Enhancing the implementation of provider-to-provider telehealth in rural and remote areas: A mixed methods study protocol.

Background: Virtual healthcare solutions are proposed as a way to combat the inequity of access to healthcare in rural and remote areas, and to better support the front-line providers who work in these areas. Rural provider-to-provider telehealth (RPPT) connects rural and remote clinicians to a 'hub' of healthcare specialists who can increase access to emergency and specialised healthcare via an integrated model. Reported benefits for the place-based provider include enhanced knowledge, expanded professional development opportunities, improved scope of practice, and increased confidence in treating more complex cases. These reported benefits could have implications for supporting and futureproofing our health workforce in terms of productivity, burnout, recruitment, and retention. Methods: The research uses an explanatory sequential mixed methods approach across multiple phases to evaluate the current implementation of Western Australia Country Health Service's (WACHS) Command Centre (CC) services and explore factors associated with their differential use. The primary population of interest and participants in this study are the place-based providers in country Western Australia (WA). Patient data constitutes the secondary population, informing the access and reach of CC services into country WA. Data collection will include service data, an online survey, and semi-structured interviews with the primary population. The data will be interpreted to inform evidence-based strategies and recommendations to improve the implementation and sustainment of RPPT. Discussion: Innovative and sustained workforce models and solutions are needed globally. Virtual healthcare, including provider-to-provider models, demonstrate potential, especially in rural and remote areas, designed to increase access to specialised expertise for patients and to support the local workforce. This research will generate new data around behaviour, perceptions, and value from the WACHS rural and remote workforce about provider-to-provider telehealth, to explore the implementation and investigate strategies for the long-term sustainment of RPPT services.

Barriers and Facilitators to Participation in Vigorous Lifestyle Physical Activity in Adults Aged 55-75 Years: A Scoping Review.

Despite the well-known benefits of physical activity, less than half of adults aged 55-75 years participate in sufficient physical activity. Short bouts of vigorous intermittent lifestyle physical activity (VILPA) accumulated throughout the day can contribute toward the recommended volume of physical activity. A rich characterization of the barriers and facilitators to participation in VILPA is needed to develop targeted interventions. This scoping review aimed to identify barriers and facilitators to participation in different components of VILPA in adults aged 55-75 years, and to map barriers and facilitators to the Theoretical Domains Framework. Within the 18 eligible studies, the most prevalent barriers were related to a person's skills, environmental context, and social influences. Most facilitators were related to a person's goals, social influences, and environmental context. Interventions to promote VILPA should test the effectiveness of behavioral change measures related to the unique barriers and facilitators in this age group.

Advancing the implementation of take-home naloxone by community pharmacists: Testing the role of COM-B.

INTRODUCTION: Opioid-related overdose fatalities are rising despite the increased accessibility of take-home naloxone (THN). Targeted implementation strategies are needed to improve the distribution of naloxone. This study investigates the effectiveness of a short video targeting pharmacists that addresses implementation barriers. METHODS: A pre-post, mixed methods design was adopted to examine the effect of a brief behaviour change intervention (an educational video informed by the capability, opportunity, motivation affecting behaviour (COM-B) model), on factors affecting pharmacists' implementation of THN in Western Australia. Paired samples t-tests for were used to investigate intentions, knowledge, skill, confidence, feasibility, appropriateness, acceptability, attitudes, anticipated patient reactions, social support and implementation climate. Structural equation modelling examined the associations between constructs and to test the proposed mediation of motivation on capability and opportunity affecting intentions to discuss and provide THN. RESULTS: We analysed data from 102 participants. At follow-up and after all participants had viewed the video, participants had significantly improved intentions, skill, confidence, anticipated reactions, social support and perceptions that THN implementation was feasible, appropriate and acceptable. No significant differences were seen for attitudes, knowledge or implementation climate. The proposed mediation effect of motivation on the associations between opportunity and intentions and capability and intentions was not supported. DISCUSSION AND CONCLUSIONS: A short video directly targeting identified implementation barriers has the ability to improve key influences in the provision of THN. Dissemination of information to community pharmacists is a challenge. Implementation strategies addressing knowledge and targeting other levels of influence on intentions and behaviour are required.

Context matters: using an Evidence to Decision (EtD) framework to develop and encourage uptake of opioid deprescribing guideline recommendations at the point-of-care.

