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Caregiver-Centred Care:
Strategies for the Scale and
Spread of Education and Training Initiatives
Dr. Jenny Ploeg, RN, PhD
Professor and Scientific Director,
Aging, Community and Health Research Unit
School of Nursing, McMaster University
1
Health Workforce Training Meeting
Edmonton, AB
March 14-15, 2019
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Agenda
1. Introduce concepts of scale up and spread
2. Describe strategies and steps for scale up
3. Discuss barriers and
facilitators
4. Application examples
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What is the Issue?
• Many effective innovations are not
sustained, spread or scaled up
• Lost opportunities, resources, impact
• Poor attention to strategies for scaling
and spreading leads to unsuccessful
dissemination of potentially important
innovations
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Part 1: Concepts:Scale-UpSpread
Sustainability
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Literature Review
• No published literature was found on scale
and spread of educational or training
resources to support caregivers
• Most of the literature discussed scale and
spread of innovations in the context of
public health interventions
• Scaling, spreading, and sustaining are
presented in the general context of health
and healthcare innovations
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Scaling Up
“Deliberate efforts to increase the impact
ofsuccessfully tested health interventions to
benefit more people and foster policy and
program development on a lasting basis”
(Milat et al, 2014)
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Scalability
“The ability of a health intervention shown to
be efficacious on a small scale and/or under
controlled conditions to be expanded under
real world conditions to reach a greater
proportion of the eligible population while
retaining effectiveness” (Milat et al., 2014)
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Four Types of Scaling
1) Spontaneous diffusion: diffusion of an intervention
occurs without a plan (rarely happens on its own)
2) Horizontal scaling up: expanding or replicating an
intervention in different settings and populations
3) Vertical scaling up: policy, political, and other
healthcare system changes required to put in place an
innovation at a national level
4) Diversification: adding and trialing an innovation
alongside a previous one that is in the middle of being
scaled-up (WHO, 2010)
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Spreading
“The process through which new working
methods developed in one setting are
adopted, perhaps with appropriate
modifications, in other organizational
contexts” (Buchanan et al., 2006)
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Sustaining
“Sustained knowledge use refers to the continued
implementation of innovations over time and
depends on the ability of workers, organizations,
and health care delivery systems to adapt to
change”
“Addressing sustainability requires planning for
both the spread and scaling up of innovations in
health systems” (Davies & Edwards, 2013)
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Issues
• Scale and spread are poorly defined
• Scale and spread are used
interchangeably in the literature, making it
challenging it to isolate features unique to
each concept
• Both terms similarly refer to
implementation of health care innovations
for a large population
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Issues• Many studies exploring scale-up strategies of
evidence-based practice in primary care were
conducted in low to middle income countries
• There is a need for literature exploring scaling
and spreading:
in middle to high income countries such as
Canada
of caregiver training resources
of educational programs for healthcare
providers
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Part 2: Strategies and Steps
for Scale Up
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Key Resources for Scale Up
• Work by Milat et al (2014, 2016) New
South Wales Ministry of Health, Australia
• World Health Organization and
EXPANDNET (2010; 2011)
• Canadian Foundation for Healthcare
Improvement
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Steps in Scaling Up Process
1. Assessment of scalability
2. Development of the scaling plan
3. Preparation for scaling up (material,
financial, and human resources)
4. Scaling up the intervention
(Milat et al, 2014; 2016)
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Step 1. Scalability Assessment
• Assess effectiveness
• Assess potential reach and adoption
• Assess alignment with strategic context
• Assess acceptability and feasibility
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Step 2. Develop a Scale-Up Plan
- The Vision -Written document including:
• Rationale
• Intervention components & modifications
• Map of the social, political and organizational
environments
• Key personnel functions
• Approach / strategy
• Evaluation & monitoring
• Resources
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Step 3. Prepare for Scale Up
Building a foundation:
• Stakeholder engagement & consultation
• Support from political & health policy
decision-makers
• Mobilize broader community of practice
• Address resources & capacity changes
• Align material, financial and personnel
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Step 4. Scaling-Up
• Strengthen organizations (staff retraining,
mentoring, leadership development, coaching)
• Develop agreements re use of resources,
governance structures
• Develop systems to measure effectiveness,
reach, fidelity, acceptability and costs on
ongoing basis
• Ensure sustainability (organizational and cultural
changes to institutionalize intervention so
becomes routine practice
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12 Recommendations for
Designing for Scale-up WHO
(2011)
Stakeholders are key:
• 5 of the WHO’s 12 recommendations on designing for scale-up directly require stakeholder participation
• the other 7 WHO recommendations are informed by stakeholder participation
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5 of 12 Steps in Designing for Scale-up Require
Direct Stakeholder Involvement (WHO, 2011)
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1. Engage in a participatory process involving key stakeholders
9. Advocate with donors and other sources of
funding for financial support
11. Plan to disseminate information
10. Advocate for necessary changes in
policies, regulations and health system
components
3. Reach consensus on expectations for scale-up
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7 of 12 Steps in Designing for Scale-up Benefit from
Stakeholder Involvement (WHO, 2011)
222. Ensure the relevance of the intervention
6. Test the intervention in the variety of
sociocultural and institutional settings where it will
be scaled-up
8. Develop plans to assess and
document implementation
7. Test the intervention under routine
operating conditions
4. Tailor the intervention to sociocultural and institutional
settings
5. Keep the intervention as simple as possible
12. Plan to be cautious in
scaling-up
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Scaling Strategies
• A literature review of studies using scaling strategies in primary care determined the following components as commonly included in the scaling plan:
human resources
healthcare infrastructure
changes in policy/regulation
financial outputs
(Charif et al, 2017)
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WHO (2011) Checklist to
Assess ScalabilityQuestions related to potential scalability Yes
(+)
No
(-)
More
information/
action
needed
Is input about the project being sought from a
range of stakeholders (e.g. Policy-makers,
programme manager, providers, NGOs,
beneficiaries)?
