Developing a roadmap for best practices in CLC resident-centered care

描述（由申请人提供）： 背景资料：退伍军人健康管理局（VHA）正在从基于医学模式的文化转变为以居民为中心的护理（RCC）。自2004年以来，为特别脆弱的退伍军人提供护理的社区生活中心（CLC）已导致向RCC的转变。区域合作委员会本身具有多方面性和复杂性，而社区合作委员会在现有措施方面差异很大。已实施多个有意义的RCC组件并同时提供高质量临床结果的CLC（即，“成功的RCC采用者”）相对罕见，并且很少有人了解他们是如何取得成功的。他们的护理结构和过程是什么？是什么促进或阻碍了在日常工作中嵌入RCC？成本结果是什么？从成功克服障碍和实施变革的社区学习中心可以学到很多东西。该项目建立在试点工作的基础上，并结合了VHA运营合作伙伴的反馈。这是对成功的RCC采用者CLC的第一次全面研究。目标：这项有理论基础的、为期3.5年的混合方法研究建立在CLC RCC的广泛试点工作基础上。结果将被汇编，以产生一个详细的了解多个途径CLC使用，以实现成功的RCC实施。在整个研究过程中，将与运营合作伙伴分享中期产品，以最大限度地发挥研究的影响。这项研究有三个目标。(1)检查RCC实施中的设施级差异。(2)在成功的采用者样本中识别有效的RCC实践。(3)制定详细说明（即，“路线图”）确定成功实施RCC的途径。方法：本研究将采用3个阶段的过程，对应于3个研究目标。第1阶段使用现有的机构级数据，使用最小数据集综合指标对CLC的住院临床结局进行排名，然后使用文化变化工具数据的伪影进一步对它们进行排名，作为RCC的指标。然后调查CLC的前四分之一（n=32），以收集关于RCC结构、流程和实施的设施级信息。32个CLC将根据关键变量进行排名，并选择8-CLC成功采用者样本。此外，还将对驻地费用进行分析。第二阶段将涉及对成功的收养者地点进行简短的现场访问，以管理居民调查并收集有关RCC的结构化观察数据。还将通过在线工作人员调查和邮寄家庭成员调查收集数据。第1阶段和第2阶段的定量结果将有助于为第3阶段的定性数据收集提供信息。半结构化的工作人员访谈将详细探讨（1）成功的采用者如何修改特定的结构和流程，以整合RCC组件并取得成功，以及（2）这些有效做法的障碍和促进因素。将使用归纳分析方法整合定性和定量数据，以创建将反馈给研究中心以供输入的路线图草案。路线图将最终确定，研究团队将与运营合作伙伴一起传播和实施路线图。预期影响：该研究将产生关于VHA中RCC的新知识。中期研究结果将汇编成可操作的报告，在第1阶段和第2阶段结束时与运营合作伙伴分享，并在第3阶段期间两次分享。定期和最终产品将提供一个成功的采用者的RCC旅程的图片。这将填补有关如何成功实施区域合作中心、促进成功的因素、如何克服障碍以及区域合作中心对驻地费用有何影响等方面的知识空白。这些发现将有助于加强对VHA一些最脆弱的退伍军人的照顾。所获得的知识将立即适用于全国范围内的CLC，并将有助于指导VHA作为一个整体进一步改善以居民为中心的护理。它还将直接导致对区域合作委员会最终路线图的执行研究。

DESCRIPTION (provided by applicant): Background: The Veterans Health Administration (VHA) is transforming from a culture based on the medical- model to one that embraces resident-centered care (RCC). Community Living Centers (CLCs), which provide care to a particularly vulnerable spectrum of Veterans, have led the shift to RCC since 2004. RCC is inherently multifaceted and complex, and CLCs vary greatly on existing measures. CLCs that have implemented multiple, meaningful RCC components and simultaneously provide high quality clinical outcomes (i.e., "successful RCC adopters") are relatively rare, and little is understood about how they achieved their success. What are their structures and processes of care? What facilitates or blocks embedding RCC in everyday work routines? And what are the cost outcomes? Much can be learned from CLCs that have successfully overcome barriers and implemented change. This project builds on pilot work and incorporates feedback from VHA operations partners. It represents the first comprehensive study of successful RCC adopter CLCs. Objectives: This theoretically grounded, 3.5-year, mixed-methods study builds upon extensive pilot work on CLC RCC. Results will be compiled to produce a detailed understanding of the multiple pathways CLCs use to achieve successful RCC implementation. Throughout the study, interim products will be shared with operations partners to maximize the study's impact. The study has 3 aims. (1) Examine facility-level variation in RCC implementation. (2) Identify effective RCC practices in a successful adopter sample. (3) Develop a detailed description (i.e., "roadmap") of identified paths to successful RCC implementation. Methods: This study will employ a 3-phase process, corresponding to the 3 study aims. Phase 1 uses existing facility-level data to rank CLCs on resident clinical outcomes using a Minimum Data Set composite measure and then rank them further using Artifacts of Culture Change tool data as a measure of RCC. Then the top quartile of CLCs will be surveyed (n=32) to gather facility-level information on RCC structures, processes, and implementation. The 32 CLCs will be ranked by key variables and the 8-CLC successful adopter sample chosen. In addition, an analysis of resident costs will be conducted. Phase 2 will involve conducting brief site visits at the successful adopter sites to administer resident surveys and collect structured observation data on RCC. Data will also be collected through an online staff survey and a mailed family member survey. The quantitative results from Phases 1 and 2 will help inform qualitative data collection in Phase 3. Semi-structured staff interview will explore in detail (1) how successful adopters modified specific structures and processes to integrate RCC components and succeed and (2) barriers to and facilitators of these effective practices. An inductive analysis approach will be used to integrate qualitative and quantitative data to create a draft roadmap that will be fed back to sites for input. The roadmap will then be finalized, and the study team will work with operations partners to disseminate and implement it. Anticipated Impacts: The study will generate new knowledge about RCC in VHA. Interim study findings will be compiled into actionable reports that will be shared with operations partners at the end of Phases 1 and 2 and twice during Phase 3. The periodic and final products will provide a picture of successful adopters' RCC journeys. This will fill the gap in knowledge about how RCC can be successfully implemented, what facilitates success, how barriers can be overcome, and what impact RCC has on resident costs. These findings will help enhance care for some of VHA's most vulnerable Veterans. The knowledge gained will be of immediate applicability to CLCs nationwide and will be helpful for guiding further improvements in resident-centered care in VHA as a whole. It will also lead directly to an implementation study of the final RCC roadmap.