Adapting Strategies for Optimal Intervention Implementation in Nursing Homes: A Formative Evaluation

Implementation Lessons Learned: Distress Behaviors in Dementia Intervention in Veterans Health Administration

BACKGROUND AND OBJECTIVES

Evidence-based practices to manage distress behaviors in dementia (DBD) are not consistently implemented despite demonstrated effectiveness. The Veterans Health Administration (VA) trained teams to implement Staff Training in Assisted Living Residences (STAR)-VA, an intervention to manage DBD in VA nursing home settings, or Community Living Centers (CLCs). This paper summarizes multiyear formative evaluation results including challenges, adaptations, and lessons learned to support sustained integration into usual care across CLCs nationwide.

RESEARCH DESIGN AND METHODS

STAR was selected as an evidence-based practice for DBD, adapted for and piloted in VA (STAR-VA), and implemented through a train-the-trainer program from 2013 to 2018. Training and consultation were provided to 92 CLC teams. Evaluation before and after training and consultation included descriptive statistics of measures of clinical impact and survey feedback from site teams regarding self-confidence, engagement, resource quality, and content analysis of implementation facilitators and challenges.

RESULTS

STAR-VA training and consultation increased staff confidence and resulted in significant decreases in DBD, depression, anxiety, and agitation for Veterans engaged in the intervention. Implementation outcomes demonstrated feasibility and identified facilitators and barriers. Key findings were interpreted using implementation frameworks and informed subsequent modifications to sustain implementation.

DISCUSSION AND IMPLICATIONS

STAR-VA successfully prepared teams to manage DBD and resulted in improved outcomes. Lessons learned include importance of behavioral health-nursing partnerships, continuous engagement, iterative feedback and adaptations, and sustainment planning. Evaluation of sustainment factors has informed selection of implementation strategies to address sustainment barriers. Lessons learned have implications for integrating team-based practices into system-level practice.

Overcoming barriers to implementation: mapping implementation strategies in four hospital in home programs within the Veterans Health Administration

The Hospital at Home model, called Hospital-in-Home (HIH) in the Department of Veterans Affairs, delivers coordinated, high-value care aligned with older adult and caregiver preferences. Documenting implementation barriers and corresponding strategies to overcome them can address challenges to widespread adoption. To evaluate HIH implementation barriers and identify strategies to address them, we conducted interviews with 8 HIH staff at 4 hospitals between 2010 and 2013. We utilized qualitative directed content analysis guided by the Consolidated Framework for Implementation Research (CFIR) and mapped identified barriers to possible strategies using the CFIR-Expert Recommendations for Implementing Change (ERIC) Matching Tool. We identified 11 barriers spanning 5 CFIR domains. Three implementation strategies - identifying and preparing champions, conducting educational meetings, and capturing and sharing local knowledge - achieved high expert endorsement for each barrier. A mix of strategies targeting resources, organizational readiness and fit, and leadership engagement should be considered to support the sustainability and spread of HIH.

Factors that influence the implementation of innovation in aged care: a scoping review

OBJECTIVE

The objective of this scoping review is to identify factors that influence the implementation of innovation in aged care.

INTRODUCTION

Aged care is a dynamic sector experiencing rapid change. Implementation of innovations in aged care has received relatively little research attention compared to health care.

INCLUSION CRITERIA

This review included studies of any design, that examined the implementation of innovations in aged care settings.

METHODS

Searches were conducted in MEDLINE, CINAHL, AgeLine, and ProQuest Social Sciences Premium Collection for studies published between January 1, 2012 and December 31, 2022. The titles and abstracts of retrieved citations were screened by two independent reviewers. Full-text articles were screened by one reviewer to determine inclusion. Data were extracted in NVivo using a tool developed by the research team. Factors that influenced implementation were inductively coded, interpreted, and grouped into categories in a series of workshops.

RESULTS

Of the 2530 studies that were screened, 193 were included. Of the included papers, the majority (74%) related to residential aged care, 28% used an implementation theory or framework, and 15% involved consumers. Five key categories of factors influencing implementation were identified: organizational context including resourcing and culture; people's attitudes and capabilities; relationships between people; the intervention and its appropriateness; and implementation actions such as stakeholder engagement and implementation strategies.

CONCLUSIONS

Our findings can be used to develop practical resources to support implementation efforts, and highlight the importance of resourcing for successful implementation. Attention to community-based aged care, and greater engagement with theory and community is needed to promote research rigor, relevance and applicability.

A Spotlight on Adaptation: Preimplementation of Montessori-Based Activity Programming in Long-Term Care Using the Framework for Reporting Adaptations and Modifications-Enhanced (FRAME)

BACKGROUND AND OBJECTIVES

Effectively adapting evidence-based interventions for nursing home (NH) implementation is a critical, yet underexamined, component of improving care quality. Montessori-based activity programming (MAP) is an evidence-based intervention that promotes person-centered care, engages persons living with dementia, and mitigates distress behaviors. Currently, there is sparse evidence of MAP in Department of Veterans Affairs NHs (i.e., community living centers [CLCs]). CLCs differ significantly from community NHs and require adaptations to support MAP use and sustainability. This study uses the Framework for Reporting Adaptations and Modifications-Enhanced (FRAME) to track changes made to MAP as an exemplar for clinicians and implementation scientists. This work fills a gap in adapting interventions through a detailed examination of the adaptation process in NHs.

