Table 1 Descriptions of the SPEC intervention: Components, theoretical rationale, and implementation information
Component | Theoretical Rationale [Elements Comparable to Wagner’s CCM] | Outcomes | Providers/Participants | Place/Time | Dose |
|---|---|---|---|---|---|
1. Comprehensive Geriatric Assessment (CGA) | [Decision support] CGA and CGA-based need/risk profiling of triggered common geriatric problems using a decision-support tool can promote a whole-person approach. | - CGA-based risk profile including key functional scales | - By the RN-SW pair at each participating nursing home | - At a nursing home - Right after the assessment by external assessor at T1 is completed | - At least one time for each of the participating residents - Anytime needed (e.g., condition change of residents) |
2. Individualized Need-Based Care Planning (CP) | [Delivery-system design/self-management support] Individualized need-based CP using standardized care protocols and checklists by onsite SPEC coordinator-led interdisciplinary care teams, along with input from the resident/family regarding preferences and choices. These approaches can promote shared goal-setting and resident/family’s engagement in care delivery. | - Individualized, written care plans with goals, timeline, and to-do list in checklist form for each member of the care team - Resident/family input | - By the care team led by the RN-SW pair at each home | - At a nursing home - Right after the CGA is done | - At least one time for each of the participating residents - Anytime plan change is needed |
3. Interdisciplinary Case Conferences (ICCs) | [Delivery system design/self-management support] Formal face-to-face interdisciplinary team meetings provide an opportunity for the care team to better understand complex case needs and develop a well-coordinated, targeted care plan; an optional intervention component due to limited financial and human resources. | - Same as above - Possibly a more coordinated action plan | - By the care team led by the RN-SW pair at each home and facilitated by the SPEC consultant | - At a nursing home - Once a month on average and when a relevant case is found | - At least once a month |
4. Care Coordination (CC) | [Community resources] Coordination of care using tailored reports based on CGA/CP between care staff (administrators and direct care members), families, and contracted physicians/medical institutions can facilitate communication and promote quality of care. | - Administrative decision-making, order change, and/or provision of information to residents and family, if needed - Better collaboration with community resources and strengthening community linkages (e.g., contracted doctor, clinic, etc.) | - The RN-SW pair facilitated by the SPEC consultant | - When CGA and CP are done - Anytime needed | - At least once a month when CGA and CP are done - Anytime needed |
5. ICT tool: the SPEC information system | [Clinical information systems] A cloud-based online ICT system can promote communication between care team members and also between care teams and the research team. The system makes it easy to store and track resident data and generates various tailored reports. It also provides resources for care providers/managers. KakaoTalk, a free instant message and phone call service in South Korea, is also actively used for communication throughout the program implementation and evaluation. | - Improved quality of CGA and CP using information system - Improved quality of documentation and monitoring of CGA, CP, and MCC | - The onsite SPEC coordinators facilitated by the SPEC consultant | - A server managed by a server manager is located at the SPEC research center - A help desk service is also provided - Users at each home can access the system anytime - E-accessed via desktop, tablet, and/or cell-phone | - Anytime needed |