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Gilmartin H, Jones C, Nunnery M, Leonard C, Connelly B, Wills A, Kelley L, Rabin B, Burke RE. An implementation strategy postmortem method developed in the VA rural Transitions Nurse Program to inform spread and scale-up. PLoS One 2024; 19:e0298552. [PMID: 38457367 PMCID: PMC10923440 DOI: 10.1371/journal.pone.0298552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 01/25/2024] [Indexed: 03/10/2024] Open
Abstract
BACKGROUND High-quality implementation evaluations report on intervention fidelity and adaptations made, but a practical process for evaluating implementation strategies is needed. A retrospective method for evaluating implementation strategies is also required as prospective methods can be resource intensive. This study aimed to establish an implementation strategy postmortem method to identify the implementation strategies used, when, and their perceived importance. We used the rural Transitions Nurse Program (TNP) as a case study, a national care coordination intervention implemented at 11 hospitals over three years. METHODS The postmortem used a retrospective, mixed method, phased approach. Implementation team and front-line staff characterized the implementation strategies used, their timing, frequency, ease of use, and their importance to implementation success. The Expert Recommendations for Implementing Change (ERIC) compilation, the Quality Enhancement Research Initiative phases, and Proctor and colleagues' guidance were used to operationalize the strategies. Survey data were analyzed descriptively, and qualitative data were analyzed using matrix content analysis. RESULTS The postmortem method identified 45 of 73 ERIC strategies introduced, including 41 during pre-implementation, 37 during implementation, and 27 during sustainment. External facilitation, centralized technical assistance, and clinical supervision were ranked as the most important and frequently used strategies. Implementation strategies were more intensively applied in the beginning of the study and tapered over time. CONCLUSIONS The postmortem method identified that more strategies were used in TNP than planned and identified the most important strategies from the perspective of the implementation team and front-line staff. The findings can inform other implementation studies as well as dissemination of the TNP intervention.
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Affiliation(s)
- Heather Gilmartin
- Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, VA Eastern Colorado Healthcare System, Aurora, Colorado, United States of America
- Department of Health Systems, Management and Policy, Colorado School of Public Health, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, United States of America
| | - Christine Jones
- Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, VA Eastern Colorado Healthcare System, Aurora, Colorado, United States of America
- Division of Geriatric Medicine and Division of Hospital Medicine, Department of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, United States of America
| | - Mary Nunnery
- Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, VA Eastern Colorado Healthcare System, Aurora, Colorado, United States of America
| | - Chelsea Leonard
- Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, VA Eastern Colorado Healthcare System, Aurora, Colorado, United States of America
| | - Brigid Connelly
- Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, VA Eastern Colorado Healthcare System, Aurora, Colorado, United States of America
| | - Ashlea Wills
- Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, VA Eastern Colorado Healthcare System, Aurora, Colorado, United States of America
| | - Lynette Kelley
- Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, VA Eastern Colorado Healthcare System, Aurora, Colorado, United States of America
| | - Borsika Rabin
- Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, VA Eastern Colorado Healthcare System, Aurora, Colorado, United States of America
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, San Diego, California, United States of America
- Altman Clinical and Translational Research Institute, Dissemination and Implementation Science Center, University of California San Diego, San Diego, California, United States of America
| | - Robert E. Burke
- Center for Health Equity Research and Promotion, Corporal Crescenz VA Medical Center, Philadelphia, Pennsylvania, United States of America
- Hospital Medicine Section – Division of General Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States of America
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
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Radcliff T, Ayele R, McCreight M, Lui W, Battaglia C. Implementation of VA care coordination program to improve transitional care for veterans post-non-VA hospital discharge: an incremental cost analysis. Implement Sci Commun 2023; 4:135. [PMID: 37957780 PMCID: PMC10642017 DOI: 10.1186/s43058-023-00513-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 10/20/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND The Veterans Affairs (VA) Healthcare System Community Hospital Transitions Program (CHTP) was implemented as a nurse-led intervention to reduce barriers that patients experience when transitioning from community hospitals to VA primary care settings. A previous analysis indicated that veterans who enrolled in CHTP received timely follow-up care and communications that improved care coordination, but did not examine cost implications for the VA. METHODS A budget impact analysis used the VA (payer) perspective. CHTP