Understanding collaborative implementation between community and academic partners in a complex intervention: a qualitative descriptive study.

BACKGROUND: Community-academic partnerships (CAPs) can improve the relevance, sustainability, and uptake of new innovations within the community. However, little is known about what topics CAPs focus on and how their discussions and decisions impact implementation at ground level. The objectives of this study were to better understand the activities and learnings from implementation of a complex health intervention by a CAP at the planner/decision-maker level, and how that compared to experiences implementing the program at local sites. METHODS: The intervention, Health TAPESTRY, was implemented by a nine-partner CAP including academic, charitable organizations, and primary care practices. Meeting minutes were analyzed using qualitative description, latent content analysis, and a member check with key implementors. An open-answer survey about the best and worst elements of the program was completed by clients and health care providers and analyzed using thematic analysis. RESULTS: In total, 128 meeting minutes were analyzed, 278 providers and clients completed the survey, and six people participated in the member check. Prominent topics of discussion categories from the meeting minutes were: primary care sites, volunteer coordination, volunteer experience, internal and external connections, and sustainability and scalability. Clients liked that they learned new things and gained awareness of community programs, but did not like the volunteer visit length. Clinicians liked the regular interprofessional team meetings but found the program time-consuming. CONCLUSIONS: An important learning was about who had "voice" at the planner/decision-maker level: many of the topics discussed in meeting minutes were not identified as issues or lasting impacts by clients or providers; this may be due to differing roles and needs, but may also identify a gap. Overall, we identified three phases that could serve as a guide for other CAPs: Phase (1) recruitment, financial support, and data ownership; Phase (2) considerations for modifications and adaptations; Phase (3) active input and reflection.

Health TAPESTRY Ontario: A Multi-Site Randomized Controlled Trial Testing Implementation and Reproducibility.

PURPOSE: Health Teams Advancing Patient Experience: Strengthening Quality (Health TAPESTRY) is a complex primary care program aimed at assisting older adults to stay healthier for longer. This study evaluated the feasibility of implementation across multiple sites, and the reproducibility of the effects found in the previous randomized controlled trial. METHODS: This was a pragmatic, unblinded, 6-month parallel group randomized controlled trial. Participants were randomized (intervention or control) using a computer-generated system. Eligible patients, aged 70 years and older, were rostered to 1 of 6 participating interprofessional primary care practices (urban and rural). In total, 599 (301 intervention, 298 control) patients were recruited from March 2018 through August 2019. Intervention participants received a home visit from volunteers to collect information on physical and mental health, and social context. An interprofessional care team created and implemented a plan of care. The primary outcomes were physical activity and number of hospitalizations. RESULTS: Based on the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework, Health TAPESTRY had widespread reach and adoption. In the intention-to-treat analysis (257 intervention, 255 control), there were no statistically significant between-group differences for hospitalizations (incidence rate ratio = 0.79; 95% CI, 0.48-1.30; P = .35) or total physical activity (mean difference = -0.26; 95% CI, -1.18 to 0.67; P = .58). There were 37 non-study related serious adverse events (19 intervention, 18 control). CONCLUSIONS: We found Health TAPESTRY was successfully implemented for patients in diverse primary care practices; however, implementation did not reproduce the effect on hospitalizations and physical activity found in the initial randomized controlled trial.

Lessons Learned Through Two Phases of Developing and Implementing a Technology Supporting Integrated Care: Case Study.

