Local interaction Strategies and Capacity for Better Care in Nursing Homes: A Multiple Case Study

To describe relationship patterns and management practices in nursing homes (NHs) that facilitate or pose barriers to better outcomes for residents and staff. Methods: We conducted comparative, multiple-case studies in selected NHs (N = 4). Data were collected over six months from managers and staff (N = 406), using direct observations, interviews, and document reviews. Manifest content analysis was used to identify and explore patterns within and between cases. Results: Participants described interaction strategies that they explained could either degrade or enhance their capacity to achieve better outcomes for residents; people in all job categories used these 'local interaction strategies'. We categorized these two sets of local interaction strategies as the 'common pattern' and the 'positive pattern' and summarize the results in two models of local interaction. Conclusions: The findings suggest the hypothesis that when staff members in NHs use the set of positive local interaction strategies, they promote inter-connections, information exchange, and diversity of cognitive schema in problem solving that, in turn, create the capacity for delivering better resident care. We propose that these positive local interaction strategies are a critical driver of care quality in NHs. Our hypothesis implies that, while staffing levels and skill mix are important factors for care quality, improvement would be difficult to achieve if staff members are not engaged with each other in these ways.National Institutes of Health 2 R01NR003178-04A2Claude A. Pepper Older American's Independence Center AG-11268Paul A. Beeson Award NIA AG024787VA Health Services Research and Development EDU 08-417John A. Hartford Building Academic Geriatric Nursing Claire M. Fagin FellowshipBusiness Administratio

Transitional care of older adults in skilled nursing facilities: A systematic review

Transitional care may be an effective strategy for preparing older adults for transitions from skilled nursing facilities (SNF) to home. In this systematic review, studies of patients discharged from SNFs to home were reviewed. Study findings were assessed (1) to identify whether transitional care interventions, as compared to usual care, improved clinical outcomes such as mortality, readmission rates, quality of life or functional status; and (2) to describe intervention characteristics, resources needed for implementation, and methodologic challenges. Of 1,082 unique studies identified in a systematic search, the full texts of six studies meeting criteria for inclusion were reviewed. Although the risk for bias was high across studies, the findings suggest that there is promising but limited evidence that transitional care improves clinical outcomes for SNF patients. Evidence in the review identifies needs for further study, such as the need for randomized studies of transitional care in SNFs, and methodological challenges to studying transitional care for SNF patients

Supporting the Dynamic Careers of Licensed Practical Nurses: A Strategy to Bolster the Long-Term Care Nurse Workforce

As the U.S. population ages and the demand for long-term care increases, an insufficient number of licensed practical nurses (LPNs) is expected in the nursing workforce. Understanding the characteristics of LPN participation in the workforce is essential to address this challenge. Drawing on the theory of boundaryless careers, the authors examined longitudinal employment data from LPNs in North Carolina and described patterns in LPN licensure and career transitions. Two career patterns were identified: (a) the continuous career, in which LPNs were licensed in 75% or more of the years they were eligible to be licensed and (b) the intermittent career, in which lapses in licensure occurred. Findings indicated that LPNs who made job transitions were more likely to demonstrate continuous careers, as were Black LPNs. These findings suggest the importance of organizational support for LPN career transitions and support for diversity in the LPN workforce

Transitional care in skilled nursing facilities: a multiple case study

Abstract Background Among hospitalized older adults who transfer to skilled nursing facilities (SNF) for short stays and subsequently transfer to home, twenty two percent require additional emergency department or hospital care within 30 days. Transitional care services, that provide continuity and coordination of care as older adults transition between settings of care, decrease complications during transitions in care, however, they have not been examined in SNFs. Thus, this study described how existing staff in SNFs delivered transitional care to identify opportunities for improvement. Methods In this prospective, multiple case study, a case was defined as an individual SNF. Using a sampling plan to assure maximum variation among SNFs, three SNFs were purposefully selected and 54 staff, patients and family caregivers participated in data collection activities, which included observations of care (N = 235), interviews (N = 66) and review of documents (N = 35). Thematic analysis was used to describe similarities and differences in transitional care provided in the SNFs as well as organizational structures and the quality of care-team interactions that supported staff who delivered transitional care services. Results Staff in Case 1 completed most key transitional care services. Staff in Cases 2 and 3, however, had incomplete and/or absent services. Staff in Case 1, but not in Cases 2 and 3, reported a clear understanding of the need for transitional care, used formal transitional care team meetings and tracking tools to plan care, and engaged in robust team interactions. Conclusions Organizational structures in SNFs that support staff and interactions among patients, families and staff appeared to promote the ability of staff in SNFs to deliver evidence-based transitional care services. Findings suggest practical approaches to develop new care routines, tools, and staff training materials to enhance the ability of existing SNF staff to effectively deliver transitional care

