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Stakeholder Perspectives on the Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care (OPTIMISTIC) Project

Stakeholder Perspectives on the Optimizing Patient Transfers, Impacting Medical Quality, and... Background and Objectives: The need to reduce burdensome and costly hospitalizations of frail nursing home residents is well documented. The Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care (OPTIMISTIC) project achieved this reduction through a multicomponent collaborative care model. We conducted an implementation-focused project evaluation to describe stakeholders’ perspectives on (a) the most and least effective components of the intervention; (b) barriers to implementation; and (c) program features that promoted its adoption. Research Design and Methods: Nineteen nursing homes participated in OPTIMISTIC. We conducted semistructured, qualitative interviews with 63 stakeholders: 23 nursing home staff and leaders, 4 primary care providers, 10 family mem- bers, and 26 OPTIMISTIC clinical staff. We used directed content analysis to analyze the data. Results: We found universal endorsement of the value of in-depth advance care planning (ACP) discussions in reducing hos- pitalizations and improving care. Similarly, all stakeholder groups emphasized that nursing home access to specially trained, project registered nurses (RNs) and nurse practitioners (NPs) with time to focus on ACP, comprehensive resident assessment, and staff education was particularly valuable in identifying residents’ goals for care. Challenges to implementation included inadequately trained facility staff and resistance to changing practice. In addition, the program sometimes failed to commu- nicate its goals and activities clearly, leaving facilities uncertain about the OPTIMISTIC clinical staff’s roles in the facilities. Discussion and Implications: These findings are important for dissemination efforts related to the OPTIMISTIC care model and may be applicable to other innovations in nursing homes. Keywords: Advance care planning, End-of-life care, Evaluation, Long-term care, Nursing homes, Palliative care, Qualitative analysis: content analysis, Teams/interdisciplinary/multidisciplinary Nursing homes provide care for a significant number of Furthermore, the number of older Americans living in nurs- older adults, where approximately 2.5% of all U.S. adults ing homes (1.2 million in 2015)  will continue to increase aged 65 or older and 9% of adults aged 85 or older reside. over the coming years (Administration on Aging, 2016). The Published by Oxford University Press on behalf of The Gerontological Society of America 2017. 1177 This work is written by (a) US Government employee(s) and is in the public domain in the US. Downloaded from https://academic.oup.com/gerontologist/article/58/6/1177/4555070 by DeepDyve user on 19 July 2022 1178 The Gerontologist, 2018, Vol. 58, No. 6 quality of nursing home care is an ongoing concern to con- on every resident who is hospitalized. Findings from sumers, advocates, health care providers, and policy mak- these analyses, which are performed by OPTIMISTIC ers. Key quality issues include the overuse of antipsychotic RNs, are shared with facility staff and leadership. In medication, falls, pressure ulcers, and inadequately man- addition, OPTIMISTIC RNs use the findings to guide aged pain (Werner & Konetzka, 2010; Werner, Konetzka, quality improvement activities in each facility. Residents & Kim, 2013). who transfer back after a hospitalization also receive a Hospitalizations also are increasingly recognized as a qual- detailed Transition Visit from an OPTIMISTIC NP; these ity issue for nursing homes. Specifically, avoidable or poten- detailed evaluations include medication reconciliation, tially avoidable hospitalizations expose residents to risks resident and family education, follow-up management of including medication errors, burdensome treatments, pres- ongoing resident needs, and communication with facil- sure ulcers, and higher mortality (Boockvar et  al., 2004, ity providers and staff (Nazir, Unroe, Buente, Sachs, & 2005; Fried, Gillick, & Lipsitz, 1997; Murray & Laditka, Arling, 2016). 2010). However, improving the quality of nursing home The Medical and Transitions Cores use modified ver - care is complicated by a lack of evidence. Even when evi- sions of several INTERACT tools, which is an evidence- dence-based interventions exist, they can be difficult to based quality improvement program aimed at identifying, implement (Ersek et al., 2016; Rantz et al., 2012). assessing, and managing acute conditions in nursing home Optimizing Patient Transfers, Impacting Medical residents to reduce hospitalizations (Ouslander et  al., Quality, and Improving Symptoms: Transforming 2009, 2010). Institutional Care (OPTIMISTIC) is a clinical demon- The Palliative Care Core supports systematic advance stration project funded by the Center for Medicare and care planning (ACP) using the Respecting Choices® Last Medicaid Innovation (CMMI) as part of its national Steps model (Gundersen Health System, 2017) to facili- Initiative to Reduce Avoidable Hospitalizations among tate the use of the Indiana Physician Orders for Scope of Nursing Facility Residents (Centers for Medicare and Treatment (POST; Hickman et  al., 2016). OPTIMISTIC Medicaid Services, 2017). In accordance with the require- RNs and NPs provide high-quality palliative and end-of- ments of the Initiative, all funded projects, including life care through facility staff education and role modeling OPTIMISTIC, focused on long-term care residents. The (Kelly, Ersek, Virani, Malloy, & Ferrell, 2008). Additional project was implemented from February 2013 to October details about the OPTIMISTIC care model have previously 2016 in 19 Indiana long-term care facilities. OPTIMISTIC been published (Unroe et al., 2015) and are available online is a collaborative care model, providing enhanced support (http://www.optimistic-care.org/) and in Supplementary but not replacing facility staff or primary care providers. Table 1. The project embeds RNs and nurse practitioners (NPs) at OPTIMISTIC outcomes are tracked and evaluated by each facility. These OPTIMISTIC clinical staff are employ- an external contractor who monitors hospitalizations in ees of the project and do not bill for their services. Primary OPTIMISTIC nursing homes and a group of matched con- roles for project RNs are to lead advance care planning trol nursing homes. Recent reports and publications docu- activities, mentor nursing home staff, and implement evi- ment the project’s success in reducing potentially avoidable dence-based tools to improve care and communication. hospitalizations. Ingber, Feng, Khatutsky, Bayliss, and col- OPTIMISTIC NPs address gaps in clinical coverage by leagues (2017) and Ingber, Feng, Khatutsky, Wang, and col- evaluating residents experiencing acute changes in condi- leagues (2017) reported that the OPTIMISTIC intervention tion and conducting evaluations following hospitalizations reduced hospitalizations for diagnoses considered poten- to enhance coordination of care between acute care and tially avoidable by nearly 40% and total hospitalizations nursing home settings (Unroe et al., 2015). by 25%. This reduction was associated with Medicare sav- Project activities are organized within three cores: ings of $236 per resident in 2014 and $408 per resident in Medical, Transitions, and Palliative Care (see Supplementary 2015 (Ingber, Feng, Khatutsky, Wang, et al., 2017). Table  1). The Medical Core is aimed at reducing hospi- The success of the OPTIMISTIC program sets the talizations primarily through a collaborative care review stage for its wider dissemination and implementation. The protocol in which OPTIMISTIC RNs and NPs conduct a OPTIMISTIC investigators conducted an evaluation to focused interview and physical exam to identify geriatric understand the implementation of program components, syndromes that can lead to hospitalization. The findings are identify barriers, and explore the factors that promote the shared with primary care providers, and changes in medical success of the intervention in preparation for expansion of orders and care are made, as needed, to prevent hospitaliza- the clinical model. The purpose of this paper is to describe tions. RNs and NPs also work together to conduct detailed the findings from group and individual semistructured, polypharmacy reviews and make recommendations for qualitative interviews with key stakeholders. Specifically, optimizing medication regimens. we aimed to (a) explore stakeholders’ perspectives about The Transitions Core activities focus on understand- the most and least effective OPTIMISTIC components in ing the antecedents and consequences of potentially meeting the overall program goal of reducing hospitaliza- avoidable transfers by conducting root cause analyses tions; (b) describe barriers to implementing the program; Downloaded from https://academic.oup.com/gerontologist/article/58/6/1177/4555070 by DeepDyve user on 19 July 2022 The Gerontologist, 2018, Vol. 58, No. 6 1179 Table 1. Description of the Sample Number of facilities represented Stakeholder (type of interview) Total N by stakeholder group Family members of residents (individual interviews) 10 4 Facility primary care providers (individual interview) 4 4 Facility leadership and staff (group interviews) Overall N = 23 3 RNs: 8 LPNs: 9 Nurse managers: 2 Administrator: 1 Director/Associate Directors of Nursing: 3 OPTIMISTIC Clinical staff RNs: 19 19 (group interviews) NPs: 7 Note: LPNs = licensed practical nurses; NPs = nurse practitioners. and (c) explore features of the program that facilitated its Sample Recruitment adoption. Group Interviews All OPTIMISTIC staff (19 RNs and 7 NPs) were asked to par- ticipate in one of five (four RN and one NP) semistructured, Methods qualitative group interviews that occurred during a regularly We conducted group interviews with 23 nursing home scheduled staff meeting. Three of the 19 participating nursing staff and leaders (e.g., administrators, Directors of Nursing homes also were invited to participate in semistructured, qual- Services) from three facilities, and five group interviews itative group interviews at each facility. This convenience sam- with all 26 OPTIMISTIC clinical staff (N  =  19 RNs and ple of facilities represented diversity in ownership, size, and N = 7 NPs). In addition, we conducted one time, semistruc- location. We invited a diverse group of staff from each facility, tured qualitative interviews with four primary care provid- including licensed nurses, nursing assistants, administrators, ers from four facilities and 10 family members, also from Directors of Nursing, social workers, and staff educators. four facilities. Table  1 summarizes the overall sample. All interviews and subsequent data analysis occurred in the Individual interviews final 12 months of the 44-month program. OPTIMISTIC RNs identified a convenience sample of eligi- Our interview guides and analysis were directed by Stetler ble family members who spoke English and who had worked and colleagues’ framework of formative evaluation (Stetler closely with OPTIMISTIC staff. Of the 14 family members et al., 2006), which they defined as a “rigorous assessment who were approached for an interview, one refused, one process designed to identify potential and actual influences stated they had no contact with the OPTIMISTIC team, on the progress and effectiveness of implementation efforts” and two were unable to be reached, thereby yielding a sam- (p. S1). The authors identified several types of formative ple of 10 family members. OPTIMISTIC clinical staff and evaluation, including two that were used in this analy- nurse managers also identified seven primary care provid- sis: implementation-focused and interpretive evaluation. ers who managed the care for residents at five participating Implementation focused-evaluation allows researchers and nursing homes. Four providers (three physicians and one implementers to describe the intervention in detail, examin- NP) who were able to be contacted agreed to participate. ing the degree to which components of the intervention were adopted and deemed effective by stakeholders. It also pro- Procedures motes the identification and evaluation of barriers to imple- mentation. Interpretive evaluation allows implementers to Semistructured, qualitative group interviews lasting approxi- explore the “black box” of the intervention, that is, factors mately 1 hr were conducted by one of the authors who is a that promote success in implementing the intervention that doctorally prepared investigator (A. Thomas). Semistructured, may not have been explicitly incorporated into the interven- qualitative individual interviews lasting 25–60 min were con- tion design. Findings from a formative evaluation can then