OBJECTIVES: To describe the development and use of an Evidence to Decision (EtD) framework when formulating recommendations for the Evidence-Based Clinical Practice Guideline for Deprescribing Opioid Analgesics. STUDY DESIGN AND SETTING: Evidence was derived from an overview of systematic reviews and qualitative studies conducted with healthcare professionals and people who take opioids for pain. A multidisciplinary guideline development group conducted extensive EtD framework review and iterative refinement to ensure that guideline recommendations captured contextual factors relevant to the guideline target setting and audience. RESULTS: The guideline development group considered and accounted for the complexities of opioid deprescribing at the individual and health system level, shaping recommendations and practice points to facilitate point-of-care use. Stakeholders exhibited diverse preferences, beliefs, and values. This variability, low certainty of evidence, and system-level policies and funding models impacted the strength of the generated recommendations, resulting in the formulation of four 'conditional' recommendations. CONCLUSION: The context within which evidence-based recommendations are considered, as well as the political and health system environment, can contribute to the success of recommendation implementation. Use of an EtD framework allowed for the development of implementable recommendations relevant at the point-of-care through consideration of limitations of the evidence and relevant contextual factors.

Implementation of interprofessional quality circles on deprescribing in Swiss nursing homes: an observational study.

BACKGROUND: Polypharmacy and potentially inappropriate medications (PIMs) are still frequent among older adults in nursing homes. Deprescribing is an intervention that has been shown to be effective in reducing their use. However, the implementation of deprescribing in clinical practice has not yet been widely evaluated. The Quality Circle Deprescribing Module (QC-DeMo) intervention has been trialled through an effectiveness-implementation hybrid type 2 design. The intervention consists of a quality circle workshop session between healthcare professionals HCPs (physicians, nurses, and pharmacists) within a nursing home, in which they define a consensus to deprescribe specific PIMs classes. The aim of this study was to evaluate the implementation of the QC-DeMo intervention in nursing homes. METHODS: This observational study focuses on the implementation part of the QC-DeMo trial. Implementation was based on the Framework for Implementation of Pharmacy Services (FISpH). Questionnaires at baseline and follow-up were used to evaluate reach, adoption, implementation effectiveness, fidelity, implementation, maintenance and the implementation strategies. Other data were collected from the QC-DeMo trial and routine data collected as part of the integrated pharmacy service where the QC-Demo trial was embedded. Implementation strategies included training of pharmacists, integration of the intervention into an existing quality circle dynamic and definition of tailored strategies to operationalise the consensus by each nursing home. RESULTS: The QC-DeMo intervention was successfully implemented in 26 nursing homes in terms of reach, fidelity, adoption, implementation and implementation effectiveness. However, the intervention was found to be implemented with low maintenance as none of the nursing homes repeated the intervention after the trial. Implementation strategies were well received by HCPs: training was adequate according to pharmacists. Pre-existing quality circle dynamic facilitated interprofessional collaboration as involvement and support of each HCP was rated as high. HCPs recognized a specific and important role for each HCP in the deprescribing process. The most relevant tailored strategies to implement the consensus defined by each nursing home were identification of the patients by the pharmacist and a systematic review of medication's patients. CONCLUSIONS: The implementation of a Quality Circle on Deprescribing is feasible but its maintenance in practice remains challenging. This study explores multiple implementation outcomes to better inform future implementation efforts of these types of interventions. TRIAL REGISTRATION: ClinicalTrials.gov ( NCT03688542 ), registered on 26.09.2018.

Barriers to and Facilitators of Implementing Guidelines for Detecting Familial Hypercholesterolaemia in Australia.

BACKGROUND: Familial hypercholesterolaemia (FH) is a genetic condition that is a preventable cause of premature cardiovascular morbidity and mortality. High-level evidence and clinical practice guidelines support preventative care for people with FH. However, it is estimated that less than 10% of people at risk of FH have been detected using any approach across Australian health settings. The aim of this study was to identify the implementation barriers to and facilitators of the detection of FH in Australia. METHODS: Four, 2-hour virtual focus groups were facilitated by implementation scientists and a clinicians as part of the 2021 Australasian FH Summit. Template analysis was used to identify themes. RESULTS: There were 28 workshop attendees across four groups (n=6-8 each), yielding 13 barriers and 10 facilitators across three themes: (1) patient related, (2) provider related, and (3) system related. A "lack of care pathways" and "upskilling clinicians in identifying and diagnosing FH" were the most interconnected barriers and facilitators for the detection of FH. CONCLUSIONS: The relationships between barriers and facilitators across the patient, provider, and system themes indicates that a comprehensive implementation strategy is needed to address these different levels. Future research is underway to develop a model for implementing the Australian FH guidelines into practice.

