目的:描述一个结构化的,迭代,数据驱动的方法,用于在全国范围内扩大计划中修改复杂的循证实践的实施策略。
方法:我们扩大了关键时间干预(CTI)的实施范围,这是一种基于证据的案例管理模式,涵盖了32个基于社区的退伍军人事务(VA)“补助金和按日计”案例管理(GPD-CM)机构,为无家可归的经验丰富的退伍军人过渡到独立生活提供服务。主要数据采用定性方法收集。
方法:我们开始了扩大规模计划,同时使用推广设计进行了务实的随机评估,比较为VA的GPD-CM计划量身定制的CTI实施包的两个版本。我们迭代地评估了环境因素和实施结果(例如,可接受性);调查结果为一揽子修改提供了依据,这些修改是使用“报告对循证实施策略的适应和修改的框架”来表征的。
方法:我们对退伍军人进行了半结构化访谈,GPD-CM员工,与VA临床医生联系;与VA临床医生和实施小组成员联系的定期思考;并借鉴了详细的会议记录。我们使用快速定性方法和内容分析来整合数据并表征修改。
结果:在针对机构级特征的变化进行的每次放大浪潮之后,我们对实施包进行了迭代修改,以提高CTI的采用率和保真度,从而在我们的放大站点的各种环境中。修改包括添加,删除,集成,并改变包装;核心包装组件被保留。
结论:针对在不同环境中进行扩展的复杂的基于证据的实践的实施包可能会受益于迭代修改,以保真度优化实践采用。我们提供一个结构化的,迭代识别数据驱动的务实方法,中游实施包调整,用于VA和非VA放大计划。我们的项目表明了评估和修改扩大计划的重要性,以及同时具有形成性和总结性评估目标的项目的权衡。
OBJECTIVE: To describe a structured, iterative, data-driven approach for modifying implementation strategies for a complex evidence-based practice during a nationwide scale-up initiative.
METHODS: We scaled-up implementation of Critical Time Intervention (CTI)-an evidence-based case management model-across 32 diverse community-based Veterans Affairs (VA) \"Grant and Per Diem\" case management (GPD-CM) agencies that serve homeless-experienced Veterans transitioning to independent living. Primary data were collected using qualitative methods.
METHODS: We embarked on a scale-up initiative while conducting a pragmatic randomized evaluation using a roll-out design, comparing two versions of a CTI implementation package tailored to VA\'s GPD-CM program. We iteratively assessed contextual factors and implementation outcomes (e.g., acceptability); findings informed package modifications that were characterized using the Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies.
METHODS: We conducted semi-structured interviews with Veterans, GPD-CM staff, and liaising VA clinicians; periodic reflections with liaising VA clinicians and implementation team members; and drew upon detailed meeting notes. We used rapid qualitative methods and content analysis to integrate data and characterize modifications.
RESULTS: After each scale-up wave-in response to variations in agency-level characteristics- we made iterative modifications to the implementation package to increase CTI adoption and fidelity across the diverse contexts of our scale-up sites. Modifications included adding, deleting, integrating, and altering the package; core package components were preserved.
CONCLUSIONS: Implementation packages for complex evidence-based practices undergoing scale-up in diverse contexts may benefit from iterative modifications to optimize practice adoption with fidelity. We offer a structured, pragmatic approach for iteratively identifying data-driven, midstream implementation package adjustments, for use in both VA and non-VA scale-up initiatives. Our project demonstrates the importance of assessing for and making modifications in a scale-up initiative, as well as the trade-offs of projects having simultaneous formative and summative evaluation aims.