ducted in person or by phone by a trained research coordina- be used to refine the intervention to increase its effectiveness tor (B. Bernard) or investigator (A. Thomas). Each interview and to facilitate wider dissemination (Stetler et al., 2006). began with a standardized statement explaining the purpose The OPTIMISTIC clinical demonstration project is of the interview and a reminder that all names would be approved as an exempt study under the Indiana University/ redacted from notes and transcripts. All interviews were con- Purdue University–Indianapolis Institutional Review Board ducted using a semistructured interview guide that included (IRB). The methods and analyses described here also were standardized questions and follow-up prompts to address declared exempt by the IRB. each of the study aims (Supplementary Table 2). The guides Downloaded from https://academic.oup.com/gerontologist/article/58/6/1177/4555070 by DeepDyve user on 19 July 2022 1180 The Gerontologist, 2018, Vol. 58, No. 6 were tailored for each stakeholder group and posed specific thematic analysis of these coded data revealed three sub- open-ended questions that directly addressed the study aims. codes. Categories and subcodes for Aim 3 were derived For example, all stakeholder groups were asked to provide by identifying themes about specific characteristics of the feedback about specific program components, including OPTIMISTIC program or the clinical staff that facilitated whether or not they were successfully implemented and effec- implementation. We used an inductive approach for Aim tive at achieving program goals. Follow-up probes requested 3 because there were no predetermined categories for fea- additional information about features of the components tures that promoted adoption, thereby following an inter- that facilitated or hindered their implementation. In explor- pretive approach to evaluation (Stetler et al., 2006). ing specific features that facilitated adoption, for instance, After completing the initial coding, the first author devel- OPTIMISTIC clinical staff were asked what attributes made oped definitions for each category and subcode, which were for a successful OPTIMISTIC RN or NP. Families were asked then shared and discussed with the two other members of the if they could provide an example of how the OPTIMISTIC analytic team (S. Hickman and B.  Bernard). Then, all tran- staff had an impact on their family member’s care. The inter- scripts and meeting notes were coded independently by a sec- view guides were neither piloted prior to their use nor adapted ond analytic team member (either S. Hickman or B. Bernard). in response to early interviews. All disagreements in coding, as well as refinements and addi- After all the interviews were completed, one of the coau- tions to the initial categories and subcodes, were discussed thors who led the evaluation team (A. Thomas) reviewed until consensus on final coding was reached. We developed all the transcribed interviews and field notes. She summa- an audit trail by creating detailed memos for each category rized the major themes from each of the stakeholder groups that included original and revised category definitions and sub- and presented it to the OPTIMISTIC leadership team. At codes, outlier data, and exemplars. We managed and analyzed that time, it was decided that additional interviews were all data using NVivo version 11.0 qualitative analysis software. not necessary to uncover new themes. Group interviews for the OPTIMISTIC RNs and NPs and Results individual family interviews were digitally recorded and tran- scribed verbatim. The facility provider and staff/administrator Stakeholders’ Perspectives About the Most and group interviews were not recorded, but the facilitator and a Least Effective Components of the OPTIMISTIC research assistant took extensive notes during the interviews. Program Table 2 summarizes stakeholders’ comments about specific components of the program. The most frequently cited suc- Data Analysis cessful component was the ACP component including POST We used directed content analysis to identify stakeholders’ completion. This view was widely shared by OPTIMISTIC views on the most and least effective components of the RNs, providers, families, and facility staff. As one facility intervention, barriers to implementation, and factors that physician commented, “You need to continue and enhance facilitated the uptake and acceptance of the overall pro- the end-of-life discussions. POST implementation has been gram. In directed content analysis, investigators use existing very helpful and it has helped everyone understand about frameworks and theories to guide the interview questions palliative care and hospice and how they are different.” and coding. Initial coding categories are derived from key Respondents identified the comprehensiveness of the concepts and variables from the framework or theory. Data ACP discussions as critical to the program’s success, as that do not fit into these preset categories are analyzed pointed out by an OPTIMISTIC RN: “I think that the later to determine whether they represent new categories advance care planning, that’s been a huge success . . . I see and themes or subcategories of existing themes (Hsieh & it as something that was really not implemented prior to Shannon, 2005). This analytic approach was appropriate OPTIMISTIC other than just getting a signature on a DNR because our interview questions and coding schema fol- form.” Family members concurred that the OPTIMISTIC lowed our specific aims, which were derived from Stetler program’s approach to ACP was effective and helpful. In and colleagues’ framework for implementation-focused the words of one family surrogate decision maker: and interpretive formative evaluation (Stetler et al., 2006). I thought that [the ACP discussion] went very well. The first author completed the initial coding, which She [OPTIMISTIC RN] covered every aspect of it. She consisted of reviewing all data and categorizing phrases talked about the different levels of care that would be or sentences into categories according to each of the aims. given. All of our questions were answered and yeah, For example, there were two predetermined categories I  just felt really good when we came away from there under Aim 1: “most effective program components” and with the care plan. We knew what my mother wanted “least effective program components.” Subcodes for Aim 1 and we kind of knew what we felt was best for her, but it consisted of each program component (e.g., advance care felt really good having it actually put down in paper that planning, transition visits). For Aim 2, references to fac- tors that hindered implementation were grouped under there is a plan that other hospitals and nursing facilities one predetermined category: “Barriers to Implementation,” can follow. Downloaded from https://academic.oup.com/gerontologist/article/58/6/1177/4555070 by DeepDyve user on 19 July 2022 The Gerontologist, 2018, Vol. 58, No. 6 1181 Table 2. Stakeholders’ Views of the Effectiveness and Ineffectiveness of Specific Components of the OPTIMISTIC Program in Reducing Hospitalizations and Improving Care Program component Examples of specific stakeholder comments Effective components of the program Advance care planning and Advance care planning. . . . Time involved in having multiple conversations and visits with the family Physicians Orders for Scope of cannot be done by usual staff. (Facility Staff) Treatment (POST) The staff at the facility absolutely love this [POST] form because it has been very beneficial to the staff to know where the family stands, so they know how to proceed and what to do. They can look at one form that tells them that. (OPTIMISTIC RN) I have seen the biggest impact with POST. The implementation has been very helpful and it has helped everyone understand about palliative care and hospice and how they are different. It has helped family members realize you are not giving up but rather can supply good care here instead of sending patients to the hospital. (Primary Care Provider) Hands down . . . POST discussions have made a huge difference. . . . We need to work on code status because that drives inappropriate readmissions. That’s what OPTIMISTIC has helped us with. I’d say that now 90% of the patients have an appropriate code status. It has changed our practice. (Primary Care Provider) Well, kind of like, I knew there was more to a DNR than the actual DNR in the sense of Do Not Resuscitate if they start tanking. But, I didn’t know where to go or who to talk to on that, and that is where they turned me on to [OPTIMISTIC RN] (Family Member) Palliative care Great with end of life care. This is a very strong point of the OPTIMISTIC RN/NP role. (Facility Staff) INTERACT tool: Stop …I think that its value added with giving [positive] strokes to CNAs for their identification of issues. and Watch (OPTIMISTIC RN) It was a really big success for us. We caught a lot of things, and now we’re doing a lot of antibiotics and dressing changes that could prevent them having to be sent out. (OPTIMISTIC RN) INTERACT tool: SBAR They are beginning to realize that there . . . is value in completing the SBAR, every time. (OPTIMISTIC Communication RN) Corporate . . . started pushing the SBAR and provided it on the computer system. Now the nursing staff knows that the facility is serious about this. . . . They do see the advantages of having it, because of the consistency between one facility and another. So, it too, is becoming something that is culture. (OPTIMISTIC RN) Having the nurses look at vital signs, what are the changes, what’s happening, and being able to communicate that, I think, makes all the difference in the world, and will make a difference in hospitalizations. (OPTIMISTIC RN) Quality improvement training But, when we look at transfers in our morning clinical meetings, we are looking at root cause analysis and root cause analysis more than we did initially. We’re thinking, "what could be causing this? What do we need to look at? (OPTIMISTIC RN) Transition visits . . . [have the greatest impact] because I don’t see the primary providers having time to do a thorough evaluation. (OPTIMISTIC NP) I think that out of everything that we do, those have been the most effective and produced the most results in terms of avoiding future hospitalizations. (OPTIMISTIC RN) Polypharmacy assessments . . . reduces the use of pharmaceuticals. Families want it. Patients, residents want it. Facilities want it. Doctors want it. (OPTIMISTIC RN) Facility-based in-services and The other big impact in my facility is education. We [OPTIMISTIC RNs] learned about the dementia . . . teaching I created posters on different types of dementia, as well as the gems of dementia care, so, if I am out of the building, and someone needs to review it, they can pull that out. I did a validation on how to access a Port-A-Cath. I got the actual port, I got the actual needles, and we validated staff and there is a poster on that. (OPTIMISTIC RN) The OPTIMISTIC RN allows us to vision and dream more than usual then creates educational programs that supports what the staff want. (Facility Staff) The [OPTIMISTIC] RN set up in-services for the staff, particularly the port training. It was very useful and can continue to use for onboarding new employees. All the information has helped to onboard new employees so that the staff is consistent in their care. (Facility Leadership) Downloaded from https://academic.oup.com/gerontologist/article/58/6/1177/4555070 by DeepDyve user on 19 July 2022 1182 The Gerontologist, 2018, Vol. 58, No. 6 Table 2. Continued Program component Examples of specific stakeholder comments Collaborative care review Helps with change in conditions and provides a second set of eyes by digging into charts, confirming (CCRs) the data, reporting back to the staff about what has been found and what is still missing. (Facility Leadership) Ineffective or less effective components of the program INTERACT tool: Stop and There was too much turnover to keep it going to keep people educated on it. (OPTIMISTIC RN) Watch Concept is good but it stinks to implement. Takes too much time, not relevant, too much paperwork . . . more forms with little emphasis on how this really impacts the patient. We want to take care of people, not computers and paper. (Facility Staff) At first, we had a big success with Stop and Watch. Then like, we’d be there for a little while and come back and, of course, it had pretty much stopped and it’s very difficult to get it going again once they stop. (OPTIMISTIC RN) INTERACT tool: SBAR SBAR hasn’t taken off. . . . Staff is too task oriented. . . . Physicians want to direct care and it isn’t nurse Communication driven. . . . the physician isn’t there most of the time. (Facility Leadership) Not convinced SBAR and other “extra” forms are worthwhile. Takes