Encouraging Best Practice in Residential Aged Care Program: Final Evaluation Report

Appendices 13 to 17

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Appendix 13 - Monash University behaviour management project
Appendix 14 - Lead organisations - essential ingredients for success
Appendix 15 - Factors influencing implementation of evidence-based practice - results from EBPRAC national workshops
Appendix 16 - Comparision of processes of care and resident outcomes
Appendix 17 - EBPRAC resources of care generalisability of those outcomes

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Appendix 13 - Monash University behaviour management project

Project title	Addressing Behaviours of Concern in the Bush: Sustainable evidence-based practice in rural and regional residential aged care.
Leader	Dr Sandra (Sam) Davis, Palliative and Supportive Services, Flinders University (at project commencement working in the School of Rural Health, Monash University).
Consortium partners	Bendigo-Loddon Primary Care Partnership, Bendigo, Victoria. McCarthy Psychology Services, Eltham, Victoria.
Participating facilities	Seven facilities participated in the project from rural Victoria, a mix of small stand-alone aged care facilities, as well as aged care settings within multi-purpose services run by the Victorian Department of Health.
Sources of evidence implemented by the project	Alzheimer’s Australia Quality in Dementia Care documents. Dementia Friendly Environments in Residential and Respite Settings, Department of Health, Victoria. Dementia Care Mapping, Bradford University, United Kingdom.
Model of change for implementing the evidence	The change management framework comprised a number of processes to target philosophy, management support, leadership, skilled staff and the environment, with three main elements: Introduction of a person-centred care philosophy to underpin care provision and understand the needs of people with dementia. Modifying the built environment to support residents and staff providing care. Using the physical and social environments to address behaviours of concern, and prevent their development. The main vehicle for change was the identification, education and support of ‘best practice champions’, who were resourced to provide a leadership role in their local facility. This included convening environmental modification working groups; participating in and facilitating face-to-face and e-learning educational sessions and ‘micro-training’ sessions. Dementia Care Mapping was used to identify and develop strategies to address behaviours of concern, using a needs-based problem solving approach.
Main intended outcomes	Reduced incidence of depression, anxiety and agitation for residents. Improved quality of life of residents. Improved orientation and training of staff. Create a dementia-friendly physical and social environment. Increased capacity of facilities to provide appropriate assessment and care for older people with behaviours of concern.
Examples of changes implemented	Increased use of resident life histories and well-being checklist. Use of needs based problem solving to address behaviours of concern. Improvements to the physical environment. Reduction in the use of psychotropic medications.
Project evaluation	The evaluation comprised a pre- and post-implementation study design, which targeted the following groups using various measures: Staff: levels of education, attitudes, perceptions and practices, which were measured by surveys which looked at measures of individualised care, perceptions, levels of personal distress and work disruption due to behaviours of concern. Families: satisfaction with care provided, information, level of involvement in decision making and perceptions regarding individualised care. Residents: general well-being as measured by clinical data (incidents, behaviours of concern, medication use); quality of life using standardised measures and Dementia Care Mapping. Conversational interviews with a sample of residents were also conducted over the course of the project. Physical environment: audit of the environment using an environmental audit tool. Policy and procedure audits were also undertaken, to determine the information management systems required to sustain person-centred care.

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Appendix 14 - Lead organisations - essential ingredients for success

The following table includes the answers given by project leaders in response to the question - are there any essential ingredients for success (the ‘must have’ or ‘must do’) of the project? Each row in the table summarises the responses for one project over the course of the four progress reports submitted by that project.

