4136 — Using implementation facilitation to integrate intimate partner violence screening in primary care: Key factors to consider

Lead/Presenter: Julianne Brady, 
All Authors: Brady JE (Center for Healthcare Organization and Implementation Research (CHOIR) Boston), Miller, CJ (Center for Healthcare Organization and Implementation Research (CHOIR) Boston) Adjognon, OL (Center for Healthcare Organization and Implementation Research (CHOIR) Boston) Stolzmann, K (Center for Healthcare Organization and Implementation Research (CHOIR) Boston) Dichter, ME (Center for Health Equity Research and Promotion, Philadelphia) Portnoy, GA (PRIME, VA Connecticut Healthcare System, Yale University School of Medicine) Gerber, MR (Albany Medical College) Iqbal, S (VA Palo Alto Healthcare System) Haskell, SG (Office of Women's Health Services, Yale University School of Medicine) Iverson KM (Center for Healthcare Organization and Implementation Research (CHOIR), Boston, and the National Center for PTSD, VA Boston Healthcare System)

Objectives:
Women Veterans experience higher risk for intimate partner violence (IPV) than non-Veteran women. VHA policy calls for routine IPV screening in women’s health primary care. But uptake of IPV screening programs is variable in women’s health mixed gender (model 1) and shared-space (model 2) primary care clinics compared to women-specific (model 3) primary care clinics, causing inequities in women Veterans’ access to quality IPV care. In response, VHA’s Office of Women’s Health initiated implementation facilitation (IF) to bolster integration of IPV screening programs in mixed gender and shared-space primary care clinics. IF consists of personalized, interactive support that can include coaching, education, technical assistance, and problem solving. This study aimed to identify barriers and facilitators to IPV screening program implementation in this operations-led initiative.

Methods:
A cluster randomized, stepped wedge, Hybrid Type II program evaluation design was used in this study. IF was staged in two waves across nine sites. We conducted post-IF qualitative phone interviews with 15 key informants (e.g., physicians, IPV Assistance Program Coordinators) involved in IPV screening implementation to assess barriers and facilitators to implementation. Qualitative data collection and analysis were guided by the integrated-Promoting Action Research in Health Services (i-PARIHS) framework, which examines program implementation through four domains: innovations, recipients, context, and implementation facilitation.

Results:
Across the four i-PARIHS domains, we identified 12 factors (i.e., facilitators and/or barriers) affecting IPV screening implementation. Innovations: (1) ability to activate the IPV screening tool in the electronic health record, and (2) viewpoints on the process of IPV screening, including the screening protocol and the associated toolkit. Recipients: (3) stakeholders’ perspectives and expertise (e.g., clear roles for IPV screening processes, comfort with screening and addressing positive screens); (4) IPV screening implementation team members availability (e.g., adequate staffing, workload and time constraints), and (5) engagement and collaborations around IPV screening (e.g., across teams or services, with the community). Context: At the inner level: (6) available resources including staff training and education; (7) infrastructure and technology (e.g., setup to conduct screening and manage positive screens), (8) multilevel leadership perspectives (e.g., support, buy-in, or competing priorities), and (9) local policy/mandate status. At the outer level: (10) VISN and/or national directives on IPV screening (e.g., leverage and accountability at the local level). Implementation facilitation: (11) external facilitator key functions (e.g., availability, problem-solving, cross-site networks establishment), and (12) stakeholders’ collaboration during IF (e.g., role clarity across facilitation, regular communication, mutual expectations).

Implications:
Factors across all four i-PARIHS domains influence IPV screening implementation in primary care. Increased understanding of factors that contribute to or hinder IPV screening implementation will enable tailoring of IF for successful spread of IPV screening programs in mixed gender and shared-space clinics, where most women VHA primary care patients receive their care.

Impacts:
Understanding factors that affect IPV screening is crucial to enhancing the uptake of IPV screening programs throughout women’s health primary care clinics, thereby ensuring women Veterans receive quality and equitable IPV care. With widespread routine IPV screening, an increased number of women will be screened and receive follow-up care for improved health outcomes.