Operationalizing Iterative RE-AIM in two pragmatic nursing home trials to support an adaptation learning cycle.

Introduction: Complex, heterogeneous settings such as nursing homes require ongoing adaptation of interventions and implementation strategies. Iterative RE-AIM offers a structured approach to guide adaptations, but how the approach is operationalized may need to vary across implementation contexts. We describe how two pragmatic nursing home trials operationalized Iterative RE-AIM with FRAME-IS to enable a systematic adaptation learning cycle. Methods: We conducted a narrative analysis of two ongoing multi-site trials: TEAM EFFORT (focused on falls reduction in State Veterans Homes) and 40 WINKS (focused on sleep improvement in nursing home residents with dementia). Both used RE-AIM for evaluation and FRAME-IS to document adaptations. Each operationalized the Iterative RE-AIM steps based on study scope, resources, team structure, and implementation timing, with a primary focus on refining a coach-supported implementation strategy. Results: TEAM EFFORT embedded adaptation-related data collection, deliberation, and decision-making within weekly team meetings, supported by an ongoing input tool; 40 WINKS used individual-level surveys followed by structured, once-per-wave team gatherings to decide on adaptations. These two operationalizations illustrate how the timing, methods, and cadence of an adaptation learning cycle based on Iterative RE-AIM can vary in response to implementation context. Discussion: Iterative RE-AIM can be operationalized differently across implementation contexts while remaining faithful to its underlying intent. Paired with FRAME-IS, Iterative RE-AIM can enable an adaptation learning cycle that integrates systematic documentation of adaptations with structured team deliberation. Rather than prescribing a single Iterative RE-AIM implementation protocol, these findings suggest that operationalization can respond to the context in which implementation occurs.