Optimizing Homecare Services: A Strategy for Improving Follow-up in the Caring of Elderly Patients

Key Implications for Decision Makers

A continuous improvement intervention for homecare services, focusing on the internal workings of organizations (public, private, and community) as well as on inter-organizational relations, was developed and tested at three pilot sites and in 14 partner organizations. The intervention proved to be relevant, realizable, and efficient for improving services and, with some adjustments, transferable to other types of programs and client groups.

The success of the intervention depends on certain prerequisites being met, specifically:

  • the existence of a hub organization capable of mobilizing partners and planning and co-ordinating the intervention at the local level;
  • the firm commitment of management from participating organizations and the personnel concerned;
  • the willingness and ability to invest the necessary resources; and
  • the realization that service improvement is an ongoing, long-term undertaking.

The testing of the intervention allowed for a number of lessons to be drawn:

  • While adapting the intervention to the particularities of each environment is important, such adaptation must be done without altering its basic philosophy and the sequence of phases (intervention start-up, problem screening, solutions seeking, implementation, and follow-up).
  • These phases are best when carried out as close together as possible.
  • The setting up of structural components, such as a steering committee, quality circles, and the designation of a local project leader, are essential to support the initiative.
  • Where possible, the choice by management of a relatively simple problem should be promoted as a means to implement a demonstration project.
  • Training on quality improvement tools as the phases proceed facilitates learning.
  • Furthermore, the use of these tools must be flexible. _ Although at times neglected, implementing solutions to quality problems requires thorough planning.
  • When these solutions concern work methods or organization, a small-scale trial should preferably be carried out before implementing them in the whole organization.
  • It is important that the outcome of introduced changes be assessed by means of indicators.
  • The provision of funding to private agencies and community partners might stimulate their commitment to the initiative.
  • Finally, although organizations can accomplish the initiative in an autonomous manner, reliance on external expertise (consultants or other organizations familiar with the method) may be desirable, especially during initial implementation.

Overall, the results indicate that the approach allows for the improvement of different aspects of quality, especially those dealing with informational and user management continuity, and the effectiveness of homecare services.

Executive Summary

Several recent reforms in Quebec and Canada in long-term care services have paid particular attention to quality. In different locations, efforts have been undertaken to develop accreditation programs for homecare service providers, to implement regulatory mechanisms or clinical audits to assess quality, and to define and measure process and outcome indicators of care quality. These initiatives, however, albeit relevant, are not usually part of an overall strategy established to promote the quality of care provided by different types of service providers. Furthermore, few studies have been conducted on the inter-organizational dimension of quality management.

The research program that is the subject of this report focused on developing, implementing, and assessing a continuous quality improvement initiative adapted to homecare and elderly patients. It took place at three pilot sites representing the main categories of typical homecare service organizations in Quebec: local community service centres (CLSCs), day care centres, homecare social economy enterprises (DHSEBs), community organizations, and private agencies. Inter-organizational bodies and individuals responsible for local service networks geared at providing services to seniors have also been targeted and have participated at two of the program sites. In total, 14 settings participated in the research as partners.

The initiative tested is grounded on a particular approach to quality management, whose strength lies on the fact (1) it strives to mobilize and involve all concerned actors; (2) it uses specific tools for resolving complex problems; (3) it analyses problems in connection with service organization and delivery processes; and (4) it encourages a strategy of small steps with gradual and progressive changes.

The three pilots were conducted in a sequential manner. The goal at Site 1 was to develop and test the approach. At Site 2, the developed tools were adapted, adjusted, and re-tested. At Site 3, the goal was supporting the participating organizations in carrying out the approach autonomously with minimal help from the research team. At each site, particular structures were set in place to allow for the management of the initiative and facilitate its completion: steering committees, local project leaders, and quality circles.

