Quality of care for elderly in residential care homes is under pressure in the Netherlands as in other countries [1
]. Facilities tend to be understaffed and the care complexity of residents increases while expertise of staff does not keep pace [2
]. Although most care organizations want to innovate and improve their quality of care, many lack the expertise or financial resources to do so [3
]. Family physicians are responsible for the medical care in Dutch residential care homes but do not regard themselves suited for systematic management and long-term monitoring of chronic diseases and disabilities associated with frail health [5
]. Around 10% of all the elderly aged 75 or older in the Netherlands live in residential care homes. These homes were used to offer sheltered living for disabled but still relatively healthy elderly. Nowadays, due to our ageing population the characteristics of the residents of residential homes have become more and more comparable with those of nursing homes, needing complex care. These homes are publically funded and subject to governmental inspection and approval. The average size of the study residences was 46 and staff included nurse assistants, team coaches and a home manager. In some residential care homes special care wards are installed for very frail or demented persons. Systems of multidisciplinary consultations and multidisciplinary meetings are not structured nor held on a regularly base. Most family physicians do not attend those meetings. These conditions were the ingredients for the development and implementation of a new care model in a north-west region of the Netherlands. This new care model was inspired by the chronic care model and was called the Multidisciplinary Integrated Care model. The design of this study is previously reported [6
Multidisciplinary Integrated Care comprised five elements:
1. A three-monthly geriatric multidimensional assessment of all residents. The web-based Long Term Care Facility version 9.0 of the Resident Assessment Instrument was used for this purpose [7
]. The identified problem areas guide the design of an individualized care plan with the intention to improve or maintain the functional health status (Additional file 1
: Figure S1).
2. The care plan was discussed with the resident, family, and family physician, and adapted to personal wishes.
3. Residents with complex care needs were scheduled at least twice a year for a multidisciplinary meeting.
4. Consultation by elderly care physician or psychologist was optional for the frailest residents with complex health care problems.
5. Data from the web based Resident Assessment Instrument was used to provide a three-monthly overview of 32 risk adjusted indicators of quality of care, which are compared to the benchmark made out of all residents of residential homes in the Netherlands using this instrument [8
The effects on quality of care of this innovation were studied in a Randomised Controlled Clinical Trial in ten residential care homes in the Netherlands. The intervention homes scored better on 30 of the 32 risk indicators for quality of care and 13 of these had improved significantly [16
]. Most notably, bowel incontinence decline dropped from 23 to 6%, bladder incontinence decline dropped from 46 to 15%, delirium risk dropped from 56 to 28%, pain worsening dropped from 41 to 13%. The residents in the intervention homes tended to be more satisfied about the quality of care than elderly in the control homes.
Reviews of dissemination and implementation strategies suggest that success depends on the type of care setting, type of intervention and specific circumstances [12
]. People working in healthcare organizations mostly focus on their own profession. This professional identification limits the level of organizational identification and limits the willingness to collaborate across specialisations or departments, which is imperative when organisations want to work on improvements and innovation on an organisational level [13
]. A review by Grimshaw et al. (1999) showed that obstacles to use guidelines can arise at different levels of the health care system: at the level of the patients, the individual professional, the health care team, the health care organization or the wider environment [8
]. The introduction of an assessment instrument like the interRAI-LTCF has consequences for the care process at all of these different levels. We studied the consequences at the level of the involved professionals and management. But not only the introduction (initial phase) but also the maintenance is often under pressure in health organisations due to shifting priorities, lack of time and money needed for ongoing and renewed training and equipment [3
The research questions that are addressed in this paper are:
1. Which factors facilitated or impeded the introduction of the interRAI-LTCF as part of the Multidisciplinary Integrated Care model in residential care homes?
2. Which factors facilitated or impeded the use of the interRAI-LTCF in the maintenance phase, three years after introduction?