential strategies for improving implementation are discussed.

Champion and audit and feedback strategy fidelity and their relationship to depression intervention fidelity: A mixed method study

Background

Globally, mental health disorders rank as the greatest cause of disability. Low and middle-income countries (LMICs) hold a disproportionate share of the mental health burden, especially as it pertains to depression. Depression is highly prevalent among those with non-communicable diseases (NCDs), creating a barrier to successful treatment. While some treatments have proven efficacy in LMIC settings, wide dissemination is challenged by multiple factors, leading researchers to call for implementation strategies to overcome barriers to care provision. However, implementation strategies are often not well defined or documented, challenging the interpretation of study results and the uptake and replication of strategies in practice settings. Assessing implementation strategy fidelity (ISF), or the extent to which a strategy was implemented as designed, overcomes these challenges. This study assessed fidelity of two implementation strategies (a 'basic' champion strategy and an 'enhanced' champion + audit and feedback strategy) to improve the integration of a depression intervention, measurement based care (MBC), at 10 NCD clinics in Malawi. The primary goal of this study was to assess the relationship between the implementation strategies and MBC fidelity using a mixed methods approach.

Methods

We developed a theory-informed mixed methods fidelity assessment that first combined an implementation strategy specification technique with a fidelity framework. We then created corresponding fidelity indicators to strategy components. Clinical process data and one-on-one in-depth interviews with 45 staff members at 6 clinics were utilized as data sources. Our final analysis used descriptive statistics, reflexive-thematic analysis (RTA), data merging, and triangulation to examine the relationship between ISF and MBC intervention fidelity.

Results

Our mixed methods analysis revealed how ISF may moderate the relationship between the strategies and MBC fidelity. Leadership engagement and implementation climate were critical for clinics to overcome implementation barriers and preserve implementation strategy and MBC fidelity. Descriptive statistics determined champion strategy fidelity to range from 61 to 93% across the 10 clinics. Fidelity to the audit and feedback strategy ranged from 82 to 91% across the 5 clinics assigned to that condition. MBC fidelity ranged from 54 to 95% across all clinics. Although correlations between ISF and MBC fidelity were not statistically significant due to the sample of 10 clinics, associations were in the expected direction and of moderate effect size. A coefficient for shared depression screening among clinicians had greater face validity compared to depression screening coverage and functioned as a proximal indicator of implementation strategy success.

Conclusion

Fidelity to the basic and enhanced strategies varied by site and were influenced by leadership engagement and implementation climate. Champion strategies may benefit from the addition of leadership strategies to help address implementation barriers outside the purview of champions. ISF may moderate the relationship between strategies and implementation outcomes.

The Longitudinal Implementation Strategy Tracking System (LISTS): feasibility, usability, and pilot testing of a novel method

BACKGROUND

Systematic approaches are needed to accurately characterize the dynamic use of implementation strategies and how they change over time. We describe the development and preliminary evaluation of the Longitudinal Implementation Strategy Tracking System (LISTS), a novel methodology to document and characterize implementation strategies use over time.

METHODS

The development and initial evaluation of the LISTS method was conducted within the Improving the Management of SymPtoms during And following Cancer Treatment (IMPACT) Research Consortium (supported by funding provided through the NCI Cancer MoonshotSM). The IMPACT Consortium includes a coordinating center and three hybrid effectiveness-implementation studies testing routine symptom surveillance and integration of symptom management interventions in ambulatory oncology care settings. LISTS was created to increase the precision and reliability of dynamic changes in implementation strategy use over time. It includes three components: (1) a strategy assessment, (2) a data capture platform, and (3) a User's Guide. An iterative process between implementation researchers and practitioners was used to develop, pilot test, and refine the LISTS method prior to evaluating its use in three stepped-wedge trials within the IMPACT Consortium. The LISTS method was used with research and practice teams for approximately 12 months and subsequently we evaluated its feasibility, acceptability, and usability using established instruments and novel questions developed specifically for this study.

RESULTS

Initial evaluation of LISTS indicates that it is a feasible and acceptable method, with content validity, for characterizing and tracking the use of implementation strategies over time. Users of LISTS highlighted several opportunities for improving the method for use in future and more diverse implementation studies.

CONCLUSIONS

The LISTS method was developed collaboratively between researchers and practitioners to fill a research gap in systematically tracking implementation strategy use and modifications in research studies and other implementation efforts. Preliminary feedback from LISTS users indicate it is feasible and usable. Potential future developments include additional features, fewer data elements, and interoperability with alternative data entry platforms. LISTS offers a systematic method that encourages the use of common data elements to support data analysis across sites and synthesis across studies. Future research is needed to further adapt, refine, and evaluate the LISTS method in studies with employ diverse study designs and address varying delivery settings, health conditions, and intervention types.

Partnering with social service staff to implement pragmatic clinical trials: an interim analysis of implementation strategies

BACKGROUND

With recent growth in the conduct of pragmatic clinical trials, the reliance on frontline staff to contribute to trial-related activities has grown as well. Active partnerships with staff members are often critical to pragmatic trial implementation, but rarely do research teams track and evaluate the specific "implementation strategies" used to support staff's involvement in trial procedures (e.g., participant recruitment). Accordingly, we adapted implementation science methodologies and conducted an interim analysis of the strategies deployed with social service staff involved in one multi-site pragmatic clinical trial.

METHODS

We used a naturalistic, observational study design to characterize strategies our research team deployed with staff during monthly, virtual meetings. Data were drawn from meeting notes and recordings from the trial's 4-month Preparation phase and 8-month Implementation phase. Strategies were mapped to the Expert Recommendations for Implementing Change taxonomy and categorized into nine implementation clusters. Survey data were also collected from staff to identify the most useful strategies the research team should deploy when onboarding new staff members in the trial's second year.

RESULTS

A total of 287 strategies were deployed. Strategies in the develop stakeholder interrelationships cluster predominated in both the Preparation (35%) and Implementation (31%) phases, followed by strategies in the use iterative and evaluative approaches cluster, though these were more prevalent during trial Preparation (24%) as compared to trial Implementation (18%). When surveyed on strategy usefulness, strategies in the provide interactive assistance, use financial approaches, and support staff clusters were most useful, per staff responses.

CONCLUSIONS

While strategies to develop stakeholder interrelationships were used most frequently during trial Preparation and Implementation, program staff perceived strategies that provided technical assistance, supported clinicians, and used financial approaches to be most useful and should be deployed when onboarding new staff members. Research teams are encouraged to adapt and apply implementation strategy tracking methods when partnering with social service staff and deploy practical strategies that support pragmatic trial success given staff needs and preferences.

TRIAL REGISTRATION

NCT05357261. May 2, 2022.

A Clinical Leadership Lens on Implementing Progress Feedback in Three Countries: Development of a Multidimensional Qualitative Coding Scheme

BACKGROUND

Progress feedback, also known as measurement-based care (MBC), is the routine collection of patient-reported measures to monitor treatment progress and inform clinical decision-making. Although a key ingredient to improving mental health care, sustained use of progress feedback is poor. Integration into everyday workflow is challenging, impacted by a complex interrelated set of factors across patient, clinician, organizational, and health system levels. This study describes the development of a qualitative coding scheme for progress feedback implementation that accounts for the dynamic nature of barriers and facilitators across multiple levels of use in mental health settings. Such a coding scheme may help promote a common language for researchers and implementers to better identify barriers that need to be addressed, as well as facilitators that could be supported in different settings and contexts.

METHODS

Clinical staff, managers, and leaders from two Dutch, three Norwegian, and four mental health organizations in the USA participated in semi-structured interviews on how intra- and extra-organizational characteristics interact to influence the use of progress feedback in clinical practice, supervision, and program improvement. Interviews were conducted in the local language, then translated to English prior to qualitative coding.

RESULTS

A team-based consensus coding approach was used to refine an a priori expert-informed and literature-based qualitative scheme to incorporate new understandings and constructs as they emerged. First, this hermeneutic approach resulted in a multi-level coding scheme with nine superordinate categories and 30 subcategories. Second-order axial coding established contextually sensitive categories for barriers and facilitators.

CONCLUSIONS

The primary outcome is an empirically derived multi-level qualitative coding scheme that can be used in progress feedback implementation research and development. It can be applied across contexts and settings, with expectations for ongoing refinement. Suggestions for future research and application in practice settings are provided. Supplementary materials include the coding scheme and a detailed playbook.

Application of the Expert Recommendations for Implementing Change (ERIC) compilation of strategies to health intervention implementation in low- and middle-income countries: a systematic review

BACKGROUND

The Expert Recommendations for Implementing Change (ERIC) project developed a compilation of implementation strategies that are intended to standardize reporting and evaluation. Little is known about the application of ERIC in low- and middle-income countries (LMICs). We systematically reviewed the literature on the use and specification of ERIC strategies for health intervention implementation in LMICs to identify gaps and inform future research.

METHODS

We searched peer-reviewed articles published through March 2023 in any language that (1) were conducted in an LMIC and (2) cited seminal ERIC articles or (3) mentioned ERIC in the title or abstract. Two co-authors independently screened all titles, abstracts, and full-text articles, then abstracted study, intervention, and implementation strategy characteristics of included studies.

RESULTS

The final sample included 60 studies describing research from all world regions, with over 30% published in the final year of our review period. Most studies took place in healthcare settings (n = 52, 86.7%), while 11 (18.2%) took place in community settings and four (6.7%) at the policy level. Across studies, 548 distinct implementation strategies were identified with a median of six strategies (range 1-46 strategies) included in each study. Most studies (n = 32, 53.3%) explicitly matched implementation strategies used for the ERIC compilation. Among those that did, 64 (87.3%) of the 73 ERIC strategies were represented. Many of the strategies not cited included those that target systems- or policy-level barriers. Nearly 85% of strategies included some component of strategy specification, though most only included specification of their action (75.2%), actor (57.3%), and action target (60.8%). A minority of studies employed randomized trials or high-quality quasi-experimental designs; only one study evaluated implementation strategy effectiveness.

CONCLUSIONS

While ERIC use in LMICs is rapidly growing, its application has not been consistent nor commonly used to test strategy effectiveness. Research in LMICs must better specify strategies and evaluate their impact on outcomes. Moreover, strategies that are tested need to be better specified, so they may be compared across contexts. Finally, strategies targeting policy-, systems-, and community-level determinants should be further explored.

