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Family level data was collected from those served in a state-wide rollout of SafeCare® in Georgia between January of 2010 and November of 2011. Families who received SafeCare were trained in the intervention’s three modules: Parent-Child or Parent-Infant Interaction, Home Safety, and Child Health. The purpose of this study was to measure changes in parental skill demonstration by analyzing pre- and post-training assessments. Additionally, parental demographic characteristics were also assessed for associations with skill acquisition within each module. Follow-up analysis concluded that families displayed increases in parenting skills among all SafeCare modules. Moderator analysis showed that those with only one child showed greater decreases in home hazards as did those with two children. Also, it was found that income level moderated performance in the Parent-Child Interaction module with participants below the median income level exhibiting a greater increase in PCI skill demonstration than those above the median income level. Further research should consider modeling multiple parental characters (e.g. CPS status and income) with skill performance over time. Lastly, additional research should aim to determine if those who exhibit increases in parenting skills are also less likely to experience future child maltreatment reports.

Nearly two decades of research on translating evidence-based care guidelines into practice has resulted in a considerable body of primary and secondary evidence about guideline implementation strategies and the individual, organizational and environmental challenges associated with closing the evidence to practice gap in primary care. Interventions to improve professional performance are complex and a disentangling of the various independent, intervening and constraining variables is required in order to be able to design and implement interventions that can improve primary care practice performance. The PRECEDE-PROCEED planning model (Green & Kreuter, 1999) provides a step-wise theoretical framework for understanding the complexity of causal relationships among the variables that affect the adoption of evidence-based practice and may assist in the design and implementation of practice-based interventions. Knowledge of an evidence-based practice guideline is important, but a consensus has emerged that having knowledge is rarely sufficient to change practice behaviour. Didactic education or passive dissemination strategies are ineffective, whereas interactive education, reminder systems and multifaceted interventions tailored to the needs of the practice are effective. Outreach or practice facilitation is a proven effective multifaceted approach that involves skilled individuals who enable others, through a range of tailored interventions, to address the challenges in implementing evidence-based care guidelines within the primary care setting. The challenges to implementing evidence-based chronic illness care practice guidelines are thought to be similar to the other contextual, organizational and individual behavioural challenges associated with the uptake of research findings into practice. A multifaceted guideline implementation strategy such as practice facilitation may be well-suited to improving the adoption of these guidelines within rural primary care settings. However, research has not systematically reviewed, through meta-analysis, the published practice facilitation trials to determine overall effects and an implementation research study of practice facilitation that has considered fidelity of implementation within the rural Ontario setting for a complex practice guideline such as chronic illness management has not been done. The systematic review in the thesis incorporated an exploratory meta-analysis of randomized and non-randomized controlled trials of interventions targeted towards implementing evidence-based practice guidelines through practice facilitation, and was conducted to gain an understanding of the overall effect of practice facilitation and the factors that moderate implementation success. The results were the identification of an improvement overtime in the methodological rigour of practice facilitation implementation research based on a critical appraisal of methods, a significant moderate overall effect size of 0.54 (95% CI 0.43 – 0.65) for 19 good quality practice facilitation intervention studies and several significant effect size modifiers; notably, tailoring to the needs of the practice, using multiple intervention components, extending duration, and increasing the intensity of practice facilitation were associated with larger effect sizes. As more practices were assigned to the practice facilitator, the effect diminished. A significant positive association between the number of PRECEDE predisposing, enabling and reinforcing strategies employed by the facilitator and the effect size was detected. The implementation research study utilized mixed methods for data collection as part of an embedded case study of four rural primary care practices to determine the implementation fidelity of the practice facilitation of chronic illness care planning and the factors that impeded and contributed to implementation success. The feasibility of and potential cost savings of practice facilitation via videoconferencing was also implemented for two of the practices. For those practices that successfully implemented care planning, fidelity was achieved for the implementation of care plans. On the other hand, the dosage, duration, component delivery of the practice facilitation intervention was low in comparison to other published studies, and tailoring of the intervention to the practice was inconsistent. Based on the qualitative analysis of physician interviews, the moderating factors for successful implementation were categorized into the broad themes of pessimism and tempered optimism. Pessimistic physicians were unsuccessful at implementation, lacked a willingness to engage and were uncomfortable with the patient-centred approach to chronic illness care. Optimists were positive about the psychosocial, patient-centred assessment aspects of the chronic illness care protocol and provided anecdotes of success in resolving patient problems. However, this was tempered as both pessimists and optimists reflected on the time intensive aspect of the protocol and the unlikelihood of widespread implementation without additional supports. Participating physicians were satisfied with the facilitator and the videoconferencing experience, and the intervention cost analysis revealed opportunities for cost saving via the use of videoconferenced facilitation. Improvements to the intervention suggested by participants included integrating chronic illness management with medical information systems, involving other health disciplines, and forming networks of community health resources and support services for health providers and patients. This work has demonstrated that although practice facilitation can successfully result in moderate significant improvements in practice behaviour, it is not necessarily singularly effective in all contexts or for all targeted behaviours. A complex practice guideline such as the chronic illness care management model is unlikely to be adopted in the current context of primary care in rural Ontario and as a consequence to have any impact on the health of chronically ill patients without further intervention supports, adaptation, and implementation research undertaken to demonstrate successful execution of chronic illness care management. Alternative care delivery models are required to address barriers and improve the delivery of chronic illness care management.