Are individuals from the future implementing
agency involved in the design and
implementation of the pilot?
Does the project have mechanisms for building
ownership in the future implementing
organization?
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Part 3: Barriers
and Facilitators
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Challenges to Scaling Up
• Leadership failing to adapt the intervention to
the local context
• Lack of human resources, intervention costs
and other financial factors
• Meeting resistance when implementing new
practice changes due to capacity constraints
• Inadequate investment in implementation
strategies such as training and evaluation
systems
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Enablers for Scaling
• Ensuring that the innovation has attributes
that optimize the potential for scaling-up
CORRECT acronym: Credible, Observable,
Relevant, Relative advantage, Easy to
understand, Compatible, and Testable
(Glaser et al., 1983; WHO, 2009)
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Six Levers for Accelerating
Healthcare Improvement (CFHI)
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Summary
• The literature on scale and spread in the general context of health can be applied to promote the uptake and sustainability of various types of innovations
• There are many strategies that exist to promote scaling, spreading, sustaining innovations
• Yet, not all programs are successfully spread and scaled
• There are many challenges to spreading and scaling including an everchanging local context
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Part 4: Examples of Spread and Scale Up from a Program of Research
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Example 1: Spreading and
Sustaining Best Practice in
Home Care
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Spreading Strategies
Model for the spread of best practices in home
care organizations:
(1) committing to change
(2) implementing on a small scale
(3) adapting locally
(4) spreading internally to multiple users and
sites
(5) disseminating externally
(Ploeg et al., 2014)
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Example 2
Spread and Scale-up of
Evidence-Informed Health Care
Delivery: A Socio-ecological
Model of Dynamic Health
Systems Change Emerging from
a Program of Research. Edwards,
Berta, Marck, Downey, Ploeg,
Grinspun, Davies, Ritchie, Virani,
Higuchi
Online book available free at
https://www.nancyedwards.ca/books/
developing-a-program-of-
research.html
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Example 2: Enablers:
Organizational Level1. Supporting and reinforcing organizational
structures (financial, human, equipment resources; policies and procedures; communication systems, formal implementation plan)
2. Shared vision among managers, champions, staff
3. Critical mass of formally recognized champions and change agents to drive the innovation
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Example 2: Enablers:
System Level1. Supporting and reinforcing system-level
structures (e.g., legislation and standards, information technology and communication infrastructures; dedicated resources)
