Background

The increasing complexity of medical care in nursing homes and the lack of coordination between settings jeopardize nursing home (NH) care quality. One particularly disturbing issue are avoidable hospitalizations, associated with potential negative clinical and psychosocial outcomes and excess cost. For older, frail persons, hospitalizations can increase mortality, functional decline, delirium, and falls. Between 19% and 67% of hospitalizations from NHs might be preventable [1]. Possible reasons are NH staff members’ limited capacity to detect and react to early changes in chronic conditions that commonly lead to hospitalization, the lack of advanced care planning with residents and family in end-of-life situations, and the limited access to primary care physicians / geriatricians and first diagnostic procedures in emergency situations [2-4]. This calls for new models of care to support NH care quality by enhancing care coordination, improving care workers’ geriatric expertise (including the use of advanced practice nurses (ANP) and expert nurses), and investing in effective (clinical) leadership in NH [5, 6]. One promising solution, well-established in other countries, but still to be implemented and tested in Switzerland, are nurse-led interprofessional care NH models. These models have shown to improve resident satisfaction, to empower NH staff, as well as clinical outcomes including a reduction in avoidable hospitalizations [5, 7-9]. Moreover, they are typically led by APN or expert nurses and focus on residents’ needs assessment, care coordination (also in view of transitions between settings), provide geriatric clinical leadership and support data-driven quality improvement [8]. APN training opportunities have only recently been introduced in Switzerland and their roles are still in development. Several barriers might hinder the implementation of these new roles, such as the lack of organizational understanding or unclear roles and competencies. Accordingly, before implementation, it is necessary to define the APN’s context, role, scope, goals, core competencies and expected impact with all relevant stakeholders [10, 11]. The main goal of the INTERCARE study is therefore to develop and evaluate a Swiss nurse-led interprofessional care NH model to improve care coordination and quality of care in NHs with a special focus on the reduction of avoidable hospitalizations.

Methodology

The project will have two stages: Stage A for the development, Stage B for the implementation and evaluation of the nurse-led care model. In Stage A, a ‘Swiss nurse-led interprofessional NH care model’ will be developed based on available international evidence, contextual information from existing local Swiss models and stakeholder involvement according to the principles of Public Patient Involvement. The ‘Swiss nurse-led interprofessional NH care model’, a multi-level complex intervention, will consist of core and peripheral components, the latter to be adaptable to the local context during the implementation phase (Stage B). Anticipated core components of the ‘Swiss nurse-led interprofessional NH care model’ are nurse experts with an expanded geriatric practice, advanced clinical leadership and competencies as well as administrative backing, which will be prepared with educational trainings and continuous coaching throughout the intervention period together with the NH leadership. The definitive content of the ‘Swiss nurse-led interprofessional NH care model’ at the end of stage A will be the resultant of the input of the different stakeholders and the contextual analysis guided by two frameworks (the PEPPA+ framework used for the evaluation of APN roles and the Consolidated Framework for Implementation Research (CFIR) guiding the implementation of the new care model) as well as the RAND/UCLA methodology.
In Stage B, using a quasi experimental step wedged design (21 months) the ‘Swiss nurse-led interprofessional NH care model’ will be implemented and tested in a convenience sample of 12 NHs across Switzerland’s German- and French-speaking regions.