A Nurse-led Model of Care’s effectiveness (INTERCARE) in Reducing Unplanned Transfers from Swiss Nursing Homes

Nursing home (NH) residents are increasingly frail and suffer from multiple chronic illnesses, combined with functional and cognitive impairment. Due to their vulnerable health, residents are increasingly prone to sudden health deterioration due to an exacerbation of a condition or injury, resulting in an unplanned transfer such as an emergency department visit with or without an ensuing hospitalisation. Hospitalisations put residents at risk for iatrogenic and nosocomial infections, complications, medication errors, and increased functional and cognitive impairment upon return to the NH. Additionally, transfers can create stress due to disorientation from isolation and changes in the environment, increase side effects from polypharmacy, delirium, and hinder mobility causing potential deleterious consequences. Some of these hospital transfers are avoidable or inappropriate. Increased geriatric expertise is needed in NHs to detect changes in residents’ conditions at an earlier stage and to also address the overall growing lack of nurses and general practitioners in NHs. Various nurse-led models of care have been developed and implemented in various countries building on different bundles of core components. Some of these models have shown effectiveness in decreasing unplanned or avoidable transfers, yet others have failed to show effectiveness. Few studies have investigated the reasons behind success or (partial) failure in reducing transfers. As well as highlighting the critical role of contextual analysis to adapt interventions to a specific context and setting, implementation science seeks to study methods and strategies to facilitate the uptake of an intervention in practice and to help interpret variations in implementation success. The overall goal of this thesis was to evaluate the clinical and implementation effectiveness (degree of implementation fidelity) of a nurse-led model of care (INTERCARE) in reducing unplanned transfers from NHs; and gaining a better understanding of which resources could be introduced to mitigate one of the most common reasons for an unplanned transfer: fall-related transfers. This thesis is embedded in the “Improving INTERprofessionalCARE for better resident outcomes (INTERCARE)” study which is a multi-centre non-randomized stepped-wedge design within a hybrid type-2 effectiveness-implementation study, implemented in 11 NHs in German-speaking Switzerland. This thesis explores and discusses how a reduction of unplanned transfers can be achieved with the example of the degree of implementation fidelity, as well as further steps needed in NHs to reduce potentially avoidable transfers, with the example of fall-related transfers. This thesis contains 6 chapters. Chapter 1 introduces the current issues faced by NHs and which contribute to unplanned transfers, the differences between avoidable hospitalisations and inappropriate emergency department visits and the different models of care which have been implemented in NHs to decrease unplanned and avoidable transfers. An overview of the INTERCARE project and its core components follows with a brief introduction to implementation science with a focus on the degree of implementation fidelity. Chapter 2 outlines the overall goal and aims of this thesis. Chapter 3 reports and discusses the clinical effectiveness of INTERCARE on the main outcome of unplanned transfers. A total of 942 residents with informed consent were included (females 69%) with a median age of 85.5 years, representing an overall consent rate of 68% across the 11 NHs which took part in the study. 303 unplanned (82.6%) and 64 planned transfers were collected during the study. The findings showed that during the baseline period, unplanned transfers increased over time after which the trend significantly changed resulting in a flattening of the average transfer rate throughout the post-intervention period. Furthermore, to confirm our results a larger anonymized dataset confirmed the trend discontinuation after intervention start, compared to the initial transfer rate trajectory. This chapter supports the effectiveness of INTERCARE and of nurses working in extended roles to enhance the geriatric expertise and provides an alternative for NHs which do not have access to advance practice registered nurses. Chapter 4 applied a mixed-methods convergent/triangulation design to investigate the influence of implementation fidelity on unplanned transfers and explores the relationship which implementation fidelity to INTERCARE has on unplanned transfers. We combined findings from qualitative notes about implementation of the core components and fidelity scores over time to better understand which moderators (qualitative data) can explain the fidelity trajectory over time (quantitative data). Higher fidelity scores showed a decreasing rate of hospital transfers post-intervention, higher fidelity scores to advance care planning were associated with lower unplanned transfers and lower fidelity scores for communication tools (ISBAR and Stop&Watch) showed higher rates in unplanned transfers. NHs with in-house physicians, with a collaborative approach and with staff who perceived the need for support from nurses working in extended roles, were factors which helped achieve and sustain high fidelity to the INTERCARE model. This chapter presents a pragmatic way of measuring fidelity to a complex intervention and the application of a conceptual framework to help link implementation fidelity to unplanned transfers. Chapter 4 provides an overview of measurement issues linked with fidelity and the difficulty to accurately tackle the complexity of the outcome. Chapter 5 focuses on fall-related transfers, one of the most common reasons for a transfer to hospital from NHs. This study uses a multi-method design to identify resources which are appropriate for the Swiss context to support NHs to better manage residents after a fall or fall-related injury. Potentially avoidable fall-related transfers were rated by an expert panel comprised of 5 experts from different fields of medicine and nursing with expertise in geriatrics. Furthermore, for every adjudicated transfer as potentially avoidable, resources needed to prevent the transfer were given. The resources were discussed in a panel of NH stakeholders and refined. An appropriateness questionnaire was sent to a larger group of NH stakeholders, to identify key appropriate resources for future implementation. Findings showed that 25% of fall-related transfers were rated as potentially avoidable and reasons included the possibility for an outpatient appointment, the transfer occurred before a medical assessment (i.e., by a NH GP) could be carried out, the resident was transferred because of an incorrect assessment and the necessary resources to handle and treat the resident were available in the NH. The findings from the appropriateness rating revealed that access to diagnostic resources such as mobile our outpatient X-ray/CT during office hours and access to timely geriatric consultation (GP, APRN, expert nurses with additional training) were deemed relevant for implementation. Further, resident care and treatment in the NH, such as wound dressing, suturing and following algorithms to assess a resident in the NH were also deemed relevant for implementation. Further research is needed to develop interventions geared to limit potentially avoidable fall-related transfers. Chapter 6 synthesizes and discusses major findings of all studies in the context of the literature. Furthermore, strengths and weaknesses of this thesis are examined and implications for future research, policy and practice are presented