implementing evidenced-based programs

Lindsey Myers, MPHInjury, Suicide and Violence Prevention Branch

Colorado Department of Public Health and Environment

Implementing Evidenced-Based

Programs

Discussion Topics

How to assess whether an evidence-based program is a good fit for the capacity of your organization?

Elements of fidelity that are important to successful program implementation.

Older adult fall prevention implementation examples

Where to find resources to better understand implementation science

Questions & Answers

What are Evidence-based Programs?

• Evidence-Based Programs are interventions based on evidence that is generated by scientific studies published in peer-reviewed journals.

• Model Programs are a type of evidence-based program

What are evidence-based programs?

• Previously implemented• Evaluated using measured outcomes• Have been replicated• Have been previously replicated• Found to make positive differences in the lives of

participants

Evidence-based Program have been:

Slide adapted from presentation by Marcia Ory, PhD, MPH and Ashley Wilson, MPH, (2012)

Spend limited resources efficientlyFunders require itAgencies want proven resultsImplementers like “packaged” programsParticipants want programs that workEasier to spread the adoption of programs

Why use Evidence-based or Best Practices?

The Evidence-based PublicHealth Framework

Slide adopted from presentation by Ross Brownson, PhD (2011)

Falls are the leading cause of injury death among Coloradans ages 65 and older.

Falls are also the leading cause of injury hospitalization for Coloradans age 65 and older.

Each year, the hospitalization charges for older adults hospitalized for fall-related injuries in Colorado total more than $391 million.

Identify the Problem: Older Adult Falls Prevention

Packaged ProgramsTypes of Evidence-based ProgramsGuidelines

ProsShelf readyOften has

implementation guidelines

May not require extensive evaluation

Proven track record helps with funders

Technical support often available

Level of evidence may not be clear

Expenses due to licenses and material costs

Limited flexibilityNot always a good fit May conflict with

other existing programs

Packaged programsCons

ProsBased on evaluated

programs Often provides

guidelines on key elements

Adaptable to local situation

Technical support may be available

Not all programs are evaluated at the level of RCT

Key elements are not always clarified

Time/effort/skills need to design the actual program

Needs more rigorous evaluation

Guideline-basedCons

May be able to prove laws lead to positive behavior or positive outcomes

Few evaluation studies for policy strategies; emerging science

Not always easy/possible to evaluate

Evidence-based policies

Centers for Disease Control and Prevention http://www.cdc.gov/HomeandRecreationalSafety/Falls/pubs.html

National Council on Aging http://www.ncoa.org/improve-health/center-for-healthy-aging/where-to-find-evidence-based.html

Administration On Aging http://www.aoa.gov/AoARoot/AoA_Programs/HPW/Title_IIID/index.aspx

Evidence-based Programs for Older Adult Falls Prevention

Compendium of Effective Fall InterventionsProvide public health

practitioners and others with detailed information about rigorously-tested, effective interventions

DataMomentum Political Will Funding Partner PrioritiesAvailability of evidence-based

programs

Intervention Priority Considerations

Deciding which program is best for your community?

Community readinessGoal alignmentCapacity to deliver

programsTarget audienceAbility to implementAbility to sustainAppropriate

approach (e.g. individual vs. group)

Choosing an intervention

Program Match

•Does the program fit your mission?•Is leadership supportive of the program?•Are clients interested in the program?•Can you implement the program as designed?

Costs and Resources

•Is there a licensing fee?•What type of facilitator is needed?•Is facilitator training required?•What equipment and supplies are needed?•Is the program ongoing or periodic?

Cultural and Contextual Relevance

•Is the program culturally appropriate?•Are materials written at the correct literacy level and in the correct language?•Does the program have regional appeal?

