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2023 HSR&D/QUERI National Conference Abstract

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1034 — Implementation of “Age-Friendly” Evidence-Based Practices in the VA Healthcare System: An Examination of Facilitators and Barriers

Lead/Presenter: Connor Warren,  COIN - Pittsburgh/Philadelphia
All Authors: Warren CM (Safer Aging Through Geriatrics-Informed Evidence-Based Practices Quality Enhancement Research Initiative, Philadelphia), Ashcraft LE (Safer Aging Through Geriatrics-Informed Evidence-Based Practices Quality Enhancement Research Initiative, Philadelphia) Riser T (Safer Aging Through Geriatrics-Informed Evidence-Based Practices Quality Enhancement Research Initiative, Philadelphia) Brown R (Safer Aging Through Geriatrics-Informed Evidence-Based Practices Quality Enhancement Research Initiative, Philadelphia) Mavandadi S (Safer Aging Through Geriatrics-Informed Evidence-Based Practices Quality Enhancement Research Initiative, Philadelphia) Bowen ME (Safer Aging Through Geriatrics-Informed Evidence-Based Practices Quality Enhancement Research Initiative, Philadelphia)

Objectives:
The Safer Aging Through Geriatrics-Informed Evidence-Based Practices (SAGE) Quality Enhancement Research Initiative (QUERI) program is implementing four evidence-based practices (EBPs) across VISN 4 VAMCs. EBPs are aligned with the 4Ms of the Institute for Healthcare Improvement’s Age-Friendly Health System model. This project focuses on examining implementation facilitators and barriers of the Tailored Activity Program (TAP) and Community Aging in Place-Advancing Better Living for Elders (CAPABLE) EBPs. These home-based programs correspond to “Mentation” and “Mobility,” respectively. TAP uses occupational therapist-based strategies to decrease dementia-related behavioral symptoms and caregiver burden. CAPABLE, delivered by a multidisciplinary team (nurse, OT, and handyperson), increases mobility, functionality, and capacity to age in place.

Methods:
SAGE QUERI conducted extensive (6/2021-6/2022) pre-implementation activities across 6 VAMCs to determine facilitators, barriers, and needed adaptations for successful implementation within the VA-context. We solicited information from key stakeholder groups (e.g., medical center leadership, leaders from geriatrics and extended care, home-based primary care, and rehabilitation, front-line staff). We used the Practical, Robust Implementation and Sustainability Model (PRISM) framework to guide semi-structured interviews focused on the stakeholders’ 1) initial impressions of TAP and CAPABLE, 2) perceived implementation facilitators and barriers, and 3) potential adaptations to EBPs based on existing facility and department processes and workflows. Guided by the PRISM framework, we used rapid thematic content analysis to evaluate interview transcripts.

Results:
Overarching themes related to the intervention, staff characteristics, organizational and patient characteristics, external factors, and fit in existing workflows were identified. Primary facilitators to implementation included staff characteristics (e.g., clinician dedication to providing EBPs to Veterans), organizational characteristics (e.g., existing home-based programs where EBPs could be integrated and sustained), and perceived positive contributions of TAP and CAPABLE (e.g., recognition that the EBPs fill a gap in home-based programs for older Veterans). Primary barriers to implementation included VA staffing and related factors (e.g., fewer occupational therapists compared to physical therapists; hiring and reallocating clinician FTE) and department and organizational characteristics (e.g., workflow processes, number of visits for dosing EBPs, resistance to change). Participants identified several adaptations needed for each EBP - specifically, integrating intervention components into existing programs (e.g., home-based visits) and processes, decreasing the number of visits for each EBP, utilizing telehealth services, and utilizing community-based clinicians to supplement care teams where needed.

Implications:
Study findings demonstrate both challenges and potential leverage points for successful EBP implementation within a complex healthcare system. Study findings suggest adaptations regarding dosage and staffing may be particularly effective. Recognizing this, measures collected during implementation should include effectiveness to continue to assess EBP fidelity.

Impacts:
The VA’s existing home-based programs for older Veterans and their caregivers provide the structure to support the implementation of new “Age-Friendly” EBPs shown to improve health outcomes outside of the VA. Consistent with implementation science frameworks, EBPs will be adapted to fit into existing VA programs and workflows which will encourage sustainability. Findings from this study may be applied across the VA healthcare system to increase effectiveness and efficiency of EBP implementation within the VA.