Context and mechanisms that enable implementation of specialist palliative care Needs Rounds in care homes: results from a qualitative interview study

Background: Improving quality of palliative and end of life care in older people's care homes is essential. Increasing numbers of people die in these settings, yet access to high quality palliative care is not routinely provided. While evidence for models of care are growing, there remains little insight regarding how to translate evidence-based models into practice. Palliative Care Needs Rounds (hereafter Needs Rounds) have a robust evidence base, for providing palliative care in care homes, reducing resident hospitalisations, improving residents' quality of death, and increasing staff confidence in caring for dying residents. This study aimed to identify and describe the context and mechanisms of change that facilitate implementation of Needs Rounds in care homes, and enable other services to reap the benefits of the Needs Rounds approach to care provision. Methods: Qualitative interviews, embedded within a large randomised control trial, were conducted with a purposive sample of 21 staff from 11 care homes using Needs Rounds. The sample included managers, nurses, and care assistants. Staff participated in individual or dyadic semi-structured interviews. Implementation science frameworks and thematic analysis were used to interpret and analyse the data. Results: Contextual factors affecting implementation included facility preparedness for change, leadership, staff knowledge and skills, and organisational policies. Mechanisms of change that facilitated implementation included staff as facilitators, identifying and triaging residents, strategizing knowledge exchange, and changing clinical approaches to care. Care home staff also identified planning and documentation, and shifts in communication. The outcomes reported by staff suggest reductions in hospitalisations and problematic symptoms for residents, improved staff skills and confidence in caring for residents in their last months, weeks and days of life. Conclusions: The significance of this paper is in offering care homes detailed insights into service contexts and mechanisms of change that will enable them to reap the benefits of Needs Rounds in their own services. The paper thus will support the implementation of an approach to care that has a robust evidence base, for a population underserved by specialist palliative care.