Barriers to implementation of STRIDE, a national study to prevent fall-related injuries

Reframing Fall Prevention and Risk Management as a Chronic Condition Through the Lens of the Expanded Chronic Care Model: Will Integrating Clinical Care and Public Health Improve Outcomes?

Falls are a leading cause of morbidity and mortality among adults aged 65 years and older (older adults) and are increasingly recognized as a chronic condition. Yet, fall-related care is infrequently provided in a chronic care context despite fall-related death rates increasing by 41% between 2012 and 2021. One of the many challenges to addressing falls is the absence of fall-focused chronic disease management programs, which improve outcomes of other chronic conditions, like diabetes. Policies, information systems, and clinical-community connections help form the backbone of chronic disease management programs, yet these elements are often missing in fall prevention. Reframing fall prevention through the Expanded Chronic Care Model (ECCM) guided by implementation science to simultaneously support the uptake of evidence-based practices could help improve the care of older adults at risk for falling. The ECCM includes seven components: (1) self-management/develop personal skills, (2) decision support, (3) delivery system design/re-orient health services, (4) information systems, (5) build healthy public policy, (6) create supportive environments, and (7) strengthen community action. Applying the ECCM to falls-related care by integrating health care delivery system changes, community resources, and public policies to support patient-centered engagement for self-management offers the potential to prevent falls more effectively among older adults.

Reducing Falls Among Community-Dwelling Older Adults From Clinicians' Perspectives: A Systems Modeling Approach

Background and Objectives

Falls among older adults are a significant health problem globally. Studies of multicomponent fall prevention programs in randomized controlled trials demonstrate effectiveness in reducing falls; however, the translation of research into the community remains challenging. Although there is an increasing interest to understand the factors contributing to implementation barriers, the dynamic relationships between factors are less well examined. Furthermore, evidence on implementation barriers from Asia is lacking as most of these studies originate from the West. As such, this study aims to engage stakeholders in uncovering the factors that facilitate or inhibit implementing community-based fall prevention programs in Singapore, with a focus on the interrelationship between those factors.

Research Design and Methods

Health care professionals familiar with fall prevention programs were invited to discuss the enablers and challenges to the implementation. This effort was facilitated using a systems modeling methodology of Group Model Building (GMB) to share ideas and create a common conceptual model of the challenges. The GMB employs various engagement techniques to draw on the experiences and perceptions of all stakeholders involved.

Results

This process led to the development of a Causal Loop Diagram (CLD), a qualitative conceptual model of the dynamic relationships between the barriers and facilitators of implementing fall prevention programs. Results from the CLD show that implementation is influenced by two main drivers: health care provider factors that influenced referrals, and patient factors that influenced referral acceptance and long-term adherence. Key leverage points for potential interventions were identified as well.

Discussion and Implications

The overall recommendation emphasized closer coordination and collaboration across providers to ensure sustainable and effective community-based fall prevention programs. This has to be supported by a national effort, involving a multidisciplinary stakeholder advisory group. These findings generated would be promising to guide future approaches to fall prevention.

Contextual determinants influencing the implementation of fall prevention in the community: a scoping review

Background

Successful implementation of multifactorial fall prevention interventions (FPIs) is essential to reduce increasing fall rates in community-dwelling older adults. However, implementation often fails due to the complex context of the community involving multiple stakeholders within and across settings, sectors, and organizations. As there is a need for a better understanding of the occurring context-related challenges, the current scoping review purposes to identify what contextual determinants (i.e., barriers and facilitators) influence the implementation of FPIs in the community.

Methods

A scoping review was performed using the Arksey and O'Malley framework. First, electronic databases (Pubmed, CINAHL, SPORTDiscus, PsycINFO) were searched. Studies that identified contextual determinants that influence the implementation of FPIs in the community were included. Second, to both validate the findings from the literature and identify complementary determinants, health and social care professionals were consulted during consensus meetings (CMs) in four districts in the region of Utrecht, the Netherlands. Data were analyzed following a directed qualitative content analysis approach, according to the 39 constructs of the Consolidated Framework for Implementation Research.

