Guided by the CFIR framework, we identified several unique barriers and facilitators to implementing a cancer survivorship program in rural communities of Upstate New York.6 The identified barriers included regional variation in infrastructure and healthcare delivery processes, fragmentation in oncology and primary care services across individual regions, and misalignment between clinical guideline recommendations and health insurance reimbursement policies. Because of these and other challenges in providing cancer care for rural patients and the resulting rural/urban disparities in cancer outcomes, the National Institutes of Health and American Society of Clinical Oncology (ASCO) have made rural cancer care a priority area in recent years.90–92
In our study, stakeholders identified the principles of effective teamwork as important facilitators for rural cancer care delivery (Table 2, Table 3) even if they have not met other members of the “care team”.93–100 Attitudes toward virtual and remote teamwork were more positive among stakeholders who typically work in teams in their current job (e.g., nurses, social workers, public health department employees) compared to solo practitioners (e.g., physicians in solo practice). In Table 2, we present triangulated results - teamwork principles are on the far left, the corresponding CFIR domain is middle, and the implementation outcome assessment finding is the far-right column. Mapping core teamwork principles to implementation frameworks could provide a road map for optimizing program staffing, training, resource sharing, communication and program organization within the context of local healthcare resources availability and local referral patterns.5,101 Synthesizing implementation science and team science frameworks could further assist with program adaptation to minimize implementation failure and improve continuity of care for complex pathway management (Fig. 2).
Table 2
Integration of teamwork principles and implementation constructs (CFIR) to improve implementation of a rural cancer survivorship program
Team
Science
|
CFIR
|
Barrier/
Facilitator
|
Finding
|
Capability
|
Adaptability
|
Barrier
|
Tailored interventions that adapt and change over time require dedicated staff time and consistent iterations and interaction between stakeholder partners and implementers #ǂΔ
|
|
Structural characteristics
|
Barrier
|
There is a need for capacity building among APPs and PCPs to fill gaps in specialty services in rural areas ǂ
|
|
Design quality and packaging
|
Barrier
|
The more diverse the stakeholder population, the more diverse the needs are, and perceived intervention quality requires the feedback from all relevant stakeholders which can be inconvenient and expensive ǂ
|
|
Networks and communications
|
Barrier
|
Building networks and communications requires dedicated program staff. Real-time communication is a challenge if working with stretched resources ǂ
|
|
Planning
|
Barrier
|
Capacity and person-time requirements in the planning stage are high, but critical to overall success of the program ǂ
|
|
Engaging
|
Facilitator
|
Identification of key gatekeepers opens tremendous opportunity for engagement ǂ
|
|
Engaging
|
Barrier
|
Identifying key gatekeepers takes time and luck ǂ
|
Cooperation
|
Adaptability
|
Facilitator
|
Feedback, pilot testing and focus groups provided critical information that tailored the intervention and changed the course of the implementation ǂ
|
|
Engaging
|
Barrier
|
Interventions based on "disruptive innovation" can lead to dis-engagement of affected partners (PCPs) ǂ
|
|
Relative advantage
|
Barrier
|
Conflicting preferences or perceptions of relative advantage of specific interventions over others require compromise in program outputs ǂ Δ
|
|
Implementation climate
|
Barrier
|
Competing priorities may challenge implementation ǂ Δ
|
|
Individual identification with organization
|
Facilitator
|
Stakeholders' identification with the organization and perception of membership of a team increased participation in generating community resources and participation in portal activities ǂ Δ
|
Coordination
|
Patient needs and resources
|
Barrier / facilitator
|
Tailoring interventions to patient preferences and abilities (limited broad band internet, transportation challenges, preference for personal contact) ǂ Δ
|
|
Reflecting and evaluating
|
Facilitator
|
Debriefing and soliciting stakeholder reflections during implementation of one regional program may help with planning and implementation of other programs in the same area ǂ
|
Communication
|
Network and communications
|
Facilitator
|
Building on existing networks creates trusted relationships and quick dissemination ǂ Δ
|
|
Intervention source
|
Facilitator
|
Engaging stakeholders from the outset led to a more appropriate and acceptable intervention ǂ
|
|
Intervention source
|
Facilitator
|
Partnerships as "stakeholder engagement" are more effective than relationships that simply elicit information from stakeholders (i.e. survey) ǂ Δ
|
|
Networks and communications
|
Facilitator
|
An online portal or other communication tool that addresses gaps in social networks may build a sense of "community" among rural cancer survivors Δ
|
|
Opinion leaders
|
Facilitator
|
Rural patients know and trust their opinion leaders (e.g., local healthcare providers, pastors and ministers, school and library directors, public health administrators and local business leaders), and look up to them for advice in difficult circumstances
|
Cognition
|
Goals and feedback
|
Facilitator
|