Scale-up of the Australian Fans in Training (Aussie-FIT) men's health behaviour change program: a protocol for a randomised controlled hybrid effectiveness-implementation trial.

INTRODUCTION: Improving physical activity (PA) and healthy eating is critical for primary and secondary prevention of cardiovascular disease (CVD). Behaviour change programmes delivered in sporting clubs can engage men in health behaviour change, but are rarely sustained or scaled-up post trial. Following the success of pilot studies of the Australian Fans in Training (Aussie-FIT) programme, a hybrid effectiveness-implementation trial protocol was developed. This protocol outlines methods to: (1) establish if Aussie-FIT is effective at supporting men with or at risk of CVD to sustain improvements in moderate-to-vigorous PA (primary outcome), diet and physical and psychological health and (2) examine the feasibility and utility of implementation strategies to support programme adoption, implementation and sustainment. METHODS AND ANALYSIS: A pragmatic multistate/territory hybrid type 2 effectiveness-implementation parallel group randomised controlled trial with a 6-month wait list control arm in Australia. 320 men aged 35-75 years with or at risk of CVD will be recruited. Aussie-FIT involves 12 weekly face-to-face sessions including coach-led interactive education workshops and PA delivered in Australian Football League (Western Australia, Northern Territory) and rugby (Queensland) sports club settings. Follow-up measures will be at 3 and 6 months (both groups) and at 12 months to assess maintenance (intervention group only). Implementation outcomes will be reported using the Reach, Effectiveness, Adoption, Implementation, Maintenance framework. ETHICS AND DISSEMINATION: This multisite study has been approved by the lead ethics committees in the lead site's jurisdiction, the South Metropolitan Health Service Human Research Ethics Committee (Reference RGS4254) and the West Australian Aboriginal Health Ethics Committee (HREC1221). Findings will be disseminated at academic conferences, peer-reviewed journals and via presentations and reports to stakeholders, including consumers. Findings will inform a blueprint to support the sustainment and scale-up of Aussie-FIT across diverse Australian settings and populations to benefit men's health. TRIAL REGISTRATION NUMBER: This trial is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12623000437662).

Evaluation of an online advanced suicide prevention training for pharmacists.

BACKGROUND: With the pharmacist role extending internationally to include health promotion and harm reduction, pharmacists are well-suited to adopt a frontline role within suicide prevention efforts. To maximise their abilities to implement suicide prevention strategies, suicide prevention training is essential to improve pharmacists' knowledge of, attitudes towards, and confidence in pharmacy-based suicide prevention. AIM: This study aimed to evaluate the impact of an online Advanced Suicide Prevention Training for Pharmacists and explore how participant feedback may direct training improvements. METHOD: One hundred and fifty pharmacists in Tasmania, Australia, completed the training. Of these, 109 participants completed surveys pre-, post- and 6-months post-training to evaluate changes in suicide prevention knowledge, confidence, and attitudes, and explore participants' perceptions of the training. RESULTS: Significant improvements were observed in suicide prevention attitudes (F(2, 20) = 4.12, p = 0.032, partial η2 = 0.292), and self-efficacy (F(2, 20) = 7.84, p = 0.003, partial η2 = 0.439), across the three timepoints, with improvements to knowledge and confidence evident between pre- and post-training (p < 0.05). Qualitative data reflected that the training was beneficial in aiding the identification and support of at-risk individuals, however barriers such as the pharmacy setting, personal discomfort, and perceptions of the pharmacist role were identified as impeding the implementation of suicide prevention within pharmacy practice. CONCLUSION: Training is an effective means of improving pharmacists' suicide prevention knowledge, confidence, and attitudes. While personal barriers to suicide prevention improved, contextual and social barriers continue to impede pharmacists' implementation of suicide prevention in practice.

Developing a single-session strategy for the implementation of take-home naloxone by community pharmacists using COM-B and design-thinking.

