Accessible solutions are needed to help frail older adults manage their incontinence, so we enhanced a telephone coaching program provided by incontinence product service representatives to meet this need. We present an evaluation of the implementation and adoption of our intervention by interventionists and participants.

Our single group pre-test post-test implementation study used the NIH Dissemination and Implementation Framework to create and evaluate implementation (fidelity, attrition, costs) and adoption (receipt of treatment, enactment of skills) processes and outcomes [1]. The 9-month intervention included 16 telephone coaching sessions from incontinence product representatives. Coaching focused on implementing tailored conservative management strategies to address voiding behavior, bladder and bowel training, food and fluid modifications, medication adherence, mobility, falls, skin health, urinary and fecal leakage, and appropriate incontinence product selection. Participants received incentives, such as, magnets, fleece blankets, fitness watches, pill boxes, and lighted magnifiers at baseline, 6 and 9 months. Interventionist fidelity measures included completion of training from continence nurse specialists on conservative bladder and bowel management, training on obtaining consent, and quality assurance checks and attending bimonthly study meetings. Labor costs included interventionist FTE and tracking the number of phone sessions completed and attempted. Training costs included tracking the number of trainees and trainers, and the number of training hours. Other costs included standard telephone usage fees and the standard license for the patient management system. Participant adoption measures included receipt of treatment (# sessions and topics discussed) and enactment of treatment skills through six verbal teach back sessions. Reasons for attrition were monitored. Although this implementation study was exempt from IRB oversight, we still obtained verbal consent from participants. Descriptive statistics were used to describe the implementation and adoption outcomes.

The 82 participants were mostly white (67%) women (90%) with a mean(SD) age of 66.5(7.85) years receiving Medicaid benefits. All lived in the community and 28% received home health services. Over 72% were frail as defined by the Vulnerable Elders Survey. Of the 51% that lived with others, 17% required assistance with toileting. Three interventionists attended an 8-hour training session from two continence nurse specialists to learn the coaching content and from one supervisor to learn how to document program activities into the patient management system. All passed the quality assurance checks and attended the bimonthly meetings. Over the 9-month program interventionists spent 1200 hours implementing the program accounting for 0.58 FTE and completed 1084 telephone calls. Participants received 1 to 39 calls with a median of 15 and mean(SD) of 13.2(8.1). On average participants completed 63% of the 16 prescribed sessions, with 27% completing all of them. 89% of participants had on average 7 successful teach back sessions. The number of participants decreased over time with 82 at the start of the intervention, 54 at 3 months, 42 at 6 months, and 41 at 9 months. The most common reasons for withdrawal were losing interest (N=25), and being unreachable (N = 9).

Interventionist fidelity was strong and program costs did not exceed normal operating costs. Participant retention was poor with 50% dropping out over the 9-month program mostly due to losing interest. Participant adoption was acceptable with active participants completing on average 63% of required sessions. Participant enactment was high with 89% demonstrating knowledge attainment through teach back.

Incorporating incontinence telephone coaching into the work of incontinence product service representatives is feasible and can be done with high treatment fidelity. For interested participants adoption and engagement are good, suggesting telephone coaching by trained lay health workers is acceptable to frail older adults with incontinence.

1.	G. Neta, R.E. Glasgow, C.R. Carpenter, J.M. Grimshaw, B.A. Rabin, M.E. Fernandez, et al., A framework for enhancing the value of research for dissemination and implementation, Am. J. Public Health 105 (1) (2015) 49-57. https://doi.org/10.2105/ajph.2014.302206