Needs Assessment and Best Practices for Digital Trainings for Health Professionals in Ethiopia Using the RE-AIM Framework: COVID-19, Case Study.

OBJECTIVES: To assess the implementation science outcomes of a COVID-19 e-health educational intervention in Ethiopia targeting healthcare workers via the RE-AIM (Reach, Effectiveness, Adaption, Implementation, Maintenance) framework. METHODS: A series of three one-hour medical seminars focused on COVID-19 prevention and treatment education were conducted between May-August 2020. Educational content was built from medical sites previously impacted by COVID-19. Post-seminar evaluation information was collected from physician and other participants by a survey instrument. Cross-sectional evaluation results are reported here by RE-AIM constructs. RESULTS: The medical seminars reached 324 participants. Key success metrics include that 90% reporting the information delivered in a culturally sensitive/tailored manner (effectiveness), 80% reporting that they planned to share the information presented with someone else (adoption and implementation), and 64% reporting using information presented in their daily clinical responsibilities 6 months after the first medical seminars (maintenance). CONCLUSION: Grounded in a theoretical framework and following evidenced-based best practices, this intervention advances the field of dissemination and implementation science by demonstrating how to transition healthcare training and delivery from an in-person to digital medium in low-resource settings like Ethiopia.

Insights from Washington State's COVID-19 Response: A Mixed-Methods Evaluation of WIC Remote Services and Expanded Food Options Using the RE-AIM Framework

Background In response to the COVID-19 pandemic, Washington State's Supplemental Nutrition Program for Women, Infants, and Children (WA WIC) adopted federal waivers to transition to remote service delivery for certification and education appointments. WA WIC also expanded the approved food list without using federal waivers, adding more than 600 new items to offset challenges participants experienced accessing foods in stores. Objective This study aimed to assess the reach and effectiveness of the programmatic changes instituted by WA WIC during the COVID-19 pandemic;the processes, facilitators, and challenges involved in their implementation;and considerations for their continuation in the future. Design A mixed-methods design, guided by the RE-AIM framework, including virtual, semi-structured focus groups and interviews with WA WIC staff and participants, and quantitative programmatic data from WIC agencies across the state. Participants/setting This study included data from 52 state and local WIC staff and 40 WIC participants across the state of Washington and from various WA WIC programmatic records (2017-2021). The research team collected data and conducted analyses between January 2021 and August 2021. Analysis An inductive thematic analysis approach with Dedoose software was used to code qualitative data, generate themes, and interpret qualitative data. Descriptive statistics were calculated for quantitative programmatic data, including total participant count, percent increase and decrease in participation, percent of food benefits redeemed monthly, and appointment completion rates. Results All WA WIC participants (n = 125,279 in May 2020) experienced the programmatic changes. Participation increased by 2% from March to December 2020 after WA WIC adopted programmatic changes in response to the COVID-19 pandemic. Certification and nutrition education completion rates increased by 5% and 18% in a comparison of June 2019 with June 2020. Food benefit redemption also increased immediately after the food list was expanded in April 2020. Staff and participants were highly satisfied with remote service delivery, predominantly via the phone, and participants appreciated the expanded food options. Staff and participants want a remote service option to continue and suggested various changes to improve service quality. Conclusions Participation in WIC and appointment completion rates increased after WA WIC implemented service changes in response to the COVID-19 pandemic. Staff and participants were highly satisfied with remote services, and both desire a continued hybrid model of remote and in-person WIC appointments. Some of the suggested changes to WIC, especially the continuation of remote services, would require federal policy change, and others could be implemented under existing federal regulations.

Education program promoting report of elder abuse by nursing students: a pilot study.

BACKGROUND: Elder abuse is an important public health concern that requires urgent attention. One main barrier to active responses to elder abuse in clinical settings is a low level of relevant knowledge among nurses. This study aims to develop an educational program to promote an intent to report elder abuse among nursing students and assess its effectiveness, with a focus on the rights of older adults. METHODS: A mixed method design was used with the Analyze, Design, Develop, Implement, and Evaluate model. Twenty-five nursing students from Chungbuk Province participated in the study. Attitude toward older adults and knowledge of, awareness of, attitude towards, and intent to report elder abuse were assessed quantitatively and analyzed using paired t-test. The feasibility of the program and feedback were collected qualitatively through group interviews and analyzed using content analysis. RESULTS: After the education program, attitude toward older adults (Cohen's d = 1.08), knowledge of (Cohen's d = 2.15), awareness of (Cohen's d = 1.56), attitude towards (Cohen's d = 1.85), and intent to report elder abuse (Cohen's d = 2.78) increased, confirming the positive effects of this program. Overall, all participants were satisfied with the contents and method of the program. CONCLUSIONS: The method of program delivery should be improved and tailored strategies to boost program engagement among nursing students should be explored to implement and disseminate the program.