Restarting the Cycle: Incidence and Predictors of First Acute Care Use After Nursing Home Discharge

The primary objective of this study was to describe the time to first acute-care use (e.g., emergency department use without hospitalization or rehospitalization)for older adults who discharged to home after receiving post-acute care in skilled nursing facilities (SNFs). The secondary objective was to identify predictors of patients' first acute-care use

Balancing act: exploring the tone of The Life Aquatic with Steve Zissou

This paper provides an analysis of The Life Aquatic in the context of debates around tone, irony, the Smart Film, the New Sincerity and the Quirky. It argues that Anderson is one of a small but significant number of filmmakers to escape from the indiscriminate irony of fin de sie`cle cinema, and finds The Life Aquatic Aquatic a particularly interesting film in which to explore such matters because of its ready artifice, strong elements of pastiche and measuredly preposterous excesses. Offering a critical analysis, the paper balances an engagement with some of the systemic elements of the film’s tone with the detailed organisation of tonal elements in particular sequences

Sustaining complex interventions in long-term care: a qualitative study of direct care staff and managers

Abstract Background Little is known about the sustainability of behavioral change interventions in long-term care (LTC). Following a cluster randomized trial of an intervention to improve staff communication (CONNECT), we conducted focus groups of direct care staff and managers to elicit their perceptions of factors that enhance or reduce sustainability in the LTC setting. The overall aim was to generate hypotheses about how to sustain complex interventions in LTC. Methods In eight facilities, we conducted 15 focus groups with 83 staff who had participated in at least one intervention session. Where possible, separate groups were conducted with direct care staff and managers. An interview guide probed for staff perceptions of intervention salience and sustainability. Framework analysis of coded transcripts was used to distill insights about sustainability related to intervention features, organizational context, and external supports. Results Staff described important factors for intervention sustainability that are particularly challenging in LTC. Because of the tremendous diversity in staff roles and education level, interventions should balance complexity and simplicity, use a variety of delivery methods and venues (e.g., group and individual sessions, role-play/storytelling), and be inclusive of many work positions. Intervention customizability and flexibility was particularly prized in this unpredictable and resource-strapped environment. Contextual features noted to be important include addressing the frequent lack of trust between direct care staff and managers and ensuring that direct care staff directly observe manager participation and support for the program. External supports suggested to be useful for sustainability include formalization of changes into facility routines, using “train the trainer” approaches and refresher sessions. High staff turnover is common in LTC, and providing materials for new staff orientation was reported to be important for sustainability. Conclusions When designing or implementing complex behavior change interventions in LTC, consideration of these particularly salient intervention features, contextual factors, and external supports identified by staff may enhance sustainability. Trial registration ClinicalTrial.gov, NCT0063667

CONNECT for quality: protocol of a cluster randomized controlled trial to improve fall prevention in nursing homes

<p>Abstract</p> <p>Background</p> <p>Quality improvement (QI) programs focused on mastery of content by individual staff members are the current standard to improve resident outcomes in nursing homes. However, complexity science suggests that learning is a social process that occurs within the context of relationships and interactions among individuals. Thus, QI programs will not result in optimal changes in staff behavior unless the context for social learning is present. Accordingly, we developed CONNECT, an intervention to foster systematic use of management practices, which we propose will enhance effectiveness of a nursing home Falls QI program by strengthening the staff-to-staff interactions necessary for clinical problem-solving about complex problems such as falls. The study aims are to compare the impact of the CONNECT intervention, plus a falls reduction QI intervention (CONNECT + FALLS), to the falls reduction QI intervention alone (FALLS), on fall-related process measures, fall rates, and staff interaction measures.</p> <p>Methods/design</p> <p>Sixteen nursing homes will be randomized to one of two study arms, CONNECT + FALLS or FALLS alone. Subjects (staff and residents) are clustered within nursing homes because the intervention addresses social processes and thus must be delivered within the social context, rather than to individuals. Nursing homes randomized to CONNECT + FALLS will receive three months of CONNECT first, followed by three months of FALLS. Nursing homes randomized to FALLS alone receive three months of FALLs QI and are offered CONNECT after data collection is completed. Complexity science measures, which reflect staff perceptions of communication, safety climate, and care quality, will be collected from staff at baseline, three months after, and six months after baseline to evaluate immediate and sustained impacts. FALLS measures including quality indicators (process measures) and fall rates will be collected for the six months prior to baseline and the six months after the end of the intervention. Analysis will use a three-level mixed model.</p> <p>Discussion</p> <p>By focusing on improving local interactions, CONNECT is expected to maximize staff's ability to implement content learned in a falls QI program and integrate it into knowledge and action. Our previous pilot work shows that CONNECT is feasible, acceptable and appropriate.</p> <p>Trial Registration</p> <p>ClinicalTrials.gov: <a href="http://www.clinicaltrials.gov/ct2/show/NCT00636675">NCT00636675</a></p