Slide from presentation by Marcia Ory, PhD, MPH and Ashley Wilson, MPH, (2012)

Colorado Injury Prevention Winnable BattleBy 2016, decrease the rate of fall-related

hospitalization among adults ages 65 and older in Colorado by 10 percent (from 1818/100,000 to 1636/100,000)

CDC Core VIPP Falls Component FOA

Tri-County Health Department Colorado Trust GrantFalls Prevention Network

State Unit on Aging Matter of Balance Program

Selecting EB Falls Programs in Colorado

Core VIPP Falls ComponentStepping On Fall Prevention ProgramTaiChi Moving for Better BalanceOtago Exercise Program

STEADI Toolkit

(Clinical Integration)

Policy Changes at Multiple Levels(Local, organizational, reimbursement,

legislation)

Translation of EBP to Practice

Translation

• The process of taking a program originally implemented in a controlled “laboratory-like” setting and making it suitable for implementation in the community

Fidelity

• The faithful and accurate adherence to the core elements of an intervention, must be maintained

• Preserves the evidence-base


Translation of EBP to Practice

Core elements

• Program components that generated the positive outcomes• Goal setting, identifying barriers, monitoring behavior

change, etc.

Key characteristics

• Attributes that make the program “fit” the population• Size of fonts and reading level of materials, marketing techniques, etc. • Key characteristics can be adapted, but core elements cannot be adapted

(jeopardizes fidelity)


Build in Sustainability from the BeginningElements of a sustainable infrastructure and delivery system

1 • Effective leadership

2 • Adequate delivery infrastructure

3 • Partnerships

4 • Centralized and coordinated logistical processes

5 • Business planning and financial sustainability

6 • Quality assurance and fidelity to interventions


Group class designed to prevent falls Exercise and progression of exercise is

key Seven weekly 2 hour program sessions Led by health professional Access to team of experts that are guest

presenters (PT, pharmacist, community safety expert)

Evidence: 30% reduction in falls

Stepping On

Training and implementation assistance available

Evidence-based makes it easy to sell to partners

Technical assistance available Key elements/requirements are spelled

out

Stepping On- Pros

Training and implementation requirements are a significant expense

Key elements requirements are not so easy (Led by health professional; access to specific guest presenters (PT, pharmacist, community safety expert)

Overlapping niche with Matter of Balance

Stepping On- Challenges

Build infrastructure within hospital systemsAccess to professional disciplines required for programLocating programs where there are fewer Matter of

Balance programsAbility to spread across the state

Build sustainable training infrastructureConsortium for Older Adult Wellness Training Academy

Train Colorado-based master trainersMaster trainers conduct fidelity checks per program

guidelinesSupport trainers by supplying weights as neededRequire evaluation data to be collected from the

beginningHelp promote Matter of Balance

Colorado Approach to Stepping On

Group exercise program Focused on increasing balance and physical function One hour classes delivered by an instructor Total program time: 36 hours over 12 weeks For older adults aged 60 and older, who can walk

easily with or without assistive devices Evidence: 55% reduction of fall risk

Tai Chi: Moving for Better Balance

• Easy to sell the program to partners

• Effectiveness evaluation supports maintaining the key elements of the program (program dose, reach and instructor training)

• YMCA has funding to develop complementary program

• Training available

• Implementation Guide and technical support available

• Outcome evaluation can be manageable

Tai Chi: Moving for Better Balance –Pros

Time and money needed to develop infrastructure

Instructor prerequisites not always easy to meet

Expensive to develop local training programRequired schedule does not always fit into

existing organizations (Parks and Rec like drop-in classes for < 12 weeks)

Not clear how to integrate with other established Tai Chi classes

Tai Chi: Moving for Better Balance - Challenges

Bring master trainer from OregonWork with the YMCA training structurePay for instructor trainingTrain on evaluation data collection from the

beginningAllow instructors to charge for classesBuild relationships with senior centers, churches,

and rec centersUse previous experience to inform class recruitmentDeveloping: Colorado-based master trainer, fidelity

plan, instructor quality check system

Colorado Approach to Tai Chi: Moving for Better Balance

One-on-one exercise program delivered by Physical Therapist

7 home visits and 7 phone calls over a year In home exercises and walking plan (Med A

and B) For older adults that live at home, with or

without a walking aid Most effective for age 80+ or those that

have fallen with moderate to severe strength and balance impairments

Evidence: 35% reduction in falls

Otago Exercise Program

Delivered by trained Physical Therapists2-hour webinar-based training for PTs availableBuilt-in reimbursement strategyReaches older adults that may not access

community classesMost effective for age 80+ or those that have

fallen in the last year, with moderate to severe strength and balance impairments

