Utilizing Implementation Science to Advance Care Planning After Gestational Diabetes
Jul 18, 2024, 14:54 PM
By Kerri Lynn Knippen, PhD, RDN, LD, BC-ADM, FAND
Associate Professor, Bowling Green State University
Despite ongoing research and evidence-based standards of care, knowledge and practice gaps exist in translating this evidence to benefit people living with or at risk for diabetes. One such group is those with history of gestational diabetes mellitus (GDM). In many ways, GDM can serve as a “litmus test” or indicator of one’s potential for cardiometabolic disease. Despite ongoing risk, postpartum care remains insufficient. This transition has been called a missed opportunity.
With this context in mind, I share highlights from our project, Advancing Care Planning after Gestational Diabetes: An Implementation Science Approach Project, which was funded from the ADCES Foundation’s 2022 Advancing the Science of Diabetes Care and Education Grant. It was our view that the diabetes care and education specialist (DCES) is underutilized in the postpartum transition of care, yet uniquely positioned to coordinate care focused on diabetes prevention and cardiometabolic outcomes. It was our intention to integrate a care planning innovation that expanded the role of the DCES for postpartum care and beyond. The patient centered care planning innovation was guided by expert recommendations, evidence-based guidelines, and organized by the ADCES7® framework. The project was a collaboration between Bowling Green State University and Mercy Health - St. Vincent Medical Center, Toledo, Ohio.
As we embarked on the complex process of implementing new practices in clinical care, we knew there would be inherent challenges. With this in mind, we chose to use the lens of implementation science to drive the integration, test the effects and understand the factors that facilitated or hindered implementation.
Why implementation science?
Traditional clinical trials examine the efficacy of an intervention; and rightfully so. They are guided by rigorous methods, and strict inclusion and exclusion criteria. While these standards improve internal validity, methods may not always be practical, which can limit the translation and generalizability of research into the ‘real world’ setting. As change is being introduced, it is important to consider ‘how to’ implement. Implementation science can provide this alternative perspective – providing an understanding of the factors, facilitators, barriers and strategies that influence the uptake and sustainability of change.
We chose to integrate the Exploration, Preparation, Implementation, Sustainability (EPIS) Implementation Framework, which is a four-phase, multi-level approach to guide the implementation process. EPIS was originally developed to address the process of implementation in the public sector, especially those serving families and children. Through this defined, phased approach, we engaged in purposeful dialogue to explore the current and future state of GDM care. While we had a blueprint of ideas for the innovation, we had to unpack many factors and operationalize “how” the diabetes care team would put the care planning innovation into practice.
In this process, we considered the inner and outer context of implementation. At the inner level we evaluated organizational characteristics, supports available, workflow processes and individual perceptions of the DCES team. Relative to the outer context, the diabetes care team engaged with leadership, external networks and community organizations, and considered patient characteristics.
Change can come with resistance and uncertainty. We observed a shift in the DCES team’s readiness to make change – moving from contemplation to preparation, then action, and eventually maintenance. Although there was a departure from previous episodic care practices to holistic care planning, which integrated shared decision making, the team became excited about their expanded role. Overtime, the DCES team became more confident in their interdisciplinary scope – as the care plan innovation was centered around ADCES7® – a framework they were familiar with.
Establishing a new electronic medical record template for GDM, creation of an inpatient labor and delivery after visit summary, implementation of patient level decision aid tools and collaboration with internal and external stakeholders were some of the implementation strategies that made this work successful. Leveraging the bi-directional partnership between the academic institution and the health system was an important strategy of implementation.
The implementation science process provided many benefits.
- Implementation science kept the work moving even when other demands might have normally taken over.
- The framework provided structure, but was loose enough that the DCES team did not feel boxed in. The process gave the DCES team permission to engage in new clinical practices.
- The work led to job enrichment and satisfaction among the DCES team.
- The innovation was accepted by patients, clinicians, stakeholders and leadership.
- The innovation appeared to have efficacy relative to patient level outcomes. Patients engaged in postpartum risk reduction behavior.
- Recognizing both the inner and outer context improved our ability to address equity.
- The DCES team built important connections and was successful in acting as a bridge to support postpartum care goals.
- Ideas for sustaining and scaling the innovation emerged.
For more information about this work, refer to this episode of The Huddle podcast featuring Kerri Knippen and Rachel Stahl-Salzman, or visit the poster presentation at ADCES24. You can also contact Principal Investigator Kerri Lynn Knippen at [email protected].