Table 2 Themes, categories and exemplar verbatim quotes related to the implementation process

Evidence-based model

GEDI model – based on the GEDI Toolkit – structure, process and outcome evaluations published [11,12,13, 22]

A dedicated team operating 12-hour days a week and 8 hours at weekends not necessarily comprised of the same workforce as original GEDI model

“GEDI needed a physio because the majority of the patients present with falls, or they’ve fractured something, or just they’ve got pains in the knees. So, we funded for a physio.” [Hosp B: Int 5_]

“(The GEDI service is) staffed by nursing and pharmacy and with the intention of, if possible, reducing the number of elderly patients that get admitted to hospital.” [Director EM: Hosp A].

Collaboration between clinicians and managers

Managers fully supportive of GEDI implementation, advocating for GEDI with Executive.

Supportive managers moved, new managers not aware of extensive background for model.

“Initially, one of our (ED physicians) that’s his portfolio, is aged care. So, he definitely gained a lot of support” (ED NUM: Hosp A]

“The only thing that got this lot moving was the CE (Hospital Chief Executive).” [GEDI CNC: Hosp B]

“I do feel that there’s not the support there anymore.” [GEDI CNC: Hosp A]

Governance

GEDI team to be managed by ED managers with GEDI senior nurse part of ED management team. Physician champion involved in day-to-day management and support of GEDI nurses.

Physician champion involved in initial change management – then transferred.

GEDI seen as primary care ED nurses with additional older adult focus.

“…our Champions got sidestepped into other roles, so we were left a little bit. “[GEDI CN: Hosp A].

“… (an ED nurse who took on the role of a GEDI CN) seemed really keen and really interested, but with every patient she reverted back to being an ED nurse. She saw the patient and she was doing the bloods, ECGs…” [GEDI CNC: Hosp B]

Funds for i-PARIHS implementation

Funding provided to backfill staff to be involved in GEDI model facilitation and for travel and accommodation to support site visits.

Funds transferred from Health Department to original GEDI site. Used to fund only 25% of planned implementation activities.

“We were just told we would not be able to be released to support (Hospitals A and B). Nothing we said changed her mind” (External Facilitator B).

Accountability for acquittal of project funds

Management at original GEDI test site were responsible for funds transferred from Health Dept. for implementation project.

Funding was managed in ED operational budget and not used to support EF release to engage in implementation site support.

“The funds were transferred to the ED operational budget from (State Health Department). No-one had to report back to State Health Department)” (External Facilitator B).

Recurrent funding of GEDI model

Senior staff at implementation sites to develop business plan

Managers changed roles. GEDI senior nurse asked to develop Business Plan

“So, (the Health Dept.) is set up for innovation for? 12 months and then we have to pick up recurrent funding. All I know is (physician champion) was putting in a business case to apply for funding to continue the program but I don’t know where we’re at.” (ED NUM: Hosp A)

“I’m not sure that there is capacity within the financial situation of the (hospital) to fund anything above what is currently funded. I think even with demonstrated benefits of financial savings and support, I’m not sure how many services will get additional funding over baseline at the moment. I think there’s a good level of knowledge of the benefits for GEDI” (Geriatrician: Hosp A)

Support of internal facilitators by external facilitators

• Having the External Facilitators (EFs) attend the implementation sites 2–3 times.

• Have GEDI Implementation internal facilitators visit main GEDI site

• Have weekly then monthly post-implementation meetings.

• Have external facilitators available during service hours for consultation by telephone.

(From interviews with external facilitators)

• EF B visited the two sites once. EF A visited one site once.

• Some staff – mainly managers visited host site once

• Four meetings with site A over 3 months EF A only able to attend one meeting

• One visit to host site by Hosp B. No meetings.

• Phone consultations between GEDI CNC at host hospital and both implementation sites for six months as needed.

• No contact between physician champions after visits.

“I think the disappointing thing for me (…), is we were hoping (Hospital providing the external facilitators) would release (Physician Champion) and (GEDI CNC) for a day a month. Because their energy is infectious. I can sell it as much as I want but to have them in the room, you know how lively (External Facilitator A) is. (…) We hit a bit of a political barrier (…). (GEDI CNC: Hosp A)

“So, we went down there for about three days or four days in January when it first started, and then (Dept. of Health staff member) and (External Facilitator B) came up here when we first implemented it and spent about three days here with us. And then I’ve been in a meeting with a couple of teleconferences since then, but not for months”. GEDI CN: Hosp A)

“I: …have you had any other contact with (the EFs) since championing the role here in the ED? R: Not since the meetings were stopped, so I’ve only met them once.” (GEDI Physician champion: Hosp B)

Middle management support for GEDI model

Middle managers to continue enthusiastic support for GEDI model development and evaluation.

Managers changed. New managers did not see relevance of model in times of fiscal constraint.

“I (ED NUM) found it interesting and thought this is a good program we’d like to take on. So, (ED ND) and I both went down there to that, along with I think (middle manager) may have come as well. I can’t remember.” (ED NUM: Hosp A)

“…we hit a bit of a political barrier” (ED ND: Hosp A)

Role of physician champion

A senior medical officer would act as a boundary spanner working with the senior GEDI nurse to develop business case, recruit and support GEDI nursing team. Also, would engage ED physicians in working collaboratively with GEDI nurses and supply decision support to GEDI nurses.

In one implementation site the ED physician was only involved during the initial change process. The decision support changed to a geriatrician not employed within ED. When this geriatrician changed jobs, the new geriatrician did not continue to support the GEDI team in the same way.

“(I wasn’t) directly involved in (setting up the GEDI service) but when I heard that it was the geriatricians who were interested in getting involved, I was happy to be the champion in my department. (GEDI physician champion: Hosp B)

“(The GEDI geriatrician is) very particular on what patients they see… (The first GEDI geriatrician) did a role (description for the geriatrician (role) and it says (the GEDI geriatrician is) mainly for patients with the geriatric syndromes” (GEDI CNC: Hosp B)

Toolkit utility

Written Toolkit provided as a pdf document that included (i) Background, rationale and evidence for GEDI, (ii) Explanation of the GEDI model, (iii) Resources to assist in setting up a GEDI service

Written toolkit available as a pdf document. Also, an online version and additional video vignettes explaining aspects of the model.

“It’s very long. It’s probably too long I’d say. (But) its comprehensiveness is good and it’s useful if you have a specific question. (…) So, if you use it like a sort of like a reference text. Then, yes. It was useful.” (ED Physician: Hosp A).