implementation team members and study records identified key resources required to initially implement and run the CHTP. Statistical analysis of program participants and matched controls at two study sites was used to estimate incremental VA primary care costs per veteran. Using combined program implementation, operations, and healthcare cost estimates to guide key model assumptions, overall CHTP costs were estimated for a 5-year time horizon, including a discount rate of 3%, annual inflation of 2.5%, and a sensitivity analysis that considered two options for staffing the program at VA Medical Center (VAMC) sites. RESULTS Implementation at two VAMCs required 3 months, including central program support and site-level onboarding, with costs of $34,094 (range: $25,355-$51,602), which included direct and indirect resource costs of personnel time, materials, space, and equipment. Subsequent annual costs to run the program at each site depended heavily on the staffing mix and caseload of veterans, with a baseline estimate of $193,802 to $264,868. Patients enrolled in CHTP had post-hospitalization VA primary care costs that were higher than matched controls. Over 5 years, CHTP sites staffed to serve 25-30 veterans per full-time equivalent transition team member per month had an estimated budget impact of $625 per veteran served if the transitional team included a medical social worker to support veterans with more social behavioral needs and less complex medical cases or $815 per veteran if nurses served all cases. CONCLUSIONS Evidence-based care coordination programs that support patients' return to VA primary care after a community hospital stay are feasible to implement and run. Further, flexibility in staffing this type of program is increasingly relevant as the VA and other healthcare systems consider methods to reduce provider burnout, optimize staffing, reduce costs, and address other staffing challenges while improving patient care.
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Affiliation(s)
- Tiffany Radcliff
- Denver-Seattle Center of Innovation, Department of Veterans Affairs, VA Eastern Colorado Healthcare System, MS 151, Aurora, CO, USA.
- School of Public Health, Texas A&M University, 157B SPH Administration Building, MS 1266, College Station, TX, 77843-1266, USA.
| | - Roman Ayele
- Denver-Seattle Center of Innovation, Department of Veterans Affairs, VA Eastern Colorado Healthcare System, MS 151, Aurora, CO, USA
- Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Marina McCreight
- Denver-Seattle Center of Innovation, Department of Veterans Affairs, VA Eastern Colorado Healthcare System, MS 151, Aurora, CO, USA
- Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Wenhui Lui
- Denver-Seattle Center of Innovation, Department of Veterans Affairs, VA Eastern Colorado Healthcare System, MS 151, Aurora, CO, USA
| | - Catherine Battaglia
- Denver-Seattle Center of Innovation, Department of Veterans Affairs, VA Eastern Colorado Healthcare System, MS 151, Aurora, CO, USA
- Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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Patzel M, Barnes C, Ramalingam N, Gunn R, Kenzie ES, Ono SS, Davis MM. Jumping Through Hoops: Community Care Clinician and Staff Experiences Providing Primary Care to Rural Veterans. J Gen Intern Med 2023:10.1007/s11606-023-08126-2. [PMID: 37340259 DOI: 10.1007/s11606-023-08126-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 02/24/2023] [Indexed: 06/22/2023]
Abstract
BACKGROUND The 2019 VA Maintaining Systems and Strengthening Integrated Outside Networks Act, or MISSION Act, aimed to improve rural veteran access to care by expanding coverage for services in the community. Increased access to clinicians outside the US Department of Veterans Affairs (VA) could benefit rural veterans, who often face obstacles obtaining VA care. This solution, however, relies on clinics willing to navigate VA administrative processes. OBJECTIVE To investigate the experiences rural, non-VA clinicians and staff have while providing care to rural veterans and inform challenges and opportunities for high-quality, equitable care access and delivery. DESIGN Phenomenological qualitative study. PARTICIPANTS Non-VA-affiliated primary care clinicians and staff in the Pacific Northwest. APPROACH Semi-structured interviews with a purposive sample of eligible clinicians and staff between May and August 2020; data analyzed using thematic analysis. KEY RESULTS We interviewed 13 clinicians and staff and identified four themes and multiple challenges related to providing care for rural veterans: (1) Confusion, variability and delays for VA administrative processes, (2) clarifying responsibility for dual-user veteran care, (3) accessing and sharing medical records outside the VA, and (4) negotiating communication pathways between systems and clinicians. Informants reported using workarounds to combat challenges, including using trial and error to gain expertise in VA system navigation, relying on veterans to act as intermediaries to coordinate their care, and depending on individual VA employees to support provider-to-provider communication and share system knowledge. Informants expressed concerns that dual-user veterans were more likely to have duplication or gaps in services. CONCLUSIONS Findings highlight the need to reduce the bureaucratic burden of interacting with the VA. Further work is needed to tailor structures to address challenges rural community providers experience and to identify strategies to reduce care fragmentation across VA and non-VA providers and encourage long-term commitment to care for veterans.