Adapting Evidence-Based Falls Prevention Programs for Remote Delivery - Implementation Insights through the RE-AIM Evaluation Framework to Promote Health Equity.

COVID-19 disproportionally impacted the health and well-being of older adults-many of whom live with chronic conditions-due to their higher risk of dying and being hospitalized. It also created several secondary pandemics, including increased falls risk, sedentary behavior, social isolation, and physical inactivity due to limitations in mobility from lock-down policies. With falls as the leading cause of preventable death and hospitalizations, it became vital for in-person evidence-based falls prevention programs (EBFPPs) to pivot to remote delivery. In Spring 2020, many EBFPP administrators began re-designing programs for remote delivery to accommodate physical distancing guidelines necessitated by the pandemic. Transition to remote delivery was essential for older adults and persons with disabilities to access EBFPPs for staying healthy, falls and injury free, out of hospitals, and also keeping them socially engaged. We collaborated with the Administration on Community Living (ACL), the National Council on Aging (NCOA), and the National Falls Prevention Resource Center (NFPRC), for an in-depth implementation evaluation of remotely delivered EBFPPs. We examined the process of adapting and implementing four EBFPPs for remote delivery, best practices for implementing the programs remotely within the RE-AIM evaluation framework. This enhances NFPRC's ongoing work supporting dissemination, implementation, and sustainability of EBFPPs. We purposively sampled organizations for maximum variation in organization and provider type, geographic location, and reach of underserved older populations (Black, Indigenous, or other People of Color (BIPOC), rural, disabilities). This qualitative evaluation includes provider-level data from semi-structured interviews (N = 22) with program administrators, staff, and leaders. The interview guide included what, why, and how adaptations were made to EBFPP interventions and implementation strategies using Wiltsey-Stirman (2019) adaptations framework (FRAME), reach, and implementation outcomes (acceptability, feasibility, fidelity, and costs; Proctor et al., 2011), focusing on equity to learn for whom these programs were working and opportunities to address inequities. Findings demonstrate remote EBFPPs made planned and fidelity-consistent adaptations to remote delivery in partnership with researchers and community organizations, focusing on participant safety both in program content and delivery. Supports using and accessing technology were needed for delivery sites and leaders to facilitate engagement, and improved over time. While remote EBFPP delivery has increased access to EBFPPs for some populations from the perspective of program administrator, leaders, and staff (e.g., caregivers, rural-dwellers, persons with physical disabilities), the digital divide remains a barrier in access to and comfort using technology. Remote-delivered EBFPPs were acceptable and feasible to delivery organizations and leaders, were able to be delivered with fidelity using adaptations from program developers, but were more resource intensive and costly to implement compared to in-person. This work has important implications beyond the pandemic. Remote delivery has expanded access to groups traditionally underserved by in-person programming, particularly disability communities. This work will help answer important questions about reach, accessibility, feasibility, and cost of program delivery for older adults and people with disabilities at risk for falls, those living with chronic conditions, and communities most vulnerable to disparities in access to health care, health promotion programming, and health outcomes. It will also provide critical information to funders about elements required to adapt EBFPPs proven effective in in-person settings for remote delivery with fidelity to achieve comparable outcomes.

The Implementation of a Nutrition Intervention in Food Pantries: The Spirit of SWAP.

Background. Food insecurity, affecting approximately 10% of the U.S. population, with up to 40% or higher in some communities, is associated with higher rates of chronic conditions and inversely associated with diet quality. Nutrition interventions implemented at food pantries are an effective strategy to increase healthy food choices and improve health outcomes for people experiencing food and nutrition insecurity. Supporting Wellness at Pantries (SWAP), a stoplight nutrition ranking system, can facilitate healthy food procurement and distribution at pantries. Purpose. Guided by the RE-AIM Framework, this study assesses the implementation and outcomes of SWAP as nutritional guidance and institutional policy intervention, to increase procurement and distribution of healthy foods in pantries. Method. Mixed-methods evaluation included observations, process forms, and in-depth interviews. Food inventory assessments were conducted at baseline and 2-year follow-up. Results. Two large pantries in New Haven, Connecticut, collectively reaching more than 12,200 individuals yearly, implemented SWAP in 2019. Implementation was consistent prepandemic at both pantries. Due to COVID-mandated distribution changes, pantries adapted SWAP implementation during the pandemic while still maintaining the "spirit of SWAP." One pantry increased the percentage of Green foods offered. Challenges to healthy food distribution are considered. Discussion. This study has implications for policy, systems, and environmental changes. It shows the potential for SWAP adoption at pantries, which can serve as a guide for continued healthy food procurement and advocacy. Maintaining the "spirit of SWAP" shows promising results for food pantries looking to implement nutrition interventions when standard practice may not be possible.

