Penny Hollander Feldman1, Margaret V McDonald. 1. Center for Home Care Policy and Research, Visiting Nurse Service of New York, New York, NY 10021, USA. pfeldman@vnsny.org
Abstract
BACKGROUND: Home care organizations are relatively isolated from academic health centers, university-based schools of nursing, and centers of health services research that have advanced the knowledge base for quality improvement. Thus limited information exists about how best to promote evidence-based practice in this setting. AIMS: This article examines research and translation issues posed by the decentralized home care setting and considers how these issues compare to issues in other settings. METHODS: A case study approach is used to frame a discussion of the contextual and practical factors that can influence the design and future acceptance of different translation strategies in the home care setting. Use of a recently concluded randomized trial that tested the effectiveness of two interventions designed to improve the adoption of evidence-based practices by home health nurses has been made to inform this discussion. DISCUSSION: Effective translation interventions in home health care need to address the unique nature of this setting including the dispersed, generalist workforce that serves a diverse patient population and lacks strong peer contact or on-site support and supervision. Proactive push translation strategies such as reminders that have been effective in other settings show promise in this service area but had a differential effect across conditions. Significantly, the cost-effectiveness analysis of this intervention showed that net patient care costs actually increased for one condition. IMPLICATIONS: The study described in this article demonstrates that rigorous translation research can be conducted in highly decentralized practice settings. It also points to the value of assessing different levels of intensity of interventions in a single study, looking at process measures and patient outcomes, and conducting a cost-effectiveness analysis. To encourage broader adoption of translation strategies, additional incentives from purchasing or regulatory agencies may be needed.
BACKGROUND: Home care organizations are relatively isolated from academic health centers, university-based schools of nursing, and centers of health services research that have advanced the knowledge base for quality improvement. Thus limited information exists about how best to promote evidence-based practice in this setting. AIMS: This article examines research and translation issues posed by the decentralized home care setting and considers how these issues compare to issues in other settings. METHODS: A case study approach is used to frame a discussion of the contextual and practical factors that can influence the design and future acceptance of different translation strategies in the home care setting. Use of a recently concluded randomized trial that tested the effectiveness of two interventions designed to improve the adoption of evidence-based practices by home health nurses has been made to inform this discussion. DISCUSSION: Effective translation interventions in home health care need to address the unique nature of this setting including the dispersed, generalist workforce that serves a diverse patient population and lacks strong peer contact or on-site support and supervision. Proactive push translation strategies such as reminders that have been effective in other settings show promise in this service area but had a differential effect across conditions. Significantly, the cost-effectiveness analysis of this intervention showed that net patient care costs actually increased for one condition. IMPLICATIONS: The study described in this article demonstrates that rigorous translation research can be conducted in highly decentralized practice settings. It also points to the value of assessing different levels of intensity of interventions in a single study, looking at process measures and patient outcomes, and conducting a cost-effectiveness analysis. To encourage broader adoption of translation strategies, additional incentives from purchasing or regulatory agencies may be needed.