Background: Despite the overwhelming evidence of its effectiveness, there is poor implementation of take-home naloxone by pharmacists. Barriers have been explored and mapped to the capability, opportunity, motivation-behaviour (COM-B) model of behaviour change, yet no theoretically informed implementation strategies that target known barriers have been developed. Single-session implementation strategies have been proposed as a simple, scalable way to target multiple barriers. Methods: Qualitative participatory methods, incorporating design-thinking principles, were used to develop the key messages of a single-session implementation strategy. The key messages were drafted against COM-B mapped implementation barriers identified in the literature. A participatory workshop involving a pre-mortem exercise and incorporating design-thinking principles were used to refine the messages and generate methods for dissemination. Messages were mapped to interview questions to naturally illicit stories and delivered via storytelling from a pharmacist, a general practitioner, and a person with lived experience of using naloxone. Results: A 3 minute 40 second video and a two-page printable infographic were developed and hosted on a website, with links to additional downloadable resources as a single-session implementation strategy. Email was the preferred method for receiving simple professional development communications, with social media also widely accessed. Discussion: Implementation science, behavioural change theory, and participatory design methods are a complementary combination to develop implementation strategies. Some pharmacists questioned the participatory design approach to developing an implementation strategy, as it was outside of their comfort zone. However, the participatory process involving end-users resulted in unique ideas that are unlikely to have been generated using more traditional consultative approaches. The delivery as a single-session implementation strategy allows for widespread dissemination and delivery at scale.

Where is "policy" in dissemination and implementation science? Recommendations to advance theories, models, and frameworks: EPIS as a case example.

BACKGROUND: Implementation science aims to accelerate the public health impact of evidence-based interventions. However, implementation science has had too little focus on the role of health policy - and its inseparable politics, polity structures, and policymakers - in the implementation and sustainment of evidence-based healthcare. Policies can serve as determinants, implementation strategies, the evidence-based "thing" to be implemented, or another variable in the causal pathway to healthcare access, quality, and patient outcomes. Research describing the roles of policy in dissemination and implementation (D&I) efforts is needed to resolve persistent knowledge gaps about policymakers' evidence use, how evidence-based policies are implemented and sustained, and methods to de-implement policies that are ineffective or cause harm. Few D&I theories, models, or frameworks (TMF) explicitly guide researchers in conceptualizing where, how, and when policy should be empirically investigated. We conducted and reflected on the results of a scoping review to identify gaps of existing Exploration, Preparation, Implementation, and Sustainment (EPIS) framework-guided policy D&I studies. We argue that rather than creating new TMF, researchers should optimize existing TMF to examine policy's role in D&I. We describe six recommendations to help researchers optimize existing D&I TMF. Recommendations are applied to EPIS, as one example for advancing TMF for policy D&I. RECOMMENDATIONS: (1) Specify dimensions of a policy's function (policy goals, type, contexts, capital exchanged). (2) Specify dimensions of a policy's form (origin, structure, dynamism, outcomes). (3) Identify and define the nonlinear phases of policy D&I across outer and inner contexts. (4) Describe the temporal roles that stakeholders play in policy D&I over time. (5) Consider policy-relevant outer and inner context adaptations. (6) Identify and describe bridging factors necessary for policy D&I success. CONCLUSION: Researchers should use TMF to meaningfully conceptualize policy's role in D&I efforts to accelerate the public health impact of evidence-based policies or practices and de-implement ineffective and harmful policies. Applying these six recommendations to existing D&I TMF advances existing theoretical knowledge, especially EPIS application, rather than introducing new models. Using these recommendations will sensitize researchers to help them investigate the multifaceted roles policy can play within a causal pathway leading to D&I success.

Retrospective analysis of patterns of opioid overdose and interventions delivered at a tertiary hospital emergency department: impact of COVID-19.

