Strengthening research to improve the practice and management of long-term care

Video Conferencing With Residents and Families for Care Planning During COVID-19: Experiences in Canadian Long-Term Care

BACKGROUND AND OBJECTIVES

Government-mandated health and safety restrictions to mitigate the effects of coronavirus disease 2019 (COVID-19) intensified challenges in caring for older adults in long-term care (LTC) without family/care partners. This article describes the experiences of a multidisciplinary research team in implementing an evidence-based intervention for family-centered, team-based, virtual care planning-PIECESTM approach-into clinical practice. We highlight challenges and considerations for implementation science to support care practices for older adults in LTC, their families, and the workforce.

RESEARCH DESIGN AND METHODS

A qualitative descriptive design was used. Data included meetings with LTC directors and Registered Practical Nurses (i.e., licensed nurse who graduated with a 2-year diploma program that allows them to provide basic nursing care); one-on-one interviews with family/care partners, residents, Registered Practical Nurses, and PIECES mentors; and reflections of the academic team. The Consolidated Framework for Implementation Research provided sensitizing constructs for deductive coding, while an inductive approach also allowed themes to emerge.

RESULTS

Findings highlighted how aspects related to planning, engagement, execution, reflection, and evaluation influenced the implementation process from the perspectives of stakeholders. Involving expert partners on the research team to bridge research and practice, developing relationships from a distance, empowering frontline champions, and adapting to challenging circumstances led to shared commitments for intervention success.

DISCUSSION AND IMPLICATIONS

Lessons learned include the significance of stakeholder involvement throughout all research activities, the importance of clarity around expectations of all team members, and the consequence of readiness for implementation with respect to circumstances (e.g., COVID-19) and capacity for change.

Champions for improved adherence to guidelines in long-term care homes: a systematic review

BACKGROUND

The champion model is increasingly being adopted to improve uptake of guideline-based care in long-term care (LTC). Studies suggest that an on-site champion may improve the quality of care residents' health outcomes. This review assessed the effectiveness of the champion on staff adherence to guidelines and subsequent resident outcomes in LTC homes.

METHOD

This was a systematic review and meta-analyses of randomised controlled trials. Eligible studies included residents aged 65 or over and nursing staff in LTC homes where there was a stand-alone or multi-component intervention that used a champion to improve staff adherence to guidelines and resident outcomes. The measured outcomes included staff adherence to guidelines, resident health outcomes, quality of life, adverse events, satisfaction with care, or resource use. Study quality was assessed with the Cochrane Risk of Bias tool; evidence certainty was assessed using the GRADE approach.

RESULTS

After screening 4367 citations, we identified 12 articles that included the results of 1 RCT and 11 cluster-RCTs. All included papers evaluated the effects of a champion as part of a multicomponent intervention. We found low certainty evidence that champions as part of multicomponent interventions may improve staff adherence to guidelines. Effect sizes varied in magnitude across studies including unadjusted risk differences (RD) of 4.1% [95% CI: - 3%, 9%] to 44.8% [95% CI: 32%, 61%] for improving pressure ulcer prevention in a bed and a chair, respectively, RD of 44% [95% CI: 17%, 71%] for improving depression identification and RD of 21% [95% CI: 12%, 30%] for improving function-focused care to residents.

CONCLUSION

Champions may improve staff adherence to evidence-based guidelines in LTC homes. However, methodological issues and poor reporting creates uncertainty around these findings. It is premature to recommend the widespread use of champions to improve uptake of guideline-based care in LTC without further study of the champion role and its impact on cost.

TRIAL REGISTRATION

PROSPERO CRD42019145579 . Registered on 20 August 2019.

Report and Research Agenda of the American Geriatrics Society and National Institute on Aging Bedside-to-Bench Conference on Urinary Incontinence in Older Adults: A Translational Research Agenda for a Complex Geriatric Syndrome

The American Geriatrics Society, with support from the National Institute on Aging and other funders, held its ninth Bedside-to-Bench research conference, entitled "Urinary Incontinence in the Older Adult: A Translational Research Agenda for a Complex Geriatric Syndrome," October 16 to 18, 2016, in Bethesda, Maryland. As part of a conference series addressing three common geriatric syndromes-delirium, sleep and circadian rhythm disturbance, and urinary incontinence-the series highlighted relationships and pertinent clinical and pathophysiological commonalities between these conditions. The conference provided a forum for discussing current epidemiology, basic science, and clinical and translational research on urinary incontinence in older adults; for identifying gaps in knowledge; and for developing a research agenda to inform future investigative efforts. The conference also promoted networking involving emerging researchers and thought leaders in the field of incontinence, aging, and other fields of research, as well as National Institutes of Health program personnel.

