Beyond the 'iron lungs of gerontology': using evidence to shape the future of nursing homes in Canada

What are the differences among occupational groups related to their palliative care-specific educational needs and intensity of interprofessional collaboration in long-term care homes?

Background

The purpose of this study was to compare the differences across occupational groups related to their end-of-life care-specific educational needs and reported intensity of interprofessional collaboration in long-term care (LTC) homes.

Methods

A cross-sectional survey, based on two questionnaires, was administered at four LTC homes in Ontario, Canada using a modified Dilman’s approach. The first questionnaire, End of Life Professional Caregiver Survey, included three domains: patients and family-centered communication, cultural and ethical values, effective care delivery. The Intensity of Interprofessional Collaboration Scale included two subscales: care sharing activities, and interprofessional coordination. In total, 697 LTC staff were given surveys, including personal support workers, support staff (housekeeping, kitchen, recreation, laundry, dietician aids, office staff), and registered staff (licensed nurses, physiotherapists, social workers, pharmacists, physicians).

Results

A total of 317 participants completed the survey (126 personal support workers, 109 support staff, 82 registered staff) for a response rate of 45%. Significant differences emerged among occupational groups across all scales and subscales. Specifically, support staff rated their comfort of working with dying patients significantly lower than both nurses and PSWs. Support staff also reported significantly lower ratings of care sharing activities and interprofessional coordination compared to both registered staff and personal support workers.

Conclusions

These study findings suggest there are differing educational needs and sense of interprofessional collaboration among LTC staff, specific to discipline group. Both the personal support workers and support staff groups appeared to have higher needs for education; support staff also reported higher needs related to integration on the interdisciplinary team. Efforts to build capacity within support staff related to working with dying residents and their families are needed. Optimal palliative care may require resources to increase the availability of support for all staff involved in the care of patients.

Barriers and facilitators in providing oral care to nursing home residents, from the perspective of care aides: A systematic review and meta-analysis

BACKGROUND

Oral health of nursing home residents is generally poor, with severe consequences for residents' general health and quality of life and for the health care system. Care aides in nursing homes provide up to 80% of direct care (including oral care) to residents, but providing oral care is often challenging. Interventions to improve oral care must tailor to identified barriers and facilitators to be effective. This review identifies and synthesizes the evidence on barriers and facilitators care aides perceive in providing oral care to nursing home residents.

METHODS

We systematically searched the databases MEDLINE, Embase, Evidence Based Reviews-Cochrane Central Register of Controlled Trials, CINAHL, and Web of Science. We also searched by hand the contents of key journals, publications of key authors, and reference lists of all studies included. We included qualitative and quantitative research studies that assess barriers and facilitators, as perceived by care aides, to providing oral care to nursing home residents. We conducted a thematic analysis of barriers and facilitators, extracted prevalence of care aides reporting certain barriers and facilitators from studies reporting quantitative data, and conducted random-effects meta-analyses of prevalence.

RESULTS

We included 45 references that represent 41 unique studies: 15 cross-sectional studies, 13 qualitative studies, 7 mixed methods studies, 3 one-group pre-post studies, and 3 randomized controlled trials. Methodological quality was generally weak. We identified barriers and facilitators related to residents, their family members, care providers, organization of care services, and social interactions. Pooled estimates (95% confidence intervals) of barriers were: residents resisting care=45% (15%-77%); care providers' lack of knowledge, education or training in providing oral care=24% (7%-47%); general difficulties in providing oral care=26% (19%-33%); lack of time=31% (17%-47%); general dislike of oral care=19% (8%-33%); and lack of staff=22% (13%-31%).

CONCLUSIONS

We found a lack of robust evidence on barriers and facilitators that care aides perceive in providing oral care to nursing home residents, suggesting a need for robust research studies in this area. Effective strategies to overcome barriers and to increase facilitators in providing oral care are one of the most critical research gaps in the area of improving oral care for nursing home residents. Strategies to prevent or manage residents' responsive behaviors and to improve care aides' oral care knowledge are especially needed.

"When I Said I Wanted to Die at Home I Didn't Mean a Nursing Home": Care Trajectories at the End of Life

Background and Objectives

Little is known regarding the care trajectories older adults experience at the end of life (EOL). We drew on a structural/institutional life course perspective to examine the trajectories evident among older adults transitioning through the Canadian formal long-term care system. The sequence of care transitions as well as the impact of social location, social and economic resources, and health-related factors on these trajectories were examined.

Research Design and Methods

To identify EOL care trajectories, we used administrative data collected on older adults (aged 65+) who received publicly subsidized long-term care services (e.g., nursing home and home and community-based care) in one health region in British Columbia, Canada from January 1, 2008 through December 31, 2011 and who died by March 31, 2012 (n = 11,816). Multinomial logistic regression analyses assessed the impact of selected covariates on these trajectories.

Results

The majority of those studied (65.4%) died outside of acute hospital settings. The most common trajectories involved transitions from home care to nursing home/residential care to non-hospital death (39.5%) and transitions from in-home care to hospital death (22.4%). These and other trajectories were shaped by social structural factors, access to social and economic resources, as well as health status and prior hospitalizations.

Discussion and Implications

Despite calls for minimizing hospital-based deaths and maximizing home-based deaths, older LTC recipients often experience EOL care trajectories that end in death in a nursing home care setting. Our findings point to the value of a structural/institutional life course perspective in informing an understanding of who experiences this and other major EOL care trajectories. In doing so, they also provide direction for policy and practice designed to address inequalities and enhance the quality of EOL care.

Disability in long-term care residents explained by prevalent geriatric syndromes, not long-term care home characteristics: a cross-sectional study

Background

Self-care disability is dependence on others to conduct activities of daily living, such as bathing, eating and dressing. Among long-term care residents, self-care disability lowers quality of life and increases health care costs. Understanding the correlates of self-care disability in this population is critical to guide clinical care and ongoing research in Geriatrics. This study examines which resident geriatric syndromes and chronic conditions are associated with residents’ self-care disability and whether these relationships vary across strata of age, sex and cognitive status. It also describes the proportion of variance in residents’ self-care disability that is explained by residents’ geriatric syndromes versus long-term care home characteristics.

Methods

We conducted a cross-sectional study using a health administrative cohort of 77,165 long-term care home residents residing in 614 Ontario long-term care homes. Eligible residents had their self-care disability assessed using the RAI-MDS 2.0 activities of daily living long-form score (range: 0–28) within 90 days of April 1st, 2011. Hierarchical multivariable regression models with random effects for long-term care homes were used to estimate the association between self-care disability and resident geriatric syndromes, chronic conditions and long-term care home characteristics. Differences in findings across strata of sex, age and cognitive status (cognitively intact versus cognitively impaired) were examined.

Results

Geriatric syndromes were much more strongly associated with self-care disability than chronic conditions in multivariable models. The direction and size of some of these effects were different for cognitively impaired versus cognitively intact residents. Residents’ geriatric syndromes explained 50% of the variation in their self-care disability scores, while characteristics of long-term care homes explained an additional 2% of variation.

