Co-developing implementation plans for a cardiovascular digital health intervention in rural clinics: A step-by-step tutorial (Preprint)

BACKGROUND Given the rapid growth of digital healthcare, greater transparency in engaging end-users in developing implementation plans is needed to improve the sustained delivery and effectiveness of digital healthcare. PREVENT is a patient-centered digital health tool designed to engage patients with overweight or obesity in conversations about behavior change to lower their cardiovascular disease (CVD) risk. We are implementing PREVENT in a rural federally qualified health center network with eight clinics. OBJECTIVE Objective: The objective of this paper is to present a multi-method approach used to engage clinic teams, including healthcare team members and administrators, to co-develop an implementation plan for the PREVENT digital health tool. METHODS Methods: Healthcare team members (e.g., clinicians, community health workers) and administrators (e.g., informatics professionals, clinic managers, CEO) were engaged through qualitative interviews, advisory board meetings, and site visits to develop an implementation plan prior to implementation. Qualitative interviews were coded using the Consolidated Framework for Implementation Research to identify potential barriers and facilitators of implementing PREVENT and paired with learnings from previous trials of PREVENT to inform the selection and tailoring of implementation strategies. Direct clinic observations generated clinic workflow maps, roles and responsibilities of team members, clinic resources (e.g., technology, space), and an understanding of the clinic and community context and readiness for implementation. A mixed-methods evaluation plan was developed using validated measures, input from the advisory board, and implementation research logic models. RESULTS Results: Implementation of the PREVENT tool was facilitated by a positive clinic culture, alignment with chronic disease priorities, an easy-to-use and adaptable design with EHR integration, and CHWs’ experience addressing social needs. Key barriers included limited technology infrastructure, variable staffing across clinics, patients’ digital access and literacy challenges, and the need for additional training and support for care team members. An implementation plan that includes thirteen strategies across six implementation strategy clusters was created to leverage facilitators and address barriers. A multi-modal evaluation plan was created to examine implementation and effectiveness. CONCLUSIONS Conclusions: This paper provides an example of how to develop implementation and evaluation plans tailored to the healthcare context that engage end users to increase the impact of a digital health intervention. This work may be replicated to support the successful implementation of other digital health tools, particularly in under-resourced, complex healthcare contexts such as rural clinics where resources are less available.