Fidelity and Adaptation of Implementation Strategies to Support - PowerPoint PPT Presentation

Fidelity and Adaptation of Implementation Strategies to Support Primary Care in Improving Cardiovascular Preventive Care Bijal Balasubramanian, MBBS, PhD 10 th Annual Conference on the Science of Dissemination and Implementation in Health Dec 5, 2017

Background | Practice Facilitation  Multifaceted approach to improve adoption of evidence-based guidelines and innovative care delivery models  Identify areas of improvement, set care improvement goals and  Effective in helping practices make quality improvements and is provide tools and approaches to reach these goals associated with:  Support may be provided on site, virtually or through a  Increasing practice’s ability to make and sustain changes combination of modes  Assisting VA practices with integrating mental health services into primary care clinics (Ritchie et al., 2017)  Improving prevention, diabetes care, smoking cessation and cancer care (Armstrong et al., 2016)  Increasing PCPs adoption of evidence based practices into routine care (Baskerville et al., 2011)

Challenges  Intervention fidelity is considered a hallmark of rigorous practice improvement trials and of scrupulous implementation and dissemination  Trade-off between:  fid ity 1 fideli lity and fle flexi xibil ilit  rig levance 2 rigor and rele  A growing literature suggests that facilitation may increase the transportability and effectiveness of practice change interventions 3 through local adaptation and tailoring  We had the opportunity to examine variation in facilitation frequency and dose in a large D&I initiative called EvidenceNOW 1 Cohen DJ, Crabtree BF, Etz RS, Balasubramnaian, et al. Fidelity versus flexibility: translating evidence-based research into practice. Am J Prev Med. 2008;35:S381-S389.Werner JJ, 2 Stange KC. Praxis-based research networks: An emerging paradigm for research that is rigorous, relevant, and inclusive. J Am Board Fam Med. 2014;27(6):730-735

Background | EvidenceNOW EvidenceNOW is focusing on helping primary care practices use the latest evidence to improve the heart health of Americans

Background | EvidenceNOW

Background | ESCALATES  Evaluating System Change and Learning and Taking Evidence to Scale  ESCALATES is the national evaluation for EvidenceNOW.  The ESCALATES team is studying which practice implementation and quality improvement strategies are most effective across the seven regional cooperatives participating in this initiative.

Background | Practice Characteristics 100% 80% Urban core 63.5% 60% 2-5 clinicians 46.6% Clinician owned 40.4% 40% Hospital, FQHC,RHC, Solo practice HS IHS,Fed Rural 23.9% 22.9% 6-10 21.6% area 11+ clinicians Large town 20% 15.8% clinicians Other/none 13.7% 13.5% Suburban 10.7% 9.9% 7.2% 0% Practice size Practice ownership Location

Introduction | Objective  Cooperative philosophy to PF and facilitators’ perspectives on need for adaptations  Assess fidelity to intervention  Number of f PF encounters pla lanned vs. received  Describe variation in dose of practice facilitation received by practices across EvidenceNow

Methods | Measures  Facilitator Intervention Logs  Duration: le length of vis isit its or amount of tim ime per in interval  Mode: method of contact. In In-person, , web, , phone, , etc.  Date: date of contact or in interval l of contact  Qualitative observations  Sit Site vis isit its to cooperatives and practices  Onlin line dia iary ry entrie ies  Se Semi-structured in interviews

EvidenceNOW Practice Facilitators Healthy Hearts Heart Healthy Healthy Evidence Heart of HealthyHearts Cooperative Name in the Health Hearts Hearts for NOW Virginia NYC Heartland Now! Northwest Oklahoma Southwest Healthcare Illinois Idaho Colorado North Cooperative Region Indiana Oregon New York City Oklahoma New Mexico Virginia Carolina Wisconsin Washington Median Distance to 26 116 107 10 107 61 104 Practices in Miles (0-331) (2-290) (1-819) (0-24) (0-351) (5-380) (1-375) (range) # of Organizations Providing 6 9 2 2 2 14 2* Facilitation # of Practice 17 15 16 17 24 32 21 Facilitators # of Practices 227 245 209 315 254 211 249 Enrolled *One system used 5 internal PFs

