Blended Facilitation as an Effective Implementation Strategy for Quality Improvement and Research in Nursing Homes.

BACKGROUND: Blended facilitation, which leverages the complementary skills and expertise of external and internal facilitators, is a powerful strategy that nursing stakeholders and researchers may use to improve implementation of quality improvement (QI) innovations and research performed in nursing homes. PROBLEM: Nursing homes present myriad challenges (eg, time constraints, top-down flow of communication, high staff turnover) to QI implementation and research. APPROACH: This methods article describes the theory and practical application of blended facilitation and its components (external facilitation, internal facilitation, relationship building, and skill building), using examples from a mixed QI and research intervention in Veterans Health Administration nursing homes. CONCLUSIONS: Blended facilitation invites nursing home stakeholders to be equal partners in QI and research processes. Its intentional use may overcome many existing barriers to QI and research performed in nursing homes and, by strengthening relationships between researchers and stakeholders, may accelerate implementation of innovative care practices.

Statewide initiative of intensive psychiatric rehabilitation: outcomes and relationship to other mental health service use.

OBJECTIVE: This study examines the outcomes of a statewide implementation of Intensive Psychiatric Rehabilitation (IPR) for improving residential and employment status and earnings among individuals with severe mental illnesses and also examines its implementation with respect to mental health service utilization and costs. METHODS: This study employs a pre-post design with participants acting as their own controls for rehabilitation outcomes (residential status, vocational outcomes and earnings) comparing those who "completed" or had a sufficiently intense dose of IPR (one year) to those who dropped out early (before six months of service) and those who dropped out later in service (6-12 months). A separate analysis was conducted examining the relationship of IPR to other mental service use and costs using a quasi-experimental design that contrasted IPR completers with a control group matched via propensity scores. RESULTS: The results suggested significant improvement in residential status, employment status and gross monthly earnings for IPR completers relative to other groups. IPR completers also tended to use more mental health services or have more shallow decreases in use and cost of services relative to matched controls. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Gains in rehabilitation outcomes can be expected for those who engage in and complete IPR services, but IPR cannot be expected to result in reduced overall mental health service use and costs. Rather, IPR may improve service access or perhaps ameliorate any containment effect of managed care on service use.

Motivational interviewing: Key ingredients associated with taking a step toward employment.

Objective: This study sought to identify key ingredients of motivational interviewing (MI) associated with taking a step in the direction of competitive employment (CE) for unemployed veterans with serious mental illness (SMI). Method: Data were analyzed from 195 audiotaped MI sessions targeted to employment conducted with 39 veterans with SMI. Sessions were coded and analyzed to identify components of MI practice predictive of taking any step in the direction of CE (e.g., asking for a referral to supported employment or conducting a job search). Predictor variables were (a) counselor MI talk behaviors and adherence to MI technical and relational principles and (b) client intensity and frequency of change talk and sustain talk. Covariates were age, gender, race, duration of unemployment, receipt of disability income, health status, work importance, work confidence, mental health diagnosis, and session number. Generalized estimating equations were used to create multivariate models. Results: After controlling for session number, work importance, work confidence and duration of unemployment, variables significant in the adjusted multivariate model were intensity of client change talk and sustain talk and counselor adherence to MI technical principles of cultivating change talk and softening sustain talk. Conclusions and Implications for Practice: Findings suggest that change talk and sustain talk during counseling sessions are associated with taking a step toward employment and that counseling focused on cultivating change talk and softening sustain talk increases the likelihood that unemployed veterans with SMI will take steps toward becoming competitively employed. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Adapting Strategies for Optimal Intervention Implementation in Nursing Homes: A Formative Evaluation.

