Damush HSR&D Research Career Scientist Award Application

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Background: New policies and healthcare processes are constantly rolling out to the front lines of clinical staff and providers across clinical conditions and multiple settings within VHA. Less is known about the investment needed into evidence based implementation strategies by VHA healthcare organizations to achieve systematic implementation. Moreover, implementation science has only recently begun to identify a set of implementation strategies. Research is needed to elucidate upon the appropriate dose of the intervention strategy tailored to the local context to modify provider behaviors' and patients' behaviors and systems of care with sustainable implementation. Through the Precision Monitoring (PRIS-M QUERI Center) to Transform Care program we are conducting the following implementation evaluations: 1) Conduct scalable clinical quality improvement projects that link electronic data to provider actions and reporting; 2) Investigate the effects of providing actionable data on care team behaviors and processes and Veteran behaviors and satisfaction; 3) Identify the implementation strategies including the investment needed in and contextual factors that activate VHA providers, leaders, and Veterans to use data to transform and improve care and patient outcomes; and 4) activate Veteran patients to engage in the healthcare system to manage their health. Methods: With the ongoing input of our core VHA Operational partners, we are accomplishing these aims via core research and quality improvement projects that cover multiple conditions and care settings. Our projects focus on: 1) national implementation of TeleStroke in rural VHA, 2) testing telehealth modules and electronic quality measures for improving rapid transient ischemic attack (TIA) care, 3) decision support to deimplement inappropriate carotid ultrasound image ordering, and 4) regional implementation of TeleRobotics in rural VHA. These projects are supported by an Implementation and Data Core that I lead which works across all projects to facilitate efficient use of data; usability testing of new tools; and standardized use of implementation measures, methods, and analytic approaches. Our overarching implementation strategy focuses on activating individuals and groups to use data to transform care, and we use the CFIR framework to plan data collection and analyses across projects to identify core implementation strategies and contextual factors that impact how people use data to transform care. Key partners include the Office of Specialty Care, the Office of Rural Health, the Office of Telehealth, the Roudebush VAMC, and the VA Center for Applied Systems Engineering. We have developed a professional video modeling a multidisciplinary VA healthcare team which uses data to activate provider changes across services in a data driven way to improve the quality of care, and provider/patient satisfaction. Using Planning, Goal Setting, and Reflection and Evaluation, we are promoting provider behavior modification and team activation. Moreover, we employ the strategy of external facilitation to guide clinical teams in the VHA field. In addition, my research on patient self-management programs attempts to reach Veterans where they are to engage in the healthcare system to promote their optimal health and functioning. I am piloting the adaptation of cardiac rehabilitation to delivery adjuvant recovery programs for Veterans with cerebrovascular events and other conditions. Anticipated impacts: Our project evaluations are addressing the important implementation questions about how best to activate providers, healthcare teams, and Veterans to improve healthcare delivery and outcomes across clinical conditions and settings. We anticipate demonstrating the effectiveness of our implementation strategies as well elucidating upon the tailoring to the local contexts and the adequate dose of the strategies to achieve sustainable implementation within the VHA system with applications to other healthcare systems. Moreover, my Veteran centered patient programs may help Veterans to engage with providers of their care and thus improving Veteran satisfaction and outcomes of care.