title: Identifying and overcoming implementation challenges: Experience of 59 noninstitutional long-term services and support pilot programs in the Veterans Health Administration.
abstract: From 2010 to 2013, the Department of Veterans Affairs (VA) funded a large pilot initiative to implement noninstitutional long-term services and supports (LTSS) programs to support aging Veterans. Our team evaluated implementation of 59 VA noninstitutional LTSS programs.
  
  
  
  The specific objectives of this study are to (a) examine the challenges influencing program implementation comparing active sites that remained open and inactive sites that closed during the funding period and (b) identify ways that active sites overcame the challenges they experienced.
  
  
  
  Key informant semistructured interviews occurred between 2011 and 2013. We conducted 217 telephone interviews over four time points. Content analysis was used to identify emergent themes. The study team met regularly to define each challenge, review all codes, and discuss discrepancies. For each follow-up interview with the sites, the list of established challenges was used as a priori themes. Emergent data were also coded.
  
  
  
  The challenges affecting implementation included human resources and staffing issues, infrastructure, resources allocation and geography, referrals and marketing, leadership support, and team dynamics and processes. Programs were able to overcome challenges by communicating with team members and other areas in the organization, utilizing information technology solutions, creative use of staff and flexible schedules, and obtaining additional resources.
  
  
  
  This study highlights several common challenges programs can address during the program implementation. The most often mentioned strategy was effective communication. Strategies also targeted several components of the organization including organizational functions and processes (e.g., importance of coordination within a team and across disciplines to provide good care), infrastructure (e.g., information technology and human resources), and program fit with priorities in the organization (e.g., leadership support).
  
  
  
  Anticipating potential pitfalls of program implementation for future noninstitutional LTSS programs can improve implementation efficiency and program sustainability. Staff at multiple levels in the organization must fully support noninstitutional LTSS programs to address these challenges.
authors.affiliation: Jennifer L. Sullivan, PhD, is Health Science Specialist, Center for Healthcare Organization and Implementation Research (CHOIR) VA Boston Healthcare System, and Research Assistant Professor, Boston University School of Public Health, Massachusetts. E-mail: jennifer.sullivan@va.gov. Omonyêlé L. Adjognon, ScM, is Research Health Scientist, Center for Healthcare Organization and Implementation Research (CHOIR) VA Boston Healthcare System, Massachusetts. Ryann L. Engle, MPH, is Research Health Scientist, Center for Healthcare Organization and Implementation Research (CHOIR) VA Boston Healthcare System, Massachusetts. Marlena H. Shin, JD, MPH, is Health Science Specialist, Center for Healthcare Organization and Implementation Research (CHOIR) VA Boston Healthcare System, Massachusetts. Melissa K. Afable, MPH, is Program Manager, Center for Healthcare Organization and Implementation Research (CHOIR) VA Boston Healthcare System, Massachusetts. Whitney Rudin, MPH, MSW, is MassHealth Policy Analyst, Commonwealth of Massachusetts, Boston. Bert White, DMin, MBA, is Program Manager, Center for Healthcare Organization and Implementation Research (CHOIR) VA Boston Healthcare System, Massachusetts. Kenneth Shay, DDS, MS, is Director, Geriatrics Programs VHA, U.S. Department of Veteran Affairs, Washington, DC. Carol VanDeusen Lukas, EdD, is Health Science Specialist, Center for Healthcare Organization and Implementation Research (CHOIR) VA Boston Healthcare System, and Clinical Associate Professor, Boston University School of Public Health, Massachusetts.
authors.forename: Jennifer L
authors.initials: JL
authors.lastname: Sullivan
authors.forename: Omonyêlé L
authors.initials: OL
authors.lastname: Adjognon
authors.forename: Ryann L
authors.initials: RL
authors.lastname: Engle
authors.forename: Marlena H
authors.initials: MH
authors.lastname: Shin
authors.forename: Melissa K
authors.initials: MK
authors.lastname: Afable
authors.forename: Whitney
authors.initials: W
authors.lastname: Rudin
authors.forename: Bert
authors.initials: B
authors.lastname: White
authors.forename: Kenneth
authors.initials: K
authors.lastname: Shay
authors.forename: Carol VanDeusen
authors.initials: CV
authors.lastname: Lukas
mesh_terms: D003142:Communication; D003695:Delivery of Health Care / Q000379:methods* / Q000458:organization & administration*; D006801:Humans; D000077626:Implementation Science; D000073256:Information Technology; D007407:Interviews as Topic; D007857:Leadership; D010865:Pilot Projects; D011320:Primary Health Care / Q000458:organization & administration*; D036301:Qualitative Research; D040841:Resource Allocation; D014481:United States; D014493:United States Department of Veterans Affairs; D058014:Veterans Health