Episode # 72: Implementation Science, Aphasia, and Sauce: A Conversation with Natalie Douglas

Dr. Katie Strong, Assistant Professor in the Department of Communication Sciences and Disorders at Central Michigan University talks with Dr. Natalie Douglas from Central Michigan University implementation science and how this applies to aphasia practice.   Natalie Douglas is Lead Collaborator at Practical Implementation Collaborative, an Associate Professor in the Department of Communication Sciences & Disorders at Central Michigan University, and an Editor at the Informed SLP. She completed her B.S. and M.A. degrees at Ohio University and after a decade of clinical practice as a speech-language pathologist in hospital and long-term care environments, she completed her Ph.D. at the University of South Florida. Her work aims to advance best, person-centered practices in communication and quality of life interventions for people with dementia, aphasia and other acquired communication disorders in adults. She additionally aims to empower local healthcare and educational teams to support best practices, quality improvement initiatives and person-centered care through applying principles of implementation science. In this episode you will:  Learn about what implementation science is and how this applies to aphasia practice Hear about how using an implementation lens can lead to better outcomes with clients and families.  Learn about Sam, the Bocce player, his sauce, and the importance of a person-centered approach to care in people living with dementia. KS: Natalie, welcome to the Aphasia Access Conversations Podcast. Thank you for joining us today.  I’m looking forward talking with you and having our listeners learn about your work.   ND: Thank you, Katie. I’m always so happy to talk with you, especially here today.  KS: So, I feel like we should share with our guests, a couple of fun tidbits about how you and I are connected before we get into the meat of today’s conversation.  ND: Okay, let’s do it. KS: So first and foremost, we are colleagues at Central Michigan University. We share actually share a wall. Our offices are in the same hallway, although with pandemic, it’s been awhile since we have both been in the office together. So, we are colleagues and have a lot of great fun together. But we have another way that we are connected as well.  ND: Yes. So, we crossed paths. I think in the early 2000s. So, I was working at a certain hospital system from 2003 to about 2013. And then I came to find…this was in Florida, by the way, we're in Michigan now. And then I found out that you worked for that same hospital system, also as an SLP right before I started, or something close to it.  KS: I did! Yes, we came up to Michigan in 1999 so I was there just a couple of years before you were, and we had shared colleagues! ND: Amazing. KS: Crazy. ND: It was meant to be can't get away for me, I was going to find you!  KS: Absolutely, well fate! Fate. I love it! NS: Indeed. KS: Let me first congratulate you on being named a Tavistock Trust for Aphasia Distinguished Scholar. It’s fabulous! Tell me a bit about what this award means to you.  ND: Thanks for that so much. And this award really means a lot to me. I'm just so truly honored, grateful and humbled to receive it, along with people such as yourself and many other esteemed colleagues. And upon finding out about the receipt of this award, it really kind of prompted me into a lot of reflection from when I first started studying speech language pathology. So, this was, you know, in my undergrad degree in 1997. And I, a couple years after that, was introduced to what aphasia was. And, you know, this was further nurtured by working with Dr. Brooke Hallowell. And then continuing, you know, through clinical practice and trying to improve life for people with aphasia, working with Jackie Hinckley in my PhD program. And it really had me become extremely reflective upon what I've been doing recently, which is more system level changes. So how can we ensure that people with aphasia and other communication disorders, how does everybody have access to the best interventions? How do we make it so that best practice is not based on where you have your stroke, geographically speaking? You know, how do we spread what we know, works for people? How do we get the word out so that it becomes routine based care? So, this award, it just served as a catalyst for a lot of deep reflection and gratitude for the work that I've done in the past and now and also for the work that needs to be done in the future. So, I'm just extremely grateful to the Tavistock Trust and colleagues and mentors for this really humbling award. So, thank you for that. KS: Congratulations! The award is well deserved, and we are excited to hear about your work, both the work you have been doing and the work the will come in the future too. Natalie, as we get started, I’d love to hear the story of how you became interested in implementation science as an area of research and expertise.  ND: Sure, so, I think like many of us, when I was working in a clinical setting, there were many problems that I didn't feel like I had the ability to solve with my clinical training. So, you know, I just, quite honestly would leave clinical practice at times feeling honestly, full of guilt and shame, quite frankly, because I felt like I wasn't giving clients and patients and people the best possible services for one reason or another.  