Application of an Implementation Science Framework to Policies on Immediate Postpartum Long-Acting Reversible Contraception

Abstract

Objectives:

Implementation science provides useful tools for guiding and evaluating the integration of evidence-based interventions with standard practice. The objective of our study was to demonstrate the usefulness of applying an implementation science framework—the Consolidated Framework for Implementation Research (CFIR)—to increase understanding of implementation of complex statewide public health initiatives, using the example of Medicaid immediate postpartum long-acting reversible contraception (LARC) policies.

Methods:

We conducted semistructured telephone interviews with the 13 state teams participating in the Immediate Postpartum LARC Learning Community. We asked teams to describe the implementation facilitators, barriers, and strategies in 8 focus areas of the Learning Community. We audio-recorded and transcribed interviews and then coded each interview according to the domains and constructs (ie, theoretical concepts) of the CFIR.

Results:

Cosmopolitanism (ie, networking with external organizations) was the most frequently coded construct of the framework. A related construct was networks and communications (ie, the nature and quality of social networks and formal and informal communications in an organization). Within the construct of cost, state teams identified barriers that were often unable to be overcome. Trialability (ie, ability to test the intervention on a small scale) and engaging champions (ie, attracting and involving persons who dedicate themselves to supporting the intervention in an organization) were among the most salient constructs of the framework and were the sources of many implementation strategies.

Conclusions:

State leaders and program staff members may benefit from considering the CFIR domains and constructs in the planning, implementation, and evaluation of complex statewide public health initiatives.

Implementation science provides useful tools for guiding and evaluating the integration of evidence-based interventions into standard practice. One well-used organizing framework in the field is the Consolidated Framework for Implementation Research (CFIR), which synthesizes the concepts of several models into 5 interrelated domains that may influence implementation of an intervention: intervention characteristics (key attributes of an intervention), outer setting (economic, political, and social context of an intervention), inner setting (structural, political, and cultural context through which implementation proceeds), characteristics of individuals involved, and the process of implementation (active change process).¹ Each domain includes multiple theoretical concepts, referred to as constructs.

The CFIR is used as a guide for the implementation of evidence-based health programs.^2,3 This model is well-suited for studying complex interventions because it acknowledges the often nonlinear process of implementation, incorporating the adaptations needed to successfully implement interventions in various contexts or at various levels. Although the CFIR has most commonly been applied to the implementation of interventions in clinical settings, it also can be used to identify and/or define implementation factors affecting state-level public health initiatives.^4-6

One such complex, state-level initiative is the implementation of policy on immediate postpartum long-acting reversible contraception (LARC). LARC, which consists of subdermal implants and intrauterine devices, is the most effective form of reversible contraception.⁷ Providing LARC immediately after delivery, before hospital discharge, can increase women’s access to effective contraception and prevent subsequent unintended pregnancy and short interpregnancy intervals.⁸ However, most payers reimburse for labor and delivery based on the diagnosis-related group (DRG) codes, and these DRG codes may not account for the cost of LARC devices or insertion fees associated with LARC provided immediately after delivery. The average cost of a LARC device and associated insertion fees ranges from $800 to $1000.⁹ To overcome this cost barrier, several state Medicaid agencies have changed policy to allow reimbursement for immediate postpartum LARC outside the DRG rate for labor and delivery.^10,11 However, experiences of the first states to adopt this change demonstrated that policy change alone, without complementary implementation activities, was insufficient for increasing women’s access to immediate postpartum LARC.^12,13

In 2014, the Association of State and Territorial Health Officials convened the Immediate Postpartum LARC Learning Community (hereinafter, Learning Community), a multistate learning collaborative aimed at increasing access to immediate postpartum LARC. Six states (Colorado, Georgia, Iowa, Massachusetts, New Mexico, and South Carolina) were invited to participate in this collaborative to identify, document, and address technical assistance needs, promising practices, and barriers to immediate postpartum LARC policy implementation.¹⁴ In 2015, an additional 7 states (Delaware, Indiana, Louisiana, Maryland, Montana, Oklahoma, and Texas) joined the Learning Community.

In this article, we identify facilitators for, barriers to, and strategies for the implementation of Medicaid immediate postpartum LARC policies according to the domains and constructs of the CFIR, using data from key informant interviews with the 13 states in the Learning Community. Our findings may inform states at different stages of policy implementation and have implications for the implementation of other state-level activities and programs.

