Evaluating the Implementation of the Individualized Positive Psychosocial Interaction (IPPI) as a Quality Improvement Project in Nursing Homes

OBJECTIVES

The Individualized Positive Psychosocial Interaction (IPPI) is a non-pharmacological, person-centered, intervention for nursing home (NH) residents living with moderate to severe dementia. The purpose of this study was to assess the pragmatic implementation of the IPPI by leveraging Ohio's Nursing Home Quality Improvement Program (QIP).

METHODS

Implementation teams collected resident mood ratings pre- and post-IPPI and completed virtual interviews to assess their Organizational Readiness for Implementing Change as well as the acceptability, feasibility, and appropriateness of the IPPI. Implementation strategies included: providing ongoing consultation; identifying and preparing champions; assessing for readiness and identifying barriers; and developing and distributing effective educational materials.

RESULTS

Fifteen NHs completed the QIP (65% completion rate) and reported high organizational commitment to change and high change efficacy. NHs engaged n = 65 residents in n = 638 IPPIs. Residents experienced a positive mood change after 47% of IPPIs. NHs found the IPPI program to be highly acceptable, feasible, and appropriate.

CONCLUSIONS

Overall, 65% of NHs successfully implemented the IPPI QIP with people living with moderate to severe dementia.

CLINICAL IMPLICATIONS

Given the positive mood changes and high staff satisfaction, results suggest that these brief, individualized activities can be effective strategies to address the communication of distress among PLWD.

THAT'S JUST MY SUPERPOWER: THE ROLE OF NURSING HOME PROVIDER CHAMPIONS IN IMPLEMENTING A PERSON-CENTERED PROJECT

Champions are crucial to successful intervention implementation; however, as an area of research champions have only recently begun to gain empirical focus. The purpose of this study was to identify the barriers and facilitators regarding champion qualities using the domain “Characteristics of the Individual” from CFIR. Qualitative interviews were conducted with nursing home provider champions (n=16) who led efforts to create PAL Cards for 15-20 residents and participated in a total of n=50 monthly interviews that were audio-recorded and transcribed verbatim. The following themes regarding characteristics of the individual emerged: champions’ investment in their community, capacity and existing workload, and willingness to ask for help. While some champions saw the value of the PAL Cards, they lacked the bandwidth necessary to widely implement the intervention in their community. Champions who recruited a supportive team and valued person-centered care exhibited success in implementing PAL Cards.

IT'S A VERY MANIPULATABLE TOOL: CHARACTERISTICS OF PAL CARD USE THAT IMPACT SUCCESSFUL IMPLEMENTATION

Understanding the barriers and facilitators of an intervention can inform implementation efforts. The purpose of this study was to understand the characteristics associated with the PAL Card intervention that led to successful implementation in nursing home (NH) settings. Qualitative telephone interviews were conducted with n=11 NH champions who completed the PAL Card QIP. Interviews were recorded, transcribed verbatim, and coded using the CFIR Intervention Characteristics domain in Dedoose. Three main themes regarding the intervention characteristics emerged including, relative advantage (i.e., advantage of using PAL Cards versus an alternate intervention), adaptability (i.e., how well the PAL Cards can be altered to meet community needs), and complexity (i.e., perceived difficulty of PAL Card usage). Participants voiced the simplicity and benefit of PAL Card implementation within their communities for both staff and residents alike. Implications for policy and practice will be discussed.

UNDERSTANDING PROCESSES NEEDED TO SUCCESSFULLY IMPLEMENT PAL CARDS IN NURSING HOMES

Background

The CFIR Process domain can be used to evaluate practices that are associated with successful or unsuccessful implementation. The purpose of this study was to understand the processes that led to successful implementation of the PAL Card QIP during the height of the pandemic from the provider champion’s perspective.

Methods

Qualitative interviews with n=11 champions who completed the PAL Card QIP were audio recorded, transcribed verbatim, and coded using the CFIR Process Domain.

Results

Major themes regarding the process of implementation included engaging (e.g., staff and family), executing (adapting to different situations), planning (e.g., having a clear plan of implementation), and reflecting and evaluating (e.g., taking time to evaluate the project). Discussion: Providers articulated strategies that contributed to successful implementation during a global pandemic, which can help inform future quality improvement projects. Implications for practice and policy will be discussed.

