Bruyère Reports

Implementation of care planning in long term care: A Bruyère Rapid Review

Report Authors: Elizabeth Ghogomu, Emily Kuurstra, Melissa Donskov, Bahareh Ghaedi, Kayla Richardson, Kerry Moloney, Michelle Grouchy, Zsofia Orosz, Vivian Welch

Executive summary

Elderly people living with multiple, complex and chronic health conditions need care and support from various health care providers. Individual resident-centered care plans have been developed to facilitate coordination of care for this population.

One of the main areas of non-compliance with the Ontario Long Term Care Homes Act is in the area of care planning/plan of care. The Bruyère Centre for Learning, Research and Innovation in Long Term Care in association with Ontario Long Term Care Association (OLTCA), and Ontario Association of Non-Profit Homes and Services for Seniors (OANHSS) is working on a plan of care initiative to identify the root causes of non-compliance related to plan of care and the success factors for compliance, and to devise and implement strategies to improve compliance with plan of care/care planning. This rapid review was done to support this initiative. Due to the limited literature on the evidence of effectiveness of strategies to improve implementation, we assessed the evidence of the challenges and solutions to implementing optimal evidence-informed care planning for long term care residents.

Given the limited availability of systematic reviews, we also searched for primary study designs and found 2364 articles. Thirty four met our inclusion criteria: 5 reviews and 29 primary research studies. Different qualitative research methods were used and various participants including staff, residents and their families were involved.

We used thematic analysis of the qualitative evidence about challenges and solutions. We categorized according to key themes at the provider level, resident/family level and work environment level.

Common barriers were:

• Lack of staff knowledge and training, lack of communication, inconsistent and fragmented location of documentation at the provider level;
• Lack of family involvement, and communication at the resident/family level;
• Issues with staffing and the length of the care plan at the work environment level.

Key strategies to overcome common barriers were:

• Providing education, training and support to staff;
• Facilitating communication between staff;
• Providing guidance to staff how to approach and facilitate discussions with residents and their families;
• Using standardized forms and consistent terminology, and having a centralized or consistent location for documentation.

Based on our findings, we recommend that LTC homes should identify relevant barriers then contextualize and prioritize strategies and solutions that are feasible.

The full report is available for download. 

Table of contents

• Key messages
• Context
• Objective
• Methods
• Evidence review
• Synthesis of findings
• Recommendations

Key messages 

Individual resident-centered care plans have been developed to facilitate coordination of care provided by various health care providers for elderly people living with multiple, complex and chronic health conditions. The most commonly reported barriers and solutions to implementing optimal evidence-informed care planning for long term care residents were the following:  

• Common barriers were: lack of staff knowledge and training, lack of communication, inconsistent and fragmented location of documentation at the provider level; lack of family involvement, and communication at the resident/family level; and issues with staffing and the length of the care plan at the work environment level.
• Key strategies to overcome common barriers were: providing education, training and support to staff; facilitating communication between staff; providing guidance to staff how to approach and facilitate discussions with residents and their families; using standardized forms and consistent terminology, and having a centralized or consistent location for documentation.

Context

The Bruyère Centre for Learning, Research and Innovation in Long Term Care in association with Ontario Long Term Care Association (OLTCA), and Ontario Association of Non-Profit Homes and Services for Seniors (OANHSS) is working on a plan of care initiative to identify the root causes of non-compliance related to plan of care and the success factors for compliance, and to devise and implement strategies to improve compliance with plan of care/care planning.

This rapid review was done to provide evidence-based information to support this initiative in identifying best practices to inform recommendations on implementation of plan of care. We did a preliminary search and found one systematic review that assessed the effectiveness of plan of care on quality of care in the long-term care setting [11]. Due to the limited literature on the evidence of effectiveness of strategies to improve implementation, we assessed the evidence of the challenges and solutions to implementing optimal evidence-informed care planning for long term care residents.

Objective

The objective of this review is to assess the evidence of the challenges and solutions to implementing optimal evidence-informed care planning for long term care residents.

Methods

We developed an a priori plan for the review including the eligibility criteria and methods, in collaboration with the clinical leads. The inclusion criteria were defined by the following PICO statement:

Population:

Health care providers (RN, RPN, PSW), residents in the long term care setting and their families. We excluded acute care setting. 

Intervention:  

• Interventions to improve or implement care planning/plan of care for LTC residents.
• Interventions to improve care planning include organizational, delivery, financial, governance or implementation strategies (using EPOC classification criteria) e.g. implementation of Resident Assessment Instrument (RAI); in-service education of staff. 

Comparison:   

• No intervention or usual care or no comparison.

Outcome:

Reported findings on at least one of the following outcomes:  

• Process outcomes - compliance or adherence to care planning strategies; improved workflow; staff satisfaction; resource use.
• Observed challenges - challenges at resident/family-level (e.g., what is impact of poor care planning, what is the level of detail that is needed in an optimal care plan, how should residents/family be engaged (how to engage cognitively impaired residents)?; challenges at provider-level (e.g., lack of training/education, lack of motivation, lack of communication, too many different places to document); challenges related to the work environment (e.g., lack of time/staffing/ resources).
• Solutions to optimal evidence informed care planning - solutions at resident/family-level (e.g., engagement in care planning process); solutions at provider-level (e.g., sufficient training/education, high motivation, adherence to care planning, use of tools, ability to consistently report); solutions related to the work environment (e.g., sufficient time/staffing, regular educational sessions, regular review of care plans, processes and tools).

