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Background: Evidence-based interventions that optimize physical function for disabled and older adults living in the community who have difficulty with daily living tasks are available. However, to date, their implementation has been limited, particularly in state Medicaid home and community-based waiver programs. Furthermore, it is unknown whether implementation strategies commonly used in other settings would result in adoption and sustainability of these effective interventions in resource-constrained Medicaid programs.Methods: In a hybrid type III trial, waiver sites (N=18) were randomly assigned to implement the intervention using a bundle of strategies with either internal facilitation (IF) or IF and external facilitation (EF). Adoption and sustainability were assessed via stages of implementation completion (SIC) for each site. Clinician attitudes toward evidence-based practice and self-efficacy were evaluated among 539 registered nurses, social workers, and occupational therapists. Medicaid beneficiary outcomes of activities of daily living, depression, pain, falls, emergency department visits, and hospitalizations were evaluated in a sample of N=7,030 as reflected by electronic health records data of the Medicaid waiver program. Linear mixed effects models were used to compare outcomes between trial arms while accounting for cluster-randomized design.Results: The mean SIC scores were 72.22 (standard deviation [SD]=16.98) in the IF arm (9 sites), and 61.33 (SD=19.29) in the IF+EF arm (9 sites). The difference was not statistically significant, but corresponded to the medium clinically important effect size Cohen’s d=0.60. Clinician implementation outcomes of attitudes and self-efficacy did not differ according to the IF versus IF+EF. Beneficiary depression was reduced significantly in IF+EF arm compared to IF (p=.04, 95% confidence interval for the difference [0.01, 0.24]). No differences between trial arms were found for other beneficiary outcomes. Conclusions: Level of facilitation did not enhance capacity for adoption and sustainability of an evidence-based intervention in an under-resourced Medicaid setting that cares for disabled and older adults. Improved beneficiary depression favored external and internal facilitation strategy, but no differences for other outcomes compared to interval facilitation only suggest that the addition of external facilitation may not be warranted.Trial registration: ClinicalTrials.gov, NCT03634033; date registered August 16, 2018. https://clinicaltrials.gov/ct2/show/NCT03634033 |
