Randomized Multilevel Intervention to Improve Outcomes of Residents in Nursing Homes in Need of Improvement

Abstract

Purpose A comprehensive multilevel intervention was tested to build organizational capacity to create and sustain improvement in quality of care and subsequently improve resident outcomes in nursing homes in need of improvement. Intervention facilities (n=29) received a two-year multilevel intervention with monthly on-site consultation from expert nurses with graduate education in gerontological nursing. Attention control facilities (n=29) that also needed to improve resident outcomes received monthly information about aging and physical assessment of elders. Design and Methods Randomized clinical trial of nursing homes in need of improving resident outcomes of bladder and bowel incontinence, weight loss, pressure ulcers, and decline in activities of daily living (ADL). It was hypothesized that following the intervention, experimental facilities would have better resident outcomes, higher quality of care, higher staff retention, more organizational attributes of improved working conditions than control facilities, similar staffing and staff mix, and lower total and direct care costs. Results The intervention did improve quality of care (p=0.02); there were improvements in pressure ulcers (p=0.05), weight loss (p=0.05). Staff retention, organizational working conditions, staffing, and staff mix and most costs were not affected by the intervention. Leadership turnover was surprisingly excessive in both intervention and control groups. Implications Some facilities that are in need of improving quality of care and resident outcomes are able to build the organizational capacity to improve while not increasing staffing or costs of care. Improvement requires continuous supportive consultation and leadership willing to involve staff and work together to build the systematic improvements in care delivery needed.

Local interaction strategies and capacity for better care in nursing homes: a multiple case study

“…The fact that we saw these behaviors at least intermittently in every NH suggests that existing capacity is present in NHs and it that can be more widely developed. Rantz et al [38] came to a similar conclusion in their quality improvement intervention which improved outcomes such as pressure ulcers and weight loss without adding staffing or costs. Our findings are supported by other prior work suggesting that improving organizational capacity has to do with seemingly “ordinary activities” [39], p. 384 that are embedded in social structures that “make use of real-time information, simultaneously explore multiple alternatives, [and] rely on quickly created new knowledge….” [40], p. 919, to facilitate the ability of staff to continuously create solutions to emerging problems.…”

A staff training and management intervention in VA long-term care: impact on feeding assistance care quality

“…Participants were deemed responsive to mealtime assistance based on a gain of 15 % or more in meal intake based on a previous research [2,18]. Table 2 displays the primary intervention components, which were consistent with those necessary for an effective translational research effort (see "Introduction") [1,3,[7][8][9]. Staff training activities were conducted at the unit level and included all scheduled nurse aides and supervisory nurses (e.g., unit charge nurse) on each of the seven units for all three shifts (day, evening, and night).…”

“…Unfortunately, despite this growing evidence base, efforts to translate efficacious clinical interventions into LTC practice have had limited success [3][4][5][6]. However, research has identified several key issues important to address to facilitate the successful translation of care quality improvements into LTC practice [1,3,[7][8][9]. First, multiple levels of staff should be involved in training-namely, licensed nurses in a supervisory role and nurse aides responsible for direct care [4][5][6].…”

The Aged Residential Care Healthcare Utilization Study (ARCHUS): A Multidisciplinary, Cluster Randomized Controlled Trial Designed to Reduce Acute Avoidable Hospitalizations From Long-Term Care Facilities

“…These interventions have comprised the following: MDTs providing an integrated care approach, 13 more skilled RAC staff for assessment/recognition of illness, 9,13,16,17 education and clinical coaching, 13,18 improved care coordination by, for example nurse practitioners, better assessment of acute/subacute changes in condition, 14 nutritional screening/intervention, 19 advance care planning, 20 and medication review. 21 It was based on these studies that we developed the ARCHUS intervention.…”