The nation's 'safety net'community health centers (CHCs) could benefit greatly from implementing interventions shown to be effective at improving health care processes and outcomes in other settings. However, a lack of knowledge about the most effective strategies for supporting implementation of evidence-based interventions in CHCs presents a major barrier to the timely dissemination of clinical innovations. Our long-term goal is to learn how best to disseminate evidence-based interventions into CHCs nationwide. Working towards that goal, we propose to compare the effectiveness of different 'support strategies'at helping diverse CHCs sustainably implement an intervention shown to reduce patients'cardiovascular disease (CVD) event risk. Kaiser Permanente developed and implemented the 'ALL Initiative'(a.k.a. 'ALL'), a clinic-level intervention designed to increase rates of adult patients with diabetes mellitus (DM) or CVD who are prescribed cardio-protective medications (statins and ACE-Inhibitors) according to evidence-based guidelines. After ALL was shown to be highly effective in Kaiser Permanente's integrated care setting, our team demonstrated the feasibility of adapting it for successful implementation in 11 CHCs - with the help of substantial implementation support. The next step in this body of research is to identify the amount and type of support needed to effectively implement and sustain this intervention in a greater number of CHCs. To that end, we will conduct a trial in which 30 CHCs are cluster-randomized to receive low, medium, or high-intensity support in implementing ALL. We will conduct this work with CHC members of OCHIN, a community health information technology network that hosts one of the nation's largest CHC electronic health record (EHR) platforms;study CHCs share a single, linked EHR. Guided by the Practice Change Model and RE-AIM framework, we will use mixed-methods to:
Aim 1 : Compare how effectively the low, medium, and high-intensity strategies support the CHCs'implementation of ALL, and assess change in rates of clinic patients with (i) guideline-appropriate cardioprotective prescriptions, and (ii) controlled blood pressure and low-density lipoprotein, as associated with implementation supported by the different strategies;
Aim 2 : Assess the strategies'effectiveness at supporting intervention sustainability over 3 years;
and Aim 3 : Identify clinic characteristics associated wit success at different levels of support. Our team includes CHC clinicians, and experts in dissemination and implementation (D&I), health economics, and health services research mixed-methods. Our study is designed to inform future implementation of ALL as well as other interventions known to improve outcomes among CHC patients with DM / CVD. Our results could also have high impact on D&I science, by comparing practical, generalizable methods for supporting the implementation of clinical innovations in CHCs and other ambulatory settings.

Public Health Relevance

Our nation's 'safety net'community health centers could benefit greatly from implementing clinical and care process interventions that have been shown to be effective at improving cardiovascular disease outcomes in other settings. However, the timely dissemination of evidence-based interventions into community clinics'routine care is hampered by a lack of knowledge about the best methods for helping such clinics implement new practices. We seek to address this knowledge gap by comparing how effectively different 'support strategies'help diverse clinics to sustainably implement an intervention that reduces patients'cardiovascular disease event risk.

National Institute of Health (NIH)
National Heart, Lung, and Blood Institute (NHLBI)
Research Project (R01)
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Dissemination and Implementation Research in Health Study Section (DIRH)
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Wells, Barbara L
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Kaiser Foundation Research Institute
United States
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