Examples of previous interventions

This chapter presents examples of the literature on previous training interventions concerning LTCF residents’ EOL care. The grouping follows that applied by Collingridge Moore et al. in their recent review: care planning interventions, care focused interventions and multicomponent interventions

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(Collingridge Moore et al. 2020). The different interventions related to EOL care development show considerable variability related to the general complexity of these interventions (Low et al. 2015).

Care planning interventions

“Goals of care” intervention used by Hanson et al. (2017) was aimed at ACP promotion and for both residents’ proxies, and facility staff. The intervention consisted of a video decision aid introducing three general goals setting categories: prolonging life, supporting function, and maximizing comfort. The treatment decisions and considerations associated with each preference were also presented. In addition to the video, the staff members attended a one-hour training session on principles of emotionally attentive communication and practical examples. Thirdly, the staff received a written discussion guide along with reminders to organize discussions about care preferences with family members. The RCT revealed that the intervention improved the communication aspect of QoC measured a questionnaire, but general QoC assessed by using the SWC-EOLD did not differ. Additionally, QoD rated by using the SM-EOLD instrument did not improve, but hospitalizations among the residents in the intervention facilities were significantly less common (Hanson et al. 2017).

A classic example of an ACP-promoting intervention is the advance directive concerning educational intervention by Molloy and colleagues (Molloy et al. 2000). In the trial the “Let me decide” AD program was systematically implemented in six Canadian LTCFs. It included education for facility and hospital staff, residents and their proxies. In addition, directive choices were systematically discussed with each resident or their proxies. In the RCT, this intervention did not affect satisfaction with care, but it significantly reduced hospitalizations and related costs (Molloy et al. 2000).

“Respecting Choices” is another care planning intervention often targeted to whole communities. In a German study, formation of advance care plans and physician orders for life-sustaining treatment (POLST) forms was facilitated by using the Respecting Choices framework. Trained facilitators were provided to a group of LTCFs, as well as education for physicians, staff members and nearby hospitals. During follow-up, the increase in ADs was much greater in the intervention group (from 16% to 52% of residents) compared to the control group (from 21% to 25%). The preference for POLST forms also contributed to the intervention group residents’ ADs being judged to be more clinically relevant by the authors. They more often included clear instructions regarding key medical decisions such as resuscitation preference (der Schmitten et al. 2014).

41 Care focused interventions

In a systematic review of both randomized and non-randomized trials it was shown that implementing person-centered care strategies is likely to be effective in reducing agitation, neuropsychiatric symptoms and depression and in improving QoL (Kim and Park 2017). In a Norwegian RCT person-centered care was implemented using two different tools, Dementia Care Mapping (DCM) and the VIPS Practice Model (VPM), compared with a control group receiving video lectures only. Both tools used elements such as observation, benchmarking and feedback, but the difference was that DCM was implemented using considerable external engagement in observing staff–

resident interaction and giving feedback, while VPM implementation relied only on facility staff using the instrument with limited facilitation. Person-centered care appeared to be favorable, since both interventions reduced neuropsychiatric symptoms, often found to significantly affect resident and proxy evaluations of QoL. Additionally, DCM was directly beneficial to QoL (using the QUALID scale), and VPM intervention reduced depressive symptoms (Rokstad et al. 2013).

Teamwork, joint working and external engagement were used in a recent study by Forbat and colleagues in Australia. They offered intervention facilities monthly palliative “needs rounds” joined by external palliative care experts.

Each monthly 60-minute meetings concerned ten resident cases. The residents were chosen to be included in the rounds by facility staff using a previously developed checklist to find the residents most likely to have a high symptom burden or imminent palliative needs (Chapman et al. 2018).

Evaluation of the intervention was carried out in a stepped-wedge randomized design and the intervention was found to be effective both in reducing hospital inpatient days of the residents and improving their QoD (Liu et al. 2019;

Forbat et al. 2020).

