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

Appendices 7 to 12

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• Appendix 7 - PivotWest infection control project
• Appendix 8 - Murrumbidgee General Practice Network palliative care project
• Appendix 9 - North East Valley Division of General Practice palliative care project
• Appendix 10 - University of Queensland palliative care project
• Appendix 11 - University of Technology Sydney behaviour management project
• Appendix 12 - Hammond Care behaviour management project

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Appendix 7 - PivotWest infection control project

Project title	The infection control collaborative
Leader	No one individual could be considered the leader of this project. Various staff from PivotWest provided project leadership over the two years of the project. PivotWest is a division of general practice based in the western suburbs of Melbourne.
Consortium partners	Aged Services Management Unit, Victoria University, Melbourne, Victoria (evaluator) Improvement Foundation Australia, Adelaide, South Australia. MarJen Education Services, Eltham, Victoria.
Participating facilities	Eight facilities in the western suburbs of Melbourne, of which one withdrew from the project in early 2010. A positive aspect of the project is that it included a higher proportion of private ‘for profit’ facilities. Private facilities were generally under-represented across the EBPRAC program.
Sources of evidence implemented by the project	Australian Government Department of Health and Ageing (2004) Infection Control Guidelines for the Prevention and Transmission of Infectious Diseases in the Health Care Setting.
Model of change for implementing the evidence	The project built on previous work undertaken by Improvement Foundation Australia as part of the Australian Primary Care Collaboratives Program which aims to improve a range of health indicators in general practice. The project used a quality improvement approach to implementation, based on the Collaborative Methodology. There are different versions of the methodology but the basic concept is that ‘every system is perfectly designed to give the result that it gives’ and hence the focus is on changing systems to achieve improvements. Key features of the methodology included an expert reference panel which set the aims and measures for the Collaborative; local teams in each facility; three learning workshops where the local teams came together to share what they had learnt; action periods using Plan-Do-Study-Act (PDSA) cycles to bring about change; setting targets and monitoring improvements and using a set of change principles. An infection control handbook was developed to guide the facilities in what they did and education provided to facility staff on infection control.
Main intended outcomes	Reduced infections and better quality of life. To have up-to-date information and knowledge in infection control within aged care facilities. Reduce infections by 30% within 18 months (1 April 2009 to 30 September 2010). Spread what has been learnt to other residential aged care facilities beyond the project’s initial catchment area.
Examples of changes implemented	Reducing overloading of linen skips (to reduce the incidence of soiled linen touching staff clothing). Encouraging visitors to wash their hands when entering a facility. Chest physiotherapy for resident with signs of infection. Reinforcing the wearing of hairnets by staff in the kitchen.
Project evaluation	Each facility collected their own data on the ten clinical indicators. Collection of the data was as much a part of the intervention as the evaluation. The qualitative component of the evaluation was intended to consist of observing on-site education of facility staff; focus groups in each facility with staff, residents and family; and semi-structured interviews with staff, residents and families. Involvement of residents and families in this component of the evaluation is described in the project final report as ‘very informal and low key’, with involvement of staff described as ‘similarly low key’. Only one focus group (with staff) was undertaken, with no semi-structured interviews. Various reasons are given for this in the report - the difficulty of obtaining consent, frailty of the residents, staff with low levels of literacy. The project evaluators intended to conduct an economic evaluation. This has not been done. The justification for not doing so is that it was not possible to collect any cost data during the project but there are no reasons given for why this was not possible. The project final report states that the Collaborative methodology ‘could not be independently evaluated’ by the evaluator from Victoria University.

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Appendix 8 - Murrumbidgee General Practice Network palliative care project

