Adapting the Consolidated Framework for Implementation Research to Create Organizational Readiness and Implementation Tools for Project ECHO

Facilitators and barriers to implementing the Project ECHO model: perspectives of 8 ECHO implementation teams

BACKGROUND

Project ECHO has emerged as a leading telementoring modality for continuing medical education, particularly for providers practicing in rural and underserved areas with limited access to specialty care. The efficacy and utility of the ECHO model in healthcare training is well documented, though there is less literature focused on the determinants of ECHO implementation.

OBJECTIVE

This study aims to assess facilitators and barriers to implementing the ECHO model.

METHODS

We conducted virtual focus groups with eight Project ECHO implementation teams (n = 29 individuals) across the United States. Guided by the Consolidated Framework for Implementation Research (CFIR), focus groups explored experiences implementing the ECHO model and assessed facilitators and barriers to program uptake, delivery, and sustainability.

RESULTS

Qualitative analysis revealed implementation determinants across CFIR levels. Participants recognized the advantage of ECHO's virtual, learner-centric, case-based learning approach compared to other continuing medical education modalities. Participants recommended recruiting subject matter expert presenters with skills as educators and understanding of the ECHO model. Because of Project ECHO's emphasis on case-based learning, participants highlighted the importance of balancing didactics with case presentations and discussion. Scheduling and finding time to participate was reported as a challenge for provider engagement, though most participants suggested that the length, frequency of sessions, and number of participants can be tailored for each program to accommodate needs. Providing CME credit and setting expectations for attendance and case presentation were said to improve provider engagement. Support and mentorship from the ECHO Institute was described as a facilitator in planning for ECHO implementation and delivery. Funding was reported as a barrier to sustainability.

CONCLUSION

By addressing barriers prior to implementing the ECHO model, future ECHOs can be tailored to leverage program resources, maximize attendance, expand reach, and ultimately improve outcomes.

Visualization analysis of CBL application in Chinese and international medical education based on big data mining

OBJECTIVE

To employ big data mining to provide a visualization analysis of Case-Based Learning (CBL) application in Chinese and international medical education, with the aim of observing the potential applications of CBL.

METHODS

All included literature was obtained from the Web of Science (WoS) core collection database, Chinese core periodicals database, Chinese Social Sciences Citation Index (CSSCI), Chinese Science Citation Database of China National Knowledge Infrastructure (CNKI), Wangfang Database, and CQVIP Database. CiteSpace software (6.1.6R6) was used to conduct an in-depth investigation from four perspectives: quantitative analysis of literature, network analysis of co-occurring authors, network analysis of co-occurring research institutions, keyword clustering and burst analysis.

RESULTS

A total of 721 Chinese articles and 537 English articles were included, demonstrating an exponential growth trend. Notably, no author exhibited a prolific publication rate within a short timeframe. Bursting keywords in English literature encompassed topics related to students' learning, teaching curriculum, methods, and location. In contrast, Chinese literature focused on students' learning, teaching methods, courses, application fields as well as national policy and the Ministry of Education of the People's Republic of China (MOE) guidance. The keyword clusters include research on care, community practice, special projects and groups, teaching methods, and capacity development of participants in English literature. For Chinese literature, the clusters include research national policy guidance, teaching reform, mode and evaluation and various disciplines.

CONCLUSION

CBL holds immense potential for implementation across diverse disciplines, community practices, and special projects within medical education. The practical application of CBL is continuously evolving in response to changing times and can be seamlessly integrated into different contexts influenced by environmental factors and policies.

Barriers and facilitators to the implementation of screening and intervention for co-use of opioid medications and alcohol among community pharmacy patients

INTRODUCTION

A significant risk for overdose among patients prescribed opioid medications is co-use of alcohol. Community pharmacies are underutilized as a resource to prevent and address co-use. The barriers and facilitators that promote or impede the adoption of universal alcohol screening and intervention at point of opioid medication dispensing are unknown. We assessed community pharmacy leaders, pharmacists, and technician's perceptions towards the implementation of a pharmacy-based screening/intervention for the co-use of opioids and alcohol among patients.

METHODS

We conducted a multi-method study that included one-time key informant interviews combined with a close-ended survey to inform our understanding of pharmacy system/practice-level barriers and facilitators for universal screening and intervention. Participants were recruited from Utah and Tennessee and were required to have active employment as pharmacy leaders, pharmacists, or technicians, be English-speaking, and believe they could provide feedback regarding co-use screening and intervention within community pharmacies. Interviews used the Consolidated Framework for Implementation Research and the Organizational Readiness for Implementing Change assessment. Qualitative analysis included both inductive and deductive coding. Themes followed a cycle of open, initial coding whereby codes were derived inductively from the data.

RESULTS

Themes from interviews (N = 68) included a) emphasizing a need to overcome the stigma associated with patients who engage in co-use and a mindset shift to treat the challenges and risks associated, b) need for corporate-level support, management buy-in, and c) appropriate technology to support the workflow including system-wide changes to support the integration of medication therapy management services within community pharmacies. However, barriers were offset by pharmacists eager to understand their role in screening patients and reiterated a focus on patient-centered care to achieve this goal. From the ORIC assessment, 75 % (n = 51) of respondents reported that community pharmacy staff wanted to implement the screening and intervention, and 69.1 % (n = 47) reported motivation to implement the screening and intervention. Finally, 67.6 % (n = 46) felt that community pharmacies are committed to implementing the screening and intervention, but only 10.3 % (n = 7) expressed strong support to do "whatever it takes" to implement the screening and intervention.

CONCLUSION

These results provide critical insights into implementation strategies for the adoption of brief intervention by community pharmacists. These data are foundational to developing strategies for a powered trial and possible future system/practice-level implementation of universal alcohol screening and intervention for co-use.

CTN-0138: adaptation, implementation, and cluster randomized trial of a Community Pharmacy-Based Prescription Drug Monitoring Program Opioid Risk Assessment Tool-a protocol paper

BACKGROUND

As the opioid epidemic continues to have a major negative impact across the US, community pharmacies have come under scrutiny from legal systems attempting to hold them accountable for their role in over dispensing and lack of patient intervention. While the most available tool for monitoring patients' opioid use is Prescription Drug Monitoring Programs (PDMP), these do not provide pharmacists with actionable information and decision support. Our study addresses this gap through three objectives: [1] incorporate validated opioid risk metric thresholds into a PDMP platform to create the Opioid Risk Reduction Clinical Decision Support (ORRCDS) tool; [2] assess ORRCDS' ability to reduce patient opioid risk; [3] assess ORRCDS' sustainability and viability for broader dissemination in community pharmacy.

METHODS

For objective 1, our team is partnering with leadership from the largest US PDMP organization and a top-five pharmacy chain to implement ORRCDS into the pharmacy chain's workflow following the Guideline Implementation with Decision Support (GUIDES) framework. For objective 2, our team will conduct a type-1 implementation mixed methods study using a 2-arm parallel group clustered randomized design. We anticipate enrolling ~ 6,600 patients with moderate and high opioid use risk during the 6-month enrollment phase across 80 pharmacies. This sample size will provide 96.3% power to detect a 5% or greater difference in responder rate between the intervention and control arm. Responders are patients with moderate-risk at baseline who reduce to low-risk or those with high-risk at baseline who reduce to moderate or low-risk at 180 days post last intervention. To accomplish objective 3, we will use the Consolidated Framework for Implementation Research (CFIR) to develop and execute cross-sectional qualitative interviews with pharmacists (n = 15), pharmacy leaders (n = 15), and PDMP leaders (n = 15) regarding long term adoption and sustainability of the ORRCDS tool.

CONCLUSIONS

A PDMP tool that addresses moderate- and high-risk opioid use is not available in community pharmacy. This study will implement ORRCDS in a large retail pharmacy chain that will include additional screening and guidance to pharmacy staff to address risky opioid medication use. Our results will make critical advancements for protecting patient health and addressing the opioid epidemic.

Six years of Project ECHO: Implementation and evaluation of a hospice-led multiprofessional education programme

Objectives: This article reports on the implementation and evaluation of an established technology-enabled collaborative learning programme (Project ECHO) at an independent UK hospice in the North of England over a 6-year period. Methods: An independent audit of collated, anonymised data from the programme is used to report attendance patterns and session evaluations. Results: The results show a gradual increase in attendances, programmes, sessions and hours of education, coupled with consistently positive evaluation reports. Conclusion: This supports existing evidence that Project ECHO is an effective method of delivering remote healthcare education, demonstrating impact on the first three levels of Moore's education framework; participation, satisfaction and learning. Future expansion in terms of geography and topics covered is proposed, alongside enhanced evaluation methods to demonstrate impact at the higher levels of Moore's framework.

Organizational readiness and implementation fidelity of an early childhood education and care-specific physical activity policy intervention: findings from the Play Active trial

BACKGROUND

Many children do not accumulate sufficient physical activity for good health and development at early childhood education and care (ECEC). This study examined the association between ECEC organizational readiness and implementation fidelity of an ECEC-specific physical activity policy intervention.

METHODS

Play Active aimed to improve the ECEC educator's physical activity practices. We investigated the implementation of Play Active using a Type 1 hybrid study (January 2021-March 2022). Associations between organizational readiness factors and service-level implementation fidelity were examined using linear regressions. Fidelity data were collected from project records, educator surveys and website analytics.

