Caregiver-Centred Care:

Strategies for the Scale and

Spread of Education and Training Initiatives

Dr. Jenny Ploeg, RN, PhD

Professor and Scientific Director,

Aging, Community and Health Research Unit

School of Nursing, McMaster University

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Health Workforce Training Meeting

Edmonton, AB

March 14-15, 2019

Agenda

1. Introduce concepts of scale up and spread

2. Describe strategies and steps for scale up

3. Discuss barriers and

facilitators

4. Application examples

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What is the Issue?

• Many effective innovations are not

sustained, spread or scaled up

• Lost opportunities, resources, impact

• Poor attention to strategies for scaling

and spreading leads to unsuccessful

dissemination of potentially important

innovations

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Part 1: Concepts:Scale-UpSpread

Sustainability

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This Photo by Unknown Author is licensed under CC BY-NC

Literature Review

• No published literature was found on scale

and spread of educational or training

resources to support caregivers

• Most of the literature discussed scale and

spread of innovations in the context of

public health interventions

• Scaling, spreading, and sustaining are

presented in the general context of health

and healthcare innovations

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Scaling Up

“Deliberate efforts to increase the impact

ofsuccessfully tested health interventions to

benefit more people and foster policy and

program development on a lasting basis”

(Milat et al, 2014)

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Scalability

“The ability of a health intervention shown to

be efficacious on a small scale and/or under

controlled conditions to be expanded under

real world conditions to reach a greater

proportion of the eligible population while

retaining effectiveness” (Milat et al., 2014)

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Four Types of Scaling

1) Spontaneous diffusion: diffusion of an intervention

occurs without a plan (rarely happens on its own)

2) Horizontal scaling up: expanding or replicating an

intervention in different settings and populations

3) Vertical scaling up: policy, political, and other

healthcare system changes required to put in place an

innovation at a national level

4) Diversification: adding and trialing an innovation

alongside a previous one that is in the middle of being

scaled-up (WHO, 2010)

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Spreading

“The process through which new working

methods developed in one setting are

adopted, perhaps with appropriate

modifications, in other organizational

contexts” (Buchanan et al., 2006)

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Sustaining

“Sustained knowledge use refers to the continued

implementation of innovations over time and

depends on the ability of workers, organizations,

and health care delivery systems to adapt to

change”

“Addressing sustainability requires planning for

both the spread and scaling up of innovations in

health systems” (Davies & Edwards, 2013)

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Issues

• Scale and spread are poorly defined

• Scale and spread are used

interchangeably in the literature, making it

challenging it to isolate features unique to

each concept

• Both terms similarly refer to

implementation of health care innovations

for a large population

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Issues• Many studies exploring scale-up strategies of

evidence-based practice in primary care were

conducted in low to middle income countries

• There is a need for literature exploring scaling

and spreading:

in middle to high income countries such as

Canada

of caregiver training resources

of educational programs for healthcare

providers

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Part 2: Strategies and Steps

for Scale Up

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This Photo by Unknown Author is licensed under CC BY-NC

Key Resources for Scale Up

• Work by Milat et al (2014, 2016) New

South Wales Ministry of Health, Australia

• World Health Organization and

EXPANDNET (2010; 2011)

• Canadian Foundation for Healthcare

Improvement

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Steps in Scaling Up Process

1. Assessment of scalability

2. Development of the scaling plan

3. Preparation for scaling up (material,

financial, and human resources)

4. Scaling up the intervention

(Milat et al, 2014; 2016)

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Step 1. Scalability Assessment

• Assess effectiveness

• Assess potential reach and adoption

• Assess alignment with strategic context

• Assess acceptability and feasibility

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Step 2. Develop a Scale-Up Plan

- The Vision -Written document including:

• Rationale

• Intervention components & modifications

• Map of the social, political and organizational

environments

• Key personnel functions

• Approach / strategy

• Evaluation & monitoring

• Resources

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Step 3. Prepare for Scale Up

Building a foundation:

• Stakeholder engagement & consultation

• Support from political & health policy

decision-makers

• Mobilize broader community of practice

• Address resources & capacity changes

• Align material, financial and personnel

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Step 4. Scaling-Up

• Strengthen organizations (staff retraining,

mentoring, leadership development, coaching)

• Develop agreements re use of resources,

governance structures

• Develop systems to measure effectiveness,

reach, fidelity, acceptability and costs on

ongoing basis

• Ensure sustainability (organizational and cultural

changes to institutionalize intervention so

becomes routine practice

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12 Recommendations for

Designing for Scale-up WHO

(2011)

Stakeholders are key:

• 5 of the WHO’s 12 recommendations on designing for scale-up directly require stakeholder participation

• the other 7 WHO recommendations are informed by stakeholder participation

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5 of 12 Steps in Designing for Scale-up Require

Direct Stakeholder Involvement (WHO, 2011)

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1. Engage in a participatory process involving key stakeholders