KS: I feel like a lot of people listening who are working clinically or have worked clinically in the past can really relate to that. You know, we all get into this field to help people and then when you get into it, sometimes that help isn’t as easy to do with a lot of the barriers that are in place.  ND: Yeah, exactly. You know, and for me, you know, there were some cases where it wasn't necessarily an issue of me not knowing what to do. So in in many cases, I had the knowledge and in some cases, I had the skills. Not in all cases, there was often a skill gap to but in some cases, I did have the knowledge and skills to provide a certain evidence-based practice, but I still wasn't. And until I came across implementation science, I thought it was my own personal, I mean, honestly, moral failing why I wasn't. KS: That’s heavy. ND: Yeah. I don't know that everyone hits existential crisis, like I do. But I mean, I really did, because it didn't feel right. You know, it didn't. It didn't feel right. Um, so it was, you know, the inability to solve those types of problems that really kind of propelled me back into academia. And so, when I first started my Ph D program, with Dr. Jackie Hinckley, I thought I was going to do something with aphasia treatment research. And I don't know how she remembers this, but it was sometime around in 2009. Jackie gave me a monograph, just a little book by Dean Fixen and colleagues and it was about implementation science. And it talked about how there was an entire discipline, dedicated to really merging the gap between research and practice. And it showed that there are mechanisms kind of outside of me as a person that influenced what I was able to do clinically. So factors like, what the organizational culture is like, what the organizational climate is like, things like insurance, reimbursement, policy. You know, all of these factors that are really outside the individual realm of the clinician, that we have data to show that it really does, those other factors influence what we're able to implement on a clinical level. And so I just kind of devoured that monograph, and quite honestly, been thinking about it, ever since in one iteration or the other. Because it's not just our field, you know, it's not just speech language pathology, it's not just aphasia, you know. This is across education, mental health services, every medical specialty. You know, we the way that we've created these systems of academics and practice, we've kind of reinforced silos. And so, the two don't always meet without active work. And that, I think, is what implementation science can really do. It can provide tools to kind of bring those realms together.  KS: It sounds like it was really a mind-blowing experience for you to have that monograph in your hands. ND It was mind blowing. Indeed.  KS: And how lucky we are that it got into your hands. Well, I know many of us have heard that term, Implementation Science, but it isn’t always clear what is meant by that. Could you help us to understand that a little bit more? ND: Right. I think that's a really great question. And I think it's definitely not something to take for granted. You know, as helpful as, as implementation science is to our discipline. Within implementation science, there are a lot of constraints in terms of like language and terms, so it can get a little bit foggy, hazy pretty quickly. But the NIH or the National Institutes of Health definition of implementation science is really the study of strategies to help to determine how to best implement an intervention or evidence-based practice into a typical practice setting, usually as delivered by typical practitioners. So, this is not a situation where you would hire an interventionist or a graduate student, for example, to implement your assessment or intervention tool in a typical setting. I mean, there's definitely nothing wrong with that. But that's not in that could be, you know, if you're following a stage model, you know, that could be a direction that you go. But I think the guts of implementation is having, you know, and I think the routine typical clinician is a beautiful, amazing thing. So, I hope it doesn't don't when I say routine and typical, I really don't mean it in a negative way. But to get just really everybody on board.  KS: You mean your average, fabulous, SLP who is out there working directly with clients and families.  ND: Exactly, exactly. So, what we can do is just like how you would study the effectiveness of an intervention, okay. So, you have, for example, communication partner training. That's an example of an intervention in our discipline has a lot of effectiveness data, right? We know that it works, right? When it under certain parameters, we know that it can support communication and other quality of life outcomes. So, what you would do is, in addition to studying the effectiveness of an intervention, or if the intervention has already been studied, you could study the effectiveness of an implementation strategy. So, for example, you might say, “Okay, if we put in some type of audit and feedback system, does that increase the uptake of communication partner training?” Or if we provide incentives in some way, like some type of certification, or honestly, you know, the ultimate, not the ultimate, but a very effective implementation strategy is paying people to do something, right. And so that's, we don't do that in our field. But if, you know, as I said, a little bit earlier, you know, this is something that's, you know, grown outside and kind of encompasses many disciplines. You know, if I think about myself, and what causes me, you know, to want to change my individual level behaviors, right? There's like, certain incentives that might get me to do that. But those are implementation strategies, and not necessarily the intervention itself. Right? So, implementation sciences, like how do we get it into that typical setting, delivered by a typical practitioner, in the best way? So, just like how you could comparatively assess, you know, two different naming interventions for aphasia, you could assess two different implementation strategies. You can say, “Okay, if I put audit and feedback in one condition, and then I put education and training and another condition, am I going to get different adoption rates?” Right, will, more people do it in x condition versus y condition? Does that make sense?  