Applying the consolidated framework for implementation research to identify barriers affecting implementation of an online frailty tool into primary health care: a qualitative study

Applying the consolidated framework for implementation research to identify barriers affecting... Background: Frailty is associated with multi-system deterioration, and typically increases susceptibility to adverse events such as falls. Frailty can be better managed with early screening and intervention, ideally conducted in primary health care (PHC) settings. This study used the Consolidated Framework for Implementation Research (CFIR) as an evaluation framework during the second stage piloting of a novel web-based tool called the Frailty Portal, developed to aid in the screening, identification, and care planning of frail patients in community PHC. Methods: This qualitative study conducted semi-structured key informant interviews with a purposive sample of PHC providers (family physicians, nurse practitioners) and key PHC stakeholders who were administrators, decision makers and staff. The CFIR was used to guide data collection and analysis. Framework Analysis was used to determine the relevance of the CFIR constructs to implementing the Frailty Portal. Results: A total of 17 interviews were conducted. The CFIR-inspired interview questions helped clarify critical aspects of implementation that need to be addressed at multiple levels if the Frailty Portal is to be successfully implemented in PHC. Finding were organized into three themes 1) PHC Practice Context, 2) Intervention attributes affecting implementation, and 3) Targeting providers with frail patients. At the intervention level the Frailty Portal was viewed positively, despite the multi-level challenges to implementing it in PHC practice settings. Provider participants perceived high opportunity costs to using the Frailty Portal due to changes they needed to make to their practice routines. However, those who had older patients, took the time to learn how to use the Frailty Portal, and created processes for sharing tasks with other PHC personnel become proficient at using the Frailty Portal. Conclusions: Structuring our evaluation around the CFIR was instrumental in identifying multi-level factors that will affect large-scale adoption of the Frailty Portal in PHC practices. Incorporating CFIR constructs into evaluation instruments can flag factors likely to impede future implementation and impact the effectiveness of innovative practices. Future research is encouraged to identify how best to facilitate changes in PHC practices to address frailty and to use implementation frameworks that honor the complexity of implementing innovations in PHC. Keywords: Frail elderly, Primary health care, Patient care planning, Web-based frailty portal * Correspondence: Grace.Warner@dal.ca Dalhousie University, Halifax, NS, Canada Healthy Populations Institute, Halifax, NS, Canada Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Warner et al. BMC Health Services Research (2018) 18:395 Page 2 of 11 Background with multiple constructs to create a typology of what af- While the word frail is common to many health care fects successful implementation of an intervention [16]. settings, the actual diagnosis of frailty is complex due to It has 39 constructs organized into five major domains varied presentations and causes [1]. Frailty is often de- found to influence the successful implementation of in- fined as a physiologic syndrome characterized by de- novative programs. The domains assess i) Intervention creased reserve and resistance to stressors, resulting characteristics (eight constructs), ii) Outer setting (four from a cumulative decline across multiple physiologic constructs), iii) Inner setting (14 constructs), iv) Charac- systems; causing vulnerability to adverse outcomes [2]. It teristics of individuals (five constructs) and, v) Process is generally associated with multi-system (e.g., mobility, (eight constructs) [17]. Table 1 lists all the CFIR domains cognition, function, endurance) deterioration, and typic- and constructs. ally impacts the geriatric population. Persons experien- A recent systematic review by Kirk et al. (2016) [17] cing frailty are highly susceptible to adverse events such examined how studies currently use the CFIR and how as falls, hospitalization, disability, dependence, place- it might be used in the future. They found the CFIR had ment in long-term care facilities and death [2, 3]. Since most often been employed in doing a post-hoc analysis frailty is a robust marker of vulnerability it is important on what facilitated or hindered implementation. It has to accurately identify those who are frail, so they can be been less frequently used at the pre-implementation better managed with early identification and appropriate stage to identify barriers and facilitators that could affect interventions that reduce adverse events [4, 5]. future implementation [18, 19]. The aim of the study Given the majority of frail persons live in the commu- was to use the CFIR as an evaluation framework at the nity, and providers who work in primary health care pre-implementation stage to clarify critical barriers and (PHC) regularly encounter frail persons in their daily facilitators to implementation that need to be addressed clinical work [6], strengthening PHC for frail adults is at multiple levels if the Frailty Portal is to be successfully crucial. Identification of frail patients in PHC is a implemented in PHC practices. pro-active approach to providing care [7] that can im- prove patient understanding of their overall health and Methods engage them and their family in the decision-making Development of the frailty portal process with their health provider regarding preventive The Nova Scotia Health Authority PHC (NSHA-PHC) strategies [8, 9]. Routine identification of frailty offers initiated a Frailty Strategy in 2012 to achieve its goal of opportunities for targeted care including the application improving care for its frail population. An objective of of newly developed clinical practice guidelines for frailty the strategy was to assess and address Frailty in PHC. [10, 11]. However, routine identification and measure- To achieve this objective NSHA-PHC created a ment of frailty is not part of standard care and is only web-based tool called the Frailty Portal in collaboration now emerging as a concept for primary care [12, 13]. with community partners from other health care sectors To enable frailty screening and interventions to effect- such as home care and geriatrics, and community volun- ively and consistently occur in PHC, providers need ap- teer agencies that addressed the needs of older adults. propriate tools for identifying frailty [14]. Recent The Frailty Portal has two essential components: 1. an advances in technology have enabled easy, timely and assessment phase, and 2. practice visit goals. Within the relevant access and application of tools at the point of assessment phase the provider is to first identify con- care [15]. The use of technology has evolved as a prac- ceivably frail patients and then screen those identified to tical and feasible option for embedding tools to support determine their level of frailty using a web-based version evidence-informed care, increasing the application of of the Frailty Assessment for Careplanning Tool (FACT) knowledge into practice. To assess and address the [20], which is a modification of the Clinical Frailty Scale needs of frail individuals in the community a web-based [21]. The FACT assesses essential domains that contrib- tool called the Frailty Portal was created to be used in ute to frailty (cognition, mobility, function and social cir- PHC practices. cumstances) and provides a score to measure the patient’s frailty level (thriving to terminally ill). Based on Consolidated framework for implementation research this frailty level, the second component of the Frailty As part of the evaluation of the Frailty Portal, barriers Portal provides practical visit goals, tailored to the pa- and facilitators to implementation were assessed using tient’s identified frailty level, for use in care plan devel- the Consolidated Framework for Implementation Re- opment and links to relevant resources for providers, search (CFIR) as an evaluation framework. The CFIR patients and caregivers. Additional detail about the inter- was chosen because it is a relatively new framework, that vention has been previously published [22]. has synthesized prior research evidence representing a The assessment component was initially piloted in spectrum of disciplines into one consolidated framework 2014 among a limited number of PHC physicians who Warner et al. BMC Health Services Research (2018) 18:395 Page 3 of 11 Table 1 CFIR domains and associated constructs 1. Intervention Characteristics 4. Characteristics of Individuals ○ Intervention source ○ Knowledge and beliefs about the intervention ○ Evidence strength and quality ○ Self-efficacy ○ Relative advantage ○ Individual stage of change ○ Adaptability ○ Other personal attributes ○ Trialability ○ Complexity ○ Design quality and packaging ○ Cost 2. Outer Setting 5. Process ○ Patient needs and resources ○ Planning ○ Cosmopolitanism ○ Engaging ○ Peer pressure ○ Executing ○ External policy and incentives ○ Reflecting and Evaluation 3. Inner Setting ○ Structural characteristics ○ Networks and communication ○ Culture ○ Implementation climate ○ Readiness for implementation were asked to provide their impressions of the required the CFIR inner setting domain, PHC includes both steps for identification and screening of patients using team-based and individual practices that are remuner- the FACT as well as the overall usability of the ated through various payment plans, the majority web-based tool within community PHC care practice. through fee-for-service. In some practice settings PHC Based on these suggestions modifications were made to providers, the individuals involved in implementing the the web-based interface to improve usability of the as- Frailty Portal, were employees of the NSHA while others sessment tool and maneuverability within the site. As were from private practices Although the work of most well a second component was added that provided prac- community-based family physicians is not under the dir- tical visit goals and a toolkit of currently available ect responsibility of the NSHA; the NSHA directly en- resources. gages and supports family practices in their work and In this article we focus on data gathered during the involves them in health authority driven initiatives. This second piloting of the Frailty Portal in 2015–2016 which study was part of a health authority initiative. followed modifications from the first pilot and the The NSHA research ethics board reviewed our protocol addition of the second component. For this second pilot and procedures, the