Implementing evidence- based interventions in health care: application of the replicating effective programs framework . National Institutes of Health, Veterans Health Administration (VHA) and the Agency for Healthcare Research and Quality . Despite the development of effective interventions to improve health care quality, most of these interventions have only been implemented in the academic settings in which they were developed, and few have been successfully disseminated into non- academic- affiliated (i. A primary reason for this research- to- practice gap is the lack of a framework for implementing effective interventions in community- based organizations that maintains fidelity while maximizing transferability when the interventions are adopted across different settings . Many interventions fail to achieve the outcomes observed when tested in research settings once they are implemented in community- based organizations. Moreover, stakeholders (e. Prevention and Systems Improvement Strategies. Use evidence/empirically based strategies. Promising DMC Delinquency Prevention and Systems Improvement. Research-based Interventions and Eligibility for Special Education. DEVELOPMENT AND EVALUATION OF AN INTERVENTION TO REDUCE VICTIMS RISK OF. Develop five empirically based Web. Using Community-Based Participatory Research to Develop the PARTNERS Youth Violence Prevention Program. Use the Resource and Program. This two-hour online training helps educators and school staff understand their role in suicide prevention and covers strategies. At the same time, these stakeholders need to ensure that the intervention will be accepted and adopted across different organizations. A number of strategies for guiding implementation efforts have been proposed . Empirically Based Strategies for. Program staff provide. The Center for Effective Schools is. The focus of service delivery is on empirically-based strategies for prevention. The framework is based on the experiences of the U.S. Centers for Disease Control and Prevention (CDC). Strategies that foster the. Implementation Science. Crisis Intervention, and Trauma Treatment. Assessment, Crisis Intervention, and Trauma Treatment. For example, the VA's Quality Enhancement Research Initiative (QUERI) framework outlines a process for choosing, implementing, and marketing evidence- based interventions in health care organizations . Simpson describes the underlying organizational characteristics that need to be considered (readiness to change, resources, and culture) when planning an implementation of evidence- based interventions . To date, no implementation frameworks have outlined strategies for maintaining treatment fidelity while providing opportunities to adapt interventions to fit local needs. For example, previous frameworks do not provide specific guidance in replicating interventions for use in community- based organizations, and do not specify training or technical assistance programs for facilitating implementation across different settings. Without the appropriate tools and materials available in a user- friendly format, community- based organizations are less likely to implement an evidence- based intervention; or if implemented, treatment fidelity may be suboptimal. In this article, we describe an innovative implementation framework: Replicating Effective Programs (REP). In contrast to previously published implementation frameworks, REP provides a roadmap for implementing evidence- based interventions into community- based settings through a combination of intervention . REP has been empirically evaluated through a randomized controlled trial of its effectiveness in achieving intervention uptake and fidelity across different organizations . To date, other implementation frameworks have included some but not all of the components of REP . Centers for Disease Control and Prevention (CDC) to package and disseminate HIV behavioral and treatment interventions for implementation in community- based service settings, notably AIDS service organizations . CDC's REP project was initiated in 1. Extensive research has focused on developing and evaluating interventions designed to change risk behaviors related to HIV transmission since shortly after the first cases of AIDS were reported in the United States . The CDC's approach involved: applying rigorous criteria to identify effective interventions . The concepts underlying the REP packaging process derive from action anthropology (wherein a neutral party mediates interaction and exchange between two cultures . The foundational theories for disseminating the interventions are Diffusion of Innovation, which posits that innovations pass through particular communication channels among members of a social system over time . This figure outlines the Replicating Effective Programs (REP) process as it can be applied to health care interventions. REP components. There are four phases to REP . The four phases are described in detail in Table 1 as they would apply to health care interventions. When disseminating interventions, the first three phases of REP (pre- conditions, pre- implementation, and implementation) are most appropriate for the . The final phase, maintenance and evolution, is more appropriate for organizations described as the . Many community- based organizations serve a disproportionate number of low income, minority, and co- morbidly ill patients when compared to patients from academic settings. Another consideration is determining what the . Often academic