How do inner and outer settings affect implementation of a community-based innovation for older adults with a serious illness: a qualitative study

Abstract

Background Implementing community-based innovations for older adults with serious illness, who are appropriate for a palliative approach to care, requires developing partnerships between health and community. Nav-CARE is an evidence-based innovation wherein trained volunteer navigators advocate, facilitate community connections, coordinate access to resources, and promote active engagement of older adults within their communities. Acknowledging the importance of partnerships between organizations, the aim of our study was to use the Consolidated Framework for Implementation Research (CFIR) to explore organizational (Inner Setting) and community or health system level (Outer Setting) barriers and facilitators to Nav-CARE implementation. Methods Guided by CFIR, qualitative individual and group interviews were conducted to examine the implementation of Nav-CARE in a Canadian community. Participants were individuals who delivered or managed Nav-CARE research, and stakeholders who provided services in the community. The Framework Method was used to analyse the data. Particular attention was paid to the host organization’s external network and community context. Results Implementation was affected by several inter-related CFIR domains, making it difficult to meaningfully separate key findings by only inner and outer settings. Thus, findings were organized into themes informed by CFIR, that cut across other domains and incorporated inductive findings: intraorganizational perceptions of Nav-CARE; public and healthcare professionals’ perceptions of palliative care; interorganizational partnerships and relationships; community and national-level factors that should have facilitated Nav-CARE implementation; and suggested changes to Nav-CARE. Themes demonstrated barriers to implementing Nav-CARE, such as poor organizational readiness for implementation, and public and health provider perceptions palliative care was synonymous with fast-approaching death. Conclusions Implementation science frameworks and theories commonly focus on assessing implementation of innovations within facilities and changing behaviours of individuals within that organizational structure. Implementation frameworks need to be adapted to better assess Outer Setting factors that affect implementation of community-based programs. Although applying the CFIR helped uncover critical elements in the Inner and Outer Settings that affected implementation of Nav-CARE. Our study suggests that the CFIR could expand the Outer Setting to acknowledge and assess organizational structures and beliefs of individuals within organizations external to the host organization who impact successful implementation of community-based innovations.

Scaling out a palliative compassionate community innovation: Nav-CARE

“…These barriers and facilitators related to public knowledge and perceptions of palliative care; social and financial organizational capital; and skilled leadership. 24 , 28 In the study reported in this article, we were able to analyze those factors across diverse contexts to develop a more nuanced understanding of the factors that must be in place to produce a robust and sustainable program. These four factors were organizational capacity, stable and engaged leadership, a focused client population, and skillful messaging.…”

“…health and community systems), the inner organizational setting where Nav-CARE was implemented, the characteristics of the individuals involved in implementing Nav-CARE, and the process of delivering Nav-CARE. 28 The mixed-method data collection strategy was guided by the four research questions:…”

User Perspectives on a Resilience-Building App (JoyPop): Qualitative Study

“…Because the nature of each laboratory session was group based, this same format was selected for the interviews in an effort to maximize involvement while minimizing scheduling challenges and participant burden. This structure also enabled questions to be asked systematically in a direct manner by the interviewer to each participant on an individual level (in contrast with a focus group, where participants interact more with one another) [ 48 - 50 ]. One-on-one interviews were conducted when only 1 participant among those attending the post-app session expressed interest in participating or when a participant wished to participate but had a scheduling conflict with the group-based session.…”

Around the EQUATOR with clinician‐scientists transdisciplinary aging research (Clin‐STAR) principles: Implementation science challenges and opportunities

“…More frequently, older adult researchers have used CFIR in nursing homes and acute care settings 10,13 . Ongoing efforts to adapt CFIR for frail older adult primary care populations are underway, as is the work to conceptualize inner and outer settings that affect community‐based innovations for those with more severe injury or illness in complex healthcare settings 17–19 …”