Logistical Considerations and Clinical Outcomes Associated With Converting Operating Rooms Into an Intensive Care Unit During the Coronavirus Disease 2019 Pandemic in a New York City Hospital.

BACKGROUND: Coronavirus disease 2019 (COVID-19) emerged as a public health crisis that disrupted normal patterns of health care in the New York City metropolitan area. In preparation for a large influx of critically ill patients, operating rooms (ORs) at NewYork-Presbyterian/Columbia University Irving Medical Center (NYP-Columbia) were converted into a novel intensive care unit (ICU) area, the operating room intensive care unit (ORICU). METHODS: Twenty-three ORs were converted into an 82-bed ORICU. Adaptations to the OR environment permitted the delivery of standard critical care therapies. Nonintensive-care-trained staff were educated on the basics of critical care and deployed in a hybrid staffing model. Anesthesia machines were repurposed as critical care ventilators, with accommodations to ensure reliable function and patient safety. To compare ORICU survivorship to outcomes in more traditional environments, we performed Kaplan-Meier survival analysis of all patients cared for in the ORICU, censoring data at the time of ORICU closure. We hypothesized that age, sex, and obesity may have influenced the risk of death. Thus, we estimated hazard ratios (HR) for death using Cox proportional hazard regression models with age, sex, and body mass index (BMI) as covariables and, separately, using older age (65 years and older) adjusted for sex and BMI. RESULTS: The ORICU cared for 133 patients from March 24 to May 14, 2020. Patients were transferred to the ORICU from other ICUs, inpatient wards, the emergency department, and other institutions. Patients remained in the ORICU until either transfer to another unit or death. As the hospital patient load decreased, patients were transferred out of the ORICU. This process was completed on May 14, 2020. At time of data censoring, 55 (41.4%) of patients had died. The estimated probability of survival 30 days after admission was 0.61 (95% confidence interval [CI], 0.52-0.69). Age was significantly associated with increased risk of mortality (HR = 1.05, 95% CI, 1.03-1.08, P < .001 for a 1-year increase in age). Patients who were ≥65 years were an estimated 3.17 times more likely to die than younger patients (95% CI, 1.78-5.63; P < .001) when adjusting for sex and BMI. CONCLUSIONS: A large number of critically ill COVID-19 patients were cared for in the ORICU, which substantially increased ICU capacity at NYP-Columbia. The estimated ORICU survival rate at 30 days was comparable to other reported rates, suggesting this was an effective approach to manage the influx of critically ill COVID-19 patients during a time of crisis.

Work disability negotiations between supervisors and occupational health services: factors that support supervisors in work disability management.

PURPOSE: A work disability negotiation takes place between a supervisor, the disabled employee and the occupational health service (OHS) to support the disabled employee in returning to their work, often with temporary work accommodation. The objective of this study was to define the factors of a work disability negotiation with OHS that supported or hindered supervisors in their task/role in work disability management. METHODS: The study setting comprised two parts: the creation of survey questions and the actual survey of supervisors (N = 254) from six public and private organizations in Finland. Of these, 133 (52%) had participated in one or more work disability negotiations. The responses covered about 240 work disability cases and considerably more negotiations. RESULTS: The study identified four key elements that the supervisors expressed as major success factors in the negotiations. First, it was crucial that the supervisors learned about the employee's health restrictions and understood the issues relating to their work disability. Second, the parties should aim for common solutions and conclusions through collaboration. Third, active participation of all the negotiation parties is important. The supervisors gave a high rating to OHS taking their views seriously. Last, the supervisors appreciated collaboration in a constructive atmosphere. CONCLUSION: In order for a negotiation to help supervisors in their challenges, it should reach solutions, conclusions and a restructured comprehension of the work disability problem in a constructive atmosphere and with active communication between stakeholders.

Implementation of Supervised Exercise Therapy for Patients With Symptomatic Peripheral Artery Disease: A Science Advisory From the American Heart Association.

Patients with lower-extremity peripheral artery disease (PAD) have greater functional impairment, faster functional decline, increased rates of mobility loss, and poorer quality of life than people without PAD. Supervised exercise therapy (SET) improves walking ability, overall functional status, and health-related quality of life in patients with symptomatic PAD. In 2017, the Centers for Medicare & Medicaid Services released a National Coverage Determination (CAG-00449N) for SET programs for patients with symptomatic PAD. This advisory provides a practical guide for delivering SET programs to patients with PAD according to Centers for Medicare & Medicaid Services criteria. It summarizes the Centers for Medicare & Medicaid Services process and requirements for referral and coverage of SET and provides guidance on how to implement SET for patients with PAD, including the SET protocol, options for outcome measurement, and transition to home-based exercise. This advisory is based on the guidelines established by the Centers for Medicare & Medicaid Services for Medicare beneficiaries in the United States and is intended to assist clinicians and administrators who are implementing SET programs for patients with PAD.

