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Kaufman BG, Hastings SN, Meyer C, Stechuchak KM, Choate A, Decosimo K, Sullivan C, Wang V, Allen KD, Van Houtven CH. The business case for hospital mobility programs in the veterans health care system: Results from multi-hospital implementation of the STRIDE program. Health Serv Res 2024. [PMID: 38632179 DOI: 10.1111/1475-6773.14307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024] Open
Abstract
OBJECTIVE To conduct a business case analysis for Department of Veterans Affairs (VA) program STRIDE (ASsisTed EaRly MobIlization for hospitalizeD older VEterans), which was designed to address immobility for hospitalized older adults. DATA SOURCES AND STUDY SETTING This was a secondary analysis of primary data from a VA 8-hospital implementation trial conducted by the Function and Independence Quality Enhancement Research Initiative (QUERI). In partnership with VA operational partners, we estimated resources needed for program delivery in and out of the VA as well as national implementation facilitation in the VA. A scenario analysis using wage data from the Bureau of Labor Statistics informs implementation decisions outside the VA. STUDY DESIGN This budget impact analysis compared delivery and implementation costs for two implementation strategies (Replicating Effective Programs [REP]+CONNECT and REP-only). To simulate national budget scenarios for implementation, we estimated the number of eligible hospitalizations nationally and varied key parameters (e.g., enrollment rates) to evaluate the impact of uncertainty. DATA COLLECTION Personnel time and implementation outcomes were collected from hospitals (2017-2019). Hospital average daily census and wage data were estimated as of 2022 to improve relevance to future implementation. PRINCIPAL FINDINGS Average implementation costs were $9450 for REP+CONNECT and $5622 for REP-only; average program delivery costs were less than $30 per participant in both VA and non-VA hospital settings. Number of walks had the most impact on delivery costs and ranged from 1 to 5 walks per participant. In sensitivity analyses, cost increased to $35 per participant if a physical therapist assistant conducts the walks. Among study hospitals, mean enrollment rates were higher among the REP+CONNECT hospitals (12%) than the REP-only hospitals (4%) and VA implementation costs ranged from $66 to $100 per enrolled. CONCLUSIONS STRIDE is a low-cost intervention, and program participation has the biggest impact on the resources needed for delivering STRIDE. TRIAL REGISTRATION ClinicalsTrials.gov NCT03300336. Prospectively registered on 3 October 2017.
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Affiliation(s)
- Brystana G Kaufman
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, North Carolina, USA
- Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Margolis Institute for Health Policy, Duke University, Durham, North Carolina, USA
| | - S Nicole Hastings
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, North Carolina, USA
- Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Medicine, Duke University, Durham, North Carolina, USA
| | - Cassie Meyer
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, North Carolina, USA
| | - Karen M Stechuchak
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, North Carolina, USA
| | - Ashley Choate
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, North Carolina, USA
| | - Kasey Decosimo
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, North Carolina, USA
| | - Caitlin Sullivan
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, North Carolina, USA
| | - Virginia Wang
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, North Carolina, USA
- Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Margolis Institute for Health Policy, Duke University, Durham, North Carolina, USA
- Department of Medicine, Duke University, Durham, North Carolina, USA
| | - Kelli D Allen
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, North Carolina, USA
- Department of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Courtney H Van Houtven
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, North Carolina, USA
- Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Margolis Institute for Health Policy, Duke University, Durham, North Carolina, USA
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Putrik P, Grobler L, Lalor A, Ramsay H, Gorelik A, Karnon J, Parker D, Morgan M, Buchbinder R, O'Connor D. Models for delivery and co-ordination of primary or secondary health care (or both) to older adults living in aged care facilities. Cochrane Database Syst Rev 2024; 3:CD013880. [PMID: 38426600 PMCID: PMC10905654 DOI: 10.1002/14651858.cd013880.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
BACKGROUND The number of older people is increasing worldwide and public expenditure on residential aged care facilities (ACFs) is expected to at least double, and possibly triple, by 2050. Co-ordinated and timely care in residential ACFs that reduces unnecessary hospital transfers may improve residents' health outcomes and increase satisfaction with care among ACF residents, their families and staff. These benefits may outweigh the resources needed to sustain the changes in care delivery and potentially lead to cost savings. Our systematic review comprehensively and systematically presents the available evidence of the effectiveness, safety and cost-effectiveness of alternative models of providing health care to ACF residents. OBJECTIVES Main objective To assess the effectiveness and safety of alternative models of delivering primary or secondary health care (or both) to older adults living in ACFs. Secondary objective To assess the cost-effectiveness of the alternative models. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, five other databases and two trials registers (WHO ICTRP, ClinicalTrials.gov) on 26 October 2022, together with reference checking, citation searching and contact with study authors to identify additional studies. SELECTION CRITERIA We included individual and cluster-randomised trials, and cost/cost-effectiveness data collected alongside eligible effectiveness studies. Eligible study participants included older people who reside in an ACF as their place of permanent abode and healthcare professionals delivering or co-ordinating the delivery of healthcare at ACFs. Eligible interventions focused on either ways of delivering primary or secondary health care (or both) or ways of co-ordinating the delivery of this care. Eligible comparators included usual care or another model of care. Primary outcomes were emergency department visits, unplanned hospital admissions and adverse effects (defined as infections, falls and pressure ulcers). Secondary outcomes included adherence to clinical guideline-recommended care, health-related quality of life of residents, mortality, resource use, access to primary or specialist healthcare services, any hospital admissions, length of hospital stay, satisfaction with the health care by residents and their families, work-related satisfaction and work-related stress of ACF staff. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies for inclusion, extracted data, and assessed risk of bias and certainty of evidence using GRADE. The primary comparison was any alternative model of care versus usual care. MAIN RESULTS We included 40 randomised trials (21,787 participants; three studies only reported number of beds) in this review. Included trials evaluated alternative models of care aimed at either all residents of the ACF (i.e. no specific health condition; 11 studies), ACF residents with mental health conditions or behavioural problems (12 studies), ACF residents with a specific condition (e.g. residents with pressure ulcers, 13 studies) or residents requiring a specific type of care (e.g. residents after hospital discharge, four studies). Most alternative models of care focused on 'co-ordination of care' (n = 31). Three alternative models of care focused on 'who provides care' and two focused on 'where care is provided' (i.e. care provided within ACF versus outside of ACF). Four models focused on the use of information and communication technology. Usual care, the comparator in all studies, was highly heterogeneous across studies and, in most cases, was poorly reported. Most of the included trials were susceptible to some form of bias; in particular, performance (89%), reporting (66%) and detection (42%) bias. Compared to usual care, alternative models of care may make little or no difference to the proportion of residents with at least one emergency department visit (risk ratio (RR) 1.01, 95% confidence interval (CI) 0.84 to 1.20; 7 trials, 1276 participants; low-certainty evidence), but may reduce the proportion of residents with at least one unplanned hospital admission (RR 0.74, 95% CI 0.56 to 0.99, I2 = 53%; 8 trials, 1263 participants; low-certainty evidence). We are uncertain of the effect of alternative models of care on adverse events (proportion of residents with a fall: RR 1.15, 95% CI 0.83 to 1.60, I² = 74%; 3 trials, 1061 participants; very low-certainty evidence) and adherence to guideline-recommended care (proportion of residents receiving adequate antidepressant medication: RR 5.29, 95% CI 1.08 to 26.00; 1 study, 65 participants) as the certainty of the evidence is very low. Compared to usual care, alternative models of care may have little or no effect on the health-related quality of life of ACF residents (MD -0.016, 95% CI -0.036 to 0.004; I² = 23%; 12 studies, 4016 participants; low-certainty evidence) and probably make little or no difference to the number of deaths in residents of ACFs (RR 1.03, 95% CI 0.92 to 1.16, 24 trials, 3881 participants, moderate-certainty evidence). We did not pool the cost-effectiveness or cost data as the specific costs associated with the various alternative models of care were incomparable, both across models of care as well as across settings. Based on the findings of five economic evaluations (all interventions focused on co-ordination of care), we are uncertain of the cost-effectiveness of alternative models of care compared to usual care as the certainty of the evidence is very low. AUTHORS' CONCLUSIONS Compared to usual care, alternative models of care may make little or no difference to the number of emergency department visits but may reduce unplanned hospital admissions. We are uncertain of the effect of alternative care models on adverse events (i.e. falls, pressure ulcers, infections) and adherence to guidelines compared to usual care, as the certainty of the evidence is very low. Alternative models of care may have little or no effect on health-related quality of life and probably have no effect on mortality of ACF residents compared to usual care. Importantly, we are uncertain of the cost-effectiveness of alternative models of care due to the limited, disparate data available.
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Affiliation(s)
- Polina Putrik
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Liesl Grobler
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Aislinn Lalor
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- School of Primary and Allied Health Care, Monash University, Melbourne, Australia
| | - Helen Ramsay
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Alexandra Gorelik
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Jonathan Karnon
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Deborah Parker
- Faculty of Health, The University of Technology Sydney, Sydney, NSW, Australia
| | - Mark Morgan
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia
| | - Rachelle Buchbinder
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Denise O'Connor
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
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Hughes JM, Zullig LL, Choate AL, Decosimo KP, Wang V, Van Houtven CH, Allen KD, Nicole Hastings S. Intensification of Implementation Strategies: Developing a Model of Foundational and Enhanced Implementation Approaches to Support National Adoption and Scale-up. THE GERONTOLOGIST 2023; 63:604-613. [PMID: 36029028 PMCID: PMC10461172 DOI: 10.1093/geront/gnac130] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Indexed: 11/13/2022] Open
Abstract
Implementation strategies are activities to support integration of evidence-based programs (EBPs) into routine care. Comprised of 170+ facilities, the Veterans Affairs Healthcare System is conducive to evaluating feasibility and scalability of implementation strategies on a national level. In previous work evaluating implementation of three EBPs for older Veterans (hospital-based walking, caregiver skills training, group physical therapy), we found facilities varied in their need for implementation support, with some needing minimal guidance and others requiring intensive support. Committed to national scalability, our team developed an implementation intensification model consisting of foundational (low-touch) and enhanced (high-touch) implementation support. This Forum article describes our multilevel and multistep process to develop and evaluate implementation intensification. Steps included (a) review completed trial data; (b) conduct listening sessions; (c) review literature; (d) draft foundational and enhanced implementation support packages; (e) iteratively refine packages; and (7) devise an evaluation plan. Our model of implementation intensification may be relevant to other health care systems seeking strategies that can adapt to diverse delivery settings, optimize resources, help build capacity, and ultimately enhance implementation outcomes. As more health care systems focus on spread of EBPs into routine care, identifying scalable and effective implementation strategies will be critical.
