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.
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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 ].
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.
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Fidelity to the intervention was variable and fidelity checks were difficult to conduct within the homecare organisations. COPE is a non-pharmacological intervention designed to reduce functional disability in people with dementia. The program comprises occupational therapy and nursing input involving 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. At four months carers reported significantly higher levels of wellbeing. How is COPE adopted, implemented and made sustainable within different community health contexts in Australia? 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.
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? This implementation research project employs a mixed methods research design [ 27 ] to evaluate the process of implementation of the COPE project. The study seeks to understand what, why and how the COPE intervention will work in the Australian setting within existing programs and resources.
The mixed methods design [ 27 ] includes collection of qualitative and quantitative data from both health professionals employed by the partner organisations and the people receiving the program people with dementia and their carers. An overview of the implementation model used within the project is presented in Fig. The intervention strategy is the COPE program, an evidence based dyadic intervention, which has been described briefly above as well as in the original paper published by Gitlin and colleagues [ 26 ]. These organisations include government services, not-for-profit aged care services, and private services; this will allow us to explore the settings in which implementation is most likely to work and will assist with sustainability and scaling up where implementation is successful.
Implementation model used within the project. This figure depicts an overview of the project using the reporting format recommended by Proctor et al. As portrayed in Fig.
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Most aged care services in Australia are funded by the state or federal government and are delivered either via a state government health service or a non-government organisation [ 30 ]. There are also services offered by private practitioners. Care may be provided for a short period or on an ongoing basis.
Short term services include restorative care early intervention to optimise function and independence and transition programs post hospital or illness which are goal-oriented, time-limited and therapy focussed. People with dementia and their carers are also able to access helplines and advisory services which provide education about dementia and advice regarding managing changed behaviours [ 31 ].
In summary, care of community-dwelling people with dementia in Australia is currently fragmented and services are provided in a number of different settings by a range of different health professionals [ 32 ]. While there are existing services that provide intervention and care for people with dementia and their carers in the community, care approaches tend to focus on assessment and case management and there are a lack of programs which offer evidence based non-pharmacological treatments to optimise independence and manage the symptoms of dementia [ 32 , 33 ].
We aim to recruit a mix of government services, non-government organisations and private practitioners within both of these states. All organisations will provide services for community dwelling people with dementia and will employ occupational therapists. All organisations will either employ nurses or be able to link with community nursing services to provide the nursing component of the intervention.
As stated, we will deliberately seek to establish agreements with a mix of government and non-government organisations as well as private occupational therapy services in order to examine adoption in different contexts. Each participating organisation will be asked to nominate a team who will be key players in the implementation of COPE comprising someone in a management position, an occupational therapist and a nurse. Occupational therapists and nurses who work at the participating organisations will be nominated to be involved in the study by their participating organisation.
These staff will have an existing caseload which includes people with dementia. Participating occupational therapists and nurses will attend training in the intervention and will be asked to consent five dyads people with dementia and their carer to participate in the research project. They will deliver the intervention with these five dyads and provide data on these clients for the purposes of the project.
Therapists will be provided with certification after attendance at training and upon completion of the program with three dyads. Occupational therapists and nurses will be supported through mentoring and coaching sessions. We will recruit at least 30 therapists which provides considerable allowance for dropout and other circumstances which may prevent therapists from providing the COPE program to five dyads.
The dyads involved in this study will be clients of the participating organisations and more specifically, clients of the participating occupational therapists and nurses. These participants will be identified as having the potential to benefit from the COPE intervention by the participating occupational therapists. Participants deemed to be unable to consent will still be included in discussion about the study and verbal assent will be obtained as well as proxy consent. A diagram of the relationship between the participating organisations, participating occupational therapists and nurses and participating people with dementia and their carers is presented in Fig.
We will draw on a number of implementation strategies including planning, education, restructuring, and quality management presented in Fig. Implementation strategies used within the project are guided by barriers and enablers and proposed solutions suggested using the behaviour change wheel. Description of implementation strategies used presented using the framework devised by Powell et al.
This phase involves establishing relationships with participating organisations and exploration of preparation for change within these organisations. This process will involve sharing of information in order to understand the scope and work of COPE and how this may fit with the implementation of COPE within their organisation and the role of the research team. Discussions with managers and potential interventionists will enable identification of common work, values and goals. Planning for sustainability will be encouraged from the beginning through collection of data to contribute to a business case, formalizing partnerships with enough partners involved to sustain changes if some withdraw , creation of master trainers and tools and materials for ongoing planning as well as wide promotion of the program for a diverse group of audiences which will raise awareness of the program.
