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Pellowski JA, Price DM, Desir A, Golub S, Operario D, Purtle J. Using audience segmentation to identify implementation strategies to improve PrEP uptake among at-risk cisgender women: a mixed-methods study protocol. Implement Sci Commun 2023; 4:140. [PMID: 37978402 PMCID: PMC10656952 DOI: 10.1186/s43058-023-00518-z] [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: 08/22/2023] [Accepted: 10/28/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND In the USA, 19% of new HIV infections occur among cisgender women (cis women); however, only 10% of eligible cis women have been prescribed pre-exposure prophylaxis (PrEP) for the prevention of HIV infection (an evidence-based intervention). A fundamental challenge for expanding HIV prevention to cis women is ensuring implementation strategies are tailored to the various healthcare settings in which cis women seek care and the heterogeneous providers nested within these settings. This project's specific aims are to (1) explore clinician-level characteristics and organizational climate factors that are related to variability in adoption of PrEP service delivery as an evidence-based intervention for cis women; (2) identify latent audience segments of women's health providers as the related to PrEP acceptability, adoption, and maintenance and analyze demographic correlates of these segments; and (3) identify audience segment-specific implementation strategies to facilitate the adoption of PrEP as an evidence-based intervention among at-risk cis women. METHODS Using the i-PARIHS framework, this mixed-methods study examines three domains for guiding audience segmentation to facilitate PrEP implementation for cis women: innovation (degree of fit with existing practices, usability), recipient beliefs and knowledge and context factors (organizational culture, readiness for change), needs to determine appropriate facilitation methods. To achieve aim 1, qualitative interviews will be conducted with PrEP-eligible cis women, women's health providers, and other key stakeholders. Aim 2 will consist of a quantitative survey among 340 women's health providers. Latent class analysis will be used to facilitate audience segmentation. To achieve aim 3, a panel of 5-8 providers for each audience segment will meet and engage in iterative discussions guided by Fernandez's implementation mapping to identify (1) implementation outcomes and performance objectives, determinants, and change objectives and (2) determine and refine of implementation strategies for each audience segment. DISCUSSION This exploratory mixed methods study will provide an empirical foundation to inform the development implementations strategies aimed at increasing PrEP delivery to cis women among heterogenous groups of providers.
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Affiliation(s)
- Jennifer A Pellowski
- Department of Behavioral and Social Sciences, Brown University School of Public Health, International Health Institute, 121 South Main Street, Providence, RI, 02903, USA.
| | - Devon M Price
- Department of Psychology, Hunter College & Graduate Center of the City University of New York, 695 Park Avenue, New York, NY, 10065, USA
| | - Arielle Desir
- Department of Behavioral and Social Sciences, Brown University School of Public Health, 121 South Main Street, Providence, RI, 02903, USA
| | - Sarit Golub
- Department of Psychology, Hunter College & Graduate Center of the City University of New York, 695 Park Avenue, New York, NY, 10065, USA
| | - Don Operario
- Department of Behavioral, Social, and Health Education Sciences, Emory University Rollins School of Public Health, 1518 Clifton Road, Atlanta, GA, 30322, USA
| | - Jonathan Purtle
- Department of Public Health Policy & Management, Global Center for Implementation Science, New York University School of Global Public Health, 708 Broadway, New York, NY, 10003, USA
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Piazza KM, Ashcraft LE, Rose L, Hall DE, Brown RT, Bowen MEL, Mavandadi S, Brecher AC, Keddem S, Kiosian B, Long JA, Werner RM, Burke RE. Study protocol: Type III hybrid effectiveness-implementation study implementing Age-Friendly evidence-based practices in the VA to improve outcomes in older adults. Implement Sci Commun 2023; 4:57. [PMID: 37231459 PMCID: PMC10209584 DOI: 10.1186/s43058-023-00431-5] [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: 01/19/2023] [Accepted: 04/23/2023] [Indexed: 05/27/2023] Open
Abstract
BACKGROUND Unmet care needs among older adults accelerate cognitive and functional decline and increase medical harms, leading to poorer quality of life, more frequent hospitalizations, and premature nursing home admission. The Department of Veterans Affairs (VA) is invested in becoming an "Age-Friendly Health System" to better address four tenets associated with reduced harm and improved outcomes among the 4 million Veterans aged 65 and over receiving VA care. These four tenets focus on "4Ms" that are fundamental to the care of older adults, including (1) what Matters (ensuring that care is consistent with each person's goals and preferences); (2) Medications (only using necessary medications and ensuring that they do not interfere with what matters, mobility, or mentation); (3) Mentation (preventing, identifying, treating, and managing dementia, depression, and delirium); and (4) Mobility (promoting safe movement to maintain function and independence). The Safer Aging through Geriatrics-Informed Evidence-Based Practices (SAGE) Quality Enhancement Research Initiative (QUERI) seeks to implement four evidence-based practices (EBPs) that have shown efficacy in addressing these core tenets of an "Age-Friendly Health System," leading to reduced harm and improved outcomes in older adults. METHODS We will implement four EBPs in 9 VA medical centers and associated outpatient clinics using a type III hybrid effectiveness-implementation stepped-wedge trial design. We selected four EBPs that align with Age-Friendly Health System principles: Surgical Pause, EMPOWER (Eliminating Medications Through Patient Ownership of End Results), TAP (Tailored Activities Program), and CAPABLE (Community Aging in Place - Advancing Better Living for Elders). Guided by the Pragmatic Robust Implementation and Sustainability Model (PRISM), we are comparing implementation as usual vs. active facilitation. Reach is our primary implementation outcome, while "facility-free days" is our primary effectiveness outcome across evidence-based practice interventions. DISCUSSION To our knowledge, this is the first large-scale randomized effort to implement "Age-Friendly" aligned evidence-based practices. Understanding the barriers and facilitators to implementing these evidence-based practices is essential to successfully help shift current healthcare systems to become Age-Friendly. Effective implementation of this project will improve the care and outcomes of older Veterans and help them age safely within their communities. TRIAL REGISTRATION Registered 05 May 2021, at ISRCTN #60,657,985. REPORTING GUIDELINES Standards for Reporting Implementation Studies (see attached).
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Affiliation(s)
- Kirstin Manges Piazza
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, 3900 Woodland Ave, Philadelphia, PA, USA.
| | - Laura Ellen Ashcraft
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, 3900 Woodland Ave, Philadelphia, PA, USA
- Division of General Internal Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Liam Rose
- Stanford-Surgery Policy Improvement Research & Education Center, Stanford University, Stanford, CA, USA
- Health Economics Resource Center, VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Daniel E Hall
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Geriatric Research Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Rebecca T Brown
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, 3900 Woodland Ave, Philadelphia, PA, USA
- Division of General Internal Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Geriatrics and Extended Care Program, Corporal Michael Crescenz VA Medical Center, Philadelphia, PA, USA
| | - Mary Elizabeth Libbey Bowen
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, 3900 Woodland Ave, Philadelphia, PA, USA
- Education, and Clinical Center, VISN4 Mental Illness Research, Corporal Michael JCrescenz VA Medical Center, Philadelphia, PA, USA
| | - Shahrzad Mavandadi
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, 3900 Woodland Ave, Philadelphia, PA, USA
- School of Nursing, University of Delaware, Newark, DE, USA
| | | | - Shimrit Keddem
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, 3900 Woodland Ave, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Department of Family Medicine & Community Health, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Bruce Kiosian
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, 3900 Woodland Ave, Philadelphia, PA, USA
- Division of General Internal Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Geriatrics and Extended Care Program, Corporal Michael Crescenz VA Medical Center, Philadelphia, PA, USA
| | - Judith A Long
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, 3900 Woodland Ave, Philadelphia, PA, USA
- Division of General Internal Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Rachel M Werner
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, 3900 Woodland Ave, Philadelphia, PA, USA
- Division of General Internal Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert E Burke
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, 3900 Woodland Ave, Philadelphia, PA, USA
- Division of General Internal Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
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Estabrooks C, Song Y, Anderson R, Beeber A, Berta W, Chamberlain S, Cummings G, Duan Y, Hayduk L, Hoben M, Iaconi A, Lanham H, Perez J, Wang J, Norton P. The Influence of Context on Implementation and Improvement: Protocol for a Mixed Methods, Secondary Analyses Study. JMIR Res Protoc 2022; 11:e40611. [PMID: 36107475 PMCID: PMC9523530 DOI: 10.2196/40611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 07/13/2022] [Accepted: 07/30/2022] [Indexed: 12/05/2022] Open
Abstract
Background Caring for the well-being of older adults is one of the greatest challenges in modern societies. Improving the quality of care and life for older adults and the work lives of their care providers calls for effective knowledge translation of evidence-based best practices. Objective This study’s purpose is to contribute to knowledge translation by better understanding the roles of organizational context (workplace environment) and facilitation (process or role) in implementation and improvement success. Our study has 2 goals: (1) to advance knowledge translation science by further developing and testing the Promoting Action on Research Implementation in Health Services framework (which outlines how implementation relies on the interplay of context, facilitation, and evidence) and (2) to advance research by optimizing implementation success via tailoring of modifiable elements of organizational context and facilitation. Methods This is secondary analyses of 15 years of longitudinal data from the Translating Research in Elder Care (TREC) program’s multiple data sources. This research is ongoing in long-term care (LTC) homes in western Canada. TREC data include the following: 5 waves of survey collection, 2 clinical trials, and regular ongoing outcome data for LTC residents. We will use a sequential exploratory and confirmatory mixed methods design. We will analyze qualitative and quantitative data holdings in an iterative process: (1) comprehensive reanalysis of qualitative data to derive hypotheses, (2) quantitative modeling to test hypotheses, and (3) action cycles to further refine and integrate qualitative and quantitative analyses. The research team includes 4 stakeholder panels: (1) system decision- and policy makers, (2) care home managers, (3) direct care staff, and (4) a citizen engagement group of people living with dementia and family members of LTC residents. A fifth group is our panel of external scientific advisors. Each panel will engage periodically, providing their perspectives on project direction and findings. Results This study is funded by the Canadian Institutes of Health Research. Ethics approval was obtained from the University of Alberta (Pro00096541). The results of the secondary analyses are expected by the end of 2023. Conclusions The project will advance knowledge translation science by deepening our understanding of the roles of context, the interactions between context and facilitation, and their influence on resident and staff quality outcomes. Importantly, findings will inform understanding of the mechanisms by which context and facilitation affect the success of implementation and offer insights into factors that influence the implementation success of interventions in nursing homes. International Registered Report Identifier (IRRID) DERR1-10.2196/40611
