Implementation of a Transitional Care Model for Stroke: Perspectives From Frontline Clinicians, Administrators, and COMPASS-TC Implementation Staff

Lutz, Barbara; Reimold, Alexandria E; Coleman, Sylvia; Guzik, Amy K; Russell, Laurie P.; Radman, Meghan; Johnson, Anna; Duncan, Pamela W.; Bushnell, Cheryl; Rosamond, Wayne D.; Gesell, Sabina B.

doi:10.1093/geront/gnaa029

Cited by 27 publications

(30 citation statements)

References 42 publications

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“…This finding is consistent with research that suggests unit managers as critical change agents who support adoption of practice change by diffusing and synthesizing information and integrating the innovation into daily practice while “selling” the implementation [ 24 ]. Also consistent with previous implementation research [ 25 , 26 ], the stakeholders offered clear direction about the resources that supported adoption of EIT-4-BPSD, and include all four steps of the strategy (staff education; care planning processes; staff mentoring, and attention to promoting an environment that supports function, social engagement, and comfort).…”

Section: Discussionsupporting

confidence: 56%

Process evaluation of an implementation study in dementia care (EIT-4-BPSD): stakeholder perspectives

Behrens

Boltz

Riley

et al. 2021

BMC Health Serv Res

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Background Behavioral and psychological symptoms of distress in dementia (BPSD) are major drivers of poor quality of life, caregiver burden, institutionalization, and cost of care in nursing homes. The Evidence Integration Triangle (EIT)-4-BPSD in nursing homes was a pragmatic Hybrid III trial of an implementation strategy to help staff use evidence-based non-pharmacological interventions to prevent and manage BPSD. This study aimed to describe and explore the stakeholders’ perceptions of the process to implement the EIT-4-BPSD strategy including its utility, and the barriers and facilitators to implementation in real-world settings. Methods EIT-4-BPSD was a multi-layer implementation strategy that engaged nursing home stakeholder groups to define community specific goals towards reducing BPSD over a 12-month period. Stakeholder groups from nursing homes that completed all 12-months of the implementation strategy were invited to participate in this process evaluation study. Qualitative data from focus group transcripts were analyzed using a conventional content analysis. Emerging codes were sorted into categories, then organized in meaningful clusters based on the domains of the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework. Results The EIT-4-BPSD implementation strategy was completed in 21 nursing homes; 93 stakeholders participated in focus groups. Over half of participating nursing homes reported meeting their BPSD goals as expected or more. Challenges, facilitators, and contextual factors reported by stakeholder members explains variability in the implementation of EIT-4-BPSD strategy in 11 key categories: family; staff; organizational; staff, environmental, and resident outcomes; utility of EIT resources; adoption barriers and facilitators; care process adaptations; and future planning. Conclusion Stakeholders offered guidance on salient factors influencing the feasibility and utility of EIT-4-BPSD adoption and implementation to consider in future implementation research that aims to improve behavioral well-being in NH residents living with dementia. Engagement of family and staff at all levels of the organization (Management, leadership, and direct care); and measurement of staff, environmental, and resident outcomes were perceived as critical for future implementation success. While regulations, finances, and competing demands on staff time were perceived as reducing implementation success. Trial Registration The Testing the Implementation of EIT-4-BPSD study was registered in the ClinicalTrials.gov (NCT03014570) January 9, 2017.

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Section: Discussionsupporting

confidence: 56%

Process evaluation of an implementation study in dementia care (EIT-4-BPSD): stakeholder perspectives

Behrens

Boltz

Riley

et al. 2021

BMC Health Serv Res

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“…In quantitative and qualitative implementation analyses, we noted multiple factors that characterized successful hospital implementation and delivery of the intervention, which included organizational readiness at the hospital level and consistent buy‐in from billing providers and nurses who treated the INV as their standard of care rather than a research study. 39 , 42 These findings are a critical contribution of our trial overall and suggest that not all acute care hospitals are prepared to be the hub for TC.…”

Section: Discussionmentioning

confidence: 87%

Hospital Readmissions and Mortality Among Fee‐for‐Service Medicare Patients With Minor Stroke or Transient Ischemic Attack: Findings From the COMPASS Cluster‐Randomized Pragmatic Trial