too much time to complete them and we don’t see any benefit to our efforts. (Facility Staff) INTERACT tool: Care Paths They [staff] don’t use the Pathways even though I have copied them, laminated them, attached them to each medical cart throughout the facility and done one-on-one training with nurses about how to use them and what to use. (OPTIMISTIC RN) In-services/teaching I like the in-services for the staff but is that part of their job? Is it working? What do we need to do better? (Primary Care Provider) Note: NPs = nurse practitioners; SBAR, Situation, Background, Assessment, Recommendation. Other effective components were identified, though Barriers to Implementation mostly by OPTIMISTIC staff and sometimes by facil- We identified 14 barriers to implementation, which were ity staff. These features included palliative care more grouped under three subthemes: (a) OPTIMISTIC program broadly (i.e., beyond ACP), collaborative care reviews, factors, (b) miscommunication between OPTIMISTIC and and facility-based in-services that covered a broad range nursing homes, and (c) nursing home environment factors of topics. Two OPTIMISTIC NPs mentioned the value of (Figure 1). the transition visits. Respondents also identified components that they felt OPTIMISTIC Program-Related Barriers were less impactful. Most comments came from nurs- Some challenges to implementation involved characteristics ing home staff and OPTIMISTIC RNs and involved of the OPTIMISTIC program that hindered its adoption. INTERACT tools and processes. Specifically, some These features included eligibility criteria, lack of authority thought that the Stop and Watch tool, which guides nurs- to promote changes in the nursing home, and lack of clarity ing assistants’ observations and communication about and consistency in the early implementation phases. changes in residents’ condition, was too time-consuming. Two OPTIMISTIC staff commented that the exclusion Others thought that the Care Pathways for assessing and of short-stay nursing home patients was a hindrance to its managing acute conditions such as fever were too com- success, as many of these patients eventually move from plex. Some respondents saw the Situation, Background, short-stay to long-term care; moreover, these patients were Assessment, Recommendation (SBAR) tool for nursing more likely to be rehospitalized. This theme was echoed by evaluation and reporting of acute changes as highly effec- nursing home staff, as reflected in this nurse’s comment, “. . . tive. In contrast, others believed that overworked nurs- not including rehab patients is a barrier. We move a lot of ing staff were too task oriented and reliant on physicians patients from rehab to long-term care so need help with the to use a tool that required time and critical thinking. In transitions.” addition to the modified INTERACT tools, one facility Another barrier was that OPTIMISTIC NPs and RNs primary care provider questioned the effectiveness of the felt that they lacked the authority to promote change in in-services provided by OPTIMISTIC RNs, wondering their facilities. The NPs elaborated on this issue, stating that whether or not the educational offerings actually changed because they were not employees of the facility, many of them clinical practice. were unable to write orders. The project RNs also stated that Downloaded from https://academic.oup.com/gerontologist/article/58/6/1177/4555070 by DeepDyve user on 19 July 2022 The Gerontologist, 2018, Vol. 58, No. 6 1183 Lack of communication also resulted in confusion among Miscommunicaon OPTIMISTIC Program between OPTIMISTIC Nursing Home Factors Factors and Nursing Homes nursing home staff and primary care providers about how OPTIMISTIC differed from the attending primary care Lack of Awareness or OPTIMISTIC Eligibility Knowledge about Time Constraints Staff Turnover providers’ roles and managed-care partnerships that sent Criteria OPTIMISTIC NPs into the facility to coordinate care. The project NPs Confusion and Resistance/Lack of Inadequate training Lack of Authority to Compeon with Support from and resources for also felt that there may be some competition between Create Change in NH Other Programs Primary Care Providers facility staff them and these other groups, as reflected in the comment: Lack of Clarity and Lack of Consistency in the Coordinaon Between “we [OPTIMISTIC NPs] are limited as to what we can do Nursing Home Culture Facility Leadership Early Phases of the the Program and Program Nursing Homes because [Director of Nursing] is trying to get [managed care provider group] in there.” Residents’ Financial Constraints Clinical Complexity Another problem was inadequate communication between the program and the nursing home providers and Figure 1. Barriers to implementation. staff. As one family member commented, “I’m not sure that the facility understands what OPTIMISTIC is there for. they did not have sufficient power to influence practices. As Because it seems like – at least the nurses on the floor – or the one commented: “at [facility name], they like things we have aides – don’t ever seem to interact with [the OPTIMISTIC to offer, but they don’t want us to overstep our bounds.” RN].” Project NPs and RNs added that there needed to be A final challenge was early missteps in rolling out the established lines of communication between program and program. Although program activities and clinical staff facility providers and staff; without these changes, there roles were developed as part of the grant, there was some would be no assurance that the recommendations of the lack of clarity regarding exactly how the project RNs and OPTIMISTIC staff were integrated into residents’ care. NPs would implement the OPTIMISTIC components. As a result, there were inconsistencies in how much emphasis Nursing Home Factors was placed on particular components and roles. For exam- For the third subtheme, we identified eight nursing home ple, some OPTIMISTIC RNs focused on advance care plan- factors that affected facilities’ ability to implement the ning, whereas others devoted much of their time to teaching OPTIMISTIC program. Some of these factors existed and supporting nursing home staff. While some variation to some extent in every facility. For example, time con- was intended as a way to tailor the program to the specific straints and staff turnover were major barriers to having needs of each nursing home, these differences in implemen- an adequately trained nursing home team that could use tation sometimes led to confusion and uncertainty, both the program tools such as SBAR. Heavy workloads pre- among the participating facilities and among OPTIMISTIC vented staff from attending in-services and financial con- staff. As one project RN commented, it sometimes seemed straints hindered the nursing home from being able to as though “there were nineteen OPTIMISTIC programs.” pay staff to attend educational offerings outside of regu- lar work hours. Respondents also recognized that nursing Miscommunication Between the OPTIMISTIC Program home staff often lacked the time, education, and resources and the Participating Nursing Homes to identify acute changes and intervene promptly, especially Another major hindrance to adoption involved inadequate given the complex health care needs of frail residents. As communication. The source of the miscommunication was one OPTIMISTIC RN stated, “the higher acuity level that not always clear (i.e., whether the problem originated with we are seeing in all of our facilities, does not allow those the program or with the facilities). Nonetheless, it led to nurses the time to do what the OPTIMISTIC nurse can do.” confusion and lack of coordination in providing care. Another common factor that stymied progress was what The most widely endorsed communication problem, one OPTIMISTIC staff referred to as traditional “nursing home voiced by every respondent group, was the lack of knowl- culture.” They described this culture as one in which staff edge or awareness about the OPTIMISTIC program. A few and providers are most concerned about completing tasks respondents suggested that they were unsure what the and are resistant to change. As one project RN put it, “It’s OPTIMISTIC program was and how they were expected to all so task-oriented. My task today is to pass a pill. And if interact with program staff. As one physician commented: I’ve passed this pill to this patient, my job is done.” Finally, nurses also talked about the punitive nature of the nursing . . . there needs to be a better communication path to the home environment, where mistakes are met with rebuke staff so we all know what to expect of the different pro- and staff are afraid to ask questions for fear of being viders on the team. As a physician, I am aware of some labeled incompetent. higher level issues than the CNAs, nurses, and activity Some of the implementation challenges resulted from director. I  don’t know if they understand any of this. lack of support and/or conflicts with facility leadership Can the OPTIMISTIC RN/NP sit in on meetings and or primary care providers. Two OPTIMISTIC NPs and case reviews? If so, what do they contribute and how do one RN commented that facility physicians routinely dis- we use their information? regarded their clinical recommendations. Nursing home Downloaded from https://academic.oup.com/gerontologist/article/58/6/1177/4555070 by DeepDyve user on 19 July 2022 1184 The Gerontologist, 2018, Vol. 58, No. 6 leadership also could be a major hindrance to the program. positions, OPTIMISTIC clinical staff had time to address a Sometimes, OPTIMISTIC staff described open opposition: myriad of diverse needs and undertake time-consuming but “She [Director of Nursing Services] felt we were being lit- important tasks. These responsibilities included engaging in erally jammed down her throat. And she didn’t want us robust ACP discussions, conducting a thorough assessment there.” In other cases, leadership was simply too distracted of residents who were experiencing acute problems, and or absent to provide the support necessary for successful providing in-services as well as one-on-one training and implementation. All respondents agreed, however, that buy- mentoring. Although time was one resource, OPTIMISTIC in and active, ongoing support from nursing home admin- clinical staff also had ready access to computers, educa- istrators was critical. OPTIMISTIC staff also believed that tional materials, clinical expertise, and hospital medical success could be enhanced if the facilities “had more skin records that facility staff lacked. in the game.” As one project RN commented, “I guess I felt Another critical piece to program adoption concerned like they [the facility] needed to have an investment or relationship building and communication. The clinical accountability” in supporting OPTIMISTIC’s efforts. staff, in particular the OPTIMISTIC RN, was seen as a trusted role model and mentor to facility staff. Because the OPTIMISTIC RNs were not employees of the nursing home, Facilitators to Adoption the project RNs were seen as a “safe” source of informa- tion and support. This sense of trustworthiness extended to Three themes emerged from our analysis to identify factors family members. Although families were unable to explic- that stakeholders viewed as important for program adop- itly describe the OPTIMISTIC program or its components, tion: “providing an extra set of hands,” “fostering relation- all identified the importance of the OPTIMISTIC RN in ships and communication,” and “what makes an effective facilitating communication of critical clinical information OPTIMISTIC nurse” (Table 3). to nursing home staff and providers, contacting family Across all respondent groups, OPTIMISTIC RNs and members to alert them of changes or following up when NPS were seen as providing “an extra set of hands” to concerns arose, advocating for the resident, and supporting help facility staff and primary care providers manage their nursing home staff in delivering high-quality, coordinated heavy workloads. Because they were not in traditional staff Table 3. Facilitators to Program Adoption Providing “an extra set of hands” and much-needed resources OPTIMISTIC RNs and NPs are “outsiders” with flexibility and freedom from facility responsibilities OPTIMISTIC RNs and NPs have the time to do things that facility staff do not have time for, including engaging in ACP conversations; teaching staff, residents, and families; communicating with families; problem solving; evaluating changes in residents’ condition and care OPTIMISTIC RNs and NPs are proactive in identifying and ensuring that residents’ and families’ needs are met OPTIMISTIC RNs and NPs have access to resources that are not otherwise available to facility staff, including access to hospital electronic medical records Fostering relationships and communication RNs are role