Nearly two decades of research on translating evidence-based care guidelines into practice has resulted in a considerable body of primary and secondary evidence about guideline implementation strategies and the individual, organizational and environmental challenges associated with closing the evidence to practice gap in primary care. Interventions to improve professional performance are complex and a disentangling of the various independent, intervening and constraining variables is required in order to be able to design and implement interventions that can improve primary care practice performance. The PRECEDE-PROCEED planning model (Green & Kreuter, 1999) provides a step-wise theoretical framework for understanding the complexity of causal relationships among the variables that affect the adoption of evidence-based practice and may assist in the design and implementation of practice-based interventions. Knowledge of an evidence-based practice guideline is important, but a consensus has emerged that having knowledge is rarely sufficient to change practice behaviour. Didactic education or passive dissemination strategies are ineffective, whereas interactive education, reminder systems and multifaceted interventions tailored to the needs of the practice are effective. Outreach or practice facilitation is a proven effective multifaceted approach that involves skilled individuals who enable others, through a range of tailored interventions, to address the challenges in implementing evidence-based care guidelines within the primary care setting. The challenges to implementing evidence-based chronic illness care practice guidelines are thought to be similar to the other contextual, organizational and individual behavioural challenges associated with the uptake of research findings into practice. A multifaceted guideline implementation strategy such as practice facilitation may be well-suited to improving the adoption of these guidelines within rural primary care settings. However, research has not systematically reviewed, through meta-analysis, the published practice facilitation trials to determine overall effects and an implementation research study of practice facilitation that has considered fidelity of implementation within the rural Ontario setting for a complex practice guideline such as chronic illness management has not been done. The systematic review in the thesis incorporated an exploratory meta-analysis of randomized and non-randomized controlled trials of interventions targeted towards implementing evidence-based practice guidelines through practice facilitation, and was conducted to gain an understanding of the overall effect of practice facilitation and the factors that moderate implementation success. The results were the identification of an improvement overtime in the methodological rigour of practice facilitation implementation research based on a critical appraisal of methods, a significant moderate overall effect size of 0.54 (95% CI 0.43 – 0.65) for 19 good quality practice facilitation intervention studies and several significant effect size modifiers; notably, tailoring to the needs of the practice, using multiple intervention components, extending duration, and increasing the intensity of practice facilitation were associated with larger effect sizes. As more practices were assigned to the practice facilitator, the effect diminished. A significant positive association between the number of PRECEDE predisposing, enabling and reinforcing strategies employed by the facilitator and the effect size was detected. The implementation research study utilized mixed methods for data collection as part of an embedded case study of four rural primary care practices to determine the implementation fidelity of the practice facilitation of chronic illness care planning and the factors that impeded and contributed to implementation success. The feasibility of and potential cost savings of practice facilitation via videoconferencing was also implemented for two of the practices. For those practices that successfully implemented care planning, fidelity was achieved for the implementation of care plans. On the other hand, the dosage, duration, component delivery of the practice facilitation intervention was low in comparison to other published studies, and tailoring of the intervention to the practice was inconsistent. Based on the qualitative analysis of physician interviews, the moderating factors for successful implementation were categorized into the broad themes of pessimism and tempered optimism. Pessimistic physicians were unsuccessful at implementation, lacked a willingness to engage and were uncomfortable with the patient-centred approach to chronic illness care. Optimists were positive about the psychosocial, patient-centred assessment aspects of the chronic illness care protocol and provided anecdotes of success in resolving patient problems. However, this was tempered as both pessimists and optimists reflected on the time intensive aspect of the protocol and the unlikelihood of widespread implementation