Logistics of an advanced therapy medicinal product during COVID-19 pandemic in Italy: successful delivery of mesenchymal stromal cells in dry ice.

BACKGROUND: During the coronavirus disease-2019 (COVID-19) pandemic, Italian hospitals faced the most daunting challenges of their recent history, and only essential therapeutic interventions were feasible. From March to April 2020, the Laboratory of Advanced Cellular Therapies (Vicenza, Italy) received requests to treat a patient with severe COVID-19 and a patient with acute graft-versus-host disease with umbilical cord-derived mesenchymal stromal cells (UC-MSCs). Access to clinics was restricted due to the risk of contagion. Transport of UC-MSCs in liquid nitrogen was unmanageable, leaving shipment in dry ice as the only option. METHODS: We assessed effects of the transition from liquid nitrogen to dry ice on cell viability; apoptosis; phenotype; proliferation; immunomodulation; and clonogenesis; and validated dry ice-based transport of UC-MSCs to clinics. RESULTS: Our results showed no differences in cell functionality related to the two storage conditions, and demonstrated the preservation of immunomodulatory and clonogenic potentials in dry ice. UC-MSCs were successfully delivered to points-of-care, enabling favourable clinical outcomes. CONCLUSIONS: This experience underscores the flexibility of a public cell factory in its adaptation of the logistics of an advanced therapy medicinal product during a public health crisis. Alternative supply chains should be evaluated for other cell products to guarantee delivery during catastrophes.

A Mixed Methods Study of the Association of Non-Veterans Affairs Care With Veterans' and Clinicians' Experiences of Care Coordination.

BACKGROUND: Poor coordination between the Department of Veterans Affairs (VA) and non-VA care may negatively impact health care quality. Recent legislation is intended to increase Veterans' access to care, in part through increased use of non-VA care. However, a possible consequence may be diminished patient experiences of coordination. OBJECTIVE: The objective of this study was to determine VA patients' and clinicians' experiences of coordination across VA and non-VA settings. DESIGN: Observational mixed methods using patient surveys and clinician interviews. Sampled patients were diagnosed with type 2 diabetes mellitus and either cardiovascular or mental health comorbidities. PARTICIPANTS AND MEASURES: Patient perspectives on coordination were elicited between April and September 2016 through a national survey supplemented with VA administrative records (N=5372). Coordination was measured with the 8-dimension Patient Perceptions of Integrated Care survey. Receipt of non-VA care was measured through patient self-report. Clinician perspectives were elicited through individual interviews (N=100) between May and October 2017. RESULTS: Veterans who received both VA and non-VA care reported significantly worse care coordination experiences than Veterans who only receive care in VA. Clinicians report limited information exchange capabilities, which, combined with bureaucratic and opaque procedures, adversely impact clinical decision-making. CONCLUSIONS: VA is working through a shift in how Veterans receive health care by increasing access to care from non-VA providers. Study findings suggest that VA should prioritize coordination of care in addition to access. This could include requiring monitoring of patient-experienced care coordination, surveys of referring and consulting clinicians, and pilot testing and evaluation of interventions to improve coordination.

Use of Statewide Administrative Data to Assess Clinical Outcomes: A Retrospective Cohort Study of Therapeutic Anticoagulation for Isolated Calf Vein Thrombosis.