models and nonjudgmental teachers who consistently provide relevant, evidence-based education to empower staff RNs are a safe and helpful constant within a constantly changing environment. As a result, they are trusted by staff and family members OPTIMISTIC RNs and NPs improve communication with residents, family members, providers, and staff by providing information, serving as a liaison between nursing staff and providers and ensuring timely follow-up to clinical issues OPTIMISTIC RNs and NPs improve relationships with resident and family through advocacy, regular communication, and support What makes an effective OPTIMISTIC nurse Have a wide range of work experiences Setting: acute care, long-term care, hospice General experience as a nurse: this is not a role for a new graduate Possessing strong clinical skills Assessment skills to identify acute changes in a resident’s condition and intervene quickly Ability to communicate clearly around clinical problems Technical skills, e.g., starting IVs Ability to assess the “culture” of the building and adapt to meet the needs of that particular setting Being knowledgeable about the OPTIMISTIC program Understand all the components and how they fit together Ability to present the program to residents, families, staff, and providers Ability to role model and teach clinical and organizational skills needed to implement the program Note: ACP = advance care planning; IVs = intravenous lines; NPs = nurse practitioners. Downloaded from https://academic.oup.com/gerontologist/article/58/6/1177/4555070 by DeepDyve user on 19 July 2022 The Gerontologist, 2018, Vol. 58, No. 6 1185 care. As one family member commented, “I’ll get informa- that the initial lack of clarity and communication about the tion from the nurses, like “Your mothers had a fall,” but as program goals and structure hindered its effectiveness. This far as knowing somebody is following up and really try- barrier was addressed through several strategies. For exam- ing to do something about that, I  feel really good having ple, OPTIMISTIC developed and launched a website that OPTIMISTIC RN involved with her case.” describes the program, its mission and vision, evidence for Finally, many respondents described critical attributes, its effectiveness and a full calendar of educational offerings knowledge, and experiences that enabled OPTIMISTIC for participating nursing home staff, primary care providers, staff to be valuable resources. For example, OPTIMISTIC and leadership. The OPTIMISTIC RNs now wear branded RNs spoke at length about how important it was for them scrubs and OPTIMISTIC NPs wear branded lab coats to to have experience and expertise in hospice/palliative ensure that facility personnel, residents, families, and oth- care, acute care, and long-term care. Moreover, successful ers readily identify them as OPTIMISTIC staff. To address OPTIMISTIC RNs needed clinical skills in assessment and the issue of unwanted variation in implementation, detailed management of a broad range of acute and chronic geri- job descriptions, performance benchmarks, and protocols atric conditions, as well as competence in technical skills were developed for OPTIMISTIC RNs and NPs. In rec- such as starting IVs. As key ambassadors and implement- ognition that the RN role, in particular, required a wide ers, these OPTIMISTIC RNs needed to know each program range of knowledge and skills, the program now requires component and be able to role model the behavior, practice all OPTIMISTIC RNs to receive standardized didactic and the skills, and teach others how to use the information in a skills training. These changes underscore the value of form- patient and nonthreatening manner. ative evaluation as a means to “optimize the likelihood of affecting change by resolving actionable barriers, enhancing identified levers of change and refining components of the Discussion intervention. . .” (Stetler et al., 2006, p. S4). The OPTIMISTIC project has demonstrated success in the Stakeholders had differing perspectives about the effec- reduction of all-cause and potentially avoidable hospitali- tiveness of certain program components and features. zations (Ingber, Feng, Khatutsky, Wang, et al., 2017). We For example, the SBAR communication tool was seen as used formative evaluation to examine the views of diverse an ineffective tool by some stakeholders because it added stakeholders regarding the effectiveness of specific pro- unnecessary paperwork whereas others believed that the gram components as well as the barriers and facilitators to SBAR was effective in identifying and managing acute implementing this large, complex project in nursing homes. changes in a resident’s condition early, thereby avoiding The lessons learned are important for dissemination efforts unnecessary hospitalizations. The difference appeared to related to the OPTIMISTIC care model and may be appli- be, in part, attributable to how it was implemented. In one cable to other innovations in the nursing home setting. facility, corporate leadership communicated the value of Some of the implementation barriers that stakeholders the tool and integrated the SBAR into the electronic medi- described are common issues in nursing homes. For exam- cal record, making it easier to use. When nurses observed ple, limited resources; overworked, inadequately trained for themselves how the SBAR helped facilitate effective staff; and high staff turnover conspire against making posi- assessment and communication, they used it more consist- tive changes in this environment. These challenges have sty- ently. This finding suggests that implementation strategies mied the efforts of other investigators who have sought to that are effective in one facility or setting can be used in change nursing home practices to enhance care and outcomes other settings to promote adoption of certain practices. (Ersek & Jablonski, 2014; Jones et al., 2004; Ploeg, Davies, One component that all stakeholders identified as highly Edwards, Gifford, & Miller, 2007; Rantz et  al., 2012). effective was advance care planning, especially POST imple- Although the OPTIMISTIC program could not address all of mentation, a finding that also was reported in the exter - these problems, it was clear that one of its most valuable con- nal evaluation of OPTIMISTIC (Ingber, Feng, Khatutsky, tributions was to bring much-needed human resources to the Bayliss, et al., 2017). The POST (also called POLST: facilities. The OPTIMISTIC clinical model created novel RN Physicians’ Orders for Life-Sustaining Treatments in other and NP roles in the nursing home setting. Integrating skilled states) program is well established in most states and is par- RNs and NPs who are free from the day-to-day clinical tasks ticularly effective in ensuring that nursing home residents that overwhelm nursing home staff and primary care provid- receive appropriate care that is concordant with their pref- ers—including facilitation of high-quality ACP discussions, erences (Hickman et al., 2011, 2016; Kim, Ersek, Bradway, early identification and management of acute problems, and & Hickman, 2015). In addition to honoring residents’ pref- investigation of the root causes for potentially avoidable hos- erences for care, ACP discussions and POST completion pitalizations—was critical to the program’s success. may decrease unnecessary hospitalizations because many Other barriers and challenges were modifiable. As a result long-stay nursing home residents choose comfort care over of our evaluation, the OPTIMISTIC program subsequently aggressive, potentially burdensome treatments (Hickman et underwent changes to address some barriers and weak- al., 2010; Rahman, Bressette, Gassoumis, & Enguidanos, nesses. For example, every stakeholder group mentioned 2016). Many participants in our study attributed the success Downloaded from https://academic.oup.com/gerontologist/article/58/6/1177/4555070 by DeepDyve user on 19 July 2022 1186 The Gerontologist, 2018, Vol. 58, No. 6 of ACP and POST to the availability of OPTIMISTIC RNs Conclusion to conduct in-depth discussions with residents and their Our study adds to the extant literature by integrating sys- families about goals of care and life-sustaining treatment tematic feedback from multiple sources to identify strengths, choices. This success, however, was not easy to achieve even challenges, and avenues for enhancing the implementation with dedicated staff—specialized training and consistent of complex interventions in nursing homes. Our evalua- monitoring of results is necessary (Hickman et al., 2016). tion uncovered significant challenges to implementation. We Our findings also highlight the importance of building found that many barriers to integrating the OPTIMISTIC relationships between the program team and facility staff. program are common to health care settings, especially nurs- Several OPTIMISTIC RNs spoke about earning the trust ing homes. Other barriers reflected areas for improvement of the nursing home staff, primary care providers, admin- within the program itself. Nonetheless, the program was able istrators, residents, and families by demonstrating clinical to overcome some barriers through persistence and building competence, providing critical follow-up, collaborating, relationships and trust over time, flexibility, and offering val- and offering support and education in a nonjudgmental ued resources. The multicomponent initiative succeeded in its manner. They emphasized that fostering trust required time primary goal of reducing potentially avoidable hospitaliza- and persistence. Facility staff and families echoed the belief tions (Ingber, Feng, Khatutsky, Bayliss, et  al., 2017), which that personal relationships and trust in the skill and integ- was likely due to the value of having embedded, project RNs rity of the OPTIMISTIC RN were cornerstones to program and NPs with the skills and time to support high-quality care. success. Similarly, Ingber, Feng, Khatutsky, Bayliss, and Additional changes that were made as a result of the evalua- colleagues (2017) reported that relationship building was tion offer promise for even greater effectiveness in the future. an essential feature of all the CMMI-funded programs to reduce avoidable hospitalizations in nursing home resi- dents. Thus, any efforts to enhance the quality of care in Supplementary Material nursing homes must be attentive to this need. Ingber, Feng, Supplementary data is available at The Gerontologist Khatutsky, Bayliss, and colleagues’ (2017) findings also online. echo another theme that we saw in our data, that is, the availability of skilled, project clinicians who are embed- ded at the facility and have sufficient time to focus on ACP, Funding comprehensive resident assessment, and facility staff educa- This work was supported by the U.S. Department of Health and tion is particularly valuable in achieving positive outcomes. Human Services, Centers for Medicare and Medicaid Services Limitations of this study include use of convenience sam- (Funding Opportunity 1E1CMS331082-04-00) and The John ples for all but the OPTIMISTIC clinical staff stakeholder A. Hartford Foundation. groups. Although we sought diversity among the family, facil- ity staff, and primary care provider respondents, it is possible that we did not capture the full range of experiences, particu- Acknowledgments larly because our primary care provider and family member The authors thank the nursing home residents, family members, and samples were quite small. However, in analyzing the data, we facility staff providers who participated in this analysis, as well as found considerable consistency in responses within each group the nursing homes and nursing home staff who collaborated with and do not believe additional interviews would have yielded the OPTIMISTIC project. We are also deeply appreciative of the OPTIMISTIC nurses and nurse practitioners who implement this new themes. Another possible limitation is that we used semi- intervention daily. Finally, we want to acknowledge the contribu- structured guides for each type of individual and group inter- tions of Ellen Miller and Lidia Dubicki in helping us with scheduling view but may have failed to ask critical questions. We also and conducting the interviews. did not audio-record the facility staff group or the provider interviews. Although both the interviewer and a trained staff person took extensive notes during these interviews that were Conflict of Interest used in the analysis, it is possible that we did not capture the None reported. full range of responses. 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Stakeholder Perspectives on the Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care (OPTIMISTIC) Project

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Oxford University Press
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Copyright © 2022 The Gerontological Society of America