Project title	Encouraging best practice palliative care in residential aged care facilities from rural communities within NSW, South Australia and Victoria.
Leader	Dr. Keith McDonald, Murrumbidgee General Practice Network, New South Wales.
Consortium partners	Mallee Division of General Practice, Victoria. Murray Plains Division of General Practice, Victoria Riverland Division of General Practice, South Australia. Discipline of General Practice & Mater Centre for Primary Health Care Innovation, University of Queensland.
Participating facilities	Fourteen facilities in twelve locations, ranging in size from 19 - 100 beds and incorporating a mix of high and low care facilities in rural New South Wales, Victoria and South Australia.
Sources of evidence implemented by the project	Australian Government Department of Health and Ageing (2006) Guidelines for a palliative approach in residential aged care - enhanced version. Canberra. Palliative Care Outcomes Collaboration benchmarking tools. Brisbane South Palliative Care Collaborative and Lyell McEwin End of Life Care pathways.
Model of change for implementing the evidence	The change management activities undertaken by the project included using audit and feedback, the introduction of end-of-life care pathways and promotion of advance care planning, supported by specific resource development and training opportunities in different aspects of the project (e.g. advance care planning, end-of-life care pathways). The project also included the development of a minimum data set based on Palliative Care Outcomes Collaboration benchmarking tools which were modified for residential aged care. Palliative care clinical competencies were developed for facility staff, general practitioners, and other visiting health and social service providers.
Main intended outcomes	Improved quality of palliative care provided in rural residential aged care facilities. A multi-professional evidence-based framework for coordinated end-of-life care. Up skilling through access to competency-based training. Advance care plans systematically implemented. End-of-life care pathways systemically implemented. Minimal data sets consistent with relevant Palliative Care Outcomes Collaboration recommendations.
Examples of changes implemented	The division of general practice from South Australia implemented one end-of-life care pathway as part of a state-wide roll-out across all sectors. The other three divisions of general practice involved in the project implemented another end-of-life care pathway which was the same one used by the other two EBPRAC palliative care projects (the Brisbane South Palliative Care Collaborative End of Life Care pathway). Two models of advance care planning were implemented, both adaptations of the well-recognised Respecting Choices Program. Pre-implementation audits revealed that most facilities had advance care plans in place for many residents. Post-implementation audits showed an increase in some facilities, and decrease in others. The minimum data set was used for the project evaluation but nurse managers said that they would not implement the minimum data set due to concerns regarding ‘overloading staff already under stress due to staff shortages’ (project evaluation report, p 40). There was no change in the proportion of residents who had a case conference, and phase of palliative care did not influence whether care preferences were recorded or whether a case conference took place. The project evaluation report did note, however, that there were a greater percentage of residents transferred to hospital in the deteriorating or terminal phases of palliative care, which was interpreted to mean an increased awareness by staff of symptoms that may respond to treatment, and the overall limited availability of general practice services out-of-hours.
Project evaluation	An independent evaluator was employed to conduct baseline and post-implementation chart audits; semi-structured interviews, focus groups and surveys of staff and key stakeholders, relatives/carers of residents; and document reviews.

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Appendix 9 - North East Valley Division of General Practice palliative care project

Project title	A good death in residential aged care: optimising the use of medications to manage symptoms in the end-of-life phase.
Leader	Alison Sands and Melanie Rayner, North East Valley Division of General Practice Victoria.
Consortium partners	La Trobe University (lead partner and evaluator). Two divisions of general practice in South Australia (Adelaide North East Division of General Practice, General Practice Network South). Two Melbourne-based community palliative care services (Banksia Palliative Care Service, Melbourne City Mission Palliative Care Service). Drug and Therapeutics Information Service, Repatriation General Hospital, Adelaide, South Australia. National Prescribing Service. Department of Health, Victoria.
Participating facilities	14 participating facilities (at 13 different locations), nine from Victoria and five from South Australia.
Sources of evidence implemented by the project	The project was designed around two main evidence-based guidelines: Australian Government Department of Health and Ageing (2006) Guidelines for a palliative approach in residential aged care - enhanced version. Canberra. Therapeutic Guidelines: Palliative Care, 2005 and 2010 The education modules included material from other sources of evidence, including the Australian Medicines Handbook and the AMH, Drug Choice Companion: Aged Care. The end-of-life care pathway implemented was the one developed by the Brisbane South Palliative Care Collaborative.
Model of change for implementing the evidence	An action research approach was used at the project level (i.e. between the project evaluators and project team). A pilot was conducted to introduce the care pathway in three facilities and refine the evaluation tools and training materials. Change management focused on improving the knowledge and skills of general practitioners and facility staff; establishing policies, procedures and end-of-life care pathways; and promoting collaboration between general practitioners, pharmacists and facility staff. This included audit and feedback and use of link nurses in South Australian facilities. Some facilities established palliative care committees or special interest groups to promote collaborative practice. The Change Management Framework was used at project commencement to identify current practice and develop strategies to improve that practice. The Framework facilitated review of four domains related to end-of-life care - resident outcomes, policies and processes, education and clinical support. Education on medication management primarily used 1:1 education (academic detailing) with two modules (one on pain and one on agitation, breathing difficulties and mouth discomfort). In some instances education was conducted in small groups rather than 1:1. Education on use of end-of-life care pathways was delivered in South Australian facilities with a ‘train the trainer’ model - facility staff were trained by link nurses who had themselves been trained by the project team. Education in Victoria was delivered by the project team. Existing educational programs e.g. Program of Experience in the Palliative Approach program, were actively promoted during the project.
Main intended outcomes	Enhanced and consistent provision of symptom management at the end of life, that is informed by best practice. Improved communication and support for informed choice by residents and families. Improved clinical skills & confidence including: recognition, assessment and monitoring of symptoms and knowledge of medicine use at the end of life. Enhanced ability to conduct conversations with families about symptom management and medicine use at the end of life, including access to printed resources. Improved systems & processes to support anticipatory planning and the use of medicines for symptom management at end of life, in particular the successful implementation of an end of life care pathway. Improved collaboration with general practitioners, palliative care services and pharmacists. Improved systems and processes to support anticipatory planning and the use of medicines for symptom management at the end of life, in particular the successful implementation of an end of life care pathway. Improved staff capacity/skills. Improved medication supply chain. Improved relationships with residents, families, general practitioners, pharmacists & specialist palliative care services.
Examples of changes implemented	Implementation of end-of-life care pathway.
Project evaluation	Data collection included a resident chart audit, an Institutional Audit Tool (to collect data about participating facilities); telephone interviews with general practitioners; post-education questionnaires which included self-assessments of knowledge, skills and confidence; and telephone interviews with staff to collect data on their experiences with the project. Deaths and use of end-of-life care pathways were audited during the project.

