Enhancing Implementation Science- 13 -Department of Veteran Affairs

Intro Program Session 4: The Role and Selection of Theoretical Frameworks in Implementation Research

**Department of Veteran Affairs**

**Enhancing Implementation Science**

**Teresa Damush**

**Intro Program Session 4: The Role and Selection of Theoretical Frameworks in Implementation Research**

**June 21, 2012**

Moderator:  I would like to welcome everyone to today’s QUERI enhancing implementation finance framework seminar.  We have reached the top of the hour.  So at this time, I would like to turn it over to Brian Mittman to introduce our speaker.  Brian are you available?

Brian Mittman:  I am available.  Hopefully you can hear me.

Moderator:  We can.  Thank you.

Brian Mittman:  Great.  Okay.  I don’t know that I need to take any time at all other than to welcome everyone and to repeat Molly, what you’d indicated that this is session four of our six session series.  Our thanks to Molly for the organizational logistical support and Theresa for your presentation.  We will have two more sessions in this series.  If we have time at the end of the session we will provide a brief preview but we look forward to your questions.  Thank you.

Moderator:  Thank you very much.  Dr. Damush your screen is being shared.

Teresa M. Damush:  Thank you, Molly.  Thank you Brian.  As Molly and Brian indicated this is the session two of the role and selection of theoretical frameworks and lecture four of the series.  I’d like to just begin and acknowledge that this was funded by QUERI and acknowledge my collaborators on this presentation.  Laura Damschroder, Brian Mittman, and Cheryl Stetler.

Moderator:  We are going to begin with a poll question at this time, so the question is what is your primary role in VA.  Please select one of the options available and submit your answers.  We do have about 36% of our attendees have responded thus far and we will leave the poll open for another thirty five or forty seconds until the responses have stopped rolling in.  Thank you.  Okay.  it looks like about 75% of our attendees have responded and we will give people just a few more seconds as the responses are still coming in.  Momentarily I will close the poll and Dr. Damush I will show you the results and you can speak through them.  We’ll go ahead and do that at this time.  Okay.  And Dr. Damush can you see the results now?

Teresa M. Damush:  Yes, I can.  Thank you.  It looks like about 9% of the audience are students, trainees or fellows.  10% are clinicians.  56% have identified themselves as a researcher.  8% as a manager or policymaker and 18% have identified themselves as other.  

Moderator:  Okay and so we are moving on to our next poll question which best describes your research experience.  We have about 30% of our attendees respond thus far and the responses are still streaming in so we’ll go ahead and give people a few more seconds to respond to this poll question.  The options are I have not done research.  I have collaborated on research.  I have conducted research myself.  I have applied for research funding or I have led a funded research grant.  And it looks like we have about 75%.  Just a few more seconds and then we’ll go ahead and close out the poll.  Okay.

Teresa M. Damush:  It looks like about 4% have not done any research.  24% have collaborated on research.  About a third.  28% have conducted research themselves.  9% have applied for research funding and about 36% have led a funded grant.  Okay.

Moderator:  Thank you, Dr. Damush—and we are now going to launch—the third question which best describes your implementation intervention design experience?  Please select one of the options.  You have designing implementation interventions in the VA settings.  Designing implementation interventions outside VA settings.  Designing interventions both outside and in VA settings or no experience in designing implementation interventions.  It looks like we have had about 60% of our audience vote at this time, so we will leave that open for a few more seconds.  Responses are still streaming in.  So we will give our attendees a few more moments to respond.

And I’m going to go ahead and close the poll now and share the results.  

Teresa M. Damush:  So about 18% have reported designing implementation interventions in the VA.  23 have designed implementation interventions outside of the VA and about 8% have done both outside and in the VA settings.  About half of us, half of the audience have reported no experience at all in designing implementation interventions.

Moderator:  Thank you very much.  I’m going to turn the screen back over to you now.

Teresa M. Damush:  Okay.  I’m going to go ahead and—try minimum—I’m trying to minimize the—the screen there.  Okay.  So our outline for today’s presentation is I’m going to talk about some resources available. Practice changes for designing implementation intervention.  And also present some tools for planning the implementation strategy design.  One of the tools is called intervention mapping.  And I’m going to go into more detail on that and provide an example that our study group have done.