Supporting people affected by problematic alcohol, substance use and other behaviours under pandemic conditions: A pragmatic evaluation of how SMART recovery Australia responded to COVID-19.

BACKGROUND: The COVID-19 pandemic prompted rapid, reflexive transition from face-to-face to online healthcare. For group-based addiction services, evidence for the impact on service delivery and participant experience is limited. METHODS: A 12-month (plus 2-month follow-up) pragmatic evaluation of the upscaling of online mutual-help groups by SMART Recovery Australia (SRAU) was conducted using The Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) framework. Data captured by SRAU between 1st July 2020 and 31st August 2021 included participant questionnaires, Zoom Data Analytics and administrative logs. RESULTS: Reach: The number of online groups increased from just 6 pre-COVID-19 to 132. These groups were delivered on 2786 (M = 232.16, SD = 42.34 per month) occasions, to 41,752 (M = 3479.33, SD = 576.34) attendees. EFFECTIVENESS: Participants (n = 1052) reported finding the online group meetings highly engaging and a positive, recovery supportive experience. 91 % of people with experience of face-to-face group meetings rated their online experience as equivalent or better. Adoption: Eleven services (including SRAU) and five volunteers delivered group meetings for the entire 12-months. IMPLEMENTATION: SRAU surpassed their goal of establishing 100 groups. Maintenance: The average number of meetings delivered [t(11.14) = -1.45, p = 0.1737] and attendees [t(1.95) = -3.28, p = 0.1880] per month were maintained across a two-month follow-up period. CONCLUSIONS: SRAU scaled-up the delivery of online mutual-help groups in response to the COVID-19 pandemic. Findings support the accessibility, acceptability and sustainability of delivering SMART Recovery mutual-help groups online. Not only are these findings important in light of the global pandemic and public safety, but they demonstrate the potential for reaching and supporting difficult and under-served populations.

Implementing DASH-Aligned Meals and Self-Measured Blood Pressure to Reduce Hypertension at Senior Centers: A RE-AIM Analysis.

Low-income, minority seniors face high rates of hypertension that increase cardiovascular risk. Senior centers offer services, including congregate meals, that can be a valuable platform to reach older adults in underserved communities. We implemented two evidence-based interventions not previously tested in this setting: DASH-aligned congregate meals and Self-Measured Blood Pressure (SMBP), to lower blood pressure (BP) at two senior centers serving low-income, racially diverse communities. The study enrolled congregate meal program participants, provided training and support for SMPB, and nutrition and BP education. DASH-aligned meals delivered 40% (lunch) or 70% (breakfast and lunch) of DASH requirements/day. Primary outcomes were change in BP, and BP control, at Month 1. Implementation data collected included client characteristics, menu fidelity, meal attendance, SMBP adherence, meal satisfaction, input from partner organizations and stakeholders, effort, and food costs. We used the RE-AIM framework to analyze implementation. Study Reach included 94 older, racially diverse participants reflecting neighborhood characteristics. Effectiveness: change in systolic BP at Month 1 trended towards significance (-4 mmHg, p = 0.07); change in SMBP reached significance at Month 6 (-6.9 mmHg, p = 0.004). We leveraged existing community-academic partnerships, leading to Adoption at both target sites. The COVID pandemic interrupted Implementation and Maintenance and may have attenuated BP effectiveness. DASH meals served were largely aligned with planned menus. Meal attendance remained consistent; meal satisfaction was high. Food costs increased by 10%. This RE-AIM analysis highlights the acceptability, feasibility, and fidelity of this DASH/SMBP health intervention to lower BP at senior centers. It encourages future research and offers important lessons for organizations delivering services to older adults and addressing cardiovascular risk among vulnerable populations.

Health care professionals' perspectives on the utilisation of a remote surveillance and care tool for patients with COVID-19 in general practice: a qualitative study.

