The coach is in: improving nutritional care in nursing homes

Impact of Project ECHO Models of Medical Tele-Education: a Systematic Review

BACKGROUND

Extension for Community Healthcare Outcomes (ECHO) and related models of medical tele-education are rapidly expanding; however, their effectiveness remains unclear. This systematic review examines the effectiveness of ECHO and ECHO-like medical tele-education models of healthcare delivery in terms of improved provider- and patient-related outcomes.

METHODS

We searched English-language studies in PubMed, Embase, and PsycINFO databases from 1 January 2007 to 1 December 2018 as well as bibliography review. Two reviewers independently screened citations for peer-reviewed publications reporting provider- and/or patient-related outcomes of technology-enabled collaborative learning models that satisfied six criteria of the ECHO framework. Reviewers then independently abstracted data, assessed study quality, and rated strength of evidence (SOE) based on Cochrane GRADE criteria.

RESULTS

Data from 52 peer-reviewed articles were included. Forty-three reported provider-related outcomes; 15 reported patient-related outcomes. Studies on provider-related outcomes suggested favorable results across three domains: satisfaction, increased knowledge, and increased clinical confidence. However, SOE was low, relying primarily on self-reports and surveys with low response rates. One randomized trial has been conducted. For patient-related outcomes, 11 of 15 studies incorporated a comparison group; none involved randomization. Four studies reported care outcomes, while 11 reported changes in care processes. Evidence suggested effectiveness at improving outcomes for patients with hepatitis C, chronic pain, dementia, and type 2 diabetes. Evidence is generally low-quality, retrospective, non-experimental, and subject to social desirability bias and low survey response rates.

DISCUSSION

The number of studies examining ECHO and ECHO-like models of medical tele-education has been modest compared with the scope and scale of implementation throughout the USA and internationally. Given the potential of ECHO to broaden access to healthcare in rural, remote, and underserved communities, more studies are needed to evaluate effectiveness. This need for evidence follows similar patterns to other service delivery models in the literature.

Mixed methods developmental evaluation of the CHOICE program: a relationship-centred mealtime intervention for long-term care

Background

Mealtimes are important to quality of life for residents in long-term care (LTC). CHOICE (which stands for Connecting, Honouring dignity, Offering support, supporting Identity, Creating opportunities, and Enjoyment) is a multi-component intervention to improve relationship-centred care (RCC) and overall mealtime experience for residents. The objective of this developmental evaluation was to determine: a) if the dining experience (e.g. physical, social and RCC practices) could be modified with the CHOICE Program, and b) how program components needed to be adapted and/or if new components were required.

Methods

A mixed methods study conducted between April–November 2016 included two home areas (64 residents; 25 care staff/home management) within a single LTC home in Ontario. Mealtime Scan (MTS), which measures mealtime experience at the level of the dining room, was used to evaluate the effectiveness of CHOICE implementation at four time points. Change in physical, social, RCC dining environment ratings and overall quality of the mealtime experience over time was determined with linear mixed-effects analyses (i.e., repeated measures). Semi-structured interviews (n = 9) were conducted with home staff to identify what components of the intervention worked well and what improvements could be made.

Results

Physical and overall mealtime environment ratings showed improvement over time in both areas; one home area also improved social ratings (p < 0.05). Interviews revealed in-depth insights into the program and implementation process: i) Knowing the context and culture to meet staff and resident needs; ii) Getting everyone on board, including management; iii) Keeping communication lines open throughout the process; iv) Sharing responsibility and accountability for mealtime goals and challenges; v) Empowering and supporting staff’s creative mealtime initiatives.

Conclusions

This developmental evaluation demonstrated the potential value of CHOICE. Findings suggest a need to: extend the time to tailor program components; empower home staff in change management; and provide increased coaching.

Electronic supplementary material

The online version of this article (10.1186/s12877-018-0964-3) contains supplementary material, which is available to authorized users.

The effects of nutritional guideline implementation on nursing home staff performance: a controlled trial

RATIONALE

Suboptimal nutritional practices in elderly care settings may be resolved by an efficient introduction of nutritional guidelines.

AIMS

To compare two different implementation strategies, external facilitation (EF) and educational outreach visits (EOVs), when introducing nutritional guidelines in nursing homes (NHs), and study the impact on staff performance.

METHODOLOGICAL DESIGN

A quasi-experimental study with baseline and follow-up measurements.

OUTCOME MEASURES

The primary outcome was staff performance as a function of mealtime ambience and food service routines.