2. Distributed leadership that values system change, with reach across the health care system
3. Alignment of innovations with 1 above.
4. Feasible and tangible plans for scale up
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Aging, Community and Health
Research Unit
ACHRU Research Program Goals
•To promote optimal aging at home for older
adults with multiple chronic conditions
(MCC) and to support family caregivers
•To design, evaluate and translate new and
innovative interprofessional community-
based interventions to improve quality of
life and care
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ACHRU: 13 Funded Studies
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Example 3: Aging, Community and Health
Research Unit (ACHRU) Community
Partnership Program
Community Partnership Program for Diabetes
Self-Management for Older Adults-Canada
funded by CIHR SPOR Network in Primary and
Integrated Health Care Innovations (PICHI)
Implementing, evaluating and planning for scale
of an innovative community-based model that
aims to improve management of diabetes and
multiple chronic conditions and quality of life of
older adults and support family caregivers
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Example 3: Community Partnership
Program
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Example 3: Community
Partnership Program
Planning for scale-up from the start of the program:
• Program will be implemented in three provinces (ON, QC, PEI) and within multiple health and social care settings and adapted to each context
• Engage stakeholders from start of project:
Patient/caregiver and public research partners in planning research, patient advisory council, steering committee, Community Advisory Boards (CAB)
Policy and decision makers in steering committee and CABs
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• CABs will ensure that the voice of important members are being heard and that the program reflects the local context
• Caregivers will also be on the boards to provide advice to the research team
• By engaging key players at the start of the program we hope to create a sustainable program to improve the healthcare experience
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Example 3: ACHRU Community
Partnership Program
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Looking for Support for the
Innovation at the End of a Study is a
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lonely and uphill battle
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Lessons Learned #1:
Engage Stakeholders Early
Carefully consider:
• Who: patients, caregivers, decision
makers, providers, researchers
• When: throughout process
• What: roles do stakeholders play
• Where: are stakeholders needed
• How: to sustain engagement
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The Backbone Organization
• Collective impact literature stresses the importance of the backbone organization, whose functions include:– Guiding vision & strategy
– Supporting aligned activities
– Establishing shared measurement practices
– Building public will/support
– Advancing policy
– Mobilizing continued funding
• The lack of a strong backbone organization is the number one reason why collective impact initiatives fail (The Collective Impact Forum, 2018, website: https://collectiveimpactforum.org/resources/value-backbone-organizations-collective-impact)
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Lessons Learned #2: Secure a
Backbone Organization(s)• Scaling-up an innovation can be seen as a
collective impact initiative, so the importance of a backbone organization is critical
• Key considerations regarding the organization:
Leadership
Membership (e.g., implementation teams, early adopters)
Technical expertise
Local representation
Sustainability (e.g., people, ongoing funding)
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Lessons Learned: #3:
Plan for Scale Up While
Building an Evidence Base
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Cart before
the Horse?• Some people are uncomfortable with designing for
scale-up while still collecting evidence on effects of the innovation
• WHO (201) recommends planning for scale-up early on because:
Policy & System Change: scaling up usually requires this & it takes time to implement (so start early)
Study Support: study inputs disappear at study end, so need to put mechanisms in place to sustain innovation
Scale-up Pressure: there is pressure to scale-up, so design process & outcome measures early to continue to build the evidence
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Lessons Learned #4: Advance
the State of Science
on Scale Up
• We have never planned for scaling up, or scaled up, an
ACHRU intervention:
Reflects stage of research process
Funding agency pressure (e.g., recent PICHI grant)
• A number of frameworks and guides exist to inform
scale-up planning, but most “have not been informed by
empirical examination of how scaling up decision making
and processes occur” (Milat et al., 2016, pg. 2)
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Opportunities
• Metrics to evaluate the scale-up process
develop preliminary outcome measures (e.g., coverage of targeted population, number of targeted sites/settings)
develop preliminary tools
test measures/tools at RCT sites
conduct cross-provincial comparisons
• potential data sources & data quality issues
• structural issues (e.g., leadership for scale-up, sustainability of backbone organization)
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Opportunities
•Document our experience in scale-up planning
What works and doesn’t work?
What is unclear or complex?
Are there core components/strategies to scale-up that apply across populations/sites?
What is the right balance in terms of research team involvement in scale-up planning (we can’t just provide a tool kit and leave analysis/planning up to the sites)?
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Thank you
Questions?
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Selected References• Ben Charif A, Hasani K, Wong S, Zomahoun HTV, Fortin M, Frietas A, Katz
A, Kendall CE, Liddy C, Nicholson K, Petrovic B, Ploeg J, Legare F. (2018).
Assessment of scalability of evidence-based innovations in community-
based primary health care: A cross sectional study. CMAJ Open, 6(4)
• Centre for Epidemiology and Evidence. Milat, AJ, Newson R & King L.
(2014). Increasing the scale of population health interventions: A guide.
NSW Ministry of Health.
• Edwards N, Berta W, Marck P, Downey A, Ploeg J, Grinspun D, Davies B,
Ritchie J, Virani T, Highuchi K. (2018) Spread and scale-up of evidence-
informed health care delivery: A socio-ecological model of dynamic health
systems change emerging from a program of research. In N. Edwards and
S. Roelofs (Eds). Developing a Program of Research: An Essential Process
for a Successful Research Career.
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Selected References• Indig et al., 2018. Pathways for scaling up public health interventions. BMC
Public Health 2018;18:68
• Milat AJ, King L, Bauman AE, & Redman S. (2012). The concept of
scalability: Increasing the scale and potential adoption of health promotion
interventions into policy and practice. Health Promotion International, 28,
285-298.
• Ploeg J, Markle-Reid M, Davies B, Higuchi, K, Gifford W, Bajnok, I,
McConnell H, Plenderleith J, Foster S, Bookey-Bassett S. (2014).
Spreading and sustaining best practices for home care of older adults: A
grounded theory study. Implementation Science, 9:162.
• World Health Organization and EXPANDNET. (2010). Nine steps for
developing a scaling-up strategy. WHO.
• World Health Organization and EXPANDNET. (2011). Beginning with the
end in mind: Planning pilot projects and other programmatic research for
successful scaling up.
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