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Implementation Determinants and Strategy Selection for Guideline-Recommended Cognitive Rehabilitation in the VHA
Adam R Kinney1, Morgan Nance2, Molly E Penzenik1
1Veteran Affairs Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC) for Suicide Prevention, Aurora, CO; Department of Physical Medicine and Rehabilitation, Anschutz Medical Campus, University of Colorado, Aurora, CO.
Objective:
To identify barriers and facilitators to implementing guideline-recommended cognitive rehabilitation within the Veterans Health Administration (VHA) Polytrauma/Traumatic Brain Injury System of Care (PSC) and to systematically identify implementation strategies targeting these determinants.
Design:
Qualitative study using semistructured interviews informed by the Consolidated Framework for Implementation Research (CFIR), followed by CFIR-Expert Recommendations for Implementing Change (CFIR-ERIC) mapping to identify implementation strategies aligned with identified determinants.
Setting:
VHA PSC.
Participants:
PSC providers involved in delivery of cognitive rehabilitation for Veterans with traumatic brain injury (TBI; n=14), including referring providers and cognitive rehabilitation specialists.
Interventions:
None.
Main Outcome Measures:
CFIR-based implementation determinants and implementation strategies aligned with identified determinants, identified using CFIR-ERIC query results.
Results:
Barriers and facilitators to implementing guideline-recommended cognitive rehabilitation were identified across multiple CFIR domains. Key barriers included perceived misalignment between manualized treatments and individualized Veteran needs, intervention complexity, limited staffing and organizational prioritization, gaps in provider knowledge of evidence-based practices, and lack of systematic implementation planning and evaluation. Facilitators were primarily concentrated within the inner setting and included interdisciplinary collaboration, support for provider training, and leadership prioritization of cognitive rehabilitation. CFIR-ERIC mapping identified 23 discrete implementation strategies aligned with these determinants. The most aligned strategies included identifying and preparing champions, assessing readiness and barriers, developing an implementation blueprint, capturing and sharing local knowledge, and conducting local needs assessments.
Conclusions:
Implementation of guideline-recommended cognitive rehabilitation within the PSC is shaped by multilevel determinants. Findings underscore the need for coordinated, multicomponent implementation strategies that extend beyond training alone and are tailored to the organizational context of the PSC. This work provides a strong foundation for future implementation efforts capable of expanding access to evidence-based cognitive rehabilitation for Veterans with TBI.