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Affiliation(s)
- Mary Patzel
- Oregon Rural Practice-Based Research Network, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Mail Code: L222, Portland, OR, 97239, USA.
| | - Chrystal Barnes
- Oregon Rural Practice-Based Research Network, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Mail Code: L222, Portland, OR, 97239, USA
| | - NithyaPriya Ramalingam
- Oregon Rural Practice-Based Research Network, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Mail Code: L222, Portland, OR, 97239, USA
| | | | - Erin S Kenzie
- Oregon Rural Practice-Based Research Network, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Mail Code: L222, Portland, OR, 97239, USA
| | - Sarah S Ono
- Department of Veterans Affairs Office of Rural Health, Veteran Rural Health Resources Center, Portland, OR, USA
- Department of Psychiatry, Oregon Health & Science University, Portland, OR, USA
| | - Melinda M Davis
- Oregon Rural Practice-Based Research Network, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Mail Code: L222, Portland, OR, 97239, USA
- Department of Family Medicine and OHSU-PSU School of Public Health, Oregon Health & Science University, Portland, OR, USA
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Williams PH, Gilmartin HM, Leonard C, McCarthy MS, Kelley L, Grunwald GK, Jones CD, Whittington MD. The Influence of the Rural Transitions Nurse Program for Veterans on Healthcare Utilization Costs. J Gen Intern Med 2022; 37:3529-3534. [PMID: 36042072 PMCID: PMC9585107 DOI: 10.1007/s11606-022-07401-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 01/05/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND The Veterans Affairs (VA) Healthcare System Rural Transitions Nurse Program (TNP) addresses barriers veterans face when transitioning from urban tertiary VA hospitals to home. Previous clinical evaluations of TNP have shown that enrolled veterans were more likely to follow up with their primary care provider within 14 days of discharge and experience a significant reduction in mortality within 30 days compared to propensity-score matched controls. OBJECTIVE Examine changes from pre- to post-hospitalization in total, inpatient, and outpatient 30-day healthcare utilization costs for TNP enrollees compared to controls. DESIGN Quantitative analyses modeling the changes in cost via multivariable linear mixed-effects models to determine the association between TNP enrollment and changes in these costs. PARTICIPANTS Veterans meeting TNP eligibility criteria who were discharged home following an inpatient hospitalization at one of the 11 implementation sites from April 2017 to September 2019. INTERVENTION The four-step TNP transitional care intervention. MAIN MEASURES Changes in 30-day total, inpatient, and outpatient healthcare utilization costs were calculated for TNP enrollees and controls. KEY RESULTS Among 3001 TNP enrollees and 6002 controls, no statistically significant difference in the change in total costs (p = 0.65, 95% CI: (- $675, $350)) was identified. However, on average, the increase in inpatient costs from pre- to post-hospitalization was approximately $549 less for TNP enrollees (p = 0.02, 95% CI: (- $856, - $246)). The average increase in outpatient costs from pre- to post-hospitalization was approximately $421 more for TNP enrollees compared to controls (p = 0.003, 95% CI: ($109, $671)). CONCLUSIONS Although we found no difference in change in total costs between veterans enrolled in TNP and controls, TNP was associated with a smaller increase in direct inpatient medical costs and a larger increase in direct outpatient medical costs. This suggests a shifting of costs from the inpatient to outpatient setting.