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Affiliation(s)
- Jaime M Hughes
- Department of Implementation Science, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
| | - Leah L Zullig
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Ashley L Choate
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
| | - Kasey P Decosimo
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
| | - Virginia Wang
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Courtney H Van Houtven
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Kelli D Allen
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
- Department of Medicine, University of North Carolina at Chapel Hill School of Medicine , Chapel Hill, North Carolina, USA
| | - S Nicole Hastings
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
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Albasha N, Ahern L, O’Mahony L, McCullagh R, Cornally N, McHugh S, Timmons S. Implementation strategies to support fall prevention interventions in long-term care facilities for older persons: a systematic review. BMC Geriatr 2023; 23:47. [PMID: 36698065 PMCID: PMC9878796 DOI: 10.1186/s12877-023-03738-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 01/09/2023] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Falls are common among older people in long-term care facilities (LTCFs). Falls cause considerable morbidity, mortality and reduced quality of life. Of numerous interventional studies of fall prevention interventions in LTCFs, some reduced falls. However, there are challenges to implementing these interventions in real-world (non-trial) clinical practice, and the implementation techniques may be crucial to successful translation. This systematic review thus aimed to synthesise the evidence on implementation strategies, implementation outcomes and clinical outcomes included in fall prevention intervention studies. METHODS A systematic search of six electronic databases (PubMed, CINAHL, EMBASE, PsycINFO, SCOPUS, Web of Science) and eight grey literature databases was conducted, involving papers published during 2001-2021, in English or Arabic, targeting original empirical studies of fall prevention interventions (experimental and quasi-experimental). Two seminal implementation frameworks guided the categorisation of implementation strategies and outcomes: the Expert Recommendations for Implementing Change (ERIC) Taxonomy and the Implementation Outcomes Framework. Four ERIC sub-categories and three additional implementation strategies were created to clarify overlapping definitions and reflect the implementation approach. Two independent researchers completed title/abstract and full-text screening, quality appraisal assessment, data abstraction and coding of the implementation strategies and outcomes. A narrative synthesis was performed to analyse results. RESULTS Four thousand three hundred ninety-seven potential papers were identified; 31 papers were included, describing 27 different fall prevention studies. These studies used 39 implementation strategies (3-17 per study). Educational and training strategies were used in almost all (n = 26), followed by evaluative strategies (n = 20) and developing stakeholders' interrelationships (n = 20). Within educational and training strategies, education outreach/meetings (n = 17), distributing educational materials (n = 17) and developing educational materials (n = 13) were the most common, with 36 strategies coded to the ERIC taxonomy. Three strategies were added to allow coding of once-off training, dynamic education and ongoing medical consultation. Among the 15 studies reporting implementation outcomes, fidelity was the most common (n = 8). CONCLUSION This is the first study to comprehensively identify the implementation strategies used in falls prevention interventions in LTCFs. Education is the most common implementation strategy used in this setting. This review highlighted that there was poor reporting of the implementation strategies, limited assessment of implementation outcomes, and there was no discernible pattern of implementation strategies used in effective interventions, which should be improved and clearly defined. TRIAL REGISTRATION This systematic review was registered on the PROSPERO database; registration number: CRD42021239604.
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Affiliation(s)
- Neah Albasha
- grid.7872.a0000000123318773Center for Gerontology and Rehabilitation, School of Medicine, University College Cork, St Finbarr’s Hospital, The Bungalow, Block 13, Douglas Road, Cork City, Ireland ,grid.449346.80000 0004 0501 7602Rehabilitation Department, College of Health and Rehabilitation Sciences, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Leanne Ahern
- grid.7872.a0000000123318773School of Clinical Therapies, University College Cork, Cork City, Ireland
| | - Lauren O’Mahony
- grid.7872.a0000000123318773Center for Gerontology and Rehabilitation, School of Medicine, University College Cork, St Finbarr’s Hospital, The Bungalow, Block 13, Douglas Road, Cork City, Ireland
| | - Ruth McCullagh
- grid.7872.a0000000123318773School of Clinical Therapies, University College Cork, Cork City, Ireland
| | - Nicola Cornally
- grid.7872.a0000000123318773School of Nursing and Midwifery, University College Cork, Cork City, Ireland
| | - Sheena McHugh
- grid.7872.a0000000123318773School of Public Health, University College Cork, Cork City, Ireland
| | - Suzanne Timmons
- grid.7872.a0000000123318773Center for Gerontology and Rehabilitation, School of Medicine, University College Cork, St Finbarr’s Hospital, The Bungalow, Block 13, Douglas Road, Cork City, Ireland
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Wang V, D'Adolf J, Decosimo K, Robinson K, Choate A, Bruening R, Sperber N, Mahanna E, Van Houtven CH, Allen KD, Colón-Emeric C, Damush TM, Hastings SN. Adapting to CONNECT: modifying a nursing home-based team-building intervention to improve hospital care team interactions, functioning, and implementation readiness. BMC Health Serv Res 2022; 22:968. [PMID: 35906589 PMCID: PMC9335996 DOI: 10.1186/s12913-022-08270-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 06/29/2022] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Clinical interventions often need to be adapted from their original design when they are applied to new settings. There is a growing literature describing frameworks and approaches to deploying and documenting adaptations of evidence-based practices in healthcare. Still, intervention modifications are often limited in detail and justification, which may prevent rigorous evaluation of interventions and intervention adaptation effectiveness in new contexts. We describe our approach in a case study, combining two complementary intervention adaptation frameworks to modify CONNECT for Quality, a provider-facing team building and communication intervention designed to facilitate implementation of a new clinical program. METHODS This process of intervention adaptation involved the use of the Planned Adaptation Framework and the Framework for Reporting Adaptations and Modifications, for systematically identifying key drivers, core and non-core components of interventions for documenting planned and unplanned changes to intervention design. RESULTS The CONNECT intervention's original context and setting is first described and then compared with its new application. This lays the groundwork for the intentional modifications to intervention design, which are developed before intervention delivery to participating providers. The unpredictable nature of implementation in real-world practice required unplanned adaptations, which were also considered and documented. Attendance and participation rates were examined and qualitative assessment of reported participant experience supported the feasibility and acceptability of adaptations of the original CONNECT intervention in a new clinical context. CONCLUSION This approach may serve as a useful guide for intervention implementation efforts applied in diverse clinical contexts and subsequent evaluations of intervention effectiveness. TRIAL REGISTRATION The study was registered at ClinicalTrials.gov ( NCT03300336 ) on September 28, 2017.
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Affiliation(s)
- Virginia Wang
- Health Services Research and Development Center of Innovation, Durham VA Health Care System, Durham, NC, USA.
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA.
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA.
| | - Joshua D'Adolf
- Health Services Research and Development Center of Innovation, Durham VA Health Care System, Durham, NC, USA
| | - Kasey Decosimo
- Health Services Research and Development Center of Innovation, Durham VA Health Care System, Durham, NC, USA
| | - Katina Robinson
- Health Services Research and Development Center of Innovation, Durham VA Health Care System, Durham, NC, USA
| | - Ashley Choate
- Health Services Research and Development Center of Innovation, Durham VA Health Care System, Durham, NC, USA
| | - Rebecca Bruening
- Health Services Research and Development Center of Innovation, Durham VA Health Care System, Durham, NC, USA
| | - Nina Sperber
- Health Services Research and Development Center of Innovation, Durham VA Health Care System, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Elizabeth Mahanna
- Health Services Research and Development Center of Innovation, Durham VA Health Care System, Durham, NC, USA
| | - Courtney H Van Houtven
- Health Services Research and Development Center of Innovation, Durham VA Health Care System, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Kelli D Allen
- Health Services Research and Development Center of Innovation, Durham VA Health Care System, Durham, NC, USA
- Department of Medicine & Thurston Arthritis Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Cathleen Colón-Emeric
- Health Services Research and Development Center of Innovation, Durham VA Health Care System, Durham, NC, USA
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
- Geriatric Research Education and Clinical Center, Durham VA Health Care System, Durham, NC, USA
| | - Teresa M Damush
- Health Services Research and Development Center for Health Information and Communication, Richard L. Roudebush VAMC, Indianapolis, IN, USA
- Department of General Internal Medicine and Geriatrics, Indiana University School of Medicine, Indianapolis, IN, USA
- Regenstrief Institute, Inc., Indianapolis, IN, USA
| | - Susan N Hastings
- Health Services Research and Development Center of Innovation, Durham VA Health Care System, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
- Department of Medicine & Thurston Arthritis Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, NC, USA
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Galambos C, Vogelsmeier A, Popejoy L, Crecelius C, Canada K, Alexander GL, Rollin L, Rantz M. Enhancing Physician Relationships, Communication, and Engagement to Reduce Nursing Home Residents Hospitalizations. J Nurs Care Qual 2021; 36:99-104. [PMID: 33534347 DOI: 10.1097/ncq.0000000000000542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Colleen Galambos
- Helen Bader School of Social Welfare, University of Wisconsin-Milwaukee (Dr Galambos and Ms Rollin); Sinclair School of Nursing (Drs Vogelsmeier, Popejoy, Crecelius, and Rantz) and School of Social Work (Dr Canada), University of Missouri, St Louis; and Columbia University, School of Nursing (Dr Alexander)
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Chadborn NH, Devi R, Hinsliff-Smith K, Banerjee J, Gordon AL. Quality improvement in long-term care settings: a scoping review of effective strategies used in care homes. Eur Geriatr Med 2020; 12:17-26. [PMID: 32888183 PMCID: PMC7472942 DOI: 10.1007/s41999-020-00389-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 08/26/2020] [Indexed: 01/08/2023]
Abstract
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.
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Affiliation(s)
- Neil H Chadborn
- Division of Medical Science and Graduate Entry Medicine, School of Medicine, University of Nottingham, Nottingham, UK. .,NIHR Applied Research Collaboration East Midlands, Nottingham, UK.
| | - Reena Devi
- School of Healthcare, University of Leeds, Leeds, UK
| | | | - Jay Banerjee
- School of Life Sciences, University of Leicester, Leicester, UK
| | - Adam L Gordon
- Division of Medical Science and Graduate Entry Medicine, School of Medicine, University of Nottingham, Nottingham, UK.,NIHR Applied Research Collaboration East Midlands, Nottingham, UK
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Coe NB, Guo J, Konetzka RT, Van Houtven CH. What is the marginal benefit of payment-induced family care? Impact on Medicaid spending and health of care recipients. HEALTH ECONOMICS 2019; 28:678-692. [PMID: 30887623 PMCID: PMC6528172 DOI: 10.1002/hec.3873] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Revised: 01/07/2019] [Accepted: 01/22/2019] [Indexed: 06/09/2023]
Abstract
Research on home-based long-term care has centered almost solely on the costs; there has been very little, if any, attention paid to the relative benefits. This study exploits the randomization built into the Cash and Counseling Demonstration and Evaluation program that directly impacted the likelihood of having family involved in home care delivery. Randomization in the trial is used as an instrumental variable for family involvement in care, resulting in a causal estimate of the effect of changing the combination of home health-care providers on health-care utilization and health outcomes of the beneficiary. We find that some family involvement in home-based care significantly decreases health-care utilization: lower likelihood of emergency room use, Medicaid-financed inpatient days, any Medicaid hospital expenditures, and fewer months with Medicaid-paid inpatient use. We find that individuals who have some family involved in home-based care are less likely to have several adverse health outcomes within the first 9 months of the trial, including lower prevalence of infections, bedsores, or shortness of breath, suggesting that the lower utilization may be due to better health outcomes.