RESULTS

ECEC services with higher levels of organizational commitment and capacity at pre-implementation reported higher fidelity scores compared to services with lower organizational commitment and capacity (all Ps < 0.05). Similarly, services who perceived intervention acceptability and appropriateness at pre-implementation to be high had higher fidelity scores (P < 0.05). Perceived feasibility and organizational efficacy of Play Active were associated with higher but nonsignificant fidelity scores.

CONCLUSIONS

Results indicate that organizational readiness factors may influence the implementation of ECEC-specific physical activity policy interventions. Therefore, strategies to improve organizational readiness should be developed and tested. These findings warrant confirmation in the ECEC and other settings and with other health behavior interventions.

Improving care for veterans' environmental exposure concerns: applications of the consolidated framework for implementation research in program evaluation

BACKGROUND

Healthcare systems, like the US Department of Veterans Affairs (VA), need policies and procedures for delivering care to special populations including those with environmental exposure concerns. Despite being common and pervasive, especially among Veterans, environmental exposures are largely overlooked by healthcare providers. To successfully implement care for Veterans with military environmental exposure concerns, an understanding of contextual factors impeding care on the provider (e.g., knowledge and beliefs) and organizational (e.g., leadership's priorities) level is needed. Our goal was to conduct an operational needs assessment of providers to examine provider educational needs regarding Veterans' military environmental exposure concerns.

METHODS

In 2020, we surveyed 2,775 VA medical and behavioral health providers. Our cross-sectional assessment was informed by the Consolidated Framework for Implementation Research (CFIR) and assessed barriers and facilitators to the uptake and application of knowledge regarding interdisciplinary care for environmental exposure concerns. The web-based survey was emailed to providers across the United States representing a variety of disciplines and practice settings to reflect the interdisciplinary approach to care for environmental exposures. We used bivariate statistics to investigate the intervention setting, inner setting, and individual characteristics of providers regarding care for environmental exposure concerns.

RESULTS

Approximately one-third of VA medical and behavioral health clinicians report low to no knowledge of environmental exposure concerns. We find 88% of medical and 91% of behavioral health providers report they are ready to learn more about environmental exposures. Half of medical and behavioral health providers report they have access to information on environmental exposures and less than half report care for environmental exposures is a priority where they practice.

CONCLUSIONS

Our findings suggest interdisciplinary providers' knowledge of and discussion with Veterans about environmental exposures may be influenced by contextual factors at the organizational level. Considering individual-level factors and organizational culture is important to consider when supporting care for environmental exposures. Since this needs assessment, VA established targeted programs to improve care related to military environmental exposures in response to legislation; future exploration of these same variables or contextual factors is warranted.

Integrating mental health into primary care in Nigeria: Implementation outcomes and clinical impact of the HAPPINESS intervention

Background

The Health Action for Psychiatric Problems In Nigeria including Epilepsy and SubstanceS (HAPPINESS) intervention is a multicomponent, community-based, mobile technology-supported intervention that integrates mental health into primary health care centers in Nigeria using the World Health Organization's Mental Health Gap Action Programme-Intervention Guide (mhGAP-IG). This study evaluates its implementation and patient-level clinical impact using a quasi-experimental design (single cohort with pre- and post-measures).

Findings

The HAPPINESS intervention implementation demonstrated high feasibility with 84% adoption rate (% of participating primary health centers that completed its roll out) and 81% fidelity (% of clinicians who completed required intervention components according to the protocol). Retention rate in care at 12 months was 86%. Among patients with complete clinical records analyzed (n = 178), there was a statistically significant reduction in 9-item Patient Health Questionnaire scores from baseline (Md = 9.5) to 6 months (Md = 3.0) post-intervention (z = 80.5, p < 0.001), with a large effect size (r = 0.8) and statistically significant reduction in Brief Psychiatric Rating Scale scores from baseline (Md = 36.0) to 6 months (Md = 17.0) post-intervention (z = 128.5, p < 0.001), with a large effect size (r = 0.9).

Implications

Mobile technology-enhanced, mhGAP-IG-based efforts to scale-up mental health services in Nigeria are feasible and effective.

Using ERIC to Assess Implementation Science in Drowning Prevention Interventions in High-Income Countries: A Systematic Review

This systematic review identifies and describes the use of the Expert Recommendation for Implementing Change (ERIC) concepts and strategies using public health approaches to drowning prevention interventions as a case study. International calls for action have identified the need to better understand the implementation of drowning prevention interventions so that intervention design and implementation is improved. In high-income countries (HICs), interventions are sophisticated but still little is known or written about their implementation. The review was registered on PROSPERO (number CRD42022347789) and followed the PRISMA guidelines. Eight databases were searched. Articles were assessed using the Public Health Ontario Meta-tool for quality appraisal of public health evidence. Forty-nine articles were included. Where ERIC strategies were reported, the focus was on evaluative and iterative strategies, developing partnerships and engaging the target group. The review identified few articles that discussed intervention development and implementation sufficiently for strategies to be replicated. Findings will inform further research into the use and measurement of implementation strategies by practitioners and researchers undertaking work in drowning prevention in HICs and supports a call to action for better documentation of implementation in public health interventions.

Palliative care teaching in the new internal medicine curriculum: Project ECHO-an innovative approach to postgraduate education

BACKGROUND

The Internal Medicine Training (IMT) Programme is an evolution of Core Medical Training introduced in 2019. The IMT curriculum places an increased emphasis on palliative care; however, access to palliative care training is variable. Project ECHO (Extension of Community Healthcare Outcomes) develops communities of practice and is a valuable tool for medical education. We report on an evaluation of Project ECHO to deliver palliative medicine training across a geographically large deanery in the North of England.

METHODS

The Project ECHO training programme involved multipoint video technology, telementoring, expert talks and case-based discussions over six sessions, and was fully mapped to the palliative care component of the IMT curriculum. We collected data particularly around attendance and self-reported confidence and knowledge.

RESULTS

By creating a community of practice, we provided virtual placements and over 9 hours of virtual direct contact with palliative medicine consultants; and in total, 921 individual attendances occurred, with 62% attending all six sessions. The course was associated with an increase in self-reported confidence and high satisfaction.

DISCUSSION

Project ECHO is an effective method of delivering teaching to trainees across a large geographical area. Course evaluation shows outstanding results in trainee satisfaction, confidence, knowledge, patient care, clinical skills and reduction in fear when managing death and dying.

Integrating Technology Adoption Models Into Implementation Science Methodologies: A Mixed-Methods Preimplementation Study

BACKGROUND AND OBJECTIVES

Sustainable implementation of patient-oriented technologies in health care settings is challenging. Preimplementation studies guided by the Consolidated Framework for Implementation Research (CFIR) can provide opportunities to address barriers and leverage facilitators that can maximize the likelihood of successful implementation. When looking to implement patient-oriented technologies, preimplementation studies may also benefit from guidance from a conceptual framework specific to technology adoption such as the Unified Theory of Acceptance and Use of Technology. This study was, therefore, aimed at identifying determinants for the successful implementation of a patient-oriented technology (i.e., automated pain behavior monitoring [APBM] system) within a health care setting (i.e., long-term care [LTC] facility).

RESEARCH DESIGN AND METHODS

Using a mixed-methods study design, 164 LTC nurses completed a set of questionnaires and 68 LTC staff participated in individual interviews involving their perceptions of an APBM system in LTC environments. Quantitative data were analyzed using a series of mediation analyses and narrative responses were examined using directed content analysis.

RESULTS

Performance expectancy and effort expectancy partially and fully mediated the influence of implementation, readiness for organizational change, and technology readiness constructs on behavioral intentions to use the APBM system in LTC environments. Findings from the qualitative portion of this study provide guidance for the development of an intervention that is grounded in the CFIR.

DISCUSSION AND IMPLICATIONS

Based on our results, we offer recommendations for the implementation of patient-oriented technologies in health care settings.

Survey results on training in developmental disabilities in Canadian psychiatry residency programs

Objective

Mental health problems in children, adolescents, and adults with developmental disabilities (DD) are an underserviced clinical area. Although the Royal College of Physicians and Surgeons of Canada requires that experiences with patients with DD must be included during psychiatry residency training, the type and extent of this experience is not specified. The purpose of this study was to examine the current educational opportunities regarding DD in Canadian psychiatry residency programs.

Methods

A survey asking about training in DD was sent to psychiatry residency directors at all 17 medical schools in Canada. The survey consisted of three sections focused on didactic teaching and clinical rotations (required and elective) in DD for residents.

Results

Program directors of all psychiatry residency programs noted that their program included didactic teaching specific to DD, although the time dedicated to this differed greatly, ranging from 2 to 20 hours. Although 13 programs offered electives in DD, only five programs required residents to complete a clinical rotation specific to DD. Two programs did not have required or elective rotations in DD.

Conclusion

These results suggest that training specific to DD is probably inadequate for most residents. This is likely to result in limitations in knowledge and skills required to assess and treat people with DD, decreased comfort working with them, and ultimately reduced quality and availability of psychiatric care for this underserved population. More specific and comprehensive training requirements and opportunities are needed to ensure that residents receive appropriate training in this area.