Conclusion

Differences in long-term care residents’ self-care disability are largely explained by prevalent geriatric syndromes. After adjusting for resident characteristics, there is little variation in self-care disability associated with long-term care home characteristics. This suggests that residents’ geriatric syndromes—not the homes in which they live—may be the appropriate target of interventions to reduce self-care disability, and that such interventions may need to differ for cognitively impaired versus unimpaired residents.

Electronic supplementary material

The online version of this article (doi:10.1186/s12877-017-0444-1) contains supplementary material, which is available to authorized users.

Pathways for best practice diffusion: the structure of informal relationships in Canada's long-term care sector

Background

Initiatives to accelerate the adoption and implementation of evidence-based practices benefit from an association with influential individuals and organizations. When opinion leaders advocate or adopt a best practice, others adopt too, resulting in diffusion. We sought to identify existing influence throughout Canada’s long-term care sector and the extent to which informal advice-seeking relationships tie the sector together as a network.

Methods

We conducted a sociometric survey of senior leaders in 958 long-term care facilities operating in 11 of Canada’s 13 provinces and territories. We used an integrated knowledge translation approach to involve knowledge users in planning and administering the survey and in analyzing and interpreting the results. Responses from 482 senior leaders generated the names of 794 individuals and 587 organizations as sources of advice for improving resident care in long-term care facilities.

Results

A single advice-seeking network appears to span the nation. Proximity exhibits a strong effect on network structure, with provincial inter-organizational networks having more connections and thus a denser structure than interpersonal networks. We found credible individuals and organizations within groups (opinion leaders and opinion-leading organizations) and individuals and organizations that function as weak ties across groups (boundary spanners and bridges) for all studied provinces and territories. A good deal of influence in the Canadian long-term care sector rests with professionals such as provincial health administrators not employed in long-term care facilities.

Conclusions

The Canadian long-term care sector is tied together through informal advice-seeking relationships that have given rise to an emergent network structure. Knowledge of this structure and engagement with its opinion leaders and boundary spanners may provide a route for stimulating the adoption and effective implementation of best practices, improving resident care and strengthening the long-term care advice network. We conclude that informal relational pathways hold promise for helping to transform the Canadian long-term care sector.

Making the Most of Mealtimes (M3): protocol of a multi-centre cross-sectional study of food intake and its determinants in older adults living in long term care homes

BACKGROUND

Older adults living in long term care (LTC) homes are nutritionally vulnerable, often consuming insufficient energy, macro- and micronutrients to sustain their health and function. Multiple factors are proposed to influence food intake, yet our understanding of these diverse factors and their interactions are limited. The purpose of this paper is to fully describe the protocol used to examine determinants of food and fluid intake among older adults participating in the Making the Most of Mealtimes (M3) study.

METHODS

A conceptual framework that considers multi-level influences on mealtime experience, meal quality and meal access was used to design this multi-site cross-sectional study. Data were collected from 639 participants residing in 32 LTC homes in four Canadian provinces by trained researchers. Food intake was assessed with three-days of weighed food intake (main plate items), as well as estimations of side dishes, beverages and snacks and compared to the Dietary Reference Intake. Resident-level measures included: nutritional status, nutritional risk; disease conditions, medication, and diet prescriptions; oral health exam, signs of swallowing difficulty and olfactory ability; observed eating behaviours, type and number of staff assisting with eating; and food and foodservice satisfaction. Function, cognition, depression and pain were assessed using interRAI LTCF with selected items completed by researchers with care staff. Care staff completed a standardized person-directed care questionnaire. Researchers assessed dining rooms for physical and psychosocial aspects that could influence food intake. Management from each site completed a questionnaire that described the home, menu development, food production, out-sourcing of food, staffing levels, and staff training. Hierarchical regression models, accounting for clustering within province, home and dining room will be used to determine factors independently associated with energy and protein intake, as proxies for intake. Proportions of residents at risk of inadequate diets will also be determined.

DISCUSSION

This rigorous and comprehensive data collection in a large and diverse sample will provide, for the first time, the opportunity to consider important modifiable factors associated with poor food intake of residents in LTC. Identification of factors that are independently associated with food intake will help to develop effective interventions that support food intake.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT02800291 , retrospectively registered June 7, 2016.

Improving Nursing Home Care through Feedback On PerfoRMance Data (INFORM): Protocol for a cluster-randomized trial

BACKGROUND

Audit and feedback is effective in improving the quality of care. However, methods and results of international studies are heterogeneous, and studies have been criticized for a lack of systematic use of theory. In TREC (Translating Research in Elder Care), a longitudinal health services research program, we collect comprehensive data from care providers and residents in Canadian nursing homes to improve quality of care and life of residents, and quality of worklife of caregivers. The study aims are to a) systematically feed back TREC research data to nursing home care units, and b) compare the effectiveness of three different theory-based feedback strategies in improving performance within care units.

METHODS

INFORM (Improving Nursing Home Care through Feedback On PerfoRMance Data) is a 3.5-year pragmatic, three-arm, parallel, cluster-randomized trial. We will randomize 67 Western Canadian nursing homes with 203 care units to the three study arms, a standard feedback strategy and two assisted and goal-directed feedback strategies. Interventions will target care unit managerial teams. They are based on theory and evidence related to audit and feedback, goal setting, complex adaptive systems, and empirical work on feeding back research results. The primary outcome is the increased number of formal interactions (e.g., resident rounds or family conferences) involving care aides - non-registered caregivers providing up to 80% of direct care. Secondary outcomes are a) other modifiable features of care unit context (improved feedback, social capital, slack time) b) care aides' quality of worklife (improved psychological empowerment, job satisfaction), c) more use of best practices, and d) resident outcomes based on the Resident Assessment Instrument - Minimum Data Set 2.0. Outcomes will be assessed at baseline, immediately after the 12-month intervention period, and 18 months post intervention.

DISCUSSION

INFORM is the first study to systematically assess the effectiveness of different strategies to feed back research data to nursing home care units in order to improve their performance. Results of this study will enable development of a practical, sustainable, effective, and cost-effective feedback strategy for routine use by managers, policy makers and researchers. The results may also be generalizable to care settings other than nursing homes.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02695836 . Date of registration: 24 February 2016.

Managing Heart Failure in Long-Term Care: Recommendations from an Interprofessional Stakeholder Consultation

Insuffisance cardiaque (IC) affecte autant que 20 pour cent des résidents en soins de longue durée (SLD), et est associée à la morbidité substantielle, la mortalité et l’utilisation des services de santé. L’objectif de notre étude était de formuler des recommandations sur la mise en œuvre de processus pour prendre soin de l’insuffisance cardiaque dans SLD. Un processus de consultation itérative triphasé avec les parties prenantes a été guidé par la participation d’un panel d’experts et a servi à élaborer des recommandations. Dix-sept recommandations ont été faites. Éléments clés des celles-ci se concentrent sur l’amélioration de la communication interprofessionnelle et accroître les connaissances relatives à l’insuffisance cardiaque entre tous les intervenants dans SLD. Des recommandations systématiques incluent améliorer la communication entre les foyers de SLD et soins aigus et autres prestataires de santé externes, et développer des interventions dans l’ensemble des installations afin de réduire les apports de sodium alimentaire et d’augmenter l’activité physique.

