Phase 1: Process maps and conceptual model.

Approaches to measurement varied across sites [53]. While some clinics primarily used informal approaches to assess and document function (e.g., visually assessing patients, relying on patient concerns), others used standardized electronic screening tools to assess ADLs and/or IADLs. At sites with screening tools, workflows, content, and documentation approaches differed. We developed a conceptual model illustrating the relationship between contextual factors (e.g., policies/incentives, leadership support, staffing, IT infrastructure), measurement processes (i.e., screening and assessment, documentation, use of data), and outcomes (e.g., patient access to services, improved function/quality of life) [57].

Phase 2: Barriers, facilitators, and contextual factors.

Using findings from interviews, we identified barriers and facilitators to each aspect of measurement (screening and assessment; documentation and use of data). We also identified contextual factors and cross-cutting themes related to participants’ perceptions of and preferences for measurement.

(2a) Barriers and facilitators to screening and assessment. Factors impacting routine screening and assessment were related to three aspects of clinic organization: workflows, communication, and infrastructure and staffing (Table 4).

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Table 4. Barriers and facilitators to screening and assessment of functional status.

https://doi.org/10.1371/journal.pone.0290741.t004

Common barriers included limited time and competing clinical priorities. LVNs frequently noted how limited triage time constrained their ability to complete electronic screening tools. An LVN observed, “If the patient arrives late, then no, [the screener does not get completed]. I’ll do the vitals and do the intake afterwards, because I don’t want to take up the doctor’s time.” Given time constraints, LVNs tended to rely on ad hoc approaches to screening, such as patient observation. One LVN noted, “A lot of times I don’t ask [screening questions] because most of these people are walking…[I]f you see them walking or talking, you already know they’re competent enough to [live independently].” PCPs noted that due to time limitations during patient visits, they often focused on more pressing priorities such as acute complaints or medication management; this tendency was more pronounced in clinics without clear processes for measuring function. One PCP noted, “You’re only going to be able to tackle so much…sometimes these patients are pretty complex and you have to really focus on the medical management and so some of those questions about function will not be asked all the time.” Thus, a lack of standardized processes could result in “haphazard” approaches to measuring function, including greater reliance on patient observation and red flags.

Participants also described concerns with increased workload and “alert fatigue” from electronic screening tools. A PCP noted, “The volume of alerts I get in a given day is large and the number of them that actually are meaningful are small.” Inadequate staffing and large patient panels exacerbated alert fatigue, leading to “overstretched” and “overworked” staff.

Unclear interprofessional roles and responsibilities also hindered routine screening and assessment. In clinics where responsibilities for measurement were unclear, clinicians reported being less likely to measure function and feeling less motivated to do so. For example, LVNs noted that they were unsure how their screening informed PCP assessments. An LVN reported, “I often question how much [PCPs] actually look at our notes.” To encourage measurement, participants emphasized the importance of “meaningful metrics,” or directly connecting measurement to use of data to improve care. A PCP noted, “Does something get done with the data? Does it actually make a difference in the outcomes of the patients, or is it just another something that we’re documenting and nothing’s happening with it?”

Patients and clinicians frequently noted that the accuracy of a patient’s self-reported function was impacted by factors including embarrassment, stigma associated with needing help with activities, and cognitive impairment. These factors could hinder screening and assessment, especially in clinics without routine measurement processes. Some functionally independent patients questioned if function, particularly IADLs, was within the scope of medical care. Other patients worried that when a clinician asked about function, they were being evaluated for nursing home admission. As one patient stated, “When I hear [those questions], my little brain is going, ‘uh-oh, they’re evaluating me. They’re going to lock me up [in a nursing home] or something.’”