BACKGROUND: Most COVID-19 patients with severe symptoms are treated in hospitals. General practices are responsible for assessing most ambulatory patients. However, they face several challenges managing COVID-19 patients, and those with non-COVID-19 conditions. In April of 2020, we designed a software tool for the structured surveillance of high-risk home-quarantined COVID-19 patients in general practice (CovidCare) including several telephone monitorings, in order to support general practices and early identification of severe courses. This study presents the qualitative results of a mixed-methods process evaluation study on CovidCare. METHODS: In a qualitative process evaluation study conducted between March and May 2021, we explored the perspectives of seven general practitioners (GPs) and twelve VERAHs (medical care assistants with special training) on CovidCare using semi-structured interviews based on the RE-AIM framework (reach, effectiveness, adoption, implementation, maintenance). We used deductive qualitative content analysis employing the RE-AIM framework to assess the utilisation and implementation of CovidCare. RESULTS: Overall, most health care professionals were satisfied with CovidCare. They highlighted 1) a good orientation for the management of COVID-19 patients, especially due to a high level of uncertainty at the beginning of the pandemic, 2) the possibility to gain new knowledge, and 3) the structured data collection as facilitators for the implementation of CovidCare. Moreover, CovidCare reduced the workload for GPs while some VERAHs perceived a higher workload as they were responsible for large parts of the CovidCare management. However, CovidCare positively affected the VERAHs' job satisfaction as most patients provided positive feedback and felt less anxious about coping with their disease. Previous experience with the software and an easy integration into daily practice were considered to be crucial utilisation drivers. Time and personnel resources were identified as major barriers. To further improve CovidCare, participants suggested a less comprehensive version of CovidCare, the expansion of inclusion criteria as well as an app for the patients' self-management. CONCLUSION: The COVID-19 surveillance and care tool for COVID-19 patients with increased risk was perceived as useful by GPs and VERAHs. Supportive remote health care tools such as CovidCare are a viable means to maintain comprehensive and continuous health care during a pandemic and may strengthen the primary care system. TRIAL REGISTRATION: German Clinical Trials Register DRKS00022054 ; date of registration: 02/06/2020.

Telehealth in the Post Pandemic Era

As we look towards post-pandemic health delivery, the role of telehealth must be examined. We use the RE-AIM framework to discuss the challenges and successes of telehealth during the pandemic in the United States, and propose critical aspects to consider for optimizing telehealth care in the future.

Using Iterative RE-AIM to enhance hospitalist adoption of lung ultrasound in the management of patients with COVID-19: an implementation pilot study.

BACKGROUND: Lung ultrasound (LUS) is a clinician-performed evidence-based imaging modality that has multiple advantages in the evaluation of dyspnea caused by multiple disease processes, including COVID-19. Despite these advantages, few hospitalists have been trained to perform LUS. The aim of this study was to increase adoption and implementation of LUS during the 2020 COVID-19 pandemic by using recurrent assessments of RE-AIM outcomes to iteratively revise our implementation strategies. METHODS: In an academic hospital, we implemented guidelines for the use of LUS in patients with COVID-19 in July 2020. Using a novel "RE-AIM dashboard," we used an iterative process of evaluating the high-priority outcomes of Reach, Adoption, and Implementation at twice monthly intervals to inform revisions of our implementation strategies for LUS delivery (i.e., Iterative RE-AIM process). Using a convergent mixed methods design, we integrated quantitative RE-AIM outcomes with qualitative hospitalist interview data to understand the dynamic determinants of LUS Reach, Adoption, and Implementation. RESULTS: Over the 1-year study period, 453 LUSs were performed in 298 of 12,567 eligible inpatients with COVID-19 (Reach = 2%). These 453 LUS were ordered by 43 out of 86 eligible hospitalists (LUS order adoption = 50%). However, the LUSs were performed/supervised by only 8 of these 86 hospitalists, 4 of whom were required to complete LUS credentialing as members of the hospitalist procedure service (proceduralist adoption 75% vs 1.2% non-procedural hospitalists adoption). Qualitative and quantitative data obtained to evaluate this Iterative RE-AIM process led to the deployment of six sequential implementation strategies and 3 key findings including (1) there were COVID-19-specific barriers to LUS adoption, (2) hospitalists were more willing to learn to make clinical decisions using LUS images than obtain the images themselves, and (3) mandating the credentialing of a strategically selected sub-group may be a successful strategy for improving Reach. CONCLUSIONS: Mandating use of a strategically selected subset of clinicians may be an effective strategy for improving Reach of LUS. Additionally, use of Iterative RE-AIM allowed for timely adjustments to implementation strategies, facilitating higher levels of LUS Adoption and Reach. Future studies should explore the replicability of these preliminary findings.

Implementation Evaluation of HUGS/Abrazos During the COVID-19 Pandemic: A Program to Foster Resiliency in Pregnancy and Early Childhood.

