Caregiver.com

For About and By Caregivers
 
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

 

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.

  • Encourage coaching, cheerleading, and certification. As a purveyor, it is critical to become a coach for those caregiver interventions that lacked quality implementation materials, as well as a cheerleader for those programs that have created outstanding training and certification standards.  It is necessary to encourage an open dialogue around legal issues. Development of a licensure/certification process helps to ensure the program is delivered with fidelity. Indemnification is important as well so that risk is minimized and intellectual property is protected.

  • Assess fit and address technical assistance needs. In order to successfully implement an evidence-based caregiver program in a community-based setting, a series of questions must be addressed. How can we do it in the most cost-effective way possible? Who’s doing it? What is the training going to cost and what is the mode of delivery? Does our agency have personnel that can do this? Do we have the resources? Does it fit culturally? Does it meet an identified need in our community?

  • Value needed marketing/recruitment efforts. Common implementation issues exist across translational sites, although needs vary in their intensity.  Researchers (Gul & Ali, 2010; Nichols, et al, 2004; Thomas, 2002) have revealed that recruiting and retaining program participants is the most difficult piece of implementation. RCI’s experience in implementing evidence-based programs validates that finding.  From a technical assistance point of view, a significant amount of resources have to be devoted to marketing. Sites need to be able to show that the program helps to achieve the organization’s mission and helps establish new partnerships in the community.

  • Plan ahead for sustainability. Another best practice issue is sustainability. In order for a program to be completely sustainable, it must have a line item in the agency’s budget. Many agencies lack expertise in this area. Identifying potential funding streams to embed a program into an agency should begin immediately, not after grant funding has been depleted and the program is at risk of discontinuation.

  • Manage the data appropriately. Program evaluation is another concern. Many community-based agencies lack expertise in properly obtaining data that will not only indicate whether or not their program produced the expected benefits to caregivers, but also the cost effectiveness of the program. Through technical assistance, agency staff can be taught to identify the proper tools to measure the outcomes they are expecting, but they must also be taught the correct protocols for collecting data both pre- and post-intervention. Depending upon the capacity of the agency, it may be necessary to contract out the statistical analysis of this data.  Data will help make the case for future funding as well.

As a purveyor of evidence-based caregiver programs, RCI continues to refine its training and technical assistance offerings to assist community agencies that have varying degrees of expertise in adopting evidence-based caregiver programs with fidelity. We have launched the RCI National Training Center of Excellence and offer training and certification as well as intensive technical assistance,  in three evidence-based programs: RCI REACH (Resources Enhancing Alzheimer’s Caregiver Health); BRI Care Consultation (telephonic support for Alzheimer’s) and Operation Family Caregiver (program for service member and veteran families).  For more information, contact the RCI at 229-931-1234 or www.rosalynncarter.org.

 

Leisa R. Easom, PhD, RN is the Executive Director of the Rosalynn Carter Institute for Caregiving (RCI) and Pope Eminent Scholar at Georgia Southwestern State University (GSW). The mission of the RCI is to establish local, state, national and international partnerships committed to building quality long-term, home and community-based services for caregivers in the promotion of caregiver health, skills, and resilience. Dr. Easom was a Professor of Nursing and served as the Chair in the GSW School of Nursing from 2007-2010. Prior to this, she served as the Program Coordinator of the RN-BSN program at Macon State College in Macon, Georgia. She has served as an adjunct professor for the Clinical Nurse Leader graduate program at the Medical College of Georgia. Dr. Easom has been a Registered Nurse for over 30 years and devoted much of her nursing practice to addressing the mental and physical health needs of the older adult population.

Laura Bauer is the Director of National Initiatives for the Rosalynn Carter Institute for Caregiving (RCI) at Georgia Southwestern State University (GSW) in Americus, Georgia. Co-author of the RCI’s signature training program, Caring for You, Caring for Me – Education and Support for Family and Professional Caregivers, 2nd Edition; Laura has co-authored journal articles in Health & Social Work (2006) Educational Gerontology (2004), Generations (2010), and Aging Today (2012) and contributed chapters to Voices of Caregiving (LaChance Publishing, 2008) and Re-Creating Neighborhoods for Successful Aging (Health Professions Press, 2008).  Laura is a Certified Trainer in 5 evidence-based caregiving interventions: Savvy Caregiver, The Future is Now, RCI REACH, Care Consultation, and Operation Family Caregiver (Problem-Solving Training for Family Caregivers of Returning Service Members). She also teaches 3 courses in the RCI’s Certificate in Caregiving Program at Georgia Southwestern.

References 
Gul, R. &  Ali, P. (2010). Clinical trials: The challenge of recruitment and participants Journal of Clinical Nursing, 19(1/2), 227-233.

Nichols, L., Martindale-Adams, J., Burns, R., Coon, D., Ory, M., Mahoney, D., &  Winter, L. (2004). Social marketing as a framework for recruitment: illustrations from the REACH study. Journal Of Aging & Health, 16(5), 157S-176s.

NIRN. (2012). The National Implementation Research Network. Retrieved from http://nirn.fpg.unc.edu/
RCI Caregiver Intervention Database. (RCI CID). (2012). The Rosalynn Carter Institute for Caregiving. Retrieved from http://www.rosalynncarter.org/caregiver_intervention_database/

Sackett D. , Rosenberg W. , Gray J., et al. (1996). Evidence based medicine: what it is and what it isn’t: it’s about integrating individual clinical expertise and the best external evidence. BMJ, 312, 71 – 72.

Thomas V. (2002). Conducting research with community agencies: Meeting recruitment and community challenges. Journal Of Marital And Family Therapy, 28(1), 9-14.

 Subscribe to our weekly e-newsletter