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Affiliation(s)
- Piper H. Williams
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora, CO USA
| | - Heather M. Gilmartin
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora, CO USA
- Health Systems, Management and Policy, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO USA
| | - Chelsea Leonard
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora, CO USA
| | - Michaela S. McCarthy
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora, CO USA
| | - Lynette Kelley
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora, CO USA
| | - Gary K. Grunwald
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora, CO USA
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO USA
| | - Christine D. Jones
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora, CO USA
- Division of Hospital Medicine, Department of Medicine, University of Colorado, Aurora, CO USA
| | - Melanie D. Whittington
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora, CO USA
- University of Kansas Medical Center, Kansas City, KS USA
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Sjoberg H, Kenney RR, Morgan B, Connelly B, Jones CD, Ali HN, Battaglia C, Gilmartin HM. Adaptations to relational facilitation for two national care coordination programs during COVID-19. FRONTIERS IN HEALTH SERVICES 2022; 2:952272. [PMID: 36925807 PMCID: PMC10012763 DOI: 10.3389/frhs.2022.952272] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 06/29/2022] [Indexed: 11/13/2022]
Abstract
Background Adaptations to implementation strategies are often necessary to support adoption and scale-up of evidence-based practices. Tracking adaptations to implementation strategies is critical for understanding any impacts on outcomes. However, these adaptations are infrequently collected. In this article we present a case study of how we used a new method during COVID-19 to systematically track and report adaptations to relational facilitation, a novel implementation strategy grounded in relational coordination theory. Relational facilitation aims to assess and improve communication and relationships in teams and is being implemented to support adoption of two Quadruple Aim Quality Enhancement Research Initiative (QA QUERI) initiatives: Care Coordination and Integrated Case Management (CC&ICM) and the Transitions Nurse Program for Home Health Care (TNP-HHC) in the Veterans Health Administration (VA). Methods During 2021-2022, relational facilitation training, activities and support were designed as in-person and/or virtual sessions. These included a site group coaching session to create a social network map of care coordination roles and assessment of baseline relationships and communication between roles. Following this we administered the Relational Coordination Survey to assess the relational coordination strength within and between roles. COVID-19 caused challenges implementing relational facilitation, warranting adaptations. We tracked relational facilitation adaptations using a logic model, REDCap tracking tool based on the Framework for Reporting Adaptations and Modifications-Enhanced (FRAME) with expanded Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) dimensions, and member checking. Adaptations were analyzed descriptively and for themes using matrix content analysis. Results COVID-19's impact within the VA caused barriers for implementing relational facilitation, warranting eight unique adaptations to the implementation strategy. Most adaptations pertained to changing the format of relational facilitation activities (n = 6; 75%), were based on external factors (n = 8; 100%), were planned (n = 8; 100%) and initiated by the QA QUERI implementation team (n = 8; 100%). Most adaptations impacted adoption (n = 6; 75%) and some impacted implementation (n = 2; 25%) of the CC&ICM and TNP-HHC interventions. Discussion Systematically tracking and discussing adaptations to relational facilitation during the COVID-19 pandemic enhanced engagement and adoption of two VA care coordination interventions. The impact of these rapid, early course adaptations will be followed in subsequent years of CC&ICM and TNP-HHC implementation.
