Implementation Intervention Example
Background: Adverse Childhood Experiences (ACEs) are potentially traumatic events occurring before age 18, such as maltreatment or exposure to violence. ACEs screening is increasingly recommended to prevent and address physical and mental health conditions associated with ACEs. Few rigorous studies have developed and tested implementation strategies supporting the implementation of ACEs pediatric screenings in primary care settings. We used Implementation Mapping, with a study process and consideration of determinants and mechanisms guided by the EPIS framework, to co-create and refine a multifaceted implementation strategy.
The tested implementation strategy was comprised of:- Online training videos,
- A customized algorithm and use of technology (iPads) for care team to gather additional information on children (e.g., resiliency questions and scores on the Pediatric Symptoms Checklist (PSC)) to complement ACEs screenings information and inform pediatrician’s decision making and improve workflow efficiency,
- Implementation training for internal FQHC personnel, clinic support and coaching, and ongoing coaching and peer support during implementation
- Written implementation protocols
Visual Overview of the Mechanism of Change for the ACEs Multifaceted Implementation Strategy
Table to Determine Why Its a Complex Intervention?
| CI Domain | ACEs Study: Implementation Strategy | |
 | The intervention has multiple components that are dependent on each other | The implementation strategy was comprised of activities at multiple levels that include managerial involvement, coaching, and peer support for partner clinics and each care team of practitioners, use of technology to gather information, and monitoring/ data tracking through patient health records and Functions and Forms tracking matrix. |
| The individuals delivering and receiving the intervention often exhibit a high set of coordinated behaviors | ACEs screenings in this project were implemented as a team-based approach where each member of a 4-5 care team was responsible for a particular action, step and/or procedure in the tailored workflow. |
| The CI requires changes at the organizational, workforce, and patient levels | The strategy included ‘breakfast with leadership’ to maintain their buy-in and support for care teams’ efforts, activities to support care team actions (i.e., peer support and coaching calls), and changes to data collection and tracking systems (e.g., additional fields in reporting dashboards) as well as preparation for patients to feel comfortable with ACEs screenings as a new universal screening initiative and increased education about toxic stress and impact on children’s developmental trajectories and wellbeing. |
| Outcomes are numerous and they can change over time | As shown in Figure 2, outcomes are multiple. Acceptability of the ACEs policy outcome changed over time with the impact of COVID-19 on clinical capacity to implement the screenings, and extreme clinical turnover impacting care team members’ strain in adding ACEs screenings to their workflow. |
| | There is a need for flexibility in how the intervention is implemented daily | Contextual changes at the study clinics impacted the implementation of strategies such as the need for ongoing training due to high turnover, peer support not available due to staff absences, and lack of access to the online REDCap system and iPads by care teams to conduct the study psychosocial screenings due to unreliable internet access in some of the clinics. |
Key Reference
- Publication: Pérez Jolles, M., Mack, W. J., Reaves, C., Saldana, L., Stadnick, N.A., Fernandez, M.E., Aarons, G. (2021). Using a participatory method to test a strategy supporting the implementation of a state policy on screening children for Adverse Childhood Experiences (ACEs) in a Federally Qualified Health Center system: A stepped-wedge cluster randomized trial. Implementation Science Communications Journal, 2, 143.