BACKGROUND: As health care becomes more fragmented, it is even more important to focus on the provision of integrated, coordinated care between health and social care systems. With the aging population, this coordination is even more vital. Information and communication technology (ICT) can support integrated care if the form of technology follows and supports functional integration. Health TAPESTRY (Teams Advancing Patient Experience: Strengthening Quality) is a program centered on the health of older adults, supported by volunteers, primary care teams, community engagement and connections, and an ICT known as the Health TAPESTRY application (TAP-App), a web-based application that supports volunteers in completing client surveys, volunteer coordinators in managing the volunteer program, and primary care teams in requesting and receiving information. OBJECTIVE: This paper describes the development, evolution, and implementation of the TAP-App ICT to share the lessons learned. METHODS: A case study was conducted with the TAP-App as the case and the perspectives of end users and stakeholders as the units of analysis. The data consisted of researchers' perspectives on the TAP-App from their own experiences, as well as feedback from other stakeholders and end user groups. Data were collected through written retrospective reflection with the program manager, a specific interview with the technology lead, key emailed questions to the TAP-App developer, and viewpoints and feedback during paper drafting from other research team members. There were 2 iterations of Health TAPESTRY and the TAP-App and we focused on learnings from the second implementation (2018-2020) which was a pragmatic implementation scale-up trial using the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework at 6 primary care sites across Ontario, Canada. RESULTS: TAP-App (version 1.0), which was iteratively developed, was introduced as a tool to schedule volunteer and client visits and collect survey data using a tablet computer. TAP-App (version 2.0) was developed based on this initial experience and a desire for a program management tool that focused more on dual flow among users and provided better support for research. The themes of the lessons learned were as follows: iterative feedback is valuable; if ICT will be used for research, develop it with research in mind; prepare for challenges in the integration of ICT into the existing workflow; ask whether interoperability should be a goal; and know that technology cannot do it alone yet-the importance of human touch points. CONCLUSIONS: Health TAPESTRY is human-centered. The TAP-App does not replace these elements but rather helps enable them. Despite this shift in supporting integrated care, barriers remained to the uptake of the TAP-App that would have allowed a full flow of information between health and social settings in supporting patient care. This indicates the need for an ongoing focus on the human use of ICT in similar programs.

Community Volunteers and Primary Care Providers Supporting Older Adults in System Navigation: A Mixed Methods Study.

Introduction: Primary care providers and community volunteers have important roles in supporting patient system navigation and utilization of community-based health and social services (CBHSS). This study aimed to explore the experiences and impacts of system navigation in a complex intervention supporting older adults. Methods: We used a convergent mixed methods design. Participants included primary care team members (n = 67), community volunteers (n = 38), and programme clients (n = 128) across six communities in Ontario, Canada. Data sources included focus groups, interviews, system navigation function survey for volunteers, CBHSS use survey for clients, and implementation data on CBHSS recommended by providers and volunteers and used by clients. Results: Results showed the different patterns of how CBHSS categories were recommended and ultimately used. Exercise-related CBHSS were both recommended and used, independence-related CBHSS were mostly only recommended with less uptake, and chronic health condition and diet/nutrition CBHSS were most often used by clients. Discussion: Primary care teams' practice of system navigation was impacted by programme participation, including through learning about local CBHSS. However, volunteers felt more confident in tasks that did not include connecting to CBHSS. The programme did seem to result in many referrals, though the actual client uptake tended to be to more clinical rather than healthy lifestyle resources.

Understanding volunteer retention in a complex, community-centred intervention: A mixed methods study in Ontario, Canada.

Volunteers are critical to supporting health care systems worldwide. For organisations that rely on volunteers, service to clients can be disrupted when volunteers leave their roles. Volunteer retention is a multi-layered phenomenon. In this mixed methods case-control study, we compared two naturally-occurring volunteer groups supporting a complex primary care-based programme for older adults in the community: volunteers retained by the programme, and volunteers that left. Our objectives were to describe differences between the groups and also understand how compassion changed over time for those that stayed. We collected quantitative data on demographics, the UCLA Geriatric Attitudes Scale, the Professional Quality of Life Index, the Basic Empathy Scale, the Reasons for Volunteering subscale of the Volunteerism Questionnaire and the 5-level EQ-5D. Qualitative data were collected through focus groups/interviews. Overall, 78 volunteers completed surveys and 23 participated in focus groups/interviews. Volunteers that stayed were more likely to be a little older and were a slightly higher proportion male than those who left. They also had significantly less positive attitudes towards older adults, descriptively lower Cognitive Empathy and descriptively higher Secondary Traumatic Stress. Compared to volunteers who left, volunteers retained were more likely to have said they were volunteering for Enhancement or Social purposes; however, these differences were non-significant. Over time, Compassion Satisfaction decreased with a medium effect size for those that stayed, and Burnout decreased with a small effect size. Volunteers that stayed described more logistical and client-related aspects of the programme were working well. We recommend that volunteer programmes communicate positive programme impacts that could enhance volunteers' development, communicate any client impacts to volunteers to reinforce volunteers' purposes for volunteering (thus reinforcing that their work is meaningful), and ensure logistical aspects of volunteer role work well.

