Children and Youth Services Review 39 (2014) 160–168Conten.docx

Children and Youth Services Review 39 (2014) 160–168
Contents lists available at ScienceDirect
Children and Youth Services Review
journal homepage: www.elsevier.com/locate/childyouth
Interagency Collaborative Team model for capacity building to
scale-up
evidence-based practice
Michael Hurlburt a,b,⁎, Gregory A. Aarons b,c, Danielle Fettes
b,c, Cathleen Willging d,
Lara Gunderson d, Mark J. Chaffin e
a School of Social Work, University of Southern California, Los
Angeles, CA, United States
b Child and Adolescent Services Research Center, United States
c Department of Psychiatry, University of California, San
Diego, La Jolla, CA,United States
d Pacific Institute for Research and Evaluation, Albuquerque,
NM, United States
e Department of Pediatrics, University of Oklahoma Health
Sciences Center, Oklahoma City, OK, United States
⁎ Corresponding author at: School of Social Work, Un
University Park Campus, Los Angeles, CA 90089, United Sta
fax: +1 858 675 0857.
0190-7409/$ – see front matter © 2013 Elsevier Ltd. All ri
http://dx.doi.org/10.1016/j.childyouth.2013.10.005
a b s t r a c t
a r t i c l e i n f o

Available online 10 October 2013
Keywords:
Implementation
Sustainment
Teams
Process model
Evidence-based practice
Background: System-wide scale up of evidence-based practice
(EBP) is a complex process. Yet, few strategic
approaches exist to support EBP implementation and
sustainment across a service system. Building on the Explo-
ration, Preparation, Implementation, and Sustainment (EPIS)
implementation framework, we developed and are
testing the Interagency Collaborative Team (ICT) process model
to implement an evidence-based child neglect
intervention (i.e., SafeCare®) within a large children's service
system. The ICT model emphasizes the role of
local agency collaborations in creating structural supports for
successful implementation.
Methods: We describe the ICT model and present preliminary
qualitative results from the use of the implemen-
tation model in one large scale EBP implementation. Qualitative
interviews were conducted to assess challenges
in building system, organization, and home visitor collaboration
and capacity to implement the EBP. Data collec-
tion and analysis centered on EBP implementation issues, as
well as the experiences of home visitors under the
ICT model.
Results: Six notable issues relating to implementation process
emerged from participant interviews, including:
(a) initial commitment and collaboration among stakeholders,
(b) leadership, (c) communication, (d) practice
fit with local context, (e) ongoing negotiation and problem
solving, and (f) early successes. These issues highlight

strengths and areas for development in the ICT model.
Conclusions: Use of the ICT model led to sustained and
widespread use of SafeCare in one large county. Although
some aspects of the implementation model may benefit from
enhancement, qualitative findings suggest that the
ICT process generates strong structural supports for
implementation and creates conditions in which tensions
between EBP structure and local contextual variations can be
resolved in ways that support the expansion and
maintenance of an EBP while preserving potential for public
health benefit.
© 2013 Elsevier Ltd. All rights reserved.
1. Introduction
Introduction of evidence-based practices (EBPs) can lead to
substan-
tial public health benefits. However, the implementation process
can
shape whether intended outcomes are actually achieved (Aarons
&
Palinkas, 2007; Allen, Brownson, Duggan, Stamatakis, &
Erwin, 2012;
Crea, Crampton, Abramson-Madden, & Usher, 2008; Fixsen,
Naoon,
Blase, Friedman, & Wallace, 2005; Greenhalgh, Robert,
Macfarlane,
Bate, & Kyriakidou, 2004; Palinkas & Aarons, 2009). Well-
established
practice models, implemented poorly or not sustained, will fail
to
achieve intended goals despite research evidence supporting
their
iversity of Southern California,
tes. Tel.: +1 858 675 0167x253;

ghts reserved.
clinical effectiveness (Backer, 2000; Bond, Drake, McHugo,
Rapp, &
Whitley, 2009). Thus, an effective implementation approach is
often as
important as the practice to be utilized.
Several conceptual models describe factors that can influence
imple-
mentation effectiveness. Some models emphasize structural
features
hypothesized to be core components of effective implementation
(Aarons, Hurlburt, & Horwitz, 2011; Damschroder et al., 2009;
Feldstein & Glasgow, 2008; Greenhalgh et al., 2004; Mendel,
Meredith,
Schoenbaum, Sherbourne, & Wells, 2008). Other models
emphasize
implementation processes, outlining key steps (and their timing)
hy-
pothesized to contribute to successful implementation of service
inno-
vations (Glisson & Schoenwald, 2005; Sosna & Marsenich,
2006;
Stetler, McQueen, Demakis, & Mittman, 2008). Structural and
process
implementation models are often conceptually aligned. For
example,
both types of models address the central importance of issues
such as
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161M. Hurlburt et al. / Children and Youth Services Review 39
(2014) 160–168
strong and effective leadership to support change initiatives,
establish-
ing a strong fit between change efforts and organizational and
service
system culture and values, creating methods for ensuring quality
pro-
gram delivery (i.e., fidelity), and clarifying/addressing financial
supports
for a change initiative.
This paper describes the Interagency Collaborative Team (ICT)
im-
plementation process model. The ICT model provides an
approach to
support successful roll-out of human service innovations in
large geo-
graphic areas, particularly change efforts involving EBPs. It is
directly
relevant to improving outcomes of service enhancements in
child and
family service systems. The ICT model is designed to enable
organiza-
tions to work together in ways that generate the structural and
process
supports associated with successful implementation and
sustainment of
innovations. We discuss some core areas of difference and
similarity be-
tween the ICT model and other implementation strategies,
connecting
core features to one structural implementation framework, the
Explora-
tion, Preparation, Implementation, and Sustainment (EPIS)

framework
(Aarons et al., 2011). Qualitative data from the scale-up of an
EBP in
one large county illustrate areas of strength and some
limitations in
the ICT model and provide perspective on other process models
of EBP
implementation.
1.1. Interagency Collaborative Team (ICT) model in the EPIS
Framework
Like a number of implementation frameworks, the EPIS
framework
summarizes variables that can positively or negatively affect the
imple-
mentation of an evidence-based practice. The EPIS framework
is unusual
in identifying key variables thought to particularly affect
implementa-
tion efforts during each of four major implementation stages in
public
sector child welfare and mental health settings. For example,
some key
variables identified as influencing the preparation and early
implemen-
tation stages of a quality improvement effort include strength of
the
leadership supporting change (Aarons, 2006; Edmondson, 2004;
Klein,
Conn, & Sorra, 2001), the degree of fit of an innovation with
the service
system context (Klein & Sorra, 1996), clarity of financial
support for
proposed changes (Aarons, Wells, Zagursky, Fettes, & Palinkas,
2009;

Frambach & Schillewaert, 2002), level of involvement of
practice devel-
opers in the implementation process (Aarons et al., 2011), and
the pres-
ence of cross-organizational knowledge of and commitment to
the new
practice (Glisson & Schoenwald, 2005; Sosna & Marsenich,
2006).
The ICT implementation process model outlines steps designed
to
lead directly to the kinds of key implementation supports
described in
the EPIS framework. The model takes its name from the fact
that it
emphasizes the key role of collaboration among stakeholders
and staff
members at the system level, from multiple partnering
organizations,
and of developing or utilizing a local “seed” team to embody
and sup-
port promotion and maintenance of expertise and ongoing
fidelity in
the practice to be implemented. Inter-agency collaboration and
willing-
ness to share expertise is central to multiple steps in the
implementa-
tion process and across organizational levels. Conceptually, the
ICT
model has much in common with other implementation process
models
(Chamberlain, Price, Reid, & Landsverk, 2008; Glisson &
Schoenwald,
2005; Sosna & Marsenich, 2006), which describe logically
ordered sets
of activities designed to create a context in which EBP

implementation
occurs effectively and intended public health benefits are
realized.
1.1.1. ICT processes and action steps
Fig. 1 provides a graphical representation of key
implementation
processes included in the ICT model, with the stages of the
EPIS frame-
work listed temporally down the left side of the figure. In the
ICT model,
a process is considered to be a goal-driven domain of focus that
extends
over a period of time within the longer implementation effort.
For exam-
ple, the initial EBP education and stakeholder development and
align-
ment processes involve an initial phase of identifying
community-
based stakeholders with interests in a particular practice change
effort,
and discussions and education efforts designed to lead to joint
selection
of and commitment to a common practice change initiative. The
practice
fit assessment process involves a careful analysis by key
stakeholders at
system and organizational levels of EBPs under consideration to
identify
aspects of practices that fit with existing policies, contracting,
and ser-
vice routines and those where modifications might be required.
Brief de-
scriptions of each ICT process are provided at the bottom of
Fig. 1.