THE INFLUENCE OF NURSING HOME CHAMPIONS ON THE IMPLEMENTATION OF A PERSON-CENTERED QUALITY IMPROVEMENT PROJECT

Preferences for Activity and Leisure (PAL) Cards are a communication tool designed to alert nursing home staff to important resident preferences. This study explored the role of nursing home provider champions implementing (PAL) Cards in their community. Champions (n=35) created PAL Cards for 15-20 residents. A total of 88 monthly interviews were audio-recorded, transcribed, checked for accuracy, and coded using the domain “Characteristics of the Individual” from the Consolidated Framework for Implementation Research. Each construct was assigned a general valence rating based on consensus. Four constructs received the highest positive valence ratings and were identified as important facilitators to implementation success, and one construct received a neutral valence. Champions who anticipated the benefits of PAL Cards for their community and recruited a supportive team exhibited high implementation success. Additionally, the champion’s perception of help from staff seemed to increase their own self-efficacy to achieve their goals.

EXAMINING THE NURSING HOME INNER SETTING CHARACTERISTICS THAT LEAD TO THE SUCCESSFUL IMPLEMENTATION OF PAL CARDS

Implementation efforts of evidence-based practices focusing on the nursing home setting remain understudied. The purpose of this study was to explore the role of the Consolidated Framework for Implementation Research (CFIR) inner setting domain on the implementation of PAL Cards. Monthly qualitative interviews (n=50) with project champions (n=16) were audio-recorded, transcribed, checked for accuracy, and coded using the domain “Inner Setting” from the CFIR in Dedoose. Major themes emerging from the data included networks and communication (e.g., including PAL Card information in employee newsletter) among staff, compatibility of the PAL Cards (e.g., aligns with community values and fits into existing workflows), and available resources (e.g., adequate time and staff to implement the QIP). High-quality communication channels to educate and collaborate were shown to be an integral component of successful implementation. Implications for policy and practice will be discussed.

DIRECT CARE STAFF PERSPECTIVES ON THE IMPACT OF PAL CARDS IN CARE DELIVERY

This was the third time replicating the Preferences for Activity and Leisure (PAL) Card quality improvement project, but the first conducted entirely during the height of the pandemic. Nursing home providers attempted n=174 PAL Cards and completed n=166 (96%). Feedback from surveys with n=68 staff who came in daily contact with residents (e.g., 26% CNAs, 10% housekeepers, 6% maintenance, 9% dining) were collected by project champions. Staff had worked on average 6 years, indicated that they remember being been told about PAL Cards (81%), noticed them (94%), reported that the information on the PAL Card helped them start a conversation with a resident (79%), and helped them provide care (59%). PAL Cards are a feasible method to communicate important resident preferences to staff who come in daily contact with residents and may not have access to electronic health records. Recommendations for practice will be discussed including staff recommendations for improvements.

"It's Been a Whole New World": Staff Perceptions of Implementing a Person-Centered Communication Intervention During the COVID-19 Pandemic

The coronavirus disease 2019 (COVID-19) has challenged the way nursing homes deliver person-centered care (PCC). Preferences for Activity and Leisure (PAL) Cards are a tool to communicate residents' important preferences to staff. Monthly interviews (N = 32) were conducted with champions who were conducting a PAL Card quality improvement project in Tennessee nursing homes (N = 11) between March and August 2020. Three major themes emerged: Structural Changes (e.g., halting admissions, adding an isolation unit), Resident Burden (e.g., physical isolation, loneliness), and Provider Burnout (e.g., increased workload, mental exhaustion). Further, providers expressed the benefits to using PAL Cards, specifically in regard to blunting the negative impact of each theme. Results showed the overall negative impact of COVID-19 on nursing home communities. Nursing staff experienced greater burden than other staff, reflecting their prominent role in providing direct care to residents with COVID-19. Staff reported that PAL Cards helped promote PCC. [Journal of Gerontological Nursing, 47(5), 9-13.].