Operationalizing an Implementation Framework to Disseminate a Care Coordination Program for Rural Veterans.

OBJECTIVE: Understanding how to successfully implement care coordination programs across diverse settings is critical for disseminating best practices. We describe how we operationalized the Practical Robust Implementation and Sustainability Model (PRISM) to guide the assessment of local context prior to implementation of the rural Transitions Nurse Program (TNP) at five facilities across the Veterans Health Administration (VHA). METHODS: We operationalized PRISM to create qualitative data collection techniques (interview guides, semi-structured observations, and a group brainwriting premortem) to assess local context, the current state of care coordination, and perceptions of TNP prior to implementation at five facilities. We analyzed data using deductive-inductive framework analysis to identify themes related to PRISM. We adapted implementation strategies at each site using these findings. RESULTS: We identified actionable themes within PRISM domains to address during implementation. The most commonly occurring PRISM domains were "organizational characteristics" and "implementation and sustainability infrastructure." Themes included a disconnect between primary care and hospital inpatient teams, concerns about work duplication, and concerns that one nurse could not meet the demand for the program. These themes informed TNP implementation. CONCLUSIONS: The use of PRISM for pre-implementation site assessments yielded important findings that guided adaptations to our implementation approach. Further, barriers and facilitators to TNP implementation may be common to other care coordination interventions. Generating a common language of barriers and facilitators in care coordination initiatives will enhance generalizability and establish best practices. IMPACT STATEMENTS: TNP is a national intensive care coordination program targeting rural Veterans. We operationalized PRISM to guide implementation efforts. We effectively elucidated facilitators, barriers, and unique contextual factors at diverse VHA facilities. The use of PRISM enhances the generalizability of findings across care settings and may optimize implementation of care coordination interventions in the VHA.

Practical Use of Process Mapping to Guide Implementation of a Care Coordination Program for Rural Veterans.

BACKGROUND: Transitions of care are high risk for vulnerable populations such as rural Veterans, and adequate care coordination can alleviate many risks. Single-center care coordination programs have shown promise in improving transitional care practices. However, best practices for implementing effective transitional care interventions are unknown, and a common pitfall is lack of understanding of the current process at different sites. The rural Transitions Nurse Program (TNP) is a Veterans Health Administration (VA) intervention that addresses the unique transitional care coordination needs of rural Veterans, and it is currently being implemented in five VA facilities. OBJECTIVE: We sought to employ and study process mapping as a tool for assessing site context prior to implementation of TNP, a new care coordination program. DESIGN AND PARTICIPANTS: Observational qualitative study guided by the Lean Six Sigma approach. Data were collected in January-March 2017 through interviews, direct observations, and group sessions with front-line staff, including VA providers, nurses, and administrative staff from five VA Medical Centers and nine rural Patient-Aligned Care Teams. KEY RESULTS: We integrated key informant interviews, observational data, and group sessions to create ten process maps depicting the care coordination process prior to TNP implementation at each expansion site. These maps were used to adapt implementation through informing the unique role of the Transitions Nurse at each site and will be used in evaluating the program, which is essential to understanding the program's impact. CONCLUSIONS: Process mapping can be a valuable and practical approach to accurately assess site processes before implementation of care coordination programs in complex systems. The process mapping activities were useful in engaging the local staff and simultaneously guided adaptations to the TNP intervention to meet local needs. Our approach-combining multiple data sources while adapting Lean Six Sigma principles into practical use-may be generalizable to other care coordination programs.

Brainwriting Premortem: A Novel Focus Group Method to Engage Stakeholders and Identify Preimplementation Barriers.

