Systematic development of an implementation strategy to promote high-intensity rehabilitation uptake in skilled nursing facilities.

Abstract

Background: Effective implementation of rehabilitation research into clinical practice is imperative to optimize patient outcomes; however, limitations persist. A systematic approach to develop implementation strategies can address known limitations.

Objective: To detail the systematic process for developing a strategy to implement high-intensity resistance rehabilitation (HIR) in skilled nursing facilities (SNFs), to be evaluated in future pragmatic trials.

Design: Expert-informed, theory-driven development study.

Setting: Academic research institute.

Participants: An expert panel of clinician-researchers (n = 5) and SNF clinicians (n = 4) with experience implementing HIR collaborated on strategy development.

Interventions: Development followed steps of implementation mapping: (1) identifying barriers and facilitators, (2) defining performance objectives, (3) selecting theory and evidence to develop the strategy, (4) producing the implementation strategy, and (5) planning for evaluation. Panel consensus meetings were held throughout the process.

Main outcome measure(s): Not applicable.

Results: Barriers and facilitators were identified at patient, clinician, and facility levels. Performance objectives included: (1) screening all patients for suitability, (2) dosing rehabilitation interventions at a high intensity for appropriate patients, (3) monitoring and adjusting dosage per patient response, and (4) progressing patients each session. Adult learning theories, social cognitive theory, and a review of the literature on effective implementation strategies guided development of a multicomponent implementation strategy: (1) train and educate clinicians (e.g., online modules); (2) provide interactive assistance (e.g., external implementation facilitator, check-ins); (3) support clinicians (e.g., job aids); and (4) change infrastructure (e.g., equipment provision). An evaluation plan was constructed.

Conclusion: This work illustrates a systematic approach, guided by implementation, adult learning, and behavior change principles, for developing an implementation strategy to promote HIR implementation in diverse SNFs. Health care leaders, clinicians, and researchers can replicate this approach to enhance rehabilitation practices, improving patient care and outcomes. Future work will evaluate this strategy for HIR implementation in SNFs.