Table 7.
Contextual adaptations
| Adaptations | Original protocol | What was adapted | When adaptation occurred | Planned or reactive | At what level of delivery | Intent of adaptation |
|---|---|---|---|---|---|---|
| MO SOP was revised to involve patients in decision-making and to assign wellness partners with documentation responsibilities, including REDCap forms on medication changes. | The original MO SOP did not factor patients into the decisions that wellness partners made during sessions. | Adding elements | Pre-implementation | Planned: Part of the plan to modify to maximize fit and implementation success | Target intervention group level | To increase reach, participation, access |
| Sessions were conducted in-person 1:1 informally at first and then over the phone/Zoom following the first session. | Sessions were conducted in accordance with patient preference. | Tailoring/rewording/refining | Pre-implementation | Planned: Part of the plan to modify to maximize fit and implementation success | Target intervention group level | To increase reach, participation, access |
| Wellness partners used a medication management algorithm in addition to receiving supervision from pharmacists and a geriatric psychiatrist. | Wellness partners originally did MO themselves, in consultation with pharmacists and a geriatric psychiatrist. | 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 |
| MO and BA sessions were scheduled to be biweekly or weekly for a total of 8–12 sessions. Additional sessions were added if necessary or if goals were not met. | Previously, there was no number of sessions or frequency set – wellness partners were expected to schedule them based on each patient’s individual preferences and availability. | 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 |
| BA session documentation forms were different for Sessions 1, 2, 3, 4–9, and 10. | Originally, forms were different for Sessions 1, 2, 3–9, and 10. | 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 |
| 2–4 BA sessions were conducted pre-operatively if possible, ideally starting 30 days prior to surgery and ending sessions 90 days after surgery. | Originally, there was no formal schedule or split between pre-operative and post-operative sessions. | 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 reach, participation, access |
| Patients were contacted virtually up to 3 times for intervention sessions and follow-up before wellness partners reached out via mail. | Patients were contacted over email or by phone indefinitely. | Lengthening/extending (pacing/timing) | Post-implementation | Reactive: Unplanned often in response to an obstacle, challenge, deviation from the plan | Individual patient/practitioner level | To increase reach, participation, access |
| 6 pharmacy students assisted wellness partners with MO (with supervision from pharmacists). | Originally, pharmacy students were not included in the study or intervention bundle. | Adding elements | Post-implementation | Reactive: Unplanned often in response to an obstacle, challenge, deviation from the plan | Target intervention group level | To increase implementation/ability of staff to deliver intervention successfully |
| MO SOP was revised to reflect medication data collection between first session and all other sessions. | The same type of medication data was originally collected at each session, causing some redundancy. | Tailoring/rewording/refining | Post-implementation | Reactive: Unplanned often in response to an obstacle, challenge, deviation from the plan | Target intervention group level | To increase implementation/ability of staff to deliver intervention successfully |
| MO SOP was revised to reflect the pharmacy team’s roles and responsibilities. | Originally, the pharmacy team’s roles and responsibilities did not extend to MO. | Tailoring/rewording/refining | Post-implementation | Reactive: Unplanned often in response to an obstacle, challenge, deviation from the plan | Target intervention group level | To increase implementation/ability of staff to deliver intervention successfully |
| BA and MO began in the same session. | Originally, BA began one session after MO. | Adjusting the order of intervention components | Post-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 |
| Patients were reminded of their goals and about activities that made them feel good or mattered to them. They were also reminded that the goals of the study were to support overall surgical recovery, not just mental health. | Originally, BA SOP language emphasized mental health improvement and recovery, rather than overall surgical recovery. | 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 |
| Patients were offered opportunities to reach out to their wellness partners as needed within the 3-month intervention period, and were encouraged to check in monthly. | Originally, there was no guideline for patients to keep in touch with their wellness partners. | 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 |
| Exclusion criteria were modified to exclude revisions to joint replacement surgery patients, patients with immediate suicidal ideation, and rescheduled surgical patients who have canceled or postponed surgeries within the past 3 months following enrollment into the study; inclusion criteria were modified to include patients 60 years of age and older. | The study originally included all joint replacement patients (primary and revisions), patients with suicidal ideation, and rescheduled surgical patients. The study originally excluded patients under 65 years of age. | Removing/skipping 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 |
| Follow-up assessment surveys were optionally emailed to patients. | Follow-up assessment surveys were originally only administered via phone call. | 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 |
| Employment status was collected during enrollment. | Originally, employment status was not collected. | 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 |
| Auto-generated calendars with follow-ups (throughout study and at end of study) were suggested for future RCT use. | Originally, wellness partners notified the research coordinator of patient progress via email. | Substituting components | Post-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 |
| Data collection was revised to gather all medication lists from Epic and confirm them in each session to ensure in the future that the research coordinator is blinded. | The study team originally planned that data would be collected by the research coordinator, who would then know which patients were in each arm of the study. | Tailoring/rewording/refining | Post-implementation | Planned: Part of the plan to modify to maximize fit and implementation success | Individual patient/practitioner level | To increase effectiveness |
| Intervention sessions could be scheduled differently based on type of surgery -- orthopedic patients typically scheduled their surgeries 3 + months in advance and had more time for pre-operative sessions. In contrast, oncologic patients scheduled their surgeries about 2 weeks in advance, and cardiac patients scheduled their surgeries about 2–3 days in advance, leaving little room for pre-operative sessions. | Originally, there was no plan of scheduling sessions differently based on type of surgery. | Adjusting the order of intervention components | Post-implementation | Reactive: Unplanned often in response to an obstacle, challenge, deviation from the plan | Target intervention group level | To increase reach, participation, access |
| Caregivers were not included in the intervention bundle. | Originally, caregiver involvement was optional and encouraged. | Removing/skipping elements | Post-implementation | Planned: Part of the plan to modify to maximize fit and implementation success | Individual patient/practitioner level | To increase effectiveness |
| Wellness partners were instructed to deliver the intervention bundle with elements of compassion and patient-sensitivity. | Originally, wellness partners did not intentionally incorporate elements of compassion into their sessions. | 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 |