TRIAL REGISTRATION

PROSPERO, CRD42021268374.

Preventing Suicide in Health Systems: How Can Implementation Science Help?

Suicide prevention is an emotive, complex goal for clinicians and health systems. Effective interventions for suicidality do exist; however, many patients do not receive them because implementation efforts tend to be time-limited and unsystematic. Implementation science is the study of methods to promote the systematic uptake of research findings and other evidence-based practices into routine practice. This narrative review introduces implementation science to suicide researchers, with a special focus on healthcare settings. We outline prominent theories, methods, and measures, as well as examples of implementation research from suicidology. By embracing the principles of implementation science, suicidologists can help to close the gap between evidence-based practice and routine practice, thereby improving the delivery and uptake of suicide-related interventions and prevention programs.

Using audit and feedback to guide tailored implementations of measurement-based care in community mental health: a multiple case study

BACKGROUND

Audit and feedback (A&F) is an implementation strategy that can facilitate implementation tailoring by identifying gaps between desired and actual clinical care. While there are several theory-based propositions on which A&F components lead to better implementation outcomes, many have not been empirically investigated, and there is limited guidance for stakeholders when applying A&F in practice. The current study aims to illustrate A&F procedures in six community mental health clinics, with an emphasis on reporting A&F components that are relevant to theories of how feedback elicits behavior change.

METHODS

Six clinics from a larger trial using a tailored approach to implement measurement-based care (MBC) were analyzed for feedback content, delivery mechanisms, barriers to feedback, and outcomes of feedback using archival data. Pattern analysis was conducted to examine relations between A&F components and changes in MBC use.

RESULTS

Several sites utilized both aggregate and individualized data summaries, and data accuracy concerns were common. Feedback cycles featuring individual-level clinician data, data relevant to MBC barriers, and information requested by data recipients were related to patterns of increased MBC use.

CONCLUSIONS

These findings support extant theory, such as Feedback Intervention Theory. Mental health professionals wishing to apply A&F should consider establishing reciprocal feedback mechanisms on the quality and amount of data being received and adopting specific roles communicating and addressing data quality concerns.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02266134.

"Now is the time for institutions to be investing in growing exercise programs as part of standard of care": a multiple case study examining the implementation of exercise oncology interventions

BACKGROUND

Implementation science seeks to systematically identify determinants, strategies, and outcomes within a causal pathway to help explain successful implementation. This process is applied to evidence-based interventions (EBIs) to improve their adoption, implementation, and sustainment. However, this method has not been applied to exercise oncology services, meaning we lack knowledge about implementing exercise EBIs in routine practice. This study aimed to develop causal pathways from the determinants, strategies (including mechanism of change), and implementation outcomes to explain exercise EBIs implementation in routine cancer care.

METHODS

A multiple-case study was conducted across three healthcare sites in Australia. Sites selected had implemented exercise within routine care for people diagnosed with cancer and sustained the delivery of services for at least 12 months. Four data sources informed the study: semi-structured interviews with staff, document reviews, observations, and the Program Sustainability Assessment Tool (survey). Framework analysis was applied to understand the findings. The Implementation Research Logic Model was used to identify commonalities in implementation across sites and develop causal pathways.

RESULTS

Two hundred and eighteen data points informed our findings. Across sites, 18 determinants and 22 implementation strategies were consistent. Sixteen determinants and 24 implementation strategies differed across sites and results of implementation outcomes varied. We identified 11 common pathways that when combined, help explain implementation processes. The mechanisms of implementation strategies operating within the pathways included (1) knowledge, (2) skills, (3) secure resources, (4) optimism, and (5) simplified decision-making processes associated with exercise; (6) relationships (social and professional) and support for the workforce; (7) reinforcing positive outcomes; (8) capability to action plan through evaluations and (9) interactive learning; (10) aligned goals between the organisation and the EBI; and (11) consumer-responsiveness.

CONCLUSION

This study developed causal pathways that explain the how and why of successful implementation of exercise EBIs in cancer care. These findings can support future planning and optimisation activities by creating more opportunities for people with cancer to access evidence-based exercise oncology services.

IMPLICATIONS FOR CANCER SURVIVORS

Understanding how to implement exercise within routine cancer care successfully is important so cancer survivors can experience the benefits of exercise.

Anticipating adaptation: tracking the impact of planned and unplanned adaptations during the implementation of a complex population-based genomic screening program

In 2021, the Medical University of South Carolina (MUSC) launched In Our DNA SC. This large-scale initiative will screen 100,000 individuals in South Carolina for three preventable hereditary conditions that impact approximately two million people in the USA but often go undetected. In anticipation of inevitable changes to the delivery of this complex initiative, we developed an approach to track and assess the impact of evaluate adaptations made during the pilot phase of program implementation. We used a modified version of the Framework for Reporting Adaptations and Modification-Enhanced (FRAME) and Adaptations to code adaptations made during the 3-month pilot phase of In Our DNA SC. Adaptations were documented in real-time using a REDCap database. We used segmented linear regression models to independently test three hypotheses about the impact of adaptations on program reach (rate of enrollment in the program, rate of messages viewed) and implementation (rate of samples collected) 7 days pre- and post-adaptation. Effectiveness was assessed using qualitative observations. Ten adaptations occurred during the pilot phase of program implementation. Most adaptations (60%) were designed to increase the number and type of patient contacted (reach). Adaptations were primarily made based on knowledge and experience (40%) or from quality improvement data (30%). Of the three adaptations designed to increase reach, shortening the recruitment message potential patients received significantly increased the average rate of invitations viewed by 7.3% (p = 0.0106). There was no effect of adaptations on implementation (number of DNA samples collected). Qualitative findings support improvement in effectiveness of the intervention after shortening the consent form and short-term positive impact on uptake of the intervention as measured by team member's participation. Our approach to tracking adaptations of In Our DNA SC allowed our team to quantify the utility of modifications, make decisions about pursuing the adaptation, and understand consequences of the change. Streamlining tools for tracking and responding to adaptations can help monitor the incremental impact of interventions to support continued learning and problem solving for complex interventions being delivered in health systems based on real-time data.

Development of an Implementation Blueprint to Scale-Up Contraception Care for Adolescents with Psychiatric Conditions in a Pediatric Hospital

Implementation blueprints are comprehensive plans that describe implementation strategies, goals, timelines, and key personnel necessary for launching new interventions. Although blueprints are a foundational step in driving intervention rollout, little is known about how blueprints are developed, refined, and used in practice. The objective of this study was to describe a systematic, collaborative approach to developing, refining, and utilizing a formal implementation blueprint for scaling up the Contraception Care at Behavioral Health Pavilion (CC@BHP) intervention for adolescents hospitalized in psychiatric units within a pediatric hospital in the United States. In Stage 1 (Planning/Preparation), we assembled a Research Advisory Board (RAB) of 41 multidisciplinary members and conducted a formative evaluation to identify potential barriers to CC@BHP implementation. Barriers were mapped to implementation strategies using the Consolidated Framework for Implementation Research (CFIR) and Expert Recommendations for Implementing Change (ERIC) tool and used to create an initial blueprint. In Stage 2 (Development/Implementation), RAB members used activity logs to track implementation activities over the 18-month study period, which were then mapped to formal implementation strategies used to further develop the blueprint. About 30% of strategies were situated in the 'Train and Educate Stakeholders' ERIC category, 20% in 'Use Evaluative and Iterative Strategies,' and 16% in 'Develop Stakeholder Interrelationships' category. In Stage 3 (Synthesis/Refinement), the final blueprint was refined, consisting of 16 goals linked to 10 strategies for pre-implementation and 6 strategies for implementation. Feedback on the blueprint emphasized the role of the project champion in translating the blueprint into smaller, actionable steps for implementers.

Improving measurement-based care implementation in adult ambulatory psychiatry: a virtual focus group interview with multidisciplinary healthcare professionals

BACKGROUND

Measurement-Based Care (MBC) is an evidence-based practice shown to enhance patient care. Despite being efficacious, MBC is not commonly used in practice. While barriers and facilitators of MBC implementation have been described in the literature, the type of clinicians and populations studied vary widely, even within the same practice setting. The current study aims to improve MBC implementation in adult ambulatory psychiatry by conducting focus group interviews while utilizing a novel virtual brainwriting premortem method.

METHODS

Semi-structured focus group interviews were conducted with clinicians (n = 18) and staff (n = 7) to identify their current attitudes, facilitators, and barriers of MBC implementation in their healthcare setting. Virtual video-conferencing software was used to conduct focus groups, and based on transcribed verbatin, emergent barriers/facilitators and four themes were identified. Mixed methods approach was utilized for this study. Specifically, qualitative data was aggregated and re-coded separately by three doctoral-level coders. Quantitative analyses were conducted from a follow-up questionnaire surveying clinician attitudes and satisfaction with MBC.

RESULTS

The clinician and staff focus groups resulted in 291 and 91 unique codes, respectively. While clinicians identified a similar number of barriers (40.9%) and facilitators (44.3%), staff identified more barriers (67%) than facilitators (24.7%) for MBC. Four themes emerged from the analysis; (1) a description of current status/neutral opinion on MBC; (2) positive themes that include benefits of MBC, facilitators, enablers, or reasons on why they conduct MBC in their practice, (3) negative themes that include barriers or issues that hinder them from incorporating MBC into their practice, and (4) requests and suggestions for future MBC implementation. Both participant groups raised more negative themes highlighting critical challenges to MBC implementation than positive themes. The follow-up questionnaire regarding MBC attitudes showed the areas that clinicians emphasized the most and the least in their clinical practice.

CONCLUSION

The virtual brainwriting premortem focus groups provided critical information on the shortcomings and strengths of MBC in adult ambulatory psychiatry. Our findings underscore implementation challenges in healthcare settings and provide insight for both research and clinical practice in mental health fields. The barriers and facilitators identified in this study can inform future training to increase sustainability and better integrate MBC with positive downstream outcomes in patient care.

The Implementation Playbook: study protocol for the development and feasibility evaluation of a digital tool for effective implementation of evidence-based innovations

BACKGROUND

Evidence-based innovations can improve health outcomes, but only if successfully implemented. Implementation can be complex, highly susceptible to failure, costly and resource intensive. Internationally, there is an urgent need to improve the implementation of effective innovations. Successful implementation is best guided by implementation science, but organizations lack implementation know-how and have difficulty applying it. Implementation support is typically shared in static, non-interactive, overly academic guides and is rarely evaluated. In-person implementation facilitation is often soft-funded, costly, and scarce. This study seeks to improve effective implementation by (1) developing a first-in-kind digital tool to guide pragmatic, empirically based and self-directed implementation planning in real-time; and (2) exploring the tool's feasibility in six health organizations implementing different innovations.

