Improving heart failure disease management in skilled nursing facilities: lessons learned

Leading the way: implementing aged care innovations

OBJECTIVES

The objective of this study was to identify the key characteristics of leaders that support the implementation of innovations in aged care settings.

METHODS

We conducted a secondary analysis of papers from a large scoping review that identified how leaders supported the implementation of innovations in aged care. Once imported into NVivo12, the findings were deductively coded using the domains of Bloom's taxonomy of learning. Each parent code was then inductively analyzed to identify key characteristics within each domain.

RESULTS

Our review identified four types of knowledge, five skills, and six attitudes that leaders should exhibit to better support the implementation of innovations within aged care settings. In addition to our findings regarding Bloom's learning domains, we identified nine leadership behaviors that participants in the included papers perceived as valuable for enhancing the implementation process. Furthermore, we identified four key organizational elements that support leaders in navigating and facilitating the implementation of innovations within aged care settings.

CONCLUSION

Our review identified the characteristics that leaders should demonstrate when supporting the implementation of innovations in aged care. Importantly, our findings also emphasized the changing role of leadership from a hierarchical approach to a more collaborative, supportive, and empowering style. The insights identified in this review will help to guide aged care leaders, stressing the significance of adaptable and relational leadership styles that will guide the implementation of innovations within the aged care sector.

SPANISH ABSTRACT

http://links.lww.com/IJEBH/A271.

Fostering an aged care organizational culture that supports innovation

AIM

This study aimed to identify how aged care organizations can foster a culture that supports the implementation of innovation.

INTRODUCTION

The aged care sector must innovate to meet clients' evolving needs and increased regulatory requirements. Given the need to account for the values, beliefs, expectations, and assumptions held by a diverse range of stakeholders, implementing innovations within aged care can be exceptionally complex. Fostering a supportive organizational culture can facilitate the implementation of these critical innovations.

METHODS

Papers from a large scoping review that identified organizational culture as a barrier and/or enabler to implementing innovations in aged care were imported into NVivo. Data relating to how organizations fostered (or could foster) a culture that supported the implementation of innovations were then extracted, inductively coded, interpreted, and grouped into approaches.

RESULTS

Of the 193 papers from the original scoping review, 109 were included in this secondary analysis. From these 109 papers, we identified six key approaches: cultivating collaboration; valuing contributions; ensuring alignment between the organizational vision, culture, and innovation; demonstrating organizational commitment; developing and communicating the implementation plan; and accounting for stability.

CONCLUSIONS

Our study outlines effective approaches that can be used by aged care organizations to cultivate a culture that supports the implementation of innovations. However, these approaches should not be viewed in isolation; rather, they are interconnected and mutually reinforcing. Together, these insights offer practical guidance for aged care entities seeking to adapt and evolve through innovation implementation.

SPANISH ABSTRACT

http://links.lww.com/IJEBH/A264.

Increasing Follow-Up Appointment Completion Rates in Transitions of Care

PURPOSE OF STUDY

Noncompletion of follow-up appointment requests is an ongoing problem due to competing staff responsibilities, technology challenges, and inadequate communication during hospital transitions to post-acute care. From 1 January 2019 to 31 March 2019, 58% of follow-up appointments requested by an acute care hospital on discharge were not ordered after transition of care to a skilled nursing facility (SNF) and 44% of SNF residents were readmitted to acute care within 30 days. The follow-up appointment completion rate was 42%. Barriers associated with poor attendance of follow-up appointments were not documented. The purpose of the study is to implement a follow-up appointment completion protocol to increase follow-up appointment completion rates and identify barriers to decrease hospital readmission rates with the use of a computerized clinical information system.

PRIMARY PRACTICE SETTING

A 232-bed for-profit, corporate-owned SNF in the west suburb of Chicago that offers a variety of services in addition to skilled nursing care including short-term rehabilitation, physical therapy, and long-term care.

