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

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.

Systematic development of a set of implementation strategies for transitional care innovations in long-term care

“…Persuasive communication Guiding individuals and environmental agents toward the adoption of an idea, attitude, or action by using arguments or other means Communication-Persuasion Matrix, Elaboration Likelihood Model, Diffusion of Innovations Theory [ 23 , 28 ] ➣ The use of persuasive, novel, relatable, and important arguments and communication with leaders can be effective to achieve change 2. Public commitment Stimulating pledging, promising or engaging oneself to perform the healthful behavior, and announcing that decision to others Theories of Automatic, Impulsive and Habitual Behavior [ 23 , 28 ] ➣ Indications for positive effect: organizational leaders committed to implementing an intervention to reduce hospitalization from a nursing home directly increased the staff commitment to implementation [ 42 ] 3. Sense-making Leaders reinterpret and relabel processes in organization, create meaning through dialogue, and model and redirect change Organizational Development Theory [ 23 , 28 ] ➣ Indications for positive effect: a committed organizational leadership who created an encouraging environment within healthcare organizations (e.g., supportive policies and practices, allocation of funds and resources) to implement an innovation increased directly the staff commitment to implementation [ 43 ] 4.…”

“…➣ Indications for positive effect: organizational leaders committed to implementing an intervention to reduce hospitalization from a nursing home directly increased the staff commitment to implementation [ 42 ]…”

Evaluating the implementation fidelity to a successful nurse-led model (INTERCARE) which reduced nursing home unplanned hospitalisations

“…Moreover, the implementation was supported through availability of the tools in different formats such as laminated pockets cards, to help staff become acquainted with the tools and facilitate higher fidelity. These tools were also found to be highly acceptable and feasible to implement [39]. Despite achieving high fidelity at the start of the INTERCARE project, the fidelity scores for STOP&WATCH decreased after a year.…”

“…Overall fidelity to INTERCARE is represented in blue and depicts high fidelity reached at 6 months and sustained thereafter strengthening the quality of information handed over to various professionals, contributing to the attractiveness for STOP&WATCH and ISBAR tools which both received very positive attitudes mainly from nursing aides (STOP&WATCH) and from nurses and physicians (ISBAR), during the first six months after implementation. Unclear processes regarding the handling of STOP&WATCH impeded the usage affecting fidelity to this component [39]. ACP is an example of a component which requires changes at several levels (policy level, NH level, individual level) and requires time for NHs to tackle the associated requirements.…”

“…The Improving INTERprofessionalCARE for better resident outcomes -the INTERCARE model, comprised six evidence-based core components and was developed within a theory-based implementation science study which relied on a thorough contextual analysis, continuous stakeholder involvement, evidence-based interventions and the development of implementation strategies targeting specific barriers and facilitators [11][12][13]. The INTERCARE model was successful in decreasing unplanned hospitalisations of NH residents [14] as well as cost-effective [15] and highly acceptable from the NH staff 's perspective [16].…”