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1.  MOVE! multidisciplinary programs: Challenges and resources for weight management treatment in VHA 
ABSTRACT
The MOVE! program has been a successful weight management and physical activity initiative from the Veteran's Health Administration. While it embraces a multicomponent approach to weight management, local facilities have primarily focused on the implementation of delivery of MOVE! educational materials to groups or individuals. We discuss additional MOVE!-related weight management efforts within VHA that reflect treatment strategies beyond delivery of these educational materials. First, we present a case study that highlights the special challenges associated with the Veteran overweight/obese population. Second, we describe the implementation of our local, multidisciplinary, individualized weight management clinic as an example of on-the-ground provision of a higher treatment intensity program as part of MOVE!'s multicomponent model. Third, we present program outcomes and consider challenges to program sustainability.
doi:10.1007/s13142-011-0092-5
PMCID: PMC3717680  PMID: 24073087
Obesity; Overweight; Weight loss; Weight management; Primary care; Veterans
2.  Implementation outcomes of evidence-based quality improvement for depression in VA community based outpatient clinics 
Background
Collaborative-care management is an evidence-based practice for improving depression outcomes in primary care. The Department of Veterans Affairs (VA) has mandated the implementation of collaborative-care management in its satellite clinics, known as Community Based Outpatient Clinics (CBOCs). However, the organizational characteristics of CBOCs present added challenges to implementation. The objective of this study was to evaluate the effectiveness of evidence-based quality improvement (EBQI) as a strategy to facilitate the adoption of collaborative-care management in CBOCs.
Methods
This nonrandomized, small-scale, multisite evaluation of EBQI was conducted at three VA Medical Centers and 11 of their affiliated CBOCs. The Plan phase of the EBQI process involved the localized tailoring of the collaborative-care management program to each CBOC. Researchers ensured that the adaptations were evidence based. Clinical and administrative staff were responsible for adapting the collaborative-care management program for local needs, priorities, preferences and resources. Plan-Do-Study-Act cycles were used to refine the program over time. The evaluation was based on the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) Framework and used data from multiple sources: administrative records, web-based decision-support systems, surveys, and key-informant interviews.
Results
Adoption: 69.0% (58/84) of primary care providers referred patients to the program. Reach: 9.0% (298/3,296) of primary care patients diagnosed with depression who were not already receiving specialty care were enrolled in the program. Fidelity: During baseline care manager encounters, education/activation was provided to 100% (298/298) of patients, barriers were assessed and addressed for 100% (298/298) of patients, and depression severity was monitored for 100% (298/298) of patients. Less than half (42.5%, 681/1603) of follow-up encounters during the acute stage were completed within the timeframe specified. During the acute phase of treatment for all trials, the Patient Health Questionnaire (PHQ9) symptom-monitoring tool was used at 100% (681/681) of completed follow-up encounters, and self-management goals were discussed during 15.3% (104/681) of completed follow-up encounters. During the acute phase of treatment for pharmacotherapy and combination trials, medication adherence was assessed at 99.1% (575/580) of completed follow-up encounters, and side effects were assessed at 92.4% (536/580) of completed follow-up encounters. During the acute phase of treatment for psychotherapy and combination trials, counseling session adherence was assessed at 83.3% (239/287) of completed follow-up encounters. Effectiveness: 18.8% (56/298) of enrolled patients remitted (symptom free) and another 22.1% (66/298) responded to treatment (50% reduction in symptom severity). Maintenance: 91.9% (10/11) of the CBOCs chose to sustain the program after research funds were withdrawn.
Conclusions
Provider adoption was good, although reach into the target population was relatively low. Fidelity and maintenance were excellent, and clinical outcomes were comparable to those in randomized controlled trials. Despite the organizational barriers, these findings suggest that EBQI is an effective facilitation strategy for CBOCs.
Trial registration
Clinical trial # NCT00317018.
doi:10.1186/1748-5908-7-30
PMCID: PMC3353178  PMID: 22494428
3.  Implementing a Farmers’ Market Incentive Program: Perspectives on the New York City Health Bucks Program 
Introduction
One strategy for lowering the prevalence of obesity is to increase access to and affordability of fruits and vegetables through farmers’ markets. However, little has been documented in the literature on the implementation of such efforts. To address this gap, the Division of Nutrition, Physical Activity, and Obesity (DNPAO) sponsored an evaluation of the New York City Health Bucks program, a farmers’ market coupon incentive program intended to increase access to fresh fruits and vegetables in underserved neighborhoods while supporting local farmers.