without additional supports. Participating physicians were satisfied with the facilitator and the videoconferencing experience, and the intervention cost analysis revealed opportunities for cost saving via the use of videoconferenced facilitation. Improvements to the intervention suggested by participants included integrating chronic illness management with medical information systems, involving other health disciplines, and forming networks of community health resources and support services for health providers and patients. This work has demonstrated that although practice facilitation can successfully result in moderate significant improvements in practice behaviour, it is not necessarily singularly effective in all contexts or for all targeted behaviours. A complex practice guideline such as the chronic illness care management model is unlikely to be adopted in the current context of primary care in rural Ontario and as a consequence to have any impact on the health of chronically ill patients without further intervention supports, adaptation, and implementation research undertaken to demonstrate successful execution of chronic illness care management. Alternative care delivery models are required to address barriers and improve the delivery of chronic illness care management.

Foodborne illness is a serious and preventable public health problem affecting 1 in 6 Americans with cost estimates over $50 billion annually. Local health departments license and inspect restaurants to ensure food safety and respond to reports of suspected foodborne illness. The City of St. Louis Department of Health adopted the HealthMap Foodborne Dashboard (Dashboard), a tool that monitors Twitter for tweets about food poisoning in a geographic area and allows the health department to respond. We evaluated the implementation by interviewing employees of the City of St. Louis Department of Health involved in food safety. We interviewed epidemiologists, environmental health specialists, health services specialists, food inspectors, and public information officers. Participants viewed engaging innovation participants and executing the innovation as challenges while they felt the Dashboard had relative advantage over existing reporting methods and was not complex once in place. This study is the first to examine practitioner perceptions of the implementation of a new technology in a local health department. Similar implementation projects should focus more on process by developing clear and comprehensive plans to educate and involve stakeholders prior to implementation.

Therapeutic Day Treatment (TDT) is a community-based mental health treatment program regulated and funded by the Department of Medical Assistance Services (DMAS) in the Commonwealth of Virginia. This case study sought to understand how DMAS regulatory changes impacted the implementation of the TDT program in the Commonwealth between fiscal years 2004 and 2011. In an effort to respond to this question, sources of qualitative and quantitative data were collected including: TDT fee-for-service data, regulations in the Community Mental Health and Rehabilitative Services manual guiding the implementation of the TDT program, and structured interviews with eight key stakeholders who interface with the TDT program. The fee-for-services analysis found that there was a 269% increase in fee-for-service expenditures between fiscal years 2007 and 2011. The analysis of the regulations found DMAS added language to provide greater clarity to the existing regulators. Some of these changes include the implementation of the PA process with KePRO as well as the VICAP process. Additionally, staff requirements changed and paraprofessionals were no longer able to provide TDT programming. Caseload limits were also set for TDT programming. Four themes emerged through the analysis of the structured interviews. These themes include: 1) fraudulent practices and misuse of TDT services, 2) regulatory oversight, 3) cost containment, and 4) evaluation. Implications focused on the areas of policy, practice, and research by suggesting further research studies focusing on TDT and policy, offering the foundation of a more comprehensive theory focusing on policy implementation, and lastly the researcher provided a logic model for the TDT program in an effort to propel evaluation research forward.

Self-directed supports, as a method of service delivery, have grown from small pilot programs in a handful of states to at least one program in every state. For individuals with intellectual and developmental disabilities (IDD), self-direction presents unique opportunities to engage in self-determined behavior and shape the services upon which they rely. Although the evidence base for self-direction is relatively robust, there is a significant lack of information on how implementation of self-direction is faring on the national level. The purpose of this study is to understand how the political and economic factors within and across states have impacted the implementation of a self-directed service delivery system.

