Background
The problem addressed by the digital health intervention
The intervention
Theoretical approach
Approach to implementation
Aims and objectives
Methods
Evidence synthesis
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The need for careful consideration of the effects of the intervention on existing systems and work practices
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Key stakeholders and implementation champions should be included as early as possible in the implementation process
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Planning implementation is a critical step which includes ensuring that organisations are in a state of readiness.
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The provision of training and education to all those involved with implementation is a key success factor
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Implementation does not stop with ‘go-live’—there is a need for ongoing monitoring, evaluation and adaptation of systems to ensure intended goals are being met, benefits realised, and ongoing identification of barriers to effective use, along with strategies to overcome these barriers.
Engagement of key stakeholders
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Referral to diabetes education was recommended by NICE for all patients newly diagnosed with type 2 diabetes
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Referrals to this education for patients with T2DM were provided mainly through primary care setting
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The national figures (at the time of the study) of the numbers of referrals made to education were very low (only 11.5% of people with T2DM were being offered structured education (with 5.6% actually attending) [49]
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Referring to education was part of current practice for health professionals working in primary care and therefore referring to HeLP-Diabetes was a recognised and accepted practice.
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However, using HeLP-Diabetes would require an entirely new set of practices to be enacted by healthcare professionals (the concrete targets for change for primary care practices and staff are detailed in Table 1).
Practice targets: • To adopt HeLP-Diabetes as an additional service for their patients with T2DM, • Provide resources (time, healthcare professionals, and space) to allow staff to offer the intervention to patients | |
Healthcare professional targets: Behaviours additional to normal practice were required to: • Recommend HeLP-Diabetes to patients during routine appointments • Register patients (or assist patients to register) to use HeLP-Diabetes, either within routine appointments or at a separate time • Facilitate patient use of HeLP-Diabetes through a facilitation appointment where key features of HeLP-Diabetes are shown to patients by staff • Encourage ongoing use of HeLP-Diabetes in patients by discussing use in subsequent appointments. |
Setting selection
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Diabetes should be a local priority for the CCG;
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There should be interest in promoting self-management by patients;
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It should be reasonably local to the research team, since implementation is promoted by good communication and local ownership (as identified by the systematic review);
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The CCG should be interested in working with the research team.
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There were 34 GP practices within the CCG
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Within the CCG self-management of T2DM was high on the agenda
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There was a specific diabetes working group within the CCG comprised of GPs
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Many practices had a lead for diabetes (usually a GP)
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Much of the work within practices around self-management was the responsibility of nurses
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Most practices had clinical meetings at lunchtime where they were used to new working practices being introduced to them
Selection of implementation strategies
Execution
Feedback
Interviews
Usage data
Adaptations
Results
Strategy | Strategies operationalised for HeLP-Diabetes |
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To target coherence: | |
Local opinion leaders | • Key people within the CCG were identified at a CCG local policy meeting. • All practice managers and lead GPs for diabetes were informed about HeLP-Diabetes by email |
Educational materials | • Information email sent to all practice managers and leads emphasised that HeLP-Diabetes was an online programme thus different from other self-management programmes, that it was free to use and had been developed by a university. • Flyers, posters and other advertising materials were developed and circulated throughout the CCG. |
Educational outreach visits, or academic detailing | Meetings were arranged between practices and the research team to provide health care professionals (HCPs) with information about HeLP-Diabetes and discuss the implications for their working practice, in order to allow them to decide whether or not to adopt it. Informed by the need to promote coherence (sense-making), during these meetings we emphasised the online nature of the programme, its evidence-base, theoretical underpinning and participatory design, and the potential benefits to patients, practices and the healthcare system. |
To target cognitive participation: | |
