Implementing Evidenced-Based Programs
description
Transcript of Implementing Evidenced-Based Programs
Lindsey Myers, MPHInjury, Suicide and Violence Prevention Branch
Colorado Department of Public Health and Environment
Implementing Evidenced-Based
Programs
Discussion Topics
How to assess whether an evidence-based program is a good fit for the capacity of your organization?
Elements of fidelity that are important to successful program implementation.
Older adult fall prevention implementation examples
Where to find resources to better understand implementation science
Questions & Answers
What are Evidence-based Programs?
• Evidence-Based Programs are interventions based on evidence that is generated by scientific studies published in peer-reviewed journals.
• Model Programs are a type of evidence-based program
What are evidence-based programs?
• Previously implemented• Evaluated using measured outcomes• Have been replicated• Have been previously replicated• Found to make positive differences in the lives of
participants
Evidence-based Program have been:
Slide adapted from presentation by Marcia Ory, PhD, MPH and Ashley Wilson, MPH, (2012)
Spend limited resources efficientlyFunders require itAgencies want proven resultsImplementers like “packaged” programsParticipants want programs that workEasier to spread the adoption of programs
Why use Evidence-based or Best Practices?
The Evidence-based PublicHealth Framework
Slide adopted from presentation by Ross Brownson, PhD (2011)
Falls are the leading cause of injury death among Coloradans ages 65 and older.
Falls are also the leading cause of injury hospitalization for Coloradans age 65 and older.
Each year, the hospitalization charges for older adults hospitalized for fall-related injuries in Colorado total more than $391 million.
Identify the Problem: Older Adult Falls Prevention
The Evidence-based PublicHealth Framework
Slide adopted from presentation by Ross Brownson, PhD (2011)
Packaged ProgramsTypes of Evidence-based ProgramsGuidelines
ProsShelf readyOften has
implementation guidelines
May not require extensive evaluation
Proven track record helps with funders
Technical support often available
Level of evidence may not be clear
Expenses due to licenses and material costs
Limited flexibilityNot always a good fit May conflict with
other existing programs
Packaged programsCons
ProsBased on evaluated
programs Often provides
guidelines on key elements
Adaptable to local situation
Technical support may be available
Not all programs are evaluated at the level of RCT
Key elements are not always clarified
Time/effort/skills need to design the actual program
Needs more rigorous evaluation
Guideline-basedCons
May be able to prove laws lead to positive behavior or positive outcomes
Few evaluation studies for policy strategies; emerging science
Not always easy/possible to evaluate
Evidence-based policies
Centers for Disease Control and Prevention http://www.cdc.gov/HomeandRecreationalSafety/Falls/pubs.html
National Council on Aging http://www.ncoa.org/improve-health/center-for-healthy-aging/where-to-find-evidence-based.html
Administration On Aging http://www.aoa.gov/AoARoot/AoA_Programs/HPW/Title_IIID/index.aspx
Evidence-based Programs for Older Adult Falls Prevention
Compendium of Effective Fall InterventionsProvide public health
practitioners and others with detailed information about rigorously-tested, effective interventions
The Evidence-based PublicHealth Framework
Slide adopted from presentation by Ross Brownson, PhD (2011)
DataMomentum Political Will Funding Partner PrioritiesAvailability of evidence-based
programs
Intervention Priority Considerations
Deciding which program is best for your community?
Community readinessGoal alignmentCapacity to deliver
programsTarget audienceAbility to implementAbility to sustainAppropriate
approach (e.g. individual vs. group)
Choosing an intervention
Program Match
•Does the program fit your mission?•Is leadership supportive of the program?•Are clients interested in the program?•Can you implement the program as designed?
Costs and Resources
•Is there a licensing fee?•What type of facilitator is needed?•Is facilitator training required?•What equipment and supplies are needed?•Is the program ongoing or periodic?
Cultural and Contextual Relevance
•Is the program culturally appropriate?•Are materials written at the correct literacy level and in the correct language?•Does the program have regional appeal?