Methods

From November 2015 through March 2016, Learning Community evaluators from the University of Illinois at Chicago (UIC) conducted semistructured telephone interviews with each of the 13 state teams participating in the Learning Community. State teams were multidisciplinary and multiagency, consisting of 3-7 persons. Each team was a unit of analysis, and team members included state health department staff members (eg, state health officials, Title V and Title X directors), Medicaid representatives (eg, Medicaid medical directors), clinical providers, and other stakeholders (eg, local health department staff members, representatives from community-based organizations).

The semistructured interview guide was organized into 8 focus areas of the Learning Community: provider training, reimbursement and sustainability, informed consent and ethical considerations, stocking and supply, outreach, stakeholder partnerships, service locations, and data, monitoring, and evaluation.^15,16 In each focus area, we asked teams to describe facilitators (ie, what makes implementation possible), barriers, and strategies related to the implementation of immediate postpartum LARC reimbursement policies in their state.

Interviews were audio-recorded and transcribed by a third-party vendor. We coded each interview according to the 39 constructs in the 5 domains of the CFIR, conceptualizing the state team as part of the inner setting domain to delineate it from the outer setting domain. Two researchers independently coded all 16 interviews by using Dedoose version 7.0.23¹⁷ and then met to resolve coding discrepancies. The primary research team discussed themes that emerged from the data, focusing on constructs of the CFIR that were most prominent or coded most often and appeared most salient in the process of implementing immediate postpartum LARC policies. We also targeted constructs that could help inform future implementation activities among the Learning Community and other states interested in increasing access to immediate postpartum LARC.

This project received an exemption from the institutional review board at UIC and was determined to be public health practice by the Centers for Disease Control and Prevention.

Results

The principal investigator conducted 16 hour-long interviews, which included 41 participants. On average, 4 state team members joined the telephone calls; supplemental telephone calls were held for individual team members who were unavailable for the team call.

Of the 5 domains of the CFIR, 4 domains had several constructs coded more than 200 times each, whereas 1 domain, “characteristics of individuals,” was coded only 51 times. Therefore, we tabulated results for only 4 domains: “intervention characteristics,” “outer setting,” “inner setting,” and “process of implementation.” We present the facilitators, barriers, and implementation strategies for 9 of the 39 constructs of the CFIR that were most prominent and appeared most salient in the process of implementing immediate postpartum LARC policies (Table). We include construct definitions for clarity. The ordering of the selected domains and constructs does not reflect priority or importance.

Table.

Facilitators, barriers, and strategies for implementation of immediate postpartum long-acting reversible contraception (LARC) policies, by domain and construct of the Consolidated Framework for Implementation Research (CFIR),^a 13 US states, 2015-2016