Then I’m going to go through another implementation study example and the representation of some key points.  I just want to say for those who just might be joining us.  I didn’t say at the beginning but I was originally trained as a research health psychologist.  That’s my background.  I currently work as a one of the implementation research coordinators for the Stroke QUERI based in Indianapolis.

And so the objectives of today’s presentation is to understand the application of theory and implementation research and learn about tools of implementation strategy design.  I brought three of the definition slides from Laura’s presentation several weeks ago just so that the definitions are standardized across penetrations.  So that the first slide talks about what is the definition of theory.  And the next slide talks about what is implementation.  So it is as defined efforts to get evidence based practices and related products into use and implementation typically follows dissemination and include identifying barriers associated with strategies to overcome and leverage them, and adapting targeted practices to the context and development of tailored implementation strategy.

The third slide for defining purposes, what is implementation research and these are some references.  It’s the scientific study of methods to promote the uptake of research findings for the purpose of improving quality of care.  Okay.  So over half of the audience responded that they’ve never been involved in implementation intervention design.  And so these are some resources that you can go to to get started and I would say that the Powell reference has—is, as it says a menu of implementation strategies and maybe a good starting point to find out what are some strategies that have been used previously and exist in the bank of strategies.  

And some of the tools that have been used for implementation strategy design are intervention mapping and that’s originally developed by Jay Bartholomew, pragmatic explanatory indictor summary tools abbreviated PRECIS and the PRECEDE-PROCEED model by Green and colleagues and the RE-AIM framework.  These are just some tools and you can find more information about them in the recent book that was published—I believe in this year, 2012 on dissemination and implementation methods.  And for our presentation today I’m going to talk about intervention mapping.  Okay?  So intervention mapping is what some would call a planning framework and it helps you as the name indicates plan your project from start to finish and Bartholomew lists out six steps staring with a needs assessment, secondly moving onto creating a matrices of expected change and what are the determinates of those changes.  From there identifying a theory based methods and practical strategies to define interventions strategies and step four is plan the program.  So develop and pretest your materials.  Five is specify the adoption and implementation plan and six is the evaluation plan.  How you’re going to analyze the processes and outcomes.

And I would say the original intervention mapping by Bartholomew had five steps.  So it was actually step two to six were originally steps one to five and she later went back and added the needs assessment as step zero.  But when she republished her book, she then reordered the numbers.  So it’s now six steps.  Okay.  So now I’m going to talk about what intervention mapping is in a little bit more detail and of those six steps and go over an example that we’ve recently did the front of our stroke project.

So it is a planning framework that utilizes theory, evidence, practical strategies to design implementation intervention.  The main target multi-level changes.  It was originally designed for health promotion programs, but it’s been applied across fields including the healthcare industry.  And it’s been used internationally around the world.  Okay.  And as part of the materials for today’s presentation, we included this article along with the tables that went along with this, but this is out of a project we did to develop and implemental locally tailored evidence based and secondary stroke prevention program in two VA medical centers.  So our practice gap was that this secondary stroke prevention was not being systematically delivered throughout the VA.  

So we started this project.  We started doing needs assessment so we just barely tried to identify the barriers and facilitators in each of the two facilities to deliver secondary stroke prevention.  We tried to target what our population was and understand current processes.  What we did was we identified all the clinical providers who had any involvement in a patient who came in to one of the VA hospitals as an acute stroke patient.  They had an acute stroke event. And they would enter in.  So that process that work process of how they flowed through the hospital.  We would try to sample all the clinicians—the type of clinicians who would have any type of involvement with the patient so it was emergency care doctors.  The nurses, the neurologists.  The rehab professionals and some administrators to understand the processes.