Early life adversity can significantly impact child development and health outcomes throughout the life course. With the COVID-19 pandemic exacerbating preexisting and introducing new sources of toxic stress, social programs that foster resilience are more necessary now than ever. The Helping Us Grow Stronger (HUGS/Abrazos) program fills a crucial need for protective buffers during the COVID-19 pandemic, which has escalated toxic stressors affecting pregnant women and families with young children. HUGS/Abrazos combines patient navigation, behavioral health support, and innovative tools to ameliorate these heightened toxic stressors. We used a mixed-methods approach, guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework, to evaluate the implementation of the HUGS/Abrazos program at Massachusetts General Hospital from 6/30/2020-8/31/2021. Results of the quality improvement evaluation revealed that the program was widely adopted across the hospital and 392 unique families were referred to the program. The referred patients were representative of the communities in Massachusetts disproportionately affected by the COVID-19 pandemic. Furthermore, 79% of referred patients followed up with the initial referral, with sustained high participation rates throughout the program course; and they were provided with an average of four community resource referrals. Adoption and implementation of the key components in HUGS/Abrazos were found to be appropriate and acceptable. Furthermore, the implemented program remained consistent to the original design. Overall, HUGS/Abrazos was well adopted as an emergency relief program with strong post-COVID-19 applicability to ameliorate continuing toxic stressors while decreasing burden on the health system.

Mindfulness and Understanding of Self-Care for Leaders of Extension: Promoting Well-Being for Health Educators and Their Clients.

Background: Mindfulness and self-care, practiced through a variety of methods like meditation and exercise, can improve overall sense of holistic well-being (i.e., flourishing). Increasing mindfulness and self-care may lead to increased flourishing and job satisfaction among the nation-wide Cooperative Extension system delivery personnel (agents) through a theory-based online program and an extended experiential program. Methods: Cooperative Extension agents from two states were invited to participate in MUSCLE via statewide listservs. Participants were invited to attend sessions and complete competency checks and between-session assignments each week. The study was conducted using Zoom. Pre- and post- program surveys included validated scales for flourishing and physical activity status. Due to high demand for mindfulness programing during the onset of the COVID-19 pandemic, experiential "Mindful Meet-up" 30-minute sessions were held on Zoom. Dissemination and implementation of the two differing interventions (i.e., MUSCLE and Mindful Meet-ups) were examined. Results: MUSCLE (more intensive program with assignments and competency checks) had lower reach, and did not show statistically increased flourishing or physical activity. Mindful Meet-ups had higher attendance and proportional reach during the beginning of the pandemic, but no practical measure of flourishing or physical activity behaviors. Unsolicited qualitative feedback was encouraging because the interventions were well-received and participants felt as though they were more mindful. Conclusions: While agents anecdotally reported personal improvements, capturing data on outcomes was challenging. Complementing outcome data with implementation and dissemination outcomes allowed for a richer picture to inform intervention decision-making (i.e., offering the same or new programming depending on participant needs).

Insights from Washington State's COVID-19 Response: A Mixed-Methods Evaluation of WIC Remote Services and Expanded Food Options Using the RE-AIM Framework.

BACKGROUND: In response to the COVID-19 pandemic, Washington State's Supplemental Nutrition Program for Women, Infants, and Children (WA WIC) adopted federal waivers to transition to remote service delivery for certification and education appointments. WA WIC also expanded the approved food list without using federal waivers, adding more than 600 new items to offset challenges participants experienced accessing foods in stores. OBJECTIVE: This study aimed to assess the reach and effectiveness of the programmatic changes instituted by WA WIC during the COVID-19 pandemic; the processes, facilitators, and challenges involved in their implementation; and considerations for their continuation in the future. DESIGN: A mixed-methods design, guided by the RE-AIM framework, including virtual, semi-structured focus groups and interviews with WA WIC staff and participants, and quantitative programmatic data from WIC agencies across the state. PARTICIPANTS/SETTING: This study included data from 52 state and local WIC staff and 40 WIC participants across the state of Washington and from various WA WIC programmatic records (2017-2021). The research team collected data and conducted analyses between January 2021 and August 2021. ANALYSIS: An inductive thematic analysis approach with Dedoose software was used to code qualitative data, generate themes, and interpret qualitative data. Descriptive statistics were calculated for quantitative programmatic data, including total participant count, percent increase and decrease in participation, percent of food benefits redeemed monthly, and appointment completion rates. RESULTS: All WA WIC participants (n = 125,279 in May 2020) experienced the programmatic changes. Participation increased by 2% from March to December 2020 after WA WIC adopted programmatic changes in response to the COVID-19 pandemic. Certification and nutrition education completion rates increased by 5% and 18% in a comparison of June 2019 with June 2020. Food benefit redemption also increased immediately after the food list was expanded in April 2020. Staff and participants were highly satisfied with remote service delivery, predominantly via the phone, and participants appreciated the expanded food options. Staff and participants want a remote service option to continue and suggested various changes to improve service quality. CONCLUSIONS: Participation in WIC and appointment completion rates increased after WA WIC implemented service changes in response to the COVID-19 pandemic. Staff and participants were highly satisfied with remote services, and both desire a continued hybrid model of remote and in-person WIC appointments. Some of the suggested changes to WIC, especially the continuation of remote services, would require federal policy change, and others could be implemented under existing federal regulations.

