Patients discharged from skilled nursing facilities (SNFs) are at high risk for adverse events. High-intensity resistance rehabilitation (HIR) is a promising approach to mitigate this risk, with early evidence supporting improvements in physical function and discharge outcomes. However, the best strategy for implementing HIR within the complex environment of SNF remains unclear. The purpose of this work was to develop and evaluate a pragmatic, resource-conscious implementation strategy to support the delivery of HIR in SNFs. Our initial efforts demonstrated that resource-intensive implementation support led to superior implementation and patient outcomes compared to low-resourced approaches. Recognizing the need for a feasible, scalable strategy, we adopted a systematic, partner-informed approach to develop and evaluate a more targeted implementation strategy.  

In 2020, we convened an expert panel of clinician-researchers and SNF clinicians and followed the steps of implementation mapping to identify barriers and facilitators, specify behavior changes necessary for HIR implementation, select theory and evidence, and produce the implementation strategy and plan for its evaluation. This process led to an 18-week, multicomponent implementation strategy centered on clinician education and training. It also included an external implementation facilitator, clinician decision aids, and equipment provision. We piloted this strategy in eight geographically diverse SNFs between 2021 and 2022 as part of a quality improvement initiative within the Veterans Health Administration (VHA).

The strategy improved clinician knowledge, self-efficacy, and perspectives related to HIR and led to acceptable program adoption, although full integration into routine practice remained limited. Implementation was influenced by patient openness to high-intensity rehabilitation; clinician creativity, adaptability, and professional commitment; and observation of positive patient responses, such as increased confidence and functional gains. Team cohesion, care continuity, efforts to make HIR salient in daily practice, and leadership support further reinforced uptake. Clinicians found the initial strategy highly acceptable and moderately feasible, recommending streamlining the training and expanding video examples to illustrate real-world application. The strong influence of leadership support highlighted the need for resources targeting leadership engagement. These findings informed refinements aimed at enhancing facilitators and addressing barriers.

We are currently in the process of refining our implementation strategy to streamline training by incorporating a broader range of video examples that illustrate clinical application in commonly challenging scenarios. Additionally, we are developing a leadership-focused HIR implementation toolkit. These resources are being consolidated on a shared virtual platform to support broader dissemination across the VHA and to explore applicability in another healthcare system.