Lead/Presenter: Courtney Van Houtven, COIN - Durham
All Authors: Van Houtven CH (COIN-Durham), Coffman CJ, (Center of Innovation, Durham) Grubber JM, (Center of Innovation, Durham) Decosimo K, (Center of Innovation, Durham) D’Adolf J,(Center of Innovation, Durham) Sullivan C,(Center of Innovation, Durham) Tucker M, (Center of Innovation, Durham) Bruening R (Center of Innovation, Durham) Sperber N (Center of Innovation, Durham) Stechuchak KM, (Center of Innovation, Durham) Shepherd-Banigan M, (Center of Innovation, Durham) Boucher N, (Center of Innovation, Durham) Ma J, (Center of Innovation, Durham) Colon-Emeric C (Center of Innovation, Durham) Jackson G, (Center of Innovation, Durham) Damush T, (Center of Innovation, Durham) Christensen L, (VA Caregiver Support Program, Washington D.C) Wang V, (Center of Innovation, Durham) Allen KD, (Center of Innovation, Durham) Hastings SN, (Center of Innovation, Durham)
Objectives:
To assess the implementation of an evidence-based family caregiver skills training program (IHIFIVES) for caregivers of veterans with functional limitations, delivered in the U.S Veterans Affairs Health Care System (VAHCS). We evaluate whether a team collaboration intervention (CONNECT) improves implementation outcomes of penetration and fidelity.
Methods:
We conducted a Type III hybrid implementation-effectiveness, 30-month stepped wedge cluster randomized trial with five 6-month time intervals to evaluate implementation and effectiveness of IHIFIVES. (ClinicalTrials.gov ID: NCT03474380). Site participants included 8 VAHCSs; patient participants included 898 Veterans referred to VA home- and community-based services who were receiving informal care and their caregivers. Sites were randomized 1:1 to receive brief technical support to address implementation barriers and promote customization to fit local conditions using the low cost Replicating Effective Programs (REP) or receive REP plus a complexity-science intervention focused on multi-disciplinary team collaboration (REP+ CONNECT). REP or REP+CONNECT began at each site on their randomly assigned 6-month time interval for program launch based on the stepped-wedge design. Pre-implementation (usual care) for a site were the 6-month time interval(s) prior to program launch and post-implementation (intervention) were the 6-month time interval(s) after program launch. The last 6-month time interval in the study occurred at the start of the Covid-19 pandemic when most sites shifted delivery of IHIFIVES training from in-person to virtual. Site-level implementation outcomes of interest were penetration (proportion of eligible caregivers enrolled in training) and fidelity defined as the proportion of training rounds (2 per six-month interval) in which sites delivered the full training curriculum (4 x 1.25 hour classes).
Results:
327 Veterans were in usual care time intervals and 571 were in intervention time intervals, with an average of 8.4 caregivers enrolled in each 6-month intervention time interval across sites. Mean Veteran age was 76.5 (SD = 11.9), 95.2% were male and 76.2% were white. Mean overall penetration was 29.0% (165 caregivers enrolled/571 eligible caregivers), ranging from 21.4% at REP+CONNECT sites to 35.4% at REP-only sites. Penetration rates varied by 6-month time interval and site, between 12%-66%. Fidelity was high across all sites with the full curriculum delivered in 88% of training rounds. Fidelity was notably higher among REP only sites compared to REP+CONNECT sites (95% vs 80%)
Implications:
CONNECT did not appear to enhance penetration or fidelity. Fidelity was generally high with all sites delivering at least one round of training. Penetration varied over time and by site. Qualitative data may help explain reasons for variation in penetration across all intervals.
Impacts:
Adding a team collaboration strategy (CONNECT) increases the resources needed to implement iHIFIVES with no measurable gains in implementation outcomes. It is possible to implement a caregiver skills training program with fidelity in a large integrated health system using a low-cost, structured implementation strategy (REP).