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Affiliation(s)
- Norma B Coe
- Perelman School of Medicine, Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- National Bureau of Economic Research (NBER), Cambridge, Massachusetts, USA
| | - Jing Guo
- Agency for Healthcare Research and Quality, Center for Delivery, Organization, and Markets, Rockville, Maryland, USA
| | - R Tamara Konetzka
- Department of Public Health Sciences, University of Chicago, Chicago, Illinois, USA
| | - Courtney Harold Van Houtven
- Department of General Internal Medicine, Duke University Medical Center, Durham, North Carolina, USA
- Health Services Research and Development in Primary Care, Durham Veteran's Affairs Medical Center, Durham, North Carolina, USA
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Quality of care to nursing home residents with incontinence. Geriatr Nurs 2018; 40:166-173. [PMID: 30322735 DOI: 10.1016/j.gerinurse.2018.09.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 09/10/2018] [Accepted: 09/13/2018] [Indexed: 11/22/2022]
Abstract
Quality of care for residents with urinary incontinence (UI) living in nursing facilities was analyzed using data collected from 815 facilities for the Nursing Facility Quality Review in Texas. Overall, of the 1,560 residents, 48.4% (n = 755) experienced UI. The risk of developing UI over a ten-year-period in a nursing facility was 6%. Only 54% of residents with UI had a care plan for their incontinence. For those with a UI plan in their chart, 143 (35%) had a person entered UI plan developed based on that resident's voiding pattern and needs. Further, the creation of a UI plan of care by a RN for a person with UI was associated with a higher perceived level of health after controlling for gender, and age. Finally, the more satisfied the resident was with the response to their calls for help with voiding the more satisfied with the nursing facility.
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Cameron ID, Dyer SM, Panagoda CE, Murray GR, Hill KD, Cumming RG, Kerse N. Interventions for preventing falls in older people in care facilities and hospitals. Cochrane Database Syst Rev 2018; 9:CD005465. [PMID: 30191554 PMCID: PMC6148705 DOI: 10.1002/14651858.cd005465.pub4] [Citation(s) in RCA: 169] [Impact Index Per Article: 28.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Falls in care facilities and hospitals are common events that cause considerable morbidity and mortality for older people. This is an update of a review first published in 2010 and updated in 2012. OBJECTIVES To assess the effects of interventions designed to reduce the incidence of falls in older people in care facilities and hospitals. SEARCH METHODS We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (August 2017); Cochrane Central Register of Controlled Trials (2017, Issue 8); and MEDLINE, Embase, CINAHL and trial registers to August 2017. SELECTION CRITERIA Randomised controlled trials of interventions for preventing falls in older people in residential or nursing care facilities, or hospitals. DATA COLLECTION AND ANALYSIS One review author screened abstracts; two review authors screened full-text articles for inclusion. Two review authors independently performed study selection, 'Risk of bias' assessment and data extraction. We calculated rate ratios (RaR) with 95% confidence intervals (CIs) for rate of falls and risk ratios (RRs) and 95% CIs for outcomes such as risk of falling (number of people falling). We pooled results where appropriate. We used GRADE to assess the quality of evidence. MAIN RESULTS Thirty-five new trials (77,869 participants) were included in this update. Overall, we included 95 trials (138,164 participants), 71 (40,374 participants; mean age 84 years; 75% women) in care facilities and 24 (97,790 participants; mean age 78 years; 52% women) in hospitals. The majority of trials were at high risk of bias in one or more domains, mostly relating to lack of blinding. With few exceptions, the quality of evidence for individual interventions in either setting was generally rated as low or very low. Risk of fracture and adverse events were generally poorly reported and, where reported, the evidence was very low-quality, which means that we are uncertain of the estimates. Only the falls outcomes for the main comparisons are reported here.Care facilitiesSeventeen trials compared exercise with control (typically usual care alone). We are uncertain of the effect of exercise on rate of falls (RaR 0.93, 95% CI 0.72 to 1.20; 2002 participants, 10 studies; I² = 76%; very low-quality evidence). Exercise may make little or no difference to the risk of falling (RR 1.02, 95% CI 0.88 to 1.18; 2090 participants, 10 studies; I² = 23%; low-quality evidence).There is low-quality evidence that general medication review (tested in 12 trials) may make little or no difference to the rate of falls (RaR 0.93, 95% CI 0.64 to 1.35; 2409 participants, 6 studies; I² = 93%) or the risk of falling (RR 0.93, 95% CI 0.80 to 1.09; 5139 participants, 6 studies; I² = 48%).There is moderate-quality evidence that vitamin D supplementation (4512 participants, 4 studies) probably reduces the rate of falls (RaR 0.72, 95% CI 0.55 to 0.95; I² = 62%), but probably makes little or no difference to the risk of falling (RR 0.92, 95% CI 0.76 to 1.12; I² = 42%). The population included in these studies had low vitamin D levels.Multifactorial interventions were tested in 13 trials. We are uncertain of the effect of multifactorial interventions on the rate of falls (RaR 0.88, 95% CI 0.66 to 1.18; 3439 participants, 10 studies; I² = 84%; very low-quality evidence). They may make little or no difference to the risk of falling (RR 0.92, 95% CI 0.81 to 1.05; 3153 participants, 9 studies; I² = 42%; low-quality evidence).HospitalsThree trials tested the effect of additional physiotherapy (supervised exercises) in rehabilitation wards (subacute setting). The very low-quality evidence means we are uncertain of the effect of additional physiotherapy on the rate of falls (RaR 0.59, 95% CI 0.26 to 1.34; 215 participants, 2 studies; I² = 0%), or whether it reduces the risk of falling (RR 0.36, 95% CI 0.14 to 0.93; 83 participants, 2 studies; I² = 0%).We are uncertain of the effects of bed and chair sensor alarms in hospitals, tested in two trials (28,649 participants) on rate of falls (RaR 0.60, 95% CI 0.27 to 1.34; I² = 0%; very low-quality evidence) or risk of falling (RR 0.93, 95% CI 0.38 to 2.24; I² = 0%; very low-quality evidence).Multifactorial interventions in hospitals may reduce rate of falls in hospitals (RaR 0.80, 95% CI 0.64 to 1.01; 44,664 participants, 5 studies; I² = 52%). A subgroup analysis by setting suggests the reduction may be more likely in a subacute setting (RaR 0.67, 95% CI 0.54 to 0.83; 3747 participants, 2 studies; I² = 0%; low-quality evidence). We are uncertain of the effect of multifactorial interventions on the risk of falling (RR 0.82, 95% CI 0.62 to 1.09; 39,889 participants; 3 studies; I² = 0%; very low-quality evidence). AUTHORS' CONCLUSIONS In care facilities: we are uncertain of the effect of exercise on rate of falls and it may make little or no difference to the risk of falling. General medication review may make little or no difference to the rate of falls or risk of falling. Vitamin D supplementation probably reduces the rate of falls but not risk of falling. We are uncertain of the effect of multifactorial interventions on the rate of falls; they may make little or no difference to the risk of falling.In hospitals: we are uncertain of the effect of additional physiotherapy on the rate of falls or whether it reduces the risk of falling. We are uncertain of the effect of providing bed sensor alarms on the rate of falls or risk of falling. Multifactorial interventions may reduce rate of falls, although subgroup analysis suggests this may apply mostly to a subacute setting; we are uncertain of the effect of these interventions on risk of falling.
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Affiliation(s)
- Ian D Cameron
- The University of SydneyJohn Walsh Centre for Rehabilitation Research, Sydney Medical School, Northern Clinical SchoolReserve RoadSt LeonardsNSWAustralia2065
| | - Suzanne M Dyer
- DHATR Consulting120 Robsart StreetParksideSouth AustraliaAustralia5063
| | - Claire E Panagoda
- John Walsh Centre for Rehabilitation Research, Kolling Institute, Northern Sydney Local Health DistrictSt LeonardsNSWAustralia2065
| | - Geoffrey R Murray
- Illawarra Shoalhaven Local Health DistrictAged Care, Rehabilitation and Palliative CareWarrawongAustralia
| | - Keith D Hill
- Curtin UniversitySchool of Physiotherapy and Exercise Science, Faculty of Health SciencesGPO Box U1987PerthWestern AustraliaAustralia6845
| | - Robert G Cumming
- Sydney Medical School, University of SydneySchool of Public HealthRoom 306, Edward Ford Building (A27)Fisher RoadSydneyNSWAustralia2006
| | - Ngaire Kerse
- University of AucklandDepartment of General Practice and Primary Health CarePrivate Bag 92019AucklandNew Zealand
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Wang V, Allen K, Van Houtven CH, Coffman C, Sperber N, Mahanna EP, Colón-Emeric C, Hoenig H, Jackson GL, Damush TM, Price E, Hastings SN. Supporting teams to optimize function and independence in Veterans: a multi-study program and mixed methods protocol. Implement Sci 2018; 13:58. [PMID: 29678137 PMCID: PMC5910600 DOI: 10.1186/s13012-018-0748-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 04/10/2018] [Indexed: 11/10/2022] Open
Abstract
Background Successful implementation of new clinical programs depends on effectively establishing, reorganizing, or enhancing team structures and processes to coordinate the work of individuals who are interdependent in their tasks, manage relationships, and share responsibility for outcomes. However, a one-size-fits-all approach is rarely effective. In partnership with VA national clinical leaders and local clinical champions, the Optimizing Function and Independence VA Quality Enhancement Research Initiative program (Function QUERI) will evaluate efforts to implement team-based clinical programs for Veterans at risk for functional decline and disability. Methods Function QUERI will implement and evaluate three innovative, evidence-based clinical programs in VA medical centers: (1) a group physical therapy program for knee osteoarthritis (Group PT); (2) assisted early mobility for hospitalized older veterans (STRIDE), a supervised walking program for hospitalized older veterans; and (3) implementation of helping invested family members improve veteran experiences study (iHI-FIVES), a skills training program for caregivers of disabled Veterans. A common reason for clinical care gaps in these populations is poor communication and coordination among the many interdisciplinary providers involved in their care. To facilitate the implementation of the clinical programs, Function QUERI will evaluate the impact of complexity science-based implementation intervention to promote team readiness (CONNECT), an implementation intervention designed as a bundle of interaction-oriented activities to promote team function and readiness for change, on the implementation of clinical programs across multiple sites. The evaluation will use a mixed methods design. Group PT is a local, single-site quality improvement project where a modified CONNECT intervention will be tested to inform the remaining program implementation projects. For STRIDE and iHI-FIVES projects, we will randomize participating sites to implement the clinical program, with the CONNECT intervention or not, and will use a stepped-wedge cluster randomized trial design. Discussion Function QUERI will translate its findings across its projects to identify the contextual factors and components from CONNECT that improve team processes and function to optimize effective implementation for future rollout of VA clinical programs. Synthesizing findings within and across projects, we will specify dimensions of team characteristics and function that enhance capacity for clinical innovation and uptake of evidence-based programs. Trial registration NCT03300336 Registered September 28, 2017, NCT03474380 Registered March 15, 2018. Electronic supplementary material The online version of this article (10.1186/s13012-018-0748-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Virginia Wang
- Health Services Research and Development Center of Innovation, Durham Veterans Affairs Health Care System, 508 Fulton St., Durham, NC, 27705, USA. .,Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA. .,Department of Medicine, Duke University School of Medicine, Durham, NC, USA.
