Despite a pressing need to improve outcomes and address inequities in nursing homes, there is limited evidence about the specific factors required to successfully implement real-world interventions in the complex and understudied nursing home setting.
In a pragmatic clinical trial, a team of researchers from Regenstrief Institute, Indiana University School of Medicine and the IU School of Nursing found that leadership stability and engagement with peers in nursing home settings are critical to successfully implementing patient care programs.
“Once we know that something works, we have evidence of efficacy. The next step is the delivery of interventions in real-world settings,” said Regenstrief Research Scientist and IU School of Medicine Professor Kathleen Unroe, M.D., MHA. “Through the trial we found that stability of leadership and engagement with peers were critical to successful implementation.”
The research team examined the implementation of the APPROACHES (Aligning Patient Preferences – Role Offering Alzheimer’s Patients, Caregivers, and Healthcare Providers Education and Support) intervention. The program was designed to improve advance care planning (ACP) for nursing home residents living with dementia by training existing staff to lead structured conversations about goals of care. These ACP conversations help prepare residents and caregivers for communication and decision-making.
Using Coincidence Analysis, an analytic method that examines how components of an intervention interact with the setting in which it is delivered, researchers identified two primary pathways:
- No executive director turnover during the intervention period combined with participation in monthly peer calls.
- Higher baseline hospitalization rates combined with smaller facility size.
“When there is turnover in those key leadership positions, that represents potential challenges and threats to ongoing successful implementation,” said Dr. Unroe. “Smaller facilities with greater opportunity for improvement were more likely to successfully implement the program.”
Additionally, the researchers found that among the 44 intervention nursing homes included in the implementation analysis, 41 percent achieved robust implementation, defined as documenting ACP conversations for more than 75 percent of eligible residents.
The study also underscores the importance of peer engagement. Corporate leads facilitated monthly calls where ACP Specialists could share strategies, highlight successes and problem-solve challenges together.
“Successfully implementing an invervention depends on more than just having a strong intervention. It also requires a receptive environment,” said Susan Hickman, PhD, a former research scientist at Regenstrief, IU School of Nursing and IU School of Medicine. “In our study, stable leadership and meaningful peer connections created the conditions that allowed staff to consistently carry out ACP conversations. In order to create real-world impact in nursing homes, we need to design and implement programs with those environmental characteristics in mind.”
With federal policy already encouraging ACP in nursing homes, the study’s authors say understanding how to successfully implement these programs in real-world settings – where consistent training and infrastructure have often been lacking — is a critical priority for researchers, health systems and policymakers.
The APPROACHES ACP training modules are now available through Pathway Health’s learning management system, broadening access to the program beyond the original study sites.
“Difference-Makers for Robust Implementation of a Nursing Home Advance Care Planning Embedded Pragmatic Clinical Trial,” is published in the Journal of the American Geriatric Society.
This work was supported by the National Institute on Aging (Grant number: R33AG057463, Clinicaltrials.gov number: NCT03323502). Research reported in this publication was supported by the National Institute on Aging of the National Institutes of Health under Award Number R33AG057463.
Kathleen Unroe, M.D., MHA
In addition to being a research scientist with the Indiana University Center for Aging Research at Regenstrief Institute, Kathleen T. Unroe, M.D., MHA, is the Cornelius and Yvonne Pettinga Professor of Medicine at Indiana University School of Medicine and a practicing geriatrician.
Authors
Susan E Hickman1,2,3, Edward J Miech4, Timothy E Stump5, Wanzhu Tu2,3,5, Kathleen T Unroe2,3
Affiliations
1School of Nursing, Indiana University, Indiana, USA.
2School of Medicine, Indiana University, Indiana, USA.
3IU Center for Aging Research, Regenstrief Institute Inc., Indiana, USA.
4Department of Emergency Medicine, Indiana University School of Medicine, Indiana, USA.
5Department of Biostatistics and Health Data Science, Indiana University, Indiana, USA.
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