Measures, data sources and data collection timeline by RE-AIM dimension and assessment level
| Assessment level(s) | Measures | Data sources | Timeline |
|---|---|---|---|
| Reach | |||
| Individual | ▸ Eligibility criteria | ▸ Patient-recruitment tracking system | ▸ Ongoing |
| ▸ Demographic information | ▸ Survey items | ▸ HEALD-PCN specific:
baseline, 3–6 months ▸ TeamCare-PCN specific: baseline, 612 months | |
| ▸ Identified facilitators and barriers to recruitment ▸ Identified recommendations for improvement | ▸ Interview data (PCN staff and ABCD team) | ▸ Baseline and midpoint | |
| ▸ Patient characteristics (participants vs population) | ▸ PCNs’ patient registry ▸ AH/ADSS data | ▸ Post-intervention | |
| Organisation | ▸ Ability to estimate and identify targeted patient populations | ▸ Document review (standardised checklist) | ▸ Baseline |
| ▸ Registry development and maintenance process issues, including identified facilitators and barriers ▸ Identified recommendations for improvement | ▸ Interview data (PCN staff and ABCD team) | ▸ Baseline and midpoint | |
| ▸ Document review (field notes) | ▸ Ongoing | ||
| Effectiveness | |||
| Individual | Primary outcomes: A1c, blood pressure, total cholesterol, & BMI ▸ HEALD-PCN specific: total # of steps ▸ TeamCare-PCN specific: Composite of PHQ-9 Secondary outcomes: self-reported quality of life, quality of care, self-efficacy, & satisfaction with care ▸ HEALD-PCN specific: nutritional behaviours & satisfaction with intervention ▸ TeamCare-PCN specific: process care indictors including: # of visits with healthcare providers, referrals, psychotherapy sessions, medication adjustments, and adherence to treatment | ▸ Clinical assessment recorded in patient outcome tracking systems ▸ Survey items | ▸ Ongoing ▸ HEALD-PCN specific: baseline, 3–6 months ▸ TeamCare-PCN specific: baseline, 6–12-months |
| ▸ Perceptions of impact/ consequences (positive or negative) | ▸ Interview data (PCN staff) | ▸ Baseline, midpoint, and post-intervention | |
| Adoption | |||
| Individual | ▸ Total number of member physicians participating in ABCD project | ▸ Document review (PCN and ABCD project documents) | ▸ Post-intervention |
| Organisation | ▸ Criteria for PCN participation in ABCD Project ▸ PCN Board agreement to participate ▸ Features of participating PCNs ▸ Comparison of characteristics between participating and non-participating PCNs, as possible ▸ Description of usual care in the focus areas ▸ Perception of extent to which ABCD Project has been adopted by PCNs and modified to fit their context(s) ▸ Identified facilitators, barriers, and recommendations at organisational level | ▸ Document review (project and PCI/PCN documents –websites and business plans, availability of secondary data e.g., PCI evaluation) ▸ Standardised checklist ▸ Interview data (PCN staff) | ▸ Baseline, midpoint, and post-intervention |
| Implementaton | |||
| Individual | ▸ HEALD-PCN specific: # of steps in log and
self-reported physical activity ▸ TeamCare-PCN specific: adherence to treatment plan, including medications and behavioural modifications | ▸ Patient outcome tracking systems ▸ Survey items | ▸ Post-intervention |
| Organisation | Development of: ▸ Project materials: job descriptions for intervention staff, recruitment and data collection protocols and forms ▸ Training and resource materials: project binders, algorithms, patient resources ▸ Systems/processes: patient registries, patient recruitment & outcome tracking systems | ▸ Document review (PCN and ABCD Project documents) | ▸ Baseline |
| ▸ # and type of intervention staff hired by PCNs, including turnover | ▸ Document review (eg, contracts) | ▸ Ongoing | |
| ▸ Provision of and quality of training in ABCD Project and interventions: # and type of staff trained, detailing sessions, and training materials provided; attendance in training sessions; assessment of change in knowledge and satisfaction | ▸ Document review (ABCD Project documents) ▸ Presurvey /postsurvey items ▸ Interviews with PCN intervention staff | ▸ Baseline, midpoint, and post-intervention | |
| Service delivery: ▸ HEALD-PCN specific: # and type of group meetings and patient resources distributed; level of attendance ▸ TeamCare-PCN specific: # and type of screenings, assessments, patient management plans, follow-up sessions, specialist consultations; time of service delivery; and QI assessment through monthly teleconferences | ▸ Document review:(class attendance lists) ▸ Patient outcome tracking systems | ▸ Ongoing and post-intervention | |
| ▸ Perceptions of implementation as intended ▸ Identified facilitators and barriers to implementation ▸ Identified recommendations for improvement | ▸ Interviews with PCN staff | ▸ Baseline, midpoint, and post-intervention | |
| ▸ Document review (field notes, communications, meeting minutes) | ▸ Ongoing | ||
| ▸ Economic Evaluation: Decrease in # of family physician and ER visits; reduction in complications, co-morbidities, and mortality; reduction in direct medical costs; and reduction in projected future healthcare costs | ▸ Document review (budget and invoices) ▸ AH/ADSS data | ▸ Post-intervention | |
| Maintenance | |||
| Individual | ▸ Sustained awareness, knowledge, and management of type 2 diabetes and depression or lifestyle behaviours | ▸ Survey items (ABCD Cohort Study) regarding health behaviours and self-care | ▸ Post-intervention & ongoing (minimum 4-year follow-up) |
| ▸ Interviews with HEALD-PCN intervention group participants | ▸ Post-intervention | ||
| Organisation | ▸ PCN level: integration of aspects of the model into usual care; and/or incorporation of models into future business planning | ▸ Interviews with PCN staff | ▸ Post-intervention |
| ▸ More appropriate healthcare utilisation: decrease in # of family physician and ER visits; reduction in complications, comorbidities, and mortality; reduction in direct medical costs; and reduction in projected future health care costs | ▸ AH data | ▸ Post-intervention | |