Family and Other Unpaid Caregivers and Older Adults with and without Dementia and Disability

OBJECTIVES

To estimate the number of caregivers providing assistance to community-dwelling older persons with and without dementia and with or without substantial disability; to describe the characteristics of caregivers and care recipients in these groups; to characterize the health-related tasks that caregivers provide; and to estimate associations between the numbers of tasks and caregiver burden.

DESIGN

Nationally representative surveys of caregivers and older adults in the United States.

SETTING

2011 National Health and Aging Trends Study and National Study of Caregiving.

PARTICIPANTS

Community-dwelling older adults and their family caregivers, who were selected on the basis of having assisted with mobility, self-care, household activities, transportation, or medical tasks.

MEASUREMENTS

Caregiver burden (emotional, physical, financial difficulties) and restrictions on social participation.

RESULTS

Although much larger proportions of older adults with dementia and disability (98.4%, n = 1.0 million) and dementia but not disability (95.5%, n = 1.3 million) received caregiving assistance, the largest absolute number of individuals receiving assistance were older adults without dementia or disability (4.0 million). Within each caregiver group, caregivers provided assistance with at least one task across domains of activity of daily living and instrumental activity of daily living-related assistance (>98%), health systems logistics (>70%), and health management (>50%). There was a significant linear association between number of tasks provided and risk of burden in virtually all caregiver groups and domains of assistance.

CONCLUSION

Caregivers of care recipients without dementia or disability accounted for the largest absolute number of helpers. These caregivers, similar to caregivers of care recipients with dementia or disability, delivered a broad spectrum of health-related tasks and experienced caregiver burden and restrictions on social participation. Findings support the need for interventions that address the needs of caregivers who have not typically been defined as high risk.

Professionals' Beliefs About Nursing Home Regulations in Missouri

The process of nursing home regulation continues to need improvement to ensure the best possible quality of care. This study uses mixed methods to explore opinions of nursing home professionals and state nursing home regulation inspection team members about the regulation process and ideas for changing it in the State of Missouri. Data come from a survey of nursing home professionals (n = 334) and state regulation inspectors (n = 123) conducted in early 2004. Findings show disagreement about who is responsible for facilitating nursing home compliance; nursing home professionals desire state assistance in interpreting and applying regulations, whereas inspectors do not believe this will improve quality of care. Greater focus on resident needs may provide common ground for bridging this divide and developing interventions to ensure regulatory success.

Pay-for-performance policy and data-driven decision making within nursing homes: a qualitative study

INTRODUCTION

Health systems globally and within the USA have introduced nursing home pay-for-performance (P4P) programmes in response to the need for improved nursing home quality. Central to the challenge of administering effective P4P is the availability of accurate, timely and clinically appropriate data for decision making. We aimed to explore ways in which data were collected, thought about and used as a result of participation in a P4P programme.

METHODS

Semistructured interviews were conducted with 232 nursing home employees from within 70 nursing homes that participated in P4P-sponsored quality improvement (QI) projects. Interview data were analysed to identify themes surrounding collecting, thinking about and using data for QI decision making.

RESULTS

The term 'data' appeared 247 times in the interviews, and over 92% of these instances (228/247) were spontaneous references by nursing home staff. Overall, 34% of respondents (79/232) referred directly to 'data' in their interviews. Nursing home leadership more frequently discussed data use than direct care staff. Emergent themes included using data to identify a QI problem, gathering data in new ways at the local level, and measuring outcomes in response to P4P participation. Alterations in data use as a result of policy change were theoretically consistent with the revised version of the Promoting Action on Research Implementation in Health Services framework, which posits that successful implementation is a function of evidence, context and facilitation.

CONCLUSIONS

Providing a reimbursement context that facilitates the collection and use of reliable local evidence may be an important consideration to others contemplating the adaptation of P4P policies.

"As needed" case management across aging services in response to depression

A lack of clarity on how and where case management for older adults is delivered persists, even as evidence supports its use to respond to depression. We used in-depth interviews with managers (n = 20) and staff surveys (n = 142) from 17 service agencies to explore the provision of case management services in adult day services, homecare, senior centers, and supportive housing. Limited case management services were found. Barriers included limited time and resources, especially for senior centers and supportive housing. Results revealed a concern about the role, feasibility, and availability of case management for older adults within these settings.

Evidence based practice in long term care settings

PURPOSE

The purpose of this manuscript is to discuss the need for use of evidence based practice (EBP) in LTC, the current use of evidence in long term care facilities and what we know about adoption of the use of EBP in LTC.

METHODS

Literature review and reporting of findings from the M-TRAIN study that was a quasi-experimental design to test the effectiveness of an intervention to increase the use of EBPs for urinary incontinence and pain in 48 LTC facilities.

RESULTS

Barriers to adopting EBPs include lack of available time, lack of access to current research literature, limited critical appraisal skills, excessive literature to review, non-receptive organizational culture, limited resources, and limited decision-making authority of staff to implement change. Strategies to promote adoption of EBP include the commitment of management; the culture of the home; leadership; staff knowledge, time, and reward; and facility size, complexity, the extent that members are involved outside the facility, NH chain membership, and high level of private pay residents. Findings from the M-TRAIN add, stability of nurse leader and congruency between the leaders perception of their leadership and the staff's perception of the leadership.

