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- Implementation: The linchpin of evidence-based practice changes - American Nurse Today
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This review focused on evaluations of IC programs for older adults with complex care needs e. In the first few months of the review, the research team refined the research question and identified initial middle-range theories of the potential mechanisms and contexts or CMOcs that facilitate IC program success [ 17 , 20 ].
The theories were identified through an initial review of key literature and consultations with stakeholders. Given the complexity of IC programs, several broader theories [ 20 ] were identified, which can explain the successful workings of these programs. Specifically, the literature describes how the mechanism of trusting relationships in multidisciplinary teams facilitates effective interdisciplinary collaboration and communication, which allows teams to create continuity of care and coordinate care around the patient through regular team meetings and care planning, leading to better patient health outcomes and satisfaction [ 24 ].
Shared IT systems that link IC partners and multidisciplinary team members is a contextual factor that has been identified as effective for communication between providers, data management and transfer of patient information to improve patient care [ 25 , 26 ]. Another theory relates to the contextual factor of funding models e. The role of leadership in establishing an organizational culture is a contextual factor that supports implementation of IC programs [ 25 , 26 , 28 , 29 ].
Leadership has an important impact in establishing governance structures and processes that guide partnering organizations and support joint accountability and decision-making [ 25 ]. It was also hypothesized that contextual factors such as common IT solutions that support team communication, leadership that establishes an organizational culture in support of IC program implementation, governance structures that guide implementation, and funding models that involve provider incentives would support trusting and committed teams to implement and achieve desired outcomes.
To test the initial theories and hypotheses, a systematic review of the scholarly and gray, unpublished literature was performed. The research team worked with two information specialists to develop a search strategy and to perform the search. In addition, Google Scholar and open Google searches were conducted to capture non-indexed articles and gray literature. The team developed a comprehensive list of search terms in collaboration with the information specialists. The searches were conducted in June and July of by the information specialists. Articles that were published after January were captured in the search.
All identified articles were independently screened based on their titles and abstracts by three members of the research team J. Articles met the study inclusion criteria if they described integrated health and social community-based services, that employed multidisciplinary teams, were targeted to older adults with complex needs, were long-stay programs defined as providing patient care for longer than 60 days , were evaluative, published after , and written in English. Descriptive, non-evaluative articles were also included if they were related to a program that had been formally evaluated and included in the review.
Articles that were not program specific, focused on transitional programs, or focused on a single-disease were excluded. Any discrepancies in article eligibility were discussed at regular meetings until consensus was reached. The articles that passed the full-text screening stage were included the review. The quality appraisal process in realist reviews involves judgements of the rigor and relevance of the evidence [ 20 ]. Rigor assesses whether or not a study is methodologically strong from which to draw inferences, and relevance assesses a study's ability to explain the theory being tested [ 18 ].
Two members of the research team J. Any discrepancies in the ratings were resolved through discussions and also by re-reviewing studies that received different ratings. The quality appraisal process facilitated the identification of the strongest evidence on which to base the synthesis, but no evidence was excluded from the review based on appraisal ratings.
Information regarding the study purpose, period, setting, design, population, sample size, outcomes and study results were extracted as well as any explanations of mechanisms and contextual factors. Once the extraction process was complete, the evidence gathered was sorted by program to begin the synthesis process. In this stage, the extracted information was examined for mechanisms and contextual influences in each program.
Programs were analyzed by their outcomes to determine whether they yielded successful, mixed, or unsuccessful results, and then classified based on these categories.
Programs that achieved a statistically significant change in study outcomes i. The review included eleven programs considered to be successful. The unsuccessful programs were then examined to see if the same CMOcs identified in the successful and mixed results programs were present or absent. The electronic search of the gray and scholarly literature yielded a total of articles after removing duplicates.
Upon reviewing the titles and abstracts of these articles, articles were included for full-text review. Forty-one articles met the inclusion criteria and searching the reference lists of these articles combined with expert consultations yielded an additional 24 articles. Finally, a total of 65 articles, representing 28 IC programs, were included in the review see Fig. See Table 1 for a list of study types included in the review, and Table 2 for a description of program details.
Table 1 Description of types of studies included in the realist review. Healthcare utilization e. Patient and caregiver experience e. A description of programs included in the realist review of IC programs for older adults with complex needs.