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Affiliation(s)
| | - Yuting Song
- School of Nursing, Qingdao University, Qingdao, China
| | - Ruth Anderson
- School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Anna Beeber
- School of Nursing, Johns Hopkins University, Baltimore, MD, United States
| | - Whitney Berta
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | | | - Greta Cummings
- Faculty of Nursing, University of Alberta, Edmonton, AB, Canada
| | - Yinfei Duan
- Faculty of Nursing, University of Alberta, Edmonton, AB, Canada
| | - Leslie Hayduk
- Faculty of Nursing, University of Alberta, Edmonton, AB, Canada
| | - Matthias Hoben
- Faculty of Nursing, University of Alberta, Edmonton, AB, Canada
| | - Alba Iaconi
- Faculty of Nursing, University of Alberta, Edmonton, AB, Canada
| | - Holly Lanham
- Department of Medicine, University of Texas Health Sciences Center San Antonio, San Antonio, TX, United States
| | - Janelle Perez
- School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Jing Wang
- School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Peter Norton
- Department of Family Medicine, University of Calgary, Calgary, AB, Canada
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Ritchie MJ, Drummond KL, Smith BN, Sullivan JL, Landes SJ. Development of a qualitative data analysis codebook informed by the i-PARIHS framework. Implement Sci Commun 2022; 3:98. [PMID: 36104801 PMCID: PMC9476709 DOI: 10.1186/s43058-022-00344-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 09/05/2022] [Indexed: 11/10/2022] Open
Abstract
Background The Integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) framework and its predecessor, PARIHS, have been widely utilized in implementation studies. Although i-PARIHS developers have focused on creating tools to guide facilitators in its application in practice, tools are also needed for evaluation and research. Codebooks with clear and meaningful code labels and definitions are an important component of qualitative data analysis and have been developed for other widely used frameworks. There is no such codebook for i-PARIHS. Additionally, sub-constructs for the Innovation, Recipients, and Context constructs lack definitions, and there is no sub-classification of facilitation activities for the Facilitation construct. The lack of a standardized codebook hinders our ability to synthesize research findings across studies, explore and test the range of activities that are utilized in facilitation efforts, and potentially validate and further refine i-PARIHS. This paper describes a rigorous process of developing a detailed qualitative codebook informed by the i-PARIHS framework. Methods A workgroup of qualitative researchers conducted a rigorous four-phase process to develop a codebook informed by i-PARIHS. In phase 1, workgroup members reviewed and discussed literature, consulted an organizational scientist, and drafted and refined subcodes and definitions for i-PARIHS constructs. In phase 2, they obtained feedback from an expert panel and further refined subcodes and definitions. In phase 3, they obtained feedback from i-PARIHS developers/experts and incorporated it into the codebook. Finally, two studies piloted the application of the codebook which informed the final version. Results The resulting i-PARIHS-informed codebook includes definitions for the four main constructs of the framework: Innovation, Recipients, Context, and Facilitation; subcodes and definitions for characteristics of each of these constructs; and instructions for the suggested application of individual codes and use of the codebook generally. Conclusions The standardized codes and definitions in the codebook can facilitate data exploration, pattern identification, and insight development informed by the i-PARIHS framework. Qualitative analysts can also use them to explore interactions between i-PARIHS constructs, maximize the potential for comparing findings across studies, and support the refinement of the i-PARIHS framework using empirical findings from multiple studies. Supplementary Information The online version contains supplementary material available at 10.1186/s43058-022-00344-9.
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Belenko S, Dembo R, Knight DK, Elkington KS, Wasserman GA, Robertson AA, Welsh WN, Schmeidler J, Joe GW, Wiley T. Using structured implementation interventions to improve referral to substance use treatment among justice-involved youth: Findings from a multisite cluster randomized trial. J Subst Abuse Treat 2022; 140:108829. [PMID: 35751945 PMCID: PMC9357202 DOI: 10.1016/j.jsat.2022.108829] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 03/25/2022] [Accepted: 06/15/2022] [Indexed: 10/17/2022]
Abstract
INTRODUCTION Youth involved in the justice system have high rates of alcohol and other drug use, but limited treatment engagement. JJ-TRIALS tested implementation activities with community supervision (CS) and behavioral health (BH) agencies to improve screening, identification of substance use service need, referral, and treatment initiation and engagement, guided by the BH Services Cascade and EPIS frameworks. This paper summarizes intervention impacts on referrals to treatment among youth on CS. METHODS This multisite cluster-randomized trial involved 18 matched pairs of sites in 36 counties in seven states randomly assigned to core or enhanced conditions after implementing the core intervention at all sites for six months. Enhanced sites received external facilitation for local change team activities to reduce unmet treatment needs; Core sites were encouraged to form interagency workgroups. The dependent variable was percentage referred to treatment among youth in need (N = 14,012). Two-level Bayesian regression assessed factors predicting referral across all sites and time periods. Generalized linear mixed models using logit transformation tested two hypotheses: (H1) referrals will increase from baseline to the experimental period, (H2) referral increases will be larger in enhanced sites than in core sites. RESULTS Although the intervention significantly increased referral, condition did not significantly predict referral across all time periods. Youth who tested drug positive, had an alcohol/other drug-related or felony charge, were placed in secure detention or assigned more intensive supervision, or who were White were more likely to be referred. H1 (p < .05) and H2 (p < .0001) were both significant in the hypothesized direction. Interaction analyses comparing site pair differences showed that findings were not consistent across sites. CONCLUSIONS The percentage of youth referred to treatment increased compared with baseline overall, and enhanced sites showed larger increases in referrals over time. However, variations in effects suggest that site-level differences were important. Researchers should carry out mixed methods studies to further understand reasons for the inconsistent findings within randomized site pairs, and how to further improve treatment referrals across CS and BH systems. Findings also highlight that even when CS agencies work collaboratively with BH providers to improve referrals, most justice-involved youth who need SU services are not referred.
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Affiliation(s)
| | - Richard Dembo
- University of South Florida, United States of America
| | | | - Katherine S Elkington
- Columbia University and New York State Psychiatric Institute, United States of America
| | - Gail A Wasserman
- Columbia University and New York State Psychiatric Institute, United States of America
| | | | | | - James Schmeidler
- Icahn School of Medicine at Mount Sinai, United States of America
| | - George W Joe
- Texas Christian University, United States of America
| | - Tisha Wiley
- National Institute on Drug Abuse, United States of America
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Spoelstra SL, Schueller M, Basso V, Sikorskii A. Results of a multi-site pragmatic hybrid type 3 cluster randomized trial comparing level of facilitation while implementing an intervention in community-dwelling disabled and older adults in a Medicaid waiver. Implement Sci 2022; 17:57. [PMID: 36028873 PMCID: PMC9419328 DOI: 10.1186/s13012-022-01232-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 08/14/2022] [Indexed: 01/28/2023] Open
Abstract
Background Evidence-based interventions that optimize physical function for disabled and older adults living in the community who have difficulty with daily living tasks are available. However, uptake has been limited, particularly in resource-constrained (Medicaid) settings. Facilitation may be an effective implementation strategy. This study’s aim was to compare internal facilitation (IF) versus IF and external facilitation (EF) on adoption and sustainability of an intervention in a Medicaid home and community-based waiver. Methods In a hybrid type 3 trial, waiver sites (N = 18) were randomly assigned to implement the intervention using a bundle of strategies with either IF or IF and EF. Adoption and sustainability were assessed via Stages of Implementation Completion (SIC) for each site. Clinician attitudes toward evidence-based practice and self-efficacy were evaluated among 539 registered nurses, social workers, and occupational therapists. Medicaid beneficiary outcomes of activities of daily living, depression, pain, falls, emergency department visits, and hospitalizations were evaluated in a sample of N = 7030 as reflected by electronic health records data of the Medicaid waiver program. Linear mixed-effects models were used to compare outcomes between trial arms while accounting for cluster-randomized design. Results The mean SIC scores were 72.22 (standard deviation [SD] = 16.98) in the IF arm (9 sites) and 61.33 (SD = 19.29) in the IF + EF arm (9 sites). The difference was not statistically significant but corresponded to the medium clinically important effect size Cohen’s d = 0.60. Clinician implementation outcomes of attitudes and self-efficacy did not differ by trial arm. Beneficiary depression was reduced significantly in the IF + EF arm compared to the IF arm (p = .04, 95% confidence interval for the difference [0.01, 0.24]). No differences between trial arms were found for other beneficiary outcomes. Conclusions Level of facilitation did not enhance capacity for adoption and sustainability of an evidence-based intervention in a Medicaid setting that cares for disabled and older adults. Improved beneficiary depression favored use of IF and EF compared to IF alone, and no differences were found for other outcomes. These findings also suggest level of facilitation may not have impacted beneficiary outcomes. Trial registration ClinicalTrials.gov, NCT03634033; date registered August 16, 2018. Supplementary Information The online version contains supplementary material available at 10.1186/s13012-022-01232-5.
