Evaluation of the Encouraging Better Practice in Aged Care (ebpac) Initiative Final Report

7.4Continuing the new processes

The capacity for organisations to sustain change is very much influenced by systemic factors at the organisational, broader sector and societal levels. For example, formal linkages among organisations tend to underpin the success and sustainability of projects.⁵⁴ In this respect, the EBPAC projects had a strong foundation for sustainability, as their contracts required a consortium approach. Partnerships were established at the beginning of the program, with a commitment to change and clear expectations for the contribution from each participating organisation. This approach has numerous advantages for implementation, including establishing shared understandings of the purpose and methods of the project, minimising barriers and ensuring access to necessary expertise and resources.⁵⁵ Similarly, the wider political and social climate can either support or undermine the sustainability of innovative programs.⁵⁶ The inclusion of key stakeholders in governance arrangements is one means to ensure the projects are aligned with contemporary developments.

To be sustainable at a system level, programs need to be accepted by stakeholders and integrated into organisational practice. At the same time they need to be supported by adequate infrastructure and resources.⁵⁷ All the EBPAC projects aimed to make system-level changes to increase the use of evidence to drive improvements in aged care services. Project documents reveal a high level of awareness of the need to build capacity in the system (i.e., within and among organisations) to sustain these changes. Projects employed a range of strategies to address system-level factors known to contribute to sustainability.

Continuing the processes of leadership and change projects

Building capacity in the system to promote and sustain evidence-based practice was the main focus for the two leadership (CL1, CL2) and two organisational change (RC3, CC6) projects. These projects exhibited some of the features of sustainable innovations, discussed above. CL1, CL2 and RC3 used an action research approach which empowers participants to drive changes in practice. Participants were supported by change champions, clinical mentors or workshop facilitators. Partnerships were built among participating organisations, and training materials, assessment tools, guidelines and evaluation outcomes were shared, providing evidence to drive and embed change in organisational policies and procedures.

For CL1, training was carefully targeted at highly motivated and influential individuals, guided by a tool designed to assess leadership potential. The project’s final report acknowledged that the commitment required by organisations was considerable, but the ‘benefits were commensurate’ (p. 6). CL2 also relied on the selection of suitable mentors and site champions to initiate and sustain changes in practice. Champions need to be recognised by their peers as experts, and to demonstrate leadership. Seven attributes of successful mentors were identified in the focus groups. In addition to demonstrated leadership ability and expertise in the project area, mentors required high-level interpersonal and communication skills, research translation expertise, and the ability to network with other mentors, to assess the needs of trainees and design appropriate training methods, and to evaluate their own work. The final report also noted that mentors had to act as advocates, negotiating with management to release workers for training and to include evidence-based materials in daily practice. The question of how to fund such expert and experienced staff inevitably arises. In the case of CL2, two participating organisations have decided to continue the role. At the first site, the residential care management role was restructured to create three clinical nurse positions, one of which is dedicated to clinical mentoring. At another site, a clinical nurse position (with a strong emphasis on clinical mentoring in the job description) has been created in the clinical priority area addressed during the project. There are signs that other organisations are considering business cases for the role.

Nevertheless, the cost of employing clinical mentors represents a serious challenge to the sustainability of CL2. Clear guidelines and expectations around the mentor’s responsibilities will be required, and they will need to continue demonstrating the value of the mentor role to their organisations, using data to show impacts on practices and outcomes. This will mean ensuring that individual projects are consistent with the organisation’s strategic directions for continuous quality improvement, thus maintaining a steady flow of resources, adequate infrastructure and management support. For CL1, demonstrating benefits and maintaining management support will require project champions to keep bringing the focus back to the leadership capacity being built, as well as the action learning outcomes themselves.

Both CL1 and CL2 produced educational materials, which will need to be embedded in organisational training strategies and methods to be sustainable. Sustainability of the CL1 training materials could be promoted by linking the content to ‘accredited units of training under the Australian Quality Training Framework’; while this was specifically excluded under EBPAC funding agreement, the alignment of competencies to the Industry Skills Council enhances both the generalisability and sustainability of the model.