BACKGROUND: Single-center comparative effectiveness studies evaluating outcomes that can occur posthospitalization may become biased if outcomes diagnosed at other facilities are not ascertained. Administrative datasets that link patients' records across facilities may improve outcome ascertainment. OBJECTIVE: To determine whether use of linked administrative data significantly augments thromboembolic outcome ascertainment. RESEARCH DESIGN: Retrospective cohort study. SUBJECTS: Patients with an acute isolated calf deep vein thrombosis (DVT) diagnosed at 1 Californian center during 2010-2013. MEASURES: Proximal DVT or pulmonary embolism (PE) within 180 days. We ascertained outcomes from linked California hospitalization, emergency department, and ambulatory surgery data and compared this information to outcomes previously identified from review of the center's medical records. RESULTS: Among 384 patients with an isolated calf DVT, 333 could be linked to longitudinal administrative data records. Ten patients had a possible proximal DVT or PE (4 more clearly so) from administrative data; all were unknown from medical record review. Eleven patients with known outcomes from medical record review had no outcome from administrative data. The adjusted odds ratio of proximal DVT or PE with therapeutic anticoagulation attenuated from 0.33 [95% confidence interval (CI), 0.12-0.87] using only medical record review to 0.64 (95% CI, 0.29-1.40) using both medical record review and possible outcomes from administrative data. Restricting the outcome to diagnoses clearly involving proximal DVT or PE, the adjusted odds ratio was 0.46 (95% CI, 0.19-1.10). CONCLUSIONS: Use of linked hospital administrative data augmented detection of outcomes but imperfect linkage, nonspecific diagnoses, and documentation/coding errors introduced uncertainty regarding the accuracy of outcome ascertainment.

Planning and coordination of the radiological response to the coronavirus disease 2019 (COVID-19) pandemic: the Singapore experience.

Coronavirus disease 2019 (COVID-19) has spread fast and extensively around the world, with significant mortality and morbidity. As this is a respiratory infection, chest radiography and computed tomography (CT) are important imaging techniques in the work-up of this disease. Given its highly infectious nature, cross-infection within the healthcare setting and radiology departments needs to be addressed actively and prevented. We describe the response of radiology departments in Singapore to this pandemic, in terms of diagnosis, re-configuration of the department, re-organisation and segregation of staff, infection control, managerial, and leadership issues.

Fisheries management impacts on target species status.

Fisheries management systems around the world are highly diverse in their design, operation, and effectiveness at meeting objectives. A variety of management institutions, strategies, and tactics are used across disparate regions, fishing fleets, and taxonomic groups. At a global level, it is unclear which particular management attributes have greatest influence on the status of fished populations, and also unclear which external factors affect the overall success of fisheries management systems. We used expert surveys to characterize the management systems by species of 28 major fishing nations and examined influences of economic, geographic, and fishery-related factors. A Fisheries Management Index, which integrated research, management, enforcement, and socioeconomic attributes, showed wide variation among countries and was strongly affected by per capita gross domestic product (positively) and capacity-enhancing subsidies (negatively). Among 13 management attributes considered, three were particularly influential in whether stock size and fishing mortality are currently in or trending toward desirable states: extensiveness of stock assessments, strength of fishing pressure limits, and comprehensiveness of enforcement programs. These results support arguments that the key to successful fisheries management is the implementation and enforcement of science-based catch or effort limits, and that monetary investment into fisheries can help achieve management objectives if used to limit fishing pressure rather than enhance fishing capacity. Countries with currently less-effective management systems have the greatest potential for improving long-term stock status outcomes and should be the focus of efforts to improve fisheries management globally.

Clinical supervision in cognitive behavior therapy improves therapists' competence: a single-case experimental pilot study.

Clinical supervision is a cornerstone in psychotherapists' training but there are few empirical evaluations on the effects of supervision on therapists' competencies. The aim of this study was therefore to evaluate the effects of standardized supervision on rater-assessed competency in Cognitive Behavior Therapy (CBT). Six therapists with basic training in CBT were provided with protocol-based clinical supervision in CBT in a single-case experimental multiple baseline design. The supervision focused on specific CBT competencies and used experiential learning methods such as role-play. Each therapist recorded weekly treatment sessions during phases without and with supervision. The therapists' CBT competence was assessed by third-party raters using the Revised Cognitive Therapy Scale (CTS-R). Statistical analyses showed that the therapists' CTS-R scores increased significantly during the phase with supervision with a mean item increase of M = 0.71 (range = 0.50-1.0) on the supervision focus areas. This is one of the first empirical studies that can confirm that supervision affect CBT competencies. The results also suggest that supervision can be manualized and that supervisees have a positive perception of more active training methods. Further studies are needed to replicate the results and to find ways to improve the impact of supervision.

How collaborative practice agreements impede the provision of vital behavioral health services.