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Affiliation(s)
- Heidi Sjoberg
- Rocky Mountain Regional VA Medical Center, VA Eastern Colorado Healthcare System, Aurora, CO, United States
| | - Rachael R. Kenney
- Rocky Mountain Regional VA Medical Center, VA Eastern Colorado Healthcare System, Aurora, CO, United States
| | - Brianne Morgan
- Rocky Mountain Regional VA Medical Center, VA Eastern Colorado Healthcare System, Aurora, CO, United States
| | - Brigid Connelly
- Rocky Mountain Regional VA Medical Center, VA Eastern Colorado Healthcare System, Aurora, CO, United States
| | - Christine D. Jones
- Rocky Mountain Regional VA Medical Center, VA Eastern Colorado Healthcare System, Aurora, CO, United States
- Division of Hospital Medicine, Department of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, CO, United States
| | - Hebatallah Naim Ali
- Heller School for Social Policy and Management, Brandeis University, Waltham, MA, United States
| | - Catherine Battaglia
- Rocky Mountain Regional VA Medical Center, VA Eastern Colorado Healthcare System, Aurora, CO, United States
- Colorado School of Public Health, Department of Health Systems, Management and Policy, University of Colorado, Anschutz Medical Campus, Aurora, CO, United States
| | - Heather M. Gilmartin
- Rocky Mountain Regional VA Medical Center, VA Eastern Colorado Healthcare System, Aurora, CO, United States
- Colorado School of Public Health, Department of Health Systems, Management and Policy, University of Colorado, Anschutz Medical Campus, Aurora, CO, United States
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Albright K, Jones CD. Methodological progress note: The case for mixed methods in quality improvement and research projects. J Hosp Med 2022; 17:468-471. [PMID: 35535915 DOI: 10.1002/jhm.12806] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 02/02/2022] [Indexed: 11/08/2022]
Affiliation(s)
- Karen Albright
- Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, Veterans Health Affairs Eastern Colorado Healthcare System, Aurora, Colorado, USA
- Division of General Internal Medicine, Department of Medicine, Anschutz Medical Campus, University of Colorado, Aurora, Colorado, USA
| | - Christine D Jones
- Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, Veterans Health Affairs Eastern Colorado Healthcare System, Aurora, Colorado, USA
- Division of Hospital Medicine, Department of Medicine, Anschutz Medical Campus, University of Colorado, Aurora, Colorado, USA
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Connelly B, Battaglia C, Gilmartin HM. A dissemination strategy to promote relational coordination in the veterans health administration: a case study. BMC Health Serv Res 2021; 21:1018. [PMID: 34579712 PMCID: PMC8474939 DOI: 10.1186/s12913-021-07009-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 09/09/2021] [Indexed: 11/16/2022] Open
Abstract
Background Large healthcare institutions like the Veterans Health Administration (VA) continually seek best practices to improve clinical care. Relational coordination is an evidence-based organizational theory of communicating and relating to coordinate work and drive performance outcomes. Implementing relational coordination-guided practices can be difficult due to challenges with spreading information across large systems. Using social marketing theory and evidence-based dissemination strategies, we developed an evidence-based dissemination plan to educate and motivate researchers and operational staff to study and implement relational coordination in the VA. Methods In this case study, we used the four Ps (product, price, place, promotion) of social marketing theory to develop a 2-phase dissemination strategy. In phase one, we created and distributed relational coordination information and invited VA staff to join the Relational Coordination Research Collaborative. In phase two, dissemination efforts targeted researchers ready to implement relational coordination within existing programs of research. Process and outcome measures included dissemination, engagement and adoption data and a post-project survey. Quantitative results were calculated using descriptive statistics. Survey text responses were analyzed using deductive content analysis and a structured categorization matrix. Results Phase one included social media dissemination, virtual and in-person presentations, as well as phone and email communication between project staff and the target audience. In total, 47 VA staff became members of the Relational Coordination Research Collaborative and 27 routinely participated in online research seminars. In phase 2, 13 researchers expressed interest in studying relational coordination and 5 projects were selected to participate. Multiple relational coordination-related trainings and publications originated from this program. Conclusions Dissemination approaches that involved personalized, one-on-one efforts (e.g., phone or email) seemed to be more effective at disseminating relational coordination compared to social media or online presentations. Participants in phase 2 agreed that relational coordination should be adopted in the VA but indicated that cost would be a barrier. Results support the importance of evidence-based dissemination planning that address the unique costs and benefits of programs.