Facilitators to routine screening and assessment included standardized measurement processes. Clinicians noted that standardized screening enabled them to proactively identify impairments and understand patient needs. Another facilitator was a strong interprofessional environment. An LVN noted, “What I do like about where I work is that we function really well as a team. I think that the hand-offs are really good. So, after the [LVNs] do their thing and hand-off to the doctor or the nurse, I actually feel like we’ve covered the ADLs.” Participants noted that LVN screening serves as a “conversation starter” that prompts patients to think about function and informs PCP assessment, showing the importance of interprofessional coordination.

Participants noted that flexible workflows were necessary to accommodate varied clinic needs. For example, nurses reported that telephone screening before scheduled visits could save valuable in-office triage time during a busy clinic session. An LVN noted, “We have a template in place that allows me to call [before the visit], and I’m not just confirming an appointment but also doing some of the [screening] that can be done [ahead of time].” Flexible workflows facilitated real-time interprofessional communication, including the use of varied strategies (e.g., paper forms, instant messaging) to alert PCPs to concerns related to patient function, and warm hand-offs between LVNs, PCPs, and social workers.

Patients’ and clinicians’ preferences and beliefs also facilitated measurement. Patients were generally open to varied forms of measurement, including self-assessment, in-person, or telephone screening, which supported the flexible workflows preferred by clinicians. Additionally, although some functionally independent patients perceived functional status as outside the scope of medical care, most were open to assessment when appropriate context was provided. Many patients noted that when clinicians ask about their ability to perform daily activities, it shows concern for their “wellbeing” and provides a more holistic view of their health. Similarly, most clinicians who routinely measured function perceived function as clinically important and a core element of “complete” and quality patient care.

(2b) Barriers and facilitators to documentation and use of data. Factors that influenced documentation and use of functional status data were related to usability of screening tools; data availability and access; and availability and knowledge of services to address impairments (Table 5).

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Table 5. Barriers and facilitators to documenting and using functional status data to improve care and outcomes.

https://doi.org/10.1371/journal.pone.0290741.t005

At sites with existing tools for measuring function, participants pointed to poor usability as a key barrier to documentation. An LVN noted, “Now you have to click an extra button to open the [tool] and then click more buttons to answer the question, so that’s kind of annoying. [The] more mouse clicks and the more steps there are, the longer it takes and we’re already crunched for time as it is because we share rooms with other nurses.”

LVNs also pointed to limited response options within screening tools as a barrier. An LVN observed, “I do like to have the option of a free text box at the end of each of the questions, just in case you need to add in a comment or the patient says something that you can’t put in the [check box].” Some clinicians commented on the limitations of a numeric score for capturing function. A social worker noted, “The [tool] is so undescriptive. It’s basically a yes or no and then you just add the points, but it doesn’t tell me exactly what it means or [if] they need help with bathing.” Conversely, several clinicians noted that a numeric score had value for tracking changes in function and in efforts to improve population health. A social worker reflected, “The one thing I actually like about the point value system is that you can see differences [in function over time]…a lot of times [functional decline] could just be a temporary thing and they get better, or they’re definitely bed-bound and nothing’s going to change”.

An additional barrier to using data was the lack of standardized EHR data collection and documentation. Without standardized data collection, PCPs were unable to use data to inform care or track function over time. A PCP noted, “In an outpatient [setting], there’s no way to go into the chart and [see] what’s happening with ADLs over the last year.” Social workers noted the need to “dig” through notes to glean information on function, and the lack of detail when information was available. A social worker observed, “It would be nice if there was a specific functional status note title or something with that information that could easily be found…, rather than looking at every person’s individual notes to [find] it.” Another social worker noted that when information was available, “It’s just really quick–‘independent.’ It’s not detailed”.

Several factors limited clinicians’ ability to use functional status data to make referrals to address impairments. These included a lack of interprofessional coordination and communication, an issue which was exacerbated in busy clinics without clear measurement processes. Additionally, clinicians often lacked knowledge of services to address impairments. A PCP said, “I honestly don’t always know…what available services are out there…Things are always changing about what services [VA is] going to provide and fund”.

