Purpose: We describe an approach to rapidly adapt and implement an education and skills improvement intervention to address the needs of family caregivers of functionally impaired veterans-Helping Invested Families Improve Veterans' Experience Study (HI-FIVES). Design: Prior to implementation in eight sites, a multidisciplinary study team made systematic adaptations to the curriculum content and delivery process using input from the original randomized controlled trial (RCT); a stakeholder advisory board comprised of national experts in caregiver education, nursing, and implementation; and a veteran/caregiver engagement panel. To address site-specific implementation barriers in diverse settings, we applied the Replicating Effective Programs implementation framework. Findings: Adaptations to HI-FIVES content and delivery included identifying core/noncore curriculum components, reducing instruction time, and simplifying caregiver recruitment for clinical settings. To enhance curriculum flexibility and potential uptake, site personnel were able to choose which staff would deliver the intervention and whether to offer class sessions in person or remotely. Curriculum materials were standardized and packaged to reduce the time required for implementation and to promote fidelity to the intervention.
Background
Caring for a growing aging population using existing long-term care resources while simultaneously supporting and educating family caregivers, is a public health challenge.
We describe the application of the Replicating Effective Programs (REP) framework, developed by the Centers for Disease Control Prevention and used in public health program implementation, to scale up an evidence-based family caregiver training intervention in the Veterans Affairs (VA) healthcare system.
Methods
From 2018 to 2020, clinicians at eight VA medical centers received REP-guided implementation including facilitation, technical assistance, and implementation tools to deliver the training program. The project team used the REP framework to develop activities across four distinct phases – (1) pre-conditions, (2) pre-implementation, (3) implementation, and (4) maintenance and evolution – and systematically tracked implementation facilitators, barriers, and adaptations.
Results
Within the REP framework, results describe how each medical center adapted implementation approaches to fit local needs. We highlight examples of how sites balanced adaptations and intervention fidelity.
Conclusions
The REP framework shows promise for national expansion of the caregiver training intervention, including to non-VA systems of care, because it allows sites to adapt while maintaining intervention fidelity.
Trial registration
NCT03474380. Date registered: March 22, 2018.
Despite access to a growing menu of evidence-based interventions, public health practitioners continue to underuse them, in part because practitioners may require new knowledge, skills, and resources to do so. Numerous foundations, universities, governmental agencies, and consultants are providing trainings to address the gaps in practitioners' capacity. To most significantly affect population health, these trainings need to reach practitioners who may have limited access to on-site trainings. Despite the number of organizations offering trainings, little is known about how to scale up trainings to efficiently extend their reach or how to tailor trainings to the needs of different intervention. The Cancer Prevention and Control Research Network and its collaborating centers have developed a training curriculum and delivered it in both in-person and distance formats to a range of audiences. The purpose of this article is to describe the training curriculum and findings from the Network's evaluation of approaches used to scale up delivery of the "Putting Public Health Evidence in Action" curriculum and tailor content for specific evidence-based interventions.
Implementation strategies are activities to support integration of evidence-based programs (EBPs) into routine care. Comprised of 170+ facilities, the Veterans Affairs (VA) Healthcare System is conducive to evaluating feasibility and scalability of implementation strategies on a national level. In previous work evaluating implementation of three EBPs for older Veterans (hospital-based walking, caregiver skills training, group physical therapy), we found facilities varied in their need for implementation support, with some needing minimal guidance and others requiring intensive support. Committed to national scalability, our team developed an implementation intensification model consisting of foundational (low-touch) and enhanced (high-touch) implementation support. This Forum article describes our multi-level and multi-step process to develop and evaluate implementation intensification. Steps included: (1) Review completed trial data; (2) Conduct listening sessions; (3) Review literature; (4) Draft foundational and enhanced implementation support packages; (5) Iteratively refine packages; and, (6) Devise an evaluation plan. Our model of implementation intensification may be relevant to other healthcare systems seeking strategies that can adapt to diverse delivery settings, optimize resources, help build capacity, and ultimately enhance implementation outcomes. As more healthcare systems focus on spread of EBPs into routine care, identifying scalable and effective implementation strategies will be critical.
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