Background
Functional decline is one of the core features of dementia [
1,
2]. As the symptoms of dementia worsen, the person becomes increasingly dependent on others for assistance with activities of daily living. Decline in cognitive and physical function is associated with reduced quality of life in the person with dementia, considerable impact on carers, increased use of health and social care resources and often culminates in the need to move to residential care [
3‐
5].
There is now evidence from multiple randomised controlled trials that functional decline can be delayed in people with dementia [
6‐
11]. Moreover, non-pharmacological interventions that work with both the person with dementia and their carers (dyadic interventions) and include strategies to promote independence and manage symptoms are more effective than pharmacological agents [
12] and do not have the associated side effects [
13]. Dyadic interventions are associated with a range of other benefits including: reduced carer burden, anxiety and depression, improved carer knowledge, and delayed time to institutionalisation [
14‐
16]. While the ingredients of interventions vary, research suggests that interventions that are tailored and involve multiple components (e.g. carer education plus skills training plus engaging the person with dementia in activities) are most effective [
14].
Despite evidence in favour of dyadic interventions and public support for such programs [
17], access is limited [
18]. Most of the programs found to be effective in research trials have been tested outside of existing care systems therefore the feasibility of providing the programs in routine service delivery is unclear [
15]. Implementation is the use of strategies to adopt and integrate evidence-based health interventions and change practice patterns within specific settings [
19]. The need for improved translation of research into practice has been recognised by the World Health Organization who have called for implementation of evidence based interventions that enhance function and capability in people with dementia in their global action plan [
20]. The plan also calls for more research to provide information about
how to translate evidence based programs into action [
20].
There are currently few examples of the implementation of evidence based interventions for community dwelling people with dementia and their carers into real-world settings [
15,
21] and none of these have taken place in Australia. Of those that do exist, a modified version of the original evidence based treatment has been applied suggesting that some adaptations are required to enhance feasibility in translation [
22,
23]. One such program, the Community Occupational Therapy in Dementia (COTiD) project in the Netherlands, involved looking at barriers and facilitators to delivering the intervention as perceived by occupational therapists who had received training in the intervention [
24]. COTiD involves ten consultations with an occupational therapist delivered over a shorter time frame (five weeks) and tends to focus mostly on activities of daily living. Focus groups revealed that therapists did not feel competent in implementing the program, had difficulty providing the amount of treatment recommended in the intervention guideline and struggled with the structured nature of the intervention including the amount of documentation associated. Yet, they valued the resources provided within the program, were positive about the evidence supporting the program and benefited from support from their colleagues. Physicians and managers who were involved in the study reported a lack of awareness about the COTiD intervention and referral mechanisms to occupational therapists were not clear or easy to complete. An additional implementation project involving the COTiD intervention, which aimed to address these barriers and facilitators, involved training days, outreach visits, regional meetings and a web based discussion platform. The effectiveness of the implementation strategy was tested in a cluster randomised trial and process evaluation. Results of the study revealed that the referrals to the COTiD program could be increased but adherence to the intervention was not enhanced following the implementation strategies [
23,
25].
A second program of implementation conducted in the United States involved implementation of the Environmental Skill-Building Program (ESP; renamed as Skills
2Care
R) within a homecare practice [
22]. The implementation involved site preparation, training, establishing referral mechanisms and evaluation. A total of 22 therapists were trained to provide the intervention and provided an average of 4.7 sessions; the implementation was considered moderately successful. Fidelity to the intervention was variable and fidelity checks were difficult to conduct within the homecare organisations.
This study examines implementation of the ‘Care of People with dementia in their Environments’ (COPE) program in the Australian context [
26]. COPE is a non-pharmacological intervention designed to reduce functional disability in people with dementia. The program comprises occupational therapy and nursing input (involving 8-10 consultations with an occupational therapist and two consultations with a nurse) delivered over four months. Core elements of the program include: focusing on the capabilities of the person with dementia, prevention and management of changed behaviours and carer support and education. Strategies applied by the therapist and nurse include carer education and strategies to modify communication, tasks and the environment. A large randomised trial (
n = 237) conducted in the United States found that the program was effective in reducing dependency and increasing engagement of the person with dementia and improving carer wellbeing [
26]. At four months carers reported significantly higher levels of wellbeing. At nine months carers in the intervention group reported a “great deal” of improvement in their lives overall, confidence managing changed behaviours and improved ability to keep living at home.
