Implementation and Adaptation Guide
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Adaptations In Later Stages For Sustainment and Scale Out
As you approach the end of your initial implementation of the program, it is important to continue tracking your progress. You can do this by repeating the iterative RE-AIM assessment in later stages of the program implementation and pay special attention to the Maintenance dimension of RE-AIM. Adaptations at this later stage will be mostly focused on two main areas:
- Sustaining program use including exploring changes that are necessary to support ongoing delivery of the program (e.g., integrating the program activities into the workflow of a clinic, secure resources locally for the delivery of the program)
- Identifying adaptations that can support the scale-out and scale-up of the program at additional sites within or outside of the VA (e.g., highlighting key functions, identifying common adaptations across various stages of the program delivery, and providing list of resources needed for adoption, implementation, and sustained use of the program).
How to modify your program to make it sustainable
Review the results above with your decision makers. Who these people are will depend on your center, but should include those responsible for making budget and hiring decisions and those responsible for conducting the activities (or at least their supervisor).
Ask the following questions:
❯ How well have adaptations made to date worked?
❯ What would make it possible to keep offering this program (assuming it is effective- or how would we need to change it to make it so)?
Specify the modifications that would need to be made- who does what differently when using what resources to get which groups?
What commitment and actions will leadership need to make for this to happen – how often and what type of feedback on what do they need? NOTE- this will need to be iterative with sharing your results
Specify in writing with a Memorandum of Understanding
Worksheet: Further Customizing a Program for Sustainment
First see if this intervention is right for your setting at this time on earlier Is a Program Right for Us?
Next, try to identify ways in which the key functions of the program can be operationalized in your setting. The following “ Form and Function” table illustrates what we mean by key functions- or goals- or purposes. The form consists of the specifics to accomplish this function in your setting- e.g. WHO will do WHAT to accomplish each function or goal
Include costs- and especially time (see Time and Cost Tracking and Reporting)- and decide if it will be possible to maintain this level of attention and resource allocation. If not, then where are reductions needed? Estimate the likely impact on effectiveness (see first figure above about higher vs. lower intensity program on different RE-AIM dimensions)
The table below outlines the description of the program described as function and form. At the sustainment and scale-up stage, it is important to review this table and make modifications and refinements based on the experience from the implementation. Some functions and forms might be changed as a result of this experience and can be very helpful to guide ongoing use of the program and scale-out and scale-up to other sites.
Example of Evaluation Summary
| Component | Function | Forms |
|---|---|---|
| Notification of Community Hospitalization | CHTP clinical staff is notified of a Veteran hospitalization at a community hospital | Community hospital notifies CHTP staff; CHTP staff receives referrals; CHTP staff receives CPRS notification |
| Summary/Information Transfer | Clinically relevant information is sent to CHTP staff (discharge instructions, etc.) | Discharge instructions are sent via a secure electronic fax line; CHTP staff uploads discharge instructions and relevant notes to CPRS |
| Handoff to VA Provider | CHTP Staff notifies VA provider of a Veteran hospitalization in a community and necessary follow up care | CHTP staff communicates with PACT staff about Veteran hospitalization via phone, email, or DM platform |
| Follow-up Coordination | CHTP contacts Veteran and assists with follow up care needs as needed | CHTP staff contacts Veteran over the phone 2 weeks after discharge; Assists with follow up care as needed (medication check, follow up appointment with provider, etc.) |
Spreading the Program
Before you implement the program at a new clinic or site, it is a good idea to review your documentation of adaptations and lessons learned as a team (and with all stakeholders ).
Decide whether the adaptations you made prior to program use or during program use led to the desired outcomes of improved reach, adoption, implementation, effectiveness, and/or maintenance. Discuss if these changes should be made right at the get go at the new site or should be recommended as various acceptable variations on the program activities to the new site.
Remember that changes to the key functions of the program need to be made thoughtfully as these can make the program less effective. Repeat tables above- BUT construct these after meeting with potential NEW adapting sites- be sure to get input from at least 2-3 new sites that are diverse across the characteristics of settings you want to target.
In these interviews:
❯ be sure to get them to describe their process map for how this would roll out in their settings; and
❯ calculate and share the estimated ‘replication costs’ (what it would likely cost their setting to successfully deliver and sustain the program in their setting)- modifying the actual costs you found in delivering your program.
Some Final Questions:
❯ What commitment and actions will leadership need to make for this to happen – how often and what type of feedback on what do they need?
❯ Reply in writing with a Memorandum of Understanding
Previous: Evaluating and Summarizing Impact and Effectiveness / Next: Sharing Your Findings
