Implementation and dissemination of a transition of care program for rural veterans: a controlled before and after study
Implementation and dissemination of a transition of care program for rural veterans: a controlled before and after study
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DOI：
10.1186/s13012-017-0653-1
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发表时间：
2017-10-23
影响因子：
7.2
通讯作者：
Burke, Robert
中科院分区：
文献类型：
--
作者：
Leonard, Chelsea;Lawrence, Emily;Burke, Robert
背景：使有希望的卫生保健干预措施适应当地环境是传播和实施过程中的一个关键组成部分。退伍军人健康管理局(VHA)农村过渡期护士计划(TNP)是一项由护士主导、以退伍军人为中心的干预措施，旨在改善由退伍军人管理局全国办公室资助的农村退伍军人的过渡期护理，并传播到其他退伍军人服务点，服务于以农村退伍军人为主的人口。在这里，我们描述了我们实施和评估的新方法=TNP。方法：这是一项前后对照研究，评估实施和干预结果。在实施前，我们使用混合方法评估现场环境，使用来自不同来源的数据，包括设施级别的定量数据、关键线人和退伍军人访谈、对出院过程的观察，以及小组集思广益活动。我们使用实用的稳健执行和可持续发展模型(PRISM)为我们的查询提供信息，整合来自所有来源的数据，并确定可能影响执行的因素。在实施阶段，我们将利用内部和外部促进，并辅之以审计和反馈，以鼓励适当的背景调整。我们将使用修改后的Stirman框架来记录改编。在评估阶段，我们将使用RE-AIM框架衡量每个站点的干预和实施成果(REACH、有效性、采用、实施和维护)。我们将以倾向匹配的退伍军人和退伍军人设施作为对照进行差异分析。我们的主要干预结果是30天的再住院率和急诊科就诊率。我们将利用我们的研究结果来开发一个实施工具包，为在退伍军人管理局更大范围内扩大TNP提供信息。讨论：使用PRISM为实施前评估提供信息并综合来自多个来源的数据，再加上内部和外部促进，是一种让现场参与适应干预措施，同时提高干预措施保真度的新方法。我们将PRISM应用于实施前和中期评估，以及记录适应情况，提供了一个机会，以确定和解决可能阻碍或加强卫生干预措施的实施和可持续性的背景因素，并提供信息传播。
Background: Adapting promising health care interventions to local settings is a critical component in the dissemination and implementation process. The Veterans Health Administration (VHA) rural transitions nurse program (TNP) is a nurse-led, Veteran-centered intervention designed to improve transitional care for rural Veterans funded by VA national offices for dissemination to other VA sites serving a predominantly rural Veteran population. Here, we describe our novel approach to the implementation and evaluation = the TNP.Methods: This is a controlled before and after study that assesses both implementation and intervention outcomes. During pre-implementation, we assessed site context using a mixed method approach with data from diverse sources including facility-level quantitative data, key informant and Veteran interviews, observations of the discharge process, and a group brainstorming activity. We used the Practical Robust Implementation and Sustainability Model (PRISM) to inform our inquiries, to integrate data from all sources, and to identify factors that may affect implementation. In the implementation phase, we will use internal and external facilitation, paired with audit and feedback, to encourage appropriate contextual adaptations. We will use a modified Stirman framework to document adaptations. During the evaluation phase, we will measure intervention and implementation outcomes at each site using the RE-AIM framework (Reach, Effectiveness, Adoption, Implementation, and Maintenance). We will conduct a difference-in-differences analysis with propensity-matched Veterans and VA facilities as a control. Our primary intervention outcome is 30-day readmission and Emergency Department visit rates. We will use our findings to develop an implementation toolkit that will inform the larger scale-up of the TNP across the VA.Discussion: The use of PRISM to inform pre-implementation evaluation and synthesize data from multiple sources, coupled with internal and external facilitation, is a novel approach to engaging sites in adapting interventions while promoting fidelity to the intervention. Our application of PRISM to pre-implementation and midline evaluation, as well as documentation of adaptations, provides an opportunity to identify and address contextual factors that may impede or enhance implementation and sustainability of health interventions and inform dissemination.