Specific ICT model action steps are listed in Table 1 that
animate the
processes shown in Fig. 1. Their contributions to each
implementation
process are noted in the figure. For example, the Initial EBP
Education
process occurs as part of ICT action steps A (convening of
stakeholders)
and B (soliciting expertise). Education about the EBP becomes
an in-
tense process focus that occurs in the context of meetings
among inter-
ested stakeholders, supplemented by expertise about the EBP
solicited
from appropriate sources. Sources may be multiple, including
EBP
developers, other users of the EBP, researchers having
familiarity with
the practice, and/or materials available from sources such as
journals
or intermediary organizations that summarize information about
EBPs. Structural supports designed to arise from the ICT
processes are
represented as planks beneath the model processes that generate
them. We represent the ICT model in this manner because it is
best con-
ceptualized as a series of major actions that address core
implementa-
tion processes. Specific action steps animate these processes
and give
rise to or strengthen key structural supports viewed as creating
an envi-
ronment that can sustain an innovative practice as it is scaled
up.

1.1.2. ICT initial steps: exploration/adoption decision
The ICT model initially revolves around a service system and
multi-
agency commitment to invest in the long-term viability of an
EBP-
centered quality improvement initiative, with an ultimate goal
to im-
prove selected client level outcomes. Partnering agencies may
include
a range of stakeholder organizations, but particularly involve
funding,
administration, and service delivery organizations from the
outset. Dur-
ing an initial exploration phase, stakeholders convene and meet
to dis-
cuss need for a practice change effort that involves investment
by
multiple individuals and organizations. Although no specified
leader is
required to initiate such meetings, it is expected that one local
or region-
al organization will often take responsibility for convening and
leading
such discussions. For example, a health and human service
administra-
tion may convene discussions around maltreatment prevention,
reduc-
tion in delinquency, or some other practice change effort.
Within an
ICT model-guided implementation, convening of stakeholders
should in-
clude efforts to identify those stakeholders with substantial
interests in
the identified substantive area (e.g., child neglect).

A second important step in the process of exploring a possible
prac-
tice change involves concentrated efforts to obtain wide-ranging
factual
information about the costs, benefits, and tradeoffs associated
with spe-
cific practice changes. Outside expertise is identified and
sought to help
answer questions and reduce uncertainty about the change effort
under
discussion. The joint process of participating in education about
possible
practice change efforts and discussing the advantages and
disadvan-
tages of various options is aimed at developing a shared
commitment
and direction among stakeholders at an inter-agency level to a
jointly
supported EBP implementation.
1.1.3. Interagency seed team development: preparation and
implementation
Once a specific EBP is selected as the focal point for a broad
practice
change effort, stakeholders in the ICT process initiate
implementation of
the EBP by creating a formative interagency collaborative
“seed” team
(or ICST), which may consist of employees from several
different local
organizations that form a core unit of expertise in the selected
service
model. A seed team intentionally involves multiple
organizations in
the maintenance of innovation expertise to build broader

investment
in, commitment to, and communication about an innovation
among
invested stakeholders and subsequently trained practitioners.
The seed
team becomes a repository of local expertise for an EBP. It is
designed
to serve as the ongoing support structure for continued EBP
training,
Fig. 1. Implementation processes emphasized by the ICT,
including structural supports hypothesized to emerge from
following ICT model steps listed in Table 1.
162 M. Hurlburt et al. / Children and Youth Services Review 39
(2014) 160–168
coaching, and roll-out across a geographic area and as a
facilitator of
minor practice adjustments that help to fit a practice to diverse
regional
contexts (Aarons et al., 2012). Members of the seed team
maintain a
central liaison role between the EBP developer and other actors
at
multiple levels within the service system so that issues,
decisions, and
adaptations can be negotiated during initial experimentation
with
implementation.
1.1.4. Seed team: ongoing responsibilities
Following inception of the seed team and initial EBP training,
certifi-

cation, and service delivery, the team is then responsible for
training
and supporting additional teams of individuals that can then
implement
the selected EBP as it is scaled up across a service system. The
seed team
assumes responsibility for ongoing training of new teams of
practitioners that may consist of employees from several local
non-
profit organizations, hereafter referred to as Interagency
Collaborative
Teams (ICTs). These ICTs form for the express purpose of
learning and
mastering delivery of the EBP to be implemented, under the
guidance
of the original seed team. Although members include staff from
multiple
organizations, they meet together with a seed team coach during
a su-
pervision and knowledge transfer phase. ICTs trained by the
seed
team are responsible for the primary delivery of the EBP. This
imple-
mentation structure, with regional teams having interagency
composi-
tion, results in a network of local providers that allows for high
inter-
agency communication, and information and possible workload
sharing.
The seed team maintains relationships with ICTs following EBP
training. In order to maintain and continually enhance quality
delivery

Table 1
Steps involved in the Interagency Collaborative Team (ICT)
implementation process
model.
ICT steps
A. Identify and convene stakeholders with likely interests in a
shared quality
improvement initiative (may be iterative)
B. Solicit relevant expertise required to address questions about
selected quality
improvement directions and EBP alternatives
C. Develop commitment and direction among stakeholders to a
jointly supported,
EBP-centered change effort
D. Create an interagency seed team to:
1. Learn the EBP
2. Conduct initial local delivery of the EBP
3. Train new local EBP practitioners
4. Serve in a liaison role with external EBP developers/trainers
5. Monitor and provide feedback about quality of EBP delivery
6. Communicate and support a commitment to quality EBP
delivery
7. Communicate with stakeholders about implementation
progress
E. Form additional interagency training teams that:
1. Deliver the EBP
2. Relay feedback about implementation to the seed team
3. Share information with one another about implementation
progress

F. Plan a phased reduction in EBP developer involvement
(2014) 160–168
of the EBP, newly trained providers continue to receive
constructive
support and feedback in the form of supervision and coaching
from
seed team members for a defined period of time, which may
vary by
practice or situation. In the case of SafeCare, ongoing fidelity
monitoring
and coaching are integral components of the EBP. Organizing
supervi-
sion and coaching through the seed team has many potential
benefits
in the short and longer term. This structure is designed to
provide a
clear source of leadership and information to newly trained
providers.
Ideally having the seed team serve as the source of ongoing
training
and coaching facilitates a gradual reduction of EBP developer
involve-
ment whereby the local service system and its contracted
agencies be-
come the repository of expertise in the practice being adopted.
Based
on its initial key role within a multi-organizational
implementation ef-
fort, the seed team continues to serve as a locus of information
about
needs for adaptations to make a practice work within a
particular local
context. Such adaptations may involve changes to aspects of the
inter-

vention itself or to the structure of the service setting in which
the
EBP is delivered (e.g., Finno-Velasquez, Fettes, Aarons, &
Hurlburt,
under review). Cross-organizational membership on the seed
team con-
tributes to ensuring a continuing locus of expertise available to
all orga-
nizations within the ICT partnership, reducing the kinds of
expertise
loss that regularly occur within individual organizations and
agencies
due to staff turnover and organizational changes.
As noted above, the ICT model seeks to foster implementation
sup-
ports in the areas of practice fit, leadership, communication,
expertise
distribution, EBP quality (fidelity) management, effective
developer in-
volvement, and program adaptation. A large California county
used the
ICT model to implement an evidence-based neglect prevention
program
throughout the county. Qualitative inquiry into this effort helps
to illus-
trate several key elements of the implementation approach.
1.2. The present study
Implementation of the SafeCare neglect prevention model
occurred
in one large California county. With approximately 3 million
total resi-
dents, the county population is similar in size or larger than that
of
many smaller U.S. states. The county encompasses urban, semi-

urban,
and rural areas that are home to a diverse cultural mix of
residents, in-
cluding significant Mexican-American and Native American
popula-
tions. Planning for many aspects of public human services in the
county is organized into local planning regions, each with some
of its
own local history, demographic and cultural characteristics,
climate,
and topography. Implementation of any new practice at a county
level
represents a large-scale system and organizational change effort
that
occurs across the planning regions.
In 2007, the Department of Health and Human Services (DHHS)
agency and the local chapter of a national foundation embarked
upon
an effort to transition one category of county maltreatment
prevention
services toward an EBP. County DHHS leaders (responsible for
child wel-
fare services), members of the local branch of a national
foundation, and
research partners convened to consider three different child
focused
EBPs to improve outcomes for children and families involved
with the
child welfare system. After consideration of research evidence,
program-
matic fit, and financial resources required, SafeCare®, an
evidence-based
child neglect prevention program utilizing home visiting
(Chaffin, Hecht,
Bard, Silovsky, & Beasley, 2012; Lutzker, Bigelow, Doctor,