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Affiliation(s)
- Sandra L Spoelstra
- Kirkhof College of Nursing, Grand Valley State University, 301 Michigan St, Room C352, Grand Rapids, MI, 49504, USA.
| | - Monica Schueller
- Kirkhof College of Nursing, Grand Valley State University, 301 Michigan St, Room C352, Grand Rapids, MI, 49504, USA
| | - Viktoria Basso
- Statistics Department, Grand Valley State University, Grand Rapids, USA
| | - Alla Sikorskii
- Department of Psychiatry, Michigan State University, East Lansing, USA
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Hartveit M, Hovlid E, Øvretveit J, Assmus J, Bond G, Joa I, Heiervang K, Stensrud B, Høifødt TS, Biringer E, Ruud T. Can systematic implementation support improve programme fidelity by improving care providers' perceptions of implementation factors? A cluster randomized trial. BMC Health Serv Res 2022; 22:808. [PMID: 35733211 PMCID: PMC9215018 DOI: 10.1186/s12913-022-08168-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 06/02/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Investigations of implementation factors (e.g., collegial support and sense of coherence) are recommended to better understand and address inadequate implementation outcomes. Little is known about the relationship between implementation factors and outcomes, especially in later phases of an implementation effort. The aims of this study were to assess the association between implementation success (measured by programme fidelity) and care providers' perceptions of implementation factors during an implementation process and to investigate whether these perceptions are affected by systematic implementation support. METHODS Using a cluster-randomized design, mental health clinics were drawn to receive implementation support for one (intervention) and not for another (control) of four evidence-based practices. Programme fidelity and care providers' perceptions (Implementation Process Assessment Tool questionnaire) were scored for both intervention and control groups at baseline, 6-, 12- and 18-months. Associations and group differences were tested by means of descriptive statistics (mean, standard deviation and confidence interval) and linear mixed effect analysis. RESULTS Including 33 mental health centres or wards, we found care providers' perceptions of a set of implementation factors to be associated with fidelity but not at baseline. After 18 months of implementation effort, fidelity and care providers' perceptions were strongly correlated (B (95% CI) = .7 (.2, 1.1), p = .004). Care providers perceived implementation factors more positively when implementation support was provided than when it was not (t (140) = 2.22, p = .028). CONCLUSIONS Implementation support can facilitate positive perceptions among care providers, which is associated with higher programme fidelity. To improve implementation success, we should pay more attention to how care providers constantly perceive implementation factors during all phases of the implementation effort. Further research is needed to investigate the validity of our findings in other settings and to improve our understanding of ongoing decision-making among care providers, i.e., the mechanisms of sustaining the high fidelity of recommended practices. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03271242 (registration date: 05.09.2017).
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Affiliation(s)
- Miriam Hartveit
- Valen Hospital Helse Fonna HF, 5451, Valen, Norway. .,Department of Global Public Health and Primary Care, University of Bergen, Box 7804, 5020, Bergen, Norway.
| | - Einar Hovlid
- Department of Social Science, Western Norway University of Applied Sciences, Røyrgata 6, 6856, Sogndal, Norway
| | - John Øvretveit
- Stockholm Health Care Services, Region Stockholm (SLSO) and LIME/MMC, Tomtebodavägen 18A, Karolinska Institutet, Stockholm, Sweden
| | - Jørg Assmus
- Centre for Clinical Research, Haukeland University Hospital, Box 1400, 5021, Bergen, Norway
| | - Gary Bond
- Westat, Rivermill Commercial Center, 85 Mechanic Street, Lebanon, NH, USA
| | - Inge Joa
- Network for Clinical Research in Psychosis, Stavanger University Hospital, Box 8100, 4068, Stavanger, Norway.,Network for Medical Sciences, Faculty of Health, University of Stavanger, Stavanger, Norway
| | - Kristin Heiervang
- Division of Mental Health Services, Akershus University Hospital, Box 1000, 1478, Lørenskog, Norway
| | - Bjørn Stensrud
- Division of Mental Health, Innlandet Hospital Trust, Box 104, 2381, Brumunddal, Norway
| | | | - Eva Biringer
- Valen Hospital Helse Fonna HF, 5451, Valen, Norway.,Department of Research and Innovation, Helse Fonna HF, 5416, Stord, Norway
| | - Torleif Ruud
- Division of Mental Health Services, Akershus University Hospital, Box 1000, 1478, Lørenskog, Norway.,Institute of Clinical Medicine, University of Oslo, Box 1171 Blindern, 0318, Oslo, Norway
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Carter PM, Cunningham RM, Eisman AB, Resnicow K, Roche JS, Cole JT, Goldstick J, Kilbourne AM, Walton MA. Translating Violence Prevention Programs from Research to Practice: SafERteens Implementation in an Urban Emergency Department. J Emerg Med 2022; 62:109-124. [PMID: 34688506 PMCID: PMC8810595 DOI: 10.1016/j.jemermed.2021.09.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 08/06/2021] [Accepted: 09/11/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Youth violence is a leading cause of adolescent mortality, underscoring the need to integrate evidence-based violence prevention programs into routine emergency department (ED) care. OBJECTIVES To examine the translation of the SafERteens program into clinical care. METHODS Hospital staff provided input on implementation facilitators/barriers to inform toolkit development. Implementation was piloted in a four-arm effectiveness-implementation trial, with youth (ages 14-18 years) screening positive for past 3-month aggression randomized to either SafERteens (delivered remotely or in-person) or enhanced usual care (EUC; remote or in-person), with follow-up at post-test and 3 months. During maintenance, ED staff continued in-person SafERteens delivery and external facilitation was provided. Outcomes were measured using the RE-AIM implementation framework. RESULTS SafERteens completion rates were 77.6% (52/67) for remote and 49.1% (27/55) for in-person delivery. In addition to high acceptability ratings (e.g., helpfulness), post-test data demonstrated increased self-efficacy to avoid fighting among patients receiving remote (incidence rate ratio [IRR] 1.22, 95% confidence interval [CI] 1.09-1.36) and in-person (IRR 1.23, 95% CI 1.12-1.36) SafERteens, as well as decreased pro-violence attitudes among patients receiving remote (IRR 0.83, 95% CI 0.75-0.91) and in-person (IRR 0.87, 95% CI 0.77-0.99) SafERteens when compared with their respective EUC groups. At 3 months, youth receiving remote SafERteens reported less non-partner aggression (IRR 0.52, 95% CI 0.31-0.87, Cohen's d -0.39) and violence consequences (IRR 0.47, 95% CI 0.22-1.00, Cohen's d -0.49) compared with remote EUC; no differences were noted for in-person SafERteens delivery. Barriers to implementation maintenance included limited staff availability and a lack of reimbursement codes. CONCLUSIONS Implementing behavioral interventions such as SafERteens into routine ED care is feasible using remote delivery. Policymakers should consider reimbursement for violence prevention services to sustain long-term implementation.
