Health economic evaluation of a nurse-led care model from the nursing home perspective focusing on residents' hospitalisations.

BACKGROUND: Health economic evaluations of the implementation of evidence-based interventions (EBIs) into practice provide vital information but are rarely conducted. We evaluated the health economic impact associated with implementation and intervention of the INTERCARE model-an EBI to reduce hospitalisations of nursing home (NH) residents-compared to usual NH care. METHODS: The INTERCARE model was conducted in 11 NHs in Switzerland. It was implemented as a hybrid type 2 effectiveness-implementation study with a multi-centre non-randomised stepped-wedge design. To isolate the implementation strategies' costs, time and other resources from the NHs' perspective, we applied time-driven activity-based costing. To define its intervention costs, time and other resources, we considered intervention-relevant expenditures, particularly the work of the INTERCARE nurse-a core INTERCARE element. Further, the costs and revenues from the hotel and nursing services were analysed to calculate the NHs' losses and savings per resident hospitalisation. Finally, alongside our cost-effectiveness analysis (CEA), a sensitivity analysis focused on the intervention's effectiveness-i.e., regarding reduction of the hospitalisation rate-relative to the INTERCARE costs. All economic variables and CEA were assessed from the NHs' perspective. RESULTS: Implementation strategy costs and time consumption per bed averaged 685CHF and 9.35 h respectively, with possibilities to adjust material and human resources to each NH's needs. Average yearly intervention costs for the INTERCARE nurse salary per bed were 939CHF with an average of 1.4 INTERCARE nurses per 100 beds and an average employment rate of 76% of full-time equivalent per nurse. Resident hospitalisation represented a total average loss of 52% of NH revenues, but negligible cost savings. The incremental cost-effectiveness ratio of the INTERCARE model compared to usual care was 22'595CHF per avoided hospitalisation. As expected, the most influential sensitivity analysis variable regarding the CEA was the pre- to post-INTERCARE change in hospitalisation rate. CONCLUSIONS: As initial health-economic evidence, these results indicate that the INTERCARE model was more costly but also more effective compared to usual care in participating Swiss German NHs. Further implementation and evaluation of this model in randomised controlled studies are planned to build stronger evidential support for its clinical and economic effectiveness. TRIAL REGISTRATION: clinicaltrials.gov ( NCT03590470 ).

[How nurse experts in Swiss nursing homes shape their role development: A qualitative secondary analysis]. / Wie Pflegeexpert_innen in Deutschschweizer Pflegeheimen ihre Rollenentwicklung gestalten.

How nurse experts in Swiss nursing homes shape their role development: A qualitative secondary analysis Abstract. Background: In Swiss nursing homes, often registered nurses in expanded roles are responsible for developing and maintaining quality of care. These are qualified nurses with a heterogeneous educational background and extensive professional experience. However, little is known of how they develop their roles in nursing homes. Aim: The aim of this study is to show how nurses in expanded roles in nursing homes create the development of their professional roles. Method: Using a constructivist approach, we conducted a qualitative secondary data analysis of 14 semi-structured interviews with nurses in expanded roles from nursing homes in German-speaking Switzerland. The data were analyzed inductively using reflexive thematic analysis. Results: We found the constituent theme "vision as motivation" and a three-phase cycle of role development in the reports of the fourteen nurses in expanded roles. The vision of high-quality care of residents motivates nurses in expanded roles to shape and further develop their role in three phases: 1) Shaping their roles successively; 2) Developing their roles continuously; and 3) Realign their roles. Conclusions: Nursing professionals continuously adapt their roles to the shifting context to improve the quality of nursing care. To succeed, they and their supervisors need a shared vision for quality of care.

Implementation of a complex intervention to reduce hospitalizations from nursing homes: a mixed-method evaluation of implementation processes and outcomes.

