VA Greater Los Angeles Healthcare System, Geriatric Research Education and Clinical Center, 16111, St (11E), North Hills, Plummer, CA, 91343, USA.
David Geffen School of Medicine at UCLA, Division of Geriatric Medicine, 10945 Le Conte Avenue, Suite 2339, Los Angeles, CA, 90095, USA.
Implement Sci. 2017 Sep 2;12(1):109. doi: 10.1186/s13012-017-0632-6.
Veterans Health Affairs (VA) home-based primary care (HBPC) is an evidence-based interdisciplinary approach to non-institutional long-term care that was developed in urban settings to provide longitudinal care for vulnerable older patients. Under the authority of a Memorandum of Understanding between VA and Indian Health Service (IHS) to improve access to healthcare, 14 VA medical centers (VAMC) independently initiated plans to expand HBPC programs to rural American Indian reservations and 12 VAMC successfully implemented programs. The purpose of this study is to describe barriers and facilitators to implementation in rural Native communities with the aim of informing planners and policy-makers for future program expansions.
A qualitative comparative case study approach was used, treating each of the 14 VAMC as a case. Using the Consolidated Framework for Implementation Research (CFIR) to inform an open-ended interview guide, telephone interviews (n = 37) were conducted with HBPC staff and clinicians and local/regional managers, who participated or oversaw implementation. The interviews were transcribed, coded, and then analyzed using CFIR domains and constructs to describe and compare experiences and to identify facilitators, barriers, and adaptations that emerged in common across VAMC and HBPC programs.
There was considerable variation in local contexts across VAMC. Nevertheless, implementation was typically facilitated by key individuals who were able to build trust and faith in VA healthcare among American Indian communities. Policy promoted clinical collaboration but collaborations generally occurred on an ad hoc basis between VA and IHS clinicians to optimize patient resources. All programs required some adaptations to address barriers in rural areas, such as distances, caseloads, or delays in hiring additional clinicians. VA funding opportunities facilitated expansion and sustainment of these programs.
Since program expansion is a responsibility of the HBPC program director, there is little sharing of lessons learned across VA facilities. Opportunities for shared learning would benefit federal healthcare organizations to expand other medical services to additional American Indian communities and other rural and underserved communities, as well as to coordinate with other healthcare organizations. The CFIR structure was an effective analytic tool to compare programs addressing multiple inner and outer settings.
退伍军人事务部（VA）居家初级保健（HBPC）是一种循证的跨学科方法，用于为弱势老年患者提供非机构化的长期护理，最初是在城市环境中开发的，以提供纵向护理。根据 VA 和印第安人健康服务局（IHS）之间的谅解备忘录的授权，为改善医疗保健的可及性，14 个 VA 医疗中心（VAMC）独立启动了将 HBPC 计划扩展到农村美国印第安人保留地的计划，其中 12 个 VAMC 成功实施了该计划。本研究的目的是描述在农村原住民社区实施的障碍和促进因素，旨在为未来的项目扩展为规划者和政策制定者提供信息。
采用定性比较案例研究方法，将每个 14 个 VAMC 作为一个案例进行处理。使用实施研究综合框架（CFIR）为开放式访谈指南提供信息，对 HBPC 工作人员和临床医生以及当地/区域经理进行了电话访谈（n=37），他们参与或监督了实施。访谈记录、编码，然后使用 CFIR 领域和结构进行分析，以描述和比较经验，并确定在 VAMC 和 HBPC 计划中普遍出现的促进因素、障碍和调整。
尽管 VAMC 之间存在相当大的地方差异，但实施通常是由能够在美洲印第安社区中建立对 VA 医疗保健的信任和信心的关键个人促成的。政策促进了临床合作，但合作通常是 VA 和 IHS 临床医生之间的临时合作，以优化患者资源。所有计划都需要进行一些调整，以解决农村地区的障碍，例如距离、工作量或招聘额外临床医生的延迟。VA 的供资机会促进了这些计划的扩展和维持。
由于 HBPC 项目主任负责计划扩展，因此 VA 设施之间几乎没有共享经验教训。联邦医疗保健组织共享学习机会将使他们能够将其他医疗服务扩展到更多的美国印第安社区和其他农村和服务不足的社区，并与其他医疗保健组织协调。CFIR 结构是一种有效的分析工具，可用于比较针对多个内部和外部环境的计划。
