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Table 3 Factors that influence the sustainability and scalability of the Health TAPESTRY interventiona,b across identified themes; and questions that can be considered by intervention team to address barriers according to the National Health Service (NHS) Sustainability modelc

From: Sustainability and scalability of a volunteer-based primary care intervention (Health TAPESTRY): a mixed-methods analysis

Theme

Summary of sub-themes by challenges and facilitators

Challenges are described in the context of specific stakeholder groups

Suggested recommendations (as informed by participants)

NHS sustainability modelc factor level

Sustainability

Program complexity

Inter-professional team challenges:

• Regulations for changing coding in the EMR

• Health TAPESTRY (Health TAP) report provides too much information, which could overload clinicians

• Potential for clinicians to misinterpret data generated by volunteers during client visits

Volunteer team challenges:

• How Health TAP and volunteers fit in with existing programs (e.g., Health Links)

• No suggestions were provided

Process:

• Adaptability of improved process

Organization:

• Infrastructure for sustainability

Program coordination and comnication

Inter-professional team challenges:

• No process in place for how clinicians will use the Health TAP report (e.g., who will take care of the patient once the report is generated, what resource are available to support activities as suggested by the report, and the fear that the report will get lost among other incoming electronic paperwork)

• Functionality of the data transmission from iPads to inter-professional team, and how clinicians will recognize that it is a Health TAP report

• Interpretation of the Health TAP report by non-clinicians

• Clarifying role and expectations about the report and outline correct health care responses for report findings

• \Adjust care processes so that Health TAP becomes part of the what the inter-professional team are already doing

Process:

• Benefits beyond helping patients

• Credibility of the evidence

Volunteer team challenges

• Increasing number of clients enrolled may make it more difficult to sustain the volunteer pool

• Availability of students or younger volunteers (e.g., during exam time and when school is not in session over the summer months)

• Coordinating or scheduling the visits and volunteers (e.g., to be able to match volunteers with clients that live near them)

• Involvement of a well-established volunteer community organization

• Evaluating volunteer competency for appropriately administering data gathering tools

• Keep the volunteer numbers reflective of the program growth

• Start recruiting student volunteers at the beginning of the semester and early in their studies to maximize their availability & keep them longer

• Have ongoing support for volunteers and volunteer coordinators (keep them updated so they know the details of the visit in advance)

• Consider how to prepare volunteers for unknown situations (e.g., hoarding, bed bugs, safety in the client environment)

Process:

• Adaptability of improved processs,b

Organization:

• Infrastructure for sustainability

Staff:

• Staff involvement and training to sustain the process

• Senior leadership engagement

Resource capacity

Inter-professional team challenges:

• Managing resources as the number of clients involved increases

• Feasibility of administering the many data tools during volunteer-client visits

• Not having proper IT requirements during technology development

• Resources to upload information into the PHR

• Feasibility of Health TAP report (burden on clinicians’ time and workflow to read patient files; how the report fits in their workflow; the effort to use the report; the time it takes away from regular work)

• Setting (i.e., the report requires physical space to discuss with colleagues)

• Lack of provider skills and knowledge or the supports to manage patients identified as at risk

• Bringing Health TAP into an already busy primary care context

Volunteer team challenges:

• Funding volunteer program since these organizations are largely non-profit

• Lack of adequate human resources to recruit enough volunteers, and enough volunteer coordination support to sustain the volunteer pool

Client challenges

• Health TAP may become too much during the visit (too many questions and data tools)

• Provide support to primary care to manage issues and to incorporate Health TAP report data in a way that integrates its elements into what is already being done at the clinics

• Look at opportunity costs (e.g., are the volunteer visits increasing the visits to health care providers, and are these truly necessary)

• Make sure that the client visits are accessible or not too far for volunteers

• Have a point person for volunteers who would brief them about expectations and to provide positive feedback when they do well

Organization:

• Infrastructure for sustainability

Process:

• Adaptability of improved processa,b

Stakeholder buy-in

Inter-professional team facilitators:

• The inter-professional team staff are enthusiastic, innovative, and open-minded

Inter-professional team challenges:

• Slow adoption by clinics and the inter-professional team

• Success is dependent on clinicians’ willingness to follow-up on Health TAP reports

• Clinical relevance of data gathering tools

• Opportunity for inter-professional staff to customize questions in data tools

• Competing priorities in primary care to be able to screen patients for Health TAP

• Inter-professional team research fatigue

Client (patient) challenges:

• Lack of buy-in, and feeling uncomfortable with technology

• May not believe the value of Health TAP (i.e., the right approach for their health care)

• Discomfort with data being shared by many people at the primary care practice

• May not always be receptive of volunteers as part of Health TAP

• Poor uptake of the PHR by clients

• Research fatigue

Community agency challenges:

• Community engagement (i.e. involving and linking to community organizations that fit with Health TAP’s goals)

Volunteer challenges:

• \Keeping volunteers engaged and satisfied

• It would be important to integrate Health TAP within the current clinic infrastructure

• Ensure that data/data tools are clinically relevant and provide room for adaptation to meet the needs of the inter-professional team

• Effectiveness of Health TAP needs to be demonstated and shared (early wins and successes) so people appreciate its potential to benefit patients