Methods
We conducted a process evaluation of Health Bucks program implementation. We interviewed 6 farmer/vendors, 3 market managers, and 4 program administrators, and collected data on site at 86 farmers’ markets, including surveys of 81 managers and 141 farmer/vendors on their perspectives on promotion and redemption of the incentive coupons; knowledge and attitudes regarding the program; experiences with markets and products; and facilitators and barriers to program participation.
Results
Results indicate that respondents view Health Bucks as a positive program model. Farmers’ market incentive coupon programs like Health Bucks are one strategy to address the problem of obesity and were associated with higher fruit and vegetable access and purchases in low-income communities.
Conclusions
This evaluation identified some areas for improving implementation of the Health Bucks program. Farmers’ market incentive programs like Health Bucks may be one avenue to increase access to and affordability of fruits and vegetables among low-income persons. Further research is needed to assess the potential effects of these programs on access and health outcomes.
doi:10.5888/pcd10.120285
PMCID: PMC3760082  PMID: 23987251
4.  Gastroenterology fellowship training: Approaches to curriculum assessment and evaluation 
BACKGROUND:
Medical education requires ongoing curriculum development and evaluation to incorporate new knowledge and competencies. The Kern model of curricular development is a generic model to guide curriculum design, whereas the Royal College of Physicians and Surgeons of Canada (RCPSC) has a specific model for curriculum development through its accreditation structure.
OBJECTIVE:
To apply the Kern model to an assessment of a residency program in gastroenterology.
METHODS:
A case study was used, which is a method of qualitative research designed to help researchers understand people and the societal contexts in which they live.
RESULTS:
The six steps involved in the Kern model of curricular development include problem identification; needs assessment; establishing objectives; establishing educational strategies; implementation; and evaluation. The steps of the RCPSC model of curriculum development include establishing an administrative structure for the program; objectives; structure and organization of the program; resources; clinical, academic and scholarly content of the program; and evaluation. Two differences between the models for curriculum development include the ability of the Kern model to conduct problem identification and learner needs assessment. Identifying problems that exist suggests a need for an educational program, such as the long wait times for gastroenterology referrals. Assessing learner needs allows for the development of a tailored curriculum for the trainee.
CONCLUSIONS:
The Kern model and RCPSC model for curriculum development are complementary. Consideration by the RCPSC should be provided to add the missing elements of curriculum design to the accreditation structure for completeness.
PMCID: PMC2660814  PMID: 18560634
Case study; Curriculum; Development; Gastroenterology
5.  Management perspectives on research contributions to practice through collaboration in the U.S. Veterans Health Administration: QUERI Series 
The Quality Enhancement Research Initiative (QUERI) is a unique quality improvement program designed to connect health services researchers to Veterans Health Administration (VHA) management and operations, as well as to provide the science and initiative for making change. Through this process, QUERI stakeholders have learned that success and impact in improving healthcare quality and outcomes largely depends on coordination and collaboration among numerous VHA programs and organizations working to develop and implement evidence-based clinical policies, practices, and quality improvement strategies. This Commentary discusses some of these collaborative efforts and perceived successes in achieving common goals from the viewpoints of two closely involved VHA Operations/Support stakeholders.
The Commentary is part of a Series of articles documenting implementation science frameworks and tools developed by the U.S. Department of Veterans Affairs Quality Enhancement Research Initiative (QUERI).
doi:10.1186/1748-5908-4-8
PMCID: PMC2650677  PMID: 19245708
6.  Developing an active implementation model for a chronic disease management program 
Background
Introduction and diffusion of new disease management programs in healthcare is usually slow, but active theory-driven implementation seems to outperform other implementation strategies. However, we have only scarce evidence on the feasibility and real effect of such strategies in complex primary care settings where municipalities, general practitioners and hospitals should work together. The Central Denmark Region recently implemented a disease management program for chronic obstructive pulmonary disease (COPD) which presented an opportunity to test an active implementation model against the usual implementation model. The aim of the present paper is to describe the development of an active implementation model using the Medical Research Council’s model for complex interventions and the Chronic Care Model.
Methods
We used the Medical Research Council’s five-stage model for developing complex interventions to design an implementation model for a disease management program for COPD. First, literature on implementing change in general practice was scrutinised and empirical knowledge was assessed for suitability. In phase I, the intervention was developed; and in phases II and III, it was tested in a block- and cluster-randomised study. In phase IV, we evaluated the feasibility for others to use our active implementation model.
Results
The Chronic Care Model was identified as a model for designing efficient implementation elements. These elements were combined into a multifaceted intervention, and a timeline for the trial in a randomised study was decided upon in accordance with the five stages in the Medical Research Council’s model; this was captured in a PaTPlot, which allowed us to focus on the structure and the timing of the intervention. The implementation strategies identified as efficient were use of the Breakthrough Series, academic detailing, provision of patient material and meetings between providers. The active implementation model was tested in a randomised trial (results reported elsewhere).
