Table 1.
Discrete implementation strategies used, activities completed, and resources developed
| Strategy # | Strategy | Activities completed |
|---|---|---|
| 1 | Access new funding | Funding provided through VA’s Central Office of Connected Care budget |
| 2 | Alter incentive/allowance structures | Primary care leadership and program performance-based performance goals |
| 3 | Alter patient/consumer fees | Co-pay was eliminated for patients using VA Video Connect for a telehealth visit as a national initiative |
| 4* | Assess for readiness and identify barriers and facilitators | Site readiness assessed at all barriers/facilitators identified; site implementation plans developed |
| 5* | Audit and provide feedback | Created clinical performance and compliance data reports and deliver leadership briefings |
| 6* | Build a coalition | Learning collaboratives established; Leadership meetings held; Collaboration with implementation stakeholders; Identified champions |
| 7* | Capture and share local knowledge | Evaluated implementation strategies, document results in implementation reports |
| 8* | Centralize technical assistance | Establishment of Virtual Health Resource Centers (VHRCs) providing one-stop support for virtual care technologies; establishment of toll-free number (1–844-813–4361) for centralized access |
| 9 | Change accreditation or membership requirements | n/a |
| 10 | Change liability laws | n/a |
| 11 | Change physical structure and equipment | Acquired space in facility and equipment for staff for VHRC |
| 12 | Change record systems | Created and implemented EHR templates and consults for facilities |
| 13* | Change service sites | Change delivery of clinical services to be provided ‘anywhere to anywhere’ |
| 14* | Conduct cyclical small tests of change | Implementation pilots incorporating virtual tools and services into a specific clinic |
| 15* | Conduct educational meetings | Weekly education strategy and planning meetings; community of practice |
| 16* | Conduct educational outreach visits | Developed and distributed implementation toolkits training and promotional materials to sites |
| 17* | Conduct local consensus discussions | Established interdisciplinary learning collaboratives; Established steering committee |
| 18* | Conduct local needs assessment | Site level needs assessments and gap analysis |
| 19* | Conduct ongoing training | Delivery of training and marketing events |
| 20* | Create a learning collaborative | Established earning collaboratives |
| 21 | Create new clinical teams | Evaluated existing clinical workflows and guided improvements to increase efficiency and effectiveness in using health technologies; team-based approach |
| 22 | Create or change credentialing and/or licensure standards | VA expanded access to care by allowing healthcare providers to provide care through telehealth across state lines |
| 23* | Develop a formal implementation blueprint | Developed implementation plans based on recommendations in VA Facilitation and Implementation Guide (Ritchie et al., 2017) |
| 24* | Develop academic partnerships | Partnered with local universities to deliver marketing and training opportunities; Mentorship of interns |
| 25* | Develop an implementation glossary | Developed at national level, deployed at each site |
| 26* | Develop and implement tools for quality monitoring | Created implementation and quality monitoring tools; developed at national level, deployed at each site |
| 27* | Develop and organize quality monitoring systems | Developed at national level, deployed at each site; quarterly reports regarding progress toward goals |
| 28 | Develop disincentives | n/a |
| 29* | Develop educational materials | Targeted training to increase awareness and knowledge of health technologies |
| 30* | Develop resource sharing agreements | Centers of Excellence were established in partnership with facilities to increase access to resources related to virtual care implementation |
| 31* | Distribute educational materials | Targeted training to increase product knowledge (Annie, My VA Images, Patient Viewer, Mental Health Checkup, VA Video Connect, Self-Health VA Apps (PTSD Coach, Mindfulness Coach, etc.); weekly group meetings; weekly individual and site meetings |
| 32* | Facilitate relay of clinical data to providers | Established learning collaboratives; created leadership reports |
| 33* | Facilitation | Weekly national and site meetings |
| 34 | Fund and contract for the clinical innovation | All products implemented were all developed and funded by VHA |
| 35* | Identify and prepare champions | Identified and trained local clinical champions; trained internal facilitators on knowledge and skills in facilitation; Recruited members to learning collaboratives; Provided ongoing training and collaboration with these individuals; Workflow analysis |
| 36* | Identify early adopters | Identified early adopters at local sites and conducted field tests to understand their experience with the health technology |
| 37* | Increase demand | Provided regularly scheduled presentations to service leadership and staff; Marketing and education provided to Veterans and VHA staff |
| 38* | Inform local opinion leaders | Identified and collaborated with local opinion leaders; provided quarterly reports on progress toward goals |
