Abstract
Background and aim. Implementing complex interventions for integrated care often presents significant challenges in achieving the expected results. The involvement of external facilitators who provide training and support for healthcare providers and managers can strengthen implementation strategies, foster cooperation among diverse partners, and ultimately improve the patient experience of integrated care. However, the mechanisms occurring during external facilitation (EF) in different contexts are not well documented. The aim of the study is to explain how, why, under what circumstances and for whom EF works when implementing complex interventions for integrated care.
Approach: A realist synthesis was conducted as the first phase of a realist evaluation. A participatory approach involving collaboration amongst various partners was used to gather diverse competencies around a common vision. Working sessions were organized to train all team members (patient partners, healthcare providers, decision makers, and academic researchers) on the realist approach and to identify research questions and refine the scope of the review. An initial program theory was developed and used as a framework for data collection and analysis of studies included in the synthesis. Empirical studies identified in a previous scoping review about EF when implementing complex interventions (hereafter “intervention(s)”) were included, along with relevant associated documents. Data were extracted to identify contexts (C) in which EF strategies activate mechanisms (M), leading to specific outcomes (O) (CMO configurations). Analysis of CMO configurations led to the refinement of the initial program theory. Results were validated by team members.
Results: The scoping review identified 36 articles (including 33 interventions), and a manual search identified 104 relevant documents. EF yielded positive outcomes, including: improved intervention delivery and fidelity; enhanced feasibility and acceptability of the intervention among partners; improved reach of both healthcare providers and patients; improved uptake and ownership of the intervention by healthcare providers; and improved sustainability of the intervention. These outcomes were achieved when EF strategies triggered the following mechanisms: internal facilitators felt more confident in performing the intervention; healthcare providers positively changed their perceptions of the intervention, felt supported and were committed to iterative learnings and active problem-solving; interpersonal relationships among healthcare providers were strengthened; and partners’ engagement in the intervention was stimulated at the local level. The success of each mechanism was influenced by contextual factors such as: leadership from both external and internal facilitators, as well as managers and decision makers; collaborative climate within the organization; resources availability; the capacity for individual, collective, and organizational adaptation and learning; and existing expertise, practices, national programs or policies that align with the intervention.
Implications: The findings provide researchers, managers, healthcare providers and patient partners with valuable insights into EF, offering a deeper understanding of how it can enhance and optimize the implementation process for integrated care interventions. The next phase of the study, a realist evaluation, will test and iteratively refine the program theory on EF when implementing complex interventions for integrated care.