BACKGROUND: Opioid-related overdoses cause substantial numbers of preventable deaths. Naloxone is an opioid antagonist available in take-home naloxone (THN) kits as a lifesaving measure for opioid overdose. As the emergency department (ED) is a primary point of contact for patients with high-risk opioid use, evidence-based recommendations from the Society of Hospital Pharmacists of Australia THN practice guidelines include the provision of THN, accompanied by psychosocial interventions. However, implementation of these guidelines in practice is unknown. This study investigated ED opioid-related overdose presentations, concordance of post-overdose interventions with the THN practice guidelines, and the impact, if any, of the SARS-CoV-2 (COVID-19) pandemic on case presentations. METHODS: A single-centre retrospective audit was conducted at a major tertiary hospital of patients presenting with overdoses involving opioids and non-opioids between March to August 2019 and March to August 2020. Patient presentations and interventions delivered by the paramedics, ED and upon discharge from the ED were collated from medical records and analysed using descriptive statistics, chi square and independent T-tests. RESULTS: The majority (66.2%) of patients presented to hospital with mixed drug overdoses involving opioids and non-opioids. Pharmaceutical opioids were implicated in a greater proportion (72.1%) of overdoses than illicit opioids. Fewer patients presented in March to August 2020 as compared with 2019 (26 vs. 42), and mixed drug overdoses were more frequent in 2020 than 2019 (80.8% vs. 57.1%). Referral to outpatient psychology (22.0%) and drug and alcohol services (20.3%) were amongst the most common post-discharge interventions. Naloxone was provided to 28 patients (41.2%) by the paramedics and/or ED. No patients received THN upon discharge. CONCLUSIONS: This study highlights opportunities to improve ED provision of THN and other interventions post-opioid overdose. Large-scale multi-centre studies are required to ascertain the capacity of EDs to provide THN and the impact of COVID-19 on opioid overdose presentations.

Developing a tailored implementation action plan for a suicide prevention clinical intervention in an Australian mental health service: A qualitative study using the EPIS framework.

Background: Tailoring implementation strategies to local contexts is a promising approach to supporting implementation and sustainment of evidence-based practices in health settings. While there is increasing research on tailored implementation of mental health interventions, implementation research on suicide prevention interventions is limited. This study aimed to evaluate implementation and subsequently develop a tailored action plan to support sustainment of an evidence-based suicide prevention intervention; Collaborative Assessment and Management of Suicidality (CAMS) in an Australian public mental health service. Methods: Approximately 150 mental health staff working within a regional and remote Local Health District in Australia were trained in CAMS. Semi-structured interviews and focus groups with frontline staff and clinical leaders were conducted to examine barriers and facilitators to using CAMS. Data were analysed using a reflexive thematic analysis approach and mapped to the Exploration, Preparation, Implementation and Sustainment (EPIS) framework and followed by stakeholder engagement to design a tailored implementation action plan based on a 'tailored blueprint' methodology. Results: A total of 22 barriers to implementing CAMS were identified. Based on the perceived impact on implementation fidelity and the feasibility of addressing identified barriers, six barriers were prioritised for addressing through an implementation action plan. These barriers were mapped to evidence-based implementation strategies and, in collaboration with local health district staff, goals and actionable steps for each strategy were generated. This information was combined into a tailored implementation plan to support the sustainable use of CAMS as part of routine care within this mental health service. Conclusions: This study provides an example of a collaborative approach to tailoring strategies for implementation on a large scale. Novel insights were obtained into the challenges of evaluating the implementation process and barriers to implementing an evidence-based suicide prevention treatment approach within a geographically large and varied mental health service in Australia. Plain language abstract: This study outlines the process of using a collaborative stakeholder engagement approach to develop tailored implementation plans. Using the Exploration Preparation Implementation Sustainment Framework, findings identify the barriers to and strategies for implementing a clinical suicide prevention intervention in an Australian community mental health setting. This is the first known study to use an implementation science framework to investigate the implementation of the clinical suicide prevention intervention (Collaborative Assessment and Management of Suicidality) within a community mental health setting. This work highlights the challenges of conducting implementation research in a dynamic public health service.

The value of implementation science in bridging the evidence gap in bereavement care.

There is a gap in the use of evidence in bereavement care. Implementation science is a field focused on moving evidence into practice and therefore may help close the gap. Implementation science advances the design, relevance, and dissemination of research and the adoption, implementation, and maintenance of evidence-based practices. We provide an overview of implementation science, describe five implementation frameworks (Knowledge to Action; Behavior Change Wheel; Exploration Preparation Implementation Sustainment; Interactive Systems Framework; and Reach, Adoption, Implementation, Maintenance), and illustrate their application in bereavement care. These advancements will promote high-quality bereavement care that improves the lives of bereaved people.

Using an online nominal group technique to determine key implementation factors for COVID-19 vaccination programmes in community pharmacies.

