TABLE 6.

Program component evaluation

Site one core component categories	Operational description of the components	Delivery method (Site One)	Implemented as intended at Site Two (yes/no)	Moderators descriptor of adaptation modified? Omitted? Added components?	Reviewer ‐ negative or positive impact	Refined core components descriptions
Decision‐support tools	RADD index ™: A flip‐chart guide to help staff identify and proactively manage changes in a resident's condition related to eight conditions.	Introduced at mandatory initial face‐to‐face intensive training session Posted at all work stations.	Yes	MODIFIED: Introduced at non‐mandatory introductory meeting; reinforced at regularly scheduled staff meetings. Posted at all work stations.	Nursing staff benefitted from having guidelines available to follow when a resident's health deteriorated. Facilitators acknowledge the necessity of having this decision‐support guide.	Clinical decision‐making guidelines (or protocol) for managing acute deterioration are needed for staff to follow.
	Resident Early Warning Observation chart: track and trigger tool for documenting vital signs	Introduced in initial face‐to‐face training session with staff. Available at all work stations.	Yes	MODIFIED/ ADDED COMPONENTS: Initially seen to conflict with current documentation of vital signs but eventually introduced, along with a policy document outlining its usage	A track and trigger tool is needed to detect changes in observations / vital signs. Facility policy is needed to support usage.	Track and trigger tool to monitor vital signs is needed to identify changes
	SBAR (Situation, Background, Assessment, Recommendation) Communication tool	Introduced during mandatory training	Yes	MODIFIED/ADDED COMPONENT: Staff were trained to use the tool and it was posted at all workstations. A SBAR‐based fax form was developed to use with GP offices.	A standardised communication tool, such as SBAR, is needed to facilitate effective communication; the tool was used to create a fax form to communicate resident deterioration between the nursing home and GP or other medical service.	Use of standard communication tool (such as SBAR) for written and oral communication
	Advanced Care Planning	Introduced during mandatory training	No	Omitted in initial introduction
	Clinical Management Guidelines: UTI, chest pain, dyspnea, constipation delirium, dehydration, falls, palliative care	Based on current procedures; Introduced in the initial mandatory training.	No	Omitted: Maintained their own clinical management guidelines.	Guidelines on clinical care requirements are important and should be linked to the advanced clinical skills training.	Clinical Management Guidelines linked with advanced clinical skills training.
	Advanced Clinical Policies & Procedures	Introduced during pilot implementation	Yes	Introduced during programme implementation.	Nursing staff asked for policies to support the use of the programme tools and steps undertaken. Policies were seen as important in supporting nursing staff in their clinical care.	Policies and procedures are needed to support the use of the decision support tools and programme pathways.
Advanced clinical skills training	Initial mandatory face‐to‐face workshops on: Sub Acute Program, tools and resources, new equipment; and eight conditions that commonly lead to hospitalisation: UTI, chest pain, dyspnoea, constipation, delirium, dehydration, falls, palliative care	Training on the programme and eight conditions provided in one mandatory session. Emphasis was given on the idea the programme requires a behaviour change in practice around managing the conditions.	Yes	MODIFIED: Initial training was not provided on all topics; facility decided to introduce training as needed; utilised ‘on the job’ learning and ‘point of care training.’ Training sessions on chest pain, UTI and bladder scanning provided after programme commenced.	Mandatory pre‐programme introduction face‐to‐face training with nursing staff is necessary on the topics identified as contributing to hospitalisations; the mandatory training must include clarification of the term subacute, along with practical examples of application to the various conditions to help staff better understand what is required for early detection and response.	Mandatory initial face‐to‐face training on early identification of deterioration and response (around main conditions leading to transfer); must include a clear definition and description of subacute and subacute care requirements.
Specialist clinical support and collaboration	Access to clinical support from medical personnel Health Specialist In‐Reach team; Clinical lead Nurses; NP; Geriatrician; Wound Specialist; Clinical Champions	Ongoing clinical support from NP/RAC team, Clinical Nurse Lead, Clinical Champions, GPs	Yes	MODIFIED: Two clinical nurse leaders appointed; NP available but from distance and not utilised; no Clinical Champions; GP support sought; GP Practice Nurses identified as essential for support.	The programme requires an on‐site strong clinical leader who can implement the clinical guidelines, provide training on the tools and resources, and support staff; the person must be enthusiastic and knowledgeable and have full support from management. Clinical Champions should be considered to help engage staff and provide support but their role must be clear. External clinicians and their associates available for support must be identified and engaged (Example: GPs and their Practice Nurses)	Knowledgeable and enthusiastic on‐site clinical leader(s); Clinical Champions (optional); external stakeholders' engagement and support must be identified and sought (i.e., GPs, NPs, GP Practice Nurses, RAC team)
Diagnostic medical equipment	Diagnostic equipment not typically found in nursing home setting that can be used to assess and manage clinical deterioration	All equipment available when programme commenced; training provided. Equipment included: ECG machine, bladder scanner, infusion pumps, pulse oximeters, vital sign monitors.	Yes	MODIFIED: Equipment available in stages, along with training.	Diagnostic medical equipment helps to support the decision‐making process and may even lead to shorter hospital length of stay. Equipment seen as important but staff need clinical support while learning to use it; equipment is costly and if cost prohibitive should not forestall introduction of the programme	Diagnostic medical equipment (optional item)
Core items added
Facility policy and procedures			Yes	ADDED: Identified a need to have facility policy and procedures around early identification of deteriorating health and providing subacute care	Practice changes around providing subacute care in the nursing home must be supported with written policies and procedures.	Facility policy and procedures on early identification of deteriorating health and providing subacute care
Family and care recipient education and engagement			Yes	ADDED: Identified family and care recipient support as important to the programme implementation and success.	Families can insist on transfers and therefore require a good understanding of the nursing home's increase capacity to manage an unwell resident; outreach activities are required.	Family and care recipient education and engagement around the SAC programme.
Culture of staff readiness to change			Yes	ADDED: Culture of staff readiness for change. Assessed by administering a questionnaire derived from Organisational Readiness to Change Assessment (ORCA), the Alberta Context Tool and the Context Assessment Index	Staff need to be willing to embrace the change in practice.	Culture of staff readiness to change
Supportive executive and facility management			Yes	ADDED: Supportive executive and facility management.	Management support was seen as required for the successful implementation of the programme.	Supportive executive and facility management.

Abbreviations: ECG, electrocardiogram machine; GP, general practitioners; NPs, Nurse Practitioners; RAC, Residential Acute Care; RADD, Residential Acute Deterioration Decision; UTI, urinary tract infection.