Results

Fourteen relevant studies were included and 35 health and social care professionals (such as general practitioners, practice nurses, and physical therapists) were consulted during four CMs. Directed qualitative content analysis of the included studies yielded determinants within 35 unique constructs operating as barriers and/or facilitators. The majority of the constructs (n = 21) were identified in both the studies and CMs, such as "networks and communications", "formally appointed internal implementation leaders", "available resources" and "patient needs and resources". The other constructs (n = 14) were identified only in the .

Discussion

Findings in this review show that a wide array of contextual determinants are essential in achieving successful implementation of FPIs in the community. However, some determinants are considered important to address, regardless of the context where the implementation occurs. Such as accounting for time constraints and financial limitations, and considering the needs of older adults. Also, broad cross-sector collaboration and coordination are required in multifactorial FPIs. Additional context analysis is always an essential part of implementation efforts, as contexts may differ greatly, requiring a locally tailored approach.

Implementing CAPABLE With Care Partners Through an Area Agency on Aging: Identifying Barriers and Facilitators Using the Consolidated Framework for Implementation Research

BACKGROUND AND OBJECTIVES

Community Aging in Place, Advancing Better Living for Elders (CAPABLE) is an evidence-based intervention to promote aging in place. Although CAPABLE has been implemented in more than 40 community sites, wide variation in implementation exists. Guided by the Consolidated Framework for Implementation Research (CFIR), this study sought to determine key barriers and facilitators that may influence CAPABLE implementation with older adult and care partner dyads through an area agency on aging (AAA).

RESEARCH DESIGN AND METHODS

A formative evaluation was completed using qualitative data from the pilot of a Hybrid Trial Type 1 study implementing CAPABLE in an AAA. Multiple sources of data were collected, including 2 focus groups, field notes, a tracking log, and meetings with CAPABLE interventionists. Data were analyzed using a framework method and validated through a negative case analysis approach in NVivo 12 Pro.

RESULTS

Fourteen dyads enrolled in the pilot and 6 completed the CAPABLE intervention. Key themes aligned with 10 constructs from 5 domains of the CFIR. Facilitators included adaptability of the intervention, cost, networks and communication, and knowledge and belief of individuals. Barriers included intervention complexity, client needs and resources, and executing the planned process.

DISCUSSION AND IMPLICATIONS

Results enhance understanding of contextual factors that can influence the implementation of CAPABLE with care partners. Strategies to overcome barriers include simplifying recruitment materials and targeting older adults with recent onset of disability. The CFIR is a valuable resource for planning and evaluation of the implementation of evidence-based interventions to promote aging in place.

Around the EQUATOR with clinician-scientists transdisciplinary aging research (Clin-STAR) principles: Implementation science challenges and opportunities

The Institute of Medicine and the National Institute on Aging increasingly understand that knowledge alone is necessary but insufficient to improve healthcare outcomes. Adapting the behaviors of clinicians, patients, and stakeholders to new standards of evidence-based clinical practice is often significantly delayed. In response, over the past twenty years, Implementation Science has developed as the study of methods and strategies that facilitate the uptake of evidence-based practice into regular use by practitioners and policymakers. One important advance in Implementation Science research was the development of Standards for Reporting Implementation Studies (StaRI), which provided a 27-item checklist for researchers to consistently report essential elements of the implementation and intervention strategies. Using StaRI as a framework, this review discusses specific Implementation Science challenges for research with older adults, provides solutions for those obstacles, and opportunities to improve the value of this evolving approach to reduce the knowledge translation losses that exist between published research and clinical practice.

Engagement of older adults in STRIDE's multifactorial fall injury prevention intervention

BACKGROUND

Evidence-based multifactorial fall prevention interventions in clinical practice have been less effective than expected. One plausible reason is that older adults' engagement in fall prevention care is suboptimal.

