Background: The Veterans Health Administration (VHA) is transforming from a culture based on the medical- model to one that embraces resident-centered care (RCC). Community Living Centers (CLCs), which provide care to a particularly vulnerable spectrum of Veterans, have led the shift to RCC since 2004. RCC is inherently multifaceted and complex, and CLCs vary greatly on existing measures. CLCs that have implemented multiple, meaningful RCC components and simultaneously provide high quality clinical outcomes (i.e., successful RCC adopters) are relatively rare, and little is understood about how they achieved their success. What are their structures and processes of care? What facilitates or blocks embedding RCC in everyday work routines? And what are the cost outcomes? Much can be learned from CLCs that have successfully overcome barriers and implemented change. This project builds on pilot work and incorporates feedback from VHA operations partners. It represents the first comprehensive study of successful RCC adopter CLCs. Objectives: This theoretically grounded, 3.5-year, mixed-methods study builds upon extensive pilot work on CLC RCC. Results will be compiled to produce a detailed understanding of the multiple pathways CLCs use to achieve successful RCC implementation. Throughout the study, interim products will be shared with operations partners to maximize the study's impact. The study has 3 aims. (1) Examine facility-level variation in RCC implementation. (2) Identify effective RCC practices in a successful adopter sample. (3) Develop a detailed description (i.e., roadmap) of identified paths to successful RCC implementation. Methods: This study will employ a 3-phase process, corresponding to the 3 study aims. Phase 1 uses existing facility-level data to rank CLCs on resident clinical outcomes using a Minimum Data Set composite measure and then rank them further using Artifacts of Culture Change tool data as a measure of RCC. Then the top quartile of CLCs will be surveyed (n=32) to gather facility-level information on RCC structures, processes, and implementation. The 32 CLCs will be ranked by key variables and the 8-CLC successful adopter sample chosen. In addition, an analysis of resident costs will be conducted. Phase 2 will involve conducting brief site visits at the successful adopter sites to administer resident surveys and collect structured observation data on RCC. Data will also be collected through an online staff survey and a mailed family member survey. The quantitative results from Phases 1 and 2 will help inform qualitative data collection in Phase 3. Semi-structured staff interview will explore in detail (1) how successful adopters modified specific structures and processes to integrate RCC components and succeed and (2) barriers to and facilitators of these effective practices. An inductive analysis approach will be used to integrate qualitative and quantitative data to create a draft roadmap that will be fed back to sites for input. The roadmap will then be finalized, and the study team will work with operations partners to disseminate and implement it. Anticipated Impacts: The study will generate new knowledge about RCC in VHA. Interim study findings will be compiled into actionable reports that will be shared with operations partners at the end of Phases 1 and 2 and twice during Phase 3. The periodic and final products will provide a picture of successful adopters' RCC journeys. This will fill the gap in knowledge about how RCC can be successfully implemented, what facilitates success, how barriers can be overcome, and what impact RCC has on resident costs. These findings will help enhance care for some of VHA's most vulnerable Veterans. The knowledge gained will be of immediate applicability to CLCs nationwide and will be helpful for guiding further improvements in resident-centered care in VHA as a whole. It will also lead directly to an implementation study of the final RCC roadmap.
The proposed research is relevant to Veterans because it will provide timely and important information to support the VHA mission to provide Veteran-centered care, meaning care that centers around Veterans' needs and preferences. Community Living Centers (CLCs) provide care for 40,000 Veterans every year, and there is a lot of variation in the Veteran-centeredness of care. What CLCs need is a detailed guide for how to improve Veteran-centeredness of care but there is currently no in-depth information on what CLCs are doing and how high-performing CLCs got to where they are. This will be the first study to investigate what works best to improve Veteran-centered care in CLCs, identifying factors that help CLCs in their journeys and ways to overcome factors that act as barriers. This study will provide information on how to implement changes in CLCs that will result in positive changes in the Veteran-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.