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Robitaille A, Adams M, Heckman G, Norman M, Feldman S, Robert B, Hirdes JP. Pain in Canadian Long-Term Care Homes: A Call for Action. J Am Med Dir Assoc 2024; 25:105204. [PMID: 39142639 DOI: 10.1016/j.jamda.2024.105204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Revised: 07/09/2024] [Accepted: 07/09/2024] [Indexed: 08/16/2024]
Abstract
Navigating the evaluation and management of pain in long-term care homes is a complex task. Despite an extensive body of literature advocating for a paradigm shift in pain assessment and management within long-term care homes, much more remains to be done. The assessment of pain in long-term care is particularly challenging, given that a substantial proportion of residents live with some degree of cognitive impairment. Individuals living with dementia may encounter difficulties articulating the frequency and intensity of their pain, potentially resulting in an underestimation of their pain. In Canada and in the United States, the interRAI Minimum Data Set 2.0, Minimum Data Set 3.0, and the interRAI Long-Term Care Facilities assessments are administered to capture the presence and intensity of pain. These assessment instruments are used both on admission and quarterly, offering a reliable and validated method for comprehensive assessment. Nonetheless, the daily assessment and documentation of pain across long-term care homes, which is used to inform the interRAI Pain Scale, is not always consistent. The reality is that assessing pain can be inaccurate for several reasons, including the fact that it is rated by long-term care staff with diverse levels of expertise, resources, and education. This call for action explores the current approaches used in pain assessment and management within long-term care homes. The authors not only bring attention to the existing challenges but also emphasize the necessity of considering a more comprehensive assessment approach.
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Affiliation(s)
- Annie Robitaille
- Centre of Excellence in Frailty-Informed Care, Perley Health, Ottawa, ON, Canada; Faculty of Health Sciences, Interdisciplinary School of Health Sciences, University of Ottawa, Ottawa, ON, Canada.
| | - Michaela Adams
- Centre of Excellence in Frailty-Informed Care, Perley Health, Ottawa, ON, Canada
| | | | - Melissa Norman
- Centre of Excellence in Frailty-Informed Care, Perley Health, Ottawa, ON, Canada
| | - Sid Feldman
- Baycrest Health Sciences, Toronto, ON, Canada; The Temerty Faculty of Medicine, Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Benoit Robert
- Centre of Excellence in Frailty-Informed Care, Perley Health, Ottawa, ON, Canada
| | - John P Hirdes
- Faculty of Health, School of Public Health Sciences, University of Waterloo, Waterloo, ON, Canada
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Northwood M, Saari M, Heckman G, Alexander T, Eastway B, Gerantonis P, Gillies D, Gregg S, McKinnon Wilson J, Morrison A, Sultan H, Turcotte L. Use of an electronic wellness instrument in the integrated health and social care of older adults: a group concept mapping study. BMC Health Serv Res 2024; 24:864. [PMID: 39080598 PMCID: PMC11288113 DOI: 10.1186/s12913-024-11320-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 07/16/2024] [Indexed: 08/03/2024] Open
Abstract
BACKGROUND Health system fragmentation directly contributes to poor health and social outcomes for older adults with multiple chronic conditions and their care partners. Older adults often require support from primary care, multiple specialists, home care, community support services, and other health-care sectors and communication between these providers is unstructured and not standardized. Integrated and interprofessional team-based models of care are a recommended strategy to improve health service delivery to older adults with complex needs. Standardized assessment instruments deployed on digital platforms are considered a necessary component of integrated care. The aim of this study was to develop strategies to leverage an electronic wellness instrument, interRAI Check Up Self Report, to support integrated health and social care for older adults and their care partners in a community in Southern Ontario, Canada. METHODS Group concept mapping, a participatory mixed-methods approach, was conducted. Participants included older adults, care partners, and representatives from: home care, community support services, specialized geriatric services, primary care, and health informatics. In a series of virtual meetings, participants generated ideas to implement the interRAI Check Up and rated the relative importance of these ideas. Hierarchical cluster analysis was used to map the ideas into clusters of similar statements. Participants reviewed the map to co-create an action plan. RESULTS Forty-one participants contributed to a cluster map of ten action areas (e.g., engagement of older adults and care partners, instrument's ease of use, accessibility of the assessment process, person-centred process, training and education for providers, provider coordination, health information integration, health system decision support and quality improvement, and privacy and confidentiality). The health system decision support cluster was rated as the lowest relative importance and the health information integration was cluster rated as the highest relative importance. CONCLUSIONS Many person-, provider-, and system-level factors need to be considered when implementing and using an electronic wellness instrument across health- and social-care providers. These factors are highly relevant to the integration of other standardized instruments into interprofessional team care to ensure a compassionate care approach as technology is introduced.