Bushnell

Kucharska‐Newton

Jones

et al. 2021

JAHA

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Background Mortality and hospital readmission rates may reflect the quality of acute and postacute stroke care. Our aim was to investigate if, compared with usual care (UC), the COMPASS‐TC (Comprehensive Post‐Acute Stroke Services Transitional Care) intervention (INV) resulted in lower all‐cause and stroke‐specific readmissions and mortality among patients with minor stroke and transient ischemic attack discharged from 40 diverse North Carolina hospitals from 2016 to 2018. Methods and Results Using Medicare fee‐for‐service claims linked with COMPASS cluster‐randomized trial data, we performed intention‐to‐treat analyses for 30‐day, 90‐day, and 1‐year unplanned all‐cause and stroke‐specific readmissions and all‐cause mortality between INV and UC groups, with 90‐day unplanned all‐cause readmissions as the primary outcome. Effect estimates were determined via mixed logistic or Cox proportional hazards regression models adjusted for age, sex, race, stroke severity, stroke diagnosis, and documented history of stroke. The final analysis cohort included 1069 INV and 1193 UC patients (median age 74 years, 80% White, 52% women, 40% with transient ischemic attack) with median length of hospital stay of 2 days. The risk of unplanned all‐cause readmission was similar between INV versus UC at 30 (9.9% versus 8.7%) and 90 days (19.9% versus 18.9%), respectively. No significant differences between randomization groups were seen in 1‐year all‐cause readmissions, stroke‐specific readmissions, or mortality. Conclusions In this pragmatic trial of patients with complex minor stroke/transient ischemic attack, there was no difference in the risk of readmission or mortality with COMPASS‐TC relative to UC. Our study could not conclusively determine the reason for the lack of effectiveness of the INV. Registration URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02588664.

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“… 16 , 29 Critical to successful TC delivery is a commitment to implementing the care model as new standard practice and having sufficient capacity to do so. 39 In the COMPASS study, research staff provided ongoing, extensive support for training and implementation. Providing financial support may be necessary for future studies, given the high degree of competing demands for health care providers and systems.…”

Section: Discussionmentioning

confidence: 99%

“…Incentives may be particularly important to engage hospitals with limited capacity and to generate high-quality data that achieve the best return on investment in pragmatic trials. 14 , 29 , 39 …”

Section: Discussionmentioning

confidence: 99%

Methodological Challenges and Statistical Approaches in the COMprehensive Post-Acute Stroke Services Study

Psioda

Jones²,

Xenakis

et al. 2021

Medical Care

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Background: The COMprehensive Post-Acute Stroke Services study was a cluster-randomized pragmatic trial designed to evaluate a comprehensive care transitions model versus usual care. The data collected during this trial were complex and analysis methodology was required that could simultaneously account for the cluster-randomized design, missing patient-level covariates, outcome nonresponse, and substantial nonadherence to the intervention. Objective: The objective of this study was to discuss an array of complementary statistical methods to evaluate treatment effectiveness that appropriately addressed the challenges presented by the complex data arising from this pragmatic trial. Methods: We utilized multiple imputation combined with inverse probability weighting to account for missing covariate and outcome data in the estimation of intention-to-treat effects (ITT). The ITT estimand reflects the effectiveness of assignment to the COMprehensive Post-Acute Stroke Services intervention compared with usual care (ie, it does not take into account intervention adherence). Per-protocol analyses provide complementary information about the effect of treatment, and therefore are relevant for patients to inform their decision-making. We describe estimation of the complier average causal effect using an instrumental variables approach through 2-stage least squares estimation. For all preplanned analyses, we also discuss additional sensitivity analyses. Discussion: Pragmatic trials are well suited to inform clinical practice. Care should be taken to proactively identify the appropriate balance between control and pragmatism in trial design. Valid estimation of ITT and per-protocol effects in the presence of complex data requires application of appropriate statistical methods and concerted efforts to ensure high-quality data are collected.

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Implementation of a Transitional Care Model for Stroke: Perspectives From Frontline Clinicians, Administrators, and COMPASS-TC Implementation Staff

Cited by 27 publications

References 42 publications

Process evaluation of an implementation study in dementia care (EIT-4-BPSD): stakeholder perspectives

Process evaluation of an implementation study in dementia care (EIT-4-BPSD): stakeholder perspectives

Hospital Readmissions and Mortality Among Fee‐for‐Service Medicare Patients With Minor Stroke or Transient Ischemic Attack: Findings From the COMPASS Cluster‐Randomized Pragmatic Trial

Methodological Challenges and Statistical Approaches in the COMprehensive Post-Acute Stroke Services Study

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