Project

nursing homes; advanced practice nurse; avoidable hospitalizations; quality of care; older people; chronic disease management; new models of care

Lead
Pflegewissenschaftler und Ärzte entwickeln und erproben gemeinsam ein Versorgungsmodell für Menschen in Pflegeheimen, um die Anzahl unnötiger Hospitalisierungen zu reduzieren. Das neue Modell soll mit spezifisch trainierten Pflegefachpersonen die medizinische und pflegerische Betreuung verbessern.
Lay summary
Alte Menschen in Pflegeheimen leiden zunehmend an mehreren und komplexen Krankheiten. Die Zusammenarbeit aller beteiligten Fachpersonen ist deshalb besonders wichtig. In einem pflegegeleiteten Modell übernehmen Pflegefachpersonen mit vertieften geriatrischen Kenntnissen die klinische Führung und koordinieren die Zusammenarbeit mit Hausärzten und Spitälern. Internationale Studien zeigen, dass pflegegeleitete Modelle die Zahl der unnötigen Spitalaufenthalte reduzieren können. Das Ziel der Studie ist die Entwicklung und Erprobung eines pflegegeleiteten Versorgungmodells für chronisch kranke Bewohnerinnen und Bewohner in Schweizer Pflegeheimen zur Reduktion unnötiger Hospitalisationen. Das Modell soll so entwickelt werden, dass es in Pflegeheimen mit unterschiedlicher Grösse und Ausstattung in der Praxis angewendet werden kann. In der ersten Phase wird ein Prototyp eines pflegegeleiteten Versorgungsmodells auf Grundlage der internationalen Literatur und von Interviews mit Bewohnern und Angehörigen, Pflegenden und Hausärzten entwickelt und mit Stakeholdern konkretisiert. In der zweiten Phase werden die Behandlungsteams  von zwölf Pflegeheimen in der Deutschschweiz und Romandie vor Ort vorbereitet und die Pflegefachpersonen gezielt geschult. Abschliessend wird überprüft, wie sich der Einsatz des Modells auf die Koordination und Qualität der Versorgung, die Zufriedenheit der Fachpersonen, die Lebensqualität der Bewohner/-innen, die Zahl von Spitalaufenthalten sowie auf die Kosten auswirkt.  Das Modell wird das erste erprobte, pflegegeleitete Versorgungsmodell in Schweizer Pflegeheimen sein, welches Pflegefachpersonen mit vertieftem geriatrischem Fachwissen in zentraler Stellung einsetzt. Es verbessert den Zugang zu geriatrischer Expertise und dient der der interprofessionellen Zusammenarbeit und Koordination. Die Ergebnisse werden den Verantwortlichen von Pflegeheimen sowie der Gesundheitspolitik wertvolle Informationen zur Entscheidungsfindung liefern.

Direct link to Lay Summary

Last update: 09.01.2017

Active participation

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Communication	Title	Media	Place	Year