Clear understanding among stakeholders regarding each group's objectives and preferences fosters successful implementation ǂ Δ
|
|
Evidence of strength and quality
|
Facilitator
|
Time and opportunity to address myths and misconceptions should be accounted for ǂ
|
|
Knowledge and beliefs about the intervention
|
Barrier
|
There can be hesitancy on the part of local stakeholders who experience time-limited interventions and lack of sustainability ǂ Δ
|
Coaching
|
Culture
|
Facilitator
|
A designated leader or leadership team is critical for sustainability ǂ
|
|
Reflecting and evaluating
|
Barrier
|
Dedicated time for debriefing and a plan for evaluation must be planned for at the outset, in the planning stage ǂ
|
Conditions
|
Evidence of strength and quality
|
Barrier
|
Models of care delivery were developed mainly at large academic centers for densely populated areas with adequate provider supply ǂ
|
|
Trialability
|
Barrier
|
The ability to test interventions on a small scale or reverse course of implementation is limited by reimbursement models and the resources required to change care systems ǂ
|
|
Cost
|
Facilitator
|
Dedicated resources done centrally should be made available for maintenance of the program as a fixed program cost ǂ
|
|
Cost
|
Barrier
|
Adapting programs to fit stakeholders' changing needs requires dedicated program staff and a supportive payment model to sustain implementation cost ǂ
|
|
External policies and incentives
|
Facilitator
|
Value-based payment models that incentivize care coordination and population health facilitate cancer survivorship models ǂ
|
|
External policies and incentives
|
Barrier
|
No quality metrics or payment systems are aligned with provision of survivorship care plans at the primary care level ǂ
|
|
External policies and incentives
|
Barrier
|
Traditional fee-for-service models do not support new models of cancer survivorship care ǂ
|
|
Implementation climate
|
Barrier
|
It is a time of great consolidation and uncertainty in healthcare delivery, leading to staff turnover and uncertain referral structures ǂ
|
|
Executing
|
Barrier
|
Budget requirements for implementation must be adapted throughout the course of implementation if fidelity of implementation is expected ǂ
|
#=Academic Researcher; ǂ=Physician, other healthcare professional; Δ = patient or caregiver. |
Relevant stakeholders for translation are indicated with “#ǂΔ”.6,95,114 |
Table 3
Integration of implementation science and teamwork frameworks to generate actionable findings
Consolidated Framework for Implementation Research (CFIR)
|
♣ Networks and communications
Engaging
|
♣ Implementation climate
Individual identification with organization
|
♣ Reflecting and evaluating
|
Networks and communication
|
♣ Goals and Feedback
|
Culture
|
♣ Evidence of strength and quality
Cost
|
Effective Teamwork Principles
|
Capability
|
Cooperation
|
Coordination
|
Communication
|
Cognition
|
Coaching
|
Conditions
|
Examples of strategies and approaches
|
♣ Building networks and successfully communication real-time requires dedicated staff, which can be a challenge with stretched resources
Aim to identify key gatekeepers early (practice or community-based)
|
♣ Competing priorities may challenge implementation
Stakeholders’ perception of membership of a team increased participation in program activities
|
♣ Debriefing and soliciting stakeholder reflections in the end stages may help in implementation of future interventions
|
♣ Building on existing networks creates trusted relationships and faster dissemination
|
♣ Clear understanding among stakeholders regarding each group’s objectives and preferences fosters successful implementation
|
♣ A designated leader or leadership team is critical
|
♣ Models of delivery were developed for large academic centers for densely populated areas with adequate provider supply; tailored models for local staffing may be more successful in rural regions
|
All survivorship care guidelines recommend cancer survivorship care that is multidisciplinary and collaborative, including institutional and individual collaboration.46,102−104 The National Cancer Institute has long supported development and diffusion of team-based cancer care, including National Cancer Institute and ASCO initiatives such as the Teams in Cancer Care Delivery project in recent years.105 A multidisciplinary teamwork approach has been recommended for other specialist care and in rural populations, and teamwork and trust among involved stakeholders has been identified as a strong facilitator of successful implementation of evidence-based programs and interventions.36–38,106−110 A large proportion of cancer patients do not receive coordinated multidisciplinary team-based cancer care and that proportion is even greater among rural patients due to the complexity of rural cancer survivors’ needs and scarcity of proximate resources.14–16, 21,39–43, 94,111–113
Existing implementation strategies in the context of rural cancer care are often challenging to use because they are poorly described, rarely justified theoretically, lack operational definitions or manuals to guide their use, and are part of ‘packaged’ approaches with poor on-the-ground training.6,114 In contrast, evidence regarding the use and effectiveness of team training in healthcare settings has grown rapidly over the last 15 years, which makes it ripe for application to program implementation planning and research.115
Based on our findings, below we propose several novel teamwork-based strategies for planning and implementation of healthcare programs in resource-poor communities that could facilitate adaptation of academic care delivery models for rural communities.94,96,100,103,111 These implementation strategies to overcome identified implementation barriers map to the 7 C’s of effective teamwork proposed by Salas et al.93–98