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Affiliation(s)
- Melissa Northwood
- School of Nursing, Faculty of Health Sciences, McMaster University, Health Sciences Centre 3N25a, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada.
| | | | - George Heckman
- School of Public Health Sciences, University of Waterloo, Waterloo, ON, Canada
| | | | | | - Patricia Gerantonis
- School of Nursing, Faculty of Health Sciences, McMaster University, Health Sciences Centre 3N25a, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada
| | | | - Susie Gregg
- Canadian Mental Health Association Waterloo Wellington, Guelph, ON, Canada
| | | | - Adam Morrison
- Provincial Geriatrics Leadership Ontario, Toronto, ON, Canada
| | | | - Luke Turcotte
- Health Sciences, Brock University, St. Catharines, ON, Canada
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Dash D, Moser A, Feldman S, Saliba D, Bakaev I, Smalbrugge M, Robert B, Karuza J, Heckman G, Katz PR, Costa AP. Focusing on Provider Quality Measurement: Continued Consensus and Feasibility Testing of Practice-Based Quality Measures for Primary Care Providers in Long-Term Care. J Am Med Dir Assoc 2024; 25:189-194. [PMID: 38101456 DOI: 10.1016/j.jamda.2023.10.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 10/25/2023] [Accepted: 10/26/2023] [Indexed: 12/17/2023]
Abstract
Medical providers in long-term care (LTC) use a unique skillset in delivering comprehensive resident care. Publicly reported quality measures (QMs) do not directly emphasize medical provider competency and their role in care. The impact of providers is understudied and to a large extent, unknown. Our objective was to define, test, and validate QMs to pragmatically measure the practice-based quality of medical providers in a pilot study. We included 7 North American LTC homes with data from practicing medical providers for LTC residents. We engaged in a 4-phased approach. In phase 1, experts rated 95 candidate QMs using 5 pragmatic-focused criteria in a RAND-modified Delphi process. Phase 2 involved specifying 37 QMs for collection (4 QMs were dropped during pilot testing). We created an abstraction manual and data collection tool for all QMs. Phase 3 involved a retrospective chart review in 7 LTC homes on 33 QMs with trained data abstractors. Data were sufficient to analyze performance for 26 QMs. Lastly, in phase 4 results and psychometric properties were reviewed with an expert panel. They ranked the tested measures for validity and feasibility for use by a nonphysician auditor to evaluate medical provider performance based on medical record review. In total, we examined data from 343 resident charts from 7 LTC homes and 49 providers. Our process yielded 10 QMs as being specified for measurement, feasible to collect, and had good test performance. This is the only study to systematically identify a subset of QMs for feasible collection from the medical record by various data collectors. This pragmatic approach to measuring practice-based quality and quantifying select medical provider competencies allows for the evaluation of individual and facility-level performance and facilitates quality improvement initiatives. Future work should perform broader testing and validate and refine operationalized QMs.