The increasing complexity of medical care in nursing homes and the lack of coordination between settings jeopardize nursing home (NH) care quality. One particularly disturbing issue are avoidable hospitalizations, associated with potential negative clinical and psychosocial outcomes and excess cost. This calls for new models of care to support NH care quality by enhancing care coordination, improving care workers’ geriatric expertise (including the use of advanced practice nurses (ANP) and expert nurses), and investing in effective (clinical) leadership in NH. One promising solution, well-established in other countries, but still to be implemented and tested in Switzerland, are nurse-led interprofessional care NH models. These models have shown to improve resident satisfaction, to empower NH staff, as well as clinical outcomes including a reduction in avoidable hospitalizations. Moreover, they are typically led by APN or expert nurses and focus on residents’ needs assessment, care coordination (also in view of transitions between settings), provide geriatric clinical leadership and support data-driven quality improvement. The main goal of the INTERCARE study is therefore to develop and evaluate a Swiss nurse-led interprofessional care NH model to improve care coordination and quality of care in NHs with a special focus on the reduction of avoidable hospitalizations. This implementation science study will be guided by 2 frameworks: (1) the PEPPA+ framework developed to support the introduction and evaluation of care models including an APN, and (2) the Consolidated Framework for Implementation Research (CFIR) which provide a structured approach for the development and implementation of the nurse-led NH model. The project will have two stages: Stage A for the development, Stage B for the implementation and evaluation of the nurse-led care model. In Stage A, a ‘Swiss nurse-led interprofessional NH care model’ will be developed based on available international evidence, contextual information from existing local Swiss models and stakeholder involvement according to the principles of Public Patient Involvement. The ‘Swiss nurse-led interprofessional NH care model’, a multi-level complex intervention, will consist of core and peripheral components, the latter to be adaptable to the local context during the implementation phase (Stage B). Anticipated core components of the ‘Swiss nurse-led interprofessional NH care model’ are nurse experts with an expanded geriatric practice, advanced clinical leadership and competencies as well as administrative backing, which will be prepared with educational trainings and continuous coaching throughout the intervention period together with the NH leadership . The definitive content of the ‘Swiss nurse-led interprofessional NH care model’ at the end of stage A will be the resultant of the input of the different stakeholders and the contextual analysis guided by the 2 frameworks as well as the RAND/UCLA methodology. In Stage B, using a quasi experimental step wedged design (21 months) the ‘Swiss nurse-led interprofessional NH care model’ will be implemented and tested in a convenience sample of 12 NHs across Switzerland’s German- and French-speaking regions.We aim to assess the effectiveness of the nurse-led care model on unplanned hospitalizations (primary outcome) and additional resident and staff outcomes, hypothesizing that nursing homes with a nurse-led care model have lower rates of unplanned hospitalizations and show improvements in resident and staff outcomes. Furthermore, we assess the effect of the degree of the model’s adoption on client outcomes, hypothesizing that a higher degree of adoption is related to better client outcomes.Finally, we describe the implementation costs the Swiss nurse-led interprofessional NH care model on the NH level and assess the economic impact of INTERCARE with a cost-effectiveness analysis adopting a health care system perspective (comparing the increase in staff costs with the decrease of days of avoidable hospitalizations).The sample size calculation for this study (power 80%, alpha = 5%) resulting in a sample size of 12 nursing homes was estimated with a simulation of the proposed stepped wedge design assuming an average of 0.8 unplanned hospitalizations/1,000 resident days and a reduction of 25% unplanned hospitalizations based on literature data from 2 previous international studies. Outcomes will be measured using appropriate quantitative and qualitative measures/methods. Due to the complexity involved in the measurement of avoidable hospitalizations, we will follow experts’ recommendation, tracking all unplanned hospital admissions as primary outcome and then use a) a subset of specific diagnoses or conditions related to avoidable hospitalizations b) avoidable ED visits, and c) process measures as secondary outcomes. The primary outcome unplanned hospitalizations is operationalized as n of unplanned* hospitalizations /1000 care days (excluded are planned hospitalizations (e.g., non-emergency surgical procedure, blood transfusion, chemotherapy) and ED visits with discharge within 24h). In addition to the primary and secondary outcomes (see above), we will also assess service and implementation outcomes to evaluate the uptake and the degree to which the ‘Swiss nurse-led interprofessional NH care model’ will actually have been implemented during the course of the intervention period in the participating nursing homes. Data collection thus will include clinical outcome data, administrative data, questionnaire surveys, focus groups and individual interviews, and hospital discharge reports. Cost data collected will be staff costs (wages and other costs) as well as implementation costs.Data analysis: To test the main hypothesis in view of reduction of unplanned hospitalizations, a generalized linear mixed effects model with binomial error distribution and logistic link function will be applied, using nursing homes as random effect and intervention as fixed effect. A sensitivity analysis will be performed adding time as fixed factor to the model. We will perform intention-to-treat analyses and do sensitivity analyses based on whether the intervention was actually in place. The same approach will be taken for secondary outcomes (e.g., avoidable hospitalizations, ED visits). T As this is an implementation science project, qualitative data will be used to supplement the analyses of client outcomes by indicating the degree to which the nurse-led model was actually implemented, what barriers and facilitators were encountered and how the service offered was perceived by NH staff and residents. The study’s progress and results will be disseminated by newsletters, the INTERCARE website, two national reports on the model and the results, an INTERCARE congress and further project-specific events. The stakeholder group will regularly meet during the project and use their channels to support the dissemination. Expected impact: The ‘Swiss nurse-led interprofessional NH care model’ will help to address the current shortage of geriatric expertise in nursing homes and improve the allocation of health care resources. The results will support evidence-based decision making at the policy level and management level of individual nursing homes concerning the use of nurse-led care models. With the adaptation and integration of internationally established models of care to the Swiss setting, this project is well-placed to produce the first evidence of the use of contextually appropriate, sustainable nurse-led teams to foster interprofessional care coordination and collaboration in Swiss NHs. With its stepped-wedge design and strong theoretical foundations in the PEPPA+ and CFIR frameworks, the INTERCARE project provides a firm scientific basis for future implementation research regarding the care of older persons in Switzerland.