Conclusion
The combination of the theoretical model for complex interventions and the Chronic Care Model and the chosen specific implementation strategies proved feasible for a practice-based active implementation model for a chronic-disease-management-program for COPD. Using the Medical Research Council’s model added transparency to the design phase which further facilitated the process of implementing the program.
Trial registration: http://www.clinicaltrials.gov/(NCT01228708).
PMCID: PMC3718271  PMID: 23882169
implementation; disease management; Denmark; Chronic Care Model; Breakthrough Series; PaTPlot
7.  A Policy Analysis of the implementation of a Reproductive Health Vouchers Program in Kenya 
BMC Public Health  2012;12:540.
Background
Innovative financing strategies such as those that integrate supply and demand elements like the output-based approach (OBA) have been implemented to reduce financial barriers to maternal health services. The Kenyan government with support from the German Development Bank (KfW) implemented an OBA voucher program to subsidize priority reproductive health services. Little evidence exists on the experience of implementing such programs in different settings. We describe the implementation process of the Kenyan OBA program and draw implications for scale up.
Methods
Policy analysis using document review and qualitative data from 10 in-depth interviews with facility in-charges and 18 with service providers from the contracted facilities, local administration, health and field managers in Kitui, Kiambu and Kisumu districts as well as Korogocho and Viwandani slums in Nairobi.
Results
The OBA implementation process was designed in phases providing an opportunity for learning and adapting the lessons to local settings; the design consisted of five components: a defined benefit package, contracting and quality assurance; marketing and distribution of vouchers and claims processing and reimbursement. Key implementation challenges included limited feedback to providers on the outcomes of quality assurance and accreditation and budgetary constraints that limited effective marketing leading to inadequate information to clients on the benefit package. Claims processing and reimbursement was sophisticated but required adherence to time consuming procedures and in some cases private providers complained of low reimbursement rates for services provided.
Conclusions
OBA voucher schemes can be implemented successfully in similar settings. For effective scale up, strong partnership will be required between the public and private entities. The government’s role is key and should include provision of adequate funding, stewardship and looking for opportunities to utilize existing platforms to scale up such strategies.
doi:10.1186/1471-2458-12-540
PMCID: PMC3490771  PMID: 22823923
Output-based approach; Reproductive health; Vouchers; Maternal health; Safe motherhood; Family planning; Policy analysis
8.  Diabetes Self-Management Education in South Auckland, New Zealand, 2007-2008 
Preventing Chronic Disease  2011;8(2):A42.
Introduction
Self-management education programs seek to help patients realize that they are their own principal caregivers and that health care professionals are consultants who support them in this role. The aim of this study was to evaluate a diabetes self-management education program implemented as part of a district-wide approach in South Auckland, New Zealand, which has some of the highest prevalence rates for diabetes and is one of the most ethnically diverse and deprived regions of New Zealand.
Methods
Self-management attitudes and behaviors were monitored with the use of questionnaires before and after program implementation. Clinical outcomes such as hemoglobin A1c, body mass index, and blood pressure were also tracked before the program began and 3 months after the program ended. Participant focus groups and facilitator interviews were conducted to explore perceptions of the program.
Results
Participants showed improvement in attitudes toward their own ability to manage their diabetes; in diet, physical activity, and foot care; and in hemoglobin A1c levels 3 months after the end of participation. Participants also reduced their sense of isolation when dealing with their diabetes. However, catering to the needs of a multiethnic community is extremely resource-intensive because of the need to provide adequate language and cultural interpretation.
Conclusion
Self-management education can work in multiethnic, high-needs communities in New Zealand. Programs must ensure they enable the appropriate mechanisms and have appropriate resources to support the community's needs.
PMCID: PMC3073435  PMID: 21324256
9.  Implementing and Evaluating a Multicomponent Inpatient Diabetes Management Program: Putting Research into Practice 
Background
Strategies for successful implementation of hospitalwide glucose control efforts were addressed in a conceptual model for the development and implementation of an institutional inpatient glucose management program.
Conceptual Model Components
The Glucose Steering Committee incrementally developed and implemented hospitalwide glucose policies, coupled with targeted education and clinical decision support to facilitate policy acceptance and uptake by staff while incorporating process and outcome measures to objectively assess the effectiveness of quality improvement efforts. The model includes four components: (1) engaging staff and hospital executives in the importance of inpatient glycemic management, (2) educating staff involved in the care of patients with diabetes through structured knowledge dissemination, (3) executing evidence-based inpatient glucose management through development of policies and clinical decision aids, and (4) evaluating intervention effectiveness through assessing process measures, intermediary glucometric outcomes, and clinical and economic outcomes. An educational curriculum for nursing, provider, and pharmacist diabetes education programs and current glucometrics were also developed.
