Case Examples

Keeping the aforementioned caveats in mind, we evaluate three interventions along Horner and Ross’s eight elements to explore how an intervention’s characteristics drive contextual fit. In the absence, however, of a quantitative global measure of contextual fit, we examine each element qualitatively. We also impose a rating of ‘high,’ ‘medium,’ or ‘low’ congruence for each element with “high” reflecting a better fit. We recognize the need for future research to establish clear and tested evaluative criteria and response formats. As described in Table 20.1, the three interventions we use as cases have different purposes, target different populations, and were designed for, and tested in, different contexts. Thus, they serve to highlight the nuances of contextual fit along these eight elements.

Skills2CareR. Skills2CareR is a six-session intervention designed to provide family caregivers with education and skills to manage the daily challenges of caring for individuals with dementia (Gitlin et al., 2003). Delivered by occupational therapists, it was tested in a Phase III efficacy trial as one of the test sites of the National Institutes of Health (NIH) Resources for Enhancing Alzheimer’s Health (REACH) initiative. It was shown to reduce caregiver distress and behavioral symptoms of persons with dementia. The intervention was tested by enrolling families in the community that volunteered to participate; thus, it was evaluated independent of any health care or payment system or agency structure. Nevertheless, it was initially designed with the vision that it might be able to be embedded in a home care delivery system of care. Through a translational study, the intervention was shown that it could be embedded in home care practices and be reimbursed through Medicare Part A and B payment mechanisms (Gitlin, Jacobs, & Earland, 2010; Gitlin et al., 2003).

Occupational therapists were designated as the interventionists to deliver the intervention. They were chosen as interventionists because of their professional background and expertise in activity analysis, and ability to assess and integrate knowledge about cognitive status, physical function, psychosocial and environmental considerations. These considerations form the basis from which strategies are developed to help families address various care challenges including functional decline,behavioral symptoms and a caregiver’s own stress and upset. Families are then trained in the use of these strategies.

Intervention/

Target

Population

Type of Evaluation

Interventionists

Training Requirements

Intervention Characteristics

Potential Delivery Contexts and Payment Mechanisms

Skills2CareR: Dementia caregivers who are stressed and need skills training

Phase III efficacy trial tested outside of service delivery context

Occupational

therapists

? One-week training including readings, online modules, and one day of face- to-face practice sessions followed by three coach documentation

  • ? Flexible number and scheduling of sessions
  • ? Up to six home sessions of 60 to 90 minutes delivered between 2 and 6 months
  • ? Tailored to caregiver needs
  • ? Specific strategies to improve skills to manage functional decline, behaviors, and reduce caregiver stress

? Home care agencies through Medicare

Parts A and B reimbursements

? Private pay

Get Busy Get Better: African Americans 55+ with depressive symptoms

Phase III efficacy tested in senior center and homes

Tested with licensed social workers but any health professional could deliver

  • ? One-week training including readings, and face-to-face practice sessions
  • ? Ongoing supervision needed

? Up to 10 1-hour sessions at home (telephone calls can replace home visit)

  • ? Aging service network
  • ? Senior centers but no designated budget line
  • ? Behavioral health departments
  • ? Medicare reimbursement

Hospital at Home: Acutely ill older adults in need of hospitalization

Quasi-experimental

design

Three Medicare- managed care health systems at two sites and a Veterans Administration medical center

Physicians and nurses

? Training in the model and care coordination needed whereas health care protocol followed per patient reflect medical/nursing best practices

? Managed care health systems

Intervention

(Context)

Need

Addressed

Precision

Evidence

Base

Efficiency

(Practicality)

Skills

Cultural

Relevance

Resources

Organization

Support

Skills2

CareR

(home care)

  • ? High
  • ? Family education and skills training on dementia unaddressed in home care
  • ? Increasing number of dementia patients in home care
  • ? Medium
  • ? Set number of sessions and content tailored to family needs
  • ? High level of clinical reasoning needed
  • ? Medium to high
  • ? One RCT conducted but its components have been tested in other trials
  • ? Medium
  • ? Can be integrated within traditional home care session
  • ? Not practical for agencies without occupational therapists
  • ? High
  • ? Training and coaching program established and available
  • ? High
  • ? Matches professional values and caregiver needs
  • ? However, approach differs from traditional practice and may not be immediately acceptable
  • ? Medium
  • ? Resources needed include funding for training, supervision, and fidelity monitoring
  • ? High
  • ? Can be reimbursed through Medicare Parts A and B, or private pay