Janus at the Crossroads: Perspectives on Long-term Care Trajectories for Older Women With Dementia in a Canadian Context

PURPOSE OF THE STUDY

Janus, the two-faced, Roman god of beginnings and transitions, is used as a metaphor to explore our personal narratives and our quantitative research on the experiences of older women with dementia in long-term care (LTC). Two research questions are addressed: (a) How do our quantitative data map onto our mothers' experiences? (b) What lessons do our mothers' experiences offer for the care of older women with dementia?

DESIGN AND METHODS

Informed by a life-course perspective, we triangulate administrative data on 3,717 women with dementia receiving LTC in British Columbia, Canada, with personal narratives-the stories of our mothers who made the transition from home care into residential (nursing home) care.

RESULTS

Our quantitative data reveal that the home care to residential care transition is the most common LTC trajectory for women with dementia who are most likely to be widowed and living alone in suburban areas. On entry into residential care, they exhibit greater frailty in terms of activities of daily living, cognition, aggression, and incontinence. Our personal narrative data on our mothers reveals that the relatively straightforward pathways through LTC for women with dementia, are often considerably more complex in a real-world context. Attention is drawn to the public and private services, hospitalization patterns, and substantial communication gaps experienced by our moms and families.

IMPLICATIONS

A life-course perspective, and qualitative and quantitative data facilitate understanding the care journeys-health and service trajectories of older women with dementia.

Oral/dental items in the resident assessment instrument - minimum Data Set 2.0 lack validity: results of a retrospective, longitudinal validation study

Background

Oral health in nursing home residents is poor. Robust, mandated assessment tools such as the Resident Assessment Instrument – Minimum Data Set (RAI-MDS) 2.0 are key to monitoring and improving quality of oral health care in nursing homes. However, psychometric properties of RAI-MDS 2.0 oral/dental items have been challenged and criterion validity of these items has never been assessed.

Methods

We used 73,829 RAI-MDS 2.0 records (13,118 residents), collected in a stratified random sample of 30 urban nursing homes in Western Canada (2007–2012). We derived a subsample of all residents (n = 2,711) with an admission and two or more subsequent annual assessments. Using Generalized Estimating Equations, adjusted for known covariates of nursing home residents’ oral health, we assessed the association of oral/dental problems with time, dentate status, dementia, debris, and daily cleaning.

Results

Prevalence of oral/dental problems fluctuated (4.8 %–5.6 %) with no significant differences across time. This range of prevalence is substantially smaller than the ones reported by studies using clinical assessments by dental professionals. Denture wearers were less likely than dentate residents to have oral/dental problems (adjusted odds ratio [OR] = 0.458, 95 % confidence interval [CI]: 0.308, 0.680). Residents lacking teeth and not wearing dentures had higher odds than dentate residents of oral/dental problems (adjusted OR = 2.718, 95 % CI: 1.845, 4.003). Oral/dental problems were more prevalent in persons with debris (OR = 2.187, 95 % CI: 1.565, 3.057). Of the other variables assessed, only age at assessment was significantly associated with oral/dental problems.

Conclusions

Robust, reliable RAI-MDS 2.0 oral health indicators are vital to monitoring and improving oral health related quality and safety in nursing homes. However, severe underdetection of oral/dental problems and lack of association of well-known oral health predictors with oral/dental problems suggest validity problems. Lacking teeth and not wearing dentures should be considered an indicator for urgent oral/dental treatment needs.

Electronic supplementary material

The online version of this article (doi:10.1186/s12963-016-0108-y) contains supplementary material, which is available to authorized users.

Identifying Fallers among Home Care Clients with Dementia and Parkinson's Disease

Few studies have focused on falls among home care (HC) clients with neurological conditions. This study identified factors that increase risk of falling among HC clients with no recent history of falls, and explored whether risk profiles varied among those with dementia or parkinsonism compared to those without selected neurological conditions. A retrospective cohort design was used and analysis of data from community-based HC clients across Ontario was conducted on a sample of ambulatory clients with dementia, parkinsonism, or none of the selected neurological conditions. Data were obtained from the Resident Assessment Instrument for HC (RAI-HC) assessment. The outcome used in multivariable analyses was whether clients fell during follow-up. Unsteady gait was a strong predictor of falls across all three groups. Co-morbid parkinsonism most strongly predicted falls in the dementia group. Clients with borderline intact to mild cognitive impairment had higher odds of falling within the parkinsonism and comparison groups.

Normalisation Process Theory and the Implementation of Resident Assessment Instrument–Home Care in Saskatchewan, Canada

Meeting the health needs of the community client in Saskatchewan, Canada, has been theoretically improved by the home care program’s adoption of an electronic client assessment system, Resident Assessment Instrument–Home Care (RAI-HC). Valid and reliable client outcome data are generated from a completed RAI-HC, and available to home care and its assessor coordinators to support clinical and program decisions. To realize the benefits of RAI-HC, user comprehension and application of this system in totality is central. This study fostered an understanding of the association of normalisation process theory (NPT) with the implementation, utilization, and integration of RAI-HC within home care practice in Saskatchewan. The findings suggest encumbered utilization and integration of RAI-HC into day-to-day home care practice, and a parallel relationship with NPT.

Screening for Frailty in Canada's Health Care System: A Time for Action

As Canada's population ages, frailty - with its increased risk of functional decline, deterioration in health status, and death - will become increasingly common. The physiology of frailty reflects its multisystem, multi-organ origins. About a quarter of Canadians over age 65 are frail, increasing to over half in those older than 85. Our health care system is organized around single-organ systems, impairing our ability to effectively treat people having multiple disorders and functional limitations. To address frailty, we must recognize when it occurs, increase awareness of its significance, develop holistic models of care, and generate better evidence for its treatment. Recognizing how frailty impacts lifespan will allow for integration of care goals into treatment options. Different settings in the Canadian health care system will require different strategies and tools to assess frailty. Given the magnitude of challenges frailty poses for the health care system as currently organized, policy changes will be essential.

Recommendations From the International Consortium on Professional Nursing Practice in Long-Term Care Homes

In response to the International Association of Gerontology and Geriatrics' global agenda for clinical research and quality of care in long-term care homes (LTCHs), the International Consortium on Professional Nursing Practice in Long Term Care Homes (the Consortium) was formed to develop nursing leadership capacity and address the concerns regarding the current state of professional nursing practice in LTCHs. At its invitational, 2-day inaugural meeting, the Consortium brought together international nurse experts to explore the potential of registered nurses (RNs) who work as supervisors or charge nurses within the LTCHs and the value of their contribution in nursing homes, consider what RN competencies might be needed, discuss effective educational (curriculum and practice) experiences, health care policy, and human resources planning requirements, and to identify what sustainable nurse leadership strategies and models might enhance the effectiveness of RNs in improving resident, family, and staff outcomes. The Consortium made recommendations about the following priority issues for action: (1) define the competencies of RNs required to care for older adults in LTCHs; (2) create an LTCH environment in which the RN role is differentiated from other team members and RNs can practice to their full scope; and (3) prepare RN leaders to operate effectively in person-centered care LTCH environments. In addition to clear recommendations for practice, the Consortium identified several areas in which further research is needed. The Consortium advocated for a research agenda that emphasizes an international coordination of research efforts to explore similar issues, the pursuit of examining the impact of nursing and organizational models, and the showcasing of excellence in nursing practice in care homes, so that others might learn from what works. Several studies already under way are also described.