INTERVENTIONS/RESEARCH METHODS

The EF strategy was a 1-year, multifaceted intervention that included support, guidance, practice audit and feedback in two NH units. The EOV strategy comprised one-three-hour lecture about nutritional guidelines in two other NH units. Both strategies were targeted to selected NH teams, which consisted of a unit manager, a nurse and 5-10 care staff. Mealtime ambience was evaluated by 47 observations using a structured mealtime instrument. Food service routines were evaluated by 109 food records performed by the staff.

RESULTS

Mealtime ambience was more strongly improved in the EF group than in the EOV group after the implementation. Factors improved were laying a table (p = 0.03), offering a choice of beverage (p = 0.02), the serving of the meal (p = 0.02), interactions between staff and residents (p = 0.02) and less noise from the kitchen (p = 0.01). Food service routines remained unchanged in both groups.

CONCLUSIONS

An EF strategy that included guidance, audit and feedback improved mealtime ambience when nutritional guidelines were introduced in a nursing home setting, whereas food service routines were unchanged by the EF strategy.

A staff training and management intervention in VA long-term care: impact on feeding assistance care quality

Efforts to translate efficacious interventions into long-term care practice have had limited success due to the lack of consideration of key translational intervention components. A multi-faceted intervention was implemented in two veteran affairs facilities to improve feeding assistance care. There were three study phases: baseline, intervention, and follow-up. During each phase, trained research staff conducted standardized observations of 12 meals/participant to assess feeding assistance care quality. The staff received three initial training sessions followed by six consecutive weeks of feedback sessions wherein the observation-based care process measures were shared with the staff. There were significant, but modest, improvements in mealtime feeding assistance care processes, and most of the improvements were maintained during follow-up. A multi-faceted intervention resulted in significant, but modest, improvements in mealtime feeding assistance care quality. Organizational (staff schedules, communication) and environmental (dining location) barriers were identified that interfered with improvement efforts.

A controlled trial of an intervention to increase resident choice in long term care

OBJECTIVE

The purpose of this study was to evaluate an intervention to improve staff offers of choice to nursing home residents during morning care.

DESIGN

A controlled trial with a delayed intervention design.

SETTING

Four community, for-profit nursing homes.

PARTICIPANTS

A total of 169 long-stay nursing home residents who required staff assistance with morning care and were able to express their care preferences.

INTERVENTION

Research staff held weekly training sessions with nurse aides (NAs) for 12 consecutive weeks focused on how to offer choice during four targeted morning care areas: when to get out of bed, when to get dressed/what to wear, incontinence care (changing and/or toileting), and where to dine. Training sessions consisted of brief video vignettes illustrating staff-resident interactions followed by weekly feedback about how often choice was being provided based on standardized observations of care conducted weekly by research staff.

MEASUREMENTS

Research staff conducted standardized observations during a minimum of 4 consecutive morning hours per participant per week for 12 weeks of baseline and 12 weeks of intervention.

RESULTS

There was a significant increase in the frequency that choice was offered for 3 of the 4 targeted morning care areas from baseline to intervention: (1) out of bed, 21% to 33% (P < .001); dressing, 20% to 32% (P < .001); incontinence care, 18% to 23%, (P < .014). Dining location (8% to 13%) was not significant. There was also a significant increase in the amount of NA staff time to provide care from baseline to intervention (8.01 ± 9.0 to 9.68 ± 9.9 minutes per person, P < .001).

CONCLUSION

A staff training intervention improved the frequency with which NAs offered choice during morning care but also required more time. Despite significant improvements, choice was still offered one-third or less of the time during morning care.

Translating research into practice in nursing homes: can we close the gap?

PURPOSE

A gap between research and practice in many nursing home (NH) care areas persists despite efforts by researchers, policy makers, advocacy groups, and NHs themselves to close it. The reasons are many, but two factors that have received scant attention are the dissemination process itself and the work of the disseminators or change agents. This review article examines these two elements through the conceptual lens of Roger's innovation dissemination model.

DESIGN AND METHODS

The application of general principles of innovation dissemination suggests that NHs are characteristically slow to innovate and thus may need more time as well as more contact with outside change agents to adopt improved practices.

RESULTS

A review of the translation strategies used by NH change agents to promote adoption of evidence-based practice in NHs suggests that their strategies inconsistently reflect lessons learned from the broader dissemination literature.

IMPLICATIONS

NH-related research, policy, and practice recommendations for improving dissemination strategies are presented. If we can make better use of the resources currently devoted to disseminating best practices to NHs, we may be able to speed NHs' adoption of these practices.