CFIR Construct and Definition	Facilitators	Barriers	Implementation Strategies
Domain: Intervention characteristics (key attributes of the intervention)
Complexity: perceived difficulty of implementation	NA	Technical complexity of information technology system for claims processing Process change for coders and pharmacy staff members	Visit selected hospitals and develop toolkit based on those site visits Hire a dedicated person to manage implementation
Trialability: the ability to test the intervention on a small scale	NA	Belief that it is unfair to only implement at 1 site for a period “Heavy lift” to change payment stream for a single hospital	Pilot at an academic medical center with residents Pilot prenatal counseling and consent with 1 prenatal care provider
Cost: costs of the intervention and costs associated with implementation	Ryan Residency Program and other family planning funds to buy LARC devices	Birthing facilities must pay for and stock expensive devices upfront and wait for Medicaid reimbursement	Project cost savings to help convince leadership of policy’s value Partner with organizations that can pay for training providers and other staff members
Domain: Outer setting (economic, political, and social context of the intervention)
Cosmopolitanism: the degree to which an organization is networked with other external organizations	Ability to work with other states in the Learning Community and share resources Preexisting personal connections of state team members Active professional associations (eg, ACOG, American Academy of Pediatrics)	Difficulty of translating what works across various state contexts Challenging to engage private insurance companies Difficulty of connecting with rural birthing facilities	Use perinatal quality collaboratives to lead work and bring together a diverse set of partners Leverage financial and human resources from external partner organizations Create a shared agenda with nontraditional stakeholders Share lessons learned with other states Use telehealth technology to connect with providers and facilities in remote areas
Domain: Inner setting (structural, political, and cultural context through which implementation proceeds)
Networks and communications: the nature and quality of webs of social networks and the nature and quality of formal and informal communications within an organization	Co-location of state health department and Medicaid agency and/or strong preexisting working relationship between agencies Opportunities to meet as a state team	Competing priorities within health department and/or Medicaid Geographic distance between state team members	Integrate immediate postpartum LARC policy implementation with other state maternal and child health initiatives (eg, Collaborative Improvement and Innovation Networks) to increase efficiency
Implementation climate: the absorptive capacity for change, shared receptivity of involved individuals to an intervention, and the extent to which use of that intervention will be rewarded, supported, and expected within their organization	Team members’ long and continuous involvement with immediate postpartum LARC initiative Support from high-level leadership (eg, governor, health department director, Medicaid director)	Turnover in state team members Effect of political sensitivity around contraception on state team’s ability to work on increasing LARC access	Capitalize on energy from champions and stakeholder partners to catalyze implementation Educate on the benefits of immediate postpartum LARC policy for women’s and the public’s health Disseminate existing educational materials from national partners to dispel myths about immediate postpartum LARC
Domain: Process of implementation (active change)
Planning: the degree to which a scheme or method of behavior and tasks for implementing an intervention are developed in advance	Hearing about process from other states in the Learning Community	Long duration for resolving technical billing issues, leading to delays for subsequent implementation steps	NA
Engaging champions: attracting and involving persons who dedicate themselves to supporting the intervention in an organization	Medical residency programs	Competing priorities for champions	Use early provider champions to recruit providers at other facilities Identify champions in various areas of hospitals (eg, pharmacy, billing) Educate on immediate postpartum LARC policy and recruit champions at professional meetings (eg, local ACOG chapter)
Reflecting and evaluating: quantitative and qualitative feedback about the progress and quality of implementation	Preexisting strong collaboration across agencies with respect to data	Challenges in acquiring data use agreements between public health and Medicaid Difficulty analyzing raw Medicaid claims data Lack of data timeliness Uncertainty about reasonable goal for immediate postpartum uptake	Investigate process measures (eg, number of providers trained) before examining outcomes (eg, number of LARC placed immediately postpartum) Partner with academic institutions for evaluation technical assistance Use continuous data monitoring to identify problems and rectify them early Include data analysts in immediate postpartum LARC work Use assistance from the Centers for Medicare & Medicaid Services to calculate contraceptive care performance measures

Abbreviations: ACOG, American Congress of Obstetricians and Gynecologists; NA, not applicable.

^a Data source: Damschroder et al.¹

^b Data obtained through telephone interviews that took place during November 2015–March 2016 with 13 state teams (Colorado, Delaware, Georgia, Indiana, Iowa, Louisiana, Maryland, Massachusetts, Montana, New Mexico, Oklahoma, South Carolina, and Texas) that participated in the Immediate Postpartum LARC Learning Community.

Intervention Characteristics

In the domain of “intervention characteristics,” or the key attributes of the intervention, the most salient constructs were complexity, trialability, and cost.

Complexity (ie, the perceived difficulty of implementation)

Barriers related to the complexity of the policy change and related implementation hampered state implementation progress. For example, many states struggled with the technical complexity of the information technology system for processing claims for immediate postpartum LARC. Several teams reported confusion about how hospitals bill and are reimbursed for costs associated with immediate postpartum LARC. To better understand and overcome the latter barriers, some state teams conducted site visits with hospitals and developed toolkits for hospitals to use in facilitating policy implementation. A few states also hired a dedicated person to understand the complexities and manage the barriers related to immediate postpartum LARC policy implementation.

Trialability (ie, the ability to test the intervention on a small scale)

Some teams chose to pilot immediate postpartum LARC policy implementation at 1 medical center or with 1 prenatal care provider before implementing statewide. Although piloting at 1 site was helpful to many states, a few states noted that it was time and resource intensive and may be inequitable to begin implementing at only 1 site.

Cost (ie, the costs of the intervention and costs associated with implementation)

Some states reported using projected cost savings resulting from prevented unintended pregnancies as a facilitator to convince Medicaid leadership of the value of immediate postpartum LARC investment. Further funding was often needed for immediate postpartum LARC policy implementation activities, such as provider training on patient-centered counseling and LARC insertion. Some states used various internal funds (eg, Title V, Title X), whereas other states partnered with external organizations to pay for these activities. One barrier faced by hospitals was the upfront cost of stocking expensive LARC devices, which are reimbursed by Medicaid only after insertion. This stocking barrier was overcome in some states by purchasing devices using other sources of family planning funding, such as Ryan Residency Programs,¹⁸ in certain teaching hospitals.

Outer Setting

The “outer setting” domain includes the economic, political, and social context of the intervention.

