Effectiveness of a multifaceted implementation strategy on physicians' referral behavior to an evidence-based psychosocial intervention in dementia: a cluster randomized controlled trial

Implementation of an Arts at Home program for people living with dementia: Learnings from key stakeholders

ISSUE ADDRESSED

This study explores experiences of people with dementia and family carers who participated in an Arts on Prescription at Home (AoP@Home) program, artists who delivered the AoP@Home program and the managers who coordinated the AoP@Home programs.

METHODS

Semi structured interviews were conducted with the three stakeholder groups to explore experiences around implementation of AoP@Home. Interview questions were specific to each stakeholder group, and designed to capture the varied experiences around coordinating, delivering and participating in AoP@Home programs when delivered as a standard service offering. Qualitative content analysis was applied to evaluate the transcripts.

RESULTS

A total of 13 stakeholders participated in interviews: four people living with dementia and four family carers, three artists and two AoP program managers. Three overarching themes emerged across the stakeholder groups: 'what worked well', 'challenges' and 'moving forward'.

CONCLUSIONS

AoP@Home has potential as an important offering for community-dwelling people with dementia who may no longer be able to access group-based community programs. As AoP@Home is expanded, ongoing implementation monitoring and quality improvement will be essential to ensure maximal applicability of the program across the community aged care sector. SO WHAT?: The implementation of a new AoP@home service has been examined, and finds consumer satisfaction (person with dementia and their carer), and support from staff (artists and program managers). The novel nature of the service, however, requires considerable work to educate service referrers about the service and its benefits.

Implementing a home-based personalised cognitive rehabilitation intervention for people with mild-to-moderate dementia: GREAT into Practice

BACKGROUND

Evidence-based rehabilitative interventions, if widely implemented, could equip people with dementia and their families to manage life with the condition and reduce the need for health and care services. The aim of this translational study, building on evidence from the GREAT randomised controlled trial, was to develop a foundation for implementing the GREAT Cognitive Rehabilitation intervention in community-based services for people with mild-to-moderate dementia.

METHODS

Key elements of the implementation strategy were identifying and supporting managerial and clinical leadership, conducting collaborative planning and target-setting, training and supporting practitioners, and providing external facilitation. We developed implementation plans with, and trained staff in, 14 organisations. We subsequently worked closely with 11 of these, 10 National Health Service organisations and one private home care provider, to support practitioners to deliver GREAT Cognitive Rehabilitation over a 12-month period. Outcome evaluation examined the perspectives of local steering group members, practitioners and service users, and the reach, effectiveness and cost of the intervention.

RESULTS

Implementation was disrupted by the COVID-19 pandemic, but six organisations completed at least six months of intervention delivery. Forty-one practitioners, mainly occupational therapists, provided the intervention, and 54 people with dementia completed a course of GREAT Cognitive Rehabilitation. Goal attainment by people with dementia exceeded levels of improvement seen in the original trial. People with dementia, carers, practitioners and steering group members all evaluated the intervention positively, and economic analysis indicated that the intervention could be provided at modest cost. However, we identified a range of mainly organisational barriers that impeded implementation and limited the potential for sustainability.

CONCLUSIONS

GREAT Cognitive Rehabilitation benefits people with dementia, can be delivered effectively at modest cost in routine services, and is viewed positively by people with dementia, family carers and practitioners. To fully realise these benefits and achieve widespread and sustainable implementation, however, requires sufficient resources and a reorientation of service priorities towards preventive and rehabilitative approaches.

TRIAL REGISTRATION

National Institute for Health Research (NIHR) Central Portfolio Management System, registration number 38994.

Implementation of the Community Occupational Therapy in Dementia program in Italy (COTiD-IT): qualitative survey to identify barriers and facilitators in implementation

BACKGROUND

Community Occupational Therapy in Dementia in Italy (COTID-IT) is a feasible and effective treatment that aims improving the quality of life and well-being of people with dementia and caregivers. The implementation of the program in the national context has not been studied yet.

AIM

The objective of this study is to identify barriers and facilitators in the Italian implementation of the program.

METHODS

We designed a quantitative cross-sectional survey. A questionnaire was developed to collect descriptive data regarding the respondents, the perceived barriers and facilitators regarding the application of COTiD and possible actions to promote the implementation process.

RESULTS

The questionnaire was sent to all 90 Italian OTs trained in the use of COTiD-IT from 2013 to 2020. 50 people responded (61%). Barriers to the implementation of the COTID-IT included lack of knowledge about Occupational Therapy and the COTID-IT program by other health professionals. In addition, the scarcity of economic funds invested in home rehabilitation is experienced as another significant barrier. Facilitators were found to be the presence of an interprofessional team interested in the COTID-IT program and occupational therapy and the fact that COTID-IT is supported by scientific evidence. The creation of national and regional inter professional education and support groups, the availability of online resources are seen as opportunities to better implement the COTID-IT program.