A Telehealth and Telepsychiatry Economic Cost Analysis Framework: Scoping Review

Introduction: Despite a good evidence base for telepsychiatry (TP), economic cost analyses are infrequent and vary in quality. Methods: A scoping review was conducted based on the research question, "From the perspective of an economic cost analysis for telehealth and telepsychiatry, what are the most meaningful ways to ensure a study/intervention improved clinical care, provided value to participants, had population level impact, and is sustainable?" The search in seven databases focused on keywords in four concept areas: (1) economic cost analysis, (2) evaluation, (3) telehealth and telepsychiatry, and (4) quantifiable health status outcomes. The authors reviewed the full-text articles based on the inclusion (Medical Subject Headings [MeSH] of the keywords) and exclusion criteria. Results: Of a total of 2,585 potential references, a total of 99 articles met the inclusion criteria. The evaluation of telehealth and TP has focused on access, quality, patient outcomes, feasibility, effectiveness, outcomes, and cost. Cost-effectiveness, cost-benefit, and other analytic models are more common with telehealth than TP studies, and these studies show favorable clinical, quality of life, and economic impact. A standard framework for economic cost analysis should include: an economist for planning, implementation, and evaluation; a tool kit or guideline; comprehensive analysis (e.g., cost-effectiveness or cost-benefit) with an incremental cost-effectiveness ratio; measures for health, quality of life, and utility outcomes for populations; methods to convert outcomes into economic benefits (e.g., monetary, quality of adjusted life year); broad perspective (e.g., societal perspective); sensitivity analysis for uncertainty in modeling; and adjustments for differential timing (e.g., discounting and future costs). Conclusions: Technology assessment and economic cost analysis-such as effectiveness and implementation science approaches-contribute to clinical, training, research, and other organizational missions. More research is needed with a framework that enables comparisons across studies and meta-analyses.

Creating virtual communities of practice for ambulance paramedics: a qualitative evaluation of the use of Project ECHO in end-of-life care

Introduction

Ambulance services play a key role in the recognition and care of patients nearing their end of life, yet are expected to recognise and manage these complex presentations often with limited education. Paramedics operate across large geographical areas, meaning education delivery is challenging. Yorkshire Ambulance Service implemented Project Extension for Community Healthcare Outcomes (ECHO), which is the creation of virtual communities of practice to address this problem and increase access to specialist supervision, education and sharing of practice. We undertook a service evaluation of the programme and interviewed paramedics about their experiences with ECHO.

Methods

Semi-structured interviews were conducted with eight ambulance clinicians who took part in the end-of-life care (EoLC) ECHO programme. Thematic analysis and coding was undertaken to identify and develop the emerging themes.

Results

This study identified three key themes: programme structure, factors influencing engagement and professional impact. The provision of a virtual community of practice through Project ECHO was a unique and highly valued experience, which was accessible and allowed for networking, peer support and sharing of practice. The concept of a ripple effect was reported in disseminating learning across the wider team.

Conclusion

The development of virtual communities of practice as a novel educational intervention has the potential to transform clinical supervision and ongoing education for ambulance clinicians who are often isolated by the nature of ambulance services that cover large regions.

A scoping review of applications of the Consolidated Framework for Implementation Research (CFIR) to telehealth service implementation initiatives

BACKGROUND

The Consolidated Framework for Implementation Research (CFIR), introduced in 2009, has the potential to provide a comprehensive understanding of the determinants of implementation-effectiveness of health service innovations. Although the CFIR has been increasingly used in recent years to examine factors influencing telehealth implementation, no comprehensive reviews currently exist on the scope of knowledge gained exclusively from applications of the CFIR to telehealth implementation initiatives. This review sought to address this gap.

METHODS

PRISMA-ScR criteria were used to inform a scoping review of the literature. Five academic databases (PUBMED, PROQUEST, SCIDIRECT, CINAHL, and WoS) were searched for eligible sources of evidence from 01.01.2010 through 12.31.2021. The initial search yielded a total of 18,388 records, of which, 64 peer-reviewed articles met the inclusion criteria for the review. Included articles were reviewed in full to extract data, and data collected were synthesized to address the review questions.

RESULTS

Most included articles were published during or after 2020 (64%), and a majority (77%) were qualitative or mixed-method studies seeking to understand barriers or facilitators to telehealth implementation using the CFIR. There were few comparative- or implementation-effectiveness studies containing outcome measures (5%). The database search however, revealed a growing number of protocols for implementation-effectiveness studies published since 2020. Most articles (91%) reported the CFIR Inner Setting domain (e.g., leadership engagement) to have a predominant influence over telehealth implementation success. By comparison, few articles (14%) reported the CFIR Outer Setting domain (e.g., telehealth policies) to have notable influence. While more (63%) telehealth initiatives were focused on specialty (vs primary) care, a vast majority (78%) were focused on clinical practice over medical education, healthcare administration, or population health.

CONCLUSIONS

Organized provider groups have historically paid considerable attention to advocating for telehealth policy (Outer Setting) reform. However, results suggest that for effective telehealth implementation, provider groups need to refocus their efforts on educating individual providers on the complex inter-relationships between Inner Setting constructs and telehealth implementation-effectiveness. On a separate note, the growth in implementation-effectiveness study protocols since 2020, suggests that additional outcome measures may soon be available, to provide a more nuanced understanding of the determinants of effective telehealth implementation based on the CFIR domains and constructs.

Going Local to Global through Technology-Needs Assessment and Development of a Virtual Arctic Youth Wellbeing Network

Strengths-based approaches to suicide prevention and life promotion in circumpolar regions must engage youth participation and leadership given the impact of suicide on this demographic. We describe the development of a youth-engaged community of practice (CoP) across circumpolar regions, and adaptations to the ECHO model as a foundation for this virtual CoP. We describe youth priorities for learning in the area of mental health and wellbeing, identified through a learning needs assessment. A curriculum was developed to address key areas of interest, including: cultural approaches to mental wellbeing; language-based approaches to mental wellbeing; resilience; government and policy; and suicide prevention. We describe steps taken to adapt the ECHO model, and to introduce Indigenous pedagogical and knowledge sharing approaches into the CoP in order to meet youth learning interests. We conclude that this virtual CoP was a feasible way to create a learning community, and suggest that a priority future direction will be to evaluate the impacts of this virtual CoP on youth engagement, satisfaction and learning.

Integration intrapreneurship: implementing innovation in a public healthcare organization

AIM

As global events impact the way organizations operate and innovate in response to regional, workforce and consumer needs, the concept of intrapreneurism is attracting growing interest from policymakers and executives, particularly within the healthcare sector. The aim of this study was to capture the key learnings from the implementation of a telementoring pilot, to understand how intrapreneurship can embed innovation within an established organization to effect more integrated healthcare.

PURPOSE

A qualitative approach was used with a phenomenological lens to explore the key learnings of the Project ECHO^® (Extension for Community Healthcare Outcomes) pilot implementation to provide an understanding of what the project team's strategies and tactics were during the process of embedding a new business innovation. The implementation and piloting of Project ECHO^®, a telementoring model, in a large-scale public healthcare organization in Queensland, Australia, was investigated as an exemplar of integration intrapreneurship.

FINDINGS

Through an inductive approach, this qualitative study found the implementation of the Project ECHO^® pilot had specific dimensions and strategies/tactics which were exemplars of intrapreneurism. The organizational context and workforce characteristics described in this study presented new knowledge of how intrapreneurs implemented an innovation to address fragmentation of healthcare service delivery, professional isolation and instances of low-value care. This research contributes to a better understanding of the strategic and tactical approaches to implementing intrapreneurial innovations within a public healthcare organization, with learnings that can be adapted by intrapreneurs in other contexts.

Co-creating physical activity interventions: Findings from a multiple case study using mixed methods

Introduction

In health and physical activity promotion, there is growing interest in co-creation approaches that involve researchers and non-academic stakeholders in developing new interventions. Previous research has shown the promising results of cooperative planning as a co-creation approach in building new capacities and implementing physical activity-promoting interventions in nursing care and automotive mechatronics. However, it remains unclear whether (1) cooperative planning for physical activity promotion can be successfully transferred to other settings in the nursing care and automotive mechatronic sectors and (2) what key factors influence its success or failure.

Methods

We conducted a multiple case study in three settings in the nursing care and automotive mechatronics sectors. Following a mixed methods approach, we collected, analyzed, and triangulated data from documents (n = 17), questionnaires (n = 66), and interviews (n = 6). Quantitative data were analyzed descriptively and through using nonparametric analyses of variance; qualitative data were analyzed using qualitative content analysis by extraction.

Results

The transfer of cooperative planning to new settings was realized, though the impact varied by setting. While the interventions were developed and implemented in nursing care settings, interventions were developed but not implemented in the automotive mechatronics setting. In this context, intervention implementation was influenced by 11 key factors: champion, commitment, embedment, empowerment, engagement, health-promoting leadership, ownership, relevance, resources, responsibility, and strategic planning. Furthermore, the transfer of cooperative planning was influenced by different activity characteristics, namely elaboration & reconsideration, group composition, number of meetings, participation, period, prioritization, and researchers' input & support.

Discussion

The present article contributes to a better understanding of a co-creation approach utilized for physical activity promotion and provides new insights into (1) the transferability of cooperative planning and (2) the associated key factors influencing intervention implementation. The success of cooperative planning varied by setting and was influenced by several activity characteristics and key factors, some of which showed complex relationships. This raises the question of whether some settings might benefit more from a co-creation approach than others. Therefore, future co-creation initiatives should carefully consider the specific characteristics of a setting to select and apply the most appropriate approach.

