Edward Christopher Portillo

Objectives: Patients living in rural settings are among the least likely to receive care, contributing to excess deaths in rural communities from respiratory conditions. We examine barriers that impede implementation of a care bundle for chronic obstructive pulmonary disease (COPD) management that was widely implemented across rural communities in the USA. Setting: 17 rural medical centres implementing the care bundle in the US Department of Veteran Affairs (VA). Medical centres were located across 13 states, with 3 VA medical centres (VAMC) in the Southeast, 4 in the South, 9 in the Midwest and 1 in the Northwest. Participants: Clinician participants engaged in programme implementation included pharmacy leaders, hired clinical pharmacists, nurse care managers and pharmacy technicians. Participation was offered to all clinicians engaged in the implementation process and was voluntary. Primary outcome measures: This evaluation identifies barriers that impede implementation of a care bundle for COPD management. To guide our analysis, we identified challenges that strongly aligned with work system factors within the Systems Engineering Initiative for Patient Safety (SEIPS) 2.0 model. Results: Challenges experienced during the implementation of a COPD service in rural settings included (1) limited staff availability, (2) fragmentation of care, (3) technology challenges, (4) limited referral opportunities, (5) competing demands on pharmacist time and (6) clinician apprehension regarding their ability to manage a new disease state. Conclusions: This evaluation furthers what is understood regarding barriers to implementing care bundles within rural healthcare contexts. Our findings suggested that clinicians in rural settings felt constrained in their ability to take on new tasks and expand their practice models due to staffing shortages and heavy workload demands. Some clinicians reported approaches they used to address barriers they encountered, such as leveraging relationships with other healthcare practitioners to enhance communication and minimise technology limitations.

Introduction: Chronic Obstructive Pulmonary Disease (COPD) is a leading cause of morbidity and mortality globally, and rural patients are at higher risk for poor COPD health outcomes. The United States National Institutes of Health (NIH) has issued a call for innovative care delivery models to address this gap in COPD care quality in rural communities. This paper explores the perspective of healthcare teams at two rural VA medical centers sustaining an innovative interprofessional COPD care delivery model, COPD Coordinated Access to Reduce Exacerbations (CARE). Methods: This qualitative evaluation was conducted at two rural VA medical centers in the Southeast and Midwest regions of the US. Eleven semi-structured interviews with diverse clinical stakeholders were conducted including: facility leaders, hired pharmacists, clinical pharmacists, nurse care managers, primary care providers, and referral champions. The Practical Robust Implementation and Sustainability Model (PRISM) was applied to develop interview guides and informed data analysis. Interviews were transcribed and a mixed inductive-deductive approach was used for data analysis, involving iterative coding and consensus-building among five evaluators to identify emerging themes. Results: Five overarching themes emerged as key facilitators of COPD CARE sustainment including (1) leadership support, (2) value alignment, (3) service institutionalization, (4) service adaptation, and (5) interprofessional collaboration. Notably, clinical pharmacists were described as filling care gaps in these under-resourced facilities. Conclusion: This evaluation demonstrated the impact of clinical pharmacists serving as prescribers in improving COPD management in rural settings. The sustainment factors identified can be utilized to inform the expansion of similar, team-based healthcare programs across rural settings.

Clinical training content for real-world care delivery is important to promote high-quality care. Clinical training promotes knowledge acquisition and additional implementation strategies are needed to translate those acquired skills into practice-based changes. The Chronic Obstructive Pulmonary Disease Coordinated Access to Reduce Exacerbations (COPD CARE) Academy is a training initiative implemented at ≥ 49 US Department of Veterans Affairs (VA) medical centers. The Academy provides training on the implementation of COPD CARE programs and promotes complex care transitions. The Academy offers implementation strategies for local champions to leverage VA and academic institution partnerships. The COPD CARE Academy represents an interprofessional collaboration among frontline clinicians and VA leadership to design a training program using quality improvement methodology for better care for patients with COPD.

Background: US Veterans are four times more likely to be diagnosed with chronic obstructive pulmonary disease (COPD) compared to the civilian population with no care model that consistently improves Veteran outcomes when scaled. COPD Coordinated Access to Reduce Exacerbations (CARE) is a care bundle intended to improve the delivery of evidence-based practices to Veterans. To address challenges to scaling this program in the Veterans’ Health Administration (VA), the COPD CARE Academy (Academy), an implementation facilitation package comprised of five implementation strategies was designed and implemented. Methods: This evaluation utilized a mixed-methods approach to assess the impact of the Academy’s implementation strategies on the RE-AIM framework implementation outcomes and the extent to which they were effective at increasing clinicians’ perceived capability to implement COPD CARE. A survey was administered one week after Academy participation and a semi-structured interview conducted 8 to 12 months later. Descriptive statistics were calculated for quantitative items and thematic analysis was used to analyze open-ended items. Results: Thirty-six clinicians from 13 VA medical centers (VAMCs) participated in the Academy in 2020 and 2021 and 264 front-line clinicians completed COPD CARE training. Adoption of the Academy was indicated by high rates of Academy session attendance (90%) and high utilization of Academy resources. Clinicians reported the Academy to be acceptable and appropriate as an implementation package and clinicians from 92% of VAMCs reported long-term utilization of Academy resources. Effectiveness of the Academy was represented by clinicians’ significant increases (p < 0.05) in their capability to complete ten implementation tasks after Academy participation. Conclusions: This evaluation found that the use of implementation facilitation paired with additional strategies enhanced the capacity of clinicians to implement COPD CARE. Future assessments are needed to explore post-academy resources that would help VAMCs to strategize localized approaches to overcome barriers.

Chronic obstructive pulmonary disease (COPD) is the third leading cause of death worldwide and is estimated to be the leading cause of death in the next 15 years. Patients with COPD suffer from persistent chronic cough, sputum production and exacerbations leading to deteriorating lung function, worsening quality of life and loss of independence. While evidence-based interventions exist to improve the well-being of patients with COPD, incorporation of these interventions into routine clinical care is challenging. Chronic Obstructive Pulmonary Disease Coordinated Access to Reduce Exacerbations (COPD CARE) is a team-based, coordinated care transitions service integrating evidence-based interventions for COPD management within the patient care delivery model to reduce readmissions. This evaluation considers the process of scaling the COPD CARE service across medical facilities using an implementation package designed for service expansion. The implementation package was developed at the United States Veterans Health Administration and implemented at two medical centres. Core dissemination and implementation science methods were applied to guide design and delivery of the implementation package. The aims of this evaluation were to (1) evaluate the impact of the implementation package on use of evidence-based interventions for COPD management and (2) explore clinician perceptions of the implementation package. This prospective mixed-methods quality improvement project included two Plan Do Check Act (PDCA) cycles conducted over a 24-month period. Electronic health record data demonstrated significant improvements in the count of evidence-based interventions incorporated into routine clinical care after training completion (p<0.001), offering preliminary effectiveness of the package to improve uptake of best practices for COPD management. Clinician perceptions of the implementation package, measured by questionnaire at multiple time points, demonstrated significant improvements for all scales at the end of the final PDCA cycle. Clinicians described the implementation package as positively impacting clinician confidence, interprofessional collaboration and patient care delivery.