So we did semi-structured interviews and we also did some focus groups with the patients and their partners to understand their perspective of the information that they have received through these events but also what were their preferences and what they’re suggestions were for future patients who would come in on the same circumstances.  Okay.  So we interviewed about forty five clinicians at the two sites, and some of the themes that came out of those interviews were that the clinicians knew that both—it was similar at both sites.  They knew that both of their hospitals had resources that pertained to secondary stoke prevention, but what they didn’t know was how could they get access to those resources.  How could they find out you know readily, easily where they were located and how could they get their patients to their programs and then they also reported that they just felt that they were unprepared to motivate patients on lifestyle modifications that they thought were needed in order to really reduce their risks for further stroke.  So some clinicians said that they wanted tools to be able to deal with this topic with their patients.  Others said that they would prefer to that they could just have a referral out to somebody else who would [inaudible].  Okay.  So we held several focus groups across the two facilities and we also as part of the focus group, we presented existing tools that other programs had used and we had asked them to give us their perception of the usefulness of these programs and the ratings and also we looked for suggestions for how to implement such tools again in the usual care system after an acute stroke.  So one of the tools was called the American Stroke Association Peer Visitor program.  And it’s really a—in a nutshell a peer support program where you train patients who had the same clinical condition.  So those who have had a stroke.  You train them on providing support and risk factor education to new patients with stroke.  And so the patients rated that quite favorably and they gave some suggestions about how we could implement it.  They wanted to make sure that any visitors would stay within the realm of the hospitals or the clinics.  They didn’t want anybody come visit in the home.  They recommended a sunny personality of the peer visitor and that is a—said logistically would be hard for one person to do this and so they recommended a team of volunteers so that it wasn’t to any one volunteer.  They thought patients would be able to open up more with a peer than with a physician and that it would be very helpful for recovery.  

Okay.  So once we had that information our next step was to try to understand what were the processed that were needed to change.  In step two you want to take a look at the performance objectives and there are usually in an implementation project there are many—there’s not just one.  There’s several behavioral processes or processes in general that need to be modified.  You would list those out and this is the exact performance expected by someone by the intervention.  What do the participants in this program or organization need to do to perform the behavior and make the environmental change?  So if you were targeting a practice for instance if there was a neurologist.  What would the neurologist have to do?  If it were an ED physician or a primary care doctor or the nurses, what would each of them have to do to perform the behavior or make environmental change?  And there’s usually are subgroups that you would target in an implementation intervention.  In our case we had both providers and patients.  And then you want to take a look at what might be some of the determinants of factors associated with these processes or the behaviors and you can look at them as personal determinants, so skill levels of the doctors—by the patients and also the clinicians.  External determinants would be resources needed, policies to be changed, social norms to be established.  So what are the sources of influence on these behaviors?  This would be when we talk about the steps to be in a matrix, the determinants would be listed across the top of the team matrix while the performance objectives would be listed down the rest of the columns.  Okay and this is just an example of again from our paper.  Some of our performance objectives from the provider what they would need to do to provide systematic secondary stroke prevention programs and then some of the determinants at the top.  So there would be community resources for stroke risk management, a delivery system redesign for some of our determinants.  And then you would go ahead and operationalize those and these are some examples here and so we would—so the design issues we would try to change the workflow of the discharge planning so that they included stroke risk factor management so that the performance on the left is that the doctor assessed or the clinician addressed stroke risk factors during hospitalization for acute stroke and under system redesign we’ve decided we would put it under the discharge process.  

Step three is taking a look at some—what theories would apply to our particular targeted evidence based practice changes that we’re looking at and again we were interested in one of the things that had to be done to try to establish the social norms.  And one of the theories that include establishing social normal, perceived social norms is that theory of planned behavior.  So we listed that as trying to establish a clinical champion to promote these practice changes.  And underneath perceived social norms are some of the other concepts that are involved in that theory so attitudes, beliefs and values to try training to try to maybe target attitudes about [inaudible] performing secondary stroke risk factor management or attitudes about the clear perception the real perception about motivating patients to change their behaviors or risk factor reductions.

Self-efficacy is another concept and so it’s about that concept is about improving the skills or the competence to perform these behaviors so one way to operationalize what the providers can do is maybe through peer modeling or role playing they can practice trying to practice their skills on how to modify their patients risk factors.  Let’s see—and then alongside of the theoretical strategies you can list practical strategies and we tend to get these from our provider interviews.  So when you’re doing your needs assessment or your formative evaluation before you get started on the design of the implementation, talking to—intervening the folks that are on the front line that are actively doing in the area that you are targeting for change and practices are very helpful.  They usually do have a lot of insight needed to make those changes or how it could be improved.  So with the VA of course they have a very established electronic medical record and so we did get the feedback that stroke risk factor assessment template could be easily be incorporated into the medical record and I believe at our Houston site they have been testing that out and developed some templates as well.

What we got from the neurology resident who often are responsible for the discharge planning is to simply put a checklist available at their workstation—their computer workstation where they have to plan out the discharge process for stroke patients.