KS: Yeah it does. So, taking the example you used for communication partner training, and we know that it has a high level of evidence that it works, but I’m not sure if our fabulous, everyday clinicians are using it on a regular basis. So that would be a step to then have some sort of implementation study or protocol to help basically get the evidence out into practice. Is that what we’re talking about?  ND: Yeah, it is right. So right. And you kind of said it without saying it. So, one example of an implementation outcome would be something like reach. Okay. So, it's like, if we looked at all of the potential places where communication partner training might be beneficial, right? How do we get that number up? You know, with fidelity to what communication partner training actually is, right? Which we know is not just handing somebody a handout, right? So, you know, those are the types of kind of questions that you might ask, you know, and we can use an implementation science framework to kind of guide our thinking, you know, like, how do we get this reach up? or higher? How do we know, you know? And it gets messy, you know, it definitely gets messy and there's, it's complex, a lot of these questions. But these are the types of questions that I really think we need to be asking if we're wanting to advance these positive outcomes for families. KS: Yeah. And I think that messiness kind of substantiates how you were feeling back when you were working clinically. Right? That you had this knowledge and skill.. ND: That is true. KS: But you can’t actually get it going into your day to day practice.  ND: That's right. Yeah. KS: Thank you for explaining that. I really appreciate that, and I think our listeners will also. I do think it seems clear, and then it gets fuzzy. I know it’s a deep area of science. Well, you and a few colleagues are working on a scoping review on the landscape of implementation science in communication sciences and disorders. Can you tell us a bit about what you did, what you found, and why this is important specifically for aphasia?   ND: Sure. Right. So, this is a project that I've been working on with some other colleagues. So, with Dr. Megan Schliep, Dr. Julie Firestein and Jen Oshita, and we're working on and again, we're, this is not published, so please take this with a with a grain of salt or 10. I mean, we tried to have good rigorous methods. So, we basically wanted to see because, you know, I, this, when I say this, like I, myself have wrote a lot of these papers. So, I'm like talking about myself, but we have a lot of talking about implementation science, and we have a lot of concept papers. And it's good, you know. We need to be talking about it. It's a new area. But we don't we wanted to know, where is the science, right? Like been we’ve been talking about it. So, the Journal of Speech Language and Hearing Research, they had a special issue in 2015. So that's like, you know, a few years ago now, the ASHA Foundation had an Implementation Science Summit in 2014. So, years are going by right? And so, we wanted to know, have these initiatives, you know, this discussion that we've been having has it resulted in any changes, right? Are we moving the needle when it comes to incorporating some of these methods into our clinical practice research? So, at this point, we ended up finding 82 studies that met our criteria. But what I think is really interesting for people with aphasia, is we did this communication sciences and disorders wide, so including all you know, pediatrics, adults, we did, you know, speech language pathology and audiology. We came up with 82 studies, but the, the patient population that was most represented, was aphasia. Out of all of those different, you know, potential patient populations. And I thought it was a really fascinating finding. You know, it makes me think that clinical practice, researchers in aphasia are really kind of on the cutting edge, you know, when it comes to studying how to get these best practices into typical settings. And I think it also means that in aphasia, we have a unique opportunity to move things down the implementation pipeline. So, like, we started, you know, you and I started talking a little bit about reach, right? So, it's like, how do we get something out? You know, get people doing it? Well another, you know, kind of further down that implementation pipeline would be an outcome such as sustainability, right? So, like, when there is no researcher in sight, right, like this clinical trial has ended years ago, how do we put mechanisms in place so that that intervention is still sustained right, within that own system? So I think in aphasia, we've got really, yeah, interesting