Implementation of a Complex Improvement Program in Aged Care

  • Henna HassonEmail author
  • Päivi Topo
Part of the International Perspectives on Aging book series (Int. Perspect. Aging, volume 10)


Efficient implementation of care improvement programs is increasingly important, since care organizations are expected to work in accordance with the latest evidence-based methods. This chapter presents findings from an evaluation of the implementation of a care continuum model for frail older people living in their own homes. The Conceptual Framework for Implementation Fidelity was used to guide the evaluation. A longitudinal case study design using both quantitative and qualitative methods was applied. In general, the intervention was implemented with high fidelity, that is, in accordance with the original program description. However, the findings also illustrate the difficult balance for staff to both implement the intervention in accordance with the program model, and take into consideration organizational circumstances and other factors such as older people’s preferences. This chapter also suggests ways in which practitioners and managers could improve future implementation processes. We propose that future research should focus on investigating how different types of adaptations to a program or evidence-based method are made and what the immediate and long-term impact of these are on participants’ health and well-being. We also emphasize the importance of investigating the interrelationships between different factors affecting implementation fidelity. It would also be important to examine the relative impact of these factors on each other and on fidelity. Methodological recommendations are also given, including the use of direct observations when analyzing implementation processes.


Case Manager Program Logic Implementation Process High Fidelity Implementation Fidelity 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



The authors would like to thank all the interview respondents. The Vårdal Institute financed the development and evaluation of the intervention “Continuum of care for frail elderly persons, from the emergency ward to living at home intervention.” In addition, the project received funding from the Vinnvård research program. The involvement of the first author was funded by ERA-AGE2, Future Leaders of Ageing Research in Europe (FLARE)/Swedish Council for Working Life and Social Research. Special thanks go to Ulrica von Thiele Schwarz, Associate professor, Karolinska Insitutet, for reviewing this chapter.