The initiative comprised four major phases: (1) ensuring its implementation in a particular region; (2) identifying the most prevalent and significant quality problems; (3) analysing a limited number of those problems and formulating solutions; and (4) implementing those solutions and assessing them over a given timeframe. Several instruments were used to identify quality problems, targeting professionals, elderly users, and their caregivers. First of all, nominal groups were organized at each setting and with the inter-organizational bodies to collect the views of different categories of personnel (n=99). Individual interviews and focus groups were conducted with elderly users (n=108) and caregivers (n=25). The stripping of a certain number of users' clinical files was also tested (n=20) at one of the sites. All the collected data were triangulated, thus allowing for the identification of priority areas or problems to be dealt with by the organizations participating in the research.

After the first phase was completed, the analysis of problems and identification of solutions were ensured by the quality circles, created in all the organizations and inter-organizational bodies through the voluntary participation of management, clinical, administrative, and volunteer personnel. The size and composition of the circles varied according to the characteristics of the setting and the nature of the problems to be corrected. Their work was carried out in accordance with the set objectives by drawing on quality tools widely used in initiatives of this nature (brainstorming, analytic hierarchy process analysis, affinity diagrams, Pareto diagrams, etc.).

The last phase of the initiative, consisting of implementing solutions and assessing their effectiveness, was also carried out by the quality circles in close collaboration with management from the participating organizations and the research team. The task was to plan the implementation of solutions, to define follow-up indicators and to monitor them. Nearly all organizations participating in the program succeeded in implementing improvements on one or two quality problems.

All aspects of the intervention were evaluated with regard to process, which looked at its implementation and deployment conditions in each site, and impact, specifically the capacity of quality interventions and solutions to change the work processes and practices of the concerned professionals. The results of the investigation show that its implementation in a given region is possible, allowing for the participation of the main homecare service providers in a collective and co-operative approach to quality management. The steering committees set in place to manage and supervise the intervention at the local level and project leaders contributed greatly to this pooled-work dynamic. Although it could be expected that there would be some concerns among community and private sector partners about the imposition of a work method initiated by the public sector, that did not seem to influence their level of commitment and involvement in the process. Some partners made suggestions on the necessity, on the one hand, of better documenting the scope of the approach and the investments required from them and, on the other hand, of making the vocabulary for presenting the method and work tools as accessible as possible.

The problem screening phase posed the most difficulty at the three sites, due to the scope of the work accomplished and the expertise it demanded, which the participating organizations could not accomplish without the support of an external resource.

Conducting interviews with elderly people and the triangulation of data proved to be particularly time-consuming, despite adjustments to the method at each site. Compared to the interviews, and excluding the CLSCs, where service organization is more complex, the focus groups were easier to conduct and may be performed by stakeholders in other locations fairly autonomously. Despite these difficulties, a wealth of relevant information on quality problems was produced during this phase of the research.

The work of analysing problems and seeking solutions, carried out in the framework of quality circles, allowed the contribution of a wide range of professionals assuming different roles in their organizations, while encouraging a dynamic of mobilization among local actors working together. The participation of management personnel in the quality circles as facilitators, and their firm commitment to the intervention, was an asset and a significant success factor. Generally speaking, the quality tools used in this phase of the initiative produced good results, allowing the circles to accomplish their task within reasonable timeframes. Furthermore, the time needed to process a second problem proved to be an average of 27-percent shorter compared with the first problem.

The implementation phase allowed the introduction in all settings of a series of changes, tools, or improvement actions, with fairly positive results. Particular attention must be paid to this phase of the initiative given the frequent tendency on the part of stakeholders to act hastily without adequate and rigorous preparation of the activities to be undertaken. Small-scale trials are often necessary for the implementation of solutions related to work methods or organization. A gradual implementation of solutions may also help counter the initial resistance from some stakeholders when faced with the changes that are being promoted. The utility of indicators to assess the effectiveness of solutions is recognized by all stakeholders, yet their use often seems problematic or not fully appreciated. Several stakeholders emphasized the benefits of the intervention with regard to the internal organizational dynamic, as well as in their relationships with other homecare service providers in their area.