An Evaluation of a Commercialized mHealth Intervention to Promote Physical Activity in the Workplace.

Background: UPnGO with ParticipACTION (UPnGO) was a commercialized 12-month workplace physical activity intervention, aimed at encouraging employees to sit less and move more at work. Its design took advantage of the ubiquitous nature of mobile fitness trackers and aimed to be implemented in any office-based workplace in Canada. The program was available at cost from June 2017 to April 2020. The objectives of this study are to evaluate the program and identify key lessons from the commercialization of UPnGO. Methods: Using a quasi-experimental design over 3 time points: baseline, 6 months, 12 months, five evaluation indicators were measured as guided by the RE-AIM framework. Reach was defined as the number and percentage of employees who registered for UPnGO and the number and percentage of sedentary participants registered. Effectiveness was assessed through average daily step count. Adoption was determined by workplace champion and senior leadership responses to the off-platform survey. Implementation was assessed as the percentage of participants who engaged with specific program elements at the 3-evaluation time points. Maintenance was assessed by the number of companies who renewed their contracts for UPnGO. Results: Reach across 17 organizations, 1980 employees participated in UPnGO, with 27% of participants identified as sedentary at baseline. Effectiveness Daily step count declined from 7,116 ± 3,558 steps at baseline to 6,969 ± 6,702 (p = <0.001) at 12 months. Adoption Workplace champion and senior leadership engagement declined from 189 to 21 and 106 to 5 from baseline to 12 months, respectively. Maintenance Two companies renewed their contracts beyond the first year. Conclusions: The commercialization of UPnGO was an ambitious initiative that met with limited success; however, some key lessons can be generated from the attempt. The workplace remains an important environment for PA interventions but effective mHealth PA programs may be difficult to implement and sustain long-term.

Evaluation of a social determinants of health screening questionnaire and workflow pilot within an adult ambulatory clinic.

BACKGROUND: There is increased recognition in clinical settings of the importance of documenting, understanding, and addressing patients' social determinants of health (SDOH) to improve health and address health inequities. This study evaluated a pilot of a standardized SDOH screening questionnaire and workflow in an ambulatory clinic within a large integrated health network in Northern California. METHODS: The pilot screened for SDOH needs using an 11-question Epic-compatible paper questionnaire assessing eight SDOH and health behavior domains: financial resource, transportation, stress, depression, intimate partner violence, social connections, physical activity, and alcohol consumption. Eligible patients for the pilot receiving a Medicare wellness, adult annual, or new patient visits during a five-week period (February-March, 2020), and a comparison group from the same time period in 2019 were identified. Sociodemographic data (age, sex, race/ethnicity, and payment type), visit type, length of visit, and responses to SDOH questions were extracted from electronic health records, and a staff experience survey was administered. The evaluation was guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. RESULTS: Two-hundred eighty-nine patients were eligible for SDOH screening. Responsiveness by domain ranged from 55 to 67%, except for depression. Half of patients had at least one identified social need, the most common being stress (33%), physical activity (22%), alcohol (12%), and social connections (6%). Physical activity needs were identified more in females (81% vs. 19% in males, p < .01) and at new patient/transfer visits (48% vs. 13% at Medicare wellness and 38% at adult wellness visits, p < .05). Average length of visit was 39.8 min, which was 1.7 min longer than that in 2019. Visit lengths were longer among patients 65+ (43.4 min) and patients having public insurance (43.6 min). Most staff agreed that collecting SDOH data was relevant and accepted the SDOH questionnaire and workflow but highlighted opportunities for improvement in training and connecting patients to resources. CONCLUSION: Use of evidence-based SDOH screening questions and associated workflow was effective in gathering patient SDOH information and identifying social needs in an ambulatory setting. Future studies should use qualitative data to understand patient and staff experiences with collecting SDOH information in healthcare settings.

Implementation of an Anticoagulation Practice Guideline for COVID-19 via a Clinical Decision Support System in a Large Academic Health System and Its Evaluation: Observational Study.