BACKGROUND AND OBJECTIVES: Nursing homes pose unique challenges for implementation of research and quality improvement (QI). We previously demonstrated successful implementation of a nursing home-led intervention to improve relationships between frontline staff and residents in 6 U.S. Department of Veterans Affairs (VA) Community Living Centers (CLCs). This article discusses early adaptations made to the intervention and its implementation to enhance frontline staff participation. RESEARCH DESIGN AND METHODS: This is a formative evaluation of intervention implementation at the first 2 participating CLCs. Formative evidence-including site visitors' field notes, implementation facilitation records, and semistructured frontline staff interviews-were collected throughout the study period. Data analysis was informed by the Capability, Opportunity, Motivation, and Behavior model of behavior change. RESULTS: Adaptations were made to 5 a priori intervention implementation strategies: (a) training leaders, (b) training frontline staff, (c) adapting the intervention to meet local needs, (d) auditing and providing feedback, and (e) implementation facilitation. On the basis of a 6-month implementation period at the first CLC, we identified elements of the intervention and aspects of the implementation strategies that could be adapted to facilitate frontline staff participation at the second CLC. DISCUSSION AND IMPLICATIONS: Incremental implementation, paired with ongoing formative evaluation, proved critical to enhancing capability, opportunity, and motivation among frontline staff. In elucidating what was required to initiate and sustain the nursing home-led intervention, we provide a blueprint for responding to emergent challenges when performing research and QI in the nursing home setting.

Development and Validation of an Instrument to Measure Staff Perceptions of Recovery Climate and Culture in Mental Health Programs.

OBJECTIVE: Few existing instruments measure recovery-oriented organizational climate and culture. This study developed, psychometrically assessed, and validated an instrument to measure recovery climate and culture. METHODS: Organizational theory and an evidence-based conceptualization of mental health recovery guided instrument development. Items from existing instruments were reviewed and adapted, and new items were developed as needed. All items were rated by recovery experts. A 35-item instrument was pilot-tested and administered to a national sample of mental health staff in U.S. Department of Veterans Affairs Psychosocial Rehabilitation and Recovery Centers (PRRCs). Analysis entailed an exploratory factor analysis (EFA) and inter-item reliability and scale correlation assessment. Blinded site visits to four PRRCs were performed to validate the instrument. RESULTS: The EFA determined a seven-factor solution for the data. The factors identified were staff expectations, values, leadership, rewards, policies, education and training, and quality improvement. Seven items did not meet retention criteria and were dropped from the final instrument. The instrument exhibited good internal consistency (Cronbach's α=0.81; subscales, α=0.84-0.88). Scale correlations were between 0.16 and 0.61, well below the threshold (α=0.9) for indicating overlapping constructs. Site visitors validated the instrument by correctly identifying high-scoring and low-scoring centers. CONCLUSIONS: These findings provide a psychometrically tested and validated instrument for measuring recovery climate and culture in mental health programs. This instrument can be used in evaluation of mental health services to determine the extent to which programs possess the organizational precursors that drive recovery-oriented service delivery.

Toward understanding the usefulness of complementary and alternative medicine for individuals with serious mental illnesses: classification of perceived benefits.

Complementary and alternative medicine (CAM) has been gaining interest among individuals with serious mental illnesses. Yet, very little is known about how CAM may be beneficial to mental health. This study explored the specific benefits attributed to CAM by a national sample of 255 individuals with a serious mental illness who experienced CAM as having a positive impact on their mental health. Data about the CAM benefits were gathered through open-ended questions embedded in a mail survey that examined the patterns of CAM use in this population. Qualitative analysis revealed a wide spectrum of benefits that encompassed all major areas of human functioning, including physical, emotional, cognitive, self, social, spiritual, and overall functioning, and addressed both the improvement of psychiatric symptomatology and the promotion of functional recovery. Study findings provide useful information that can guide both everyday clinical practice and future research on the efficacy of CAM for psychiatric populations.

A site visit protocol for assessing recovery promotion at the program level: An example from the Veterans Health Administration.

OBJECTIVE: A site visit protocol was developed to assess recovery promotion in the organizational climate and culture of programs for veterans with serious mental illnesses. METHOD: The protocol was pilot-tested in 4 programs: 2 that had scored high on the pilot version of a staff survey measure of program-level recovery promotion and 2 that had scored low. Two-person teams conducted onsite visits and assigned global and organizational domain ratings. Interrater agreement was assessed by examining adjacent agreement and computing weighted kappa. RESULTS: The on-site protocol had good interrater agreement and discriminated between sites that scored high and low on the staff survey. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: This site visit protocol and procedure shows promise for evaluating recovery promotion in milieu-based programs. After further refinement of this tool, adaptations could be developed for accreditation protocols or for program self-assessment and quality improvement efforts. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Nursing Home Staff Perceptions of Barriers and Facilitators to Implementing a Quality Improvement Intervention.