The main research questions for this project are:
(1)
How is COPE adopted, implemented and made sustainable within different community health contexts in Australia?
(2)
What are the costs associated with delivery of COPE and are there changes in resource utilisation of people with dementia before and after intervention, and
We will also conduct a pragmatic pre-post evaluation to investigate:
When implemented into existing services, does COPE have the same size of effect for activity engagement outcomes for the person with dementia and wellbeing outcomes for the carer as when tested in the randomised controlled trial?
Discussion
Implementation research is the scientific study of methods to promote the integration of research findings and evidence-based interventions into healthcare practice and policy [
19]. The importance of implementation science is that it can accelerate the translation of effective interventions. This project is novel in that it is underpinned by theory and includes a broad framework approach that has enabled a focus on multi-component strategies that would best leverage implementation across a range of levels and practice settings, and utilises an iterative mixed method approach to understand the processes, context and complexity of changing practice. We seek to understand at the level of client, occupational therapist, nurse, manager and organisation and contribute to the knowledge base of how evidence-based interventions can be transported to real-world practice settings.
Evidence in favour of dyadic interventions is accumulating. Such interventions have the potential to delay functional decline, reduce carer impact, increase carer knowledge, reduce carer anxiety, reduce carer depression and delay time to institutionalisation [
14‐
16]. Yet, implementation into routine practice has been poor. Surveys suggest that occupational therapists, who could provide these dyadic interventions, tend to focus on assessment and lack confidence in treating people with the symptoms associated with dementia [
33]. This research project evaluates the process of implementation of the COPE intervention into a range of different service delivery contexts in Australia.
Strength of this study is its reach to three different types of practice settings which will enable comparison of differences and similarities within and between them. This project confirms the importance of attention to the local context, the engagement of stakeholder organisations, health care delivery settings and the role of individuals in dissemination and implementation [
41]. It demonstrates that researchers and stakeholders need to work in partnership, develop working relationships and researchers to be attentive to need and context at individual and organisational levels. We know that elements such as ‘packaging’ the intervention through development of training, identifying core elements and skills training along with preparation for sustainability are important ([
42,
43]) but the kinds of strategies and processes to achieve these are still evolving. In the case of dementia care in the community implementation will require a shift from ‘assessment’ to ‘intervention’ focused practice [
15,
33]. It will also need to bridge the gap between the potential of empirically proven re-ablement programs, supported in current commonwealth aged care policies [
44], to achieve their research aims in real-world settings. This project will provide information about how organisations fit these programs into the funding models they can already access. The extent that this project will impact on policy at the level of organisation, referral pathways and changing landscapes of access to re-ablement programs remains to be seen.
There will be future opportunities to compare cross-cultural implementation issues with another COPE study currently being undertaken in the US [
45]. People with dementia who receive services through the Connecticut Home Care Program for Elders will be randomly allocated to receive COPE or usual care. The study aims to look at outcomes for the person with dementia and carer as well as net financial benefit, feasibility and acceptability when delivered within that home care program.
Our implementation study will provide detailed information about the process and outcomes of translation into Australian health contexts with rich qualitative data which will provide understanding about factors influencing implementation. Examining implementation in a range of settings and contexts will help inform the best models of fitting such programs within existing services. Further, challenges in scaling and building sustainability from early stages have received little attention [
46]. Learnings from the study will outline strategies and processes for implementation and sustainability and we will better understand how establishing links with policy makers can support ongoing program delivery.
Acknowledgements
Our steering committee plays an integral role in guiding our project, advising on a broad range of issues from how COPE can be framed and marketed to how COPE fits with existing policy and how to disseminate information to the public. We gratefully acknowledge the input of the steering committee members: Danijela Hlis, Glenys Petrie, Jane Thompson, Joan Jackman, John Quinn, Meredith Gresham and Wendy Hudson.