Outcomes
Overall the average patient-day–weighted mean blood glucose (PDWMBG) was below the currently recommended maximum of 180 mg/dL in patients with diabetes and hyperglycemia, with a significant decrease in PDWMBG of 7.8 mg/dL in patients with hyperglycemia. The program resulted in an 18.8% reduction in hypoglycemia event rates, which was sustained.
Conclusion
Inpatient glucose management remains an important area for patient safety, quality improvement, and clinical research, and the implementation model should guide other hospitals in their glucose management initiatives.
PMCID: PMC3697928  PMID: 22649859
10.  Integrated Advanced Information Management Systems: a twenty-year history at the University of Cincinnati* 
The University of Cincinnati (UC) has been active in the National Library of Medicine's Integrated Advanced Information Management Systems (IAIMS) program since IAIMS' inception in 1984. UC received IAIMS planning and modeling grants in the 1980s, spent the 1990s practicing its own form of “iaims” and refining its vision, and, in May 2003, received an IAIMS operations grant in the first round of awards under “the next generation” program. This paper discusses the history of IAIMS at UC and describes the goals, methods, and strategies of the current IAIMS program. The goals of UC's IAIMS program are to: improve teaching effectiveness by improving the assessment of health professional students and residents in laboratory and clinical teaching and learning environments; improve the ability of researchers, educators, and students to acquire and apply the knowledge required to be more productive in genomic research and education; and increase the productivity of researchers and administrators in the pre-award, post-award, and compliance phases of the research lifecycle.
PMCID: PMC385297  PMID: 15098045
11.  Healthy eating and active living for diabetes in primary care networks (HEALD-PCN): rationale, design, and evaluation of a pragmatic controlled trial for adults with type 2 diabetes 
BMC Public Health  2012;12:455.
Background
While strong and consistent evidence supports the role of lifestyle modification in the prevention and management of type 2 diabetes (T2DM), the best strategies for program implementation to support lifestyle modification within primary care remain to be determined. The objective of the study is to evaluate the implementation of an evidence-based self- management program for patients with T2DM within a newly established primary care network (PCN) environment.
Method
Using a non-randomized design, participants (total N = 110 per group) will be consecutively allocated in bi-monthly blocks to either a 6-month self-management program lead by an Exercise Specialist or to usual care. Our primary outcome is self-reported physical activity and pedometer steps.
Discussion
The present study will assess whether a diabetes self-management program lead by an Exercise Specialist provided within a newly emerging model of primary care and linked to available community-based resources, can lead to positive changes in self-management behaviours for adults with T2DM. Ultimately, our work will serve as a platform upon which an emerging model of primary care can incorporate effective and efficient chronic disease management practices that are sustainable through partnerships with local community partners.
Clinical Trials Registration
ClinicalTrials.gov identifier: NCT00991380
doi:10.1186/1471-2458-12-455
PMCID: PMC3441468  PMID: 22712881
Type 2 diabetes; Primary care; Physical activity; Diet; Exercise specialist; Health service research
12.  Health Services Research and Development: the Veterans Administration Program. 
Health Services Research  1986;20(6 Pt 2):789-824.
Health expenditures are rising inexorably; health status shows relatively little gain; technological possibilities are outstripping our ability or willingness to provide a commensurate level of resources. Clinical and administrative managers face increasingly difficult choices among alternative interventions in attempting to resolve these problems. If health services research is to succeed as a tool for assisting these decisions, clinicians, administrators, and researchers must view it as an integral part of management. This paper describes this concept of health services research and its implementation by the VA HSR&D Service, results from 1981 to date, and future directions. Four programs implement the Service's system to make relevant, valid information accessible to VA staff who can use it to improve veterans' health care: Investigator-Initiated Research (IIR) Program; HSR&D Field Program, which implements the Service's mission in various local areas VA-wide; Special Projects Program, responsive to system-wide issues, including technology assessment and transfer; and Resources Program, the Service's own management system. The Service's impact on improving veterans health care is already apparent. However, the true value of the HSR&D system will become apparent only in the 1990s, after the capacity for conducting health services research has been built and integrated fully with clinical and administrative practice. The VA, the nation's largest health care system, has a unique opportunity to demonstrate how health services research can improve health care.
PMCID: PMC1068908  PMID: 3081467
13.  Fostering shared decision making by occupational therapists and workers involved in accidents resulting in persistent musculoskeletal disorders: A study protocol 
Background
From many empirical and theoretical points of view, the implementation of shared decision making (SDM) in work rehabilitation for pain due to a musculoskeletal disorder (MSD) is justified but typically the SDM model applies to a one on one encounter between a healthcare provider and a patient and not to an interdisciplinary team.
