Rural primary care facilities face many challenges in meeting complex healthcare needs of their clients, stemming from various social determinants of health. Trauma-Informed Integrated Primary Care provides a model of care that can holistically address multidimensional needs of rural populations while taking into account the impact of various social determinants of health. However, such innovation can impose substantial strain on rural primary care facilities that are already overburdened with many competing priorities. Strategic community partnership may help build primary healthcare organizational capacity to successfully carry out innovation. Using a realist approach, this study sought to identify contexts and mechanisms that facilitate or interfere with the process of rural primary healthcare organizational changes toward trauma-informed Integrated Primary Care by integrating a behavioral parenting intervention, Behavior Checker, into the routine care practice.
This study was a community engaged realist evaluation study pursued by the community partnership among; 1) a rural primary healthcare facility in a Health Professional Shortage Area (HPSA) in rural areas of Midwestern state; 2) a non-profit organization dedicated to promoting positive parenting and child well-being; 3) a university affiliated research and development center, specializing in telehealth. The study collected multiple forms of data through key informant interviews, focus groups and surveys with healthcare staff, direct observation of meetings as well as other formal and informal interactions with healthcare staff and organizational leaders. Data were analyzed following the realist evaluation protocol and using the convergent parallel mixed method, focusing on constructing refined program theories in the form of the context-mechanism-outcome (CMO) configuration.
High level of unmet needs in the community, increased awareness of social determinants of health among healthcare leaders, and heightened awareness of service gap/opportunities for improvement among healthcare staff facilitated the organizational change efforts via positive engagement among key stakeholders. Partnering was a key process that facilitated the change efforts via improved organizational change readiness supported by leveraged resources and shared expertise. Staff education and training facilitated the organizational change efforts via improved attitudes, knowledge, and confidence among staff. However, training and education also had a negative influence on the change efforts via increased complexity compression among relatively less educated and experienced staff members in the context of the fast-paced clinic environment and staff overload. Workflow integration involving the Electronic Health Record (EHR) integration was perceived as a key strategy to contain complexity compression among clinical staff. However, partial EHR integration due to the system mismatch limited intervention utilization and interfered with performance evaluation due to the lack of systematic pathways to prompt Behavior Checker delivery and documentation.
Conclusions and Implications
Healthcare innovation is a multifaceted social phenomenon shaped by a complex interplay among various factors in multiple contextual domains. Better understanding of the contexts and mechanisms that facilitate and interfere with healthcare organizational changes can inform future efforts to develop and evaluate organizational change strategies that work in real-world settings.