METHODS

Ideation emerged from a paper-based resource, The Implementation Game©, and a revision called The Implementation Roadmap©; both integrate core implementation components from evidence, models and frameworks to guide structured, explicit, and pragmatic planning. Prior funding also generated user personas and high-level product requirements. This study will design, develop, and evaluate the feasibility of a digital tool called The Implementation Playbook©. In Phase 1, user-centred design and usability testing will inform tool content, visual interface, and functions to produce a minimum viable product. Phase 2 will explore the Playbook's feasibility in six purposefully selected health organizations sampled for maximum variation. Organizations will use the Playbook for up to 24 months to implement an innovation of their choosing. Mixed methods will gather: (i) field notes from implementation team check-in meetings; (ii) interviews with implementation teams about their experience using the tool; (iii) user free-form content entered into the tool as teams work through implementation planning; (iv) Organizational Readiness for Implementing Change questionnaire; (v) System Usability Scale; and (vi) tool metrics on how users progressed through activities and the time required to do so.

DISCUSSION

Effective implementation of evidence-based innovations is essential for optimal health. We seek to develop a prototype digital tool and demonstrate its feasibility and usefulness across organizations implementing different innovations. This technology could fill a significant need globally, be highly scalable, and potentially valid for diverse organizations implementing various innovations.

Strategies for implementing the interRAI home care frailty scale with home-delivered meal clients

Introduction

Frailty is a complex condition that is highly associated with health decline and the loss of independence. Home-delivered meal programs are designed to provide older adults with health and nutritional support that can attenuate the risk of frailty. However, home-delivered meal agencies do not routinely assess frailty using standardized instruments, leading to uncertainty over the longitudinal impact of home-delivered meals on frailty levels. Considering this knowledge gap, this study aimed to facilitate home-delivered meal staff's implementation of a standardized frailty instrument with meal clients as part of routine programming. This article (a) describes the use of Implementation Mapping principles to develop strategies supporting frailty instrument implementation in one home-delivered meal agency and (b) examines the degree to which a combination of strategies influenced the feasibility of frailty instrument use by home-delivered meal staff at multiple time points.

Methods and materials

This retrospective observational study evaluated staff's implementation of the interRAI Home Care Frailty Scale (HCFS) with newly enrolled home-delivered meal clients at baseline-, 3-months, and 6-months. The process of implementing the HCFS was supported by five implementation strategies that were developed based on tenets of Implementation Mapping. Rates of implementation and reasons clients were lost to 3- and 6-month follow-up were evaluated using univariate analyses. Client-level data were also examined to identify demographic factors associated with attrition at both follow-up time points.

Results

Staff implemented the HCFS with 94.8% (n = 561) of eligible home-delivered meal clients at baseline. Of those clients with baseline HCFS data, staff implemented the follow-up HCFS with 43% of clients (n = 241) at 3-months and 18.0% of clients (n = 101) at 6-months. Insufficient client tracking and documentation procedures complicated staff's ability to complete the HCFS at follow-up time points.

Discussion

While the HCFS assesses important frailty domains that are relevant to home-delivered meal clients, its longitudinal implementation was complicated by several agency- and client-level factors that limited the extent to which the HCFS could be feasibly implemented over multiple time points. Future empirical studies are needed to design and test theoretically derived implementation strategies to support frailty instrument use in the home- and community-based service setting.

Tracking, naming, specifying, and comparing implementation strategies for person-centred care in a real-world setting: a case study with seven embedded units

BACKGROUND

The implementation of person-centred care (PCC) is advocated worldwide. Stakeholders in charge of implementing PCC as a broad-scale change across the health care sector face two intertwined and complex challenges. First, making sense of PCC as an intervention with complex innovation characteristics and second, staging implementation of PCC by choosing appropriate implementation strategies. We aimed to explore one of these challenges by tracking, naming, specifying, and comparing which strategies and how strategies were enacted to support the implementation of more PCC in a real-world setting represented by one health care region in Sweden.

METHODS

A case study with seven embedded units at two organisational levels within a health care region was conducted from 2016 to 2019. Data were collected from three sources: activity logs, interviews, and written documents. Strategies were identified from all sources and triangulated deductively by name, definition, and cluster in line with the taxonomy Expert Recommendations for Implementing Change (ERIC) and specified according to recommendations by Proctor and colleagues as actor, action, action target, temporality, dose, outcome, and justification.

RESULTS

Four hundred thirteen activities were reported in logs, representing 43 discrete strategies identified in ERIC (n = 38), elsewhere (n = 1), or as emerging strategies (n = 4). The highest reported frequencies of discrete strategies were identified as belonging to two clusters: Train and educate stakeholders (40%) and Develop stakeholder interrelationships (38%). We identified a limited number of strategies belonging to the cluster Use evaluative and iterative strategies (4.6%) and an even smaller number of strategies targeting information to patients about the change initiative (0.8%). Most of the total dose of 11,076 person-hours in the 7 units was spent on strategies targeting health care professionals who provide PCC (81.5%) while the dose of strategies targeting support functions was 18.5%.

CONCLUSIONS

Our findings show both challenges and merits when strategies for implementation of PCC are conducted in a real-world setting. The results can be used to support and guide both scientists and practitioners in future implementation initiatives.

Conceptual tensions and practical trade-offs in tailoring implementation interventions

Tailored interventions have been shown to be effective and tailoring is a popular process with intuitive appeal for researchers and practitioners. However, the concept and process are ill-defined in implementation science. Descriptions of how tailoring has been applied in practice are often absent or insufficient in detail. This lack of transparency makes it difficult to synthesize and replicate efforts. It also hides the trade-offs for researchers and practitioners that are inherent in the process. In this article we juxtapose the growing prominence of tailoring with four key questions surrounding the process. Specifically, we ask: (1) what constitutes tailoring and when does it begin and end?; (2) how is it expected to work?; (3) who and what does the tailoring process involve?; and (4) how should tailoring be evaluated? We discuss these questions as a call to action for better reporting and further research to bring clarity, consistency, and coherence to tailoring, a key process in implementation science.

Tracking dynamic changes in implementation strategies over time within a hybrid type 2 trial of an electronic patient-reported oncology symptom and needs monitoring program

Background

Longitudinal tracking of implementation strategies is critical in accurately reporting when and why they are used, for promoting rigor and reproducibility in implementation research, and could facilitate generalizable knowledge if similar methods are used across research projects. This article focuses on tracking dynamic changes in the use of implementation strategies over time within a hybrid type 2 effectiveness-implementation trial of an evidence-based electronic patient-reported oncology symptom assessment for cancer patient-reported outcomes in a single large healthcare system.

Methods

The Longitudinal Implementation Strategies Tracking System (LISTS), a timeline follow-back procedure for documenting strategy use and modifications, was applied to the multiyear study. The research team used observation, study records, and reports from implementers to complete LISTS in an electronic data entry system. Types of modifications and reasons were categorized. Determinants associated with each strategy were collected as a justification for strategy use and a potential explanation for strategy modifications.

Results

Thirty-four discrete implementation strategies were used and at least one strategy was used from each of the nine strategy categories from the Expert Recommendations for Implementing Change (ERIC) taxonomy. Most of the strategies were introduced, used, and continued or discontinued according to a prospective implementation plan. Relatedly, a small number of strategies were introduced, the majority unplanned, because of the changing healthcare landscape, or to address an emergent barrier. Despite changing implementation context, there were relatively few modifications to the way strategies were enacted, such as a change in the actor, action, or dose. Few differences were noted between the trial's three regional units under investigation.

Conclusion

This study occurred within the ambulatory oncology clinics of a large, academic medical center and was supported by the Quality team of the health system to ensure greater uptake, uniformity, and implementation within established practice change processes. The centralized nature of the implementation likely contributed to the relatively low proportion of modified strategies and the high degree of uniformity across regions. These results demonstrate the potential of LISTS in gathering the level of data needed to understand the impact of the many implementation strategies used to support adoption and delivery of a multilevel innovation.

Clinical trial registration

https://clinicaltrials.gov/ct2/show/NCT04014751, identifier: NCT04014751.

"We start where we are": a qualitative study of barriers and pragmatic solutions to the assessment and reporting of implementation strategy fidelity

BACKGROUND

Fidelity measurement of implementation strategies is underdeveloped and underreported, and the level of reporting is decreasing over time. Failing to properly measure the factors that affect the delivery of an implementation strategy may obscure the link between a strategy and its outcomes. Barriers to assessing and reporting implementation strategy fidelity among researchers are not well understood. The aims of this qualitative study were to identify barriers to fidelity measurement and pragmatic pathways towards improvement.

METHODS

We conducted in-depth interviews among researchers conducting implementation trials. We utilized a theory-informed interview approach to elicit the barriers and possible solutions to implementation strategy fidelity assessment and reporting. Reflexive-thematic analysis guided coding and memo-writing to determine key themes regarding barriers and solutions.

RESULTS

Twenty-two implementation researchers were interviewed. Participants agreed that implementation strategy fidelity was an essential element of implementation trials and that its assessment and reporting should improve. Key thematic barriers focused on (1) a current lack of validated fidelity tools with the need to assess fidelity in the short term, (2) the complex nature of some implementation strategies, (3) conceptual complications when assessing fidelity within mechanisms-focused implementation research, and (4) structural issues related to funding and publishing. Researchers also suggested pragmatic solutions to overcome each barrier. Respondents reported using specification and tracking data in the short term until validated tools become available. Participants suggested that researchers with strategy-specific content expertise lead the way in identifying core components and setting fidelity requirements for them. Addressing the third barrier, participants provided examples of what pragmatic prospective and retrospective fidelity assessments might look like along a mechanistic pathway. Finally, researchers described approaches to minimize costs of data collection, as well as more structural accountability like adopting and enforcing reporting guidelines or changing the structure of funding opportunities.

DISCUSSION

We propose short- and long-term priorities for improving the assessment and reporting of implementation strategy fidelity and the quality of implementation research.

CONCLUSIONS

A better understanding of the barriers to implementation strategy fidelity assessment may pave the way towards pragmatic solutions.

