title: Improving functional outcomes in home care patients: impact and challenges of disseminating a quality improvement initiative.
abstract: Most older adults are admitted to home health care with some functional impairment related to chronic illness and/or hospitalization. This article describes: (1) the impact of a quality improvement initiative (QI) on functional outcomes of older, chronically ill patients served by a large homecare organization; and (2) key implementation challenges affecting intervention outcomes. Over 6,000 patients were included in two dissemination phases. Phase 1 randomly assigned service delivery teams to intervention (QI) or usual care (UC). Phase 2 spread the intervention to UC teams. Phase 1 yielded statistically significant, albeit modest, functional improvements among intervention team patients relative to UC. Phase 2 improvements in the original intervention group were smaller, suggesting some regression to the mean. UC teams did not "catch up" when exposed to the intervention in Phase 2. Analysis of the implementation process suggested that modification of improvement strategies and "dilution" of peer-to-peer communication hindered additional Phase 2 improvements. The findings highlight the challenges of relying on peer-to-peer spread, and of distinguishing the core elements of an effective improvement strategy that must be spread consistently from those that can be adapted to variations within and across organizations.
authors.affiliation: Center for Home Care Policy and Research, Visiting Nurse Service of New York, NY, USA. miriam.ryvicker@vnsny.org
authors.forename: Miriam
authors.initials: M
authors.lastname: Ryvicker
authors.forename: Penny Hollander
authors.initials: PH
authors.lastname: Feldman
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Rosati
authors.forename: Sally
authors.initials: S
authors.lastname: Sobolewski
authors.forename: Gil A
authors.initials: GA
authors.lastname: Maduro
authors.forename: Theresa
authors.initials: T
authors.lastname: Schwartz
mesh_terms: D000203:Activities of Daily Living; D000368:Aged; D000369:Aged, 80 and over; D002908:Chronic Disease / Q000628:therapy; D005260:Female; D006699:Home Care Services / Q000592:standards; D006801:Humans; D033183:Interdisciplinary Communication; D008297:Male; D008875:Middle Aged; D009518:New York; D064691:Nurses, Community Health / Q000592:standards; D010348:Patient Care Team; D058996:Quality Improvement / Q000592:standards*
keywords: dissemination and sustainability; home health care; patient function; practice improvement; self-management