| | - Kelli Allen
- Health Services Research and Development Center of Innovation, Durham Veterans Affairs Health Care System, 508 Fulton St., Durham, NC, 27705, USA.,Department of Medicine and Thurston Arthritis Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Courtney H Van Houtven
- Health Services Research and Development Center of Innovation, Durham Veterans Affairs Health Care System, 508 Fulton St., Durham, NC, 27705, USA.,Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Cynthia Coffman
- Health Services Research and Development Center of Innovation, Durham Veterans Affairs Health Care System, 508 Fulton St., Durham, NC, 27705, USA.,Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | - Nina Sperber
- Health Services Research and Development Center of Innovation, Durham Veterans Affairs Health Care System, 508 Fulton St., Durham, NC, 27705, USA.,Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Elizabeth P Mahanna
- Health Services Research and Development Center of Innovation, Durham Veterans Affairs Health Care System, 508 Fulton St., Durham, NC, 27705, USA
| | - Cathleen Colón-Emeric
- Health Services Research and Development Center of Innovation, Durham Veterans Affairs Health Care System, 508 Fulton St., Durham, NC, 27705, USA.,Department of Medicine, Duke University School of Medicine, Durham, NC, USA.,Geriatric Research Education and Clinical Center, Durham VA Health Care System, Durham, NC, USA
| | - Helen Hoenig
- Health Services Research and Development Center of Innovation, Durham Veterans Affairs Health Care System, 508 Fulton St., Durham, NC, 27705, USA.,Department of Medicine, Duke University School of Medicine, Durham, NC, USA.,Physical Medicine and Rehabilitation Service, Durham VA Health Care System, Durham, NC, USA
| | - George L Jackson
- Health Services Research and Development Center of Innovation, Durham Veterans Affairs Health Care System, 508 Fulton St., Durham, NC, 27705, USA.,Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA.,Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Teresa M Damush
- Health Services Research and Development Center for Health Information and Communication, Roudebush Veterans Affairs Medical Center, 1481 W. 10th St., HSRD 11H, Indianapolis, IN, 46202, USA.,Department of General Internal Medicine and Geriatrics, Indiana University School of Medicine, Indianapolis, IN, USA.,Regenstrief Institute, Inc., Indianapolis, IN, USA
| | - Erika Price
- San Francisco VA Care System, 94121, 4150 Celement St., Box 111, San Francisco, CA, USA.,Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Susan N Hastings
- Health Services Research and Development Center of Innovation, Durham Veterans Affairs Health Care System, 508 Fulton St., Durham, NC, 27705, USA.,Department of Medicine, Duke University School of Medicine, Durham, NC, USA.,Geriatric Research Education and Clinical Center, Durham VA Health Care System, Durham, NC, USA
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12
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Miller CJ, Kim B, Silverman A, Bauer MS. A systematic review of team-building interventions in non-acute healthcare settings. BMC Health Serv Res 2018; 18:146. [PMID: 29490664 PMCID: PMC5831839 DOI: 10.1186/s12913-018-2961-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 02/21/2018] [Indexed: 11/17/2022] Open
Abstract
Background Healthcare is increasingly delivered in a team-based format emphasizing interdisciplinary coordination. While recent reviews have investigated team-building interventions primarily in acute healthcare settings (e.g. emergency or surgery departments), we aimed to systematically review the evidence base for team-building interventions in non-acute settings (e.g. primary care or rehabilitation clinics). Methods We conducted a systematic review in PubMed and Embase to identify team-building interventions, and conducted follow-up literature searches to identify articles describing empirical studies of those interventions. This process identified 14 team-building interventions for non-acute healthcare settings, and 25 manuscripts describing empirical studies of these interventions. We evaluated outcomes in four domains: trainee evaluations, teamwork attitudes/knowledge, team functioning, and patient impact. Results Trainee evaluations for team-building interventions were generally positive, but only one study associated team-building with statistically significant improvement in teamwork attitudes/knowledge. Similarly mixed results emerged for team functioning and patient impact. Conclusions The evidence base for healthcare team-building interventions in non-acute healthcare settings is much less developed than the parallel literature for short-term team function in acute care settings. Only one intervention we identified has been tested in multiple non-acute settings by distinct research teams. Positive findings regarding the utility of team-building interventions are tempered by a lack of control conditions, inconsistency in outcome measures, and high probability of bias. Considering these results alongside the well-recognized costs of poor healthcare teamwork suggests that additional research is sorely needed to develop the evidence base for team-building in non-acute settings.
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Affiliation(s)
- Christopher J Miller
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System (152M), 150 South Huntington Avenue, Boston, MA, 02130, USA. .,Harvard Medical School, Department of Psychiatry, Boston, USA.
| | - Bo Kim
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System (152M), 150 South Huntington Avenue, Boston, MA, 02130, USA.,Harvard Medical School, Department of Psychiatry, Boston, USA
| | - Allie Silverman
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System (152M), 150 South Huntington Avenue, Boston, MA, 02130, USA
| | - Mark S Bauer
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System (152M), 150 South Huntington Avenue, Boston, MA, 02130, USA.,Harvard Medical School, Department of Psychiatry, Boston, USA
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13
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Resident Vignettes for Assessing Care Quality in Nursing Homes. J Am Med Dir Assoc 2017; 19:405-410. [PMID: 29174560 DOI: 10.1016/j.jamda.2017.10.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 10/18/2017] [Accepted: 10/18/2017] [Indexed: 11/21/2022]
Abstract
OBJECTIVES Validated process measures that correlate with patient outcomes are needed for research and quality improvement. DESIGN Cross-sectional analysis within a cluster-randomized fall prevention study. SETTING Nursing homes in North Carolina (n = 16). PARTICIPANTS Nursing home staff (n = 541) and residents with 1 or more falls in 6 months (n = 597). MEASUREMENTS Fall-prevention process measures in 4 categories derived from Assessing Care of Vulnerable Elders quality indicators were measured in 2 ways: (1) chart abstraction; and (2) staff responses to clinical vignettes of hypothetical residents at risk for falls. Recurrent fall rates (falls/resident/year) were measured. The proportion of the total variation in falls rates explained by the scores for each method (chart abstraction or vignette) was calculated using multilevel adjusted models. RESULTS Chart and vignette measures of comorbidity management were moderately correlated (Pearson correlation coefficient 0.43), whereas other process measure categories had low or negative correlation between the 2 methods (psychoactive medication reduction 0.13, environmental modification -0.42, and exercise/rehabilitation -0.08). Measures of environmental modification and comorbidity management explained a moderate amount of the total variation in recurrent fall fates, vignettes (7%-10% variation explained) were superior to chart abstraction (2%-6% variation explained). Vignette responses from unlicensed staff (nurse aides and rehabilitation aides) explained more variance than registered nurses, licensed practical nurses, or other licensed staff in these categories. Process measures for psychoactive medication reduction and exercise/rehabilitation did not explain any of the variation in fall outcomes. Overall, vignette process measures explained 3.9% and chart abstraction measures explained 0% of the variation in fall outcomes. CONCLUSIONS Clinical vignettes completed by nursing home staff had greater association with resident recurrent fall rates than traditional chart abstraction process measures.
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14
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Colón-Emeric CS, Corazzini K, McConnell ES, Pan W, Toles M, Hall R, Cary MP, Batchelor-Murphy M, Yap T, Anderson AL, Burd A, Amarasekara S, Anderson RA. Effect of Promoting High-Quality Staff Interactions on Fall Prevention in Nursing Homes: A Cluster-Randomized Trial. JAMA Intern Med 2017; 177:1634-1641. [PMID: 28973516 PMCID: PMC5710274 DOI: 10.1001/jamainternmed.2017.5073] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
IMPORTANCE New approaches are needed to enhance implementation of complex interventions for geriatric syndromes such as falls. OBJECTIVE To test whether a complexity science-based staff training intervention (CONNECT) promoting high-quality staff interactions improves the impact of an evidence-based falls quality improvement program (FALLS). DESIGN, SETTING, AND PARTICIPANTS Cluster-randomized trial in 24 nursing homes receiving either CONNECT followed by FALLS (intervention), or FALLS alone (control). Nursing home staff in all positions were asked to complete surveys at baseline, 3, 6, and 9 months. Medical records of residents with at least 1 fall in the 6-month pre- and postintervention windows (n = 1794) were abstracted for fall risk reduction measures, falls, and injurious falls. INTERVENTIONS CONNECT taught staff to improve their connections with coworkers, increase information flow, and use cognitive diversity in problem solving. Intervention components included 2 classroom sessions, relationship mapping, and self-monitoring. FALLS provided instruction in the Agency for Healthcare Research and Quality's Falls Management Program. MAIN OUTCOMES AND MEASURES Primary outcomes were (1) mean number of fall risk reduction activities documented within 30 days of falls and (2) median fall rates among residents with at least 1 fall during the study period. In addition, validated scales measured staff communication quality, frequency, timeliness, and safety climate. RESULTS Surveys were completed by 1545 staff members, representing 734 (37%) and 811 (44%) of eligible staff in intervention and control facilities, respectively; 511 (33%) respondents were hands-on care workers. Neither the CONNECT nor the FALLS-only facilities improved the mean count of fall risk reduction activities following FALLS (3.3 [1.6] vs 3.2 [1.5] of 10); furthermore, adjusted median recurrent fall rates did not differ between the groups (4.06 [interquartile range {IQR}, 2.03-8.11] vs 4.06 [IQR, 2.04-8.11] falls/resident/y). A modest improvement in staff communication measures was observed overall (mean, 0.03 [SE, 0.01] points on a 5-point scale; P = .03) and for communication timeliness (mean, 0.8 [SE, 0.03] points on a 5-point scale; P = .02). There was wide variation across facilities in intervention penetration. CONCLUSIONS AND RELEVANCE An intervention targeting gaps in staff communication and coordination did not improve the impact of a falls quality improvement program. New approaches to implementing evidence-based care for complex conditions in the nursing home are urgently needed. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00636675.
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Affiliation(s)
- Cathleen S Colón-Emeric
- Duke University School of Medicine, Duke University Medical Center, Durham, North Carolina.,Durham VA Geriatric Research Education and Clinical Center, Durham, North Carolina
| | | | - Eleanor S McConnell
- Durham VA Geriatric Research Education and Clinical Center, Durham, North Carolina.,Duke University School of Nursing, Durham, North Carolina
| | - Wei Pan
- Duke University School of Nursing, Durham, North Carolina
| | - Mark Toles
- University of North Carolina at Chapel Hill School of Nursing, Chapel Hill
| | - Rasheeda Hall
- Duke University School of Medicine, Duke University Medical Center, Durham, North Carolina.,Durham VA Geriatric Research Education and Clinical Center, Durham, North Carolina
| | - Michael P Cary
- Duke University School of Nursing, Durham, North Carolina
| | | | - Tracey Yap
- Duke University School of Nursing, Durham, North Carolina
| | | | - Andrew Burd
- Duke University School of Nursing, Durham, North Carolina
| | | | - Ruth A Anderson
- University of North Carolina at Chapel Hill School of Nursing, Chapel Hill
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Colón-Emeric CS, Corazzini K, McConnell E, Pan W, Toles M, Hall R, Batchelor-Murphy M, Yap TL, Anderson AL, Burd A, Anderson RA. Study of Individualization and Bias in Nursing Home Fall Prevention Practices. J Am Geriatr Soc 2017; 65:815-821. [PMID: 28186618 DOI: 10.1111/jgs.14675] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVES Little is known about how nursing home staff use resident characteristics to individualize care delivery or whether care is affected by implicit bias. DESIGN Randomized factorial clinical vignette survey. SETTING Sixteen nursing homes in North Carolina. PARTICIPANTS Nursing, rehabilitation, and social services staff (n = 433). MEASUREMENTS Vignettes describing hypothetical residents were generated from a matrix of clinical and demographic characteristics. Resident age, race and gender were suggested by a photo. Participants completed up to four randomly assigned vignettes (n = 1615), rating the likelihood that 12 fall prevention activities would be used for the resident. Fixed and random effects mixed model analysis examined the impact of vignette resident characteristics and staff characteristics on four intervention categories. RESULTS Staff reported a higher likelihood of fall prevention activities in all four categories for residents with a prior fall (0.2-0.5 points higher, 10 point scale, P < 0.05), but other risk factors did not affect scores. There was little evidence of individualization; only dementia increased the reported likelihood of environmental modification (0.3, P < 0.001, 95% CI 0.2-0.5). Individualization did not vary with staff licensure category or clinical experience. Registered nurses consistently reported higher likelihoods of all fall prevention activities than did licensed practical nurses, unlicensed staff and other professional staff (1.0-2.7 points, P < 0.001 to 0.005). There was a small degree of implicit racial bias; staff indicated that environmental modification would be less likely to occur in otherwise identical vignettes including a photo of a black rather than a white resident (-0.2 points, 95% CI -0.3 to -0.1). CONCLUSION Nursing home staff report a standardized approach to fall prevention without individualization. We found a small impact from implicit racial bias that should be further explored.