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Affiliation(s)
- Patrick M. Carter
- Univ. of Michigan Injury Prevention Center, 2800 Plymouth Road, NCRC 10-G080, Ann Arbor, MI 48109,Department of Emergency Medicine, Univ. of Michigan Medical School, 1500 East Medical Center Drive, Ann Arbor, MI 48105,Youth Violence Prevention Center, Univ. of Michigan School of Public Health, 1415 Washington Heights, Ann Arbor, MI 48109,Dept of Health Behavior/Health Education, Univ. of Michigan School of Public Health, 1415 Washington Heights 3790A, SPH I, Ann Arbor, MI 48109
| | - Rebecca M. Cunningham
- Univ. of Michigan Injury Prevention Center, 2800 Plymouth Road, NCRC 10-G080, Ann Arbor, MI 48109,Department of Emergency Medicine, Univ. of Michigan Medical School, 1500 East Medical Center Drive, Ann Arbor, MI 48105,Youth Violence Prevention Center, Univ. of Michigan School of Public Health, 1415 Washington Heights, Ann Arbor, MI 48109,Dept of Health Behavior/Health Education, Univ. of Michigan School of Public Health, 1415 Washington Heights 3790A, SPH I, Ann Arbor, MI 48109,Hurley Medical Center, Dept of Emergency Medicine, 1 Hurley Plaza, Flint, MI 48503
| | - Andria B. Eisman
- Youth Violence Prevention Center, Univ. of Michigan School of Public Health, 1415 Washington Heights, Ann Arbor, MI 48109,Dept of Health Behavior/Health Education, Univ. of Michigan School of Public Health, 1415 Washington Heights 3790A, SPH I, Ann Arbor, MI 48109,Division of Kinesiology, Health and Sport Studies, College of Education, Wayne State University, 656 West Kirby, Detroit, MI 48202
| | - Ken Resnicow
- Dept of Health Behavior/Health Education, Univ. of Michigan School of Public Health, 1415 Washington Heights 3790A, SPH I, Ann Arbor, MI 48109
| | - Jessica S. Roche
- Univ. of Michigan Injury Prevention Center, 2800 Plymouth Road, NCRC 10-G080, Ann Arbor, MI 48109,Department of Emergency Medicine, Univ. of Michigan Medical School, 1500 East Medical Center Drive, Ann Arbor, MI 48105
| | - Jennifer Tang Cole
- Univ. of Michigan Injury Prevention Center, 2800 Plymouth Road, NCRC 10-G080, Ann Arbor, MI 48109,Department of Emergency Medicine, Univ. of Michigan Medical School, 1500 East Medical Center Drive, Ann Arbor, MI 48105
| | - Jason Goldstick
- Univ. of Michigan Injury Prevention Center, 2800 Plymouth Road, NCRC 10-G080, Ann Arbor, MI 48109,Department of Emergency Medicine, Univ. of Michigan Medical School, 1500 East Medical Center Drive, Ann Arbor, MI 48105
| | - Amy M. Kilbourne
- Health Services Research and Development Service, Veterans Health Administration, U.S. Dept of Veterans Affairs, Washington, D.C,Department of Learning Health Sciences, Univ. of Michigan Medical School, 1500 East Medical Center Drive, Ann Arbor, MI 48105
| | - Maureen A. Walton
- Univ. of Michigan Injury Prevention Center, 2800 Plymouth Road, NCRC 10-G080, Ann Arbor, MI 48109,Addiction Center, Department of Psychiatry, Univ of Michigan Medical School, 4250 Plymouth Road, Ann Arbor, MI 48109
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9
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Beidas RS, Ahmedani BK, Linn KA, Marcus SC, Johnson C, Maye M, Westphal J, Wright L, Beck AL, Buttenheim AM, Daley MF, Davis M, Elias ME, Jager-Hyman S, Hoskins K, Lieberman A, McArdle B, Ritzwoller DP, Small DS, Wolk CB, Williams NJ, Boggs JM. Study protocol for a type III hybrid effectiveness-implementation trial of strategies to implement firearm safety promotion as a universal suicide prevention strategy in pediatric primary care. Implement Sci 2021; 16:89. [PMID: 34551811 PMCID: PMC8456701 DOI: 10.1186/s13012-021-01154-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 08/24/2021] [Indexed: 01/23/2023] Open
Abstract
Background Insights from behavioral economics, or how individuals’ decisions and behaviors are shaped by finite cognitive resources (e.g., time, attention) and mental heuristics, have been underutilized in efforts to increase the use of evidence-based practices in implementation science. Using the example of firearm safety promotion in pediatric primary care, which addresses an evidence-to-practice gap in universal suicide prevention, we aim to determine: is a less costly and more scalable behavioral economic-informed implementation strategy (i.e., “Nudge”) powerful enough to change clinician behavior or is a more intensive and expensive facilitation strategy needed to overcome implementation barriers? Methods The Adolescent and child Suicide Prevention in Routine clinical Encounters (ASPIRE) hybrid type III effectiveness-implementation trial uses a longitudinal cluster randomized design. We will test the comparative effectiveness of two implementation strategies to support clinicians’ use of an evidence-based firearm safety practice, S.A.F.E. Firearm, in 32 pediatric practices across two health systems. All pediatric practices in the two health systems will receive S.A.F.E. Firearm materials, including training and cable locks. Half of the practices (k = 16) will be randomized to receive Nudge; the other half (k = 16) will be randomized to receive Nudge plus 1 year of facilitation to target additional practice and clinician implementation barriers (Nudge+). The primary implementation outcome is parent-reported clinician fidelity to the S.A.F.E Firearm program. Secondary implementation outcomes include reach and cost. To understand how the implementation strategies work, the primary mechanism to be tested is practice adaptive reserve, a self-report practice-level measure that includes relationship infrastructure, facilitative leadership, sense-making, teamwork, work environment, and culture of learning. Discussion The ASPIRE trial will integrate implementation science and behavioral economic approaches to advance our understanding of methods for implementing evidence-based firearm safety promotion practices in pediatric primary care. The study answers a question at the heart of many practice change efforts: which strategies are sufficient to support change, and why? Results of the trial will offer valuable insights into how best to implement evidence-based practices that address sensitive health matters in pediatric primary care. Trial registration ClinicalTrials.gov, NCT04844021. Registered 14 April 2021. Supplementary Information The online version contains supplementary material available at 10.1186/s13012-021-01154-8.
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Affiliation(s)
- Rinad S Beidas
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Brian K Ahmedani
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, MI, USA
| | - Kristin A Linn
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Steven C Marcus
- School of Social Policy and Practice, University of Pennsylvania, Philadelphia, PA, USA
| | - Christina Johnson
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Melissa Maye
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, MI, USA
| | - Joslyn Westphal
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, MI, USA
| | - Leslie Wright
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Arne L Beck
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | | | - Matthew F Daley
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Molly Davis
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Marisa E Elias
- Department of Pediatrics, Henry Ford Health System, Detroit, MI, USA
| | - Shari Jager-Hyman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Katelin Hoskins
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Adina Lieberman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Bridget McArdle
- Department of Pediatrics, Henry Ford Health System, Detroit, MI, USA
| | - Debra P Ritzwoller
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Dylan S Small
- Wharton School of Business, University of Pennsylvania, Philadelphia, PA, USA
| | | | | | - Jennifer M Boggs
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
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10
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Gloston GF, Day GA, Touchett HN, Marchant-Miros KE, Hogan JB, Chen PV, Amspoker AB, Fletcher TL, Giordano TP, Lindsay JA. Pivoting to Video Telehealth for Delivery of HIV Care During COVID-19: A Brief Report. TELEMEDICINE REPORTS 2021; 2:205-210. [PMID: 34841420 PMCID: PMC8621621 DOI: 10.1089/tmr.2021.0010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/30/2021] [Indexed: 06/13/2023]
Abstract
Background: The rapid spread of the SARS-CoV-2 pandemic obstructed human subjects research, including our own randomized hybrid type 2 effectiveness-implementation trial comparing multidisciplinary HIV care delivered by video telehealth to home (VTH) versus in-person delivery. Methods: Given the Veteran Health Administration's extensive telehealth infrastructure and our team's expertise in personalized implementation of virtual treatments (PIVOT), we shifted our focus to meet the immediate needs of our primary study site (implementation). Our implementation team began training the interdisciplinary infectious diseases clinical team in VTH after declaration of the pandemic in March 2020. We pivoted from a randomized clinical trial recruitment and supported modifications in clinic processes by introducing patients to VTH through personalized telephone calls and mailed brochures to inform them of telehealth options during the pandemic. Adaptations were made to provider locations, with some providers delivering care remotely from home and others delivering virtual care from the clinic. We also modified the external and internal facilitator roles to allow external facilitators to provide one-on-one training, troubleshooting assistance, and delivery of necessary equipment. Results: Within 6 weeks of the emergency declaration of the pandemic, 100% of providers (n = 27) had conducted at least one appointment, with 24.1% (n = 124) of unique patients using VTH. Despite challenges, we capitalized on temporary mandates to assist providers in delivering care virtually. Given our successes, we encourage researchers to be flexible and seek alternative approaches to preserve research efforts in extenuating circumstances. RCT registration: NCT04055207 at clinicaltrials.gov.