CONCLUSIONS

Implementation of psychosocial interventions is complex. OTs in Italy should be increasingly included within health policies and care programs of people with dementia to promote the use of COTID-IT. Further studies are needed to detail the policy and methodological actions that OTs should take in the future to disseminate and consolidate this intervention.

Implementation of evidence-based, non-pharmacological interventions addressing behavior and psychological symptoms of dementia: a systematic review focused on implementation strategies

OBJECTIVE

This study aimed to identify the nature and effects of implementation strategies to increase the use of evidence-based, non-pharmacological interventions designed to reduce the frequency and/or severity of behavioral and psychological symptoms associated with dementia, for people living in the community.

DESIGN

This was a systematic review of implementation studies. We searched six databases (in January 2019) and hand-searched reference lists of reports. Studies were included if they used quantitative methods evaluating the use of implementation strategies to increase the use of non-pharmacological interventions. These interventions had to have been tested in a randomized controlled trial (RCT) and found to reduce behavioral and psychological symptoms of dementia, for those living in the community. Studies needed to report the effect of the implementation on clinical practice, for example, a change in practice or the adoption of the intervention in community settings.

RESULTS

Twelve studies were included: 11 one-group pre-post design studies and 1 cluster RCT. All studies reported practice change - the majority implementing a new intervention, with six different types of interventions implemented. All studies reported including using partnerships, new funding, educational strategies, and ongoing support and consultation. Seven implementation studies reported positive outcomes for clients on some aspect of behavior or depression for the person with dementia.

CONCLUSIONS

Implementation studies using multiple implementation strategies to increase the use of non-pharmacological interventions have demonstrated improvements in behavioral and psychological symptoms common in people with dementia, when provided by clinicians as part of their everyday work routines.

Promoting occupational therapy interventions in the Australian community aged care sector

BACKGROUND

With the introduction of consumer-directed care in the Australian community aged care sector, there are more opportunities for occupational therapists to provide evidence-based services that meet consumer needs. There is also an increasing requirement for health professionals to promote their interventions to consumers. Particularly for the implementation of new programs within organisations. However, occupational therapists have historically neglected widely promoting the role of occupational therapy services for older people. This study examines the perceptions of occupational therapists and their managers in promoting their service; the Care of People in their Environment (COPE) Program.

METHODS

This study utilised a qualitative interpretative description; including 28 in-depth interviews. Purposeful sampling ensured a variety of occupational therapists from different health contexts. Thematic analysis captured key emergent themes related to promoting occupational therapy interventions and implementation.

RESULTS

Many occupational therapists were apprehensive about promoting or selling their services and interventions. Greater levels of confidence in promoting the program were present when the program aligned with traditional models of service delivery and organisational processes. Occupational therapists described having limited opportunity to directly promote the program to consumers as community case managers were mostly the main contact at the organisation. There was limited consideration of promotion strategies and therefore limited enactment of strategies by organisations. Not-for-profit and non-government organisations recognise that the changed community aged care market provided new business opportunities.

CONCLUSION

With changes in the Australian aged care system, occupational therapy has great opportunity to provide diverse, evidence-based interventions driven by the needs of consumers. Reframing the notion of 'selling', to empowering consumers to be more informed about their options, will allow occupational therapists to build confidence in their promotional skills. Promoting evidence-based programs will have positive outcomes for the visibility, professional identity and recognition of occupational therapy.

Implementing a Reablement Intervention, “Care of People With Dementia in Their Environments (COPE)”: A Hybrid Implementation-Effectiveness Study

Background and Objectives

The translation of reablement programs into practice is lagging despite strong evidence for interventions that maintain function for the person living with dementia as well as improve carer well-being. The aim was to evaluate the implementation of an evidence-based program, Care of People with Dementia in Their Environments (COPE), into health services.

Research Design and Methods

An implementation-effectiveness hybrid design was used to evaluate implementation outcomes while simultaneously involving a pragmatic pre–post evaluation of outcomes for people with dementia. We report uptake, fidelity to intervention, outcomes for people living with dementia and carers, and beliefs and behaviors of interventionists contributing to successful implementation.