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Affiliation(s)
- Cathleen S Colón-Emeric
- School of Medicine, Duke University, Durham, North Carolina.,Durham VA Geriatric Research Education and Clinical Center, Durham, North Carolina
| | - Kirsten Corazzini
- School of Medicine, Duke University, Durham, North Carolina.,Durham VA Geriatric Research Education and Clinical Center, Durham, North Carolina.,School of Nursing, Duke University, Durham, North Carolina
| | | | - Wei Pan
- School of Nursing, Duke University, Durham, North Carolina
| | - Mark Toles
- School of Nursing, University of North Carolina, Chapel Hill, North Carolina
| | - Rasheeda Hall
- School of Medicine, Duke University, Durham, North Carolina.,Durham VA Geriatric Research Education and Clinical Center, Durham, North Carolina
| | | | - Tracey L Yap
- School of Nursing, Duke University, Durham, North Carolina
| | | | - Andrew Burd
- School of Nursing, Duke University, Durham, North Carolina
| | - Ruth A Anderson
- School of Nursing, University of North Carolina, Chapel Hill, North Carolina
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16
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Verloo H, Desmedt M, Morin D. Beliefs and implementation of evidence-based practice among nurses and allied healthcare providers in the Valais hospital, Switzerland. J Eval Clin Pract 2017; 23:139-148. [PMID: 27687154 DOI: 10.1111/jep.12653] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 08/17/2016] [Accepted: 08/17/2016] [Indexed: 11/28/2022]
Abstract
RATIONALE Evidence-based practice (EBP) is upheld as a means for patients to receive the most efficient care in a given context. Despite the available evidence and positive beliefs about it, implementing EBP as standard daily practice still faces many obstacles. AIMS AND OBJECTIVES This study investigated the beliefs about and implementation of EBP among nurses and allied healthcare providers (AHP) in 9 acute care hospitals in the canton of Valais, Switzerland. MATERIALS AND METHODS A cross-sectional descriptive survey was conducted. The target population was composed of 1899 nurses and 126 AHPs. Beliefs about and implementation of EBP were measured using EBP-Beliefs and EBP-Implementation scales of Melnyk et al. RESULTS The initial sample consisted in 491 participants (overall response rate 24.2%): 421 nurses (22.4% response rate) and 78 AHPs (61.9% response rate). The final sample, composed only of those who declared previous exposure to EBP, included 391 participants (329 nurses and 62 AHPs). Overall, participants had positive attitudes towards EBP and were willing to increase their knowledge to guide practice. However, they acknowledged poor implementation of EBP in daily practice. A significantly higher level of EBP implementation was declared by those formally trained in it (P = 0.006) and by those occupying more senior professional functions (P = 0.004). EBP-Belief scores predicted 13% of the variance in the EBP-Implementation scores (R2 = 0.13). DISCUSSION EBP is poorly implemented despite positive beliefs about it. Continuing education and support on EBP would help to ensure that patients receive the best available care based on high-quality evidence, patient needs, clinical expertise, and a fair distribution of healthcare resources. CONCLUSION This study's results will be used to guide institutional strategy to increase the use of EBP in daily practice.
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Affiliation(s)
- Henk Verloo
- University of Applied Sciences and Arts Western Switzerland, 5, Chemin de l'Agasse, CH, -1950, Sion, Switzerland.,Department of Nursing Sciences, Valais Hospital, 86, Avenue de Grand-Champsec, CH, -1951, Sion, Switzerland
| | - Mario Desmedt
- Valais Hospital, Directorate General, 86, Avenue de Grand-Champsec, CH, -1951, Sion, Switzerland
| | - Diane Morin
- Institut Universitaire de Formation et Recherche en Soins (IUFRS), Faculty of Biology and Medicine, University of Lausanne and Lausanne University Hospital, 10, Route de la Corniche, CH, -1010, Lausanne, Switzerland.,Faculty of Nursing Sciences, Université Laval, Québec, Canada
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Hoben M, Norton PG, Ginsburg LR, Anderson RA, Cummings GG, Lanham HJ, Squires JE, Taylor D, Wagg AS, Estabrooks CA. Improving Nursing Home Care through Feedback On PerfoRMance Data (INFORM): Protocol for a cluster-randomized trial. Trials 2017; 18:9. [PMID: 28069045 PMCID: PMC5223357 DOI: 10.1186/s13063-016-1748-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Accepted: 12/08/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Audit and feedback is effective in improving the quality of care. However, methods and results of international studies are heterogeneous, and studies have been criticized for a lack of systematic use of theory. In TREC (Translating Research in Elder Care), a longitudinal health services research program, we collect comprehensive data from care providers and residents in Canadian nursing homes to improve quality of care and life of residents, and quality of worklife of caregivers. The study aims are to a) systematically feed back TREC research data to nursing home care units, and b) compare the effectiveness of three different theory-based feedback strategies in improving performance within care units. METHODS INFORM (Improving Nursing Home Care through Feedback On PerfoRMance Data) is a 3.5-year pragmatic, three-arm, parallel, cluster-randomized trial. We will randomize 67 Western Canadian nursing homes with 203 care units to the three study arms, a standard feedback strategy and two assisted and goal-directed feedback strategies. Interventions will target care unit managerial teams. They are based on theory and evidence related to audit and feedback, goal setting, complex adaptive systems, and empirical work on feeding back research results. The primary outcome is the increased number of formal interactions (e.g., resident rounds or family conferences) involving care aides - non-registered caregivers providing up to 80% of direct care. Secondary outcomes are a) other modifiable features of care unit context (improved feedback, social capital, slack time) b) care aides' quality of worklife (improved psychological empowerment, job satisfaction), c) more use of best practices, and d) resident outcomes based on the Resident Assessment Instrument - Minimum Data Set 2.0. Outcomes will be assessed at baseline, immediately after the 12-month intervention period, and 18 months post intervention. DISCUSSION INFORM is the first study to systematically assess the effectiveness of different strategies to feed back research data to nursing home care units in order to improve their performance. Results of this study will enable development of a practical, sustainable, effective, and cost-effective feedback strategy for routine use by managers, policy makers and researchers. The results may also be generalizable to care settings other than nursing homes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02695836 . Date of registration: 24 February 2016.
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Affiliation(s)
- Matthias Hoben
- Faculty of Nursing, University of Alberta, Edmonton, Alberta Canada
- Alberta Innovates-Health Solutions (AIHS) post-doctoral fellow, Translating Research in Elder Care (TREC), Faculty of Nursing, University of Alberta, 5-006 Edmonton Clinic Health Academy (ECHA), 11405 87 Avenue, Edmonton, AB T6G 1C9 Canada
| | - Peter G. Norton
- Department of Family Medicine, University of Calgary, Cumming School of Medicine, Calgary, Alberta Canada
| | - Liane R. Ginsburg
- Faculty of Health, York University, School of Health Policy and Management, Toronto, Ontario Canada
| | - Ruth A. Anderson
- School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina USA
| | | | - Holly J. Lanham
- Department of Medicine and Department of Family and Community Medicine, University of Texas, Health Science Center San Antonio, San Antonio, Texas USA
| | | | - Deanne Taylor
- Interior Health Authority, Kelowna, British Columbia Canada
| | - Adrian S. Wagg
- Faculty of Medicine and Dentistry, University of Alberta, Division of Geriatric Medicine, Edmonton, Alberta Canada
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Francis-Coad J, Etherton-Beer C, Bulsara C, Nobre D, Hill AM. Using a community of practice to evaluate falls prevention activity in a residential aged care organisation: a clinical audit. AUST HEALTH REV 2017; 41:13-18. [PMID: 26982888 DOI: 10.1071/ah15189] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Accepted: 02/01/2016] [Indexed: 11/23/2022]
Abstract
Objective
This study evaluates whether a community of practice (CoP) could conduct a falls prevention clinical audit and identify gaps in falls prevention practice requiring action.
Methods
Cross-sectional falls prevention clinical audits were conducted in 13 residential aged care (RAC) sites of a not-for-profit organisation providing care to a total of 779 residents. The audits were led by an operationalised CoP assisted by site clinical staff. A CoP is a group of people with a shared interest who get together to innovate for change. The CoP was made up of self-nominated staff representing all RAC sites and comprised of staff from various disciplines with a shared interest in falls prevention.
Results
All 13 (100%) sites completed the audit. CoP conduct of the audit met identified criteria for an effective clinical audit. The priorities for improvement were identified as increasing the proportion of residents receiving vitamin D supplementation (mean 41.5%, s.d. 23.7) and development of mandatory falls prevention education for staff and a falls prevention policy, as neither was in place at any site. CoP actions undertaken included a letter to visiting GPs requesting support for vitamin D prescription, surveys of care staff and residents to inform falls education development, defining falls and writing a falls prevention policy.
Conclusion
A CoP was able to effectively conduct an evidence-based falls prevention activity audit and identify gaps in practice. CoP members were well positioned, as site staff, to overcome barriers and facilitate action in falls prevention practice.
What is known about the topic?
Audit and feedback is an effective way of measuring clinical quality and safety. CoPs have been established in healthcare using workplace staff to address clinical problems but little is known about their ability to audit and influence practice change.
What does this paper add?
This study contributes to the body of knowledge on CoPs in healthcare by evaluating the performance of one in the domain of falls prevention audit action.
What are the implications for practitioners?
A CoP is an effective model to engage staff in the clinical audit process. Clinical audits can raise staff awareness of gaps in practice and motivate staff to plan and action change as recommended in best practice guidelines.
