Table 6.

Content adaptations

Adaptations	Original protocol	What was adapted	When adaptation occurred	Planned or reactive	At what level of delivery	Intent of adaptation
Interventionists were renamed to “perioperative wellness partners” or “wellness partners” to use patient-friendly language that accurately and positively describes the clinician-patient relationship.	Originally, study personnel who were trained to deliver the intervention bundle to patients were called “interventionists.”	Tailoring/rewording/refining	Pre-implementation	Planned: Part of the plan to modify to maximize fit and implementation success	Individual patient/practitioner level	To make intervention more aligned with organization goals
Specific mental health-based needs, expectations, and goals were identified.	BA was not tailored specifically towards patient mental health needs.	Tailoring/rewording/refining	Pre-implementation	Planned: Part of the plan to modify to maximize fit and implementation success	Individual patient/practitioner level	To increase effectiveness
Wellness partners served as liaisons for mental health support, referring patients to other resources, social work referrals, and financial aid when necessary.	Original protocols gave wellness partners more responsibility over social work and other resources.	Removing/skipping elements	Pre-implementation	Planned: Part of the plan to modify to maximize fit and implementation success	Individual patient/practitioner level	To increase implementation/ability of staff to deliver intervention successfully
Medication optimization and deprescription was renamed to medication optimization (MO) and MO SOP was revised to focus on pre-operative psych medications and post-operative psych medication changes (including name, dose, units, frequency of sessions, start date and stop date, indication).	The pharmacotherapy component was originally called “medication optimization and deprescription.” The original SOP focused on all medications.	Tailoring/rewording/refining	Pre-implementation	Planned: Part of the plan to modify to maximize fit and implementation success	Target intervention group level	To increase effectiveness
MO SOP was revised to assess potential for stopping muscle relaxants pre-operatively and reflect the difference between PRN/OTC and other prescribed medications.	The original MO SOP did not differentiate between specific medications that did not pertain to intervention bundle goals.	Tailoring/rewording/refining	Pre-implementation	Planned: Part of the plan to modify to maximize fit and implementation success	Target intervention group level	To increase effectiveness
The first session of BA was focused on building trust and rapport and introducing the patient to the intervention and its core components (e.g., personalized rationale). Activity scheduling followed in the next sessions.	Previously, the first session of BA began therapy and goal-setting exercises immediately.	Adjusting the order of intervention components	Pre-implementation	Planned: Part of the plan to modify to maximize fit and implementation success	Individual patient/practitioner level	To increase effectiveness
BA forms included simple activity planning.	BA documentation forms were originally more complex and harder to use.	Tailoring/rewording/refining	Pre-implementation	Planned: Part of the plan to modify to maximize fit and implementation success	Individual patient/practitioner level	To increase implementation/ability of staff to deliver intervention successfully
Wellness partners made medication adjustments and assessed the responses to each adjustment.	Wellness partners originally did not need to check for side effects and responses to medication adjustments.	Adding elements	Pre-implementation	Planned: Part of the plan to modify to maximize fit and implementation success	Target intervention group level	To increase implementation/ability of staff to deliver intervention successfully
Wellness partners coordinated with the hospital team to ensure that medication changes introduced pre-operatively were maintained in-house.	No check-ins were originally conducted to ensure continuity of care and medication use in-house.	Adding elements	Pre-implementation	Planned: Part of the plan to modify to maximize fit and implementation success	Target intervention group level	To increase effectiveness
SOPs and documentation forms were revised to use simpler, layman terms for patients to understand.	SOPs originally had too much complex language that was hard for patients to understand.	Tailoring/rewording/refining	Post-implementation	Reactive: Unplanned often in response to an obstacle, challenge, deviation from the plan	Individual patient/practitioner level	To increase implementation/ability of staff to deliver intervention successfully
BA SOP was revised to create tailored sessions (timing, frequency of sessions, referrals, resources, etc.).	The BA SOP originally was not tailored to each patient’s personal preference for timing, frequency of sessions, etc.	Tailoring/rewording/refining	Post-implementation	Reactive: Unplanned often in response to an obstacle, challenge, deviation from the plan	Individual patient/practitioner level	To increase implementation/ability of staff to deliver intervention successfully