METHODS

This was a post-hoc analysis of 2403 older adults' engagement in a multifactorial fall prevention intervention in the Strategies to Reduce Injuries and Develop Confidence in Elders (STRIDE) pragmatic trial. Based on the direct clinical care level of the Patient and Family Continuum of Engagement (CE) framework, three indicators of progressively interactive engagement were assessed: (1) Consultation (receiving information), (2) Involvement (prioritizing risks), and (3) Partnership (identifying prevention actions). Drop off at each step was determined as well as predictors of engagement.

RESULTS

The participants' engagement waned with increasingly interactive CE domains. Although all participants received information about their positive fall risk factors (consultation) and most (51%-96%) prioritized them (involvement), fewer participants (33%-55%) identified fall prevention actions (partnership) for most of their risk factors, except for strength gait or balance problems (95%). More participants (70%) identified home exercises than other actions. Finally, fall prevention actions were identified more commonly among participants who received two visits compared to one (OR = 2.33 [95% CI, 2.06-2.64]), were ≥80 years old (OR = 1.83 [95% CI, 1.51-2.23]), and had fewer fall risk factors (OR = 0.90 [95% CI, 0.83-0.99]).

CONCLUSIONS

The drop-off in participants' engagement based on the level of their interaction with clinicians suggests that future multifactorial fall prevention interventions need to be more focused on interactive patient-clinician partnerships that help older adults increase and maintain fall prevention actions. Our analyses suggest that more frequent contact with clinicians and more monitoring of the implementation and outcomes of Fall Prevention Care Plans could potentially improve engagement and help older adults maintain fall prevention actions.

Effect of the STRIDE fall injury prevention intervention on falls, fall injuries, and health-related quality of life

BACKGROUND

Falls are common in older adults and can lead to severe injuries. The Strategies to Reduce Injuries and Develop Confidence in Elders (STRIDE) trial cluster-randomized 86 primary care practices across 10 health systems to a multifactorial intervention to prevent fall injuries, delivered by registered nurses trained as falls care managers, or enhanced usual care. STRIDE enrolled 5451 community-dwelling older adults age ≥70 at increased fall injury risk.

METHODS

We assessed fall-related outcomes via telephone interviews of participants (or proxies) every 4 months. At baseline, 12 and 24 months, we assessed health-related quality of life (HRQOL) using the EQ-5D-5L and EQ-VAS. We used Poisson models to assess intervention effects on falls, fall-related fractures, fall injuries leading to hospital admission, and fall injuries leading to medical attention. We used hierarchical longitudinal linear models to assess HRQOL.

RESULTS

For recurrent event models, intervention versus control incidence rate ratios were 0.97 (95% confidence interval [CI], 0.93-1.00; p = 0.048) for falls, 0.93 (95% CI, 0.80-1.08; p = 0.337) for self-reported fractures, 0.89 (95% CI, 0.73-1.07; p = 0.205) for adjudicated fractures, 0.91 (95% CI, 0.77-1.07; p = 0.263) for falls leading to hospital admission, and 0.97 (95% CI, 0.89-1.06; p = 0.477) for falls leading to medical attention. Similar effect sizes (non-significant) were obtained for dichotomous outcomes (e.g., participants with ≥1 events). The difference in least square mean change over time in EQ-5D-5L (intervention minus control) was 0.009 (95% CI, -0.002 to 0.019; p = 0.106) at 12 months and 0.005 (95% CI, -0.006 to 0.015; p = 0.384) at 24 months.

CONCLUSIONS

Across a standard set of outcomes typically reported in fall prevention studies, we observed modest improvements, one of which was statistically significant. Future work should focus on patient-, practice-, and organization-level operational strategies to increase the real-world effectiveness of interventions, and improving the ability to detect small but potentially meaningful clinical effects.

CLINICALTRIALS

gov identifier: NCT02475850.

Dissemination of a successful dementia care program: Lessons to facilitate spread of innovations

BACKGROUND

Despite the effectiveness of innovations to improve the care of persons with dementia, there has been limited diffusion of these into widespread clinical practice. We aimed to identify common barriers and address them directly in the initial phase of dissemination of a successful dementia care program.

METHODS

Description of and early experience with a dissemination strategy of the UCLA Alzheimer's and Dementia Care Program to health care systems nationwide. We measured site-identified goals for the program and indicators of success, number of adopting sites, and participants in their programs.