Training and manuals originally designed for use in research trials in the United States will be refined for the Australian context to ensure cultural appropriateness.
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A member of the research team will pilot the modified program with five dyads to ensure applicability to the Australian context and seek informal feedback regarding the utility and content of the program. Participating occupational therapists and nurses will attend training to understand the theory and application of the intervention.
They will be taught the program structure and content as designed by the original developers of the program with modifications for the Australian context. Training in delivering the intervention will be provided over two days for occupational therapists and approximately two hours for nursing staff. Training methods have been deliberately designed to build self-efficacy in clinicians by: a facilitating mastery through experience role play , b hearing descriptions of scenarios in which the program has been delivered and had good results modelling , c hearing descriptions of the supporting evidence and ability for therapists and nurses to make a difference to facilitate belief in the intervention and d positive feedback and validation.
Clinicians will be informed that the training enables them to deliver the intervention as developed by the team in the US but that in practice, they may need to make some amendments so that the intervention fits within their existing role and resources for example where they are unable to provide services over four months. We will work with our participating organisations to promote the implementation work within the media, professional organisations and local newsletters or newspapers.
The goal of this promotional work is to inform and influence stakeholders both those who are already participating and other related organisations. Barriers and enablers to implementation which are identified by the participating health professionals during the implementation phase will be noted and addressed.
For example, if clinicians identify that they have trouble explaining the intervention to their colleagues or clients we can provide educational leaflets and strategies to assist with this. Participation in the implementation project involves therapists and nurses delivering the program to five or more dyads. This ensures that the therapist completes the training with the expectation that changes to practice will occur.
Furthermore, the expectation that the occupational therapist and nurse will work together to deliver the program may provide the opportunity to create new working relationships in some organisations. Following the training, clinicians will receive support through regular, small group coaching calls with their peers and a member of the research team and direct mentoring or supervision if sought.
The coaching calls provide the opportunity to share case scenarios and learn from the trainers and their peers. If needed, we will visit the site and meet with staff responsible for implementation as well as other people within the organisation who can provide support for implementation, such as managerial staff. The primary outcome of interest relates to the implementation of the intervention which will be measured in terms of feasibility, fidelity, acceptability, uptake and costs. Evaluation will also determine the efficacy of the COPE intervention when provided by participating organisations.
We will assess whether there are beneficial outcomes for the person with dementia and their carer by comparing pre and post measures and then comparing any changes by effect size to the effect sizes reported in the original research trial We will also examine similarities and differences within the different service delivery contexts. Outcomes assessed within the project are presented in Fig. Implementation will be measured by considering the number and type of organisations agreeing to participate.
We will also assess uptake of the intervention over time; this information will be recorded by therapists who will provide information regarding on how many occasions they delivered the intervention. In addition, we will chart the duration between attending training and commencing implementation. Interviews with health professionals will be repeated after implementation of COPE and will provide information about acceptability from their perspective.
These interviews aim to understand their experience of COPE, perceptions of change or not and factors that may have influenced uptake. Normalisation Process Theory can be seen as a framework to identify factors that encourage or impede the implementation of complex interventions. Normalisation Process Theory will be used as a tool in developing the interview guide, as it highlights the work that individuals do to incorporate innovation into the context of their organisational constructs and culture [ 34 ].
This information will be supplemented with information from the Determinants of Implementation Behaviour Questionnaire [ 35 ] which was developed to measure the behavioural determinants of implementation. Uptake will also be assessed via a fidelity checklist completed by the occupational therapist providing the intervention. The fidelity check was designed specifically for this study. Fidelity will be assessed primarily in terms of adherence to the duration and content of the intervention provided and how this relates to the duration and content of the original trial.
In addition to the number and length of sessions and the assessments conducted therapists are asked to record information about collaboration with the carer, how well the carer was able to use strategies and the perceived level of carer engagement. Although AD is usually associated with aging, it is also found in younger persons.
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With deteriorating memory, judgment, and ability to communicate, the person with dementia becomes increasingly more dependent upon others. This continuous decline leads to the need for greater involvement of family members, who provide the majority of the care. Care for persons with dementia raises many ethical dilemmas for caregivers, both family members and professionals, particularly when aggressive behavior, restlessness, wandering, and eating problems are involved.
Issues of decision making, formal and informal assessments of capacity, and respect for the personhood of persons with dementia are central in this respect. The need to decide whether the value of autonomy or the value of safety of the person with dementia should be favored can be a burden for caregivers.