Mediators of measurement-based care implementation in community mental health settings: results from a mixed-methods evaluation

Background

Tailored implementation approaches are touted as superior to standardized ones with the reasoning that tailored approaches afford opportunities to select strategies to resolve determinants of the local context. However, results from implementation trials on this topic are equivocal. Therefore, it is important to explore relevant contextual factors that function as determinants to evaluate if they are improved by tailoring and subsequently associated with changes in implementation outcomes (i.e., via statistical mediation) to better understand how tailoring achieves (or does not achieve) its effects. The present study examined the association between a tailored and standardized implementation approach, contextual factors that might mediate change, and a target implementation outcome in an initiative to implement measurement-based care (specifically the clinical integration of the Patient Health Questionnaire [PHQ-9] for depression) in a community mental health organization.

Methods

Using a cluster randomized control design, twelve community-based mental health clinics were assigned to a tailored or standardized implementation group. Clinicians completed a self-report battery assessing contextual factors that served as candidate mediators informed by the Framework for Dissemination at three time points: baseline, 5 months after active implementation support, and 10 months after sustainment monitoring. A subset of clinicians also participated in focus groups at 5 months. The routine use of the PHQ-9 (implementation outcome) was monitored during the 10-month sustainment period. Multi-level mediation analyses assessed the association between the implementation group and contextual factors and the association between contextual factors and PHQ-9 completion. Quantitative results were then elaborated by analyzing qualitative data from exemplar sites.

Results

Although tailored clinics outperformed standard clinics in terms of PHQ-9 completion at the end of active implementation, these group differences disappeared post sustainment monitoring. Perhaps related to this, no significant mediators emerged from our quantitative analyses. Exploratory qualitative analyses of focus group content emphasized the importance of support from colleagues, supervisors, and leadership when implementing clinical innovations in practice.

Conclusions

Although rates of PHQ-9 completion improved across the study, their sustained levels were roughly equivalent across groups and low overall. No mediators were established using quantitative methods; however, several partial quantitative pathways, as well as themes from the qualitative data, reveal fruitful areas for future research.

Trial registration

Standardized versus tailored implementation of measurement-based care for depression. ClinicalTrials.gov NCT02266134, first posted on October 16, 2014

What implementation strategies are relational? Using Relational Theory to explore the ERIC implementation strategies

The identification and use of implementation strategies in implementation research and practice have strengthened our understanding of the implementation process as well as the causal pathways between mechanisms, strategies, and implementation outcomes. Although these contributions have advanced the application of strategies, there is still a need to learn more about how strategies might integrate relational exchanges and interactions. The inclusion of critical perspectives has been limited in implementation science, and theories such as Relational Theory can expand our understanding of the relational nature of implementation and enhance rigor through alternative theoretical applications. This study applied Relational Theory through a qualitative directed content analysis of the 73 Expert Recommendations for Implementation Change (ERIC) implementation strategies and examine relational components in strategy descriptions. Three reviewers used the structured approach to review and categorize the implementation strategies based on the Relational and Transactional Strategy Continuum measure, which operationalizes types of interactions, exchanges and alliances. Relational alliance strategies are those in which there is mutual growth and accountability, frequent interaction, shared power, and potential vulnerability. Operational alliances include forms of working exchanges between parties with balanced transactional and relational features. Operational alliances can be somewhat interactive in nature, with minor exchanges and limited accountability. Transactional alliance strategies are mostly uni-directional, influenced by power differentials, and do not require mutual growth, commitment, or exchange; thus, the power of growth is inherently one-sided. Results from the review suggest more implementation strategies with relational alliance features (highly relational, n = 17, semi-relational, n = 19) compared to transactional (highly transactional, n = 9, semi-transactional, n = 10) and 18 strategies coded as operational alliances. The qualitative review revealed opportunities to further expand how relational exchanges are considered within the implementation strategies descriptions, as well as the role of actors and power dynamics within strategy exchanges. The Relational and Transactional Strategy Continuum measure can help practitioners and researchers consider the sequencing, pairing, and impact on outcomes of different types and combinations of strategies in implementation practice and research. Additionally, the measure can support reflection on strategies that promote positive alliances, frequent connections, bi-directional communication, and power sharing.

Standardized Versus Tailored Implementation of Measurement-Based Care for Depression in Community Mental Health Clinics

Objective

Measurement-based care (MBC) is an evidence-based practice that is rarely integrated into psychotherapy. The authors sought to determine whether tailored MBC implementation can improve clinician fidelity and depression outcomes compared with standardized implementation.

Methods

This cluster-randomized trial enrolled 12 community behavioral health clinics to receive 5 months of implementation support. Clinics randomized to the standardized implementation received electronic health record data captured with the nine-item Patient Health Questionnaire (PHQ-9), a needs assessment, clinical training, guidelines, and group consultation in MBC fidelity. Tailored implementation support included these strategies, but the training content was tailored to clinics’ barriers to MBC, and group consultation centered on overcoming these barriers. Clinicians (N=83, tailored; N=71, standardized) delivering individual psychotherapy to 4,025 adults participated. Adult patients (N=87, tailored; N=141, standardized) contributed data for depression outcome analyses.

Results

The odds of PHQ-9 completion were lower in the tailored group at baseline (odds ratio [OR]=0.28, 95% CI=0.08–0.96) but greater at 5 months (OR=3.39, 95% CI=1.00–11.48). The two implementation groups did not differ in full MBC fidelity. PHQ-9 scores decreased significantly from baseline (mean±SD=17.6±4.4) to 12 weeks (mean=12.6±5.9) (p<0.001), but neither implementation group nor MBC fidelity significantly predicted PHQ-9 scores at week 12.

Conclusions

Tailored MBC implementation outperformed standardized implementation with respect to PHQ-9 completion, but discussion of PHQ-9 scores in clinician-patient sessions remained suboptimal. MBC fidelity did not predict week-12 depression severity. MBC can critically inform collaborative adjustments to session or treatment plans, but more strategic system-level implementation support or longer implementation periods may be needed.

Operationalisation of person-centred care in a real-world setting: a case study with six embedded units

Background

Although person-centred care (PCC) is growing globally in popularity it is often vague and lacks conceptual clarity and definition. The ambiguity stretches from PCC’s underlying philosophical principles and definitions of the concept to how it is operationalised and practised on the ground by health care professionals. We explore how the PCC model by the Gothenburg University Centre for Person-centred Care (GPCC) was operationalised in a real-world setting by using a set of recommendations by Fixsen and others that define and structure the core components of innovations in four distinct but interrelated components: philosophical principles and values, contextual factors, structural elements and core practices. Thus, this study aimed to increase knowledge about core practices in PCC in six health care units in real-world circumstances.

Methods

A case study with six embedded health care units was conducted from 2016 to 2019. We collected data from three sources: interviews (n = 12) with change agents, activity logs and written documents. Data were triangulated, and core practices were identified and deductively coded to the PCC model’s structural elements: initiating, working and safeguarding the partnership with patients.

Results

We identified operationalisations of PCC in line with the three structural elements in the GPCC model at all included health care units. A range of both similarities and dissimilarities between units were identified, including the level of detail in describing PCC practices, when these practices were conducted and by whom at the workplace. The recommendations for describing the core components of PCC also helped us identify how some operationalisations of PCC seemed more driven by contextual factors, including a new regulation for planning and documenting care across health care specialities.

Conclusions

Our findings show how PCC is operationalised in different health care units in a real-world setting based on change agents’ understanding of the concept and their unique context. Increased knowledge of PCC and its philosophical principles and values, contextual factors, structural elements and core practices, is necessary to build a common understanding of the PCC-concept. Such knowledge is essential when PCC is operationalised as part of implementation efforts in health care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08516-y.

Interpersonal Theory of Nursing for Anxiety Management in People with Substance Use Disorder (ITASUD): A Feasibility Study

This study aim to evaluate the feasibility, based on six feasibility study criteria, of using a one-week intervention of interpersonal theory of nursing for anxiety management in people who are taking part in a substance use disorders (ITASUD). The study adopted a feasibility mixed methods approach. The ITASUD was implemented with 39 male users of cocaine/crack as their principal drug with high levels of anxiety. The outcome (anxiety) was assessed by the Beck anxiety inventory. To address the feasibility criteria, data were gathered during appointments. Additionally, qualitative open-ended interviews were conducted in the final appointment. The assessment of the six feasibility criteria indicated the following: (1) demand: there was high demand among eligible participants; (2) acceptability: the ITASUD had better acceptability until the 3^rd appointment; (3) implementation: the ITASUD's complexity and design was acceptable for participants; (4) practicality: 61.54% of participants used strategies from the ITASUD to manage their anxiety; (5) adaptation: there was no contamination and cointervention; and (6) safety: the ITASUD was safe. The exploratory analysis showed a relation between the level of anxiety and ITASUD (p < 0.0001). The ITASUD appears to be feasible. The participants reported positive experiences with the implementation of the ITASUD. The findings support the design of a powered larger trial to evaluate the effectiveness of the ITASUD.

Implementation mapping to plan for a hybrid trial testing the effectiveness and implementation of a behavioral intervention for HIV medication adherence and care retention

Background

Implementation mapping is a systematic, collaborative, and contextually-attentive method for developing implementation strategies. As an exemplar, we applied this method to strategy development for Managed Problem Solving Plus (MAPS+), an adapted evidence-based intervention for HIV medication adherence and care retention that will be delivered by community health workers and tested in an upcoming trial.

Methods

In Step 1: Conduct Needs Assessment, we interviewed 31 stakeholders to identify determinants of MAPS+ implementation in 13 clinics serving people with HIV in Philadelphia County. In Step 2: Develop Logic Model, we used these determinants as inputs for a working logic model guided by the Consolidated Framework for Implementation Research. In Step 3: Operationalize Implementation Strategies, our team held a virtual stakeholder meeting to confirm determinants. We synthesized stakeholder feedback, then identified implementation strategies that conceptually matched to determinants using the Expert Recommendations for Implementing Change taxonomy. Next, we operationalized implementation strategies with specific examples for clinic settings. We linked strategies to behavior change theories to allow for a mechanistic understanding. We then held a second virtual stakeholder meeting to present the implementation menu for feedback and glean generalizable insights for how these strategies could be operationalized in each stakeholder's clinic. In Step 4: Protocolize Strategies, we incorporated stakeholder feedback and finalized the implementation strategy menu.