BACKGROUND: Studies evaluating strategies for the rapid development, implementation, and evaluation of clinical decision support (CDS) systems supporting guidelines for diseases with a poor knowledge base, such as COVID-19, are limited. OBJECTIVE: We developed an anticoagulation clinical practice guideline (CPG) for COVID-19, which was delivered and scaled via CDS across a 12-hospital Midwest health care system. This study represents a preplanned 6-month postimplementation evaluation guided by the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework. METHODS: The implementation outcomes evaluated were reach, adoption, implementation, and maintenance. To evaluate effectiveness, the association of CPG adherence on hospital admission with clinical outcomes was assessed via multivariable logistic regression and nearest neighbor propensity score matching. A time-to-event analysis was conducted. Sensitivity analyses were also conducted to evaluate the competing risk of death prior to intensive care unit (ICU) admission. The models were risk adjusted to account for age, gender, race/ethnicity, non-English speaking status, area deprivation index, month of admission, remdesivir treatment, tocilizumab treatment, steroid treatment, BMI, Elixhauser comorbidity index, oxygen saturation/fraction of inspired oxygen ratio, systolic blood pressure, respiratory rate, treating hospital, and source of admission. A preplanned subgroup analysis was also conducted in patients who had laboratory values (D-dimer, C-reactive protein, creatinine, and absolute neutrophil to absolute lymphocyte ratio) present. The primary effectiveness endpoint was the need for ICU admission within 48 hours of hospital admission. RESULTS: A total of 2503 patients were included in this study. CDS reach approached 95% during implementation. Adherence achieved a peak of 72% during implementation. Variation was noted in adoption across sites and nursing units. Adoption was the highest at hospitals that were specifically transformed to only provide care to patients with COVID-19 (COVID-19 cohorted hospitals; 74%-82%) and the lowest in academic settings (47%-55%). CPG delivery via the CDS system was associated with improved adherence (odds ratio [OR] 1.43, 95% CI 1.2-1.7; P<.001). Adherence with the anticoagulation CPG was associated with a significant reduction in the need for ICU admission within 48 hours (OR 0.39, 95% CI 0.30-0.51; P<.001) on multivariable logistic regression analysis. Similar findings were noted following 1:1 propensity score matching for patients who received adherent versus nonadherent care (21.5% vs 34.3% incidence of ICU admission within 48 hours; log-rank test P<.001). CONCLUSIONS: Our institutional experience demonstrated that adherence with the institutional CPG delivered via the CDS system resulted in improved clinical outcomes for patients with COVID-19. CDS systems are an effective means to rapidly scale a CPG across a heterogeneous health care system. Further research is needed to investigate factors associated with adherence at low and high adopting sites and nursing units.

Inpatient Telemedicine Implementation as an Infection Control Response to COVID-19: Qualitative Process Evaluation Study.

BACKGROUND: The COVID-19 pandemic created new challenges to delivering safe and effective health care while minimizing virus exposure among staff and patients without COVID-19. Health systems worldwide have moved quickly to implement telemedicine in diverse settings to reduce infection, but little is understood about how best to connect patients who are acutely ill with nearby clinical team members, even in the next room. OBJECTIVE: To inform these efforts, this paper aims to provide an early example of inpatient telemedicine implementation and its perceived acceptability and effectiveness. METHODS: Using purposive sampling, this study conducted 15 semistructured interviews with nurses (5/15, 33%), attending physicians (5/15, 33%), and resident physicians (5/15, 33%) on a single COVID-19 unit within Stanford Health Care to evaluate implementation outcomes and perceived effectiveness of inpatient telemedicine. Semistructured interview protocols and qualitative analysis were framed around the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework, and key themes were identified using a rapid analytic process and consensus approach. RESULTS: All clinical team members reported wide reach of inpatient telemedicine, with some use for almost all patients with COVID-19. Inpatient telemedicine was perceived to be effective in reducing COVID-19 exposure and use of personal protective equipment (PPE) without significantly compromising quality of care. Physician workflows remained relatively stable, as most standard clinical activities were conducted via telemedicine following the initial intake examination, though resident physicians reported reduced educational opportunities given limited opportunities to conduct physical exams. Nurse workflows required significant adaptations to cover nonnursing duties, such as food delivery and facilitating technology connections for patients and physicians alike. Perceived patient impact included consistent care quality, with some considerations around privacy. Reported challenges included patient-clinical team communication and personal connection with the patient, perceptions of patient isolation, ongoing technical challenges, and certain aspects of the physical exam. CONCLUSIONS: Clinical team members reported inpatient telemedicine encounters to be acceptable and effective in reducing COVID-19 exposure and PPE use. Nurses adapted their workflows more than physicians in order to implement the new technology and bore a higher burden of in-person care and technical support. Recommendations for improved inpatient telemedicine use include information technology support and training, increased technical functionality, and remote access for the clinical team.