Literature search:

We ran a search in Medline on July 22, 2016 using the following mesh terms: Long-term care, Homes for the aged, Nursing homes, Plan of care, Service agreement, Care planning, Service user plan, Care plan, Service plan, Patient care planning. We identified 2364 articles. 

Relevance assessment: 

We screened the search results in duplicate and disagreements were resolved by consensus. The screening was limited to studies published after 2010 (when the LTCHA came into force) and studies published in English or French. We identified 34 articles that met all the inclusion criteria.

Evidence review 

We included 29 primary research studies and 5 literature reviews. Different qualitative research methods were used in the included studies comprising interviews, questionnaires, surveys, focus groups, field observations, shadowing encounters, case studies, and document analysis (nursing care plans, charts, field notes, advanced care plans and advanced care directives) to identify the challenges and/or solutions of plan of care implementation. Different participants were involved: staff (physicians, nurses, personal support workers, social workers, therapists, and care home managers), residents and their families. Advanced care plans were the most assessed interventions in 20 (59%) of the included articles. Only four (12%) of the 34 articles assessed holistic care plans. Over half (56%) of the articles addressed both challenges and solutions while 32% addressed only challenges and 12% addressed only solutions. See Table 2 (in PDF).

Synthesis of findings

We summarized the qualitative evidence of challenges and solutions according to key themes and concepts. The key themes were categorized as provider-level, resident/family level and work environment level. 

Provider Level:

We identified four subthemes at the provider level: knowledge, communication, documentation and personal characteristics

The most commonly reported barriers were lack of staff knowledge and training; lack of communication between staff and between staff and residents/families; inconsistent documentation often due to lack of time and variability of language used; fragmentation in location of documents. Barriers related to personal characteristics were seen especially with the introduction of new processes and with advanced care planning as a result of lack of motivation for change and differing cultural beliefs. 

The most suggested solutions were providing education, training and support to staff; facilitating communication between staff; providing guidance to staff how to approach and facilitate discussions with residents and their families. Solutions for issues with documentation include using standardized forms and consistent terminology, and having a centralized or consistent location. See table 3 (in PDF).

Resident or family level:

Four subthemes were identified at the resident or family level: family involvement, communication, personal characteristics and relationship with staff.

The most commonly reported barriers were lack of family involvement, family struggles with decision making, communication barriers especially due to cultural/religious factors around end of life or transition into end of life care, cognitive impairment of the resident, and conflicts with the staff.

Possible solutions were to educate the family about person-centered care and involve the family in establishing the resident’s preferences and a care plan as well as involve family in all subsequent follow ups; to educate the residents and their families about end-of-life care; and facilitate discussions and involvement in care meetings.  See Table 4 (in PDF).

Work environment level: 

The subthemes at the work environment level are: staffing, documentation, resources, and structure and culture of nursing home. 

Common barriers were high staff turnover and shortages, the length of the care plan – too long and lack of time to complete it adequately, poor resource setting and dispersion of responsibility.

Possible solutions identified are: implementation of a good system with a good structure and guidance in the nursing care process; development of a system that is concise and user friendly; adequate resourcing for care plan implementation; allocation of responsibility for program implementation and having efficient organizational systems with staff support and education resources. See Table 5 (in PDF).

Discussion

Applicability of evidence/implementation:

Although care planning is mandatory and a key element in providing continuity of care in the long term care setting, there is growing concern about non-compliance in plan of care. Most of the research evidence is on identifying factors that influence the implementation of plan of care rather than the effectiveness of strategies to improve implementation. A preliminary search found one systematic review on effectiveness of the plan of care in the long-term care setting  [11]. There is limited evidence of implementation strategies in the long term care setting.

A key step in assessing implementation is to identify potential challenges and solutions [9]. Almost 60% of the included articles were on the implementation of advanced care planning and the challenges and solutions for implementing advanced care plan were consistent with those for implementing the plan of care. The challenges were also consistent with those from the home inspection reports.

Our findings showed that different types of challenges may operate at different levels of the healthcare system. It is important to understand the type of challenges, whether they are modifiable or not, and identify potential solutions then prioritize challenges by importance and consider which solutions are feasible and the resources available to implement them. Different strategies may work for different people and different situations and a combination of strategies may be more effective than single strategies.

Strengths and limitations: 

Consistent themes and proposed challenges and solutions were found across included studies. We grouped the findings according to themes which might facilitate decision about implementation. 

Due to limited literature on this topic, the search strategy required the use of many text words which might restrict the retrieval of potential articles. We included articles on the implementation of the advanced care plan and the care plan and the findings were consistent. 

Recommendations

Practice recommendations:

Based on our findings we recommend that LTC homes should identify relevant barriers then contextualize and prioritize strategies and solutions that are feasible. 

• Long-term care homes should identify and prioritize the barriers in their context that need to be changed.
• Long term care homes should implement strategies to monitor impact of implementing these changes on processes of care as well as the resident, family and staff experience 
• Long-term care homes should choose which solutions work best for them.

Research recommendations:

• Given the lack of evidence on implementation of interventions to improve communication about plans of care in long term care, there is a need for implementation research in this area.
• Implementation research should be designed to build on existing knowledge about implementation, by comparing new strategies and combinations of strategies to methods known to be effective.
• More quality research is needed to provide evidence on the effectiveness of the plan of care in long-term care setting.