ISSN
0016-9013
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1758-5341
DOI
10.1093/geront/gnx155
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Abstract

Background and Objectives: The need to reduce burdensome and costly hospitalizations of frail nursing home residents is well documented. The Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care (OPTIMISTIC) project achieved this reduction through a multicomponent collaborative care model. We conducted an implementation-focused project evaluation to describe stakeholders’ perspectives on (a) the most and least effective components of the intervention; (b) barriers to implementation; and (c) program features that promoted its adoption. Research Design and Methods: Nineteen nursing homes participated in OPTIMISTIC. We conducted semistructured, qualitative interviews with 63 stakeholders: 23 nursing home staff and leaders, 4 primary care providers, 10 family mem- bers, and 26 OPTIMISTIC clinical staff. We used directed content analysis to analyze the data. Results: We found universal endorsement of the value of in-depth advance care planning (ACP) discussions in reducing hos- pitalizations and improving care. Similarly, all stakeholder groups emphasized that nursing home access to specially trained, project registered nurses (RNs) and nurse practitioners (NPs) with time to focus on ACP, comprehensive resident assessment, and staff education was particularly valuable in identifying residents’ goals for care. Challenges to implementation included inadequately trained facility staff and resistance to changing practice. In addition, the program sometimes failed to commu- nicate its goals and activities clearly, leaving facilities uncertain about the OPTIMISTIC clinical staff’s roles in the facilities. Discussion and Implications: These findings are important for dissemination efforts related to the OPTIMISTIC care model and may be applicable to other innovations in nursing homes. Keywords: Advance care planning, End-of-life care, Evaluation, Long-term care, Nursing homes, Palliative care, Qualitative analysis: content analysis, Teams/interdisciplinary/multidisciplinary Nursing homes provide care for a significant number of Furthermore, the number of older Americans living in nurs- older adults, where approximately 2.5% of all U.S. adults ing homes (1.2 million in 2015)  will continue to increase aged 65 or older and 9% of adults aged 85 or older reside. over the coming years (Administration on Aging, 2016). The Published by Oxford University Press on behalf of The Gerontological Society of America 2017. 1177 This work is written by (a) US Government employee(s) and is in the public domain in the US. Downloaded from https://academic.oup.com/gerontologist/article/58/6/1177/4555070 by DeepDyve user on 19 July 2022 1178 The Gerontologist, 2018, Vol. 58, No. 6 quality of nursing home care is an ongoing concern to con- on every resident who is hospitalized. Findings from sumers, advocates, health care providers, and policy mak- these analyses, which are performed by OPTIMISTIC ers. Key quality issues include the overuse of antipsychotic RNs, are shared with facility staff and leadership. In medication, falls, pressure ulcers, and inadequately man- addition, OPTIMISTIC RNs use the findings to guide aged pain (Werner & Konetzka, 2010; Werner, Konetzka, quality improvement activities in each facility. Residents & Kim, 2013). who transfer back after a hospitalization also receive a Hospitalizations also are increasingly recognized as a qual- detailed Transition Visit from an OPTIMISTIC NP; these ity issue for nursing homes. Specifically, avoidable or poten- detailed evaluations include medication reconciliation, tially avoidable hospitalizations expose residents to risks resident and family education, follow-up management of including medication errors, burdensome treatments, pres- ongoing resident needs, and communication with facil- sure ulcers, and higher mortality (Boockvar et  al., 2004, ity providers and staff (Nazir, Unroe, Buente, Sachs, & 2005; Fried, Gillick, & Lipsitz, 1997; Murray & Laditka, Arling, 2016). 2010). However, improving the quality of nursing home The Medical and Transitions Cores use modified ver - care is complicated by a lack of evidence. Even when evi- sions of several INTERACT tools, which is an evidence- dence-based interventions exist, they can be difficult to based quality improvement program aimed at identifying, implement (Ersek et al., 2016; Rantz et al., 2012). assessing, and managing acute conditions in nursing home Optimizing Patient Transfers, Impacting Medical residents to reduce hospitalizations (Ouslander et  al., Quality, and Improving Symptoms: Transforming 2009, 2010). Institutional Care (OPTIMISTIC) is a clinical demon- The Palliative Care Core supports systematic advance stration project funded by the Center for Medicare and care planning (ACP) using the Respecting Choices® Last Medicaid Innovation (CMMI) as part of its national Steps model (Gundersen Health System, 2017) to facili- Initiative to Reduce Avoidable Hospitalizations among tate the use of the Indiana Physician Orders for Scope of Nursing Facility Residents (Centers for Medicare and Treatment (POST; Hickman et  al., 2016). OPTIMISTIC Medicaid Services, 2017). In accordance with the require- RNs and NPs provide high-quality palliative and end-of- ments of the Initiative, all funded projects, including life care through facility staff education and role modeling OPTIMISTIC, focused on long-term care residents. The (Kelly, Ersek, Virani, Malloy, & Ferrell, 2008). Additional project was implemented from February 2013 to October details about the OPTIMISTIC care model have previously 2016 in 19 Indiana long-term care facilities. OPTIMISTIC been published (Unroe et al., 2015) and are available online is a collaborative care model, providing enhanced support (http://www.optimistic-care.org/) and in Supplementary but not replacing facility staff or primary care providers. Table 1. The project embeds RNs and nurse practitioners (NPs) at OPTIMISTIC outcomes are tracked and evaluated by each facility. These OPTIMISTIC clinical staff are employ- an external contractor who monitors hospitalizations in ees of the project and do not bill for their services. Primary OPTIMISTIC nursing homes and a group of matched con- roles for project RNs are to lead advance care planning trol nursing homes. Recent reports and publications docu- activities, mentor nursing home staff, and implement evi- ment the project’s success in reducing potentially avoidable dence-based tools to improve care and communication. hospitalizations. Ingber, Feng, Khatutsky, Bayliss, and col- OPTIMISTIC NPs address gaps in clinical coverage by leagues (2017) and Ingber, Feng, Khatutsky, Wang, and col- evaluating residents experiencing acute changes in condi- leagues (2017) reported that the OPTIMISTIC intervention tion and conducting evaluations following hospitalizations reduced hospitalizations for diagnoses considered poten- to enhance coordination of care between acute care and tially avoidable by nearly 40% and total hospitalizations nursing home settings (Unroe et al., 2015). by 25%. This reduction was associated with Medicare sav- Project activities are organized within three cores: ings of $236 per resident in 2014 and $408 per resident in Medical, Transitions, and Palliative Care (see Supplementary 2015 (Ingber, Feng, Khatutsky, Wang, et al., 2017). Table  1). The Medical Core is aimed at reducing hospi- The success of the OPTIMISTIC program sets the talizations primarily through a collaborative care review stage for its wider dissemination and implementation. The protocol in which OPTIMISTIC RNs and NPs conduct a OPTIMISTIC investigators conducted an evaluation to focused interview and physical exam to identify geriatric understand the implementation of program components, syndromes that can lead to hospitalization. The findings are identify barriers, and explore the factors that promote the shared with primary care providers, and changes in medical success of the intervention in preparation for expansion of orders and care are made, as needed, to prevent hospitaliza- the clinical model. The purpose of this paper is to describe tions. RNs and NPs also work together to conduct detailed the findings from group and individual semistructured, polypharmacy reviews and make recommendations for qualitative interviews with key stakeholders. Specifically, optimizing medication regimens. we aimed to (a) explore stakeholders’ perspectives about The Transitions Core activities focus on understand- the most and least effective OPTIMISTIC components in ing the antecedents and consequences of potentially meeting the overall program goal of reducing hospitaliza- avoidable transfers by conducting root cause analyses tions; (b) describe barriers to implementing the program; Downloaded from https://academic.oup.com/gerontologist/article/58/6/1177/4555070 by DeepDyve user on 19 July 2022 The Gerontologist, 2018, Vol. 58, No. 6 1179 Table 1. Description of the Sample Number of facilities represented Stakeholder (type of interview) Total N by stakeholder group Family members of residents (individual interviews) 10 4 Facility primary care providers (individual interview) 4 4 Facility leadership and staff (group interviews) Overall N = 23 3 RNs: 8 LPNs: 9 Nurse managers: 2 Administrator: 1 Director/Associate Directors of Nursing: 3 OPTIMISTIC Clinical staff RNs: 19 19 (group interviews) NPs: 7 Note: LPNs = licensed practical nurses; NPs = nurse practitioners. and (c) explore features of the program that facilitated its Sample Recruitment adoption. Group Interviews All OPTIMISTIC staff (19 RNs and 7 NPs) were asked to par- ticipate in one of five (four RN and one NP) semistructured, Methods qualitative group interviews that occurred during a regularly We conducted group interviews with 23 nursing home scheduled staff meeting. Three of the 19 participating nursing staff and leaders (e.g., administrators, Directors of Nursing homes also were invited to participate in semistructured, qual- Services) from three facilities, and five group interviews itative group interviews at each facility. This convenience sam- with all 26 OPTIMISTIC clinical staff (N  =  19 RNs and ple of facilities represented diversity in ownership, size, and N = 7 NPs). In addition, we conducted one time, semistruc- location. We invited a diverse group of staff from each facility, tured qualitative interviews with four primary care provid- including licensed nurses, nursing assistants, administrators, ers from four facilities and 10 family members, also from Directors of Nursing, social workers, and staff educators. four facilities. Table  1 summarizes the overall sample. All interviews and subsequent data analysis occurred in the Individual interviews final 12 months of the 44-month program. OPTIMISTIC RNs identified a convenience sample of eligi- Our interview guides and analysis were directed by Stetler ble family members who spoke English and who had worked and colleagues’ framework of formative evaluation (Stetler closely with OPTIMISTIC staff. Of the 14 family members et al., 2006), which they defined as a “rigorous assessment who were approached for an interview, one refused, one process designed to identify potential and actual influences stated they had no contact with the OPTIMISTIC team, on the progress and effectiveness of implementation efforts” and two were unable to be reached, thereby yielding a sam- (p. S1). The authors identified several types of formative ple of 10 family members. OPTIMISTIC clinical staff and evaluation, including two that were used in this analy- nurse managers also identified seven primary care provid- sis: implementation-focused and interpretive evaluation. ers who managed the care for residents at five participating Implementation focused-evaluation allows researchers and nursing homes. Four providers (three physicians and one implementers to describe the intervention in detail, examin- NP) who were able to be contacted agreed to participate. ing the degree to which components of the intervention were adopted and deemed effective by stakeholders. It also pro- Procedures motes the identification and evaluation of barriers to imple- mentation. Interpretive evaluation allows implementers to Semistructured, qualitative group interviews lasting approxi- explore the “black box” of the intervention, that is, factors mately 1 hr were conducted by one of the authors who is a that promote success in implementing the intervention that doctorally prepared investigator (A. Thomas). Semistructured, may not have been explicitly incorporated into the interven- qualitative individual interviews lasting 25–60 min were con- tion design. Findings from a formative evaluation can then ducted in person or by phone by a trained research coordina- be used