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Affiliation(s)
- Brigid Connelly
- Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, VA Eastern Colorado Healthcare System, 1700 N. Wheeling St, Aurora, CO, 80045, USA.
| | - Catherine Battaglia
- Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, VA Eastern Colorado Healthcare System, 1700 N. Wheeling St, Aurora, CO, 80045, USA.,Health Systems, Management and Policy, University of Colorado, School of Public Health, Aurora, CO, 80045, USA
| | - Heather M Gilmartin
- Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, VA Eastern Colorado Healthcare System, 1700 N. Wheeling St, Aurora, CO, 80045, USA.,Health Systems, Management and Policy, University of Colorado, School of Public Health, Aurora, CO, 80045, USA
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McCarthy MS, Ujano-De Motta LL, Nunnery MA, Gilmartin H, Kelley L, Wills A, Leonard C, Jones CD, Rabin BA. Understanding adaptations in the Veteran Health Administration's Transitions Nurse Program: refining methodology and pragmatic implications for scale-up. Implement Sci 2021; 16:71. [PMID: 34256763 PMCID: PMC8276503 DOI: 10.1186/s13012-021-01126-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 05/12/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND When complex health services interventions are implemented in real-world settings, adaptations are inevitable. Adaptations are changes made to an intervention, implementation strategy, or context prior to, during, and after implementation to improve uptake and fit. There is a growing interest in systematically documenting and understanding adaptations including what is changed, why, when, by whom, and with what impact. The rural Transitions Nurse Program (TNP) is a program in the Veterans Health Administration (VHA), designed to safely transition a rural veteran from a tertiary hospital back home. TNP has been implemented in multiple cohorts across 11 sites nationwide over 4 years. In this paper, we describe adaptations in five TNP sites from the first cohort of sites and implications for the scale-up of TNP and discuss lessons learned for the systematic documentation and analysis of adaptations. METHODS We used the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) expanded version of the original Stirman framework to guide the rapid qualitative matrix analysis of adaptations. Adaptations were documented using multiple approaches: real-time database, semi-structured midpoint and exit interviews with implementors, and member checking with the implementation team. Interviews were recorded and transcribed. To combine multiple sources of adaptations, we used key domains from our framework and organized adaptations by time when the adaptation occurred (pre-, early, mid-, late implementation; sustainment) and categorized them as proactive or reactive. RESULTS Forty-one unique adaptations were reported during the study period. The most common type of adaptation was changes in target populations (patient enrollment criteria) followed by personnel changes (staff turnover). Most adaptations occurred during the mid-implementation time period and varied in number and type of adaptation. The reasons for this are discussed, and suggestions for future adaptation protocols are included. CONCLUSIONS This study demonstrates the feasibility of systematically documenting adaptations using multiple methods across time points. Implementors were able to track adaptations in real time across the course of an intervention, which provided timely and actionable feedback to the implementation team overseeing the national roll-out of the program. Longitudinal semi-structured interviews can complement the real-time database and elicit reflective adaptations.
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Affiliation(s)
- Michaela S McCarthy
- Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care (COIN), VA Eastern Colorado Health Care System, 1700 N. Wheeling Street, P1-151 Research, Denver, CO, 80045, USA.