METHODOLOGY AND SAMPLE

An attendance log was utilized to evaluate stakeholder agreement and completion of staff training. Data were collected electronically via a password-protected Microsoft Excel spreadsheet by the project director to evaluate the completion of orders placed for follow-up appointments and chart audits were completed. A quantitative data analysis was completed to obtain the percentage of the number of key stakeholders in agreement of interventions, staff attendance to training sessions, and residents whose orders for follow-up appointments were entered into PointClickCare (PCC). To evaluate the barriers identified, completion of follow-up appointments, hospital readmission rates, and chart audits were completed throughout the project implementation and data were collected electronically via a password-protected Microsoft Excel spreadsheet by the project director. Post implementation data were collected biweekly for 1 month, and then again for 1, 2, and 3 months throughout the project implementation. A quantitative data analysis was completed to obtain the percentage of barriers identified, completion of follow-up appointments, and hospital readmission rates.

RESULTS

81% of admitted residents to the short-term care stay unit had orders for follow-up appointments. The follow-up appointment completion rate increased to 46% and the readmission rate decreased by 20%. Barriers were identified as non-scheduled appointments and resident refusal.

IMPLICATIONS FOR CASE MANAGEMENT PRACTICE

Implementing a follow-up appointment protocol can significantly enhance the quality of patient care and operational efficiency. Regular follow-up appointments allow health care professionals to assess progress, manage medications, detect complications early, and provide necessary guidance and interventions for optimal outcomes. A follow-up appointment protocol can help streamline transitions between levels of care, ensuring patients receive timely and appropriate services.

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.

Research translation to improve carer smoking cessation support in a paediatric ward of a regional hospital in the Northern Territory

ISSUE ADDRESSED

Health professionals have described barriers to providing carer smoking cessation support in children's wards. This article reports the findings of a research translation process that explored opportunities and developed pathways for change.

METHODS

A facilitated discussion workshop and scheduled stakeholder meetings were used to evaluate research evidence and translate it to an evidence-informed organisational change process, with actions for implementation. Workshop and meeting participants were senior health staff with either a pharmacist, personnel with expertise in alcohol and other drugs, medical or nursing backgrounds, and who held senior managerial roles who worked in a hospital in the Northern Territory. A qualitative approach was used. The data from the workshop were transcribed and analysed using thematic analysis. The first author took notes for meetings that were not recorded and analysed these alongside the transcripts.

RESULTS

The process was able to initiate change to overcome barriers to providing carer smoking cessation support. All participants agreed to prioritise and make carer smoking cessation everybody's responsibility and supported a systematic approach, including provision of nicotine replacement therapy, new record-keeping systems, and training to address staff knowledge deficits and skills gaps. This movement to solution-focused change continued after the workshop.

CONCLUSIONS

With some preparation, a research translation workshop and meetings with selected leaders can initiate organisational change in similar settings and is consistent with theories of planned change. SO WHAT?: This article describes the use of a process to support health promotion through new policies and practices following research which identified barriers in a hospital ward.

Challenges in Heart Failure Disease Management in Skilled Nursing Facilities: A Qualitative Study

Clinical guidelines recommend clinicians in skilled nursing facilities (SNFs) monitor body weight and signs and symptoms related to heart failure (HF) and encourage a sodium restricted diet to improve HF outcomes; however, SNFs face considerable challenges in HF disease management (HF-DM). In the current study, we characterized the challenges of HF-DM with data from semi-structured, in-depth interviews with patients, caregivers, staff, and physicians from nine SNFs. Patients receiving skilled nursing care were interviewed together as a dyad with their caregiver. A data-driven, qualitative descriptive approach was used to understand the process and challenges of HF-DM. Coded text was categorized into descriptive themes. Interviews with five dyads (n = 10 individuals), SNF nurses and certified nursing assistants (n = 13), and physicians (n = 2) revealed that, among the sample, HF care was not prioritized above other competing health concerns. Staff operated in the challenging SNF environment largely without protocols or educational materials to prompt HF-DM. [Journal of Gerontological Nursing, 48(5), 13-17.].

Change Management and Digital Innovations in Hospitals of Five European Countries

The objective of the paper is to evaluate the quality of systemic change management (CHM) and readiness for change in five Central European countries. The secondary goal is to identify trends and upcoming changes in the field of digital innovations in healthcare. The results show that all compared countries (regardless of their historical context) deal with similar CHM challenges with a rather similar degree of success. A questionnaire distributed to hospitals clearly showed that there is still considerable room for improvement in terms of the use of specific CHM tools. A review focused on digital innovations based on the PRISMA statement showed that there are five main directions, namely, data collection and integration, telemedicine, artificial intelligence, electronic medical records, and M-Health. In the hospital environment, there are considerable reservations in applying change management principles, as well as the absence of a systemic approach. The main factors that must be monitored for a successful and sustainable CHM include a clearly defined and widely communicated vision, early engagement of all stakeholders, precisely set rules, adaptation to the local context and culture, provision of a technical base, and a step-by-step implementation with strong feedback.

