Exploring climate and context to inform implementation of a brief sleep health program for older primary care patients

抽象的。健康的睡眠模式对老年人的认知健康、功能能力、 情绪和整体生活质量。多达三分之二的老年人抱怨有失眠症状，包括 入睡困难或睡眠困难，或夜间睡眠不佳，导致白天功能障碍。尽管有很高的 失眠症状的流行，只有25%的老年人曾与医生讨论过睡眠问题。 失眠可以通过循证行为疗法安全有效地治疗，包括认知疗法 失眠的行为疗法(CBTI)。然而，对CBTI的访问仍然有限，几乎没有程序 专为满足老年人的需求而设计。确定现有的护理途径，包括初级保健 服务，可能有助于改善进入CBTI的机会。我们的团队之前已经开发并测试了一种有效的 旨在适应老年人认知和功能需求的行为睡眠干预。植根于 根据CBTI的原则，我们的四次干预与夜间睡眠的客观改善有关 白天功能障碍的主观减少。拟议的研究扩展了我们团队之前的工作，并 将这种有效的老年失眠干预措施从退伍军人管理局扩展到非退伍军人管理局的第一步 设置。本提案以探索、准备、实施和可持续发展(EPIS)为指导 探讨当地初级保健诊所在以下方面的实施环境和文化的框架 实施短暂的失眠干预。这项分两个阶段进行的研究包括一项解释性顺序研究 混合方法研究，随后是一系列联合设计会议，以了解实施环境和 了解当地初级保健环境的情况，并完善干预程序和实施战略。这个 研究目标如下：目标1.审查与一体化有关的执行环境和背景 在初级保健诊所寻求护理的老年人的循证失眠干预。目标1a。识别 目前与老年人失眠有关的临床实践，包括估计的失眠频率 投诉、当前评估程序和可用的治疗方法。目标1b。与患者和 提供商利益相关者，探索实施障碍和促进者。目标2.吸引关键利益相关者参与 (患者和提供者)参与协作、共同设计流程，以完善干预程序和 实施战略。从Aim 1a的患者和提供者那里收集的定量调查将确定 失眠知识、信念和态度以及以往初级保健失眠的经历 筛查和治疗。调查结果将为AIM 1b的半结构化面试提供信息。联合设计会议 每个患者和提供者将确定如何将干预整合到当地实践中(例如， 培训提供者、筛查程序和干预提供方式)。由这些目标产生的结果 将提供初步数据，为R01混合有效性实施试验提供参考，以检查 将老年失眠干预纳入初级保健的实施战略的有效性。

ABSTRACT. Healthy-sleep wake patterns are critical to older adults’ cognitive health, functional capacity, mood, and overall quality-of-life. Up to two-thirds of older adults complain of insomnia symptoms, including difficulty falling or staying asleep, or poor nighttime sleep that results in daytime dysfunction. Despite the high prevalence of insomnia symptoms, as few as 25% of older adults have discussed sleep with a doctor. Insomnia can be safely and effectively treated with evidence-based behavioral treatments, including Cognitive Behavioral Therapy for Insomnia (CBTI). However, access to CBTI remains limited and few programs have been designed to meet the needs of older adults. Identifying existing care pathways, including primary care services, may help improve access to CBTI. Our team has previously developed and tested an effective behavioral sleep intervention designed to accommodate older adults’ cognitive and functional needs. Rooted in principles of CBTI, our four-session intervention was associated with objective improvements in nighttime sleep and subjective decreases in daytime dysfunction. The proposed research extends our team’s prior work and is the first step towards scale out of this effective geriatric insomnia intervention from VA to non-VA medical settings. This proposal is guided by the Exploration, Preparation, Implementation, and Sustainability (EPIS) Framework to explore the implementation climate and culture of local primary care clinics in regards to implementation of a brief insomnia intervention. This two-phased study includes an explanatory sequential mixed methods study followed by a series of co-design sessions to understand the implementation climate and context of local primary care settings, and to refine intervention procedures and implementation strategies. The study aims are as follows: Aim 1. Examine implementation climate and context related to integration of an evidence-based insomnia intervention for older adults seeking care in primary care clinics. Aim 1a. Identify current clinical practices related to insomnia in older adults, including estimated frequency of insomnia complaints, current assessment procedures, and available treatments. Aim 1b. In collaboration with patient and provider stakeholders, explore implementation barriers and facilitators. Aim 2. Engage key stakeholders (patients and providers) in a collaborative, co-design process to refine intervention procedures and implementation strategies. Quantitative surveys collected from patients and providers in Aim 1a will identify insomnia knowledge, beliefs, and attitudes as well past experiences with primary care-based insomnia screening and treatment. Survey findings will inform semi-structured interviews in Aim 1b. Co-design sessions with each patients and providers will determine how to integrate the intervention into local practices (e.g., training providers, screening procedures, and mode of intervention delivery). Findings generated by these aims will provide preliminary data to inform a R01 hybrid effectiveness implementation trial to examine the effectiveness of implementation strategies to integrate a geriatric insomnia intervention into primary care.