Cosmopolitanism (ie, the degree to which an organization is networked with other external organizations)

Cosmopolitanism was the most salient construct in the outer setting domain and the most frequently coded construct overall. Facilitators included the opportunity provided by the Learning Community to develop partnerships and work with other states to share resources. However, some teams identified the difficulty in translation of best practices across states because of various state settings, including size, urban/rural mix, and competing priorities at state agencies. States identified the rich existing connections of the diverse state team members with external partners as facilitators for engaging and collaborating with stakeholders. For example, providers and administrators at hospitals had existing relationships with Medicaid managed care organizations, and several team members held shared affiliations with professional associations such as the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics. To capitalize on strong stakeholder partnerships, a common strategy used by state teams was to engage perinatal quality collaboratives in leading immediate postpartum LARC policy implementation. However, barriers existed in engaging with some stakeholders, such as private insurance companies and rural hospitals. Teams identified few strategies for engaging insurance companies and acknowledged that more work was needed. Some states with substantial rural and frontier areas identified telehealth technology as a strategy for connecting and communicating with providers and facilities in these areas.

Inner Setting

The “inner setting” domain refers to the structural, political, and cultural context through which implementation proceeds. In this domain, the most prominent constructs were networks and communications and implementation climate.

Networks and communications (ie, the nature and quality of webs of social networks and of formal and informal communications within an organization)

States in which the health department and Medicaid agency were either co-located or had strong existing working relationships identified the networks and communications construct as a facilitator, whereas states organized differently identified their setup as a barrier. In some states, large geographic distances between state team members was an additional barrier. Setting aside dedicated time for improving working relationships among the state team members, such as that afforded by the annual in-person Learning Community meeting, facilitated communication. Regularly scheduled team check-in meetings also facilitated progress. However, competing priorities often prevented important team members from sustained engagement in this initiative, hampering the teams’ ability to make progress on planned timelines. To increase efficiency, several teams integrated the immediate postpartum LARC work with other maternal and child health initiatives, such as Collaborative Improvement and Innovation Networks (CoIINs).¹⁹

Implementation climate (ie, the absorptive capacity for change, shared receptivity of involved individuals to an intervention, and the extent to which use of that intervention will be rewarded, supported, and expected within the organization)

For many state teams, the implementation climate was influenced by political sensitivities about the use of state resources to fund contraception access, although some teams cited support from their governor or other high-level leadership as facilitators of a favorable implementation climate. To cultivate increased political will for immediate postpartum LARC policy implementation, some state teams educated leadership about the potential for immediate postpartum LARC as a benefit to women’s health and public health, such as preterm birth reduction.²⁰ Teams also widely disseminated existing educational materials from national partners to dispel common myths, such as immediate postpartum intrauterine device insertion being associated with high expulsion rates and breast-feeding mothers not being appropriate candidates for immediate postpartum LARC.²¹ Higher state team turnover was a barrier to a favorable implementation climate in some states, and other states’ work was facilitated by having a stable team of experienced persons with sustained involvement in this effort and similar efforts over time. State teams capitalized on energy from stakeholder partners to help advance implementation, especially when state team membership was in flux.

Process of Implementation

In the “process of implementation” domain, or active change, the most salient constructs were planning, engaging champions, and reflecting and evaluating.

Planning (ie, the degree to which a scheme or method of behavior and tasks for implementing an intervention are developed in advance)

Some states reported that technical billing issues or information technology system modifications took longer than expected to resolve, thus delaying other planned implementation steps. One facilitator of planning was learning about the later stages in the implementation process from states in the Learning Community that were further along.

Engaging champions (ie, attracting and involving persons who dedicate themselves to supporting the intervention in an organization)

State teams highlighted the importance of engaging champions for promoting their implementation work. One facilitator for engaging champions was medical residency programs, because residents often have the time and energy to commit to immediate postpartum LARC policy implementation and can continue to be champions beyond residency. Several states have recruited champions by providing education on immediate postpartum LARC policy at meetings of professional organizations (eg, state American College of Obstetricians and Gynecologists sections). Furthermore, teams have encouraged existing champions to recruit providers at other hospitals and identify administrative, pharmacy, and billing department champions in their own hospitals. A few states struggled to engage champions, often because of competing priorities of identified persons.

