NUR 8200 Module 6 Program Evaluation Paper: RE-AIM, CFIR and Implementation Outcomes for a Falls Prevention Rollout Example

From One Clinic to Twelve: Planning and Evaluating the Spread of a Falls Prevention Program With RE-AIM and CFIR

Student Name

Doctor of Nursing Practice, Thomas Edison State University

NUR-8200: Integrating and Evaluating Population Health in Advanced Nursing Practice

Mentor Name

Month Day, Year

From One Clinic to Twelve: Planning and Evaluating the Spread of a Falls Prevention Program With RE-AIM and CFIR

The Spread Question

For this sample, the setting is invented: the health system is twelve primary care clinics in Morris County serving about 22,000 adults aged 65 or older. Falls are the leading cause of injury in this group, and the county's emergency departments see hundreds of older adults after falls each year. One clinic piloted a falls prevention program over two years: annual screening with three questions, a gait and balance check for those who screen positive, a medication review to reduce drugs that raise fall risk, referral to physical therapy or a community exercise class and a home safety check. Falls with injury among its older patients dropped in the pilot. The system now wants to spread the program to all twelve clinics, and the DNP-prepared director of population health must plan the spread and its evaluation.

The pilot's results were promising but small. Over two years, the pilot clinic screened 78 percent of its older patients, referred 410 to physical therapy or a community class and recorded a fall in falls with injury from 31 to 22 per 1,000 older patients a year. The clinic had an unusually committed nurse practitioner, a physical therapist in the building on Tuesdays and Thursdays and a quieter schedule than most. Those advantages are exactly why the spread needs planning: the other eleven clinics have none of them.

Why Frameworks Matter

Programs that work in a pilot often fade when spread, because the pilot clinic had a champion, extra time or particular staff. Frameworks help leaders plan for the conditions that affect spread and measure more than whether the program worked once.

RE-AIM

Glasgow et al. (1999) proposed RE-AIM for judging a health promotion program by its reach into the target group, its effect, the share of sites and staff that adopt it, the faithfulness of delivery and whether results and delivery persist. In their view the five multiply rather than add, so a highly effective program that reaches few people has little population benefit.

For the falls program, RE-AIM shifts the question from "does it work?" to "does it reach older adults across all twelve clinics, delivered as designed, and does it last?"

CFIR

Damschroder et al. (2009) merged constructs from many earlier implementation theories into a single framework, CFIR, organized into five domains: the characteristics of the intervention, such as evidence strength and complexity; the outer setting, such as patient needs and external policies; the inner setting, such as culture and leadership engagement; the people who carry the work; and how it is carried out, from planning and engaging through executing and reflecting.

Before spreading the program, the director uses the framework to interview leaders and staff at each clinic. The interviews reveal barriers: two clinics have no space for gait testing, several clinicians see medication reduction as time-consuming, the community exercise classes have waiting lists in the western part of the county, and three clinics lack a nurse champion.

Implementation Outcomes

Proctor et al. (2011) separated delivery outcomes from service and patient outcomes and named eight of them: whether staff accept it, take it up and find it fitting and feasible, whether they deliver it faithfully, what it costs, how far it penetrates and whether it lasts. They argued that when a program fails, these outcomes help tell whether the program itself was weak or whether it was poorly implemented.

The director uses this taxonomy to measure delivery. Acceptability and appropriateness are measured with a brief staff survey. Fidelity is the share of screened-positive patients who receive each component. Penetration is the share of older patients screened. Cost is tracked per clinic. Sustainability is assessed at two years.

Separating these outcomes matters when results disappoint. If falls with injury do not drop at a clinic, the team will look first at fidelity and penetration. If only a third of older patients were screened, or medication reviews were skipped, the program was never really tried there, and the answer is better implementation rather than abandoning the program. If fidelity was high and falls still did not drop, the program itself may not suit that clinic's patients, and the team will look for reasons.

Cost is tracked from the start. Each clinic's spending on staff time, training, exercise class vouchers and pharmacist reviews is recorded, so that leaders can compare the cost per older adult reached across sites and judge whether the program can be sustained without the grant that paid for the pilot.

The Measurement Plan

Rollout and Adjustment

The program spreads in three waves of four clinics, six months apart, so lessons from each wave improve the next. Monthly dashboards show each clinic's reach and fidelity. Champions meet quarterly to share solutions. When a clinic falls behind, the director uses the framework again to find the cause.

Conclusion

The falls program worked in one clinic, but spreading it to twelve requires planning for the conditions that let it work. RE-AIM defines success across reach, effectiveness, adoption, implementation and maintenance; the Consolidated Framework for Implementation Research identifies barriers at each site before they cause failure; and implementation outcomes such as fidelity and sustainability reveal whether staff deliver the program the way it was built. Waves, dashboards and champions turn the frameworks into daily management.

References

Damschroder, L. J., Aron, D. C., Keith, R. E., Kirsh, S. R., Alexander, J. A., & Lowery, J. C. (2009). Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science. Implementation Science, 4, Article 50. https://doi.org/10.1186/1748-5908-4-50

Glasgow, R. E., Vogt, T. M., & Boles, S. M. (1999). Evaluating the public health impact of health promotion interventions: The RE-AIM framework. American Journal of Public Health, 89(9), 1322-1327. https://doi.org/10.2105/AJPH.89.9.1322

Proctor, E., Silmere, H., Raghavan, R., Hovmand, P., Aarons, G., Bunger, A., Griffey, R., & Hensley, M. (2011). Outcomes for implementation research: Conceptual distinctions, measurement challenges, and research agenda. Administration and Policy in Mental Health and Mental Health Services Research, 38(2), 65-76. https://doi.org/10.1007/s10488-010-0319-7