Understanding how context and culture in six communities can shape implementation of a complex intervention: a comparative case study.

BACKGROUND: Contextual factors can act as barriers or facilitators to scaling-up health care interventions, but there is limited understanding of how context and local culture can lead to differences in implementation of complex interventions with multiple stakeholder groups. This study aimed to explore and describe the nature of and differences between communities implementing Health TAPESTRY, a complex primary care intervention aiming to keep older adults healthier in their homes for longer, as it was scaled beyond its initial effectiveness trial. METHODS: We conducted a comparative case study with six communities in Ontario, Canada implementing Health TAPESTRY. We focused on differences between three key elements: interprofessional primary care teams, volunteer program coordination, and the client experience. Sources of data included semi-structured focus groups and interviews. Data were analyzed through the steps of thematic analysis. We then created matrices in NVivo by splitting the qualitative data by community and comparing across the key elements of the Health TAPESTRY intervention. RESULTS: Overall 135 people participated (39 clients, 8 clinical managers, 59 health providers, 6 volunteer coordinators, and 23 volunteers). The six communities had differences in size and composition of both their primary care practices and communities, and how the volunteer program and Health TAPESTRY were implemented. Distinctions between communities relating to the work of the interprofessional teams included characteristics of the huddle lead, involvement of physicians and the volunteer coordinator, and clarity of providers' role with Health TAPESTRY. Key differences between communities relating to volunteer program coordination included the relationship between the volunteers and primary care practices, volunteer coordinator characteristics, volunteer training, and connections with the community. Differences regarding the client experience between communities included differing approaches used in implementation, such as recruitment methods. CONCLUSIONS: Although all six communities had the same key program elements, implementation differed community-by-community. Key aspects that seemed to lead to differences across categories included the size and spread of communities, size of primary care practices, and linkages between program elements. We suggest future programs engaging stakeholders from the beginning and provide clear roles; target the most appropriate clients; and consider the size of communities and practices in implementation. TRIAL REGISTRATION: ClinicalTrials.gov: NCT03397836 .

Health TAPESTRY Ontario: protocol for a randomized controlled trial to test reproducibility and implementation.

BACKGROUND: Health TAPESTRY (Health Teams Advancing Patient Experience: STRengthening qualitY) aims to help people stay healthier for longer where they live by providing person-focused care through the integration of four key program components: (1) trained volunteers who visit clients in their homes, (2) an interprofessional primary health care team, (3) use of technology to collect and share information, and (4) improved connections to community health and social services. The initial randomized controlled trial of Health TAPESTRY found promising results in terms of health care use and patient outcomes, indicating a shift from reactive to preventive care. The trial was based on one clinical academic center, thus limiting generalizability. The study objectives are (1) to test reproducibility of the established effectiveness of Health TAPESTRY on physical activity and hospitalizations, (2) to test the feasibility of, and understand the contributing factors to, the implementation of Health TAPESTRY in six diverse communities across Ontario, Canada, and (3) to determine the value for money of implementing Health TAPESTRY. METHODS: This planned study is a pragmatic parallel randomized controlled trial with a delayed intervention for control participants at 6 months. This trial will simultaneously assess effectiveness and implementation in a real-world setting (type II hybrid) in six diverse communities across Ontario. Participants 70 years of age and older will be randomized into the Health TAPESTRY intervention or the control group (usual care). Intervention clients will receive an individualized plan of care from an interprofessional care team. The plan will be based on a client's goals and current health risks identified through volunteer visits. The study's outcomes are mapped onto the RE-AIM framework, with levels of physical activity and number of hospitalizations as the co-primary outcomes. The main analysis will be a comparison at 6 months. DISCUSSION: It is important to evaluate the effectiveness and implementation of Health TAPESTRY in multiple communities prior to scaling or widespread adoption. TRIAL REGISTRATION: ClinicalTrials.gov NCT03397836 . Registered on 12 January 2018.