Publications by authors named "Jane E Mahoney"

44 Publications

Encouraging the scale-up of proven interventions: Infrastructure development for the "Evidence-to-Implementation" award.

J Clin Transl Sci 2021 26;5(1):e160. Epub 2021 Jul 26.

D & I (Dissemination and Implementation) Launchpad, Institute for Clinical and Translational Research, School of Medicine and Public Health, University of Wisconsin - Madison, Madison, WI, USA.

Background/objective: Although most research universities offer investigators help in obtaining patents for inventions, investigators generally have few resources for scaling up non-patentable innovations, such as health behavior change interventions. In 2017, the dissemination and implementation (D & I) team at the University of Wisconsin's Clinical and Translational Science Award (CTSA) created the Evidence-to-Implementation (E2I) award to encourage the scale-up of proven, non-patentable health interventions. The award was intended to give investigators financial support and business expertise to prepare evidence-based interventions for scale-up.

Methods: The D & I team adapted a set of criteria named Critical Factors Assessment, which has proven effective in predicting the success of entrepreneurial ventures outside the health care environment, to use as review criteria for the program. In March 2018 and February 2020, multidisciplinary panels assessed proposals using a review process loosely based on the one used by the NIH for grant proposals, replacing the traditional NIH scoring criteria with the eight predictive factors included in Critical Factors Assessment.

Results: two applications in 2018 and three applications in 2020 earned awards. Funding has ended for the first two awardees, and both innovations have advanced successfully.

Conclusion: Late-stage translation, though often overlooked by the academic community, is essential to maximizing the overall impact of the science generated by CTSAs. The Evidence-to-implementation award provides a working model for supporting late-stage translation within a CTSA environment.
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http://dx.doi.org/10.1017/cts.2021.828DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8427544PMC
July 2021

Implementation for Sustained Impact in Teleophthalmology (I-SITE): applying the NIATx Model for tailored implementation of diabetic retinopathy screening in primary care.

Implement Sci Commun 2021 Jul 6;2(1):74. Epub 2021 Jul 6.

Department of Ophthalmology and Visual Sciences, University of Wisconsin School of Medicine and Public Health, 2870 University Ave., Ste. 206, Madison, WI, 53705, USA.

Background: Teleophthalmology provides evidence-based, telehealth diabetic retinopathy screening that is underused even when readily available in primary care clinics. There is an urgent need to increase teleophthalmology use in the US primary care clinics. In this study, we describe the development of a tailored teleophthalmology implementation program and report outcomes related to primary care provider (PCP) adoption.

Methods: We applied the 5 principles and 10 steps of the NIATx healthcare process improvement model to develop and test I-SITE (Implementation for Sustained Impact in Teleophthalmology) in a rural, the US multi-payer health system. This implementation program allows patients and clinical stakeholders to systematically tailor teleophthalmology implementation to their local context. We aligned I-SITE components and implementation strategies to an updated ERIC (Expert Recommendations for Implementing Change) framework. We compared teleophthalmology adoption between PCPs who did or did not participate in various components of I-SITE. We surveyed PCPs and clinical staff to identify the strategies they believed to have the highest impact on teleophthalmology use.

Results: To test I-SITE, we initiated a year-long series of 14 meetings with clinical stakeholders (n=22) and met quarterly with patient stakeholders (n=9) in 2017. Clinical and patient stakeholder groups had 90.9% and 88.9% participant retention at 1 year, respectively. The increase in teleophthalmology use was greater among PCPs participating in the I-SITE implementation team than among other PCPs (p < 0.006). The proportion of all PCPs who used the implementation strategy of electing diabetic eye screening for their annual performance-based financial incentive increased from 0% (n=0) at baseline to 56% (n=14) following I-SITE implementation (p = 0.004). PCPs and clinical staff reported the following implementation strategies as having the highest impact on teleophthalmology use: reminders to ask patients about diabetic eye screening during clinic visits, improving electronic health record (EHR) documentation, and patient outreach.

Conclusions: We applied the NIATx Model to develop and test a teleophthalmology implementation program for tailored integration into primary care clinics. The NIATx Model provides a systematic approach to engaging key stakeholders for tailoring implementation of evidence-based telehealth interventions into their local context.
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http://dx.doi.org/10.1186/s43058-021-00175-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8258481PMC
July 2021

Effect of an eHealth intervention on older adults' quality of life and health-related outcomes: a randomized clinical trial.

J Gen Intern Med 2021 Jun 7. Epub 2021 Jun 7.

School of Journalism and Mass Communication, University of Wisconsin-Madison, Madison, Wisconsin, USA.

Background: By 2030, the number of US adults age ≥65 will exceed 70 million. Their quality of life has been declared a national priority by the US government.

Objective: Assess effects of an eHealth intervention for older adults on quality of life, independence, and related outcomes.

Design: Multi-site, 2-arm (1:1), non-blinded randomized clinical trial. Recruitment November 2013 to May 2015; data collection through November 2016.

Setting: Three Wisconsin communities (urban, suburban, and rural).

Participants: Purposive community-based sample, 390 adults age ≥65 with health challenges.

Exclusions: long-term care, inability to get out of bed/chair unassisted.

Intervention: Access (vs. no access) to interactive website (ElderTree) designed to improve quality of life, social connection, and independence.

Measures: Primary outcome: quality of life (PROMIS Global Health). Secondary: independence (Instrumental Activities of Daily Living); social support (MOS Social Support); depression (Patient Health Questionnaire-8); falls prevention (Falls Behavioral Scale). Moderation: healthcare use (Medical Services Utilization). Both groups completed all measures at baseline, 6, and 12 months.

Results: Three hundred ten participants (79%) completed the 12-month survey. There were no main effects of ElderTree over time. Moderation analyses indicated that among participants with high primary care use, ElderTree (vs. control) led to better trajectories for mental quality of life (OR=0.32, 95% CI 0.10-0.54, P=0.005), social support received (OR=0.17, 95% CI 0.05-0.29, P=0.007), social support provided (OR=0.29, 95% CI 0.13-0.45, P<0.001), and depression (OR= -0.20, 95% CI -0.39 to -0.01, P=0.034). Supplemental analyses suggested ElderTree may be more effective among people with multiple (vs. 0 or 1) chronic conditions.

Limitations: Once randomized, participants were not blind to the condition; self-reports may be subject to memory bias.

Conclusion: Interventions like ET may help improve quality of life and socio-emotional outcomes among older adults with more illness burden. Our next study focuses on this population.

Trial Registration: ClinicalTrials.gov ; registration ID number: NCT02128789.
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http://dx.doi.org/10.1007/s11606-021-06888-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8183591PMC
June 2021

A Web-Based eHealth Intervention to Improve the Quality of Life of Older Adults With Multiple Chronic Conditions: Protocol for a Randomized Controlled Trial.