Get Busy Get Better (senior centers)

? High

  • ? Medium
  • ? Up to 10 1-hour sessions
  • ? Five treatment components
  • ? Medium to high
  • ? One RCT but each component tested in other trials
  • ? High
  • ? Any health and

human service professional can deliver making it very practical

  • ? Low
  • ? Training and coaching programs being established but not currently available
  • ? High
  • ? Matches values of targeted population and service provider
  • ? Low
  • ? Resources needed include funding for training and staffing and travel to homes
  • ? Low
  • ? May be reimbursed through Medicare with licensed staff

(Continued)

Intervention

(Context)

Need

Addressed

Precision

Evidence

Base

Efficiency

(Practicality)

Skills

Cultural

Relevance

Resources

Organization

Support

? Depressive symptoms in African Americans underdetected and undertreated in aging network services

? Tailored to needs of participants

? Tested only with home visits, which adds cost to its delivery

? Costs would have to be absorbed by existing budgets of aging services

Hospital at Home (managed care health systems)

  • ? High
  • ? Can reduce adverse events associated with hospitalization

? Medium- to-high variability dependent upon local resources and patient needs

  • ? Medium to high
  • ? One quasi- experimental test at three sites with some variability by site
  • ? High
  • ? Can be integrated in health care system and delivered by local practitioners
  • ? Medium
  • ? Training mechanisms currently under development
  • ? High
  • ? Matches desire of older adults to remain at home; reduced costs
  • ? High
  • ? Minimal resource needs; reflects reorganization of existing resources
  • ? High with
  • ? value- based care
  • ? Low with capitated fee-for- service care

RCT, randomized controlled trial.

As shown in Table 20.2, and with regard to the first contextual fit criteria, Skills2CareR addresses a critical unmet “need” of dementia caregivers. The intervention provides education and skills tailored to the specific daily care challenges families identify as most difficult for them and which would not otherwise be addressed in current home or health care systems. As such, Skills2CareR can be scored as “high” on the dimension of need. However, this characteristic may negatively impact its “precision,” which we rate as “medium.” Also its flexible visit schedule and approach to delivery increase its fit with dynamic clinical settings; yet, its tailoring feature (e.g., developing strategies specific to a caregiver’s home context and working with families differentially on the basis of their level of “readiness”) introduces less precision as it relies upon a high level of clinical reasoning and decision making by interventionists. As one strategy does not fit all families, interventionists must derive specific approaches by applying the principles of the intervention (e.g., client- centered, culturally relevant strategies, tailoring). This increases the acceptability and cultural relevance of the intervention to families, yet simultaneously decreases its precision in the delivery of the intervention. Thus, not all therapists may feel comfortable or feel they are able to deliver this intervention. It can also be challenging to practically evaluate treatment fidelity (see Chapter 12).

We rate its effectiveness as “high” as Skills2CareR was tested using a single-blind, prospective randomized trial followed by a translational or pre-post preimplementation study (Gitlin et al., 2010). Its various components have been tested further in different combinations in other trials contributing in part to support of its evidence base. Nevertheless, there are some elements of effectiveness that are missing. The intervention was tested with African American and Caucasian caregivers and it was found that women tended to benefit more than men. Thus, its effectiveness with other caregiver groups is unknown and the mechanisms or why this approach results in reduced distress is not clear. Also, a formal economic evaluation (see Chapter 18) has not been conducted.