RESULTS

From January 2019 to December 2021, 80 sites expressed interest in adopting the program, 14 (18%) sites adopted it, and 10 of these sites have begun caring for patients. Another 4 sites have implemented the program as part of a randomized clinical trial. To date, over 1690 persons living with dementia and their caregivers have received Alzheimer's and Dementia Care (ADC) care at 14 adopting sites. Key lessons from the early dissemination efforts include the importance of identifying a strong product champion at the adopting site, creating a business case for adoption, training of clinical staff and adapting the model to fit local cultures and workflow, as well as recognizing the likely long length of time needed for the decision to adopt and implementation process.

CONCLUSIONS

Despite many obstacles to dissemination, with local champions and technical assistance, successful innovations in dementia care can be implemented in diverse health systems. The ability to adopt sites to bring the program to full scale and achieve comparable outcomes to the original program remains to be determined.

Translation of the geriatric emergency department intervention into other emergency departments: a post implementation evaluation of outcomes for older adults

Background

Increasing numbers of older adults with complex health deficits presenting to emergency departments has prompted the development of innovative models of care. One such model designed to reduce poor outcomes associated with acute healthcare, is the Geriatric Emergency Department Intervention. This intervention is a nurse-led, physician-championed, Emergency Department intervention that improves the health outcomes for frail older adults in the emergency department.

Methods

This quantitative cohort study aimed to evaluate the healthcare outcomes and costs associated with the implementation of the Geriatric Emergency Department Intervention (GEDI) for adults aged 70 years and over at two hospital sites that implemented the model using the integrated-Promoting Action on Research Implementation in Health Services (i-PARHIS) framework. Hospital A was large teaching hospital located in the tropical north of Australia. Hospital B was a medium sized teaching hospital near Brisbane, Queensland Australia.

The effect of the intervention was examined in two ways. Outcomes were compared between: 1) all patients in the pre- and post- implementation periods, and 2) patients seen or not seen by the Geriatric Emergency Department Intervention team in the post-implementation period. The outcomes measured were disposition (discharged home, admitted); emergency department length of stay; hospital length of stay; all cause in-hospital mortality within 28 days; time to re-presentation up to 28 days post-discharge; emergency department and in-hospital costs.

Survival analyses were used for the primary and secondary outcome variables and a Cox survival model was used to estimate the associations between variables and outcomes. Multiple regression models were used to examine other secondary outcomes whilst controlling for a range of confounders.

Results

The Geriatric Emergency Department Intervention was successfully translated into two different emergency departments. Both demonstrated an increased likelihood of discharge, decreased emergency department length of stay, decreased hospital costs for those who were admitted, with an associated reduction in risk of mortality, for adults aged 70 years and over.

Conclusions

The Geriatric Emergency Department Intervention was successfully translated into new sites that adapted the model design. Improvement in healthcare outcomes for older adults presenting to the emergency department was demonstrated, although this was more subtle than in the original model setting.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-02999-4.

Dementia Caregiver Virtual Support-An Implementation Evaluation of Two Pragmatic Models during COVID-19

Caregivers of people with Alzheimer's and related dementias (ADRD) require support. Organizations have pivoted from traditional in-person support groups to virtual care in the face of the COVID-19 pandemic. We describe two model programs and their pragmatic implementation of virtual care platforms for ADRD caregiver support. A mixed methods analysis of quantitative outcomes as well as a thematic analysis from semi-structured interviews of facilitators was performed as part of a pragmatic quality improvement project to enhance delivery of virtual support services for ADRD caregivers. Implementation differed among individual organizations but was well received by facilitators and caregivers. While virtual platforms can present challenges, older adults appreciated the strength of group facilitators and reported enhanced connectedness related to virtual support. Barriers to success include the limitations of virtual programming, including technological issues and distractions from program delivery. Virtual support can extend outreach, addressing access and providing safe care during a pandemic. Implementation differs among organizations; however, some elements of virtual support may be long-lasting.