Findings

Implementation mapping produced a menu of 39 strategies including revise professional roles, identify and prepare champions, use warm handoffs, and change record systems. The process of implementation mapping generated key challenges for implementation strategy development: lack of implementation strategies targeting the outer setting (i.e., sociopolitical context); tension between a one-size-fits-all and individualized approach for all clinics; conceptual confusion between facilitators and strategies; and challenges in translating the implementation science lexicon for partners.

Implications

This case exemplar advances both MAPS+ implementation and implementation science methods by furthering our understanding of the use of implementation mapping to develop strategies that enhance uptake of evidence-based interventions. The implementation menu will inform MAPS+ deployment across Philadelphia in an upcoming hybrid trial. We will carry out Step 5: Test Strategies to test the effectiveness and implementation of MAPS+.

Study protocol for a cluster-randomized trial of a bundle of implementation support strategies to improve the fidelity of implementation of schoolwide Positive Behavioral Interventions and Supports in rural schools

Background

Improving the implementation of evidence-based interventions is important for population-level impacts. Positive Behavioral Interventions and Supports (PBIS) is effective for improving school climate and students’ behavioral outcomes, but rural schools often lag behind urban and suburban schools in implementing such initiatives.

Methods/Design

This paper describes a Type 3 hybrid implementation-effectiveness trial of Rural School Support Strategies (RS3), a bundle of implementation support strategies selected to improve implementation outcomes in rural schools. In this two-arm parallel group trial, 40 rural public schools are randomized to receive: 1) a series of trainings about PBIS; or 2) an enhanced condition with training plus RS3. The trial was planned for two years, but due to the pandemic has been extended another year. RS3 draws from the Interactive Systems Framework, with a university-based team (support system) that works with a team at each school (school-based delivery system), increasing engagement through strategies such as: providing technical assistance, facilitating school team functioning, and educating implementers. The primary organizational-level outcome is fidelity of implementation, with additional implementation outcomes of feasibility, acceptability, appropriateness, and cost. Staff-level outcomes include perceived climate and self-reported adoption of PBIS core components. Student-level outcomes include disciplinary referrals, academic achievement, and perceived climate. Mediators being evaluated include organizational readiness, school team functioning, and psychological safety.

Discussion

The study tests implementation strategies, with strengths including a theory-based design, mixed methods data collection, and consideration of mediational mechanisms. Results will yield knowledge about how to improve implementation of universal prevention initiatives in rural schools.

Scoping review of costs of implementation strategies in community, public health and healthcare settings

OBJECTIVES

To identify existing evidence concerning the cost of dissemination and implementation (D&I) strategies in community, public health and health service research, mapped with the 'Expert Recommendations for Implementing Change' (ERIC) taxonomy.

DESIGN

Scoping review.

DATA SOURCES

MEDLINE, EMBASE, CINAHL, PsycINFO, Scopus and the Cochrane Library were searched to identify any English language reports that had been published between January 2008 and December 2019 concerning the cost of D&I strategies.

DATA EXTRACTION

We matched the strategies identified in each article using ERIC taxonomies; further classified them into five areas (eg, dissemination, implementation, integration, capacity building and scale-up); and extracted the corresponding costs (total costs and cots per action target and per evidence-based programme (EBP) participant). We also recorded the reported level of costing methodology used for cost assessment of D&I strategies.

RESULTS

Of the 6445 articles identified, 52 studies were eligible for data extraction. Lack of D&I strategy cost data was the predominant reason (55% of the excluded studies) for study exclusion. Predominant topic, setting, country and research design in the included studies were mental health (19%), primary care settings (44%), the US (35%) and observational (42%). Thirty-five (67%) studies used multicomponent D&I strategies (ranging from two to five discrete strategies). The most frequently applied strategies were Conduct ongoing training (50%) and Conduct educational meetings (23%). Adoption (42%) and reach (27%) were the two most frequently assessed outcomes. The overall costs of Conduct ongoing training ranged from $199 to $105 772 ($1-$13 973 per action target and $0.02-$412 per EBP participant); whereas the cost of Conduct educational meetings ranged from $987 to $1.1-$2.9 million/year ($33-$54 869 per action target and $0.2-$146 per EBP participant). The wide range of costs was due to the varying scales of the studies, intended audiences/diseases and the complexities of the strategy components. Most studies presented limited information on costing methodology, making interpretation difficult.

CONCLUSIONS

The quantity of published D&I strategy cost analyses is increasing, yet guidance on conducting and reporting of D&I strategy cost analysis is necessary to facilitate and promote the application of comparative economic evaluation in the field of D&I research.

A pragmatic implementation research study for In Our DNA SC: a protocol to identify multi-level factors that support the implementation of a population-wide genomic screening initiative in diverse populations

BACKGROUND

In 2021, the Medical University of South Carolina (MUSC) partnered with Helix, a population genetic testing company, to offer population-wide genomic screening for Centers for Disease Control and Preventions' Tier 1 conditions of hereditary breast and ovarian cancer, Lynch syndrome, and familial hypercholesterolemia to 100,000 individuals in South Carolina. We developed an implementation science protocol to study the multi-level factors that influence the successful implementation of the In Our DNA SC initiative.

METHODS

We will use a convergent parallel mixed-methods study design to evaluate the implementation of planned strategies and associated outcomes for In Our DNA SC. Aims focus on monitoring participation to ensure engagement of diverse populations, assessing contextual factors that influence implementation in community and clinical settings, describing the implementation team's facilitators and barriers, and tracking program adaptations. We report details about each data collection tool and analyses planned, including surveys, interview guides, and tracking logs to capture and code work group meetings, adaptations, and technical assistance needs.

DISCUSSION

The goal of In Our DNA SC is to provide population-level screening for actionable genetic conditions and to foster ongoing translational research. The use of implementation science can help better understand how to support the success of In Our DNA SC, identify barriers and facilitators to program implementation, and can ensure the sustainability of population-level genetic testing. The model-based components of our implementation science protocol can support the identification of best practices to streamline the expansion of similar population genomics programs at other institutions.

Barriers, frameworks, and mitigating strategies influencing the dissemination and implementation of health promotion interventions in indigenous communities: a scoping review

BACKGROUND

Many Indigenous communities across the USA and Canada experience a disproportionate burden of health disparities. Effective programs and interventions are essential to build protective skills for different age groups to improve health outcomes. Understanding the relevant barriers and facilitators to the successful dissemination, implementation, and retention of evidence-based interventions and/or evidence-informed programs in Indigenous communities can help guide their dissemination.

PURPOSE

To identify common barriers to dissemination and implementation (D&I) and effective mitigating frameworks and strategies used to successfully disseminate and implement evidence-based interventions and/or evidence-informed programs in American Indian/Alaska Native (AI/AN), Native Hawaiian/Pacific Islander (NH/PI), and Canadian Indigenous communities.

METHODS

A scoping review, informed by the York methodology, comprised five steps: (1) identification of the research questions; (2) searching for relevant studies; (3) selection of studies relevant to the research questions; (4) data charting; and (5) collation, summarization, and reporting of results. The established D&I SISTER strategy taxonomy provided criteria for categorizing reported strategies.

RESULTS

Candidate studies that met inclusion/exclusion criteria were extracted from PubMed (n = 19), Embase (n = 18), and Scopus (n = 1). Seventeen studies were excluded following full review resulting in 21 included studies. The most frequently cited category of barriers was "Social Determinants of Health in Communities." Forty-three percent of barriers were categorized in this community/society-policy level of the SEM and most studies (n = 12, 57%) cited this category. Sixteen studies (76%) used a D&I framework or model (mainly CBPR) to disseminate and implement health promotion evidence-based programs in Indigenous communities. Most highly ranked strategies (80%) corresponded with those previously identified as "important" and "feasible" for D&I The most commonly reported SISTER strategy was "Build partnerships (i.e., coalitions) to support implementation" (86%).

CONCLUSION

D&I frameworks and strategies are increasingly cited as informing the adoption, implementation, and sustainability of evidence-based programs within Indigenous communities. This study contributes towards identifying barriers and effective D&I frameworks and strategies critical to improving reach and sustainability of evidence-based programs in Indigenous communities.

REGISTRATION NUMBER

N/A (scoping review).

Communication strategies to facilitate the implementation of new clinical practices: a qualitative study of community mental health therapists

Although communication is widely observed to be central to the implementation process, the field of implementation science has largely overlooked the details of how communication may best be utilized to facilitate implementation. This paper draws on relevant insights from Rogers' Diffusion of Innovations Theory, which laid the foundation for explicitly attending to the role of communication as a mechanism for implementation strategies to exert their effects. To offer empirically-derived and theory-informed recommendations regarding communication processes to support the effective introduction of new clinical practices. This investigation leverages data from 61 therapists poised to undergo implementation of measurement-based care (MBC) for depressed adults receiving psychotherapy in community mental health settings. Data were collected via focus groups across 12 sites. Themes emergent in the data analysis suggest five practices to facilitate effective communication in the introduction of new clinical practices like MBC: the communication of a clear rationale for the new practice; the provision of necessary procedural knowledge; communication about the change via multiple methods; sufficient lead time to prepare for the change; and the opportunity for bidirectional engagement. In addition to indicating several best practices to improve communication prior to implementation, our results suggest that the current conceptualization of implementation strategies may not yet be complete. Components and/or methods of effective communication about new practices should be included among the growing set of implementation strategies. Existing implementation strategies might also benefit from more temporal specificity, with more attention to the exploration and preparation phases. (Trial Registration: Clinicaltrials.gov NCT02266134. Registered 12 October 2014.).

The case for prioritizing implementation strategy fidelity measurement: benefits and challenges

Implementation strategies are systematic approaches to improve the uptake and sustainability of evidence-based interventions. They frequently focus on changing provider behavior through the provision of interventions such as training, coaching, and audit-and-feedback. Implementation strategies often impact intermediate behavioral outcomes like provider guideline adherence, in turn improving patient outcomes. Fidelity of implementation strategy delivery is defined as the extent to which an implementation strategy is carried out as it was designed. Implementation strategy fidelity measurement is under-developed and under-reported, with the quality of reporting decreasing over time. Benefits of fidelity measurement include the exploration of the extent to which observed effects are moderated by fidelity, and critical information about Type-III research errors, or the likelihood that null findings result from implementation strategy fidelity failure. Reviews of implementation strategy efficacy often report wide variation across studies, commonly calling for increased implementation strategy fidelity measurement to help explain variations. Despite the methodological benefits of rigorous fidelity measurement, implementation researchers face multi-level challenges and complexities. Challenges include the measurement of a complex variable, multiple data collection modalities with varying precision and costs, and the need for fidelity measurement to change in-step with adaptations. In this position paper, we weigh these costs and benefits and ultimately contend that implementation strategy fidelity measurement and reporting should be improved in trials of implementation strategies. We offer pragmatic solutions for researchers to make immediate improvements like the use of mixed methods or innovative data collection and analysis techniques, the inclusion of implementation strategy fidelity assessment in reporting guidelines, and the staged development of fidelity tools across the evolution of an implementation strategy. We also call for additional research into the barriers and facilitators of implementation strategy fidelity measurement to further clarify the best path forward.