And in Bartholomew’s book she has a little section on how to find theories.  This—I included a slide on this part because I often get this question when folks want to know how do I find a theory for my work and where can I go and so you—one of the places you want to do is search the literature and of course there are a lot of theories, but how to find ones that belong alongside of what you’re trying to do.  These are some suggestions.  One you can search by the topic—the clinical topic for example.  And usually this is a broad search.  You’re going to get theoretical and empirically based literature. Another way you can target your search is by a concept—a theoretical concept.  If you have some idea.  For instance, we often use a lot in our interventions facilitation.  SO you might want to start with—if you’re interested in a theory and facilitation you can do a search on that and see what type of theories include this concept and the nice part about searching that way is you can learn about other related concepts that might be even more applicable to what you want to do.  And then you can search along more sides of general theories.  theories about organization change, change in individual behaviors if you’re trying to target a group to change your behaviors and overall theories on change can also get you may be closer to a theory that you’re—you might be useful for you.  Okay.  

For our project we used several theories.  For the overall change—organization change at the two sites, we use the chronic care model as a way to conceptualize all the different parts of the system that would need to be targeted for a system to systemically offer secondary stroke prevention.  So that what we’re trying to say is it wasn’t one person’s job or it wasn’t the patients’ sole responsibility.  It was a system and we thought the chronic care model captures a different part of the system that would have to interplay in order to help us reach our results.

And from there you want the next step is to plan your program.  You want to operationalize strategy in the plans, develop your protocols and develop your program materials and pretest those program materials with the target group.  Lastly I put in here that to consult with the attendant participants and implementers.  So after you’ve done your needs assessment, your formative evaluation and you’ve looked at—you’ve researched your theories and you’ve tried to operationalize the components and come up with a plan, I think it’s very helpful to bring that plan back again to the frontline folks who are the users of this intended program so that any—a representation of the participants.  So whether it be patients or clinicians or administrators, whoever it may be.  Consult with them and it can be just a few folks just to get some feedback.  And they usually do have a good sense of what the realistic probability of what you’re proposing.  So we met with the chief of neurology at both sites and some of the clinic managers and fed back to what the results were and how we came up with the plan.  They had some really good suggestions.  They were the ones who helped them target the neurology residents and where in the workflow those neurology residents could be targeted for reminders for secondary stroke prevention and also help them actually deliver secondary stroke prevention and deliver secondary stroke prevention.

This is a menu of tools that we called for secondary stroke prevention and again it’s broken down by the chronic care model, so there’s different concept of the chronic care model and we’ve then outlined our tools for delivering secondary stroke prevention. Based on those interviews we targeted lifestyle counseling training to staff.  It’s across the board to the different type of providers.  The rehab clinicians, the physical therapists, occupational therapists, the nurses, the doctors, the neurology residents.  We targeted everybody and gave you materials to help them some of it lifestyle or risk through risk factor reduction training.  We also made tried to implement a peer support program at both facilities and stroke health management as well and also tried to provide community resources.  So the system of provider intervention again was a motivation intervening skills and also designing a template for them so that they can have access to all the programs available at each of the facilities.  So in the implementation science article that we attach, they’re in one of the attached files is an example of the risk factor prescription pad that we came up with.  That was a way to get all of the risk factor programs available to the clinicians.  So where they were located, the contact person.  The number and we did that for both of the sites.

So for patient activation we tried to deliver stroke self-management sessions and establish stroke support groups, delivered the stroke peer support program and tried a variation to in how that was being delivered at both of the sites.  They had flexibility in how they could get these programs to their patients.

And step five adoption implementation plan.  Here you want to specify the performance objectives for program option, implementation and sustainability of that as your goal.  And likewise so just like the previous matrix, you want to look at the determinants of the factors associated with implementation.  Then you create your matrixes. And again, the performance objectives are on the left hand column and the determinants are across the row on the top.  Implementation is often multiple tasks performed by a variety of roles.  Let’s use a program [inaudible] mentors need to do to implement the program with fidelity.  That’s really what you want to ask here.  So the performance objectives are a little sample is providers who give stroke patients relative stroke risk factor education material.  So for [inaudible] it would be documented notes in the electronic medical records at these two sites.  The patient enrolled in a VA support program such as a smoking cessation.  It would be documented.  We would look for documentation in the electronic medical records.  And then finally came up an evaluation plan for provider practices and a patient level data and for instance we are looking at the pharmacy benefit data on how often the patients refill their medications that have to do with risk factor management.