Measuring the Success of a Project ECHO Implementation: Results from an International e-Delphi Study

There is an increasing global need for organisations to utilise high-quality telementoring models to support workforce development and mentorship. Project ECHO is a validated telementoring model that has been adopted by over 700 organisations globally across multiple sectors. To date there is no consolidated list of success indicators by which organisational teams can assess or benchmark their implementation of Project ECHO across sectors. An e-Delphi methodology was adopted to facilitate a comprehensive means of identifying indicators that could be used to assess the implementations of Project ECHO globally. This paper presents a consolidated framework of indicators that support teams to assess their implementation of Project ECHO. These indicators have been derived by an international panel of experts across the healthcare, education, and university sectors. The final framework identified 54 distinct indicators across four domains: (1) spoke participant engagement, (2) ECHO Hub/teleECHO Network design and operation, (3) ECHO Hub team engagement and (4) Local Impact. This paper highlights that Project ECHO implementation indicators can vary between being dynamic, static, and iterative, depending on the phase of implementation. These findings are significant because they are generalisable to any organisation/sector implementing Project ECHO or similar telementoring models.

Supplementary Information

The online version contains supplementary material available at 10.1007/s43477-022-00050-7.

Profile of the Portfolio of NIH-Funded HIV Implementation Research Projects to Inform Ending the HIV Epidemic Strategies

BACKGROUND

The US government created an initiative to end the HIV epidemic in the United States by the year 2030 (EHE). This multiagency initiative was structured around four pillars: Prevent, Diagnose, Treat, and Respond to improve HIV programs, resources, and service delivery infrastructure. In support of its research mission, the National Institutes of Health (NIH) has funded implementation research (IR) projects by addressing the four pillars and encouraging investigators to collaborate with local partners and Health and Human Services (HHS) grantees in 57 priority jurisdictions.

METHODS

This paper analyzed data from the NIH funded CFAR/ARC supplement projects from 2019 to 2021. The Exploration, Preparation, Implementation, Sustainment (EPIS) framework was used to characterize projects by stage of implementation.

RESULTS

The Prevent pillar was most frequently studied, with Pre-Exposure Prophylaxis (PrEP) being the most studied intervention. The most common partners were health departments, community-based organizations (CBOs), and Federally Qualified Health Centers (FQHCs). The Consolidated Framework for Implementation Research (CFIR) framework was the most utilized to investigate implementation determinants, followed by the RE-AIM framework and Proctor model to assess implementation outcomes.

CONCLUSION

Monitoring the projects resulting from NIH investments is fundamental to understanding the response to EHE, and achieving these results requires systematic and continuous effort that can support the generalizable implementation knowledge emerging from individual studies. There are some remaining gaps in the project portfolio, including geographical coverage, range of implementation outcomes being measured, and interventions still requiring further research to ensure equitable scale-up of evidence based interventions and achieve EHE goals.

Efficacy of pediatric dermatology Extension for Community Healthcare Outcomes (ECHO) sessions on augmenting primary care providers' confidence and abilities

Due to the shortage of pediatric dermatologists and the abundance of skin disorders presenting in childhood, general pediatricians shoulder the management of many pediatric dermatologic disorders and would benefit from additional dermatology-specific training. To address this educational gap, general pediatricians were enrolled in a pediatric dermatology-specific Project Extension for Community Healthcare Outcomes (ECHO) program and surveyed to assess the efficacy of the program in increasing providers' ability and confidence in managing pediatric dermatologic conditions. Providers unanimously reported increased confidence and abilities in assessment and management of pediatric dermatologic conditions. Pediatric dermatology Project ECHO demonstrated high efficacy in improving general practitioners' comfort and knowledge on dermatology-specific topics and may be used as an education model for enhancing primary care providers' knowledge and management of common disorders.

Enhancing cancer prevention and survivorship care with a videoconferencing model for continuing education: a mixed-methods study to identify barriers and incentives to participation

OBJECTIVE

To enhance cancer prevention and survivorship care by local health care providers, a school of public health introduced an innovative telelearning continuing education program using the Extension for Community Healthcare Outcomes (ECHO) model. In ECHO's hub and spoke structure, synchronous videoconferencing connects frontline health professionals at various locations ("spokes") with experts at the facilitation center ("hub"). Sessions include experts' didactic presentations and case discussions led by spoke site participants. The objective of this study was to gain a better understanding of the reasons individuals choose or decline to participate in the Cancer ECHO program and to identify incentives and barriers to doing so.

MATERIALS AND METHODS

Study participants were recruited from the hub team, spoke site participants, and providers who attended another ECHO program but not this one. Participants chose to take a survey or be interviewed. The Consolidated Framework for Implementation Research guided qualitative data coding and analysis.

RESULTS

We conducted 22 semistructured interviews and collected 30 surveys. Incentives identified included the program's high-quality design, supportive learning climate, and access to information. Barriers included a lack of external incentives to participate and limited time available. Participants wanted more adaptability in program timing to fit providers' busy schedules.

CONCLUSION

Although the merits of the Cancer ECHO program were widely acknowledged, adaptations to facilitate participation and emphasize the program's benefits may help overcome barriers to attending. As the number of telelearning programs grows, the results of this study point to ways to expand participation and spread health benefits more widely.

Describing implementation outcomes for a virtual community of practice: The ECHO Ontario Mental Health experience

Background

Project ECHO is a virtual education model aimed at building capacity among healthcare providers to support optimal management for a range of health conditions. The expansion of the ECHO model, further amplified by the pandemic, has demonstrated an increased need to evaluate implementation success to ensure that interventions are implemented as planned. This study describes how Proctor et al.’s implementation outcomes (acceptability, adoption, appropriateness, costs, feasibility, fidelity, penetration, and sustainability) were adapted and used to assess the implementation of ECHO Ontario Mental Health (ECHO-ONMH), a mental health-focused capacity-building programme.

Methods

Using Proctor et al.’s implementation outcomes, the authors developed an implementation outcomes framework for ECHO-ONMH more generally. Using this, outcome measures and success thresholds were identified for each outcome for the ECHO-ONMH context, and then applied to evaluate the implementation of ECHO-ONMH using data from the first 4 years of the programme.

Results

An ECHO-ONMH implementation outcomes framework was developed using Proctor’s implementation outcomes. ECHO-ONMH adapted implementation outcomes suggest that ECHO-ONMH was implemented successfully in all domains except for penetration, which only had participation from 13/14 regions. Acceptability, appropriateness and adoption success thresholds were surpassed for all 4 years, showing strong signs of sustainability. The programme was deemed feasible all 4 years and was found to be more cost-effective. ECHO-ONMH also showed high rates of fidelity to the ECHO model, and high rates of penetration.

Conclusions

This is the first study to use Proctor et al.’s implementation outcomes to describe implementation success for a virtual capacity-building model. The proposed ECHO implementation outcomes framework provides a base for similar interventions to evaluate implementation success, which is an important precursor to understanding learning, service or health outcomes related to the model. Additionally, these findings can act as a benchmark for other international ECHOs and educational programmes.

The Urban Youth Trauma Center: A Trauma-Informed Continuum for Addressing Community Violence Among Youth

Contemporary community violence has escalated into a national public health crisis with urban youth, particularly ethnic minorities, suffering disproportionate negative impacts. The Urban Youth Trauma Center (UYTC) promotes a trauma-informed continuum of prevention-to-intervention services that combines community-based and clinic-based manualized protocols designed to reduce and prevent community violence for youth and families. Based on a socio-ecological model, UYTC has the main goals of addressing community violence and related traumatic stress as well as co-occurring conditions of substance abuse and disruptive behavior problems in urban youth by: (1) raising public awareness; (2) disseminating specialized trauma-informed training; and (3) mobilizing service system coalitions. UYTC employs this evidence-based yet flexible structure for disseminating, implementing, and evaluating trauma-informed training as a means of contributing to the reduction and prevention of community violence for low-income urban minority youth and families who bear the biggest burden of this current crisis.

Conceptualizing outcomes for use with the Consolidated Framework for Implementation Research (CFIR): the CFIR Outcomes Addendum

BACKGROUND

The challenges of implementing evidence-based innovations (EBIs) are widely recognized among practitioners and researchers. Context, broadly defined as everything outside the EBI, includes the dynamic and diverse array of forces working for or against implementation efforts. The Consolidated Framework for Implementation Research (CFIR) is one of the most widely used frameworks to guide assessment of contextual determinants of implementation. The original 2009 article invited critique in recognition for the need for the framework to evolve. As implementation science has matured, gaps in the CFIR have been identified and updates are needed. Our team is developing the CFIR 2.0 based on a literature review and follow-up survey with authors. We propose an Outcomes Addendum to the CFIR to address recommendations from these sources to include outcomes in the framework.

MAIN TEXT

We conducted a literature review and surveyed corresponding authors of included articles to identify recommendations for the CFIR. There were recommendations to add both implementation and innovation outcomes from these sources. Based on these recommendations, we make conceptual distinctions between (1) anticipated implementation outcomes and actual implementation outcomes, (2) implementation outcomes and innovation outcomes, and (3) CFIR-based implementation determinants and innovation determinants.

CONCLUSION

An Outcomes Addendum to the CFIR is proposed. Our goal is to offer clear conceptual distinctions between types of outcomes for use with the CFIR, and perhaps other determinant implementation frameworks as well. These distinctions can help bring clarity as researchers consider which outcomes are most appropriate to evaluate in their research. We hope that sharing this in advance will generate feedback and debate about the merits of our proposed addendum.

