Making research integral to home care services

Inaugural work to establish and grow partnerships

In 2004, VON Canada identified risk mitigation and improvement in the delivery of quality home care services to individuals and families as a priority. This was fitting for this home care organization for several reasons: (1) VON is at the interface between acute care and transition to the community and therefore well placed to identify the conduits for ensuring continuity of care across sectors; (2) its clinical and program emphasis is on the elderly, palliative care and chronic care management, which together makeup the largest proportion of home care users; (3) VON is recognized as a pioneer and champion in the field of caregiver/family information, support, and education. With interest in patient safety growing, the time was right to partner with the Canadian Patient Safety Institute (CPSI) and encourage the addition of home care to its patient safety agenda. At the same time, VON was cementing commitment to research within the organization. With its history of promoting the use of research evidence to improve care, VON was aware of the need for strong reciprocal relationships among researchers, practitioners, and decision-makers for integrating research in practice. ^8,9 That same year (2004), VON’s newly appointed president and Chief Executive Officer partnered to mentor and integrate a postdoctoral fellow into VON’s quest to improve home care safety for Canadians. In order to ensure that research evidence would inform home care practice and in turn that practice would inform research, this partnership led to subsequently expanding VON’s Practice and Quality Leadership Team in 2007 to include that fellow as a full-time nurse researcher with cross appointments in Nursing at McGill University and Université de Montréal. The goal of anchoring the researcher position within this home care organization was twofold; first, to ensure that the research conducted was relevant to real, practical, current needs, based on what other members of the team were seeing and doing; second, to facilitate and promote VON managers, educators, and frontline staff to engage and collaborate in the development, implementation, analysis, and evaluation of various research studies. ^8,9 As a member of this team with regular opportunities to participate in organizational meetings and activities, discuss organizational issues, and contemplate prospective research questions, the researcher gained a better understanding of the decision-making context and extended the research/decision-maker relationship beyond the confines of individual research studies. ^9,11

Initiation of Canadian patient safety initiatives in home care

Recognizing the home care safety research gap, VON Canada spearheaded a number of initiatives in collaboration with CPSI. Together, in 2005, these organizations commissioned the development of a background paper that initiated a national roundtable dialogue on systematically identifying the key issues in home care safety and developing a research program to fill significant gaps in our understanding. They discussed safety as it pertains not only to physical aspects but also to emotional, social, functional, and financial aspects of home care as well as the importance of considering the caregivers, including the family, when planning and providing home care services. The ensuing report ¹² and peer-reviewed publication ² entitled Safety in Home Care: Broadening the Patient Safety Agenda to Include Home Care described how home care presented unique challenges and required a major rethink of underlying assumptions and guiding frameworks that had been used to examine patient safety in institutional settings. There was consensus that research on safety in home care was needed to identify: the types and patterns of safety concerns for clients, family members, caregivers, and providers; how family/caregiver involvement in care delivery affects safety for all involved; how to attend to safety, given that some variables cannot be regulated or controlled as they traditionally are in institutions such as hospitals or long-term care facilities; the impact of advances in treatments, assistive devices, medications profiles of home care clientele; and the challenges of transitions, communication, and continuity of care amongst an array of recipients as well as caregivers and paid providers. ^2,12 This initial work, which helped launch the national research agenda on home care safety, has formed the basis for the work that CPSI and others are doing in home care safety research and also became the cornerstone of VON’s program of research.

Program of research focused on safety in home care

Building on that foundational work, CPSI convened an interdisciplinary Pan-Canadian Core Safety in Home care Team in 2008, composed of researchers and knowledge users to identify priority areas for home care safety research. Since then, this Team, of which VON’s nurse researcher is a member, has completed and continues to collaborate on multiple complementary and interconnected home care safety studies in seven provinces. The most recent is The Pan-Canadian Home Care Safety Study, ¹³ the first of its kind in Canada and internationally, composed of five sub-projects and funded by a stakeholder alliance between national (ie, CPSI, Canadian Institutes of Health Research [CIHR], Canadian Foundation for Health Care Improvement, formerly known as the Canadian Foundation for Health Services Research) and provincial (ie, The Change Foundation, Nova Scotia Health Research Foundation, Quebec’s Ministère de la santé et des services sociaux) along with regional and local decision- and policy-makers. The sub-project co-led by VON’s nurse researcher yielded first-hand accounts about safety issues, from elderly home care recipients with multiple chronic illnesses, as well as their family/caregivers and providers, in British Columbia, Manitoba, and New Brunswick. ¹⁴ As part of the larger study, these findings were combined with data on safety indicators from the Resident Assessment Instrument for Home Care (RAI-HC) across Canadian jurisdictions, ¹⁵ data from chart reviews in jurisdictions without RAI-HC data, ¹⁶ and data from root cause analyses of sentinel events. Extending the previous work conducted by the Core Home Care Safety Team, this multi-project study revealed the incidence and reasons for harmful incidents, determined the impact on families, and made suggestions on how to make home care safer for Canadians. ¹³

