Nursing home performance in a trial to reduce hospitalizations: Implications for future trials

Abstract

Background Experience in trials of implementing quality improvement (QI) programs in nursing homes (NHs) has been variable. Understanding the characteristics of NHs that demonstrate improvements during these trials is critical to improving NH care. Design Secondary analysis of a randomized controlled trial of implementation of a QI program to reduce hospital transfers. Participants Seventy‐one NHs that completed the 12‐month trial Intervention Implementation included distance‐learning strategies, involvement of a champion, regular submission of data on hospitalizations and root cause analyses of transfers, and training, feedback and support. Measurements Primary outcomes included all‐cause and potentially avoidable hospitalizations and emergency department (ED) visits per 1000 NH resident days, and the percentage of residents readmitted in 30‐days. We compared multiple other variables that could influence effective program implementation in NHs in the highest versus lowest quartile of changes in the primary outcomes. Results The 18 high‐performing NHs had significant reductions in hospitalization and ED visits, whereas the 18 NHs in the low‐performing group had increases. The difference in changes in each outcome varied between a reduction of 0.75 and 2.30 events relative to a NH with a census of 100; the absolute difference in 30‐day readmissions was 19%. None of the variables we examined reached significance after adjustment for multiple comparisons between the groups. There was no consistent pattern of differences in nonprofit status, nursing staffing, and quality ratings. Conclusion Our experience and reviews of other NH trials suggest that key factors contributing to successful implementation QI programs in NHs remain unclear. To improve NH care, implementation trials should account for intervention fidelity and factors that have not been examined in detail, such as degree and nature of leadership support, financial and regulatory incentives, quality measures, resident and family perspectives, and the availability of onsite high‐quality medical care and support of the medical director.

Understanding Pathways into Care-homes using Data (UnPiCD study): a two-part model to estimate inpatient and care-home costs using national linked health and social care data

“…People living in care homes are recognised to use secondary care services, including emergency admissions and Emergency Department attendances [ 32 ]. There has been significant interest in the UK [ 33 – 35 ] and internationally [ 36 ] on how to support residents within the care-home setting to reduce demand for unscheduled care use. Our findings, in terms of reduced hospital costs in the year after moving-in to a care home, add further weight to the growing evidence around the positive contribution care homes can provide in supporting individuals with complex needs to receive care in a familiar, homely setting [ 37 , 38 ].…”

Protecting seriously ill populations during pragmatic clinical trials

“…A second trial tested a multifaceted quality improvement intervention employing distance learning, the involvement of champions, feedback on regular data submission on hospitalizations, and root cause analysis of hospital transfers for their impact on all cause and potentially avoidable emergency department transfers and hospitalizations. 7 This study tested the intervention in 264 nursing homes. A secondary analysis found that the intervention resulted in significant reductions in high-performing nursing homes, but not in low-performing nursing homes.…”

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

“…Very few studies conducted in NHs have measured or reported on the degree of fidelity of a complex intervention. Thus, efficient ways of measuring fidelity in the NH setting are lacking [21,23], although approaches have been developed and reported to guide fidelity assessments, these are limited to NH behavioral interventions [49,50]. There are a number of barriers to the evaluation of implementation fidelity which may explain why few NH studies measure and report fidelity.…”

“…Few multi-component interventions or studies specifically referred to as quality improvement (QI) studies conducted in NHs examine the relationship between implementation fidelity and its influence on clinical outcomes (e.g., unplanned hospital transfers) [23]. Only 3% of NH QI studies report fidelity, however QI guidelines do not emphasize reporting this outcome [24].…”

“…The Interventions to Reduce Acute Care Transfers (INTERACT) quality improvement (QI) program was the first initiative to develop a bundle of tools that can be implemented in NHs to drive staff clinical reasoning and communication with the goal of reducing avoidable hospitalisations [4]. The degree of implementation of the INTERACT was evaluated and found that the increased usage -a way of measuring fidelity -of the INTERACT package was associated with a greater reduction of hospitalisations [4], but underlined the need to further assess implementation fidelity as factors which contribute to decreasing hospital transfers remain unclear [23]. Moreover, uncertainty remains regarding the variability of results on the outcome of reducing hospital transfers between studies that used similar components, as some had a positive effect and reduced unplanned hospitalisations from NHs [25][26][27], whilst others did not [7,8,28].…”