Health Care Innovation and Quality Assurance

Collection of articles on Health Care Innovation and Quality Assurance is available here.

Policies and Transformation of Long-Term Care System in Taiwan.
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C. F. Chen and T. H. Fu.
Ann Geriatr Med Res 2020 Sep;24(3):187-194
The Taiwanese government has been facing severe challenges pressed by population ageing. The government started taking the issue of long-term care seriously since the first rotation of the political parties in 2000. However, early plans for long-term care were limited in terms of coverage. The Long-Term Care 2.0 Plan-a tax-funded, universal plan-was implemented in 2016. Soon after its implementation, the number of service organizations and the coverage of service increased sharply. This paper takes Taiwan as an example to discuss the designs of long-term care, and strategies to expand service. Many countries nowadays are under pressure to expand long-term care services. Taiwan’s experience could serve as a good example on how to achieve such policy goal within a short period of time. In addition, policy challenges for expanding long-term care are discussed.

Adaptation and Piloting for Hospice Social Workers of Aliviado Dementia Care, a Dementia Symptom Management Program.
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T. M. Jones and A. A. Brody.
Am J Hosp Palliat Care 2020 Oct 5:1049909120962459
Forty-five percent of hospice patients currently have a primary or secondary diagnosis of Alzheimer’s disease or related disorders. However, few programs have focused specifically on assisting hospices in providing evidence-based symptom management to persons living with dementia (PLWD). OBJECTIVE: To adapt and pilot the training component of Aliviado Dementia Care, a dementia symptom management quality improvement program originally developed for home healthcare, for use by social workers as part of the hospice interdisciplinary team. DESIGN: A prospective pre-post design was utilized, measuring knowledge, confidence, and attitudes at baseline, and immediately and 1-month post-training. Analysis was performed using paired t-tests and repeated measures ANOVA. SUBJECTS: Hospice social workers currently practicing in the United States with at least 1 year of experience. MEASUREMENTS: The Dementia Symptom Knowledge Assessment and a post-training continuing education evaluation form. RESULTS: Forty-six subjects were enrolled, of whom 26 completed the first post-test and 23 both post-tests. There was a poor baseline level of knowledge and confidence in caring for PLWD. Significant improvements occurred following training, particularly in implementing non-pharmacologic interventions for behavioral and psychological symptoms of dementia (BPSD) (16.64% increase, p < .0001) and confidence in managing behavioral symptoms (16.86%, p = .01) and depression (25.18%, p < .0001). Changes were maintained over time. All respondents were either very satisfied or satisfied with the quality and content of the program. CONCLUSIONS: The training modules of Aliviado Dementia Care were successfully tailored for use by hospice social workers, showing significant improvement in knowledge and confidence in caring for behavioral symptoms in PLWD. Future work will examine whether the larger program, including this training, can subsequently improve patient outcomes in hospice.

The Effectiveness of the Positive Mood and Active Life Program on Reducing Depressive Symptoms in Long-Term Care Facilities.
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H. Luo, V. W. Q. Lou, C. Chen and I. Chi.
Gerontologist 2020 Jan 24;60(1):193-204
Depression is prevalent among long-term care facility (LTCF) residents. However, interventions are not normally part of the management of these residents due to a shortage of mental health professionals. On the basis of Lewinsohn’s behavioral model of depression, we developed a 12-week pleasant activity scheduling intervention, the Positive Mood and Active Life (PMAL) program. This study evaluated the effectiveness of the PMAL program on reducing depressive symptoms and improving quality of life among at-risk LTCF residents. RESEARCH DESIGN AND METHODS: We adopted a cluster randomized controlled trial design. Four LTCFs were randomly assigned as treatment sites and three provided care as usual. At-risk LTCF residents (N = 68) were identified using the Mood Resident Assessment Protocol from the Minimum Data Set 2.0. The PMAL program was delivered to 34 residents. The primary and secondary outcomes were depressive symptoms and quality of life, as measured by the Geriatric Depression Scale-15 (GDS-15) and the World Health Organization Quality of Life scale-BREF (WHOQoL-BREF), respectively. RESULTS: After 12 weeks, the GDS-15 score in the intervention group showed a reduction from 7.59 to 5.67, with a significant treatment by time effect (p = .006), based on the mixed model analysis; the WHOQoL-BREF score also substantially increased from 69.83 to 86.61 (p = .000). DISCUSSION AND IMPLICATIONS: The PMAL program is effective in reducing depressive symptoms of at-risk LTCF residents. It is a feasible intervention that requires minimum resources and can be integrated with standardized assessment systems.