BACKGROUND: Many health care interventions encounter implementation challenges because of inadequate stakeholder engagement and identification of barriers. The brainwriting premortem technique is the silent sharing of written ideas about why an intervention failed. The method can engage stakeholders and identify barriers more efficiently than traditional brainstorming focus groups. PURPOSE: We evaluated the method during a transition of care intervention in the Veterans Health Administration (VA). Clinicians from 10 VA facilities participated in 10 brainwriting premortem sessions. METHODS: Using descriptive and content analytic methods, we assessed the quantity and quality of ideas generated, facilitator experience, and participant psychological safety. RESULTS: In total, 217 unique ideas were generated. Many were deemed high quality. The written data were immediately available for analysis, allowing rapid feedback and real-time decision making. Participants reported high satisfaction and psychological safety. CONCLUSION: The brainwriting premortem approach is a novel, efficient alternative to brainstorming focus groups that can rapidly inform program implementation at minimal cost.

Evaluating the Quality of Patient Decision-Making Regarding Post-Acute Care.

BACKGROUND: Despite a national focus on post-acute care brought about by recent payment reforms, relatively little is known about how hospitalized older adults and their caregivers decide whether to go to a skilled nursing facility (SNF) after hospitalization. OBJECTIVE: We sought to understand to what extent hospitalized older adults and their caregivers are empowered to make a high-quality decision about utilizing an SNF for post-acute care and what contextual or process elements led to satisfaction with the outcome of their decision once in SNF. DESIGN: Qualitative inquiry using the Ottawa Decision Support Framework (ODSF), a conceptual framework that describes key components of high-quality decision-making. PARTICIPANTS: Thirty-two previously community-dwelling older adults (≥ 65 years old) and 22 caregivers interviewed at three different hospitals and three skilled nursing facilities. MAIN MEASURES: We used key components of the ODSF to identify elements of context and process that affected decision-making and to what extent the outcome was characteristic of a high-quality decision: informed, values based, and not associated with regret or blame. KEY RESULTS: The most important contextual themes were the presence of active medical conditions in the hospital that made decision-making difficult, prior experiences with hospital readmission or SNF, relative level of caregiver support, and pressure to make a decision quickly for which participants felt unprepared. Patients described playing a passive role in the decision-making process and largely relying on recommendations from the medical team. Patients commonly expressed resignation and a perceived lack of choice or autonomy, leading to dissatisfaction with the outcome. CONCLUSIONS: Understanding and intervening to improve the quality of decision-making regarding post-acute care supports is essential for improving outcomes of hospitalized older adults. Our results suggest that simply providing information is not sufficient; rather, incorporating key contextual factors and improving the decision-making process for both patients and clinicians are also essential.

How Hospital Clinicians Select Patients for Skilled Nursing Facilities.

OBJECTIVE: To understand how hospital-based clinicians evaluate older adults in the hospital and decide who will be transferred to a skilled nursing facility (SNF) for postacute care. DESIGN: Semistructured interviews paired with a qualitative analytical approach informed by Social Constructivist theory. SETTING: Inpatient care units in three hospitals. Purposive sampling was used to maximize variability in hospitals, units within hospitals, and staff on those units. PARTICIPANTS: Clinicians (hospitalists, nurses, therapists, social workers, case managers) involved in evaluation and decision-making regarding postacute care (N = 25). MEASUREMENTS: Central themes related to clinician evaluation and discharge decision-making. RESULTS: Clinicians described pressure to expedite evaluation and discharge decisions, resulting in the use of SNFs as a "safety net" for older adults being discharged from the hospital. The lack of hospital-based clinician knowledge of SNF care practices, quality, or patient outcomes resulted in lack of a standardized evaluation process or a clear primary decision-maker. CONCLUSION: Hospital clinician evaluation and decision-making about postacute care in SNFs may be characterized as rushed, without a clear system or framework for making decisions and uninformed by knowledge of SNF or patient outcomes in those discharged to SNFs. This leads to SNFs being used as a "safety net" for many older adults. As hospitals and SNFs are increasingly held jointly accountable for outcomes of individuals transitioning between hospitals and SNFs, novel solutions for improving evaluation and decision-making are urgently needed.

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

BACKGROUND: Adapting 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. METHODS: This 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. DISCUSSION: The 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.