Results

Seventeen organizations in Australia across 3 health contexts, 38 occupational therapists, and 17 nurses participated in training and implementation. While there were challenges and delays in implementation, most organizations were able to offer the program and utilized different models of funding. Overall, we found there was moderate fidelity to components of the program. Pre–post outcomes for carer well-being and coping (Perceived Change Index, p < .001) and activity engagement of the person living with dementia (p = .002) were significantly increased, replicating previous trial results. What contributed most to therapists implementing the program (Determinants of Implementation Behaviour Questionnaire) was a stronger intent to deliver (p < .001), higher confidence (p < .001), a sense of control in delivery (p = .004), and a belief the program was very useful to their clients (p = .002).

Discussion and Implications

This study demonstrated that implementation is possible in multiple health systems and beneficial to individuals and their families.

Clinical perspectives on hospitals' role in the opioid epidemic

BACKGROUND

Policymakers, legislators, and clinicians have raised concerns that hospital-based clinicians may be incentivized to inappropriately prescribe and administer opioids when addressing pain care needs of their patients, thus potentially contributing to the ongoing opioid epidemic in the United States. Given the need to involve all healthcare settings, including hospitals, in joint efforts to curb the opioid epidemic, it is essential to understand if clinicians perceive hospitals as contributors to the problem. Therefore, we examined clinical perspectives on the role of hospitals in the opioid epidemic.

METHODS

We conducted individual semi-structured interviews with 23 clinicians from 6 different acute care hospitals that are part of a single healthcare system in the Midwestern United States. Our participants were hospitalists (N = 12), inpatient registered nurses (N = 9), and inpatient adult nurse practitioners (N = 2). In the interviews, we asked clinicians whether hospitals play a role in the opioid epidemic, and if so, how hospitals may contribute to the epidemic. We used a qualitative thematic analysis approach to analyze coded text for patterns and themes and examined potential differences in themes by respondent type using Dedoose software.

RESULTS

The majority of clinicians believed hospitals contribute to the opioid epidemic. Multiple clinicians cited Center for Medicare and Medicaid Services' (CMS) reimbursement policy and the Joint Commission's report as drivers of inappropriate opioid prescribing in hospitals. Furthermore, numerous clinicians stated that opioids are inappropriately administered in the emergency department (ED), potentially as a mechanism to facilitate discharge and prevent re-admission. Many clinicians also described how overreliance on pre-populated pain care orders for surgical (orthopedic) patients, may be contributing to inappropriate opioid use in the hospital. Finally, clinicians suggested the following initiatives for hospitals to help address the crisis: 1) educating patients about negative consequences of using opioids long-term and setting realistic pain expectations; 2) educating medical staff about appropriate opioid prescribing practices, particularly for patients with complex chronic conditions (chronic pain; opioid use disorder (OUD)); and 3) strengthening the hospital leadership efforts to decrease inappropriate opioid use.

CONCLUSIONS

Our findings can inform efforts at decreasing inappropriate opioid use in hospitals.

Implementation of an evidence-based intervention to improve the wellbeing of people with dementia and their carers: study protocol for 'Care of People with dementia in their Environments (COPE)' in the Australian context

BACKGROUND

There are effective non-pharmacological treatment programs that reduce functional disability and changed behaviours in people with dementia. However, these programs (such as the Care of People with dementia in their Environments (COPE) program) are not widely available. The primary aim of this study is to determine the strategies and processes that enable the COPE program to be implemented into existing dementia care services in Australia.

METHODS

This study uses a mixed methods approach to test an implementation strategy. The COPE intervention (up to ten consultations with an occupational therapist and up to two consultations with a nurse) will be implemented using a number of strategies including planning (such as developing and building relationships with dementia care community service providers), educating (training nurses and occupational therapists in how to apply the intervention), restructuring (organisations establishing referral systems; therapist commitment to provide COPE to five clients following training) and quality management (coaching, support, reminders and fidelity checks). Qualitative and quantitative data will contribute to understanding how COPE is adopted and implemented. Feasibility, fidelity, acceptability, uptake and service delivery contexts will be explored and a cost/benefit evaluation conducted. Client outcomes of activity engagement and caregiver wellbeing will be assessed in a pragmatic pre-post evaluation.

DISCUSSION

While interventions that promote independence and wellbeing are effective and highly valued by people with dementia and their carers, access to such programs is limited. Barriers to translation that have been previously identified are addressed in this study, including limited training opportunities and a lack of confidence in clinicians working with complex symptoms of dementia. A strength of the study is that it involves implementation within different types of existing services, such as government and private providers, so the study will provide useful guidance for further future rollout.