| 39* | Intervene with patients/consumers to enhance uptake and adherence | Established ongoing information/education sessions; expanded expand virtual outreach options; developed ongoing training and marketing efforts |
| 40* | Involve executive boards | Reports to site executive leadership; Provided leadership briefings |
| 41* | Involve patients/consumers and family members | Outreach to Veterans to recruit peer-trainers for connected devices pilot; Established Virtual Health Resource Centers providing services to Veterans and family members; Field testing with Veterans |
| 42 | Make billing easier | n/a |
| 43* | Make training dynamic | Developed training materials based on Adult Learning Theory with the aim to increase engagement with learners; Evaluate training and marketing materials and delivery for satisfaction |
| 44* | Mandate change | Communicated to stakeholders existing mandates and alignment of strategic goals: VHA strategic goals include meeting needs of Veterans, enhancing Veteran experience, modernizing systems, and improving patient experience; Performance goals related to health technology use |
| 45* | Model and simulate change | Facilitation training specific to integration of health technologies in clinical care |
| 46* | Obtain and use patients/consumers and family feedback | Established VHRCs to meet the need of VHA staff and Veterans in integration of health technologies providing individualized consultation services; data reports on results |
| 47* | Obtain formal commitments | Signed Memoranda of Understanding (MOU) at each site |
| 48* | Organize clinician implementation team meetings | Implementation project plans and reports that include results, lessons learned, improved clinical workflows, and road maps |
| 49 | Place innovation on fee for service lists/formularies | n/a |
| 50* | Prepare patients/consumers to be active participants | Established VHRCs to meet the need of VHA staff and Veterans in integration of health technologies providing individualized consultation services |
| 51* | Promote adaptability | Assessed needs for service lines regarding barriers for use of health technologies, and implementation plans, to include marketing and training, specific to the site and service line needs |
| 52* | Promote network weaving | Identified staff willing to collaborate to promote utilization of virtual health; Established national Connected Care Community of Practice engaging VHA staff |
| 53* | Provide clinical supervision | Leveraged train the trainer model to provide mentorship and guidance to champions |
| 54* | Provide local technical assistance | Developed VHRCs providing technical assistance to Veterans and VHA staff; Internal facilitators partnered with local personnel to increase reach |
| 55* | Provide ongoing consultation | Developed VHRCs providing consultation to Veterans and VHA staff |
| 56* | Purposely reexamine the implementation | Provided outcome monitoring (aka control plan) in each implementation plan; post training follow-up completed to encourage adoption of virtual tools and detect barriers to utilization |
| 57* | Recruit, designate, and train for leadership | Established process to educate and train local champions |
| 58* | Remind clinicians | Assessed and modified clinical workflows to increase efficiency and effectiveness |
| 59 | Revise professional roles | n/a |
| 60* | Shadow other experts | Identified subject matter experts on various health technologies and effective implementation strategies for team members to shadow and improve knowledge and skills |
| 61* | Stage implementation scale up | Completed eight implementation studies to assess implementation strategies for combinations of health technologies; Established VHRC Implementation Consult Service to provide guidance and resources to additional VHA sites wanting to build VHRC |
| 62 | Start a dissemination organization | n/a |
| 63* | Tailor strategies | Met with service lines and multiple disciplines to identify barriers to implementation; Incorporated feedback into implementation planning; Completed site specific assessment |
| 64* | Use advisory boards and workgroups | Connected Care Steering Committee consisting of all service established to discuss implementation strategies and expansion |
| 65* | Use an implementation advisor | Implementation team completed formal training in facilitation and implementation; Implementation advisor review and guidance regarding implementation plans |
| 66 | Use capitated payments | n/a |
| 67* | Use data experts | Applied data analytics and informatics project planning and monitoring of implementation efforts; Worked with local group practice managers to develop local data reports based on electronic health records entered for virtual programs |
| 68* | Use data warehousing techniques | Utilized healthcare system data warehouse to create reports to track site progress toward goals |
| 69* | Use mass media | Collaborated with Public Affairs Office (national and at facilities) to promote virtual programs across platforms (e.g., GovDelivery email, social media, blog posts, videos, radio, etc.) |
| 70 | Use other payment schemes | n/a |
| 71* | Use train-the-trainer strategies | Staff education and training using a train-the-trainer model |
| 72 | Site visits | In-person site visits were completed for two sites. Due to COVID-19 pandemic, in-person site visits were put on hold |
