The effect of using telehealth to train residential aged care facility staff in delivery of palliative care to residents on the rate of unplanned hospitalisation admissions and quality of end-of-life care

The IMPART intervention is actively implemented over a 6-month period. There are 10 residential aged care facilities (RACFs) completing the stepped-wedge trial. At the start of the trial all facilities will be randomised to receive the intervention at one of 5 steps with two RACFs actively implementing the intervention during each step. Therefore the trial will occur over 2.5 years (5 X 6-month steps). The 6-month intervention involves five components described in a manual to support facility staff to implement the intervention. If the intervention is successful, the manual will be made publicly available on the NARI website so that other facilities can implement the intervention and access the templates required. After each RACF completes their active 6-month part of the intervention, the RACF will be able to use the knowledge, strategies and specialist connections and apply them for the subsequent 6-month steps of the trial and into the future. For each active 6 -month intervention period, the specialist in-reach support will be funded 0.1 EFT to support engagement with the facility. We will aim to hold meetings and workshops in person at the facility, however, we also aim to enable video-conferencing to facilitate external staff involvement. COMPONENT 1: ESTABLISH PLANNING AHEAD TEAMS (Month 1) The research team will work collaboratively with the RACF to establish the facility ‘Planning Ahead Team’. The RACF will identify staff to be involved, which could include nurses with a portfolio of palliative care, clinical care coordinators, or staff who have an interest in end-of-life care. We will engage senior nurses as care champions who will be able to support other staff in palliative care discussions and processes. The lead of the Planning Ahead Team will support RACF staff and work with GPs to promote end-of-life discussions with residents and families, and document decision-making. We aim to involve at least two RACF staff to maintain continuity. We will engage a GP who has an existing visiting role at the RACF. All Planning Ahead Team members will be invited to a 1-hour workshop (registered with Continuing Professional Development points) covering goals of care facilitated by a palliative care consultant. COMPONENT 2: END-OF-LIFE CARE NEEDS ANALYSIS (Month 1) The Planning Ahead Team will undertake a needs analysis to identify areas for improvement in end-of-life care discussions, documentation and care provision. They will review current documentation in resident files using templates designed specifically for this study. Template 1 recommends reviewing 5-10 resident files to evaluate the quality of end-of-life care planning documentation (what is documented, whether resident wishes are incorporated and whether it has been recently reviewed). A second template prompts evaluating documentation from 5-10 residents who have died in the last 6 months. Questions include place of death, services involved, recognition of dying, whether end-of-life care was consistent with residents’ wishes and end-of-life planning documentation. These templates will help inform completion of the Needs Analysis Checklist that assess the extent to which each facility’s existing processes, policies and procedures enable shared-decision making, person-centred care and are responsive to cultural, language and spiritual requirements and values. This Checklist, designed specifically for this study, summarises overall RACF processes, policies and procedures. The Needs Analysis Checklist will be completed jointly by the Planning Ahead Team with support from the research team and input from the external palliative care and aged care specialists. The research team will invite the Planning Ahead Team to complete a survey assessing confidence in providing, discussing and planning for end-of-life care. This survey is based on existing end-of-life confidence measures (Dowling M, et al, …Journal of Palliative Medicine, 2020. 23[2]: 179-183 and Phillips J, et al. … Int J Nurs Stud, 2011. 48[9]: 1096-100). The research team will assess the availability and confidence of RACF staff in using end-of-life related equipment such as syringe drivers, lifting machines, pressure relieving devices or catheter equipment and the availability of medication related to end of life including Imprest stock. Planning Ahead Teams will explore opportunities for obtaining resident and family input on end-of-life care planning undertaken in the facility. They will also review documented complaints and complements to the facility and see whether any relate to end-of-life care. COMPONENT 3: WORKSHOP WITH PLANNING AHEAD TEAMS (Month 2) AND ACTION PLANNING (Months 2-6) The research team will facilitate an initial workshop with the Planning Ahead Team. During this 1-2-hour workshop, the research team will present findings from the needs analysis, highlighting