How to Implement and Sustain Better Oral Health in Home Care for Older People: A Realist Mixed Method Case Study

Background Robust evidence demonstrates good oral health is essential for healthy ageing, yet it is described as one of the most neglected aspects of care experienced by older people. The aged care sector’s lack of insight into the consequences of poor oral health and inadequate oral health content in entry-level nursing and aged care qualifications are cited as contributing factors. Although various interventions have demonstrated short-term oral healthcare improvements, longlong-term sustainability has been elusive. Aim To identify the factors that influenced the implementation and sustainability of an evidence-based community aged care (home care) model called ‘Better Oral Health in Home Care’ between Time 1 i mplementation 2012 20142014) and Time 2 (p ost implementation 2017 2018)2018). This included evaluating the relevance of the m odel’s learning and teaching package for students undertaking entry level nursing or aged care qualifications. Design The study was a realist mixed method case study based on three interrelated elements of inquiry. Participants included home care staff, clients, students and educators. Qualitative and quantitative data analyses were reported on in three publications. The first publication, guided by the Promoting Action on Research Implementation in Health Services framework, explored the implementation of the model at Time 1. The second publication used the Kirkpatrick model to evaluate the relevance of the learning and teaching package for students undertaking entry-level nursing or aged care qualifications. The third publication applied Normalisation Process Theory with Realist Evaluation to explain the extent to which the model had been embedded in sustainable practice at Time 2. Results At Time 1, the model led to improvements in older people’s oral health by providing community-based prevention and early detection of oral health problems. Process analysis identified multi-level facilitation as instrumental to the successful development of tailored implementation strategies that were highly suitable to home care. Home care workers’ responses to the learning and teaching package were positive; they reported improved oral health knowledge and skills. The package was also found to be relevant for students undertaking entry-level nursing or aged care qualifications. High levels of student and educator satisfaction were reported, with students describing positive attitudes and significant improvements in oral health knowledge and skills. At Time 2, findings showed that ongoing benefits for clients, continued use of the model and sustained home care workforce capacity had not eventuated. A range of contextual factors were identified, and a lack of facilitation hindered the model’s long-term sustainability. Conclusion This study uniquely captured the journey from implementation to evaluating sustainability in a way not previously demonstrated in oral healthcare research. The realist approach provided a deeper understanding of how contextual factors influenced the ability of home care staff to implement and sustain oral healthcare at macro, meso and micro levels of practice. This study contributes to a theoretical understanding of the importance of facilitation as a key element in the processes of implementation and sustainability. Practical strategies and recommendations for future research are suggested, highlighting the need for greater inter-sectorial collaboration to embed sustainable evidence-based oral healthcare for older people.Thesis (Ph.D.) -- University of Adelaide, Adelaide Nursing School, 201