Gershater, &
Greene, 1998), was selected for implementation.
Qualitative interviews and focus groups allowed us to document
the
roll-out of SafeCare, provided insight into how the ICT model
generated
key structural supports for implementation, and helped to
identify
process issues worthy of more careful consideration. The
following sec-
tion summarizes at a general level what we learned from that
qualita-
tive work about themes related to implementation process,
including:
(a) initial commitment and collaboration among stakeholders,
(b) lead-
ership, (c) communication, (d) practice fit with local context,
(e) ongo-
ing negotiation and problem solving, and (f) early successes.
2. Methods
2.1. Overview
From August, 2008 to January, 2009 we undertook in-depth
qualita-
tive interviews with key stakeholders involved in the early
stages of
system-wide implementation of SafeCare that followed the ICT
imple-
mentation model. Data collection and informed consent
procedures
were approved by the appropriate Institutional Review Boards.
2.2. Participants

Participants in this study included 27 stakeholders involved in
vari-
ous facets of the early implementation process. Participants
were re-
cruited through an initial telephone call or email describing the
study
purpose and participation. One of the authors either made the
initial
contact or was available to answer questions about
participation. Our
purposive sample consisted of all individuals who took part in
initial
EBP planning meetings, including representatives from the
county
(n = 3) a foundation supporting part of the implementation
effort
(n=9), and the executive directors of the community-based
organiza-
tions (n=3) that were eventually contracted to deliver SafeCare.
Next,
we interviewed key individuals involved in supporting delivery
of the
EBP, including SafeCare supervisors, trainers, and coaches (n =
6) and
front line providers (n= 6).
2.3. Semi-structured interviews
Interview guides consisted of open-ended questions that were
tai-
lored to each stakeholder group. The interviews with
representatives
of the county, the foundation, and community-based
organizations fo-
cused on the initial planning process, their roles and

responsibilities
and interactions with one another, and perceptions overall of
SafeCare
implementation. These interviews also sought to capture data on
organizational- and system-level factors affecting
implementation. The
interviews with supervisors, trainers, coaches, and seed team
members
centered on each person's involvement in the ICT approach,
knowledge
of and experiences with SafeCare, and the “fit” of the
intervention with
local populations and service delivery contexts. All participants
agreed
to recorded interviews, which lasted approximately 60 min, and
were
professionally transcribed. Transcriptions were reviewed for
accuracy
(2014) 160–168
by a research assistant. In addition, ethnographer interview
notes were
typed and uploaded to an electronic database.
2.4. Data analysis
We employed an iterative process to review the textual data
from in-
terviews and utilized NVivo 9 (2009) qualitative data analysis
software
to facilitate this work. Data analysis proceeded first by
engaging in an
open coding approach to locate the themes and issues that

emerged
from the interview transcripts. Focused coding was then used to
deter-
mine which of these themes emerged frequently and which
represent-
ed unusual or particular concerns (Emerson, Fretz, & Shaw,
1995). In
this staged approach to analysis, our research team coded sets of
tran-
scripts, created detailed memos linking codes to each theme and
issue,
and then passed their work to other team members for review.
Discrep-
ancies in coding and analysis were identified and resolved
through con-
sensus during team meetings (Sandelowski & Barroso, 2003).
Themes
emerging from analyses were cross-walked with objectives of
the ICT
model to identify areas in which language used by participants
might
differ from that used in the model but have similar meaning.
Principal
themes from the interviews are presented, supplemented by
relevant
comments from participants. In some cases, quotations are
edited slight-
ly to smooth readability.
3. Results
Results confirmed the significance of a number of the processes
and
structural supports outlined in the ICT model, including initial
commit-
ment and collaboration, cross-level leadership, and practice fit

to the
local context. Other key themes also arose, such as the
importance of
early successes, and of negotiating roles and responsibilities
among
stakeholder organizations. Interconnections among these themes
are
highlighted below.
3.1. Commitment and collaboration
The first step in implementing the ICT model involves
identifying
and then bringing together key stakeholders invested in a
change ef-
fort in order to discuss shared interests in undertaking a
particular
initiative. In this case, interest from stakeholders in the child
welfare
system and the foundation chapter in supporting a system-wide
im-
provement in the area of child maltreatment led to the creation
of a
“Council” focused on a possible quality/capacity enhancement
effort
that eventually centered on SafeCare. The Council included
represen-
tatives not simply from county child welfare services and the
local
foundation, but from community-based non-profit organizations,
advocacy organizations, a children's hospital, EBP developers,
and
researchers. Initial conversations about directions for the
intervention
were critical in setting the foundation for the long-term
collaboration

among stakeholders that would be required to implement and
sustain
SafeCare.
A potentially underappreciated aspect of building initial
commit-
ment is the fact that stakeholders do not necessarily share the
same
organizational culture or values when they begin to collaborate.
In
the case of SafeCare, some stakeholders worked in large
government
organizations, others in small non-profit organizations.
Consequent-
ly, stakeholders often had very different ideas about how to
pursue
change and their respective roles in this process, which at times
led
to tension and conflict that added complexity to the
implementation,
some examples of which are described in a later section.
Nonethe-
less, the stakeholders pushed forward, buoyed by the belief that
the specific EBP they had agreed to implement would improve
child welfare services and reduce neglect. County officials, for
exam-
ple, were enthusiastic about ensuring that services provided in
the
child welfare system were evidence-based. Their confidence in
mov-
ing forward with SafeCare was bolstered after a presentation
and
discussion period with a research team knowledgeable about the
EBP,
its underlying evidence base, and the benefits of the
intervention.

The initial commitment process involved frank discussion and
eval-
uation of whether interests were broadly shared among
stakeholders
amidst differences in organizational directions, cultures, and
values.
Although this process of group reflection may not have been
sufficient
to guarantee the overall success of the implementation effort, it
did ap-
pear to have been a central component in laying an appropriate
founda-
tion for positive outcomes. This process put the diverse
interests of the
stakeholders on the table, fostered commitment to a common
direction,
and engendered a sense of top-level leadership support for the
change
effort that was ultimately reinforced by additional leadership
tiers.
3.2. Leadership
Once an intervention is selected, the ICT model calls for
develop-
ment of a “seed team,” an initial cadre of service providers
responsible
for acquiring expertise in the service model, for transmitting
this
knowledge to other teams of individuals involved in day-to-day
service
provision, and for providing ongoing fidelity assessment and
support.
By virtue of their roles as trainers and supervisors of future
cohorts of

SafeCare-trained home visitors, the nine seed team members
were
placed in a structural position of leadership. As the
implementation
progressed, three of the original seed team members were
selected to
assume the roles of trainers/coaches, and one emerged as the
team
leader and SafeCare supervisor. As noted by several
participants, these
individuals could be counted on to guide newly trained home
visitors
in consistent SafeCare practice and thus were paramount to
implemen-
tation success.
As noted, one SafeCare supervisor became the primary
identified
team leader and source of support for home visitors. Several
home vis-
itors commented on the support provided by the SafeCare
supervisor in
particular. One home visitor stated, “She's very good at
answering our
questions”, while a second added, “I find her very helpful and
she's
available if I need her.” Although not expressed in terms of
leadership
from the home visitor perspective, we interpreted the regular
com-
ments regarding the support and information provided by the
SafeCare
supervisor as a reflection of the clinical leadership provided by
the seed
team, as viewed by home visitors.

