Discussion
LENS
To our knowledge, no studies have used implementation frameworks to assess postpartum patient navigation in the United States. Assessing factors responsible for successful implementation is imperative to identify best practices and gaps that may inhibit its effectiveness or dissemination, even if it is shown to be efficacious in a trial setting. In the context of an ongoing RCT, we evaluated the implementation of postpartum navigation. Using the CFIR framework, we identified multiple features associated with successful implementation. Although a complex and fragmented healthcare system impedes patients’ ability to receive quality care, especially during the postpartum period, patient navigation offers an opportunity to support patients in an individualized manner during this period of transition [The individualized nature of the innovation addressed patients’ unique needs at individual, systems-based, and community levels. Over time, the health system and care team members demonstrated a high readiness for implementation, as navigators used consistent communication and the electronic medical record to successfully integrate into the postpartum care team. Both systems-focused and personal development throughout the year facilitated navigation’s implementation, as navigators honed their skills. Importantly, however, the need for individualization contributed to a high degree of implementation complexity. Wide-ranging patient needs and levels of engagement, along with the fragmented healthcare and social services ecosystem, challenged the implementation of postpartum navigation yet also supported the rationale for the intervention. Complexity, varied engagement, and systems fragmentation all served as barriers to implementation. Navigator training and the support of care team members mitigated some of these challenges. These barriers and facilitators to implementation mirror those identified in existing literature that analyzes patient navigation in non-postpartum settings such as oncology [Optimized postpartum care requires the coordination of patient care with multiple care teams and community resources [Our findings also demonstrated the depth of navigation activities that are needed in the first year, as well as the wide range of interactions with both patients and care team members. Descriptive notes in log entries illustrated the complexity of navigators’ interactions with patients, as a single interaction usually covered multiple topics and one topic typically crossed multiple interactions. Our log and interview data suggest individuals with more complex needs and willingness to participate in healthcare are more likely to engage with and benefit from postpartum navigation. Further, log entries varied widely between patients, demonstrating the breadth and individuality of postpartum needs. Likewise, activities mirrored those completed by oncologic navigators, where navigation was first implemented, demonstrating consistent navigation practices across specialties [Several specific features of the implementation context warrant mention. The site of study, a well-resourced urban academic medical center, may not represent the spectrum of postpartum care settings, and facilitators of and barriers to implementation may differ in other contexts. Further, this navigation program, occurring in the context of a clinical trial, included training and opportunities for continued education regarding navigation practices. Translating navigation from a research setting to sustainable long-term implementation will require additional facilitators, such as the financial and organizational support of health system administrators, who were not interviewed for this investigation. However, the knowledge this study provides regarding workload, complexity, and facilitators for navigation, along with future data regarding the innovation’s efficacy, can augment future cost-benefit analyses of postpartum patient navigation.Despite the novelty of this analysis and its rich, layered use of real-time trial data, there are limitations to note. The relatively small sample of patients (N = 50) and navigators (N = 3) means the complete variability in navigator tasks may not have been appreciated. However, thematic saturation in interview and log data occurred, and consistent quantitative patterns of log data emerged. Additionally, it is possible that despite tracking their activities, the complexity and scope of the innovation may have caused navigators to miss documentation of interactions or tasks throughout the postpartum year. These omissions, however, would only underestimate the need for and breadth of navigation. Moreover, standardized training, programmatic goals and check-ins, and documentation logs likely limited such omissions or variability between navigators. Assessing implementation through the lens of navigators may also introduce bias, as individuals are likely to express pride in and highlight the successes of their work. Likewise, navigator interviews were not anonymous, potentially introducing social desirability bias. Nevertheless, positive attitudes about navigation came not only from navigators themselves but were also relayed to navigators by participants and care team members. Future investigation into the opinions of patients and care team members would further supplement implementation analysis. Finally, our data demonstrated changes in navigation implementation that occurred with increasing experience; this evolution of implementation suggests stories and experiences may differ for future participants.