• Provide assistance to clients in how to access and use the PHR

• Persuade other stakeholders in the system (e.g., government, other 3rd party payers, patient advocacy groups, seniors groups) that there are advantages to Health TAP

• Foster strong relationships with relevant community organizations early in the implementation process

• Engage these organisations in updates and program progress, and provide information on how they can be involved

Process:

• Adaptability of improved process (i.e., Health TAP)

• Credibility of the evidence

• Benefits beyond helping patients

Staff:

• Staff (i.e., clinicians) involvement and training to sustain Health TAP

• Staff (i.e., clients) attitude toward sustaining the change (Health TAP)

Organization:

• Infrastructure for sustainability

• Fit with organization’s strategic aims and culture

Scalability

Adopter site characteristics

Inter-professional team challenges:

• Recognize that partnerships that were built in the pilot site may not resemble partnerships made at adopter sites

• There may be varying levels of motivation and interest in Health TAP in other environments

• Adopter sites may not know or understand their own environment or jurisdiction

• It might be difficult to apply or implement Health TAP in settings without a PHR, a different PHR,if the concept of a PHR is very new, and in paper-based primary care settings

• Bringing new ideas and a new program into an already existing culture

• Assess the infrastructure, needs and resources that are already available at adopter sites

• Understand the current capacity of adopter sites, and assess how it fits within Health TAP

• Recognize that other communities are typically very different or have a different culture

• There should be cultural awareness

• Have dedicate resources to facilitate program uptake

• It will take time to get to know adopter environment and how their system works

Organization:

• Fit with organization’s strategic aims and culture

Infrastructure for sustainability

Stakeholder buy-in

Inter-professional team challenges:

• Inter-professional team may not understand the value added with the Health TAP report

Volunteer team challenges:

• Keeping volunteers engaged and satisfied as their sense of belonging (as part of Health TAP) may decrease as the program expands

• Display the relative advantage of the Health TAP report to primary care physicians (e.g., no extra time on the part of the clinician to do things)

• Persuade other stakeholders in the system (e.g., government, other 3rd party payers, patient advocacy groups, seniors groups) that there are advantages to Health TAP

• Facilitate buy-in through employing credible and respected champions in local primary care practices

Process: Credibility of the evidence

Staff:

• Staff attitude toward sustaining the change

Staff involvement and training to sustain the processa,b

Resource capacity

Inter-professional team challenges:

• In private or solo practices, Health TAP may be perceived as overwhelming

• The capacity of physicians in other settings to address the problems identified by the Health TAP report

• Solo practices may lack the human resources to handle the information generated by Health TAP (e.g., getting volunteers to gather data, processing the reports, and following-up with patients)

• Lack of funding at new sites to implement technological requirements of Health TAP (e.g. tablet devices; automated transmission of data to primary care)

• Health TAP may not work for family health teams unless they are linked with volunteer and community resources to coordinate volunteers

• Engage with people and organizations outside of the health realm that can support solo practitioners

• Map out how Health TAP can move into a smaller community with just a family physician and their nurse

• Consider including Health TAP as part of the primary care visit

• Have the physician and nurse work together to follow-up with clients

• Promote group medical visits

• Train a lay person that could deliver educational sessions to a group of patients

• Create an IT application that will allow Health TAP to be accessed through any operating system and hardware device

Organization

• Infrastructure for sustainability

• Fit with organization’s strategic aims and culture

Process:

Adaptability of improved process

Volunteer team challenges

• Lack of resources in rural settings to coordinate the volunteer component of Health TAP (e.g., lack of access to and recruiting volunteers, lack of transportation of volunteers, lack of a person/organization who can train and support the volunteers)

• Ensuring quality of volunteer-client visits as volume increases (i.e., if number of clients expands as program grows)

• Keep volunteer numbers reflective of the expanding client numbers

• Find enough skilled people to serve as volunteers

• Expand the scope of volunteers (i.e. don’t rely so heavily on students) to consider clients’ relatives, friends or neighbours

• Build another category of volunteers called peer support volunteers, who can be trained on the Health TAP approach

• Understand the volunteer’s unique settings and adapt volunteer expectations and training accordingly

• Ensure the quality of volunteer training is equivalent across the different trainers

Community challenges:

• The recognition that remote areas may not have the same community resources, supports and manpower to address clients’ needs identified through Health TAP report

Other challenges:

•Feasibility of adapting Health TAP to other countries with different health systems

• Assess what community services are available and how these systems work at the adopter site

• Link family health teams to existing health care programs

  1. aHealth TAPESTRY intervention refers to factors that are associated with the intervention and its elements, and the implementation efforts provided by the interprofessional clinical team, community organizations (e.g. CCAC, meals on wheels), volunteer agency, volunteers, and patients. Examples of activities the implementation team performs includes recruiting volunteers, conducting patient home visits, assessing the Health TAPESTRY report, and developing an action plan to help patients meet their health goals
  2. bFor the NHS sustainability factor: Adaptability of improved process, “process” is referring to the Health TAPESTRY intervention
  3. cAdapted from: Maher L, Gustafson D, Evans A. NHS Sustainability Model. NHS Institute for Innovation and Improvement; 2010. Available at: www.institute.nhs.uk/sustainability