opportunities to be able to look at some of these longer term outcomes. You know. Overall, like as a field, it seems like we're really, potentially overly relying on like training and education as an implementation strategy. And I think that can be, you know, a number of reasons that I'm speculating here but you know, most of us are trained from a behavioral education standpoint. So I think we're really comfortable, you know, in that realm, you know, in some of these other implementation strategies, I don't know that we really know about them or use them, you know, to this point. But I think, you know, overall, a lot of progress has been made. But of course, we have a lot of room for growth. But I think we have some really unique opportunities, especially in the aphasia world, which I think is very exciting. KS: Yeah, that is exciting. And I guess I’m feeling excited and proud and that kind of like ‘eek’ as we are stretching ourselves and learning things about how we might move the science forward ultimately so we can help the people living with aphasia to live better lives or reach their goals or whatever it is that they are wanting to pursue. ND: Yes. Absolutely. KS: As you know, this podcast has a wide listener base with shared interests in aphasia. Researchers, clinicians, program managers, people living with aphasia, their care partners and family members. What are some steps that they can take to support implementation science? ND: I think that all of those people that you mentioned those different groups, so you've got researchers, clinicians, you know, program managers, administrators, people living with aphasia, and their families and friends, right? Every single group that you mentioned, right through an implementation lens, they are a stakeholder, an equal stakeholder, where their input engagement is not only valued, but also, I think, required, if we're going to have optimal implementations to support all the outcomes that we want, you know. And so, I think one of the biggest steps that we can all make, is kind of reaching across our silos are relationship silos, right? So, for a researcher reaching out to a clinician, if we're clinician reaching out to a researcher. We don't need to have these silos. Even though we might, we might say there's not a hierarchy with our mouths between researchers and clinicians. I think we kind of know that's not quite true, right? It's a thing that is maybe unspoken, but it can make people feel intimidated to reach out. But I think that, and it's not just clinicians and researchers, but also administrators, families, people living with aphasia, if we can all start to break down some of those silos. So, I think the project that you're involved in with Jackie Hinckley, the Project BRIDGE, is a really phenomenal example of that, where people are actively listening, and learning from another, you know. I think it's not just a nice thing to do, but there's data to support better implementation outcomes, if we do that kind of engagement work upfront. You know and something that I try to ask myself when we're having these types of discussions is who is missing? Right? Who was missing during these discussions? And how do we get them to the discussion? How do we get them to the table to discuss and to really, so that we can figure out what's important, and how do we reach across some of the boundaries that we have and start to have this conversation? KS: I’m envisioning a ‘talk with’ instead of ‘about’.  ND: Absolutely. And you know, this is not…I see this as like a both a “both and” thing. And so, this is in no way minimizing or to the detriment of basic science work, right? Like, we're specifically talking about clinical practice research, which not everyone does, right? And we know that there's different stages. But this is kind of a “both and” right”? We need our basic scientists and we need that foundational level work, we do. But I think there's enough data in that research to practice gap to say that we need to start way earlier in terms of, you know, kind of start thinking about, if I'm a clinical practice researcher, and my intervention requires a certain amount of time. You know, so if it's like time per week, you know, in minutes or in days per week. And I know for sure that Medicare is only going to reimburse three times per week, right? Then it's like, okay, that's something that's so much easier dealt with upfront, right? And so I think this can allow us this lens can allow us to be a part of some of these policy discussions when it comes to third party payers and to say, “Hey, guess what, this treatment didn't work, when you only did it four times a week, you need to do it five” right? Or whatever the case may be, but to have to be thinking about the different layers. And I it's a lot to think about, right? It's a lot to think about. As opposed to, you know, getting this amazing level of evidence on a treatment, but then understanding that it potentially is not going to be feasible or acceptable in a real-life setting. Sometimes you can't fix that gap. You know, sometimes it might be a little bit too late, you know, so I think the more we can be thinking about that upfront, the better. KS: Yeah, I love it. I’m visualizing sitting around with our implementation lenses on with stakeholders at the table from all walks of life and moving things forward. Oh wow. I’ve got goosebumps, Natalie. ND: You do.  