study was considered to be a program a broader group of PHC providers that included physi- quality initiative that did not require individual consent cians and nurse practitioners were asked to take part. As from participants. Although consent was not deemed ne- part of the second pilot a formal half-day education cessary all participants were informed that no personal in- workshop offering detailed information about identifying formation would be shared in our summaries, but they frailty with hands-on learning using the Frailty Portal would be labeled by PHC role. Also, that any personal in- tool was provided. formation they shared with us would remain confidential and necessary precautions would be taken to ensure their Setting data was kept in a secure password-protected location. In Canada, PHC is partially funded through public funds that are allocated by the health authorities within each Participants province. The outer setting for this study is NSHA-PHC, This qualitative descriptive study was one part of a lar- which encompasses urban, sub-urban, and rural service ger convergent mixed methods study. The protocol for locations. Diverse support services are available in the the entire study is described in a previous publication different locations. At the level of the practice setting, [22]. Semi-structured key informant interviews were Warner et al. BMC Health Services Research (2018) 18:395 Page 4 of 11 conducted with a purposive sample of PHC providers device following each interview and transcribed verbatim and key PHC stakeholders who were administrators, by an experienced transcriptionist. Following review of staff, and decision makers. Decision makers were higher the interview transcription the interviews were uploaded level administrators who had the authority to make pol- into NVivo For Mac 11.2.2 qualitative software for ana- icy and funding decisions in PHC-NSHA. Potential par- lysis. All interviews were de-identified; a code was given ticipants were identified by NSHA then purposively to each interview and personal identifiers were stripped sampled to provide different perspectives on the history, from the data. development and implementation of the Frailty Portal. Analysis Interview guides Descriptive qualitative research, using a Framework The initial interview guides were based on sample inter- Analysis approach [23, 24] was used during the study to views available on http://cfirguide.org/ then tailored to determine the relevance of the CFIR constructs. Qualita- gather specific information about the Frailty Portal inter- tive description is used to describe rather than interpret vention [18]. Damschroder et al. (2009) [18] recommend phenomenon through an identified theoretical frame- that implementation researchers try to pre-identify CFIR work, such as phenomenology or grounded theory [25]. constructs they will assess based on the relevancy to the In qualitative description, the researcher collects data to study, then determine what level each construct should understand the area of study then describes this data be measured. They also recommend that researchers using everyday terms as they relate to the event or area report their decisions and rationales for choosing certain of study. Content Analysis, the process of making sense constructs, along with findings for each construct that is of the meanings in the data, was also used during our ultimately selected. For this study, the CFIR domains thematic analysis [26]. aligned with the following entities: Intervention The Framework Analysis followed the five-step process characteristics (of the Frailty Portal); Outer setting outlined by Richie and Spencer (1994); 1) familiarization, (NSHA-PHC); Inner setting (PHC practices); Character- 2) identifying a thematic framework, 3) indexing, 4) istics of individuals (PHC providers who piloted the charting, and 5) mapping/interpretation. The analysis Frailty Portal); and, Process (aspects of developing, deliv- was an ongoing iterative process. A research assistant ering and evaluating the Frailty Portal). There were CFIR worked with the first and second author to conduct constructs within these domains that the literature sug- multiple reviews of the transcripts and tapes to gested might be less salient to Frailty Portal implementa- familiarize (Step 1) themselves with the data and identify tion success; however, the research team decided to initial themes that were reflexive and interactive. Ana- probe all the CFIR domains and constructs in the inter- lysis was initiated as soon as the first interview was com- views because there was no definitive evidence. pleted and continued concurrently with data collection The same semi-structured interview guide was used to help determine when new information was no longer for all stakeholders; however, because stakeholders had being generated from interviews. Although the team varying backgrounds they were first queried whether identified the CFIR as the apriori framework, additional they had specific knowledge related to a section to deter- codes emerged during the familiarization process to de- mine if the questions were relevant. The interview guide velop a thematic framework (Step 2) that reflected the was divided into sections that covered 1) background language and experiences of participants. The codes also information on the initial development and first piloting reflected relevant CFIR constructs across the five do- of the Frailty Portal, and 2) an evaluation of the Frailty mains and were indexed (Step 3) to sections of the tran- Portal process and tool based on experiences during the scripts using NVivo. An audit trail was used to second piloting. The first section provided the re- document our decision-making process. Sections of the searchers with supplemental information on the devel- transcripts were charted into themes using Excel (Step opment of the Frailty Portal. The second section was the 4). First they were organized by CFIR domains and con- focus of our study. If participants felt they could not structs, then re-framed to better reflect descriptions contribute information to particular questions, they were from participants. All three analysts reviewed the codes skipped. Interviews were completed in-person at a loca- and associated themes multiple times to check for po- tion convenient to the interviewee, or by telephone if tential biases, to ensure they reflected participants’ distance was prohibitive. All interviews were conducted words, and improve the credibility of their interpretation by the first author, who was an independent qualitative (Step 5) of the interviews. Additional interviews were researcher outside of the NSHA trained in qualitative added with physicians when new themes emerged, to en- interviewing and analysis. The interviews were recorded sure saturation was reached. Initial findings were shared using a digital audio recording device for ease of tran- with a group of participants to help with interpretation scription and review. Data were transferred from the and generate meaning from the data. To ensure the data Warner et al. BMC Health Services Research (2018) 18:395 Page 5 of 11 was collected, analyzed and interpreted accurately, so it felt pressured to see a patient every 15–20 min, this conveyed the experiences of participants, processes asso- was not conducive to completing the Frailty Portal ciated with trustworthiness were enacted such as mem- which took more time. In a fee-for-service environ- ber checking and reflexivity [27]. ment it would have been helpful to pair the interven- tion with a specific payment mechanism that would Results compensate providers for longer assessment visits. In A total of 17 interviews were conducted. PHC stake- the CFIR this would be classified as an incentive at holder participants (noted as SH in the quotes) included thelevel oftheouter setting. decision makers (n = 2), health authority administrators (n = 4), and staff (n = 2). PHC providers interviewed If you happen to have two physicians doing a couple (noted as HP in the quotes) were family physicians (n = of frailty assessments taking 45 min each, that 6) and nurse practitioners (n = 3). The interviews lasted drastically reduces your patient capacity. HP3 from 40 min to 1.5 h. Although we considered present- ing our findings by CFIR domains, our thematic frame- …we need more resources to be able to really roll it work indicated the domains overlapped. The complexity out [to other practices]... HP7 of the intervention and implementation processes made it difficult to separate key findings by domain. As such …Is there a [fee] code for the extra time? HP8 our findings are organized into three themes that (medical lead) reflected participants’ experiences with the Frailty Portal but are informed by the CFIR framework; 1) PHC Prac- Outer setting constraints made the intervention in- tice Context, 2) Intervention attributes affecting imple- compatible with routines used within the inner setting mentation, and 3) Targeting providers with frail patients. of PHC practices to see patients. Integrating the Quotes are provided to illustrate each theme. The CFIR Frailty Portal into practice routines required time, constructs identified in the themes are listed in Table 2. which was an opportunity cost to the physician. Opportunity costs refers to a situation where the Theme 1: PHC practice context physician loses the potential gain from seeing another The PHC Practice Context is affected by several CFIR patient because they have used that time to complete domains. Most providers identified constraints at the the Frailty Portal. Providers who took time to level of the health authority that affected how they complete the Frailty Portal or learned how to inte- set up practice routines, thus identifying outer setting grate it into their practice routines became proficient factors such as resources and external policies that at using the Frailty Portal, had increased self-efficacy put pressure on providers to see a certain number of with the intervention, and were likely to use the tool patients within a given timeframe. Family physicians more regularly. Table 2 CFiR Domains and Constructs Associated with Qualitative Themes Theme CFIR Domain CFIR constructs 1: PHC Practice Context Outer Setting Patient needs and resources, external policy, incentives, peer pressure, cosmopolitanism Inner Setting Compatibility, networks, communications, learning climate, culture Characteristics of individuals Self-efficacy Intervention Costs (opportunity). Process Planning 2: Intervention attributes that affected implementation. Inner Setting Access to knowledge and information Characteristics of Individuals Knowledge & Beliefs about the Intervention, self-efficacy Intervention Evidence strength, complexity, adaptability, design quality & packaging; cost (opportunity). Process Planning, engaging, champions 3: The