Use of Project ECHO to promote evidence based care for justice involved adults with opioid use disorder

Background: People with opioid use disorders (OUDs) are at heightened risk for involvement with the criminal justice system. Growing evidence supports the safety and effectiveness of providing empirically supported treatments for OUD, such as medications for OUD (M-OUD), to people with criminal justice involvement including during incarceration or upon reentry into the community. However, several barriers limit availability and accessibility of these treatment options for people with OUDs, including a shortage of healthcare and justice professionals trained in how to implement them. This study evaluated a novel education program, the Indiana Jail OUD Treatment ECHO, designed to disseminate specialty knowledge and improve attitudes about providing M-OUD in justice settings. Methods: Through didactic presentations and case-based learning (10 bimonthly, 90-min sessions), a multidisciplinary panel of specialists interacted with a diverse group of community-based participants from healthcare, criminal justice, law enforcement, and related fields. Participants completed standardized surveys about OUD knowledge and attitudes about delivering M-OUD in correctional settings. Thematic analysis of case presentations was conducted. Results: Among 43 participants with pre- and post-series evaluation data, knowledge about OUD increased and treatment was viewed as more practical after the ECHO series compared to before. Cases presented during the program typically involved complicated medical and psychiatric comorbidities, and recommendations addressed several themes including harm reduction, post-release supports, and integration of M-OUD and non-pharmacological interventions. Conclusions: Evaluation of future iterations of this innovative program should address attendance and provider behavior change as well as patient and community outcomes associated with ECHO participation.

Low-touch, team-based care for co-morbidity management in cancer patients: the ONE TEAM randomized controlled trial

Background

As treatments for cancer have improved, more people are surviving cancer. However, compared to people without a history of cancer, cancer survivors are more likely to die of cardiovascular disease (CVD). Increased risk for CVD-related mortality among cancer survivors is partially due to lack of medication adherence and problems that exist in care coordination between cancer specialists, primary care physicians, and cardiologists.

Methods/Design

The Onco-primary care networking to support TEAM-based care (ONE TEAM) study is an 18-month cluster-randomized controlled trial with clustering at the primary care clinic level. ONE TEAM compares the provision of the iGuide intervention to patients and primary care providers versus an education-only control. For phase 1, at the patient level, the intervention includes video vignettes and a live webinar; provider-level interventions include electronic health records-based communication and case-based webinars. Participants will be enrolled from across North Carolina one of their first visits with a cancer specialist (e.g., surgeon, radiation or medical oncologist). We use a sequential multiple assignment randomized trial (SMART) design.

Outcomes (measured at the patient level) will include Healthcare Effectiveness Data and Information Set (HEDIS) quality measures of management of three CVD comorbidities using laboratory testing (glycated hemoglobin [A1c], lipid profile) and blood pressure measurements; (2) medication adherence assessed pharmacy refill data using Proportion of Days Covered (PDC); and (3) patient-provider communication (Patient-Centered Communication in Cancer Care, PCC-Ca-36).

Primary care clinics in the intervention arm will be considered non-responders if 90% or more of their participating patients do not meet the modified HEDIS quality metrics at the 6-month measurement, assessed once the first enrollee from each practice reaches the 12-month mark. Non-responders will be re-randomized to either continue to receive the iGuide 1 intervention, or to receive the iGuide 2 intervention, which includes tailored videos for participants and specialist consults with primary care providers.

Discussion

As the population of cancer survivors grows, ONE TEAM will contribute to closing the CVD outcomes gap among cancer survivors by optimizing and integrating cancer care and primary care teams. ONE TEAM is designed so that it will be possible for others to emulate and implement at scale.

Trial registration

This study (NCT04258813) was registered in clinicaltrals.gov on February 6, 2020.

Clinician Perspectives on Barriers and Facilitators to Implementing e-Health Technology in Substance Use Disorder (SUD) Treatment Facilities

BACKGROUND

Substance use disorders (SUDs) in the United States cause many preventable deaths each year. Finding effective ways to manage SUDs is vital to improving outcomes for individuals seeking treatment. This has increased interest in using e-health technologies in behavioral healthcare settings. This research is part of a larger study evaluating the efficacy of the NIATx coaching intervention for implementing RISE Iowa, an e-health patient recovery app, in SUD treatment organizations and seeks to examine clinician perspectives of the barriers and facilitators to its implementation.

METHOD

Semi-structured qualitative interviews were conducted with 13 clinicians from 9 different intervention sites involved in the study.

RESULTS

Major barriers to implementing e-health technology include inability to access the technology, lack of time for both patients and clinicians, and a perceived lack of patient motivation to make changes. Facilitators to implementation include collaboration with other staff using e-health technology and integrating technology use into typical workflows.

CONCLUSIONS

Implementation of e-health technology in SUD treatment will require integrating the technology into clinical workflows and improving patient access to the technology.

Evaluating the sector-wide implementation of virtual child and youth mental health services in response to the COVID-19 pandemic: Perspectives from service providers, agency leaders and clients

Background

The COVID-19 pandemic prompted an abrupt shift in the delivery of community-based child and youth mental health services as virtual care was rapidly adopted. The objective of this study was to evaluate the sector-wide transition to virtual care across Ontario, with a focus on implementation facilitators and barriers.

Methods

We used a multi-level mixed-methods design where agency leaders, service providers, and clients shared their experiences planning, implementing, and accessing virtual care. In total, 97 agency leaders, and 192 youth and family members responded to the surveys; 13 agency leaders, and 11 service providers participated in interviews or focus groups.

Results

Most agencies undertook a similar journey to implement virtual care. Stakeholders described common facilitators such as staff engagement, leadership support, and training activities. Barriers included internet connection issues, lack of resources, and privacy concerns. Service providers innovated as they implemented by partnering with agencies to meet clients’ needs, using multiple platforms to engage clients, and altering session duration to reduce fatigue. Clients found virtual care easy to use, felt confident using it, and intend to continue accessing virtual care.

Conclusion

Implementation of virtual care during the pandemic was complex and the evaluation involved obtaining perspectives at multiple levels. This research provides a blueprint for evaluations of the implementation of virtual mental health services, particularly in a child/youth context. Virtual care is a viable way to deliver mental health services, however, equity, accessibility, and appropriateness need to be addressed to ensure services are effective for children, youth, and their families.

Plain language abstract

Academic literature suggests that using technology to deliver child and youth mental health services is a promising way to enhance access to care and improve engagement for many children and youth. Despite this, the provision of virtual child and youth mental health services in Ontario prior to the COVID-19 pandemic was limited. Efforts that did exist were largely focused on providing care to those in rural and remote areas. The COVID-19 pandemic prompted a rapid shift to virtual care, as most in-person mental health services were suspended. This paper presents new insight into how virtual mental health services were quickly established and used across Ontario from the perspectives of senior leaders, service providers, and clients. Results from this evaluation showed that agencies followed similar steps to prepare to use virtual services. Staff engagement, support from leadership, and opportunities for staff training supported the implementation of virtual care while internet connections issues, lack of resources (like computers or phones), and privacy and safety concerns hindered the implementation. Most youth and family members found virtual services easy to use and intend to continue using them. Most agencies intend to continue to offer virtual services post-pandemic but noted that it was not appropriate or accessible for all clients. This study provides a foundation for additional research to examine situations and conditions that are most conducive to virtual care delivery to address child and youth mental health concerns. These results may encourage agencies to rely more confidently on virtual services as another means to meet clients’ needs and preferences.

Facilitators of and barriers to buprenorphine initiation for people with opioid use disorder in the emergency department: protocol for a scoping review

INTRODUCTION

Buprenorphine-naloxone is recommended as a first-line agent for the treatment of opioid use disorder. Although initiation of buprenorphine in the emergency department (ED) is evidence based, barriers to implementation persist. A comprehensive review and critical analysis of both facilitators of and barriers to buprenorphine initiation in ED has yet to be published. Our objectives are (1) to map the implementation of buprenorphine induction pathway literature and synthesise what we know about buprenorphine pathways in EDs and (2) to identify gaps in this literature with respect to barriers and facilitators of implementation.

METHODS AND ANALYSIS

We will conduct a scoping review to comprehensively search the literature, map the evidence and identify gaps in knowledge. The review will adhere to the Preferred Reporting Items for Systematic Reviews and Meta-analyses Protocols Extension for Scoping Reviews and guidance from the Joanna Briggs Institution for conduct of scoping reviews. We will search Medline, APA, PsycINFO, CINAHL, Embase and IBSS from 1995 to present and the search will be restricted to English and French language publications. Citations will be screened in Covidence by two trained reviewers. Discrepancies will be mediated by consensus. Data will be synthesised using a hybrid, inductive-deductive approach, informed by the Consolidated Framework for Implementation Research as well as critical theory to guide further interpretation.

ETHICS AND DISSEMINATION

This review does not require ethics approval. A group of primary knowledge users, including clinicians and people with lived experience, will be involved in the dissemination of findings including publication in peer-reviewed journals. Results will inform future research, current quality improvement efforts in affiliated hospitals, and aide the creation of a more robust ED response to the escalating overdose crisis.

Understanding barriers and facilitators to implementation of psychosocial care within orthopedic trauma centers: a qualitative study with multidisciplinary stakeholders from geographically diverse settings

Background

Psychosocial factors are pivotal in recovery after acute orthopedic traumatic injuries. Addressing psychosocial factors is an important opportunity for preventing persistent pain and disability. We aim to identify barriers and facilitators to the implementation of psychosocial care within outpatient orthopedic trauma settings using the Consolidated Framework for Implementation Research (CFIR) and Proctor’s taxonomy of implementation outcomes, and to provide implementation strategies derived from qualitative data and supplemented by the Expert Recommendations for Implementing Change.

