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

10CONCLUSION AND RECOMMENDATIONS

The significant investment by the Australian Government in recent years to improve evidence based practice has impacted directly on the many clinical and care workers who have participated in the training and workshops provided, as well as their improved access to evidence-based resources. The projects have explicitly sought to address organisational and systemic factors likely to impact on implementation, through development of new resources, tools, processes and aligning innovations with regulatory frameworks and strategic reforms. The extent to which these two aspects are integrated at the local level is ultimately dependant on whether there is organisational commitment to the innovations which is followed through by enabling policies, processes and, importantly, resources.

Importantly, the EBPAC program has also resulted in a better understanding of what works in aged care, and what needs to be in place in order for innovations to succeed. The heterogeneous and dynamic nature of the aged care sector means there is no one simple formula to facilitating change in a consistent and coherent manner. The complex interaction between consumer, workforce, organisational and systemic factors will continue to pose challenges to the provision of evidence-based practice and will need to be explicitly addressed to ensure that the benefits of any future investments are realised. What is clear from the emerging research evidence, and the experience of the EBPAC program however, is that the development of resources and delivery of education alone will not lead to sustainable outcomes.

Each project included a series of recommendations to the Department arising from the lessons learned. The evaluation team does not purport to be experts in the clinical areas addressed in each of the EBPAC projects, and therefore is not in a position to judge the merit or otherwise of these project level recommendations; however, we would strongly recommend that the Department carefully review the project level recommendations in light of the evidence provided in each report, and consider these on an individual basis.

What is clear from the overall program evaluation is the importance of any new initiative to be underpinned by the evidence regarding implementation. There are clear opportunities for government to leverage off the important foundations laid by the three EBPAC rounds and the numerous workforce development activities currently underway. In particular, these investments have built capacity amongst the many project leaders, team members and participants; developed and strengthened intra- and inter-sector partnerships; and, significantly, initiated and/or revived enthusiasm and commitment amongst those directly responsible for the day to day support and care of aged care clients. To ensure that these gains are not lost, and the resources developed are not just added to the already crowded aged care educators’ shelves, the evaluation team suggests the following recommendations:

1. 
   A central repository and electronic portal be developed to host and disseminate the resources developed under EBPAC and similar Commonwealth-funded initiatives, and linked with existing websites accessed by the sector, as appropriate. e.g., Dementia Training Studies Centres, Aged Care Quality Agency.
   
2. 
   Sector development initiatives to be co-ordinated across government and in partnership with stakeholder representatives to ensure the multiple perspectives are appropriately captured, optimise learnings and avoid duplication of effort.
   
3. 
   Consumer outcomes to be integrated into quality reporting across the sector, and directly linked to funding and licencing agreements.
   
4. 
   Future sector development initiatives to reflect contemporary evidence-based practice and utilise multi-level interventions.
   
5. 
   Evaluation should be seen as an integral part of the policy cycle and utilised in assessing whether previous government funding initiatives have achieved their objectives. This approach will facilitate ongoing improvements in the outcomes of future funding initiatives.
   

APPENDIX 1 - TARGETED LITERATURE REVIEW

Implementing evidence based practice within a community care context: a targeted literature review.

Objective:

To identify the factors that are important to assist in the ability of those working in the community care sector to access and implement evidence based practice.

Method:

Undertake targeted literature review of journal articles published from 2000 to current.

Searches included: PubMed, Cochrane Database, EBSCO (Medline, Cinahl, Econlit, Academic Search Complete, Health Source: nursing/academic edition). In addition, a snowball approach was used, reviewing references in key articles, as well as searching websites that are known to contain information on the subject, e.g., Canadian Health Services Research Foundation; Department of Health and Ageing, US Centre for Disease Control and Prevention

Search terms:

Community care; evidence; best practice; aged; elderly; clinical leadership

Results:

PubMed: 238 articles; 5 of which were considered relevant: Seers et al (2012); Van’t Leven et al (2011); Peel et al (2010); Hunter, DJ (2010); Cherry et al (2009)

Cochrane: 1st search (no ‘leadership’): 322 articles; 2 relevant: Renders et al (2000) and Forsetlund et al (2009); 2nd search (incl. ‘leadership’): 15 articles; 2 relevant: Grimshaw et al (2012) & Flodgren et al (2011)

EBSCO: 64 articles; 3 relevant: DeCicco J (2008); Bryant et al (2006); Perkins et al (2011)

Additional articles identified through snowballing techniques:

Whitelaw (2010); McCallion and Ferretti (2010); Walsh (2010); Stevens et al (2012)

Peel et al (2010); Hollander and Prince (2008);

Discussion:

There was limited information available that specifically targeted the implementation of evidence based practice for clients in receipt of, and services providing, community aged care services. The predominant literature regarding knowledge translation and implementation science tends to be within the acute health, primary care and residential aged care settings.

Of the limited articles and resources found, there were a number of themes emerging that needed to be taken into account in implementing evidence based practice within community care services. These include:

Numerous services/stakeholders involved in delivering community care, arising from the often complex nature of health and care needs of recipients (DeCiccio 2008; Whitelaw 2010)

Workforce issues arising from, and required to address, this complexity of service/care/stakeholders (Bryant et al 2006);

Turf/boundaries between services (Hollander and Prince 2008);

Cultural differences between service types – e.g., medical model versus psychosocial enablement and personal independence (McCallion and Ferretti 2010; Hollander and Prince).

Consequently, there is greater need for services to work in partnership and collaboratively, both within and across different services and stakeholder groups (Peel et al, Stevens et al). This heightened, therefore, the need for a planned approach to implementing evidence-based interventions in a community context, to enable the following issues to be addressed:

Building consensus on the evidence base, and the perceived outcomes for clients, amongst the various stakeholders (Whitelaw 2010; McCallion and Ferretti, 2010);

Identifying organisational readiness for change; (Bryant et al 2006; Peel et al 2010);

Targeting interventions to select population groups and addressing contextual factors (Hunter 2010);

Building effective working relationships through planning days, workshops etc. (Peel et al 2010);

Providing technical assistance of staff (training) to undertake and implement new processes (Perkins 2010);

Providing sufficient resources and time to support implementation (Peel et al 2010; Hunter 2010; McCallion and Ferretti 2010);

Development of appropriate communication plans and integrated information systems across different sites and work groups (Hollander and Prince 2008);

Importance of evaluation and continuous quality improvement culture and systems (Hunter 2010)

Perhaps the most comprehensive approach to implementing evidence-based client-centred care for older people receiving community care services is the framework developed by Hollander and Prince (2008), which was developed for organising health care delivery for people within ongoing care needs and their families. The framework arose from the results of a Canadian project to study systems of care for four populations with ongoing care needs, including the elderly, people with disabilities, persons with chronic mental health conditions and children with special needs. The complex care needs associated with these groups, and the associated stakeholder engagement and contextual factors associated with delivering that care, resonate with those of the population groups being targeted under EBPAC.

They identified the following factors to address the challenges associated with care coordination and implementation of evidence based practice:

Philosophical and policy prerequisites – that articulate commitments regarding the model of care, appropriate resourcing, analysis and evidence-based decision making.

Organisational design factors addressing administrative and clinical issues. These include services having a clear articulation of the philosophy of care, which is enacted through streamlined administrative arrangements, single reporting and funding streams, integrated electronic information systems and the use of rewards and incentives for evidence based management. On the clinical side, the best practice included the capacity to coordinate entry into the system (through consistent screening tools), consistent assessment of need and classification of care; case management and the involvement of clients and families.

Coordination and boundary spanning linkage mechanisms, across population groups, service administrative systems and, potentially, staff.