Intervention mapping is a useful planning tool.  It can help guide you through the processes and help you get started from the beginning all the way through the evaluation plan.  It’s very helpful for specifying multi level intervention; an intervention that has multiple levels.  One intervention but there’s many parts.  It’s a way to keep track of those parts.  And also it’s a process for applying theory to implement the intervention.  Then the evaluation plan enables us to assess the value of that theory or the goodness of the fit.

So using theory is just a few notes.  There are better fitting theories that explain why a specific strategy or mechanism causes tend to change.  that’s why there are—there is obviously there are many theories out there so what you want to do is really try to find one that is really targeting the mechanisms or strategy that you wish to use and evaluating the practice gap can help guide you to the implementation of theory and the implementation strategy may be operationalized from the theoretical concepts.

I’m going to move on from intervention mapping now and talk about another implementation example. Using the framework from the last lecture from Ann Sales and colleagues.  So what you again, it’s like intervention mapping, you want to try to understand or articulate what is the mechanism or strategy for which you expect your change to occur, so whether it’s an Evans based practice you’re trying to move to, a change in the organization or you want individuals to change.  What where are they now?  Currently what is the status now?  Where do you want them to be?  Where are the barrier to change?  What are some possible facilitators?  This is the framework from Laura’s presentation and it’s adapted from Dr. Ann Sales and colleagues.  And it’s a framework for conducting theory based implementation studies.  Again, step one is assessing what is evidence based change and context.  So some questions to ask you and your team are what are the change objectives.  

Who are the targets?  Again, what is the level in which change occurs?  In the previous example is both clinical providers, nephrologists, nurses, rehab professionals and also we were targeting the patient simultaneously.  Identify characteristics of the change.  So I’m going to go through another implementation example that our group has recently completed and this is on post stroke depression screening and treatment.  The evidence had shown that depression, post stroke depression was highly related to mortality and morbidity and so we were interested in adapting the VA’s annual depression, clinical reminder for screening of veterans yearly and adapt it for stroke patients who are coming up for follow-up care in primary care clinics or neurology outpatient services.  An objective list of depression screening of veterans with recent ischemic stroke and to support providers in taking action when post stroke depression was detected.  SO this project was done at two VA medical centers so it was another two VA centers and we targeted primary care clinics and the neurology outpatient clinics.    And this was a quasi experimental design.  And we compared patients post stroke depression outpatient care one year prior to the intervention, which was our control group to patients receiving the stroke patient care within the intervention period.  We formed teams at the two sites including the front line clinicians, the clinical application coordinators who are responsible for the clinical reminders and we would then help develop the local clinical reminders and implementation strategies.

So this particular example is a hybrid type three project as we focus on the implementation intervention.  Okay.   So the question what are the change objectives?  We were interested in changing the health delivery system.  We wanted to increase screening for depression within six months post stroke during primary care and neurology outpatient clinics and we wanted the providers to provide treatment when post stroke depression was detected.  Who were our targets?  The individual clinicians and clinic check-in.  So the primary care doctors, the neurologists the nurses in two different regions of the VA.  So what are some characteristics of the changes?  Well the change is peripheral to the perception of current practices.  So by that statement I meant it was not part of usual care.  Outside of their annual—outside of the veteran patient annual screen for depression for all veteran patients, there was nothing the entire year for stroke patients specifically.  What was the motivation to change?  The motivation to change—there was no performance indicator or performance measure dictating that they do this.  It was simply that it was the best thing for the patient based on the evidence so it was to improve patient outcomes.  As I said, previously, the patient was at risk and those who developed post stroke depression were at risk for worse functional outcomes and mortality.

So the next step in this framework is select in the targeted theory and provide a rationale on why we use it.  So what we did is we mapped out the current state.  What was usual care at the time?  In a neurology outpatient visit, the patient checked into the clinic with the nurse and the patient would see the neurologist, and the neurologist may or may not screen for depression it really depended on the individual, and they referred either to mental health or they prescribed some medication.  Patient accepted or refused the treatment or the referral.  So ideally what you wanted to happen in these clinics was after the patient checked in, we wanted the patient to be screened for stroke during the past six months.  So first they needed to be the acute stroke patients needed to be flagged or identified.  We believe during the past six months would capture the recent events.  so if they if they were to reply yes to that check in question, they would be screened for depression and then a positive screen would then be flagged to the neurologist and the neurologist—the primary care doc would confirm the diagnosis and either treat or refer to a mental health specialist and again just like usual care, patient accepts or refuses treatment.