Implementation of the National Early Warning Score in UK care homes: a qualitative evaluation.
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S. Russell, R. Stocker, R. O. Barker, J. Liddle, J. Adamson and B. Hanratty.
Br J Gen Pract 2020 Oct 5
The National Early Warning Score (NEWS) is a tool for identifying and responding to acute illness. When used in care homes, staff measure residents’ vital signs and record them on a tablet computer, which calculates a NEWS to share with health services. This article outlines an evaluation of NEWS implementation in care homes across one clinical commissioning group area in northern England. AIM: To identify challenges to implementation of NEWS in care homes. DESIGN AND SETTING: Qualitative analysis of interviews conducted with 15 staff members from six care homes, five health professionals, and one clinical commissioning group employee. METHOD: Interviews were intended to capture people’s attitudes and experiences of using the intervention. Following an inductive thematic analysis, data were considered deductively against normalisation process theory constructs to identify the challenges and successes of implementing NEWS in care homes. RESULTS: Care home staff and other stakeholders acknowledged that NEWS could enhance the response to acute illness, improve communication with the NHS, and increase the confidence of care home staff. However, the implementation did not account for the complexity of either the intervention or the care home setting. Challenges to engagement included competing priorities, insufficient training, and shortcomings in communication. CONCLUSION: This evaluation highlights the need to involve care home staff and the primary care services that support them when developing and implementing interventions in care homes. The appropriateness and value of NEWS in non-acute settings requires ongoing monitoring.

Increasing the uptake of vitamin D supplement use in Australian residential aged care facilities: results from the vitamin D implementation (ViDAus) study.
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P. Walker, A. Kifley, S. Kurrle and I. D. Cameron.
BMC Geriatr 2020 Oct 6;20(1):383-020-01784-5
Adequate (≥800 IU/day) vitamin D supplement use in Australian residential aged care facilities (RACFs) is variable and non-optimal. The vitamin D implementation (ViDAus) study aimed to employ a range of strategies to support the uptake of this best practice in participating facilities. The aim of this paper is to report on facility level prevalence outcomes and factors associated with vitamin D supplement use. METHODS: This trial followed a stepped wedge cluster, non-randomised design with 41 individual facilities serving as clusters pragmatically allocated into two wedges that commenced the intervention six months apart. This multifaceted, interdisciplinary knowledge translation intervention was led by a project officer, who worked with nominated champions at participating facilities to provide education and undertake quality improvement (QI) planning. Local barriers and responsive strategies were identified to engage stakeholders and promote widespread uptake of vitamin D supplement use. RESULTS: This study found no significant difference in the change of vitamin D supplement use between the intervention (17 facilities with approx. 1500 residents) and control group (24 facilities with approx. 1900 residents) at six months (difference in prevalence change between groups was 1.10, 95% CI - 3.8 to 6.0, p = 0.6). The average overall facility change in adequate (≥800 IU/day) vitamin D supplement use over 12 months was 3.86% (95% CI 0.6 to 7.2, p = 0.02), which achieved a facility level average prevalence of 59.6%. The variation in uptake at 12 months ranged from 25 to 88% of residents at each facility. In terms of the types of strategies employed for implementation, there were no statistical differences between facilities that achieved a clinically meaningful improvement (≥10%) or a desired prevalence of vitamin D supplement use (80% of residents) compared to those that did not. CONCLUSIONS: This work confirms the complex nature of implementation of best practice in the RACF setting and indicates that more needs to be done to ensure best practice is translated into action. Whilst some strategies appeared to be associated with better outcomes, the statistical insignificance of these findings and the overall limited impact of the intervention suggests that the role of broader organisational and governmental support for implementation should be investigated further. TRIAL REGISTRATION: Retrospectively registered (ANZCTR ID: ACTRN12616000782437 ).

Identifying Practice Facilitation Delays and Barriers in Primary Care Quality Improvement: A Report From Evidence NOW.
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J. Ye, R. Zhang, J. E. Bannon, et al.
J Am Board Fam Med 2020 Sep-Oct;33(5):655-664
Practice facilitation is an effective approach to implementing quality improvement (QI) interventions in practice-based research networks (PBRNs). Regular facilitator-practice interactions are necessary for successful facilitation, and missed engagements may hinder the process of practice improvement. This study employs a mixed-methods approach to characterize the dynamics of practice facilitation and examine facilitation delays and barriers, as well as their association with the achievement of QI program goals in a PBRN initiative. METHODS: This study presents a secondary analysis of data from 226 primary care practices that participated in the Healthy Hearts in the Heartland (H3) initiative. We performed a time series analysis to identify delays in facilitation activities, and then qualitatively analyzed practice facilitators’ notes (n = 4358) to uncover facilitation barriers. Finally, we assessed the relationship between delays, barriers, and QI intervention completion. RESULTS: While most facilitation activities occurred at regular, practice-specific tempos, nearly all practices experienced at least 1 delay. Practices with more delays had lower QI intervention completion rates. Practices with more delays were more likely to have encountered barriers such as lack of time and staff, lack of staff engagement, technical issues, and staff turnover. DISCUSSION AND CONCLUSION: This study is the first to quantify irregular intervals between facilitation activities and demonstrate their negative association with project completion. The analytic method can be applied to identify at-risk practices and to accelerate timely interventions in future studies. Our delay detection algorithm could inform the design of a decision support system that notifies facilitators which practices may benefit from timely attention and resources.