Identifying the Implementation Conditions Associated With Positive Outcomes in a Successful Nursing Facility Demonstration Project

Background and objectives: To identify the implementation barriers, facilitators, and conditions associated with successful outcomes from a clinical demonstration project to reduce potentially avoidable hospitalizations of long-stay nursing facility residents in 19 Indiana nursing homes. Research design and methods: Optimizing Patient Transfers, Impacting Medical quality, Improving Symptoms-Transforming Institutional Care (OPTIMISTIC) is a multicomponent intervention that includes enhanced geriatric care, transition support, and palliative care. The configurational analysis was used to analyze descriptive and quantitative data collected during the project. The primary outcome was reductions in hospitalizations per 1,000 eligible resident days. Results: Analysis of barriers, facilitators, and conditions for success yielded a model with 2 solution pathways associated with a 10% reduction in potentially avoidable hospitalizations per 1,000 resident days: (a) lower baseline hospitalization rates and investment of senior management; or (b) turnover by the director of nursing during the observation period. Conditions for success were similar for a 20% reduction, with the addition of increased resident acuity. Discussion and implications: Key conditions for successful implementation of the OPTIMISTIC intervention include strong investment by senior leadership and an environment in which baseline hospitalization rates leave ample room for improvement. Turnover in the position of director of nursing also linked to successful implementation; this switch in leadership may represent an opportunity for culture change by bringing in new perspectives and viewpoints. These findings help define the conditions for the successful implementation of the OPTIMISTIC model and have implications for the successful implementation of interventions in the nursing facility more generally