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Affiliation(s)
- Jacqueline Francis-Coad
- School of Physiotherapy, Institute of Health Research, The University of Notre Dame Australia, 19 Mouat Street, Fremantle, WA 6959, Australia
| | - Christopher Etherton-Beer
- School of Medicine and Pharmacology, The University of Western Australia, 35 Stirling Highway, Crawley, WA 6009, Australia. Email
| | - Caroline Bulsara
- School of Nursing and Midwifery, The University of Notre Dame Australia, 19 Mouat Street, Fremantle, WA 6959, Australia. Email
| | - Debbie Nobre
- Brightwater Care Group, Level 3, 355 Scarborough Beach Road, Osborne Park, WA 6017, Australia. Email
| | - Anne-Marie Hill
- School of Physiotherapy, Institute of Health Research, The University of Notre Dame Australia, 19 Mouat Street, Fremantle, WA 6959, Australia
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Colón-Emeric C, Toles M, Cary MP, Batchelor-Murphy M, Yap T, Song Y, Hall R, Anderson A, Burd A, Anderson RA. Sustaining complex interventions in long-term care: a qualitative study of direct care staff and managers. Implement Sci 2016; 11:94. [PMID: 27422011 PMCID: PMC4947307 DOI: 10.1186/s13012-016-0454-y] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Accepted: 06/16/2016] [Indexed: 12/02/2022] Open
Abstract
Background Little is known about the sustainability of behavioral change interventions in long-term care (LTC). Following a cluster randomized trial of an intervention to improve staff communication (CONNECT), we conducted focus groups of direct care staff and managers to elicit their perceptions of factors that enhance or reduce sustainability in the LTC setting. The overall aim was to generate hypotheses about how to sustain complex interventions in LTC. Methods In eight facilities, we conducted 15 focus groups with 83 staff who had participated in at least one intervention session. Where possible, separate groups were conducted with direct care staff and managers. An interview guide probed for staff perceptions of intervention salience and sustainability. Framework analysis of coded transcripts was used to distill insights about sustainability related to intervention features, organizational context, and external supports. Results Staff described important factors for intervention sustainability that are particularly challenging in LTC. Because of the tremendous diversity in staff roles and education level, interventions should balance complexity and simplicity, use a variety of delivery methods and venues (e.g., group and individual sessions, role-play/storytelling), and be inclusive of many work positions. Intervention customizability and flexibility was particularly prized in this unpredictable and resource-strapped environment. Contextual features noted to be important include addressing the frequent lack of trust between direct care staff and managers and ensuring that direct care staff directly observe manager participation and support for the program. External supports suggested to be useful for sustainability include formalization of changes into facility routines, using “train the trainer” approaches and refresher sessions. High staff turnover is common in LTC, and providing materials for new staff orientation was reported to be important for sustainability. Conclusions When designing or implementing complex behavior change interventions in LTC, consideration of these particularly salient intervention features, contextual factors, and external supports identified by staff may enhance sustainability. Trial registration ClinicalTrial.gov, NCT00636675
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Affiliation(s)
- Cathleen Colón-Emeric
- Duke University School of Medicine, Box 3003 DUMC, Durham, NC, 27710, USA. .,Durham VA Geriatric Research Education and Clinical Center, 508 Fulton St., Durham, NC, 27705, USA.
| | - Mark Toles
- University of North Carolina School of Nursing, Carrington Hall CB #7460, Chapel Hill, NC, 27599, USA
| | - Michael P Cary
- Duke University School of Nursing, 307 Trent Dr, Durham, NC, 27710, USA
| | | | - Tracey Yap
- Duke University School of Nursing, 307 Trent Dr, Durham, NC, 27710, USA
| | - Yuting Song
- Duke University School of Nursing, 307 Trent Dr, Durham, NC, 27710, USA
| | - Rasheeda Hall
- Duke University School of Medicine, Box 3003 DUMC, Durham, NC, 27710, USA.,Durham VA Geriatric Research Education and Clinical Center, 508 Fulton St., Durham, NC, 27705, USA
| | - Amber Anderson
- Duke University School of Nursing, 307 Trent Dr, Durham, NC, 27710, USA
| | - Andrew Burd
- Duke University School of Nursing, 307 Trent Dr, Durham, NC, 27710, USA
| | - Ruth A Anderson
- University of North Carolina School of Nursing, Carrington Hall CB #7460, Chapel Hill, NC, 27599, USA
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Toles M, Colón-Emeric C, Naylor MD, Barroso J, Anderson RA. Transitional care in skilled nursing facilities: a multiple case study. BMC Health Serv Res 2016; 16:186. [PMID: 27184902 PMCID: PMC4869313 DOI: 10.1186/s12913-016-1427-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Accepted: 05/05/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Among hospitalized older adults who transfer to skilled nursing facilities (SNF) for short stays and subsequently transfer to home, twenty two percent require additional emergency department or hospital care within 30 days. Transitional care services, that provide continuity and coordination of care as older adults transition between settings of care, decrease complications during transitions in care, however, they have not been examined in SNFs. Thus, this study described how existing staff in SNFs delivered transitional care to identify opportunities for improvement. METHODS In this prospective, multiple case study, a case was defined as an individual SNF. Using a sampling plan to assure maximum variation among SNFs, three SNFs were purposefully selected and 54 staff, patients and family caregivers participated in data collection activities, which included observations of care (N = 235), interviews (N = 66) and review of documents (N = 35). Thematic analysis was used to describe similarities and differences in transitional care provided in the SNFs as well as organizational structures and the quality of care-team interactions that supported staff who delivered transitional care services. RESULTS Staff in Case 1 completed most key transitional care services. Staff in Cases 2 and 3, however, had incomplete and/or absent services. Staff in Case 1, but not in Cases 2 and 3, reported a clear understanding of the need for transitional care, used formal transitional care team meetings and tracking tools to plan care, and engaged in robust team interactions. CONCLUSIONS Organizational structures in SNFs that support staff and interactions among patients, families and staff appeared to promote the ability of staff in SNFs to deliver evidence-based transitional care services. Findings suggest practical approaches to develop new care routines, tools, and staff training materials to enhance the ability of existing SNF staff to effectively deliver transitional care.
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Affiliation(s)
- Mark Toles
- University of North Carolina at Chapel Hill, School of Nursing, 7460 Carrington Hall, Chapel Hill, NC, 27599, USA.
| | - Cathleen Colón-Emeric
- School of Medicine and the Geriatric Research, Education and Clinical Center (GRECC), Durham Veterans Affairs Medical Center, Duke University, DUMC 3469, Durham, NC, 27710, USA
| | - Mary D Naylor
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Room 341 Fagin Hall, 418 Curie Blvd., Philadelphia, PA, 19104-4217, USA
| | - Julie Barroso
- Medical University of South CarolinaCollege of Nursing, Room 508 99 Jonathan Lucas St., Charleston, SC, 29425-1600, USA
| | - Ruth A Anderson
- University of North Carolina at Chapel Hill, School of Nursing, 7460 Carrington Hall, Chapel Hill, NC, 27599, USA
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21
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Francis-Coad J, Etherton-Beer C, Bulsara C, Nobre D, Hill AM. Investigating the impact of a falls prevention community of practice in a residential aged-care setting: a mixed methods study protocol. J Adv Nurs 2015; 71:2977-86. [DOI: 10.1111/jan.12725] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Jacqueline Francis-Coad
- School of Physiotherapy; Institute of Health Research; The University of Notre Dame Australia; Fremantle Western Australia Australia
| | - Christopher Etherton-Beer
- School of Medicine and Pharmacology; University of Western Australia; Crawley Western Australia Australia
| | - Caroline Bulsara
- School of Nursing and Midwifery; The University of Notre Dame Australia; Fremantle Western Australia Australia
| | - Debbie Nobre
- Brightwater Care Group; Osborne Park Western Australia Australia
| | - Anne-Marie Hill
- School of Physiotherapy; Institute of Health Research; The University of Notre Dame Australia; Fremantle Western Australia Australia
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22
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Kennedy CC, Ioannidis G, Thabane L, Adachi JD, Marr S, Giangregorio LM, Morin SN, Crilly RG, Josse RG, Lohfeld L, Pickard LE, van der Horst ML, Campbell G, Stroud J, Dolovich L, Sawka AM, Jain R, Nash L, Papaioannou A. Successful knowledge translation intervention in long-term care: final results from the vitamin D and osteoporosis study (ViDOS) pilot cluster randomized controlled trial. Trials 2015; 16:214. [PMID: 25962885 PMCID: PMC4431601 DOI: 10.1186/s13063-015-0720-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Accepted: 04/13/2015] [Indexed: 01/02/2023] Open
Abstract
Background Few studies have systematically examined whether knowledge translation (KT) strategies can be successfully implemented within the long-term care (LTC) setting. In this study, we examined the effectiveness of a multifaceted, interdisciplinary KT intervention for improving the prescribing of vitamin D, calcium and osteoporosis medications over 12-months. Methods We conducted a pilot, cluster randomized controlled trial in 40 LTC homes (21 control; 19 intervention) in Ontario, Canada. LTC homes were eligible if they had more than one prescribing physician and received services from a large pharmacy provider. Participants were interdisciplinary care teams (physicians, nurses, consultant pharmacists, and other staff) who met quarterly. Intervention homes participated in three educational meetings over 12 months, including a standardized presentation led by expert opinion leaders, action planning for quality improvement, and audit and feedback review. Control homes did not receive any additional intervention. Resident-level prescribing and clinical outcomes were collected from the pharmacy database; data collectors and analysts were blinded. In addition to feasibility measures, study outcomes were the proportion of residents taking vitamin D (≥800 IU/daily; primary), calcium ≥500 mg/day and osteoporosis medications (high-risk residents) over 12 months. Data were analyzed using the generalized estimating equations technique accounting for clustering within the LTC homes. Results At baseline, 5,478 residents, mean age 84.4 (standard deviation (SD) 10.9), 71% female, resided in 40 LTC homes, mean size = 137 beds (SD 76.7). In the intention-to-treat analysis (21 control; 19 intervention clusters), the intervention resulted in a significantly greater increase in prescribing from baseline to 12 months between intervention versus control arms for vitamin D (odds ratio (OR) 1.82, 95% confidence interval (CI): 1.12, 2.96) and calcium (OR 1.33, 95% CI: 1.01, 1.74), but not for osteoporosis medications (OR 1.17, 95% CI: 0.91, 1.51). In secondary analyses, excluding seven nonparticipating intervention homes, ORs were 3.06 (95% CI: 2.18, 4.29), 1.57 (95% CI: 1.12, 2.21), 1.20 (95% CI: 0.90, 1.60) for vitamin D, calcium and osteoporosis medications, respectively. Conclusions Our KT intervention significantly improved the prescribing of vitamin D and calcium and is a model that could potentially be applied to other areas requiring quality improvement. Trial Registration ClinicalTrials.gov: NCT01398527. Registered: 19 July 2011.
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Affiliation(s)
- Courtney C Kennedy
- McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada.
| | - George Ioannidis
- McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada.
| | - Lehana Thabane
- McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada.
| | - Jonathan D Adachi
- McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada.
| | - Sharon Marr
- McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada.
| | - Lora M Giangregorio
- University of Waterloo, 200 University Avenue West, Waterloo, ON, N2L 3G1, Canada.
| | - Suzanne N Morin
- McGill University, 845Sherbrooke Street West, Montreal, QC, H3A 0G4, Canada.
| | - Richard G Crilly
- Western University, Parkwood Hospital, 801 Commissioners Road East, London, ON, N6C 5 J1, Canada.
| | - Robert G Josse
- University of Toronto, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1 W8, Canada.
| | - Lynne Lohfeld
- McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada.
| | - Laura E Pickard
- McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada.
| | | | - Glenda Campbell
- McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada.
| | - Jackie Stroud
- Medical Pharmacies Group Limited, 590 Granite Crt, Pickering, ON, L1W 3X6, Canada.
| | - Lisa Dolovich
- McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada.
| | - Anna M Sawka
- University of Toronto, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1 W8, Canada.
| | - Ravi Jain
- Osteoporosis Canada, Suite 301, 1090 Don Mills Road, Toronto, ON, M3C 3R6, Canada.
| | - Lynn Nash
- McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada.
| | - Alexandra Papaioannou
- McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada. .,Division of Geriatrics, Department of Medicine, McMaster University, Geriatric Education and Research in Aging Sciences (GERAS) Centre, St. Peter's Hospital, Room 151, 88 Maplewood Avenue, Hamilton, ON, L8M 1 W9, Canada.