The key to sustainability of both RC3 and CC6 is dissemination and uptake of the resources developed. RC3 created a toolkit of five tools designed to guide work teams through action research processes in order to address workplace challenges and promote change. The resources are highly flexible and could be applied more widely than the aged care sector. The sustainability plan involves making the toolkit, including guides for work teams and leaders and additional resources, available online on the WACHA website. They could then be printed and used freely. This strategy is unlikely to be sufficient without some sort of active promotion (as acknowledged in the project response to Evaluation Tool 4). At the time of writing, the project team was planning to present the resources to the Aged Care Standards Accreditation Agency and the Dementia Training Study Centres in the hope that these organisations would promote the toolkit as a quality improvement resource.

Although RC3 incorporated many aspects of a sustainable innovation, including drawing on the evidence base in its design, addressing issues relevant to each organisation, engaging the support of project partners and ensuring senior managers were behind the project, the impacts of the project on participating organisations were unclear. The case for sustainability would be strengthened by clearer evidence of benefits but these were not available from the evaluation activities (organisational and staff surveys). Further, it was clear that project officers provided considerable hands-on guidance to work teams implementing the toolkit, especially during Cycle 1 when they attended the first two meetings, the final meeting and any other meetings as needed. Less support was given during Cycle 2 in an effort to encourage independence, but project officers were available when required. It is hard to imagine how the toolkit could be implemented and work teams’ activities sustained (in the face of many competing pressures) without this source of encouragement and expertise.

The Valuing People document and website (CC6) were evidence-based and consistent with the Australian Government Living Longer Living Better policy directions. There was extensive consultation with consumer groups during development but aged care industry representatives were less involved. The resources will be hosted, maintained and (presumably) updated by the national office of Alzheimer’s Australia but a national strategy for engaging state offices and industry peak bodies is required. The original sustainability strategy involved Alzheimer’s Australia, through its State and Territory offices, undertaking a paid consultancy role with aged care providers to provide training in how best to implement the resources within their organisations. At the time of writing, this was in its infancy; one consultancy was being negotiated with a single Victorian provider. Further, it appears that the resources will be made available online and can be used without training, or with the assistance of a series of tutorial videos that are currently being developed. Organisations that do not feel confident to implement the resources without formal training can approach Alzheimer’s Australia for support. These arrangements would appear to close off the consultancy role as a potential source of revenue. Stimulating uptake of the resources will be a challenge, given that the project was unable to demonstrate positive impacts within its timeframe. However, its capacity to demonstrate organisational alignment with the aged care reforms, particularly CDC, is still a key enabler.

Continuing the processes of community care projects

The use of organisational policies and procedures and alignment with quality improvement systems was common amongst the five community care projects that introduced new ways of delivering care to clients. As discussed above, there are promising signs that the project activities will continue in some form. Several projects reported that the new activities were now part of usual practice; for example, incorporating social and recreational goals into clients’ admission documentation and care plans and making LEAP an item on staff meeting agendas (CC2); offering preferred music listening as part of existing home care packages (CC3); or distributing leg ulcer kits via the organisation’s equipment supplier (CC1). These measures provide a mechanism for supporting and reminding staff, which is necessary to ensure project activities are not overtaken by competing priorities or squeezed out by demands for greater efficiencies (e.g., as highlighted in CC4, reductions in case manager/client ratios may mean there is less time to spend with consumers). Ideally, organisations would continue to assess outcomes and communicate progress to staff and leaders (Maher et al., 2003); however, there is no indication in projects’ final reports that this kind of ongoing monitoring is planned.

The use of influential leaders and champions was a strategy also employed by several of the community care projects. The CC5 final report notes that minimal investment in staff development is characteristic of the home care sector, and home care workers themselves have little incentive or opportunity to undertake further education. Despite this, they found that the workers could be ‘enablers’ of the oral health program, given their established knowledge of, and relationships with, their clients. Oral health and hygiene issues can be personal and sensitive and therefore a level of trust is required in order to discuss these subjects. Qualitative findings from the evaluation demonstrated that home care workers themselves were well aware of these sensitivities. Not only were they using their new knowledge with the clients, they had begun to share it with family and friends, taking a wider ‘champion’ role than first envisaged.

Champions were an important feature of CC2. Five champions were employed (0.2 FTE) to drive change and support case managers adopting the LEAP model of care. It was found that this model worked best when the champion was a staff member at that site; working across geographical locations created difficulties with acceptance by other staff members, as well as travel and logistics. In addition, champions were most effective when backed by supportive managers; this was especially important if a champion was absent or unable to carry out their tasks for some reason. In CC5 the role of ‘dedicated facilitation’ of project activities was recognised as a key contributor to their uptake and sustainability in the participating organisations. Facilitation was seen as more than project management:

It was recognised as a distinctive role which required a sophisticated range of knowledge and skills, including the ability to boundary span across the multi levels within organisations plus traverse across sectors (CC5 Final Report)

It should be noted that each home care provider released a staff member (0.5 FTE) for the duration of the project to enable this facilitation to take place, and it is unclear whether this staffing support will continue beyond the end of the EBPAC program.