JMIR Res Protoc 2021 Feb 19;10(2):e25175. Epub 2021 Feb 19.

School of Journalism and Mass Communication, University of Wisconsin-Madison, Madison, WI, United States.

Background: Multiple chronic conditions (MCCs) are common among older adults and expensive to manage. Two-thirds of Medicare beneficiaries have multiple conditions (eg, diabetes and osteoarthritis) and account for more than 90% of Medicare spending. Patients with MCCs also experience lower quality of life and worse medical and psychiatric outcomes than patients without MCCs. In primary care settings, where MCCs are generally treated, care often focuses on laboratory results and medication management, and not quality of life, due in part to time constraints. eHealth systems, which have been shown to improve multiple outcomes, may be able to fill the gap, supplementing primary care and improving these patients' lives.

Objective: This study aims to assess the effects of ElderTree (ET), an eHealth intervention for older adults with MCCs, on quality of life and related measures.

Methods: In this unblinded study, 346 adults aged 65 years and older with at least 3 of 5 targeted high-risk chronic conditions (hypertension, hyperlipidemia, diabetes, osteoarthritis, and BMI ≥30 kg/m2) were recruited from primary care clinics and randomized in a ratio of 1:1 to one of 2 conditions: usual care (UC) plus laptop computer, internet service, and ET or a control consisting of UC plus laptop and internet but no ET. Patients with ET have access for 12 months and will be followed up for an additional 6 months, for a total of 18 months. The primary outcomes of this study are the differences between the 2 groups with regard to measures of quality of life, psychological well-being, and loneliness. The secondary outcomes are between-group differences in laboratory scores, falls, symptom distress, medication adherence, and crisis and long-term health care use. We will also examine the mediators and moderators of the effects of ET. At baseline and months 6, 12, and 18, patients complete written surveys comprising validated scales selected for good psychometric properties with similar populations; laboratory data are collected from eHealth records; health care use and chronic conditions are collected from health records and patient surveys; and ET use data are collected continuously in system logs. We will use general linear models and linear mixed models to evaluate primary and secondary outcomes over time, with treatment condition as a between-subjects factor. Separate analyses will be conducted for outcomes that are noncontinuous or not correlated with other outcomes.

Results: Recruitment was conducted from January 2018 to December 2019, and 346 participants were recruited. The intervention period will end in June 2021.

Conclusions: With self-management and motivational strategies, health tracking, educational tools, and peer community and support, ET may help improve outcomes for patients coping with ongoing, complex MCCs. In addition, it may relieve some stress on the primary care system, with potential cost implications.

Trial Registration: ClinicalTrials.gov NCT03387735; https://www.clinicaltrials.gov/ct2/show/NCT03387735.

International Registered Report Identifier (irrid): DERR1-10.2196/25175.
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http://dx.doi.org/10.2196/25175DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7935655PMC
February 2021

Essential elements to "design for dissemination" within a research network-a modified Delphi study of the Community-Academic Aging Research Network (CAARN).

Implement Sci Commun 2021 Feb 12;2(1):18. Epub 2021 Feb 12.

Department of Medicine, Division of Geriatrics and Gerontology, School of Medicine and Public Health, University of Wisconsin - Madison, Madison, WI, USA.

Background: The Community-Academic Aging Research Network (CAARN) was developed in 2010 to build partnerships, facilitate research, and ultimately accelerate the pace of development, testing, and dissemination of evidence-based programs related to healthy aging. CAARN has facilitated development and testing of 32 interventions, two of which are being packaged for scale-up, and three of which are being scaled up nationally by non-profit organizations. The purpose of this study is to describe CAARN's essential elements required to replicate its success in designing for dissemination.

Methods: We conducted a modified Delphi technique with 31 participants who represented CAARN's organization (staff and Executive Committee) and academic and community partners. Participants received three rounds of a web-based survey to rate and provide feedback about the importance of a list of potential key elements compiled by the authors. The criterion for establishing consensus was 80% of responses to consider the element to be extremely or very important.

Results: Response rate was 90% in Round 1, 82% in Round 2, and 87% in Round 3. A total of 115 items were included across rounds. Overall, consensus was achieved in 77 (67%) elements: 8 of 11 elements about academic partners, 8 of 11 about community partners, 29 of 49 about the role of the community research associate, 16 of 21 about the role of the director, 9 of 17 about the purveyor (i.e., the organization that scales up an intervention with fidelity), and 7 of 7 about the overall characteristics of the network.

Conclusions: The development of evidence-based programs designed for dissemination requires the involvement of community partners, the presence of a liaison that facilitates communications among academic and community stakeholders and a purveyor, and the presence of a pathway to dissemination through a relationship with a purveyor. This study delineates essential elements that meet the priorities of adopters, implementers, and end-users and provide the necessary support to community and academic partners to develop and test interventions with those priorities in mind. Replication of these key elements of the CAARN model may facilitate quicker development, testing, and subsequent dissemination of evidence-based programs that are feasible to implement by community organizations.
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http://dx.doi.org/10.1186/s43058-021-00122-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7881665PMC
February 2021

The Feasibility and Effectiveness of a Community-Based Intervention to Reduce Sedentary Behavior in Older Adults.

J Appl Gerontol 2021 Jan 27:733464820987919. Epub 2021 Jan 27.

University of Wisconsin-Madison, USA.

The purpose of this study was to examine the effectiveness and feasibility of translating a 4-week "Stand Up and Move More" (SUMM) intervention by state aging units to older adults ( = 56, age = 74 years). A randomized controlled trial assessed sedentary behavior, physical function, and health-related quality of life (HRQoL) before and after the intervention. Participants included healthy community-dwelling, sedentary (sit > 6 hr/day) and aged ≥ 55 years adults. For the primary outcome, the SUMM group ( = 31) significantly ( < .05) reduced total sedentary time post-intervention by 68 min/day on average (Cohen's = -0.56) compared with no change in the wait-list control group ( = 25, Cohen's = 0.12). HRQoL and function also improved ( < .05) in the SUMM group post-intervention. Workshop facilitators indicated the intervention was easy to implement, and participants expressed high satisfaction. The SUMM intervention reduced sedentary time, improved physical function and HRQoL, and was feasible to implement in community settings.
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http://dx.doi.org/10.1177/0733464820987919DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8313650PMC
January 2021

Sustaining Gains in Diabetic Eye Screening: Outcomes from a Stakeholder-Based Implementation Program for Teleophthalmology in Primary Care.

Telemed J E Health 2021 09 19;27(9):1021-1028. Epub 2020 Nov 19.

Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.