Transitional Care in a Nursing Home

<p>Background: Each year, 2 million older Americans complete three to four week courses of post-acute care in nursing homes and return home; however, scant research describes services to protect older adults during their transitions from nursing homes to home. In hospital-based studies, transitional care interventions were associated with improved health outcomes for older adults, but these interventions added new staff positions, which are likely cost-prohibitive in nursing homes. Further, no prior study explored transitional care provided for vulnerable, post-acute care patients in nursing homes. Thus, this dissertation was designed to develop new understandings about transitional care provided by existing staff members in nursing homes. The study has two specific aims: (a) describe transitional care and outcomes for older adults who obtain post-acute care in nursing homes from the day of admission through discharge; (b) explore the influence of interactions, among selected older adult patients and their group of nursing home caregivers, on their ability to accomplish transitional care processes.</p><p>Method: Using data from a literature review and theoretical models, including Donabedian's Model of Healthcare Quality and Anderson's Local Interaction Model, a conceptual model of transitional care for post-acute care patients in nursing homes was constructed. The conceptual model was then used to guide exploration of the research aims with a longitudinal, multiple case study of transitional care in a nursing home. The unit of analysis was the patient care-team, defined as individual post-acute care patients, family caregivers, and 6 to 8 professional staff in each team (e.g., rehabilitation therapists, physicians, nurses and social workers). Three patient care-team members were purposively sampled for study. Moreover, longitudinal data were collected using repeated interviews and observations with patients, family caregivers, and staff; document and daily chart reviews; and surveys of patient preparedness for discharge. Manifest content analysis and thematic analysis (qualitative methods) were used to conduct within- and across-case analyses of trajectories of transitional care and to identify strengths, gaps and inconsistencies in care. </p><p>Results: Findings related to the first research aim include a description of transitional care in the study nursing home. Serious gaps and inconsistencies in transitional care exposed older, post-acute care patients to risks for complications in their transitions from the study nursing home to home: (a) systemic supports were not available to support nursing home staff who provided transitional care; further, nursing home staff and leadership were unaware that they provided transitional care; (b) care processes were not in place to prepare older adults and their caregivers to continue care at home; (c) care-team interactions often excluded family members; and (d) post-acute care patients left the nursing home without resources needed to support safe transitions in care, including transitional care plans, education to appropriately respond to acute changes in health, written materials to guide care at home, referrals for medical follow-up after discharge, and transfers of clinical information to primary care physicians. </p><p>Findings related to the second research aim include a description of local interaction strategies and the effectiveness of transitional care processes. When professional staff more consistently used local interaction strategies, specified in the model, care-team members exhibited greater capacity for connections, information exchange, and cognitive diversity. Further, when care-team interactions were of high quality and sufficient frequency, there were multiple indications of more effective transitional care, such as patient engagement in care, inclusion of patient priorities in care plans, and problem solving which included family members and diverse members of the patient care-team. Thus, local interaction strategies were essential staff behaviors needed to adapt care processes to the specific transitional care needs of individual patients.</p><p>Because transitional care is a grossly under-developed care process in nursing homes, these findings will likely have immediate implications for practice and research. Findings will provide nursing home administrators and staff with resources to develop and evaluate care in nursing homes; further, the findings will help to create targets for protocol and care process development to strengthen existing practice and address deficiencies. Findings will provide researchers with resources for studying transitional care in diverse samples of nursing homes, which should facilitate development of testable hypotheses for needed intervention studies. In addition, the local interaction strategies findings in the study may generalize to other settings of care, where interdependent staff work is required to establish connections, information networks, and to coordinate care among multiple staff members.</p>Dissertatio