Objectives
To adapt and implement an SDM program adapted to the realities of work rehabilitation for pain associated with a MSD. More specific objectives are to adapt an SDM program applicable to existing rehabilitation programs, and to evaluate the extent of implementation of the SDM program in four rehabilitation centres.
Method
For objective one, we will use a mixed perspective combining a theory-based development program/intervention and a user-based perspective. The users are the occupational therapists (OTs) and clinical coordinators. The strategies for developing an SDM program will include consulting the scientific literature and group consensus with clinicians-experts. A sample of convenience of eight OTs, four clinical coordinators and four psychologists all of whom have been working full-time in MSD rehabilitation for more than two years will be recruited from four collaborating rehabilitation centres. For objective two, using the same criteria as for objective one, we will first train eight OTs in SDM. Second, using a descriptive design, the extent to which the SDM program has been implemented will be assessed through observations of the SDM process. The observation data will be triangulated with the dyadic working alliance questionnaire, and findings from a final individual interview with each OT. A total of five patients per trained OT will be recruited, for a total of 40 patients. Patients will be eligible if they have a work-related disability for more than 12 weeks due to musculoskeletal pain and plan to start their work rehabilitation programs.
Discussion
This study will be the first evaluation of the program and it is expected that improvements will be made prior to a broader-scale implementation. The ultimate aim is to improve the quality of decision making, patients' quality of life, and reduce the duration of their work-related disability by improving the services offered during the rehabilitation process.
doi:10.1186/1748-5908-6-22
PMCID: PMC3068973  PMID: 21414207
14.  Evaluation of the implementation of an integrated primary care network for prevention and management of cardiometabolic risk in Montréal 
BMC Family Practice  2011;12:126.
Background
The goal of this project is to evaluate the implementation of an integrated and interdisciplinary program for prevention and management of cardiometabolic risk (PCMR). The intervention is based on the Chronic Care Model. The study will evaluate the implementation of the PCMR in 6 of the 12 health and social services centres (CSSS) in Montréal, and the effects of the PCMR on patients and the practice of their primary care physicians up to 40 months following implementation, as well as the sustainability of the program. Objectives are: 1-to evaluate the effects of the PCMR and their persistence on patients registered in the program and the practice of their primary care physicians, by implementation site and degree of exposure to the program; 2-to assess the degree of implementation of PCMR in each CSSS territory and identify related contextual factors; 3-to establish the relationships between the effects observed, the degree of PCMR implementation and the related contextual factors; 4-to assess the impact of the PCMR on strengthening local services networks.
Methods/Design
The evaluation will use a mixed design that includes two complementary research strategies. The first strategy is similar to a quasi-experimental "before-after" design, based on a quantitative approach; it will look at the program's effects and their variations among the six territories. The effects analysis will use data from a clinical database and from questionnaires completed by participating patients and physicians. Over 3000 patients will be recruited. The second strategy corresponds to a multiple case study approach, where each of the six CSSS constitutes a case. With this strategy, qualitative methods will set out the context of implementation using data from semi-structured interviews with program managers. The quantitative data will be analyzed using linear or multilevel models complemented with an interpretive approach to qualitative data analysis.
Discussion
Our study will identify contextual factors associated with the effectiveness, successful implementation and sustainability of such a program. The contextual information will enable us to extrapolate our results to other contexts with similar conditions.
Trial registration
ClinicalTrials.gov: NCT01326130
doi:10.1186/1471-2296-12-126
PMCID: PMC3282661  PMID: 22074614
15.  A new combined strategy to implement a community occupational therapy intervention: designing a cluster randomized controlled trial 
BMC Geriatrics  2011;11:13.
Background
Even effective interventions for people with dementia and their caregivers require specific implementation efforts. A pilot study showed that the highly effective community occupational therapy in dementia (COTiD) program was not implemented optimally due to various barriers. To decrease these barriers and make implementation of the program more effective a combined implementation (CI) strategy was developed. In our study we will compare the effectiveness of this CI strategy with the usual educational (ED) strategy.
Methods
In this cluster randomized, single-blinded, controlled trial, each cluster consists of at least two occupational therapists, a manager, and a physician working at Dutch healthcare organizations that deliver community occupational therapy. Forty-five clusters, stratified by healthcare setting (nursing home, hospital, mental health service), have been allocated randomly to either the intervention group (CI strategy) or the control group (ED strategy). The study population consists of the professionals included in each cluster and community-dwelling people with dementia and their caregivers. The primary outcome measures are the use of community OT, the adherence of OTs to the COTiD program, and the cost effectiveness of implementing the COTiD program in outpatient care. Secondary outcome measures are patient and caregiver outcomes and knowledge of managers, physicians and OTs about the COTiD program.