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Affiliation(s)
- Gabrielle F. Gloston
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas, USA
- VA South Central Mental Illness Research, Education and Clinical Center, A Virtual Center, Houston, Texas, USA
| | - Giselle A. Day
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas, USA
- VA South Central Mental Illness Research, Education and Clinical Center, A Virtual Center, Houston, Texas, USA
| | - Hilary N. Touchett
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
| | - Kathy E. Marchant-Miros
- VA South Central Mental Illness Research, Education and Clinical Center, A Virtual Center, Houston, Texas, USA
| | - Julianna B. Hogan
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas, USA
- VA South Central Mental Illness Research, Education and Clinical Center, A Virtual Center, Houston, Texas, USA
| | - Patricia V. Chen
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Amber B. Amspoker
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Terri L. Fletcher
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas, USA
- VA South Central Mental Illness Research, Education and Clinical Center, A Virtual Center, Houston, Texas, USA
| | - Thomas P. Giordano
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Jan A. Lindsay
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas, USA
- VA South Central Mental Illness Research, Education and Clinical Center, A Virtual Center, Houston, Texas, USA
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11
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Penney LS, Damush TM, Rattray NA, Miech EJ, Baird SA, Homoya BJ, Myers LJ, Bravata DM. Multi-tiered external facilitation: the role of feedback loops and tailored interventions in supporting change in a stepped-wedge implementation trial. Implement Sci Commun 2021; 2:82. [PMID: 34315540 PMCID: PMC8317410 DOI: 10.1186/s43058-021-00180-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 06/29/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Facilitation is a complex, relational implementation strategy that guides change processes. Facilitators engage in multiple activities and tailor efforts to local contexts. How this work is coordinated and shared among multiple, external actors and the contextual factors that prompt and moderate facilitators to tailor activities have not been well-described. METHODS We conducted a mixed methods evaluation of a trial to improve the quality of transient ischemic attack care. Six sites in the Veterans Health Administration received external facilitation (EF) before and during a 1-year active implementation period. We examined how EF was employed and activated. Data analysis included prospective logs of facilitator correspondence with sites (160 site-directed episodes), stakeholder interviews (a total of 78 interviews, involving 42 unique individuals), and collaborative call debriefs (n=22) spanning implementation stages. Logs were descriptively analyzed across facilitators, sites, time periods, and activity types. Interview transcripts were coded for content related to EF and themes were identified. Debriefs were reviewed to identify instances of and utilization of EF during site critical junctures. RESULTS Multi-tiered EF was supported by two groups (site-facing quality improvement [QI] facilitators and the implementation support team) that were connected by feedback loops. Each site received an average of 24 episodes of site-directed EF; most of the EF was delivered by the QI nurse. For each site, site-directed EF frequently involved networking (45%), preparation and planning (44%), process monitoring (44%), and/or education (36%). EF less commonly involved audit and feedback (20%), brainstorming solutions (16%), and/or stakeholder engagement (5%). However, site-directed EF varied widely across sites and time periods in terms of these facilitation types. Site participants recognized the responsiveness of the QI nurse and valued her problem-solving, feedback, and accountability support. External facilitators used monitoring and dialogue to intervene by facilitating redirection during challenging periods of uncertainty about project direction and feasibility for sites. External facilitators, in collaboration with the implementation support team, successfully used strategies tailored to diverse local contexts, including networking, providing data, and brainstorming solutions. CONCLUSIONS Multi-tiered facilitation capitalizing on emergent feedback loops allowed for tailored, site-directed facilitation. Critical juncture cases illustrate the complexity of EF and the need to often try multiple strategies in combination to facilitate implementation progress. TRIAL REGISTRATION The Protocol-guided Rapid Evaluation of Veterans Experiencing New Transient Neurological Symptoms (PREVENT) is a registered trial ( NCT02769338 ), May 11, 2016-prospectively registered.
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Affiliation(s)
- Lauren S. Penney
- grid.280682.60000 0004 0420 5695VA HSR&D Elizabeth Dole Center of Excellence for Veteran and Caregiver Research, South Texas Veterans Health Care System, San Antonio, TX USA ,grid.267309.90000 0001 0629 5880School of Medicine, University of Texas Health at San Antonio, San Antonio, TX USA
| | - Teresa M. Damush
- grid.280828.80000 0000 9681 3540VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, IN USA ,grid.448342.d0000 0001 2287 2027Regenstrief Institute, Inc., Indianapolis, IN USA ,grid.257413.60000 0001 2287 3919Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN USA
| | - Nicholas A. Rattray
- grid.280828.80000 0000 9681 3540VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, IN USA ,grid.448342.d0000 0001 2287 2027Regenstrief Institute, Inc., Indianapolis, IN USA ,grid.257413.60000 0001 2287 3919Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN USA ,grid.257413.60000 0001 2287 3919Department of Anthropology, Indiana University-Purdue University, Indianapolis, IN USA
| | - Edward J. Miech
- grid.280828.80000 0000 9681 3540VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, IN USA ,grid.448342.d0000 0001 2287 2027Regenstrief Institute, Inc., Indianapolis, IN USA ,grid.257413.60000 0001 2287 3919Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN USA
| | - Sean A. Baird
- grid.280828.80000 0000 9681 3540VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, IN USA
| | - Barbara J. Homoya
- grid.280828.80000 0000 9681 3540VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, IN USA
| | - Laura J. Myers
- grid.280828.80000 0000 9681 3540VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, IN USA
| | - Dawn M. Bravata
- grid.280828.80000 0000 9681 3540VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, IN USA ,grid.448342.d0000 0001 2287 2027Regenstrief Institute, Inc., Indianapolis, IN USA ,grid.257413.60000 0001 2287 3919Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN USA ,grid.257413.60000 0001 2287 3919Department of Neurology, Indiana University School of Medicine, Indianapolis, IN USA
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12
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Ritchie MJ, Parker LE, Kirchner JE. From novice to expert: a qualitative study of implementation facilitation skills. Implement Sci Commun 2020; 1:25. [PMID: 32885184 PMCID: PMC7427882 DOI: 10.1186/s43058-020-00006-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 12/09/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND It is widely reported that facilitation can aid implementation of evidence-based practices. Although scholars agree that facilitators need a diverse range of skills, only a few retrospective studies have identified some of these. During the test of a facilitation strategy within the context of a VA initiative to implement evidence-based care delivery models, we documented the skills an expert external facilitator transferred to two initially novice internal regional facilitators. Ours is the first study to explore facilitation skills as they are being applied and transferred. METHODS Facilitators applied the strategy at eight primary care clinics that lacked implementation capacity in two VA networks. We conducted monthly debriefing interviews over a 30-month period and documented these in detailed notes. External facilitator interviews focused specifically on training and mentoring internal facilitators and the skills that she transferred. We also conducted, recorded, and transcribed two qualitative interviews with each facilitator and queried them about training content and process. We conducted a content analysis of the data, using deductive and inductive methods, to identify skills the external facilitator helped internal facilitators learn. We also explored the complexity of facilitation skills and grouped them into overarching skillsets. RESULTS The external facilitator helped internal facilitators learn 22 complex skills; with few exceptions, these skills were not unique but overlapped with one another. We clustered 21 of these into 5 groups of overarching skillsets: (1) building relationships and creating a supportive environment, (2) changing the system of care and the structure and processes that support it, (3) transferring knowledge and skills and creating infrastructure support for ongoing learning, (4) planning and leading change efforts, and (5) assessing people, processes, and outcomes and creating infrastructure for program monitoring. CONCLUSIONS This study documented a broad range of implementation facilitation skills that are complex and overlapping. Findings suggest that studies and initiatives planning or applying facilitation as an implementation strategy should ensure that facilitators have or have the opportunity to learn the skills they need. Because facilitation skills are complex, the use of didactic methods alone may not be sufficient for transferring skills; future work should explore other methods and techniques.
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Affiliation(s)
- Mona J. Ritchie
- VA Quality Enhancement Research Initiative (QUERI) Program for Team-Based Behavioral Health, Department of Veterans Affairs, 2200 Ft Roots Dr, Building 58, North Little Rock, AR 72114 USA
- Department of Psychiatry, University of Arkansas for Medical Sciences, 4301 W Markham St, #755, Little Rock, AR 72205 USA
| | - Louise E. Parker
- VA Quality Enhancement Research Initiative (QUERI) Program for Team-Based Behavioral Health, Department of Veterans Affairs, 2200 Ft Roots Dr, Building 58, North Little Rock, AR 72114 USA
- Department of Management and Marketing, College of Management, University of Massachusetts, 100 Morrissey Blvd, Boston, MA 02125 USA
| | - JoAnn E. Kirchner
- VA Quality Enhancement Research Initiative (QUERI) Program for Team-Based Behavioral Health, Department of Veterans Affairs, 2200 Ft Roots Dr, Building 58, North Little Rock, AR 72114 USA
- Department of Psychiatry, University of Arkansas for Medical Sciences, 4301 W Markham St, #755, Little Rock, AR 72205 USA
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13
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Miele GM, Caton L, Freese TE, McGovern M, Darfler K, Antonini VP, Perez M, Rawson R. Implementation of the hub and spoke model for opioid use disorders in California: Rationale, design and anticipated impact. J Subst Abuse Treat 2019; 108:20-25. [PMID: 31399272 DOI: 10.1016/j.jsat.2019.07.013] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 05/25/2019] [Accepted: 07/22/2019] [Indexed: 11/18/2022]
Abstract
As part of the State Targeted Response to the opioid epidemic, California has adopted the Hub and Spoke model to expand access to medications for opioid use disorder, particularly buprenorphine, throughout the state. By aligning opioid treatment programs as hubs with primary care, office-based practitioners, and other health care settings as spokes, a broader treatment model can reach more people with opioid use disorder, improve access to medications for opioid use disorders, and decrease overdose deaths. Expanding access requires expanding knowledge and intensive implementation support of new practices. This paper describes the rationale, specific activities and anticipated impact of the implementation plan in California's Hub and Spoke system. Training and technical assistance are designed to: increase the number and capacity of waivered prescribers; enhance skills of prescribers and multidisciplinary teams; and create systems change. Activities include buprenorphine waiver trainings and provider support, a practice facilitator program, Project ECHO sessions, webinars, clinical skills trainings, and regional learning collaboratives. This overview highlights the steps California is taking to build treatment capacity to address the opioid epidemic.