The reliance on project funds or partnership agreements that terminate when program funding ends to pay for project champions raises a wider issue around continuation of resources. The CC5 project requires home care providers to invest in training of their workers, although at an average of two hours in total (usually delivered as two, one-hour sessions facilitated by a trainer) this does not seem an onerous financial burden on the participating organisations. Two of the community care projects were designed to run within usual budgets (CC2, CC3). CC4 relies on clients’ willingness to pay for case management, which naturally creates pressures to ensure it provides value for money (CC4_4). In some of the community care projects, home care staff were expected to attend training in their own time; it is questionable whether asking low-paid workers to subsidise a program in this way is sustainable (or indeed ethical).

An example of how strategic partnerships can promote sustainability is available from the SAP component of CC1. As discussed above, client education proved time consuming and resource intensive, but was considered an essential part of promoting skin care and health. Members of the stakeholder advisory group suggested that peer education might be a more efficient way to disseminate this information to elderly people. As a result, the project team and Council on the Ageing put together a successful proposal for funding to develop and evaluate a peer education model.

The wider political and social climate proved to be used to great effect in facilitating the systemic embedding of changes within participating organisations. This is particularly relevant for the community care projects, which tap into prevailing philosophies around the desirability of holistic and consumer-directed care. CC1 and CC5 recognised that home care services could do more than attend to house work and shopping; their regular contact and established relationships with older people provide opportunities for timely and appropriate health promotion activities as well. CC2 and CC3 broadened the focus further to include simple measures that might boost elderly people’s social and emotional well-being. CC4 developed tools and trained the aged care workforce with the ultimate goal of empowering clients to plan their own care packages wherever possible. The design of CC4 is consistent with Australian Government aged care reforms which mean that by July 2015 all aged care packages will have a CDC focus. The CHOICES model is seen by some community providers as a promising way to prepare their service models for the CDC approach.

CC5 illustrates how the policy context and wider environment can both help and hinder a project. This project fitted neatly within national aged care and dental reforms, which emphasise ageing well at home. According to the project’s final report

This gave a credible sense of purpose uniting the participating dental providers and home care organisations to engage in efforts to improve older people’s oral health.

Nevertheless, the project faced a major barrier in the form of the historical disconnect between home care and dental services. This was overcome temporarily through a partnership agreement under which public dental service providers agreed to give priority to clients referred via the project as an ‘in kind’ contribution. However, more lasting arrangements and a greater visibility of the home care sector within health will be needed to promote sustainability of the oral health initiatives.

Continuing the processes of national roll-out projects

RC1 and RC2 did not seek to influence practice directly and hence had no immediate power to alter organisational policies or procedures to enhance sustainability. Instead, they used the strategy of selecting and educating champions to lead these changes in their own workplaces. By focusing on influential clinical leaders (e.g., nurse educators and nurse consultants in RC2) and training multiple champions across different parts of an organisation, these projects have enhanced the likelihood that any impacts will be sustained.⁵⁸ There are some indications that this strategy was successful; for example, of the workshop participants who reported back to RC2, many represented large organisations with multiple sites and care settings. Sustainability strategies employed by these workshop participants included conducting research with the CSI resources; integrating the resources into policies and procedures, e-learning portals, e-pathways and/or organisational intranet materials; and gaining support at high levels of the organisation (such as the board) to consider CSI in governance and planning. For RC1, the workshops resulted in the PA Toolkit being incorporated into the models of care, policies and procedures of several large residential aged care providers and individual facilities, such as Blue Care, TriCare, Uniting AgeWell, Churches of Christ Care and LHI Retirement Services. In addition, the model of care underpinning the PA Toolkit has been adapted for community aged care (under the Decision Assist project).

Extra funding from the Department of Health has enabled RC1 to produce additional resources for care workers in residential aged care settings, based on the PA Toolkit resources. These are expected to be available in late 2015. In Brisbane, clinical education sessions will be delivered to local RACF staff to support their use of the PA Toolkit. A specialist palliative care nurse has been employed to deliver the workshops and other support to the 75 RACFs in the MSPCS catchment.