Methods

We conducted live video qualitative focus groups, exit interviews and individual interviews with stakeholders within 3 geographically diverse level 1 trauma settings (N = 79; 20 attendings, 28 residents, 10 nurses, 13 medical assistants, 5 physical therapists/social workers, and 3 fellows) at 3 trauma centers in Texas, Kentucky, and Massachusetts. We used directed and conventional content analyses to derive information on barriers, facilitators, and implementation strategies within 26 CFIR constructs nested within 3 relevant Proctor outcomes of acceptability, appropriateness, and feasibility.

Results

Stakeholders noted that implementing psychosocial care within their practice can be acceptable, appropriate, and feasible. Many perceived integrated psychosocial care as crucial for preventing persistent pain and reducing provider burden, noting they lack the time and specialized training to address patients’ psychosocial needs. Providers suggested strategies for integrating psychosocial care within orthopedic settings, including obtaining buy-in from leadership, providing concise and data-driven education to providers, bypassing stigma, and flexibly adapting to fast-paced clinics.

Conclusions

Results provide a blueprint for successful implementation of psychosocial care in orthopedic trauma settings, with important implications for prevention of persistent pain and disability.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-021-00208-8.

Use of Project ECHO Telementoring Model in Continuing Medical Education for Pediatricians in Vietnam: Preliminary Results

The ECHO (Extension for Community Health Outcomes) model has been introduced and implemented in several hospitals and health programs in Vietnam since 2015. In 2018, Vietnam National Children’s Hospital (VNCH) officially implemented the ECHO model to provide continuing medical education (CME) credits on pediatrics topics for medical staff in its satellite hospitals and health centers in the Northern region of Vietnam. This paper presents preliminary results of the ECHO program at VNCH. Methods included pre- and post-program assessments of pediatricians’ clinical knowledge, self-efficacy, and professional satisfaction. The analysis compared the differences between pre/post scores descriptively. Knowledge of participants increased by 22.5% points on average. More than 90% of Project ECHO-Pediatrics participants experienced increased confidence. Overall, there was an improvement in participants’ self-efficacy in the post-training compared to the pre-training (range 14.7%-22.6% difference from pre-training). All participants improved on their results in the clinical test immediately after the training and maintained it after 3 months. The study demonstrated the ability Project ECHO to improve healthcare worker knowledge and satisfaction.

Barriers and facilitators to knowledge translation activities within academic institutions in low- and middle-income countries

The barriers and facilitators of conducting knowledge translation (KT) activities are well-established but less is known about the institutional forces that drive these barriers, particularly in low resource settings. Understanding organizational readiness has been used to assess and address such barriers but the employment of readiness assessments has largely been done in high-income countries. We conducted a qualitative study to describe the institutional needs and barriers in KT specific to academic institutions in low- and middle-income countries. We conducted a review of the grey and published literature to identify country health priorities and established barriers and facilitators for KT. Key-informant interviews (KII) were conducted to elicit perceptions of institutional readiness to conduct KT, including experiences with KT, and views on motivation and capacity building. Participants included representatives from academic institutions and Ministries of Health in six countries (Bangladesh, Democratic Republic of the Congo, Ethiopia, India, Indonesia, Nigeria). We conducted 18 KIIs, 11 with members of academic institutions and 7 with policymakers. KIIs were analysed using a deductive and inductive coding approach. Our findings support many well-documented barriers including lack of time, skills and institutional support to conduct KT. Three additional institutional drivers emerged around soft skills and the complexity of the policy process, alignment of incentives and institutional missions, and the role of networks. Participants reflected on often-lacking soft-skills needed by researchers to engage policy makers. Continuous engagement was viewed as a challenge given competing demands for time (both researchers and policy makers) and lack of institutional incentives to conduct KT. Strong networks, both within the institution and between institutions, were described as important for conducting KT but difficult to establish and maintain. Attention to the cross-cutting themes representing barriers and facilitators for both individuals and institutions can inform the development of capacity building strategies that meet readiness needs.

The Role of Tele-Education in Advancing Mental Health Quality of Care: A Content Analysis of Project ECHO Recommendations

Introduction: Project Extension for Community Healthcare Outcomes (Project ECHO^®) is a global-guided practice initiative aimed at building primary care capacity and improving health care quality for underserved populations. This tele-education model brings together primary care providers and subject-matter specialists in online communities of practice to share knowledge, discuss complexities in patient care, and collaborate to reduce health disparities. Methods: Using co-generated clinical care recommendations from ECHO Ontario Mental Health, a mental health focused ECHO program, we explored alignment of recommendations across the Institute of Medicine's (IOM) six domains of health care quality to characterize its impact. A total of 417 recommendations, made for 32 patient cases, were analyzed using a modified directed content analysis method. Each recommendation was coded with one or multiple codes, representing each of the six IOM domains. Key examples of recommendations within each domain are described. Results: An average of 13 recommendations were generated per patient case. The effective domain occurred at least once in each complete set of patient care recommendations. The next highest occurring domain was safe (71.9%), followed by patient-centered (68.8%), efficient (40.6%), equitable (18.8%), and timely (12.5%). Recommendation distribution across the entire data set was effective (97.8%), safe (15.6%), patient-centered (12.0%), efficient (3.6%), equitable (1.9%), and timely (1.4%). Discussion: As the first study to characterize ECHO's impact using health care quality domains, the study highlights ECHO's significant focus on effective, safe, and patient-centered care. These findings can inform ways for ECHO to target quality improvement and measure impact in additional health care quality domains, such as efficient, equitable, and timely.

Development and validation of the Readiness to Train Assessment Tool (RTAT)

BACKGROUND

In recent years, health centers in the United States have embraced the opportunity to train the next generation of health professionals. The uniqueness of the health centers as teaching settings emphasizes the need to determine if health professions training programs align with health center priorities and the nature of any adjustments that would be needed to successfully implement a training program. We sought to address this need by developing and validating a new survey that measures organizational readiness constructs important for the implementation of health professions training programs at health centers where the primary role of the organizations and individuals is healthcare delivery.

METHODS

The study incorporated several methodological steps for developing and validating a measure for assessing health center readiness to engage with health professions programs. A conceptual framework was developed based on literature review and later validated by 20 experts in two focus groups. A survey-item pool was generated and mapped to the conceptual framework and further refined and validated by 13 experts in three modified Delphi rounds. The survey items were pilot-tested with 212 health center employees. The final survey structure was derived through exploratory factor analysis. The internal consistency reliability of the scale and subscales was evaluated using Chronbach's alpha.

RESULTS

The exploratory factor analysis revealed a 41-item, 7-subscale solution for the survey structure, with 72% of total variance explained. Cronbach's alphas (.79-.97) indicated high internal consistency reliability. The survey measures: readiness to engage, evidence strength and quality of the health professions training program, relative advantage of the program, financial resources, additional resources, implementation team, and implementation plan.

CONCLUSIONS

The final survey, the Readiness to Train Assessment Tool (RTAT), is theoretically-based, valid and reliable. It provides an opportunity to evaluate health centers' readiness to implement health professions programs. When followed with appropriate change strategies, the readiness evaluations could make the implementation of health professions training programs, and their spread across the United States, more efficient and cost-effective. While developed specifically for health centers, the survey may be useful to other healthcare organizations willing to assess their readiness to implement education and training programs.

Brief intervention medication therapy management: Establishment of an opioid misuse intervention model delivered in a community pharmacy

PURPOSE

Medication expertise and close patient contact position community pharmacists to make significant contributions to combatting the opioid epidemic. This position facilitated the development and initial implementation of the Brief Intervention Medication Therapy Management (BIMTM) model to detect and address patient opioid misuse. BIMTM is an intervention consisting of 9 sessions. One medication management session is delivered by a pharmacist in a community pharmacy setting, and the remaining sessions are delivered telephonically by a patient navigator to follow up with goals established with the pharmacist and address concomitant health concerns that increase risk for misuse.

METHODS

We employed the Consolidated Framework for Implementation Research (CFIR) to summarize and present key findings from 4 distinct studies. CFIR domains addressed were (1) intervention characteristics, (2) outer setting, (3) inner setting, (4) process, and (5) characteristics of individuals. The study results show sequential development of evidence for BIMTM.

RESULTS

A multistate cross-sectional pharmacist survey (n = 739) demonstrated limited pharmacist training and/or resources to address misuse, suggesting the need for external intervention development. Our multistakeholder intervention planning project showed limitations of current evidence-based models of care and of intervention implementation, which resulted in construction of the BIMTM. A multisite cross-sectional screening survey of patients (n = 333) established an electronic misuse screening protocol within 4 community pharmacies and identified opioid misuse in 15% of screened patients; among those patients, 98% had concomitant health conditions that contribute to the risk of opioid misuse. Presentation of study results to pharmacy leaders produced commitment for intervention implementation and a partnership to develop a grant proposal supporting this action. Our small-scale randomized trial evinced success in recruitment and retention and BIMTM patient benefit. The small-scale randomized trial likewise showed high levels of satisfaction with BIMTM.

CONCLUSION

The establishment of BIMTM supports community pharmacist identification and intervention with patients engaged in misuse. Continued use of this research-based strategy may further empower pharmacists to address the opioid epidemic.