Discussion
Implementation research is fairly new in the field of occupational therapy, making this a unique study. This study does not only evaluate the effects of the CI-strategy on professionals, but also the effects of professionals' degree of implementation on client and caregiver outcomes.
Clinical trials registration
NCT01117285
doi:10.1186/1471-2318-11-13
PMCID: PMC3078849  PMID: 21450063
16.  eHealth in Queensland: Progressing towards a Patient Centric, Networked Model of Care 
Healthcare Informatics Research  2011;17(3):190-195.
Objectives
Factors such as an ageing and rapidly growing population, an increase in chronic disease rates and a global shortage of health professionals place increased pressure on Australian health departments to deliver more with less. To address the challenge faced by clinicians and support staff, the Queensland Department of Health established an eHealth strategy in 2006 with a vision to deliver a patient centric, networked model of care.
Methods
Queensland Health's eHealth program is a complex program which brings together the outputs and products of numerous projects to provide new clinical capabilities across the state. To ensure the potential benefits of the Queensland Government investment are realised, the eHealth program is implementing comprehensive benefits management to plan for key outcomes and benefits, support projects to deliver those benefits and ensure that they are delivered through ongoing measurement.
Results
The first stage of the eHealth program is already delivering benefits across the health department with a number of projects currently live in numerous sites across Queensland.
Conclusions
By adopting an evidence based benefits management approach, Queensland Health's eHealth program is able to demonstrate the achievement of these benefits with tangible evidence that will create momentum for change in the short term, provide the evidence for future funding applications in the medium term, and build an understanding of the economic impacts of eHealth in the long term.
doi:10.4258/hir.2011.17.3.190
PMCID: PMC3212747  PMID: 22084815
Public Health Informatics; Electronic Health Record; Radiology Information Systems; Information Management
17.  HIV Rapid Testing in Substance Abuse Treatment: Implementation Following a Clinical Trial 
Evaluation and program planning  2011;34(4):399-406.
The Substance Abuse Mental Health Services Administration has promoted HIV testing and counseling as an evidence-based practice. Nevertheless, adoption of HIV testing in substance abuse treatment programs has been slow. This article describes the experience of a substance abuse treatment agency where, following participation in a clinical trial, the agency implemented an HIV testing and counseling program. During the trial, a post-trial pilot, and early implementation the agency identified challenges and developed strategies to overcome barriers to adoption of the intervention. Their experience may be instructive for other treatment providers seeking to implement an HIV testing program. Lessons learned encompassed the observed acceptability of testing and counseling to clients, the importance of a “champion” and staff buy-in, the necessity of multiple levels of community and agency support and collaboration, the ability to streamline staff training, the need for a clear chain of command, the need to develop program specific strategies, and the requirement for sufficient funding . An examination of costs indicated that some staff time may not be adequately reimbursed by funding sources for activities such as adapting the intervention, start-up training, ongoing supervision and quality assurance, and overhead costs
doi:10.1016/j.evalprogplan.2011.02.007
PMCID: PMC3124222  PMID: 21367457
HIV; drug treatment; implementation; evidence-based practice
18.  Leadership's Role in Support of Online Academic Programs: Implementing an Administrative Support Matrix 
The proliferation of online education programs creates a myriad of challenges for those charged with implementation and delivery of these programs. Although creating and sustaining quality education is a shared responsibility of faculty, staff, and academic leaders, this article focuses on the pivotal role of leadership in securing the necessary resources, developing the organizational structures, and influencing organizational culture. The vital foundation for a successful outcome when implementing online education programs is the role of leadership in providing adequate and appropriate support. Abundant literature extols the roles of leadership in project management; however, there is a dearth of models or systematic methods for leaders to follow regarding how to implement and sustain online programs. Research conducted by the authors culminated in the development of an Administrative Support Matrix, thus addressing the current gap in the literature.
PMCID: PMC3544146  PMID: 23346030
Keywords online teaching; faculty support; leadership; e-learning
19.  Challenges in knowledge translation: the early years of Cancer Care Ontario’s Program in Evidence-Based Care 
Current Oncology  2012;19(1):27-35.
Background
Cancer Care Ontario’s Program in Evidence-Based Care (pebc) was formalized in 1997 to produce clinical practice guidelines for cancer management for the Province of Ontario. At the time, the gap between guideline development and implementation was beginning to be acknowledged. The Program implemented strategies to promote use of guidelines.
Methods
The program had to overcome numerous social challenges to survive.
Prospective strategies useful to practitioners—including participation, transparent communication, a methodological vision, and methodology skills development offerings—were used to create a culture of research-informed oncology practice within a broad community of practitioners.