CONCLUSION

There is clear evidence of the need and the benefits to residents of LTC and to the health care system yet adoption of EBP continues to be slow and sporadic. There is also evidence for the process of establishing best evidence and many resources to find the available EBPs. The urgent need now is finding ways to best get the EBPs implemented in LTC. There is growing evidence about best methods to do this but continued research is needed. Clearly, residents in LTC deserve the best care possible and EBPs represent an important vehicle by which to do this.

Explaining the success or failure of quality improvement initiatives in long-term care organizations from a dynamic perspective

The purpose of this study was to better understand why change initiatives succeed or fail in long-term care organizations. Four case studies from Québec, Canada were contrasted retrospectively. A constipation and restraints program succeeded, while an incontinence and falls program failed. Successful programs were distinguished by the use of a change strategy that combined "let-it happen," "help-it happen," and "make-it happen" interventions to create senses of urgency, solidarity, intensity, and accumulation. These four active ingredients of the successful change strategies propelled their respective change processes forward to completion. This paper provides concrete examples of successful and unsuccessful combinations of "let-it happen," "help-it happen," and "make-it happen" change management interventions. Change managers (CM) can draw upon these examples to best tailor and energize change management strategies in their own organizations.

Improving functional outcomes in home care patients: impact and challenges of disseminating a quality improvement initiative

Most older adults are admitted to home health care with some functional impairment related to chronic illness and/or hospitalization. This article describes: (1) the impact of a quality improvement initiative (QI) on functional outcomes of older, chronically ill patients served by a large homecare organization; and (2) key implementation challenges affecting intervention outcomes. Over 6,000 patients were included in two dissemination phases. Phase 1 randomly assigned service delivery teams to intervention (QI) or usual care (UC). Phase 2 spread the intervention to UC teams. Phase 1 yielded statistically significant, albeit modest, functional improvements among intervention team patients relative to UC. Phase 2 improvements in the original intervention group were smaller, suggesting some regression to the mean. UC teams did not "catch up" when exposed to the intervention in Phase 2. Analysis of the implementation process suggested that modification of improvement strategies and "dilution" of peer-to-peer communication hindered additional Phase 2 improvements. The findings highlight the challenges of relying on peer-to-peer spread, and of distinguishing the core elements of an effective improvement strategy that must be spread consistently from those that can be adapted to variations within and across organizations.

Sustaining clinical programs during difficult economic times: a case series from the Hospital Elder Life Program

OBJECTIVES

To explore strategies used by clinical programs to justify operations to decision-makers using the example of the Hospital Elder Life Program (HELP), an evidence-based, cost-effective program to improve care for hospitalized older adults.

DESIGN

Qualitative study design using 62 in-depth, semistructured interviews conducted with HELP staff members and hospital administrators between September 2008 and August 2009.

SETTING

Nineteen HELP sites in hospitals across the United States and Canada that had been recruiting patients for at least 6 months.

PARTICIPANTS

HELP staff and hospital administrators.

MEASUREMENTS

Participant experiences sustaining the program in the face of actual or perceived financial threats, with a focus on factors they believe are effective in justifying the program to decision-makers in the hospital or health system.

RESULTS

Using the constant comparative method, a standard qualitative analysis technique, three major themes were identified across interviews. Each focuses on a strategy for successfully justifying the program and securing funds for continued operations: interact meaningfully with decision-makers, including formal presentations that showcase operational successes and informal means that highlight the benefits of HELP to the hospital or health system; document day-to-day, operational successes in metrics that resonate with decision-maker priorities; and garner support from influential hospital staff that feed into administrative decision-making, particularly nurses and physicians.

CONCLUSION

As clinical programs face financially challenging times, it is important to find effective ways to justify their operations to decision-makers. Strategies described here may help clinically effective and cost-effective programs sustain themselves and thus may help improve care in their institutions.

Evidence-based clinical pathways to manage urinary tract infections in long-term care facilities: a qualitative case study describing administrator and nursing staff views

OBJECTIVES

This article examines the views of nursing staff and administrators in long-term care facilities (LTCFs) regarding a clinical pathway for managing urinary tract infections (UTIs) in LTCF residents.

DESIGN

A qualitative (case study) design was used.

SETTING

Data were collected from 8 LTCFs in southern Ontario and 2 in Iowa enrolled in a larger randomized controlled trial of clinical pathway for managing UTIs in LTCF residents, conducted between September 2001 and March 2003. The clinical pathway, designed to more effectively identify, diagnose, and treat UTIs, and reduce inappropriate antibiotics use for asymptomatic UTIs, introduced 2 decision tools to determine when to order a urine culture and initiate antibiotic treatment for suspected UTIs.