Developing and Evaluating a Quality Improvement Intervention to Facilitate Patient Navigation in the Accountable Health Communities Model

Introduction: The Accountable Health Communities (AHC) Model was designed to address the health-related social needs of Centers for Medicare & Medicaid Services beneficiaries. Bridge organizations across the AHC Model have identified lack of technical assistance and peer planning as potential barriers to Model success, particularly around patient navigation. The technical assistance and peer planning literature lacks an organizing, conceptual framework, but implementation science frameworks could serve as useful guides. The Strengthening Peer AHC Navigation (SPAN) research protocol seeks to fill this gap and will apply three implementation science frameworks, Consolidated Framework for Implementation Research, Intervention Mapping, and the Expert Recommendations for Implementing Change compilation, to develop a multi-level quality improvement intervention and evaluate the impact of peer planning on Model outcomes. The aims of the SPAN study are to implement and evaluate a novel multi-level quality improvement intervention to improve AHC implementation and navigation milestones through structured peer planning and to provide successful technical assistance for the AHC Model.

Methods and Analysis: The quality improvement intervention is outlined in four Tasks: (1) Assessment – to conduct an assessment of each bridge organization's current implementation, needs, and readiness in AHC Model navigation activities; (2) Planning – to engage in a peer planning approach to build capacity for AHC Model navigation activities; (3) Implementation with technical assistance – Co-creation of a quality improvement protocol for AHC Model navigation activities; and (4) Evaluation – measure the impact of the peer planning and technical assistance approach. Alongside the development and implementation of the quality improvement intervention, this protocol describes a mixed method, convergent parallel study design which will be used to evaluate whether the quality improvement intervention will lead to better outcomes. Tasks will be replicated with five bridge organizations participating in the AHC Model.

Discussion: This research protocol provides a framework that can be used to conduct structured peer planning with technical assistance for social needs programs. This study will provide data on both implementation and outcomes which eventually may impact healthcare cost and utilization.

Development of a managed clinical network for children's palliative care - a qualitative evaluation

BACKGROUND

Consistent evidence suggests that children's palliative care is not equitable and managed clinical networks (MCNs) have been recommended as a solution. This study explored the perspectives of health professionals involved in the development of a children's palliative care MCN, with an aim to identify barriers and enablers of successful implementation.

METHODS

Thematic analysis of semi-structured interviews and focus groups with 45 healthcare staff with a role in developing the MCN or in the delivery of children's palliative care (September 2019-March 2020).

RESULTS

The study explored health professionals' perceptions of the MCN features that had helped to formalise governance processes, establish training and networking opportunities, standardise practice, and improve collaboration between organisations. These include the funded MCN co-ordinator, committed individuals who lead the MCN, and a governance structure that fosters collaboration. However, the MCN's development was impeded by cross-cutting barriers including limited funding for the MCN and children's palliative care more generally, no shared technology, lack of standards and evidence base for children's palliative care, and shortage of palliative care staff. These barriers impacted on the MCN's ability to improve and evaluate palliative care provision and affected member engagement. Competing organisational priorities and differences between NHS and non-NHS members also impeded progress. Training provision was well received, although barriers to access were identified.

CONCLUSIONS

Key features of children's palliative care can act as barriers to developing a managed clinical network. Managing expectations and raising awareness, providing accessible and relevant training, and sharing early achievements through ongoing evaluation can help to sustain member engagement, which is crucial to a network's success.

Using Rapid Design Thinking to Overcome COVID-19 Challenges in Medical Education

The rapid rise of cases of coronavirus disease 2019 (COVID-19) has led to the implementation of public health measures on an unprecedented scale. These measures have significantly affected the training environment and the mental health of health care providers and learners. Design thinking offers creative and innovative solutions to emergent complex problems, including those related to training and patient care that have arisen as a result of the COVID-19 pandemic. Design thinking can accelerate the development and implementation of solution prototypes through a process of inspiration, ideation, and implementation. Digital technology can be leveraged as part of this process to provide care and education in new or enhanced ways. Online knowledge hubs, videoconference-based interactive sessions, virtual simulations, and technology-enhanced coaching for health care providers are potential solutions to address identified issues. Limitations of this model include inherent bias toward utilitarian instead of egalitarian principles and the subsequent threat to diversity, equity, and inclusion in solutions. Although medical educators have embraced digital transformation during the COVID-19 pandemic, there is a need to ensure that these changes are sustained.

Executive Decision-Making: Piloting Project ECHO® to Integrate Care in Queensland

Introduction:

A Queensland project team secured grant funding to pilot Project ECHO®, a telementoring model, to drive vertical and horizontal integration across paediatric, education and primary care services. This study sought to understand what influenced healthcare executives’ decision-making processes to organisationally commit to and financially invest in the pilot proposal within an organisational context.

Theory and Methods:

A phenomenological approach methodology was adopted to investigate healthcare executives’ conscious decision-making processes. Semi-structured interviews with key stakeholders were conducted alongside project documentation analyses to create a thematic framework.

Results:

The qualitative thematic analysis identified five key themes that influenced the decision-making processes of healthcare executives to invest in Project ECHO® as an integrated care pilot. The themes were: (i) personal experiences, (ii) benefits, (iii) risks, (iv) partnerships, and (v) timing. Executives’ reflections explored how their decision-making processes considered the intrapreneurial project team as an indicator of future sustainability.

Discussion:

Findings highlighted healthcare intrapreneurs’ drive to foster more integrated and people-centred approaches to care. Intrapreneurial aims of financial sustainability, ongoing improvement and scalability of the proposal positively influenced investment confidence.

Conclusion:

Intrapreneurial champions must provide a compelling narrative to convince executive decision-makers that benefits will outweigh risks, that integration is achievable through strengthened partnerships as well as future sustainability beyond the pilot phase.

Addressing opioid use disorder among rural pregnant and postpartum women: a study protocol

BACKGROUND

Opioid use disorder (OUD) among women delivering at a hospital has increased 400% from 1999-2014 in the United States. From the years 2007 to 2016, opioid-related mortality during pregnancy increased over 200%, and drug-overdose deaths made up nearly 10% of all pregnancy-associated mortality in 2016 in the US. Disproportionately higher rates of neonatal opioid withdrawal syndrome (NOWS) have been reported in rural areas of the country, suggesting that perinatal OUD is a pressing issue among these communities. There is an urgent need for comprehensive, evidence-based treatment services for pregnant women experiencing OUD. The purpose of this article is to describe a study protocol aimed at developing and evaluating a perinatal OUD curriculum, enhancing evidence-based perinatal OUD treatment in a rural setting, and evaluating the implementation of such collaborative care for perinatal OUD.

METHODS

This two-year study employed a one group, repeated measures, hybrid type-1 effectiveness-implementation design. This study delivered interventions at 2 levels, both targeting improvement of care for pregnant women with OUD. The first area of focus was at the community healthcare provider-level, which aimed to evaluate the acceptability and feasibility of perinatal OUD education across time and to improve provider education by increasing knowledge specific to: MOUD provision; screening, brief intervention, and referral to treatment (SBIRT) utilization; and NOWS treatment. The second area of intervention focus was at the patient-level, which assessed the preliminary effect of perinatal OUD provider education in promoting illicit opioid abstinence and treatment engagement among pregnant women with OUD. We adopted constructs from the Consolidated Framework for Implementation Research (CFIR) to assess contextual factors that may influence implementation, and the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) model to comprehensively evaluate implementation outcomes.

DISCUSSION

This article presents the protocol of an implementation study that is employing the CFIR and RE-AIM frameworks to implement and evaluate a perinatal OUD education and service coordination program in two rural counties. This protocol could serve as a model for clinicians and researchers seeking to implement improvements in perinatal care for women with OUD in other rural communities. Trial registration NCT04448015 clinicaltrials.gov.

Barriers and facilitators in implementing a pilot, pragmatic, telemedicine-delivered healthy lifestyle program for obesity management in a rural, academic obesity clinic

PURPOSE

Few evidence-based strategies are specifically tailored for disparity populations such as rural adults. Two-way video-conferencing using telemedicine can potentially surmount geographic barriers that impede participation in high-intensity treatment programs offering frequent visits to clinic facilities. We aimed to understand barriers and facilitators of implementing a telemedicine-delivered tertiary-care, rural academic weight-loss program for the management of obesity.

METHODS

A single-arm study of a 16-week, weight-loss pilot evaluated barriers and facilitators to program participation and exploratory measures of program adoption and staff confidence in implementation and intervention delivery. A program was delivered using video-conferencing within an existing clinical infrastructure. Elements of Consolidated Framework for Implementation Research (CFIR) provided a basis for assessing intervention characteristics, inner and outer settings, and individual characteristics using surveys and semi-structured interviews. We evaluated elements of the RE-AIM model (reach, adoption) to assess staff barriers to success for future scalability.

FINDINGS

There were 27 patients and 8 staff completing measures. Using CFIR, the intervention was valuable from a patient participant standpoint; staff equally had positive feelings about using telemedicine as useful for patient care. The RE-AIM framework demonstrated limited reach but willingness to adopt was above average. A significant barrier limiting sustainability was physical space for intervention delivery and privacy and dedicated resources for staff. Scheduling stressors were also a challenge in its implementation.

CONCLUSIONS

The need to engage staff, enhance organizational culture, and increase reach are major factors for rural health obesity clinics to enhance sustainability of using telemedicine for the management of obesity.

