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Implementation Science at UW

Keywords: RE-AIM

✪ Development of an Asthma Home-Visit Training Program for Community Health Workers and Their Supervisors in Washington State

Authors:

Nuha Elkugia, Mary E. Crocker, James W. Stout, Kaylin Bolt, Bryan J. Weiner, and C. Bradley Kramer

University of Washington affiliated authors are displayed in bold.

✪ Open Access

Published: June 2021

Read the full text in the open access journal Frontiers in Public Health
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Abstract:

The community health worker (CHW) asthma home-visiting model developed by Public Health-Seattle & King County (PHSKC) is an evidence-based approach proven to improve health outcomes and quality of life. In addition, it has been shown to be an effective and culturally appropriate approach to helping people with asthma understand the environmental and behavioral causes of uncontrolled asthma, while acquiring the skills they need to control their asthma.

This paper describes the development and implementation of training curricula for CHWs and supervisors in the asthma home visiting program. To facilitate dissemination, this program took advantage of the current healthcare landscape in Washington State resulting from Centers for Medicare & Medicaid Services (CMS) approval of the 1115 Medicaid Waiver project. Key aspects of the training program development included: (1) Engagement: forming a Community Advisory Board with multiple stakeholders to help prioritize training content; (2) Curriculum Development: building the training on evidence-based home-visit protocols previously developed at PHSKC; (3) Implementation of the training program; (4) Evaluation of the training; and (5) Adaptation of the training based on lessons learned.

We describe key factors in the training program's improvement including the use of a community-based participatory approach to engage stakeholders at multiple phases of the project and ensure regional adaption; combining in-person and online modules for delivery; and holding learning collaboratives for post-training and technical support. We also outline our training program evaluation plan and the planned evaluation of the home visit program which the trainees will deliver, both of which follow the RE-AIM framework. However, because the COVID-19 pandemic has curtailed training activities and prohibited the trainees from implementation of these CHW home visit practices, our evaluation is currently incomplete. Therefore, this case study provides insight into the adaptation of the training program, but not the delivery of the home visit program, the outcomes of which remain to be seen.

Implementation and Scale-Up of Integrated Depression Care in South Africa: An Observational Implementation Research Protocol

Authors:

Inge Petersen, Christopher G. Kemp, Deepa Rao, Bradley H. Wagenaar, Kenneth Sherr, Merridy Grant, Max Bachmann, Ruanne V. Barnabas, Ntokozo Mntambo, Sithabisile Gigaba, André Van Rensburg, Zamasomi Luvuno, Ishmael Amarreh, Lara Fairall, Nikiwe N. Hongo, & Arvin Bhana

University of Washington affiliated authors are displayed in bold.

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Published: March 2021

Read the full text in the subscription access journal Psychiatric Services
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✪ Implementation of a Telemental Health Training Program Across a Mental Health Department

Authors:

Bradford L. Felker, Meghan M. McGinn, Erika M. Shearer, Gina T. Raza, Sari D. Gold, Jean M. Kim, Sasha M. Rojas, Milena S. Roussev, Ruth L. Varkovitzky, Huiting Liu, Kate L. Morrison, and Russell A. McCann

University of Washington affiliated authors are displayed in bold.

✪ Open Access

Published: January 2021

Read the full text in the open access journal Telemedicine Reports

Abstract:

Introduction

Telemental health (TMH) has increased substantially. However, health care systems have found it challenging to implement TMH ubiquitously. A quality improvement project guided by implementation science methodology was used to design and implement a TMH training program.

Materials and Methods

Implementation science methodology (Promoting Access to Research Implementation in Health Services, Reach-Effectiveness-Adoption-Implementation-Maintenance, Implementation/Facilitation) provided the framework to design and implement the training program. A total of 100 interdisciplinary mental health providers from outpatient mental health clinics participated.

Results

Providers reported satisfaction with the training program. Results indicated that the training increased providers' TMH knowledge and competence. The number of providers using TMH and patients who received TMH nearly doubled.

Conclusions

Implementation science methodology was important in creating an organizational framework at this facility to design, evaluate, and implement an innovative TMH training program.

**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**

✪ Defining gaps in pre-exposure prophylaxis delivery for pregnant and post-partum women in high-burden settings using an implementation science framework

Authors:

Jillian Pintye, Dvora L. Joseph Davey, Anjuli D. Wagner, Grace John-Stewart, Rachel Baggaley, Linda-Gail Bekker, Connie Celum, Benjamin H. Chi, Thomas J. Coates, Allison K. Groves, Jessica E. Haberer, Renee Heffron, John Kinuthia, Lynn T. Matthews, James A. McIntyre, Dhayendre Moodley, Lynne M. Mofenson, Nelly Mugo, Andrew Mujugira, Landon Myer, Steven Shoptaw, Lynda Stranix-Chibanda, Jared M. Baeten, for the PrEP in Pregnancy Working Group

University of Washington affiliated authors are displayed in bold.

