Table 3.
Practical measures for monitoring outcomes and progress of the implementation of the improvement plans.
| Item | Data collection tool | Short description |
|---|---|---|
|
DEMOGRAPHIC INFORMATION | ||
| Socio-demographics of older people (users) | Demographic data sheet – older people, administered to older people | Survey developed by SUSTAIN researchers requesting information on age, gender, education, marital status, living situation and self-reported medical conditions |
| Socio-demographics of informal carers | Demographic data sheet – carers, administered to informal carers | Survey developed by SUSTAIN researchers requesting information on age, gender, education, marital status, relationship and distance to older person (user), paid work and caregiving activities |
| Socio-demographics of professionals | Demographic data sheet – professionals, administered to professionals | Survey developed by SUSTAIN researchers requesting information on age, gender, nationality and occupation |
| Socio-demographics of managers | Demographic data sheet – managers, administered to managers | Survey developed by SUSTAIN researchers requesting information on age, gender, nationality and occupation |
|
OUTCOMES | ||
| Person-centredness | ||
| Patient perceptions of quality and coordination of care and support | The Person Centred Coordinated Care Experience Questionnaire (P3CEQ) [43], administered to older people | Survey measuring older people’s experience and understanding of the care and support they have received from health and social care services |
| Proportion of older people with a needs assessment | Care plan template (in case sites do not work with care plans, information will be retrieved from clinical notes or other documentation) | Template developed by SUSTAIN researchers for predetermined content analysis of care plans of older people |
| Proportion of care plans actioned (i.e. defined activities in care plan actually implemented) | ||
| Proportion of care plans shared across different professionals and/or organisations | ||
| Proportion of informal carers with a needs assessment and/or care plan | ||
| Perception and experiences of older people, informal carers, professionals and managers with person-centredness | Semi-structured interviews and focus group interviews with older people, informal carers, professionals and managers | Interview and focus group schedules developed by SUSTAIN researchers including interview items on perception and experiences with receiving person-centred care |
| Prevention orientation | ||
| Perceived control in care and support of older people | Perceived Control in Health Care (PCHC) [37], administered to older people | Survey addressing older people’s perceived own abilities to organise professional care and to take care of themselves in their own homes, and perceived support from the social network |
| Proportion of older people receiving a medication review | Care plan template (in case sites do not work with care plans, information will be retrieved from clinical notes or other documentation) | Template developed by SUSTAIN researchers for predetermined content analysis of care plans of older people |
| Proportion of older people receiving advice on medication adherence | ||
| Proportion of older people receiving advice on self-management and maintaining independence | ||
| Perception and experiences of older people, informal carers, professionals and managers with prevention | Semi-structured interviews and focus group interviews with older people, informal carers, professionals and managers | Interview and focus group schedules developed by SUSTAIN researchers including interview items on perception and experiences with receiving prevention-oriented care |
| Safety | ||
| Proportion of older people receiving safety advice | Care plan template (in case sites do not work with care plans, information will be retrieved from clinical notes or other documentation) | Template developed by SUSTAIN researchers for predetermined content analysis of care plans of older people |
| Proportion of older people with falls recorded in the care plan | ||
| Perception of older people, informal carers, professionals and managers with safety | Semi-structured interviews and focus group interviews with older people, informal carers, professionals and managers | Interview and focus group schedules developed by SUSTAIN researchers including interview items on perception and experiences with receiving safe care, and safety consciousness |
| Efficiency | ||
| Number of emergency hospital admissions of older people | Care plan template (in case sites do not work with care plans, information will be retrieved from clinical notes or other documentation); template to register staff hours and costs | Template developed by SUSTAIN researchers for predetermined content analysis of care plans of older people; template developed by SUSTAIN researchers to collect data on costs and the number of staff hours from local services, organisations or registries |
| Length of stay per emergency admission of older people | ||
| Number of hospital readmissions of older people | ||
| Number of staff hours dedicated to improvement project | ||
| Costs related to equipment and technology for improvement project | ||
| Perception of older people, informal carers, professionals and managers with efficiency | Semi-structured interviews and focus group interviews with older people, informal carers, professionals and managers | Interview and focus group schedules developed by SUSTAIN researchers including interview items on perception and experiences with receiving efficient care, and finances |
|
IMPLEMENTATION PROGRESS | ||
| Team coherence of improvement team (professionals) | Team Climate Inventory – short version (TCI-14) [44,45], administered to professionals | Survey measuring vision, participative safety, task orientation and experienced support for innovation of the improvement team |
| Perception and experiences of professionals | Focus group interviews with professionals and minutes from steering group meetings | Focus group schedule developed by SUSTAIN researchers including interview items on experienced factors facilitating and impeding outcomes and implementation progress |
| Minutes cover progress, issues and contextual issues impacting on outcomes and implementation progress | ||
| Perception and experiences of managers | Semi-structured interviews with managers and minutes from steering group meetings | Interview schedule developed by SUSTAIN researchers including interview items on experienced factors facilitating and impeding outcomes and implementation progress |
| Minutes cover progress, issues and contextual issues impacting on outcomes and implementation progress | ||