Comparing implementation strategies to promote the adoption of virtual and team-based care in the Veterans Health Administration

Bauer M, Fortney J, Kirchner J, Reisinger HS, Ritchie M, Smith J. Comparing implementation strategies to promote the adoption of virtual and team-based care in the Veterans Health Administration. Paper presented at: National Institutes of Health / AcademyHealth Conference on the Science of Dissemination and Implementation; 2015 Dec 14; Washington, DC.

Background: Facilitation is emerging as promising implementation strategy for promoting the adoption of clinical interventions in low resourced settings and late adopter sites. We describe two funded QUERI programs that will compare the effectiveness of facilitation strategies to support the implementation of team-based and technology-facilitated clinical interventions. Methods: Both QUERI programs are grounded within the PARiHS implementation conceptual model and apply facilitation as an implementation strategy. The Virtual Specialty Care QUERI is also based on the Dynamic Sustainability Framework which is founded on the premise that technology-facilitated clinical interventions will evolve over time and be adapted from setting to setting with regard to content, provider roles and delivery platform (e.g., face to face, ehealth, mhealth, telehealth). As such this QUERI program emphasizes protocol flexibility over fidelity to encourage and enable adaptation in order to maximize fit between the evolving clinical intervention and diverse practice settings. The QUERI for Team-Based Behavioral Health is also guided by the Clinical Microsystems Model which is a patient-centered, quality-focused, implementation-oriented model that accommodates multi-level analyses of complex, interdependent processes. This model will be used to understand team-based healthcare delivery and guide facilitation efforts. Both QUERI Programs incorporate new evaluation designs that have supported the rapid advancement of implementation science over the past decade. These include the use of Hybrid Effectiveness-Implementation, Stepped Wedge, and SMART trial designs. In addition, the RE-AIM evaluation framework will enable the use of consistent measurement domains across projects. Finally, both QUERI programs are highly partnered with clinical and operational stakeholders. Findings: One of the major contributions of these QUERI programs will be to test and refine enhanced implementation strategies for eventual use by our operational partners. Many of the projects compare two alternative implementations strategies, typically a traditional low cost approach, such as local team-based quality improvement or technical assistance, with a more resource intensive approach involving facilitation. Implications for DandI Research: These two QUERI programs will inform the knowledge of and applied use of facilitation as an implementation strategy, as well as advance our understanding of the effectiveness of team-based care and virtual care technologies in routine health care.