Teleophthalmology is a validated method for diabetic eye screening that is underutilized in U.S. primary care clinics. Even when made available to patients, its long-term effectiveness for increasing screening rates is often limited. We hypothesized that a stakeholder-based implementation program could increase teleophthalmology use and sustain improvements in diabetic eye screening. NIATx Model p p p p p Our stakeholder-based implementation program achieved a significant increase in overall teleophthalmology use and maintained increased post-teleophthalmology diabetic eye screening rates. Stakeholder-based implementation may increase the long-term reach and effectiveness of teleophthalmology to reduce vision loss from diabetes. Our approach may improve integration of telehealth interventions into primary care.
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http://dx.doi.org/10.1089/tmj.2020.0270DOI Listing
September 2021

After the Randomized Trial: Implementation of Community-Based Continence Promotion in the Real World.

J Am Geriatr Soc 2020 11 17;68(11):2668-2674. Epub 2020 Aug 17.

Department of Obstetrics and Gynecology, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA.

Background/objectives: Most women aged 65 and older have incontinence, associated with high healthcare costs, institutionalization, and negative quality of life, but few seek care. Mind over Matter: Healthy Bowels, Healthy Bladder (MOM) is a small-group self-management workshop, led by a trained facilitator in a community setting, proven to improve incontinence in older women.

Design: We used mixed methods to gather information on the real-world adoption, maintenance, and implementation of MOM by community agencies following a randomized controlled trial (RCT) that tested intervention effects on incontinence.

Setting: Community agencies serving older adults in six Wisconsin communities.

Participants: Community agency administrators and facilitators trained to offer MOM for the RCT.

Measurements: Investigators tracked rates of adoption (offering MOM in the 12 months following the RCT) and maintenance (offering MOM more than once in the next 18 months) in six communities. Individual interviews and focus groups (N = 17) generated qualitative data about barriers and facilitators related to adoption and maintenance. Trained observers assessed implementation fidelity (alignment with program protocol) at 42 MOM sessions.

Results: A total of 67% of communities (four of six) adopted MOM, and 50% (three of six) maintained MOM. No implementation fidelity lapses occurred. Facilitators of adoption and maintenance included MOM's well-organized protocol and lean time commitment, sharing of implementation efforts between partner organizations, staff specifically assigned to health promotion activities, and high community interest in continence promotion. Other than stigma associated with incontinence, barriers were similar to those seen with other community-based programs for older adults: limited funding/staffing, competing organizational priorities, challenges identifying/training facilitators, and difficulty engaging community partners/participants.

Conclusion: Using design for dissemination and community engagement, assessment of implementation outcomes is feasible in conjunction with a clinical RCT. Partner-centered implementation packages can address barriers to adoption and maintenance.
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http://dx.doi.org/10.1111/jgs.16771DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7857672PMC
November 2020

Outcomes associated with scale-up of the Stepping On falls prevention program: A case study in redesigning for dissemination.

J Clin Transl Sci 2020 Mar 4;4(3):250-259. Epub 2020 Mar 4.

Wisconsin Institute for Healthy Aging, Madison, WI, USA.

Introduction: Translating complex behavior change interventions into practice can be accompanied by a loss of fidelity and effectiveness. We present the evaluation of two sequential phases of implementation of a complex evidence-based community workshop to reduce falls, using the Replicating Effective Programs Framework. Between the two phases, workshop training and delivery were revised to improve fidelity with key elements.

Methods: Stepping On program participants completed a questionnaire at baseline (phase 1: = 361; phase 2: = 2219) and 6 months post-workshop (phase 1: = 232; phase 2: = 1281). Phase 2 participants had an additional follow-up at 12 months ( = 883). Outcomes were the number of falls in the prior 6 months and the Falls Behavioral Scale (FaB) score.

Results: Workshop participation in phase 1 was associated with a 6% reduction in falls (RR = 0.94, 95% CI 0.74-1.20) and a 0.14 improvement in FaB score (95% CI, 0.11- 0.18) at 6 months. Workshop participation in phase 2 was associated with a 38% reduction in falls (RR = 0.62, 95% CI 0.57-0.68) and a 0.16 improvement in FaB score (95% CI 0.14-0.18) at 6 months, and a 28% reduction in falls (RR = 0.72, 95% CI 0.65-0.80) and a 0.19 score improvement in FaB score (95% CI 0.17-0.21) at 12-month follow-up.

Conclusions: Effectiveness can be maintained with widespread dissemination of a complex behavior change intervention if attention is paid to fidelity of key elements. An essential role for implementation science is to ensure effectiveness as programs transition from research to practice.
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http://dx.doi.org/10.1017/cts.2020.17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7348035PMC
March 2020

Situating dissemination and implementation sciences within and across the translational research spectrum.

J Clin Transl Sci 2019 Jul 29;4(3):152-158. Epub 2019 Jul 29.

Department of Family and Social Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY, USA.

The efficient and effective movement of research into practice is acknowledged as crucial to improving population health and assuring return on investment in healthcare research. The National Center for Advancing Translational Science which sponsors Clinical and Translational Science Awards (CTSA) recognizes that dissemination and implementation (D&I) sciences have matured over the last 15 years and are central to its goals to shift academic health institutions to better align with this reality. In 2016, the CTSA Collaboration and Engagement Domain Task Force chartered a D&I Science Workgroup to explore the role of D&I sciences across the translational research spectrum. This special communication discusses the conceptual distinctions and purposes of dissemination, implementation, and translational sciences. We propose an integrated framework and provide real-world examples for articulating the role of D&I sciences within and across all of the translational research spectrum. The framework's major proposition is that it situates D&I sciences as targeted "sub-sciences" of translational science to be used by CTSAs, and others, to identify and investigate coherent strategies for more routinely and proactively accelerating research translation. The framework highlights the importance of D&I thought leaders in extending D&I principles to all research stages.
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http://dx.doi.org/10.1017/cts.2019.392DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7348034PMC
July 2019

Reasons Behind Preferences for Community-Based Continence Promotion.

Female Pelvic Med Reconstr Surg 2020 07;26(7):425-430

Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI.

Objectives: This study aimed to understand the potential reach of continence promotion intervention formats among incontinent women.

Methods: The Survey of the Health of Wisconsin conducts household interviews on a population-based sample. In 2016, 399 adult women were asked about incontinence and likelihood of participation in continence promotion via 3 formats: single lecture, interactive 3-session workshop, or online. Descriptive analyses compared women likely versus unlikely to participate in continence promotion. To understand format preferences, modified grounded theory was used to conduct and analyze telephone interviews.

Results: One hundred eighty-seven (76%) of 246 incontinent women reported being likely to attend continence promotion: 111 (45%) for a single lecture, 43 (17%) for an interactive 3-session workshop, and 156 (64%) for an online program. Obesity, older age, nonwhite race, prior health program participation, and Internet use for health information were associated with reported continence promotion participation. Cited advantages of a single lecture included convenience and ability to ask questions. A workshop offered accountability, hands-on learning, and opportunity to learn from others; online format offered privacy, convenience, and self-directed learning.