- College of Nursing, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
| | - Lexus L Ujano-De Motta
- Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care (COIN), VA Eastern Colorado Health Care System, 1700 N. Wheeling Street, P1-151 Research, Denver, CO, 80045, USA
| | - Mary A Nunnery
- Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care (COIN), VA Eastern Colorado Health Care System, 1700 N. Wheeling Street, P1-151 Research, Denver, CO, 80045, USA
| | - Heather Gilmartin
- Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care (COIN), VA Eastern Colorado Health Care System, 1700 N. Wheeling Street, P1-151 Research, Denver, CO, 80045, USA
- Health Systems, Management, and Policy, Colorado School of Public Health, Anschutz Medical Campus, Aurora, CO, USA
| | - Lynette Kelley
- Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care (COIN), VA Eastern Colorado Health Care System, 1700 N. Wheeling Street, P1-151 Research, Denver, CO, 80045, USA
| | - Ashlea Wills
- Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care (COIN), VA Eastern Colorado Health Care System, 1700 N. Wheeling Street, P1-151 Research, Denver, CO, 80045, USA
| | - Chelsea Leonard
- Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care (COIN), VA Eastern Colorado Health Care System, 1700 N. Wheeling Street, P1-151 Research, Denver, CO, 80045, USA
| | - Christine D Jones
- Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care (COIN), VA Eastern Colorado Health Care System, 1700 N. Wheeling Street, P1-151 Research, Denver, CO, 80045, USA
- Division of Hospital Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Borsika A Rabin
- Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care (COIN), VA Eastern Colorado Health Care System, 1700 N. Wheeling Street, P1-151 Research, Denver, CO, 80045, USA
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, La Jolla, CA, USA
- UC San Diego Dissemination and Implementation Science Center, University of California San Diego, La Jolla, CA, USA
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Butler CR, Wong SPY, Vig EK, Neely CS, O'Hare AM. Professional roles and relationships during the COVID-19 pandemic: a qualitative study among US clinicians. BMJ Open 2021; 11:e047782. [PMID: 33766845 PMCID: PMC7995668 DOI: 10.1136/bmjopen-2020-047782] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 03/09/2021] [Accepted: 03/11/2021] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE The COVID-19 pandemic has transformed healthcare delivery in the USA, but there has been little empirical work describing the impact of these changes on clinicians. We conducted a study to address the following question: how has the pandemic impacted US clinicians' professional roles and relationships? DESIGN Inductive thematic analysis of semi-structured interviews. SETTING Clinical settings across the USA in April and May of 2020. PARTICIPANTS Clinicians with leadership and/or clinical roles during the COVID-19 pandemic. MEASURES Emergent themes related to professional roles and relationships. RESULTS Sixty-one clinicians participated in semi-structured interviews. Study participants were practising in 15 states across the USA, and the majority were White physicians from large academic centres. Three overlapping and inter-related themes emerged from qualitative analysis of interview transcripts: (1) disruption: boundaries between work and home life became blurred and professional identity and usual clinical roles were upended; (2) constructive adaptation: some clinicians were able to find new meaning in their work and described a spirit of collaboration, shared goals, open communication and mutual respect among colleagues; and (3) discord and estrangement: other clinicians felt alienated from their clinical roles and experienced demoralising work environments marked by division, value conflicts and mistrust. CONCLUSIONS Clinicians encountered marked disruption of their professional roles, identities and relationships during the pandemic to which they and their colleagues responded in a range of different ways. Some described a spirit of collaboration and camaraderie, while others felt alienated by their new roles and experienced work environments marked by division, value conflicts and mistrust. Our findings highlight the importance of effective teamwork and efforts to support clinician well-being during the COVID-19 pandemic.
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Affiliation(s)
- Catherine R Butler
- Department of Medicine, Division of Nephrology and the Kidney Research Institute, University of Washington, Seattle, Washington, USA
- Department of Hospital and Specialty Medicine, Nephrology Section and Health Services Research & Development, Seattle-Denver Center of Innovation, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
| | - Susan P Y Wong
- Department of Medicine, Division of Nephrology and the Kidney Research Institute, University of Washington, Seattle, Washington, USA
- Department of Hospital and Specialty Medicine, Nephrology Section and Health Services Research & Development, Seattle-Denver Center of Innovation, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
| | - Elizabeth K Vig
- Department of Hospital and Specialty Medicine, Geriatrics and Extended Care Section, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
| | - Claire S Neely
- Institute for Clinical Systems Improvement, Bloomington, Minnesota, USA
| | - Ann M O'Hare
- Department of Medicine, Division of Nephrology and the Kidney Research Institute, University of Washington, Seattle, Washington, USA
- Department of Hospital and Specialty Medicine, Nephrology Section and Health Services Research & Development, Seattle-Denver Center of Innovation, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
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