Participants pointed to structural barriers in accessing services, including geography (e.g., limited resources in rural areas), lack of transportation, and limited program funding. A social worker noted, “Our [contracted home health] agencies are not available in certain areas, so even though [patients are] approved for [services], they can’t find any agency that has staff in the area.” Clinicians noted that the referral process itself could pose a barrier, due to bureaucracy and eligibility criteria. These limitations impacted patient care and outcomes. A social worker observed, “Sometimes veterans fail at home because we can only offer a few [home health aide] hours for them…And so, there’s…a gap where if we had more [in-home care], it’s possible that…[the patient] would never have to go to a skilled nursing facility”.

Facilitators for documenting and using functional status data included standardized, user-friendly electronic screening tools. An IT specialist observed that usability testing was key to ensure that tools “match what the user’s thinking and how they’re processing the information and where to find it.” A performance measurement specialist noted the importance of standardized tools for ensuring quality care, by “help[ing] keep things consistent, so that everybody answers the same way.” Participants also advocated for integrating referral options within the EHR to facilitate use of data. Such integration linked measurement to referrals with the potential to improve patient outcomes, contributing to “meaningful measurement.” Participants noted that knowledge of services by clinicians could help facilitate referrals, by identifying services to meet needs.

Participants pointed to broader benefits of documenting and using functional status data, including informing strategic planning and keeping patients at home rather than in more costly institutional settings. Many noted that “population data” could be used to create reports to help better manage patients’ care. Reports could help achieve the ultimate goal, summarized by one leader, of allowing “every veteran, regardless of age, to be functional and outside of an institution for as long as they can be.”

Patients shared several preferences for measurement. First, most preferred being asked questions about function in person versus filling out questionnaires on their own. They described face-to-face assessment as more “intimate” and able to prompt self-reflection on one’s difficulty with ADLs. In addition, patients and caregivers noted that when clinicians ask about both difficulty and need for help with daily tasks, this provides a more complete and holistic view of function. A caregiver of an 82-year-old man who needed help with ADLs stated, “I think they’re two different questions. I would prefer that they were separate. Does he have trouble? Does he require help?”

Phase 4: Intervention components.

Qualitative findings informed the development of five intervention components designed to address barriers, facilitators, and preferences for measurement (Table 6). Components included: (1) routine, standardized functional status measurement; (2) screening by nurses and follow-up PCP assessment when impairments were identified; (3) electronic tools and templates to facilitate screening and assessment; (4) an interprofessional educational session; and (5) tailored reports on functional status.

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Table 6. Intervention components and rationale.

https://doi.org/10.1371/journal.pone.0290741.t006

Component 1: Routine, standardized measurement. Annual, standardized measurement addressed barriers to screening and assessment, including competing priorities and a lack of standardized processes. This approach also leveraged facilitators, including standardized screening to systematically identify impairments and understand patient needs. Similarly, standardized measurement addressed barriers to documenting and using data, including the lack of a standardized data location and poor team coordination. Standardized measurement also contributed to “meaningful measurement” by allowing use of data to improve care.

Component 2: Annual LVN screening and follow-up PCP assessment. To operationalize this standardized process, the intervention incorporated annual LVN screening during triage and follow-up PCP assessment when impairments were identified. This team-based approach addressed a key barrier to screening and assessment, unclear team roles and responsibilities. It also leveraged facilitators by fostering a strong interprofessional environment to optimize measurement.

Component 3: Electronic tools and templates. To facilitate standardized data collection and EHR integration, we designed an electronic decision-support tool to be completed annually among patients aged ≥75. The tool had two parts: (1) an LVN screening questionnaire, and (2) a PCP alert when patients screened positive for impairment, linked to an optional referral menu.

LVN questionnaire. The questionnaire included suggested introductory text to read to the patient explaining the purpose of screening, followed by a two-part screener. This text provided context for measurement, proactively addressing patient concerns that asking about function was irrelevant or being used to screen for nursing home admission. It also built on observations that when context is provided, patients are more open to screening and likely to perceive it as part of quality, holistic care.

