Affecting culture change and performance improvement in Medicaid nursing homes: The Promote Understanding, Leadership, and Learning (PULL) Program

Factors that influence the implementation of innovation in aged care: a scoping review

OBJECTIVE

The objective of this scoping review is to identify factors that influence the implementation of innovation in aged care.

INTRODUCTION

Aged care is a dynamic sector experiencing rapid change. Implementation of innovations in aged care has received relatively little research attention compared to health care.

INCLUSION CRITERIA

This review included studies of any design, that examined the implementation of innovations in aged care settings.

METHODS

Searches were conducted in MEDLINE, CINAHL, AgeLine, and ProQuest Social Sciences Premium Collection for studies published between January 1, 2012 and December 31, 2022. The titles and abstracts of retrieved citations were screened by two independent reviewers. Full-text articles were screened by one reviewer to determine inclusion. Data were extracted in NVivo using a tool developed by the research team. Factors that influenced implementation were inductively coded, interpreted, and grouped into categories in a series of workshops.

RESULTS

Of the 2530 studies that were screened, 193 were included. Of the included papers, the majority (74%) related to residential aged care, 28% used an implementation theory or framework, and 15% involved consumers. Five key categories of factors influencing implementation were identified: organizational context including resourcing and culture; people's attitudes and capabilities; relationships between people; the intervention and its appropriateness; and implementation actions such as stakeholder engagement and implementation strategies.

CONCLUSIONS

Our findings can be used to develop practical resources to support implementation efforts, and highlight the importance of resourcing for successful implementation. Attention to community-based aged care, and greater engagement with theory and community is needed to promote research rigor, relevance and applicability.

Results of the Missouri Quality Initiative in Sustaining Changes in Nursing Home Care: Six-Year Trends of Reducing Hospitalizations of Nursing Home Residents

OBJECTIVES

The purpose of this article is to present six-year findings of the Missouri Quality Initiative (MOQI) to reduce unnecessary hospitalizations for long-stay nursing home residents.

DESIGN

A CMS funded demonstration project analyzed over 6-years using a single group design.

SETTING AND PARTICIPANTS

The setting was 16 Midwestern US nursing homes ranging in size between 121 and 321 beds located in urban and rural areas in one geographic region. The sample of eligible residents averaged from 1819 in 2014 to 1068 in 2019.

MEASURES

Resident data were analyzed using descriptive methods of aggregate facilities' hospital transfer rates per 1000 resident days and changes per year of average hospital transfer rates. Individual facility transfer rates were grouped by level of performance (best, mixed, and low). Leadership turnover and engagement were also described.

INTERVENTION

Full-time advanced practice registered nurses (APRN) and an operations support team focused on reducing unnecessary hospitalizations for long-stay nursing home residents.

RESULTS

Total transfers for 2014-2019 was 6913 and the average transfer rate per 1000 resident days declined from 2.48 in 2014 to a low of 1.89 in 2018 and slightly increased to 1.99 in 2019. Eleven nursing homes achieved sustained improvement, five did not. Differences in leadership turnover and engagement were noted by level of performance; however, three outlier facilities were identified.

CONCLUSIONS/IMPLICATIONS

The MOQI intervention achieved improved outcomes over six-years in the majority of nursing homes in the project. The embedded APRN's daily focus on project goals supported by a multi-disciplinary operations team facilitated success. Facility leadership stability and engagement in the project likely contributed to outcomes. Full-time presence of APRNs coupled with an operations' support team improved nursing homes outcomes, however Medicare currently restricts APRNs hired by nursing homes from billing Medicare for direct care services. This unnecessary restriction of practice discourages nursing homes from hiring APRNs and should be abolished.

Quality improvement in long-term care settings: a scoping review of effective strategies used in care homes

PURPOSE

We conducted a scoping review of quality improvement in care homes. We aimed to identify participating occupational groups and methods for evaluation. Secondly, we aimed to describe resident-level interventions and which outcomes were measured.