TRIAL REGISTRATION

Clinicaltrials.gov NCT03309787. Registered on 16 October 2017.

A mixed methods evaluation of the feasibility, acceptability, and impact of a pilot project ECHO for community health workers (CHWs)

BACKGROUND

Despite the positive effects of community health workers (CHWs) on addressing social determinants of health, improving patient health outcomes, and decreasing overall healthcare costs, there is a lack of standardization in training and certifying this workforce, resulting in different approaches to integrating this role into medical home models. The purpose of the current study is to evaluate the application of Project ECHO (Extension for Community Healthcare Outcomes) in enhancing CHWs' capacity to address health and social issues of vulnerable populations.

METHODS

An explanatory sequential mixed methods design was applied in which all participants (N = 49) completed pre (January 2019) and post (July 2019) quantitative online surveys measuring changes in self-efficacy, behavior change intent, and knowledge. Virtual focus groups were conducted with a subset of participants (n = 20) in July 2019 to assess the feasibility, acceptability, and impact of Project ECHO.

RESULTS

There was a statistically significant difference of + 0.453 in the composite self-efficacy mean score pre- to post-series. For every 1 additional Project ECHO CHW session attended, there was a .05 improvement in participants' self-efficacy to perform CHW-related job duties and address social determinants of health (SDOH). Four major themes emerged from the qualitative focus group data: value in learning from other participants' caseloads, CHW-care team integration, availability of training and resources, and shared decision-making with patients.

CONCLUSIONS

This evaluation suggests that ECHO is a viable means of increasing access to training resources for CHWs. Future studies on the ECHO model as a means of educating and broadening implementation of CHWs are warranted. Programs such as Project ECHO can support CHWs by providing continuing education opportunities, as well as standardizing training content across large geographic areas.

Early Psychosis Intervention-Spreading Evidence-based Treatment (EPI-SET): protocol for an effectiveness-implementation study of a structured model of care for psychosis in youth and emerging adults

INTRODUCTION

While early psychosis intervention (EPI) has proliferated in recent years amid evidence of its effectiveness, programmes often struggle to deliver consistent, recovery-based care. NAVIGATE is a manualised model of EPI with demonstrated effectiveness consisting of four components: individualised medication management, individual resiliency training, supported employment and education and family education. We aim to implement NAVIGATE in geographically diverse EPI programmes in Ontario, Canada, evaluating implementation and its effect on fidelity to the EPI model, as well as individual-level outcomes (patient/family member-reported and interviewer-rated), system-level outcomes (captured in provincial administrative databases) and engagement of participants with lived experience.

METHODS AND ANALYSIS

This is a multisite, non-randomised pragmatic hybrid effectiveness-implementation type III mixed methods study coordinated at the Centre for Addiction and Mental Health (CAMH) in Toronto. Implementation is supported by the Provincial System Support Program, a CAMH-based programme with provincial offices across Ontario, and Extension of Community Healthcare Outcomes Ontario Mental Health at CAMH and the University of Toronto. The primary outcome is fidelity to the EPI model as measured using the First Episode Psychosis Services-Fidelity Scale. Four hundred participants in the EPI programmes will be recruited and followed using both individual-level assessments and health administrative data for 2 years following NAVIGATE initiation. People with lived experience will be engaged in all aspects of the project, including through youth and family advisory committees.

ETHICS AND DISSEMINATION

Research ethics board approval has been obtained from CAMH and institutions overseeing the local EPI programmes. Study findings will be reported in scientific journal articles and shared with key stakeholders including youth, family members, programme staff and policymakers.

TRIAL REGISTRATION NUMBER

NCT03919760; Pre-results.

Responding to Health Care Professionals' Mental Health Needs During COVID-19 Through the Rapid Implementation of Project ECHO

INTRODUCTION

The COVID-19 pandemic can cause significant mental health distress among health care professionals (HCPs). We describe the psychological needs of HCPs during COVID-19 and the implementation of Project Extension for Community Healthcare Outcomes (ECHO) Coping with COVID (ECHO-CWC) to help HCPs manage COVID-19 distress.

METHODS

We used an established rapid implementation approach to accelerate the development and delivery of ECHO-CWC to address the emerging needs of HCPs. Participants' needs were identified using a 10-question survey of participants' perceived risk of COVID-19 and a five-item self-efficacy measure. Implementation outcomes consisted of participant engagement and session satisfaction scores using a five-point Likert scale.

RESULTS

A total of 426 participants registered for ECHO-CWC. Needs assessment data (n = 129) showed that most participants reported feeling increased stress at work (84.5%), fear of infecting others (75.2%), and fear of falling ill (70.5%) from COVID-19, yet most participants accepted the risk associated with work during this time (59.7%). Participants were highly satisfied with the initial five sessions (mean = 4.26).

DISCUSSION

HCPs reported the greatest concern with fears of infection and infecting others during the acute phase of the pandemic. Using an iterative curriculum design approach and existing implementation frameworks, the ECHO tele-education model can be rapidly mobilized to address HCPs' mental health needs during the COVID-19 pandemic.

Barriers and perceived usefulness of an ECHO intervention for office-based buprenorphine treatment for opioid use disorder in North Carolina: A qualitative study

BACKGROUND

Medication treatment for opioid use disorder (M-OUD) is underutilized, despite research demonstrating its effectiveness in treating opioid use disorder (OUD). The UNC Extension for Community Healthcare Outcomes for Rural Primary Care Medication Assisted Treatment (UNC ECHO for MAT) project was designed to evaluate interventions for reducing barriers to delivery of M-OUD by rural primary care providers in North Carolina. A key element was tele-conferenced sessions based on the University of New Mexico Project ECHO model, comprised of case discussions and didactic presentations using a "hub and spoke" model, with expert team members at the hub site and community-based providers participating from their offices (i.e., spoke sites). Although federal funders have promoted use of the model, barriers for providers to participate in ECHO sessions are not well documented. Methods: UNC ECHO for MAT included ECHO sessions, provider-to-provider consultations, and practice coaching. We conducted 20 semi-structured interviews to assess perceived usefulness of the UNC ECHO for MAT intervention, barriers to participation in the intervention, and persistent barriers to prescribing M-OUD. Results: Participants were generally satisfied with ECHO sessions and provider-to-provider consultations; however, perceived value of practice support was less clear. Primary barriers to participating in ECHO sessions were timing and length of sessions. Participants recommended recording ECHO sessions for viewing later, and some thought incentives for either the practice or provider could facilitate participation. Providers who had participated in ECHO sessions valued the expertise on the expert team; the team's ability to develop a supportive, collegial environment; and the value of a community of providers interested in learning from each other, particularly through case discussions. Conclusions: Despite the perceived value of ECHO, barriers may prevent consistent participation. Also, barriers to M-OUD delivery remain, including some that ECHO alone cannot address, such as Medicaid and private-insurer policies and availability of psychosocial resources.

Engagement With Project ECHO to Increase Medication-Assisted Treatment in Rural Primary Care

OBJECTIVE

The purpose of this study was to understand the barriers and facilitators that affect engagement with Project ECHO (Extension for Community Healthcare Outcomes) to implement medication-assisted treatment (MAT) in primary care settings.

METHODS

A 12-session weekly curriculum was delivered to participating primary care providers and clinic staff (N=24 participants from 13 clinics). Participants completed attendance logs and a qualitative interview in order to identify factors that influence engagement in the ECHO sessions and the potential integration of MAT.

RESULTS

Primary care providers and staff valued the ECHO sessions, but overall attendance was low and variable. Participants generally valued the didactic and interactive nature of the sessions but identified system-level constraints that limited engagement. Major barriers to participation included competing demands in patient care and the low degree of endorsement by clinic leadership.

CONCLUSIONS

This brief report identifies key systematic challenges that may directly limit primary care providers' engagement in telementoring models such as Project ECHO.

Strengthening the Health Workforce through the ECHO Stages of Participation: Participants' Perspectives on Key Facilitators and Barriers

INTRODUCTION

Project Extension for Community Health Outcomes (ECHO) was originally developed by the University of New Mexico's Health Science Center (UNMHSC) to build the capacities of primary-care providers and to increase specialty-care access to rural and underserved populations. ECHO Colorado, a replication site at the University of Colorado Anschutz Medical Campus (CUAMC), was developed with the same purpose and to help build the health workforce of Colorado. The CUAMC and its community-based partners recognized that by reducing unnecessary referrals to the medical campus and building primary-care capacity in communities, both would increase their scope and expand overall capacity. This study examines the key factors that influence participant engagement, how participants value the ECHO experience, and the utility of the ECHO Colorado experience according to participants.

METHODS

This study used a mixed-methods approach including 42 interviews and 34 completed surveys. Transcribed interview recordings were coded in NVivo 11, and codes were queried in NVivo and Excel to identify key themes. Survey responses were analyzed in SPSS. Data were examined between and across four attendance groups and triangulated to assess the reliability of the data and validity of overall findings.

FINDINGS

Key factors increasing registrant engagement included relevant and practical curriculum content; strong and supportive relationships among learners, ECHO faculty, and workplace colleagues; and innovative learning approaches that included opportunities for active, virtual participation through technology, participant management activities, and ECHO's unique curriculum design.

CONCLUSION

Findings from this study validated many of the important elements of ECHO Colorado that make it unique from other iterations of the model being implemented nationally and internationally and identified participant-driven strategies for further amplifying its impact.