Quality improvement studies in nursing homes: a scoping review

BACKGROUND

Quality improvement (QI) is used in nursing homes (NH) to implement and sustain improvements in patient outcomes. Little is known about how QI strategies are used in NHs. This lack of information is a barrier to replicating successful strategies. Guided by the Framework for Implementation Research, the purpose of this study was to map-out the use, evaluation, and reporting of QI strategies in NHs.

METHODS

This scoping review was completed to identify reports published between July 2003 through February 2019. Two reviewers screened articles and included those with (1) the term "quality improvement" to describe their methods, or reported use of a QI model (e.g., Six Sigma) or strategy (e.g., process mapping) (2), findings related to impact on service and/or resident outcomes, and (3) two or more NHs included. Reviewers extracted data on study design, setting, population, problem, solution to address problem, QI strategies, and outcomes (implementation, service, and resident). Vote counting and narrative synthesis were used to describe the use of QI strategies, implementation outcomes, and service and/or resident outcomes.

RESULTS

Of 2302 articles identified, the full text of 77 articles reporting on 59 studies were included. Studies focused on 23 clinical problems, most commonly pressure ulcers, falls, and pain. Studies used an average of 6 to 7 QI strategies. The rate that strategies were used varied substantially, e.g., the rate of in-person training (55%) was more than twice the rate of plan-do-study-act cycles (20%). On average, studies assessed two implementation outcomes; the rate these outcomes were used varied widely, with 37% reporting on staff perceptions (e.g., feasibility) of solutions or QI strategies vs. 8% reporting on fidelity and sustainment. Most studies (n = 49) reported service outcomes and over half (n = 34) reported resident outcomes. In studies with statistical tests of improvement, service outcomes improved more often than resident outcomes.

CONCLUSIONS

This study maps-out the scope of published, peer-reviewed studies of QI in NHs. The findings suggest preliminary guidance for future studies designed to promote the replication and synthesis of promising solutions. The findings also suggest strategies to refine procedures for more effective improvement work in NHs.

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.

Symptoms, Nutrition, Pressure Ulcers, and Return to Community Among Older Women With Heart Failure at Skilled Nursing Facilities: A Pilot Study

BACKGROUND

Mortality rate is high for older women with heart failure (HF) who are discharged to skilled nursing facilities (SNFs) after hospitalization, but little is known about their symptoms, nutritional factors, and pressure ulcer status and whether these variables predict the women's return to the community.

OBJECTIVES

The aims of this study are to characterize symptoms (ie, dyspnea, cognitive dysfunction, depression, and pain) and nutritional and pressure ulcer status, evaluate relationships among symptoms, and examine predictors of return to the community among older women with HF admitted to SNFs.

METHODS

In this pilot observational study, data were collected retrospectively from the electronic medical records and the Minimum Data Set 3.0.

RESULTS

Data were obtained for 45 women with HF (mean age, 84.8 years). Frequency of symptoms was dyspnea 18%, cognitive dysfunction 20%, depression 5%, and pain 78%. Mean body mass index (BMI) was 29.8 kg/m. Frequency of pressure ulcer risk was 85% and 18% had pressure ulcers. The 4 symptoms were not significantly related. Younger age (odds ratio, 0.90; P = .023) and BMI of 25 kg/m or greater (odds ratio, 5.31; P = .017) predicted return to the community.

CONCLUSIONS

The women in this study had frequent pain, moderately frequent cognitive dysfunction, and high pressure ulcer risk. Surprisingly, few women had dyspnea or depression. Women who were younger with higher BMI were more likely to return to the community. The study needs to be replicated in a larger more diverse group of older patients with HF.

Implementing team huddles in small rural hospitals: How does the Kotter model of change apply?

