Implementation of a complex intervention to reduce hospitalizations from nursing homes: a mixed-method evaluation of implementation processes and outcomes

Kornelia Basinska, Franziska Zúñiga, Michael Simon, Sabina De Geest, Raphaëlle Ashley Guerbaai, Nathalie I H Wellens, Dunja Nicca, Thekla Brunkert, Kornelia Basinska, Franziska Zúñiga, Michael Simon, Sabina De Geest, Raphaëlle Ashley Guerbaai, Nathalie I H Wellens, Dunja Nicca, Thekla Brunkert

Abstract

BACKGROUND | OBJECTIVE: To evaluate the implementation of three intervention elements to reduce hospitalizations in nursing home residents.

Design: Convergent mixed-method design within a hybrid type-2 effectiveness-implementation study.

Setting: Eleven nursing homes in the German-speaking region of Switzerland.

Participants: Quantitative data were collected from 573 care workers; qualitative data were collected from 108 care workers and the leadership from 11 nursing homes.

Intervention: Three intervention elements targeting care workers were implemented to reduce unplanned hospitalizations: (1) the STOP&WATCH instrument for early recognition of changes in resident condition; (2) the ISBAR instrument for structured communication; and (3) specially-trained INTERCARE nurses providing on-site geriatric support. Multifaceted implementation strategies focusing both on the overall nursing home organization and on the care workers were used.

Methods: The quantitative part comprised surveys of care workers six- and twelve-months post-intervention. The intervention's acceptability, feasibility and uptake were assessed using validated and self-developed scales. Qualitative data were collected in 22 focus groups with care workers, then analyzed using thematic analysis methodology. Data on implementation processes were collected during implementation meetings with nursing home leadership and were analyzed via content analysis. Findings were integrated using a complementary approach.

Results: The ISBAR instrument and the INTERCARE nurse role were considered acceptable, feasible, and taken up by > 70% of care workers. The STOP&WATCH instrument showed the lowest acceptance (mean: 68%), ranging from 24 to 100% across eleven nursing homes. A combination of factors, including the amount of information received, the amount of support provided in daily practice, the users' perceived ease of using the intervention and its adaptations, and the intervention's usefulness, appeared to influence the implementation's success. Two exemplary nursing homes illustrated context-specific implementation processes that serve as either barriers or facilitators to implementation.

Conclusions: Our findings suggest that, alongside the provision of information shortly before intervention start, constant daily support is crucial for implementation success. Ideally, this support is provided by designated and trained individuals who oversee implementation at the organizational and unit levels. Leaders who seek to implement interventions in nursing homes should consider their complexity and their consequences for workflow to optimize implementation processes accordingly.

Trial registration: This study was registered at clinicaltrials.gov ( NCT03590470 ) on the 18/06/2018.

Keywords: Implementation science; Intervention; Nursing homes; Uptake.

Conflict of interest statement

The authors declare no conflict of interest.

© 2022. The Author(s).