Outer setting: Barriers to care integration across practices, providers and systems
The challenges: Networks and Communication
Unlike many surgical or clinic-based teams where teamwork is dependent on face-to-face interaction, rural cancer survivorship care requires the coordinated work of several dispersed health providers with different clinical expertise who often never meet and are only connected through shared patients.116 Members of such regional teams may never or rarely meet face-to-face while managing patient care that is fragmented by organizational boundaries, geographic distance, health insurance, information systems, and privacy constraints.116
Proposed strategy: Enhanced Communication
Recent studies in cancer and other fields have provided evidence that quality care depends upon timely information exchanges and regular communication flow between all those stakeholders involved in treatment (including patients, specialist physicians, other specialty disciplines, primary care physicians [PCPs], and support services).11,12,31−33 Assessing and tailoring communication strategies to the preferences and needs of all key stakeholders could reduce opportunities for miscommunication and lost information. For instance, when scheduling a new cancer patient visit, a scheduler should query patients about all providers that the patient is seeing for their cancer to ensure that communication with providers is arranged ahead of time (including information exchanges and privacy forms) and all relevant and necessary information about prior treatment, care plans, scans and diagnostic tests has been received and reviewed by the new physician. Remote communication options such as Zoom meetings or regular conference calls between physicians have become more acceptable post- COVID-19 pandemic and may improve communication between physicians who do not routinely see each other.
Inner setting: Misalignment between patient-centered care quality and provider-centered reimbursement
The challenge: Cost
Survivorship care plans and other team-based care delivery models were originally developed at large academic health centers. Large healthcare organizations in the United States often employ their providers, and hence, could use financial and behavioral incentives to encourage desired provider behavior. 117,118 Such models do not translate easily to rural settings where solo provider practices and fee-for-service reimbursement still dominate.13,119 Thus, an academic multidisciplinary cancer care model requires a significant adaption to meet the needs of the rural providers.13,119
Between 2009 and 2017, the CDC reported 264 cases of tetanus in the US. Many rural practice’s quality metrics include tetanus vaccination rates but not cancer survivorship.120 Many survivorship-related activities desired and needed by patients are not billable (e.g., discussion about outstanding cancer treatment bills and extending disability time off from work), are out of pocket (exercise and nutrition therapy), have varied reimbursement structures depending on the insurance plan (physical therapy and rehabilitation), or are only available in certain regions (genetic counseling, peer-support groups).119,121 Finally, the existing reimbursement schedule does not offset the clinic staff time and efforts required to coordinate survivorship care. Proposed amendments to the Social Security Act addressing payment models for cancer survivorship have been introduced but have not moved forward.122
In large academic centers, staff efforts on survivorship programs could often be covered through other mechanisms, such as research or administration. In small rural clinics, funding opportunities for health providers are limited to billable revenue. Therefore, without a reimbursement structure directly aligned with survivorship services, such care is prohibitive and unsustainable for rural patients.
Proposed strategies: Top-down planning approach including organization leadership in addition to bottom-up approach; Focus on competencies and skill set instead of licensing and accreditation.
Long-term success of any healthcare innovation is dependent upon its financial sustainability; therefore, ensuring support and buy-in from the clinical leadership and administration should be one of the implementation strategies. Successful examples include Medicaid financing models for state-wide hub-and-spoke care delivery models and the Veteran’s Administration’s regional care management programs for special populations .4,123 Identifying the new billing codes and appropriate level of staff (e.g., health educator instead of an NP) for performing the necessary activities and adhering to the recommended care pathways is another strategy in making existing reimbursement models work for resource-poor settings. When referring rural patients to services, we suggest focusing on the functions/qualifications necessary to address the needs of rural cancer survivors (e.g., financial counseling, exercise therapy) instead of the recommended qualification (e.g., 20% FTE of cancer PT specialist) that may not be available locally. With appropriate coaching and training, the services could be provided by the next best available substitute (e.g., a nurse educator instead of a social worker). In addition, rural practices could push for insurance companies to include survivorship care metrics as part of their quality metrics.