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Appendix 10 - University of Queensland palliative care project

Project title	Implementation of a comprehensive evidence based palliative approach in residential aged care (CEBPARAC).
Leader	Associate Professor Deborah Parker, University of Queensland / Blue Care Research and Practice Development Centre, Brisbane, Queensland.
Consortium partners	Brisbane South Palliative Care Collaborative, Queensland. Southern Adelaide Palliative Care Service, South Australia. Cancer and Palliative Care Network, Department of Health, Western Australia.
Participating facilities	Nine facilities across three states, of which two provided a mix of high and low level care, and seven provided high care. Facilities included not-for-profit, private and government-operated, in metropolitan and rural areas.
Sources of evidence implemented by the project	Australian Government Department of Health and Ageing (2006) Guidelines for a palliative approach in residential aged care - enhanced version. Canberra. Australian Pain Society (2005) Pain in residential aged care facilities: management strategies. Brisbane South Palliative Care Collaborative End of Life Care Pathway.
Model of change for implementing the evidence	Implementation was based on the Registered Nurses' Association of Ontario Toolkit: implementation of clinical practice guidelines published in 2002, which is a well-recognised approach for those seeking to achieve evidence-based practice. Change management strategies included education, use of link nurses, and translation of evidence into more ‘user friendly’ formats to focus on the key processes involved in a palliative approach to care – advance care planning, care planning (end-of-life care pathway) and review of the care required by residents (palliative care case conferences and monthly reviews). In most, but not all, facilities this was supported by involvement of local community palliative care services who played an important role in palliative care case conferences and monthly reviews. The work developing the role of link nurses built on the expertise of the project team in previous projects using the link nurse model. The project took a broad palliative approach to care, with a focus on one aspect of that broad approach (end-of-life care).
Main intended outcomes	Palliative care case conferences convened for residents with a prognosis of less than six months. End-of-life care pathways implemented for residents who require terminal care. Changed work practices in relation to palliative care. Increased knowledge and skills of clinicians. Increased capacity of organisations to provide palliative care.
Examples of changes implemented	Palliative care case conferences for residents with a prognosis of less than six months. Monthly reviews of palliative residents by specialist palliative care nurses. Use of end-of-life care pathways for residents who are terminally ill. Promotion of advance care planning.
Project evaluation	Data was collected pre and post intervention using a stakeholder assessment tool, a tool to assess organisational readiness, telephone interviews with carers, chart audits, a survey of staff knowledge and a palliative care self assessment tool. The first two of these tools were developed by the Registered Nurses' Association of Ontario and are designed to identify who the key stakeholders are and possible barriers and facilitators for the implementation of evidence-based practice.

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Appendix 11 - University of Technology Sydney behaviour management project

