Background: The Veterans Health Administration (VHA) is in the process of transforming from a culture based on the medical-model to one that embraces a patient- (resident-) centered perspective. Community Living Centers (CLCs), which provide care to a substantial spectrum of veterans who need long-term care, rehabilitation, or hospice services, are undertaking this cultural transformation as well. This transformation involves alterations in the physical environment of CLCs and in staff care and work practices, although changes implemented to date are highly variable nationally and have generally focused on modifications to the physical environment. Arguably, two of the most substantial barriers to implementing resident-centered care in CLCs are (1) established practices that support the medical model and (2) lack of evidence to guide the selection of potential innovations. The Developing and Implementing Resident-centered Efforts in Cultural Transformation (DIRECT) study addresses these barriers. Objectives: The DIRECT study builds upon extensive developmental work on cultural transformation at three CLCs. Out of the developmental work emerged a standardized, observation-based tool to measure staff behaviors related to staff-resident interactions and staff members' engagement of residents: the Resident- centered Assessment of Interactions with Staff and Engagement tool (RAISE). This is a tool for use primarily by researchers. A preliminary version of an action-oriented protocol to help busy frontline staff adopt resident- centered care improvements, the Advancing Cultural Transformation in Our Neighborhoods! Plan (ACTION! Plan), was also developed. The DIRECT study expands on this previous work and has the following objectives. The first objective is to collaborate with staff at 2 CLCs in the development of a draft program implementation guide (i.e., a comprehensive set of resources for implementing a program to improve resident-centeredness of care) for the RAISE and the ACTION! Plan. This objective has 3 secondary objectives: (a) refine the RAISE and ACTION! Plan, (b) adapt the RAISE into a shortened, staff-friendly version (RAISE-sf), then test the RAISE-sf, and (c) develop and test a staff training video for the RAISE-sf and ACTION! Plan. The second objective is to evaluate two types of implementation strategies for the draft guide at 6 sites. The third objective is to finalize a practical and effective program implementation guide to enable sustainable implementation of the RAISE-sf and ACTION! Plan. Methods: The study will take place in 3 phases using mixed-methods and a purposive sample of CLCs. The CLCs recruited for participation in the DIRECT study are all strongly committed to and have already made significant strides in cultural transformation. In Phase I, at 2 CLCs researchers will (a) conduct telephone interviews with CLC staff about tool implementation and development of the RAISE-sf and (b) will test the RAISE and ACTION! Plan for user comprehensibility with CLC staff and CLC inspectors. They will then create and test the RAISE-sf and a training video and develop the implementation program guide. In Phase II, 6 sites will implement the guide, each over a 6-month period. For this, three sites will have on-site training and check- in for the implementation, while 3 will have remote training and check-in. Phase III will be dedicated to finalizing the guide and its contents based on the input received from and data collected at the 6 Phase II sites. Anticipated Impacts: The proposed research will provide systematic information about (1) how best to measure resident-centeredness of care and how best to implement changes in staff members' routine workflow to improve the resident-centeredness of care and (2) how best to implement a guide to facilitate CLCs' progress on improving resident-centeredness of care. The knowledge gained and the refined tools and protocols developed will be of immediate applicability to CLCs nationwide and will be helpful for guiding further improvements in resident-centered care in the VHA.
The proposed research is relevant to veterans because it will provide timely and important information to support the VHA mission to provide more patient- (resident-) centered care to veterans. Community Living Centers (CLCs) provide care for 40,000 unique veterans every year. But there is currently no systematic, objective, observational measure of the resident-centeredness of care provided to veterans residing in CLCs. There are also no protocols for how to implement changes to improve resident-centeredness. This will be the first study to implement a measurement tool and an action-oriented protocol aimed at improving CLC staff members' interactions and engagement with residents. This study will provide information on how best to implement changes in CLCs that will result in positive changes in the resident-centeredness of care. The results will be immediately and directly relevant to staff and residents of CLCs and will be designed to be useful throughout VHA.
| Hartmann, Christine W; Palmer, Jennifer A; Mills, Whitney L et al. (2017) Adaptation of a nursing home culture change research instrument for frontline staff quality improvement use. Psychol Serv 14:337-346 |