Essential ingredients for success
Must understand the health literacy of the workforce and the environment in which they work. Ability to engage interested people with a variety of skills (multidisciplinary team) who have trust and willingness to work together. Project team must have a service philosophy which is underpinned by enthusiasm and a collaborative team approach.
Trust and good communication between the key staff.
Sound governance structures. Regular, clear lines of communication at all levels of the project. Committed project officers with a sound knowledge of facility procedures and issues faced. Key drivers to engage project participants, maintain momentum and lead change. An evaluation team who appreciate the limitations of the project and can adapt evaluation to suit the project. Identify evidence-based processes and tools that are readily available, user-friendly and have intuitive logic in their application (i.e. find and use the best bet that provides the best fit). Adequate time and resources are necessary to plan, implement and assess the impact of new strategies to subsequently drive change.
The funded champion position is essential not only in terms of their role within the organisation and the consortium activities, but also as a demonstration to the organisation that having such a role, even with a minimal .2 EFT can be effective in implementing change and how it can be cost effective for organisation to write such a role into key staff position descriptions to ensure sustainability. The champion position must be supplemented by assistants as a risk management strategy in larger facilities. A stand alone position leaves organisations open to significant risk of not being able to manage the implementation process in their organisation. It is essential to have a dedicated driver within the organisation to implement best practice. However, we also feel it is essential to have a clear directive identifying tasks and responsibilities for others in the organisation to support the Champion and effect change that sustainable. We see this clearly sitting with the Quality Manager or the individual responsible for quality improvement and should include a multidisciplinary best practice group representing all levels of staff.
Regular communication, reporting and documentation between all partners within the project. Support from management is critical. Also, it appears important that managers of facilities have volunteered to be involved as this appears to lead to greater involvement and uptake of activities than in facilities where a health service has volunteered one of their facilities to participate, without consulting the actual facility and the manager in much discussion about what the project will involve. Having an enthusiastic and dedicated resource nurse also appears to be critical.
Regular communication between all members of the project consortium (both within each organisation and between the different consortium members) A committed and enthusiastic senior member of the aged care staff to facilitate uptake of the learning initiatives amongst all staff (loyalty to the team leader seems to engender better training outcomes and greater compliance with the project goals) More broadly, the goodwill and commitment of the residents to be ready to undertake change and assist staff in providing best evidence based options is an absolute requirement. A committed and knowledgeable project team who are experienced in the delivery of training and evaluation activities within the specific context of residential aged care is an important requirement and also seems to influence outcomes (this is currently being examined as the level of experience and specific knowledge in pain management varied between the clinical nurse educators/project officer across the different facilities). Sufficient funding to help cover the increased workload associated with the implementation of a new quality improvement initiative.
Project team - commitment and team work; effective communication between all team members; access to relevant expertise. Participants - committed leadership within facilities; effective communication and team work; commitment to providing evidence-based practice and care
Ensure the delivery of information, presentations, feedback and training is appropriate for target audiences within facilities, due to cultural and linguistic diversity among staff members. Remuneration to the facilities needs to be more generous.
High level of communication and engagement with direct care staff and management and provision of information and educational materials. Need to develop ways of informing residents and family about changes in treatments. Recruit a supportive team with leadership and change management skills.
The engagement of the aged care sector and all consortium partners is the essential ingredient for success. The partnership approach has paid dividends. We have presented academic focused best practice in simple and user friendly messages using a minimum of terminology.
To achieve success the project must: be adequately resourced and administered be supported by credible, known local leaders allow time for development of collaborative, trusting and collegial working relationships allow time for development of understanding of what each partner wants and needs, ability and willingness to negotiate to achieve this engage all levels of facility staff, residents and carers assist facility staff to identify areas of need and opportunities for practice involvement provide resources and avenues for facilities to act on areas of need provide continuous feedback on planning and progress towards goals maintain good communication all along the way – and perseverance to achieve this.
At this point the key ingredients include: collaboration with the facilities at early inception of the project and as the project is conducted. management support that is evident to staff for the project frequent support and encouragement from the project team to all levels of staff appointment of project liaisons as one point of communication reporting back successes to all levels of staff clarity on how implementing evidence based practice will benefit the residents and their families. engagement with key stakeholders both within the organisation and those external such as general practioners, specialist palliative care services and other health professionals who provide expert consultancy. appointment and training of link nurses to be the key change agents and drivers of palliative care enough link nurses to cover all shifts/days of the week including holiday relief.
Effective communication between the project team and the facility managers, champions and the project trainers. Collegiality, respect for one another’s contributions, patience and commitment to achieving the project goals. Ensuring all staff are ready for change, including the champions, the service and care managers and the staff, i.e. agreeing to the need for looking more deeply into services and their impacts on the organisation, residents, families and staff; and agreeing to putting in some effort into reviewing and improving some services, and being open to suggested improvements in a range of services for the benefit of residents.

