Qualitative study of the implementation of long-term care plus: An intervention-in-systems approach

ObjectivesReducing resident transfers from long-term care (LTC) to emergency departments (ED) is a well-established quality target. LTC plus (LTC+) provides medical consultations, healthcare navigation, rapid diagnostics, and education to LTC home providers, based on the logic that providing enhanced medical care in LTC homes will decrease ED transfers. LTC+ was implemented across six hospital-hubs and 54 homes in Toronto, Canada. An evaluation demonstrated positive program satisfaction and impacts on care, however limited program uptake and impact on ED transfers. We examine LTC+ intervention components and their implementation and adaptations to understand these discrepancies and identify improvement opportunities.MethodsWe conducted 32 qualitative interviews with LTC home providers and administrators and consultant physicians, and three focus groups with residents and family members, at six LTC homes and three hospital-hubs. Analysis drew on Lennox et al.'s conceptualization of "intervention-in-systems" which outlines four spheres to categorize intervention components (accessibility of evidence base, process of enactment, dependent processes and sociocultural issues) and their interconnectedness and adaptations when implemented and spread in complex systems.ResultsLTC+ design and implementation was centered within the accessibility of evidence base (e.g., educating about LTC+) and process of enactment (e.g., identify residents being considered for ED transfer) spheres to support program goals. LTC+ use was aligned with original program logic, however, providers also accessed LTC+ in cases where an ED transfer was not being considered highlighting limitations of a logic focused solely on ED transfers. LTC+ design and implementation was less attentive to intervention components in the dependant processes and sociocultural issues spheres (e.g., staffing models, interprofessional interactions) impacting adoption.ConclusionThe "intervention-in-systems" analytic lens was useful in examining intervention components across the four spheres, including their gaps, adaptations and interconnections. Study findings informed revisions to program goals, intervention components, and evaluative approach, reinforcing program and financial sustainability.