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

描述(由申请人提供)： 背景：退伍军人健康管理局(VHA)正在从基于医疗模式的文化转变为拥抱以居民为中心的护理(RCC)的文化。社区生活中心(CLCs)为特别脆弱的退伍军人提供护理，自2004年以来一直引领着向RCC的转变。农村信用社本质上是多方面的和复杂的，农村信用社对现有措施的差异很大。已经实施了多个有意义的RCC组件并同时提供高质量临床结果的CLC相对较少(即“成功的RCC采用者”)，并且对它们如何取得成功知之甚少。他们的护理结构和过程是什么？是什么促进或阻碍了RCC在日常工作中的嵌入？成本结果是什么？从成功克服障碍和实施变革的CLC中可以学到很多东西。该项目建立在试点工作的基础上，并纳入了VHA运营伙伴的反馈。这是对成功的RCC采用者CLCS进行的第一次全面研究。目的：这项以理论为基础、为期3.5年的混合方法研究建立在广泛的CLC RCC试点工作的基础上。将对结果进行汇编，以详细了解CLC为实现成功的RCC实施所使用的多条途径。在整个研究过程中，临时产品将与运营合作伙伴共享，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实施中设施级别的变化。(2)在成功的采用者样本中确定有效的RCC实践。(3)对已确定的成功实施农村合作伙伴关系的路径进行详细说明(即“路线图”)。方法：本研究将采用三个阶段的过程，与三个研究目标相对应。阶段1使用现有设施级别的数据，使用最小数据集复合测量对常驻临床结果的CLC进行排名，然后使用文化变革工具数据的人工制品进一步对它们进行排名，作为RCC的衡量标准。然后，将对CLC的最高四分之一进行调查(n=32)，以收集有关RCC结构、流程和实施的设施级信息。这32个CLC将根据关键变量和选择的8-CLC成功采用者样本进行排名。此外，还将对居民成本进行分析。第二阶段将包括在成功采用者的地点进行简短的现场访问，以管理居民调查和收集关于RCC的结构化观测数据。数据还将通过在线工作人员调查和邮寄的家庭成员调查来收集。第一阶段和第二阶段的量化结果将有助于为第三阶段的定性数据收集提供信息。半结构化工作人员访谈将详细探讨(1)成功采用者如何修改特定的结构和流程，以整合RCC组成部分并取得成功，以及(2)这些有效做法的障碍和促进者。将使用归纳分析方法整合定性和定量数据，以创建路线图草稿，该路线图将反馈给各站点以供输入。然后将最终确定路线图，研究小组将与业务合作伙伴合作传播和实施路线图。预期影响：这项研究将产生关于VHA碾压混凝土的新知识。中期研究结果将汇编成可操作的报告，将在第一阶段和第二阶段结束时与运营合作伙伴共享，并在第三阶段期间共享两次。定期和最终产品将提供成功采用者RCC旅程的图景。这将填补在以下方面的知识空白：如何成功实施RCC、什么有助于成功、如何克服障碍以及RCC对居民成本有什么影响。这些发现将有助于加强对VHA中一些最脆弱的退伍军人的护理。所获得的知识将立即适用于全国的社区卫生服务，并将有助于指导整个VHA以居民为中心的护理的进一步改进。它还将直接导致对RCC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.