Implementation: The linchpin of evidence-based practice changes - American Nurse Today
The strongest evidence supported two inter-related CMOcs, confirming many aspects of the study hypotheses: trusting multidisciplinary team relationships and provider understanding of and commitment to the program model. Trusting multidisciplinary team relationships see Fig. In programs that were successful, cross-sector multidisciplinary teams, that span different organizations, trusted each other, were clear in their roles, and could rely on each other to perform their respective roles.
These teams collaborated closely and communicated effectively, shared knowledge about their work and patient information more effectively, which allowed for continuity of care and better coordination of care. As in the hypotheses, strong leadership to guide teams in their work was a contextual factor that helped to build trust and support team collaboration [ 33 , 39 — 41 , 44 , 47 , 55 , 58 , 68 ].
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Leadership that promoted an organizational culture that fostered a shared vision of IC programs, involved joint ownership and accountability across partnering organizations, supported trust building and collaborative team functioning. For example, developing a shared vision supported by leadership was a key component of trust building between community nurses, allied health providers and general practitioners GPs in the Australian Health One Mount Druitt program. Leadership's efforts to instill a shared vision of the new IC model helped providers overcome suspicions of each other's professional groups and build trust in order to work together across disciplines [ 46 , 47 ].
In the American Program for All-Inclusive Care for the Elderly PACE program, a significant relationship between multidisciplinary team performance and patient functional status, as well as other health outcomes such as long-term urinary incontinence, was found. Creating a culture of team participation supported by leadership generated a sense of ownership and strengthened relationships among team members. This made staff feel comfortable with the model, encouraging them to take an active role in team work [ 68 ].
Open team communication supported timely transfers of information between team members, and supported them in making informed, collaborative decisions regarding patient care [ 68 ]. Furthermore, the provision by leadership of time and support for teams to build trusting relationships facilitated collaboration and communication [ 33 , 40 , 44 , 47 , 50 , 52 , 80 , 85 ]. Provider commitment to and understanding of the program model see Fig. However, provider understanding of and belief in this model, which were mechanisms not discussed in the initial theories and hypotheses, were also found to be important for program success.
For example, in the English Department of Health's Integrated Care Pilots, GP engagement was critical to implementation due to their links with the rest of the healthcare system, but also because their commitment to and endorsement of the pilots served to build confidence among other team staff in implementing the model [ 41 ]. Providers having an understanding of the process of care under the model, their roles in this process, and the benefits of the model for patient care were also important for implementation [ 47 , 50 , 52 , 54 , 85 ].
Contextual factors that facilitated provider commitment and understanding included funding models that involved incentives for providers to implement IC. GPs in capitated programs and programs with salaried staff had more flexibility and resources to implement IC, while GPs working under a fee-for-service model were less likely to become engaged and commit to the model because they were not compensated for time involved in multidisciplinary team meetings and other program activities [ 2 , 47 , 50 , 64 , 81 ].
The expertise of providers was also important for building an understanding of the model as well as team work, and subsequently program implementation [ 7 , 8 , 40 , 47 , 52 , 55 , 78 ]. In the Health One Mount Druitt program in Australia, the seniority and expertise of GP liaison nurses were instrumental in building partnerships across sites, and their credibility garnered respect and support from community health colleagues and GPs [ 47 ].
Investment in ongoing training of providers in model implementation and how to work together effectively in teams was also an important element in building provider expertise [ 8 , 54 , 55 , 78 ]. As in the previous CMOc, the establishment of an organizational culture that involved a shared vision fostered by strong leadership, increased provider understanding of the model and subsequent collaborative team functioning, as well as providing guidance in implementation [ 33 , 40 , 47 , 55 , 68 ].
The creation of an organizational culture in support of the system and practice changes required by the IC model helped providers to understand and renegotiate professional boundaries for joint working in the English Department of Health Integrated Care Pilots [ 40 ]. Time to set up an infrastructure for program implementation, involving building team relationships, establishing coordination across partnering organizations, establishing information management systems, enrolling patients and developing appropriate care plans, was another important contextual factor that further fostered provider commitment to the model and motivation to implement [ 2 , 7 , 33 , 40 , 47 , 50 , 52 , 54 , 55 , 79 — 81 , 85 ].
Flexibility in implementation also supported provider commitment to the model. Programs that adapted to the local needs of the population by allowing operational changes, and generally aligning care with population needs over time served to build provider commitment, enthusiasm and confidence in implementing the model [ 36 , 47 , 54 , 55 , 58 , 60 , 84 , 85 ]. For example, evaluation of the Te Whiringa Ora program in New Zealand attributed understanding the cultural context and value of the Maori population needs to the success of the program in increasing patient quality of life and reducing hospitalizations.
