Table 2 Facilitators and Barriers of the Rural Primary Health Care Memory Clinic Intervention using the Consolidated Framework for Implementation Research
CFIR Domain and Constructs | Barrier | Facilitator |
|---|---|---|
Innovation Characteristics | ||
Relative Advantage | Evidence-based flow sheets provided standardized assessment tool for all team members Team approach and standardized tools increased team members’ confidence in providing care without having to refer all patients Team members felt valued for their unique contribution to assessment and management Benefits to families including giving them a voice, providing direction, supporting future planning, connecting with services, avoiding crises | |
Trialability | Small-scale, iterative implementation and testing of the EMR flow sheets hampered by time intensiveness of modifying the EMR | Despite EMR challenges, the intervention could be implemented on a small scale to assess feasibility and iteratively test modifications to improve fit to context |
Complexity | Having the assessment flow sheets in the EMR was critical to implementation, but having multiple team members accessing the EMR created challenges that had to be resolved | The EMR created implementation challenges but it also reduced complexity by supporting team-based care and access to evidence-based decision support tools |
Outer Setting | ||
Needs and resources of those served by the innovation | Team members concerned about unmet needs of patients and families with usual care approach; late diagnosis and lack of support contributed to crisis situations Team approach and case conference facilitates discussion with family about services and planning for future needs Alzheimer Society participation in the memory clinics may increase use of supports by developing a relationship at time of diagnosis | |
External policy and incentives | Home care used a different EMR system that was not compatible with the PHC team EMR Policy of not funding licences for home care nurses to access the PHC team EMR Dementia not included in provincially funded incentive program for family physicians to use evidence-based tools with chronic disease patients | Improving access to primary health care teams is a priority for Ministry of Health |
Inner Setting | ||
Networks and Communications | Not all team members had EMR access initially Not all team members co-located Busy clinical schedules made it difficult to schedule meetings to develop and implement the clinic Researchers did not have direct communication with physicians | The team’s facilitator was critical to communication among team members and with the researchers. They could view calendars and book team members into meetings. Their formal role in team development benefited implementation by supporting communication. The memory clinic EMR was set up to accommodate access to the patient record by all team members |
Tension for change (Implementation Climate sub-construct) | Dissatisfaction with current approach to care; uncertainty about assessment process led to late diagnosis, often precipitated by a crisis situation Silo approach and lack of care coordination was less effective than a collaborative team approach Discussion about driving capacity in the team case conference removed the burden from one team member and reinforced the message to patients and families | |
Compatibility with existing workflows and processes (Implementation Climate sub-construct) | Team physicians perceived the team-based memory clinic model as inconsistent with their usual iterative approach to assessment Physicians’ involvement with other chronic disease case was less intensive; other team members managed most of the assessments and communication with patients and families. | Some team members were already experimenting with involving the Alzheimer Society and home care in a case conference when dementia suspected |
Leadership engagement (Readiness for Implementation sub-construct) | The support and active engagement of leaders was critical to ensuring adequate resources for the intervention, communicating the importance of the intervention, and giving permission to team members to participate | |
Available resources (Readiness for Implementation sub-construct) | Workload was a challenge to participation in the memory clinic for all team members Lack of personnel such as Dementia Care Managers to support the clinic and ease workload for team members Challenges in recruitment and retention of family physicians was a major barrier | The team facilitator and EMR manager were committed to the project and supported implementation despite workload issues The primary health care site had multiple allied health care providers linked to the site who could be accessed to participate in the memory clinic intervention |
Access to Knowledge and information (Readiness for Implementation sub-construct) | Few educational opportunities were available prior to the intervention; education by RaDAR specialists and PC-DATA™ developer helped build confidence in assessment and management Observing in the University-based interdisciplinary specialist memory clinic run by the RaDAR team inspired the rural PHC team to adopt the one-day clinic vs. the initial sequential approach Workgroup meetings with the researchers, RaDAR Handbooka, and tools embedded in the EMR were helpful | |
Characteristics of Individuals | ||
Self-efficacy | Team members’ self-efficacy and ownership of the intervention increased over the study. Growing confidence and feelings of contributing to improved outcomes for patients and families motivated continued involvement | |
Process | ||
Champions | Key individuals within the team who facilitated implementation were the nurse practitioner, PHC facilitator, and EMR manager | |
External change agents | Absence of a formally appointed internal facilitator | Participants identified the RaDAR researchers and PC-DATA™ developer as supporting implementation by providing education and working closely with the team at all stages to facilitate implementation and maintain momentum |
Innovation Sustainability | Physician turnover Lack of process to engage and orient new team members, especially physicians, to the flow sheets and memory clinic processes | Continued contact with the researchers Consistent leadership in the region Increased community awareness of the memory clinic |