BACKGROUND: The critical shortage of behavioral health professionals impairs the ability of the U.S. health care system to respond to the growing demand for services to address mental illness and substance use disorders. PURPOSE: To identify how restrictive state regulations act as barriers to full utilization of psychiatric mental health advanced practice registered nurses (PMH-APRN), whose scope of practice enables them to provide a full range of behavioral health services. METHODS: A sequential mixed methods study combining interview data (n = 94) from a qualitative study of PMH-APRN practice with a subset of quantitative data (n = 699) from a national APRN survey examining the impact of state-mandated APRN/MD collaborative practice agreements. DISCUSSION: Data sources converged to portray challenges to optimal use of APRNs providing psychiatric/mental health services, including high out-of-pocket fees, irregular communication with supervisors, mandated chart reviews, and supervisor turnover. CONCLUSION: Inconsistent and burdensome supervision requirements contribute to cost inflation and may limit patient access.

Patient safety from executive hospital management to wards: A qualitative study identifying factors influencing implementation.

AIM: To examine the journey of safety initiatives from executive hospital management to ward. BACKGROUND: Hospital management teams are often responsible for identifying safety priorities and ensuring delivery of these. METHOD: Naturalistic study design within a large NHS Hospital Trust. Using semi-structured interviews, focus groups and secondary data analysis, the study examines the implementation of safety initiatives. RESULTS: While hospital management developed five safety initiatives, only one of these (falls prevention) was actually seen to permeate all layers of the organisation. Other initiatives stopped one layer down. Both middle management and ward staff added to the list of initiatives developed, resulting in 16 priorities. A range of positive and negative influences to successful implementation are identified. CONCLUSIONS: Safety initiatives need positive reinforcement at all levels to be addressed appropriately. The research suggests that a model related to improvement science may prove useful in ensuring that priorities are addressed. IMPLICATIONS FOR NURSING MANAGEMENT: Care should be taken to ensure that safety initiatives are successfully implemented at all levels within an organisation. Identifying priorities with staff and sharing values and priorities are a key approach to leading such initiatives.

Supervisee perceptions of the use of metacommunication in the supervisory relationship.

Objective: This study examined the use of metacommunication in supervision from supervisees' perspectives. Method: A total of 129 supervisees completed the Metacommunication in Supervision Questionnaire-MSQ, a measure devised for the purpose of this study to explore the frequency and willingness to use various forms of metacommunication in clinical supervision. Measures of the nature of the supervisory relationship (also from the supervisee's perspective) were taken to explore whether a relationship exists between the nature of supervision and supervisees' perspectives on the use of metacommunication. Results: There was general concordance between supervisee ratings of their own willingness and their perception of their supervisor's willingness to use various forms of metacommunication in supervision. There were significant differences in the reported frequency with which the different types of metacommunication are actually used. A factor analysis elicited a two-factor structure underlying the MSQ and significant correlations with measures of the nature of the supervision relationship were observed. It appears that metacommunication around difficult or uncomfortable feelings in the supervisory relationship occurs less often than other components of metacommunication. Conclusion: Future research needs to further validate the MSQ and assess whether the frequency of metacommunication in the supervisory relationship is related to metacommunication in supervisees' psychotherapy with clients.

Genetic Programming Hyper-Heuristics with Vehicle Collaboration for Uncertain Capacitated Arc Routing Problems.

Due to its direct relevance to post-disaster operations, meter reading and civil refuse collection, the Uncertain Capacitated Arc Routing Problem (UCARP) is an important optimisation problem. Stochastic models are critical to study as they more accurately represent the real world than their deterministic counterparts. Although there have been extensive studies in solving routing problems under uncertainty, very few have considered UCARP, and none consider collaboration between vehicles to handle the negative effects of uncertainty. This article proposes a novel Solution Construction Procedure (SCP) that generates solutions to UCARP within a collaborative, multi-vehicle framework. It consists of two types of collaborative activities: one when a vehicle unexpectedly expends capacity (route failure), and the other during the refill process. Then, we propose a Genetic Programming Hyper-Heuristic (GPHH) algorithm to evolve the routing policy used within the collaborative framework. The experimental studies show that the new heuristic with vehicle collaboration and GP-evolved routing policy significantly outperforms the compared state-of-the-art algorithms on commonly studied test problems. This is shown to be especially true on instances with larger numbers of tasks and vehicles. This clearly shows the advantage of vehicle collaboration in handling the uncertain environment, and the effectiveness of the newly proposed algorithm.

A Regional System of High-Quality Care: Rural Hastings Health Link - A Collaborative Initiative.

