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2023 HSR&D/QUERI National Conference Abstract

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1058 — Facilitators and Barriers to Implementation of the VA Redefining Elder Care in America Project (RECAP) Program: A Qualitative Evaluation

Lead/Presenter: Kate Magid,  COIN - Seattle/Denver
All Authors: Magid KH (Denver-Seattle Center of Innovation for Veteran-Centered & Value-Driven Care VA Eastern Colorado Health Care System), Nunnery M (Denver-Seattle Center of Innovation for Veteran-Centered & Value-Driven Care VA Eastern Colorado Health Care System); Haverhals LM (Denver-Seattle Center of Innovation for Veteran-Centered & Value-Driven Care VA Eastern Colorado Health Care System); Manheim C (Denver-Seattle Center of Innovation for Veteran-Centered & Value-Driven Care VA Eastern Colorado Health Care System); Young J (VA Puget Sound Health Care System, Seattle, WA); Roczen M (University of Colorado School of Medicine, Aurora, CO); Levy C (Denver-Seattle Center of Innovation for Veteran-Centered & Value-Driven Care VA Eastern Colorado Health Care System)

Objectives:
As the United States (US) population ages, the number of Veterans that the Department of Veterans Affairs (VA) must provide long-term care for continues to climb. Older adults prefer to live in their own homes or in community settings when they need more long-term services and supports rather than in institutional care settings like nursing homes. Currently, less than one-third of Veterans who enter nursing homes had received services and supports to delay or prevent admission. In 2021, the VA began piloting the Redefining Elder Care in America Program (RECAP) at two VA medical centers (VAMCs). The goal of RECAP is to provide geriatric care coordination for Veterans identified as being high-risk for nursing home placement and link these Veterans and their caregivers to non-institutional care services and support. The objective of this evaluation is to describe facilitators and barriers to early-phase implementation of RECAP at two VAMCs.

Methods:
Between August-November 2021, we conducted semi-structured phone interviews with VA staff involved in RECAP at the two pilot sites. Interviews were recorded and transcribed verbatim. Three team members analyzed transcripts line-by-line using constructs from the Consolidated Framework for Implementation Research (CFIR) to identify barriers and facilitators to implementation, with CFIR constructs acting as deductive codes. Analysts coded two transcripts jointly, subsequently meeting to establish consensus on coding and code definitions. Analysts then coded the remaining transcripts independently. Data were analyzed using Atlas.ti software. We interviewed nine individuals at the two VAMCs, including pilot site leadership (n = 5), social workers serving as RECAP coordinators (n = 2), and RECAP program support assistants (PSAs) (n = 2).

Results:
Five CFIR constructs emerged as facilitators or barriers to implementation: relative advantage, leadership engagement, networks and communication, available resources, and readiness for implementation. Facilitators included viewing the RECAP approach as more proactive in identifying high-risk Veterans needing non-institutional care than existing processes. RECAP staff received leadership support through biweekly meetings, which enabled program adaptations and opportunities to troubleshoot issues. Additional facilitators included having a dedicated PSA and a dashboard to identify Veterans who would benefit from RECAP. At one site, absence of a full-time coordinator served as a barrier to initial implementation. Other barriers included lack of readiness for implementation due to uncertainty of the roles of the RECAP coordinator and PSA and how to best delineate tasks between them.

Implications:
RECAP is in its early stages and applying the CFIR to describe facilitators and barriers to early implementation is advantageous. While we identified challenges related to inadequate staffing and lack of clarity around staff responsibilities, leadership engagement, clear communication, and program-specific resources facilitated initial RECAP implementation.

Impacts:
Ongoing evaluation of RECAP will allow for a comprehensive understanding of barriers and facilitators throughout the implementation, adaptations, and determinants of program sustainability. These findings will be integral to successful implementation if RECAP is expanded to other VAMCs. Use of the CFIR to study RECAP implementation is an effective tool to provide rapid and actionable feedback to program staff throughout implementation.