Conclusions: Most incontinent women are willing to participate in continence promotion, especially online.
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http://dx.doi.org/10.1097/SPV.0000000000000806DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7329600PMC
July 2020

Core Elements of Shared Decision-making for Women Considering Breast Cancer Screening: Results of a Modified Delphi Survey.

J Gen Intern Med 2020 06 19;35(6):1668-1677. Epub 2020 Mar 19.

University of Wisconsin-Madison, School of Medicine and Public Health, Madison, WI, USA.

Background: The United States Preventive Services Task Force recommends individualized breast cancer screening for average-risk women before age 50, advised by risk assessment and shared decision-making (SDM). However, the foundational principles of this recommendation that would inform decision support tools for patients and primary care physicians at the point of care have not been codified. Determining the core elements of SDM for breast cancer screening as valued by patients and primary care providers (PCPs) is necessary for implementing effective SDM tools. The aim of this study is to affirm core elements of SDM in the context of clinical interactions, through a Delphi consensus process.

Methods: A Delphi was conducted with 30 participants (10 women aged 40-49, 10 PCPs, and 10 healthcare decision scientists), to codify core elements of breast cancer screening SDM. The criterion for establishing consensus was a threshold of 80% agreement. The Delphi concluded with an 83% response rate.

Results: Of 48 items fielded, 44 met the threshold on the high-importance end of the response scale and were accepted as core elements. Core elements across three thematic categories-information delivery and patient education, interpersonal clinician-patient communication, and framework of the decision-received panelists' support in nearly equal measure. Panelists unanimously agreed that SDM should include provision of clearly understandable information, including that of personal breast cancer risk factors, and benefits and harms of mammography screening, and that PCPs should convey they are listening, knowledgeable, and demonstrate cultural sensitivity.

Discussion: This research codifies the core elements of SDM for mammography in women 40-49, augmenting the evidence to inform discussions between patients and physicians. These core elements of SDM have the potential to operationalize SDM for breast cancer screening in an effort to improve public health outcomes.
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http://dx.doi.org/10.1007/s11606-019-05298-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7280383PMC
June 2020

The Community-Academic Aging Research Network: A Pipeline for Dissemination.

J Am Geriatr Soc 2020 06 10;68(6):1325-1333. Epub 2020 Feb 10.

Division of Geriatrics and Gerontology, Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin.

Background/objectives: The Community-Academic Aging Research Network (CAARN) was created to increase the capacity and effectiveness of Wisconsin's Aging Network and the University of Wisconsin to conduct community-based research related to aging. The purpose of this article is to describe CAARN's infrastructure, outcomes, and lessons learned.

Design: Using principles of community-based participatory research, CAARN engages stakeholders to participate in the design, development, and testing of older adult health interventions that address community needs, are sustainable, and improve health equity.

Setting: Academic healthcare and community organizations.

Participants: Researchers, community members, and community organizations.

Intervention: CAARN matches academic and community partners to develop and test evidence-based programs to be distributed by a dissemination partner.

Measurements: Number of partnerships and funding received.

Results: CAARN has facilitated 33 projects since its inception in 2010 (30 including rural populations), involving 46 academic investigators, 52 Wisconsin counties, and 1 tribe. These projects have garnered 52 grants totaling $20 million in extramural and $3 million in intramural funding. Four proven interventions are being prepared for national dissemination by the Wisconsin Institute for Healthy Aging: one to improve physical activity; one to reduce bowel and bladder incontinence; one to reduce sedentary behavior; and one to reduce falls risk among Latinx older adults. Additionally, one intervention to improve balance using a modified tai chi program is being disseminated by another organization.

Conclusion: CAARN's innovative structure creates a pipeline to dissemination by designing for real-world settings through inclusion of stakeholders in the early stages of design and by packaging community-based health interventions for older adults so they can be disseminated after the research has been completed. These interventions provide opportunities for clinicians to engage with community organizations to improve the health of their patients through self-management. J Am Geriatr Soc 68:1325-1333, 2020.
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http://dx.doi.org/10.1111/jgs.16363DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7299796PMC
June 2020

Small-Group, Community-Member Intervention for Urinary and Bowel Incontinence: A Randomized Controlled Trial.

Obstet Gynecol 2019 09;134(3):600-610

Departments of Obstetrics and Gynecology, Urology, Biostatistics, Population Health Sciences, and Medicine, University of Wisconsin-Madison School of Medicine and Public Health, the University of Wisconsin-Madison School of Pharmacy, Sonderegger Research Center, and the Wisconsin Institute for Healthy Aging, Community-Academic Aging Research Network, Madison, and the Medical College of Wisconsin, Milwaukee, Wisconsin; and the Department of Women's Health, Dell Medical School, the University of Texas at Austin, Austin, Texas.

Objective: To evaluate the effects of Mind Over Matter: Healthy Bowels, Healthy Bladder, a small-group intervention, on urinary and bowel incontinence symptoms among older women with incontinence.

Methods: In this individually randomized group treatment trial, women aged 50 years and older with urinary, bowel incontinence, or both, were randomly allocated at baseline to participate in Mind Over Matter: Healthy Bowels, Healthy Bladder immediately (treatment group) or after final data collection (waitlist control group). The primary outcome was urinary incontinence (UI) improvement on the Patient Global Impression of Improvement at 4 months. Validated instruments assessed incontinence, self-efficacy, depression, and barriers to care-seeking. Intent-to-treat analyses compared differences between groups. Target sample size, based on an anticipated improvement rate of 45% in treated women vs 11% in the control group, 90% power, type I error of 0.05, with anticipated attrition of 25%, was 110.

Results: Among 121 women randomized (62 treatment group; 59 control group), 116 (95%) completed the 4-month assessment. Most participants were non-Hispanic white (97%), with a mean age of 75 years (SD 9.2, range 51-98); 66% had attended some college. There were no significant between-group differences at baseline. At 4 months, 71% of treated women vs 23% of women in the control group reported improved UI on Patient Global Impression of Improvement (P<.001); 39% vs 5% were much improved (P<.001). Regarding bowel incontinence, 55% of treated women vs 27% of women in the control group improved on Patient Global Impression of Improvement (P<.005), with 35% vs 11% reporting much improvement (P<.005). Treated women improved significantly more than women in the control group on all validated instruments of incontinence severity, quality of life, and self-efficacy. Care-seeking rates were similar between groups.

Conclusion: Participation in a small-group intervention improves symptoms of both urinary and bowel incontinence in older women. Mind Over Matter is a feasible model with potential to bring effective behavioral solutions to the community.