For “efficiency” or practicality, Skills2CareR can be rated as “mixed” or “medium.” Given that it must be delivered by occupational therapists, this may not be a practical intervention for all agencies in the United States or in other countries that do not have access to or the resources to support delivery by this professional group. However, for home care agencies involving occupational therapists, this is a highly practical intervention in that the intervention can be embedded into traditional home care therapeutic practices. With respect to “skills,” there are clearly articulated competencies, an established training program, and certification process with follow-up coaching available (see information about training at www.jefferson.edu/university/ health_professions/elder_care/jec_team.html); thus, Skills2 CareR receives a “high” rating for this contextual element. Nevertheless, at the time of this writing, training is dependent upon a handful of individuals, thus limiting its potential for large- scale dissemination (see Chapter 21) and scaling up, although a master train- the-trainers program is currently being designed. The intervention also has high “cultural relevance”; therapists often comment that, given its family-centered approach, Skills2CareR enables them to practice the way they would like to and also to be creative in applying strategies. Families equally value the education and skills they acquire and testify that the intervention makes a difference in their own lives and the care they are able to provide. For “resources,” the intervention receives a “low” to “medium” rating as funding is needed for training therapists and there must be an organizational commitment to ongoing supervision and fidelity monitoring. Also, it is highly recommended that a guide book be purchased, which details the strategies offered to families; thus, this represents a potential ongoing cost to either agencies or families (Gitlin & Piersol, 2014). Finally, with regard to “organizational support,” Skills2 CareR can be rated as “medium.” The intervention can be reimbursed through Medicare Parts A and B; however, reimbursement levels do not cover the actual costs of intervention delivery, thus requiring a large volume of participants to be enrolled in the program for it to have economic value to a home care agency to invest in training its therapists.

Taken as a whole, this intervention has potential for scalability in the home care delivery context. Its essential contextual challenge is: advancing its training approach to be self-sustaining versus being dependent upon a few trainers; developing a dissemination infrastructure (see Chapter 21) that effectively markets widely to home care agencies; and possibly developing a derivative of the intervention that can be delivered by other health and human service professionals to broaden its adoption potential by organizations and hence reach to family caregivers. This case also highlights the evolution that occurs through the implementation process. As an increasing number of organizations have gained interest in adopting the intervention, a train-the-trainers program now must be put into place to enable continued training activities and sustainability.

Get Busy Get Better. Our second example is the Get Busy Get Better (GBGB) intervention (also discussed in Chapter 4). GBGB (Table 20.1) involves up to 10, 1-hour home-based sessions delivered by licensed social workers. The intervention, having five treatment components (care management, referral/linkage, stress reduction, depression education, behavioral activation), is designed to reduce depressive symptoms, improve daily function, and enhance engagement in meaningful activities of African Americans with depressive symptoms and also to be provided by senior center staff (Gitlin et al., 2013). Rigorously tested in a Phase III efficacy trial, it was shown to reduce depressive symptoms and improve daily functioning. In this efficacy trial, staff at the test site—a large senior center—screened individuals by telephone or on site for depressive symptoms, and for those who were eligible (PHQ-9 score >5), deliver the home-based intervention. Analyses revealed that all groups (men vs. women, young vs. old, those with high or low financial strain) benefited (Gitlin et al., 2013; Szanton, Thorpe, & Gitlin, 2014). Also, mediation analyses provided guidance as to the mechanisms by which the intervention reduced depressive symptoms and suggested that each of its treatment components contributes to reductions in depressive symptoms (Gitlin, Roth, & Huang, 2014; Gitlin, Szanton, Huang, & Roth, 2014). A formal cost-effectiveness analysis also demonstrated the economic value of GBGB (Pizzi et al., 2014). The intervention was designed with the intent of having senior centers implement the intervention, but it was tested only in one site and there is not a viable payment mechanism to support its implementation. As grant funds supported its evaluation, the senior center that served as the test site has not been able to continue with the home visit portion owing to its associated costs and lack of reimbursement avenues at this point in time.

As to contextual fit (Table 20.2) with senior centers, GBGB receives a high score for addressing an identified unmet need (Gitlin et al., in press). Similar to

Skills2CareR, GBGB has prescribed assessments and clearly articulated treatment components; yet, the tailoring of each component to the specific needs of participants adds complexity to its delivery. The tailoring aspect of the intervention makes its delivery dependent upon skilled interventionists who can apply clinical reasoning, and thus it has medium precision.

As to effectiveness, we give GBGB a “medium” to “high” rating. It was rigorously tested but only in one randomized controlled trial (RCT) with 208 participants. Its efficacy for populations other than African Americans and delivery in other senior centers or aging network service settings is unknown. This limits its contextual fit with settings providing mental health services to other minority groups such as behavioral health departments that seek evidence-based home depression programs for highly diverse communities. It is unclear whether and what types of adaptations may be needed for diverse linguistic and cultural groups. GBGB, however, can be rated as having high efficiency or practicality. Although it was tested with licensed social workers as interventionists, the investigative team believes any health and human service professional with some psychosocial background (e.g., psychiatric nurse, occupational therapist with psychosocial training) could be trained to deliver the intervention. For skills, it receives a “low” rating; while a well-designed training and certification approach was followed during the trial, a translational phase would be needed to modify the training program and manuals and these are not yet available on a larger scale, although they are under construction. Whereas cultural relevance to agencies targeting African American communities and to African Americans with depressive symptoms themselves can be rated as “high,” GBGB receives “low” ratings for resources and organizational support as there are no existing funding mechanisms that are available to support this highly efficacious program. Also, low-resourced agencies may not have access to skilled service providers who have the comfort level to deliver a behavioral activation form of mental health treatment.