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Appendix 15 - Factors influencing implementation of evidence-based practice - results from EBPRAC national workshops

Round 1 workshop March 2009

At the second Round 1 workshop conducted in March 2009 a session using a modified Nominal Group Technique was held for those attending from facilities. Participants were asked ‘what factors influence the implementation of evidenced-based practice in residential aged care based on your experience with the EBPRAC project and any similar projects or attempts to change practice that you have been involved in?’

Participants self-selected into two groups, with 12 opting to answer ‘what helps’ and 23 opting to answer ‘what hinders’. Each group was facilitated by a member of the evaluation team. In total, participants identified 102 descriptions of what helped or hindered which were then entered into an Excel spreadsheet to be sorted and analysed. Descriptions of what helps or hinders essentially represented ‘two sides of the same coin’ e.g. adequate resources helps, inadequate resources hinder; a receptive context helps, a non-receptive context hinders. The most frequently cited factors were the context for change (37% of the total), resources (26%), staff with the necessary skills (11%) and engagement of stakeholders (10%). The availability of resources was identified most frequently as a factor helping implementation (29% of ‘helping’ factors) and context most frequently as a factor hindering implementation (46% of ‘hindering’ factors).

Round 2 workshop February 2010

A similar session to the one undertaken at the March 2009 workshop took place at the equivalent Round 2 workshop in February 2010. Participants were asked ‘what factors influence the implementation of evidence-based practice in residential aged care?’ However, rather than being asked to identify ‘what helps’ and ‘what hinders’, they were asked to apply a ranking to the eight factors identified in the literature review plus one other factor (leadership) which has emerged as a factor over the course of the evaluation. Up until then leadership had been subsumed into the working definition of context.

Participants were given a form listing the factors and asked to allocate 100 points across the factors i.e. to give an indication of what they thought was the relative importance of the factors. The factors were listed alphabetically. Options for allocation of points potentially ranged from all 100 points allocated to one factor to 100 points allocated equally across all factors. Participants also had the option of identifying additional factors and allocating points to those factors. Sixty people working in facilities completed the exercise and the results are summarised in the table below.

Factors that influence implementation of evidence-based practice

Factor	Average score
Adequate resources	25.0
Leadership	18.7
Demonstrable benefits of the change for residents or staff	12.3
Stakeholder engagement	12.1
Staff with the necessary skills	8.9
Receptive context for change (other than leadership)	7.2
Systems in place to support the use of evidence	6.0
Model for change/implementation	5.1
The nature of the change in practice	3.1
Other factors	1.3
Total	99.7

‘Other factors’ (as written by participants) included ‘clinical issue – responsibility’, ‘accreditation’, ‘skill mix needed to meet resident care’, ‘defining role and clinical competence requirements’. The results for five participants did not sum to 100, with total scores of 102, 101, 109.5, 115 and 50. Adjusting the scores that these participants assigned to individual factors to sum to 100, while maintaining the relative importance of each factor identified by the participant, had no impact on the ranking of the factors and little impact (maximum change of 0.3) on the average scores.

Both groups identified adequate resources and stakeholder engagement as important factors. Adding the scores for ‘receptive context for change’ and ‘leadership’ in the second of these sessions identifies the importance of context in a similar way as the first session did. The main difference between the two sessions is the importance placed on ‘demonstrable benefits’ by the second group. Of the eight factors from the initial literature review three were identified as relatively unimportant by both groups – the nature of the change in practice, model for change/implementation and systems in place to support the use of evidence.
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Appendix 16 - Comparision of processes of care and resident outcomes

The following table summarises changes in resident care and resident outcomes for the EBPRAC projects. The former are those changes that influence resident care in some way e.g. environmental changes are included because such changes can influence the experience of care for residents. Four projects did not evaluate resident outcomes, but rather focused on evaluating changes in practices. This was entirely appropriate and in accordance with the original funding submission for each project.

