AUTHOR=King Diane K. , Shoup Jo Ann , Raebel Marsha A. , Anderson Courtney B. , Wagner Nicole M. , Ritzwoller Debra P. , Bender Bruce G. 

TITLE=Planning for Implementation Success Using RE-AIM and CFIR Frameworks: A Qualitative Study

JOURNAL=Frontiers in Public Health

VOLUME=8

YEAR=2020

URL=https://www.frontiersin.org/journals/public-health/articles/10.3389/fpubh.2020.00059

DOI=10.3389/fpubh.2020.00059

ISSN=2296-2565

ABSTRACT=<p><bold>Background:</bold> RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) and CFIR (Consolidated Framework for Implementation Research) dissemination and implementation frameworks define theory-based domains associated with the adoption, implementation and maintenance of evidence-based interventions. Used together, the two frameworks identify metrics for evaluating implementation success, i.e., high reach and effectiveness resulting in sustained practice change (RE-AIM), and modifiable factors that explain and enhance implementation outcomes (CFIR). We applied both frameworks to study the implementation planning process for a technology-delivered asthma care intervention called Breathewell within an integrated care organization. The goal of the Breathewell intervention is to increase the efficiency of delivering resource-intensive asthma care services.</p><p><bold>Methods:</bold> We reviewed historical documents (i.e., meeting agendas; minutes) from 14 months of planning to evaluate alignment of implementation team priorities with RE-AIM domains. Key content was extracted and analyzed on topics, frequency and amount of discussion within each RE-AIM domain. Implementation team members were interviewed using questions adapted from the <italic>CFIR Interview Guide Tool</italic> to focus their reflection on the process and contextual factors considered during pre-implementation planning. Documents and transcripts were initially coded using RE-AIM domain definitions, and recoded using CFIR constructs, with intent to help explain how team decisions and actions can contribute to adoption, implementation and maintenance outcomes.</p><p><bold>Results:</bold> Qualitative analysis of team documents and interviews demonstrated strong alignment with the RE-AIM domains: Reach, Effectiveness, and Implementation; and with the CFIR constructs: <italic>formal inclusion</italic> of provider and staff stakeholders in implementation planning, <italic>compatibility</italic> of the intervention with workflows and systems, and alignment of the intervention with organizational <italic>culture</italic>. Focus on these factors likely contributed to RE-AIM outcomes of high implementation fidelity. However, team members expressed low confidence that Breathewell would be adopted and maintained post-trial. A potential explanation was weak alignment with several CFIR constructs, including <italic>tension for change, relative priority, and leadership engagement</italic> that contribute to organizational receptivity and motivation to sustain change.</p><p><bold>Conclusions:</bold> While RE-AIM provides a practical framework for planning and evaluating practice change interventions to assure their external validity, CFIR explains <italic>why</italic> implementation succeeded or failed, and when used proactively, identifies relevant modifiable factors that can promote or undermine adoption, implementation, and maintenance.</p>