9. Advocate with donors and other sources of

funding for financial support

11. Plan to disseminate information

10. Advocate for necessary changes in

policies, regulations and health system

components

3. Reach consensus on expectations for scale-up

7 of 12 Steps in Designing for Scale-up Benefit from

Stakeholder Involvement (WHO, 2011)

222. Ensure the relevance of the intervention

6. Test the intervention in the variety of

sociocultural and institutional settings where it will

be scaled-up

8. Develop plans to assess and

document implementation

7. Test the intervention under routine

operating conditions

4. Tailor the intervention to sociocultural and institutional

settings

5. Keep the intervention as simple as possible

12. Plan to be cautious in

scaling-up

Scaling Strategies

• A literature review of studies using scaling strategies in primary care determined the following components as commonly included in the scaling plan:

human resources

healthcare infrastructure

changes in policy/regulation

financial outputs

(Charif et al, 2017)

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WHO (2011) Checklist to

Assess ScalabilityQuestions related to potential scalability Yes

(+)

No

(-)

More

information/

action

needed

Is input about the project being sought from a

range of stakeholders (e.g. Policy-makers,

programme manager, providers, NGOs,

beneficiaries)?

Are individuals from the future implementing

agency involved in the design and

implementation of the pilot?

Does the project have mechanisms for building

ownership in the future implementing

organization?

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Part 3: Barriers

and Facilitators

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Challenges to Scaling Up

• Leadership failing to adapt the intervention to

the local context

• Lack of human resources, intervention costs

and other financial factors

• Meeting resistance when implementing new

practice changes due to capacity constraints

• Inadequate investment in implementation

strategies such as training and evaluation

systems

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Enablers for Scaling

• Ensuring that the innovation has attributes

that optimize the potential for scaling-up

CORRECT acronym: Credible, Observable,

Relevant, Relative advantage, Easy to

understand, Compatible, and Testable

(Glaser et al., 1983; WHO, 2009)

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Six Levers for Accelerating

Healthcare Improvement (CFHI)

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Summary

• The literature on scale and spread in the general context of health can be applied to promote the uptake and sustainability of various types of innovations

• There are many strategies that exist to promote scaling, spreading, sustaining innovations

• Yet, not all programs are successfully spread and scaled

• There are many challenges to spreading and scaling including an everchanging local context

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Part 4: Examples of Spread and Scale Up from a Program of Research

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Example 1: Spreading and

Sustaining Best Practice in

Home Care

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Spreading Strategies

Model for the spread of best practices in home

care organizations:

(1) committing to change

(2) implementing on a small scale

(3) adapting locally

(4) spreading internally to multiple users and

sites

(5) disseminating externally

(Ploeg et al., 2014)

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Example 2

Spread and Scale-up of

Evidence-Informed Health Care

Delivery: A Socio-ecological

Model of Dynamic Health

Systems Change Emerging from

a Program of Research. Edwards,

Berta, Marck, Downey, Ploeg,

Grinspun, Davies, Ritchie, Virani,

Higuchi

Online book available free at

https://www.nancyedwards.ca/books/

developing-a-program-of-

research.html

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Example 2: Enablers:

Organizational Level1. Supporting and reinforcing organizational

structures (financial, human, equipment resources; policies and procedures; communication systems, formal implementation plan)

2. Shared vision among managers, champions, staff

3. Critical mass of formally recognized champions and change agents to drive the innovation

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Example 2: Enablers:

System Level1. Supporting and reinforcing system-level

structures (e.g., legislation and standards, information technology and communication infrastructures; dedicated resources)

2. Distributed leadership that values system change, with reach across the health care system

3. Alignment of innovations with 1 above.

4. Feasible and tangible plans for scale up

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Aging, Community and Health

Research Unit

ACHRU Research Program Goals

•To promote optimal aging at home for older

adults with multiple chronic conditions

(MCC) and to support family caregivers

•To design, evaluate and translate new and

innovative interprofessional community-

based interventions to improve quality of

life and care

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ACHRU: 13 Funded Studies

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Example 3: Aging, Community and Health

Research Unit (ACHRU) Community

Partnership Program

Community Partnership Program for Diabetes

Self-Management for Older Adults-Canada

funded by CIHR SPOR Network in Primary and

Integrated Health Care Innovations (PICHI)

Implementing, evaluating and planning for scale

of an innovative community-based model that

aims to improve management of diabetes and

multiple chronic conditions and quality of life of

older adults and support family caregivers

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Example 3: Community Partnership

Program

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Example 3: Community

Partnership Program

Planning for scale-up from the start of the program:

• Program will be implemented in three provinces (ON, QC, PEI) and within multiple health and social care settings and adapted to each context

• Engage stakeholders from start of project:

Patient/caregiver and public research partners in planning research, patient advisory council, steering committee, Community Advisory Boards (CAB)