BACKGROUND | OBJECTIVE: To evaluate the implementation of three intervention elements to reduce hospitalizations in nursing home residents. DESIGN: Convergent mixed-method design within a hybrid type-2 effectiveness-implementation study. SETTING: Eleven nursing homes in the German-speaking region of Switzerland. PARTICIPANTS: Quantitative data were collected from 573 care workers; qualitative data were collected from 108 care workers and the leadership from 11 nursing homes. INTERVENTION: Three intervention elements targeting care workers were implemented to reduce unplanned hospitalizations: (1) the STOP&WATCH instrument for early recognition of changes in resident condition; (2) the ISBAR instrument for structured communication; and (3) specially-trained INTERCARE nurses providing on-site geriatric support. Multifaceted implementation strategies focusing both on the overall nursing home organization and on the care workers were used. METHODS: The quantitative part comprised surveys of care workers six- and twelve-months post-intervention. The intervention's acceptability, feasibility and uptake were assessed using validated and self-developed scales. Qualitative data were collected in 22 focus groups with care workers, then analyzed using thematic analysis methodology. Data on implementation processes were collected during implementation meetings with nursing home leadership and were analyzed via content analysis. Findings were integrated using a complementary approach. RESULTS: The ISBAR instrument and the INTERCARE nurse role were considered acceptable, feasible, and taken up by > 70% of care workers. The STOP&WATCH instrument showed the lowest acceptance (mean: 68%), ranging from 24 to 100% across eleven nursing homes. A combination of factors, including the amount of information received, the amount of support provided in daily practice, the users' perceived ease of using the intervention and its adaptations, and the intervention's usefulness, appeared to influence the implementation's success. Two exemplary nursing homes illustrated context-specific implementation processes that serve as either barriers or facilitators to implementation. CONCLUSIONS: Our findings suggest that, alongside the provision of information shortly before intervention start, constant daily support is crucial for implementation success. Ideally, this support is provided by designated and trained individuals who oversee implementation at the organizational and unit levels. Leaders who seek to implement interventions in nursing homes should consider their complexity and their consequences for workflow to optimize implementation processes accordingly. TRIAL REGISTRATION: This study was registered at clinicaltrials.gov ( NCT03590470 ) on the 18/06/2018.

Positive effect of the INTERCARE nurse-led model on reducing nursing home transfers: A nonrandomized stepped-wedge design.

BACKGROUND: Unplanned nursing home (NH) transfers are burdensome for residents and costly for health systems. Innovative nurse-led models of care focusing on improving in-house geriatric expertise are needed to decrease unplanned transfers. The aim was to test the clinical effectiveness of a comprehensive, contextually adapted geriatric nurse-led model of care (INTERCARE) in reducing unplanned transfers from NHs to hospitals. METHODS: A multicenter nonrandomized stepped-wedge design within a hybrid type-2 effectiveness-implementation study was implemented in 11 NHs in German-speaking Switzerland. The first NH enrolled in June 2018 and the last in November 2019. The study lasted 18 months, with a baseline period of 3 months for each NH. Inclusion criteria were 60 or more long-term care beds and 0.8 or more hospitalizations per 1'000 resident care days. Nine hundred and forty two long-term NH residents were included between June 2018 and January 2020 with informed consent. Short-term residents were excluded. The primary outcome was unplanned hospitalizations. A fully anonymized dataset of overall transfers of all NH residents served as validation. Analysis was performed with segmented mixed regression modeling. RESULTS: Three hundred and three unplanned and 64 planned hospitalizations occurred. During the baseline period, unplanned transfers increased over time (ß1  = 0.52), after which the trend significantly changed by a similar but opposite amount (ß2  = -0.52; p = 0.0001), resulting in a flattening of the average transfer rate throughout the postimplementation period (ß1  + ß2  ≈ 0). Controlling for age, gender, and cognitive performance did not affect these trends. The validation set showed a similar flattening trend. CONCLUSION: A complex intervention with six evidence-based components demonstrated effectiveness in significantly reducing unplanned transfers of NH residents to hospitals. INTERCARE's success was driven by registered nurses in expanded roles and the use of tools for clinical decision-making.