importance of targeting providers with frail patients. Outer setting Patients’ needs and resources Characteristics of individuals Knowledge and beliefs about the intervention, individual stage of change Intervention Costs (opportunity) Warner et al. BMC Health Services Research (2018) 18:395 Page 6 of 11 …two to five visits with somebody in order to get reviewing some of the [Frailty Portal] care planning through the assessment and planning is not a typical with them, [it] would be a good use of time. HP11 structure [for seeing patients]. …. HP4 In contrast, the practice context of the PHC nurse Theme 2: Intervention attributes that affected practitioners was different from physicians. The nurse implementation practitioners who were interviewed felt the Frailty Portal Providers commented positively on the half-day training was compatible with their practice as it aligned with session for the Frailty Portal and felt it was informative. their capacity for longer appointment times and scope of The session was co-led by providers viewed as leaders in practice regarding chronic condition management (e.g. their practice community who demonstrated their sup- frailty). As such they were better able to fit the use of port for the intervention. The support from practice the Frailty Portal into their practice routines, however, leaders and the health authority satisfied attendees that they still had to ensure other providers in the practice the Frailty Portal was evidence-based. However, pro- were supportive of their allocating time to implement viders felt the training would have benefited from a the Frailty Portal instead of seeing additional patients. follow-up session shortly after the initial training. This This required communication and negotiations with follow-up session could address problems that occurred other individuals in the practice. when the Provider first attempted to use the Frailty Portal in their practice setting. Most of the comments ….the nurse practitioners that are using the Portal. were around the difficulty of implementing processes They’ve got a little bit more flexibility… for them to in their practice to do all the steps associated with bring a patient in for half an hour, 45 min to do a the Frailty Portal. frailty assessment, no big deal... SH2 The training was excellent. I would have liked more It makes perfect sense and it fits right in keeping with around the planning part because that’s where I really what we’re [nurse practitioners] doing…The problem feel like I fell short. HP6 is the time pressure. And it’s not always accepted by the general culture of the clinic. HP6 … a two-part [training] session where you are introduced The PHC practice setting is unique; family physicians to it [Frailty Portal], you go ahead and try it, and then do not work in a typical “organizational” structure. They you’re scheduled to come back…would have been are often independent businesses that are not networked helpful. HP1 with other practices in the health authority. Not working within a typical organizational structure lowered the ef- Providers felt the Frailty Portal was attractive and well fectiveness of using peer pressure or organizational cul- designed. The Frailty Portal functioned outside of the ture to stimulate change. There was no group culture to existing system for documenting patient medical infor- support change in PHC practices. PHC physicians who mation, which for many practices was the electronic worked in larger teams with access to nurse practi- medical record (EMR). The Frailty Portal required log- tioners, or support staff, could share the workload and ging into a secure web-based system with firewalls cre- reduce the time needed to implement the Frailty Portal. ated to ensure patient privacy. Some providers had Teams were encouraged to work together to develop a challenges accessing the site due to these security fea- plan for identifying potentially frail patients in advance, tures. They had trouble with passwords expiring and not and schedule appointments for assessing and addressing remembering how to reset them. Solving the problem frailty. These teams were more successful at implement- required a real-time phone conversation with a help ing the Frailty Portal. desk. Often the provider made their first attempt at accessing the Frailty Portal post training during a patient …the plan had been to send out [a report to provide encounter. If there was a problem logging into the sys- an incentive to providers saying]…“this is how many tem (e.g., web page not displaying, passwords expired) assessments have been done by your group, here’s the immediate assistance was needed, the providers often level of frailty, here’s the average age”,…that really didn’t remember who to call or where to reach out. If didn’t seem to be an incentive for folks. SH6 they did not get assistance quickly, the provider was frustrated and likely abandoned using the Frailty Portal If I had her [family practice nurse] probably book all together. Data from the Frailty Portal was saved sep- even an hour of her time…to do a lot of the [Frailty arately from the EMR; therefore, it needed to be entered Portal] questions and getting the information, and… into the EMR at a later time. Administrators were aware Warner et al. BMC Health Services Research (2018) 18:395 Page 7 of 11 of this problem and were actively working to identify …making sure that you’ve referred to all the ways to integrate the Frailty Portal with existing EMR appropriate places…really puts it all together and provider software. it gives you an overall picture of…what you need to do for clients. HP9 I attempted to get into the Portal a number of times when I had a client in front of me, … and I had …I like some of the links and the resources…But to difficult logging on. I couldn’t figure out what was be able to work through that whole care plan…that going on. HP1 you’ve completed that assessment for that person, that’s a big ask...HP2 …they feel that what they enter here [in the Frailty Portal] is redundant with what they’re going to enter A final challenge identified was using the Frailty Portal in their own EMR….we’re looking at, is there a way over multiple visits. If a patient’s condition was to that we can send the results… directly to their EMR? change over time the provider may be required to SH1 re-assess and develop new care plans without finishing the first one. Some providers mentioned they never I had a lot of difficulty with logging into the Portal…. completed the “record” for their patient. This lowered she was going to call me back and help me with the their self-efficacy for using the tool. username and password. But I never received anything…until I called them back. HP10 So… I don’t really get it finished because their care plan is so complex that it’s overwhelming. …I get lost Within the FACT, the frailty assessment tool embed- in trying to keep it going. HP11 ded in the Frailty Portal, was a separate collateral form which providers were to ask family members to Basically, it’s when should the chart be closed? SH1 complete. This information was to confirm providers’ as- sessments of frailty. However, providers felt challenged When interview participants were asked, “On a scale scheduling patient appointments that included family of 1-10, with one being very easy and 10 being nearly im- members. This often resulted in the form not being possible, how difficult was the Frailty Portal Initiative to completed. Instead some providers used their own implement?” judgement rather than confirming their frailty assess- Administrators and providers commonly rated the dif- ment with the family; others realized the importance of ficulty, or complexity, of the intervention between 6 and getting family input. One provider wondered about priv- 7. The reason for the high rating was usually due to the acy concerns if they asked family members about the multiple Frailty Portal components and the necessary patient. changes that needed to be made to practice routines to incorporate it into their practice. You know, what does your patient think about you asking their family members about them? HP3 The first nine screens are a one – very easy. It’s that last screen that’s challenging because it’s just … where we’re trying to assess for frailty, it’s not information overload. HP6 typical that a caregiver would be part of that… HP4 Maybe six, seven because of the obstacles… for the I’m suspecting that it’s probably better that you do ask last care plan page, that I think it is very difficult, very somebody in the family who sees them the other time-consuming and needs training. HP2 364 days of the year what’s really going on. HP8 (medical lead) Theme 3: The importance of targeting providers with frail The last stage of the Frailty Portal provided sugges- patients tions for care plans based on the patient’s frailty level. The NSHA-PHC decision makers had identified frailty The care plans occasionally involved referrals to com- as an important condition to address their patient popu- munity organizations. When providers had limited lation’s needs so health system changes could be knowledge of an organization it was difficult for them to resourced and implemented to improve current quality quickly judge the relevance and appropriateness of the of care and reduce long term costs. They identified PHC referral. Although the Frailty Portal referred providers to providers as the first point of contact for frail patients the organization’s website for information about the and felt early identification of frailty would benefit the organization, this learning process was time consuming. health system. Warner et al. BMC Health Services Research (2018) 18:395 Page 8 of 11 We identified that we had a growing problem with in other implementation literature, interventions must our frailty populations.. SH3 be tailored to fit within different practice contexts, and it is important for providers to believe there is a need So… it sort of fell in a bucket of things we were trying for the intervention [28]. The study identified key inter- to do…so that we can improve the care of the vention characteristics that can be modified to reduce population and help family doctors do their job the complexity, increase its adaptability, and reduce pro- better or more efficiently. HP8 (medical lead) vider opportunity costs. For some providers, only slight modifications are needed such as removing barriers to The administrators made the decision to pilot the logging onto the server where the tool is housed or pro- Frailty Portal with providers who cared for a wide range viding direction on how to integrate the Frailty Portal of patient populations in their practices. The level of into practice routines. provider support for the Frailty Portal varied depending At the provider level, study participants perceived a on their patient population. Providers who