Factors associated with acute care use among nursing home residents dying of cancer: a population-based study

BACKGROUND

Little is known about residents of long-term care (LTC) facilities who die of cancer. The authors examined factors among this cohort prognostic of greater acute care use to identify areas for improving support in LTC.

METHODS

The authors used administrative data representing all cancer decedents in Ontario, Canada, who had been living in LTC. Binary logistic regression was used to examine the contribution of covariates to having an emergency department (ED) visit in the last 6 months of life or to death in hospital.

RESULTS

Among the 1196 LTC residents in the study cohort, 61% had visited an ED in the last 6 months of life and 20% had died in hospital. Cancer type, income, gender, time in LTC and rural location were not strong predictors of the acute care outcomes. However, certain comorbidities, being younger and region of residence significantly increased the odds of an ED visit and/or hospital death (all P<0.05).

CONCLUSIONS

Determining the characteristics of LTC patients more likely to access acute care services can help to inform interventions that avoid costly and potentially adverse transfers to hospital. The study of cancer patients in LTC represents a starting point for clarifying the potential of specialised palliative care nursing and other support that is often lacking in these facilities.

Risk and protective factors associated with intentional self-harm among older community-residing home care clients in Ontario, Canada

OBJECTIVE

We aim to concurrently examine risk and protective factors associated with intentional self-harm among community-residing older adults receiving home care services in Ontario, Canada.

METHODS

Administrative health data from the home care sector were linked to hospital administrative data to carry out the analyses. Home care data are collected in Ontario using the Resident Assessment Instrument-Home Care (RAI-HC), an assessment tool that identifies strengths, preferences and needs of long-stay home care clients. The sample included Ontario home care clients aged 60 years or older assessed with the RAI-HC between 2007 and 2010 (N = 222,149). Multivariable analyses were performed using SAS.

RESULTS

Hospital records of intentional self-harm (ISH) were present in 9.3 cases per 1000 home care clients. Risks of ISH included younger age (60-74 years; OR = 3.14, CI: 2.75-3.59), psychiatric diagnosis (OR = 2.29, CI: 2.06-2.54), alcohol use and dependence (OR = 1.69, CI: 1.34-2.14), psychotropic medication (OR = 1.94, CI: 1.75-2.15) and depressive symptoms (OR = 1.58, CI: 1.40-1.78). Protective effects were found for marital status and positive social relationships, yet these effects were more pronounced for men. Cognitive performance measures showed the odds of ISH 1.86 times higher for older adults with moderate to severe cognitive impairment.

CONCLUSIONS

This study based on provincial data points to tangible areas for preventative assessment by frontline home care professionals. Of interest were the risk and protective factors that differed by sex. As demand for home care in Canada is expected to increase, these findings may inform home care professionals' appraisal and approach to suicide prevention among community-residing older adults.

Delivery of institutional long-term care under two social insurances: Lessons from the Korean experience

Little is known about health and social care provision for people with long-term care (LTC) needs under multiple insurances. The aim of this study is to compare the profile, case-mix, and service provision to older people at long-term care hospitals (LTCHs) covered by the national health insurance (NHI) with those of older people at long-term care facilities (LTCFs) covered by the public long-term care insurance (LTCI) in Korea. A national LTC survey using common functional measures and a case-mix classification system was conducted with a nationally representative sample of older people at LTCFs and LTCHs in 2013. The majority of older people in both settings were female and frail, with complex chronic diseases. About one fourth were a low-income population with Medical-Aid. The key functional status was similar between the two groups. As for case-mix, more than half of the LTCH population were categorized as having lower medical care needs, while more than one fourth of the LTCF residents had moderate or higher medical care needs. Those with high medical care needs at LTCFs were significantly more likely to be admitted to acute-care hospitals than their counterparts at LTCHs. The current delivery of institutional LTC under the two insurances in Korea is not coordinated well. It is necessary to redefine the roles of LTCHs and strengthen health care in LTCFs. A systems approach is critical to establish person-centered, integrated LTC delivery across different financial sources.

Factors associated with rushed and missed resident care in western Canadian nursing homes: a cross-sectional survey of health care aides

AIMS AND OBJECTIVES

To describe the nature, frequency and factors associated with care that was rushed or missed by health care aides in western Canadian nursing homes.

BACKGROUND

The growing number of nursing home residents with dementia has created job strain for frontline health care providers, the majority of whom are health care aides. Due to the associated complexity of care, health care aides are challenged to complete more care tasks in less time. Rushed or missed resident care are associated with adverse resident outcomes (e.g. falls) and poorer quality of staff work life (e.g. burnout) making this an important quality of care concern.

DESIGN

Cross-sectional survey of health care aides (n = 583) working in a representative sample of nursing homes (30 urban, six rural) in western Canada.

METHODS

Data were collected in 2010 as part of the Translating Research in Elder Care study. We collected data on individual health care aides (demographic characteristics, job and vocational satisfaction, physical and mental health, burnout), unit level characteristics associated with organisational context, facility characteristics (location, size, owner/operator model), and the outcome variables of rushed and missed resident care.

RESULTS

Most health care aides (86%) reported being rushed. Due to lack of time, 75% left at least one care task missed during their previous shift. Tasks most frequently missed were talking with residents (52% of health care aides) and assisting with mobility (51%). Health care aides working on units with higher organisational context scores were less likely to report rushed and missed care.

CONCLUSION

Health care aides frequently report care that is rushed and tasks omitted due to lack of time.

RELEVANCE TO CLINICAL PRACTICE

Considering the resident population in nursing homes today--many with advanced dementia and all with complex care needs--health care aides having enough time to provide physical and psychosocial care of high quality is a critical concern.

Predictors of frequent emergency department visits among rural older adults in Ontario using the Resident Assessment Instrument-Home Care

OBJECTIVE

To describe factors predicting frequent emergency department (ED) use among rural older adults receiving home care services in Ontario, Canada.

DESIGN

A cross-sectional examination of Ontario hospital administrative data linked to provincial home care data compares frequent ED users (i.e. >4 visits/year) with regular users (i.e. 1-3 visits/year) and no ED use over a 1-year period. Multiple logistic regression analysis was performed using independent variables from home care health assessments.

MAIN OUTCOME MEASURES

Predictors of frequent ED use among rural older adults receiving home care services using adjusted odds ratios (ORs) and 95% confidence intervals (CI).

RESULTS

Ontario's rural home care clients visited the ED an average of 4.9 times (SD = 11.9) over a year. Frequent ED users were observed in 170 cases per 1000 home care clients. Congestive heart failure was the most frequently cited reason for frequent ED use; however, it was not a main driver in the adjusted model. Frequent ED use was predicted by younger age (i.e. 60-74 years) (OR = 1.9; 95% CI, 1.7-2.2), a recent ED visit in the last 3 months (OR = 1.5; 95% CI, 1.4-1.7), regularly taking >9 medications (OR = 1.5; 95% CI, 1.3-1.6), and poor self-rated health (OR = 1.4; 95% CI, 1.2-1.5).