Project title	Changes in resident care (primarily changes in processes)	Resident outcomes
NARI pain	Major improvements in compliance with a set of 27 standards developed for the project, with 21-24 of the standards being met by the facilities at project end (compared to 6-12 pre implementation). Improved uptake of standardised pain assessment tools in some facilities. Increase in appropriate use of analgesic medications for management of persistent pain and greater utilisation of non-pharmacological approaches.	Considerable variability in resident outcomes at different facilities. Some facilities reported a reduction in observer rated pain, whereas most facilities found no change or even a slight increase in reported pain.
UN nutrition	Different changes in practice implemented in each facility, none of which were measured to identify extent of changes.	Mixed picture for changes in the nutritional status. Between baseline nutrition assessment and final nutrition assessment the level of nutrition improved for 16% of residents, was maintained at a good level of nutrition for 26% of residents, maintained at a poor level of nutrition for 24% of residents and deteriorated for 33% of residents. No significant change in Body Mass Index. No clear pattern for quality of life scores with most facilities having a mean change close to zero.
NARI falls	Of the 16 areas of falls prevention interventions that were measured, all eight facilities reported improving practice in at least four areas and six facilities reported improvements in at least ten areas.	9% increase in rate of falls. No consistent pattern in individual facilities with falls rates either declining or increasing. Reduction in fall related injuries.
SA dental	Use of oral health assessments. Project focused on six ways of maintaining a healthy mouth: brush teeth morning and night; high fluoride toothpaste on teeth; soft toothbrush on gums, tongue and teeth; antibacterial product after lunch; keep the mouth moist; cut down on sugar. Extent of changes not measured directly but residents reported improved practices.	Improvement in oral health status (as measured by oral health assessments). Resident’s own rating of oral health improved. Need for dental referral decreased. No significant change in residents’ self-rated general health, or the percentage of those who reported problems in eating and enjoying food. Oral health-related quality of life did not change significantly.
DATIS meds	Increased use of panadol on a regular basis. Decreased use of prn benzodiazepines. Increased use of alternative strategies to deal with pain, behaviours of concern and sleep issues.	Not measured.
QUT wounds	Increased use of pressure reducing strategies, other strategies to prevent pressure ulcers and strategies to prevent other wound types. Increased use of pressure risk assessment on admission. Improved documentation of wound assessments and wound management. Significant increase in the use of an emollient or soap alternative for bathing residents. Residents reported appreciation of the opportunity to take control and be able to implement preventative strategies and appropriate wound care themselves.	Decreased prevalence and severity of wounds, including pressure ulcers, leg ulcers.
PW inf control	Different changes in practice implemented in each facility. The changes were not measured.	None of the ten clinical indicators showed a pattern of improvement, including the four indicators for infections.
MGPN pall care	Increased discussion with residents and families regarding advance care planning. There is no evidence of consistent changes in work practices. End-of-life care pathways introduced but extent of use not measured (most facilities expressed an intention to adopt pathways). No change in proportion of residents who had a case conference. Poor uptake of palliative care assessment tools.	Not measured.
NEVDGP pall care	Use of end-of-life care pathway in 43% of instances where it could have been used, with use highly variable between facilities. Increased provision of written information to residents and families. Fewer residents transferred to hospital and subsequently returned to facility prior to death.	Not measured.
UQ pall care	Improvements in documentation of advanced care planning, end-of-life care (with use of end-of-life care pathway) and symptom assessment. Improved use of assessment tools. Improved pharmacological treatment of depression and referral to specialist services. Use of palliative care case conferences.	Not measured.
UTS behav	Increase in positive social interaction between staff and residents. Mixed results for changes in number of psychoactive drugs administered. Changes to physical environment, including improved signage.	Mix of results for number of reported incidents (decrease in one facility, increase in four facilities). No change in level of apathy experienced. Reduction in aggression. Improvement in agitation scores. Decline in risky wandering in four facilities. Little change in quality of life. Mixed results for measure of well-being, with some small improvements.
HC behav	Fortnightly mentoring meetings involving mentor and staff caring for residents with challenging behaviour. Improvements to the physical environment.	Steady decline in agitated behaviour and psychiatric symptoms. Reduction in depression.
MU behav	Increased use of resident life histories and well-being checklist. Use of needs based problem solving to address behaviours of concern. Increased proportion of staff saying they knew the resident as unique individuals. Increased personal enhancers and decreased personal detractors of person-centred dementia care. Improvements to the physical environment. Reduction in use of psychotropic medications.	Improvement in resident autonomy. Reduction in behaviours of concern e.g. verbal disruption, physical aggression, socially inappropriate behaviour, wandering or intrusiveness. Reduction in day-time sleep. No change in overall quality of life. More meaningful occupation of residents.