had a more high opportunity cost to using the Frailty Portal result- geriatric patient population believed in the value of using ing in an inability to see other patients. These opportun- the Frailty Portal and viewed it positively. However, pro- ity costs were less if their scope of practice included vider interviews showed there was limited motivation for time to address prevention or their practices had a high changing current practices, or individual stage of change, proportion of older patients. Although it is likely most to implement the Frailty Portal. The current culture in providers will become faster at completing the Frailty PHC practice settings did not view the Frailty Portal as a Portal with practice, and their self-efficacy should priority compared with other daily tasks and activities increase, they first need to commit time to becoming they needed to perform. proficient. Organizational changes (inner setting) that facilitate I’m not saying I shouldn’t do it and it’s not the right sharing administrative and assessment responsibilities thing to do for that patient but you’ve now created within the team could reduce providers’ opportunity another mammoth load of work for me… HP4 costs. For example, administrative staff can pre-identify frail patients and set up frailty-specific appointments I think we could better have tailored…which practices with patients and their family members. Furthermore, have the patient population to use for this [pilot]. On creating networks between PHC practices and trusted the other hand, it would be a little bit like preaching community programs could increase team members’ to the converted …And it really is the physicians who confidence referring patients outside of the health care aren’t as geriatric savvy who could benefit from this system. However, the larger issue is the need to cultivate tool and using it. HP3 a practice culture that values the need to screen for and address frailty. The findings suggest, and the literature I just think we need to think about why we’re doing it confirms [29] that until that shift in culture occurs it and…the benefits that are coming from investing the would be beneficial to concentrate on providers who are time in doing that …you know, there are opportunity more likely to use the Frailty Portal, leaving those who costs. HP1 are less ready for change to do so at a later time. In conjunction with practice level changes, external policies, incentives and training should be considered by Discussion the appropriate external bodies (outer setting) such as The aim of the study was to use the CFIR as an evalu- the provincial health authorities in Canada. Incentives ation framework at the pre-implementation stage of a may include creating billing codes to provide monetary web-based tool called the Frailty Portal to clarify critical compensation for the additional time necessary to access barriers and facilitators to implementation that need to and develop care plans for frail patients. Training and be addressed at multiple levels if the Frailty Portal is to education may also improve implementation. Education be successfully implemented in PHC practices. Although on the importance of assessing frailty could improve be- some of the obstacles to implementation were expected, liefs about the need to assess frailty, and training on how the CFIR-inspired interview questions helped clarify crit- to distribute Frailty Portal tasks within the team should ical aspects of implementation that need to be addressed increase self-efficacy for implementing the Frailty Portal. if the Frailty Portal is to be successfully integrated into Other research has shown these types of incentives fa- PHC practices. cilitate uptake [28]. Most importantly, strategies need to At the intervention level the Frailty Portal was viewed be developed for how best to communicate with PHC positively, despite the multi-level challenges to imple- providers. The Frailty Portal training staff tried several menting it in their practice settings. Similar to findings communication strategies to provide helpful suggestions Warner et al. BMC Health Services Research (2018) 18:395 Page 9 of 11 on how best to integrate the Frailty Portal into providers’ occurs stimulating further decline leading to hospitaliza- practice routines, but they were unsuccessful due to pro- tions and possibly long- term institutionalization [4, 5]. viders’ busy schedules and lack of dedicated time for PHC providers in our study confirmed they felt it was training and education. This is a major barrier to imple- important to assess and address frailty in their menting innovative tools such as the Frailty Portal. community-based practices. Unfortunately, they also Our findings may be limited by our choice of partici- found it challenging to implement the Frailty Portal into pants. Although the number of interviews was small, practice routines. For some it may have been due to the participants included those who had both experience complexity of the Frailty Portal tool itself, for others it using the Frailty Portal in a PHC setting and stake- was due to difficulty accessing the online platform. For holders who created and helped implement the Frailty most providers using the Frailty Portal required a signifi- Portal. Additional interviews were added when new cant time commitment to assess frailty then enact result- themes emerged to ensure themes reflected participants’ ant care plans. A more easily accessible tool that is less experiences. Furthermore, findings were presented to time consuming to administer such as the Clinical participants and other PHC stakeholders to confirm re- Frailty Scale [21] would likely have less barriers to im- searchers’ interpretation of the interviews. Presentations plementation; however, it does not link to an actionable also helped clarify aspects of the practice setting that care plan so it may not facilitate better patient care. A need to be considered when NSHA-PHC initiates imple- better option is to integrate the Frailty Portal into the mentation of the Frailty Portal in other PHC practices. EMR, and to share frailty assessment and care plan de- Prior research has used the CFIR to identify distin- velopment with appropriate PHC team members, de- guishing constructs between high and low implementa- pending on their scope of practice, to reduce individual tion success [30]. This was not the intent of our study, burden and improve quality of care. but one construct found to be associated with successful implementation was also identified across all three of Conclusions our themes; opportunity costs. Our findings highlight Our study supports prior recommendations for using the interconnectivity of the constructs. High opportunity CFIR [19, 35], and more broadly implementation science costs relate to the providers’ perceptions that the inter- frameworks [36, 37], to facilitate implementation of vention takes too much time to implement. However, complex interventions. Despite the fact that the CFIR is this perception is affected by other domains and con- biased toward institutional care and would benefit from structs also identified in the study. Opportunity costs are modifications to better capture attributes unique to affected by individual providers’ beliefs regarding the im- PHC, structuring our evaluation around the CFIR was portance of assessing frailty, the inner setting construct instrumental in identifying multi-level factors that will identifying the importance of having a learning climate affect large-scale adoption of the Frailty Portal in PHC in the practice setting, and outer setting constructs in practices. The implementation of the Frailty Portal control of the health authority such as billing codes. The within community PHC practices is representative of a CFIR was useful for not only identifying constructs, but complex, transformation, health system intervention. for acknowledging the relationships between constructs. Not only are the needs of the patient and their caregiver Similar to other implementation science frameworks multifaceted and complex, but the context of primary [31, 32], the CFIR is better suited to assessing imple- care practice is as well. mentation in facilities where individuals work within a To successfully integrate the Frailty Portal into every- clear organizational structure. Within community PHC day routines of PHC providers barriers need to be ad- practices, CFIR constructs such as organizational net- dressed at multiple levels. At the NSHA-PHC outer working and communication and peer pressure did not setting level linking it to the EMR will facilitate pro- facilitate implementation. PHC providers are often inde- viders’ initial use of the tool and establishing appropriate pendent practitioners, so group pressure is virtually non- fee structures that compensate providers for the add- existent. The field of implementation science has largely itional time necessary to assess and address frailty will developed frameworks for institutional settings, rather sustain its long-term use. Furthermore, at the PHC prac- than community settings. Despite this drawback, the tice level it is better to initially implement the Frailty CFIR framework was easily adapted for PHC settings Portal in primarily geriatric practices. Also practices that and helpful for identifying key factors important to suc- have team members who can share administrative and cessful implementation. assessment responsibilities with the provider will reduce Finally, there are important reasons for PHC providers individual opportunity costs. to identify and treat frailty; the rising number of older It is beneficial to identify barriers at the adults [33], the parallel increase in frailty [34], and the pre-implementation stage so they can be addressed need to initiate care proactively before an adverse event early. One barrier that will hopefully reduce over time Warner et al. BMC Health Services Research (2018) 18:395 Page 10 of 11 is the development of a PHC practice culture that Health Authority, Halifax, NS, Canada. Department of Family Practice, Nova Scotia Health Authority, Halifax, NS, Canada. values the need to screen for and address frailty, and considers it part of best practices in PHC. Future re- Received: 8 January 2018 Accepted: 30 April 2018 search is encouraged to identify how best to facilitate changes in PHC practices to address frailty and to use models that honor the complexity of implement- References ing innovations that can improve care for frail pa- 1. Muscedere J, Andrew MK, Bagshaw SM, Estabrooks C, Hogan D, Holroyd- Leduc J, et al. Screening for frailty in Canada’s health care system: a time for tients and their caregivers in the community. action. Can J Aging / La Rev Can du Vieil. 2016;35:281–97. https://doi.org/10. 1017/S0714980816000301. Abbreviations 2. Fried LP, Ferrucci L, Darer J, Williamson JD, Anderson G. Untangling the CFIR: Consolidated Framework for Implementation Research framework; concepts of disability, frailty, and comorbidity: implications for improved EMR: Electronic medical record; FACT: Frailty Assessment for Careplanning targeting and care. J Gerontol Ser A Biol Sci Med Sci. 2004;59:M255–63. 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Applying the consolidated framework for implementation research to identify barriers affecting implementation of an online frailty tool into primary health care: a qualitative study