Residents' and Relatives' Experiences of Acute Situations: A Qualitative Study to Inform a Care Model.

BACKGROUND AND OBJECTIVES: As new models of care aiming to reduce hospitalizations from nursing homes emerge, their implementers must consider residents' and relatives' needs and experiences with acute changes in the residents' health situations. As part of the larger INTERCARE implementation study, we explored these persons' experiences of acute situations in Swiss nursing homes. RESEARCH DESIGN AND METHODS: 3 focus groups were conducted with residents and their relatives and analyzed via reflexive thematic analysis. RESULTS: The first theme, the orchestra plays its standards, describes experiences of structured everyday care in nursing homes, which functions well despite limited professional and competency resources. The second theme, the orchestra reaches its limits, illustrates accounts of acute situations in which resources were insufficient to meet residents' needs. Interestingly, participants' perceptions of acute situations went well beyond our own professional view, that is, changes in health situations, and included situations best summarized as "changes that might have negative consequences for residents if not handled adequately by care workers." Within the third theme, the audience compensates for the orchestra's limitations, participants' strategies to cope with resource limitations in acute situations are summarized. DISCUSSION AND IMPLICATIONS: Our findings suggest differences between care providers' and participants' perspectives regarding acute situations and care priority setting. Alongside efforts to promote staff awareness of and responsiveness to acute situations, care staff must commit to learning and meeting individual residents' and relatives' needs. Implications for the development and implementation of a new nurse-led model of care are discussed.

Registered nurses in expanded roles improve care in nursing homes: Swiss perspective based on the modified Delphi method.

AIM: To define both competencies and envisaged outcomes for registered nurses in expanded roles in Swiss nursing homes to be implemented and evaluated within a new model of care. BACKGROUND: In regions where Advanced Practice Nurses are rare or absent, registered nurses take up clinical leadership and expanded roles. To allow effective implementation, monitoring and evaluation of these nurses, stakeholders need a shared understanding of the competencies they require and what outcomes they should achieve. DESIGN: RAND/UCLA Appropriateness Method - a modified Delphi method. METHODS: A critical literature review and case studies were conducted to identify possible competencies and outcomes for registered nurses in expanded roles. In 2017, a two-round rating process and an in-person panel discussion was completed by a group of multi-professional stakeholders. FINDINGS: Two rounds generated 190 competencies and 72 outcomes relevant to registered nurses in expanded roles. CONCLUSION: The relevant competencies and outcomes of registered nurses in expanded roles indicate their support for care teams and development of nursing care in nursing homes. Their geriatric expertise allows them to function as role models and innovators, reinforcing overall perceptions of nursing as a profession. These nurses are especially important in countries and settings where Advanced Practice Nurses are scarce or unavailable. IMPACT: The identified competencies clarify the duties of expanded-role registered nurses, thereby differentiating them from other care providers. Although conducted in the Swiss healthcare system, our methods and findings can be adapted to other healthcare settings. The results of this study will guide the development of an educational programme in a multi-centre study to reduce avoidable hospitalizations, while the defined outcomes guide the evaluation of their impact.

Budget Impact of Improved Diabetes Management by Utilization of Glucose Meters With a Color-Range Indicator-Comparison of Five European Healthcare Systems.

BACKGROUND AND AIM: Costs for the treatment of diabetes and its comorbidities are a major international issue. A recent randomized clinical trial showed that the introduction of color range indicator (CRI)-based glucose meters (GMs) positively affects the HbA1c of patients with type 1 and type 2 diabetes, when compared to GMs without a CRI. This budget impact analysis aimed to translate this beneficial effect of CRI-based GMs, OneTouch Verio Flex and OneTouch Verio, into potential monetary impact for the healthcare systems of five European countries, Germany, Spain, Italy, France, and the United Kingdom. MATERIAL AND METHODS: Data from a randomized controlled trial, evaluating the effect of CRI-based GMs, were used to estimate the ten-year risk of patients for fatal myocardial infarction (MI) as calculated by the UK Prospective Diabetes Study (UKPDS) risk engine. On the basis of assessed risks for MI, the potential monetary impact for the healthcare systems in five European countries was modeled. RESULTS: Based on a mean HbA1c reduction of 0.36%, as demonstrated in a randomized controlled trial, the UKPDS risk engine estimated a reduction of 2.4% of the ten-year risk of patients for fatal MI. When applied to our economic model, substantial potential cost savings for the healthcare systems of five European countries were calculated: €547 472 (France), €9.0 million (Germany), €6.0 million (Italy), €841 799 (Spain), and €421 069 (United Kingdom) per year. CONCLUSION: Improving metabolic control in patients with diabetes by the utilization of CRI-based GMs may have substantial positive effects on the expenditure of the healthcare systems of several European countries.

