Overall, the majority (74%) of providers were successful in completing the PAL Card quality improvement project. Providers implemented PAL Cards with virtual coaching support and reported them to effective in communicating important preferences. The RE-AIM framework was utilized to evaluate the implementation strategy.
Offering the intervention as a state-approved quality improvement project facilitated reaching several providers from across Ohio. By advertising the project through multiple avenues, including conferences and newsletters, providers of varying locations, sizes, for-profit status, and star ratings were reached. Providers dropped out for numerous reasons, but the most common cause was leadership and/or staff turnover. Leadership turnover has been identified as a barrier in other nursing home quality improvement studies [29–30]. Dedicated high-level leaders and project champions are essential to keeping a project on track, so turnover in these key positions made it challenging to move the project forward .
Providers who completed the project perceived the intervention to be effective via three pragmatic outcome indicators associated with adoption of evidence-based practices . First, the intervention was reported as acceptable or appealing. Providers welcomed the PAL Cards and reported that they met their approval. Second, the intervention was perceived as appropriate or compatible in the nursing home setting for use with residents and families to communicate important preferences. Providers reported that the PAL cards were suitable and seemed like a good match. Third, PAL Cards were deemed feasible. Providers reported that the evidence-based intervention was implementable, possible, doable, and easy to use. In addition, residents reported that the information on the PAL Cards was highly accurate. This validates prior research that shows that older adults can communicate their preferences, and preferences remain stable over time . These outcomes are relevant to assessing stakeholder’s perceptions of interventions, as well as assessing perceptions of implementation strategies. Assessing these outcomes early in the research process may ensure that interventions and implementation strategies are optimized and fit with each user’s preferences.
The built-in flexibility of the intervention was an aspect that led to success. Providers had choice and could adapt the intervention to their context in a number of ways. Depending on their perceived bandwidth, providers could choose from a shorter, 8-item preference interview or a longer 33-item version. Some providers started with 8-items, but added additional items when they felt limited in the information obtained. There was also flexibility in terms of who implemented the intervention. Staff from a variety of positions including social work, activities, nursing, and volunteers took on roles in the project. Some providers used teams of staff, while others took on the project solo (either by choice, or by necessity).
The flexibility in approach led to a wide range of times to complete the preference interviews and PAL Cards. Some providers viewed the preference interviews as more of a relationship-building activity, and, for example, interviewed residents over lunch, which increased the time. Other providers took a more focused approached and tried to complete the cards as quickly as possible to fit in with their other job responsibilities. Comfort levels with technology was another factor that influenced the time needed to create the PAL Cards, as some providers who lacked the technical skills, such as how to download a file, needed more time to learn the process. The flexibility providers had regarding placement of the PAL Card also assisted with meeting their needs. Our initial recommendation was to have the resident decide where their card was placed, i.e., on their walker, wheelchair, or in their room. During the project, some providers reported it was easier to have a uniform location for all PAL Cards in their community, such as on a bulletin board or by residents’ doors. This allowed staff to consistently know where to find the cards. Finally, family members played an important role in the project, especially in providing information about residents’ preferences. While we have always acknowledged the potential to involve family in the process, especially as proxies for residents who are unable to communicate, we knew it would add complexity to the project. Therefore, we did not foresee providers involving families to the extent they did in this study, nor did we systematically ask about the assistance from family in the PAL Card process. This is an important consideration for future studies.
The implementation strategy of a virtual coach (one of the research team members) played a vital role in collaborative problem solving with providers. For example, technology was often a barrier and some providers needed one-to-one support with downloading the PAL Card template, printing and laminating the cards, and using video conference software. The coach also helped providers problem solve components of their implementation strategy. Two of the most common conversations were deciding which preference interview version to use and which residents the provider would trial the project with. Discussions with the coach helped providers adapt the intervention to their local contexts while facilitating information sharing with other providers. Finally, the research team created resources to remediate barriers, when possible. One example was that some providers struggled to collect residents’ biographical information needed for the front of the PAL Card. The team created a tip sheet addressing this topic to share with providers. The role of an external advisor as a problem solver has been validated in other nursing home QIPs .
We estimated the cost of initial implementation in order to understand the intervention’s scalability and impact on resources (e.g., staff time). While the materials cost for the PAL Cards (paper, printing, laminating) is low, it is also based on providers already having the tools needed to create the cards, such as a printer, laminator, and lamination supplies. The staff time needed to conduct the preference interview and make the card accounts for the bulk of the intervention’s cost. We viewed this as an important investment due to the ability to build relationships between residents and staff through the process. However, we also recognized that some providers were able to use volunteers to implement the intervention. Therefore, we encouraged providers to delegate aspects of the PAL Card process when possible to contain costs and sustain the intervention. In addition, we collected the time needed for the initial learning curve. It is likely that costs may decrease as the learning curve levels off and staff become more efficient with PAL Card creation. It is unlikely that preference interview time would decrease substantially.
PAL Cards overwhelmingly remained in place throughout the duration of the project. Despite champions’ concerns that cards would be accidentally removed or lost, only a small percentage of cards went missing or needed to be replaced. One consideration to maintaining the cards is that because they often are placed on a wheelchair or walker, they are at risk of being lost when these ambulatory devices are cleaned. In addition, one provider discussed how residents occasionally ended up using wheelchairs/walkers that were not their own, which caused confusion when staff would associate the PAL Cards with the wrong individual. While the majority of PAL Cards remained in place, it is unknown to what extent providers continued on with the project. Prior research on evidence-based programs has found that long-term implementation suffers once intervention supports (such as an external research team) are removed . Staff turnover is another potential barrier to maintenance if the responsibilities for interviewing and PAL Card creation are not incorporated into staff job descriptions and standard operating procedures.
Limitations and Future Directions:
The findings of this study are limited by several factors. First, providers self-selected into the QIP. It is possible that the characteristics of the providers who opted in are different compared to providers who either chose another QIP offered by the State, or did not need a QIP during the timeframe ours was offered. In addition, we were only able to collect data from providers who completed the project. Despite multiple follow up email and telephone calls, we were unable to reach some of the participants to follow-up. Therefore, we have very limited information on those providers who did not complete. Learning more about those who did not complete the project would help us better understand the barriers to implementation. Additionaly, all the data in this study was self-reported. The findings, such as time to complete preference interviews and PAL Cards, may not accurately represent the actual time as providers may have ‘rounded up’ or estimated the length of time either the interview or PAL Card creation took. In addition, the cost of implementing the PAL Cards should also be interpreted with caution. Staff wages used to calculate the costs were taken from online sources, which may not accurately reflect the wages of providers in Ohio. Additionally, there may be a wider range of costs than what was presented depending on the specific staff position. For example, within the category of nursing, there are a variety of positions including LPNs, RNs, and DONs, which have a wide range of salaries. We did not ask for staff to specify beyond ‘nursing’ as a department. We estimated the value of volunteers because while volunteers may not encumber salary costs, there are costs associated with their training and supervision. We recommend that providers using volunteers be trained in how to conduct the preference interviews (training video available at www.preferencebasedliving.com at no cost) . In the future, qualitative research on PAL Card implementation is needed to understand the varying approaches providers used. The results of this study show a large variation in the preference interview time and PAL Card creation time, which makes it difficult to generalize to what other providers will experience. Obtaining qualitative data on the barriers and facilitators to implementing the PAL Cards will allow for the implementation process to be improved.