While several mixed results programs had a number of mechanisms of success identified in the CMOcs, they generally had fewer of these drivers than did successful programs. Provider commitment to the model was also challenged in the High-Intensity Case Management Demonstration Program due to limited provider enthusiasm resulting from the significant changes in practice necessary for implementation, and limited flexibility for providers to make operational changes [ 48 ].
Unsuccessful programs experienced a number of barriers to enacting the mechanisms of success identified in the CMOcs. The Dutch Prevention of Care PoC program suffered from a lack of provider commitment to the model as providers viewed team meetings as time-consuming, and they did not fully understand how to use program protocols due to limited training [ 91 ].
The evaluators of the CareWell program noted that the month trial period may not have been long enough for providers to build trusting relationships within multidisciplinary teams, challenging team collaboration [ 32 ]. The PoC evaluation and the Dutch CareWell primary care program evaluation both suffered from a number of methodological limitations, including baseline similarities between experimental and control arms, potential contamination between study arms, and loss of high-risk participants to follow-up [ 32 , 91 ].
This review isolates key mechanisms and contextual factors CMOcs that may lead to the success of integrated health and social care programs for older adults.
The review confirmed many aspects of the initial theories and hypotheses, in that it emphasized the importance of trusting multidisciplinary team relationships for effective collaboration, communication and knowledge sharing and their role in program success. Provider commitment to and understanding of the IC model, as fostered by strong leadership, clear governance, time to build an infrastructure to implement and flexibility in implementation, emerged as key processes instrumental to success of these programs.
In several programs, the contextual factor of common IT solutions across partnering organizations which was articulated in the initial theories facilitated effective team communication and collaboration [ 10 , 52 , 54 , 55 , 78 , 87 ], but some successful and mixed results programs achieved change in outcomes without common IT structures [ 46 — 48 ]. Thus, contrary to the initial theories, it was not a necessary condition for success included in the CMOcs. A limitation of this review is one that is common to most realist reviews.
In the case of this review, several study authors had published separate, more detailed program descriptions. The inclusion of gray literature in the review also provided more information on certain programs. This information was lacking for a number of programs, thus limiting the research team's ability to fully test the initial theories. In order to advance our understanding of how and why programs are successful through realist review methods, journals should allow evaluators to report more detailed descriptions of program workings and contextual factors that may affect success [ 20 , 92 ].
Another limitation is that in any complex realm such as the implementation of IC programs, identification of two important CMOcs does not rule out the further elaboration of these CMOcs or the existence of others. The strengths of this review compared to traditional systematic reviews involve the inclusion of a range of types of evidence and a theory-driven process to refine theory as well as arrive at a detailed understanding of underlying program workings and their relationship to achieving successful outcomes.
The review findings have supported theoretical constructs that were identified at the initial stages of the review and were found in other non-theory-driven reviews e. However, this review goes beyond findings in previous reviews with the identification of important mechanisms and contextual factors linked to program success. For example, other reviews have identified the importance of the role of providers like case managers, and PCPs, and the centrality of care coordination in the effective delivery of IC programs, but these statements simply underscore the relevance of program components for implementation, and do not necessarily explain why and how these components matter.
Further examination through a realist approach allowed us to identify underlying mechanisms and contextual factors that facilitate program success or failure, beyond the presence of simple program components. This review also emphasizes the importance of processes that can be instrumental for IC program success that have not been mentioned in most of these reviews, including the investment in time to build trusting relationships between multidisciplinary team members, time to establish an infrastructure for implementation, as well as flexibility in implementation.
While most of the evaluative literature was rather vague concerning the amount of time necessary for an appropriate infrastructure to be built for implementation, a few studies alluded to a more specific timeframe. Program planners, leaders and evaluators should note that given the complexity of IC programs, longer periods of implementation and evaluation e. Future evaluations should place greater focus on this developmental stage to shed further light on the length of time needed to support this important preliminary organizational work.
Using a systematic, theory-driven method, this review included a wide range of international evidence, and identified key processes for successful implementation of IC programs that should be considered for implementation by program planners and leaders, as well as by evaluators. These findings should inform the development of effective integrated programs that will support older adults to age at home successfully, and alleviate increasing costs to the healthcare system as this population ages.
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