AIMS

To examine how the process of change prescribed in Kotter's change model applies in implementing team huddles, and to assess the impact of the execution of early change phases on change success in later phases.

BACKGROUND

Kotter's model can help to guide hospital leaders to implement change and potentially to improve success rates. However, the model is under studied, particularly in health care.

METHODS

We followed eight hospitals implementing team huddles for 2 years, interviewing the change teams quarterly to inquire about implementation progress. We assessed how the hospitals performed in the three overarching phases of the Kotter model, and examined whether performance in the initial phase influenced subsequent performance.

RESULTS

In half of the hospitals, change processes were congruent with Kotter's model, where performance in the initial phase influenced their success in subsequent phases. In other hospitals, change processes were incongruent with the model, and their success depended on implementation scope and the strategies employed.

CONCLUSIONS

We found mixed support for the Kotter model. It better fits implementation that aims to spread to multiple hospital units. When the scope is limited, changes can be successful even when steps are skipped.

IMPLICATIONS FOR NURSING MANAGEMENT

Kotter's model can be a useful guide for nurse managers implementing changes.

Characteristics of Quality Improvement Champions in Nursing Homes: A Systematic Review With Implications for Evidence-Based Practice

BACKGROUND

Improving care quality while reducing cost has always been a focus of nursing homes. Certified nursing assistants comprise the largest proportion of the workforce in nursing homes and have the potential to contribute to the quality of care provided. Quality improvement (QI) initiatives using certified nursing assistants as champions have the potential to improve job satisfaction, which has been associated with care quality.

AIMS

To identify the role, use and preparation of champions in a nursing home setting as a way of informing future QI strategies in nursing homes.

METHODS

A systematic literature review. Medical Subject Headings and text words for "quality improvement" were combined with those for "champion*" to search Medline, CINAHL, Joanna Briggs Institute, MedLine In-Process, and other Nonindexed Citations. After duplicates were removed, a total of 337 potential articles were identified for further review. After full text review, seven articles from five original studies met inclusion criteria and were included in the synthesis.

RESULTS

Various types of QI initiatives and implementation strategies were used together with champions. Champions were identified by study authors as one of the single most effective strategies employed in all studies. The majority of studies described the champion role as that of a leader, who fosters and reinforces changes for improvement. Although all the included studies suggested that implementing nurse or aid champions in their QI initiatives were important facilitators of success, how the champions were selected and trained in their role is either missing or not described in any detail in the studies included in the review.

LINKING EVIDENCE TO ACTION

Utilizing certified nursing assistants as QI champions can increase participation in QI projects and has the potential to improve job satisfaction and contribute to improve quality of care and improved patient outcomes in nursing homes.

Enhancing Knowledge and InterProfessional care for Heart Failure (EKWIP-HF) in long-term care: a pilot study

Background

Heart failure (HF) affects 20% of long-term care (LTC) residents and is associated with significant morbidity, acute care visits, and mortality. Barriers to HF management are staff knowledge gaps and ineffective interprofessional (IP) communication. This pilot study assessed the acceptability, feasibility, and impact of an intervention to (1) improve HF knowledge; (2) improve IP communication; and (3) integrate improved knowledge and communication processes into work routines.

Methods

The intervention provides multimodal IP education about HF in LTC, including specialist-supported bedside teaching. It was piloted on single units in two facilities. A mixed-methods repeated-measures approach was used to collect qualitative and quantitative process and outcome data at baseline and 6 months post-intervention.

Results

Results were similar at both sites. Participants developed optimized IP communication to promote HF care. Results indicate a perceived increase in staff confidence and self-efficacy, strengthened assessment and clinical proficiency skills, and more effective IP collaboration. Staff deemed the intervention useful and feasible.

Conclusions

This pilot study suggests that a novel intervention in which HF-specific knowledge is applied by LTC staff to improve IP collaboration in their own work place is acceptable and feasible and has a favourable preliminary impact on staff knowledge and IP communication.

Skilled Nursing Facility Care for Patients With Heart Failure: Can We Make It "Heart Failure Ready?"

