When it comes to scaling a model of care on a national level, there are numerous challenges around safeguarding this model and ensuring fidelity, regardless of who is delivering it. NIA Fellows Karina Allen and Mike Hurley, describe some of the measures and strategies they have put in place to ensure the fidelity of their innovative care models. 

Karina Allen
Model of care: FREED

“Developing a model of care takes a lot of thought, effort, evaluation and learning. When you are ready to scale the model to new settings, it will be an exciting milestone. It’s also then that a new wave of learning starts. How do you ensure that other people use the model correctly? How do you define ‘correct’? And if something is done ‘wrong’, what will you do about it? All of a sudden, ‘your’ model is outside of your control.

“FREED (First episode Rapid Early intervention service for Eating Disorders) is an evidence-based early intervention initiative for 16 to 25-year-olds with an eating disorder of up to three years duration. It consists of a service model and care package.”FREED was developed at the Maudsley Eating Disorders Service, South London and Maudsley NHS Foundation Trust, and has scaled to three additional eating disorder services in England. With NIA support, FREED is now scaling further.

“As this scaling occurs, there is a need to ensure fidelity whilst also allowing for necessary local adaptations. There are three broad challenges associated with this process.

“The first is how to define fidelity – or in other words, deciding how much variation can occur before the delivery of FREED is ‘wrong’. This requires identifying and clearly defining the core components of the model. For FREED, core components include waiting time targets for assessment and treatment; an engagement call by a FREED Champion within 48 hours of a FREED referral being received; and use of FREED care package materials to adapt treatment to the specific needs of young people with eating disorders.

“The second challenge is ensuring that new services are appropriately skilled to deliver FREED. This requires attention to service characteristics, a comprehensive training package, and an implementation toolkit.

“The third challenge is monitoring adherence and outcomes. Services joining the FREED network agree to share core data. This allows monitoring of adherence to the model, as well as the effectiveness of FREED in new settings.

“Without attending to fidelity, all of the hard work involved with developing an effective model of care may be lost. Changes to the model may make it ineffective, wasting resources and damaging the reputation of the original intervention. So – if you are about to scale a model of care, be excited! But also work out how you will define, support and monitor adherence.”

Mike Hurley
Model of care: ESCAPE-pain

“Enabling Self-management and Coping with Arthritic Pain using Exercise – or ESCAPE-pain – is a programme for older people with chronic knee and/or hip pain. Clinical trials show ESCAPE-pain reduces pain, improves function, quality of life and reduces healthcare utilisation.

“These benefits are achieved in ‘real-world’ settings if the programme delivered is faithful to the ethos, format and content of the original programme.

“Unfortunately, pressures to make the programme cheaper, often mean that people change its content and format, usually by reducing the number of sessions or their content. This reduces its effectiveness.“To encourage fidelity to the original evidence-based programme, we stress the need to replicate it. To do this we identified four ‘core’ components that ‘define’ the ESCAPE-pain programme and are essential for its effectiveness:

  1. The programme is delivered in 12 sessions (two each week over six weeks)
  2. Each session must include an education and exercise component
  3. It is delivered to groups of about ten participants who start and go through the programme together
  4. Outcomes measuring effectiveness are collected and shared with the central team

“The importance of the ‘Core 4’ are emphasised to providers during a mandatory training programme that is a key way that we assure quality of the programme delivered.

“A major problem for people is collecting data, as it takes time and effort, and is seen as an unnecessary luxury. But if outcomes are not being measured, we cannot know if we are being effective, or ensure that we are not wasting precious time, effort and resources. We are trying to minimise the burden of data collection, but it remains a difficult problem to solve for many reasons.

“Several other strategies have been used to encourage fidelity to the programme:

  • We constructed an implementation toolkit that succinctly distils all the information required to set up and deliver the programme
  • Endorsement by professional bodies has been attained to validate ESCAPE-pain’s importance and effectiveness
  • We have tried to create a brand, and to support people delivering ESCAPE-pain to feel some ownership of the programme, so that they want to remain true to it and so that their participants feel its benefits

“Finally, as ESCAPE-pain’s ‘custodians’, we have had to firmly resist pressures to move too far from the programme. This can be uncomfortable at times, but ensuring fidelity is paramount to delivering effective treatment.”