Reactive strategies ensured the survival of the program in the early years, when some within the influential academic community and among decision-makers were skeptical about the feasibility of a rigorous methodologic approach meeting the fast turnaround times necessary for policy.
Results
The paper details the pebc strategies within the context of what was known about knowledge translation (kt) at the time, and it tries to identify key success factors.
Conclusions
Many of the barriers faced in the implementation of kt—and the strategies for overcoming them—are unavailable in the public domain because the relevant reporting does not fit the traditional paradigm for publication. Telling the “stories behind the story” should be encouraged to enhance the practice of kt beyond the science.
doi:10.3747/co.19.985
PMCID: PMC3267588  PMID: 22328839
Knowledge translation challenges; cancer guidelines; Cancer Care Ontario
20.  Using Mobile Health to Support the Chronic Care Model: Developing an Institutional Initiative 
Background. Self-management support and team-based care are essential elements of the Chronic Care Model but are often limited by staff availability and reimbursement. Mobile phones are a promising platform for improving chronic care but there are few examples of successful health system implementation. Program Development. An iterative process of program design was built upon a pilot study and engaged multiple institutional stakeholders. Patients identified having a “human face” to the pilot program as essential. Stakeholders recognized the need to integrate the program with primary and specialty care but voiced concerns about competing demands on clinician time. Program Description. Nurse administrators at a university-affiliated health plan use automated text messaging to provide personalized self-management support for member patients with diabetes and facilitate care coordination with the primary care team. For example, when a patient texts a request to meet with a dietitian, a nurse-administrator coordinates with the primary care team to provide a referral. Conclusion. Our innovative program enables the existing health system to support a de novo care management program by leveraging mobile technology. The program supports self-management and team-based care in a way that we believe engages patients yet meets the limited availability of providers and needs of health plan administrators.
doi:10.1155/2012/871925
PMCID: PMC3523146  PMID: 23304135
21.  Self-management for osteoarthritis of the knee: Does mode of delivery influence outcome? 
Background
Self-management has become increasingly popular in the management of chronic diseases. There are many different self-management models. Meta analyses of arthritis self-management have concluded that it is difficult to recommend any one program in preference to another due to inconsistencies in the study designs used to evaluate different programs.
The Stanford Arthritis Self-Management Program (ASMP), most commonly delivered by trained lay leaders, is a generic program widely used for people with rheumatological disorders. We have developed a more specific program expressly for people with osteoarthritis of the knee (OAKP). It includes information designed to be delivered by health professionals and results in improvements in pain, function and quality of life.
Aim: To determine whether, for people with osteoarthritis (OA) of the knee, the OAKP implemented in a primary health care setting can achieve and maintain clinically meaningful improvements in more participants than ASMP delivered in the same environment.
Methods/Design
The effectiveness of the programs will be compared in a single-blind randomized study.
Participants: 146 participants with established OA knee will be recruited. Volunteers with coexistent inflammatory joint disease or serious co-morbidities will be excluded.
Interventions: Participants will be randomised into either OAKP or ASMP groups and followed for 6 months.
Measurements: Assessments will be immediately before and after the intervention and at 6 months. Primary outcome measures will be WOMAC and SF-36 questionnaires and a VAS for pain. Secondary outcomes will include balance, tested using a timed single leg balance test and a timed step test and self-efficacy. Data will be analysed using repeated measures ANOVA.
Discussion
With an aging population the health care costs for people with arthritis are ever increasing. Although cost analysis is beyond the scope of this study, it is reasonable to expect that costs will be greater when health professionals deliver self-management programs as opposed to lay leaders. Consequently it is critical to examine the relative effectiveness of the primary care management strategies available for OA.
Trial Registration
This study is registered with the Australian New Zealand Clinical Trials Registry: 12607000031460
doi:10.1186/1471-2474-11-56
PMCID: PMC2850876  PMID: 20334688
22.  Vital Sign Monitoring Using Human Patient Simulators at Pharmacy Schools in Japan 
Objective
To develop, implement, and assess an experience-based education program using human patient simulators to instruct pharmacy students in monitoring vital signs to identify drug treatment effects and adverse events.
Design
Medical emergency care programs using human patient simulators were prepared and facilitated practical clinical training in resuscitation, which required selecting drugs while monitoring changes in blood pressure, pulse, and arterial blood oxygen saturation. Training encompassed the monitoring of routes of drug administration, drawing of simulated blood, vital-sign monitoring based on a pharmaceutical universal training model, vital-sign monitoring devices and simulators, and medical emergency education using biological simulators.
Assessment
Before and after bedside training, students were asked to complete a questionnaire to assess their understanding of vital sign monitoring and emergency care. Students successfully learned how to monitor routes of drug administration, vital signs, and pathological conditions. There was a significant increase in students' recognition of the importance of vital-sign monitoring.