Policy and decision makers in steering committee and CABs

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• CABs will ensure that the voice of important members are being heard and that the program reflects the local context

• Caregivers will also be on the boards to provide advice to the research team

• By engaging key players at the start of the program we hope to create a sustainable program to improve the healthcare experience

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Example 3: ACHRU Community

Partnership Program

Looking for Support for the

Innovation at the End of a Study is a

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lonely and uphill battle

Lessons Learned #1:

Engage Stakeholders Early

Carefully consider:

• Who: patients, caregivers, decision

makers, providers, researchers

• When: throughout process

• What: roles do stakeholders play

• Where: are stakeholders needed

• How: to sustain engagement

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The Backbone Organization

• Collective impact literature stresses the importance of the backbone organization, whose functions include:– Guiding vision & strategy

– Supporting aligned activities

– Establishing shared measurement practices

– Building public will/support

– Advancing policy

– Mobilizing continued funding

• The lack of a strong backbone organization is the number one reason why collective impact initiatives fail (The Collective Impact Forum, 2018, website: https://collectiveimpactforum.org/resources/value-backbone-organizations-collective-impact)

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Lessons Learned #2: Secure a

Backbone Organization(s)• Scaling-up an innovation can be seen as a

collective impact initiative, so the importance of a backbone organization is critical

• Key considerations regarding the organization:

Leadership

Membership (e.g., implementation teams, early adopters)

Technical expertise

Local representation

Sustainability (e.g., people, ongoing funding)

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Lessons Learned: #3:

Plan for Scale Up While

Building an Evidence Base

Cart before

the Horse?• Some people are uncomfortable with designing for

scale-up while still collecting evidence on effects of the innovation

• WHO (201) recommends planning for scale-up early on because:

Policy & System Change: scaling up usually requires this & it takes time to implement (so start early)

Study Support: study inputs disappear at study end, so need to put mechanisms in place to sustain innovation

Scale-up Pressure: there is pressure to scale-up, so design process & outcome measures early to continue to build the evidence

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Lessons Learned #4: Advance

the State of Science

on Scale Up

• We have never planned for scaling up, or scaled up, an

ACHRU intervention:

Reflects stage of research process

Funding agency pressure (e.g., recent PICHI grant)

• A number of frameworks and guides exist to inform

scale-up planning, but most “have not been informed by

empirical examination of how scaling up decision making

and processes occur” (Milat et al., 2016, pg. 2)

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Opportunities

• Metrics to evaluate the scale-up process

develop preliminary outcome measures (e.g., coverage of targeted population, number of targeted sites/settings)

develop preliminary tools

test measures/tools at RCT sites

conduct cross-provincial comparisons

• potential data sources & data quality issues

• structural issues (e.g., leadership for scale-up, sustainability of backbone organization)

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Opportunities

•Document our experience in scale-up planning

What works and doesn’t work?

What is unclear or complex?

Are there core components/strategies to scale-up that apply across populations/sites?

What is the right balance in terms of research team involvement in scale-up planning (we can’t just provide a tool kit and leave analysis/planning up to the sites)?

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Thank you

Questions?

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Selected References• Ben Charif A, Hasani K, Wong S, Zomahoun HTV, Fortin M, Frietas A, Katz

A, Kendall CE, Liddy C, Nicholson K, Petrovic B, Ploeg J, Legare F. (2018).

Assessment of scalability of evidence-based innovations in community-

based primary health care: A cross sectional study. CMAJ Open, 6(4)

• Centre for Epidemiology and Evidence. Milat, AJ, Newson R & King L.

(2014). Increasing the scale of population health interventions: A guide.

NSW Ministry of Health.

• Edwards N, Berta W, Marck P, Downey A, Ploeg J, Grinspun D, Davies B,

Ritchie J, Virani T, Highuchi K. (2018) Spread and scale-up of evidence-

informed health care delivery: A socio-ecological model of dynamic health

systems change emerging from a program of research. In N. Edwards and

S. Roelofs (Eds). Developing a Program of Research: An Essential Process

for a Successful Research Career.

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Selected References• Indig et al., 2018. Pathways for scaling up public health interventions. BMC

Public Health 2018;18:68

• Milat AJ, King L, Bauman AE, & Redman S. (2012). The concept of

scalability: Increasing the scale and potential adoption of health promotion

interventions into policy and practice. Health Promotion International, 28,

285-298.

• Ploeg J, Markle-Reid M, Davies B, Higuchi, K, Gifford W, Bajnok, I,

McConnell H, Plenderleith J, Foster S, Bookey-Bassett S. (2014).

Spreading and sustaining best practices for home care of older adults: A

grounded theory study. Implementation Science, 9:162.

• World Health Organization and EXPANDNET. (2010). Nine steps for

developing a scaling-up strategy. WHO.

• World Health Organization and EXPANDNET. (2011). Beginning with the

end in mind: Planning pilot projects and other programmatic research for

successful scaling up.

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