Using Palliative Care Needs Rounds in the UK for care home staff and residents: an implementation science study

Background
Care home residents often lack access to end-of-life care from specialist palliative care providers. Palliative Care Needs Rounds, developed and tested in Australia, is a novel approach to addressing this.


Objective
To co-design and implement a scalable UK model of Needs Rounds.


Design
A pragmatic implementation study using the integrated Promoting Action on Research Implementation in Health Services framework.


Setting
Implementation was conducted in six case study sites (England, n = 4, and Scotland, n = 2) encompassing specialist palliative care service working with three to six care homes each.


Participants
Phase 1: interviews (n = 28 care home staff, specialist palliative care staff, relatives, primary care, acute care and allied health practitioners) and four workshops (n = 43 care home staff, clinicians and managers from specialist palliative care teams and patient and public involvement and engagement representatives). Phase 2: interviews (n = 58 care home and specialist palliative care staff); family questionnaire (n = 13 relatives); staff questionnaire (n = 171 care home staff); quality of death/dying questionnaire (n = 81); patient and public involvement and engagement evaluation interviews (n = 11); fidelity assessment (n = 14 Needs Rounds recordings).


Interventions
(1) Monthly hour-long discussions of residents' physical, psychosocial and spiritual needs, alongside case-based learning, (2) clinical work and (3) relative/multidisciplinary team meetings.


Main outcome measures
A programme theory describing what works for whom under what circumstances with UK Needs Rounds. Secondary outcomes focus on health service use and cost effectiveness, quality of death and dying, care home staff confidence and capability, and the use of patient and public involvement and engagement.


Data sources
Semistructured interviews and workshops with key stakeholders from the six sites; capability of adopting a palliative approach, quality of death and dying index, and Canadian Health Care Evaluation Project Lite questionnaires; recordings of Needs Rounds; care home data on resident demographics/health service use; assessments and interventions triggered by Needs Rounds; semistructured interviews with academic and patient and public involvement and engagement members.


Results
The programme theory: while care home staff experience workforce challenges such as high turnover, variable skills and confidence, Needs Rounds can provide care home and specialist palliative care staff the opportunity to collaborate during a protected time, to plan for residents' last months of life. Needs Rounds build care home staff confidence and can strengthen relationships and trust, while harnessing services' complementary expertise. Needs Rounds strengthen understandings of dying, symptom management, advance/anticipatory care planning and communication. This can improve resident care, enabling residents to be cared for and die in their preferred place, and may benefit relatives by increasing their confidence in care quality.


Limitations
COVID-19 restricted intervention and data collection. Due to an insufficient sample size, it was not possible to conduct a cost-benefit analysis of Needs Rounds or calculate the treatment effect or family perceptions of care.


Conclusions
Our work suggests that Needs Rounds can improve the quality of life and death for care home residents, by enhancing staff skills and confidence, including symptom management, communications with general practitioners and relatives, and strengthen relationships between care home and specialist palliative care staff.


Future work
Conduct analysis of costs-benefits and treatment effects. Engagement with commissioners and policy-makers could examine integration of Needs Rounds into care homes and primary care across the UK to ensure equitable access to specialist care.


Study registration
This study is registered as ISRCTN15863801.


Funding
This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR128799) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 19. See the NIHR Funding and Awards website for further award information.


Objectives
The implementation objectives were to: 1. co-design a UK version of Needs Rounds, which is responsive to different contextual characteristics of the UK CH sector (Phase 1) 2. implement the adapted model of care, assess feasibility, acceptability and effectiveness and ultimately propose how the model of care can be further refined and adopted in the UK context, to reap the benefits demonstrated in the Australian work (Phase 2).
The intervention objectives were to: 3. determine the transferability of the core elements of the Australian Needs Rounds intervention in the UK context (Phase 1 and 2) 4. delineate the mechanisms of action that enable more effective palliative and end-of-life care practices to be applied in UK CHs (Phase 2) 5. identify the relationships between (1) the mechanisms of action embedded in Needs Rounds, (2) how these mechanisms function in different CH contexts and (3) the outcomes arising for different stakeholders and parts of the care system (Phase 2).
The process evaluation objectives were to: 6. document the outcomes of UK Needs Rounds on hospitalisations (including costs), quality of death/ dying and CH staff capability (Phase 2) 7. assess and report the perspectives of CH residents, relatives, CH staff and palliative care staff on using UK Needs Rounds (Phase 2).

