In order to expedite implementation of research findings, the barriers to knowledge translation must be found. Two managed care companies received funding to replicate a new palliative care program that had shown to reduce costs and improve patient satisfaction in a previous study. The objective of the research study described was to identify the barriers and facilitators encountered by these two sites during implementation of the new palliative care program. This study found that cultivating strong physician leadership; clearly communicating program goals, benefits and processes to physicians; ensuring administrative support; and ongoing training and mentorship for staff were important ingredients in a successful implementation of this palliative care program.

Background: In order to expedite implementation of research findings, the barriers to knowledge translation must be found. Research findings take an average of 20 years before being implemented in practice in real-world settings. Recently, a multi-disciplinary palliative care model, called the "In-home Palliative Care Program", was designed to improve patients' comfort and quality of life in their last year of life. A study comparing the new program to standard care, conducted at Kaiser Permanente in Southern California, found that this new program cost 45% less and left patients more satisfied with their care after 60 days on the program. In April 2001, a project to replicate this new program at two new managed care organizations was initiated. The objective of the research study described in this review was to identify the barriers and facilitators encountered by these two sites during implementation of the new palliative care program.

Methods: Program staff, referring physicians and managed care organization administrators participated in focus groups and interviews. The authors used a theoretical framework for understanding innovation to guide analysis of the data. The theory proposes that implementation of an innovation, such as the new palliative care program, is influenced by the characteristics of the innovation, the characteristics of the people who adopt the innovation and the characteristics of the context into which the innovation is being adopted. To implement this program in the two new sites, a lengthy orientation process was designed, including visits to the original program site to review end of life care information, discussion of the daily operations of the program, training visits to new sites by original program staff, and marketing strategies at the new program sites.

Findings: The main recommendations regarding barriers and facilitators to implementation concern the contextual factors. First, strong physician leadership was very important since physicians controlled referral of patients to the program. Physicians who referred the most number of patients had a high number of older and dying patients, expressed concerns about their patient's overall well-being, and had fewer issues about controlling the care of their patients. On the other hand, physicians who often expressed concerns about giving up control over treatment rarely referred patients. Furthermore, these physicians did not refer enough patients to learn that loss of control did not occur with the program. Second, clear communication about the goals, benefits, and processes of the program was required, especially because referring physicians had different backgrounds and assumptions about palliative care. Third, the need for administrative support for the entire duration of the new programs was key because the sites faced ongoing difficulties with insufficient resources and insufficient staff. Finally, ongoing training and mentorship of program staff were required once the program started so that clinicians could gain adequate experience in delivering palliative care.

Conclusions: Changing behaviour and implementing a new program are always difficult endeavours. This study found that cultivating strong physician leadership; clearly communicating program goals, benefits and processes to physicians; ensuring administrative support; and ongoing training and mentorship for staff were important ingredients to successful implementation.

Reference: Davis EM, Jamison P, Brumley R, Enguidanos S. "Barriers and facilitators to replicating an evidence-based palliative care model." Home Health Care Services Quarterly, 2006; 25, 149-165.

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