Understanding Implementation of a Technology-Facilitated Hypertension Model in Federally Qualified Health Centers: A Realist Evaluation of Staff Experiences

Background

Remote patient monitoring (RPM) and telehealth improve hypertension management but remain underutilized in resource-constrained settings. The Advancing Long-term Improvements in Hypertension Outcomes through a Team-based Care Approach (ALTA) intervention integrates RPM and virtual health coaching into routine care across a large urban FQHC network and has improved blood pressure outcomes.

Objective

Explore contextual and mechanistic factors shaping ALTA’s implementation outcomes from the perspective of intervention deliverers.

Design

Following 1 year of ALTA implementation, we conducted a realist-informed qualitative evaluation to examine factors influencing intervention uptake using semi-structured interviews and focus groups conducted from September to November 2023.

Participants

Practice leadership, clinicians, and staff.

Approach

Participants were recruited through convenience sampling. Transcripts were analyzed using a stepwise deductive and inductive coding approach. Deductive codes were drawn from Proctor’s taxonomy of implementation outcomes. Themes were developed using context-mechanism-outcome (C-M-O) configurations.

Key Results

Analysis of 32 semi-structured interviews and four focus groups with a total of 46 intervention deliverers revealed five primary C-M–O-oriented themes: (1) Appropriateness, determined by perceptions of fit, drives acceptability. (2) Demanding workflows raise concerns around ALTA’s additional burden, influencing perceptions of appropriateness. (3) Intervention challenges are mitigated by practice facilitation and team-based problem-solving, enhancing acceptability, feasibility, and fidelity. (4) Repeated exposure promotes workflow optimizations, fostering intervention penetration over time. (5) Staff desire insight into ALTA’s impact, and communication about intervention progress increases motivation and buy-in. Five of Proctor’s implementation outcomes emerged most prominently: appropriateness, acceptability, feasibility, fidelity, and penetration. Notably, these outcomes were interdependent, with one acting as an important contextual factor or mechanistic element for another.

Conclusions

This evaluation highlights important contextual factors, mechanisms, and interconnected outcomes underlying implementation of ALTA. Shared understanding and peer learning, workflow optimization, and communication of outcomes with frontline staff improve reach, equity, and sustainability of RPM-enabled interventions for hypertension management in FQHCs.

Trial Registration

ClinicalTrials.gov NCT03713515, date of registration: October 19, 2018, https://classic.clinicaltrials.gov/ct2/show/NCT03713515

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