METHODS

Following extended PRISMA guideline for scoping reviews, we conducted systematic searches of Medline, CINAHL, Psychinfo, and ASSIA (2000-2019). Furthermore, we searched systematic reviews databases including Cochrane Library and JBI, and the grey literature database, Greylit. Four co-authors contributed to selection and data extraction.

RESULTS

Sixty five studies were included, 6 of which had multiple publications (75 articles overall). A range of quality improvement strategies were implemented, including audit feedback and quality improvement collaboratives. Methods consisted of controlled trials, quantitative time series and qualitative interview and observational studies. Process evaluations, involving staff of various occupational groups, described experiences and implementation measures. Many studies measured resident-level outputs and health outcomes. 14 studies reported improvements to a clinical measure; however, four of these articles were of low quality. Larger randomised controlled studies did not show statistically significant benefits to resident health outcomes.

CONCLUSION

In care homes, quality improvement has been applied with several different strategies, being evaluated by a variety of measures. In terms of measuring benefits to residents, process outputs and health outcomes have been reported. There was no pattern of which quality improvement strategy was used for which clinical problem. Further development of reporting of quality improvement projects and outcomes could facilitate implementation.

Culture Change in Nursing Homes: What Is the Role of Nursing Home Resources?

Quality of care has been a long-standing issue in US nursing homes. The culture change movement attempts to transition nursing homes from health care institutions to person-centered homes. While the adoption of culture change has been spreading across nursing homes, barriers to adoption persist. Nursing homes that disproportionately serve minority residents may have additional challenges implementing culture change compared with other facilities due to limited financial and staffing resources. The objective of this study was to examine how nursing home characteristics are associated with culture change adoption in Central Florida nursing homes. This cross-sectional study included 81 directors of nursing (DONs) who completed the Artifacts of Culture Change survey. In addition, nursing home organizational data were obtained from the Certification and Survey Provider Enhanced Reports (CASPER). A logistic regression was conducted to examine the relationship between high culture change adoption and nursing home characteristics. The overall adoption of culture change scores in Central Florida nursing homes was low. Nevertheless, there was variability across nursing homes in the adoption of culture change. High culture change adoption was associated with nursing homes having lower proportions of Medicaid residents.

The influence of leadership behavior, organizational commitment, organizational support, subjective career success on organizational readiness for change in healthcare organizations

Purpose The purpose of this study is to investigate the influence of leadership behavior, organizational commitment, organizational support and subjective career success on organizational readiness for change in the healthcare organizations. The authors want to determine if nurses who had higher levels of organizational commitment, organizational support and subjective career success relationships were more open and prepared for change. Design/methodology/approach Cross-sectional, descriptive-correlational survey design was conducted using self-reported questionnaires to collect data from registered nurses. Findings The subjective career success was the strongest predictors ( β = 0.36, p < 0.001) followed by leadership behavior ( β = -0.19, p = 0.03) and participants' age ( β = -0.13, p = 0.049). Research limitations/implications This study highlights the influence of leadership behavior, organizational commitment, organizational support and subjective career success on the organizational readiness for change in healthcare organizations. Therefore, this study forms baseline data for future local and national studies. Moreover, it will strengthen the research findings if future research includes a qualitative approach that explores other healthcare professionals regarding readiness for organizational change. Practical implications This study provides information to policymakers and healthcare leaders who seek to improve management and leadership skills and respond to organizational change efforts. Social implications It is important to know the extent to which healthcare professionals, especially nurses, understand how the influence of organizational support and organizational commitment on organizational readiness for change, as well as why specific leadership behavior and subjective career success, is important in implementing the change. Originality/value This study examined the nurses' readiness for change in hospitals. Organizational readiness for change could occur in situations where nurses can exert extra efforts at work because of leaders' behaviors and the relationship between nurses and the institution.