| 73* | Work with educational institutions | Partnered with academic institutions and provide mentorship for three graduate student interns |
| Strategy # | Resources developed |
|---|---|
| 1 | Performance work statement |
| 2 | Performance goals |
| 3 | VA policy |
| 4* | Clinical Coach Quick Guide and Implementation Plan for each site |
| 5* | Data reports and presentations of progress toward performance goals |
| 6* | Agendas, meeting notes, presentations |
| 7* | Implementation reports created; development of implementation team SharePoint site for knowledge management |
| 8* | Development of videos and placed on YouTube publicizing services and phone number |
| 9 | n/a |
| 10 | n/a |
| 11 | Created VHRC Toolkit establishing minimum, standard, and optimum parameters for space, equipment, and materials needed |
| 12 | Creation of: scheduling clinic template, sample progress notes template to document use of tools, referral order for VHRC; VVC national blood pressure template; Digital divide consult; Clinical video telehealth consult |
| 13* | n/a |
| 14* | Created implementation project plans, implementation reports including results and lessons learned |
| 15* | Development of meeting agendas and notes, presentations |
| 16* | Development and delivery of education and training and training materials |
| 17* | Meeting agendas and notes gathering of feedback and ideas for advancing the use of virtual tools and services |
| 18* | Needs assessment, gap analysis, site implementation plan |
| 19* | Developed PowerPoints on training plans; preparatory email; follow-up emails: developed control plan to ensure VVC visits completed and barriers addressed post training |
| 20* | Meeting agenda and notes; presentations through Connected Care Community of Practice |
| 21 | Meeting agenda and notes; presentations; new clinical workflows |
| 22 | n/a |
| 23* | Developed national implementation strategic plan and iplementation plan for each site based on site specific needs |
| 24* | Office of Connected Care Internship Orientation Guide |
| 25* | Site implementation guide; VA Mobile Health Practice Guide (Armstrong et al., 2021) |
| 26* | Performance goals; tracking spreadsheets |
| 27* | Developed tracking systems for activities and Power BI dashboards to provide access to results across sites |
| 28 | n/a |
| 29* | VA Virtual Care Toolkit: Clinicians Guide and Prescription Pad; VA Mobile Health Practice Guide 1st Edition; VA Virtual Care Best Practices training series (8 one-hour trainings) |
| 30* | Central SharePoint site developed to provide access to resources across sites |
| 31* | Training and marketing materials (flyers, training slides, wallet cards, etc.) |
| 32* | Meeting agenda and notes; reports; presentations |
| 33* | Meeting agendas and notes; presentations |
| 34 | n/a |
| 35* | Developed purpose statements, meeting notes and agendas, presentations |
| 36* | Results of field tests with early adopters |
| 37* | Training and marketing materials |
| 38* | Data and progress reports; presentations |
| 39* | Training and marketing materials |
| 40* | Data and progress reports; presentations |
| 41* | Marketing and training materials for Veterans and family members; Field testing reports; newsletters; blogs; social media posts |
| 42 | n/a |
| 43* | Reports including feedback from learners and level of satisfaction |
| 44* | Training and marketing materials; establishment of performance measures |
| 45* | Presentations; scripts; checklists; scenarios to role play |
| 46* | VHRC customer service feedback; training feedback |
| 47* | n/a |
| 48* | Implementation plans and reports |
| 49 | n/a |
| 50* | Marketing and promotional items to increase effectiveness of sharing nationally developed market materials (backpacks, folders, etc.); |
| 51* | Presentations; flyers; videos; clinical workflows |
| 52* | Ongoing collaboration through trainings and meetings |
| 53* | Implementation toolkit; training and marketing materials specific to clinical disciplines; train the trainer materials |
| 54* | System to track all encounters related to technical assistance |
| 55* | System to track all encounters related to consultation |
| 56* | Implementation project plans and reports; tracking spreadsheets |
| 57* | Training and marketing materials; tracking system for champions |
| 58* | Clinical workflows |
| 59 | n/a |
| 60* | Training and marketing materials |
| 61* | Implementation project reports including results and lessons learned; Developed of VHRC Implementation Road Map |
| 62 | n/a |
| 63* | Implementation project reports including results and lessons learned |
| 64* | Meeting agendas and notes; presentations |
| 65* | Updated implementation strategy and plans |
| 66 | n/a |
| 67* | Metrics and analytics reports |
| 68* | Metrics and analytics reports |
| 69* | Marketing materials (videos, blogs, social media posts, email, text, etc.) |
| 70 | n/a |
| 71* | Meeting agendas and notes, presentation, implementation toolkits |
| 72 | Meeting agendas and notes; presentations; updated implementation plans based on lessons learned |
| 73* | Office of Connected Care Internship Orientation Guide |
*Strategies that were used at the national program level and at all sites. (Compilation of implementation strategies from the Expert Recommendations for Implementing Change (ERIC); Powell et al., 2015)