PARTICIPANTS

We conducted 19 individual interviews with administrators and 10 focus groups with 52 nurses.

FINDINGS

Nurses generally thought that the pathways were well developed and easy to use, and administrators believed they were an important educational resource. Barriers to their use varied by group-initial lack of buy-in from nurses (medical directors), additional work (directors of nursing), and the need to change the protocol to exclude certain residents based on prior health conditions and/or pressure from physicians or families (nurses).

CONCLUSIONS

Both administrators and staff, once familiar with a new clinical protocol to improve UTI management in LTCFs, generally supported its use.

Improving the quality of residential care using goal attainment scaling

OBJECTIVE

To illustrate the potential of goal attainment scaling (GAS) as a means to improve the quality of care provided by residential care facilities to frail older adults.

DESIGN

A pre-test/post-test single-group design.

SETTINGS/PARTICIPANTS

Twenty facilities providing inadequate care to at least one resident. These facilities were identified with a case-finding questionnaire followed by a thorough investigation of the quality of care delivered to a sample of frail older adults.

INTERVENTION

The 6-month intervention was conducted by three interdisciplinary teams of health professionals experienced in caring for frail older adults. The intervention was tailored to the main quality problems identified at baseline in the facility. The first task of the intervention team was to set weighted priority goals in conjunction with the facility manager. Subsequent monthly on-site visits, interspersed with frequent telephone calls, were devoted to assisting the manager and staff implement permanent changes in the areas of care targeted for improvement.

MEASUREMENTS

Pre- and post-intervention GAS scores.

RESULTS

Two facilities were lost to follow-up. A total of 81 facility goals were established at the onset of the study. Goals per facility ranged from 2 to 9 (mean = 4.5, SD = 2.04). GAS scores increased significantly between pre- and post-intervention (P < .001). Goal achievement varied with the manager's own rating of the quality of care provided in the facility (P = .008), his/her education level (P = .037), and the intervention team (P = .049).

CONCLUSIONS

This study shows that quality improvement objectives established with the manager following a thorough evaluation of the quality of care provided in the facility can, on average, be attained with the help of experienced health professionals. It also provides some insight into the types of facilities where preset objectives are more likely to be achieved.

The application of the Olmstead decision on housing and eldercare

This article reviews the Supreme Court's interpretation of Title II of the Americans with Disabilities Act (ADA) and discusses its application for the frail older person. The parallels and differences between the societal ideas about, and the development of, community-based housing programs for younger populations of people with disabilities and for aging populations will be examined. This article explains how frail older people may be included in the ADA's definition of persons with disabilities. It then explains the Supreme Court's interpretation of discrimination in Olmstead v. L.C. ex rel Zimring (1999). Lastly, it examines the implications of the Olmstead decision for long-term care as it relates to housing for older people.

Functional status decline as a measure of adverse events in home health care: an observational study

BACKGROUND

Research that examines the quality of home health care is complex because no gold standard exists for measuring adverse outcomes, and because the patient and clinician populations are highly heterogeneous. The objectives in this study are to develop models to predict functional decline for three indices of functional status as measures of adverse events in home health care and determine which index is most appropriate for risk-adjusting for future quality research.

METHODS

Data come from the Outcomes and Assessment Information Set (OASIS) from a large urban home health care agency and other agency data. Prognostic data yields 49,437 episodes, while follow-up data yields 47,684 episodes. We tested three indices defined as substantial decline in three or more (gt3_ADLs), two or more (gt2_ADLs), and one or more (gt1_ADLs) ADLs. Multivariate logistic regression determines the performance of the models for each index as measured by the c-statistic and Hosmer-Lemeshow chi square (chi2).

RESULTS

Frequencies for gt3_ADLs, gt2_ADLs, and gt1_ADLs are 212 (0.43%), 783 (1.58%), and 4,271 (8.64%) respectively. Follow-up results are comparable with frequencies of 218 (0.46%), 763 (1.60%), and 3,949 (8.28%) for each index. Gt3_ADLs does not produce valid models. The model for gt2_ADLs consistently yields a higher c-statistic compared to gt1_ADLs (0.754 vs. 0.679, respectively). Both indices' models yield non-significant Hosmer-Lemeshow chi square indicating reasonable model fit. Findings for gt2_ADLs and gt1_ADLs are consistent over time as indicated by follow-up data results.

CONCLUSION

Gt2_ADLs yields the best models as indicated by a high c-statistic and a non-significant Hosmer-Lemeshow chi2, both of which exhibit exceptional consistency. We conclude that gt2_ADLs may be preferable in defining ADL adverse events in the context of home health care.

