Implementation of Goals of Care Communication Innovation Among Nursing Homes: A Multiple Case Study Design

Abstract

Objective: Nursing homes (NHs) provide care to residents with serious illness and related complex health care needs. As such, discussions about end-of-life care between NH staff and residents and families are necessary to ensure residents receive care consistent with their goals. Interventions such as video decision aids have been developed to promote discussions and improve advance care planning, but few studies have examined how NH characteristics may relate to the implementation of these interventions; such information might lead toward more use of successful interventions. The purpose of this study is to understand NH characteristics that are associated with the implementation of the Goals of Care (GOC) intervention, which combined a video decision aid with a structured discussion to guide decision-making in advanced dementia.

Design: A multiple case study.

Setting and participants: Staff surveys were conducted to examine factors related to implementation effectiveness in 11 NHs in North Carolina that participated in the GOC trial.

Methods: Questions measured the dependent variable of implementation effectiveness: the consistency and quality of use of the GOC intervention. NH organizational characteristics were measured using publicly available data and an administrator survey. The analysis consisted of pattern matching logic.

Results: High management support aligned with implementation effectiveness within NHs. In addition, the within case pattern analysis indicated additional characteristics related to implementation effectiveness. Facility size, Medicare beds, residents' racial composition, and star rating were related to implementation effectiveness across 6 of the 11 NHs. NH financial resources, such as size and number of Medicare beds, may be important factors for successful implementation.

Conclusion and implications: NHs seeking to implement advance care planning interventions should focus on within and across NH differences, such as adequate management and financial support prior to implementation to increase the likelihood of implementation effectiveness.

Keywords: Nursing homes; case study; goals of care; implementation; resources.

Fig. 1.

Theory of innovation implementation that guides this study. Klein et al: Theory of Innovation Implementation Framework Adapted Version. The dotted lines indicate the pathways depicted in the original Klein et al framework. The solid lines indicate how the conceptual framework was adapted for this study.