The timing of implementation is critically important when partnering with community stakeholders from resource-limited regions. Implementation of program steps may need to be postponed or delayed to account for the availability of the local partners. For example, staffing may be more limited during summer months when practices are more likely to be short-staffed due to school breaks and family vacations. Public health programs could be delayed or postponed if deemed low-priority. During the time of the V-ROC study in the summer of 2017, county health departments’ priorities shifted to managing Zika virus; therefore, health department staff and resources were unavailable for cancer survivorship programming. In the current climate where care inequities are being exacerbated due to the COVID-19 pandemic, health departments are even further stretched and most, if not all, resources are being diverted to management of the pandemic in regions that have limited capacity.
Individuals involved: Regional variation
The challenges: Patient needs and resources
Provider availability and care delivery patterns vary greatly among the rural counties.23 We observed significant variation in the structure of county health departments, availability of county hospitals, cancer and primary care clinics, cancer services programs, availability of public transportation, and existence of local formal (e.g., provider collaborations) and informal (e.g., patient support) networks. Other studies have noted similar challenges that necessitate extensive tailoring and adaptation of evidence-based programs and care protocols to fit the needs of rural community practices and their patients.124,125 Despite the observed variation in resources and infrastructure, rural patients across all regions were consistent in their preference to involve their local providers, both primary care and oncology, in their cancer care as much as possible. Rural cancer patients and their caregivers also reported significant challenges with identifying relevant information and making decisions affecting their cancer care, from treatment options to insurance coverage to disability payments and palliative care options. These results present a challenging paradox: patients prefer local care but report distance to care as a barrier. Within the context of the COVID-19 pandemic and the current acceleration of telemedicine roll-out, there may be unique opportunities for enhancing the technology for virtual oncology care and patient receptiveness to telemedicine technology, though patient preferences may change in the post-COVID-19 era.
Proposed strategies: Enhanced care coordination, cooperation and coaching
Coordination means synthesizing care goals and decisions across the multiple groups involved in patient care, as well as mutually aligning, timing, and adapting key care tasks among different care teams or team members over time.20,126 Cooperation is the attitude that team members need to insure coordination. In application to rural cancer care, coordination requires proactive cooperation and readily sharing available resources (e.g., nutrition therapy, pain management), upcoming appointments (e.g., mammogram every 6 months for the next 5 years, chest CT every 12 months) and helping patients prioritize their goals (e.g., what surgical option will allow the patient to go back to work as soon as possible, resource availability to complete physical therapy at home instead of the hospital). Evidence-based implementation strategies supporting coordination include provider tele-coaching via hub-and-spoke models (e.g. Project ECHO), patient-centered models such as individual care navigators, or practice-based quality improvement assistance such as practice facilitators (Table A1).10,127-131 A hub-and-spoke model could serve as a platform to coach rural and remote providers to improve provider teamwork and care coordination across the region. Care coordinators such as Community Health Workers are a patient-centered approach that could help patients with making decisions about their care, better communicate with their providers and identify and more efficiently manage available local resources. Such care navigators are often employed by county health departments or social services agencies and are not disease-specific.10,124,132
Strengths and Limitations
The study was limited by publicly available data that informed our understanding of contextual characteristics. We faced several key barriers to program implementation; however, limitations faced in implementation informed recommendations on how to improve use of implementation frameworks and introduction of novel implementation strategies. In addition, we had limited direct measures of implementation cost, future research should include economic evaluation to assess program sustainability and feasibility. Despite the limited geographic scope, there was a wide variation in population to care provider ratios across V-ROC counties, and thus, the findings may be generalizable to a variety of rural settings.
Despite these limitations, integrating implementation strategies with the principles of teamwork offered a useful lens and may fill a critical gap in adaptation and dissemination of evidence-based guidelines. Use of team science frameworks is a novel approach to evaluating health innovations with implications for integration in future studies. The CFIR is one of the most commonly used implementation science frameworks.5 Our application of standardized, validated implementation frameworks allows for comparability across studies and will help researchers to understand gaps and strengths in program development.6,94,101,114