From theory to practice: A mixed-method evaluation of a program to implement high-intensity rehabilitation in skilled nursing facilities

IMPORTANCE: Implementing evidence-based dosing of rehabilitation in skilled nursing facilities (SNFs) is essential to improve functional outcomes in a medically complex population. OBJECTIVE: The objective was to evaluate an implementation program promoting high-intensity resistance rehabilitation (HIR) in SNFs by (1) measuring proximal (clinician knowledge, self-efficacy, and HIR perspective) and distal (HIR adoption and implementation) outcomes; (2) exploring how the program influenced distal outcomes (program processes); and (3) investigating clinician factors influencing HIR implementation. DESIGN: The design was a prospective convergent mixed-methods, theory-driven program evaluation. SETTING: This study was conducted across 8 rural Department of Veterans Affairs SNFs. PARTICIPANTS: Rehabilitation clinicians (n = 38) and leaders (n = 16) were included. INTERVENTIONS OR EXPOSURES: All sites received a multicomponent implementation program promoting HIR. MAIN OUTCOMES AND MEASURES: Validated questionnaires assessed HIR perspective (Perceived Characteristics of Intervention Scale) and adoption (Commitment to Change Scale). Study-specific questionnaires measured clinician HIR knowledge, self-efficacy, and implementation. Interviews and focus groups explored program processes and clinician factors. RESULTS: The program improved clinician HIR knowledge, self-efficacy, and perspective, leading to acceptable adoption rates. Implementation was marginally affected. Only the clinician perspective correlated with adoption (P = .47). Qualitatively, the program supported distal outcomes by keeping HIR at the forefront of clinicians' mind, fostering positive outcome expectations, and enhancing team cohesion and accountability. Clinician creativity, adaptability, resilience, professional discipline, and previous experience influenced implementation. CONCLUSION: The program influenced HIR adoption primarily by enhancing clinicians' positive perspectives of HIR. Future efforts could strengthen implementation by fostering team cohesion, accountability, and clinician creativity while also assessing environmental factors. RELEVANCE: Effective HIR implementation can optimize patient outcomes. Strategies that enhance clinician perspective and creativity, keep HIR at the forefront, and foster team cohesion and accountability may improve adoption. Additionally, assessing and addressing environmental factors may further support sustainable integration of HIR into clinical practice.