Subscription Required for Full Text Access

Published: August 2020

Read the full text open access in the subscription access journal The Lancet: HIV

ImPlementation REsearCh to DEvelop Interventions for People Living with HIV (the PRECluDE consortium): Combatting chronic disease comorbidities in HIV populations through implementation research

Authors:

Joyonna Carrie Gamble-George, Christopher T. Longenecker, Allison R. Webel, David H. Au, Arleen F. Brown, Hayden Bosworth, Kristina Crothers, William E. Cunningham, Kevin A. Fiscella, Alison B. Hamilton, Christian D. Helfrich, Joseph A. Ladapo, Amneris Luque, Jonathan N. Tobin, Gail E. Wyatt, Implementation Research to Develop Interventions for People Living with HIV (PRECluDE) Consortium

University of Washington affiliated authors are displayed in bold.

Subscription Required for Full Text Access

Published: March 2020

Read the full text in the subscription access journal Progress in Cardiovascular Diseases

The impact of localized implementation: Determining the cost-effectiveness of HIV prevention and care interventions across six United States cities

Authors:

Emanuel Krebs, Xiao Zang, Benjamin Enns, Jeong E. Min, Czarina N. Behrends, Carlos del Rio, Julia C. Dombrowski, Daniel J. Feaster, Kelly A. Gebo, Matthew Golden, Brandon D.L. Marshall, Lisa R. Metsch, Bruce R. Schackman, Steven Shoptaw, Steffanie A. Strathdee, Bohdan Nosyk on behalf of the Localized Economic Modeling Study Group

University of Washington affiliated authors are displayed in bold.

Subscription Required for Full Text Access

Published: March 2020

Read the full text in the subscription access journal AIDS

✪ Adapting and Operationalizing the RE-AIM Framework for Implementation Science in Environmental Health: Clean Fuel Cooking Programs in Low Resource Countries

Authors:

Ashlinn K. Quinn, Gila Neta, Rachel Sturke, Christopher O. Olopade, Suzanne L. Pollard, Kenneth Sherr and Joshua P. Rosenthal

University of Washington affiliated authors are displayed in bold.

Published: December 2019

✪ Open Access
Read the full text in the open access journal Frontiers in Public Health

Abstract:

Introduction

The use of models and frameworks to design and evaluate strategies to improve delivery of evidence-based interventions is a foundational element of implementation science. To date, however, evaluative implementation science frameworks such as Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) have not been widely employed to examine environmental health interventions. We take advantage of a unique opportunity to utilize and iteratively adapt the RE-AIM framework to guide NIH-funded case studies of the implementation of clean cooking fuel programs in eleven low- and middle-income countries.

Methods

We used existing literature and expert consultation to translate and iteratively adapt the RE-AIM framework across several stages of the NIH Clean Cooking Implementation Science case study project. Checklists and templates to guide investigators were developed at each stage.

Results

The RE-AIM framework facilitated identification of important emerging issues across this set of case studies, in particular highlighting the fact that data associated with certain important outcomes related to health and welfare are chronically lacking in clean fuel programs. Monitoring of these outcomes should be prioritized in future implementation efforts. As RE-AIM was not originally designed to evaluate household energy interventions, employing the framework required adaptation. Specific adaptations include the broadening of Effectiveness to encompass indicators of success toward any stated programmatic goal, and expansion of Adoption to include household-level uptake of technology.

Conclusions

The RE-AIM implementation science framework proved to be a useful organizing schema for 11 case studies of clean fuel cooking programs, in particular highlighting areas requiring emphasis in future research and evaluation efforts. The iterative approach used here to adapt an implementation science framework to a specific programmatic goal may be of value to other multi-country program efforts, such as those led by international development agencies. The checklists and templates developed for this project are publicly available for others to use and/or further modify.

**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**

✪ Scaling-up the Systems Analysis and Improvement Approach for prevention of mother-to-child HIV transmission in Mozambique (SAIA-SCALE): a stepped-wedge cluster randomized trial

Authors:

Kenneth Sherr, Kristjana Ásbjörnsdóttir, Jonny Crocker, Joana Coutinho, Maria de Fatima Cuembelo, Esperança Tavede, Nélia Manaca, Keshet Ronen, Felipe Murgorgo, Ruanne Barnabas, Grace John-Stewart, Sarah Holte, Bryan J. Weiner, James Pfeiffer & Sarah Gimbel

University of Washington affiliated authors are displayed in bold.

