Translating Evidence-Based Protocols Into the Home Healthcare Setting

Abstract

Activity-limiting pain is common among older home care patients and pain management is complicated by the high prevalence of physical frailty and multimorbidity in the home care population. A comparative effectiveness study was undertaken at a large urban home care agency to examine an evidence-based pain self-management program delivered by physical therapists (PTs). This article focuses on PT training, methods implemented to reinforce content after training and to encourage uptake of the program with appropriate patients, and therapists’ fidelity to the program. Seventeen physical therapy teams were included in the cluster randomized controlled trial, with 8 teams (155 PTs) assigned to a control and 9 teams (165 PTs) assigned to a treatment arm. Treatment therapists received interactive training over two sessions, with a follow-up session 6 months later. Additional support was provided via emails, e-learning materials including videos, and a therapist manual. Program fidelity was assessed by examining PT pain documentation in the agency’s electronic health record. PT feedback on the program was obtained via semistructured surveys. There were no between-group differences in the number of PTs documenting program elements with the exception of instruction in the use of imagery, which was documented by a higher percentage of intervention therapists (p = 0.002). PTs felt comfortable teaching the program elements, but cited time as the biggest barrier to implementing the protocol. Possible explanations for study results suggesting limited adherence to the program protocol by intervention-group PTs include the top-down implementation strategy, competing organizational priorities, program complexity, competing patient priorities, and inadequate patient buy-in. Implications for the implementation of complex new programs in the home healthcare setting are discussed.

Implementing a Pain Self‐Management Protocol in Home Care: A Cluster‐Randomized Pragmatic Trial

“…Intervention PTs also shared that not all patients adhered to the activity journals or practiced the techniques between sessions. 47 Power calculations performed at the time of the study design indicated adequate power to detect mean differences between usual care and intervention of 1.07 on Roland Morris, 0.51 on pain intensity, and similar magnitudes for other outcomes, differences that are clinically meaningful and have been shown in other work to be achievable. That the current study has not demonstrated significant treatment differences is not from a lack of statistical power but from small mean differences.…”

“…The most likely explanation is that intervention PTs did not deliver the protocol as instructed despite a booster session being provided to intervention PTs to minimize "drift" in provider skills, and continued protocol implementation being encouraged with monthly email reminders to intervention PTs. As reported elsewhere, 47 treatment fidelity was assessed by examining the extent to which PTs documented elements of their treatment sessions in the electronic medical record pain problem fields. This allowed intervention and usual care group PT documentation of the self-management techniques, which was similar and relatively low for both groups, to be compared.…”

“…This allowed intervention and usual care group PT documentation of the self-management techniques, which was similar and relatively low for both groups, to be compared. 47 Individual interviews were also conducted with intervention PTs after follow-up assessments of study participants were completed. Questions were included regarding PT use of the program, their perceived comfort delivering program elements, their perceptions of patient responses to the protocol, and challenges encountered implementing it.…”

“…Although the response rate was low (roughly 16% completed an on-line survey), these data suggest that intervention therapists were comfortable delivering the protocol but did so infrequently. 47 The most common implementation barrier was insufficient time during the visit. Therapists indicated that the delivery of the protocol required an additional 15 to 20 minutes per visit and that time spent on the protocol limited their ability to address other problems.…”

“…Therapists indicated that the delivery of the protocol required an additional 15 to 20 minutes per visit and that time spent on the protocol limited their ability to address other problems. 47 Additional feedback from PTs included comments from their patients that some patients did not think the techniques would work and that the Pain from recent surgery only, back pain, neuropathic pain; 78 participants in this group reported pain from surgery that was not arthritis-related (e.g., back or joint surgery). SD = standard deviation.…”