Implementation of the Wolverine Mental Health Program, Part 3: Sustainment Phase

Sustaining the implementation of an evidence-based practice (EBP) is the ultimate goal of often years of significant personnel and financial investment. Some conceptualize sustainment as a distinct phase following an active implementation period where the contextual factors, processes, and supports are bolstered to ensure continued EBP delivery. This study provides an overview of the sustainment strategies deployed to embed cognitive-behavioral therapy (CBT) in a Midwestern residential treatment facility serving youth with complex mental health needs. Seven key strategies and their outcomes are described: use of CBT teams, new hire orientation plans, monthly campaigns, change in job descriptions and performance evaluations, development of a behavioral reinforcement system for youth, and a pathway to CBT certification. This study provides a window into how one might sustain an EBP by addressing barriers unique to this phase of work.

Translating Medicaid policy into practice: policy implementation strategies from three US states' experiences enhancing substance use disorder treatment

BACKGROUND

Despite the important upstream impact policy has on population health outcomes, few studies in implementation science in health have examined implementation processes and strategies used to translate state and federal policies into accessible services in the community. This study examines the policy implementation strategies and experiences of Medicaid programs in three US states that responded to a federal prompt to improve access to evidence-based practice (EBP) substance use disorder (SUD) treatment.

METHODS

Three US state Medicaid programs implementing American Society of Addiction Medicine (ASAM) Criteria-driven SUD services under Section 1115 waiver authority were used as cases. We conducted 44 semi-structured interviews with Medicaid staff, providers and health systems partners in California, Virginia, and West Virginia. Interviews were triangulated with document review of state readiness and implementation plans. The Exploration, Preparation, Implementation, Sustainment Framework (EPIS) guided qualitative theme analysis. The Expert Recommendations for Implementing Change and Specify It criteria were used to create a taxonomy of policy implementation strategies used by policymakers to promote providers' uptake of statewide EBP SUD care continuums.

RESULTS

Four themes describe states' experiences and outcomes implementing a complex EBP SUD treatment policy directive: (1) Medicaid agencies adapted their inner/outer contexts to align with EBPs and adapted EBPs to fit their local context; (2) enhanced financial reimbursement arrangements were inadequate bridging factors to achieve statewide adoption of new SUD services; (3) despite trainings, service providers and managed care organizations demonstrated poor fidelity to the ASAM Criteria; and (4) successful policy adoption at the state level did not guarantee service providers' uptake of EBPs. States used 29 implementation strategies to implement EBP SUD care continuums. Implementation strategies were used in the Exploration (n=6), Preparation (n=10), Implementation (n=19), and Sustainment (n=6) phases, and primarily focused on developing stakeholder interrelationships, evaluative and iterative approaches, and financing.

CONCLUSIONS

This study enhances our understanding of statewide policy implementation outcomes in low-resource, public healthcare settings. Themes highlight the need for additional pre-implementation and sustainment focused implementation strategies. The taxonomy of detailed policy implementation strategies employed by policymakers across states should be tested in future policy implementation research.

Strategies for implementing music-based interventions for people with dementia in long-term care facilities: A systematic review

OBJECTIVES

Research has found that music-based interventions can decrease behavioral and psychological symptoms of dementia or behaviors that challenge (BPSD/BtC). However, how to effectively implement these interventions is unclear. This study synthesizes available evidence regarding implementation strategies and outcomes of music-based interventions for people with dementia at residential long-term care facilities.

METHODS

Study registered with PROSPERO (registration number: CRD42020194354). We searched the following databases: PsychInfo, PubMed, MEDLINE, CINAHL, and The Cochrane Library. Inclusion criteria included articles targeting music-based interventions conducted for people with dementia, studies conducted in residential long-term care facilities, and articles that reported implementation strategies and outcomes of the intervention.

RESULTS

Of the included eight studies, half were studies of music therapy and the other half were on individualized music. 49 implementation strategies were reported. The most frequently reported category of strategies was planning (34.7%), followed by education (24.5%), quality management (24.5%), restructuring (12.2%), and finance (4.1%). No strategies under the category of attending to the policy context were reported. The most frequently reported implementation outcomes were appropriateness (27.3%), followed by adoption (22.7%), fidelity (22.7%), acceptability (9.1%), sustainability (9.1%), and cost (9.1%). No studies measured feasibility or penetration.

CONCLUSIONS

Although various effective implementation strategies were identified, we were unable to examine the effectiveness of individual implementation strategies due to the designs of the selected studies. Less attention has been paid to strategies that aim at structural changes of intervention delivery systems. Future studies should investigate facilitators and barriers of implementing music-based interventions especially focusing on structural aspects.

Community-based implementation strategy use and satisfaction: A mixed-methods approach to using the ERIC compilation for organizations serving children on the autism spectrum

Background

Despite efforts to use standardized taxonomy and research reporting, documenting implementation strategies utilized in community settings remains challenging. This case study demonstrates a practical approach to gather use of and satisfaction with implementation strategies utilized within community-based sites to understand community providers’ perspectives of implementing an early intensive behavioral intervention (EIBI) for children on the autism spectrum across different settings.

Methods

Using a sequential explanatory mixed-methods design, survey and interview data were collected from directors/supervisors and direct providers ( n = 26) across three sites (one university and two community-based replication sites). The Implementation Strategies and Satisfaction Survey (ISSS) was administered to identify staff-reported implementation strategy use and satisfaction. Informed by quantitative results, follow-up semi-structured interviews were conducted with a subsample ( n = 13) to further understand staff experiences with endorsed implementation strategies and elicit recommendations for future efforts.

Results

Survey results were used to demonstrate frequencies of implementation strategies endorsed by site and role. Overall, staff felt satisfied with implementation strategies used within their agencies. Content analysis of qualitative data revealed three salient themes related to implementation strategy use—context, communication, and successes and challenges—providing in-depth detail on how strategies were utilized, and strategy effectiveness based on community providers’ experiences. Recommendations were also elicited to improve strategy use within “broader” community settings.

Conclusions

The project demonstrated a practical approach to identifying and evaluating implementation strategies used within sites delivering autism services. Reporting implementation strategies using the ISSS can provide insight into community providers’ perspectives and satisfaction with agency implementation strategy use that can generate more relevant and responsive strategies to address barriers in community settings. Plain language abstract Examining community providers’ preferences and experiences with implementation strategies used to facilitate evidence-based practice uptake can broaden our understanding of what, how, and why implementation strategies work in community-based settings ( Chaudoir et al., 2013 ; Leeman et al., 2017 ; Proctor et al., 2013 ). Such efforts have great potential to tailor implementation strategies to address barriers/facilitators typically found in community-based settings. This case study demonstrates a practical approach using mixed methodology to: (a) gather self-reported use of and satisfaction with implementation strategies to understand community providers’ perspectives of implementation strategy success. Using a new survey, the Implementation Strategies and Satisfaction Survey (ISSS) conjoined with interviews, the study demonstrated a practical approach using standardized language to report strategies used in one university-based site and two community-based replication sites that deliver an early intensive behavioral intervention (EIBI) for children on the autism spectrum. This paper contributes to one of the five priorities to enhance public health impact—improve tracking and reporting of implementation strategies utilized when translating research into practice ( Dingfelder & Mandell, 2011 ; Powell et al., 2019 ; Stahmer et al., 2019 ). This approach emphasizes the importance of understanding context (e.g., community organizations providing services to children on the autism spectrum) to develop strategies that work better for EIBI implementation and scale-up. Understanding community provider's preferences and experiences with implementation strategies can support use of implementation strategies that better fit usual care contexts, with the ultimate goal of improving implementation practice in community-based settings.

Specifying and Reporting Implementation Strategies Used in a School-Based Prevention Efficacy Trial

Background

Implementation strategies used to enhance the implementation of interventions during efficacy and effectiveness studies are rarely reported. Tracking and reporting implementation strategies during these phases has potential to improve future research studies and real-world implementation. We present an exemplar of how this might be executed by specifying and reporting the implementation strategies that were used during a school-based efficacy trial, Project POWER, which tested a trauma-informed prevention program delivered by a university research team, community members, and school staff facilitators in 29 schools.

Methods

Following the conclusion of the 4-year trial, core Project POWER research team members identified the implementation strategies that supported intervention delivery during the trial using an established taxonomy of school-based implementation strategies. The actors, actions, action targets, temporality, dose, and implementation outcomes were specified using established implementation strategies reporting guidelines.

Results

The research team identified 37 implementation strategies that were used during the Project POWER trial. Most strategies fell within the categories of Train and Educate Stakeholders, Use Evaluative and Iterative Strategies, and Develop Stakeholder Interrelationships. Actors included members of the research team and partner schools. Strategies were used multiple times during the preparation and implementation phases. Action targets were most often characteristics of individuals, implementation process, and characteristics of the inner setting. Strategies predominantly targeted the implementation outcomes of fidelity, acceptability, feasibility, and adoption.

Conclusions

This study provided evidence that implementation strategies are used and can be identified in efficacy research using a retrospective approach. Identifying and specifying implementation strategies used during the initial phases of the translational research pipeline can inform the implementation strategies that are carried forward, adapted, or discontinued in future trials and routine practice to improve implementation and effectiveness outcomes.