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Medicine & Public Health; Public Health; Health Administration; Health Informatics; Nursing Research
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Abstract

Background: Frailty is associated with multi-system deterioration, and typically increases susceptibility to adverse events such as falls. Frailty can be better managed with early screening and intervention, ideally conducted in primary health care (PHC) settings. This study used the Consolidated Framework for Implementation Research (CFIR) as an evaluation framework during the second stage piloting of a novel web-based tool called the Frailty Portal, developed to aid in the screening, identification, and care planning of frail patients in community PHC. Methods: This qualitative study conducted semi-structured key informant interviews with a purposive sample of PHC providers (family physicians, nurse practitioners) and key PHC stakeholders who were administrators, decision makers and staff. The CFIR was used to guide data collection and analysis. Framework Analysis was used to determine the relevance of the CFIR constructs to implementing the Frailty Portal. Results: A total of 17 interviews were conducted. The CFIR-inspired interview questions helped clarify critical aspects of implementation that need to be addressed at multiple levels if the Frailty Portal is to be successfully implemented in PHC. Finding were organized into three themes 1) PHC Practice Context, 2) Intervention attributes affecting implementation, and 3) Targeting providers with frail patients. At the intervention level the Frailty Portal was viewed positively, despite the multi-level challenges to implementing it in PHC practice settings. Provider participants perceived high opportunity costs to using the Frailty Portal due to changes they needed to make to their practice routines. However, those who had older patients, took the time to learn how to use the Frailty Portal, and created processes for sharing tasks with other PHC personnel become proficient at using the Frailty Portal. Conclusions: Structuring our evaluation around the CFIR was instrumental in identifying multi-level factors that will affect large-scale adoption of the Frailty Portal in PHC practices. Incorporating CFIR constructs into evaluation instruments can flag factors likely to impede future implementation and impact the effectiveness of innovative practices. Future research is encouraged to identify how best to facilitate changes in PHC practices to address frailty and to use implementation frameworks that honor the complexity of implementing innovations in PHC. Keywords: Frail elderly, Primary health care, Patient care planning, Web-based frailty portal * Correspondence: Grace.Warner@dal.ca Dalhousie University, Halifax, NS, Canada Healthy Populations Institute, Halifax, NS, Canada Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Warner et al. BMC Health Services Research (2018) 18:395 Page 2 of 11 Background with multiple constructs to create a typology of what af- While the word frail is common to many health care fects successful implementation of an intervention [16]. settings, the actual diagnosis of frailty is complex due to It has 39 constructs organized into five major domains varied presentations and causes [1]. Frailty is often de- found to influence the successful implementation of in- fined as a physiologic syndrome characterized by de- novative programs. The domains assess i) Intervention creased reserve and resistance to stressors, resulting characteristics (eight constructs), ii) Outer setting (four from a cumulative decline across multiple physiologic constructs), iii) Inner setting (14 constructs), iv) Charac- systems; causing vulnerability to adverse outcomes [2]. It teristics of individuals (five constructs) and, v) Process is generally associated with multi-system (e.g., mobility, (eight constructs) [17]. Table 1 lists all the CFIR domains cognition, function, endurance) deterioration, and typic- and constructs. ally impacts the geriatric population. Persons experien- A recent systematic review by Kirk et al. (2016) [17] cing frailty are highly susceptible to adverse events such examined how studies currently use the CFIR and how as falls, hospitalization, disability, dependence, place- it might be used in the future. They found the CFIR had ment in long-term care facilities and death [2, 3]. Since most often been employed in doing a post-hoc analysis frailty is a robust marker of vulnerability it is important on what facilitated or hindered implementation. It has to accurately identify those who are frail, so they can be been less frequently used at the pre-implementation better managed with early identification and appropriate stage to identify barriers and facilitators that could affect interventions that reduce adverse events [4, 5]. future implementation [18, 19]. The aim of the study Given the majority of frail persons live in the commu- was to use the CFIR as an evaluation framework at the nity, and providers who work in primary health care pre-implementation stage to clarify critical barriers and (PHC) regularly encounter frail persons in their daily facilitators to implementation that need to be addressed clinical work [6], strengthening PHC for frail adults is at multiple levels if the Frailty Portal is to be successfully crucial. Identification of frail patients in PHC is a implemented in PHC practices. pro-active approach to providing care [7] that can im- prove patient understanding of their overall health and Methods engage them and their family in the decision-making Development of the frailty portal process with their health provider regarding preventive The Nova Scotia Health Authority PHC (NSHA-PHC) strategies [8, 9]. Routine identification of frailty offers initiated a Frailty Strategy in 2012 to achieve its goal of opportunities for targeted care including the application improving care for its frail population. An objective of of newly developed clinical practice guidelines for frailty the strategy was to assess and address Frailty in PHC. [10, 11]. However, routine identification and measure- To achieve this objective NSHA-PHC created a ment of frailty is not part of standard care and is only web-based tool called the Frailty Portal in collaboration now emerging as a concept for primary care [12, 13]. with community partners from other health care sectors To enable frailty screening and interventions to effect- such as home care and geriatrics, and community volun- ively and consistently occur in PHC, providers need ap- teer agencies that addressed the needs of older adults. propriate tools for identifying frailty [14]. Recent The Frailty Portal has two essential components: 1. an advances in technology have enabled easy, timely and assessment phase, and 2. practice visit goals. Within the relevant access and application of tools at the point of assessment phase the provider is to first identify con- care [15]. The use of technology has evolved as a prac- ceivably frail patients and then screen those identified to tical and feasible option for embedding tools to support determine their level of frailty using a web-based version evidence-informed care, increasing the application of of the Frailty Assessment for Careplanning Tool (FACT) knowledge into practice. To assess and address the [20], which is a modification of the Clinical Frailty Scale needs of frail individuals in the community a web-based [21]. The FACT assesses essential domains that contrib- tool called the Frailty Portal was created to be used in ute to frailty (cognition, mobility, function and social cir- PHC practices. cumstances) and provides a score to measure the patient’s frailty level (thriving to terminally ill). Based on Consolidated framework for implementation research this frailty level, the second component of the Frailty As part of the evaluation of the Frailty Portal, barriers Portal provides practical visit goals, tailored to the pa- and facilitators to implementation were assessed using tient’s identified frailty level, for use in care plan devel- the Consolidated Framework for Implementation Re- opment and links to relevant resources for providers, search (CFIR) as an evaluation framework. The CFIR patients and caregivers. Additional detail about the inter- was chosen because it is a relatively new framework, that vention has been previously published [22]. has synthesized prior research evidence representing a The assessment component was initially piloted in spectrum of disciplines into one consolidated framework 2014 among a limited number of PHC physicians who Warner et al. BMC Health Services Research (2018) 18:395 Page 3 of 11 Table 1 CFIR domains and associated constructs 1. Intervention Characteristics 4. Characteristics of Individuals ○ Intervention source ○ Knowledge and beliefs about the intervention ○ Evidence strength and quality ○ Self-efficacy ○ Relative advantage ○ Individual stage of change ○ Adaptability ○ Other personal attributes ○ Trialability ○ Complexity ○ Design quality and packaging ○ Cost 2. Outer Setting 5. Process ○ Patient needs and resources ○ Planning ○ Cosmopolitanism ○ Engaging ○ Peer pressure ○ Executing ○ External policy and incentives ○ Reflecting and Evaluation 3. Inner Setting ○ Structural characteristics ○ Networks and communication ○ Culture ○ Implementation climate ○ Readiness for implementation were asked to provide their impressions of the required the CFIR inner setting domain, PHC includes both steps for identification and screening of patients using team-based and individual practices that are remuner- the FACT as well as the overall usability of the ated through various payment plans, the majority web-based tool within community PHC care practice. through fee-for-service. In some practice settings PHC Based on these suggestions modifications were made to providers, the individuals involved in implementing the the web-based interface to improve usability of the as- Frailty Portal, were employees of the NSHA while others sessment tool and maneuverability within the site. As were from private practices Although the work of most well a second component was added that provided prac- community-based family physicians is not under the dir- tical visit goals and a toolkit of currently available ect responsibility of the NSHA; the NSHA