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Hall RK, Landerman LR, O'Hare AM, Anderson RA, Colón-Emeric CS. Chronic kidney disease and recurrent falls in nursing home residents: a retrospective cohort study. Geriatr Nurs 2015; 36:136-41. [PMID: 25616732 DOI: 10.1016/j.gerinurse.2014.12.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Revised: 12/09/2014] [Accepted: 12/13/2014] [Indexed: 11/20/2022]
Abstract
This study examined whether chronic kidney disease (CKD) is associated with recurrent falls in older adults in nursing homes (NHs). We used data abstracted over a six month period from 510 NH residents with a history of falls. Thirty-five percent of the NH residents had CKD. In adjusted analyses, the incidence of recurrent falls was similar in those with and without CKD [fall rate ratio (FRR) 1.00, 95% confidence interval (CI) 0.97-1.02]. Orthostatic hypotension (FRR 1.52, 95% CI 1.12-2.05), history of falls during the prior six month period (FRR 1.25, 95% CI 1.05-1.49), cane or walker use (FRR 1.64, 95% CI 1.16-2.33), and ambulatory dysfunction (FRR 1.47, 95% CI 1.23-1.75) were independently associated with increased fall rate. CKD was not an important predictor of falls in this cohort of nursing home residents with prior falls. Instead, traditional fall risk factors were much more strongly associated with recurrent falls.
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Affiliation(s)
- Rasheeda K Hall
- Duke University Medical Center, Division of Nephrology, Department of Medicine, Box DUMC 2747, 2424 Erwin Road Suite 605, Durham, NC 27710, USA; Durham VA Geriatric Research, Education and Clinical Center, 508 Fulton Street, Durham, NC 27705, USA.
| | - Lawrence R Landerman
- Duke University Medical Center, Division of Geriatrics, Department of Medicine, Box DUMC 3003, Durham, NC 27710, USA; Duke University School of Nursing, DUMC Box 3322, 307 Trent Drive, Durham, NC 27710, USA
| | - Ann M O'Hare
- VA Puget Sound Healthcare System, Department of Medicine and HSR&D Center of Excellence, 1660 S. Columbian Way, Seattle, WA 98108, USA; University of Washington, Division of Nephrology, Department of Medicine, 1959 NE Pacific Street, Box 356521, HSB, BB1271, Seattle, WA 98195, USA
| | - Ruth A Anderson
- Duke University School of Nursing, DUMC Box 3322, 307 Trent Drive, Durham, NC 27710, USA
| | - Cathleen S Colón-Emeric
- Durham VA Geriatric Research, Education and Clinical Center, 508 Fulton Street, Durham, NC 27705, USA; Duke University Medical Center, Division of Geriatrics, Department of Medicine, Box DUMC 3003, Durham, NC 27710, USA
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Colon-Emeric CS, McConnell E, Pinheiro SO, Corazzini K, Porter K, Earp KM, Landerman L, Beales J, Lipscomb J, Hancock K, Anderson RA. CONNECT for better fall prevention in nursing homes: results from a pilot intervention study. J Am Geriatr Soc 2013; 61:2150-2159. [PMID: 24279686 DOI: 10.1111/jgs.12550] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To determine whether an intervention that improves nursing home (NH) staff connections, communication, and problem solving (CONNECT) would improve implementation of a falls reduction education program (FALLS). DESIGN Cluster randomized trial. SETTING Community (n=4) and Veterans Affairs (VA) NHs (n=4). PARTICIPANTS Staff in any role with resident contact (n=497). INTERVENTION NHs received FALLS alone (control) or CONNECT followed by FALLS (intervention), each delivered over 3 months. CONNECT used storytelling, relationship mapping, mentoring, self-monitoring, and feedback to help staff identify communication gaps and practice interaction strategies. FALLS included group training, modules, teleconferences, academic detailing, and audit and feedback. MEASUREMENTS NH staff completed surveys about interactions at baseline, 3 months (immediately after CONNECT or control period), and 6 months (immediately after FALLS). A random sample of resident charts was abstracted for fall risk reduction documentation (n=651). Change in facility fall rates was an exploratory outcome. Focus groups were conducted to explore changes in organizational learning. RESULTS Significant improvements in staff perceptions of communication quality, participation in decision-making, safety climate, caregiving quality, and use of local interaction strategies were observed in intervention community NHs (treatment-by-time effect P=.01) but not in VA NHs, where a ceiling effect was observed. Fall risk reduction documentation did not change significantly, and the direction of change in individual facilities did not relate to observed direction of change in fall rates. Fall rates did not change in control facilities (falls/bed per year: baseline, 2.61; after intervention, 2.64) but decreased by 12% in intervention facilities (falls/bed per year: baseline, 2.34; after intervention, 2.06); the effect of treatment on rate of change was 0.81 (95% confidence interval=0.55-1.20). CONCLUSION CONNECT has the potential to improve care delivery in NHs, but the trend toward improving fall rates requires confirmation in a larger ongoing study.
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Affiliation(s)
- Cathleen S Colon-Emeric
- Center for the Study of Aging and Human Development, Duke University, Durham, North Carolina.,Durham Veterans Affairs Geriatric Research Education and Clinical Center, Durham, North Carolina
| | - Eleanor McConnell
- Center for the Study of Aging and Human Development, Duke University, Durham, North Carolina.,Durham Veterans Affairs Geriatric Research Education and Clinical Center, Durham, North Carolina.,School of Nursing, Duke University, Durham, North Carolina
| | - Sandro O Pinheiro
- Center for the Study of Aging and Human Development, Duke University, Durham, North Carolina
| | - Kirsten Corazzini
- Center for the Study of Aging and Human Development, Duke University, Durham, North Carolina
| | - Kristie Porter
- Center for the Study of Aging and Human Development, Duke University, Durham, North Carolina
| | | | - Lawrence Landerman
- Center for the Study of Aging and Human Development, Duke University, Durham, North Carolina.,School of Nursing, Duke University, Durham, North Carolina
| | - Julie Beales
- Richmond Veterans Affairs Medical Center, Richmond, Virginia
| | - Jeffrey Lipscomb
- KayeM, Inc., Durham, North Carolina.,Salem Veterans Affairs Medical Center, Salem, Virginia
| | - Kathryn Hancock
- Asheville Veterans Affairs Medical Center, Asheville, North Carolina
| | - Ruth A Anderson
- Center for the Study of Aging and Human Development, Duke University, Durham, North Carolina.,School of Nursing, Duke University, Durham, North Carolina
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Participation in decision making as a property of complex adaptive systems: developing and testing a measure. Nurs Res Pract 2013; 2013:706842. [PMID: 24349771 PMCID: PMC3857844 DOI: 10.1155/2013/706842] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2013] [Accepted: 08/27/2013] [Indexed: 11/17/2022] Open
Abstract
Objectives. To (1) describe participation in decision-making as a systems-level property of complex adaptive systems and (2) present empirical evidence of reliability and validity of a corresponding measure. Method. Study 1 was a mail survey of a single respondent (administrators or directors of nursing) in each of 197 nursing homes. Study 2 was a field study using random, proportionally stratified sampling procedure that included 195 organizations with 3,968 respondents. Analysis. In Study 1, we analyzed the data to reduce the number of scale items and establish initial reliability and validity. In Study 2, we strengthened the psychometric test using a large sample. Results. Results demonstrated validity and reliability of the participation in decision-making instrument (PDMI) while measuring participation of workers in two distinct job categories (RNs and CNAs). We established reliability at the organizational level aggregated items scores. We established validity of the multidimensional properties using convergent and discriminant validity and confirmatory factor analysis. Conclusions. Participation in decision making, when modeled as a systems-level property of organization, has multiple dimensions and is more complex than is being traditionally measured. Managers can use this model to form decision teams that maximize the depth and breadth of expertise needed and to foster connection among them.
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Slaughter SE, Estabrooks CA, Jones CA, Wagg AS, Eliasziw M. Sustaining Transfers through Affordable Research Translation (START): study protocol to assess knowledge translation interventions in continuing care settings. Trials 2013; 14:355. [PMID: 24160483 PMCID: PMC4231466 DOI: 10.1186/1745-6215-14-355] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2013] [Accepted: 10/17/2013] [Indexed: 11/16/2022] Open
Abstract
Background Bridging the research-practice gap is an important research focus in continuing care facilities, because the population of older adults (aged 65 years and over) requiring continuing care services is the fastest growing demographic among countries in the Organisation for Economic Co-operation and Development (OECD). Unlicensed practitioners, known as health care aides, provide the majority of care for residents living in continuing care facilities. However, little research examines how to sustain health care aide behavior change following initial adoption of current research evidence. Methods/Design We will conduct a phase III, multicentre, cluster randomized controlled trial (RCT) using a stratified 2 × 2 additive factorial design, including an embedded process evaluation, in 24 supportive living facilities within the health zone of Edmonton, AB, Canada. We will determine which combination of frequency and intensity of reminders most effectively sustains the completion of the sit-to-stand activity by health care aides with residents. Frequency refers to how often a reminder is implemented; intensity refers to whether a reminder is social or paper-based. We will compare monthly reminders with reminders implemented every 3 months, and we will compare low intensity, paper-based reminders and high intensity reminders provided by a health care aide peer. Using interviews, questionnaires, and observations, Sustaining Transfers through Affordable Research Translation (START) will evaluate the processes that inhibit or promote the mobility innovation’s sustainability among health care aides in daily practice. We will examine how the reminders are implemented and perceived by health care aides and licensed practical nurses, as well as how health care aides providing peer reminders are identified, received by their peers, and supported by their supervisors. Discussion START will connect up-to-date innovation research with the practice of health care aides providing direct care to a growing population of older Albertans. The project’s reach extends to both supportive living and long-term care settings. Furthermore, START has the potential to introduce and sustain a broad range of innovations in various care areas, such as dementia care, wound care, and pain management – domains where the uptake and sustainability of innovations also encounter significant challenges. By identifying the optimal frequency and intensity of knowledge translation interventions, we hope to enable continuing care organizations to efficiently integrate care innovations into the day-to-day care of residents. Trial registration ClinicalTrials.gov, NCT01746459
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Affiliation(s)
- Susan E Slaughter
- Faculty of Nursing, Edmonton Clinic Health Academy, University of Alberta, Edmonton, AB T6G 1C9, Canada.
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Colón-Emeric CS, Pinheiro SO, Anderson RA, Porter K, McConnell E, Corazzini K, Hancock K, Lipscomb J, Beales J, Simpson KM. Connecting the learners: improving uptake of a nursing home educational program by focusing on staff interactions. THE GERONTOLOGIST 2013; 54:446-59. [PMID: 23704219 DOI: 10.1093/geront/gnt043] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
PURPOSE OF THE STUDY The CONNECT intervention is designed to improve staff connections, communication, and use of multiple perspectives for problem solving. This analysis compared staff descriptions of the learning climate, use of social constructivist learning processes, and outcomes in nursing facilities receiving CONNECT with facilities receiving a falls education program alone. DESIGN AND METHODS Qualitative evaluation of a randomized controlled trial was done using a focus group design. Facilities (n = 8) were randomized to a falls education program alone (control) or CONNECT followed by FALLS (intervention). A total of 77 staff participated in 16 focus groups using a structured interview protocol. Transcripts were analyzed using framework analysis, and summaries for each domain were compared between intervention and control facilities. RESULTS Notable differences in descriptions of the learning climate included greater learner empowerment, appreciation of the role of all disciplines, and seeking diverse viewpoints in the intervention group. Greater use of social constructivist learning processes was evidenced by the intervention group as they described greater identification of communication weaknesses, improvement in communication frequency and quality, and use of sense-making by seeking out multiple perspectives to better understand and act on information. Intervention group participants reported outcomes including more creative fall prevention plans, a more respectful work environment, and improved relationships with coworkers. No substantial difference between groups was identified in safety culture, shared responsibility, and self-reported knowledge about falls. IMPLICATIONS CONNECT appears to enhance the use of social constructivist learning processes among nursing home staff. The impact of CONNECT on clinical outcomes requires further study.