  1. Baranowski T, Stables G (2000) Process evaluations of the 5-a-day projects. Health Educ Behav 27(2):157–166CrossRefGoogle Scholar
  2. Berglund H, Wilhelmson K, Blomberg S, Dunér A, Kjellgren K, Hasson H (2013) Older people’s views of quality of care: a randomized controlled study of continuum of care. J Clin Nurs 22(19–20):2934–2944CrossRefGoogle Scholar
  3. Bond GR, Evans L, Salyers MP, Williams J, Kim HW (2000) Measurement of fidelity in psychiatric rehabilitation. Ment Health Serv Res 2(2):75–87CrossRefGoogle Scholar
  4. Borrelli B (2011) The assessment, monitoring, and enhancement of treatment fidelity in public health clinical trials. J Public Health Dent 71:S52–S63CrossRefGoogle Scholar
  5. Bradley F, Wiles R, Kinmonth AL, Mant D, Gantley M (1999) Development and evaluation of complex interventions in health services research: case study of the Southampton heart integrated care project (SHIP). The SHIP Collaborative Group. BMJ 318(7185):711–715CrossRefGoogle Scholar
  6. Burt CW, McCaig LF (2001) Trends in hospital emergency department utilization: United States, 1992-99. Vital Health Stat 13 (150):1Google Scholar
  7. Campbell M, Fitzpatrick R, Haines A, Kinmonth AL, Sandercock P, Spiegelhalter D, Tyrer P (2000) Framework for design and evaluation of complex interventions to improve health. BMJ 321(7262):694–696CrossRefGoogle Scholar
  8. Carroll C, Patterson M, Wood S, Booth A, Rick J, Balain S (2007) A conceptual framework for implementation fidelity. Implement Sci 2(1):40CrossRefGoogle Scholar
  9. Clarfield AM, Bergman H, Kane R (2001) Fragmentation of care for frail older people—an international problem. Experience from three countries: Israel, Canada, and the United States. J Am Geriatr Soc 49(12):1714–1721CrossRefGoogle Scholar
  10. Condelius A, Edberg A-K, Jakobsson U, Hallberg IR (2008) Hospital admissions among people 65+ related to multimorbidity, municipal and outpatient care. Arch Gerontol Geriatr 46(1):41–55CrossRefGoogle Scholar
  11. Medical Research Council (2000) A framework for development and evaluation of RCTs for complex interventions to improve health. MRC, LondonGoogle Scholar
  12. Czarniawska-Joerges B, Sevón G (1996) Translating organizational change. Gruyter Walter de, BerlinCrossRefGoogle Scholar
  13. Dobson D, Cook TJ (1980) Avoiding type III error in program evaluation: results from a field experiment. Eval Program Plann 3:269–276CrossRefGoogle Scholar
  14. Dunér A, Blomberg S, Hasson H (2011) Implementing a continuum of care model for older people—results from a Swedish case study. Int J Integr Care 11(18):1–11Google Scholar
  15. Dusenbury L, Brannigan R, Falco M, Hansen WB (2003) A review of research on fidelity of implementation: implications for drug abuse prevention in school settings. Health Educ Res 18(2):237–256CrossRefGoogle Scholar
  16. Fixsen DL, Naoom SF, Blase KA, Friedman RM, Wallace F (2005) Implementation research: a synthesis of the literature, vol 125. University of South Florida, Louis de la Parte Florida Mental Health Institute, The National Implementation Research Network (FMHI Publication 231), Tampa, FLGoogle Scholar
  17. Fraser MW, Richman JM, Galinsky MJ (2009) Intervention research: developing social programs. Oxford University Press, New YorkGoogle Scholar
  18. Glisson C, Hemmelgarn A (1998) The effects of organizational climate and interorganizational coordination on the quality and outcomes of children’s service systems. Child Abuse Negl 22(5):401–421CrossRefGoogle Scholar
  19. Greenhalgh T, Robert G, Macfarlane F, Bate P, Kyriakidou O (2004) Diffusion of innovations in service organizations: systematic review and recommendations. Milbank Q 82(4):581–629CrossRefGoogle Scholar
  20. Griffiths A (1999) Organizational interventions: facing the limits of the natural science paradigm. Scand J Work Environ Health 25(6):589–596CrossRefGoogle Scholar
  21. Hallberg IR, Kristensson J (2004) Preventive home care of frail older people: a review of recent case management studies. J Clin Nurs 13(6B):112–120CrossRefGoogle Scholar
  22. Hasson H (2006) Nursing staff competence, psychosocial work environment and quality of elderly care: impact of an educational intervention. Academic dissertation, Uppsala University SwedenGoogle Scholar
  23. Hasson H (2010) Study protocol: systematic evaluation of implementation fidelity of complex interventions in health and social care. Implement Sci 5:67CrossRefGoogle Scholar
  24. Hasson H, Blomberg S, Dunér A (2012) Fidelity and moderating factors in complex interventions: a case study of a continuum of care program for frail elderly people in health and social care. Implement Sci 7:23CrossRefGoogle Scholar
  25. Henry WP, Strupp HH, Butler SF, Schacht TE, Binder JL (1993) Effects of training in time-limited dynamic psychotherapy: changes in therapist behavior. J Consult Clin Psychol 61(3):434CrossRefGoogle Scholar
  26. Hulscher M, Laurant MGH, Grol R (2003) Process evaluation on quality improvement interventions. Qual Saf Health Care 12(1):40–46CrossRefGoogle Scholar
  27. Johansson G, Eklund K, Gosman-Hedstrom G (2009) Multidisciplinary team, working with elderly persons living in the community: a systematic literature review. Scand J Occup Ther. doi: 10.1080/11038120902978096 Google Scholar
  28. Leichsenring K (2004) Developing integrated health and social care services for older persons in Europe. Int J Integr Care 4:e10Google Scholar
  29. Levenson S, Morley J (2007) Evidence rocks in long-term care, but does it roll? J Am Med Dir Assoc 8(8):493CrossRefGoogle Scholar
  30. Lipsey M (1996) Key issues in intervention research: a program evaluation perspective. Am J Ind Med 29(4):298–302CrossRefGoogle Scholar
  31. Lipsey MW, Cordray DS (2000) Evaluation methods for social intervention. Annu Rev Psychol 51:345–375CrossRefGoogle Scholar
  32. Martens M, Van Assema P, Paulussen T, Schaalma H, Brug J (2006) Krachtvoer: process evaluation of a Dutch programme for lower vocational schools to promote healthful diet. Health Educ Res 21(5):695CrossRefGoogle Scholar
  33. McGlynn E, Asch S, Adams J, Keesey J, Hicks J, DeCristofaro A, Kerr E (2003) The quality of health care delivered to adults in the United States. N Engl J Med 348:2635–2645CrossRefGoogle Scholar
  34. McGrew JH, Griss ME (2005) Concurrent and predictive validity of two scales to assess the fidelity of implementation of supported employment. Psychiatr Rehabil J 29(1):41–47CrossRefGoogle Scholar
  35. Mowbray CT, Holter MC, Teague GB, Bybee D (2003) Fidelity criteria: development, measurement, and validation. Am J Eval 24(3):315CrossRefGoogle Scholar
  36. Ouwens M, Wollersheim H, Hermens R, Hulscher M, Grol R (2005) Integrated care programmes for chronically ill patients: a review of systematic reviews. Int J Qual Health Care 17(2): 141–146CrossRefGoogle Scholar
  37. Randall R, Nielsen K, Tvedt SD (2009) The development of five scales to measure employees’ appraisals of organizational-level stress management interventions. Work Stress 23(1):1–23CrossRefGoogle Scholar
  38. Rossi PH, Lipsey MW, Freeman HE (2004) Evaluation: a systematic approach. Sage, Beverly HillsGoogle Scholar
  39. Schuster MA, McGlynn EA, Brook RH (1998) How good is the quality of health care in the United States? Milbank Q 76(4):517–563CrossRefGoogle Scholar
  40. Steckler AB, Linnan L, Israel BA (2002) Process evaluation for public health interventions and research. Jossey-Bass, San Francisco, CAGoogle Scholar
  41. von Thiele SU, Hasson H (eds) (2013) Alignment in healthy organizations. Concepts of salutogenic organizations and change: the logics behind organizational health intervention research. Springer, BerlinGoogle Scholar
  42. Wideman M (2012) Geriatric care management: role, need, and benefits. Home Healthc Nurse 30(9):553–559CrossRefGoogle Scholar
  43. Wilhelmson K, Duner A, Eklund K, Gosman-Hedstrom G, Blomberg S, Hasson H, Gustafsson H, Landahl S, Dahlin-Ivanoff S (2011) Continuum of care for frail elderly people: design of a randomized controlled study of a multi-professional and multidimensional intervention targeting frail elderly people. BMC Geriatr 11(1):24CrossRefGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2014

Authors and Affiliations

  1. 1.Department of Learning, Informatics, Management and EthicsMedical Management Centre (MMC), Karolinska InstitutetStockholmSweden
  2. 2.Vårdal Institute, Swedish Institute for Health Sciences, Lund UniversityLundSweden
  3. 3.The Age InstituteHelsinkiFinland

Personalised recommendations