Implementing in VA CLCs Is Complex, We Know!

In the report of Mor et al. [1] entitled “Implementing INTERACT in Veterans Health Administration Community Living Centers: A Pragmatic Randomized Trial”, the study found that INTERACT did not reduce rates of all-cause hospitalizations. This study offers valuable insights into improving care for our nation's Veterans in long-term care settings.

The INTERACT program represents a novel and commonsense approach to reducing potentially avoidable hospitalizations among nursing home residents. It includes four basic components: quality improvement, communication, decision support and advance care planning [2]. In this article, they highlight the “stop and watch” methodology which encourages all employees to increase situational awareness of potential Veteran changes and use Situation, Background, Assessment, and Recommendation (SBAR) to communicate observations and changes in conditions across disciplines. In the day-to-day care of nursing home residents, the trees can obscure the view of the forest. INTERACT reminds us that all team members have a view and should participate in identifying resident changes.

At the Veterans Health Administration (VHA), our sacred duty is to care for those “who have borne the battle” [3]. At Community Living Centers (CLCs), we care for those who have survived the battle and compounded with the added changes of age, disability, and disease. CLC residents are among our most vulnerable and are often more complex than those in Community Nursing Homes because of higher comorbidity, concurrent mental health conditions, and increased social needs [4, 5]. The CLC provides transitional care, long term care, and hospice care.

The authors found (a) a high rate of all cause readmission with a lower rate of inappropriate readmission and (b) difficulty implementing INTERACT. These findings highlight the challenges of caring for complex Veterans in an integrated health system. As an integrated health system, where CLCs are often co-located with inpatient hospitals, CLCs play a role in decompressing the system. For example, a Veteran with advanced cancer and low social supports might reside in the CLC between rounds of hospital-based chemotherapy. Readmissions are anticipated and scheduled with the Veteran's goals as the driving force. We understand the difficulty of implementing tools such as the INTERACT methods firsthand.

For background, VHA implemented the CLCs Ongoing National Center for Enhancing Resources and Training (CONCERT) program in 2017 with a train the trainer approach [6]. CONCERT implements the LOCK bundle, a set of practices based on relational coordination theory, to create high-functioning, relationship-based teams [7]. Such an implementation required significant investment from CLCs (personnel time, cultural shifts), regional (training, coordination), and national (expertise, phone support, webinars, and coordination). The CONCERT team visited successful CLCs to identify and disseminate best practices and supported those CLCs struggling with relational coordination. Ultimately, the CONCERT team identified five foundational practices (Figure 1) that are recommended to be implemented at all CLCs. Of the five foundational practices, only one is focused on leadership; the other four are heavily dependent upon the frontline staff engagement and involvement. The true “work” of CONCERT, in our CLCs comes from the frontline nursing staff engaging in deep dives, watch list huddles, completion of the “all about me” tools and engaging in consistent assignment. Given our experience, we would like to highlight some key points concerning research implementation in the CLCs.

First, while leadership buy-in is crucial to implementation, it alone is insufficient for successful implementation. All staff members typically have ideas for improvement, but translating those concepts into practice demands robust systems and processes. The investigators spotlighted that the intervention did not work because the VA has more nursing staff, in-house physicians, and other licensed independent practitioners. While this is true, the CLC's have a higher staffing ratio because the average CLC resident population requires more complex care such as chemotherapy, radiation therapy, oxygen, respiratory therapy, and IV medications. This acuity may contribute to a possibly higher unavoidable readmission rate which the INTERACT intervention may not improve. The authors noted that while all-cause readmission were high, avoidable readmissions were low. In addition, the CLC bed turnover is much higher than the bed turnover of VHA Contract Nursing Homes (CNH) which demonstrates that CLCs are serving more short stay/subacute Veterans on average [8]. Given these nuances, the implementation strategy that is most likely to be successful is one that is customized to the individual CLCs. For example, if an intervention can improve efficiency of staff, then it is more likely to be adopted by the frontline staff members of which the CLCs have more.

Second, implementing a complex program like INTERACT in the VA system presents unique challenges. The INTERACT program requires substantial infrastructure, including local adaptations of the electronic medical record, training for all staff, technical support, and culture change. While the infrastructure changes are certainly challenging, true success lies in culture change. Changing culture can be very difficult and takes time. As discussed above, the CONCERT implementation focused on Relational Coordination, where the emphasis is on building high-functioning team skills among leaders and frontline staff members alike. A focus on frontline-leading process improvement projects resulted in improved staff communication, staff satisfaction and psychological safety. Culture change can be difficult to build and requires significant investment of time and resources. VHA's subsequent implementation of CONCERT required significant investment beyond what a research team could be expected to provide.

Third, VA CLCs exists to provide high-quality clinical care to Veterans. Quality improvement efforts that are being implemented and evaluated for potential benefit, while important, come second if they may have an impact on the core focus of providing clinical care to Veterans. Research initiatives, though valuable, rank lower in priority. This hierarchy shapes how new programs are received and implemented. A key feature of any improvement or research must be the integration with existing VA quality improvement infrastructure, leveraging established channels for data collection and analysis and minimizing additional burden on staff. If the staff feel burdened to participate in research, they are less likely to buy in and therefore the intervention is less likely to achieve the desired culture change required for success.

In conclusion, while the implementation of INTERACT in VA CLCs from 2015 to 2017 faced significant challenges, it provided valuable lessons that informed the development of CONCERT and our continued efforts at improving quality. With CONCERT, CLCs demonstrate the VA's ability to learn from external best practices, tailor interventions to our unique environment, and maintain a steadfast focus on improving care for Veterans.

The journey to optimize care in VA CLCs continues, driven by our dedication to those who have sacrificed so much for our country. We remain committed to exploring innovative approaches, always keeping the Veteran at the center of our efforts.

All authors meet the criteria of authorship as stated in the Uniform Requirements for Manuscripts Submitted to Biomedical Journals. All the listed authors made (1) substantial contributions to the conception and design, or acquisition of data, or analysis and interpretation of data; (2) drafting the article or revising it critically for important intellectual content; and (3) final approval of the version to be published.

The authors have nothing to report. Veterans Affairs funds the work of all three authors of the editorial. No role of sponsor.

The authors declare no conflicts of interest.