1. How to Conduct Toileting Trials: A Webinar Course Evaluation
Presenter: James Mittleberger, M.D.
PI: Anna Rahman, Ph.D.
Organizational affiliations:
California Association for Long Term Care Medicine
USC Davis School of Gerontology

2. Our Goal
To improve incontinence care for residents by administering a webinar course that helps NHs implement best-practice toileting trials.
To evaluate the efficacy and feasibility of the webinar course.

3. Toileting Trials Brief, typically 3-day resident assessments.
Providers, often nurse aides, attempt to assist incontinent residents to the toilet every 2 hours and record the outcome after each attempt.
A resident interview before and after the trial helps further identify resident preferences for care.
“Responsive” residents stay dry between visits, use the toilet appropriately most of the time, and express a preference to use the toilet.

4. Advantages and Current Use
MDS now includes toileting trial items because these trials help individualize care and target staff assistance.
Responsive residents continue to receive 2-hour assistance; others are referred for evaluation or placed on check-and-change.
Research suggest that few NHs conduct best-practice toileting trials.

5. The Webinar Course
Six webinars, 40 minutes in length, over 9 weeks, with 1-5 weeks between webinars.
Nationally recognized expert on NH incontinence care provided all instruction.
Online training materials and assessment forms.

6. Webinar Course, cont.
One champion at each NH; other staff invited to participate in all webinars.
Implementation assignment after 1st and 3rd webinars to practice what was learned; results faxed to project PI.
Assignment results discussed in 2nd and 4th webinars.
PI called each NH champion twice during project to encourage continued participation.

7. Course Curriculum
Webinar 1, Week 1. How-to webinar: Assess resident preferences for incontinence care.  Assignment: Interview at least 5 residents using the Resident Preference Interview Form
Between session: Follow-up call to check on progress
Webinar 2, Week 3. Webinar: Feedback, discussion of implementation assignment. 
Webinar 3, Week 4. How-to webinar: Conduct a 3-day toileting trial and analyze results.  Assignment: Conduct toileting trials for at least 5 residents
Between session: Follow-up call
Webinar 4, Week 9. Webinar: Feedback, discussion of implementation assignment.  Continue conducting toileting trials.
Webinar 5, Week 10: How-to webinar: Write-up care plans, survive the survey.
Webinar 6, Week 12: How-to webinar: Monitor toileting assistance.

8. Advantages No travel: Saves time and money for staff and instructors.
Teams can participate: Several staff members can participate; builds staff support and staff redundancy for the intervention
Extended training: There is time to practice the new intervention and get feedback.
Flexible program: The program can be tailored to meet participant needs as the arise.

9. Disadvantage Participants cannot see each other or the instructors.
NHs not accustomed to this course design.
Drop-out rates for online courses can be high.

10. Publicized Program Course offered at no cost.
Nurses and administrators receive 5 CEs.
Sent out electronic announcement to NH membership groups.
Ten NHs enrolled; 7 completed the course.
Adopted a customer service approach with participating nursing homes.

11. Evaluation Methods Course Evaluation Champion’s Final Report
Received from 16 staff members in 6 facilities.
Champion’s Final Report
Received from 6 facilities.
Course Evaluation – we asked the SOME questions of course evaluation only to the supervisors.

12. Results: Participation
7 of the originally enrolled 10 NHs completed the course by attending at least 4 webinars (median=5; mean=4.85)
Champions reported that an average of 9 staff members, mostly nurses, regularly attended, but the range was wide: 3-20, with a median=5.
CNAs participated in 2 NHs.

13. Results: Implementation
Champions reporting:
Assessed residents drier: 3 NHs
Conducted in-services on 2 or 3 of the 3 recommended standardized forms: 4 NHs
NH plans to continue use of all 3 recommended forms: 5 NHs

14. Results: Implementation, cont.
Champions reporting averages per NH:
Number of residents interviewed: 9 (range: 6-10)
Number of residents w/3-day trial: 7 (range: 4-10)
Number of residents with trial results analyzed: 7 (range: 4-10)

15. Results: Implementation, cont.
All participating NHs (n=7) submitted some implementation assignment results.
7 submitted Resident Interview forms.
4 submitted 3-day Toileting Trial Forms.
2 submitted toileting Trial Results form (analyzing data from the toileting trial).

16. Results: Training Preferences
Respondents (n=16) reporting:
Length of webinars “just right”: 12
Number and spacing of webinars “just right”: 15 (1 missing)
Would recommend course: 15 (1 missing)
Would take similar course again: 15 (1 missing)
Preferred this course to a 1-day conference or an online only course: 12

17. Worth Noting
Project results were achieved at minimal cost: about $1,000 per facility.
Enrolling more NHs would reduce cost per facility.

18. Discussion This course performed much like 2 earlier courses:
About a third of the registered NHs dropped out before or soon after the course started.
In participating NHs, multiple staff members regularly attended most webinars.
All NHs submitted some evidence that staff providers had completed implementation assignments.
Most NHs reported plans to sustain use of the recommended toileting trial protocol.
Study’s small sample size constrains our ability to draw definitive conclusions.

19. Discussion, cont.
Enthusiastic course reviews. “What did you like most about the course?”
“Everything.”
“The discussion and participation of the other facilities.”
“That participants could ask questions and provide feedback.”
“It is practical and realistic.”
“Data gathering.
Only 2 participants offered improvement recommendations, both requesting more training time.

20. Recommendation
With the course’s modest resource requirements and promising potential to prompt care improvement in NHs, we recommend that NH educator groups, including Quality Improvement Organizations and professional membership organizations, consider offering—and evaluating—similarly designed courses.

21. Tips for Similar Courses
Tailor course designs to the interventions being advocated.
Over-enroll NHs, but keep in mind your staff resources (we recommend enrollments under 35 NHs).
Use user-friendly electronic communication tools.
Treat participants like customers.
Strive to get to know participants/NHs.

22. Tips, cont. Email reminders about everything.
Promote peer-sharing by calling on individual participants to report their experiences.
Push assistance; don’t wait for NHs to call you.
Give positive feedback.
Continuously monitor and evaluate your program.

23. Visit the Course: caltcmcourses.wordpress.com

24. Thank You!
Questions?