Phase 1: development of an initial programme theory
Inclusion criteria: SPC or CH staff in one of the six sites; residents or relatives of someone residing in one of the CHs; worked in a role supporting CHs (acute care, the ambulance service or primary care); and had capacity to consent.
Participants and methods: stakeholder interviews (n = 28) across the six cases were used to develop an initial programme theory.Subsequently, we ran four online workshops to co-design UK Needs Rounds with key stakeholders (n = 43).
Analysis: Inductive thematic analysis was applied to the interview data, using NVivo for coding.Integrated Promoting Action on Research Implementation in Health Services informed subsequent deductive analysis, categorising the data into contexts, mechanisms, outcomes and innovation components.Chains of inference were identified, and context, mechanism, outcome configurations generated.
Outputs: Five theories and an initial programme theory to be tested during implementation.

Phase 2: implementing, adapting and evaluating United Kingdom Needs Rounds in the six case study sites
Inclusion criteria: interviews -SPC clinicians or a CH staff member in one of the sites; research team member for patient and public involvement and engagement (PPIE) evaluation.Capability to adopt a palliative approach (CAPA) -CH staff members in one of the six sites; Quality of Death and Dying Index (QODDI) for all CH-deceased residents; CANHELP Lite -relatives of someone discussed at Needs Rounds.
Participants and data: interviews, n = 58 CH and SPC staff; PPIE evaluation, n = 11; CANHELP Lite questionnaire, n = 13 relatives; CAPA, n = 171 CH staff; QODDI, n = 81 CH staff; fidelity, n = 14 Needs Rounds recordings.Interviewees in Phase 2 had not been interviewed in Phase 1, but participating hospices had staff involved in both Phase 1 and Phase 2 interviews.
Analysis: Qualitative data were analysed inductively using thematic analysis and coded using NVivo and organised in line with the five theories derived from Phase 1. Deductive and retroductive analysis were used to formulate the data into context, mechanism, outcomes and identify causal forces of generative causation.Data sources were triangulated in analysis to aid development of the theory.Chains of inference and connectors between and within the initial theories were subsequently refined and integrated to produce the final programme theory of implementation for the UK context.
Capability of adopting a palliative approach (CAPA) was analysed using generalised least squares random-effects models with robust standard errors; regressions were conducted for overall CAPA scores and for each individual CAPA item, and a paired t-test was conducted using the subset of CH staff members with multiple responses.
The QODDI analysis was conducted using QODDI10, a subset of the QODDI questionnaire, which included 10 items.Due to large numbers of missing data, QODDI10 was selected to preserve the largest proportion of the sample with complete responses (92.6%).
Family perceptions of care analysis used descriptive statistics for the family perceptions (CANHELP Lite) survey due to the small sample size.
Fidelity was assessed through a random sample of 20% of all audio-recorded Needs Rounds to determine adherence to the agreed approach developed in the workshop.A three-tier scoring system, of 1 (high adherence), 2 (moderate) and 3 (low), was adopted.
Estimating the treatment effect on health service outcomes was conducted using descriptive statistics for number of hospital admissions and number of hospital bed-days.
Estimating the cost effectiveness (cost-benefit analysis) was not possible due to insufficient data.
Qualitative interview data were used to describe costs associated with Needs Rounds.
Outputs: A programme theory of what works for whom under what circumstances with Needs Rounds in the UK, an implementation translation package, and policy briefing.
Patient and public involvement: three lay people were coinvestigators and contributed to protocol development, ethics paperwork, topic guides for Phase 1 and 2 interviews, content development and participation/co-facilitation at the coproduction workshops, data analysis and dissemination outputs including newsletters, blogs, Twitter, journal articles, conference abstracts and this funder report.
Training and support were provided to PPIE members.

Results
Phase 1: five theories were generated focusing on (1) Confidence and competence, (2) reducing hospitalisations, (3) interagency working and collaboration, (4) better-quality lives and deaths and (5) supporting families.These were integrated to produce one initial overarching initial programme theory to be tested during implementation.

Phase 2: primary outcome
Needs Rounds resulted in increased CH staff confidence and competence to support residents in their last months of life.Sector-wide workforce issues and associated impacts on time and resources, however, shaped the scale of change, with CHs often being limited in the number and type of staff members being able to attend.
Improved relationships were forged between CH and SPC staff.The facilitation approach was a key mechanism for this and was based on developing collaborative, reciprocal relationships where complementary expertise was harnessed.Increased confidence improved communications between CH staff and general practitioners (GPs).
Better-quality death and dying resulted from proactive discussions and action plans regarding residents' physical, psychosocial and spiritual needs.CH staff reported that families felt more informed and secure in the care their relatives received.
Fidelity to the coproduced UK model of Needs Rounds was variable.An assessment of a random selection identified that many sites achieved low scores despite qualitative interviews providing evidence of managing to achieve important outcomes.
Facilitation approaches were collaborative and involved gentle work in determining people's current knowledge and areas for extending insights as well as which residents were appropriate to discuss.Managers were key facilitators in enabling staff to attend Needs Rounds, through rotas or paid overtime.

Health and Social Care Delivery Research 2024 Vol
. 12 No. 19 (Scientific summary)