OBJECTIVES: Quality improvement (QI) may be a promising approach for staff to improve the quality of care in nursing homes. However, little is known about the challenges and facilitators to implementing QI interventions in nursing homes. This study examines staff perspectives on the implementation process. DESIGN: We conducted semistructured interviews with staff involved in implementing an evidence-based QI intervention ("LOCK") to improve interactions between residents and staff through targeted staff behavior change. The LOCK intervention consists of 4 practices: (1) Learn from the bright spots, (2) Observe, (3) Collaborate in huddles, and (4) Keep it bite sized. SETTING AND PARTICIPANTS: We interviewed staff members in 6 Veterans Health Administration nursing homes [ie, Community Living Centers (CLCs)] via opportunistic and snowball sampling. MEASURES: The semistructured interviews were grounded in the Capability, Opportunity, Motivation, Behavior (COM-B) model of behavior change and covered staff experience, challenges, facilitators, and lessons learned during the implementation process. The interviews were analyzed using thematic content analysis. RESULTS: Overall, staff accepted the intervention and appreciated the focus on the positives. Challenges fell largely within the categories of capability and opportunity and included difficulty finding time to complete intervention activities, inability to interpret data reports, need for ongoing training, and misunderstanding of study goals. Facilitators were largely within the motivation category, including incentives for participation, reinforcement of desired behavior, feasibility of intervention activities, and use of data to quantify improvements. CONCLUSIONS/IMPLICATIONS: As QI programs become more common in nursing homes, it is critical that interventions are tailored for this unique setting. We identified barriers and facilitators of our intervention's implementation and learned that no challenge was insurmountable or derailed the implementation of LOCK. This ability of frontline staff to overcome implementation challenges may be attributed to LOCK's inherently motivational features. Future nursing home QI interventions should consider including built-in motivational components.

The meaning and importance of employment to people in recovery from serious mental illness: results of a qualitative study.

OBJECTIVE: Given the high rates of unemployment and underemployment among individuals with psychiatric disabilities, only a small number of studies have investigated the role work has in the lives of people who have been successful vocationally during their recovery from serious mental illness. This study sought to add to existing literature by determining how individuals perceive work and its effect on their recovery. METHODS: We purposefully recruited self-referred participants at moderate to advanced levels of recovery and qualitatively analyzed semi-structured interviews conducted with 23 individuals to identify themes related to work in the context of recovery from serious mental illness. RESULTS: Participants described myriad positive benefits associated with paid employment, which conceptually fell across two main domains: work has personal meaning and work promotes recovery. Participants discussed the ways in which work fostered pride and self-esteem, offered financial benefits, provided coping strategies for psychiatric symptoms, and ultimately facilitated the process of recovery. Participants also discussed the importance and benefits associated with working in a helper-role and as consumer providers. CONCLUSIONS: Overall, individuals reported that employment conferred significant benefits in their process of recovery from mental illness and that work played a central role in their lives and identities. The themes from this study should be considered when developing employment or other recovery-oriented programs for people with serious mental illness.

Applying a Theory-Driven Framework to Guide Quality Improvement Efforts in Nursing Homes: The LOCK Model.