CONCLUSION

Despite popular assumptions, the main drivers for frequent ED use among rural older adults in Ontario included a mix of sociodemographic and clinical characteristics, rather than disease diagnoses.

Scoping review of physical rehabilitation interventions in long-term care: protocol for tools, models of delivery, outcomes and quality indicators

INTRODUCTION

A growing number of medically complex older adults reside in long-term care (LTC) and often require physical rehabilitation (PR). While PR is effective at maintaining or improving a patient's physical function, the breadth of PR interventions evaluated in LTC, which outcomes or quality indicators (QI) can be used to evaluate PR, and what tools or models can be used to determine eligibility for PR services remain unknown.

METHODS AND ANALYSIS

A scoping review will be conducted to address the following research questions: (1) What types of PR have been evaluated for efficacy or effectiveness in LTC? (2) Which outcomes or QIs have been used when evaluating PR interventions in LTC, and how can this inform evaluation of PR using existing QIs in the Canadian context? (3) What tools or models exist or have been validated for decision-making in the allocation of PR resources in LTC? We will conduct a comprehensive literature search in MEDLINE, EMBASE, CINAHL, Cochrane Database of Systematic Reviews, Physiotherapy Evidence Database (PEDro) and Occupational Therapy Systematic Evaluation of Evidence database (OTseeker) and a structured grey literature search. Two team members will screen articles and abstract the data. The results will be displayed according to the research question they address. Data abstracted regarding outcomes and QIs will be mapped onto existing, publicly reported QIs used in Ontario, Canada.

ETHICS AND DISSEMINATION

The scoping review will synthesise the characteristics of PR interventions described in the literature, the outcomes used to evaluate them and tools to determine eligibility for services. The review will be the first step in formally identifying what outcomes and QIs have been used to evaluate PR in LTC, and will be used to inform a stakeholder consensus process exploring the same question. The scoping review may also identify knowledge gaps. The results will be disseminated via publication and presentation at conferences, in addition to a 1-day stakeholder meeting.

Who receives rehabilitation in canadian long-term care facilities? A cross-sectional study

PURPOSE

To describe the proportion of residents receiving occupational therapy (OT) and physical therapy (PT) and the factors associated with receiving PT in long-term care (LTC) facilities across five provinces and one territory in Canada.

METHODS

Using a population-based, retrospective analysis of cross-sectional data, the proportion of LTC facility residents in each province or territory receiving three different amounts (time and frequency) of PT, OT, or both before July 1, 2013, was calculated according to the Resource Utilization Groups-III rehabilitation classifications. Twenty-three variables from the Resident Assessment Instrument 2.0, such as age and cognition, were examined as correlates; those significant at p<0.01 were included in a multivariate logistic regression.

RESULTS

Between 63.7% and 88.6% of residents did not receive any PT or OT; 0.8%-12.6% received both PT and OT; 5.8%-29.5% received an unspecified amount of PT; 1.9%-7.0% received 45 minutes or more of PT 3 days or more per week; and fewer than 1% received 150 minutes or more of PT on 5 or more days per week. Province, age, cognitive status, depression, clinical status, fracture, multiple sclerosis, and self-rated potential for improvement were associated with PT irrespective of time intensity.

CONCLUSIONS

The proportion of LTC residents receiving rehabilitation services varies across Canada and appears to be associated with physical impairments and the potential for improvement; older residents with cognitive impairment or mood disorders are less likely to receive rehabilitation services. Future recommendations should consider what is driving the patterns of service use, determine whether the resources available are appropriate, and address the most appropriate goals for residents in LTC.

The influence of organizational context on best practice use by care aides in residential long-term care settings

OBJECTIVE

This study assessed individual and organizational context (work environment) factors that influence use of best practices by care aides (nursing assistants) in nursing homes. Little scientific attention has been focused on understanding best practice use in nursing homes and almost none on care aides.

SETTING AND PARTICIPANTS

A total of 1262 care aides in 25 nursing homes in the 3 Canadian prairie provinces. Care aides are unregulated workers who provide 80% of direct care to residents in Canadian nursing homes.

METHOD

We used hierarchical linear modeling to (1) assess the amount of variance in use of best practices, as reported by care aides, that could be attributed to individual or organizational factors, and (2) identify predictors of best practices use by care aides.

RESULTS

At the individual level, statistically significant predictors of instrumental use of best practices included sex, age, shift worked, job efficacy, and belief suspension. At the unit level, significant predictors were social capital, organizational slack (staffing and time), number of informal interactions, and unit type. At the facility level, ownership model and province were significant. Significant predictors of conceptual use of best practices at the individual level included English as a first language, job efficacy, belief suspension, intent to use research, adequate knowledge, and number of information sources used. At the unit level, significant predictors were evaluation (feedback mechanisms), structural resources, and organizational slack (time). At the facility level, province was significant. The R(2) was 18.3% for instrumental use of best practices and 43.4% for conceptual use. Unit level factors added a substantial amount of explained variance whereas facility level factors added relatively little explained variance.

CONCLUSIONS

Our study suggests that context plays an important role in care aides' use of best practices in nursing homes. Individual characteristics played a more prominent role than contextual factors in predicting conceptual use of best practices.

Dying in a nursing home: treatable symptom burden and its link to modifiable features of work context

IMPORTANCE

High-quality care at the end of life supports freedom from pain and other potentially burdensome symptoms. Lowering symptom burden at the end of life is an urgent and achievable goal in delivering services in nursing home settings. Few published reports describe symptom burden among older adults in nursing homes; none examine links between symptom burden and modifiable features of nursing home organizational context (work environment).

OBJECTIVES

To examine the influence of organizational context on symptom burden and to compare symptom burden in the last year of life between nursing home residents with and without dementia.

DESIGN

Retrospective analysis of longitudinal survey data.

SETTING

A stratified random sample of 36 nursing homes in the Canadian provinces of Alberta, Manitoba, and Saskatchewan.

PARTICIPANTS

A total of 2635 residents with dementia and 1012 without dementia; 1381 front-line care staff.

MEASUREMENTS

(1) Trajectories of 6 symptoms (dyspnea, pain, pressure ulcers, urinary tract infections, challenging behavior, delirium), assessed with the Resident Assessment Instrument-Minimum Data Set, version 2.0, between 2008 and 2012. All residents received assessments in each quarter of the year before death. (2) Modifiable organizational context, assessed with the Alberta Context Tool. Hierarchical mixed model, repeated measures regression, to simultaneously evaluate effects of time, dementia, and context on symptom trajectories.

RESULTS

For all residents, prevalence of symptoms increased over time. In the last quarter before death, challenging behavior was the most frequent symptom in the dementia group (40.2%), delirium the most frequent symptom in the nondementia group (31.0%), and urinary tract infections least frequent (9.0% to 10.0%). Facilities with more favorable context had significantly higher prevalence of challenging behavior and delirium and significantly lower use of antipsychotics without diagnosis of psychosis.