Multicomponent interventions

Interventions to Reduce Acute Care Transfers (INTERACT) included three key concepts and toolsets: 1) early recognition and management of acute conditions to prevent ACSHs; 2) providing communication, documentation, and decision-support tools for managing acute scenarios in the facility instead of hospitalization; 3) promoting ACP and hospice service use. The INTERACT has been one of the largest quality improvement projects aiming to reduce hospitalizations from LTCFs. The implementation involved both external and internal facilitators, intensive training took place over ten weeks and later there were monthly webinars and long-term facilitation concerning the comprehensive set of some 30 different tools. Initial trials of the intervention reduced hospitalizations from the facilities, but later randomized trials did not affect hospitalizations. It was noted that the facilities that implemented the intervention mostly benefitted from it, but the complexity of the intervention

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was likely too much for many facilities struggling with various daily difficulties (Ouslander and Berenson 2011; Bonner et al. 2015; Kane et al. 2017).

The more recent Optimizing Patient Transfers, Impacting Medical Quality, Improving Symptoms: Transforming Institutional Care (OPTIMISTIC) demonstration project has been reported in more than ten scientific articles.

The intervention included many of the INTERACT components as well as a training framework for facilitators from the Respecting Choices project. The multicomponent intervention involved RN facilitators aiming to set appropriate goals for care, improve care of chronic conditions likely to result in hospitalization, and ensure proper documentation of resident transfers. In pre-post analysis, reductions in potentially avoidable hospitalizations were observed. ACP facilitation was a major component of the intervention. It is worth noting that despite the intervention being successful in increasing ACP activity, this activity did not affect the rate of hospitalization when adjusting for resident characteristics (Hickman et al. 2019; Blackburn et al. 2020).

The “Communication, Systematic assessment and treatment of pain, Medication review, Occupational therapy, Safety (COSMOS)” trial performed in Norwegian LTCFs was an intensive effort in training staff members to improve several aspects of care quality. The intensive training took place on-site for four months in all facilities. Notably, several QoL measures decreased during the intervention. However, after intervention these measures improved significantly (Husebø et al. 2019).

Recently, a trial by the Palliative Care for Older People (PACE) consortium utilized multicomponent intervention developed based on the basis of the earlier Gold Standards Framework (Badger et al. 2012) and Six Steps to Success (O’Brien et al. 2016). The PACE Steps to Success Program intervention consisted of six steps: (1) advance care planning with residents and families;

(2) assessment, care planning, and review of resident needs and problems; (3) coordination of care via monthly multidisciplinary palliative care review meetings; (4) high-quality care with a focus on pain and depression; (5) care in the last days of life; and (6) care after death. Additionally, it was implemented in three phases as described in Chapter 2.5.6 and in Figure 6.

The preparation step lasted for two months, followed by six months of intervention, and lastly four months of sustaining consolidation. Positive facility (improved collaboration and increased ACP documentation) and staff confidence-related outcomes were reported after implementations of the Gold Standards Framework, but no controlled implementation studies exist (Badger et al. 2012; O’Brien et al. 2016). PACE Steps to Success was implemented in a large RCT in six European countries, with minor staff-related improvements but no change in residents’ QoD (Van den Block et al.

2019).

The Aged Residential Care Healthcare Utilization Study (ARCHUS) in New Zealand also involved intervention that combined several approaches to care in a RCT design, with the aim of reducing hospitalizations. The components of the intervention included: 1) Baseline facility assessment to identify areas of

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need and to create facility care plans developed by the interdisciplinary team;

2) Monitoring and benchmarking of resident indicators linked to quality of care provided: falls, nutrition, restraint use, weight loss, infections, polypharmacy; (3) Three 1–4 hour multidisciplinary team meetings including a medication review by the study geriatrician, GP, pharmacist and nurse manager. Typically, six residents were considered per meeting, with priority given to new admissions, the recently hospitalized, those with recent

‘incidents’ (e.g. a fall) and those on >9 types of medication; (4) Gerontology education and clinical coaching for facility nurses and care-givers including EOL care planning, nutrition/hydration, early detection of illness, fall prevention, end-stage dementia care, communication with families and practical aspects of care. The gerontology nurse practitioner-led support and education ‘package’ began with weekly visits, with gradually reduced frequency throughout the nine-month intervention period, aiming to foster facility independence prior to the conclusion of active involvement. The implementation heavily relied on facilitation by external expert, the gerontology nurse practitioner. In the 14-month follow-up period, no differences were observed in the rates of hospitalization or mortality between the intervention and control groups (Connolly et al. 2015).

2.5.6 REQUIREMENTS AND BARRIERS TO STAFF TRAINING