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Affiliation(s)
- Gloria M Miele
- University of California, Los Angeles Integrated Substance Abuse Programs, 11075 Santa Monica Blvd., #200, Los Angeles, CA 90025, United States of America; David Geffen School of Medicine at UCLA, 11075 Santa Monica Blvd., #200, Los Angeles, CA 90025, United States of America.
| | - Lauren Caton
- Stanford University School of Medicine, 1520 Page Mill Road, MC 5265, Palo Alto, CA 94304, United States of America.
| | - Thomas E Freese
- University of California, Los Angeles Integrated Substance Abuse Programs, 11075 Santa Monica Blvd., #200, Los Angeles, CA 90025, United States of America; David Geffen School of Medicine at UCLA, 11075 Santa Monica Blvd., #200, Los Angeles, CA 90025, United States of America.
| | - Mark McGovern
- Stanford University School of Medicine, 1520 Page Mill Road, MC 5265, Palo Alto, CA 94304, United States of America.
| | - Kendall Darfler
- University of California, Los Angeles Integrated Substance Abuse Programs, 11075 Santa Monica Blvd., #200, Los Angeles, CA 90025, United States of America; David Geffen School of Medicine at UCLA, 11075 Santa Monica Blvd., #200, Los Angeles, CA 90025, United States of America.
| | - Valerie Pearce Antonini
- University of California, Los Angeles Integrated Substance Abuse Programs, 11075 Santa Monica Blvd., #200, Los Angeles, CA 90025, United States of America; David Geffen School of Medicine at UCLA, 11075 Santa Monica Blvd., #200, Los Angeles, CA 90025, United States of America.
| | - Marlies Perez
- California Department of Health Care Services, 1500 Capitol Ave, Sacramento, CA 95814, United States of America.
| | - Richard Rawson
- University of California, Los Angeles Integrated Substance Abuse Programs, 11075 Santa Monica Blvd., #200, Los Angeles, CA 90025, United States of America; David Geffen School of Medicine at UCLA, 11075 Santa Monica Blvd., #200, Los Angeles, CA 90025, United States of America; Center for Behavior and Health, University of Vermont, 1 So Prospect Street, Burlington, VT 05405, United States of America.
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14
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Peixoto MVDS, Chaves SCL. Analysis of the national hearing health care policy implementation in a Brazilian State. Codas 2019; 31:e20180092. [PMID: 31271577 DOI: 10.1590/2317-1782/20182018092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 10/30/2018] [Indexed: 11/21/2022] Open
Abstract
PURPOSE The present study aimed to analyze the degree of implementation of the national health care policy at the state level. METHODS This qualitative evaluation study was carried out in two stages. Firstly, the policy was modelled by means of document analysis and the application of the Delphi technique for consensus among experts. In the second stage, a qualitative, exploratory evaluative research was conducted, designed as a single case study in a Brazilian state through semi-structured interviews with health managers. RESULTS The experts reached a consensus for a logical model and an evaluation matrix of the policy implementation. The results at the state level evinced an incipient degree of implementation, as the level of government characteristics achieved 45% of the maximum score; management, 41%; and system organization, 33%. CONCLUSION The degree of implementation in the state evaluated was classified as incipient. Barriers were identified in the management and organization levels of the system, as well as in the political context.
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15
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Quanbeck A. Using Stakeholder Values to Promote Implementation of an Evidence-Based Mobile Health Intervention for Addiction Treatment in Primary Care Settings. JMIR Mhealth Uhealth 2019; 7:e13301. [PMID: 31237841 PMCID: PMC6746086 DOI: 10.2196/13301] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 04/26/2019] [Accepted: 05/11/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Most evidence-based practices (EBPs) do not find their way into clinical use, including evidence-based mobile health (mHealth) technologies. The literature offers implementers little practical guidance for successfully integrating mHealth into health care systems. OBJECTIVE The goal of this research was to describe a novel decision-framing model that gives implementers a method of eliciting the considerations of different stakeholder groups when they decide whether to implement an EBP. METHODS The decision-framing model can be generally applied to EBPs, but was applied in this case to an mHealth system (Seva) for patients with addiction. The model builds from key insights in behavioral economics and game theory. The model systematically identifies, using an inductive process, the perceived gains and losses of different stakeholder groups when they consider adopting a new intervention. The model was constructed retrospectively in a parent implementation research trial that introduced Seva to 268 patients in 3 US primary care clinics. Individual and group interviews were conducted to elicit stakeholder considerations from 6 clinic managers, 17 clinicians, and 6 patients who were involved in implementing Seva. Considerations were used to construct decision frames that trade off the perceived value of adopting Seva versus maintaining the status quo from each stakeholder group's perspective. The face validity of the decision-framing model was assessed by soliciting feedback from the stakeholders whose input was used to build it. RESULTS Primary considerations related to implementing Seva were identified for each stakeholder group. Clinic managers perceived the greatest potential gain to be better care for patients and the greatest potential loss to be cost (ie, staff time, sustainability, and opportunity cost to implement Seva). All clinical staff considered time their foremost consideration-primarily in negative terms (eg, cognitive burden associated with learning a new system) but potentially in positive terms (eg, if Seva could automate functions done manually). Patients considered safety (anonymity, privacy, and coming from a trusted source) to be paramount. Though payers were not interviewed directly, clinic managers judged cost to be most important to payers-whether Seva could reduce total care costs or had reimbursement mechanisms available. This model will be tested prospectively in a forthcoming mHealth implementation trial for its ability to predict mHealth adoption. Overall, the results suggest that implementers proactively address the cost and burden of implementation and seek to promote long-term sustainability. CONCLUSIONS This paper presents a model implementers may use to elicit stakeholders' considerations when deciding to adopt a new technology, considerations that may then be used to adapt the intervention and tailor implementation, potentially increasing the likelihood of implementation success. TRIAL REGISTRATION ClinicalTrials.gov NCT01963234; https://clinicaltrials.gov/ct2/show/NCT01963234 (Archived by WebCite at http://www.webcitation.org/78qXQJvVI).
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Affiliation(s)
- Andrew Quanbeck
- Department of Family Medicine and Community Health, University of Wisconsin-Madison, Madison, WI, United States
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Douglas NF, Affoo RH. Certified Nursing Assistants Want to Use External Memory Aids for Residents With Dementia: Survey Results Within an Implementation Science Framework. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2019; 28:591-598. [PMID: 31136234 DOI: 10.1044/2018_ajslp-18-0118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Purpose The purpose of this study was to assess the self-perceived knowledge and self-efficacy of certified nursing assistants (CNAs) when using external memory aids to enhance the communication and independence of residents with dementia living in skilled nursing facilities (SNFs). Method One hundred forty-four CNAs completed a measure pertaining to self-perceived knowledge and self-efficacy of external memory aids. Results CNAs had favorable beliefs about the usefulness of external memory aids to help both conversation and independence in activities of daily living for residents with dementia ( M = 4.0, SD = 0.84; M = 3.92, SD = 0.85) on a 5-point Likert scale, with 5 = strongly agree and 1 = strongly disagree. There were no statistically significant differences between CNAs who reported being trained to use external memory aids with residents with dementia and CNAs who reported they were not trained according to items related to self-efficacy ( U = 2203.5, z = -1.483, p = .138; U = 2179, z = -1.547, p = .122; U = 2115, z = -1.82, p = .069; U = 2320, z = -0.942, p = .346). Conclusions Results of this study indicated that the lack of uptake of external memory aids for residents with dementia in SNFs may not solely be due to lack of buy-in or lack of time on the part of the CNA. Speech-language pathologists should provide this training to support the uptake of external memory aids for residents with dementia; however, these data suggest that current training methods may not be considerate of the nuances of implementation. Speech-language pathologists and researchers should consider the finer aspects of theoretically grounded facilitation techniques as next steps to the broader implementation of this intervention for residents with dementia living in SNFs.
