Mark Schlesinger, Tashonna R. Webster, Sharon K. Inouye, Dorothy Baker, Elizabeth H. Bradley
After Adoption: Sustaining the Innovation: A Case Study of Disseminating the Hospital Elder Life Program, Elizabeth H. Bradley, Ph.D., Tashonna R. Webster, M.P.H., Dorothy Baker, Ph.D. et al., Journal of the American Geriatrics Society September 2005 53 (9): 145561
Implementing and sustaining successful health care innovations presents a challenge for institutions and clinicians—particularly in the area of geriatrics, where interventions are often complex and multifaceted. A Commonwealth Fund–supported study in the Journal of the American Geriatrics Society examining the keys to long-term sustainability finds that the presence of strong clinical leadership, the ability to adapt program requirements to fit the local setting, and access to adequate funding and resources are all paramount to an intervention program's ongoing success.
The subject of the study, After Adoption: Sustaining the Innovation—A Case Study of Disseminating the Hospital Elder Life Program (Journal of the American Geriatrics Society, Sept. 2005), is the diffusion of the Hospital Elder Life Program (HELP), a cost-effective method for improving care for hospitalized older adults. Together with her colleagues, lead author Elizabeth H. Bradley, Ph.D., of the Yale School of Medicine, interviewed 102 physicians, nurses, volunteers, and administrative staff at 13 hospitals that implemented HELP between November 2000 and November 2003.
Reported Benefits of HELP
Using a mix of geriatrics, therapy, nursing, and volunteer services, HELP focuses on reducing delirium and keeping patients mentally and physically active. Of the 13 hospitals observed by the research team, 10 were sustaining the program at the end of study, while three had terminated it. Eight hospitals had sustained HELP for at least 12 months, and two of these continued the program for at least 18 months. These eight hospitals reported substantial benefits from the program, including reduced delirium, reduced use of restraints, greater satisfaction with care, better understanding of geriatric care, and increased communication among clinical team members, including pharmacists and physical therapists. Two hospitals reported that the program improved their reputation for geriatric care. Of the two hospitals that conducted cost analyses, both reported that HELP had been cost-effective.
Presence of Clinical Leadership
Strong clinical leadership was an important element in the program's sustainability, Bradley and her coauthors found. In fact, at the three hospitals that terminated HELP, physicians and nurse leaders who had been strong advocates for the program left the hospitals and were not replaced. At these three sites, the program was terminated within two to six months of the leader's departure. The clinical leaders had various reasons for departing, but Bradley noted "...the effect on HELP in all cases was immense, suggesting that the ongoing presence of clinician leaders—the initial clinician leaders or their replacements—is a critical factor in sustaining HELP."
At hospitals that sustained HELP, leaders not only played important clinical roles but acted as strong supporters with senior administration. "[M]ore than anything, you need to identify clinical champions to make HELP work," explained one medical director interviewed for the study. "You also have to have administrative support, and, really, administrative champions."
Adapting for Survival
In addition to retaining clinician leadership, the hospitals that were successful in maintaining HELP were able to adapt the program to suit their needs and circumstances. One type of adaptation involved changing forms and documentation to avoid redundancies. Some data requirements became too time-consuming and were dropped, but more commonly, methods were modified to fit better with the existing processes.
The volunteer component of HELP was another often modified piece. In some cases, hospitals reduced the frequency of recommended interventions—for instance, ambulating patients two instead of three times per day—because of lack of volunteer availability. In others, institutional liability concerns or volunteers' personal qualms restricted their involvement, most often in cases of walking or feeding patients.
Importance of Adequate Resources
An ongoing concern for all the study hospitals was having adequate staff and funding to implement and administer HELP. Most sites initiated the program using temporary grant support, but securing more permanent funding was critical for sustaining it over the longer term. Some hospitals were able to use clinical outcome data and other evidence from the first 12 months of operation to demonstrate the benefits and obtain full funding through the hospitals' operating budget. Said one hospital chairperson, "Because I worked with the hospital's data and with people who were employed by the hospital, the administration couldn't really question the validity of the data....[I]t was generally known throughout the hospital that this had been a big success." Other hospitals were able to sustain the program by finding synergies with current staff members to help perform the HELP tasks.
Successful innovations in health care must not only be effectively adopted; they must also be sustainable over time. In studying HELP, the researchers found that some of the program's early challenges, such as securing clinical leadership and adequate resources, remained critical well after the adoption period. These issues, consequently, will require ongoing commitment and attention. Adaptation, on the other hand, says Bradley, is inevitable and may be a sign of success, as local organizations make the program their own. "Recognizing these challenges to effective diffusion," Bradley says, "can promote more realistic goals and expectations for health services researchers, clinicians, policymakers, and funding agencies in their laudable efforts to translate research into practice."
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