Gerontology's Future: An Integrative Model for Disciplinary Advancement

Scholars have debated the legitimacy of gerontology as a discipline since Metchnikoff coined the term more than 100 years ago. Recent developments such as the emergence of interdisciplinary aging theories and consensus on longitudinal research methods suggest that gerontology is materializing as a unique discipline, rather than a subset of another more established disciplinary tradition. In this article we review substantive evidence from gerontological theory and scholarship to suggest orienting principles for the emerging discipline of gerontology. We offer a conceptual framework of gerontology as a discipline that integrates contributions of biopsychosocial perspectives with well-established concepts of age, aging, and aged and multiple contextual elements. We conclude with a discussion of how our model relates to gerontology's progress, including examples of successful interdisciplinary research, and offer questions for gerontologists to consider for further advancement of the field.

Implications of translating research into practice: a medication management intervention

Through programs such as the Administration on Aging's Evidence-Based Prevention Initiative, researchers and practitioners are developing translational research studies seeking to implement rigorously tested, evidence-based interventions in new practice settings and evaluate the continuing effectiveness of these interventions. One such translational study is the Community-Based Medications Management Intervention (CBM Intervention), a collaborative effort to implement a medication management screening and intervention protocol in community-based waiver care management programs. The overall goals of the CBM Intervention are to implement an evidence-based medication management intervention in a California Medicaid waiver care management program, and to evaluate the effect of client-, intervention-, and organizational-level characteristics on resolving identified medication problems. This article presents the need for improved medication management in a frail, community-dwelling, older adult population and describes the CBM Intervention as an example of translating an evidence-based practice beyond its original efficacy trial in a home healthcare program into a care management program. It discusses critical factors involved in translating research into practice using a translational research framework, Promoting Action on Research Implementation in Health Services (PARIHS). Our experience suggests that although implementing research into practice can positively impact client care, professional skill enhancement and organizational effectiveness, this is very challenging work requiring signification facilitation for successful outcomes.

Reductions in costly healthcare service utilization: findings from the Care Advocate Program

OBJECTIVES

To determine whether a telephone care-management intervention for high-risk Medicare health maintenance organization (HMO) health plan enrollees can reduce costly medical service utilization.

DESIGN

Randomized, controlled trial measuring healthcare services utilization over three 12-month periods (pre-, during, and postintervention).

SETTING

Two social service organizations partnered with a Medicare HMO and four contracted medical groups in southern California.

PARTICIPANTS

Eight hundred twenty-three patients aged 65 and older; eligibility was determined using an algorithm to target older adults with high use of insured healthcare services.

INTERVENTION

After assessment, members in the intervention group were offered mutually agreed upon referrals to home- and community-based services (HCBS), medical groups, or Medicare HMO health plan and followed monthly for 1 year.

MEASUREMENTS

Insured medical service utilization was measured across three 12-month periods. Acceptance and utilization of Care Advocate (CA) referrals were measured during the 12-month intervention period.

RESULTS

CA intervention members were significantly more likely than controls to use primary care physician services (odds ratio (OR)=2.05, P<.001), and number of hospital admissions (OR=0.43, P<.01) and hospital days (OR=0.39, P<.05) were significantly more stable for CA group members than for controls.

CONCLUSION

Results suggest that a modest intervention linking older adults to HCBS may have important cost-saving implications for HMOs serving community-dwelling older adults with high healthcare service utilization. Future studies, using a national sample, should verify the role of telephone care management in reducing the use of costly medical services.

Effect of educational level and minority status on nursing home choice after hospital discharge

OBJECTIVES

The movement to publicly report data on provider quality to inform consumer choices is predicated on assumptions of equal access and knowledge. We examine the validity of this assumption by testing whether minority/less educated Medicare patients are at greater risk of being discharged from a hospital to the lowest-quality nursing homes in a geographic area.

METHODS

We used the 2002 national Minimum Data Set to identify 62601 new Medicare admissions to nursing homes in 95 hospital service areas with at least 4 freestanding nursing homes and at least 50 African Americans aged 65 years or older with Medicare admissions to nursing homes.

RESULTS

The probability of African Americans' being admitted to nursing homes in the lowest-quality quartile in the area was greater (relative risk [RR]=1.26; 95% confidence interval [CI]=1.0, 8.45) in comparison with Whites. Individuals without a high-school degree were also more likely to be admitted to a low-quality nursing home (RR=1.22; 95% CI=1.0, 1.46).

CONCLUSIONS

African American and poorly educated patients enter the worst-quality nursing facilities. This finding raises concerns about the usefulness of the current public reporting model for certain consumers.

Improving the quality of residential care using goal attainment scaling

OBJECTIVE

To illustrate the potential of goal attainment scaling (GAS) as a means to improve the quality of care provided by residential care facilities to frail older adults.

DESIGN

A pre-test/post-test single-group design.

SETTINGS/PARTICIPANTS

Twenty facilities providing inadequate care to at least one resident. These facilities were identified with a case-finding questionnaire followed by a thorough investigation of the quality of care delivered to a sample of frail older adults.