Reflecting and evaluating (ie, garnering feedback about the progress and quality of implementation)

State teams reported several barriers related to reflecting and evaluating. Some states had trouble acquiring data use agreements between the public health department and Medicaid, and other states with data access had difficulty extracting desired information from raw Medicaid claims data. One strategy for overcoming these barriers was involving Medicaid analysts to assist in facilitating effective data use. Many states also struggled to identify appropriate outcome measures because it was unclear what a reasonable “goal” for immediate postpartum LARC uptake might be. One strategy some state teams used was focusing on process measures (eg, number of providers trained in immediate postpartum LARC insertion). Other strategies included partnering with academic institutions for evaluation assistance, using continuous data monitoring to identify and rectify problems early, and requesting technical assistance from federal partner agencies to calculate the performance measures of contraceptive care endorsed by the National Quality Forum.²²

Discussion

Teams embarking on the statewide implementation of other policy changes or complex evidence-based public health initiatives may benefit from similarly cataloguing potential facilitators, barriers, and strategies according to the organizing framework of the CFIR. This cataloging may be particularly effective if completed during the planning process before implementation, allowing agencies or organizations to anticipate potential barriers and identify strategies to avoid or overcome barriers. Similar to most previous work using the CFIR,^4-6 our observational study used the CFIR as an evaluation tool to describe states’ experiences after implementation of immediate postpartum LARC policies had already begun. Teams in our study may have benefited from incorporating the CFIR earlier in the process, as with a recent study that applied the CFIR in a preimplementation assessment.²³

Examining facilitators, barriers, and strategies according to the CFIR domains may help states anticipate barriers for which facilitators or strategies have not been identified or may not apply to their context. In our study, the cost of immediate postpartum LARC devices was a major barrier for many states. Although some states had implemented strategies to address this barrier, such as using family planning funds to buy LARC devices or partnering with other agencies to help defray costs, several other states did not have these options. Future research could emphasize the development and testing of implementation strategies that could overcome particularly challenging barriers (eg, cost).

In our study, the 2 most salient constructs from the CFIR were cosmopolitanism (outer setting) and networks and communications (inner setting). Although some of the facilitators within these constructs were supported by the structure and activities of the Learning Community, several facilitators and strategies could be replicated in other states implementing complex initiatives, especially for interventions delivered in hospital settings. For example, states could organize multiagency teams around a common agenda and shared goals, prioritizing time for internal and external relationship building. Teams could engage professional networks, partner with organizations doing related work, and establish regular internal meetings as strategies for building strong internal and external networks to enhance policy implementation efforts.

In addition, identified strategies could be translated to the implementation of other complex public health initiatives. For example, strategies related to trialability and engaging champions may be important in the early stages of planning and implementing other initiatives focused on integrating clinical care and public health, such as the prevention of neonatal abstinence syndrome or hospital-based interventions for preventing severe maternal morbidity during hospitalization for labor and delivery.

Limitations

This study had several limitations. First, although we had the full participation of all 13 Learning Community state teams, this group was only a subset of states working on immediate postpartum LARC policy across the United States. As such, although the 13 states in the Learning Community represented a diverse subset of the country, our results are not generalizable to other states with various agency structures, populations, and contexts. Second, the interviews were conducted via telephone. Although it was the only feasible and convenient way to talk to several persons in multiple locations at once, it did not allow us to look for and probe on nonverbal communication cues. Third, we interviewed the state teams at only one point in time, which allowed us to talk to states that were at different stages of policy implementation. However, we were unable to capture data on changes over time or implementation outcomes.

Fourth, although the CFIR domain of characteristics of individuals was not commonly coded in our data, it may influence the implementation of state-level initiatives. However, our methods limited examination of this domain. State teams were interviewed together, which allowed for synergism and gave team members an opportunity to share in a group setting. At the same time, interviewing teams together may have limited information about individuals’ roles in policy implementation, because participants may have hesitated to critique other persons who were present on the call. Finally, our examination was at the state level, which aligned with the level of the Medicaid policy change and allowed us to capitalize on the knowledge of Learning Community teams. However, we were unable to capture data on facility-, provider-, and patient-level factors influencing immediate postpartum LARC implementation, thereby potentially limiting our examination of individual characteristics.

Conclusion

Compiling our interview data according to the CFIR resulted in an enhanced understanding of factors influencing the implementation of immediate postpartum LARC policies across states. Implementation science frameworks such as the CFIR could be more broadly applied to the scale-up of other evidence-based or evidence-informed strategies in public health. Applying implementation science frameworks may be particularly useful for future cross-agency collaborations, such as collaborations between Medicaid and public health. Specific to maternal and child health, implementation science frameworks such as the CFIR may help support Title V transformation, which is focused on population-based scale-up of evidence-based strategies to address maternal and child health priorities. The application of the CFIR constructs to complex statewide initiatives may be most effective when first considered to inform planning, then reconsidered while monitoring, evaluating, and improving the implementation process.