Project title	The EN-ABLE project: developing and testing a toolkit for the implementation and evaluation of person-centred evidence-based responses to need driven behaviours associated with dementia.
Leader	Professor Lynn Chenoweth, University of Technology, Sydney, New South Wales.
Consortium partners	Australian Centre for Evidence Based Aged Care, La Trobe University, Melbourne, Victoria. Dementia Collaborative Research Centre – Carers and Consumers, Queensland University of Technology, Brisbane, Queensland.
Participating facilities	Six facilities participated in the project; two each in New South Wales, Victoria and Queensland, situated in metropolitan, regional and rural areas.
Sources of evidence implemented by the project	Kitwood T. (1997) Dementia reconsidered. The person comes first (rethinking ageing). Buckingham: Open University Press. Algase D, Beck C, Kolanowski A, Whall A, Berent S, Richards K. & Beattie E. (1996) Need-driven dementia-compromised behavior: an alternative view of disruptive behavior. American Journal of Alzheimer’s Care & Related Disorders, 77(6):10-19.
Model of change for implementing the evidence	Supervised application of focused, evidence-based knowledge delivered via a participatory action methodology. This involved implementing a staff training program which combined person-centred care and needs driven behaviour models ‘actualised’ using a modified action methodology called Translation of Evidence into Aged care Methods (TEAM). This included: Local ‘champions’, who were change agents supported by project staff. Use of a clinical audit tool to identify barriers and enablers to practice improvement. Meetings to obtain agreement about process indicators to be audited, developing local change plans, identifying barriers and developing strategies to overcome the barriers.
Main intended outcomes	Reduced incidence of symptoms of distress for the four Need-driven Dementia-compromised Behaviours - anxiety, apathy, aggression and risky wandering. Reduced severity of symptoms of distress for the four Need-driven Dementia-compromised Behaviours - anxiety, apathy, aggression and risky wandering. Improved indicators of resident well-being and quality of life. Improved resident assessment and care planning. Improved skills in the recognition and assessment of the four Need-driven Dementia-compromised Behaviours - anxiety, apathy, aggression and risky wandering. Improved understanding of Need-driven Dementia-compromised Behaviours by staff. Improved staff capacity to respond to Need-driven Dementia-compromised Behaviours. Provide evidence-based education resources for nursing, care and therapy staff and family carers
Examples of changes implemented	Changes to the environment in dementia units, initially using colour, pictures, and murals. Regular use of behaviour charts. Development of individualised behaviour intervention/care plans. Use of positive communication strategies by staff. Completion of cognitive assessment tools on admission. Review of personal history when a resident exhibits a Need-driven Dementia-compromised Behaviour.
Project evaluation	The project evaluation used a suite of assessment tools to undertake baseline and post-implementation data collection, targeting the residential aged care environment/context in which care was delivered, as well as the impacts of the intervention on residents (quality of life, agitation, aggression, apathy, risky wandering and pain), family/friends of residents, quality of care and care staff. The evaluation was oversighted by an expert advisory committee of Australian and international academics.

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Appendix 12 - Hammond Care behaviour management project

Project title	Improving behaviour by working with staff, families and the environment.
Leader	Richard Fleming, Hammond Care, Sydney, New South Wales.
Consortium partners	Nil
Participating facilities	Seven facilities in New South Wales and Victoria, situated in rural, regional and metropolitan areas.
Sources of evidence implemented by the project	Fleming R, Crookes P & Sum S (2008) A review of the empirical literature on the design of physical environments for people with dementia. Primary Dementia Collaborative Research Centre, University of New South Wales. Hallberg IR, Norberg A & Erikson S (1990) Functional impairment and behavioural disturbances in vocally disruptive patients in psychogeriatric wards compared with controls. International Journal of Geriatric Psychiatry. 5(1): 53-61.
Model of change for implementing the evidence	The approach to reducing behaviours of concern comprised four elements: Modifying the physical environment. Training staff regarding the causes and possible remediation strategies for behaviours of concern. Establishing a safe psychological environment for staff to explore their feelings and discover new ways to approach people with behaviours of concern. Family support groups. The main vehicle for change was the process of mentoring. Mentors were highly skilled clinical educators who worked closely with nominated individuals in each facility, delivered education and training in both clinical aspects as well as change management techniques, and supported these individuals to train others, change care practices, and facilitate the family/carer support groups.
Main intended outcomes	Reduced number and severity of behaviours of concern. Improved recognition of resident preferences as they relate to behaviours of concern. Increased quality of life for residents with behaviours of concern. Improved care planning for residents with behaviours of concern. Decreased level of stress amongst staff and family/carers. 80% of staff participated in 2-day training course. Increased use of evidence based practice in care planning processes. Enhanced knowledge and skills of direct care staff. Improved relationships between staff and carers/family members – to assist them to engage in the care of their family members. Improved understanding of the culture of each facility (from an audit of nature of family support being provided). Improved contribution of the physical environment to reducing behaviours of concern. Greater understanding by staff and management of the relationship between environment, staff and family/carers when caring for residents with behaviours of concern.
Examples of changes implemented	Environmental audits were undertaken early on, resulting in small changes to improve personal, social and open spaces within facilities, and reduce distracting/unnecessary stimulation for residents. Through the provision of mentoring, staff were provided with education and training, as well as professional and personal support. This included regular sessions with staff in a quiet and ‘psychologically safe’ place, where staff were able to voice their concerns regarding the care of residents and work collaboratively to identify strategies to reduce behaviours of concern. The changes in practice that arose out of these mentoring sessions were individual to each resident.
Project evaluation	The evaluation used a range of methods, including audits, validated assessment tools, surveys and focus groups, focusing on the main components of the project’s interventions – environment, staff and family/carers - and the impact on residents. This included identifying the impact of the project on behaviours of concern and staff knowledge. The opinions were sought of managers and families about the impact of the project. The overall evaluation was conducted by independent evaluators.

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