INTERVENTION

The 6-month intervention was conducted by three interdisciplinary teams of health professionals experienced in caring for frail older adults. The intervention was tailored to the main quality problems identified at baseline in the facility. The first task of the intervention team was to set weighted priority goals in conjunction with the facility manager. Subsequent monthly on-site visits, interspersed with frequent telephone calls, were devoted to assisting the manager and staff implement permanent changes in the areas of care targeted for improvement.

MEASUREMENTS

Pre- and post-intervention GAS scores.

RESULTS

Two facilities were lost to follow-up. A total of 81 facility goals were established at the onset of the study. Goals per facility ranged from 2 to 9 (mean = 4.5, SD = 2.04). GAS scores increased significantly between pre- and post-intervention (P < .001). Goal achievement varied with the manager's own rating of the quality of care provided in the facility (P = .008), his/her education level (P = .037), and the intervention team (P = .049).

CONCLUSIONS

This study shows that quality improvement objectives established with the manager following a thorough evaluation of the quality of care provided in the facility can, on average, be attained with the help of experienced health professionals. It also provides some insight into the types of facilities where preset objectives are more likely to be achieved.

Dementia care and quality of life in assisted living and nursing homes

PURPOSE

There are few empirical studies relating components of long-term care to quality of life for residents with dementia. This study relates elements of dementia care in residential care/assisted living (RC/AL) facilities and nursing homes to resident quality of life and considers the guidance this information provides for practice and policy.

DESIGN AND METHODS

We used a variety of report and observational measures of the structure and process of care and 11 standardized measures of quality of life to evaluate the care for and quality of life of 421 residents with dementia in 35 RC/AL facilities and 10 nursing homes in four states. Data were collected cross sectionally on-site, and we conducted a 6-month follow-up by telephone.

RESULTS

Change in quality of life was better in facilities that used a specialized worker approach, trained more staff in more domains central to dementia care, and encouraged activity participation. Residents perceived their quality of life as better when staff was more involved in care planning and when staff attitudes were more favorable. Better resident-staff communication was related to higher quality of life as observed and reported by care providers. Also, more stable resident-staff assignment was related to care providers' lower quality-of-life ratings.

IMPLICATIONS

Improvement in resident quality of life may be achieved by improved training and deployment of staff.

A clinical pathway for treating pneumonia in the nursing home: part II: the administrators' perspective and how it differs from nurses' views

OBJECTIVES

This paper examines the utility and sustainability of a clinical pathway for treating nursing home residents with pneumonia from the perspective of nursing administrators and medical directors in Ontario, Canada. The discussion includes a comparison of the perspectives of the administrators and the nursing staff (reported in part I of this article).

DESIGN

A qualitative case study design was used.

SETTING

Data were collected from 6 nursing homes in Southern Ontario that were drawn from a larger randomized controlled trial of a clinical pathway to help identify, diagnose, and manage cases of nursing home-acquired pneumonia.

PARTICIPANTS

Six interviews were conducted with nursing administrators and 2 with medical directors (1 per facility). Key themes were identified in the interview data using the template style of analysis described by Miller and Crabtree.

FINDINGS

Administrators were in favor of using a clinical pathway for identifying and treating pneumonia in nursing home residents. Participants thought that during the study residents with pneumonia received better and more timely care, and that nurses' clinical skills, knowledge, and confidence had improved. In comparison with views expressed by nurses and medical directors in the same facilities, nursing administrators tended to report less clinical training and staff support were required to successfully implement the pathway.

CONCLUSIONS

Even though nurses and administrators strongly support the use of a pneumonia clinical pathway in nursing homes, implementation plans should be tailored to individual facilities and be informed by the perspectives of both administrators and staff.

A Nonpharmacological Intervention to Improve Sleep in Nursing Home Patients: Results of a Controlled Clinical Trial

OBJECTIVES

To improve nighttime sleep in nursing home patients.

DESIGN

Controlled clinical trial.

SETTING

Eight community nursing homes enrolled two at a time.

PARTICIPANTS

Of 1,077 patients assessed in the eight nursing homes, 638 (59%) were eligible, and consent was obtained for 273 (43% of those eligible). Of the 230 who underwent baseline assessments, 173 completed the immediate-intervention phase of the trial (77 in the intervention group and 96 in the control group). A total of 160 subjects completed the intervention (77 in the immediate-intervention group and 83 in the delayed-intervention phase).

INTERVENTION

Trained research staff provided the intervention, which included daytime physical activity and attempts to keep subjects out of bed, evening bright light exposure, a consistent bedtime routine, nighttime care routines designed to minimize sleep disruption, and strategies to reduce nighttime noise. Subjects from one nursing home received the intervention (Group 1), whereas subjects in the second nursing home served as a control group (Group 2); then Group 2 received the intervention.

MEASUREMENTS

Primary outcomes included measures of sleep recorded using wrist actigraphy in all subjects and polysomnography in a subgroup of subjects. Secondary measures included assessments of mood and behavior using the Neuropsychiatric Inventory, the Geriatric Depression Scale, and behavioral observations.