KS: I do. You are putting the challenge out. That’s for sure. I’d love to switch gears a bit and talk about another recent publication of yours. You and Ellen Hickey have recently co-authored a book titled Person Centered Care and Communication Intervention for Dementia: A Case Study Approach. What was the inspiration for the book?  ND: Sure, yes. So, thanks for bringing that up and letting us talk about that, to appreciate that. So Ellen, and I were, you know, we were thinking, as you know, clinical researchers, and we both of us had spent, you know, several years in clinical settings, we were trying to make it easier for clinicians who wanted to implement Person Centered Care, kind of across the care continuum. And from what we could find, you know, there were a lot of outstanding resources available about certain techniques. So, you know, external memory aids, or maybe the Montessori philosophy, or spaced retrieval. But what we wanted to do was put everything in one place, if possible, with a real kind of focus on treatment, and emphasis on the person. So, one thing that we thought was exciting, was we went so far as to name each chapter after a person and their role in life.    KS: You sure did, I love it!   ND: As opposed to, you know, this is a chapter about vascular dementia. This is a chapter about aphasia, you know, but again, this is a “both and” situation, you know, we need to have that detailed information.    KS: You made that message loud and clear. Person centered, loud and clear.    ND: For sure, for sure. So, for every case, there's eight cases in there. For every case, we really dive in deep on what it would look like to do, you know, a person centered assessment, and then provide some kind of flexible templates and some gold banks, you know, we're hoping that it will give, you know, very bright clinicians, you know, who are already doing great work, more ideas. You know, and by seeing clearly, not every person is going to remotely resemble these eight cases in this book, but we hope that by showing and focusing on a lot of the nuance, it will help spark some more person-centered programming for some of our clients kind of across the Health care continuum.   KS: Thank you. It’s fabulous. When I was reading the book, I noticed prominent in the chapters, you’ve adapted the Life Participation Approach to Aphasia and the Living with Aphasia: Framework for Outcome Measurement, a.k.a. the A-FROM, to working with people with dementia. You know Aphasia Access’ work is so centered around LPAA or Life Participation Approach. I love how you are expanding this vision. Can you share how this came to be?   ND: Sure, sure. So, Ellen and I had both used the A-FROM in our clinical work and it really made sense to us that when we think about some of those layers. You know, you've got issues of, at the impairment level, if that's cognitive or language, you've got issues to consider around the environment, life participation and personal identity, right? We felt that these factors were really relevant across disorder types and that this could be a very helpful way to ground some of the interventions and planning for intervention, as well as look at some of the outcomes. So, the Aphasia Institute was generous enough to allow us to use that model, you know, in the book, and we just, you know, merely suggest. It's not been tested or anything, but we just suggested it might be appropriate for people living with dementia as well. You know? And I know that we've got a segment of our population with frontotemporal lobar dementia, you know, or with primary progressive aphasia variants, potentially, so I think sometimes it's good to think about some overlap across disorder types, you know, in terms of how we want to ground intervention and outcomes, right? Because when we're thinking about people with dementia, and aphasia, really, we have to think beyond the impairment not to exclude the impairment. And, you know, we're not doing that, but just to think, to add some layers to what we might want to measure, and what we might expect to see some changes in.   KS: Well I think it’s fabulous. I wish people could see, but I’m actually holding the book in my hands as we speak. It’s the right size.   ND: It’s pretty skinny! (laughter)   KS: Yeah, the right size. (laughter) But seriously, I’d love to dig into one of the cases. In particularly, I’d like to talk about Sam, the Bocce Player who was inspired by your own grandpa. And I’m looking at the chapter and I see photos of your grandpa and our grandma and your children…and I mean Natalie, let’s talk about Sam.    ND: So Sam is my grandpa, he is no longer with us. And he was just the most unique, hilarious, funny, just complete character. He was all about his Italian heritage. And, you know, it was extremely sad for him to struggle with a communication disorder towards the end of his life. And it was just really difficult to watch and see, of course. It was devastating. You know, that's why we're all here in this field, right? But the reason that I…there were multiple reasons I wanted definitely a way to remember and honor him. I'm very grateful for the time that we had together but he is definitely one who did and would like he would be the person who you would go into their medical room, if it was rehab or hospital and with the “usual tactics”, it would be a “patient refused” [scenario]. There's just like, no way that he would attend to activities like workbooks or, you know, traditional speech and language tasks. I mean, it just would not happen. And he would refuse things all the time. He was like super stubborn, but the things that he