The two-part screening tool included (1) a brief two-question pre-screener asking about difficulty performing ADLs and IADLs, and (2) among patients who reported difficulty, an in-depth screener asking about difficulty and needing help with each task. This two-part structure was intended to quickly identify patients with impairment who would benefit from in-depth screening while “screening out” individuals without impairment in the most commonly-affected ADLs and IADLs. The pre-screening step reduced screening burden for LVNs, addressing concerns about limited time, increased workload, and “alert fatigue.” This approach also freed time for detailed screening among patients with identified impairments. Because cumbersome tools posed a barrier to measurement, we incorporated Human Factors analysis and usability testing and iterative refinement.

We reviewed the literature to identify validated screening instruments for the two-part tool. For the pre-screener, we sought a brief instrument for identifying patients with early impairments (i.e., difficulty performing tasks, rather than needing help). Among more than 20 instruments, the American Community Survey included two items meeting these criteria, one inquiring about difficulty with ADLs and one about difficulty with IADLs [65]. We adapted these questions to include impairments which are most common in older adults and typically develop first (i.e., bathing and dressing; difficulty shopping and preparing meals) [66–68]. For the in-depth screener, we identified two candidate instruments that asked about difficulty and needing help with ADLs and IADLs: the Yale Precipitating Events Project (PEP) Instrument [69–72] and the Health and Retirement Study instrument [73]. We chose the PEP because it employs conversational language and asks about 6 ADLs and 7 IADLs.

We incorporated these measures into the screening tool design. If a patient answered no to both pre-screening questions, the EHR generated a nursing note stating that the patient screened negative for impairment. If a patient reported difficulty with bathing or dressing, an additional dialogue opened, prompting the LVN to ask questions about difficulty and needing help with each ADL; similarly, if a patient reported difficulty with shopping or preparing meals, a dialogue prompted questions about IADLs. We used a validated algorithm to score each task as 0 (independent), 1 (has difficulty), or 2 (needs help) [69–72]. The results were used to auto-populate a nursing note detailing the patient’s ability to perform each task.

Because LVNs noted that a free text box could capture richer information about function, the tool also included an optional free text section to enter notes about function or contextual factors. The tool employed conversational language to be usable either in-person or via telephone, addressing user preferences for adaptable tools.

PCP alert and referral menu. If a patient screened positive for functional impairment, defined as reporting difficulty or needing help with at least one ADL or IADL, the PCP received an electronic alert linked to a referral menu. The alert prompted the PCP to review the LVN screening and perform additional assessment as needed, supporting an interprofessional approach to measurement. The PCP then had the option to select up to four referrals: physical therapy, occupational therapy, social work, or geriatric medicine. Integrated EHR referrals were intended to address concerns that data would not be used to inform care, while building on perceptions that integrated referrals facilitate use of data. By providing suggested referrals, we also sought to address concerns that a lack of knowledge of services prevented using data to improve care.

Component 4: Interprofessional educational session. We developed an educational session to be completed before implementing the intervention. The purpose was to enhance clinician knowledge of the importance of measuring function, a facilitator for measurement, and introduce the intervention components. We began with an overview of the prognostic importance of functional status and how it can be used to inform clinical care. Next, we reviewed the intervention components. We reviewed patient perspectives on measurement and explained that the screening tool incorporated introductory text to address patient concerns that function is not medically relevant. We reviewed the role that interprofessional communication can play in optimizing measurement and how the intervention supports communication.

Component 5: Tailored reports. We incorporated tailored reports of population-level metrics for functional status. Reports could be pulled at the level of the medical center, clinic (e.g., medical practice, geriatrics), and provider, and tailored to report varying statistics (e.g., proportion of veterans needing help with ADLs). Reports were intended to address observations that access to population-level data informs strategic planning and efforts to keep patients functional at home rather than in more costly institutional care.