strengths and challenges in current end-of-life care practices. For instance, the research teams will synthesise data from the Needs Analysis Checklist and the staff survey to reflect on practice. This will provide a comprehensive understanding of the end-of-life care needs in the facility, incorporating views of RACF staff, external palliative care specialists and GPs. We will discuss avenues for addressing needs and develop an action plan using the Action Plan Template developed for this study. This approach aims to engage facility staff with areas of practice change that they have identified and consider relevant to their practice. During the workshop, future meetings and steps for the Planning Ahead Team will be planned to monitor the action plan and outcomes. Over the remaining 4 months of the intervention, the Planning Ahead Team will meet approximately once a month for 1-hour to implement and review progress of the action plan. The external geriatric or palliative care specialist will contact the RACF Planning Ahead Team through a 30 minute monthly telephone/video call to discuss progress, challenges and offer information and training as needed. While developing the action plan, we will identify ways of involving residents and families in implementing the action plan, e.g. by including them in future discussions about end-of-life care processes. At the end of the 6 month intervention and to evaluate the impact of the action plan on practice, we will repeat some data collection. For example, repeating the review of resident files to see whether documentation has improved, repeat the staff end-of-life care survey or review policies, complaints and complements. COMPONENT 4: IMPETUS-D PLUS ONLINE TRAINING (Months 2-6) RACF staff will receive access to the existing ‘Improving Palliative care Education and Training Using Simulation in Dementia (IMPETUS-D) validated online training package (Tropea J, et al. ...BMC Pall Care, 2019. 18(1): 86). During the workshop described in Component 3, the Planning Ahead Team will review the modules available in the IMPETUS-D training set to identify which modules may be useful for staff in their facility. Depending on the goals identified in the action plan, they may choose training for all RACF staff or target training to specific staff, such as those in the Planning Ahead Team. It may be useful to use a section of a module or run a workshop/meeting to discuss a module and the implications for practice at that RACF. The research team will send reminders to the Planning Ahead Team to complete training as planned in the action plan. There are 11 modules that can be completed online using a computer/laptop, tablet or smartphone. Each module takes 15-30mins and contains video simulation. Topics: recognising end of life; Goals of Care planning and discussions; distinguishing dementia from delirium, managing symptoms including pain, breathlessness, not eating/drinking, and terminal restlessness; communicating with residents and families, and supporting staff when a resident dies. The training was developed for end-of-life care for people with dementia but encompasses skills required for end-of-life care for all residents. The research team will highlight other resources that may address information needs. COMPONENT 5: SPECIALIST TELEHEALTH IN-REACH END-OF-LIFE SUPPORT (Months 2-6) Local palliative care and aged care specialists will be engaged from the start of the IMPART program through their involvement in the Planning Ahead Teams in Components 1 and 3. The workshops with the Planning Ahead Teams will help RACF staff get to know the specialist team, establish communication channels and plan for specialists to provide training or shadowing/observations using online technology. An approach could involve the Planning Ahead Team and the GP completing IMPETUS-D modules and discussing this with the specialist team. This could be followed by a collaborative end-of life discussion between the resident and/or family member(s) with RACF staff, the GP and the specialist clinician using telehealth. This will involve immediate feedback after the case conference from the specialist clinician. While the IMPETUS-D training provides videos of professionals having these conversations, there may be additional benefits of getting direct feedback from an expert. We will use video-conferencing to foster rapid communication between RACFs and specialists. FIDELITY TESTING Access to and completion of IMPETUS-D modules is digitally recorded and matched to individual RACFs. A member of each Planning Ahead Team and their connected specialist service will maintain an activity log documenting time spent (to the nearest 15min) on different components of the intervention. The research team will make monthly calls to the RACF Planning Ahead Team and their specialist service to monitor progress with the intervention. We will collect completed Action Plans to monitor extent to which plans were developed and implemented and also monitor this via telephone calls with the Planning Ahead Team.