Table 3.

Strategies and Examples Organized by Emergent Themes for Implementation Phase and Implementation Maintenance and Scale-Up^a

Emergent Themes: ERIC Strategy	Implementation Phase: Strategy Application Exemplar	Maintenance and Scale-Up: Strategy Application Exemplar
ORGANIZATIONAL FACTORS
Mandate change	• The primary factors for implementation were mandated physical distancing and hospital system policies that did not restrict access to services due to insurance coverage (eg, telehealth physical therapy)	• Clinicians, supervisors, academic partners, and stakeholders will continue to advocate for ongoing telehealth insurance coverage and reimbursement • Ongoing identification and education of external opinion
Access new funding  Inform local opinion leaders	• CMS policies and other insurance providers expanded telehealth access	leaders to maintain and scale-up telehealth physical therapy by champions, supervisors, and academic partners
Conduct local consensus discussions	• Departmental consensus discussions occurred during the week prior to shelter-in-place and the decision was made to implement telehealth physical therapy	• Champions and supervisors to expand academic partnerships to facilitate telehealth physical therapy network weaving refinement and growth
Develop academic partnerships	• Existing academic partnerships facilitated the identification of data experts (eg, informatics, implementation science) to guide implementation	• Champions and academic partners will identify external organizations for information sharing to facilitate collaborative problem solving
Use data experts	• Existing collaborations to facilitate reach of telehealth were preliminarily identified	• Supervisors and clinician leaders will conduct quarterly audits for billing, consent, and documentation guidelines
Promote network weaving	• Hospital system had adequate technology and financial resources to support telehealth physical therapy implementation and educational meetings
Audit and provide feedback	• Supervisors conducted audits (eg, billing, consent documentation) and electronically reported findings to clinicians weekly
ENGAGING EXTERNAL STAKEHOLDERS
Intervene with patients/consumers to enhance uptake and adherence	• Scheduling algorithm was used by administrative staff to identify and intervene on specific patient concerns (eg, technology, perceptions of telehealth physical therapy) when needed	• Clinicians and champions will develop and refine marketing materials for patients and referring providers • Expand use of social media and clinic website • In addition to satisfaction survey use, data experts and
	• Patients with unaddressed concerns were encouraged to speak with a physical therapist to answer specific questions	academic partners will iteratively explore qualitative barriers to telehealth within specific patient populations
Use mass media	• Supervisors, champions, and clinicians contacted referring providers to inform them of telehealth implementation	• Champions, supervisors, and academic partners will target specific populations to increase reach and uptake of
Involve patients/consumers and family members	• Social media and websites were updated to reflect implementation of telehealth sessions	telehealth
	• Satisfaction survey was developed and implemented to obtain patient feedback
CLINICIAN LEADERS (CHAMPIONS)
Identify and prepare champions	• Champions were identified by supervisors for smaller implementation-focused task forces, and led small cycles of change to inform planned scale-up strategies	• Champions will be an ongoing departmental resource for supervisors, clinicians, administrative staff, and administrative staff
Identify early adopters	• Champions communicated, at least daily, with supervisors, clinicians, and administrative staff, facilitating education and problem solving	• New champions will be identified by supervisors, when needed, to lead implementation scale-up efforts
Recruit, designate, and train for leadership	• Champions and supervisors led weekly video-based implementation-focused meetings to engage clinicians as stakeholders by identifying and discussing their specific concerns	• Dependent on the implementation scale-up project, supervisors will consider the use of protected time
Organize clinician implementation team meetings	• Champions were allotted protected time to complete implementation-focused tasks
CLINICIAN EDUCATION
Develop educational materials	• Ongoing education was provided to clinicians by champions and supervisors using multiple modes (eg, staff meetings, lunch-and-learn presentations, in-services, email, videos, cheat sheets)	• Clinicians will have ongoing knowledge sharing through case presentations, one-on-one mentorship, shadowing experts, and grand rounds presentations
	• Informal communication methods (eg, email, online message boards, texting, web-conferencing) supported clinician local knowledge sharing beyond formal pathways	• Clinicians, champions, and supervisors will identify additional sources of local knowledge (eg, orthopedics, telehealth) and external experts to advance clinician education about telehealth practices
Conduct educational meetings	• Champions developed short videos and tip sheets as a reference for	• Future education topics selected by clinicians include:
Make training dynamic	dissemination to clinicians • Education topics included, but were not limited to:	Advanced telehealth clinical decision making Selecting and administering objective measures using telehealth
Conduct ongoing training	Basic telehealth software troubleshooting	Telehealth exercise prescription and progression
Capture and share local knowledge	Tips and tricks for patient education	• Clinicians, champions, and academic partners will promote
Shadow other experts	Patient scheduling workflows	relationships with consultants who have expertise in telehealth
Conduct educational outreach visits	Benefits of telehealth	technology, implementation science, and/or physical therapist
Provide ongoing consultation	Basic clinical decision making with telehealth	practice
PROCESS
Assess for readiness and identify barriers and facilitators	• Clinician needs (eg, work-from-home agreements, hardware, software) to conduct telehealth sessions were assessed by supervisors and met a minimum standard. Needs regarding telehealth sessions from home with limited exercise equipment were not specifically addressed	• Assessment of barriers, facilitators, and needs by champions and supervisors will be ongoing. For example, adjustment to clinical environment to include telehealth physical therapy while maintaining physical distancing • Supervisors and data experts will use satisfaction surveys and
Change physical structure and equipment	• Patient barriers to access (eg, technology, scheduling) were identified using satisfaction surveys and open forums for discussion with clinical and administrative staff	qualitative engagement with external stakeholders to guide targeting of specific barriers to telehealth access • Supervisors will explore centralized technical support for patients
Conduct local needs assessment	• Local technical assistance for patients was provided by Rehabilitation Aides when needed	with UCSFMC Telehealth Department for technical issues, previsit education
Centralize technical assistance	• Hospital system IT department was consulted for clinician technical assistance when needed	• Champions to lead scale-up of higher volume of in-person visits and flexibility of mixed in-person and telehealth physical therapy sessions
Provide local technical assistance	• Small tests of change throughout implementation, led by champions, created opportunities for planned scale-up	• Scale-up to include increasing reach to specialty populations (eg, neurology, pelvic health)
Stage implementation scale-up	• Patient satisfaction survey, specific to telehealth physical therapy, was developed, tested, and implemented by data experts using Redcap	• Patient satisfaction survey will continue, potentially managed by a third party to centralize data collection and management • Supervisors and champions to lead reassessment and testing
Promote adaptability	• Informal quality monitoring pathways (eg, patient report to staff) provided insight for implementation success until formal mechanisms were in place with satisfaction survey and administrative reports stabilized	electronic collection of patient-reported outcome measures
Conduct cyclical small tests of change	• Mechanisms to electronically collect patient-reported outcome measures, potential measures of quality, were identified by champions, data experts, and supervisors
Purposely reexamine the implementation
Develop and implement tools for quality monitoring

^a CMS = Centers for Medicare & Medicaid Services; ERIC = Expert Recommendations for Implementing Change; UCSFMC = University of California, San Francisco Medical Center.