A Multisite Case Study of Caregiver Advise, Record, Enable Act Implementation.

BACKGROUND AND OBJECTIVES: The Commonwealth of Pennsylvania passed the Caregiver Advise, Record, Enable (CARE) Act on April 20, 2016. We designed a study to explore early implementation at a large, integrated delivery financing system. Our goal was to assess the effects of system-level decisions on unit implementation and the incorporation of the CARE Act's three components into routine care delivery. RESEARCH DESIGN AND METHODS: We conducted a multisite, ethnographic case study at three different hospitals' medical-surgical units. We conducted observations and semi-structured interview to understand the implementation process and the approach to caregiver identification, notification, and education. We used thematic analysis to code interviews and observations and linked findings to the Promoting Action on Research Implementation in Health Services framework. RESULTS: Organizational context and electronic health record capability were instrumental to the CARE Act implementation and integration into workflow. The implementation team used a decentralized strategy and a variety of communication modes, relying on local hospital units to train staff and make the changes. We found that the system facilitated the CARE Act implementation by placing emphasis on the documentation and charting to demonstrate compliance with the legal requirements. DISCUSSION AND IMPLICATIONS: General acute hospitals will be making or have made similar decisions on how to operationalize the regulatory components and demonstrate compliance with the CARE Act. This study can help to inform others as they design and improve their compliance and implementation strategies.

A Scoping Review of Nonpharmacological Interventions to Reduce Disability in Older Adults.

BACKGROUND AND OBJECTIVES: Minimizing disability is critical to reduce the costly health care associated with disability and maintain quality of life into old age. We examined the effect sizes of nonpharmacological intervention studies in reducing disability and explored the active ingredients of interventions. RESEARCH DESIGN AND METHODS: A scoping review was conducted via PubMed, PsycINFO, and CINAHL databases. Thirty-one randomized controlled trials were included. Eight active ingredients were identified by three experts (exercise, problem-solving, cognitive behavioral therapy, environmental modification, education, goal setting, comprehensive geriatric assessment, and cognitive training). RESULTS: The range of Cohen's d was -0.85 to 1.76 across 31 studies (included 33 interventions); 67% studies (n = 22) obtained small-to-negative effect sizes (d = -0.85 to 0.18), accounting for 83% participants across studies. Interventions that incorporated exercise, problem-solving, cognitive behavior therapy, and environmental modification were associated with stronger effect sizes. Interventions that incorporated comprehensive geriatric assessment obtained small effect sizes. DISCUSSION AND IMPLICATIONS: Majority of intervention studies found little or no effect in reducing disability for older adults. To optimize the effects of nonpharmacological interventions, we recommend researchers to (i) develop a screening tool for "risk of disability" to inform those who are early on the disability progression, yet not experience any difficulties in activities of daily living and instrumental activities of daily living; (ii) specify the active ingredients embedded in complex interventions to facilitate change in disability; and (iii) select sensitive tools to capture the progression of disability in late life.