CONCLUSION

Symptom burden increases as the end of life approaches but differs between high- and low-context facilities and between residents with and without dementia. Trajectories of treatable, burdensome symptoms at the end of life in nursing homes should be a priority focus for quality improvement. Modifiable features of organizational context that are linked to symptom burden offer new potential strategies and interventions for quality improvement.

Who is looking after Mom and Dad? Unregulated workers in Canadian long-term care homes

Older adults living in residential long-term care or nursing homes have increasingly complex needs, including more dementia than in the past, yet we know little about the unregulated workforce providing care. We surveyed 1,381 care aides in a representative sample of 30 urban nursing homes in the three Canadian Prairie provinces and report demographic, health and well-being, and work-related characteristics. Over 50 per cent of respondents were not born in Canada and did not speak English as their first language. They reported moderately high levels of burnout and a strong sense of their work's worth. Few respondents reported attending educational sessions. This direct caregiver workforce is poorly understood, has limited training or standards for minimum education, and training varies widely across provinces. Workplace characteristics affecting care aides reflect factors that precipitate burnout in allied health professions, with implications for quality of care, staff health, and staff retention.

Care planning needs of palliative home care clients: Development of the interRAI palliative care assessment clinical assessment protocols (CAPs)

BACKGROUND

The interRAI Palliative Care (interRAI PC) assessment instrument provides a standardized, comprehensive means to identify person-specific need and supports clinicians to address important factors such as aspects of function, health, and social support. The interRAI Clinical Assessment Protocols (CAPs) inform clinicians of priority issues requiring further investigation where specific intervention may be warranted and equip clinicians with evidence to better inform development of a person-specific plan of care. This is the first study to describe the interRAI PC CAP development process and provide an overview of distributional properties of the eight interRAI PC CAPs among community dwelling adults receiving palliative home care services.

METHODS

Secondary data analysis used interRAI PC assessments (N = 6,769) collected as part of regular clinical practice at baseline (N = 6,769) and follow-up (N = 1,000). Clients across six regional jurisdictions in Ontario, Canada, assessed to receive palliative homecare services between 2006 and 2011 were included (mean age 70.0 years; ±13.4 years). Descriptive analyses focused on the eight interRAI PC CAPs: Fatigue, Sleep Disturbance, Nutrition, Pressure Ulcers, Pain, Dyspnea, Mood Disturbance and Delirium.

RESULTS

The majority of clients triggered at least one CAP while two thirds triggered two or more. Triggering rates ranged from 74% for the Fatigue CAP to less than 15% for the Delirium and Pressure Ulcers CAPs. The hierarchical CAP triggering structure suggested Fatigue and Dyspnea CAPs were persistent issues prevalent among the majority of clients while Delirium and Pressure Ulcers CAPs rarely trigger in isolation and most often trigger later in the illness trajectory.

CONCLUSION

When any of the eight interRAI PC CAPs are triggered, clinicians should take notice. CAPs triggered at high rates such as fatigue, dyspnea, and pain warrant increased attention for the majority of clients. Consideration of triggered CAPs provide evidence to inform a collaborative decision making process on whether or not issues raised by the CAPs should be addressed in the plan of care. Integrating evidence from the interRAI PC CAPs into the clinical decision making process support care planning to address client strengths, preferences and needs with greater acuity.

Long-Term Care of the Elderly in Uruguay

Objective: To explore the perception of care of the elderly in long-term centers. Design: Qualitative study through participant observation and 23 in-depth interviews with administrators, caregivers, and residents between January 2011 and January 2012 in nine long-term care centers in Uruguay. From analysis, three care-perception factors emerged: (a) meaning of care, (b) experience of care, and (c) care continuity. Conclusion: Care of the elderly in nursing homes is perceived as a duty. There is an exchange of feelings and recognition of the caregiver is needed. However, the need for technical or specialized training is not mentioned. Recognition of the task of care provision, duty as a moral determinant, the exchange of affection and solidarity between staff and the elderly allows care continuity despite the centers’ lack of resources. Clinical Relevance: This study contributes information that may help improve the care conditions of elderly institutionalized people.

Management considerations in the care of elderly heart failure patients in long-term care facilities

ABSTRACT: 

Heart failure, a condition that affects up to 20% of older persons residing in long-term care facilities, is an important cause of morbidity, health service utilization and death. Effective and interprofessional heart failure care processes could potentially improve care, outcomes and quality of life and delay decline or hospital admission. This article reviews the clinical aspects of heart failure, and the challenges to the diagnosis and management of this condition in long-term care residents who are frail and are affected by multiple comorbidities.

Increased health service utilization costs in the year prior to institutionalization: findings from the canadian study of health and aging

OBJECTIVES

The objective of this study was to characterize patterns of formal health service utilization costs during older adults' transition from community to institutional care.

METHODS

Participants were 127 adults (age ≥ 65) from the British Columbia sample (N = 2,057) of the Canadian Study of Health and Aging who transitioned from community to institutional care between 1991 and 2001. Health service utilization costs were measured using Cost-Per-Day-At-Risk at five time points: > 12 months, 6-12 months, and ≤ 6 months preinstitutionalization, and ≤ 6 months and 6-12 months postinstitutionalization. Cost-Per-Day-At-Risk was measured for Continuing Care, Medical Services Plan, and PharmaCare costs by calculating total health service use over time, divided by the number of days the participant was alive.

RESULTS

Significant differences in Cost-Per-Day-At-Risk were observed for Continuing Care, Medical Services Plan, and PharmaCare costs over time. All health service utilization costs increased significantly during the 6-12 months and ≤ 6 months prior to institutionalization. Postinstitutionalization Continuing Care costs continued to increase at ≤ 6 months before decreasing at 6-12 months, while decreases occurred for Medical Services Plan and PharmaCare costs relative to preinstitutionalization costs.

CONCLUSIONS

The increases in costs observed during the year prior to institutionalization, characterized by a flurry of health service utilization, provide evidence of distinct cost patterns over the transition period.

Developing Strategies to Improve Advance Care Planning in Long Term Care Homes: Giving Voice to Residents and Their Family Members

Long term care (LTC) homes, also known as residential care homes, commonly care for residents until death, making palliative care and advance care planning (ACP) important elements of care. However, limited research exists on ACP in LTC. In particular, research giving voice to family members and substitute decision makers is lacking. The objective of this research was to understand experiences, perspectives, and preferences to guide quality improvement of ACP in LTC. This qualitative descriptive study conducted 34 individual semistructured interviews in two LTC homes, located in Canada. The participants were 31 family members and three staff, consisting of a front line care worker, a registered nurse, and a nurse practitioner. All participants perceived ACP conversations as valuable to provide “resident-centred care”; however, none of the participants had a good understanding of ACP, limiting its effectiveness. Strategies generated through the research to improve ACP were as follows: educating families and staff on ACP and end-of-life care options; better preparing staff for ACP conversations; providing staff skills training and guidelines; and LTC staff initiating systematic, proactive conversations using careful timing. These strategies can guide quality improvement of palliative care and development of ACP tools and resources specific to the LTC home sector.