In addition to the above-mentioned research, VON’s nurse researcher has led and continues to lead other peer-reviewed-funded studies on home care safety with different foci including chronic illness, palliative care, and medication management. A hallmark of VON’s established program of research is its innovative methodology and its interdisciplinary nature: nursing leads the research while all the projects involve human factor engineers, members of various health professions, clinicians, and home care organizations as well as provincial and national policy- and decision-makers. Human factors provide a novel perspective to home care. The basic ideas and tools from this specialized field are needed to help health and human service providers broaden their analyses of home care safety and to develop more effective and lasting remedies to mitigate the risks to all involved, regardless of where the services are provided such as home and community. ¹⁷ Using Interpretive Description methodology ¹⁸ and a socio-ecological perspective, ^{19 -21} clients and family/caregivers were interviewed in their home followed by a photo-narrated walkabout in order to visually capture safety concerns. In addition, paid providers, most involved with each participating household, were also interviewed. By giving a voice to clients, family/caregivers, and paid providers, this innovative triadic perspective was pivotal to raising awareness of safety issues and concerns in home care, particularly for caregivers whose safety is intricately linked to the safety of the identified individual receiving home care services. ^14,22 In addition, focus groups conducted with experienced regulated and unregulated home care providers, respectively, captured their general perceptions and concerns around home care safety. Together, these pioneering projects on safety in home care have led to enhancing team and organizational partnerships and subsequently nurtured the development of an effective network of stakeholders across the country. Decision- and policy-makers (ie, Accreditation Canada, Canadian Institute for Health Information) were also integral team members on the studies, making essential contributions to the development of the proposals, recruitment, and data collection and most importantly to analyses, implication of findings, and knowledge translation. To date, this program of research has engaged with and received support from home care providers in seven Canadian provinces (namely, British Columbia, Alberta, Manitoba, Ontario, Québec, New Brunswick, Nova Scotia) as well as their respective governments.

Benefits to embedding a nurse researcher into a home care organization

In addition to influencing the national patient safety agenda to include home care, VON’s unique model of embedding a researcher into a home and community care service organization has resulted in supplementary benefits. For example, with the successful evolution of VON’s program of research, CIHR considered and ultimately recognized this home and community care organization as an institution paid and thus deemed it suitable to receive and manage CIHR and Tri-Council funding. This designation, generally reserved for academic institutions such as universities and research institutes, is exceptional for a home and community care organization. It reflects VON’s reputation as a producer of rigorous and credible peer-reviewed research as well as its established infrastructure to support the financial and administrative activities required. Having the designation of institution paid highlights the value and pertinence of embedding a researcher and thus cultivating a research-based organization that is providing home care services.

Moreover, the evolution of the relationship and synergies between CPSI and VON Canada has resulted in additional benefits for both parties with impacts on the healthcare system. Two illustrative examples include (1) VON’s Vice President for Home Care Services, Quality and Risk becoming a member of CPSI’s board of directors and (2) CPSI commissioning VON in 2011 to adapt and customize four of their internationally renowned Safer Healthcare Now! patient safety tools to home care, namely: medication reconciliation ²³ ; infection prevention and control ²⁴ ; hand hygiene ²⁵ ; and falls prevention for clients, family, and unregulated caregivers. ²⁶ Safer Healthcare Now!, the flagship program of CPSI, invests in frontline providers and the delivery system to improve the safety of patient care throughout Canada by implementing interventions known to reduce avoidable harm.

The future

While Canada is now the leading nation in research on home care safety, there is much more to be done to fully understand how to mitigate the risks for clients, family/caregivers, and providers. Home care organizations, like hospitals and other institutional care providers, have the responsibility to continue to build the evidence, including research evidence, needed to provide quality care. ^8,9 The complexity of delivering care at multiple sites and communities in several provinces may challenge some organizations to remain focused on delivering the evidence-based care that Canadians need and deserve. Embedding a nurse researcher within this national home and community care organization created a complex and synergistic environment in which health services research has flourished. ⁹ With this model, research is firmly established as a pillar of operations providing fuel to strategically propel important issues such as home care safety on to research and policy agendas. This work is most effective if done in partnership; partnerships between clinicians, managers, and researchers and between service organizations, funders, and policy-makers while consistently engaging with and listening to the voices of recipients of care to ensure the timeliness and pertinence of moving the home care safety agenda forward. ^{8 -10} It is also important to realize that the leadership to get important matters on the research and policy agenda should come from the service, frontline where practitioners identify issues and can bring them forward and work with researchers, policy-makers and decision-makers. This approach leads to the true feedback loop being exercised and the increased likelihood that frontline care providers will both contribute to the understanding of the issues like home care safety and more likely to implement the findings into their practice.