loved, you know, he loved. And I think he is somebody, that's a really great example of sometimes if we go in and we're not knowledgeable of the person, we could lose our opportunity to try to facilitate communication with somebody. So, what we have in the chapter and in real life, you know, really kind of focusing on passions, so he was able to be around my kids when they were smaller, his Italian heritage, and Bocce and food, you know. And using those things in kind of a nontraditional setting, we were able to have some really special moments of what I think were very joyful, participatory, person-centered moments. If we kind of went about it in traditional, you know, from a medical model, I just don't think that would be have been very impactful. So, the hope is that for those folks that we see that they're like “Get out of my room!” you know. We've all been involved and told to ‘get out!’.    KS: “You’re fired!”   ND: “You’re fired! Why are you here?” You know, trying to think creatively about what that might look like to support somebody’s communication.  KS: Absolutely. And I think the way the chapter is set up, how we first learn about Sam’s background, and his family, and job, and then we learn about the medical history. I know that’s not how we always come across information when we’re meeting clients, or patients, or people. Whatever we are calling them in the places that we are working, but I do think it influences how we view one another. You know. And being able to think about our clients as people. And how we might engage with them. This is fabulous. One of the things that I thought, you know I love to cook, Natalie.   ND: Yes, you do.   KS: You talk about Sam and his sauce throughout the entire chapter. And I’m guessing you aren’t the one who isn’t going to be the one to help me learn how to make the sauce, are you?   ND: I know. That’s so terrible. When I was a kid, he owned a restaurant and on Tuesdays he would take me in there and we would make the sauce for the restaurant. And so, he would show me how to do it, and I basically just stirred it. And unfortunately, that’s the only detail other than the love... I can’t give you details about the sauce itself. And as you know, that’s really not my jam at this point, but, you know.     KS: I guess as I was reading Sam’s case, as well as all of the others, I just feel like you and Ellen have done such a beautiful job of bringing this very ‘person-first’. I could really see how I could adapt some of these ideas, assessments, and treatment strategies that you’ve put into the book, even if I didn’t have someone exactly like Sam that I could implement them with. So, thank you. Thank you.    ND: Thank you.   KS: As we wrap up, do you have any final thoughts you’d like to share with our listeners?   ND: I again want to express my true, deep gratitude for chatting with you today and for the generous and forward-thinking community of Aphasia Access, truly a game changer for the field. If anyone is interested chatting more about implementation, I hope you reach out to me. I’m always more than happy to talk and brainstorm about ways that we can move this forward. There’s also an Implementation Science and Aging Special Interest Group that’s free to join. It’s interdisciplinary with some people in mental health, nursing, social work. It’s all people across disciplines who are interested in who are interested in merging the worlds of aging and implementation science, I can give you that info to put in the show-notes.    KS: Sounds great! We’ll add that and your Twitter handle and website for Practical Implementation Collaborative to the show notes. Natalie, thank you for taking time to share your story and work with us. Congratulations again on the Tavistock Scholar Award.    ND: Thank you so much, Katie.    On behalf of Aphasia Access, we thank you for listening to this episode of the Aphasia Access Conversations Podcast. For more information on Aphasia Access and to access our growing library of materials go to www.aphasiaaccess.org If you have an idea for a future podcast topic email us at [email protected]. Thanks again for your ongoing support of Aphasia Access.   Connect with Natalie Online Practical Implementation Collaborative  https://www.practicalimplementation.org/ Natalie Douglas on Twitter   @Nat_Douglas    Links Mentioned in Episode Implementation Science & Aging Research Special Interest Group  https://www.isarsig.org/  Project BRIDGE – Stakeholder Engaged Research www.projectbridge.online    Read More In-depth Bauer, M. S., Damschroder, L., Hagedorn, H., Smith, J., & Kilbourne, A. M. (2015). An introduction to implementation science for the non-specialist. BMC psychology, 3(1), 1-12. https://doi.org/10.1186/s40359-015-0089-9 Douglas, N.F. & Burshnic, V.L. (2019). Implementation science: tackling the research to practice gap in communication sciences and disorders. Perspectives of the ASHA Special Interest Groups, https://doi.org/10.1044/2018_PERS-ST-2018-0000  Hickey, E. M., & Douglas, N. F. (2021). Person-Centered Memory and Communication Interventions for Dementia: A Case Study Approach. Plural Publishing. https://www.pluralpublishing.com/publications/person-centered-memory-and-communication-interventions-for-dementia-a-case-study-approach  Schliep, M. E., Alonzo, C. N., & Morris, M. A. (2017). Beyond RCTs: innovations in research design and methods to advance implementation science. Evidence-Based Communication Assessment and Intervention, 11(3-4), 82-98. https://doi.org/10.1080/17489539.2017.1394807