Prevalence of neurological conditions across the continuum of care based on interRAI assessments

Background

Although multiple studies have estimated the prevalence of neurological conditions in the general Canadian population, limited research exists regarding the proportion affected with these conditions in non-acute health care settings in Canada. Data from standardized clinical assessments based on the interRAI suite of instruments were used to estimate the prevalence of eight neurological conditions across the continuum of care including Alzheimer’s disease, Parkinson’s disease, epilepsy, traumatic brain injury, multiple sclerosis, cerebral palsy, Huntington’s disease, and amyotrophic lateral sclerosis.

Methods

Cohorts of individuals receiving care in nursing homes (N=103,820), home care (N=91,021), complex continuing care (N=10,581), and psychiatric hospitals (N=23,119) in Canada were drawn based on their most recent interRAI assessment within each sector for a six-month period in 2010. These data were linked to the Discharge Abstract Database and National Ambulatory Care Reporting System data sets to develop five different case definition scenarios for estimating prevalence.

Results

The conditions with the highest estimated prevalences in these care settings in Canada were Alzheimer’s disease and related dementias, Parkinson’s disease, epilepsy, and traumatic brain injury. However, there were notable cross-sector differences in the prevalence of each condition, and regional variations. Prevalence estimates based on acute hospital administrative data alone were substantially lower for all conditions evaluated.

Conclusions

The proportion of persons with neurological conditions in non-acute health care settings in Canada is substantially higher than is generally reported for the general population. It is essential for these care settings to have the expertise and resources to respond effectively to the strengths, preferences, and needs of the growing population of persons with neurological conditions. The use of hospital or emergency department records alone is likely to substantially underestimate the true prevalence of neurological conditions across the continuum of care. However, interRAI assessment records provide a helpful source of information for obtaining these estimates in nursing home, home care, and mental health settings.

Needs of people with dementia in long-term care: a systematic review

With the aging of the population and the projected increase of dementia in the coming years, it is crucial that we understand the needs of people with dementia (PWD) in order to provide appropriate care. The aim of this study is to determine, using the best evidence possible, the care needs of PWD living in long-term care (LTC). A total of 68 studies, published between January 2000 and September 2010, were identified from six databases. From the selected studies, 19 needs of PWD were identified. The existing evidence suggests that psychosocial needs such as the need to engage in daily individualized activities and care must not be ignored in LTC. This review aims to provide a clearer picture of the needs of this growing patient population.

The Value of Admission Clinical Data for Diagnosing Heart Failure in Long-term Care

Background

Heart failure (HF) is common in long-term care (LTC). Diagnostic uncertainty is important barrier to optimal HF management, stemming from inadequate health information transfer upon LTC admission. We determine the utility of admission clinical information to confirm a HF diagnosis in new LTC residents.

Methods

This was a prospective cohort study. From February 2004 to November 2006, information about new residents from 41 LTC homes in Ontario, Canada, was collected from residents and caregivers, and all available health records. A prior HF diagnosis was confirmed by consensus review of available data by two independent experts. Multivariate modelling was utilized to determine the utility of the admission clinical assessment in confirming a prior HF diagnosis.

Results

A total of 449 residents were included for analysis, aged 84.3±6.5 years, and 21.6% had a prior HF diagnosis. The most useful clinical item for diagnosing HF was a “history of HF”. The final model included “history of HF’ (OR [odds ratio] 13.66, 95% CI 6.61–28.24), “fluid on the lungs” (OR 2.01, 95% CI 1.04–3.89), “orthopnea” (OR 1.76, 95% CI 0.93–3.33), “taking β-blocker” (OR 2.09, 95% CI 1.10–3.94), “taking loop diuretics” (OR 2.11, 95% CI 1.12–3.98), and “history of coronary artery disease” (OR 2.83, 95% CI 1.42–5.64).

Conclusion

Elements of the clinical assessment for new LTC residents can help confirm a prior HF diagnosis. An admission history of HF is highly predictive.

Regulated provider perceptions of feedback reports

AIM

This paper reports on regulated (or licensed) care providers' understanding and perceptions of feedback reports in a sample of Canadian long-term care settings using a cross-sectional survey design.

BACKGROUND

Audit with feedback quality improvement studies have seldom targeted front-line providers in long-term care to receive feedback information.

METHODS

Feedback reports were delivered to front-line regulated care providers in four long-term care facilities for 13 months in 2009-10. Providers completed a postfeedback survey.

RESULTS

Most (78%) regulated care providers (n = 126) understood the reports and felt they provided useful information for making changes to resident care (64%). Perceptions of the report differed, depending on the role of the regulated care provider. In multivariable logistic regression, the regulated nurses' understanding of more than half the report was negatively associated with 'usefulness of information for changing resident care', and perceiving the report as generally useful had a positive association.

CONCLUSIONS

Front-line regulated providers are an appropriate target for feedback reports in long-term care.

IMPLICATIONS FOR NURSING MANAGEMENT

Long-term care administrators should share unit-level information on care quality with unit-level managers and other professional front-line direct care providers.

Diagnostic data for neurological conditions in interRAI assessments in home care, nursing home and mental health care settings: a validity study

Background

The interRAI suite of assessment instruments can provide valuable information to support person-specific care planning across the continuum of care. Comprehensive clinical information is collected with these instruments, including disease diagnoses. In Canada, interRAI data holdings represent some of the largest repositories of clinical information in the country for persons with neurological conditions. This study examined the accuracy of the diagnostic information captured by interRAI instruments designed for use in the home care, long-term care and mental health care settings as compared with national administrative databases.

Methods

The interRAI assessments were matched with an inpatient hospital record and emergency department (ED) visit record in the preceding 90 days. Diagnoses captured on the interRAI instruments were compared to those recorded in either administrative record for each individual. Diagnostic validity was examined through sensitivity, specificity and positive predictive value analysis for the following conditions: multiple sclerosis, epilepsy, Alzheimer’s disease and other dementias, Parkinson’s disease, traumatic brain injury, stroke, diabetes mellitus, heart failure and reactive airway disease.

Results

In the three large study samples (home care: n = 128,448; long-term care: n = 26,644; mental health: n = 13,812), interRAI diagnoses demonstrated high specificity when compared to administrative records, for both neurological conditions (range 0.80 – 1.00) and comparative chronic diseases (range 0.83 – 1.00). Sensitivity and positive predictive values (PPV) were more varied by specific diagnosis, with sensitivities and PPV for neurological conditions ranging from 0.23 to 0.94 and 0.14 to 0.77, respectively. The interRAI assessments routinely captured more cases of the diagnoses of interest than the administrative records.

Conclusions

The interRAI assessment collected accurate information about disease diagnoses when compared to administrative records within three months. Such information is likely relevant to day-to-day care in these three environments and can be used to inform care planning and resource allocation decisions.