So from those ideal state we operationalize these factors as actionable, ones that we can target to be changed.  Some clinical informatics so at the check in when they—when the outpatient comes in they could be screened for stroke in the past six months by the nurse who usually checks them into the clinic.  And then because the change—the [inaudible] is that this is peripheral to the usual care practice, we believe for neurology that there was basically a social norm that needed to be modified.  So the increase or not in acceptance of depression screening in post stroke care.

I just want to define rationale for some folks I know are just beginning.  So it’s providing justification for your selection and operation delineation of the concept supplied to your specific implementation program.  Okay.  So we—again and in this example we again used the theory of plan behavior because we were targeting trying to establish the social culture norm within the clinicians that this was an acceptable practice change and this was something that was needed.  We also used a clinical champion to promote the need and the perception that this is a social norm and also to model the behavior so to include the self-efficacy of the individual provider.  And this is just a slide on that theory of planned behaviors so it includes the concept of subjective norm—a perception of what the norm and the control believes you can consider that as the [inaudible] or the control of the clinician that they have the knowledge and skills to perform and be able to perform depression screening and treat appropriately.  Okay.  So the [inaudible] we executed, implemented and evaluated our strategy.  Okay.  And this slide is really more for those in the treating program, but we assess the context and I know you’ve been working a lot with the [inaudible] models and so these are the concepts from the [inaudible] constructs that apply to this project.  Adaptability.  Because we were doing this in two different regions, we needed the intervention to be adapted, tailored, refined to meet the local needs.  So both places had the [inaudible] to adapt—clinical reminder.  They could set it up any way they wanted but the goal was to increase post stroke depression screenings and treatments.  Peer pressure.  Peer pressure is definitely a key concept in the context of this project.  Again, we really looked heavily upon our service chiefs to endorse this practice change.  In an implementation climate the capacity for change and extent to which use will be rewarded.  The capacity for change was—we tried to set at the beginning and the extent the use will be rewarded.  There were no tangible rewards for doing this behavior other than it was the right thing to do for the patient.

So the evaluation of our project—we look at the process.  So post stroke depression screening again the control group was the previous year.  The interception period was the active period when the intervention was turned on in the clinics.  So during the time when the clinical reminders and the check in were there, 85% of the time that patients were screened for depression versus 50% of the time and treatment action was received.  They either got the referral or medication prescription 83% of the time doing the intervention period versus 73%.

When we did some interviews after the project was implemented and what we found was that at one of the sites the neurology outpatient clinic was really utilized the tools and the service chief heavily endorsed the program, but the primary care clinic was less enthusiastic.  At the other site, it was just reversed so that the neurology service did not believe they should be screening for depression and so they did not recommend it among each other.  There was no role playing and they didn’t promote it among new folks coming into their systems, or their residents.  Their primary care clinics really endorsed it.  They thought it was right to do and they thought it was relatively easy.  So it was very interesting that we had two regions, two sites and the opposite—the definite clinics endorsed the project.

Was the theory useful?  I think that’s a very good question.  We used the theory to guide the intervention.  We did not evaluate each component of the theory.  This was one of our very first projects and if we had to do it over we would make sure that we survey the front line clinicians who had the opportunity to use the clinical reminders.  We would measure the constructs of the theory, particularly I would measure the perceptions of social norms and their behavioral intentions to do the screening and then we would evaluate the theoretical impact on the implementation of the reminders.

I’m going to go ahead and wrap up.  With key points to applying theory for implementation interventions.  So I would highly recommend using pre implementation work to target your implementation critical factors and again this is some folks are familiar with formative evaluations or needs assessments as Kay Bartholomew’s group called it.  Provide the rationale for the section of theories, so you—you need to provide a rationale for yourself to understand why this theory is applicable.  Rather than just pulling a theory off the shelf really try to understand if it’s applicable and what’s the rationale for it.

