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Implementation Science in Caregiving: Best Practices

Authors:
Leisa Easom, PhD, RN
Executive Director, Rosalynn Carter Institute for Caregiving

Laura Bauer, MPA
Director of National Initiatives, Rosalynn Carter Institute for Caregiving

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The Rosalynn Carter Institute for Caregiving (RCI) has conducted more than six years of work related to the integration and implementation of evidence-based programs to help family caregivers in communities across the United States. As a result, the RCI has emerged as a leader and purveyor in providing intensive technical assistance for the implementation of evidence-based caregiver interventions at the community level. In this role of purveyor, the RCI has led the transformative change required in agencies to implement and sustain evidence-based interventions with fidelity and good effect.  Resulting from this work is the knowledge of best practices to accelerate evidence-based programs into sustainable service systems, all of which serve older adults, individuals with disabilities and family caregivers. This article shares the lessons learned to assist others with successful navigation of the bridge from science to practice.
 
Historical Background 
The Rosalynn Carter Institute for Caregiving (RCI) was established in 1987 at Georgia Southwestern State University (GSW) in Americus, Georgia. The RCI was formed in honor of former First Lady Rosalynn Carter, an alumna of GSW, to enhance her long-standing commitments to human development, caregiving and mental health. At its core, the mission of RCI is to foster local, state, national, and international partnerships committed to building quality long-term, home and community- based services.
 
In 2007, RCI began an intensive study of the caregiving process, evidence-based programs to help family caregivers, and current translational strategies for making effective programs widely available to caregivers. We endeavored to bring together experts in research, program planning, and policy development in support of family caregivers. A national summit was convened with over 300 leading caregiver researchers and agency leaders from around the country to examine the evidence-base for caregiver support interventions and the extent to which it was being applied in practice. One of the summit’s key findings was that although many interventions with proven positive outcomes for caregivers had been developed, most had not been translated into programs at the community level  ̶  where caregivers reside.
 
The Journey
We began the journey by encouraging community agencies who were serving caregivers to implement evidence-based programs into their clinical practice. We encountered successes and learned many lessons. With funding from our corporate partner Johnson & Johnson, RCI awarded grants to community-based organizations that supported family caregivers from 2001- 2006  ̶  programs were wide in range and scope. The programs were creative, and most were well received in the community.  Yet, evaluative data was sparse, and outcomes were inconclusive. 
 
Striving to improve the measurement of impact and outcomes, we moved forward to break new ground in caregiving. Funding support centered on programs that had positive results in the clinical world, but yet had not been implemented in the “real” world, where caregivers and families were struggling to survive.  The National Implementation Research Network (NIRN, 2012) was identified as a model of excellence that could be easily adapted for use in ensuring successful implementation efforts of evidence-based caregiving programs. An intervention showing effectiveness in a randomized control trial would have a much higher probability of proving effective in practice with family caregivers. While new to the caregiving field, evidence-based practice had started in the medical profession some 20 years earlier (Sackett, Rosenberg, & Grey, 1996). Believing that public policy and practice should be based on the best available scientific evidence in order to be effective in the achievement of its goals and to be cost-effective, the adoption of evidence-based practice in caregiving made sense.
 
Identified Best Practices
Successful navigation of the bridge from science to practice can be a rocky road. We experienced our share of the rocks, but also gained significant knowledge as we successfully conducted and helped others to carry out this “translational research”. This work involved the translation of a randomized control trial study into the community with fidelity to the original study and achievement of positive outcomes in the community agency clinical practice. Following are lessons learned and best practices which have evolved as a result of our rocky road journey.

  •  Gauge organizational readiness and capacity. The pre-implementation environment should involve a pre-implementation assesment.  Technical assistance should include gauging the organization’s readiness and capacity to implement on the front end of program adoption.  The RCI developed a 3-session webinar series with homework assignments made (between webinar sessions). We utilized this approach with potential grant sites.  Two unintended and positive consequences occurred as a result of this process. A conversation between agency personnel and RCI was initiated prior to funding, so once sites were selected, a positive working relationship had already been established. Secondly, and most importantly, agencies that were not selected received vital information and training that would increase their probability of submitting a successful proposal to any future funding source.

  • Acknowledge the importance of the purveyor role – mediating research vs. service needs/goals. According to NIRN (2012), successful implementation of a program requires a purveyor. “A purveyor is an individual or group of individuals representing a program or practice who actively work to implement that practice or program with fidelity and good effect” (NIRN, 2012).  Purveyors accumulate data and experiential knowledge to learn what methods are most effective and efficient over time. An active purveyor wears many hats: supporting the organizational change process; assisting with training of coaches (interventionist), and evaluating trainers and coaches. Community agencies need a purveyor to guide and support through implementation and evaluation.

  • Recognize the need for clear implementation and field manuals for intervention implementation.  As we were developing our online database of evidence-based programs, we decided it would be useful to potential adopters if we sorted them according to implementation readiness. It is critical that community agency staff have access to concrete tools and standardized protocols to guide their implementation efforts, and we had learned that not all evidence-based caregiver interventions were ready to roll out.  Training materials need to be very clearly written and leave nothing to chance. A thorough review of the evidence-based caregiver interventions identified in RCI’s database (housed on our website) (RCI-CID, 2012) revealed vast variations in the training materials and certification requirements available for these interventions.

 

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