Strong leadership was also evident from the directors of each
community-based provider organization, the local foundation,
and
county child welfare services. The fact that the provider
organizations
collaborated from the outset to respond to the local foundation's
Re-
quest for Proposals to deliver SafeCare from a multi-agency
position,
and then facilitated involvement of their staff within a single
seed
team, reinforced a broad sense of cross-level leadership
commitment
to SafeCare. During the implementation phase, the local
foundation, in
partnership with the county, also spearheaded organizational
meetings
for planning purposes. This higher-level buy-in, commitment,
and sup-
port communicated a message that this new EBP was not the
“flavor of
the day” and that there was an expectation for effective
implementation
and ongoing use of SafeCare.
3.3. Communication
The majority of participants suggested that communication was
crucial to successful implementation, but attributed problems
en-
countered during the roll out of SafeCare to communication
chal-
lenges. Interviewees reported that the communication structures
around implementation were initially insufficient. Some
stakeholders
were privy to misinformation or to no information regarding

issues
impacting implementation. In one example, a county staff
member in-
correctly informed some supervisors and the local foundation
that
home visitation caseloads pre-SafeCare were half of what they
were in
reality (typically 20 vs. 10 cases per home visitor). Such
unintentional
misinformation altered the course of project planning and fueled
(2014) 160–168
concerns that implementation of the new EBP would prove to be
too ex-
pensive in the long run. Problems disseminating information
among
stakeholders across all levels were also common. Email, in
particular,
did not function as a dependable mode of communication and
informa-
tion sharing. There were times when stakeholders felt that only
a limit-
ed subset of individuals were receiving needed information
about
program implementation.
Stakeholders also described discussing or even deliberating on
SafeCare issues individually outside of group meetings, while
alluding
to underlying power dynamics that influenced communication.
One
participant lamented about being left of out of these informal
communi-

cations about SafeCare: “When I hear [other stakeholders]
talking to
each other, I can tell that [they] have talked on the side…. It
looks like
they're able to access the information they need, and [can] find
things
out.” A second participant reported running into others involved
in im-
plementation in non-SafeCare milieus and felt freer to share
ideas about
the intervention and its roll out. They admitted, “We talk about
[SafeCare] a bit. [If] I am with the county person, I'm like,
‘Don't ask
me [later at a Council meeting], I'll talk to you here. I won't talk
to you
in the meetings when there are other county people [present]’.”
Such
comments suggest that perceived power imbalances among
stake-
holders sometimes interfered with candid dialog.
Structurally, the SafeCare supervisor was expected to serve as a
locus
of communication and information exchange between home
visitors
newly trained in SafeCare and the other stakeholder groups
(e.g., county
child welfare and the local foundation). The SafeCare
supervisor com-
mented on the challenges she experienced mediating between
the
home visitors and upper-level leadership: “Right now…we're in
the
early stages [of implementation] so there's a lot of things that
are chang-
ing everyday…. [There's a need to] maintain that open

communica-
tion…. That's really the big part of it, as far as ‘we want you
guys to do
this’ or ‘we want you guys to do this differently’ or ‘don't use
this
form’ or ‘use this form.’ I tell the team, ‘There's always going
to be
some changes and as soon as I know something you guys will
know as
well. So just bear with me. The first few months are going be
like
this.’” In some respects it was difficult for the SafeCare
supervisor and
the home visitors to keep up with frequent changes initiated
from
above, due to the potential lack of clearly structured
communication
channels. Apart from the SafeCare supervisor, the home visitors
also
struggled to some degree with whom else they should be
communicat-
ing regarding SafeCare implementation. In particular, they were
often
unsure whether they should turn to or report to their immediate
team
supervisor, who was not trained in SafeCare, but who managed
their
workaday lives, or to others involved in the roll-out, such as the
re-
searchers or trainers.
3.4. Fit with existing practice and fidelity
The ICT model created an active, functional process for
addressing
the fit of SafeCare to the structure, culture, and local needs of

service
populations and the organizations delivering those services.
This oc-
curred at several points. During the initial discussion and
commitment
phase, possible EBPs were considered with respect to their
target audi-
ences and outcomes, modes of delivery, and training and
resource re-
quirements. SafeCare emerged from this phase as a top
candidate. It
had a jointly held focus of interest to Council members (child
neglect),
only involved retooling of the curricular component of existing
home
visitation services rather than a more substantial reformulation
of ser-
vice models, and had implementation costs viewed as
manageable
within a large-scale roll out of the practice. This first
participatory
phase put stakeholders on the path to selecting a model
perceived to
have good fit with organizational structure, values and needs.
At the practice level, the structure of the seed team created an
ideal
framework for adapting an EBP as it was progressively
implemented
across a larger scale service area. A major theme, widely
expressed in
our interviews, was concern for whether SafeCare could be
applied to
all families. The seed team described the service population as
having
multiple needs, not necessarily consistent with the SafeCare

curriculum.
Families, for example, struggled with serious problems, ranging
from
the procurement of basic necessities to shelter, critical issues
that
fell outside the scope of SafeCare. Commenting on the
difficulties of car-
rying out SafeCare in such circumstances, one seed team
member ex-
plained, “[Families] are having a hard time. How can somebody
want to
learn about safety or health when they don't know what they're
going
to feed their kids [or] have the money to pay their rent?” This
individual
admitted to cutting short her visits with families in order “to
help them
with resources or whatever they're going through.” One solution
ad-
vanced during the early implementation period was not to begin
SafeCare
when families were in crisis. In such cases, the seed team
member only
initiated SafeCare after he or she had the opportunity to help the
family
address other issues. Over time, the seed team helped to shift
home visi-
tation practice so that such issues could occur within the
context of ongo-
ing SafeCare visits. In fact, such issues were fit within the
broader
problem-solving framework utilized within SafeCare. The seed
team
played an instrumental role in identifying this issue and
facilitating incre-
mental solutions that helped tailor SafeCare to the local context.

The seed team was also able to undertake deliberative steps to
im-
prove the cultural responsiveness of SafeCare to populations in
the
local region. For example, the seed team actively reviewed and
translat-
ed SafeCare materials to improve their relevance to Latino,
particularly
Mexican-American, families. The seed team also discussed and
adapted
child health focused sessions and materials to the customs of
Latino im-
migrant families, who sometimes expressed values and
preferences for
homeopathic remedies not originally considered within the
health
module of the SafeCare EBP (Finno-Velasquez et al., under
review).
The ICT model requires that the seed team become the local
cross-
agency repository of expertise in an EBP for a group of
collaborating or-
ganizations. At the outset, this involved the seed team learning
and uti-
lizing the new practice model until they reached a level of
expertise
meriting certification by the model developers. While mastering
the
EBP during early service delivery, the seed team was also
immersed in
the delivery of the practice in the local context. In their
designated
roles as future trainers, coaches, and supervisors, the seed team
mem-

bers were tasked with internalizing the knowledge of and
expectations
of program developers, but also with a high level of
responsiveness to
local population needs. As noted above, the pressure to resolve
tensions
between existing SafeCare structure and knowledge of the local
service
population put the seed team in the position of developing a
locally re-
fined expertise that fit the practice to the local area and allowed
for a
planned decrease in the involvement of the original EBP
developer in
supporting sustainment of SafeCare. Documentation of the
specific ad-
aptations made by the seed team is discussed by Finno-
Velasquez
et al. (under review). Participants viewed the gradual decrease
in devel-
oper involvement as proceeding effectively, as originally
planned.
3.5. Negotiation of rights, roles, responsibilities, and interests
In addition to a need to incorporate further structure in the area
of
communication patterns, as alluded to by earlier qualitative
findings,
the ICT model might benefit from further attention to enabling
methods
for facilitating negotiation of differences among organizations
and their
members. Although many possible differences among partners
may
emerge during the implementation of any new change effort,

several
specific examples from the SafeCre implementation experience
illus-
trate the kinds of issues that arise and require negotiation
during a
large-scale collaborative EBP initiative. For example, the
appropriate
pace for SafeCare implementation and documentable change
was one
area in which stakeholders held differing expectations and
opinions. It
arose because the collaborating partners had different needs and
expec-
tations influencing their participation. The local foundation
supporting
initial training and development of the seed team had interests
in seeing
measurable outcomes quickly in order to show progress to
donors
(2014) 160–168
supporting the organization, in addition to their core interest in
improv-
ing outcomes for children and families. Other stakeholders did
not share
the pressure to accelerate change to the same degree. Discordant
expec-
tations led to some tensions related to this issue.
Differences also emerged with regard to expected roles and
respon-
sibilities. For example, one important decision during
implementation