The Rural Hastings Health Link coordinates care for the 1-5% of the local population whose complexity represents two-thirds of healthcare spending. Gateway Community Health Centre developed a primary care-led model with local partners in primary care and the broader health and social sector built on four interventions: a structure to support integrated system thinking with partners, system navigators embedded in primary care addressing medical and social needs, a digital care-coordination tool and data management supporting accountability. It has altered how providers respond to clients' needs and, as an integrated system of care, created a shared culture of change driven by trust.

Logistics of Implementing a Large-scale Typhoid Vaccine Trial in Kathmandu, Nepal.

Typhoid fever is estimated to affect over 20 million people per year worldwide, with infants, children, and adolescents in south-central and southeast Asia experiencing the greatest burden of disease. The Typhoid Vaccine Acceleration Consortium (TyVAC) aims to support the introduction of typhoid conjugate vaccines into Gavi-eligible countries in an effort to reduce morbidity and mortality from typhoid. TyVAC-Nepal is a large-scale, participant- and observer-blind, individually randomized, controlled trial evaluating the efficacy of a newly developed typhoid conjugate vaccine in an urban setting in Nepal. In order to effectively deliver the trial, a number of key elements required meticulous planning. Public engagement strategies were considered early, and involved the implementation of a tiered approach. Approximately 300 staff were employed and trained in order to achieve the mass vaccination of 20 000 children aged 9 months to ≤16 years old over a 4-month period. There were 19 vaccination clinics established across the Lalitpur metropolitan city in the Kathmandu valley. Participants will be followed for 2 years post-vaccination to measure the rate reduction of blood culture-confirmed typhoid fever in the vaccination arm as compared to the control arm. The experience of conducting this large-scale vaccine trial suggests that comprehensive planning, continuous monitoring, and an ability to adapt plans in response to feedback are key.

Chimeric antigen receptor-T cell therapy manufacturing: modelling the effect of offshore production on aggregate cost of goods.

Cell and gene therapies have demonstrated excellent clinical results across a range of indications with chimeric antigen receptor (CAR)-T cell therapies among the first to reach market. Although these therapies are currently manufactured using patient-derived cells, therapies using healthy donor cells are in development, potentially offering avenues toward process improvement and patient access. An allogeneic model could significantly reduce aggregate cost of goods (COGs), potentially improving market penetration of these life-saving treatments. Furthermore, the shift toward offshore production may help reduce manufacturing costs. In this article, we examine production costs of an allogeneic CAR-T cell process and the potential differential manufacturing costs between regions. Two offshore locations are compared with regions within the United States. The critical findings of this article identify the COGs challenges facing manufacturing of allogeneic CAR-T immunotherapies, how these may evolve as production is sent offshore and the wider implication this trend could have.

The supply chain of migrant blood donors: an organisational interview study.

BACKGROUND AND OBJECTIVES: Migrant blood donors are underrepresented worldwide resulting in shortages of compatible blood products. Prior studies focused on individual barriers and motivators of potential blood donors, but no studies addressed organisational factors of the blood supply chain. This study explored the perceptions and experiences in recruitment and retention of migrant - and potentially rare-blood donors among staff members within the blood supply chain and identified obstacles and solutions in this chain. MATERIALS AND METHODS: The study was conducted at Sanquin, the national blood supply organisation of the Netherlands. Qualitative in-depth interviews were done among key staff members (N = 17). Expert validity was assessed in three feedback meetings. RESULTS: Seven staff members believed there is a shortage of migrant blood donors, while five believed there is not. However, there was a consensus that it may become a problem in the future due to demographic changes. The perceived obstacles to recruit and retain migrant donors were difficulties in determining how many migrant donors are needed and recruiting them, excluding potentially rare donors prior to donation, limited use of extended phenotyping and high blood typing and frozen storage costs. The possible solutions to increase blood pool diversity lay in registering donor ethnicity, specialised information provision for donors, reconsidering eligibility criteria and optimising blood typing strategies. CONCLUSION: Whilst recruitment of migrant blood donors is perceived by staff as difficult, various organisational policies and guidelines seem to hinder retention. Improvements in the blood supply chain may be achieved by addressing logistics, current procedures and registration of ethnicity.

Practice guidelines for the supervising professional: intraoperative neurophysiological monitoring.