RESEARCH DESIGN AND METHODS

Qualitative and quantitative data were collected across 8 CLCs (e.g., advisory panel, staff interviews, training evaluations, field notes, and fidelity assessments). We used an iterative, rapid content analytic approach to triangulate findings and identify needed adaptations for the CLC setting.

RESULTS

Thirty-six adaptations were made. Most adaptions occurred during the preimplementation phase, were reactive, focused on training/evaluation, and involved researchers, intervention developers, and practitioners. All were fidelity-consistent with MAP. The most common goal across adaptations was increased reach/engagement of the intervention.

DISCUSSION AND IMPLICATIONS

CLCs and community NHs can use findings to support intervention adaptation, and adapt and implement MAP to improve meaningful engagement for persons living with dementia and other residents. Future research should further evaluate and standardize FRAME for diverse users of complex interventions.

Developing and Testing Remote Implementation for the Changing Talk Online (CHATO) Communication Intervention for Nursing Home Staff: A Pilot Pragmatic Randomized Controlled Trial

Background and Objectives

The Changing Talk (CHAT) communication training effectively reduces elderspeak and subsequent behavioral challenges in residents with dementia in nursing homes (NHs). As part of the pilot pragmatic clinical trial testing Changing Talk: Online Training (CHATO), a new online version, a remote implementation design, and process evaluation were developed to capture contextual factors, ensure fidelity, and determine effective implementation strategies.

Research Design and Methods

The Expert Recommendation for Implementing Change compilation informed this 2-phase approach to develop and test remote implementation. An Advisory Board guided the developmental phase while pilot testing used a cluster-randomized design. Data were analyzed to evaluate NH characteristics; implementation strategies used; CHATO participation, completion, and passing rates; and leadership evaluation.

Results

Five out of 7 NHs were nonprofit with above average quality ratings (M = 4.3 of 5). Staff participants (N = 237) were mostly female (90%), non-Hispanic White (91%), and nursing assistants (46%). Implementation time ranged from 54 to 86 days (M = 70.3, standard deviation [SD] = 9.3), with planning phase ranging from 11 to 29 days (M = 20.1, SD = 6.7), and training phase ranging from 35 to 58 days (M = 50.0, SD = 7.6). A range from 3 to 11 implementation strategies were used by each NH. Assigning champions, including the social worker on the implementation team, utilizing multiple mediums for reminders, giving rewards or public recognition, supporting onsite discussions, and other tailoring strategies were associated with improved outcomes. Participation ranged from 20% to 76%. Over 63% of participants completed training (N = 150) and 87% passed the posttest (N = 130). Leadership evaluations noted staff used CHATO concepts in practice and improved communication culture.

Discussion and Implications

Leadership who took an active role, engaged multiple team members, and varied strategies had better outcomes. Effectiveness of the strategies will be evaluated in a national pragmatic clinical trial testing CHATO’s effects on reducing behavioral and psychological symptoms in dementia care.

Pragmatic Trials in Long-Term Care: Implementation and Dissemination Challenges and Opportunities

Randomized controlled trials are considered the most rigorous research design in efficacy and effectiveness research; however, such trials present numerous challenges that limit their applicability in real-world settings. As a consequence, pragmatic trials are increasingly viewed as a research design that overcomes some of these barriers with the potential to produce findings that are more reproducible. Although pragmatic methodology in long-term care is receiving increasing attention as an approach to improve successful dissemination and implementation, pragmatic trials present complexities of their own. To address these complexities and related issues, experts with experience conducting pragmatic trials, developing nursing home policy, participating in advocacy efforts, and providing clinical care in long-term care settings participated in a virtual consensus conference funded by the National Institute on Aging in Spring 2021. Participants identified 4 cross-cutting principles key to dissemination and implementation of pragmatic trial interventions: (1) stakeholder engagement, (2) diversity and inclusion, (3) organizational strain and readiness, and (4) learn from adaptations. Participants emphasized that implementation processes must be grounded in the perspectives of the people who will ultimately be responsible for implementing the intervention once it is proven to be effective. In addition, messaging must speak to long-term care staff and all others who have a stake in its outcomes. Although our understanding of dissemination and implementation strategies remains underdeveloped, this article is designed to guide long-term care researchers and community providers who are increasingly aware of the need for pragmatism in disseminating and implementing evidence-based care interventions.