directly en- resources. gages and supports family practices in their work and In this article we focus on data gathered during the involves them in health authority driven initiatives. This second piloting of the Frailty Portal in 2015–2016 which study was part of a health authority initiative. followed modifications from the first pilot and the The NSHA research ethics board reviewed our protocol addition of the second component. For this second pilot and procedures, the study was considered to be a program a broader group of PHC providers that included physi- quality initiative that did not require individual consent cians and nurse practitioners were asked to take part. As from participants. Although consent was not deemed ne- part of the second pilot a formal half-day education cessary all participants were informed that no personal in- workshop offering detailed information about identifying formation would be shared in our summaries, but they frailty with hands-on learning using the Frailty Portal would be labeled by PHC role. Also, that any personal in- tool was provided. formation they shared with us would remain confidential and necessary precautions would be taken to ensure their Setting data was kept in a secure password-protected location. In Canada, PHC is partially funded through public funds that are allocated by the health authorities within each Participants province. The outer setting for this study is NSHA-PHC, This qualitative descriptive study was one part of a lar- which encompasses urban, sub-urban, and rural service ger convergent mixed methods study. The protocol for locations. Diverse support services are available in the the entire study is described in a previous publication different locations. At the level of the practice setting, [22]. Semi-structured key informant interviews were Warner et al. BMC Health Services Research (2018) 18:395 Page 4 of 11 conducted with a purposive sample of PHC providers device following each interview and transcribed verbatim and key PHC stakeholders who were administrators, by an experienced transcriptionist. Following review of staff, and decision makers. Decision makers were higher the interview transcription the interviews were uploaded level administrators who had the authority to make pol- into NVivo For Mac 11.2.2 qualitative software for ana- icy and funding decisions in PHC-NSHA. Potential par- lysis. All interviews were de-identified; a code was given ticipants were identified by NSHA then purposively to each interview and personal identifiers were stripped sampled to provide different perspectives on the history, from the data. development and implementation of the Frailty Portal. Analysis Interview guides Descriptive qualitative research, using a Framework The initial interview guides were based on sample inter- Analysis approach [23, 24] was used during the study to views available on http://cfirguide.org/ then tailored to determine the relevance of the CFIR constructs. Qualita- gather specific information about the Frailty Portal inter- tive description is used to describe rather than interpret vention [18]. Damschroder et al. (2009) [18] recommend phenomenon through an identified theoretical frame- that implementation researchers try to pre-identify CFIR work, such as phenomenology or grounded theory [25]. constructs they will assess based on the relevancy to the In qualitative description, the researcher collects data to study, then determine what level each construct should understand the area of study then describes this data be measured. They also recommend that researchers using everyday terms as they relate to the event or area report their decisions and rationales for choosing certain of study. Content Analysis, the process of making sense constructs, along with findings for each construct that is of the meanings in the data, was also used during our ultimately selected. For this study, the CFIR domains thematic analysis [26]. aligned with the following entities: Intervention The Framework Analysis followed the five-step process characteristics (of the Frailty Portal); Outer setting outlined by Richie and Spencer (1994); 1) familiarization, (NSHA-PHC); Inner setting (PHC practices); Character- 2) identifying a thematic framework, 3) indexing, 4) istics of individuals (PHC providers who piloted the charting, and 5) mapping/interpretation. The analysis Frailty Portal); and, Process (aspects of developing, deliv- was an ongoing iterative process. A research assistant ering and evaluating the Frailty Portal). There were CFIR worked with the first and second author to conduct constructs within these domains that the literature sug- multiple reviews of the transcripts and tapes to gested might be less salient to Frailty Portal implementa- familiarize (Step 1) themselves with the data and identify tion success; however, the research team decided to initial themes that were reflexive and interactive. Ana- probe all the CFIR domains and constructs in the inter- lysis was initiated as soon as the first interview was com- views because there was no definitive evidence. pleted and continued concurrently with data collection The same semi-structured interview guide was used to help determine when new information was no longer for all stakeholders; however, because stakeholders had being generated from interviews. Although the team varying backgrounds they were first queried whether identified the CFIR as the apriori framework, additional they had specific knowledge related to a section to deter- codes emerged during the familiarization process to de- mine if the questions were relevant. The interview guide velop a thematic framework (Step 2) that reflected the was divided into sections that covered 1) background language and experiences of participants. The codes also information on the initial development and first piloting reflected relevant CFIR constructs across the five do- of the Frailty Portal, and 2) an evaluation of the Frailty mains and were indexed (Step 3) to sections of the tran- Portal process and tool based on experiences during the scripts using NVivo. An audit trail was used to second piloting. The first section provided the re- document our decision-making process. Sections of the searchers with supplemental information on the devel- transcripts were charted into themes using Excel (Step opment of the Frailty Portal. The second section was the 4). First they were organized by CFIR domains and con- focus of our study. If participants felt they could not structs, then re-framed to better reflect descriptions contribute information to particular questions, they were from participants. All three analysts reviewed the codes skipped. Interviews were completed in-person at a loca- and associated themes multiple times to check for po- tion convenient to the interviewee, or by telephone if tential biases, to ensure they reflected participants’ distance was prohibitive. All interviews were conducted words, and improve the credibility of their interpretation by the first author, who was an independent qualitative (Step 5) of the interviews. Additional interviews were researcher outside of the NSHA trained in qualitative added with physicians when new themes emerged, to en- interviewing and analysis. The interviews were recorded sure saturation was reached. Initial findings were shared using a digital audio recording device for ease of tran- with a group of participants to help with interpretation scription and review. Data were transferred from the and generate meaning from the data. To ensure the data Warner et al. BMC Health Services Research (2018) 18:395 Page 5 of 11 was collected, analyzed and interpreted accurately, so it felt pressured to see a patient every 15–20 min, this conveyed the experiences of participants, processes asso- was not conducive to completing the Frailty Portal ciated with trustworthiness were enacted such as mem- which took more time. In a fee-for-service environ- ber checking and reflexivity [27]. ment it would have been helpful to pair the interven- tion with a specific payment mechanism that would Results compensate providers for longer assessment visits. In A total of 17 interviews were conducted. PHC stake- the CFIR this would be classified as an incentive at holder participants (noted as SH in the quotes) included thelevel oftheouter setting. decision makers (n = 2), health authority administrators (n = 4), and staff (n = 2). PHC providers interviewed If you happen to have two physicians doing a couple (noted as HP in the quotes) were family physicians (n = of frailty assessments taking 45 min each, that 6) and nurse practitioners (n = 3). The interviews lasted drastically reduces your patient capacity. HP3 from 40 min to 1.5 h. Although we considered present- ing our findings by CFIR domains, our thematic frame- …we need more resources to be able to really roll it work indicated the domains overlapped. The complexity out [to other practices]... HP7 of the intervention and implementation processes made it difficult to separate key findings by domain. As such …Is there a [fee] code for the extra time? HP8 our findings are organized into three themes that (medical lead) reflected participants’ experiences with the Frailty Portal but are informed by the CFIR framework; 1) PHC Prac- Outer setting constraints made the intervention in- tice Context, 2) Intervention attributes affecting imple- compatible with routines used within the inner setting mentation, and 3) Targeting providers with frail patients. of PHC practices to see patients. Integrating the Quotes are provided to illustrate each theme. The CFIR Frailty Portal into practice routines required time, constructs identified in the themes are listed in Table 2. which was an opportunity cost to the physician. Opportunity costs refers to a situation where the Theme 1: PHC practice context physician loses the potential gain from seeing another The PHC Practice Context is affected by several CFIR patient because they have used that time to complete domains. Most providers identified constraints at the the Frailty Portal. Providers who took time to level of the health authority that affected how they complete the Frailty Portal or learned how to inte- set up practice routines, thus identifying outer setting grate it into their practice routines became proficient factors such as resources and external policies that at using the Frailty Portal, had increased self-efficacy put pressure on providers to see a certain number of with the intervention, and were likely to use the tool patients within a given timeframe. Family physicians more regularly. Table 2 CFiR Domains and Constructs Associated with Qualitative Themes Theme CFIR Domain CFIR constructs 1: PHC Practice Context Outer Setting Patient needs and resources, external policy, incentives, peer pressure, cosmopolitanism Inner Setting Compatibility, networks, communications, learning