TRIAL REGISTRATION

16 February 2017; ACTRN12617000238370 .

Interprofessional collaboration to improve professional practice and healthcare outcomes

BACKGROUND

Poor interprofessional collaboration (IPC) can adversely affect the delivery of health services and patient care. Interventions that address IPC problems have the potential to improve professional practice and healthcare outcomes.

OBJECTIVES

To assess the impact of practice-based interventions designed to improve interprofessional collaboration (IPC) amongst health and social care professionals, compared to usual care or to an alternative intervention, on at least one of the following primary outcomes: patient health outcomes, clinical process or efficiency outcomes or secondary outcomes (collaborative behaviour).

SEARCH METHODS

We searched CENTRAL (2015, issue 11), MEDLINE, CINAHL, ClinicalTrials.gov and WHO International Clinical Trials Registry Platform to November 2015. We handsearched relevant interprofessional journals to November 2015, and reviewed the reference lists of the included studies.

SELECTION CRITERIA

We included randomised trials of practice-based IPC interventions involving health and social care professionals compared to usual care or to an alternative intervention.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the eligibility of each potentially relevant study. We extracted data from the included studies and assessed the risk of bias of each study. We were unable to perform a meta-analysis of study outcomes, given the small number of included studies and their heterogeneity in clinical settings, interventions and outcomes. Consequently, we summarised the study data and presented the results in a narrative format to report study methods, outcomes, impact and certainty of the evidence.

MAIN RESULTS

We included nine studies in total (6540 participants); six cluster-randomised trials and three individual randomised trials (1 study randomised clinicians, 1 randomised patients, and 1 randomised clinicians and patients). All studies were conducted in high-income countries (Australia, Belgium, Sweden, UK and USA) across primary, secondary, tertiary and community care settings and had a follow-up of up to 12 months. Eight studies compared an IPC intervention with usual care and evaluated the effects of different practice-based IPC interventions: externally facilitated interprofessional activities (e.g. team action planning; 4 studies), interprofessional rounds (2 studies), interprofessional meetings (1 study), and interprofessional checklists (1 study). One study compared one type of interprofessional meeting with another type of interprofessional meeting. We assessed four studies to be at high risk of attrition bias and an equal number of studies to be at high risk of detection bias.For studies comparing an IPC intervention with usual care, functional status in stroke patients may be slightly improved by externally facilitated interprofessional activities (1 study, 464 participants, low-certainty evidence). We are uncertain whether patient-assessed quality of care (1 study, 1185 participants), continuity of care (1 study, 464 participants) or collaborative working (4 studies, 1936 participants) are improved by externally facilitated interprofessional activities, as we graded the evidence as very low-certainty for these outcomes. Healthcare professionals' adherence to recommended practices may be slightly improved with externally facilitated interprofessional activities or interprofessional meetings (3 studies, 2576 participants, low certainty evidence). The use of healthcare resources may be slightly improved by externally facilitated interprofessional activities, interprofessional checklists and rounds (4 studies, 1679 participants, low-certainty evidence). None of the included studies reported on patient mortality, morbidity or complication rates.Compared to multidisciplinary audio conferencing, multidisciplinary video conferencing may reduce the average length of treatment and may reduce the number of multidisciplinary conferences needed per patient and the patient length of stay. There was little or no difference between these interventions in the number of communications between health professionals (1 study, 100 participants; low-certainty evidence).

AUTHORS' CONCLUSIONS

Given that the certainty of evidence from the included studies was judged to be low to very low, there is not sufficient evidence to draw clear conclusions on the effects of IPC interventions. Neverthess, due to the difficulties health professionals encounter when collaborating in clinical practice, it is encouraging that research on the number of interventions to improve IPC has increased since this review was last updated. While this field is developing, further rigorous, mixed-method studies are required. Future studies should focus on longer acclimatisation periods before evaluating newly implemented IPC interventions, and use longer follow-up to generate a more informed understanding of the effects of IPC on clinical practice.

Developing a Referral Protocol for Community-Based Occupational Therapy Services in Taiwan: A Logistic Regression Analysis

