Implementation and dissemination of a transition of care program for rural veterans: a controlled before and after study

Abstract

BackgroundAdapting promising health care interventions to local settings is a critical component in the dissemination and implementation process. The Veterans Health Administration (VHA) rural transitions nurse program (TNP) is a nurse-led, Veteran-centered intervention designed to improve transitional care for rural Veterans funded by VA national offices for dissemination to other VA sites serving a predominantly rural Veteran population. Here, we describe our novel approach to the implementation and evaluation = the TNP.MethodsThis is a controlled before and after study that assesses both implementation and intervention outcomes. During pre-implementation, we assessed site context using a mixed method approach with data from diverse sources including facility-level quantitative data, key informant and Veteran interviews, observations of the discharge process, and a group brainstorming activity. We used the Practical Robust Implementation and Sustainability Model (PRISM) to inform our inquiries, to integrate data from all sources, and to identify factors that may affect implementation. In the implementation phase, we will use internal and external facilitation, paired with audit and feedback, to encourage appropriate contextual adaptations. We will use a modified Stirman framework to document adaptations. During the evaluation phase, we will measure intervention and implementation outcomes at each site using the RE-AIM framework (Reach, Effectiveness, Adoption, Implementation, and Maintenance). We will conduct a difference-in-differences analysis with propensity-matched Veterans and VA facilities as a control. Our primary intervention outcome is 30-day readmission and Emergency Department visit rates. We will use our findings to develop an implementation toolkit that will inform the larger scale-up of the TNP across the VA.DiscussionThe use of PRISM to inform pre-implementation evaluation and synthesize data from multiple sources, coupled with internal and external facilitation, is a novel approach to engaging sites in adapting interventions while promoting fidelity to the intervention. Our application of PRISM to pre-implementation and midline evaluation, as well as documentation of adaptations, provides an opportunity to identify and address contextual factors that may impede or enhance implementation and sustainability of health interventions and inform dissemination.

What does it take to scale‐up a complex intervention? Lessons learned from the Connect‐Home transitional care intervention

“…The contextual factors that influenced when Connect‐Home implementation was successful were similar to those identified by other studies (Colon‐Emeric et al, ; Leonard et al, ; Norton, Ladwig, Caprio, Quill, & Temkin‐Greener, ). Staff turnover and poor communication were particularly detrimental to efforts to implement complex interventions in the SNFs.…”

Systematic, Multimethod Assessment of Adaptations Across Four Diverse Health Systems Interventions

“…The third project, titled Improving Veterans Transition Back to VA Primary Care Following Non-VHA Hospitalization (Community Transitions), focuses on care coordination of those Veterans admitted to non-VHA community hospitals for inpatient care and transition back to VHA primary care in a safe, patient-centered and timely manner ( 11 ). The fourth project, the Transitions Nurse Program (Rural Transitions), is a proactive, personalized, nurse-led and Veteran-centered intervention to improve access for rural Veterans to follow-up with their PACT teams following hospitalization at a larger urban VHA Medical Center (VAMC) ( 12 ).…”

Strengthening Patient-Centered Care in the VHA: A Relational Model of Change

“…Some structures can be redesigned locally. 10 But these local redesigns will be hard to sustain until they become the basis for a system-wide redesign of HR practices.…”