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      The dynamic sustainability framework: addressing the paradox of sustainment amid ongoing change

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          Abstract

          Background

          Despite growth in implementation research, limited scientific attention has focused on understanding and improving sustainability of health interventions. Models of sustainability have been evolving to reflect challenges in the fit between intervention and context.

          Discussion

          We examine the development of concepts of sustainability, and respond to two frequent assumptions —'voltage drop,’ whereby interventions are expected to yield lower benefits as they move from efficacy to effectiveness to implementation and sustainability, and 'program drift,’ whereby deviation from manualized protocols is assumed to decrease benefit. We posit that these assumptions limit opportunities to improve care, and instead argue for understanding the changing context of healthcare to continuously refine and improve interventions as they are sustained. Sustainability has evolved from being considered as the endgame of a translational research process to a suggested 'adaptation phase’ that integrates and institutionalizes interventions within local organizational and cultural contexts. These recent approaches locate sustainability in the implementation phase of knowledge transfer, but still do not address intervention improvement as a central theme. We propose a Dynamic Sustainability Framework that involves: continued learning and problem solving, ongoing adaptation of interventions with a primary focus on fit between interventions and multi-level contexts, and expectations for ongoing improvement as opposed to diminishing outcomes over time.

          Summary

          A Dynamic Sustainability Framework provides a foundation for research, policy and practice that supports development and testing of falsifiable hypotheses and continued learning to advance the implementation, transportability and impact of health services research.

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          Most cited references37

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          Self-management education: history, definition, outcomes, and mechanisms.

          Self-management has become a popular term for behavioral interventions as well as for healthful behaviors. This is especially true for the management of chronic conditions. This article offers a short history of self-management. It presents three self-management tasks--medical management, role management, and emotional management--and six self-management skills--problem solving, decision making, resource utilization, the formation of a patient-provider partnership, action planning, and self-tailoring. In addition, the article presents evidence of the effectiveness of self-management interventions and posits a possible mechanism, self-efficacy, through which these interventions work. In conclusion the article discusses problems and solutions for integrating self-management education into the mainstream health care systems.
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            Organizing care for patients with chronic illness.

            Usual medical care often fails to meet the needs of chronically ill patients, even in managed, integrated delivery systems. The medical literature suggests strategies to improve outcomes in these patients. Effective interventions tend to fall into one of five areas: the use of evidence-based, planned care; reorganization of practice systems and provider roles; improved patient self-management support; increased access to expertise; and greater availability of clinical information. The challenge is to organize these components into an integrated system of chronic illness care. Whether this can be done most efficiently and effectively in primary care practice rather than requiring specialized systems of care remains unanswered.
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              National Institutes of Health approaches to dissemination and implementation science: current and future directions.

              To address the vast gap between current knowledge and practice in the area of dissemination and implementation research, we address terminology, provide examples of successful applications of this research, discuss key sources of support, and highlight directions and opportunities for future advances. There is a need for research testing approaches to scaling up and sustaining effective interventions, and we propose that further advances in the field will be achieved by focusing dissemination and implementation research on 5 core values: rigor and relevance, efficiency, collaboration, improved capacity, and cumulative knowledge.
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                Author and article information

                Contributors
                Journal
                Implement Sci
                Implement Sci
                Implementation Science : IS
                BioMed Central
                1748-5908
                2013
                2 October 2013
                : 8
                : 117
                Affiliations
                [1 ]Division of Services and Intervention Research, National Institute of Mental Health, 6001 Executive Blvd, Rockville, MD, USA
                [2 ]Department of Family Medicine, University of Colorado School of Medicine, Denver, CO, USA
                [3 ]Department of Family Medicine, Case Western Reserve University, Cleveland, OH, USA
                Article
                1748-5908-8-117
                10.1186/1748-5908-8-117
                3852739
                24088228
                b405fdf6-c840-4fac-8445-704007190a09
                Copyright © 2013 Chambers et al.; licensee BioMed Central Ltd.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                Categories
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                Medicine

                sustainability, maintenance, adaptation, dissemination, implementation, framework, model

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