✪ Open Access

Published: April 2019

Read the full text in the open access journal Implementation Science

Abstract:

Background

The introduction of option B+ — rapid initiation of lifelong antiretroviral therapy regardless of disease status for HIV-infected pregnant and breastfeeding women — can dramatically reduce HIV transmission during pregnancy, birth, and breastfeeding. Despite significant investments to scale-up Option B+, results have been mixed, with high rates of loss to follow-up, sub-optimal viral suppression, continued pediatric HIV transmission, and HIV-associated maternal morbidity. The Systems Analysis and Improvement Approach (SAIA) cluster randomized trial demonstrated that a package of systems engineering tools improved flow through the prevention of mother-to-child HIV transmission (PMTCT) cascade. This five-step, facility-level intervention is designed to improve understanding of gaps (cascade analysis), guide identification and prioritization of low-cost workflow modifications (process mapping), and iteratively test and redesign these modifications (continuous quality improvement). This protocol describes a novel model for SAIA delivery (SAIA-SCALE) led by district nurse supervisors (rather than research nurses), and evaluation procedures, to serve as a foundation for national scale-up.

Methods

The SAIA-SCALE stepped wedge trial includes three implementation waves, each 12 months in duration. Districts are the unit of assignment, with four districts randomly assigned per wave, covering all 12 districts in Manica province, Mozambique. In each district, the three highest volume health facilities will receive the SAIA-SCALE intervention (totaling 36 intervention facilities). The RE-AIM framework will guide SAIA-SCALE’s evaluation. Reach describes the proportion of clinics and population in Manica province reached, and sub-groups not reached. Effectiveness assesses impact on PMTCT process measures and patient-level outcomes. Adoption describes the proportion of districts/clinics adopting SAIA-SCALE, and determinants of adoption using the Organizational Readiness for Implementing Change (ORIC) tool. Implementation will identify SAIA-SCALE core elements and determinants of successful implementation using the Consolidated Framework for Implementation Research (CFIR). Maintenance describes the proportion of districts sustaining the intervention. We will also estimate the budget and program impact from the payer perspective for national scale-up.

Discussion

SAIA packages user-friendly systems engineering tools to guide decision-making by frontline health workers, and to identify low-cost, contextually appropriate PMTCT improvement strategies. By integrating SAIA delivery into routine management structures, this pragmatic trial is designed to test a model for national intervention scale-up.

Trial Registration

ClinicalTrials.gov NCT03425136 (registered 02/06/2018).

**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**

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✪ Using implementation facilitation to implement primary care mental health integration via clinical video telehealth in rural clinics: protocol for a hybrid type 2 cluster randomized stepped-wedge design

Authors:

Richard R. Owen, Eva N. Woodward, Karen L. Drummond, Tisha L. Deen, Karen Anderson Oliver, Nancy J. Petersen, Scott S. Meit, John C. Fortney, & JoAnn E. Kirchner

University of Washington affiliated authors are displayed in bold.

✪ Open Access

Published: March 2019

Read the full text in the open access journal Implementation Science

Abstract:

Background

Integrating mental health providers into primary care clinics improves access to and outcomes of mental health care. In the Veterans Health Administration (VA) Primary Care Mental Health Integration (PCMHI) program, mental health providers are co-located in primary care clinics, but the implementation of this model is challenging outside large VA medical centers, especially for rural clinics without full mental health staffing. Long wait times for mental health care, little collaboration between mental health and primary care providers, and sub-optimal outcomes for rural veterans could result. Telehealth could be used to provide PCMHI to rural clinics; however, the clinical effectiveness of the tele-PCMHI model has not been tested. Based on evidence that implementation facilitation is an effective implementation strategy to increase uptake of PCMHI when delivered on-site at larger VA clinics, it is hypothesized that this strategy may also be effective with regard to ensuring adequate uptake of the tele-PCMHI model at rural VA clinics.

Methods

This study is a hybrid type 2 pragmatic effectiveness-implementation trial of tele-PCMHI in six sites over 24 months. Tele-PCMHI, which will be delivered by clinical staff available in routine care settings, will be compared to usual care. Fidelity to the care model will be monitored but not controlled. We will use the Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) framework to evaluate the patient-level clinical effectiveness of tele-PCMHI in rural VA clinics and also to evaluate the fidelity to and outcomes of the implementation strategy, implementation facilitation. The proposed study will employ a stepped-wedge design in which study sites sequentially begin implementation in three steps at 6-month intervals. Each step will include (1) a 6-month period of implementation planning, followed by (2) a 6-month period of active implementation, and (3) a final period of stepped-down implementation facilitation.

Discussion

This study will evaluate the effectiveness of PCMHI in a novel setting and via a novel method (clinical video telehealth). We will test the feasibility of using implementation facilitation as an implementation strategy to deploy tele-PCMHI in rural VA clinics.

Trial registration

ClinicalTrials.gov registration number NCT02713217. Registered on 18 March 2016.

**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**

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