Assessing implementation outcomes of Occupational Therapist (OT) led falls hazard reduction at home (FRH@Home).

This project will implement and evaluate the roll out and scale up of Occupational Therapy (OT) led falls hazard reduction at home (FHR@Home) to prevent falls in older people. The order in which the intervention is rolled out to health settings will be decided at random. Focus group discussions, in-depth interviews and staff surveys will explore implementation barriers and enablers (determinants) and underpin the development of implementation strategies for each health setting. These qualitative approaches will enable us to understand what worked well (or not) and why. Study design: A type III hybrid implementation design. Comprising of concurrent mixed methods research involving a pragmatic, multi-centre, stepped wedge cluster randomised controlled trial (SWCRCT), focus groups (FGs), in-depth interviews (IDIs) and implementation guided by the Consolidated Framework for Implementation Research (CFIR) or Expert Recommendations on Implementation Research (ERIC). Qualitative research will be used to identify and understand implementation barriers, enablers (determinants) and mechanisms through which implementation strategies might operate (such as:such as motivation, opportunity and capability) to select a range of implementation strategies for each site. We will co-design implementation strategies with service users (patients and carers) and end users (OTs) to support routine adoption of FHR@Home in OT clinical practice. The co-design process will involve: - Teaching OTs how to do co-design in a practical co-design workshop, delivered during the OT baseline training, so that OTs can translate these skills to the clinical setting when co-creating a hazard reduction action plan with clients, following their falls hazard assessment. This co-design workshop will last 1 hour. - The OT co-design workshop will involve didactic teaching of co-design principles and a practical session whereby the OTs identify barriers and enablers to identifying falls hazards with clients and co-creating an intervention action plans. - The OTs will use the skills learnt in the co-design workshop to identify potential implementation determinants within their organisation and co-design solutions during a focus group discussion, which will explore implementation determinants and potential strategies in-depth. The OT focus group(s) will last approximately 2 hours, will include all OTs willing to participate and who provide community based falls prevention interventions to older people at high risk of falls. Focus groups will include 5-8 OTs and will take place within a month of the co-design workshop. - Teaching our Consumer Advisory Group the principles of co-design and seeking their advice on how best to co-create falls hazard reduction solutions with clients. This session will last approximately 2 hours. - The implementation strategies, generated via the OT focus groups and the Consumer Advisory Group, will be embedded in clinical practice where feasible. - The implementation determinants and strategies, developed through this process, will be iteratively adapted and contextualised as the intervention is rolled out to new implementation sites. - Ultimately all identified implementation determinants and strategies will be used to create an implementation decision tool, to tailor implementation strategies to service context. We will build an algorithm into the decision tool to align potential barriers and enables with implementation strategies, based on key components of the organisational context. This will be available on a FHR@Home website, along with other resources to support ongoing implementation on a global scale. We will provide tailored training materials and a range of implementation strategies, including resources and managerial support for OT services to embed this evidence-based intervention in a variety of settings. Roll out of implementation strategies will involve: - Observing current service provision to establish a baseline on 1-2 occasions over the period of 1 month. - Providing OTs with 1/2 day face to face training on how to deliver the evidence-based intervention, using already piloted training resources. - Conducting OT focus groups and in-depth interviews with service managers to identify implementation determinants and devise strategies to mitigate implementation barriers. - Establishing a process to identify high falls risk older people, referred to the service, to identify those who would benefit from the intervention. - Establishing a process to extend appointment time to enable OTs to conduct a bespoke falls prevention assessment. - The falls prevention assessment takes 90 minutes and will be delivered by OTs over a 3 month period to every older person who meets the study inclusion criteria. The number of older people who receive this intervention will vary by service size and the number of older people at high risk of falls referred to the service. The assessment comprises of a one off functional assessment of the client carrying out personal and domestic care tasks within their home environment, with follow-up visits if deemed necessary as per the OT's clinical reasoning. - Client led falls hazard identification and solution generation with an action plan co-created between the client and OT. - The action plan might include: Possible Hazards addressed/removed if appropriate, referrals for equipment/modifications, private purchase of equipment (e.g. lightweight step ladders with handles, height adjustable rotary washing line). - 6m telephone review to identify any falls since the assessment and adherence to recommendations. - Fidelity will be measured via direct observations of OT practice, review of video recordings of OTs delivering the intervention, focus group/interview discussions, OT reflective logs and chart audit: - Observations of OT practice will occur: • At baseline, to identify the similarities and differences between current and best practice and provide a better understanding of context. • During implementation, to determine fidelity to the intervention protocol and identify whether changes need to be made to how the intervention is delivered. • Post implementation to establish whether the intervention that the OTs deliver is consistent with training received. This design will enable investigation of implementation strategies across public, private and non-government health services, in each state and territory in Australia, of an already established clinically effective intervention.