title: Randomized multilevel intervention to improve outcomes of residents in nursing homes in need of improvement.
abstract: OBJECTIVE
  A comprehensive multilevel intervention was tested to build organizational capacity to create and sustain improvement in quality of care and subsequently improve resident outcomes in nursing homes in need of improvement.
  
  
  METHODS
  Intervention facilities (N = 29) received a 2-year multilevel intervention with monthly on-site consultation from expert nurses with graduate education in gerontological nursing. Attention control facilities (N = 29) that also needed to improve resident outcomes received monthly information about aging and physical assessment of elders.
  
  
  METHODS
  The authors conducted a randomized clinical trial of nursing homes in need of improving resident outcomes of bladder and bowel incontinence, weight loss, pressure ulcers, and decline in activities of daily living. It was hypothesized that following the intervention, experimental facilities would have higher quality of care, better resident outcomes, more organizational attributes of improved working conditions than control facilities, higher staff retention, similar staffing and staff mix, and lower total and direct care costs.
  
  
  RESULTS
  The intervention did improve quality of care (P = .02); there were improvements in pressure ulcers (P = .05) and weight loss (P = .05). Organizational working conditions, staff retention, staffing, and staff mix and most costs were not affected by the intervention. Leadership turnover was surprisingly excessive in both intervention and control groups.
  
  
  CONCLUSIONS
  Some facilities that are in need of improving quality of care and resident outcomes are able to build the organizational capacity to improve while not increasing staffing or costs of care. Improvement requires continuous supportive consultation and leadership willing to involve staff and work together to build the systematic improvements in care delivery needed. Medical directors in collaborative practice with advanced practice nurses are ideally positioned to implement this low-cost, effective intervention nationwide.
authors.affiliation: Sinclair School of Nursing, University of Missouri, Columbia, Missouri 65211, USA. rantzm@missouri.edu
authors.forename: Marilyn J
authors.initials: MJ
authors.lastname: Rantz
authors.forename: Mary
authors.initials: M
authors.lastname: Zwygart-Stauffacher
authors.forename: Lanis
authors.initials: L
authors.lastname: Hicks
authors.forename: David
authors.initials: D
authors.lastname: Mehr
authors.forename: Marcia
authors.initials: M
authors.lastname: Flesner
authors.forename: Gregory F
authors.initials: GF
authors.lastname: Petroski
authors.forename: Richard W
authors.initials: RW
authors.lastname: Madsen
authors.forename: Jill
authors.initials: J
authors.lastname: Scott-Cawiezell
mesh_terms: D003365:Costs and Cost Analysis; D006282:Health Personnel / Q000458:organization & administration / Q000523:psychology; D006801:Humans; D008923:Missouri; D009735:Nursing Homes / Q000592:standards*; D017063:Outcome Assessment, Health Care; D058996:Quality Improvement / Q000458:organization & administration*