ABSTRACT
OBJECTIVE: We examine how frontline workers and supervisors delivering a research supported intervention (RSI) to reduce child neglect negotiated system-related challenges, the pragmatics of RSI implementation, and their professional identities and relationships with clients. METHODS: We conducted semi-structured interviews, small group discussions, and focus groups with frontline workers and supervisors in one large county over two time periods. We used iterative coding to analyze qualitative data. RESULTS: Frontline workers navigated several aspects of RSI implementation and sustainment: (1) contract requirements and information dissemination, (2) fidelity, (3) competing demands and crises, (4) structure versus creativity, and (5) relationships with clients. CONCLUSIONS: Workers dynamically negotiated multiple system- and provider-level (or outer- and inner-contextual) demands influencing RSI provision for clients with complex service needs. Results affirm the need to attend to the unintended consequences of implementing new contract, reimbursement, and other system organizational processes and to address the "committed work" supporting RSI delivery.
ABSTRACT
Pulmonary rehabilitation is beneficial for patients with chronic lung disease. However, long-term maintenance has been difficult to achieve after short-term treatment. We evaluated a telephone-based maintenance program after pulmonary rehabilitation in 172 patients with chronic lung disease recruited from pulmonary rehabilitation graduates. Subjects were randomly assigned to a 12-month maintenance intervention with weekly telephone contacts and monthly supervised reinforcement sessions (n = 87) or standard care (n = 85) and followed for 24 months. Except for a slight imbalance between sexes, experimental and control groups were equivalent at baseline and showed similar improvements after rehabilitation. During the 12-month intervention, exercise tolerance (maximum treadmill workload and 6-minute walk distance) and overall health status ratings were better maintained in the experimental group together with a reduction in hospital days. There were no group differences for other measures of pulmonary function, dyspnea, self-efficacy, generic and disease-specific quality of life, and health care use. By 24 months, there were no significant group differences. Patients returned to levels close to but above prerehabilitation measures. We conclude that a maintenance program of weekly telephone calls and monthly supervised sessions produced only modest improvements in the maintenance of benefits after pulmonary rehabilitation.