References

    1. Graverholt B, Forsetlund L, Jamtvedt G. Reducing hospital admissions from nursing homes: A systematic review. BMC Health Serv Res. 2014;14:36. doi: 10.1186/1472-6963-14-36.
    1. Fogg C, et al. Hospital outcomes of older people with cognitive impairment: An integrative review. Int J Geriatr Psychiatry. 2018;33(9):1177–1197. doi: 10.1002/gps.4919.
    1. James BD, et al. Cognitive decline after elective and nonelective hospitalizations in older adults. Neurology. 2019;92(7):e690–e699. doi: 10.1212/WNL.0000000000006918.
    1. Santosaputri E, Laver K, To T. Efficacy of interventions led by staff with geriatrics expertise in reducing hospitalisation in nursing home residents: A systematic review. Australas J Ageing. 2019;38(1):5–14. doi: 10.1111/ajag.12593.
    1. Hutchinson AF, et al. A longitudinal cohort study evaluating the impact of a geriatrician-led residential care outreach service on acute healthcare utilisation. Age Ageing. 2015;44(3):365–370. doi: 10.1093/ageing/afu196.
    1. Schippinger W, et al. mobile geriatric consultant services for rest homes. Study of the effects of consultations by internal medicine specialists in the medical care of rest home residents. Z Gerontol Geriatr. 2012;45(8):735–741. doi: 10.1007/s00391-012-0395-2.
    1. Ouslander JG, et al. The interact quality improvement program: An overview for medical directors and primary care clinicians in long-term care. J Am Med Dir Assoc. 2014;15(3):162. doi: 10.1016/j.jamda.2013.12.005.
    1. Rantz MJ, et al. Successfully reducing hospitalizations of nursing home residents: Results of the missouri quality initiative. J Am Med Dir Assoc. 2017;18(11):960–966. doi: 10.1016/j.jamda.2017.05.027.
    1. Blackburn J, et al. Reducing the risk of hospitalization for nursing home residents: Effects and facility variation from optimistic. J Am Med Dir Assoc. 2020;21(4):545–549 e1. doi: 10.1016/j.jamda.2020.02.002.
    1. Ingber MJ, et al. Initiative to reduce avoidable hospitalizations among nursing facility residents shows promising results. Health Aff (Millwood) 2017;36(3):441–450. doi: 10.1377/hlthaff.2016.1310.
    1. Peters DH, et al. Implementation research, how to do it. Sports Med. 2013:347:f6753. 10.1136/bmj.f6753.
    1. Proctor E, et al. Outcomes for implementation research: Conceptual distinctions, measurement challenges, and research agenda. Adm Policy Mental Health Mental Health Serv Res. 2010;38(2):65–76. doi: 10.1007/s10488-010-0319-7.
    1. Pulst A, Fassmer AM, Schmiemann G. Unplanned hospital transfers from nursing homes: Who is involved in the transfer decision? Results from the homern study. Aging Clin Exp Res. 2021;33(8):2231–2241. doi: 10.1007/s40520-020-01751-5.
    1. Powell BJ, et al. A refined compilation of implementation strategies: Results from the expert recommendations for implementing change (eric) project. Implement Sci. 2015;10(1):21. doi: 10.1186/s13012-015-0209-1.
    1. Li SA, et al. Organizational contextual features that influence the implementation of evidence-based practices across healthcare settings: A systematic integrative review. Syst Rev. 2018;7(1):72. doi: 10.1186/s13643-018-0734-5.
    1. Curran GM, et al. Effectiveness-implementation hybrid designs: Combining elements of clinical effectiveness and implementation research to enhance public health impact. Med Care. 2012;50(3):217–226. doi: 10.1097/MLR.0b013e3182408812.
    1. Zúñiga F, et al. Strengthening geriatric expertise in swiss nursing homes: Intercare implementation study protocol. J Am Geriatr Soc. 2019;67(10):2145–2150. doi: 10.1111/jgs.16074.
    1. Basinska K, et al. Registered nurses in expanded roles improve care in nursing homes: Swiss perspective based on the modified delphi method. J Adv Nurs. 2020;77(2) 10.1111/jan.14644.
    1. Zúñiga F, Guerbaai RA, De Geest S, Popejoy LL, Barkova J, Denhaerynck K, et al. Positive effect of the intercare nurse-led model on reducing nursing home transfers: A non-randomized stepped-wedge design. J Am Geriatr Soc. 2022; 10.1111/jgs.17677.
    1. Creswell JW, et al. Best practices for mixed methods research in the health sciences. Bethesda (Maryland): Office of Behavioral and Social Sciences Research, National Institute of Health; 2011. pp. 541–545.
    1. Presseau J, et al. Action, actor, context, target, time (aactt): A framework for specifying behaviour. Implement Sci. 2019;14(1):102. doi: 10.1186/s13012-019-0951-x.
    1. Damschroder LJ, et al. Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science. Implement Sci. 2009;4:50. doi: 10.1186/1748-5908-4-50.