Slide from presentation by Marcia Ory, PhD, MPH and Ashley Wilson, MPH, (2012)
Colorado Injury Prevention Winnable BattleBy 2016, decrease the rate of fall-related
hospitalization among adults ages 65 and older in Colorado by 10 percent (from 1818/100,000 to 1636/100,000)
CDC Core VIPP Falls Component FOA
Tri-County Health Department Colorado Trust GrantFalls Prevention Network
State Unit on Aging Matter of Balance Program
Selecting EB Falls Programs in Colorado
Core VIPP Falls ComponentStepping On Fall Prevention ProgramTaiChi Moving for Better BalanceOtago Exercise Program
STEADI Toolkit
(Clinical Integration)
Policy Changes at Multiple Levels(Local, organizational, reimbursement,
legislation)
The Evidence-based PublicHealth Framework
Slide adopted from presentation by Ross Brownson, PhD (2011)
Translation of EBP to Practice
Translation
• The process of taking a program originally implemented in a controlled “laboratory-like” setting and making it suitable for implementation in the community
Fidelity
• The faithful and accurate adherence to the core elements of an intervention, must be maintained
• Preserves the evidence-base
Slide from presentation by Marcia Ory, PhD, MPH and Ashley Wilson, MPH, (2012)
Translation of EBP to Practice
Core elements
• Program components that generated the positive outcomes• Goal setting, identifying barriers, monitoring behavior
change, etc.
Key characteristics
• Attributes that make the program “fit” the population• Size of fonts and reading level of materials, marketing techniques, etc. • Key characteristics can be adapted, but core elements cannot be adapted
(jeopardizes fidelity)
Slide from presentation by Marcia Ory, PhD, MPH and Ashley Wilson, MPH, (2012)
Build in Sustainability from the BeginningElements of a sustainable infrastructure and delivery system
1 • Effective leadership
2 • Adequate delivery infrastructure
3 • Partnerships
4 • Centralized and coordinated logistical processes
5 • Business planning and financial sustainability
6 • Quality assurance and fidelity to interventions
Slide from presentation by Marcia Ory, PhD, MPH and Ashley Wilson, MPH, (2012)
Group class designed to prevent falls Exercise and progression of exercise is
key Seven weekly 2 hour program sessions Led by health professional Access to team of experts that are guest
presenters (PT, pharmacist, community safety expert)
Evidence: 30% reduction in falls
Stepping On
Training and implementation assistance available
Evidence-based makes it easy to sell to partners
Technical assistance available Key elements/requirements are spelled
out
Stepping On- Pros
Training and implementation requirements are a significant expense
Key elements requirements are not so easy (Led by health professional; access to specific guest presenters (PT, pharmacist, community safety expert)
Overlapping niche with Matter of Balance
Stepping On- Challenges
Build infrastructure within hospital systemsAccess to professional disciplines required for programLocating programs where there are fewer Matter of
Balance programsAbility to spread across the state
Build sustainable training infrastructureConsortium for Older Adult Wellness Training Academy
Train Colorado-based master trainersMaster trainers conduct fidelity checks per program
guidelinesSupport trainers by supplying weights as neededRequire evaluation data to be collected from the
beginningHelp promote Matter of Balance
Colorado Approach to Stepping On
Group exercise program Focused on increasing balance and physical function One hour classes delivered by an instructor Total program time: 36 hours over 12 weeks For older adults aged 60 and older, who can walk
easily with or without assistive devices Evidence: 55% reduction of fall risk
Tai Chi: Moving for Better Balance
• Easy to sell the program to partners
• Effectiveness evaluation supports maintaining the key elements of the program (program dose, reach and instructor training)
• YMCA has funding to develop complementary program
• Training available
• Implementation Guide and technical support available
• Outcome evaluation can be manageable
Tai Chi: Moving for Better Balance –Pros
Time and money needed to develop infrastructure
Instructor prerequisites not always easy to meet
Expensive to develop local training programRequired schedule does not always fit into
existing organizations (Parks and Rec like drop-in classes for < 12 weeks)
Not clear how to integrate with other established Tai Chi classes
Tai Chi: Moving for Better Balance - Challenges
Bring master trainer from OregonWork with the YMCA training structurePay for instructor trainingTrain on evaluation data collection from the
beginningAllow instructors to charge for classesBuild relationships with senior centers, churches,
and rec centersUse previous experience to inform class recruitmentDeveloping: Colorado-based master trainer, fidelity