RESULTS

There were no significant differences in any of the primary actigraphic sleep outcome measures between the intervention and control group after the immediate-intervention phase of the trial. In the 160 subjects who completed the intervention, there were no significant changes in any actigraphic measure of nighttime sleep, nor were there any significant changes in measures of sleep in the 45 subjects who had baseline and intervention polysomnography.

CONCLUSION

This multicomponent, nonpharmacological intervention conducted by trained research staff had no effect on nighttime sleep in this sample of nursing home patients. Enhanced nonpharmacological interventions should be developed and tested and combined with environmental interventions to mitigate noise when feasible. Adjunctive drug therapy may be needed to improve sleep in a substantial proportion of this population and should be tested in addition to nonpharmacological interventions in rigorous clinical trials.

After adoption: sustaining the innovation. A case study of disseminating the hospital elder life program

OBJECTIVES

To examine key factors that influence sustainability in the diffusion of the Hospital Elder Life Program (HELP) as an example of an evidence-based, multifaceted, innovative program to improve care for hospitalized older adults.

DESIGN

Longitudinal, qualitative study between November 2000 and November 2003 based on 102 in-depth interviews every 6 months during HELP implementation.

SETTING

Thirteen hospitals implementing HELP.

PARTICIPANTS

Forty-two hospital staff members (physician, nursing, volunteer, and administrative staff) implementing HELP, conducted 102 interviews.

MEASUREMENTS

Staff experiences sustaining the program, including challenges and strategies that they viewed as successful in addressing these challenges.

RESULTS

Of the 13 hospitals studied, 10 were sustaining HELP at the end of the study period; three terminated the program (after 24 months, 12 months, and 6 months). Critical factors were identified as influencing whether the program was sustained: the presence of clinical leadership, the ability and willingness to adapt the original HELP protocols to local hospital circumstances and constraints, and the ability to obtain longer-term resources and funding for HELP.

CONCLUSION

Recognizing the need for sustained clinical leadership and funding as well as the inevitable modifications required to sustain innovative programs can promote more-realistic goals and expectations for health services researchers, clinicians, and policy makers in their laudable efforts to translate research into practice.

Functional Incidental Training: A Randomized, Controlled, Crossover Trial in Veterans Affairs Nursing Homes

OBJECTIVES

To test the effects of a rehabilitative intervention directed at continence, mobility, endurance, and strength (Functional Incidental Training (FIT)) in older patients in Department of Veterans Affairs (VA) nursing homes.

DESIGN

Randomized, controlled, crossover trial.

SETTING

Four VA nursing homes.

PARTICIPANTS

All 528 patients in the nursing homes were screened; 178 were eligible, and 107 were randomized to an immediate intervention group (Group 1; n=52) and a delayed intervention group (Group 2; n=55).

INTERVENTION

Trained research staff provided the FIT intervention, which included prompted voiding combined with individualized, functionally oriented endurance and strength-training exercises offered four times per day, 5 days per week, for 8 weeks. Group 1 received the intervention while Group 2 served as a control group; then Group 2 received the intervention while Group 1 crossed over to no intervention. A total of 64 subjects completed the intervention phase of the trial.

MEASUREMENTS

Timed measures of walking or wheeling a wheelchair (mobility), sit-to-stand exercises, independence in locomotion and toileting as assessed using the Functional Independence Measure (FIM), one-repetition maximum weight for several measures of upper and lower body strength, frequency of urine and stool incontinence, and appropriate toileting ratios.

RESULTS

There was a significant effect of the FIT intervention on virtually all measures of endurance, strength, and urinary incontinence but not on the FIM for locomotion or toileting. The effects of FIT were observed when Group 1 received the intervention and was compared with the control group and when Group 2 crossed over to the intervention. Group 1 deteriorated in all measures during the 8-week crossover period. Within-person comparisons also demonstrated significant effects on all measures in the 64 participants who completed the intervention; 43 (67%) of these participants were "responders" based on maintenance or improvement in at least one measure of endurance, strength, and urinary incontinence. No adverse events related to FIT occurred during the study period.

CONCLUSION

FIT improves endurance, strength, and urinary incontinence in older patients residing in VA nursing homes. Translating these positive benefits achieved under research conditions into practice will be challenging because of the implications of the intervention for staff workload and thereby the costs of care.

Functional Incidental Training: Applicability and feasibility in the Veterans Affairs nursing home patient population

OBJECTIVE

To examine the applicability and feasibility of an intervention directed at improving continence, endurance, and strength (Functional Incidental Training [FIT]), for older patients in Veterans Administration (VA) nursing homes.

DESIGN

Data were collected during a randomized, controlled, crossover trial.

SETTING

Four VA nursing homes.