Clinical Trial Registration: ClinicalTrials.gov, NCT03140852.
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http://dx.doi.org/10.1097/AOG.0000000000003422DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6732187PMC
September 2019

Translating a "Stand Up and Move More" intervention by state aging units to older adults in underserved communities: Protocol for a randomized controlled trial.

Medicine (Baltimore) 2019 Jul;98(27):e16272

Department of Kinesiology, University of Wisconsin-Madison.

Introduction: As aging is associated with functional decline, preventing functional limitations and maintaining independence throughout later life has emerged as an important public health goal. Research indicates that sedentary behavior (prolonged sitting) is associated with functional loss and diminished ability to carry out activities of daily living. Despite many efforts to increase physical activity, which can be effective in countering functional loss, only an estimated 8% of older adults meet national physical activity guidelines. Thus, shifting the focus to reducing sitting time is emerging as a potential new intervention strategy but little research has been conducted in this area. With community support and funding, we developed and pilot tested a 4-week "Stand Up and Move More" intervention and found decreases in sedentary behavior, increases in physical activity, and improvements in mobility and vitality in a small sample of older adults. The purpose of this project is to expand upon these pilot results and examine the effectiveness and feasibility of translating a "Stand Up and Move More" intervention by State Aging Units to older adults in underserved communities. Eighty older adults from 4 counties across Wisconsin predominantly made up of rural older adults and older African American adults are randomly assigned to intervention (n = 40) or wait-list control (n = 40) groups. The intervention consists of 4 weekly sessions plus a refresher session at 8 weeks, and is delivered by community partners in each county. The sessions are designed to elicit ideas from older adults regarding how they can reduce their sitting time, help them set practical goals, develop action plans to reach their goals, and refine their plans across sessions to promote behavior change. Sedentary behavior, physical activity levels, functional performance, and health-related quality of life are assessed before and after the intervention to examine the effectiveness of the program. Feasibility of implementing the program by our community partners is assessed via semi-structured interviews. Strengths of this project include strong community collaborations and a high need given that the older adult population is projected to increase substantially in the next 15 years.

Conclusion: This project will provide an important step in developing effective strategies for maintaining independence in older adults through determining the feasibility and impact of a community-based intervention to break up sitting time.
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http://dx.doi.org/10.1097/MD.0000000000016272DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6635154PMC
July 2019

Disseminating Tai Chi in the Community: Promoting Home Practice and Improving Balance.

Gerontologist 2020 05;60(4):765-775

Population Health, Department of Population Health Sciences.

Background And Objectives: Falls among older adults is a pressing public health challenge. Considerable research documents that longer tai chi courses can reduce falls and improve balance. However, longer courses can be challenging to implement. Our goal was to evaluate whether a short 6-week modified tai chi course could be effective at reducing falls risk if older adults designed a personal home practice plan to receive a greater tai chi "dose" during the 6 weeks.

Design: A 3-city wait-listed randomized trial was conducted. Habituation Intention and Social Cognitive Theories framed the "coaching" strategy by which participants designed practice plans. RE-AIM and Treatment Fidelity Frameworks were used to evaluate implementation and dissemination issues. Three advisory groups advised the study on intervention planning, implementation, and evaluation. To measure effectiveness, we used Centers for Disease Control and Prevention recommended measures for falls risk including leg strength, balance, and mobility and gait. In addition, we measured balance confidence and executive function.

Results: Program Implementation resulted in large class sizes, strong participant retention, high program fidelity and effectiveness. Participants reported practicing an average of 6 days a week and more than 25 min/day. Leg strength, tandem balance, mobility and gait, balance confidence, and executive function were significantly better for the experimental group than control group.

Conclusion: The tai chi short course resulted in substantial tai chi practice by older adults outside of class as well as better physical and executive function. The course reach, retention, fidelity, and implementation across 3 cities suggest strong potential for implementation and dissemination of the 6-week course.
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http://dx.doi.org/10.1093/geront/gnz006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7228442PMC
May 2020

Intervening to reduce sedentary behavior in older adults - pilot results.

Health Promot Perspect 2019 23;9(1):71-76. Epub 2019 Jan 23.

Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.

Older adults spend most of their day in sedentary behavior (SB) (i.e., prolonged sitting), increasing risk for negative health outcomes, functional loss, and diminished ability for activities of daily living. The purpose of this study was to develop and pilot test an intervention designed to reduce SB in older adults that could be translated to communities. Two pilot studies implementing a 4-week SB intervention were conducted. SB,physical function, and health-related quality of life were measured via self-report and objective measures. Participants (N=21) completed assessments pre- and post-intervention (studies 1 and 2) and at follow-up (4-weeks post-intervention; study 2). Due to the pilot nature of this research, data were analyzed with Cohen's d effect sizes to examine the magnitude of change in outcomes following the intervention. Results for study 1 indicated moderate (d=0.53) decreases in accelerometry-obtained total SB and increases (d=0.52) in light intensity physical activity post-intervention. In study 2,there was a moderate decrease (d=0.57) in SB evident at follow-up. On average SB decreased by approximately 60 min/d in both studies. Also, there were moderate-to-large improvements in vitality (d=0.74; study 1) and gait speed (d=1.15; study 2) following the intervention. Further,the intervention was found to be feasible for staff to implement in the community. These pilot results informed the design of an ongoing federally funded randomized controlled trial with a larger sample of older adults from underserved communities. Effective,feasible, and readily-accessible interventions have potential to improve the health and function of older adults.
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http://dx.doi.org/10.15171/hpp.2019.09DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6377700PMC
January 2019

Identification of barriers, facilitators and system-based implementation strategies to increase teleophthalmology use for diabetic eye screening in a rural US primary care clinic: a qualitative study.

BMJ Open 2019 02 18;9(2):e022594. Epub 2019 Feb 18.

Health Innovation Program, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA.

Objective: Teleophthalmology for diabetic eye screening is an evidence-based intervention substantially underused in US multipayer primary care clinics, even when equipment and trained personnel are readily available. We sought to identify patient and primary care provider (PCP) barriers, facilitators, as well as strategies to increase teleophthalmology use.

Design: We conducted standardised open-ended, individual interviews and analysed the transcripts using both inductive and directed content analysis to identify barriers and facilitators to teleophthalmology use. The Chronic Care Model was used as a framework for the development of the interview guide and for categorising implementation strategies to increase teleophthalmology use.

Setting: A rural, US multipayer primary care clinic with an established teleophthalmology programme for diabetic eye screening.

Participants: We conducted interviews with 29 participants (20 patients with diabetes and 9 PCPs).