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Appendix 17 - EBPRAC resources of care generalisability of those outcomes

Project title	Resources developed	Comments regarding generalisability
NARI pain	The clinical nurse educators involved in the project developed a range of educational materials including PowerPoint presentations and a Principles of pain management and assessment workbook, one for nurses (45 pages) and one for personal carers (35 pages).	The project has a page on the Australian Centre for Evidence Based Aged Care website that includes the workbook and other resources. People are free to select what they want to use.
	The project developed a tool for ascertaining the current level of compliance of any facility against 27 key standards for the provision of best practice pain management.	Assessment using the tool is quite a complex task requiring good knowledge of pain management. The tool could be simplified for more general use but this would require further development. The simplified tool could be used to assess quality of care and identify areas for improvement.
UN nutrition	Developed a Tool Kit for Best Practice Nutrition and Hydration in Aged Care based on experience over the course of the project. The Tool Kit has a focus on screening, assessment and measurement, including how to screen for nutritional risk, calculate Body Mass Index and energy intake, and assess plate wastage. It contains a set of ‘myth busters’ and a mix of information sheets, case studies and various charts/forms that can be used by facilities.	There is no reason why the Toolkit couldn’t be used extensively
NARI falls	Developed a web-based resource which provides a guide to implementing falls prevention interventions - Working together to prevent falls in residential aged care: resource package. The package includes ‘useful links’ to other websites and is intended to provide a guide for any facility hoping to implement a falls prevention program.	The resources are already available on the National Ageing Research Institute website.
SA dental	Developed three educational resource portfolios accompanied by a series of posters, resident information and an oral health resource kit. One portfolio is for general practitioners and registered nurses and focuses on oral health assessment, oral health care planning and dental treatment; one is for facilitators (whose job it is to train staff) and one is for facility staff.	This material formed the foundation for the national training package implemented as part of the Oral and Dental Health Care Plan for residential aged care.
DATIS meds	Developed a complete set of resources for each of the three educational modules used in the project, including an educational visiting training module and background folder, ‘detailing’ or education visiting cards, resident brochures, flow chart, information sheet and evaluation questionnaires.	The resources are designed for a particular approach to education (academic detailing) and should be used for that purpose.
QUT wounds	The RACF Wound Management Education and Self-evaluation Resource Package includes evidence based guideline summaries, tip sheets, flow charts, brochures for health professionals and brochures for residents on various aspects of wound management, including skin care, skin tears, venous leg ulcers, arterial leg ulcers, diabetic foot ulcers, pressure ulcers, wound care and assessment. A one-page audit form that can be used for ongoing assessment of wound management is also included. There is a Dressings Resource Folder on appropriate dressing types, an interactive CD with 8 self-directed education modules, a self guided quiz at the completion of each module, and links to all the project resources to complete the Wound Management Education and Self Evaluation package. A Champions for Skin Integrity Resource Folder includes the majority of the resources in addition to information on roles and processes, links for further information and tools to assist implementation.	The brochures and tip sheets can be used as stand-alone aids. Using the evidence summaries to translate the evidence into practice would require a person with some expertise in wound management to provide appropriate education to support the evidence summaries e.g. some form of ‘champion’ role. The modules on the DVD are designed for people with at least a Certificate III to learn independently but would benefit from some guidance about specific roles and responsibilities (which may vary from one facility to another) and need for skills development.
