De-implementation of low-value home-based nursing care: an effect and process evaluation

BACKGROUND: The demand for homecare is increasing, and reducing low-value care is essential for achieving sustainable healthcare. Low-value care refers to practices that are ineffective, inefficient, unwanted, or potentially harmful to the client. This study aimed to evaluate the effects of a tailored, multifaceted de-implementation strategy in reducing low-value home-based nursing care.

METHODS: A prospective, multicenter, convergent parallel mixed method design was employed, including a before-and-after study, using the Reach-Effectiveness-Adoption-Implementation-Maintenance (RE-AIM) framework. The effect of reducing low-value home-based nursing care was assessed from client records, focusing on the number of clients receiving care, minutes of care per week, frequency of visits per week, and clients no longer requiring care. The de-implementation process was evaluated qualitatively through individual interviews with de-implementation ambassadors, registered nurses, and nurse assistants, using Directed Qualitative Content Analysis. This approach served to interpret the effects of the deployment of de-implementation ambassadors and the strategies they implemented.

RESULTS: We observed a reduction in low-value home-based nursing care, with a decrease of 130 h per week in daily showering, bathing and/or dressing; 54 h per week in the assistance with compression stockings; and 8 h per week in changing bandages enabling clients to regain their independence. Important de-implementation strategies included involving clients and relatives in decision making, organizing informational meetings for homecare professionals, and fostering collaboration with other healthcare professionals. Factors that influenced adoption included providing reassurance and using a stepwise approach with clients and relatives. Homecare professionals noted that the de-implementation ambassadors were highly committed to reducing care. De-implementation ambassadors found their role to be intense, challenging, and exciting.

CONCLUSIONS: This evaluation found that the deployment of de-implementation ambassadors, paired with additional de-implementation strategies, enhanced the reduction of low-value home-based nursing care. Providing reassurance and involving clients and their relatives were identified as beneficial for the de-implementation process.