Background One vital strategy to fight the COVID-19 pandemic is the rapid roll-out of vaccination programmes. In a number of countries pharmacists are joining the vaccination programme workforce, including plans to involve community pharmacies. Objectives (1) to determine key implementation factors for rapid roll-out of COVID-19 vaccination programmes in European community pharmacies and (2) to trial an online nominal group technique to generate ideas and reach consensus on the first aim. Setting In February 2021, during a workshop at the 12th Working Conference of the Pharmaceutical Care Network Europe. Method An online nominal group technique workshop over 10 hours was conducted. Identified implementation factors were mapped to the Framework for the Implementation of Services in Pharmacy and assessed in terms of importance and changeability. Main outcome measure Consensus of key implementation factors. Results In total, 85 implementation factors were identified. The top 3 factors were the same for both criteria: "(Regular) Staff training on correct vaccination procedure/to perform hands-on injection technique"; "Training in basic life support/first aid (Cardiopulmonary resuscitation)", and; "Definition of process, roles and responsibilities in the team". Conclusion An online nominal group technique enabled international collaboration to gather diverse perspectives on the implementation of COVID-19 vaccination programmes in a time and cost-efficient manner. "Staff training on correct vaccination procedure", "training in basic life support" and "definition of process, roles and responsibilities in the team" were deemed the most important and changeable implementation factors. Online nominal group technique may be a suitable method for other implementation problems.

Does Case Management Provide Support for Staff Facing Frequent Users of Emergency Departments? A Comparative Mixed-Method Evaluation of ED Staff Perception.

OBJECTIVE: Frequent users of emergency departments (FUED) account for a disproportionate number of emergency department (ED) visits and contribute to a wide range of challenges for ED staff. While several research has documented that case management (CM) tailored to FUED leads to a reduction in ED visits and a better quality of life (QoL) among FUED, whether there is added value for ED staff remains to be explored. This study aimed to compare, among staff in two academic EDs in Switzerland (one with and one without CM), the FUED-related knowledge, perceptions of the extent of the FUED issue, FUED-related work challenges and FUEDs' legitimacy to use ED. METHOD: Mixed methods were employed. First, ED physicians and nurses (N = 253) of the two EDs completed an online survey assessing their knowledge and perceptions of FUEDs. Results between healthcare providers working in an ED with CM to those working in an ED without CM were compared using independent two-sided T-tests. Next, a sample of participants (n = 16) took part in a qualitative assessment via one-to-one interviews (n = 6) or focus groups (n = 10). RESULTS: Both quantitative and qualitative results documented that the FUED-related knowledge, the extent FUED were perceived as an issue and perceived FUEDs' legitimacy to use ED were not different between groups. The level of perceived FUED-related challenges was also similar between groups. Quantitative results showed that nurses with CM experienced more challenges related to FUED. Qualitative exploration revealed that lack of psychiatric staff within the emergency team and lack of communication between ED staff and CM team were some of the explanations behind these counterintuitive findings. CONCLUSION: Despite promising results on FUEDs' QoL and frequency of ED visits, these preliminary findings suggest that CM may provide limited support to ED staff in its current form. Given the high burden of FUED-related challenges encountered by ED staff, improved communication and FUED-related knowledge transfer between ED staff and the CM team should be prioritized to increase the value of a FUED CM intervention for ED staff.

Provider REport of Sustainment Scale (PRESS): development and validation of a brief measure of inner context sustainment.

BACKGROUND: Implementation scientists and practitioners often rely on frontline providers for reporting on implementation outcomes. Furthermore, measures of sustainment are few, and available sustainment measures are mainly setting or evidenced-based practice (EBP) specific, require organizational and system-level knowledge to complete, and often lack psychometric rigor. The aim of this study was to develop a brief, pragmatic, and generalizable measure for completion by frontline service providers of the implementation outcome, sustainment. METHODS: We utilized a Rasch measurement theory approach to scale the development and testing of psychometric parameters. Sustainment items were developed to be relevant for direct service providers to complete. In order to promote generalizability, data were collected and items were tested across four diverse psychosocial evidence-based practices (motivational interviewing [MI], SafeCare®, classroom pivotal response training [CPRT], and an individualized mental health intervention for children with autism spectrum disorder [AIM-HI]) and in four service settings (substance use disorder treatment, child welfare, education, and specialty mental health). Associations between the sustainment measure and sustainment leadership, sustainment climate, and attitudes towards the adoption and use of each of the EBPs were assessed to confirm construct validity. RESULTS: Three items for the Provider REport of Sustainment Scale (PRESS) were assessed for measuring the core component of sustainment: continued use of the EBP. Internal consistency reliability was high. The scale indicated fit to the Rasch measurement model with no response dependency, ordered thresholds, no differential item functioning, and supported unidimensionality. Additionally, construct validity evidence was provided based on the correlations with related variables. CONCLUSION: The PRESS measure is a brief, three-item measure of sustainment that is both pragmatic and useable across different EBPs, provider types, and settings. The PRESS captures frontline staffs' report of their clinic, team, or agency's continued use of an EBP. Future testing of the PRESS for concurrent and predictive validity is recommended.