Thus, the essential contextual challenge for this program is identifying or creating funding mechanisms to support its delivery in the aging network and specifically in senior centers in the United States (Gitlin et al., in press). This may entail policy changes, improving reimbursement mechanisms through Medicare, or determining how to operationalize opportunities that may become available as a consequence of the Mental Health Parity Act. Secondarily, its manuals and an infrastructure for training would have to be secured to enhance its contextual fit prior to implementing a full-blown dissemination plan.

Hospital at Home. Our final case example is the Hospital at Home program (Leff & Burton, 1996; Leff et al., 1999, 2005). Designed to provide hospital-level care to acutely ill older adults in their homes, this program was tested in three health care organizations in a prospective quasi-experimental design (Table 20.1). The program was found to be feasible, efficacious, and safe and reduced length of stay and cost.

As to its contextual fit (Table 20.2), Hospital at Home receives a “high” score for addressing a critical unmet need: medical care for acutely ill vulnerable older adults, which minimizes risk associated with hospitalizations. It offers acutely ill older adults the opportunity to heal in their home, yet with the intense medical attention they may need. Similar to the other case examples, the approach is necessarily specific to the needs of patients adding a level of complexity to its delivery; hence, we suggest precision is at a “medium” level. As to effectiveness, Hospital at Home shows very positive outcomes and was tested in three distinct health care systems, thus providing knowledge of implementation challenges under differing payment and organizational care systems. Its components and approach have also been tested in other settings and countries, and meta-analyses support its effectiveness (Caplan et al., 2013; Shepperd, et al., 2009). The level of acceptability of the program by patients varied across programs such that continued evaluation is warranted along with identifying strategies to address patient and/or practitioner concerns that prevent participation. The program, however, is rated as having “high” efficiency or practicality as any health care system has the necessary resources to adopt the program. The program uses indigenous medical staff of hospitals but organizes the way in which they deliver acute medical care. For skills, it receives a “medium” rating as training would involve multiple personnel (administrators, physicians, nurses). However, the skill level and knowledge needed to conduct this program are well articulated, and training manuals and programs are available.

Whereas currently the cultural relevance and organizational support for Hospital at Home are “high,” this has not always been the case. The program’s cost savings were initially perceived as a threat to the revenue streams of hospitals; however currently, Hospital at Home aligns well with a value-based system of health care. Thus, its implementation (and dissemination) potential has dramatically increased with recent changes in policy and payment mechanisms.

The essential contextual challenge for this program is refining and standardizing delivery components such that they can fit with a wide variety of hospital organizational systems. The model program may be implemented differently based upon the adopting organization’s areas of strength. For example, if an adopter hospital system has a strong competency in providing home-based care, then that component of the model may be delivered more easily, efficiently, and effectively. The challenge is to enable an organization without that competency to be able to fulfill the program’s goals and implement all of its components. Thus, training in the model is necessarily context specific and varies on the basis of the relative strengths and weaknesses of the adopter organization. Other related challenges include advancing training strategies to meet context-specific needs, and developing a dissemination infrastructure for deploying the model rapidly.

In summary, a comparison of these three interventions affords an understanding of the way in which specific delivery characteristics of the interventions affect contextual fit. Each program has unique challenges along the eight dimensions of context, thus highlighting how the characteristics of an intervention drive in part future implementation potential or are at least associated with distinct challenges that will be encountered in different contexts. We can also conclude that there is no right or wrong way of designing the characteristics of an intervention (discussed in Chapter 5). Also, it may not be possible for any intervention to have a “high” score across all eight dimensions of contextual fit. However, “low” fit across all elements may preclude moving forward with dissemination and implementation (discussed as well in Chapter 21).

 
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