to refine the intervention to increase its effectiveness tor (B. Bernard) or investigator (A. Thomas). Each interview and to facilitate wider dissemination (Stetler et al., 2006). began with a standardized statement explaining the purpose The OPTIMISTIC clinical demonstration project is of the interview and a reminder that all names would be approved as an exempt study under the Indiana University/ redacted from notes and transcripts. All interviews were con- Purdue University–Indianapolis Institutional Review Board ducted using a semistructured interview guide that included (IRB). The methods and analyses described here also were standardized questions and follow-up prompts to address declared exempt by the IRB. each of the study aims (Supplementary Table 2). The guides Downloaded from https://academic.oup.com/gerontologist/article/58/6/1177/4555070 by DeepDyve user on 19 July 2022 1180 The Gerontologist, 2018, Vol. 58, No. 6 were tailored for each stakeholder group and posed specific thematic analysis of these coded data revealed three sub- open-ended questions that directly addressed the study aims. codes. Categories and subcodes for Aim 3 were derived For example, all stakeholder groups were asked to provide by identifying themes about specific characteristics of the feedback about specific program components, including OPTIMISTIC program or the clinical staff that facilitated whether or not they were successfully implemented and effec- implementation. We used an inductive approach for Aim tive at achieving program goals. Follow-up probes requested 3 because there were no predetermined categories for fea- additional information about features of the components tures that promoted adoption, thereby following an inter- that facilitated or hindered their implementation. In explor- pretive approach to evaluation (Stetler et al., 2006). ing specific features that facilitated adoption, for instance, After completing the initial coding, the first author devel- OPTIMISTIC clinical staff were asked what attributes made oped definitions for each category and subcode, which were for a successful OPTIMISTIC RN or NP. Families were asked then shared and discussed with the two other members of the if they could provide an example of how the OPTIMISTIC analytic team (S. Hickman and B.  Bernard). Then, all tran- staff had an impact on their family member’s care. The inter- scripts and meeting notes were coded independently by a sec- view guides were neither piloted prior to their use nor adapted ond analytic team member (either S. Hickman or B. Bernard). in response to early interviews. All disagreements in coding, as well as refinements and addi- After all the interviews were completed, one of the coau- tions to the initial categories and subcodes, were discussed thors who led the evaluation team (A. Thomas) reviewed until consensus on final coding was reached. We developed all the transcribed interviews and field notes. She summa- an audit trail by creating detailed memos for each category rized the major themes from each of the stakeholder groups that included original and revised category definitions and sub- and presented it to the OPTIMISTIC leadership team. At codes, outlier data, and exemplars. We managed and analyzed that time, it was decided that additional interviews were all data using NVivo version 11.0 qualitative analysis software. not necessary to uncover new themes. Group interviews for the OPTIMISTIC RNs and NPs and Results individual family interviews were digitally recorded and tran- scribed verbatim. The facility provider and staff/administrator Stakeholders’ Perspectives About the Most and group interviews were not recorded, but the facilitator and a Least Effective Components of the OPTIMISTIC research assistant took extensive notes during the interviews. Program Table 2 summarizes stakeholders’ comments about specific components of the program. The most frequently cited suc- Data Analysis cessful component was the ACP component including POST We used directed content analysis to identify stakeholders’ completion. This view was widely shared by OPTIMISTIC views on the most and least effective components of the RNs, providers, families, and facility staff. As one facility intervention, barriers to implementation, and factors that physician commented, “You need to continue and enhance facilitated the uptake and acceptance of the overall pro- the end-of-life discussions. POST implementation has been gram. In directed content analysis, investigators use existing very helpful and it has helped everyone understand about frameworks and theories to guide the interview questions palliative care and hospice and how they are different.” and coding. Initial coding categories are derived from key Respondents identified the comprehensiveness of the concepts and variables from the framework or theory. Data ACP discussions as critical to the program’s success, as that do not fit into these preset categories are analyzed pointed out by an OPTIMISTIC RN: “I think that the later to determine whether they represent new categories advance care planning, that’s been a huge success . . . I see and themes or subcategories of existing themes (Hsieh & it as something that was really not implemented prior to Shannon, 2005). This analytic approach was appropriate OPTIMISTIC other than just getting a signature on a DNR because our interview questions and coding schema fol- form.” Family members concurred that the OPTIMISTIC lowed our specific aims, which were derived from Stetler program’s approach to ACP was effective and helpful. In and colleagues’ framework for implementation-focused the words of one family surrogate decision maker: and interpretive formative evaluation (Stetler et al., 2006). I thought that [the ACP discussion] went very well. The first author completed the initial coding, which She [OPTIMISTIC RN] covered every aspect of it. She consisted of reviewing all data and categorizing phrases talked about the different levels of care that would be or sentences into categories according to each of the aims. given. All of our questions were answered and yeah, For example, there were two predetermined categories I  just felt really good when we came away from there under Aim 1: “most effective program components” and with the care plan. We knew what my mother wanted “least effective program components.” Subcodes for Aim 1 and we kind of knew what we felt was best for her, but it consisted of each program component (e.g., advance care felt really good having it actually put down in paper that planning, transition visits). For Aim 2, references to fac- tors that hindered implementation were grouped under there is a plan that other hospitals and nursing facilities one predetermined category: “Barriers to Implementation,” can follow. Downloaded from https://academic.oup.com/gerontologist/article/58/6/1177/4555070 by DeepDyve user on 19 July 2022 The Gerontologist, 2018, Vol. 58, No. 6 1181 Table 2. Stakeholders’ Views of the Effectiveness and Ineffectiveness of Specific Components of the OPTIMISTIC Program in Reducing Hospitalizations and Improving Care Program component Examples of specific stakeholder comments Effective components of the program Advance care planning and Advance care planning. . . . Time involved in having multiple conversations and visits with the family Physicians Orders for Scope of cannot be done by usual staff. (Facility Staff) Treatment (POST) The staff at the facility absolutely love this [POST] form because it has been very beneficial to the staff to know where the family stands, so they know how to proceed and what to do. They can look at one form that tells them that. (OPTIMISTIC RN) I have seen the biggest impact with POST. The implementation has been very helpful and it has helped everyone understand about palliative care and hospice and how they are different. It has helped family members realize you are not giving up but rather can supply good care here instead of sending patients to the hospital. (Primary Care Provider) Hands down . . . POST discussions have made a huge difference. . . . We need to work on code status because that drives inappropriate readmissions. That’s what OPTIMISTIC has helped us with. I’d say that now 90% of the patients have an appropriate code status. It has changed our practice. (Primary Care Provider) Well, kind of like, I knew there was more to a DNR than the actual DNR in the sense of Do Not Resuscitate if they start tanking. But, I didn’t know where to go or who to talk to on that, and that is where they turned me on to [OPTIMISTIC RN] (Family Member) Palliative care Great with end of life care. This is a very strong point of the OPTIMISTIC RN/NP role. (Facility Staff) INTERACT tool: Stop …I think that its value added with giving [positive] strokes to CNAs for their identification of issues. and Watch (OPTIMISTIC RN) It was a really big success for us. We caught a lot of things, and now we’re doing a lot of antibiotics and dressing changes that could prevent them having to be sent out. (OPTIMISTIC RN) INTERACT tool: SBAR They are beginning to realize that there . . . is value in completing the SBAR, every time. (OPTIMISTIC Communication RN) Corporate . . . started pushing the SBAR and provided it on the computer system. Now the nursing staff knows that the facility is serious about this. . . . They do see the advantages of having it, because of the consistency between one facility and another. So, it too, is becoming something that is culture. (OPTIMISTIC RN) Having the nurses look at vital signs, what are the changes, what’s happening, and being able to communicate that, I think, makes all the difference in the world, and will make a difference in hospitalizations. (OPTIMISTIC RN) Quality improvement training But, when we look at transfers in our morning clinical meetings, we are looking at root cause analysis and root cause analysis more than we did initially. We’re thinking, "what could be causing this? What do we need to look at? (OPTIMISTIC RN) Transition visits . . . [have the greatest impact] because I don’t see the primary providers having time to do a thorough evaluation. (OPTIMISTIC NP) I think that out of everything that we do, those have been the most effective and produced the most results in terms of avoiding future hospitalizations. (OPTIMISTIC RN) Polypharmacy assessments . . . reduces the use of pharmaceuticals. Families want it. Patients, residents want it. Facilities want it. Doctors want it. (OPTIMISTIC RN) Facility-based in-services and The other big impact in my facility is education. We [OPTIMISTIC RNs] learned about the dementia . . . teaching I created posters on different types of dementia, as well as the gems of dementia care, so, if I am out of the building, and someone needs to review it, they can pull that out. I did a validation on how to access a Port-A-Cath. I got the actual port, I got the actual needles, and we validated staff and there is a poster on that. (OPTIMISTIC RN) The OPTIMISTIC RN allows us to vision and dream more than usual then creates educational programs that supports what the staff want. (Facility Staff) The [OPTIMISTIC] RN set up in-services for the staff, particularly the port training. It was very useful and can continue to use for onboarding new employees. All the information has helped to onboard new employees so that the staff is consistent in their care. (Facility Leadership) Downloaded from https://academic.oup.com/gerontologist/article/58/6/1177/4555070 by DeepDyve user on 19 July 2022 1182 The Gerontologist, 2018, Vol. 58, No. 6 Table 2. Continued Program component Examples of specific stakeholder comments Collaborative care review Helps with change in conditions and provides a second set of eyes by digging into charts, confirming (CCRs) the data, reporting back to the staff about what has been found and what is still missing. (Facility Leadership) Ineffective or less effective components of the program INTERACT tool: Stop and There was too much turnover to keep it going to keep people educated on it. (OPTIMISTIC RN) Watch Concept is good but it stinks to implement. Takes too much time, not relevant, too much paperwork . . . more forms with little emphasis on how this really impacts the patient. We want to take care of people, not computers and paper. (Facility Staff) At first, we had a big success with Stop and Watch. Then like, we’d be there for a little while and come back and, of course, it had pretty much stopped and it’s very difficult to get it going again once they stop. (OPTIMISTIC RN) INTERACT tool: SBAR SBAR hasn’t taken off. . . . Staff is too task oriented. . . . Physicians want to direct care and it isn’t nurse Communication driven. . . . the physician isn’t there most of the time. (Facility Leadership) Not convinced SBAR and other “extra” forms are worthwhile. Takes too much time to complete them and we don’t see any benefit to