Results: Major patient barriers to teleophthalmology use included being unfamiliar with teleophthalmology, misconceptions about diabetic eye screening and logistical challenges. Major patient facilitators included a recommendation from the patient's PCP and factors related to convenience. Major PCP barriers to referring patients for teleophthalmology included difficulty identifying when patients are due for diabetic eye screening and being unfamiliar with teleophthalmology. Major PCP facilitators included the ease of the referral process and the communication of screening results. Based on our results, we developed a model that maps where these key patient and PCP barriers occur in the teleophthalmology referral process. Patients and PCPs also identified implementation strategies to directly address barriers and facilitators to teleophthalmology use.

Conclusions: Patients and PCPs have limited familiarity with teleophthalmology for diabetic eye screening. PCPs were expected to initiate teleophthalmology referrals, but reported significant difficulty identifying when patients are due for diabetic eye screening. System-based implementation strategies primarily targeting PCP barriers in conjunction with improved patient and provider education may increase teleophthalmology use in rural, US multipayer primary care clinics.
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http://dx.doi.org/10.1136/bmjopen-2018-022594DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6398662PMC
February 2019

Factors influencing patient adherence with diabetic eye screening in rural communities: A qualitative study.

PLoS One 2018 2;13(11):e0206742. Epub 2018 Nov 2.

Health Innovation Program, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States of America.

Objective: Diabetic retinopathy remains the leading cause of blindness among working-age U.S. adults largely due to low screening rates. Rural populations face particularly greater challenges to screening because they are older, poorer, less insured, and less likely to receive guideline-concordant care than those in urban areas. Current patient education efforts may not fully address multiple barriers to screening faced by rural patients. We sought to characterize contextual factors affecting rural patient adherence with diabetic eye screening guidelines.

Research Design And Methods: We conducted semi-structured interviews with 29 participants (20 adult patients with type 2 diabetes and 9 primary care providers) in a rural, multi-payer health system. Both inductive and directed content analysis were performed.

Results: Factors influencing rural patient adherence with diabetic eye screening were categorized as environmental, social, and individual using the Ecological Model of Health. Major themes included limited access to and infrequent use of healthcare, long travel distances to obtain care, poverty and financial tradeoffs, trusting relationships with healthcare providers, family members' struggles with diabetes, anxiety about diabetes complications, and the burden of diabetes management.

Conclusions: Significant barriers exist for rural patients that affect their ability to adhere with yearly diabetic eye screening. Many studies emphasize patient education to increase adherence, but current patient education strategies fail to address major environmental, social, and individual barriers. Addressing these factors, leveraging patient trust in their healthcare providers, and strategies targeted specifically to environmental barriers such as long travel distances (e.g. teleophthalmology) may fill crucial gaps in diabetic eye screening in rural communities.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0206742PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6214545PMC
April 2019

Research on the Translation and Implementation of Stepping On in Three Wisconsin Communities.

Front Public Health 2017 12;5:128. Epub 2017 Jun 12.

University of Sydney, Sydney, NSW, Australia.

Objective: Falls are a leading cause of injury death. is a fall prevention program developed in Australia and shown to reduce falls by up to 31%. The original program was implemented in a community setting, by an occupational therapist, and included a home visit. The purpose of this study was to examine aspects of the translation and implementation of in three community settings in Wisconsin.

Methods: The investigative team identified four research questions to understand the spread and use of the program, as well as to determine whether critical components of the program could be modified to maximize use in community practice. The team evaluated program uptake, participant reach, program feasibility, program acceptability, and program fidelity by varying the implementation setting and components of . Implementation setting included type of host organization, rural versus urban location, health versus non-health background of leaders, and whether a phone call could replace the home visit. A mixed methodology of surveys and interviews completed by site managers, leaders, guest experts, participants, and content expert observations for program fidelity during classes was used.

Results: The study identified implementation challenges that varied by setting, including securing a physical therapist for the class and needing more time to recruit participants. There were no implementation differences between rural and urban locations. Potential differences emerged in program fidelity between health and non-health professional leaders, although fidelity was high overall with both. Home visits identified more home hazards than did phone calls and were perceived as of greater benefit to participants, but at 1 year no differences were apparent in uptake of strategies discussed in home versus phone visits.

Conclusion: Adaptations to the program to increase implementation include using a leader who is a non-health professional, and omitting the home visit. Our research demonstrated that a non-health professional leader can conduct with adequate fidelity, however non-health professional leaders may benefit from increased training in certain aspects of . A phone call may be substituted for the home visit, although short-term benefits are greater with the home visit.
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http://dx.doi.org/10.3389/fpubh.2017.00128DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5466948PMC
June 2017

An Examination of Brain Abnormalities and Mobility in Individuals with Mild Cognitive Impairment and Alzheimer's Disease.

Front Aging Neurosci 2017 5;9:86. Epub 2017 Apr 5.

Geriatric Research, Education, and Clinical Center, William S. Middleton Memorial Veterans HospitalMadison, WI, USA.

Mobility changes are concerning for elderly patients with cognitive decline. Given frail older individuals' vulnerability to injury, it is critical to identify contributors to limited mobility. To examine whether structural brain abnormalities, including reduced gray matter volume and white matter hyperintensities, would be associated with limited mobility among individuals with cognitive impairment, and to determine whether cognitive impairment would mediate this relationship. Thirty-four elderly individuals with mild cognitive impairment (MCI) and Alzheimer's disease underwent neuropsychological evaluation, mobility assessment, and structural brain neuroimaging. Linear regression was conducted with predictors including gray matter volume in six regions of interest (ROI) and white matter hyperintensity (WMH) burden, with mobility measures as outcomes. Lower gray matter volume in caudate nucleus was associated with slower speed on a functional mobility task. Higher cerebellar volume was also associated with slower functional mobility. White matter hyperintensity burden was not significantly associated with mobility. Our findings provide evidence for associations between subcortical gray matter volume and speed on a functional mobility task among cognitively impaired individuals.
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http://dx.doi.org/10.3389/fnagi.2017.00086DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5380746PMC
April 2017

Feasibility of Providing Web-Based Information to Breast Cancer Patients Prior to a Surgical Consult.

J Cancer Educ 2018 10;33(5):1069-1074

School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA.

Patients facing decisions for breast cancer surgery commonly search the internet. Directing patients to high-quality websites prior to the surgeon consultation may be one way of supporting patients' informational needs. The objective was to test an approach for delivering web-based information to breast cancer patients. The implementation strategy was developed using the Replicating Effective Programs framework. Pilot testing measured the proportion that accepted the web-based information. A pre-consultation survey assessed whether the information was reviewed and the acceptability to stakeholders. Reasons for declining guided refinement to the implementation package. Eighty-two percent (309/377) accepted the web-based information. Of the 309 that accepted, 244 completed the pre-consultation survey. Participants were a median 59 years, white (98%), and highly educated (>50% with a college degree). Most patients who completed the questionnaire reported reviewing the website (85%), and nearly all found it helpful. Surgeons thought implementation increased visit efficiency (5/6) and would result in patients making more informed decisions (6/6). The most common reasons patients declined information were limited internet comfort or access (n = 36), emotional distress (n = 14), and preference to receive information directly from the surgeon (n = 7). Routine delivery of web-based information to breast cancer patients prior to the surgeon consultation is feasible. High stakeholder acceptability combined with the low implementation burden means that these findings have immediate relevance for improving care quality.
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http://dx.doi.org/10.1007/s13187-017-1207-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5623157PMC
October 2018

Modified Delphi Consensus to Suggest Key Elements of Falls Prevention Program.

