Pragmatic trial to increase quality of care in State Veterans Homes: Improving safety using an evidence-based, frontline staff huddling practice

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Background: State Veterans Home nursing homes (SVHs) care for 51% of all Veterans receiving VA-funded nursing home care. SVHs cost VA $1.2 billion yearly in per diem payments. This critical system provides care to a population of over 20,000 vulnerable Veterans annually but has been little researched and is in urgent need of attention. In some SVHs, the COVID-19 pandemic has resulted in large numbers of preventable illnesses, hospitalizations, and even deaths. Congress, the Government Accountability Office, and the Secretary have all called for greater VA involvement in this system that lacks a national quality improvement infrastructure and lags behind VA on many quality measures, including falls. This proposal addresses SVHs' need to reduce high fall rates—55% of residents experience at least one fall per quarter—by implementing an effective, evidence-based program known as LOCK. In LOCK, staff (1) “Learn from bright spots” (focus on evidence of positive change); (2) “Observe” (collect data through systematic observation); (3) “Collaborate in huddles” (conduct frontline staff huddles); and (4) “Keep it bite-size” (limit activities to 5-15 minutes). The program avoids reliance on existing quality improvement infrastructures, can be easily integrated into frontline staff routines, and has demonstrated success in improving clinical outcomes, including reductions in falls. Significance: This study provides the following. (1) Timely, evidence-based research support to improve care for SVHs' vulnerable population of aging Veterans. (2) Explicit integration of frontline staff expertise, ensuring interventions are practicable and successful. (3) Direct alignment with high-reliability principles—such as sensitivity to operations and deference to expertise—helping extend VA's high-reliability focus to SVHs. Innovation and Impact: This study contributes the following. (1) Advances the science of how to intervene in settings that do not have a strong, centralized quality improvement focus through rigorous investigation of how and why an intervention works in SVHs. (2) Investigates sustainment of our intervention—the extent to which it becomes part of usual care—for up to 12 months after completion of each step of our wedge-based design. (3) Provides timely, systematic investigation of a new area for VA research, gathering information on VA researcher-SVH partnerships to support future collaborations. Specific Aims: Aim 1: Investigate the effectiveness of the LOCK program at improving our primary outcome of any resident fall. We will also investigate other resident clinical outcomes (mobility, medication changes, restraint and alarm use) and work-process outcomes for staff (job satisfaction, work engagement, burnout). We will use both primary and secondary data collection. Aim 2: Evaluate the LOCK program's implementation. We will use the replicating effective programs framework and multi-modal implementation facilitation strategies to implement the program. We will use mixed methods to evaluate the program's reach, adoption, and implementation. Aim 3: Assess the extent of program sustainment. Mixed methods will enable us to examine intervention sustainment at 3, 6, and 12 months post intervention and sustainment variability among sites. Methodology: This is a 4-year hybrid (Type 2) effectiveness-implementation study. It uses a pragmatic stepped-wedge randomized trial design and employs relational coordination theory and the RE-AIM framework to guide implementation and evaluation. Next Steps: This study (1) directly improves care for aging Veterans, (2) advances understanding of how to intervene in settings lacking quality improvement infrastructure, and (3) contributes knowledge about intervention sustainment. This study also addresses VA's Research Lifecycle stages of (a) scale up and spread and (b) sustainment. Our operational partners (Office of Geriatrics and Extended Care and the National Association of State Veterans Homes) are fully committed to using our findings to improve care across SVHs. Findings may also help improve care in other settings (e.g., inpatient mental health and domiciliary programs).