INTRODUCTION: In Canada, the role of Telehealth Coordinator is relatively new. Provider institutions and telehealth networks developed the role to support implementation and use of videoconferencing technology in health care delivery. As telehealth usage grows, an increasing number of Canadian nurses, other regulated health care professionals and unregulated workers are being called upon to function as Telehealth Coordinators. However, in some organizations, this role remains poorly understood and generally, little is known about the demographics of Canada’s Telehealth Coordinator community of practice. PURPOSE: Using Role Theory concepts and the tenets of Nursing Informatics, the broad aim of this qualitative study was to gain a better understanding of the demographics and role that nurses, other regulated health professionals and unregulated workers play in sustainable telehealth technology implementation and use in Canada. This is important in the context of leveraging technology to meet the challenges of an ageing population and increasing burden of chronic illness. METHODS: Qualitative exploratory study design using mixed methods. Telehealth Coordinators from the Canadian Society of Telehealth (CST) and Ontario Telemedicine Network (OTN) were invited to take part in an online survey (33 items) and telephone interview (20 items). RESULTS: From two identified populations – a provincial sample from Ontario and a national sample from other Canadian provinces and territories, 47 Telehealth Coordinators provided responses that could be analyzed. Over half of the respondents (56%) reported being between the ages of 40 – 59 years and 75% were female. Nurses and other regulated health care professionals comprised 53% of the sample. Of the respondents, 66% reported working in a health care provider organization. Responses to the qualitative questions are presented within the context of Role Theory and Nursing Informatics. CONCLUSIONS: Canada’s Telehealth Coordinators are an eclectic community of practice with varying roles, responsibilities, educational backgrounds and experience. Although the role of Telehealth Coordinator varied across organizations and regions in Canada, important commonalities were also found. Participants expressed a need and desire for standards, ongoing professional education opportunities and credentialing – especially if the role involved patient care. Major factors contributing to Canadian Telehealth Coordinators work satisfaction were: 1. patient contact and knowledge that they were making health care more accessible 2. educating others in the use of videoconferencing technology and 3. autonomy. Organizational issues including a lack of resources and understanding of the role by senior executives provided the least satisfaction for Telehealth Coordinators. Strong organizational support for Telehealth Coordinators will increase the probability of successful videoconferencing technology implementation and use.

Introduction. The implementation of Clinical Pharmacy Services (CPS) is a strategic action to optimize the pharmacotherapy of hospitalized patients. Although many studies have shown beneficial results for CPS, they are not uniformly established in hospitals worldwide, including in Brazil. To know the factors that influence CPS deployment and to identify where they act is the first step toward successful adoption of these services in hospitals. Aim. To identify the factors that affect the CPS implementation in the hospital setting and to analyze them using the Apoteca domains. Methods. The study was carried out in five stages. (1) Framework development to analyze factors that influence the implementation of SCF. For this, systematic observations were made during SCF implementation experiences conducted by the researchers and analysis of conceptual models based on observations of reality were performed. (2) Systematic review of the literature to identify factors that influence the implementation of CPS in the hospital setting. Six databases were searched until January 2018. The search strategy was developed using terms related to: “clinical pharmacy”, “influencing factors”, “implementation” and “hospital”. Two reviewers selected original articles, extracted data and assessed the quality of the studies. After the framework synthesis and categorization of the factors in groups of interest and Attitudinal, Political, Technical and Administrative domains (Apoteca), a diagrammatic approach was used to present the results. (3) Focus group with pharmacists and interviews with hospital managers were carried out to know the perceptions about the factors that could influence the implementation of CPS in the hospital studied. (4) Structured implementation intervention with attitudinal, political, technical and administrative approaches. (5) Interviews were carried out with the pharmacists who performed the CPS and managers, to know the participants' perceptions of the factors that actually influenced the CPS implementation in the hospital. After collecting the information, the audio records were transcribed and analyzed using framework analysis and the Apoteca domains, in order to compare the