Implementation Evaluation of an Interprofessional Programme (Siscare) for Supporting Patients with Type 2 Diabetes in a primary care setting.

BACKGROUND: In 2016, the Swiss government decided to back the implementation of an interprofessional patient support programme to redefine and extent the pharmacist's role in primary care. The programme, called Siscare, includes regular motivational interviews by pharmacists; medication adherence, patient-reported, and clinical outcomes monitoring; and pharmacist-physician interactions. OBJECTIVE: To assess, from a pharmacy team's perspective, the implementation of Siscare for patients with type 2 diabetes taking at least one oral antidiabetic treatment, followed for 15 months, in a primary care setting of the French-speaking part of Switzerland. METHODS: This prospective, multicentre, observational, cohort study used a hybrid implementation-effectiveness design and the Framework for the Implementation of Services in Pharmacy (FISpH). Quantitative and qualitative methods assessed outcomes at three levels (process, outcomes and impact) at each stage of the implementation process (exploration, preparation, operation, sustainability). RESULTS: An advisory board with 10 representatives of key national stakeholders committed to supporting the study and 41 pharmacies were trained for Siscare. Of these, 33 (80%) had at least one of five implementation strategies in place 12 weeks after the start of patient inclusion and 27 (66%) have included ≥1 patient; mean inclusion per pharmacy: 8 (SD 6) patients [range: 1-29] with a total of 212 patients. Nine pharmacies (22%) met the target of 10 patients. An ordered three-step process of the implementation was observed in pharmacies: internal organisation, preparation of interprofessional practice, and relationship building with patients. Influencing factors were pharmacists' skills in motivational interviewing, support from pharmacy owners, pre-existing local interprofessional networks, and profitability of the programme. CONCLUSIONS: This implementation evaluation supports the feasibility and acceptability from the pharmacy team's perspective of Siscare. The programme's implementation on a wider scale is still difficult due to the inertia inherent in any fundamental change in practices and the economic-political uncertainties influencing the actors in primary care.

Forms and functions of bridging factors: specifying the dynamic links between outer and inner contexts during implementation and sustainment.

BACKGROUND: Bridging factors are relational ties, formal arrangements, and processes that connect outer system and inner organizational contexts. They may be critical drivers of evidence-based practice (EBP) implementation and sustainment. Yet, the complex interplay between outer and inner contexts is often not considered. Bridging factors were recently defined in the updated Exploration, Preparation, Implementation, Sustainment (EPIS) framework. Further identification and specification of this construct will advance implementation models, measures, and methods. Our goal is to advance bridging factor research by identifying relevant dimensions and exemplifying these dimensions through illustrative case studies. METHODS: We used a multiple case study design. Each case (n = 10) represented different contexts, EBPs, and bridging factor types. Inclusion criteria were the presence of clearly distinguishable outer and inner contexts, identifiable bridging factor, sufficient information to describe how the bridging factor affected implementation, and variation from other cases. We used an iterative qualitative inquiry process to develop and refine a list of dimensions. Case data were entered into a matrix. Dimensions comprised the rows and case details comprised the columns. After a review of all cases, we collectively considered and independently coded each dimension as function or form. RESULTS: We drew upon the concepts of functions and forms, a distinction originally proposed in the complex health intervention literature. Function dimensions help define the bridging factor and illustrate its purpose as it relates to EBP implementation. Form dimensions describe the specific structures and activities that illustrate why and how the bridging factor has been customized to a local implementation experience. Function dimensions can help researchers and practitioners identify the presence and purpose of bridging factors, whereas form dimensions can help us understand how the bridging factor may be designed or modified to support EBP implementation in a specific context. We propose five function and three form bridging factor dimensions. CONCLUSIONS: Bridging factors are described in many implementation models and studies, but without explicit reference or investigation. Bridging factors are an understudied and critical construct that requires further attention to facilitate implementation research and practice. We present specific recommendations for a bridging factors research agenda.

