Bridging evidence and practice: multi-method evaluation of implementation fidelity of a multilevel hypertension intervention in a federally qualified health center.

内容摘要

Multilevel interventions targeting patients, providers, and health systems improve hypertension outcomes, but little is known about how well they are implemented in resource-limited settings. This study evaluated the implementation fidelity of ALTA, a multilevel approach for hypertension management, supported by practice facilitation, across six primary care practices in a Federally Qualified Health Center (FQHC). ALTA included five components delivered by FQHC staff. At the practice level, staff: (1) identified medication non-adherence in patients with uncontrolled hypertension and (2) referred them to a centralized nurse-led virtual team with a home blood pressure (BP) monitor. The nurse-led team: (3) delivered monthly health coaching based on home BP readings; (4) completed documentation in the electronic health record (EHR); and (5) monitored patients' BP and goals. We used a multi-method approach to assess implementation fidelity (adherence, dose, quality, responsiveness, differentiation) guided by Proctor's Implementation Outcome's Framework. Data sources included a structured EHR-embedded tool, narrative reports, and interviews over 12 months. ALTA adaptations were tracked using the Framework for Reporting Adaptations and Modifications-Expanded. From 2022-2024, 124 staff across 6 FQHC sites implemented ALTA. Implementation adherence varied across sites. The identify component ranged from 49.0% to 57.9% across sites, while the refer component showed greater variability, ranging from 50.0% to 84.4%. Enrollment into health coaching also varied substantially, ranging from 20.8% to 88.5% across sites. The centralized nurse-led team delivered coaching to 91.4% of enrolled patients, completed all documentation, and conducted monitoring for 94.5%. Median implementation dose (patient exposure) was six coaching visits over 5.5 months, and 2.1 BP readings per week. Implementation quality was high, with comprehensive documentation of coaching visits. Six fidelity-consistent adaptations were made to improve feasibility, including simplifying the adherence screener and adding asynchronous training. Interviews (n = 46) highlighted the need for team support, ongoing practice facilitation, and feedback on patients' progress as factors affecting fidelity. Implementation fidelity varied across the ALTA components and participating sites, with the greatest variability observed in delivery of the site-level components of identify and refer. Centralized components delivered by the nurse-led team (coach, document, monitor) were delivered consistently with high fidelity. Contextual factors like staffing and patient engagement shaped implementation success. ClinicalTrials.gov, NCT03713515.