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Affiliation(s)
- Cathleen S Colón-Emeric
- *Address correspondence to Cathleen Colón-Emeric, MHS, Durham VA Geriatric Research Education and Clinical Center, MD 508 Fulton St., GRECC 182, Durham, NC 27705. E-mail:
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First evidence on the validity and reliability of the Safety Organizing Scale-Nursing Home version (SOS-NH). J Am Med Dir Assoc 2013; 14:616-22. [PMID: 23684122 DOI: 10.1016/j.jamda.2013.03.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2013] [Revised: 03/12/2013] [Accepted: 03/18/2013] [Indexed: 11/21/2022]
Abstract
BACKGROUND The Safety Organizing Scale is a valid and reliable measure on safety behaviors and practices in hospitals. PURPOSE OF THE STUDY This study aimed to explore the psychometric properties of the Safety Organizing Scale-Nursing Home version (SOS-NH). DESIGN AND METHODS In a cross-sectional analysis of staff survey data, we examined validity and reliability of the 9-item Safety SOS-NH using American Educational Research Association guidelines. SUBJECTS AND SETTING This substudy of a larger trial used baseline survey data collected from staff members (n = 627) in a variety of work roles in 13 nursing homes (NHs) in North Carolina and Virginia. RESULTS Psychometric evaluation of the SOS-NH revealed good response patterns with low average of missing values across all items (3.05%). Analyses of the SOS-NH's internal structure (eg, comparative fit indices = 0.929, standardized root mean square error of approximation = 0.045) and consistency (composite reliability = 0.94) suggested its 1-dimensionality. Significant between-facility variability, intraclass correlations, within-group agreement, and design effect confirmed appropriateness of the SOS-NH for measurement at the NH level, justifying data aggregation. The SOS-NH showed discriminate validity from one related concept: communication openness. IMPLICATIONS Initial evidence regarding validity and reliability of the SOS-NH supports its utility in measuring safety behaviors and practices among a wide range of NH staff members, including those with low literacy. Further psychometric evaluation should focus on testing concurrent and criterion validity, using resident outcome measures (eg, patient fall rates).
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Corazzini KN, Mueller C, Anderson RA, Day L, Hunt-McKinney S, Porter K. Pain Medication Management in Nursing Homes and Nursing Scope of Practice. J Gerontol Nurs 2013; 39:40-6. [DOI: 10.3928/00989134-20130220-02] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2012] [Accepted: 01/18/2013] [Indexed: 11/20/2022]
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Simpson KM, Porter K, McConnell ES, Colón-Emeric C, Daily KA, Stalzer A, Anderson RA. Tool for evaluating research implementation challenges: a sense-making protocol for addressing implementation challenges in complex research settings. Implement Sci 2013; 8:2. [PMID: 23281623 PMCID: PMC3598718 DOI: 10.1186/1748-5908-8-2] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2012] [Accepted: 12/10/2012] [Indexed: 11/26/2022] Open
Abstract
Background Many challenges arise in complex organizational interventions that threaten research integrity. This article describes a Tool for Evaluating Research Implementation Challenges (TECH), developed using a complexity science framework to assist research teams in assessing and managing these challenges. Methods During the implementation of a multi-site, randomized controlled trial (RCT) of organizational interventions to reduce resident falls in eight nursing homes, we inductively developed, and later codified the TECH. The TECH was developed through processes that emerged from interactions among research team members and nursing home staff participants, including a purposive use of complexity science principles. Results The TECH provided a structure to assess challenges systematically, consider their potential impact on intervention feasibility and fidelity, and determine actions to take. We codified the process into an algorithm that can be adopted or adapted for other research projects. We present selected examples of the use of the TECH that are relevant to many complex interventions. Conclusions Complexity theory provides a useful lens through which research procedures can be developed to address implementation challenges that emerge from complex organizations and research designs. Sense-making is a group process in which diverse members interpret challenges when available information is ambiguous; the groups’ interpretations provide cues for taking action. Sense-making facilitates the creation of safe environments for generating innovative solutions that balance research integrity and practical issues. The challenges encountered during implementation of complex interventions are often unpredictable; however, adoption of a systematic process will allow investigators to address them in a consistent yet flexible manner, protecting fidelity. Research integrity is also protected by allowing for appropriate adaptations to intervention protocols that preserve the feasibility of ‘real world’ interventions.
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Affiliation(s)
- Kelly M Simpson
- Durham Veteran Affairs Medical Center, GRECC, 508 Fulton St., Durham, NC 27705, USA
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Anderson RA. Commentary on "Health care organizations as complex systems: new perspectives on design and management" by Reuben R. McDaniel, Dean J. Driebe, and Holly Jordan Lanham. Adv Health Care Manag 2013; 15:27-36. [PMID: 24749212 DOI: 10.1108/s1474-8231(2013)0000015008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
In this commentary, I highlight a few of the assertions made by McDaniel et al. (2013) about the importance of complexity science guided management practices, and extend these ideas specifically to how we might think about reducing seemingly intractable problems in health care such as patient safety, patient falls, hospital acquired infection, and the rise of chronic illness and obesity. I suggest that such changes will require managers and providers to view health care organizations and patients as complex adaptive systems and include patients as full participants in co-producing their health care.
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Corazzini KN, Anderson RA, Day L, McConnell ES, Mueller C, McKinney SH. When a situation is "not black or white": Using adaptive leadership to address complex challenges in nursing home care. DIRECTOR (CINCINNATI, OHIO) 2013; 21:34-37. [PMID: 25383063 PMCID: PMC4220552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Affiliation(s)
- Kirsten N Corazzini
- School of Nursing, Duke University ; Center for the Study of Aging and Human Development, Duke University Medical Center
| | - Ruth A Anderson
- School of Nursing, Duke University ; Center for the Study of Aging and Human Development, Duke University Medical Center
| | - Lisa Day
- School of Nursing, Duke University
| | - Eleanor S McConnell
- School of Nursing, Duke University ; Center for the Study of Aging and Human Development, Duke University Medical Center ; Geriatric Research, Education and Clinical Center, Durham Veterans Affairs Medical Center
| | | | - Selina H McKinney
- School of Nursing, Duke University ; School of Nursing, University of South Carolina
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Cameron ID, Gillespie LD, Robertson MC, Murray GR, Hill KD, Cumming RG, Kerse N. Interventions for preventing falls in older people in care facilities and hospitals. Cochrane Database Syst Rev 2012; 12:CD005465. [PMID: 23235623 DOI: 10.1002/14651858.cd005465.pub3] [Citation(s) in RCA: 254] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Falls in care facilities and hospitals are common events that cause considerable morbidity and mortality for older people. This is an update of a review first published in 2010. OBJECTIVES To assess the effectiveness of interventions designed to reduce falls by older people in care facilities and hospitals. SEARCH METHODS We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (March 2012); The Cochrane Library 2012, Issue 3; MEDLINE, EMBASE, and CINAHL (all to March 2012); ongoing trial registers (to August 2012), and reference lists of articles. SELECTION CRITERIA Randomised controlled trials of interventions to reduce falls in older people in residential or nursing care facilities or hospitals. DATA COLLECTION AND ANALYSIS Two review authors independently assessed risk of bias and extracted data. We used a rate ratio (RaR) and 95% confidence interval (CI) to compare the rate of falls (e.g. falls per person year) between intervention and control groups. For risk of falling we used a risk ratio (RR) and 95% CI based on the number of people falling (fallers) in each group. We pooled results where appropriate. MAIN RESULTS We included 60 trials (60,345 participants), 43 trials (30,373 participants) in care facilities, and 17 (29,972 participants) in hospitals.Results from 13 trials testing exercise interventions in care facilities were inconsistent. Overall, there was no difference between intervention and control groups in rate of falls (RaR 1.03, 95% CI 0.81 to 1.31; 8 trials, 1844 participants) or risk of falling (RR 1.07, 95% CI 0.94 to 1.23; 8 trials, 1887 participants). Post hoc subgroup analysis by level of care suggested that exercise might reduce falls in people in intermediate level facilities, and increase falls in facilities providing high levels of nursing care.In care facilities, vitamin D supplementation reduced the rate of falls (RaR 0.63, 95% CI 0.46 to 0.86; 5 trials, 4603 participants), but not risk of falling (RR 0.99, 95% CI 0.90 to 1.08; 6 trials, 5186 participants).For multifactorial interventions in care facilities, the rate of falls (RaR 0.78, 95% CI 0.59 to 1.04; 7 trials, 2876 participants) and risk of falling (RR 0.89, 95% CI 0.77 to 1.02; 7 trials, 2632 participants) suggested possible benefits, but this evidence was not conclusive.In subacute wards in hospital, additional physiotherapy (supervised exercises) did not significantly reduce rate of falls (RaR 0.54, 95% CI 0.16 to 1.81; 1 trial, 54 participants) but achieved a significant reduction in risk of falling (RR 0.36, 95% CI 0.14 to 0.93; 2 trials, 83 participants).In one trial in a subacute ward (54 participants), carpet flooring significantly increased the rate of falls compared with vinyl flooring (RaR 14.73, 95% CI 1.88 to 115.35) and potentially increased the risk of falling (RR 8.33, 95% CI 0.95 to 73.37).One trial (1822 participants) testing an educational session by a trained research nurse targeting individual fall risk factors in patients at high risk of falling in acute medical wards achieved a significant reduction in risk of falling (RR 0.29, 95% CI 0.11 to 0.74).Overall, multifactorial interventions in hospitals reduced the rate of falls (RaR 0.69, 95% CI 0.49 to 0.96; 4 trials, 6478 participants) and risk of falling (RR 0.71, 95% CI 0.46 to 1.09; 3 trials, 4824 participants), although the evidence for risk of falling was inconclusive. Of these, one trial in a subacute setting reported the effect was not apparent until after 45 days in hospital. Multidisciplinary care in a geriatric ward after hip fracture surgery compared with usual care in an orthopaedic ward significantly reduced rate of falls (RaR 0.38, 95% CI 0.19 to 0.74; 1 trial, 199 participants) and risk of falling (RR 0.41, 95% CI 0.20 to 0.83). More trials are needed to confirm the effectiveness of multifactorial interventions in acute and subacute hospital settings. AUTHORS' CONCLUSIONS In care facilities, vitamin D supplementation is effective in reducing the rate of falls. Exercise in subacute hospital settings appears effective but its effectiveness in care facilities remains uncertain due to conflicting results, possibly associated with differences in interventions and levels of dependency. There is evidence that multifactorial interventions reduce falls in hospitals but the evidence for risk of falling was inconclusive. Evidence for multifactorial interventions in care facilities suggests possible benefits, but this was inconclusive.
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Affiliation(s)
- Ian D Cameron
- Rehabilitation Studies Unit, SydneyMedical School Northern, The University of Sydney, Ryde, Australia.
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