PARTICIPANTS

All 528 patients in the nursing homes were screened, 178 were eligible, and 107 were randomized into the trial. A total of 64 participants completed the intervention phase of the trial.

INTERVENTION

Trained research staff provided the FIT intervention, which included prompted voiding combined with individualized, functionally oriented endurance and strength training exercises offered four times per day, 5 days per week, for 8 weeks.

MEASURES

Descriptive data were collected relevant to the translation of the FIT intervention into everyday practice, including number of patients eligible and reasons for ineligibility, attrition rates and reasons for attrition, participant adherence to and satisfaction with FIT, and the costs of FIT relative to usual care.

RESULTS

One third of the 528 patients met the eligibility criteria. The major reasons for ineligibility were being continent, age under 60, and a short anticipated length of stay. Of the 146 patients enrolled in the trial, 85 (58%) dropped out during the 9- to 10-month project. Deterioration in health status, death, and discharge accounted for two thirds of the attrition. Adherence to FIT was in general high but variable. Participants completed prompted voiding plus at least one exercise in 75% of the FIT rounds offered. Of the 60 participants who completed the protocol and who could answer simple questions, 75% indicated they enjoyed FIT, but 62% indicated that the exercise was too frequent, and 28% indicated they were offered opportunities to toilet too often. Based on timed observations, the costs of FIT are about four times as high as usual continence care.

CONCLUSIONS

FIT is applicable to a substantial number of patients in VA nursing homes. The FIT protocol tested in this trial can be further refined and individualized based on patient preferences and adherence to various components of FIT in order to make it more feasible, efficient, and cost-effective in practice. The costs of maintaining an intervention such as FIT in all VA nursing home patients who may benefit, however, are high and must be justified largely by potential positive effects on function and quality of life, as opposed to cost savings resulting from the intervention.

A comprehensive clinical assessment tool to inform policy and practice: applications of the minimum data set

The Minimum Data Set (MDS) for nursing home (NH) resident assessment, designed to assess elders functional status and care needs, exemplifies how the information needs of clinical practice are congruent with those of research. Building on a review of the published literature, this article describes the development of the MDS, its reliability and validity testing, as well as the variety of different policy and research uses to which it has been applied. Interrater reliability of items and internal consistency of MDS summary scales is generally good to excellent. Validation studies reveal good correspondence to research quality instruments for cognition, activities of daily living, and diagnoses with more variable results for vision, pain, mood, and behavior scales. To date, no consistent evidence suggests that applications of MDS data for case-mix reimbursement and quality indicator monitoring systematically bias the data. Although facility variation in data quality could compromise some applications, creation of the MDS as a clinical tool for care planning provides an example of how assessment tools with clinical use can be used in administrative databases for research and policy applications.

Conducting Translation Research in the Home Care Setting: Lessons from a Just‐in‐Time Reminder Study

BACKGROUND

Home care organizations are relatively isolated from academic health centers, university-based schools of nursing, and centers of health services research that have advanced the knowledge base for quality improvement. Thus limited information exists about how best to promote evidence-based practice in this setting.

AIMS

This article examines research and translation issues posed by the decentralized home care setting and considers how these issues compare to issues in other settings.

METHODS

A case study approach is used to frame a discussion of the contextual and practical factors that can influence the design and future acceptance of different translation strategies in the home care setting. Use of a recently concluded randomized trial that tested the effectiveness of two interventions designed to improve the adoption of evidence-based practices by home health nurses has been made to inform this discussion.

DISCUSSION

Effective translation interventions in home health care need to address the unique nature of this setting including the dispersed, generalist workforce that serves a diverse patient population and lacks strong peer contact or on-site support and supervision. Proactive push translation strategies such as reminders that have been effective in other settings show promise in this service area but had a differential effect across conditions. Significantly, the cost-effectiveness analysis of this intervention showed that net patient care costs actually increased for one condition.

IMPLICATIONS

The study described in this article demonstrates that rigorous translation research can be conducted in highly decentralized practice settings. It also points to the value of assessing different levels of intensity of interventions in a single study, looking at process measures and patient outcomes, and conducting a cost-effectiveness analysis. To encourage broader adoption of translation strategies, additional incentives from purchasing or regulatory agencies may be needed.

Long-term care research and policy

This article provides a framework for understanding how long-term care (LTC) research contributes to policy, develops a typology of research contributions to policy with examples of each type, and suggests ways to ensure that contributions continue in the future. The article draws on in-depth interviews with LTC experts working at the interface between research and policy, as well as a small, informal Internet survey and the relevant political science and health policy literature. LTC research makes important contributions to policy, but its contributions easily go unrecognized because they are subtle and often depend on research investments made many years before policy is affected. Thus, it is important to consider what investments in LTC research initiatives and infrastructure are needed to ensure the future contributions of research to policy and to identify barriers to funding such investments. A number of steps that researchers can take to enhance the future contribution of research to LTC policy are proposed.