Skilled nursing facilities (SNFs) have emerged as an integral component of care for older adults with heart failure (HF). Despite their prominent role, poor clinical outcomes for the medically complex patients with HF managed in SNFs are common. Barriers to providing quality care include poor transitional care during hospital-to-SNF and SNF-to-community discharges, lack of HF training among SNF staff, and a lack of a standardized care process among SNF facilities. Although no evidence-based practice standards have been established, various measures and tools designed to improve HF management in SNFs are being investigated. In this review, we discuss the challenges of HF care in SNFs as well as potential targets and recommendations that can help improve care with respect to transitions, HF management within SNFs, and modifiable factors within facilities. Policy considerations that might help catalyze improvements in SNF-based HF management are also discussed.

Targeting heart failure rehospitalizations in a skilled nursing facility: A case report

OBJECTIVE

We report on a skilled nursing facility (SNF) that added designated heart failure (HF) beds and created a patient registry to track the number and reasons for rehospitalization.

BACKGROUND

Targeting the reduction of rehospitalizations from SNFs is an important goal and patients with HF are particularly vulnerable for rehospitalizations as HF disease management programs in SNFs are rare.

METHODS

A case study of a local quality improvement initiative.

RESULTS

The data from the registry revealed, that compared to patients without HF, patients with HF were more often rehospitalized for cardiopulmonary symptoms and less often for infection. In addition, patients with HF were most often rehospitalized during the first 7 days of their SNF stay and if they had a primary hospital discharge diagnosis of HF.

CONCLUSION

We highlight the benefits of a patient registry to guide future quality improvement initiatives to reduce patient rehospitalization rates.

Transitional care of older adults in skilled nursing facilities: A systematic review

Transitional care may be an effective strategy for preparing older adults for transitions from skilled nursing facilities (SNF) to home. In this systematic review, studies of patients discharged from SNFs to home were reviewed. Study findings were assessed (1) to identify whether transitional care interventions, as compared to usual care, improved clinical outcomes such as mortality, readmission rates, quality of life or functional status; and (2) to describe intervention characteristics, resources needed for implementation, and methodologic challenges. Of 1082 unique studies identified in a systematic search, the full texts of six studies meeting criteria for inclusion were reviewed. Although the risk for bias was high across studies, the findings suggest that there is promising but limited evidence that transitional care improves clinical outcomes for SNF patients. Evidence in the review identifies needs for further study, such as the need for randomized studies of transitional care in SNFs, and methodological challenges to studying transitional care for SNF patients.

Heart Failure Among Older Adults in Skilled Nursing Facilities: More of a Dilemma Than Many Now Realize

Post-acute care, encompassing long-term care hospitals, home health, inpatient rehabilitation, and skilled nursing facilities, is increasingly employed as an integral part of management for more complicated patients, particularly as hospitals seek to maintain costs and decrease length of stay. Skilled nursing facilities (SNFs) in particular are progressively utilized for patients with complex medical processes, including today's growing population of older hospitalized heart failure (HF) patients who pose a prominent challenge due to their high risks of mortality, 30-day readmissions, and substantial aggregate cost burden to the healthcare system. Publications to date have largely grouped post-hospitalized HF patients together when reporting demographic or outcome data, without differentiating those at SNFs from those at traditional nursing homes or other post-acute care settings. SNF patients suffer distinctive vulnerabilities and needs, and understanding these distinctions has implications for determining goals of care. In this review we evaluate HF patients referred to SNFs, and discuss the characteristics, outcomes, and management challenges associated with this particular population.

Implementation of a heart failure quality initiative in a skilled nursing facility: lessons learned

Skilled nursing facilities (SNFs) are organizations that represent complex adaptive systems, offering barriers to the implementation of quality improvement (QI) initiatives. The current article describes the authors' efforts to use the approach of reflective adaptive process to implement a new model of care (i.e., the Skilled Heart Unit Program) for effective heart failure (HF) care in one SNF. A team of stakeholders from the local hospital system and a local SNF was convened to design and implement this new model. Evaluation of the implementation processes confirmed the value of the implementation approach, which centered on team-based approaches, staff engagement, and flexibility of processes to respect the SNF's needs and culture. Interviews with facility staff and the administrator revealed their perceptions that the strategy resulted in better HF care, enhanced teamwork between staff and clinicians, and improved staff job satisfaction. This work provides a unique blueprint of strategic QI implementation for patients with HF in the SNF setting.