Results | Cooperative Philosophy to PF Cooperativ ives var arie ied in in th their ir philo ilosophie ies rela lated to o need for ad adaptation  “ Practice facilitation is s an art rt, and you have to decipher what your team needs, what their gaps are… we wanted to make sure that each intervention was as s si simil ilar as s poss ssib ible le, and then we also understood that there was going ing to be e devi viatio ions based on what the practice needs were.” (Interview, Cooperative 3; Implementation Lead)  “We have a visi visit t number that we're trying to meet by the end of their 12-month intervention. At first I'm like, ‘I'm never going to be able to meet that. How am I going to do that?’ Then, it's like, ‘Whoa. Wait on. I have to slow down.’” (Interview, Cooperative 7; PF)  “We (Cooperative leadership) were pres rescrip iptiv ive about a few of the visits the coaches would have with their sites during the intervention. The other visits should and will be determin ined by th the e nee eeds of f th the e si site/team, the relationship of the coach with the team, the data, the knowledge of the coach about how the site is doing, etc...” (Diaries, Cooperative 4; Implementation Lead)

Results | PF views of adaptations PFs s vie viewed determ rmin inin ing the needs of the practic ice and tail ilorin ing the in interv rventio ion to th those needs as s im important  “ Being able to adapt is is a huge part of f th this pro roject. We always meet practices where they are, and work forward from there. And we are always looking for little successes to help keep our practices on track with their intervention, and understand that change is a process .” (Diaries, Cooperative 5; PF)  “ We have th the same tools, I I don't 't th think we use th them th the same ways. Also, the teams are different too. So one experience that you have at one health center is not going to be the same at a different health center.” (Interview, Cooperative 3; PF )

Results | Variation in frequency of PF Coop. 2 Coop. 3 Coop. 4 Coop. 6 Coop. 1 N=75 N=195 N=189 N=161 N=116 Planned # of PF visits 12 13 5 to 15 18 to 20 as needed % practices receiving 19 98 14 20 planned # of PF visits Mean (SD) number of 9.27 (4.95) 17.02 (4.23) 15.01 (6.91) 12.36 (7.67) received touches Minimum and maximum 1, 28 12, 53 1, 46 1, 31 number of received touches

Results Number of hours of facilitation per month Variation in dose of PF

Conclusion  Expert implementers and researchers in EvidenceNOW varied in their philosophy about adapting practice facilitation, but all expected some level of adaptation  Frequency and dose of PF varied widely in this large, multi-site initiative focused on scaling up PF as an implementation strategy to improve ABCS of heart health and practice capacity  Adapting to practice needs and QI capacity is essential in supporting practices to improve process and outcomes

Strengths and Limitations  Large, national initiative provide opportunity to examine variations in intended frequency and dose of PF strategy  All llows furt rther exp xplo loratio ion of reasons for r var aria iatio ions  Lacked data at this time on “what” types of support facilitators/coaches are providing to practices and why  Th Thus, , dif iffic icult lt to as assess nature of ad adaptatio ions they mak ake

Implications and Future Analyses  PF is an effective strategy but expensive  Understanding why PFs/coaches ad adapt im implementation strategy to practice needs is is im important for:  Determining optimal l dose, fr frequency, and duratio ion of f PF needed for im improving outcomes such as ABCS of f heart health  Important to pay attention to the trade-off between:  Fid idelity to pla lanned in interv rvention (ri (rigor) an and  Fle lexibili lity/adaptation to practice needs (r (relevance)

T HANK Y OU ! C ONTACT I NFORMATION BIJAL B ALASUBRAMANIAN , MBBS,P H D QUANTITATIVE TEAM LEAD BIJAL . A . BALASUBRAMANIAN @ UTH . TMC . EDU @ BIJALBALA PI : DEBORAH COHEN , PH . D . COHENDJ @ OHSU . EDU AHRQ Grant #: R01 HS023940-01 escalates@ohsu.edu escalates.org @ESCALATESorg

Thank you EvidenceNOW Cooperatives  Midwest – PI: Abel Kho  Northwest – PI: Michael Parchman  Southwest – PI: Perry Dickinson  North Carolina – PI: Sam Cykert  Virginia – PI: Tony Kuzel  NYC – PI: Donna Shelley  Oklahoma – PI: Dan Duffy

Q UESTIONS ? C OMMENTS ? T HOUGHTS ? AHRQ Grant #: R01 HS023940-01 escalates@ohsu.edu escalates.org @ESCALATESorg