revolved around the order in which the seed team trained new
home
visitor teams in the various county regions. As a new
partnership in
which different parties jointly contributed to the SafeCare
implementa-
tion, issues around rights and responsibilities needed to be
negotiated.
County representatives had the authority and perceived
responsibility
to make decisions about ordering of SafeCare roll-out, since
they were
entrusted by the public to provide oversight of child welfare
services.
However, foundation staff also sought to exert authority in this
area be-
cause the foundation had committed funds to support the seed
team. As
shared authority was being established, power struggles between
parties occasionally ensued. These tensions were recognized by
others
involved in the implementation. One community-based provider
orga-
nization executive stated, “It's no one's fault, but I think the
foundation
and the county still have to have some meetings about whose
role is
what, and who has decision-making authority on certain things.
And I
think right now they are still a little messy.”
One further example may also be illustrative. Having significant
in-
vestment in the success of the SafeCare implementation,
especially
given that this was the first time the foundation was investing in

a single
major capital improvement as opposed to multiple smaller local
grants,
foundation representatives indicated a need and a right to work
directly
at times with the local community-based organizations
contracted by
the county to deliver SafeCare services. County representatives,
again
having direct responsibility for management and oversight of
child wel-
fare services, also asserted a duty to be involved in
conversations and
communications around service initiatives under their purview,
some-
times leading to tensions around roles and responsibilities
among
collaboration partners. One participant described the resulting
tension
as a “strange triangulation” between the entities involved.
However,
“What I think helped move it [the intervention] along was the
enthusi-
asm of everyone on the Council, [and] the enthusiasm of the
County, for
transitioning into the SafeCare model.”
3.6. Early successes
The ICT model intentionally involves the staged deployment of
an
EBP, beginning with the experience of the seed team prior to
subse-
quent roll out to and support of other practitioners. Participants
in qual-
itative interviews consistently mentioned that the purposeful
transition

of SafeCare from an initial seed team did lead to early signs of
success
that were interpreted as facilitating and supporting efforts to
imple-
ment and sustain SafeCare. One participant noted that
stakeholders
across all levels were “…seeing it is working. They are seeing
that
they're not getting cheated or embarrassed. They are seeing that
there
is a system in place. They're just calmer. And so their control
needs are
a little less.” Markers of success appeared to help stakeholders
begin
to overcome power struggles. Evidence of success took various
forms,
including positive experiences with initial training and delivery
of ser-
vices and encouraging reports by the home visitors about how
families
were responding to the intervention. A county official noted,
“The
training went well and implementation was successful…. The
reception
actually at the line level has exceeded my expectations…. Home
visitors
are comfortable with one, embracing more of a script and, you
know,
more structure within the visit and that they're receptive to the
coaching…” Undertaking implementation in a phased roll out,
begin-
ning with exploration, appropriate preparation, and planned
imple-
mentation phases and involving the seed team as a central
training
and support component, created opportunities for shared

successes
and further commitment to ongoing problem solving.
4. Discussion
This paper describes the ICT model for EBP implementation,
which
is designed to facilitate development of many supports
hypothesized
to be central to successful quality improvement efforts
organized
around EBP implementation. Qualitative data from
implementation of
SafeCare in one large geographic area provided the opportunity
to
reflect on the strengths and limits of the ICT model and to
consider it
relative to other process models of quality improvement and
EBP
implementation.
The ICT model departs from traditional service structure and
process
by distributing local expertise across service teams, and more
focally
in a seed team, in a way that takes into account challenges faced
by
real-world public social service systems (Aarons et al., 2011;
Aarons,
Sommerfeld, Hecht, Silovsky, & Chaffin, 2009). Drawing on
computer
science and engineering theories of distributed expert systems
(Dai,
Xie, Poh, & Liu, 2003) and team decision making (Hollenbeck
et al.,
1995), the ICT model aims to increase effective team
functioning

through building greater systemic and cross agency trust
(Edmondson
& Roloff, 2009) and collaboration (Bertram, 2008). This
structuring oc-
curs at multiple levels, including among administrative and
funding
stakeholders with interest in a practice change initiative, and at
the
level of local clinical leadership (i.e., the seed team). The goal
of the
ICT process is to build interagency relationships at both levels,
and be-
tween levels, creating the structural supports central to effective
adop-
tion, implementation, and sustainment of an EBP with positive
public
health effects. With the seed team playing a substantial role in
opera-
tional implementation, the ICT model seeks to build structures
and pro-
cesses that enable the fitting of an EBP to the local context as
outside
developer involvement is reduced, and potential for EBP
sustainment
is increased.
Other implementation strategies directly relevant to EBP
implemen-
tation include such models as the Availability, Responsiveness
and
Continuity (ARC) and Community Development Team (CDT)
models.
Each arises out of somewhat different theoretical frameworks
than the
ICT model. The ARC model emerged from organizational
development

(Burke, 1993; Nadler & Tushman, 1977; Porras & Robertson,
1992)
and interorganizational domain development (Gray, 1990; Trist,
1985)
theories. The ARC model focuses strongly on improving
organizational
culture and climate and organizational processes to support
effective
care and more effective EBP implementation. ARC relies on an
organiza-
tional change agent to work with the organization to effect
intra-
organizational change to improve care. The CDT model was
developed
based on the experiences of the California Institute for Mental
Health
(CiMH), a training and technical assistance organization
supported by
county mental health agencies and child welfare systems. The
CDT
approach focuses on developing supportive collaborations
among
stakeholders, often in different counties, that are considering
and
implementing EBPs. The CDT model, like the ARC, relies
heavily on the
involvement of an outside consultant to structure
communications
among stakeholders, set priority topics for discussion, and
foster organi-
zational problem solving around issues that arise during
implementa-
tion. The outside consultant brings collected expertise acquired
from
extensive communications with multiple EBP program
developers and

local stakeholders to his/her role in supporting EBP
implementation ef-
forts (Sosna & Marsenich, 2006).
Considerable common ground exists among these models,
although
there are also some areas of difference, both qualitatively and in
overall
emphasis. For example, the ICT model devotes considerably
less atten-
tion to efforts to change intraorganizational culture and climate
than
the ARC model. However, both have many similarities
including pro-
cesses specifically targeting initial collaborative work and joint
decision
making among stakeholders, and the development of
mechanisms for
monitoring and providing feedback about implementation
progress
and quality, and for fitting practices to be implemented to the
local geo-
graphical and cultural context. The ICT and CDT process
models also
(2014) 160–168
share similarities. Both include processes specifically targeting
initial col-
laborative work among adopting stakeholders and organizations,
using
education to reduce uncertainty about EBP adoption during the
explora-
tion and preparation stages, and developing a core focus on EBP

fidelity
as part of implementation and sustainment. The models differ,
however,
in how many of the implementation processes are organized by
an exter-
nal change agent as opposed to individuals within the service
system.
Both the ARC and CDT models include a much more extensive
role for
an external change agent than the ICT model, which proposes
that the
planned actions and processes illustrated in Fig. 1 will result in
the devel-
opment of structural supports at the core of effective
implementation. The
ICT model relies more on establishing a process map for
developing local
structures to support implementation, and on facilitating desired
inter-
agency relationships, than on external consultant support.
Given notable common procedural aspects of different
implementa-
tion process models, the rich qualitative data gathered around
imple-
mentation of SafeCare in this study informs the ICT model and,
to
some degree, other implementation process models as well. One
key
finding from this qualitative study was the interconnectedness
of the
process components and the implementation supports they
facilitated.
Initial collaborative efforts among stakeholders, including
recognition
and discussion of differences, facilitated later problem solving

and ne-
gotiation around areas of disagreement and potential conflict.
Staged
roll out of implementation created opportunities for early
success,
which in turn facilitated communication and problem resolution
and
helped build “buy-in” and enthusiasm for the EBP. The presence
of the
seed team solidified perceptions of leadership at multiple levels
and di-
rectly addressed other key implementation drivers, including
sustain-
ing a focus on fidelity and fitting of the practice to be
implemented to
key local contextual variations. Our qualitative work supports
argu-
ments made by others that multi-component approaches to
implemen-
tation that address inter- and intra-organizational contextual
issues are
necessary to create an environment conducive to strong
implementa-
tion and sustainment (Aarons et al., 2011; Damschroder et al.,
2009;
Ferlie & Shortell, 2001; Fixsen, Blase, Naoom, & Wallace,
2009; Glisson
& Schoenwald, 2005; Grimshaw et al., 2001; Grol & Grimshaw,
1999).
Results from interviews clearly connected various aspects of the
imple-
mentation process to the overall supports for implementation.
The in-
terviews also are consistent with the idea that core
implementation
drivers reinforce and support one another (Fixsen et al., 2009).