    1. Weiner BJ, et al. Psychometric assessment of three newly developed implementation outcome measures. Implement Sci. 2017;12(1):108. doi: 10.1186/s13012-017-0635-3.
    1. Nuzzo RL. Making continuous measurements into dichotomous variables. PM&R. 2019;11(10):1132–1134. doi: 10.1002/pmrj.12228.
    1. Courtier N, et al. Active - a randomised feasibility trial study protocol of a behavioural intervention to reduce fatigue in women undergoing radiotherapy for early breast cancer: Study protocol. Pilot Feasib Stud. 2018;4:85. doi: 10.1186/s40814-018-0275-7.
    1. R Development Core Team, R . A language and environment for statistical computing (version 3.5.1) 2018.
    1. Mayring P. In: Qualitative inhaltsanalyse in Handbuch qualitative forschung in der psychologie. Mey G, Mruck K, editors. Wiesbaden: VS Verlag für Sozialwissenschaften; 2010. pp. 601–613.
    1. Baxter R, et al. What methods are used to apply positive deviance within healthcare organisations? A systematic review. BMJ Qual Safety. 2016;25(3):190–201. doi: 10.1136/bmjqs-2015-004386.
    1. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77–101. doi: 10.1191/1478088706qp063oa.
    1. Braun V, Clarke V. Reflecting on reflexive thematic analysis. Qual Res Sport Exerc Health. 2019;11(4):589–597. doi: 10.1080/2159676x.2019.1628806.
    1. Lincoln YS, Guba EG. In: Competing paradigms in qualitative research, in Handbook of qualitative research. Competing paradigms in qualitative research, L.Y. Denzin NK, editor. London: SAGE; 1994.
    1. Tessier S. From field notes, to transcripts, to tape recordings: Evolution or combination? Int J Qual Methods. 2012;11:446–460. doi: 10.1177/160940691201100410.
    1. VERBI Software . Maxqda 2018. VERBI Software: Berlin; 2018.
    1. Palinkas LA, et al. Mixed method designs in implementation research. Adm Policy Ment Health. 2011;38(1):44–53. doi: 10.1007/s10488-010-0314-z.
    1. Grol R, Wensing M. Characteristics of successful innovations. In: Wensing M, Grol R, Grimshaw J, editors. Improving patient care: The implementation of change in health care. Oxford: Wiley; 2020. pp. 87–102.
    1. Rogers EM. Diffusion of innovations. 4. New York: Free Press; 1995.
    1. Dopp AR, et al. Aligning implementation and user-centered design strategies to enhance the impact of health services: Results from a concept mapping study. Implement Sci Commun. 2020;1:17. doi: 10.1186/s43058-020-00020-w.
    1. Dopp AR, et al. A glossary of user-centered design strategies for implementation experts. Transl Behav Med. 2019;9(6):1057–1064. doi: 10.1093/tbm/iby119.
    1. Baker R, et al. Tailored interventions to overcome identified barriers to change: Effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2010;3:CD005470. doi: 10.1002/14651858.CD005470.pub2.
    1. Sarkies M, et al. Avoiding unnecessary hospitalisation for patients with chronic conditions: A systematic review of implementation determinants for hospital avoidance programmes. Implement Sci. 2020;15(1):91. doi: 10.1186/s13012-020-01049-0.
    1. Vogelsmeier A, et al. Results of the missouri quality initiative in sustaining changes in nursing home care: Six-year trends of reducing hospitalizations of nursing home residents. J Nutr Health Aging. 2021;25(1):5–12. doi: 10.1007/s12603-020-1552-8.
    1. Miech EJ, et al. Inside help: An integrative review of champions in healthcare-related implementation. SAGE Open Med. 2018;6:6. doi: 10.1177/2050312118773261.
    1. Flodgren G, et al. Local opinion leaders: Effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev. 2019;6:CD000125. doi: 10.1002/14651858.CD000125.pub5.
    1. Birken SA, Currie G. Using organization theory to position middle-level managers as agents of evidence-based practice implementation. Implement Sci. 2021;16(1):37. doi: 10.1186/s13012-021-01106-2.
    1. Birken S, et al. Middle managers' role in implementing evidence-based practices in healthcare: A systematic review. Implement Sci. 2018;13(1):149. doi: 10.1186/s13012-018-0843-5.
    1. Aarons GA, Ehrhart MG, Farahnak LR. The implementation leadership scale (ils): Development of a brief measure of unit level implementation leadership. Implement Sci. 2014;9(1):45. doi: 10.1186/1748-5908-9-45.
    1. World Medical. A. World medical association declaration of helsinki: Ethical principles for medical research involving human subjects. JAMA. 2013;310(20):2191–2194. doi: 10.1001/jama.2013.281053.

Source: PubMed

Sponzoři a spolupracovníci

Zdravotní podmínky

Drogové intervence

3
Předplatit