A stepped wedge cluster randomized control trial to evaluate the implementation and effectiveness of optimized initiatives in improving quality of care for ST segment elevation myocardial infarction in response to the COVID-19 outbreak.

BACKGROUND: The National Chest Pain Center Accreditation Program (CHANGE) is the first hospital-based, multifaceted, nationwide quality improvement (QI) initiative, to monitor and improve the quality of the ST segment elevation myocardial infarction (STEMI) care in China. The QI initiatives, as implementation strategies, include a bundle of evidence-based interventions adapted for implementation in China. During the pandemic of coronavirus disease 2019 (COVID-19), fear of infection with severe acute respiratory syndrome coronavirus 2, national lockdowns, and altered health care priorities have highlighted the program's importance in improving STEMI care quality. This study aims to minimize the adverse impact of the COVID-19 pandemic on the quality of STEMI care, by developing interventions that optimize the QI initiatives, implementing and evaluating the optimized QI initiatives, and developing scale-up activities of the optimized QI initiatives in response to COVID-19 and other public health emergencies. METHODS: A stepped wedge cluster randomized control trial will be conducted in three selected cities of China: Wuhan, Suzhou, and Shenzhen. Two districts have been randomly selected in each city, yielding a total of 24 registered hospitals. This study will conduct a rollout in these hospitals every 3 months. The 24 hospitals will be randomly assigned to four clusters, and each cluster will commence the intervention (optimized QI initiatives) at one of the four steps. We will conduct hospital-based assessments, questionnaire surveys among health care providers, community-based household surveys, and key informant interviews during the trial. All outcome measures will be organized using the RE-AIM (reach, effectiveness, adoption, implementation, maintenance) framework, including implementation outcomes, service outcomes (e.g., treatment time), and patient outcomes (e.g., in-hospital mortality and 1-year complication). The Consolidated Framework for Implementation Research framework will be used to identify factors that influence implementation of the optimized QI interventions. DISCUSSION: The study findings could be translated into a systematic solution to implementing QI initiatives in response to COVID-19 and future potential major public health emergencies. Such actionable knowledge is critical for implementors of scale-up activities in low- and middle-income settings. TRIAL REGISTRATION: ChiCTR 2100043319 . Registered on 10 February 2021.

Implementation and Evaluation of the Virtual Graded Repetitive Arm Supplementary Program (GRASP) for Individuals With Stroke During the COVID-19 Pandemic and Beyond.

OBJECTIVE: Given the uncertainty of the coronavirus disease 2019 (COVID-19) pandemic, implementing telerehabilitation that enables the remote delivery of rehabilitation services is needed to mitigate the spread of COVID-19. We studied the implementation and the effectiveness of the virtual Graded Repetitive Arm Supplementary Program (GRASP) delivered and evaluated via videoconferencing in individuals with stroke. METHODS: The Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework with mixed methods was used to evaluate the implementation of the 2 iterations of the program delivered by a nonprofit organization during the pandemic. RESULTS: Reach: Seventeen people were screened, 13 people were eligible, and 11 consented to participate in the study. Effectiveness: Between baseline and posttest, participants with stroke demonstrated significant improvement in upper extremity function (Arm Capacity and Movement Test) and self-perceived upper extremity (UE) function (Stroke Impact Scale). Adoption: Factors that facilitate program uptake by the staff were well-planned implementation, appropriate screening procedure, and helpful feedback from the audits. All staff felt comfortable using videoconferencing technology to deliver the program despite some technical difficulties. Factors contributing to ongoing participation included that the participants liked the group, they perceived improvements, and the instructor was encouraging. Only one participant with stroke was not comfortable using the videoconferencing technology. Implementation: The program was implemented as intended as evaluated by a fidelity checklist. Participants' adherence was high, as verified by the average attendance and practice time. Maintenance: The organization continued to offer the program. CONCLUSION: The virtual GRASP program was successfully implemented. Although the program was effective in improving both measured and perceived UE function in a small sample of individuals with stroke, caution should be taken in generalizing the results. IMPACT: Implementing telerehabilitation is crucial to optimize patient outcomes and reduce the spread of COVID-19. Our findings provide guidance on the process of delivering a UE rehabilitation program remotely via videoconferencing for stroke. Moreover, insights that arise from this study also inform the implementation of other telerehabilitation services.