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Affiliation(s)
- Natalie F Douglas
- Department of Communication Sciences and Disorders, Central Michigan University, Mount Pleasant
| | - Rebecca H Affoo
- Department of Communication Sciences and Disorders, Central Michigan University, Mount Pleasant
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Midboe AM, Martino S, Krein SL, Frank JW, Painter JT, Chandler M, Schroeder A, Fenton BT, Troszak L, Erhardt T, Kerns RD, Becker WC. Testing implementation facilitation of a primary care-based collaborative care clinical program using a hybrid type III interrupted time series design: a study protocol. Implement Sci 2018; 13:145. [PMID: 30486877 PMCID: PMC6262952 DOI: 10.1186/s13012-018-0838-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 11/13/2018] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Dissemination of evidence-based practices that can reduce morbidity and mortality is important to combat the growing opioid overdose crisis in the USA. Research and expert consensus support reducing high-dose opioid therapy, avoiding risky opioid-benzodiazepine combination therapy, and promoting multi-modal, collaborative models of pain care. Collaborative care interventions that support primary care providers have been effective in medication tapering. We developed a patient-centered Primary Care-Integrated Pain Support (PIPS) collaborative care clinical program based on effective components of previous collaborative care interventions. Implementation facilitation, a multi-faceted and dynamic strategy involving the provision of interactive problem-solving and support during implementation of a new program, is used to support key organizational staff throughout PIPS implementation. The primary aim of this study is to evaluate the effectiveness of the implementation facilitation strategy for implementing and sustaining PIPS in the Veterans Health Administration (VHA). The secondary aim is to examine the effect of the program on key patient-level clinical outcomes-transitioning to safer regimens and enhancing access to complementary and integrative health treatments. The tertiary aim is to determine the categorical costs and ultimate budget impact of PIPS implementation. METHODS This multi-site study employs an interrupted time series, hybrid type III design to evaluate the effectiveness of implementation facilitation for a collaborative care clinical program-PIPS-in primary care clinics in three geographically diverse VHA health care systems (sites). Participants include pharmacists and allied staff involved in the delivery of clinical pain management services as well as patients. Eligible patients are prescribed either an outpatient opioid prescription greater than or equal to 90 mg morphine equivalent daily dose or a combination opioid-benzodiazepine regimen. They must also have an upcoming appointment in primary care. The Consolidated Framework for Implementation Research will guide the mixed methods work across the formative evaluation phases and informs the selection of activities included in implementation facilitation. The RE-AIM framework will be used to assess Reach, Effectiveness, Adoption, Implementation, and Maintenance of PIPS. DISCUSSION This implementation study will provide important insight into the effectiveness of implementation facilitation to enhance uptake of a collaborative care program in primary care, which targets unsafe opioid prescribing practices.
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Affiliation(s)
- Amanda M Midboe
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Stanford University, 795 Willow Rd (152-MPD), Menlo Park, CA, 94025, USA.
| | - Steve Martino
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT, USA
- Yale School of Medicine, New Haven, CT, USA
| | - Sarah L Krein
- Center for Clinical Management Research (CCMR), VA Ann Arbor, Ann Arbor, MI, USA
- University of Michigan School of Medicine, Ann Arbor, MI, USA
| | - Joseph W Frank
- VA Eastern Colorado Healthcare System, HSR&D Center for Veteran-Centered and Value-Driven Care, Denver, CO, USA
- University of Colorado School of Medicine, Aurora, CO, USA
| | - Jacob T Painter
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, AR, USA
- Division of Pharmaceutical Evaluation and Policy, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Michael Chandler
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, AR, USA
- Division of Pharmaceutical Evaluation and Policy, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Allison Schroeder
- VA Eastern Colorado Healthcare System, HSR&D Center for Veteran-Centered and Value-Driven Care, Denver, CO, USA
| | - Brenda T Fenton
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT, USA
- Yale School of Medicine, New Haven, CT, USA
| | - Lara Troszak
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Stanford University, 795 Willow Rd (152-MPD), Menlo Park, CA, 94025, USA
| | - Taryn Erhardt
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Stanford University, 795 Willow Rd (152-MPD), Menlo Park, CA, 94025, USA
| | - Robert D Kerns
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT, USA
- Yale School of Medicine, New Haven, CT, USA
| | - William C Becker
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT, USA
- Yale School of Medicine, New Haven, CT, USA
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Ritchie MJ, Parker LE, Edlund CN, Kirchner JE. Using implementation facilitation to foster clinical practice quality and adherence to evidence in challenged settings: a qualitative study. BMC Health Serv Res 2017; 17:294. [PMID: 28424052 PMCID: PMC5397744 DOI: 10.1186/s12913-017-2217-0] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Accepted: 04/01/2017] [Indexed: 12/03/2022] Open
Abstract
Background We evaluated a facilitation strategy to help clinical sites likely to experience challenges implement evidence-based Primary Care-Mental Health Integration (PC-MHI) care models within the context of a Department of Veterans Affairs (VA) initiative. This article describes our assessment of whether implementation facilitation (IF) can foster development of high quality PC-MHI programs that adhere to evidence, are sustainable and likely to improve clinical practices and outcomes. Methods Utilizing a matched pair design, we conducted a qualitative descriptive evaluation of the IF strategy in sixteen VA primary care clinics. To assess program quality and adherence to evidence, we conducted one-hour structured telephone interviews, at two time points, with clinicians and leaders who knew the most about the clinics’ programs. We then created structured summaries of the interviews that VA national PC-MHI experts utilized to rate the programs on four dimensions (overall quality, adherence to evidence, sustainability and level of improvement). Results At first assessment, seven of eight IF sites and four of eight comparison sites had implemented a PC-MHI program. Our qualitative assessment suggested that experts rated IF sites’ programs higher than comparison sites’ programs with one exception. At final assessment, all eight IF but only five comparison sites had implemented a PC-MHI program. Again, experts rated IF sites’ programs higher than their matched comparison sites with one exception. Over time, all ratings improved in five of seven IF sites and two of three comparison sites. Conclusions Implementing complex evidence-based programs, particularly in settings that lack infrastructure, resources and support for such efforts, is challenging. Findings suggest that a blend of external expert and internal regional facilitation strategies that implementation scientists have developed and tested can improve PC-MHI program uptake, quality and adherence to evidence in primary care clinics with these challenges. However, not all sites showed these improvements. To be successful, facilitators likely need at least a moderate level of leaders’ support, including provision of basic resources. Additionally, we found that IF and strength of leadership structure may have a synergistic effect on ability to implement higher quality and evidence-based programs. Electronic supplementary material The online version of this article (doi:10.1186/s12913-017-2217-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Mona J Ritchie
- Department of Veterans Affairs, VA Quality Enhancement Research Initiative (QUERI) Program for Team-Based Behavioral Health, 2200 Ft Roots Dr, Bdg 58, North Little Rock, AR, 72114, USA. .,Department of Psychiatry, University of Arkansas for Medical Sciences, 4301 W Markham St, #755, Little Rock, AR, 72205, USA.
| | - Louise E Parker
- Department of Veterans Affairs, VA Quality Enhancement Research Initiative (QUERI) Program for Team-Based Behavioral Health, 2200 Ft Roots Dr, Bdg 58, North Little Rock, AR, 72114, USA.,Department of Management and Marketing, College of Management, University of Massachusetts, 100 Morrissey Blvd, Boston, MA, 02125, USA
| | - Carrie N Edlund
- Department of Veterans Affairs, VA Quality Enhancement Research Initiative (QUERI) Program for Team-Based Behavioral Health, 2200 Ft Roots Dr, Bdg 58, North Little Rock, AR, 72114, USA.,Department of Psychiatry, University of Arkansas for Medical Sciences, 4301 W Markham St, #755, Little Rock, AR, 72205, USA
| | - JoAnn E Kirchner
- Department of Veterans Affairs, VA Quality Enhancement Research Initiative (QUERI) Program for Team-Based Behavioral Health, 2200 Ft Roots Dr, Bdg 58, North Little Rock, AR, 72114, USA.,Department of Psychiatry, University of Arkansas for Medical Sciences, 4301 W Markham St, #755, Little Rock, AR, 72205, USA
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McCullough MB, Gillespie C, Petrakis BA, Jones EA, Park AM, Lukas CV, Rose AJ. Forming and activating an internal facilitation group for successful implementation: A qualitative study. Res Social Adm Pharm 2017; 13:1014-1027. [PMID: 28434918 DOI: 10.1016/j.sapharm.2017.04.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2016] [Revised: 03/19/2017] [Accepted: 04/07/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND This study focuses on an implementation facilitation strategy to improve the delivery of anticoagulation care within pharmacy-run clinics across 8 Veterans Health Administration (VA) medical centers. Other studies have explored various models of implementation facilitation, including external facilitation (EF), internal facilitation (IF), and blended facilitation (BF) combining both approaches. This study focuses on the use of an internal facilitation team of anticoagulation coordinators representing 8 VA anticoagulation clinics to enhance the implementation process. This study examines how the team became instrumental in the successful implementation of evidence-based practice change. METHODS Semi-structured interviews were conducted annually over 4 years with representatives from each site, the internal facilitators (site champions), at 8 VA hospitals (47 interviews). Additionally, five external facilitators, experts in quality improvement and anticoagulation care who guided the implementation, were interviewed. Analysis drew on a deductive approach based on the Promoting Action on Research Implementation in Health Services (PARIHS) model and emergent thematic analysis to identify factors related to effectiveness of the internal facilitation team. RESULTS Key findings are that the following factors enhanced successful uptake of the anticoagulation initiative: 1) Regular participation by the site champion in the internal facilitation team; 2) Champion strongly committed to being an agent of change; and 3) Champion received greater support from their supervisors. The first and second factors are interrelated, as internal facilitators who actively and regularly participated in the internal facilitation team often became truly committed to the improvement project. Both factors relate to the third, as supervisor support not only facilitated changes in practice, but also facilitated regular team attendance and stronger participation. CONCLUSIONS Our study adds to implementation science by detailing how internal facilitators learn their skills over time, and how a group of internal facilitators can help each other succeed. These findings can guide those who wish to incorporate internal facilitation teams as an implementation strategy, and demonstrate how sites can build capacity for implementation efforts. SYNOPSIS This study focuses on an implementation facilitation strategy to improve the delivery of anticoagulation care within pharmacy-run clinics across 8 Veterans Health Administration medical centers. Internal facilitators (IFs) guided by and supported by an external facilitators (EF), successfully implemented the clinical innovation. This study examines how the IF group became instrumental in the successful implementation of evidence-based practice change.