our efforts. (Facility Staff) INTERACT tool: Care Paths They [staff] don’t use the Pathways even though I have copied them, laminated them, attached them to each medical cart throughout the facility and done one-on-one training with nurses about how to use them and what to use. (OPTIMISTIC RN) In-services/teaching I like the in-services for the staff but is that part of their job? Is it working? What do we need to do better? (Primary Care Provider) Note: NPs = nurse practitioners; SBAR, Situation, Background, Assessment, Recommendation. Other effective components were identified, though Barriers to Implementation mostly by OPTIMISTIC staff and sometimes by facil- We identified 14 barriers to implementation, which were ity staff. These features included palliative care more grouped under three subthemes: (a) OPTIMISTIC program broadly (i.e., beyond ACP), collaborative care reviews, factors, (b) miscommunication between OPTIMISTIC and and facility-based in-services that covered a broad range nursing homes, and (c) nursing home environment factors of topics. Two OPTIMISTIC NPs mentioned the value of (Figure 1). the transition visits. Respondents also identified components that they felt OPTIMISTIC Program-Related Barriers were less impactful. Most comments came from nurs- Some challenges to implementation involved characteristics ing home staff and OPTIMISTIC RNs and involved of the OPTIMISTIC program that hindered its adoption. INTERACT tools and processes. Specifically, some These features included eligibility criteria, lack of authority thought that the Stop and Watch tool, which guides nurs- to promote changes in the nursing home, and lack of clarity ing assistants’ observations and communication about and consistency in the early implementation phases. changes in residents’ condition, was too time-consuming. Two OPTIMISTIC staff commented that the exclusion Others thought that the Care Pathways for assessing and of short-stay nursing home patients was a hindrance to its managing acute conditions such as fever were too com- success, as many of these patients eventually move from plex. Some respondents saw the Situation, Background, short-stay to long-term care; moreover, these patients were Assessment, Recommendation (SBAR) tool for nursing more likely to be rehospitalized. This theme was echoed by evaluation and reporting of acute changes as highly effec- nursing home staff, as reflected in this nurse’s comment, “. . . tive. In contrast, others believed that overworked nurs- not including rehab patients is a barrier. We move a lot of ing staff were too task oriented and reliant on physicians patients from rehab to long-term care so need help with the to use a tool that required time and critical thinking. In transitions.” addition to the modified INTERACT tools, one facility Another barrier was that OPTIMISTIC NPs and RNs primary care provider questioned the effectiveness of the felt that they lacked the authority to promote change in in-services provided by OPTIMISTIC RNs, wondering their facilities. The NPs elaborated on this issue, stating that whether or not the educational offerings actually changed because they were not employees of the facility, many of them clinical practice. were unable to write orders. The project RNs also stated that Downloaded from https://academic.oup.com/gerontologist/article/58/6/1177/4555070 by DeepDyve user on 19 July 2022 The Gerontologist, 2018, Vol. 58, No. 6 1183 Lack of communication also resulted in confusion among Miscommunicaon OPTIMISTIC Program between OPTIMISTIC Nursing Home Factors Factors and Nursing Homes nursing home staff and primary care providers about how OPTIMISTIC differed from the attending primary care Lack of Awareness or OPTIMISTIC Eligibility Knowledge about Time Constraints Staff Turnover providers’ roles and managed-care partnerships that sent Criteria OPTIMISTIC NPs into the facility to coordinate care. The project NPs Confusion and Resistance/Lack of Inadequate training Lack of Authority to Compeon with Support from and resources for also felt that there may be some competition between Create Change in NH Other Programs Primary Care Providers facility staff them and these other groups, as reflected in the comment: Lack of Clarity and Lack of Consistency in the Coordinaon Between “we [OPTIMISTIC NPs] are limited as to what we can do Nursing Home Culture Facility Leadership Early Phases of the the Program and Program Nursing Homes because [Director of Nursing] is trying to get [managed care provider group] in there.” Residents’ Financial Constraints Clinical Complexity Another problem was inadequate communication between the program and the nursing home providers and Figure 1. Barriers to implementation. staff. As one family member commented, “I’m not sure that the facility understands what OPTIMISTIC is there for. they did not have sufficient power to influence practices. As Because it seems like – at least the nurses on the floor – or the one commented: “at [facility name], they like things we have aides – don’t ever seem to interact with [the OPTIMISTIC to offer, but they don’t want us to overstep our bounds.” RN].” Project NPs and RNs added that there needed to be A final challenge was early missteps in rolling out the established lines of communication between program and program. Although program activities and clinical staff facility providers and staff; without these changes, there roles were developed as part of the grant, there was some would be no assurance that the recommendations of the lack of clarity regarding exactly how the project RNs and OPTIMISTIC staff were integrated into residents’ care. NPs would implement the OPTIMISTIC components. As a result, there were inconsistencies in how much emphasis Nursing Home Factors was placed on particular components and roles. For exam- For the third subtheme, we identified eight nursing home ple, some OPTIMISTIC RNs focused on advance care plan- factors that affected facilities’ ability to implement the ning, whereas others devoted much of their time to teaching OPTIMISTIC program. Some of these factors existed and supporting nursing home staff. While some variation to some extent in every facility. For example, time con- was intended as a way to tailor the program to the specific straints and staff turnover were major barriers to having needs of each nursing home, these differences in implemen- an adequately trained nursing home team that could use tation sometimes led to confusion and uncertainty, both the program tools such as SBAR. Heavy workloads pre- among the participating facilities and among OPTIMISTIC vented staff from attending in-services and financial con- staff. As one project RN commented, it sometimes seemed straints hindered the nursing home from being able to as though “there were nineteen OPTIMISTIC programs.” pay staff to attend educational offerings outside of regu- lar work hours. Respondents also recognized that nursing Miscommunication Between the OPTIMISTIC Program home staff often lacked the time, education, and resources and the Participating Nursing Homes to identify acute changes and intervene promptly, especially Another major hindrance to adoption involved inadequate given the complex health care needs of frail residents. As communication. The source of the miscommunication was one OPTIMISTIC RN stated, “the higher acuity level that not always clear (i.e., whether the problem originated with we are seeing in all of our facilities, does not allow those the program or with the facilities). Nonetheless, it led to nurses the time to do what the OPTIMISTIC nurse can do.” confusion and lack of coordination in providing care. Another common factor that stymied progress was what The most widely endorsed communication problem, one OPTIMISTIC staff referred to as traditional “nursing home voiced by every respondent group, was the lack of knowl- culture.” They described this culture as one in which staff edge or awareness about the OPTIMISTIC program. A few and providers are most concerned about completing tasks respondents suggested that they were unsure what the and are resistant to change. As one project RN put it, “It’s OPTIMISTIC program was and how they were expected to all so task-oriented. My task today is to pass a pill. And if interact with program staff. As one physician commented: I’ve passed this pill to this patient, my job is done.” Finally, nurses also talked about the punitive nature of the nursing . . . there needs to be a better communication path to the home environment, where mistakes are met with rebuke staff so we all know what to expect of the different pro- and staff are afraid to ask questions for fear of being viders on the team. As a physician, I am aware of some labeled incompetent. higher level issues than the CNAs, nurses, and activity Some of the implementation challenges resulted from director. I  don’t know if they understand any of this. lack of support and/or conflicts with facility leadership Can the OPTIMISTIC RN/NP sit in on meetings and or primary care providers. Two OPTIMISTIC NPs and case reviews? If so, what do they contribute and how do one RN commented that facility physicians routinely dis- we use their information? regarded their clinical recommendations. Nursing home Downloaded from https://academic.oup.com/gerontologist/article/58/6/1177/4555070 by DeepDyve user on 19 July 2022 1184 The Gerontologist, 2018, Vol. 58, No. 6 leadership also could be a major hindrance to the program. positions, OPTIMISTIC clinical staff had time to address a Sometimes, OPTIMISTIC staff described open opposition: myriad of diverse needs and undertake time-consuming but “She [Director of Nursing Services] felt we were being lit- important tasks. These responsibilities included engaging in erally jammed down her throat. And she didn’t want us robust ACP discussions, conducting a thorough assessment there.” In other cases, leadership was simply too distracted of residents who were experiencing acute problems, and or absent to provide the support necessary for successful providing in-services as well as one-on-one training and implementation. All respondents agreed, however, that buy- mentoring. Although time was one resource, OPTIMISTIC in and active, ongoing support from nursing home admin- clinical staff also had ready access to computers, educa- istrators was critical. OPTIMISTIC staff also believed that tional materials, clinical expertise, and hospital medical success could be enhanced if the facilities “had more skin records that facility staff lacked. in the game.” As one project RN commented, “I guess I felt Another critical piece to program adoption concerned like they [the facility] needed to have an investment or relationship building and communication. The clinical accountability” in supporting OPTIMISTIC’s efforts. staff, in particular the OPTIMISTIC RN, was seen as a trusted role model and mentor to facility staff. Because the OPTIMISTIC RNs were not employees of the nursing home, Facilitators to Adoption the project RNs were seen as a “safe” source of informa- tion and support. This sense of trustworthiness extended to Three themes emerged from our analysis to identify factors family members. Although families were unable to explic- that stakeholders viewed as important for program adop- itly describe the OPTIMISTIC program or its components, tion: “providing an extra set of hands,” “fostering relation- all identified the importance of the OPTIMISTIC RN in ships and communication,” and “what makes an effective facilitating communication of critical clinical information OPTIMISTIC nurse” (Table 3). to nursing home staff and providers, contacting family Across all respondent groups, OPTIMISTIC RNs and members to alert them of changes or following up when NPS were seen as providing “an extra set of hands” to concerns arose, advocating for the resident, and supporting help facility staff and primary care providers manage their nursing home staff in delivering high-quality, coordinated heavy workloads. Because they were not in traditional staff Table 3. Facilitators to Program Adoption Providing “an extra set of hands” and much-needed resources OPTIMISTIC RNs and NPs are “outsiders” with flexibility and freedom from facility responsibilities OPTIMISTIC RNs and NPs have the time to do things that facility staff do not have time for, including engaging in ACP conversations; teaching staff, residents, and families; communicating with families; problem solving; evaluating changes in residents’ condition and care OPTIMISTIC RNs and NPs are proactive in identifying and ensuring that residents’ and families’ needs are met OPTIMISTIC RNs and NPs have access to resources that are not otherwise available to facility staff, including access to hospital electronic medical records Fostering relationships and communication RNs are role models and nonjudgmental teachers who consistently provide