Front Public Health 2017 20;5:21. Epub 2017 Feb 20.

Greater Wisconsin Agency on Aging Resources, Inc. , Madison, WI , USA.

Falls among older adults result in substantial morbidity and mortality. Community-based programs have been shown to decrease the rate of falls. In 2007, the Centers for Disease Control and Prevention funded a research study to determine how to successfully disseminate the evidence-based fall prevention program () in the community setting. As the first step for this study, a panel of subject matter experts was convened to suggest which parts of the fall prevention program were considered key elements, which could not be modified by implementers.

Methods: Older adult fall prevention experts from the US, Canada, and Australia participated in a modified Delphi technique process to suggest key program elements of . Forty-four experts were invited to ensure that the panel of experts would consist of equal numbers of physical therapists, occupational therapists, geriatricians, exercise scientists, and public health researchers. Consensus was determined by percent of agreement among panelists. A Rasch analysis of item fit was conducted to explore the degree of diversity and/or homogeneity of responses across our panelists.

Results: The Rasch analysis of the 19 panelists using fit statistics shows there was a reasonable and sufficient range of diverse perspectives (Infit MnSQ 1.01, score -0.1, Outfit MnSQ 0.96, score -0.2 with a separation of 4.89). Consensus was achieved that these elements were key: 17 of 18 adult learning elements, 11 of 22 programming, 12 of 15 exercise, 7 of 8 upgrading exercises, 2 of 4 peer co-leader's role, and all of the home visits, booster sessions, group leader's role, and background and training of group leader elements. The top five key elements were: (1) use plain language, (2) develop trust, (3) engage people in what is meaningful and contextual for them, (4) train participants for cues in self-monitoring quality of exercises, and (5) group leader learns about exercises and understands how to progress them.

Discussion: The Delphi consensus process suggested key elements related to program delivery. These elements were considered essential to program effectiveness. Findings from this study laid the foundation for translation of for broad US dissemination.
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http://dx.doi.org/10.3389/fpubh.2017.00021DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5317011PMC
February 2017

Bringing Healthy Aging to Scale: A Randomized Trial of a Quality Improvement Intervention to Increase Adoption of Evidence-Based Health Promotion Programs by Community Partners.

J Public Health Manag Pract 2017 Sep/Oct;23(5):e17-e24

Center for Health Systems Research and Analysis, College of Engineering, University of Wisconsin-Madison, Madison, Wisconsin (Dr Ford); Wisconsin Institute for Healthy Aging, Madison, Wisconsin (Drs Abramson and Mahoney); Sonderegger Research Center, School of Pharmacy, University of Wisconsin-Madison, Madison, Wisconsin (Dr Wise); Division of Geriatrics and Gerontology, University of Wisconsin, Madison, Wisconsin; Advanced Fellowship in Women's Health, William S. Middleton Memorial VA Hospital, Madison, Wisconsin (Dr Dattalo); and Division of Geriatrics and Gerontology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin (Dr Mahoney).

Objective: To evaluate the effectiveness of a quality improvement intervention to increase delivery of 2 evidence-based health promotion workshops, Stepping On and Chronic Disease Self-Management Program (CDSMP), in rural communities.

Design: A cluster-randomized wait-list control group design.

Setting: Rural Wisconsin counties with trained workshop leaders but no workshops in the prior year were eligible to participate.

Intervention: Sixteen counties were randomized to receive the NIATx intervention or wait-list control. The 1-year intervention consisted of training and coaching county aging unit staff to apply NIATx methods to increase and sustain the number of Stepping On or CDSMP workshops in their community.

Main Outcomes: Mann-Whitney tests examined effect on workshops held, participants, and workshop completers. The paired Wilcoxon signed rank test explored change in participants' health behaviors and health care utilization.

Results: Counties receiving the NIATx intervention significantly increased the number of workshops per county per year as compared with baseline (1.5 vs 0.19, P < .001) and sustained improvements during the year following the intervention. Stepping On participants, during the 6 months postintervention, had reduced falls risk behaviors (P < .001), 0.43 fewer falls (P < .01), and 0.028 fewer medical record-verified emergency department visits for falls-related injuries (P < .05) compared with the 6 months before the intervention. CDSMP participants had reduced social isolation (P = .018) and improved physician communication skills (P = .005).

Implications: Our study demonstrates that coaching rural service organizations in use of the quality improvement process, NIATx, may increase implementation reach of evidence-based health promotion/disease prevention programs. Initiative findings indicate that this approach may be a new and potentially important strategy to increase reach of health promotion programs for older adults in community settings.

Conclusion: A quality improvement approach effectively increases and sustains delivery of evidence-based health promotion/workshops for older adults in rural communities. Counties or states struggling to engage older adults in evidence-based health promotion workshops could integrate quality improvement into policies and practices to increase workshop availability. Once engaged, older adults experience improved health behaviors from both programs and reduced falls and emergency department utilization from Stepping On.
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http://dx.doi.org/10.1097/PHH.0000000000000503DOI Listing
December 2016

Improving Fidelity of Translation of the Stepping On Falls Prevention Program through Root Cause Analysis.

Front Public Health 2016 14;4:251. Epub 2016 Nov 14.

Ageing, Work and Health Research Unit, Faculty of Health Sciences, University of Sydney , Sydney, NSW , Australia.

Background: Fidelity monitoring is essential with implementation of complex health interventions, but there is little description of how to use results of fidelity monitoring to improve the draft program package prior to widespread dissemination. Root cause analysis (RCA) provides a systematic approach to identifying underlying causes and devising solutions to prevent errors in complex processes. Its use has not been described in implementation science.

Methods: Stepping On (SO) is a small group, community-based intervention that has been shown to reduce falls by 31%. To prepare SO for widespread U.S. dissemination, we conducted a pilot of the draft program package, monitoring the seven SO sessions for fidelity of program delivery and assessing participant receipt and enactment through participant interviews after the workshop. Lapses to fidelity in program delivery, receipt, and enactment were identified. We performed a RCA to identify underlying causes of, and solutions to, such lapses, with the goal of preventing fidelity lapses with widespread dissemination.