Educational meetings | We promoted cognitive participation during meetings at practices by emphasising the benefits to patients, practices and healthcare system (coherence), while ensuring minimum workload and optimal fit with interactional workability, skill set workability, contextual integration and relational integration (Collective Action). |
Inter-professional education | HCPs were provided with a training session which provided the opportunity for staff to understand the actions and procedures needed to sustain HeLP-Diabetes in practice and see that HeLP-Diabetes could deliver the anticipated advantages. |
Local consensus processes | Training was with groups of staff which allowed the opportunity for them to discuss and decide how the work of implementing would be shared within the practice and how HeLP-Diabetes would be offered to patients. |
To target collective action: | |
Educational meetings | Staff were provided with login details which allowed them to try out HeLP-Diabetes. This allowed staff to see how HeLP-Diabetes fitted with the skill sets of the HCPs in the practice (skill set workability), what resources were needed to make it part of routine practice (contextual integration), what knowledge was needed to be confident with HeLP-Diabetes as a new way of working (relational integration), and the impact that HeLP-Diabetes would have on interaction with colleagues and patients (relational integration). |
Educational materials | Training booklets were developed and provided to staff at the training sessions containing information on how to access HeLP-Diabetes, how to create a login, and how to sign patients up and provided summaries of the different parts of the intervention and how to use them with patients. |
To target reflexive monitoring: | |
Continuous quality improvement | • Ongoing support and communication was provided to each service who adopted HeLP-Diabetes to allow problem solving and maintain awareness of HeLP-Diabetes. • Data on the number of patients being registered at each practice was collected • Informal discussions and interviews with staff were conducted in order to identify barriers to the implementation and to develop solutions. |
Audit and feedback | Feedback that included number of patients using HeLP-Diabetes, how each service was performing and feedback from patients using HeLP-Diabetes was provided to services via email regularly to promote positive reflexive monitoring. |
Reminders | Regular emails and newsletters were sent from the research team and the CCG to practices to remind them about HeLP-Diabetes and to encourage those who had already adopted it to keep referring patients to use it. |
Barrier | Strategy to address barrier | Strategies operationalised for HeLP-Diabetes |
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Collective action (contextual integration) | ||
Staff unwilling or unable to provide the resources to implement the facilitation aspect of the registration process (see Table 1). | Tailored intervention | For practice who identified a lack of resources to implement HeLP-Diabetes a streamlined process which removed the facilitation aspect was offered. of the process. |
Even after removal of facilitation aspect some practices still couldn’t find resources to register patients | Tailored intervention | Alternative patient registration methods including patient self-registration and peer supported were offered to practices. |
Collective action (Skill Set Workability) | ||
Nurses, who had originally been targeted to deliver the intervention, felt that the using a digital intervention underutilized their own knowledge about diabetes. Health Care Assistants with additional knowledge. | Tailored intervention | Health Care Assistants were targeted to deliver the as they were often younger, IT literate, keen to help patients, but knew there were limitations to their diabetes knowledge that the intervention could help provide them. |
Cognitive participation | ||
Some staff reported not remembering or having other competing priorities which prevented HeLP-Diabetes being offered to patients. | Reminders | To keep the new way of working in view and connect it to the people who needed to be doing the work, HeLP-Diabetes was integrated within practice templates which prompted staff during appointments with patients with T2DM to mention HeLP-Diabetes and provide a leaflet. |
Collective action (relational integration) | ||
Some staff were unaware of HeLP-Diabetes within practices where adoption had been agreed. This was often due to teams not communicating about HeLP-Diabetes or in several cases because those who made adoption decisions (usually GPs) were not the ones tasked with implementing it. | Educational meetings and materials | To increase the visibility of HeLP-Diabetes additional staff focussed advertising was introduced including exhibition stalls, talks and demonstrations at staff education events. HeLP-Diabetes was also frequently advertised in the CCG’s bulletin to GPs. HeLP-Diabetes was also included by the CCG as one of their Locally Enhanced Services and added to the Map of Medicine system used by GP practices in the CCG. |
Reflexive monitoring impacting on interactional workability | ||
Staff suggested that they would offer HeLP-Diabetes to patients more if they were receiving more requests or enquiries from patients about it. | Patient-mediated interventions | Additional patient focussed advertising strategies were introduced to promote HeLP-Diabetes to increase the requests/enquiries from patients about HeLP-Diabetes. These included TV screen adverts in waiting rooms, talks given at patient self-management groups, attendance at Diabetes UK events, coverage in Practice newsletters and a mass mail out to all patients in some practices. |