Table 4 Examples from Periodic Reflections Across EMPOWER Projects

Dynamic Implementation Ecology

• CCWV: Characteristics of the local site

“[Site] is an amazing site. I don’t think it’s inconsequential that they have such a strong PACT leader and mental health leader, and stable leaders as well, and champions in the field.

Doing really innovative things, and dedicated to quality improvement…they have a lot of good stuff going on.” [Study Lead, Pre-implementation Phase]

• DPP: Shifting national policy environment

“[There’s change in] the climate around doing remote delivery of healthcare, which I think VA is increasingly interested in….different than two years ago when we submitted the [project grant] proposal.” [Study Lead, Maintenance Phase]

Adaptations to the Intervention

• CV Toolkit: Adding a co-facilitator for Gateway for Healthy Living groups.

“One of the…recommendations that we were going to incorporate…The report said that facilitators liked when they co-facilitate with someone else – things seemed to run better. So we want every site to have a co-facilitator and probably a back-up so they could run sessions with two people or also with one.” [Study Co-Lead, Pre-implementation Phase]

• CCWV: Expansion of care manager role.

“…[W]e’re going to find it useful for [care manager] to have a little bit broader responsibility than we imagined. She won’t get perfect referrals, but doing the triage ourselves will be better than trying to get the primary care team to do it.” [Study Co-Lead, Pre-Implementation Phase]

Adaptations to the Implementation Plan

• DPP: Expansion of the program beyond initial plan.

“We have decided to send out another few hundred invitations because we have the capacity.” [Study Lead, Pre-Implementation Phase]

• CV Toolkit: Addition of a patient-facing communications plan.

“The other thing that developed…was that we ended up having to have a communication plan….The marketing strategy.” [Study Co-Lead, Implementation Phase]

Team Sensemaking and Learning

• DPP: Sensemaking around an appropriate space for in-person groups.

“The room we’d planned to use isn’t conducive because of the chairs and tables. We worked with [clinic leads] to find a space next to the clinic. We didn’t want women to have to go too far where they might be subject to harassment.” [Study Lead, Implementation Phase]

• CV Toolkit: Learning the importance of an on-site clinical partner.

“In terms of lessons learned, the most important thing that happened was [the on-site clinical partner] showing up. The moment [she] walked in, everything changed….I didn’t know she was going to have such an impact on the clinical side.” [Study Co-Lead, Pre-implementation Phase]