title: From concept to content: assessing the implementation fidelity of a chronic care model for frail, older people who live at home.
abstract: BACKGROUND
  Implementation fidelity, the degree to which a care program is implemented as intended, can influence program impact. Since results of trials that aim to implement comprehensive care programs for frail, older people have been conflicting, assessing implementation fidelity alongside these trials is essential to differentiate between flaws inherent to the program and implementation issues. This study demonstrates how a theory-based assessment of fidelity can increase insight in the implementation process of a complex intervention in primary elderly care.
  
  
  METHODS
  The Geriatric Care Model was implemented among 35 primary care practices in the Netherlands. During home visits, practice nurses conducted a comprehensive geriatric assessment and wrote a tailored care plan. Multidisciplinary team consultations were organized with the aim to enhance the coordination between professionals caring for a single patient with complex needs. To assess fidelity, we identified 5 key intervention components and formulated corresponding research questions using Carroll's framework for fidelity. Adherence (coverage, frequency, duration, content) was assessed per intervention component during and at the end of the intervention period. Two moderating factors (participant responsiveness and facilitation strategies) were assessed at the end of the intervention.
  
  
  RESULTS
  Adherence to the geriatric assessments and care plans was high, but decreased over time. Adherence to multidisciplinary consultations was initially poor, but increased over time. We found that individual differences in adherence between practice nurses and primary care physicians were moderate, while differences in participant responsiveness (satisfaction, involvement) were more distinct. Nurses deviated from protocol due to contextual factors and personal work routines.
  
  
  CONCLUSIONS
  Adherence to the Geriatric Care Model was high for most of the essential intervention components. Study limitations include the limited number of assessed moderating factors. We argue that a longitudinal investigation of adherence per intervention component is essential for a complete understanding of the implementation process, but that such investigations may be complicated by practical and methodological challenges.
  
  
  BACKGROUND
  The Netherlands National Trial Register (NTR).
  
  
  BACKGROUND
  2160 .
authors.affiliation: Department of General Practice and Elderly Care Medicine, EMGO+ Institute for Health and Care Research, VU University medical center, Amsterdam, the Netherlands. m.muntinga@vumc.nl.
authors.forename: Maaike E
authors.initials: ME
authors.lastname: Muntinga
authors.affiliation: Department of General Practice and Elderly Care Medicine, EMGO+ Institute for Health and Care Research, VU University medical center, Amsterdam, the Netherlands. k.vanleeuwen@vumc.nl.
authors.forename: Karen M
authors.initials: KM
authors.lastname: Van Leeuwen
authors.affiliation: Department of General Practice and Elderly Care Medicine, EMGO+ Institute for Health and Care Research, VU University medical center, Amsterdam, the Netherlands. f.schellevis@vumc.nl.|NIVEL (Netherlands Institute for Health Services Research), Utrecht, the Netherlands. f.schellevis@vumc.nl.
authors.forename: François G
authors.initials: FG
authors.lastname: Schellevis
authors.affiliation: Department of General Practice and Elderly Care Medicine, EMGO+ Institute for Health and Care Research, VU University medical center, Amsterdam, the Netherlands. g.nijpels@vumc.nl.
authors.forename: Giel
authors.initials: G
authors.lastname: Nijpels
authors.affiliation: Department of General Practice and Elderly Care Medicine, EMGO+ Institute for Health and Care Research, VU University medical center, Amsterdam, the Netherlands. d.jansen@vumc.nl.
authors.forename: Aaltje P D
authors.initials: AP
authors.lastname: Jansen
mesh_terms: D000368:Aged; D002908:Chronic Disease / Q000628:therapy*; D016330:Frail Elderly; D015577:Geriatric Assessment / Q000379:methods*; D006299:Health Services for the Aged / Q000458:organization & administration*; D006792:House Calls; D006801:Humans; D008134:Long-Term Care / Q000458:organization & administration; D009426:Netherlands; D010348:Patient Care Team / Q000458:organization & administration; D011320:Primary Health Care / Q000458:organization & administration; D012017:Referral and Consultation