Scaling up evidence-based treatments in youth behavioral healthcare: Social work licensing influences on task-shifting opportunities

Youth behavioral healthcare workforce shortages have inhibited the scale-up of evidence-based treatments to address longstanding unmet needs andinequitable service coverage. Task-shifting is a strategy that could bolster workforce shortages. Legal and regulatory barriers, such as scope of practice licensing regulations, have hampered the use of task-shifting. Social workers make up the majority of the behavioral healthcare workforce in the U.S. and most social workers provide services to children and families. As such, social workers would play a pivotal role in any scale-up effort. In this guest editorial, we discuss the importance of social work licensing and use a case example to illustrate the unintended consequences that certain licensing regulations have on scaling-up evidence-based treatments via task-shifting. We conclude with recommendations on how social workers could be involved in taskshifting efforts to scale-up evidence-based treatments.

Justice community opioid innovation network (JCOIN): The TCU research hub

Recognizing the current opioid crisis among justice-involved individuals and the need to intervene at the intersection of justice and community health, the JCOIN TCU hub study explores outcomes associated with a multi-level hybrid implementation approach. The study capitalizes on facilitated collaboration, training, and cross-system data sharing to leverage improvements in criminal justice (CJ) and community behavioral health (CBH) interagency collaboration. The goal is to improve local community public health and safety outcomes for reentering justice-involved individuals who have a history of (or are at risk for) using opioids. The study compares two implementation strategies: one (vertical) in which all units in a community are trained and begin the program simultaneously and another (horizontal) in which one lead-off unit in the community is trained as a prototype of the program, the prototype is tested and refined, and then the lead-off unit helps to train other units within the community. Specific aims are to 1) increase access to and retention in CBH and medications for opioid use disorder services; 2) improve outcomes associated with public health and safety; 3) compare two implementation strategies on systems-level outcomes designed to increase service initiation and receipt of implementation and services; and 4) examine the impact of these strategies on justice-involved individuals' outcomes. The study examines both implementation and implementation-effectiveness, seeking to answer the questions of which implementation strategy is most effective for rapid and sustainable uptake of evidence-based practices and for increasing service linkage and initiation, services retention, and improved opioid-related public health safety outcomes. The study uses a hybrid type 3 study design. The study's primary aim is to compare two implementation strategies and two interventions at two levels (client and system), with a secondary aim to assess client-level outcomes associated with the trial. The study design integrates 2 robust methodologies (stepped wedge and cluster randomized trial), and plans to include 18 research performance sites (communities) located in Texas, New Mexico, and Illinois. The study will contribute to the JCOIN network's effort to establish a national consortium of investigators examining promising strategies to enhance the capabilities and capacity of the justice system to more effectively address the opioid epidemic.

Strengthening methods for tracking adaptations and modifications to implementation strategies

BACKGROUND

Developing effective implementation strategies requires adequate tracking and reporting on their application. Guidelines exist for defining and reporting on implementation strategy characteristics, but not for describing how strategies are adapted and modified in practice. We built on existing implementation science methods to provide novel methods for tracking strategy modifications.

METHODS

These methods were developed within a stepped-wedge trial of an implementation strategy package designed to help community clinics adopt social determinants of health-related activities: in brief, an 'Implementation Support Team' supports clinics through a multi-step process. These methods involve five components: 1) describe planned strategy; 2) track its use; 3) monitor barriers; 4) describe modifications; and 5) identify / describe new strategies. We used the Expert Recommendations for Implementing Change taxonomy to categorize strategies, Proctor et al.'s reporting framework to describe them, the Consolidated Framework for Implementation Research to code barriers / contextual factors necessitating modifications, and elements of the Framework for Reporting Adaptations and Modifications-Enhanced to describe strategy modifications.

RESULTS

We present three examples of the use of these methods: 1) modifications made to a facilitation-focused strategy (clinics reported that certain meetings were too frequent, so their frequency was reduced in subsequent wedges); 2) a clinic-level strategy addition which involved connecting one study clinic seeking help with community health worker-related workflows to another that already had such a workflow in place; 3) a study-level strategy addition which involved providing assistance in overcoming previously encountered (rather than de novo) challenges.

CONCLUSIONS

These methods for tracking modifications made to implementation strategies build on existing methods, frameworks, and guidelines; however, as none of these were a perfect fit, we made additions to several frameworks as indicated, and used certain frameworks' components selectively. While these methods are time-intensive, and more work is needed to streamline them, they are among the first such methods presented to implementation science. As such, they may be used in research on assessing effective strategy modifications and for replication and scale-up of effective strategies. We present these methods to guide others seeking to document implementation strategies and modifications to their studies.

TRIAL REGISTRATION

clinicaltrials.gov ID: NCT03607617 (first posted 31/07/2018).

Strengthening methods for tracking adaptations and modifications to implementation strategies

BACKGROUND

Developing effective implementation strategies requires adequate tracking and reporting on their application. Guidelines exist for defining and reporting on implementation strategy characteristics, but not for describing how strategies are adapted and modified in practice. We built on existing implementation science methods to provide novel methods for tracking strategy modifications.

METHODS

These methods were developed within a stepped-wedge trial of an implementation strategy package designed to help community clinics adopt social determinants of health-related activities: in brief, an 'Implementation Support Team' supports clinics through a multi-step process. These methods involve five components: 1) describe planned strategy; 2) track its use; 3) monitor barriers; 4) describe modifications; and 5) identify / describe new strategies. We used the Expert Recommendations for Implementing Change taxonomy to categorize strategies, Proctor et al.'s reporting framework to describe them, the Consolidated Framework for Implementation Research to code barriers / contextual factors necessitating modifications, and elements of the Framework for Reporting Adaptations and Modifications-Enhanced to describe strategy modifications.

RESULTS

We present three examples of the use of these methods: 1) modifications made to a facilitation-focused strategy (clinics reported that certain meetings were too frequent, so their frequency was reduced in subsequent wedges); 2) a clinic-level strategy addition which involved connecting one study clinic seeking help with community health worker-related workflows to another that already had such a workflow in place; 3) a study-level strategy addition which involved providing assistance in overcoming previously encountered (rather than de novo) challenges.

CONCLUSIONS

These methods for tracking modifications made to implementation strategies build on existing methods, frameworks, and guidelines; however, as none of these were a perfect fit, we made additions to several frameworks as indicated, and used certain frameworks' components selectively. While these methods are time-intensive, and more work is needed to streamline them, they are among the first such methods presented to implementation science. As such, they may be used in research on assessing effective strategy modifications and for replication and scale-up of effective strategies. We present these methods to guide others seeking to document implementation strategies and modifications to their studies.

TRIAL REGISTRATION

clinicaltrials.gov ID: NCT03607617 (first posted 31/07/2018).

Tracking implementation within a community-led whole of system approach to address childhood overweight and obesity in south west Sydney, Australia

Background

Obesity is a chronic disease that contributes to additional comorbidities including diabetes, kidney disease and several cancers. Change4Campbelltown implemented a ‘whole of system’ approach to address childhood overweight and obesity. We present methods to track implementation and stakeholder engagement in Change4Campbelltown.

Methods

Change4Campbelltown aimed to build capacity among key leaders and the broader community to apply techniques from systems thinking to develop community-led actions that address childhood obesity. Change4Campbelltown comprised development of a stakeholder-informed Causal Loop Diagram (CLD) and locally-tailored action plan, formation of key stakeholder and community working groups to prioritise and implement actions, and continuous monitoring of intervention actions. Implementation data included an action register, stakeholder engagement database and key engagement activities and were collected quarterly by the project management team over 2 years of reporting.

Results

Engagement activities increased level of community engagement amongst key leaders, the school-sector and community members. Community-led action increased as engagement increased and this action is mapped directly to the primary point of influence on the CLD. As action spread diversified across the CLD, the geographical spread of action within the community increased.

Conclusions

This paper provides a pragmatic example of the methods used to track implementation of complex interventions that are addressing childhood overweight and obesity.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11288-5.

Implementing the PREP2 Algorithm to Predict Upper Limb Recovery Potential After Stroke in Clinical Practice: A Qualitative Study

OBJECTIVE

Predicting motor recovery after stroke is a key factor when planning and providing rehabilitation for individual patients. The Predict REcovery Potential (PREP2) prediction tool was developed to help clinicians predict upper limb functional outcome. In parallel to further model validation, the purpose of this study was to explore how PREP2 was implemented in clinical practice within the Auckland District Health Board (ADHB) in New Zealand.

METHODS

In this case study design using semi-structured interviews, 19 interviews were conducted with clinicians involved in stroke care at ADHB. To explore factors influencing implementation, interview content was coded and analyzed using the consolidated framework for implementation research. Strategies identified by the Expert Recommendations for Implementing Change Project were used to describe how implementation was undertaken.

RESULTS

Implementation of PREP2 was initiated and driven by therapists. Key factors driving implementation were as follows: the support given to staff from the implementation team; the knowledge, beliefs, and self-efficacy of staff; and the perceived benefits of having PREP2 prediction information. Twenty-six Expert Recommendations for Implementing Change strategies were identified relating to 3 areas: implementation team, clinical/academic partnerships, and training.

CONCLUSIONS

The PREP2 prediction tool was successfully implemented in clinical practice at ADHB. Barriers and facilitators to implementation success were identified, and implementation strategies were described. Lessons learned can aid future development and implementation of prediction models in clinical practice.

IMPACT

Translating evidence-based interventions into clinical practice can be challenging and slow; however, shortly after its local validation, PREP2 was successfully implemented into clinical practice at the same site in New Zealand. In parallel to further model validation, organizations and practices can glean useful lessons to aid future implementation.

Increasing risk-concordant cardiovascular care in diverse health systems: a mixed methods pragmatic stepped wedge cluster randomized implementation trial of shared decision making (SDM4IP)

BACKGROUND

The primary prevention of cardiovascular (CV) events is often less intense in persons at higher CV risk and vice versa. Clinical practice guidelines recommend that clinicians and patients use shared decision making (SDM) to arrive at an effective and feasible prevention plan that is congruent with each person's CV risk and informed preferences. However, SDM does not routinely happen in practice. This study aims to integrate into routine care an SDM decision tool (CV PREVENTION CHOICE) at three diverse healthcare systems in the USA and study strategies that foster its adoption and routine use.