The ICT model includes notably less involvement of external
change agents, such as intermediary or brokering organizations,
or
outside organizational development consultants than other
process
models. The foundation and its willingness to support initial
imple-
mentation phases were important to SafeCare implementation
be-
cause the foundation served as the initial convening agent and
was
responsible for providing financial support to initiate
implementa-
tion of SafeCare. However, the ICT model relies more heavily
on orga-
nizing a series of actions and local structures designed to create
inherent inter-organizational interaction and mutual support
around
an EBP implementation. Such structures can include service
system
contracts with community-based organizations that deliver
services,
or memorandums of agreement that support the ICT structure.
The lead-
ership at the system level, and at the organizational level is
needed to fa-
cilitate formal agreements for the ICT structure. In addition, the
ICT
model presumes that the presence of a local seed team will
create a
locus of leadership at the practice level that reinforces initial
commit-
ments from higher-level administrators and accountability to
service
provision and ongoing intervention fidelity. The model

presumes that
the role of the seed team, both to learn and to transmit a
practice to
other colleagues, will require the team to identify and resolve
salient ad-
aptation issues that arise in the local context. The existence of
the seed
team, with its coaching and supervision responsibilities, is
designed to
create a focus on fidelity that is transmitted directly to
practitioners
working in different organizations delivering the new practice.
The
seed team is placed in a structural role to carry a voice of
leadership
and fidelity focus throughout the course of implementation,
rather
than having this spearheaded by an external change agent. It is
worth
noting that the ICT model seeks to create conditions for
successful im-
plementation of an identified practice change, not to influence
how all
practice changes occur, although it is presumed that experience
with
the model with improve local change efforts more broadly.
Initial results suggest that the ICT model steps do lead to many
of the
intended structural supports or drivers for effective
implementation.
However, they also reveal that the ICT process may not
sufficiently fos-
ter some of the supports that receive direct attention in other
process
models. Our qualitative data suggest that including explicit

processes
for regular communication in the ICT model is crucial to
improve the
ability of involved stakeholders to identify and address
potential con-
flicts in ways that build trust and continued cooperation.
Participants'
experiences suggested that there are likely to be unexpected
areas of
conflict and disagreement in any implementation effort and that
clear
communication and a problem solving orientation will facilitate
effec-
tive resolution of such issues.
The ICT model does appear to have resulted in a systemic focus
on fi-
delity in a manner that facilitates appropriate local adaptation.
For many
years, the potential inflexibility and lack of local cultural
relevance of
EBPs have been significant limiting concerns (Bernal, 2006;
Bernal,
Jimenez-Chafey, & Rodriguez, 2009; Bernal & Scharron-del-
Rio, 2001;
Castro, Barrera, & Martinez, 2004; Kumpfer, Alvarado, Smith,
& Bellamy,
2002; Lau, 2006; Matos, Torres, Santiago, Jurado, & Rodriguez,
2006). Ex-
periences from participants using the ICT model with SafeCare
suggest
that such concerns have some validity, but that they are
addressable
through planned implementation structures and processes.
Questions
did arise about the fit of SafeCare with local cultural nuances,

particular-
ly for Latino families. The seed team, with a liaison role
between the EBP
developer and trained home visitors and families receiving
services, did
address issues of how to adapt SafeCare to local conditions
while re-
maining true to core components of the practice. The ICT model
envi-
sions this as a negotiated process between a locally based team
and
EBP developers who know that this team will assume
responsibility
over time for system-wide fidelity maintenance. These kinds of
negotia-
tions were observed as the seed team recognized the need for
SafeCare
adaptation for the county and worked with SafeCare developers
to make
appropriate adaptations (Finno-Velasquez et al., under review).
At a broad level, our qualitative results largely support the role
that
ICT model processes play in generating structural supports for
imple-
mentation and sustainment of a system-wide EBP-driven quality
im-
provement effort. Several areas were identified as likely
needing
further attention in the implementation model, including a
process for
detailing appropriate communication patterns early during
implemen-
tation and a process for creating forums in which differences
among
participating organizations can be identified, discussed, and

resolved.
In the presence of multiple implementation models a natural
question that arises concerns the conditions under which a
particu-
lar implementation model is particularly relevant. The ICT
model
seems particularly well suited to circumstances in which an EBP
is
planned for roll-out in a given organization or across a
contiguous
geographic area in which authority for initiating and supporting
the effort falls under the domain of a small number of
administrative
entities, in this case county child welfare services. As opposed
to fo-
cusing on collaborative information sharing among
organizations
implementing an EBP in different locations, or emphasizing the
internal
organizational cultural and climate of implementing
organizations, the
ICT model is relevant when local organizations are in a position
to work
together to develop a shared core infrastructure for
implementing and
sustaining expertise in a practice that will be scaled up across a
broad geo-
graphic area. The ICT model is somewhat unique in its
emphasis on creat-
ing implementation supports through formal and strategic
structuring
and staging of the implementation process rather than through
the exten-
sive involvement of an outside organization that organizes and
pushes

the implementation process forward.
(2014) 160–168
5. Conclusions
The ICT implementation process model developed out of the
collab-
orative experience of researchers and local agency partners. Use
of its
implementation processes has led to sustained and widespread
use of
SafeCare, an evidence-based neglect prevention model, in one
large
county, and resulted in the phased transitioning of expertise
from
model developers to the local context. Although some aspects of
the im-
plementation model may benefit from enhancement, results
suggest
that the process model generates strong structural supports for
imple-
mentation and creates conditions in which tensions between
EBP struc-
ture and local contextual needs can be resolved in ways that
support the
expansion and maintenance of the EBP while preserving its
potential for
public health benefit.
Acknowledgments
This study was supported by the National Institute of Mental
Health

grants 2R01MH072961 and P30MH074678. The authors thank
the
community-based organizations, case-managers, and supervisors
that
made this study possible. The authors declare no other conflicts
of
interest.
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http://refhub.elsevier.com/S0190-7409(13)00307-1/rf0005

http://refhub.elsevier.com/S0190-7409(13)00307-
1/rf0210Interagency Collaborative Team model for capacity

building to scale-�up evidence-�based practice1.
Introduction1.1. Interagency Collaborative Team (ICT) model in
the EPIS Framework1.1.1. ICT processes and action steps1.1.2.
ICT initial steps: exploration/adoption decision1.1.3.
Interagency seed team development: preparation and
implementation1.1.4. Seed team: ongoing responsibilities1.2.
The present study2. Methods2.1. Overview2.2. Participants2.3.
Semi-structured interviews2.4. Data analysis3. Results3.1.
Commitment and collaboration3.2. Leadership3.3.
Communication3.4. Fit with existing practice and fidelity3.5.
Negotiation of rights, roles, responsibilities, and interests3.6.
Early successes4. Discussion5.
ConclusionsAcknowledgmentsReferences
NURSING ECONOMIC$/September-October 2014/Vol. 32/No.
5248
I
NTERDISCIPLINARY collabora-
tion is an emerging mandate
to decrease fragmentation of
care delivery in U.S. hospi-
tals. Higher mortality rates
(Estabrooks, Midodzi, Cummings,
Ricker, & Giovannetti, 2005) and
longer lengths of hospital stay
(Zwarenstein, Goldman, & Reeves,
2009) have been found in environ-
ments where collaboration is lim-
ited or not present. As many as
98,000 people die in hospitals
each year as a result of medical
errors which may be traced to lack

of collaboration and disjointed
care. Beyond the cost of human
lives, billions of dollars are spent
annually for additional care re -
sulting from medical errors (Kohn,
Corrigan, & Donaldson, 2000). The
aim of this study was to determine
if a care delivery model based on
collaboration and coordination of
care using the CareGraph® would
improve patient outcomes.
To provide high-quality care
and meet public expectations with
limited resources, collaboration
has become a necessity. In a land-
mark study, Knaus, Draper, Wagner,
and Zimmerman (1986) found that
hospitals where collaboration was
present reported a mortality rate
41% lower than the predicted
number of deaths. Hospitals where
there was little to no collaboration
exceeded predicted mortality by
as much as 58%. Collaborative
relationships have also been tied
to reduced costs for the health
care system (Zwarenstein et al.,
2009). Although empirical evi-
dence in support of collaboration
in the health care environment is
available in the literature, there is
little evidence on how to create
this environment (Tschannen,
2004). The main structural ele-