Pragmatic Trials in Long-Term Care: Challenges, Opportunities, Recommendations

Randomized controlled trials are considered the most rigorous research design in efficacy and effectiveness research; however, such trials present numerous challenges that limit their applicability in real-world settings. As a consequence, pragmatic trials are increasingly viewed as a research design that overcomes some of these barriers with the potential to produce data that are more reproducible. Although pragmatic methodology in long-term care is receiving increasing attention as an approach to improve successful dissemination and implementation, pragmatic trials present complexities of their own. To address these complexities and related issues, experts with experience conducting pragmatic trials, developing nursing home policy, participating in advocacy efforts, and providing clinical care in long-term care settings participated in a virtual consensus conference funded by the National Institute on Aging in Spring 2021. Participants recommended 4 cross-cutting principles key to dissemination and implementation of pragmatic trial interventions: (1) engage stakeholders, (2) ensure diversity and inclusion, (3) assess organizational strain and readiness, and (4) learn from adaptations. Specifically related to implementation, participants provided 2 recommendations: (1) integrate interventions into existing workflows and (2) maintain agility and responsiveness. Finally, participants had 3 recommendations specific to dissemination: (1) package the message for the audience, (2) engage diverse audiences, and (3) apply dissemination and diffusion tools. Participants emphasized that implementation processes must be grounded in the perspectives of the people who will ultimately be responsible for implementing the intervention once it is proven to be effective. In addition, messaging must speak to long-term care staff and all others who have a stake in its outcomes. Although our understanding of dissemination and implementation strategies remains underdeveloped, this article is designed to guide long-term care researchers and community providers who are increasingly aware of the need for pragmatism in disseminating and implementing evidence-based care interventions.

Process evaluation of a tailored intervention to Reduce Inappropriate psychotropic Drug use in nursing home residents with dementia

Background

Research suggests that collaborative and tailored approaches with external expertise are important to process implementations. We therefore performed a process evaluation of an intervention using participatory action research, tailored information provision, and external coaching to reduce inappropriate psychotropic drug use among nursing home residents with dementia. The process evaluation was conducted alongside a randomized controlled trial assessing the utility of this approach.

Methods

We used Leontjevas’ model of process evaluation to guide data collection and analysis, focusing on the relevance and feasibility, extent of performance, and barriers and facilitators to implementation. Data on the relevance and feasibility and on the extent of performance were collected using a questionnaire targeting internal project leaders at nursing homes and our external coaches. Implementation barriers and facilitators were identified by individual semi-structured interviews. The Consolidated Framework for Implementation Research was used to structure and describe the identified barriers and facilitators.

Results

The intervention was viewed positively, but it was also considered time consuming due to the involvement of many people and designing a tailored action and implementation plan was viewed as complex. The extent of performance differed between nursing homes. Delays in implementation and suboptimal execution of actions may have reduced effectiveness of the RID intervention in some nursing homes. Barriers to implementation were reorganizations, staff turnover, communication issues, unclear expectations, and perceived time pressures. Implementation also depended on the involvement and skills of key stakeholders, and organizations’ readiness to change. Although external coaches stimulated implementation, their additional value was rated variably across organizations.

Conclusions

Barriers to implementation occurred on several levels and some barriers appear to be inherent to the nursing home environment and could be points of leverage of future implementation trajectories. This underlines the importance of assessing and supporting organizations in their readiness to change. Sensitivity analyses, taking into account the week in which nursing homes started with implementation and the degree to which actions were implemented as intended, will be appropriate in the effect analyses of the trial.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02357-w.

"If They Don't Like You, They Are Not Going to Eat for You": Individual and Interpersonal Factors Affecting Certified Nursing Assistants' Ability to Provide Mealtime Assistance to Residents With Dementia

BACKGROUND AND OBJECTIVES

In long-term care facilities in the United States, certified nursing assistants (CNAs) provide mealtime assistance to residents with dementia, a task that substantially increases caregiver burden due to the time and attention required. The aim of this qualitative study was to explore the individual and interpersonal barriers and facilitators CNAs experience when providing mealtime assistance to residents with dementia.

RESEARCH DESIGN AND METHODS

Focus group questions were developed based on the corresponding levels of the Social Ecological Model. Using purposive sampling, 9 focus groups were conducted with 53 CNAs who had at least 1 year of experience as a CNA working with older adults. Focus groups were audio-recorded and transcribed verbatim. Data were analyzed using the directed content analysis approach.

RESULTS

CNAs reported individual skills, training, and personal characteristics that affected their ability to provide mealtime assistance. At the interpersonal level, CNAs identified their relationships with residents, residents' family members, and other health care professionals as factors that affect their ability to provide mealtime assistance.

DISCUSSION AND IMPLICATIONS

These findings provide evidence for strategies that administrators can utilize to reduce caregiver burden by improving the mealtime experience. First, CNAs need adequate training, particularly to develop communication skills. Developing verbal communication skills may improve interpersonal relationships between CNAs and residents' family members and other coworkers. Developing nonverbal communication skills may foster an improved relationship between CNAs and their residents with dementia. Future research should evaluate interventions that seek to improve these skills to determine their impact on the mealtime experience.