BA SOP was revised to include suggestions, referrals, and resources for sleep, pain, and alternate relaxation techniques during and after the intervention time period.	The BA SOP did not originally have additional suggestions and techniques.	Adding elements	Post-implementation	Reactive: Unplanned often in response to an obstacle, challenge, deviation from the plan	Individual patient/practitioner level	To make intervention more aligned with organization goals
MO SOP was revised to encourage patients to self-advocate and empower themselves to communicate with their prescribers to implement medication changes.	The MO SOP did not originally include guidelines to encourage self-advocacy.	Adding elements	Post-implementation	Reactive: Unplanned often in response to an obstacle, challenge, deviation from the plan	Target intervention group level	To increase effectiveness
BA was tailored for older surgical patients and their specific goals and activities pre-operatively and post-operatively (including surgery recovery goals from surgical team).	BA was originally not tailored for different types of surgeries and types of older patient (e.g., retired vs. semi-retired, family vs. no family).	Integrating intervention into another framework	Post-implementation	Planned: Part of the plan to modify to maximize fit and implementation success	Individual patient/practitioner level	To make intervention more aligned with organization goals
BA SOP was revised to include motivational interviewing techniques to encourage patients who have more resistance to changing their behavior.	The BA SOP did not originally use motivational interviewing techniques.	Adding elements	Post-implementation	Reactive: Unplanned often in response to an obstacle, challenge, deviation from the plan	Individual patient/practitioner level	To increase implementation/ability of staff to deliver intervention successfully
BA documentation forms were reduced in detail and wellness partners were encouraged to reinforce activities in addition to suggesting new ones. Wellness partners were also encouraged to suggest flexible methods of activity documentation (e.g., journaling), and emphasized meeting the patient where they were, not forcing anything upon them.	Previously, wellness partners were encouraged to keep scheduling new activities and goals, without reinforcement. Furthermore, documentation forms were mandatory to the intervention bundle.	Loosening structure	Post-implementation	Reactive: Unplanned often in response to an obstacle, challenge, deviation from the plan	Individual patient/practitioner level	To increase effectiveness
Intervention bundle was renamed to perioperative wellness program (emphasizing principles of BA, compassion and coordination) and MO across all intervention documents and research documents	The original intervention bundle was called the “perioperative mental health bundle.”	Tailoring/rewording/refining	Post-implementation	Reactive: Unplanned often in response to an obstacle, challenge, deviation from the plan	Target intervention group level	To increase reach, participation, access
The activity tracking form was modified to reflect the granularity as defined by the patient	The original activity tracking form was very detailed and required patients to track all their activities	Tailoring/rewording/refining	Post-implementation	Reactive: Unplanned often in response to an obstacle, challenge, deviation from the plan	Individual patient/practitioner level	To increase implementation/ability of staff to deliver intervention successfully
MO SOP was revised to have the pharmacy team lead the MO component – review medications and optimize the targeted medications	Wellness partners originally reviewed medications and provided recommendations	Tailoring/rewording/refining	Post-implementation	Reactive: Unplanned often in response to an obstacle, challenge, deviation from the plan	Target intervention group level	To increase effectiveness
Screening procedure was revised to include a narrative showing that studies indicated BA was effective for anxiety, depression, and general well-being, followed by an explanation of the perioperative wellness program.	Previous screening procedures focused heavily on mental health screening, which was stigmatized by patients.	Adding elements	Post-implementation	Reactive: Unplanned often in response to an obstacle, challenge, deviation from the plan	Individual patient/practitioner level	To increase reach, participation, access
Consent language was revised to include a description of what to expect from the perioperative wellness program, omitting language about anxiety and depression to avoid stigma.	Previous consent language was complex and vague, which meant that patients did not understand the intervention bundle prior to participation.	Tailoring/rewording/refining	Post-implementation	Reactive: Unplanned often in response to an obstacle, challenge, deviation from the plan	Individual patient/practitioner level	To increase reach, participation, access
Both control and intervention groups in the future RCT will receive resources for mindfulness, relaxation, stress reduction, daily routines, sleep hygiene, activity rest cycle, brain training, and social activities.	Originally, the control group would only receive usual care.	Adding elements	Post-implementation	Planned: Part of the plan to modify to maximize fit and implementation success	Individual patient/practitioner level	To make intervention more aligned with organization goals