Examining the sustainability potential of a multisite pilot to integrate alcohol screening and brief intervention within three primary care systems

Abstract

The U.S. Preventive Services Task Force recommends that clinicians adopt universal alcohol screening and brief intervention as a routine preventive service for adults, and efforts are underway to support its widespread dissemination. The likelihood that healthcare systems will sustain this change, once implemented, is under-reported in the literature. This article identifies factors that were important to postimplementation sustainability of an evidence-based practice change to address alcohol misuse that was piloted within three diverse primary care organizations. The Centers for Disease Control and Prevention funded three academic teams to pilot and evaluate implementation of alcohol screening and brief intervention within multiclinic healthcare systems in their respective regions. Following the completion of the pilots, teams used the Program Sustainability Assessment Tool to retrospectively describe and compare differences across eight sustainability domains, identify strengths and potential threats to sustainability, and make recommendations for improvement. Health systems varied across all domains, with greatest differences noted for Program Evaluation, Strategic Planning, and Funding Stability. Lack of funding to sustain practice change, or data monitoring to promote fit and fidelity, was an indication of diminished Organizational Capacity in systems that discontinued the service after the pilot. Early assessment of sustainability factors may identify potential threats that could be addressed prior to, or during implementation to enhance Organizational Capacity. Although this study provides a retrospective assessment conducted by external academic teams, it identifies factors that may be relevant for translating evidence-based behavioral interventions in a way that assures that they are sustained within healthcare systems.

Planning for Implementation Success Using RE-AIM and CFIR Frameworks: A Qualitative Study

“…The interview guide was developed by an external co-investigator removed from day-to-day project operations, and an internal project manager, using the interview guide tool available on the CFIR website (20). Both developers were experienced applying RE-AIM (6,26) and other implementation frameworks (2,10). They reviewed the CFIR interview guide tool to identify questions relevant to adopting, implementing and post-trial maintenance of an internally developed, technologybased intervention.…”

“…While our use of the two frameworks in combination enabled us to not only evaluate, the who, what, where, when and how (RE-AIM) but to also explain why (CFIR) implementation may have succeeded or failed, particularly with regard to the presence or absence of pull factors (e.g., tension for change or peer pressure), other frameworks, such as PRISM, include contextual variables useful to adapting interventions to improve their fit and feasibility (38). Also, outcome-specific frameworks such as the Program Sustainability Assessment Tool (39), which focuses on setting-level maintenance, can be used to define the sets of conditions that need to be present or absent to sustain practice change (10,40).…”

“…Reflecting and evaluating Anticipate that specific preferences, needs, or demands may change given the amount of time that often elapses between proposal, funding, and study completion; Continue to engage (or re-engage) leaders throughout the study; Continue to review implementation protocols, share feedback; Disseminate progress or new evidence throughout the study, to elicit or maintain pull using CFIR constructs to explain and improve performance on RE-AIM domains. Second, applying analytic methods, such as qualitative comparative analysis (10), to compare sets of factors or conditions that are sufficient or necessary to implementation success, may help to inform appropriate implementation strategies. Third, using measures to quantitively model the pathways in which CFIR factors moderate (pull) or mediate (push) RE-AIM results may lead to an integrated conceptual model that will improve their complementary use.…”

“…The framework's emphasis on balancing rigor with relevance is clearly important to adoption, implementation and maintenance (9). Implementation success (i.e., post-trial sustainment of an intervention, with protocols and infrastructure in place to assure continued fidelity) can depend on the extent that an organization has internal capacity (10) and is willing to accommodate the intervention by modifying setting systems, protocols, and/or roles (11); and the extent that researchers are willing to adapt the intervention, so that it fits and is feasible to maintain long-term (3).…”

Influence of Participation in a Quality Improvement Collaborative on Staff Perceptions of Organizational Sustainability

“…[16] It is scored using a 7-point Likert scale (1 = little to no extent; 7 = a very great extent). The PSAT has been utilized to assess staff perceptions about sustainability for interventions targeting chronic conditions (e.g., asthma) and evidence based practices such as falls prevention strategies or alcohol screening and brief intervention [19][20][21][22][23][24].…”