Using the implementation research logic model to examine high-intensity resistance rehabilitation implementation in skilled nursing facilities: a mixed methods multi-site case study.

Abstract

Background: Implementing evidence-based rehabilitation in skilled nursing facilities (SNFs) is essential for enhancing physical function outcomes and mitigating risk of adverse events. Best implementation approaches in this complex setting are unknown. This study uses the Implementation Research Logic Model (IRLM) to retrospectively examine the implementation of high-intensity resistance rehabilitation (HIR) in SNFs, aiming to elucidate contextual factors and pathways that could enhance future HIR implementation endeavors.

Methods: We conducted a convergent, mixed-methods multi-site case study (n = 8 sites). A standardized implementation strategy was employed, allowing sites to adapt this approach. HIR use was measured using the Provider Report of Sustainment Scale (PRESS). Contextual factors were identified using the Practical Robust Implementation and Sustainability Model (PRISM) through study-specific questionnaires and validated measures (Inner Setting Scale, Provider Perspective of Team Effectiveness, Evidence Based Practice Attitudes Scale, Perceived Characteristics of Intervention Scale, Self-Defined Burnout Measure, and Utrecht Engagement Scale), and analyzed descriptively. Interviews and focus groups with leadership and clinicians revealed contextual factors and strategies influencing implementation. Heat maps visualized site patterns, while an IRLM proposed provisional implementation pathways.

Results: PRESS scores ranged from 3.75 (0.17) to 2.33 (0.67), indicating all sites implemented HIR to at least a "moderate extent". Higher-implementing sites demonstrated full-team ability to adapt HIR to diverse patients. Differentiating contextual factors between higher and lower implementing sites included clinician perspectives, site infrastructure, and satisfaction with leadership. Higher-implementing sites employed a higher volume of site-initiated implementation strategies, notably having a champion and patient engagement. Pathways that appeared to contribute to higher implementation extent included: 1) overcoming inertia of current practice through HIR salience, 2) overcoming clinician concerns of patient compatibility through affirmative experiences, 3) addressing clinician perspective of complexity with session planning, and 4) optimizing patient rehabilitation mindset through encouraging environments.

Conclusion: Improving physical function in older adults necessitates adoption of evidence-based rehabilitation like HIR. Implementation strategies that target infrastructure, including leadership support and communication channels, inertia of current practice, and clinician perspectives of HIR complexity and patient compatibility may facilitate implementation. Identifying a champion and providing guidance for effective patient engagement appear to be key.