perceptions before and after the structured SCF implementation. Results. Four domains were proposed to analyze the factors influencing the SCF implementation: Attitudinal, Political, Technical and Administrative – the Apoteca framework. Fifty-three factors were identified in the 21 studies included in the review. The most cited influencing factors were uniformly distributed in the four Apoteca domains, but in terms of interest groups, the “pharmacist” had the highest concentration of factors. “Clinical skills and knowledge” was the most cited factor, followed by “Time to implement CPS”. In the intervention study, pharmacists reported 19 obstacles in total, while managers perceived 16 different barriers. About half of the barriers cited were considered to have been overcome or not-met in the second interview. Managers and pharmacists mentioned fewer facilitators when compared to barriers (eleven and ten, respectively), and the latter were only able to perceive them after the intervention. Regarding the Apoteca classification, most of the barriers were administrative and the majority of the facilitators were political. Conclusion. The results showed the multifactorial nature of the CPS deployment process and that pharmacists and managers anticipated more barriers and less facilitators when compared to the factors actually experienced. Those findings suggest that a structure implementation, considering the four Apoteca domains, can help in planning strategies to enable the successful implementation of CPS in a hospital setting. / Introdução. A implementação de Serviços Clínicos Farmacêuticos (SCF) é uma ação estratégica para otimizar a farmacoterapia de pacientes hospitalizados. Embora muitos estudos relatem resultados benéficos dos SCF, ainda não há padronização dessa prática em hospitais, inclusive no Brasil. Conhecer os fatores que influenciam a implementação de SCF e identificar onde atuam é o primeiro passo para adoção bem-sucedida destes serviços. Objetivo. Identificar os fatores que afetam a implementação da SCF no ambiente hospitalar e analisá-los utilizando os domínios Apoteca. Metodologia. O estudo foi realizado em cinco etapas. (1) Desenvolvimento de um framework de determinantes para análise de fatores que influenciam a implementação de SCF. Para isso, foram realizadas observações sistemáticas durante experiências de implementação de SCF conduzidas pelos pesquisadores e análise de modelos conceituais fundamentados em observações da realidade. (2) Revisão sistemática da literatura para identificar fatores que influenciam a implementação de SCF em ambiente hospitalar. Seis bases de dados foram pesquisadas até janeiro de 2018. A estratégia de busca foi desenvolvida usando termos relacionados a: “farmácia clínica”, “fatores influenciadores”, “implementação” e “hospital”. Dois revisores selecionaram artigos originais, extraíram os dados e avaliaram a qualidade dos estudos. Após a síntese de framework e categorização dos fatores em grupos de interesse e domínios Atitudinais, Políticos, Técnicos e Administrativos (Apoteca), uma abordagem diagramática foi utilizada para apresentar os resultados. (3) Grupo focal com farmacêuticos e entrevistas com gerentes hospitalares para conhecer as percepções acerca dos fatores que poderiam influenciar a implementação de SCF no hospital do estudo. (4) Intervenção estruturada, com abordagens atitudinais, políticas, técnicas e administrativas. (5) Entrevistas com os farmacêuticos e gerentes ligados aos SCF para conhecer as percepções acerca dos fatores que influenciaram efetivamente a implementação de SCF no hospital do estudo. Depois de coletar as informações, os registros de áudio foram transcritos e analisados usando análise de framework e os domínios Apoteca. Resultados. Foram propostos quatro domínios para análise dos fatores influenciadores da implementação de SCF: Atitudinal, Político, Técnico e Administrativo - framework Apoteca. Na revisão foram identificados 53 fatores em 21 estudos incluídos. Os fatores mais citados foram uniformemente distribuídos nos quatro domínios Apoteca, em termos de grupos de interesse, o “farmacêutico” teve a maior concentração de fatores. O fator mais citado foi “Habilidades e conhecimento clínico”, seguido de “Tempo para implantar SCF”. No estudo de intervenção, farmacêuticos relataram 19 barreiras e gerentes perceberam 16. Cerca de metade das barreiras citadas foram consideradas superadas ou não-concretizadas na segunda entrevista. Gerentes e farmacêuticos mencionaram um número menor de facilitadores quando comparados às barreiras (onze e dez, respectivamente), e os segundos só conseguiram percebê-los após a intervenção. Em relação à classificação Apoteca, a maioria das barreiras foi administrativa e dos facilitadores foi político. Conclusão. Os resultados obtidos mostraram a natureza multifatorial do processo de implementação de SCF e que farmacêuticos e gerentes anteciparam mais barreiras e menos facilitadores quando comparados aos fatores efetivamente experimentados. Esses achados sugerem que a implementação estruturada, considerando os quatro domínios Apoteca podem auxiliar na implementação bem-sucedida de SCF em hospitais. / Aracaju