Purpose of the Study: Implementing quality improvement (QI) programs in nursing homes continues to encounter significant challenges, despite recognized need. QI approaches provide nursing home staff with opportunities to collaborate on developing and testing strategies for improving care delivery. We present a theory-driven and user-friendly adaptable framework and facilitation package to overcome existing challenges and guide QI efforts in nursing homes. Design and development: The framework is grounded in the foundational concepts of strengths-based learning, observation, relationship-based teams, efficiency, and organizational learning. We adapted these concepts to QI in the nursing home setting, creating the "LOCK" framework. The LOCK framework is currently being disseminated across the Veterans Health Administration. Results: The LOCK framework has five tenets: (a) Look for the bright spots, (b) Observe, (c) Collaborate in huddles, (d) Keep it bite-sized, and (e) facilitation. Each tenet is described. We also present a case study documenting how a fictional nursing home can implement the LOCK framework as part of a QI effort to improve engagement between staff and residents. The case study describes sample observations, processes, and outcomes. We also discuss practical applications for nursing home staff, the adaptability of LOCK for different QI projects, the specific role of facilitation, and lessons learned. Implications: The proposed framework complements national efforts to improve quality of care and quality of life for nursing home residents and may be valuable across long-term care settings and QI project types.

Promising practices in vocational services for the community reintegration of returning veterans: The individual placement and support model and beyond.

Supporting returning veterans' job-seeking, hiring, and retention issues has become an essential goal for effective community reintegration. Given both the particular strengths and challenges associated with veterans transitioning from military to civilian life, multiple models for supported employment have become integrated into Veterans Affairs health care facilities across the nation. In this article, we review the state of vocational rehabilitation for veterans, with a particular focus on individual placement and support-supported employment (IPS-SE), the current vocational services model that is considered the gold standard of vocational rehabilitation. Various modifications to the IPS-SE model are presented, including additions such as cognitive rehabilitation, contingency management, motivational interviewing, supported self-employment, and transitional work. Finally, recommendations are made about future directions and strategies to expand access to IPS-SE-based programs and to effectively meet the needs of returning veterans for employment in jobs of their choice. (PsycINFO Database Record

Development of a New Tool for Systematic Observation of Nursing Home Resident and Staff Engagement and Relationship.

Purpose of Study: To develop a structured observational tool, the Resident-centered Assessment of Interactions with Staff and Engagement tool (RAISE), to measure 2 critical, multi-faceted, organizational-level aspects of person-centered care (PCC) in nursing homes: (a) resident engagement and (b) the quality and frequency of staff-resident interactions. Design and Methods: In this multi-method psychometric development study, we conducted (a) 120 hr of ethnographic observations in one nursing home and (b) a targeted literature review to enable construct development. Two constructs for which no current structured observation measures existed emerged from this phase: nursing home resident-staff engagement and interaction. We developed the preliminary RAISE to measure these constructs and used the tool in 8 nursing homes at an average of 16 times. We conducted 8 iterative psychometric testing and refinement cycles with multi-disciplinary research team members. Each cycle consisted of observations using the draft tool, results review, and tool modification. Results: The final RAISE included a set of coding rules and procedures enabling simultaneously efficient, non-reactive, and representative quantitative measurement of the interaction and engagement components of nursing home life for staff and residents. It comprised 8 observational variables, each represented by extensive numeric codes. Raters achieved adequate to high reliability with all variables. There is preliminary evidence of face and construct validity via expert panel review. Implications: The RAISE represents a valuable step forward in the measurement of PCC, providing objective, reliable data based on systematic observation.

Impact of Intervention to Improve Nursing Home Resident-Staff Interactions and Engagement.

Background and Objectives: For nursing home residents, positive interactions with staff and engagement in daily life contribute meaningfully to quality of life. We sought to improve these aspects of person-centered care in an opportunistic snowball sample of six Veterans Health Administration nursing homes (e.g., Community Living Centers-CLCs) using an intervention that targeted staff behavior change, focusing on improving interactions between residents and staff and thereby ultimately aiming to improve resident engagement. Research Design and Methods: We grounded this mixed-methods study in the Capability, Opportunity, Motivation, Behavior (COM-B) model of behavior change. We implemented the intervention by (a) using a set of evidence-based practices for implementing quality improvement and (b) combining primarily CLC-based staff facilitation with some researcher-led facilitation. Validated resident and staff surveys and structured observations collected pre and post intervention, as well as semi-structured staff interviews conducted post intervention, helped assess intervention success. Results: Sixty-two CLC residents and 308 staff members responded to the surveys. Researchers conducted 1,490 discrete observations. Intervention implementation was associated with increased staff communication with residents during the provision of direct care and decreased negative staff interactions with residents. In the 66 interviews, staff consistently credited the intervention with helping them (a) develop awareness of the importance of identifying opportunities for engagement and (b) act to improve the quality of interactions between residents and staff. Discussion and Implications: The intervention proved feasible and influenced staff to make simple enhancements to their behaviors that improved resident-staff interactions and staff-assessed resident engagement.

