Implementation Science

Introduction

The need for rehabilitation services in health systems has increased with a subsequent desire to implement evidence-best practices (EPB). (speaker) Rehabilitation professionals utilise evidence-based practice (EBP) when making intervention decisions based on the best evidence available. (portney) It is a widely held belief among healthcare care practitioners that it is critical to know why what and how an intervention works in different settings(speaker).  A key factor guiding EBP choices is including the patient in the decision-making process. Family norms, traditions, cultures and personal beliefs all should play a role in the intervention choice. Research supports EBP has better outcomes with patient participation.(portney)  In addition to patient involvement, practitioners need to take into account costs, resources in the community and the nature of the healthcare system.(portney)

Challenges to Implementing EBP

Rehabilitation intervention evidence is growing every day. Principles and guidance on rehabilitation interventions are increasingly available such as:

1. (NHS Commissioning Guidance for Rehabilitation).
2.  (https://www.who.int/rehabilitation/Package-of-rehab-interventions-info-sheet.pdf). (speaker)

Despite the wealth of information, the uptake of this evidence into practice is a slow process, especially in lower-middle income countries. (speaker) The translation from clinical research to clinical practice can take anywhere between 10-20 years. (novak)

Barriers causing this delay can include:

• Patient preferences
• Time demands
• Skills
• Confidence
• Belief in intervention
• Clinical trials may not transfer to clinical settings
• Resources
• Informational overload
• Institutional support (novak, lynch)

In lower-middle income countries (LIMCs), the need for quality interventions is higher, however, the capacity to implement is much lower than in resource-rich countries. (YAPA) Some of the challenges LIMCs have in EBP have been described by Grimmer et al. (2019). Please see below:

Challenges to Implementing Evidence-Based Rehabilitation Interventions in LMICs

System level challenges

• Limited awareness & understanding of evidence-based rehabilitation interventions
• Limited quantification of existing rehabilitation services, workforce & service utilisation
• Lack of specific government policy, strategic planning, legislation., funding for rehabilitation services across health system level (primary, secondary & acute)

• Health Care Provider level challenges
• Lack of mandate to provide evidence-based rehabilitation interventions
• Limited rehab workforce and capacity (awareness, skills) to treat, competing priorities and heavy workloads
• Lack of coordination between services
• High re-imbursements for non-evidence-based rehabilitation interventions

Patient level challenges

• Logistics of rehabilitation services
• Affordability of rehabilitation services
• Knowledge & attitudes to interventions
• Health problem or condition specific factors

Implementation Science

Without a detailed implementation plan, it takes an average of 17 years for research evidence to be implanted into routine clinical practice. (lynch) This tremendous lag time prompted the development of implementation science which studies the process used to disseminate health information and merge it into clinical practice. (speaker, lynch, bauer, cabassa) “ Implementation science has many different layers and the following terms will describe each component:

1. Implementation research: broad term referring to research by not only the provider but the organization and policy levels of healthcare (BAUER)
2. Implementation practice: rehabilitation leaders implement evidence based research and adatpting to different contexts and settings (speaker)
3. Implementation strategies: how to strengthen the implementation, adoption and sustainability of EBP
4. Implementation Facilitation: guide rehabilitation professions regarding identifying and addressing implementation challenges and utilising positive outcomes (speaker)
5. Implementation outcome: effects of adopting the new interventiuons into practice

In summary, implementation science is concerned with the uptake and implementation of EBP. It strategically, de-implements “low-value” care while expanding effective evidence interventions. (speaker)

Implementation Frameworks

As the implementation science field has grown, many frameworks have been developed to provide pathways for implementation. Frameworks clarify the core constructs of each step and phase providing accessibility to all involved in the implementation effort. The aim of frameworks is to blend disciplines and combine insights from different approaches. (HUYBRECHTS)

Below are a sampling of various implementation frameworks and their links categorized based on their target goal:

Frameworks focused on what differences would there to implementing a new EB intervention

1. Consolidated Framework for Implementation Research (CFIR)
2. Theoretical Domains Framework
3. Integrating Promoting Action on Research Implementation in Health Services (I=PARIHS)

Many of these various frameworks are not used in isolation as they often are used together.(SPEAKER)

Implementation Facilitation Mindset

Implementation facilitation is a multi-stage process that encompasses pre-implementation, implementation and sustainment. Facilitators implementing EBP adhere to three key factors:

1. Intervention: , program or practice they want to adopt, scale up or spread

Questions they consider:

• Is there strong evidence for the intervention?
• Does this intervention have an advantage?

1. Context the setting that will either enable or hinder the implementation.

Questions they consider:

• Is there a readiness and openness for change to implement this new intervention?
• Will this new intervention receive support from senior management and organisational leadership?

1. Stakeholders: who are key implementation players for the intervention (policymakers, organisational managers, or frontline rehabilitation professionals).

Questions they consider:

• What knowledge, skills, and beliefs exist with stakeholders?
• What resources and time are available amongst the stakeholders?

In summary, implementation facilitation describes how to administer implementation science while identifying barriers and creating solutions to have a supportive sustainable evidence-based clinical practice or programs.

Resources

• Evidence Based Practice(EBP) in Physiotherapy
  1. https://www.england.nhs.uk/wp-content/uploads/2016/04/rehabilitation-comms-guid-16-17.pdf
  2. https://www.who.int/rehabilitation/Package-of-rehab-interventions-info-sheet.pdf
  3. https://episframework.com/
  4. https://implementationscience-gacd.org/implementation-science-overview/
  5. https://impsciuw.org/implementation-science/learn/implementation-science-overview/
  6. https://cfirguide.org/
  7. https://machaustralia.org/news/implementation-science-series/
  8. https://globalimplementation.org/ bulleted list
• x

or

1. numbered list
2. x