Tailoring implementation strategies to primary care clinic contexts through practice facilitation: lessons learned from the ANTECEDENT study

BACKGROUND: Tailoring implementation of an evidence-based intervention based on context is well established in implementation science. However, questions remain about tailoring implementation support via an external practice facilitator (henceforth facilitator) and methods and mechanisms of facilitator-driven tailoring. Therefore, this study examines how facilitators supported clinics in a large pragmatic study to identify contextual factors that influenced the selection and application of implementation strategies. METHODS: We conducted a descriptive qualitative study of facilitator tailoring in a 15-month implementation study to support primary care clinics in increasing screening, brief intervention and referral to treatment (SBIRT), and medication assisted treatment (MAUD) for unhealthy alcohol use. Data included bi-annual interviews and monthly periodic reflections with study-funded facilitators. A framework analysis, informed by the ERIC taxonomy and i-PARIHS, was conducted to categorize and map strategies across diverse examples of clinic factors to identify key techniques of tailoring. RESULTS: Nine facilitators who provided practice support during implementation participated in 20 interviews and 16 periodic reflections. Practice facilitators tailored their implementation support to clinics through four key domains: 1) facilitation structure and process support; 2) technical support for clinical processes; 3) assessing and monitoring support needs over time; and 4) evidence-based intervention and quality improvement skill building support. Though facilitators used common and well-established ERIC implementation strategies in their work with clinics, the techniques used to apply those strategies varied based on clinic factors across multiple levels of context. Tailoring support was found to be both proactive and reactive. According to facilitators, utilizing a tailored approach to implementation benefited clinics by reducing the burden of administrative processes related to facilitation and implementation, improving clinic study enrollment and engagement amidst challenges or disruptions, and increasing engagement in SBIRT and MAUD activities. CONCLUSION: Our study found that facilitators tailored their support to clinics via their deployment of implementation strategies according to clinic factors in four key domains. Facilitators described tailoring efforts as important for increasing clinic engagement in quality improvement efforts. Future studies should focus on assessing the effectiveness of specific tailoring techniques on performance outcomes.