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RRP 09-196 – HSR&D Study

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RRP 09-196
HTN-IMPROVE: Determining the Implementation Process
George Lee Jackson PhD MHA
Durham VA Medical Center, Durham, NC
Durham, NC
Funding Period: August 2010 - July 2011

BACKGROUND/RATIONALE:
We have previously demonstrated the effectiveness of a nurse-delivered tailored behavioral and educational intervention (HSR&D grant IIR 20-034) and have shown that the intervention improves patients' blood pressure (BP) control by 15% at 24-months compared to usual care controls. Several other studies conducted in VA on non-VA settings by the Durham VA HSR&D Center of Excellence have showed similar positive impacts of telephone-based self-management support among patients with uncontrolled chronic illness (e.g. HSR&D grant IIR 04-426). The purpose of the Hypertension Telemedicine Nurse Implementation Project for Veterans (HTN-IMPROVE) study was to examine the process of implementing nurse-delivered telephone self-management support program for patients with uncontrolled hypertension at three Veterans Affairs (VA) Medical Centers, each located in a different VA region.

OBJECTIVE(S):
The goal was to study the processes undertaken by three VA Medical Centers as part of ongoing implementation of telephone self-management support for hypertensive patients. This mixed-methods study included both staff surveys and semi-structured interviews to better understand the organization in which implementation is occurring. A survey of members of the primary care staff was designed to examine organizational readiness to change in relation to implementing the intervention and the organization of the system for providing hypertension care as related to the Wagner Chronic Care Model. Semi-structured interviews of a subset of staff members were designed to examine organizational attributes hypothesized to be associated with more successful implementation of the intervention (e.g., consistent, high-quality, appropriate intervention delivery). Initial analysis of the results as part of this grant is focused on learning more about attributes of these baseline organizational characteristics and how they are associated. While not part of this specific Rapid Response Program project, it is anticipated that results will be used after approximately two years of program implementation to also examine the relationship between baseline organizational characteristics and both the degree to which the intervention is used and potential impact on clinical outcomes.

METHODS:
All primary care providers, all primary care nurses, and a subset of other staff at the participating clinics received the opportunity to complete an electronic survey. The degree of readiness to implement the program was assessed using an Organizational Readiness to Change survey developed at the University of North Carolina at Chapel Hill and current system for caring for patients with hypertension was assessed using the Assessment of Chronic Illness Care. A subset of these groups was offered the opportunity to participate in a more in-depth semi-structured telephone qualitative interview. Interviews examined key areas that may be associated with successful implementation including: 1) organizational readiness for change; 2) quality of the implementation policies and practices that the clinic put into place; 3) adaptations that the clinic made to increase the fit of the intervention with clinic operations; 4) climate for implementation that resulted from these policies, practices, and adaptations; 5) extent to which intended users (e.g., physicians, nurses) perceived that the intervention reflected their values (e.g., professional autonomy, practice boundaries); and 6) extent to which clinic-level and organizational changes reinforced or reduce the climate for implementation. The key themes potentially related to the implementation climate and processes within participating Medical Centers have been analyzed. While not specifically part of this grant, results of the surveys and interviews will later be linked to the degree to which the Medical Centers successfully implement the nurse-delivered telephone self management support program and the impact of the program on patients' hypertension.

FINDINGS/RESULTS:
Both the survey (~30% response rate) and interviews (28 interviews) have been completed and results are being analyzed. Initial analyses have focused on the organizational readiness to change. Findings indicate that VA can measure individuals' beliefs about organizational readiness to change. However, front-line staff may not have the knowledge-base about the intervention/situation to assess commitment to new programs, which may impact enthusiasm. About 20%of respondents said they did not know how much commitment the user group (clinicians supporting/utilizing program) had to implement the program. Approximately 20% of respondents said they did not know how much commitment the user group (clinicians supporting/utilizing program) had to implement the program. About a quarter to a third of respondents did not know how much commitment the implementation group (staff actively implementing program) had to implement the program. While the survey included a brief program description, respondents who had not attended a presentation about the program were much more likely to answer "don't know" to change efficacy items and were somewhat more likely to answer "don't know" to change commitment items. Ongoing analysis of qualitative data is examining if findings from the survey are corroborated by in-depth interviews.