Because resources for long-term care services are limited, timely and appropriate referral for rehabilitation services is critical for optimizing clients' functions and successfully integrating them into the community. We investigated which client characteristics are most relevant in predicting Taiwan's community-based occupational therapy (OT) service referral based on experts' beliefs. Data were collected in face-to-face interviews using the Multidimensional Assessment Instrument (MDAI). Community-dwelling participants (n = 221) ≥ 18 years old who reported disabilities in the previous National Survey of Long-term Care Needs in Taiwan were enrolled. The standard for referral was the judgment and agreement of two experienced occupational therapists who reviewed the results of the MDAI. Logistic regressions and Generalized Additive Models were used for analysis. Two predictive models were proposed, one using basic activities of daily living (BADLs) and one using instrumental ADLs (IADLs). Dementia, psychiatric disorders, cognitive impairment, joint range-of-motion limitations, fear of falling, behavioral or emotional problems, expressive deficits (in the BADL-based model), and limitations in IADLs or BADLs were significantly correlated with the need for referral. Both models showed high area under the curve (AUC) values on receiver operating curve testing (AUC = 0.977 and 0.972, respectively). The probability of being referred for community OT services was calculated using the referral algorithm. The referral protocol facilitated communication between healthcare professionals to make appropriate decisions for OT referrals. The methods and findings should be useful for developing referral protocols for other long-term care services.

A qualitative study of the anticipated barriers and facilitators to the implementation of a lifestyle intervention in the Dutch construction industry

Background

Lifestyle interventions have proven effective for lowering a cardiovascular risk profile by improving lifestyle behaviors, blood glucose and blood cholesterol levels. However, implementation of lifestyle interventions is often met with barriers. This qualitative study sought to determine anticipated barriers and facilitators to the nationwide implementation of an effective lifestyle intervention in the construction industry in the Netherlands.

Methods

Prior to implementation, focus groups were held with 8 lifestyle counselors and semi-structured interviews with 20 employees of the construction industry, 4 occupational physicians, 4 medical assistants, and 1 manager of an occupational health service. The transcripts were coded by two coders and analyzed by constant comparison.

Results

Hypothetical employee willingness to sign up for the intervention was facilitated by a high level of perceived risk, perceived added value of the intervention, and perceived social support. It was hampered by a preference for independence and perceived interference with their work. All professionals named a lack of time as an anticipated barrier to implementation. Lifestyle counselors suggested several strategies to improve the proficiency of their counseling technique, such as training in small groups and a continuous stream of employee referrals. Occupational physicians thought they would be hampered in screening employees and referring them to a lifestyle counselor by the perception that addressing employee lifestyles was not their task, and by a counter-productive relationship with other stakeholders. The manager addressed financial incentives and a good intervention fit with the current approach of the OHS.

Conclusion

The findings suggest that employees can be motivated to sign up for a lifestyle intervention by tailoring the implementation strategy to various subgroups within the target group. Occupational physicians can be motivated to refer employees for the intervention by making a referral personally and professionally rewarding.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2458-14-1317) contains supplementary material, which is available to authorized users.

Determinants for the effectiveness of implementing an occupational therapy intervention in routine dementia care

BACKGROUND

A multifaceted implementation (MFI) strategy was used to implement an evidence-based occupational therapy program for people with dementia (COTiD program). This strategy was successful in increasing the number of referrals, but not in improving occupational therapists' (OTs) adherence. Therefore, a process evaluation was conducted to identify factors that influenced the effectiveness of the MFI strategy.

METHODS

A mixed-method approach of qualitative and quantitative research was used to evaluate the implementation process. The MFI strategy as planned and as executed were reported and evaluated based on the framework of Hulscher et al. (2003; 2006). Data on OTs attitudes and expected barriers were collected at baseline from 94 OTs using a 19-item questionnaire. Data on the experiences were collected after finishing the implementation using focus groups with OTs and telephone interviews with physicians and managers. For quantitative data, frequencies and correlations were calculated and qualitative data were analyzed using inductive content analysis.

RESULTS

The implementation strategy as executed had a stronger focus than planned on increasing OTs promotional skills due to an initial lack of referrals. This resulted in less attention for increasing OTs' skills in using the COTiD program as initially intended. At baseline, OTs had a positive attitude toward the program, however, 75% did not feel experienced enough and only 14.3% felt competent in using the program. Focus groups and interviews revealed various determinants that influenced implementation. Most managers were positive about the program. However, the degree of operational support of managers for OTs regarding the implementation was not always adequate. Managers stated that a well-defined place for occupational therapy within the dementia care network was lacking although this was perceived necessary for successful implementation. Several physicians perceived psychosocial interventions not to be in their area of expertise or not their responsibility. All professionals perceived inter-professional collaboration to be a facilitator for effective implementation, and general practitioners were perceived as key partners in this collaboration. However, collaboration was not always optimal. OTs indicated that increasing the referral rate was most effective when promoting OT via other disciplines within a physician's network.

CONCLUSION

Our data suggests that a first step in successful implementation should be to make sure that individual and organizational barriers are resolved. In addition, implementation should be network-based and encourage inter-professional collaboration. Initial promotion of COTiD should focus on physicians that have a positive attitude toward non-pharmacological interventions.