Health Services Research & Development

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IIR 14-008 – HSR&D Study

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IIR 14-008
Developing a roadmap for best practices in CLC resident-centered care
Christine W. Hartmann PhD
Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA
Bedford, MA
Funding Period: October 2015 - December 2019

BACKGROUND/RATIONALE:
Each year, over 40,000 Veterans receive care in the VHA's 134 Community Living Centers (CLCs). To each of these Veterans, the CLC is their home for the duration of their stay. PCC is central to VHA's mission of providing "personalized, proactive, patient-driven health care" to these Veterans. PCC principles require that CLCs' structures, designs, and care, work, and management practices center on and be guided by Veterans' needs and preferences. PCC has been demonstrated to improve numerous resident outcomes, including quality of life, Minimum Data Set quality indicators, and activities of daily living. There are also beneficial effects for staff, including lower turnover and higher satisfaction. Yet effective transformation from a medical model to one centered on PCC best practices requires a wide variety of interrelated changes in both structures and processes of care. CLCs currently vary significantly on GEC-collected PCC measures, indicating that much room for progress exists.

OBJECTIVE(S):
This project builds on our Health Services Research and Development (HSR&D) pilot study of CLCs implementing PCC. The study has the following specific aims. Aim 1: Examine CLC-level variation in PCC. Aim 2: Identify PCC best practices in a sample of CLC that have successfully adopted PCC principles. Aim 3: Develop a roadmap of PCC implementation.

METHODS:
In this 3.5-year study, the quantitative data collection in Phases 1 and 2 inform the subsequent Phase 3 qualitative data collection. Phase 1 has 2 steps. In Step 1 we analyzed national quality of care and PCC data to choose a preliminary 32-CLC sample. In Step 2 we collected survey data from key informants at the 32 CLCs. Results helped identify a sample of 8 PCC successful adopters. For Aim 2, we collected individual- and unit-level data at each of the 8 PCC successful adopters (a) using surveys to measure staff, resident, and family member perceptions of PCC structures, processes, and implementation and (b) through structured observations of CLC units using a tool developed in pilot work. Data collected in Phase 2 were analyzed to identify some structures and processes supporting successful PCC practices. For Aim 3, we use qualitative interviews with CLC staff to explore and describe PCC successful adopter best practices in detail at these 8 CLCs and identify best practice facilitators and barriers. We probe deeply into how PCC has been integrated into routine care. Finally, we integrate the Phase 2 and 3 results into a roadmap of successful PCC practices.

FINDINGS/RESULTS:
134 CLCs were included in the Phase 1, Step 2 analyses. At the top 32 sites, 59 key informants participated. Results indicated that top-performing CLCs were characterized by numerous PCC structures and processes. These CLCs involved residents in making daily life choices, included nursing assistants in care planning activities, and had staff who noticed residents' mood changes. But survey participants at these sites also frequently reported that staff ignored residents' concerns. In Phase 2, staff from the 8 CLCs participated in a validated survey of relational coordination. Researchers also conducted structured observations of staff and resident behavior in public areas. Analyses were descriptive. 392 staff responded to the survey. Researchers conducted 2,459 observations. Across all CLCs, staff reported the quality of their interactions within (WI) their workgroup consistently lower than the quality of their interactions between (BW) their and other workgroups. BW ratings: 24% strong, 34% moderate, 42% weak. WI ratings: 92% weak. Strong ratings varied by workgroup type and by WI and BI. Nursing was more likely to receive strong ratings than other workgroups but less likely to assign strong ratings to other groups. 31% of observations were of staff performing direct resident care while communicating with the resident and 39% were of staff having no communication with the resident during care. Phase 3 data collection and analysis is ongoing.

IMPACT:
The final roadmap will explain PCC practice combinations associated with better PCC outcomes and describe relevant barriers and facilitators. It will use multiple media formats. The roadmap will help guide further improvements in person-centered care in CLCs.

PUBLICATIONS:
None at this time.


DRA: Acute and Combat-Related Injury, Health Systems
DRE: Treatment - Implementation
Keywords: Best Practices, Management and Human Factors, Outcomes - Patient, Outcomes - System, Quality Improvement, Quality of Life
MeSH Terms: none