ments necessary for collaboration
in an acute care environment in -
clude a culture where relation-
ships are valued, health care pro-
fessionals communicate effective-
ly, and respect is shared among all
parties. A model of care delivery
consistent with these cultural val-
ues and focused on patient safety
is paramount.
A Midwestern health care sys-
tem designed an innovative model
of care delivery where collabora-
tion was purposefully woven into
the structures and processes to
effect positive change in patient
and organizational outcomes.
Called the Clinical Integration
Model (CIM) (Zander, 2007), sev-
eral of the health system hospitals
adopted it while others chose to
stay with a traditional primary
care model. Comparing hospitals
within the health system provides
an opportunity to determine if
there is a difference in survival,
length of stay (LOS), and cost for
patients receiving care in facilities
utilizing the CIM and those receiv-
EXECUTIVE SUMMARY
The current lack of collabora-
tive care is contributing to high-
er mortality rates and longer

hospital stays in the United
States.
A method for improving collabo-
ration among health profession-
als for patients with congestive
heart failure, the Clinical
Integration Model (CIM), was
implemented.
The CIM utilized a process tool
called the CareGraph® to priori-
tize care for the interdisciplinary
team.
The CareGraph was used to
focus communication and treat-
ment strategies of health pro-
fessionals on the patient rather
than the discipline or specific
task.
Hospitals who used the collab-
orative model demonstrated
shorter lengths of stay and cost
per case.
Cheryl McKay
K. Lynn Wieck
Evaluation of a Collaborative Care
Model for Hospitalized Patients
CHERYL McKAY, PhD, CNS, RN, com-
pleted this work as part of her doctoral
education at the University of Texas at

Tyler. She is presently Nurse Executive,
Healthier Populations, OrionHealth, Santa
Monica, CA.
K. LYNN WIECK, PhD, RN, FAAN, is Mary
Coulter Dowdy Distinguished Nursing
Professor, University of Texas at Tyler.
249NURSING ECONOMIC$/September-October 2014/Vol.
32/No. 5
ing care in facilities utilizing a pri-
mary care model.
Collaboration in Health Care
Collaboration, as defined by
the American Nurses’ Association
(ANA) (2010), is a partnership
based on trust with shared power,
recognition, and acceptance of
separate and combined practice
spheres of activity and responsi-
bility. Collaboration also includes
mutual safeguarding of the legiti-
mate interests of each party and a
commonality of goals. The key
components of shared power,
recognition and acceptance, and
common goals are relevant to
many of the definitions found in
the literature (Fewster-Thuente &
Velsor-Friedrich, 2008; Petri, 2010).
These components are essential for

a collaborative process and can be
operationalized in an acute care
setting.
A number of factors have
affected the ability of health care
organizations to provide a collabo-
rative environment including the
educational system and profes-
sionalization of health care practi-
tioners. Studying determinants of
successful collaboration, San Martin-
Rodriguez, Beaulieu, D’Amour, and
Ferrada-Videla (2005) found health
care practitioners develop a strong
professional identification through
education. This strong profession-
al identification often limits know -
ledge of other professionals within
the team and is considered a main
obstacle to collaboration. The
dynamics of professionalization lead
to further differentiation of health
care professionals (D’Amour &
Oandasan, 2005) and potential
conflict hindering the develop-
ment of true collaborative rela-
tionships.
Collaboration in health care
affects patient survival and de -
creases adverse patient outcomes.
Knaus and colleagues (1986)
found hospitals where collabora-
tion was present reported a signif-
icant decrease in mortality rates

(Chi square=62.9, df 12; p<0.0001,
r=0.83). Hospitals where there
was little to no perceived collabo-
ration exceeded predicted mortal-
ity. Positive collaborative relations
have also been tied to a decrease
in failure to rescue. Boyle (2004)
evaluated unit-level characteris-
tics and the impact on patient out-
comes and found a negative corre-
lation between collaboration and
failure to rescue (r= -0.53). High
levels of perceived collaboration
were linked to early detection of
change in clinical condition and
appropriate intervention leading
to a decrease in failure to rescue.
Collaborative environments
can positively affect health system
outcomes. Ovretveit (2011) evalu-
ated the impact of clinical coordi-
nation and collaboration and found
when collaboration and coor -
dination were present, patients ex -
perienced a shorter LOS with
lower costs to the health care insti-
tution. Additionally, Zwarenstein
and co-authors (2009) evaluated
multiple studies to determine the
impact of interprofessional collab-
oration and found 80% of the stud-
ies demonstrated decreased LOS
and cost savings to the health care
institutions.

Barriers to Collaboration in
Health Care
The barriers to collaboration
are rooted in the hierarchal and
long-established structures of most
health care organizations and are
difficult to change. The nurse-
physician relationship is one
example of an established hierar-
chal relationship that has been a
barrier to true collaboration in
health care facilities. Hojat and
colleagues (2001) conducted a
cross-cultural study evaluating
nurse-physician attitudes toward
collaboration and found nurses in
both the United States and Mexico
expressed more positive attitudes
toward collaboration than their
physician counterparts (p<0.01).
As a possible solution, the authors
recommended inter-professional
education to improve nurse-physi -
cian collaboration.
Empirically the link between
collaboration and improved pa -
tient and system outcomes has
been demonstrated, but there re -
mains a gap in the literature on
how to create a collaborative envi-
ronment. This study begins to fill
the gap by looking at a large scale
change of care delivery based on

essential collaborative structures
and processes and its impact at
the patient, hospital, and system
levels.
Theoretical Framework
The Donabedian Model (1966)
is proposed as a way of providing
essential structures and processes
for collaboration in the health care
setting. The model was used to
provide a comprehensive struc-
ture to move from inputs through
the process of care delivery, and
conclude with the outcomes for
this study.
In accordance with the Dona -
bedian Structure, Process, Out -
come Model (see Figure 1), struc-
ture refers to the environment in
which care is provided. Structure
encompasses the work environ-
ment, availability of equipment
and supplies, and type of unit.
These structural elements tend to
be relatively permanent in nature
and are often thought of as key
determinants to quality (Donabedian,
1988). Process elements are more
flexible and readily changeable.
Process encompasses the things
health care workers do or fail to do
which shape patient outcomes
(Montalvo & Dunton, 2007). Out -

comes are the changes in patients’
health attributable to their care
(Montalvo & Dunton, 2007). Ac -
cording to Donabedian (1988),
changes in structures and process-
es of care are required to optimize
patient outcomes.
The Structure, Process, Out -
come Model proposes the context
(structure) in which the interven-
tion (process) occurs has an influ-
ence on the outcomes. Collab -
oration is seen as the process that
occurs within a specific context
leading to the measured results or
5250
outcomes. The process of collabo-
ration not only requires health
care providers to communicate
effectively and trust each other, it
also requires a multidisciplinary
model of care delivery. The
Donabedian Model provides a
useful structure for studying pro -
cesses and outcomes of care and
was used to guide this study.
Clinical Integration Model for
Interdisciplinary Collaboration

This clinical effectiveness
study utilized the implementation
of a new approach to patient care
delivery and documentation based
on bringing health professionals
together as partners in care called
the CIM. This collaborative ap -
proach was manifested by a new
method for organizing and chart-
ing activities that was integrated,
consistent, and goal-directed
rather than discipline-specific.
The focus changed from the task
to the patient as the center of care.
This model of care delivery was
designed with a specific goal of
interweaving collaborative struc-
tures and processes into care. The
Figure 1.
Donabedian Structure, Process, Outcome Model (Adapted)
SOURCE: Adapted from Donabedian, 1966.
Modified Donabedian Model for Clinical Integration Program
Structure
Patient diagnosis
Core measure
compliance
Type of unit
Outcomes
Patient survival

