INTERSCALE – Sustainable Improvement of INTERprofessional care for better resident outcomes: SCAling up an Evidence-based care model for Residential Long-Term Care Facilities

Background: To respond to the demand for improved quality in long-term care, nurse-led care models have been introduced and proved effective in reducing unplanned hospital transfers of long-term care facility (LTCF) residents. The INTERCARE study is one such successful example of implementation in 11 Swiss LTCFs between 2018-2020. The INTERCARE model consists of the following core components: 1) strengthening interprofessional collaboration, 2) introducing an INTERCARE nurse, a registered nurse trained in geriatric knowledge and skills to take up an expanded role, 3) promoting comprehensive geriatric assessment, 4) introducing evidence-based tools to strengthen the communication within the care team (i.e. STOP&WATCH tool) and with general practitioners (i.e. ISBAR tool), 5) introducing advance care planning, and 6) applying data-driven quality improvement. Overall findings showed that the model was effective in reducing unplanned hospital transfers, had high acceptability and sustainability, but also had high-cost demands for both the LTCFs and the research team in view of the time invested for implementation. Given that the INTERCARE study demonstrated replicability of the INTERCARE model in 11 LTCFs, the INTERSCALE study is the next step to scale-up the intervention in a broader context with a more cost-effective solution of implementation strategies (IS) to support the implementation of the INTERCARE model. Research Question: Will a less-resource intensive set of IS produce the same results (i.e. show the same fidelity to the intervention) during the scale-up of an evidence-based intervention in LTCFs, when compared to the original set of IS deployed during the initial implementation of the intervention? Methods: INTERSCALE is concerned with generating information for the set-up and building of the scalable unit in a first work package (WP1) and then testing the scalable unit in a second work package (WP2). The scalable unit includes an adapted version of the INTERCARE model (the intervention) and two sets of implementation strategies: a) Set A – a newly developed set of IS (i.e., less resource-intensive) and Set O – the original set of IS used in the INTERCARE study. The IS in both sets will target the LTCF leadership and the INTERCARE nurse but will differ in whether the targets are approached individually or as a group, as well as in the temporality and dose of the implementation strategy. In WP2, a hybrid type 3 effectiveness-implementation study with a cluster randomized controlled trial design will be conducted to test the two sets of IS in view of several implementation (degree of implementation fidelity, sustainability, acceptability, feasibility and implementation costs), cost-effectiveness, clinical (unplanned hospital transfers of  LTCF residents) and organizational outcomes (staff absences, staff turnover and intention to leave). This will be a non-inferiority trial and a sample of 40  LTCFs will be randomized to receive the intervention in addition to either Set A or Set O of the IS (20  LTCFs per arm). The intervention phase will last 12 months, followed by a sustainment phase of an additional 12 months.
Expected results: INTERSCALE will add to the body of knowledge to an understudied area in implementation science by addressing a gap concerning the application of IS which best support implementing evidence-based interventions in long-term care settings.
Conclusions: The introduction of the INTERCARE model within LTCFs aims towards driving organizational change by skilling-up key staff like the INTERCARE nurse, as well as by introducing new processes and tools in these organizations. By supporting the LTCFs in implementing evidence-based yet cost-effective interventions aimed at reducing unplanned hospital transfers of residents, we address current and future challenges of meeting the increasing demand for qualitative residential care in the face of current scarce financial and qualified staff resources.