The American Society of Neurophysiological Monitoring (ASNM) was founded in 1989 as the American Society of Evoked Potential Monitoring. From the beginning, the Society has been made up of physicians, doctoral degree holders, Technologists, and all those interested in furthering the profession. The Society changed its name to the ASNM and held its first Annual Meeting in 1990. It remains the largest worldwide organization dedicated solely to the scientifically-based advancement of intraoperative neurophysiology. The primary goal of the ASNM is to assure the quality of patient care during procedures monitoring the nervous system. This goal is accomplished primarily through programs in education, advocacy of basic and clinical research, and publication of guidelines, among other endeavors. The ASNM is committed to the development of medically sound and clinically relevant guidelines for the performance of intraoperative neurophysiology. Guidelines are formulated based on exhaustive literature review, recruitment of expert opinion, and broad consensus among ASNM membership. Input is likewise sought from sister societies and related constituencies. Adherence to a literature-based, formalized process characterizes the construction of all ASNM guidelines. The guidelines covering the Professional Practice of intraoperative neurophysiological monitoring were initially published January 24th, 2013, and subsequently that document has undergone review and revision to accommodate broad inter- and intra-societal feedback. This current version of the ASNM Professional Practice Guideline was fully approved for publication according to ASNM bylaws on February 22nd, 2018, and thus overwrites and supersedes the initial guideline.

Treating Multidimensional Presenting Problems with a Mutually Integrative Approach Using the Genogram.

The present article introduces a case study and describes a mutually integrative approach to treating a complex presenting problem. This article examines the specific issues surrounding integration when a supervisor and supervisee hold different theoretical perspectives. On occasion, such a relationship demands that the supervisee adhere to the model being taught by the supervisor. Examining integration in this format presents many advantages for both treatment and training. The key to the mutual integration is that two schools of psychotherapy can be combined in a way that creates a synergy; in that, together they are more powerful than either may be in isolation. A genogram with symbols from each model is incorporated to focus the treatment and create a format for the mutual integration.

Este artículo presenta un caso práctico y describe un enfoque mutuamente integrador para el tratamiento de un problema complejo motivo de consulta. Se analizan los problemas específicos en torno a la integración cuando un supervisor y una persona supervisada tienen diferentes perspectivas teóricas. Ocasionalmente, dicha relación exige que la persona supervisada se ajuste al modelo que le enseña el supervisor. El análisis de la integración en este formato presenta muchas ventajas tanto para el tratamiento como para la capacitación. La clave para la integración mutua es que puedan combinarse dos escuelas de psicoterapia de una manera que genere una sinergia; es decir, que juntas sean más poderosas de lo que puede ser cualquiera individualmente. Se incorpora un genograma con símbolos de cada modelo para centrar el tratamiento y crear un formato para la integración mutua. El caso se conceptualiza utilizando una fusión de la teoría de sistemas y la teoría psicoanalítica sobre la base del modelo estratégico de sistemas familiares y de un modelo psicoanalítico tradicional influenciado por la psicología del yo del modelo freudiano (Hall, 1999; Fenichel, 1945) y McWilliams (2011). El genograma sistémico tradicional (con símbolos interaccionales) se transforma en un genograma "integrado", con la incorporación de símbolos nuevos para representar los mecanismos psicoanalíticos de defensa. Los problemas presentados en el caso son preocupaciones relacionales y problemas de autoestima en un "paciente identificado" adolescente, obesidad y antecedentes de trauma sexual. Se proporcionan las razones para la integración mutua en este caso específico junto con las razones para la intervención.

The Development and Evaluation of a Statewide Training Center for Home Visitors and Supervisors.

This paper informs practice in community-based home visiting workforce development by describing the development and evaluation of a university-based training certificate program for home visitors and supervisors. The Interactive Systems Framework for Dissemination and Implementation (ISF; Wandersman et al., 2008) guides our conceptualization and paper organization. The ISF describes the components involved in translating research findings into effective implementation of prevention programs. We describe implementation and lessons learned from seven development activities: (a) review of the literature, (b) survey of other training initiatives across the country, (c) focus groups with home visitors and supervisors, (d) consultation with individual home visitors, (e) creation of a state advisory board of home visiting providers and stakeholders, (f) evaluation of two pilot trainings, and (g) video development. We then present evaluation data from 49 home visitors and 23 supervisors who completed the training certificate program after the pilot trainings. Both home visitors and supervisors rated training satisfaction highly, reported significant increases in self-efficacy related to the training topics, and reported extensive use of motivational communication techniques, which are the foundational skills of the training content. These and other favorable results reflect the benefits of building on advances in theory and science-based practice and of involving providers and stakeholders repeatedly throughout the development process.