Length of stay
Cost per case
Clinical Integration Model
Patient
admitted.
CareGraph
completed.
Top three
problems and
discharge
goals identified.
Does patient
need complex
care?
Does patient
need complex
care?
Continue
interdisciplinary
care coordination.
Focus on top
three problems.
Patient
discharged

from complex
care team
meetings.
Patient
discharged
from hospital
with goals
met.
Process
Clinical Integration Model or
Traditional care delivery model
Information exchange
NO NO
Patient
progressing
toward
discharge
goals.
32/No. 5
drivers for change within this
health system were based on an

average LOS that was heading in
an upward direction, fragmenta-
tion of care delivery, increasing
complexity of patient conditions,
and increasing costs.
To confirm and chronicle
changes in the structures and pro -
cesses, the hallmarks of the collab-
orative environment included
development of a process tool, the
CareGraph; focus on the same
patient-centered goals; and care
coordination around patient needs.
Other organizational changes in -
cluded provision of essential unit-
based staff, clarification of roles
among caregivers, and communi-
cation of expectations.
Guided by the model, the
CareGraph process tool was devel-
oped (Center for Case Manage -
ment, 2004) (see Figure 2). The
tool provides a mechanism for
multiple disciplines to speak the
same language, focus on the same
patient-centered goals, coordinate
workflow around patient needs,
and document integrated care
notes. The CareGraph is imple-
mented by the nurse caring for the
patient and updated daily. The
nurse meets formally with the
entire care team three times a
week in care coordination rounds

to discuss problem foci and pro-
gression of care. Any patient
stalled in progression toward opti-
mal outcomes is referred to the
complex care team, which meets
twice weekly and is led by a case
manager and hospitalist (see
Figure 1). Other operational
changes included the provision of
unit-based case managers, social
workers, and educators. Physi -
cians and other allied health prac-
titioners were readily available to
all nursing staff. The CareGraph
serves as the common communi-
cation link between these disci-
plines.
The well-defined structure
and process changes implemented
with the CIM provide essential
elements for a collaborative, well-
coordinated care delivery model.
Health care providers have the
ability to provide care consistent
with the objectives of ANA’s
(2010) Social Policy Statement to
safeguard patients’ interests and
develop common goals with struc-
tured communication.
Variables
Operational definitions of the
three variables for the proposed

study are found in Table 1. Input,
or structure variables, used in this
study were the number of patients
admitted to each of the participat-
ing health system hospitals with
the diagnosis of congestive heart
failure (CHF). Type of patient pop-
ulation, CHF, served as the main
structural variable for this study.
The model of care delivery, CIM or
traditional care delivery model,
served as the process variable. The
hospitals that implemented the
CIM served as the intervention
hospitals. The control hospitals
continued to deliver traditional
care. The outcomes measured to
evaluate change after implement-
ing the CIM are survival, length of
stay, and cost per case for patients
with CHF.
Research Design and Methods
The purpose of this study was
to determine if there is a differ-
ence in survival, LOS, and cost
per case in the CHF population in
facilities using the Clinical Inte -
gration Model compared to those
using a traditional care delivery
model. A retrospective nonran-
domized comparative design us -
ing a convenience sample over a
time-limited period was used to

evaluate patient survival, LOS,
and cost per case for patients with
the same diagnosis in a large hos-
pital system in the Midwestern
United States. Inclusion criteria
was adult patients (> age 18)
admitted during specified dates to
one of the health system hospitals
chosen for this study with the pri-
mary diagnosis of CHF (DRGs 291,
292, and 293). All health system
Figure 2.
CareGraph Example of Wound/Skin Category
Admit
Baseline
Date Date Date
Wound/Skin:
(Identify focus__________________________________)
4 – Has large gaping wound that requires packing or complex
dressing change taking
>30 minutes >3 times/day
4 4 4
3 – Has draining wound with/without packing or complex
dressing change < 3 times/day
or unable to apply wound vac
3 3 3
2 – Has draining wound with/without packing or constant re-

enforcement or requires
wound vac
2 2 2
1 – Has reddened area with skin intact or simple dressing/open
to air 1 1 1
0 – Has intact skin/wound/incision 0 0 0
5252
hospitals have electronic medical
records and central billing sys-
tems which allowed for capturing
of data elements. A pre-imple-
mentation, post-implementation
design was used to evaluate
patient and hospital-level out-
comes.
Sample
After approval of the institu-
tional review boards from the
University of Texas at Tyler and
the health system hospitals, a
sample of patients CHF (DRG’s
291, 292 and 293) admitted to the
participating acute care facilities
within the health system were uti-
lized to assess patient and hospital
outcomes of survival, LOS, and

cost per case. The CHF population
was chosen because it is a relative-
ly homogenous group. The patient
characteristics, unit characteris-
tics, and treatment plans were
more consistent using a single
diagnosis.
Patients with heart failure
were selected as a means to con-
trol variables. These patients are
treated using standardized evi-
denced-based guidelines devel-
oped using core performance
measures by the Joint Commission
in an effort to improve consisten-
cy and quality of care for this pop-
ulation among all hospitals. Four
key quality indicators for heart
failure treatment were developed
and are required for all patients
with CHF. The first standard
requires all patients discharged
from hospitals with the primary
diagnosis of heart failure to have
left ventricular function assessed
before or during hospitalization
(Kfourny et al., 2008). The second
requires physicians to prescribe
an angio tensin-converting enzyme
inhibi tor or an angiotensin recep-
tor blocker, depending on patient
tolerance, for all patients with left-
ventricular dysfunction. The third
includes providing the patient

with self-management instruc-
tions on tracking weight, low sodi-
um diet, reporting of symptoms,
and followup care. Finally, smok-
ing cessation counseling for smok-
ers was mandated.
Major threats to internal valid-
ity for a study with a control group
have been addressed in the design
with use of a homogenous group,
the CHF population, and pre/post
evaluation. Knowing the exact
dates for implementation or non-
implementation of the CIM with
use of a control group allows com-
parison of groups. In addition,
each intervention hospital was
matched with a hospital of similar
size and service availability with-
in the health system to account for
potential historical influence.
Multiple outcome measures have
also been added to increase valid-
ity; and demographics for the geo-
graphic area demonstrate the abil-
ity to obtain a representative sam-
ple relative to gender.
Recruitment/Setting
For this study, an extant data-
base was used to access survival,
LOS, and total cost data for the
participating hospitals. A conven-

ience sample of the CHF popula-
tion from Hospital A (338 beds)
and Hospital B (139 beds) were
used as the intervention group.
These two hospitals are located in
close proximity to each other with
the same upper management staff,
and both had implemented the
CIM. Both hospitals offer full serv-
ices with cardiology a major serv-
ice line. These hospitals service
over 300,000 people in the area
and total over 300 admissions for
CHF per year. Hospital C (373
beds) was chosen from the health
system as a comparison to Hospit -
al A, and Hospital D (148 beds)
was compared to Hospital B.
These two hospitals admit a simi-
lar number of patients with CHF
and are both full-service facilities
of like size, with cardiology con-
stituting a major portion of admis-
sions. The number of people
served by these two facilities is
roughly 300,000 (U.S. Census
Bureau, 2010). Essential care ele-
ments for the CHF population are
rendered using core measure crite-
ria at each hospital with compli-
ance greater than 92%.
Procedures
To analyze the impact of the
CIM on hospital outcomes, data

were extracted from the health
system database for survival, LOS,
and cost per case for the CHF pop-
ulation from the participating hos-
pitals. The time frame is based on
Roger’s Theory of Diffusion of
Innovation (2003), which states
that full diffusion of an innovation
Table 1.
Conceptual and Operational Definitions of Study Variables
Variable Conceptual Definition Operational Definition
Structure The environment in which care
is provided.*
Inpatient acute care units where
patients with CHF (DRGs 291,
292 and 293) receive care.
Process Care provided by health profes-
sionals working in a partnership
based on trust with shared
power, recognition, and accept-
ance of separate and combined
practice spheres of activity and
responsibility. **
Integrated practice approach by
various providers indicated by the
Clinical Integration Model using
the CareGraph tool as opposed to
a traditional care delivery model
with traditional charting.

Outcome The changes in patients’ health
attributable to care.***
Survival
Length of stay in days
Cost per case (direct cost)
SOURCES: *Donabedian, 1988; **ANA, 2010; ***adapted
from Montalvo and
Dunton, 2007
32/No. 5
and cultural adherence would oc -
cur at approximately 12 months.
All outcome data were accessed
using the TSI/Eclipses relational
database. It is a closed-loop data -
set with data extracted and used
for cost accounting purposes as
well as clinical performance im -
provement.
Results
The initial data set yielded
1,192 cases after data cleaning and
time referencing. Descriptive sta-
tistics for each of the primary out-
come variables (survival, LOS,
cost) were determined using the
Statistical Package for Social
Sciences (SPSS) version 17 and

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