climate, culture Characteristics of individuals Self-efficacy Intervention Costs (opportunity). Process Planning 2: Intervention attributes that affected implementation. Inner Setting Access to knowledge and information Characteristics of Individuals Knowledge & Beliefs about the Intervention, self-efficacy Intervention Evidence strength, complexity, adaptability, design quality & packaging; cost (opportunity). Process Planning, engaging, champions 3: The importance of targeting providers with frail patients. Outer setting Patients’ needs and resources Characteristics of individuals Knowledge and beliefs about the intervention, individual stage of change Intervention Costs (opportunity) Warner et al. BMC Health Services Research (2018) 18:395 Page 6 of 11 …two to five visits with somebody in order to get reviewing some of the [Frailty Portal] care planning through the assessment and planning is not a typical with them, [it] would be a good use of time. HP11 structure [for seeing patients]. …. HP4 In contrast, the practice context of the PHC nurse Theme 2: Intervention attributes that affected practitioners was different from physicians. The nurse implementation practitioners who were interviewed felt the Frailty Portal Providers commented positively on the half-day training was compatible with their practice as it aligned with session for the Frailty Portal and felt it was informative. their capacity for longer appointment times and scope of The session was co-led by providers viewed as leaders in practice regarding chronic condition management (e.g. their practice community who demonstrated their sup- frailty). As such they were better able to fit the use of port for the intervention. The support from practice the Frailty Portal into their practice routines, however, leaders and the health authority satisfied attendees that they still had to ensure other providers in the practice the Frailty Portal was evidence-based. However, pro- were supportive of their allocating time to implement viders felt the training would have benefited from a the Frailty Portal instead of seeing additional patients. follow-up session shortly after the initial training. This This required communication and negotiations with follow-up session could address problems that occurred other individuals in the practice. when the Provider first attempted to use the Frailty Portal in their practice setting. Most of the comments ….the nurse practitioners that are using the Portal. were around the difficulty of implementing processes They’ve got a little bit more flexibility… for them to in their practice to do all the steps associated with bring a patient in for half an hour, 45 min to do a the Frailty Portal. frailty assessment, no big deal... SH2 The training was excellent. I would have liked more It makes perfect sense and it fits right in keeping with around the planning part because that’s where I really what we’re [nurse practitioners] doing…The problem feel like I fell short. HP6 is the time pressure. And it’s not always accepted by the general culture of the clinic. HP6 … a two-part [training] session where you are introduced The PHC practice setting is unique; family physicians to it [Frailty Portal], you go ahead and try it, and then do not work in a typical “organizational” structure. They you’re scheduled to come back…would have been are often independent businesses that are not networked helpful. HP1 with other practices in the health authority. Not working within a typical organizational structure lowered the ef- Providers felt the Frailty Portal was attractive and well fectiveness of using peer pressure or organizational cul- designed. The Frailty Portal functioned outside of the ture to stimulate change. There was no group culture to existing system for documenting patient medical infor- support change in PHC practices. PHC physicians who mation, which for many practices was the electronic worked in larger teams with access to nurse practi- medical record (EMR). The Frailty Portal required log- tioners, or support staff, could share the workload and ging into a secure web-based system with firewalls cre- reduce the time needed to implement the Frailty Portal. ated to ensure patient privacy. Some providers had Teams were encouraged to work together to develop a challenges accessing the site due to these security fea- plan for identifying potentially frail patients in advance, tures. They had trouble with passwords expiring and not and schedule appointments for assessing and addressing remembering how to reset them. Solving the problem frailty. These teams were more successful at implement- required a real-time phone conversation with a help ing the Frailty Portal. desk. Often the provider made their first attempt at accessing the Frailty Portal post training during a patient …the plan had been to send out [a report to provide encounter. If there was a problem logging into the sys- an incentive to providers saying]…“this is how many tem (e.g., web page not displaying, passwords expired) assessments have been done by your group, here’s the immediate assistance was needed, the providers often level of frailty, here’s the average age”,…that really didn’t remember who to call or where to reach out. If didn’t seem to be an incentive for folks. SH6 they did not get assistance quickly, the provider was frustrated and likely abandoned using the Frailty Portal If I had her [family practice nurse] probably book all together. Data from the Frailty Portal was saved sep- even an hour of her time…to do a lot of the [Frailty arately from the EMR; therefore, it needed to be entered Portal] questions and getting the information, and… into the EMR at a later time. Administrators were aware Warner et al. BMC Health Services Research (2018) 18:395 Page 7 of 11 of this problem and were actively working to identify …making sure that you’ve referred to all the ways to integrate the Frailty Portal with existing EMR appropriate places…really puts it all together and provider software. it gives you an overall picture of…what you need to do for clients. HP9 I attempted to get into the Portal a number of times when I had a client in front of me, … and I had …I like some of the links and the resources…But to difficult logging on. I couldn’t figure out what was be able to work through that whole care plan…that going on. HP1 you’ve completed that assessment for that person, that’s a big ask...HP2 …they feel that what they enter here [in the Frailty Portal] is redundant with what they’re going to enter A final challenge identified was using the Frailty Portal in their own EMR….we’re looking at, is there a way over multiple visits. If a patient’s condition was to that we can send the results… directly to their EMR? change over time the provider may be required to SH1 re-assess and develop new care plans without finishing the first one. Some providers mentioned they never I had a lot of difficulty with logging into the Portal…. completed the “record” for their patient. This lowered she was going to call me back and help me with the their self-efficacy for using the tool. username and password. But I never received anything…until I called them back. HP10 So… I don’t really get it finished because their care plan is so complex that it’s overwhelming. …I get lost Within the FACT, the frailty assessment tool embed- in trying to keep it going. HP11 ded in the Frailty Portal, was a separate collateral form which providers were to ask family members to Basically, it’s when should the chart be closed? SH1 complete. This information was to confirm providers’ as- sessments of frailty. However, providers felt challenged When interview participants were asked, “On a scale scheduling patient appointments that included family of 1-10, with one being very easy and 10 being nearly im- members. This often resulted in the form not being possible, how difficult was the Frailty Portal Initiative to completed. Instead some providers used their own implement?” judgement rather than confirming their frailty assess- Administrators and providers commonly rated the dif- ment with the family; others realized the importance of ficulty, or complexity, of the intervention between 6 and getting family input. One provider wondered about priv- 7. The reason for the high rating was usually due to the acy concerns if they asked family members about the multiple Frailty Portal components and the necessary patient. changes that needed to be made to practice routines to incorporate it into their practice. You know, what does your patient think about you asking their family members about them? HP3 The first nine screens are a one – very easy. It’s that last screen that’s challenging because it’s just … where we’re trying to assess for frailty, it’s not information overload. HP6 typical that a caregiver would be part of that… HP4 Maybe six, seven because of the obstacles… for the I’m suspecting that it’s probably better that you do ask last care plan page, that I think it is very difficult, very somebody in the family who sees them the other time-consuming and needs training. HP2 364 days of the year what’s really going on. HP8 (medical lead) Theme 3: The importance of targeting providers with frail The last stage of the Frailty Portal provided sugges- patients tions for care plans based on the patient’s frailty level. The NSHA-PHC decision makers had identified frailty The care plans occasionally involved referrals to com- as an important condition to address their patient popu- munity organizations. When providers had limited lation’s needs so health system changes could be knowledge of an organization it was difficult for them to resourced and implemented to improve current quality quickly judge the relevance and appropriateness of the of care and reduce long term costs. They identified PHC referral. Although the Frailty Portal referred providers to providers as the first point of contact for frail patients the organization’s website for information about the and felt early identification of frailty would benefit the organization, this learning process was time consuming. health system. Warner et al. BMC Health Services Research (2018) 18:395 Page 8 of 11 We identified that we had a growing problem with in other implementation literature, interventions must our frailty populations.. SH3 be tailored to fit within different practice contexts, and it is important for providers to believe there is a need So… it sort of fell in a bucket of things we were trying for the intervention [28]. The study identified key inter- to do…so that we can improve the care of the vention characteristics that can be modified to reduce population and help family doctors do their job the complexity, increase its adaptability, and reduce pro- better or more efficiently. HP8 (medical lead) vider opportunity costs. For some providers, only slight modifications are needed such as removing