Results: Lapses to fidelity in program delivery were in the domains of group leader's role, use of adult learning principles, and introducing and upgrading the exercises. Lapses in fidelity of participant receipt and enactment included lack of knowledge about balance exercises and reduced adherence to frequency of exercise practice and advancement of exercise. Root causes related to leader training and background, site characteristics and capacity, and participant frailty and expectations prior to starting the program. The RCA resulted in changes to the program manual, the training program, and training manual for new leaders, and to the methods for and criteria for participant and leader recruitment. A Site Implementation Guide was created to provide information to sites interested in the program.

Conclusion: Disseminating complex interventions can be done more smoothly by first using a systematic quality improvement technique, such as the RCA, to identify how lapses in fidelity occur during the earliest stages of implementation. This technique can also help bring about solutions to these lapses of fidelity prior to widespread dissemination across multiple domain lapses.
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http://dx.doi.org/10.3389/fpubh.2016.00251DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5107964PMC
November 2016

The relationship of individual comorbid chronic conditions to diabetes care quality.

BMJ Open Diabetes Res Care 2015 23;3(1):e000080. Epub 2015 Jul 23.

Health Innovation Program , University of Wisconsin School of Medicine and Public Health , Madison, Wisconsin , USA ; Department of Population Health Sciences , University of Wisconsin School of Medicine and Public Health , Madison, Wisconsin , USA ; Department of Family Medicine , University of Wisconsin School of Medicine and Public Health , Madison, Wisconsin , USA ; Department of Surgery , University of Wisconsin School of Medicine and Public Health , Madison, Wisconsin , USA.

Objective: Multimorbidity affects 26 million persons with diabetes, and care for comorbid chronic conditions may impact diabetes care quality. The aim of this study was to determine which chronic conditions were related to lack of achievement or achievement of diabetes care quality goals to determine potential targets for future interventions.

Research Design And Methods: This is an exploratory retrospective analysis of electronic health record data for 23 430 adults, aged 18-75, with diabetes who were seen at seven Midwestern US health systems. The main outcome measures were achievement of six diabetes quality metrics in the reporting year, 2011 (glycated haemoglobin (HbA1c) control and testing, low-density lipoprotein control and testing, blood pressure control, kidney testing). Explanatory variables were 62 chronic condition indicators. Analyses were adjusted for baseline patient sociodemographic and healthcare utilization factors.

Results: The 62 chronic conditions varied in their relationships to diabetes care goal achievement for specific care goals. Congestive heart failure was related to lack of achievement of cholesterol management goals. Obesity was related to lack of HbA1c and BP control. Mental health conditions were related to both lack of achievement and achievement of different care goals. Three conditions were related to lack of cholesterol testing, including congestive heart failure and substance-use disorders. Of 17 conditions related to achieving control goals, 16 were related to achieving HbA1c control. One-half of the comorbid conditions did not predict diabetes care quality.

Conclusions: Future interventions could target patients at risk for not achieving diabetes care for specific care goals based on their individual comorbidities.
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http://dx.doi.org/10.1136/bmjdrc-2015-000080DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4513351PMC
July 2015

The effect of an information and communication technology (ICT) on older adults' quality of life: study protocol for a randomized control trial.

Trials 2015 Apr 25;16:191. Epub 2015 Apr 25.

Mass Communication Research Center, School of Journalism and Mass Communication, University of Wisconsin-Madison, Madison, WI, 53706, USA.

Background: This study investigates the use of an information and communication technology (Elder Tree) designed for older adults and their informal caregivers to improve older adult quality of life and address challenges older adults face in maintaining their independence (for example, loneliness and isolation, falling, managing medications, driving and transportation).

Methods/design: This study, an unblinded randomized controlled trial, will evaluate the effectiveness and cost of Elder Tree. Older adults who are at risk for losing their independence - along with their informal caregivers, if they name them - are randomized to two groups. The intervention group has access to their usual sources of information and communication as well as to Elder Tree for 18 months while the control group uses only their usual sources of information and communication. The primary outcome of the study is older adult quality of life. Secondary outcomes are cost per Quality-Adjusted Life Year and the impact of the technology on independence, loneliness, falls, medication management, driving and transportation, and caregiver appraisal and mastery. We will also examine the mediating effect of self-determination theory. We will evaluate the effectiveness of Elder Tree by comparing intervention- and control-group participants at baseline and months 6, 12, and 18. We will use mixed-effect models to evaluate the primary and secondary outcomes, where pretest score functions as a covariate, treatment condition is a between-subjects factor, and the multivariate outcome reflects scores for a given assessment at the three time points. Separate analyses will be conducted for each outcome. Cost per Quality-Adjusted Life Year will be compared between the intervention and control groups. Additional analyses will examine the mediating effect of self-determination theory on each outcome.

Discussion: Elder Tree is a multifaceted intervention, making it a challenge to assess which services or combinations of services account for outcomes in which subsets of older adults. If Elder Tree can improve quality of life and reduce healthcare costs among older adults, it could suggest a promising way to ease the burden that advancing age can place on older adults, their families, and the healthcare system.

Trial Registration: ClinicalTrials.gov NCT02128789 . Registered on 26 March 2014.
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http://dx.doi.org/10.1186/s13063-015-0713-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4417513PMC
April 2015

Assessment and management of fall risk in primary care settings.

Med Clin North Am 2015 Mar;99(2):281-93

National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, 4770 Buford Highway, MS F-62, Atlanta, GA 30341, USA.

Falls among older adults are neither purely accidental nor inevitable; research has shown that many falls are preventable. Primary care providers play a key role in preventing falls. However, fall risk assessment and management is performed infrequently in primary care settings. This article provides an overview of a clinically relevant, evidence-based approach to fall risk screening and management. It describes resources, including the STEADI (Stopping Elderly Accidents, Deaths, and Injuries) tool kit that can help providers integrate fall prevention into their practice.
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http://dx.doi.org/10.1016/j.mcna.2014.11.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4707663PMC
March 2015

Enhancing palliative care for low-income elders with chronic disease: feasibility of a hospice consultation model.

J Soc Work End Life Palliat Care 2014 ;10(4):356-77

a School of Social Work , University of Wisconsin-Madison , Madison , Wisconsin , USA.

Challenges exist in assimilating palliative care within community-based services for nursing home eligible low-income elders with complex chronic illness as they approach the end of life (EOL). This study assessed the feasibility of a consultation model, with hospice clinicians working with three Care Wisconsin Partnership Program teams. Consults occurred primarily during team meetings and also informally and on joint patient visits and were primarily with the palliative care nurse addressing physical issues. Fifty-seven percent of consultant recommendations were implemented. Benefits of consultation were identified with focus groups of clinical staff as were opportunities and barriers to the implementation. Models of integration are proposed.
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http://dx.doi.org/10.1080/15524256.2014.975088DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4321750PMC
September 2015
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