Conclusion
Experienced-based training using patient simulators successfully prepared pharmacy students to monitor vitals signs and identify drug treatment effects and adverse events.
PMCID: PMC2972527  PMID: 21088738
human patient simulator; vital signs; medical emergency care; practice experience; simulation
23.  Performance evaluation of the essential dimensions of the primary health care services in six localities of Bogota–Colombia: a cross-sectional study 
Background
The high segmentation and fragmentation in the provision of services are some of the main problems of the Colombian health system. In 2004 the district government of Bogota decided to implement a Primary Health Care (PHC) strategy through the Home Health program. PHC was conceived as a model for transforming health care delivery within the network of the first-level public health care facilities. This study aims to evaluate the performance of the essential dimensions of the PHC strategy in six localities geographically distributed throughout Bogotá city.
Methods
The rapid assessment tool to measure PHC performance, validated in Brazil, was applied. The perception of participants (users, professionals, health managers) in public health facilities where the Home Health program was implemented was compared with the perception of participants in private health facilities not implementing the program. A global performance index and specific indices for each primary care dimension were calculated. A multivariate logistic regression analysis was conducted to determine possible associations between the performance of the PHC dimensions and the self-perceived health status of users.
Results
The global performance index was rated as good for all participants interviewed. In general, with the exception of professionals, the differences in most of the essential dimensions seemed to favor public health care facilities where the Home Health program was implemented. The weakest dimensions were the family focus and community orientation—rated as critical by users; the distribution of financial resources—rated as critical by health managers; and, accessibility—rated as intermediate by users.
Conclusions
The overall findings suggest that the Home Health program could be improving the performance of the network of the first-level public health care facilities in some PHC essential dimensions, but significant efforts to achieve its objectives and raise its visibility in the community are required.
doi:10.1186/1472-6963-13-315
PMCID: PMC3844402  PMID: 23947574
Primary health care; Health services evaluation; Bogota
24.  Implementation of a Chronic Illness Model for Diabetes Care in a Family Medicine Residency Program 
Journal of General Internal Medicine  2010;25(Suppl 4):615-619.
ABSTRACT
INTRODUCTION
While the Chronic Care Model (CCM) has been shown to improve the care of patients with chronic illnesses, primary care physicians have been unprepared in its use, and residencies have encountered challenges in introducing it into the academic environment.
AIM
Our residency program has implemented a diabetes management program modeled on the CCM to evaluate its impact on health outcomes of diabetic patients and educational outcomes of residents.
SETTING
University-affiliated, community-based family medicine residency program.
PROGRAM DESCRIPTION
Six residents, two faculty clinicians, and clinic staff formed a diabetes management team. We redesigned the outpatient experience for diabetic patients by incorporating elements of the CCM: multidisciplinary team care through planned and group visits; creation of a diabetes registry; use of guidelines-based flow sheets; and incorporation of self-management goal-setting. Residents received extensive instruction in diabetes management, quality improvement, and patient self-management.
PROGRAM EVALUATION
We achieved overall improvement in all metabolic and process measures for patients, with the percentage achieving HbA1c, LDL, and BP goals simultaneously increasing from 5.7% to 17.1%. Educational outcomes for residents, as measured by compliance with review of provider performance reports and self-management goal-setting with patients, also significantly improved.
DISCUSSION
Through a learning collaborative experience, residency programs can successfully incorporate chronic care training for residents while addressing gaps in care for patients with diabetes.
doi:10.1007/s11606-010-1431-9
PMCID: PMC2940436  PMID: 20737237
chronic care model; learning collaborative; diabetes; residency education
25.  A collaborative approach to identifying effective incentives for mental health clinicians to improve depression care in a large managed behavioral healthcare organization 
This descriptive study used stakeholder input to prioritize evidence-based strategies for improving depression care and to select incentives for mental health clinicians to adopt those strategies, and to conduct a feasibility test of an incentive-based program in a managed behavioral healthcare organization (MBHO). In two rounds of interviews and a stakeholder meeting, MBHO administrators and clinicians selected increasing combination treatment (antidepressant plus psychotherapy) rates as the program goal; and paying a bonus for case reviews, clinician feedback, and clinician education as incentives. We assessed program feasibility with case review and clinician surveys from a large independent practice association that contracts with the MBHO. Findings suggest that providing incentives for mental health clinicians is feasible and the incentive program did increase awareness. However, adoption may be challenging because of administrative barriers and limited clinical data available to MBHOs.
doi:10.1007/s10488-010-0313-0
PMCID: PMC3041867  PMID: 20957427
Provider behavior change; incentives; mental health services; depression; quality improvement

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