Evaluating the implementation of the PACE Steps to Success Programme in long-term care facilities in seven countries according to the RE-AIM framework

Abstract

Background: The PACE 'Steps to Success' programme is a complex educational and development intervention for staff to improve palliative care in long-term care facilities (LTCFs). In a cluster randomized controlled trial, this programme has been implemented in 37 LTCFs in 7 European countries. Alongside an effectiveness study, a process evaluation study was conducted. This paper reports on the results of this process evaluation, of which the aim was to provide a more detailed understanding of the implementation of the PACE Programme across and within countries.

Methods: The process evaluation followed the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework and involved various measures and tools, including diaries for country trainers, evaluation questionnaires for care staff, attendance lists and interviews (online and face-to-face, individual and in groups) with country trainers, managers, PACE coordinators and other staff members. Based on key elements of the PACE Programme, a priori criteria for a high, medium and low level of the RE-AIM components Reach, Adoption, Implementation and intention to Maintenance were defined. Qualitative data on factors affecting each RE-AIM component gathered in the online discussion groups and interviews were analysed according to the principles of thematic analysis.

Results: The performance of the PACE Programme on the RE-AIM components was highly variable within and across countries, with a high or medium score for in total 28 (out of 37) LTCFs on Reach, for 26 LTCFs on Adoption, for 35 LTCFs on Implementation and for 34 LTCFs on intention to Maintenance. The factors affecting performance on the different RE-AIM components could be classified into three major categories: (1) the PACE Programme itself and its way of delivery, (2) people working with the PACE Programme and (3) contextual factors. Several country-specific challenges in implementing the PACE Programme were identified.

Conclusions: The implementation of the PACE Programme was feasible but leaves room for improvement. Our analysis helps to better understand the optimal levels of training and facilitation and provides recommendations to improve implementation in the LTC setting. The results of the process evaluation will be used to further adapt and improve the PACE Programme prior to its further dissemination.

Trial registration: The PACE study was registered at www.isrctn.com-ISRCTN14741671 (FP7-HEALTH-2013-INNOVATION-1 603111) July 30, 2015.

Keywords: End-of-life care; Implementation; Intervention; Long-term care facilities; Nursing home; Palliative care; Process evaluation; RE-AIM framework.

Fig. 1

The six PACE Steps to Success

Fig. 2

Overall ratings on RE-AIM components

Fig. 3

Ratings per RE-AIM component by country

Fig. 4

Mean attendance rates per LTCF (Reach). BE Belgium, FI Finland, IT Italy, NL The Netherlands, PL Poland, EN England, CH Switzerland. < 30% = Low, 30–69% = Medium, ≥ 70% = High. Note: For 2 LTCFs in Belgium, not all 6 attendance lists were received from the PACE coordinator, but their level of Reach could be estimated as Medium, based on the attendance lists we did receive, information from the country trainer and from the (group) interviews.

Fig. 5

Proportion of residents with a Looking and Thinking Ahead document per LTCF (Adoption). BE Belgium, FI Finland, IT Italy, NL The Netherlands, PL Poland, EN England, CH Switzerland. < 40% = Low, 40–79 % = Medium, ≥ 80% = High. Notes: (1) For 1 LTCF in The Netherlands, no report was received from the PACE coordinator, but the level of Adoption could be estimated as Low, based on information from the (group) interviews. (2) Due to high resident turnover the proportion in some LTCFs exceeds 100% as it was calculated as ‘number of residents with document divided by number of beds’

Fig. 6

Proportion of residents with a pain assessment per LTCF. BE Belgium, FI Finland, IT Italy, NL The Netherlands, PL Poland, EN England, CH Switzerland. Note: Due to high resident turnover the proportion in some LTCFs exceeds 100% as it was calculated as ‘number of residents with assessment divided by number of beds’

Fig. 7

Proportion of residents with a depression assessment per LTCF. BE Belgium, FI Finland, IT Italy, NL The Netherlands, PL Poland, EN England, CH Switzerland. Note: Due to high resident turnover the proportion in some LTCFs exceeds 100% as it was calculated as ‘number of residents with assessment divided by number of beds’

Fig. 8

Scores for fidelity per LCTF (Implementation). BE Belgium, FI Finland, IT Italy, NL The Netherlands, PL Poland, EN England, CH Switzerland

Fig. 9

Scores for satisfaction with trainer and overall PACE Programme per LCTF (Implementation). BE Belgium, FI Finland, IT Italy, NL The Netherlands, PL Poland, EN England, CH Switzerland. Dark bars: score for satisfaction with trainer’s teaching competencies; light bars: score for overall evaluation PACE Programme

Fig. 10

Scores for intention to Maintenance, per LTCF. BE Belgium, FI Finland, IT Italy, NL The Netherlands, PL Poland, EN England, CH Switzerland. Dark bars: score for manager’s intention to continue with PACE; light bars: score for care staff members’ intention and recommendation to work with PACE in future. Manager = 1 and care staff ≥ 6 = High, manager = 1 and care staff 4–5.9 = medium, manager = 1 and care staff < 4 = low, manager = 0 and care staff ≥ 5 = medium, manager = 0 & care staff < 5 = low