Adaptation of a nursing home culture change research instrument for frontline staff quality improvement use.

Enhanced interpersonal relationships and meaningful resident engagement in daily life are central to nursing home cultural transformation, yet these critical components of person-centered care may be difficult for frontline staff to measure using traditional research instruments. To address the need for easy-to-use instruments to help nursing home staff members evaluate and improve person-centered care, the psychometric method of cognitive-based interviewing was used to adapt a structured observation instrument originally developed for researchers and nursing home surveyors. Twenty-eight staff members from 2 Veterans Health Administration (VHA) nursing homes participated in 1 of 3 rounds of cognitive-based interviews, using the instrument in real-life situations. Modifications to the original instrument were guided by a cognitive processing model of instrument refinement. Following 2 rounds of cognitive interviews, pretesting of the revised instrument, and another round of cognitive interviews, the resulting set of 3 short instruments mirrored the concepts of the original longer instrument but were significantly easier for frontline staff to understand and use. Final results indicated frontline staff found the revised instruments feasible to use and clinically relevant in measuring and improving the lived experience of a changing culture. This article provides a framework for developing or adapting other measurement tools for frontline culture change efforts in nursing homes, in addition to reporting on a practical set of instruments to measure aspects of person-centered care. (PsycINFO Database Record

The integration of psychiatric rehabilitation services in behavioral health care structures: a state example.

This article describes a model for integrating psychiatric rehabilitation services in a managed behavioral health care structure. Psychiatric rehabilitation and managed care are two distinct developments in the provision of mental health services that have proceeded independently though they can have compatible methods and outcomes. Descriptive detail is provided about a state initiative in Iowa to provide psychiatric rehabilitation services to those with serious mental illness through the state-contracted managed behavioral health care corporation. The article describes factors leading to the program's implementation, service delivery structures, reimbursements, personnel requirements, and performance indicators. Evidence for supporting this innovation is provided through a case-controlled outcomes study of mental health service units used and their costs for participants and matched controls.

A qualitative investigation of individual and contextual factors associated with vocational recovery among people with serious mental illness.

Most people with serious mental illness (SMI) experience difficulty in fulfilling a vocational role, with many being unemployed or underemployed. Given the profound social and economic costs of this level of work impairment, researchers have investigated ways to enhance "vocational recovery," or the processes through which people with SMI regain their role as workers and reintegrate into the workforce. Using data collected from a larger qualitative study of 23 individuals who had progressed to an advanced stage of recovery from SMI, this study explored respondents' perspectives on employment and its relationship to their vocational recovery. Text passages describing employment were analyzed inductively by a diverse team of researchers. Seven themes were identified as being important in helping participants return to work or remain employed following the onset of a serious psychiatric disability: having the confidence to work, having the motivation to work, possessing work-related skills, assessing person-job fit, creating work opportunities, receiving social support, and having access to consumer-oriented programs and services. Implications of these findings on the development of interventions and policies to improve the vocational outcomes of people with SMI are discussed.

Association between demographic and diagnostic factors and employment outcomes for people with psychiatric disabilities: a synthesis of recent research.

Employment outcome for individuals with psychiatric disabilities has been a focus of empirical research over the past decade or so. The purpose of this paper is to review recent literature on the association between demographic and diagnostic factors and employment outcome, and to conduct meta analyses of the results of studies that report the association between these variables. Seventeen studies were included in these meta analyses. Results of the meta analyses tended to corroborate most of the significant findings found in the literature review. The authors review some of the issues for the meta-analyst interested in synthesizing research findings on employment outcome, including the challenges and limitations encountered in the published research currently available.