Otago–Pros

Medicare only covers home-based physical therapy Under Med A when provided through a home

health agency and patient meets homebound criteria

Under Med B if provided by a PT not affiliated with a hospital

May need to facilitate Med A and B partnerships

Medicare Advantage and supplemental insurance carriers typically follow what is covered by Medicare

Possibly difficult to assess fidelity and track which PTs are using Otago with their patients

Otago- Challenges

Work with home health agenciesStart with home health agencies that are

Medicare Part A and Part B providersPilot test the transition from Medicare Part A

and Part B to provide guidance to other PTsAdvertise the availability of the web-based

Otago trainingIncorporate evaluation data collection from

the beginningPartner with physical therapy school

Colorado Approach to Otago

AGS, Clinical Practice Guidelines, 2010

Evidence-Based Clinical Guidelines

The STEADI Tool Kit is Based on American Geriatric Society (AGS) and British Geriatric Society (BGS) clinical guideline in addition to input from healthcare providers

Preventing Falls in Older Patients: A Provider Toolkit Provider resourcesTraining materialsAssessment toolsPatient education

STEADI

Tool Kit based on strong clinical guidelines and provider input

Evidence-based strategies for interacting with clinical care around public health issuesTobaccoObesity

Research from Tinetti et al provides implementation guidance

Technical assistance availableHealthTeam Works’ experience working with

providers in target area on other health issues

STEADI Implementation Pros

Do not have adequate resources to implement program in the same way Tinetti et al did

Evidence-based tools may not be practical and easy to apply in the primary care setting Lack electronic tools May not have the optimal space to perform the TUG in the

practice setting, etc Low levels of staff participation can hinder success

Algorithms are still complex, requires multiple steps and a lot of time.

Every primary care practice is different. What works for one may not work for others.

Determining what changes have occurred and sustaining those changes in a real-world settings is difficult.

STEADI Implementation Challenges

Colorado Approach to STEADI

Reach 66% of PCP’s (Family/General/Internal Medicine) in Adams and Arapahoe counties

Contract with HealthTeam Works Engage practices using academic detailing Provide STEADI, a comprehensive toolkit to help

healthcare providers incorporate fall risk assessment and proven interventions into their clinical practice

Explore adapting the STEADI Tool Kit to be used in electronic medical records

*Arapahoe county data consolidated from Peregrine and Colorado Medical Society. Adams county extracted from Peregrine and estimated based on assumption that 1/3 of physicians do not accept or limit # of Medicare patients.

Counties PCP’s Accept Medicare

66%

Adams ~112* 74Arapahoe ~151* 100

Putting It All Together

Pilot and Evaluate

Plan goals for process and outcome

evaluation before program

implementation

Create or find the instruments and protocols needed for data collection

Monitor program operations and make

adjustments to evaluation plan (if

needed)

Evaluate program delivery and

outcomes to assess program success

Use findings in future program

planning


Resources for Implementation ScienceNational Implementation Research Network: http://nirn.fpg.unc.edu/

The Community Tool Box : http://ctb.ku.edu

There are different types of evidence-based programs, each with their own set of implementation challenges

Successful implementation of an evidence based program takes careful planning

Think about evaluation, fidelity and sustainability from the beginning

Partnerships are key to successExternal factors outside the project can

contribute or hinder success

Conclusion

Contact Information:Lindsey [email protected]

THANK YOU!

implementing evidenced-based programs

Documents

evidencebased programs

evidencebased policiescenters

availablelevel of evidence

evaluated programs

effective interventions

prevention http

ross brownson

older adults