IMPACT:
VA is a leader in the development of patient aligned care teams (PACTs). Key goals of PACTs include improving support for patients as they manage their own chronic illness and to giving patients the opportunity to choose to receive such services outside of the traditional face-to-face appointment. Our study aimed to provide important information as to how to enhance the implementation of such PACT programs within and outside the VA. We are doing this by examining how to reduce the burden of hypertension, the leading risk factor for stroke, heart attack, and cardiovascular disease.

PUBLICATIONS:

Journal Articles

  1. Shaw RJ, Kaufman MA, Bosworth HB, Weiner BJ, Zullig LL, Lee SY, Kravetz JD, Rakley SM, Roumie CL, Bowen ME, Del Monte PS, Oddone EZ, Jackson GL. Organizational factors associated with readiness to implement and translate a primary care based telemedicine behavioral program to improve blood pressure control: the HTN-IMPROVE study. Implementation science : IS. 2013 Sep 8; 8(1):106.
  2. Bosworth HB, Almirall D, Weiner BJ, Maciejewski M, Kaufman MA, Powers BJ, Oddone EZ, Lee SY, Damush TM, Smith V, Olsen MK, Anderson D, Roumie CL, Rakley S, Del Monte PS, Bowen ME, Kravetz JD, Jackson GL. The implementation of a translational study involving a primary care based behavioral program to improve blood pressure control: The HTN-IMPROVE study protocol (01295). Implementation science : IS. 2010 Jul 16; 5:54.
Conference Presentations

  1. Kirshner M, Bosworth HB, Roumie CL, Rakley SM, Kravetz JD, Del Monte PS, Bowen ME, Oddone EZ, Weiner BJ, Shaw R, Zullig LL, Jackson GL. Challenges and Opportunities Encountered Conducting Partnered Research in Organizational Readiness to Change and Implementation of HTN-IMPROVE. Poster session presented at: VA Durham VAMC Annual Research Week; 2014 May 13; Durham, NC.
  2. Shaw R, Kaufman M, Bosworth HB, Weiner BJ, Lee SD, Kravetz JD, Rakely SM, Roumie CL, Bowen ME, Del Monte PS, Oddone EZ, Zullig LL, Jackson GL. Organizational factors associated with the effective implementation and translation of a primary care based behavioral program to improve blood pressure control: The HTN-IMPROVE study. Poster session presented at: AcademyHealth Annual Research Meeting; 2013 Jun 23; Baltimore, MD.
  3. Shaw R, Kirshner M, Bosworth HB, Weiner BJ, Zullig LL, Lee SY, Kravetz JD, Rakley SM, Roumie CL, Bowen Me, Del Monte PS, Oddone EZ, Jackson GL. Readiness to Implement a Primary Care Program to Improve Blood Pressure: The HTN-IMPROVE Project. Poster session presented at: AcademyHealth Interdisciplinary Research Group on Nursing Issues Annual Meeting; 2013 Jun 23; Baltimore, MD.
  4. Shaw R, Kirshner M, Bosworth HB, Weiner BJ, Zullig LL, Lee SY, Kravetz JD, Rakley SM, Roumie CL, Bowen ME, DelMonte PS, Oddone EZ, Jackson GL. Readiness to Implement a Primary Care Program to Improve Blood Pressure: The HTN-IMPROVE Project. Paper presented at: AcademyHealth Annual Research Meeting; 2013 Jun 20; Baltimore, MD.
  5. Bosworth HB, Weiner BJ, Lee SY, Zullig LL, Kravetz JD, Rakley SM, Roumie CL, Bowen ME, Del Monte PS, Jackson GL, Kaufman M. Measuring Organizational Readiness to Change for a Broadly Implemented Clinical Program. Poster session presented at: AcademyHealth Annual Research Meeting; 2012 Jun 24; Orlando, FL.
  6. Jackson GL, Maciejewski ML, Kaufman A, Powers BJ, Oddone EZ, Smith VA, Olsen MK, Rakley SM, Almirall D, Bosworth HB, Weiner BJ, Lee SD, Damush TM, Anderson DR, Kravetz JD, Roumie CL, Bowen ME. Implementation of a self-management program: VA HTN-IMPROVE Study. Poster session presented at: National Institutes of Health Conference on the Science of Dissemination and Implementation: Methods and Measurement; 2010 Mar 15; Bethesda, MD.


DRA: Cardiovascular Disease
DRE: Treatment - Observational, Prevention
Keywords: Care Management, Hypertension, Self-care
MeSH Terms: none

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