Health care providers' perception of the frequent emergency department user issue and of targeted case management interventions: a cross-sectional national survey in Switzerland.

BACKGROUND: Frequent users of emergency departments (FUEDs) (≥5 ED visits/year) represent a vulnerable population with complex needs accounting for a significant number of emergency department (ED) consultations, thus contributing to EDs overcrowding. Research exploring ED staff perceptions of FUEDs is scarce. OBJECTIVES: The current study aimed to evaluate in ED staff a) the extent to which FUEDs are perceived as an issue; b) their perceived levels of knowledge and understanding of FUEDs; c) levels of perceived usefulness of case management (CM) and interest in implementing this intervention in their ED service. METHODS: Head physicians of the EDs at all public hospitals in Switzerland (of various level of specialization) were sent a 19-item web-based survey, pilot tested prior to its dissemination. The head physicians were asked to forward the survey to ED staff members from different health professional backgrounds. RESULTS: The hospital response rate was 81% (85/106). The exploitable hospital response rate was 71% (75/106 hospitals) including 208 responding health professionals. Issues and difficulties around FUEDs were perceived as important by 64% of respondents. The perceived frequency of being confronted with FUEDs was higher among nurses in more specialized EDs. In total, 64% of respondents felt poorly informed about FUEDs, nurses feeling less informed than physicians. The understanding of FUEDs was lower in the French-Italian-speaking parts (FISP) of Switzerland than in the German-speaking part. Eighty-one percent of respondents had no precise knowledge of FUED-related interventions. The perceived usefulness of CM interventions after receiving explanations about it was high (92%). However, the overall level of interest for CM implementation was 59%. The interest in CM by physicians was low across all regions and ED categories. Nurses, on the other hand, showed more interest, especially those in EDs of high specialization. CONCLUSIONS: The majority of ED staff reported being confronted with FUEDs on a regular basis. Staff perceived FUEDs as a vulnerable population, yet, they felt poorly informed about how to manage the issue. The majority of ED staff thought a CM intervention would be useful for FUEDs, however there appears to be a gap in their desire or willingness to implement such interventions.

Barriers to Implementing Motivational Interviewing in Addiction Treatment: A Nominal Group Technique Process Evaluation.

BACKGROUND: The successful implementation of evidence-based practices (EBPs) in real-world settings requires an adaptive approach and ongoing process evaluation and tailoring. Although conducting a needs assessment during the preparation phase of implementation is beneficial, it is challenging to predict all barriers to EBP implementation that may arise over the course of implementation and sustainment. This article describes a process evaluation that identified emergent and persistent barriers that impacted the implementation of an EBP across multiple behavioral health organizations and clinics. METHODS: This study was conducted during the first cohort of a cluster randomized controlled trial testing the effectiveness of the Leadership and Organizational Change for Implementation (LOCI) strategy to implement motivational interviewing (MI) in substance use disorder treatment agencies and clinics. We used a modified nominal group technique (NGT) in which clinic leaders identified barriers faced during the implementation process. Barriers were categorized, then ranked and rated according to leaders' perceptions of each barrier's influence on implementation. The barriers were then contextualized through individual qualitative interviews. RESULTS: Fifteen barriers were identified, grouped into staff-level barriers, management-level barriers, and implementation program barriers. Time and resistance to MI were rated as the most influential staff-level barriers. Among management-level barriers, time was also rated highest, followed by turnover and external contractual constraints. The most influential implementation barrier was client apprehension of recording for fidelity assessment and feedback. Individual interviews supported these findings and provided suggested adaptations for future implementation efforts. CONCLUSION: EBP implementation is an ongoing process whereby implementation strategies must be proactively and strategically tailored to address emergent barriers. This research described a process evaluation that was used to identify 15 emergent and/or persistent barriers related to staff, management, and the implementation program. Using implementation strategies that can be tailored and/or adapted to such emergent barriers is critical to implementation effectiveness.