METHODS

This is a mixed method, hybrid type III stepped wedge cluster randomized study to estimate (a) the effectiveness of implementation strategies on SDM uptake and utilization and (b) the extent to which SDM results in prevention plans that are risk-congruent. Formative evaluation methods, including clinician and stakeholder interviews and surveys, will identify factors likely to impact feasibility, acceptability, and adoption of CV PREVENTION CHOICE as well as normalization of CV PREVENTION CHOICE in routine care. Implementation facilitation will be used to tailor implementation strategies to local needs, and implementation strategies will be systematically adjusted and tracked for assessment and refinement. Electronic health record data will be used to assess implementation and effectiveness outcomes, including CV PREVENTION CHOICE reach, adoption, implementation, maintenance, and effectiveness (measured as risk-concordant care plans). A sample of video-recorded clinical encounters and patient surveys will be used to assess fidelity. The study employs three theoretical approaches: a determinant framework that calls attention to categories of factors that may foster or inhibit implementation outcomes (the Consolidated Framework for Implementation Research), an implementation theory that guides explanation or understanding of causal influences on implementation outcomes (Normalization Process Theory), and an evaluation framework (RE-AIM).

DISCUSSION

By the project's end, we expect to have (a) identified the most effective implementation strategies to embed SDM in routine practice and (b) estimated the effectiveness of SDM to achieve feasible and risk-concordant CV prevention in primary care.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04450914 . Posted June 30, 2020 TRIAL STATUS: This study received ethics approval on April 17, 2020. The current trial protocol is version 2 (approved February 17, 2021). The first subject had not yet been enrolled at the time of submission.

The FRAME-IS: a framework for documenting modifications to implementation strategies in healthcare

BACKGROUND

Implementation strategies are necessary to ensure that evidence-based practices are successfully incorporated into routine clinical practice. Such strategies, however, are frequently modified to fit local populations, settings, and contexts. While such modifications can be crucial to implementation success, the literature on documenting and evaluating them is virtually nonexistent. In this paper, we therefore describe the development of a new framework for documenting modifications to implementation strategies.

DISCUSSION

We employed a multifaceted approach to developing the Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies (FRAME-IS), incorporating multiple stakeholder perspectives. Development steps included presentations of initial versions of the FRAME-IS to solicit structured feedback from individual implementation scientists ("think-aloud" exercises) and larger, international groups of researchers. The FRAME-IS includes core and supplementary modules to document modifications to implementation strategies: what is modified, the nature of the modification (including the relationship to core elements or functions), the primary goal and rationale for the modification, timing of the modification, participants in the modification decision-making process, and how widespread the modification is. We provide an example of application of the FRAME-IS to an implementation project and provide guidance on how it may be used in future work.

CONCLUSION

Increasing attention is being given to modifications to evidence-based practices, but little work has investigated modifications to the implementation strategies used to implement such practices. To fill this gap, the FRAME-IS is meant to be a flexible, practical tool for documenting modifications to implementation strategies. Its use may help illuminate the pivotal processes and mechanisms by which implementation strategies exert their effects.

Developing and implementing an exercise-based group for stroke survivors and their carers: the Carers Count group

PURPOSE

Guidelines recommend that carers of stroke survivors should be engaged early in rehabilitation. There has been limited research implementing exercise programs that include carers. The aims of this study were to develop, facilitate, and evaluate an intervention, the Carers Count group, an exercise-based group for stroke survivors and their carers.

METHODS

Over a 5-month period, a staged approach was used to design the intervention and implementation strategies which would maximise the chances of embedding the intervention within an inpatient stroke ward. Implementation strategies included planning, educating, restructuring, financing, and managing quality. Following development and facilitation of the intervention, outcomes were evaluated through collecting data about therapy time, surveys (n = 30) and interviews (n = 18) with participants, and a focus group with staff.

RESULTS

Thirty stroke survivors and their carers participated in the Carers Count group. Analysis of time spent in therapy showed that participation led to increased dose of physiotherapy time (service outcome). Survey and interview data suggested that participation in the group was a rewarding and engaging experience for participants (client outcomes).

CONCLUSION

Using multifaceted strategies, a group designed to include carers was implemented on a stroke rehabilitation ward. The intervention provided positive outcomes in terms of increased therapy dose and satisfaction according to participant feedback.

CLINICAL TRIALS REGISTRATION NUMBER

ANZCTR12620000708954Implications for rehabilitationIt is possible to develop modes of delivery in rehabilitation that include the carers of stroke survivors and these interventions are considered enjoyable and beneficial.Health professionals should consider interventions that are engaging and fun for stroke survivors and their carers.Health professionals should carefully plan and utilise appropriate implementation strategies when aiming to introduce a new intervention into an established health service.Health professionals should ensure stroke survivors and their carers have an understanding of recovery following stroke and how to maximise outcomes through increasing amount of practice.

Discussing measurement-based care with patients: An analysis of clinician-patient dyads

Abstract Measurement-based care (MBC) refers to the use of three integrated strategies to improve effectiveness of behavioral health care: routine outcomes monitoring using symptom measures; regularly sharing these data with patients; and using these data to inform treatment decisions. This study examined how clinicians discuss MBC data with patients, including identifying what aspects of these discussions contribute to clinician-patient agreement on the value of MBC, and how clinicians use MBC data to inform treatment decisions. Twenty-six clinician-patient dyads participated in semi-structured interviews and provided a treatment session recording in which MBC data were discussed. Qualitative data analyses revealed four subtypes of dyads: clinician and patient both valued MBC; clinician valued MBC, patient passively participated in MBC; clinician valued MBC, patient had mixed perceptions of MBC; clinician and patient reported moderate or low value for MBC. In dyads for whom both the clinician and patient valued MBC, the clinician provided clear and repeated rationale for MBC, discussed data with patients at every administration, and connected observed scores to patient skills or strategies. Emerging best practices for discussing MBC include providing a strong rationale, discussing results frequently, actively engaging patients in discussions, and using graphs to visualize progress.

Assessing Implementation Strategy Reporting in the Mental Health Literature: A Narrative Review

Inadequate implementation strategy reporting restricts research synthesis and replicability. We explored the implementation strategy reporting quality of a sample of mental health articles using Proctor et al.'s (Implement Sci 8:139, 2013) reporting recommendations. We conducted a narrative review to generate the sample of articles and assigned a reporting quality score to each article. The mean article reporting score was 54% (range 17-100%). The most reported domains were: name (100%), action (82%), target (80%), and actor (67%). The least reported domains included definition (6%), temporality (26%), justification (34%), and outcome (37%). We discuss limitations and provide recommendations to improve reporting.

Identifying Implementation Strategies That Address Barriers and Facilitate Implementation of Digital Interventions in HIV Primary Care Settings: Results from the Pilot Implementation of Positive Health Check

We used the 1-month pilot implementation of Positive Health Check, a brief web-based video counseling intervention that supports patients with HIV attending HIV primary care clinics, to exemplify how studying implementation strategies earlier in the evidence-generation process can improve implementation outcomes in later pragmatic trials. We identified how implementation strategies were operationalized and the barriers and facilitators these strategies addressed using multiple data sources, including adapted implementation procedures and weekly structured interviews conducted with 9 key stakeholders in 4 HIV primary care clinics. Nineteen of 73 discrete implementation strategies for clinical innovations were used in the pilot implementation of Positive Health Check. Clinic staff reported 17 barriers and facilitators related to the clinic environment, patient population, intervention characteristics, and training and technical assistance. Identifying the link between strategies, barriers, and facilitators helped plan for a subsequent larger multisite pragmatic trial.

Integrating implementation science in clinical research to maximize public health impact: a call for the reporting and alignment of implementation strategy use with implementation outcomes in clinical research

BACKGROUND

Although comprehensive reporting guidelines for implementation strategy use within implementation research exist, they are rarely used by clinical (i.e., efficacy and effectiveness) researchers. In this debate, we argue that the lack of comprehensive reporting of implementation strategy use and alignment of those strategies with implementation outcomes within clinical research is a missed opportunity to efficiently narrow research-to-practice gaps.

MAIN BODY

We review ways that comprehensively specifying implementation strategy use can advance science, including enhancing replicability of clinical trials and reducing the time from clinical research to public health impact. We then propose that revisions to frequently used reporting guidelines in clinical research (e.g., CONSORT, TIDieR) are needed, review current methods for reporting implementation strategy use (e.g., utilizing StaRI), provide pragmatic suggestions on how to both prospectively and retrospectively specify implementation strategy use and align these strategies with implementation outcomes within clinical research, and offer a case study of using these methods.

CONCLUSIONS

The approaches recommended in this article will not only contribute to shared knowledge and language among clinical and implementation researchers but also facilitate the replication of efficacy and effectiveness research. Ultimately, we hope to accelerate translation from clinical to implementation research in order to expedite improvements in public health.

Lessons learned about the effective operationalization of champions as an implementation strategy: results from a qualitative process evaluation of a pragmatic trial

BACKGROUND

Though the knowledge base on implementation strategies is growing, much remains unknown about how to most effectively operationalize these strategies in diverse contexts. For example, while evidence shows that champions can effectively support implementation efforts in some circumstances, little has been reported on how to operationalize this role optimally in different settings, or on the specific pathways through which champions enact change.

METHODS

This is a secondary analysis of data from a pragmatic trial comparing implementation strategies supporting the adoption of guideline-concordant cardioprotective prescribing in community health centers in the USA. Quantitative data came from the community health centers' shared electronic health record; qualitative data sources included community health center staff interviews over 3 years. Using a convergent mixed-methods design, data were collected concurrently and merged for interpretation to identify factors associated with improved outcomes. Qualitative analysis was guided by the constant comparative method. As results from the quantitative and initial qualitative analyses indicated the essential role that champions played in promoting guideline-concordant prescribing, we conducted multiple immersion-crystallization cycles to better understand this finding.

RESULTS

Five community health centers demonstrated statistically significant increases in guideline-concordant cardioprotective prescribing. A combination of factors appeared key to their successful practice change: (1) A clinician champion who demonstrated a sustained commitment to implementation activities and exhibited engagement, influence, credibility, and capacity; and (2) organizational support for the intervention. In contrast, the seven community health centers that did not show improved outcomes lacked a champion with the necessary characteristics, and/or organizational support. Case studies illustrate the diverse, context-specific pathways that enabled or prevented study implementers from advancing practice change.

CONCLUSION

This analysis confirms the important role of champions in implementation efforts and offers insight into the context-specific mechanisms through which champions enact practice change. The results also highlight the potential impact of misaligned implementation support and key modifiable barriers and facilitators on implementation outcomes. Here, unexamined assumptions and a lack of evidence-based guidance on how best to identify and prepare effective champions led to implementation support that failed to address important barriers to intervention success.

TRIAL REGISTRATION

ClinicalTrials.gov , NCT02325531 . Registered 15 December 2014.