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It is apparent from the TNHP's impact on specific aspects of patient care that the behavior of nursing staff, especially nurses' aides, who provide the majority of care in nursing homes, was influenced.
The TNHP has some implications for LTC quality improvement.
Of particular concern is whether clinicians such as those in the TNHP would be motivated or able to function in a capacity similar to the way they functioned in the TNHP without strong linkages with schools of nursing.
Third, several features of the TNHP, including the involvement of nurse clinicians, a strong approach to maximizing physical and cognitive functioning, enhanced incontinence care, and attentiveness to the proper administration of psychotropic medications, were accompanied by reductions in hospitalizations.
As previously mentioned, the evaluation of the TNHP was a feasibility study.
Thus, a blend of outcome, process, and structural quality measures are beneficial both for program evaluations like the TNHP and in the context of quality improvement.
As another example in the TNHP, enhanced outcomes directly linked to processes, such as lower catheter use rates, can be used to identify specific nursing activities which might be targeted for CQI.
As a result of employing different types of outcomes on the TNHP evaluation and evaluating the quality of home health care in subsequent projects (Shaughnessy, Schlenker, and Hittle, 1995; Shaughnessy et al., 1994; Schlenker, Shaughnessy, and Hittle, in press), we have developed two taxonomies that are useful in conceptualizing quality.
For example, some of the hospitalizations examined in the TNHP evaluation were undoubtedly appropriate.
If an outcome pertains to the entire period of time between start of care and discharge from (a particular type of) care, it is called an "episode-specific outcome." Many of the outcomes used in the TNHP evaluation (Tables 1 and 2) were either multi-service or episode-specific outcomes.
In the TNHP evaluation, complementary findings using different types of outcomes as well as process and structural indicators served not only to strengthen and clarify results, but assisted, to some extent, in understanding the reasons behind findings.
In conducting the TNHP evaluation and in subsequent work in the home care field, we have experimented with different ways to measure outcomes.
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