Strengthening Geriatric Expertise in Swiss Nursing Homes: INTERCARE Implementation Study Protocol.

OBJECTIVES: Nursing home (NH) residents with complex care needs ask for attentive monitoring of changes and appropriate in-house decision making. However, access to geriatric expertise is often limited with a lack of geriatricians, general practitioners, and/or nurses with advanced clinical skills, leading to potentially avoidable hospitalizations. This situation calls for the development, implementation, and evaluation of innovative, contextually adapted nurse-led care models that support NHs in improving their quality of care and reducing hospitalizations by investing in effective clinical leadership, geriatric expertise, and care coordination. DESIGN: An effectiveness-implementation hybrid type 2 design to assess clinical outcomes of a nurse-led care model and a mixed-method approach to evaluate implementation outcomes will be applied. The model development, tailoring, and implementation are based on the Consolidated Framework for Implementation Research (CFIR). SETTING: NHs in the German-speaking region of Switzerland. PARTICIPANTS: Eleven NHs were recruited. The sample size was estimated assuming an average of .8 unplanned hospitalizations/1000 resident days and a reduction of 25% in NHs with the nurse-led care model. INTERVENTION: The multilevel complex context-adapted intervention consists of six core elements (eg, specifically trained INTERCARE nurses or evidence-based tools like Identify, Situation, Background, Assessment and Recommendation [ISBAR]). Multilevel implementation strategies include leadership and INTERCARE nurse training and support. MEASUREMENTS: The primary outcomes are unplanned hospitalizations/1000 care days. Secondary outcomes include unplanned emergency department visits, quality indicators (eg, physical restraint use), and costs. Implementation outcomes included, for example, fidelity to the model's core elements. CONCLUSION: The INTERCARE study will provide evidence about the effectiveness of a nurse-led care model in the real-world setting and accompanying implementation strategies. J Am Geriatr Soc 67:2145-2150, 2019.

Pan-European Economic Analysis to Identify Cost Savings for the Health Care Systems as a Result of Integrating Glucose Monitoring Based Telemedical Approaches Into Diabetes Management.

BACKGROUND: Self-monitoring of blood glucose supported by the diabetes-app OneTouch Reveal® has demonstrated to improve HbA1c. We aimed at analyzing costs savings related the integration of telemedical features into diabetes management. METHODS: Data from a randomized controlled trial were used to assess the 10-year risk of patients for fatal myocardial infarction (MI). On the basis of this risk assessments-also related to a 5% or 10% reduction of hypoglycemic episodes-cost savings for the health care systems of five European countries-France, Germany, Italy, Spain, and the United Kingdom-were modeled. RESULTS: HbA1c reduction of 0.92% in insulin-treated type 2 diabetes patients (T2DM) was associated with a 2.3% decreased 10-year risk for fatal MI. In combination with a 10% reduction of hypoglycemic events this risk reduction led to cost savings of €16.1 million (France), €57.8 million (Germany), €30.9 million (Italy), €23.8 million (Spain), and €5.8 million (UK), considering all insulin-treated T2DM patients in the respective countries. CONCLUSION: Improving metabolic control and thus risk for comorbidities like MI by combining the glucose meter with CRI with telemedical features has the potential to reduce costs for European health care systems.