plan, instructor quality check system
Colorado Approach to Tai Chi: Moving for Better Balance
One-on-one exercise program delivered by Physical Therapist
7 home visits and 7 phone calls over a year In home exercises and walking plan (Med A
and B) For older adults that live at home, with or
without a walking aid Most effective for age 80+ or those that
have fallen with moderate to severe strength and balance impairments
Evidence: 35% reduction in falls
Otago Exercise Program
Delivered by trained Physical Therapists2-hour webinar-based training for PTs availableBuilt-in reimbursement strategyReaches older adults that may not access
community classesMost effective for age 80+ or those that have
fallen in the last year, with moderate to severe strength and balance impairments
Otago–Pros
Medicare only covers home-based physical therapy Under Med A when provided through a home
health agency and patient meets homebound criteria
Under Med B if provided by a PT not affiliated with a hospital
May need to facilitate Med A and B partnerships
Medicare Advantage and supplemental insurance carriers typically follow what is covered by Medicare
Possibly difficult to assess fidelity and track which PTs are using Otago with their patients
Otago- Challenges
Work with home health agenciesStart with home health agencies that are
Medicare Part A and Part B providersPilot test the transition from Medicare Part A
and Part B to provide guidance to other PTsAdvertise the availability of the web-based
Otago trainingIncorporate evaluation data collection from
the beginningPartner with physical therapy school
Colorado Approach to Otago
AGS, Clinical Practice Guidelines, 2010
Evidence-Based Clinical Guidelines
The STEADI Tool Kit is Based on American Geriatric Society (AGS) and British Geriatric Society (BGS) clinical guideline in addition to input from healthcare providers
Preventing Falls in Older Patients: A Provider Toolkit Provider resourcesTraining materialsAssessment toolsPatient education
STEADI
Tool Kit based on strong clinical guidelines and provider input
Evidence-based strategies for interacting with clinical care around public health issuesTobaccoObesity
Research from Tinetti et al provides implementation guidance
Technical assistance availableHealthTeam Works’ experience working with
providers in target area on other health issues
STEADI Implementation Pros
Do not have adequate resources to implement program in the same way Tinetti et al did
Evidence-based tools may not be practical and easy to apply in the primary care setting Lack electronic tools May not have the optimal space to perform the TUG in the
practice setting, etc Low levels of staff participation can hinder success
Algorithms are still complex, requires multiple steps and a lot of time.
Every primary care practice is different. What works for one may not work for others.
Determining what changes have occurred and sustaining those changes in a real-world settings is difficult.
STEADI Implementation Challenges
Colorado Approach to STEADI
Reach 66% of PCP’s (Family/General/Internal Medicine) in Adams and Arapahoe counties
Contract with HealthTeam Works Engage practices using academic detailing Provide STEADI, a comprehensive toolkit to help
healthcare providers incorporate fall risk assessment and proven interventions into their clinical practice
Explore adapting the STEADI Tool Kit to be used in electronic medical records
*Arapahoe county data consolidated from Peregrine and Colorado Medical Society. Adams county extracted from Peregrine and estimated based on assumption that 1/3 of physicians do not accept or limit # of Medicare patients.
Counties PCP’s Accept Medicare
66%
Adams ~112* 74Arapahoe ~151* 100
Putting It All Together
The Evidence-based PublicHealth Framework
Slide adopted from presentation by Ross Brownson, PhD (2011)
Pilot and Evaluate
Plan goals for process and outcome
evaluation before program
implementation
Create or find the instruments and protocols needed for data collection
Monitor program operations and make
adjustments to evaluation plan (if
needed)
Evaluate program delivery and
outcomes to assess program success
Use findings in future program
planning
Slide from presentation by Marcia Ory, PhD, MPH and Ashley Wilson, MPH, (2012)
Resources for Implementation ScienceNational Implementation Research Network: http://nirn.fpg.unc.edu/
The Community Tool Box : http://ctb.ku.edu
There are different types of evidence-based programs, each with their own set of implementation challenges
Successful implementation of an evidence based program takes careful planning
Think about evaluation, fidelity and sustainability from the beginning
Partnerships are key to successExternal factors outside the project can
contribute or hinder success
Conclusion
Contact Information:Lindsey [email protected]
THANK YOU!