Consider use of a planning theory or a tool to assist you with specification and planning.  Again, the intervention mapping is just one tool and there are others out there that I’ve listed and so it’s—it is for those who are just getting started and never done such work, it’s a nice guide to the different steps that are needed.  Clearly define your strategies so that others may replicate to generalize beyond your specific effort.  I think that’s where the major piece comes into play.  Really trying to break down the changes that need to occur.  What are all the specific processes or behaviors that need to occur by the different subgroups.  I think it helps you and your teams have an idea of all that needs to be done and also that it helps afterwards for others to understand what you’ve done and to generate beyond your specific efforts and then also I highly recommend balance your theoretical components with pragmatic factors, identified from the targeted users of evidence based practice.  So I think I often get that question about can you mix the two and I think it’s perfectly fine to mix the two.  I think the pragmatic factors really tell you about the reality of whether it’s in healthcare if it’s in everyday practice that these are the reality of what it’s like to be on the front line and I think mixing the two are certainly fine.  And finally evaluate usefulness of theories used.  And this is not always easy but it’s important to include it so we can have more knowledge on the applicability of the theory but also to understand what you’ve done with your work.

So I wanted to end just giving you my contact information.  I am primarily based at the Indianapolis VA—Roudebush VA and my e-mail is listed on the slide.  So—I’m happy to take some questions.

Moderator:  Thank you very much.  That was a great presentation and I just want to remind all of my attendees that joined after the top of the hour to submit your questions, please go to the question section on your gotowebinar-board and you can just submit it there and we will get to them in the order that they were received.  Before I get to the questions, Dr. Mittman do you have any statements or questions you’d like to make before we go to the audience?

Brian Mittman:  No.  None from us.  Thank you.

Moderator:  Okay.  The first question that came in, how—this came in towards the beginning of the presentation, how many patients were in the focus groups?

Teresa M. Damush:  That’s a good question.  I would—I can’t remember the grand total but it ended up being about six focus groups, three at each site and we generally have about six to eight people at each site.  

Moderator:  Thank you for that response.  The next question came in, and I’m sure a lot of our attendees are curious about; presenters have mentioned suggested readings re those being made available to attendees not within the VA?   The answer is yes.  There were additional materials provided today.  They were included within the PDF of the presentation handouts.  If you need a copy of those, you can refer to your reminder e-mail.  You can also write into the question section.  Go into webinar and I can provide you a link to those.  Yes.  Dr. Damush has made them available ahead of time.

The next question that came in during the discussion about how to find theories.  You mentioned a search engine.  Can you again provide the information about the specific search engine that you were discussing how would someone outside the VA access it, if possible?

Teresa M. Damush:  What I think I mentioned were just some search words that you can put into whatever engine that you’re using, so they’re in the slide and you’re more than welcome to use it.  I don’t recall that I promoted any search engine.  This is typical if you’re in pub med or anywhere that you choose to search for the theories.  I believe that’s the question they’re asking.

Moderator:  Thank you for that response.  We are waiting for more questions to come in, so our remaining attendees if you do have questions this is the time to take advantage of Dr. Damush’s experience and expertise.  

Brian Mittman:  Molly if I could—

Moderator:  Yes, Dr. Mittman.  

Brian Mittman:  I’m sorry—but to take advantage of having an open mike, Teresa, one question is are there good published examples of the use of some of these tools in implementation science.  I know that intervention mapping for example was originally developed, at least as far as I know was heavily used in the health promotion field.  Are there some examples and could we compile a list and make that available after the talk?

Teresa M. Damush:  Sure.  Certainly.  I do know implementation science has published several articles recently on that so certainly I could assist with that.

Moderator:  Thank you, Dr. Mittman.  And Dr. Damush, we do have another question that came in from the audience.  How quickly can one move through intervention mapping?

Teresa M. Damush:  Oh.  That’s a very good question.  And I mean it really depends on I think you and your research team and I think you know how complex the evidence base practice teams that you’re targeting—I would highly recommend not rapidly going through it and allowing yourself at least a year to really go through the pre-assessment phase and analyzing the data and developing your materials.  I would say at least—a good rule of thumb is about a year.

Moderator:  Thank you for that response and we do have a few more questions, but they are VA specific so I am going to respond to those people to please visit the EIS website and you can contact Deborah Derovan for access to the SharePoint if you are within the VA system.  And once again you can write into the chat—the question function and I can respond to you in writing with those addresses but once again they are within the VA intranet.

And we do have another question that has come in.  How does intervention mapping work in practice outside of a research environment?

