Phase 4: Full Implementation

At a Glance

Each phase of the implementation process includes 4 components: activities, tools, outcomes and self-reflection. Select one below to jump directly to that component.

Activities Tools Outcomes Self-Reflection

The goal of the full implementation stage is to integrate the core components of the systems into standard practice so that they are sustainable, consistent, and effective over time. At this stage, your system change may be ready to replicate in other regions or settings. Your team will continue to use data to monitor outcomes and support ongoing quality improvement. Although some family and community partners will be team members or champions of change, other partners and families may be less directly engaged with the implementation of the system change. As teams consider scaling initiatives, it will be essential to get feedback from the partners that are less directly involved in implementation to ensure the change remains aligned with evolving local needs and priorities. The focus now is on sustaining progress, scaling as appropriate, and embedding the changes within broader systems of care for CYSHCN.

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Full Implementation Phase Activities

Examples of full implementation phase activities recently carried out by Title V CYSHCN programs include:

Example Activities from Title V CYSHCN Programs

Continued statewide scaling of programs
Created layered meeting structures with external stakeholders to support fully implemented programs
Evolved measures from activity counts to quality outcomes
Increased external awareness of system change
Built logic model and website to illustrate the entire change process
Advanced sustainability through processes such as moving to internal data evaluation, building relationships with Medicaid and managed care plans
Hired permanent facilitator for programs
Created a paid parent outreach coordinator role
Expanded and/or created sustainable processes for participation, such as paid family leader participation, regular engagement opportunities, and co-leadership for family leaders in workgroups and subcommittees
Embedded continuous improvement of the program in the long-term
Customized workflows to sites and refined practices over time
Identified champions at every level to help with sustainability
Off-boarded sites that have finished implementation to help with costs and to build sustainability

Consider which activities might be relevant for your system-change effort at this phase, keeping in mind that the change process is not always linear, and you will likely return to this phase over time. Teams may do these activities in a different order, and/or omit activities as needed:

Activities to Consider

Evaluate and decide if you will make any adaptations from initial implementation, and if you will continue the intervention in the original context.
Ensure your selected system change is consistent and high-quality across settings, and that all core components are being executed as intended.
Consider what additional support might be needed for the program to continue to grow (eg, funding sources, policy changes, collaboration with other industries).
Monitor and improve implementation supports and resources as needed to sustain implementation.
Consider opportunities for more cross-sectional collaboration (eg, schools, mental health providers, and community organizations).
Determine how, why, and what you need to scale to other regions or contexts.
Continue to collect data and evaluate to ensure the intervention is still making the positive outcomes you identified.
Engage with community members, family leaders, and partners continuously to disseminate findings, find opportunities for growth, and ensure their current needs are still in alignment with your program.

In Case Study #1 Pediatric Behavioral Health Collaborative, the initiative scaled to 8 regional hubs, aligned with Medicaid and state health plans, and evolved measures from activity counts to quality outcomes, showcasing how system change can become embedded and sustainable.

Tools to Consider During Full Implementation

These tools can be useful during full implementation and have been successfully used by CYSHCN teams in their efforts to transform systems.

Implementation Plan Template

Guide the development of an implementation plan at any phase of implementation.

PDSA Cycles

Rapidly identify an issue and a needed change, measure the impact, and make an informed plan to improve.

CDC’s Program Evaluation Framework

Plan effective public health strategies, improve existing programs, and demonstrate the results of resource investments.

FESAT

Plan, assess, and improve family engagement.

30 30

Monitor progress and document anticipated action steps in ongoing work.

Action Plan

Prioritize and stay on task by naming tasks to be done and updating progress.

Initial Implementation Phase Outcomes

Evidence that program goals are being met.
Sustained use of the program.
Data is regularly being used to inform decision-making and improve implementation of the program.
Greater trust and stronger relationships with partners.
Improved implementation, service delivery, or health outcomes for CYSHCN.
There is demonstrated evidence that the system of services for CYSHCN has improved. One or more of the following are evident:
- Coordinated, continuous, and comprehensive care delivered through a centralized medical home
- Active family and caregiver engagement in decision-making at all levels of the system
- Quality access to public and/or private health insurance for CYSHCN and their families
- Early and ongoing screening to identify special health care needs
- High-quality, well-organized services that are responsive to the needs of both CYSHCN and their families
- Evidence of support for successful pediatric to adult health care transition

Full Implementation Phase Self-Reflection

Use the self-reflection questions below to prompt your thinking about the change you want to make at this phase. The reflection table can be used at any point in the system change, to process your learning and identify next steps. Begin by having each team member do individual self-reflection, then share the responses with other team members as part of a larger group discussion. The group discussion can be used during ongoing team meetings or progress check-ins. Core components are the essential parts of an intervention or innovation. You can think of them like the “active ingredients” that allow your intervention to work. Core components can be developed and refined over time but are the “what” to the system change you are hoping to make. Start by naming your core components below.

Core Components

Family or Community Partnerships

Facilitators

Barriers

Needs

Assets

Phases of Implementation

Phase 1: Exploration

In this phase, teams examine the current systems for opportunities to improve care for CYSHCN, identify core components of the system-level change, and assess feasibility of the system-level change.

Phase 2: Installation

In this phase, teams identify the key resources and infrastructure needed to implement the system-level change and build monitoring and evaluation plans to monitor if the changes are working.

Phase 3: Initial Implementation

In this phase, teams put the system-level intervention(s) in practice, work through unexpected challenges, and based on monitoring and evaluation results, make adjustments to improve how the intervention is delivered.