A Profile of Residents in Prairie Nursing Homes

Les maisons de soins infirmiers sont devenues des environnements offrant des soins complexes, dont les habitants ont des besoins importants et la plupart souffrent de la démence liée a l’âge. S’appuyant sur les recherches de Hirdes et al. (2011), nous décrivons un profil des résidents dans un échantillon représentatif de 30 maisons de soins infirmiers en milieu urbain dans les provinces des Prairies, en utilisant des données de L’Instrument d’évaluation des résidents/le recueil de données minimum (Resident Assistant Instrument – Minimum Data Set 2.0) de 5 196 évaluations résidents accomplies entre le 1ier octobre et le 31ieme décembre 3011. Les résidents avaient principalement plus de 85 ans, étaient des femmes, et souffraient d’une démence liée à l’âge. Nous avons comparé le soutien et les services connexes des établissements et les caractéristiques des résidents par province, par les modèles du propriétaire-gérant, et par le nombre d’unités dans une installation. Nous avons également constaté que les établissements publics ont tendance à s’occuper des résidents ayant des caractéristiques plus exigeants : notamment, la déficience cognitive, un comportement aggressif, et l’incontinence. Aucune tendance claire n’a été observée reliant le nombre d’unités dans un établissement aux caractéristiques des résidents.

The Hidden Complexity of Long-Term Care: how context mediates knowledge translation and use of best practices

PURPOSE

Context is increasingly recognized as a key factor to be considered when addressing healthcare practice. This study describes features of context as they pertain to knowledge use in long-term care (LTC).

DESIGN AND METHODS

As one component of the research program Translating Research in Elder Care, an in-depth qualitative case study was conducted to examine the research question "How does organizational context mediate the use of knowledge in practice in long-term care facilities?" A representative facility was chosen from the province of Saskatchewan, Canada. Data included document review, direct observation of daily care practices, and interviews with direct care, allied provider, and administrative staff.

RESULTS

The Hidden Complexity of Long-Term Care model consists of 8 categories that enmesh to create a context within which knowledge exchange and best practice are executed. These categories range from the most easily identifiable to the least observable: physical environment, resources, ambiguity, flux, relationships, and philosophies. Two categories (experience and confidence, leadership and mentoring) mediate the impact of other contextual factors. Inappropriate physical environments, inadequate resources, ambiguous situations, continual change, multiple relationships, and contradictory philosophies make for a complicated context that impacts care provision.

IMPLICATIONS

A hidden complexity underlays healthcare practices in LTC and each care provider must negotiate this complexity when providing care. Attending to this complexity in which care decisions are made will lead to improvements in knowledge exchange mechanisms and best practice uptake in LTC settings.

Gender differences in home care clients and admission to long-term care in Ontario, Canada: a population-based retrospective cohort study

Background

Home care is integral to enabling older adults to delay or avoid long-term care (LTC) admission. To date, there is little population-based data about gender differences in home care users and their subsequent outcomes. Our objectives were to quantify differences between women and men who used home care in Ontario, Canada and to determine if there were subsequent differences in LTC admission.

Methods

This is a population-based retrospective cohort study. We identified all adults aged 76+ years living in Ontario and receiving home care on April 1, 2007 (baseline). Using the Resident Assessment Instrument – Home Care (RAI-HC) linked to other databases, we characterized the cohort by living condition, health and functioning, and identified all acute care and LTC use in the year following baseline.

Results

The cohort consisted of 51,201 women and 20,102 men. Women were older, more likely to live alone, and more likely to rely on a child or child-in-law for caregiver support. Men most frequently identified a spouse as caregiver and their caregivers reported distress twice as often as women’s caregivers. Men had higher rates of most chronic conditions and were more likely to experience impairment. Men were more likely to be admitted to hospital, to have longer stays in hospital, and to be admitted to LTC.

Conclusions

Understanding who uses home care and why is critical to ensuring that these programs effectively reduce LTC use. We found that women outnumbered men but that men presented with higher levels of need. This detailed gender analysis highlights how needs differ between older women, men, and their respective caregivers.

Moving the agenda forward: a person-centred framework in long-term care

BACKGROUND

Internationally, the role of the registered nurse (RN) in long-term care (LTC) settings has evolved in response to the demands of governmental and organisational priorities. In stark contrast to the regulatory mandates, a person-centred care approach in LTC settings would require different outcomes, processes and competencies of the RN.

AIMS

This article explores the implications of defining the RN's role in delivering person-centred care in LTC homes.

METHODS

Based on a review of the literature, we present a framework that can be used to gather evidence on the outcomes, processes of care and competencies required of RNs to lead their teams to person-centred LTC homes.

RESULTS

The development of the framework highlighted several issues: (i) current measures of quality in LTC settings focus on health outcomes and avoiding adverse events rather than on resident quality of life and well-being, which influences the RN's practice; (ii) person-centred care has emerged as a focus of care, yet measures currently developed are limited, and thus, new outcomes are proposed; (iii) to practice in a person-centred way, RNs must work through others on their team to ensure that staff truly relate to their residents, tailor approaches based on the remaining abilities of the residents and manipulate environments to match the competence of the individual, while focusing on residents' personhood and (iv) competencies of RNs to deliver person-centred care include leadership, facilitation, clinical excellence and critical thinking skills.

CONCLUSIONS

RNs need to be supported, allowed and encouraged in redesigning their role, to work to their full capacity if they are truly to support person-centred care in LTC settings.

An evaluation of data quality in Canada's Continuing Care Reporting System (CCRS): secondary analyses of Ontario data submitted between 1996 and 2011

Background

Evidence informed decision making in health policy development and clinical practice depends on the availability of valid and reliable data. The introduction of interRAI assessment systems in many countries has provided valuable new information that can be used to support case mix based payment systems, quality monitoring, outcome measurement and care planning. The Continuing Care Reporting System (CCRS) managed by the Canadian Institute for Health Information has served as a data repository supporting national implementation of the Resident Assessment Instrument (RAI 2.0) in Canada for more than 15 years. The present paper aims to evaluate data quality for the CCRS using an approach that may be generalizable to comparable data holdings internationally.

Methods

Data from the RAI 2.0 implementation in Complex Continuing Care (CCC) hospitals/units and Long Term Care (LTC) homes in Ontario were analyzed using various statistical techniques that provide evidence for trends in validity, reliability, and population attributes. Time series comparisons included evaluations of scale reliability, patterns of associations between items and scales that provide evidence about convergent validity, and measures of changes in population characteristics over time.

Results

Data quality with respect to reliability, validity, completeness and freedom from logical coding errors was consistently high for the CCRS in both CCC and LTC settings. The addition of logic checks further improved data quality in both settings. The only notable change of concern was a substantial inflation in the percentage of long term care home residents qualifying for the Special Rehabilitation level of the Resource Utilization Groups (RUG-III) case mix system after the adoption of that system as part of the payment system for LTC.

Conclusions

The CCRS provides a robust, high quality data source that may be used to inform policy, clinical practice and service delivery in Ontario. Only one area of concern was noted, and the statistical techniques employed here may be readily used to target organizations with data quality problems in that (or any other) area. There was also evidence that data quality was good in both CCC and LTC settings from the outset of implementation, meaning data may be used from the entire time series. The methods employed here may continue to be used to monitor data quality in this province over time and they provide a benchmark for comparisons with other jurisdictions implementing the RAI 2.0 in similar populations.