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Affiliation(s)
- Megan B McCullough
- VA HSR&D Center for Healthcare Organization and Implementation Research, ENRM Veterans Hospital, 200 Springs Road, Bedford, MA, 01730, USA; Boston University School of Public Health, Department of Health Law, Policy and Management, 715 Albany St # 358w, Boston, MA, 02118, USA.
| | - Chris Gillespie
- VA HSR&D Center for Healthcare Organization and Implementation Research, ENRM Veterans Hospital, 200 Springs Road, Bedford, MA, 01730, USA
| | - Beth Ann Petrakis
- VA HSR&D Center for Healthcare Organization and Implementation Research, ENRM Veterans Hospital, 200 Springs Road, Bedford, MA, 01730, USA
| | - Ellen A Jones
- Central Western Massachusetts VA Healthcare System, 421 North Main Street, Leeds, MA, 01053, USA
| | - Angela M Park
- New England VERC, Boston VA Healthcare System, 1400 VFW Parkway, West Roxbury, MA, 02132, USA
| | - Carol VanDeusen Lukas
- VA HSR&D Center for Healthcare Organization and Implementation Research, VA Boston Medical Center, 1400 VFW Parkway, West Roxbury, MA, 02132, USA; Boston University School of Public Health, Department of Health Law, Policy and Management, 715 Albany St # 358w, Boston, MA, 02118, USA
| | - Adam J Rose
- VA HSR&D Center for Healthcare Organization and Implementation Research, ENRM Veterans Hospital, 200 Springs Road, Bedford, MA, 01730, USA; Department of Internal Medicine, Section of General Internal Medicine, Boston University School of Medicine, 72 East Concord Street, Boston, MA, 02118, USA
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Abstract
Purpose
Implementing health promotion programmes in schools is key to improving children’s health and well-being but difficulties in achieving expected results are often reported in the research literature. Discrepancies between expected and achieved outcomes can originate from differences in contexts. Understanding how interactions between contexts and programmes generate variable outcomes is, therefore, critical. The purpose of this paper is to explore the outputs of a programme implemented in different school contexts. The focus is to pinpoint outputs, understand the involvement of combinations of contextual factors and identify recurrences in these combinations.
Design/methodology/approach
This retrospective study covers a period from 2006 to 2016. Data collection includes two sets of data in eight high schools in the Rhône-Alpes Region in France: written documents and interviews with school staff. Realist evaluation is used to attempt to pinpoint outputs and relating contextual factors.
Findings
Results highlight the limited outputs of the programme. Differences between schools appear to originate from existing school policy prior to participation, existence of a project team, identification of the issue as priority and staff turnover. Analysis of contextual factors led to considering the implementation process as enabling health capacity building and enhanced the capacity of settings and communities to promote health.
Research limitations/implications
The data provided remain partial as there was high staff turnover, reluctance to participate due to failure to implement the project, and schools being over burdened with other requests.
Originality/value
Previous research suggests that top-down implementation of a standard programme is not an efficient strategy for all schools to engage in the development of suitable health promotion policies. A potential way forward is to base support for the local development of health promotion in schools on a better understanding of the contexts in which implementation occurs.
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Selove R, Birken SA, Skolarus TA, Hahn EE, Sales A, Proctor EK. Using Implementation Science to Examine the Impact of Cancer Survivorship Care Plans. J Clin Oncol 2016; 34:3834-3837. [PMID: 27621409 PMCID: PMC5477985 DOI: 10.1200/jco.2016.67.8060] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Affiliation(s)
- Rebecca Selove
- Rebecca Selove, Tennessee State University, Nashville, TN; Sarah A. Birken, The University of North Carolina at Chapel Hill, Chapel Hill, NC; Ted A. Skolarus, University of Michigan; Veterans Affairs Health Services Research and Development Center for Clinical Management Research; and Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI; Erin E. Hahn, Kaiser Permanente Southern California, Pasadena, CA; Anne Sales, University of Michigan, Ann Arbor, MI; and Enola K. Proctor, Washington University in St Louis, St Louis, MO
| | - Sarah A Birken
- Rebecca Selove, Tennessee State University, Nashville, TN; Sarah A. Birken, The University of North Carolina at Chapel Hill, Chapel Hill, NC; Ted A. Skolarus, University of Michigan; Veterans Affairs Health Services Research and Development Center for Clinical Management Research; and Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI; Erin E. Hahn, Kaiser Permanente Southern California, Pasadena, CA; Anne Sales, University of Michigan, Ann Arbor, MI; and Enola K. Proctor, Washington University in St Louis, St Louis, MO
| | - Ted A Skolarus
- Rebecca Selove, Tennessee State University, Nashville, TN; Sarah A. Birken, The University of North Carolina at Chapel Hill, Chapel Hill, NC; Ted A. Skolarus, University of Michigan; Veterans Affairs Health Services Research and Development Center for Clinical Management Research; and Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI; Erin E. Hahn, Kaiser Permanente Southern California, Pasadena, CA; Anne Sales, University of Michigan, Ann Arbor, MI; and Enola K. Proctor, Washington University in St Louis, St Louis, MO
| | - Erin E Hahn
- Rebecca Selove, Tennessee State University, Nashville, TN; Sarah A. Birken, The University of North Carolina at Chapel Hill, Chapel Hill, NC; Ted A. Skolarus, University of Michigan; Veterans Affairs Health Services Research and Development Center for Clinical Management Research; and Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI; Erin E. Hahn, Kaiser Permanente Southern California, Pasadena, CA; Anne Sales, University of Michigan, Ann Arbor, MI; and Enola K. Proctor, Washington University in St Louis, St Louis, MO
| | - Anne Sales
- Rebecca Selove, Tennessee State University, Nashville, TN; Sarah A. Birken, The University of North Carolina at Chapel Hill, Chapel Hill, NC; Ted A. Skolarus, University of Michigan; Veterans Affairs Health Services Research and Development Center for Clinical Management Research; and Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI; Erin E. Hahn, Kaiser Permanente Southern California, Pasadena, CA; Anne Sales, University of Michigan, Ann Arbor, MI; and Enola K. Proctor, Washington University in St Louis, St Louis, MO
| | - Enola K Proctor
- Rebecca Selove, Tennessee State University, Nashville, TN; Sarah A. Birken, The University of North Carolina at Chapel Hill, Chapel Hill, NC; Ted A. Skolarus, University of Michigan; Veterans Affairs Health Services Research and Development Center for Clinical Management Research; and Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI; Erin E. Hahn, Kaiser Permanente Southern California, Pasadena, CA; Anne Sales, University of Michigan, Ann Arbor, MI; and Enola K. Proctor, Washington University in St Louis, St Louis, MO
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PARIHS revisited: from heuristic to integrated framework for the successful implementation of knowledge into practice. Implement Sci 2016; 11:33. [PMID: 27013464 PMCID: PMC4807546 DOI: 10.1186/s13012-016-0398-2] [Citation(s) in RCA: 584] [Impact Index Per Article: 73.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Revised: 02/17/2016] [Accepted: 02/27/2016] [Indexed: 01/17/2023] Open
Abstract
Background The Promoting Action on Research Implementation in Health Services, or PARIHS framework, was first published in 1998. Since this time, work has been ongoing to further develop, refine and test it. Widely used as an organising or conceptual framework to help both explain and predict why the implementation of evidence into practice is or is not successful, PARIHS was one of the first frameworks to make explicit the multi-dimensional and complex nature of implementation as well as highlighting the central importance of context. Several critiques of the framework have also pointed out its limitations and suggested areas for improvement. Discussion Building on the published critiques and a number of empirical studies, this paper introduces a revised version of the framework, called the integrated or i-PARIHS framework. The theoretical antecedents of the framework are described as well as outlining the revised and new elements, notably, the revision of how evidence is described; how the individual and teams are incorporated; and how context is further delineated. We describe how the framework can be operationalised and draw on case study data to demonstrate the preliminary testing of the face and content validity of the revised framework. Summary This paper is presented for deliberation and discussion within the implementation science community. Responding to a series of critiques and helpful feedback on the utility of the original PARIHS framework, we seek feedback on the proposed improvements to the framework. We believe that the i-PARIHS framework creates a more integrated approach to understand the theoretical complexity from which implementation science draws its propositions and working hypotheses; that the new framework is more coherent and comprehensive and at the same time maintains it intuitive appeal; and that the models of facilitation described enable its more effective operationalisation. Electronic supplementary material The online version of this article (doi:10.1186/s13012-016-0398-2) contains supplementary material, which is available to authorized users.
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