Teresa M. Damush:  Well, I mean, I’m probably not the one to answer that I’m not sure what the other uses are beyond research.  That is where our team has used—

Moderator: Not a problem.  They can always look for other resources or contact us after the session.

Brian Mittman:  Molly, this is Brian.  Let me offer one other thought and that is again, my guess would be that within the health promotion field there may be examples of program developers who are working outside research who use this method.  I’m not familiar with any but given the higher volume of application of the method, that would be a good place to start.

Teresa M. Damush:  Right, but there usually is an evaluation component. I don’t know if it’s totally separate.  Program development is like Brian said; Hiller uses that type of tool.

Moderator:   Thank you both for those responses.  You commented on the chronic care model, but in the last seminar the speaker intentionally did not include the chronic care model as an implementation framework.  Can you explain the choice of using the chronic care model?

Teresa M. Damush:  Sure.  It’s a very good question. Technically it’s not considered an implementation framework.  It’s considered more of a health services framework and so it is a very useful framework for trying to organize a system change or a system organizing the different parts of the system that needs to be changed.  It’s not necessarily the implementation model.  So we, for the implementation aspect we put—we use the theory of planned behavior but it is—it was helpful for us to use it as a way of targeting all the different components of the healthcare system.  Yes, the last—Laura’s presentation on—and she is correct.  It is not an implementation model.  

Moderator:  Thank you for that response.  We do have about just a few minutes left before the end of the hour and I do have a few more questions.  The first one being when studying the implementation, how much do you include the theory?  For example, when I mentioned theory to people working on the floor, their eyes kind of roll back and whatever I say next is written off as some academic theory and not relevant to what they do day in and day out.   I understand the use of theory and implementation, but how much do you focus on theory when presenting the intervention/gathering of information from the stakeholders.

Teresa M. Damush:  First of all, I probably wouldn’t use the word theory if I was with the front line clinicians.  That’s the group I was talking with.  You can talk about the concepts if you can operationalize them to your particular targeted area, but I wouldn’t necessarily come and talk to them about theory because it’s not very relevant to them for what they need to do but it’s I operationalize a concept that had to do with the intervention for instance—I didn’t—we didn’t touch at all that we want to establish the social norms with them, but we were trying, through the service chiefs to get them to be the clinical champions to promote it and to really endorse it.  But again, we didn’t talk to them about the theory of planned behavior, so it’s—you kind of learn going through it about what as you saw the reaction of rolling their eyes, you kind of learn what they do react well to versus what they don’t.  I would definitely not use the word theory when talking to them.

Moderator:  Thank you for that response.  The next question we have just one moment, please.  Is—do you have experience in working with a type two hybrid trial design and if so what pitfalls have you found in evaluating a clinical approach and implementation approach simultaneously.

Teresa M. Damush:  I’m trying to think off the top of my head if we’ve done both, but it would be where actually I know we have a proposal under review that’s sort of along those lines, and so the pitfall is that you’re trying to still gather the evidence so the pitfall is in the degree of control.  So by that what I mean is that if you’re trying to establish the evidence you usually go through a randomized control trial where you know you strictly control the conditions that at the end you can contribute the change in your outcomes to the intervention or not.  Implementation there usually is some local adoption that needs to occur and so there’s less control and then you can—there are times when you need to make changes prospectively during the trial in an implementation trial so that could be a pitfall between doing a type two, but—

Moderator:  Thank you for that response.  That is the final question that has come in, so at this time I would like to allow you to make any concluding comments.

Teresa M. Damush:  Oh.  I just want to thank the attendees for coming in today.

Moderator:  Thank you for presenting for us.  And I would like to invite our attendees to join us for the next session which will be taking place on July 12 also at 2 p.m. eastern and Jeffrey Smith will be presenting on an enhancing implementation science overview and designed evaluation and components.  You will receive and e-mail about one week in advance and you can always register by going to the HSR&D webinar page and click on the cyber seminar catalog.  I want to thank our presenter very much and our attendees for joining us—and Dr. Mittman do you have anything that you’d like to add?

Brian Mittman:  My thanks as well.  Thank you.

Moderator:  Great.  Thank you all for joining us.  As you exit the session, you will have a survey that will load within a few minutes or a few seconds on your web browser, please do take the time to respond to it and I appreciate you joining us today.  This concludes today’s HSR&D cyber seminar.  Thank you.

**[End of Recording]**