practices have resources that facilitate the conduct of research studies (e. Identifying implementation barriers. To ensure that the intervention is feasible in local settings, researchers should meet with the staff members from participating organizations, introduce the intervention, and conduct an assessment of potential barriers to its implementation. Such meetings also foster buy- in, especially if the researchers develop a list of benefits of participation, from training opportunities to potential cost savings (i. During these meetings, researchers should gather information in the form of a needs assessment to benchmark usual care, including resources and functioning characteristics that may directly affect the mode by which the intervention will be implemented and the types of technical assistance that might be needed (e. This information can inform the content of the intervention package. Drafting the intervention package. An intervention package is then drafted that is suitable for implementation in community- based organizations. Training and technical assistance plans are also drafted during this phase. Packaging involves the conversion of intervention protocols into non- academic language and into a user- friendly manual that can be readily disseminated . The package should be drafted by the developers of the intervention, but edited by non- technical writers to ensure that the intervention package materials are free of technical jargon. Supporting documents, such as a staff training curriculum, a technical assistance guide, and promotional materials are also included. The package is refined and finalized during the pre- implementation phase of REP based on input from the pilot- testing organizations. The REP intervention package conveys the intervention's theoretical foundation (i. Still, while core elements are standardized, the mechanisms by which they can be operationalized may vary across organizations. The package can therefore articulate menu options for adapting intervention delivery across different organizations to allow flexibility in implementation. For example, menu options for organizations with a substantial number of minorities may include culturally appropriate options for delivering the intervention, such as outreach to families or community groups. Prior evidence from the management literature suggests that articulating a priori the core elements and adaptation options of a new product to potential users of the product is necessary for its successful adaptation . Thus, having the core elements detailed, while also providing options for implementing these core elements, is vital for optimizing both fidelity to the intervention and flexibility in its implementation. The REP packaging process has distinct advantages over current strategies for disseminating interventions. For example, a number of behavioral health intervention toolkits (i. U. S. Substance Abuse and Mental Health Services Administration's National Health Information Center Evidence- Based Practices website . However, unlike REP packages, these toolkits often lack a detailed description of the intervention's set- up procedures, underlying theories and logic flow, scripts, and other specific materials, as well as instructions for implementing these materials across different settings. In contrast, REP packages provide specific details regarding the intervention as well as operationalized options for adapting delivery of intervention core elements to local organizations in a way that does not compromise the intervention's core elements. The REP packaging process has already been widely used by the CDC to successfully implement and disseminate HIV interventions. For example, between 1. REP project packaged ten interventions for use by health departments, clinics, and community- based organizations; and more packages are now being prepared. CDC and state health departments fund the implementation of REP- packaged interventions by over 5. We use a comprehensive definition of stakeholders based on the Pincus multi- level 6- P framework that describes the different levels of health care: populations (i. Given that these different levels play an important role in the use of REP to implement interventions, representatives from all levels should be considered for active participation in the CWG. For example, providers would be knowledgeable of the day- to- day barriers to implementing the intervention, consumers can comment on participant recruitment and burden, and health plan leaders can provide input on how to sustain the intervention beyond the REP implementation phase (e. CWG participants should be persons who have influence over their peers (i. The CWG members meet regularly throughout the pre- implementation phase to review the intervention materials, finalize the prototype package, advise on the staff training and technical assistance plans, and plan the logistics of the implementation. The goal of these meetings is to review and advise on the package content and develop options suitable for customizing the intervention to specific institutions (e. The intervention developers or researchers familiar with the science and core elements of the intervention should also participate in the CWG in order to provide expertise in the intervention. Notably, core elements and menu options are refined based on CWG input, but the final decisions to include menu options are made by the intervention developers/researchers.
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