PW inf control	An Infection Control Collaborative Program Handbook was developed at the beginning of the project. The Handbook provides information about the Collaborative methodology used by the project team, as it can be applied to infection control.	The Handbook is specific to infection control and the Collaborative Methodology i.e. not generalisable
MGPN pall care	Developing new resources was not a focus of this project. Instead, existing resources were adapted for use in the project, including tools to assist with data collection, and inform staff (using folder and DVD) about how to conduct multidisciplinary team meetings. A pamphlet was developed on ‘ten things to know about grief’.	The resources used in the project were adapted to the local context and hence are not widely generalisable.
NEVDGP pall care	Audit tools for self-assessment of use of end of life care pathway. Two education modules, (one on pain and one on agitation, breathing difficulties and mouth discomfort) designed for delivery using academic detailing. Each module is adapted for use with three audiences – general practitioners, nurses and personal carers.	The educational modules are designed for a particular approach to education (academic detailing) and should be used for that purpose.
UQ pall care	The Palliative Approach Toolkit is a comprehensive 85-page document which provides practical tools for implementing a palliative approach in residential aged care. The Toolkit includes three modules, one for managers; one on the key processes in a palliative approach (advance care planning, palliative care case conferences, end of life care pathways); and one on five domains of clinical care – pain, dyspnoea, nutrition and hydration, oral care and delirium. The Toolkit is supported by three self- directed learning packages for nurses (introductory and advanced) and personal carers; two educational DVDs (entitled Suiting the needs and All on the same page) and five in-service educational flipcharts targeting personal carers.	The Toolkit could be made widely available ‘in tandem’ with the release of the updated palliative care guidelines for residential aged care.
UTS behav	The EN-ABLE Toolkit is comprehensive and contains the following sections: introduction, education program, champion’s guide, resident assessment guide, implementation and evaluation guide, and a guide to available resources. Also included are CDs which provide electronic versions of presentations and tools used during the project. The education section includes sections about dementia; person-centred care and communication; Need Driven Behaviours and behaviour assessment; a person-centred approach to Need Driven Behaviours; and evidence-based practice and implementing change. Each section of the Toolkit is bound and included in a box file for the participating facilities.	The EN-ABLE Toolkit has been designed for use as an integrated package. This limits the generalisability of the toolkit to those organisations with the resources to train the champions and staff according to the EN-ABLE approach. The toolkit is constructed in such a way that components could be used separately. Additional material in the toolkit would assist those with some elements of the model in place who would like to select components of the toolkit to suit their particular needs.
HC behav	The project assembled a toolkit which includes information about environmental auditing, staff training (student handbook, trainers manual, and presentations), mentoring, family support and evaluation of outcomes. The toolkit will include a DVD produced by the Aged Care Channel and a booklet about the experiences of the project mentors.	The audit tool can be used to audit the environment, identify areas of need and develop action plans. It would be preferable that this occur with some specialist input. The educational materials can be used in all facilities. The use of the material on mentoring will be dependent on the availability of a suitably qualified mentor. The material on the establishment of family groups can be used in most facilities, preferably with a mentor involved.
MU behav	Two interactive e-learning CDs for provision of in-house education by facilities. The first CD includes information on dementia care and needs-based problem solving. The second CD (also available as an audiotape) includes 20 ‘micro-training’ topics, each consisting of a one minute video message followed by a question which staff can try and answer as a group for another minute or two. The CDs are supported by various documents, including a well-being checklist and policy audit tool.	The resources can be taken up and used by others without the expertise available to the project team i.e. the resources are generalisable.

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