barriers to The administrators made the decision to pilot the logging onto the server where the tool is housed or pro- Frailty Portal with providers who cared for a wide range viding direction on how to integrate the Frailty Portal of patient populations in their practices. The level of into practice routines. provider support for the Frailty Portal varied depending At the provider level, study participants perceived a on their patient population. Providers who had a more high opportunity cost to using the Frailty Portal result- geriatric patient population believed in the value of using ing in an inability to see other patients. These opportun- the Frailty Portal and viewed it positively. However, pro- ity costs were less if their scope of practice included vider interviews showed there was limited motivation for time to address prevention or their practices had a high changing current practices, or individual stage of change, proportion of older patients. Although it is likely most to implement the Frailty Portal. The current culture in providers will become faster at completing the Frailty PHC practice settings did not view the Frailty Portal as a Portal with practice, and their self-efficacy should priority compared with other daily tasks and activities increase, they first need to commit time to becoming they needed to perform. proficient. Organizational changes (inner setting) that facilitate I’m not saying I shouldn’t do it and it’s not the right sharing administrative and assessment responsibilities thing to do for that patient but you’ve now created within the team could reduce providers’ opportunity another mammoth load of work for me… HP4 costs. For example, administrative staff can pre-identify frail patients and set up frailty-specific appointments I think we could better have tailored…which practices with patients and their family members. Furthermore, have the patient population to use for this [pilot]. On creating networks between PHC practices and trusted the other hand, it would be a little bit like preaching community programs could increase team members’ to the converted …And it really is the physicians who confidence referring patients outside of the health care aren’t as geriatric savvy who could benefit from this system. However, the larger issue is the need to cultivate tool and using it. HP3 a practice culture that values the need to screen for and address frailty. The findings suggest, and the literature I just think we need to think about why we’re doing it confirms [29] that until that shift in culture occurs it and…the benefits that are coming from investing the would be beneficial to concentrate on providers who are time in doing that …you know, there are opportunity more likely to use the Frailty Portal, leaving those who costs. HP1 are less ready for change to do so at a later time. In conjunction with practice level changes, external policies, incentives and training should be considered by Discussion the appropriate external bodies (outer setting) such as The aim of the study was to use the CFIR as an evalu- the provincial health authorities in Canada. Incentives ation framework at the pre-implementation stage of a may include creating billing codes to provide monetary web-based tool called the Frailty Portal to clarify critical compensation for the additional time necessary to access barriers and facilitators to implementation that need to and develop care plans for frail patients. Training and be addressed at multiple levels if the Frailty Portal is to education may also improve implementation. Education be successfully implemented in PHC practices. Although on the importance of assessing frailty could improve be- some of the obstacles to implementation were expected, liefs about the need to assess frailty, and training on how the CFIR-inspired interview questions helped clarify crit- to distribute Frailty Portal tasks within the team should ical aspects of implementation that need to be addressed increase self-efficacy for implementing the Frailty Portal. if the Frailty Portal is to be successfully integrated into Other research has shown these types of incentives fa- PHC practices. cilitate uptake [28]. Most importantly, strategies need to At the intervention level the Frailty Portal was viewed be developed for how best to communicate with PHC positively, despite the multi-level challenges to imple- providers. The Frailty Portal training staff tried several menting it in their practice settings. Similar to findings communication strategies to provide helpful suggestions Warner et al. BMC Health Services Research (2018) 18:395 Page 9 of 11 on how best to integrate the Frailty Portal into providers’ occurs stimulating further decline leading to hospitaliza- practice routines, but they were unsuccessful due to pro- tions and possibly long- term institutionalization [4, 5]. viders’ busy schedules and lack of dedicated time for PHC providers in our study confirmed they felt it was training and education. This is a major barrier to imple- important to assess and address frailty in their menting innovative tools such as the Frailty Portal. community-based practices. Unfortunately, they also Our findings may be limited by our choice of partici- found it challenging to implement the Frailty Portal into pants. Although the number of interviews was small, practice routines. For some it may have been due to the participants included those who had both experience complexity of the Frailty Portal tool itself, for others it using the Frailty Portal in a PHC setting and stake- was due to difficulty accessing the online platform. For holders who created and helped implement the Frailty most providers using the Frailty Portal required a signifi- Portal. Additional interviews were added when new cant time commitment to assess frailty then enact result- themes emerged to ensure themes reflected participants’ ant care plans. A more easily accessible tool that is less experiences. Furthermore, findings were presented to time consuming to administer such as the Clinical participants and other PHC stakeholders to confirm re- Frailty Scale [21] would likely have less barriers to im- searchers’ interpretation of the interviews. Presentations plementation; however, it does not link to an actionable also helped clarify aspects of the practice setting that care plan so it may not facilitate better patient care. A need to be considered when NSHA-PHC initiates imple- better option is to integrate the Frailty Portal into the mentation of the Frailty Portal in other PHC practices. EMR, and to share frailty assessment and care plan de- Prior research has used the CFIR to identify distin- velopment with appropriate PHC team members, de- guishing constructs between high and low implementa- pending on their scope of practice, to reduce individual tion success [30]. This was not the intent of our study, burden and improve quality of care. but one construct found to be associated with successful implementation was also identified across all three of Conclusions our themes; opportunity costs. Our findings highlight Our study supports prior recommendations for using the interconnectivity of the constructs. High opportunity CFIR [19, 35], and more broadly implementation science costs relate to the providers’ perceptions that the inter- frameworks [36, 37], to facilitate implementation of vention takes too much time to implement. However, complex interventions. Despite the fact that the CFIR is this perception is affected by other domains and con- biased toward institutional care and would benefit from structs also identified in the study. Opportunity costs are modifications to better capture attributes unique to affected by individual providers’ beliefs regarding the im- PHC, structuring our evaluation around the CFIR was portance of assessing frailty, the inner setting construct instrumental in identifying multi-level factors that will identifying the importance of having a learning climate affect large-scale adoption of the Frailty Portal in PHC in the practice setting, and outer setting constructs in practices. The implementation of the Frailty Portal control of the health authority such as billing codes. The within community PHC practices is representative of a CFIR was useful for not only identifying constructs, but complex, transformation, health system intervention. for acknowledging the relationships between constructs. Not only are the needs of the patient and their caregiver Similar to other implementation science frameworks multifaceted and complex, but the context of primary [31, 32], the CFIR is better suited to assessing imple- care practice is as well. mentation in facilities where individuals work within a To successfully integrate the Frailty Portal into every- clear organizational structure. Within community PHC day routines of PHC providers barriers need to be ad- practices, CFIR constructs such as organizational net- dressed at multiple levels. At the NSHA-PHC outer working and communication and peer pressure did not setting level linking it to the EMR will facilitate pro- facilitate implementation. PHC providers are often inde- viders’ initial use of the tool and establishing appropriate pendent practitioners, so group pressure is virtually non- fee structures that compensate providers for the add- existent. The field of implementation science has largely itional time necessary to assess and address frailty will developed frameworks for institutional settings, rather sustain its long-term use. Furthermore, at the PHC prac- than community settings. Despite this drawback, the tice level it is better to initially implement the Frailty CFIR framework was easily adapted for PHC settings Portal in primarily geriatric practices. Also practices that and helpful for identifying key factors important to suc- have team members who can share administrative and cessful implementation. assessment responsibilities with the provider will reduce Finally, there are important reasons for PHC providers individual opportunity costs. to identify and treat frailty; the rising number of older It is beneficial to identify barriers at the adults [33], the parallel increase in frailty [34], and the pre-implementation stage so they can be addressed need to initiate care proactively before an adverse event early. One barrier that will hopefully reduce over time Warner et al. BMC Health Services Research (2018) 18:395 Page 10 of 11 is the development of a PHC practice culture that Health Authority, Halifax, NS, Canada. Department of Family Practice, Nova Scotia Health Authority, Halifax, NS, Canada. values the need to screen for and address frailty, and considers it part of best practices in PHC. 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Journal

BMC Health Services ResearchSpringer Journals

Published: May 31, 2018

References

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