relevant, evidence-based education to empower staff RNs are a safe and helpful constant within a constantly changing environment. As a result, they are trusted by staff and family members OPTIMISTIC RNs and NPs improve communication with residents, family members, providers, and staff by providing information, serving as a liaison between nursing staff and providers and ensuring timely follow-up to clinical issues OPTIMISTIC RNs and NPs improve relationships with resident and family through advocacy, regular communication, and support What makes an effective OPTIMISTIC nurse Have a wide range of work experiences Setting: acute care, long-term care, hospice General experience as a nurse: this is not a role for a new graduate Possessing strong clinical skills Assessment skills to identify acute changes in a resident’s condition and intervene quickly Ability to communicate clearly around clinical problems Technical skills, e.g., starting IVs Ability to assess the “culture” of the building and adapt to meet the needs of that particular setting Being knowledgeable about the OPTIMISTIC program Understand all the components and how they fit together Ability to present the program to residents, families, staff, and providers Ability to role model and teach clinical and organizational skills needed to implement the program Note: ACP = advance care planning; IVs = intravenous lines; NPs = nurse practitioners. Downloaded from https://academic.oup.com/gerontologist/article/58/6/1177/4555070 by DeepDyve user on 19 July 2022 The Gerontologist, 2018, Vol. 58, No. 6 1185 care. As one family member commented, “I’ll get informa- that the initial lack of clarity and communication about the tion from the nurses, like “Your mothers had a fall,” but as program goals and structure hindered its effectiveness. This far as knowing somebody is following up and really try- barrier was addressed through several strategies. For exam- ing to do something about that, I  feel really good having ple, OPTIMISTIC developed and launched a website that OPTIMISTIC RN involved with her case.” describes the program, its mission and vision, evidence for Finally, many respondents described critical attributes, its effectiveness and a full calendar of educational offerings knowledge, and experiences that enabled OPTIMISTIC for participating nursing home staff, primary care providers, staff to be valuable resources. For example, OPTIMISTIC and leadership. The OPTIMISTIC RNs now wear branded RNs spoke at length about how important it was for them scrubs and OPTIMISTIC NPs wear branded lab coats to to have experience and expertise in hospice/palliative ensure that facility personnel, residents, families, and oth- care, acute care, and long-term care. Moreover, successful ers readily identify them as OPTIMISTIC staff. To address OPTIMISTIC RNs needed clinical skills in assessment and the issue of unwanted variation in implementation, detailed management of a broad range of acute and chronic geri- job descriptions, performance benchmarks, and protocols atric conditions, as well as competence in technical skills were developed for OPTIMISTIC RNs and NPs. In rec- such as starting IVs. As key ambassadors and implement- ognition that the RN role, in particular, required a wide ers, these OPTIMISTIC RNs needed to know each program range of knowledge and skills, the program now requires component and be able to role model the behavior, practice all OPTIMISTIC RNs to receive standardized didactic and the skills, and teach others how to use the information in a skills training. These changes underscore the value of form- patient and nonthreatening manner. ative evaluation as a means to “optimize the likelihood of affecting change by resolving actionable barriers, enhancing identified levers of change and refining components of the Discussion intervention. . .” (Stetler et al., 2006, p. S4). The OPTIMISTIC project has demonstrated success in the Stakeholders had differing perspectives about the effec- reduction of all-cause and potentially avoidable hospitali- tiveness of certain program components and features. zations (Ingber, Feng, Khatutsky, Wang, et al., 2017). We For example, the SBAR communication tool was seen as used formative evaluation to examine the views of diverse an ineffective tool by some stakeholders because it added stakeholders regarding the effectiveness of specific pro- unnecessary paperwork whereas others believed that the gram components as well as the barriers and facilitators to SBAR was effective in identifying and managing acute implementing this large, complex project in nursing homes. changes in a resident’s condition early, thereby avoiding The lessons learned are important for dissemination efforts unnecessary hospitalizations. The difference appeared to related to the OPTIMISTIC care model and may be appli- be, in part, attributable to how it was implemented. In one cable to other innovations in the nursing home setting. facility, corporate leadership communicated the value of Some of the implementation barriers that stakeholders the tool and integrated the SBAR into the electronic medi- described are common issues in nursing homes. For exam- cal record, making it easier to use. When nurses observed ple, limited resources; overworked, inadequately trained for themselves how the SBAR helped facilitate effective staff; and high staff turnover conspire against making posi- assessment and communication, they used it more consist- tive changes in this environment. These challenges have sty- ently. This finding suggests that implementation strategies mied the efforts of other investigators who have sought to that are effective in one facility or setting can be used in change nursing home practices to enhance care and outcomes other settings to promote adoption of certain practices. (Ersek & Jablonski, 2014; Jones et al., 2004; Ploeg, Davies, One component that all stakeholders identified as highly Edwards, Gifford, & Miller, 2007; Rantz et  al., 2012). effective was advance care planning, especially POST imple- Although the OPTIMISTIC program could not address all of mentation, a finding that also was reported in the exter - these problems, it was clear that one of its most valuable con- nal evaluation of OPTIMISTIC (Ingber, Feng, Khatutsky, tributions was to bring much-needed human resources to the Bayliss, et al., 2017). The POST (also called POLST: facilities. The OPTIMISTIC clinical model created novel RN Physicians’ Orders for Life-Sustaining Treatments in other and NP roles in the nursing home setting. Integrating skilled states) program is well established in most states and is par- RNs and NPs who are free from the day-to-day clinical tasks ticularly effective in ensuring that nursing home residents that overwhelm nursing home staff and primary care provid- receive appropriate care that is concordant with their pref- ers—including facilitation of high-quality ACP discussions, erences (Hickman et al., 2011, 2016; Kim, Ersek, Bradway, early identification and management of acute problems, and & Hickman, 2015). In addition to honoring residents’ pref- investigation of the root causes for potentially avoidable hos- erences for care, ACP discussions and POST completion pitalizations—was critical to the program’s success. may decrease unnecessary hospitalizations because many Other barriers and challenges were modifiable. As a result long-stay nursing home residents choose comfort care over of our evaluation, the OPTIMISTIC program subsequently aggressive, potentially burdensome treatments (Hickman et underwent changes to address some barriers and weak- al., 2010; Rahman, Bressette, Gassoumis, & Enguidanos, nesses. For example, every stakeholder group mentioned 2016). Many participants in our study attributed the success Downloaded from https://academic.oup.com/gerontologist/article/58/6/1177/4555070 by DeepDyve user on 19 July 2022 1186 The Gerontologist, 2018, Vol. 58, No. 6 of ACP and POST to the availability of OPTIMISTIC RNs Conclusion to conduct in-depth discussions with residents and their Our study adds to the extant literature by integrating sys- families about goals of care and life-sustaining treatment tematic feedback from multiple sources to identify strengths, choices. This success, however, was not easy to achieve even challenges, and avenues for enhancing the implementation with dedicated staff—specialized training and consistent of complex interventions in nursing homes. Our evalua- monitoring of results is necessary (Hickman et al., 2016). tion uncovered significant challenges to implementation. We Our findings also highlight the importance of building found that many barriers to integrating the OPTIMISTIC relationships between the program team and facility staff. program are common to health care settings, especially nurs- Several OPTIMISTIC RNs spoke about earning the trust ing homes. Other barriers reflected areas for improvement of the nursing home staff, primary care providers, admin- within the program itself. Nonetheless, the program was able istrators, residents, and families by demonstrating clinical to overcome some barriers through persistence and building competence, providing critical follow-up, collaborating, relationships and trust over time, flexibility, and offering val- and offering support and education in a nonjudgmental ued resources. The multicomponent initiative succeeded in its manner. They emphasized that fostering trust required time primary goal of reducing potentially avoidable hospitaliza- and persistence. Facility staff and families echoed the belief tions (Ingber, Feng, Khatutsky, Bayliss, et  al., 2017), which that personal relationships and trust in the skill and integ- was likely due to the value of having embedded, project RNs rity of the OPTIMISTIC RN were cornerstones to program and NPs with the skills and time to support high-quality care. success. Similarly, Ingber, Feng, Khatutsky, Bayliss, and Additional changes that were made as a result of the evalua- colleagues (2017) reported that relationship building was tion offer promise for even greater effectiveness in the future. an essential feature of all the CMMI-funded programs to reduce avoidable hospitalizations in nursing home resi- dents. Thus, any efforts to enhance the quality of care in Supplementary Material nursing homes must be attentive to this need. Ingber, Feng, Supplementary data is available at The Gerontologist Khatutsky, Bayliss, and colleagues’ (2017) findings also online. echo another theme that we saw in our data, that is, the availability of skilled, project clinicians who are embed- ded at the facility and have sufficient time to focus on ACP, Funding comprehensive resident assessment, and facility staff educa- This work was supported by the U.S. Department of Health and tion is particularly valuable in achieving positive outcomes. Human Services, Centers for Medicare and Medicaid Services Limitations of this study include use of convenience sam- (Funding Opportunity 1E1CMS331082-04-00) and The John ples for all but the OPTIMISTIC clinical staff stakeholder A. Hartford Foundation. groups. Although we sought diversity among the family, facil- ity staff, and primary care provider respondents, it is possible that we did not capture the full range of experiences, particu- Acknowledgments larly because our primary care provider and family member The authors thank the nursing home residents, family members, and samples were quite small. However, in analyzing the data, we facility staff providers who participated in this analysis, as well as found considerable consistency in responses within each group the nursing homes and nursing home staff who collaborated with and do not believe additional interviews would have yielded the OPTIMISTIC project. We are also deeply appreciative of the OPTIMISTIC nurses and nurse practitioners who implement this new themes. Another possible limitation is that we used semi- intervention daily. Finally, we want to acknowledge the contribu- structured guides for each type of individual and group inter- tions of Ellen Miller and Lidia Dubicki in helping us with scheduling view but may have failed to ask critical questions. We also and conducting the interviews. did not audio-record the facility staff group or the provider interviews. Although both the interviewer and a trained staff person took extensive notes during these interviews that were Conflict of Interest used in the analysis, it is possible that we did not capture the None reported. full range of responses. 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Journal

The GerontologistOxford University Press

Published: Nov 3, 2018

Keywords: internship and residency; nursing homes; patient transfer; advance care planning; medical residencies; primary care provider; nurses; palliative care; nursing home resident; nurse practitioner

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