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Affiliation(s)
- Darly Dash
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Andrea Moser
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada; Senior Services and Long-Term Care Division, City of Toronto, Toronto, ON, Canada
| | - Sid Feldman
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada; Baycrest Health Sciences, Toronto, ON, Canada
| | - Debra Saliba
- University of California Los Angeles, Borun Center at David Geffen School of Medicine, Los Angeles, CA, USA; Geriatric Research, Education, and Clinical Centers, Veterans Administration, Los Angeles, CA, USA; RAND Corporation, Santa Monica, CA, USA
| | - Innokentiy Bakaev
- Department of Medicine, Hebrew SeniorLife, Boston, MA, USA; Harvard Medical School, Harvard University, Boston, MA, USA
| | - Martin Smalbrugge
- Department of Medicine for Older People, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Benoît Robert
- Perley Health, Ottawa, ON, Canada; Faculty of Medicine, University of Ottawa, ON, Canada
| | - Jurgis Karuza
- Division of Geriatrics, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - George Heckman
- School of Public Health Sciences, Faculty of Health, University of Waterloo, Waterloo, ON, Canada
| | - Paul R Katz
- Department of Geriatrics, College of Medicine, Florida State University, Tallahassee, FL, USA
| | - Andrew P Costa
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Centre for Integrated Care, St. Joseph's Health System, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada.
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Read M, Peters S, Bennett N, Francis JJ, Fetherstonhaugh D, Lim WK, Tropea J. Communities of practice in residential aged care: A rapid review. Int J Older People Nurs 2023; 18:e12563. [PMID: 37563846 DOI: 10.1111/opn.12563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 06/24/2023] [Accepted: 07/26/2023] [Indexed: 08/12/2023]
Abstract
BACKGROUND Communities of practice (CoPs) have the potential to help address the residential aged care system's need for continuing education and quality improvement. CoPs have been used in healthcare to improve clinical practice; however, little is known about their application to the unique residential aged care context. OBJECTIVES This rapid review of CoPs for residential aged care was conducted to summarise the features of CoPs, how they are developed and maintained, and assess their effectiveness. METHODS MEDLINE and CINAHL databases were searched for studies published from January 1991 to November 2022 about CoPs in residential aged care. Data were extracted regarding the CoPs' three key features of 'domain', 'community' and 'practice' as described by Wenger and colleagues. Kirkpatrick's four levels of evaluation (members' reactions, learning, behaviour and results) was used to examine studies on the effectiveness of CoPs. The Mixed Methods Appraisal Tool was used for quality appraisal. RESULTS Nineteen articles reported on 13 residential aged care CoPs. Most CoPs aimed to improve care quality (n = 9, 69%) while others aimed to educate members (n = 3, 23%). Membership was often multidisciplinary (n = 8, 62%), and interactions were in-person (n = 6, 46%), online (n = 3, 23%) or both (n = 4, 31%). Some CoPs were developed with the aid of a planning group (n = 4, 31%) or as part of a larger collaborative (n = 4, 31%), and were maintained using a facilitator (n = 7, 54%) or adapted to member feedback (n = 2, 15%). Thirteen (81%) studies evaluated members' reactions, and three (24%) studies assessed members' behaviour. The heterogeneity of studies and levels of reporting made it difficult to synthesise findings. CONCLUSIONS This review revealed the variation in why, and how, CoPs have been used in residential aged care, which is consistent with previous reviews of CoPs in healthcare. While these findings can inform the development of CoPs in this context, further research is needed to understand how CoPs, including the membership makeup, delivery mode, facilitator type and frequency of meetings, impact quality of care.
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Affiliation(s)
- Martin Read
- Department of Medicine - Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Sanne Peters
- School of Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Noleen Bennett
- Victorian Healthcare Associated Infection Surveillance System (VICNISS) Coordinating Centre, Melbourne, Victoria, Australia
- Department of Nursing, School of Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Jill J Francis
- School of Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
- Centre for Implementation Research, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Deirdre Fetherstonhaugh
- Australian Centre for Evidence Based Aged Care (ACEBAC), AIPCA, La Trobe University, Bundoora, Victoria, Australia
| | - Wen Kwang Lim
- Department of Medicine - Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
- Department of Aged Care, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Joanne Tropea
- Department of Medicine - Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
- Department of Aged Care, Royal Melbourne Hospital, Parkville, Victoria, Australia
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Xu D, Lewis T, Rurka M, Arling G. Approach to systematically examine the usefulness of quality measures in practice: Minnesota's nursing home quality indicators and scoring approach. BMJ Qual Saf 2022; 32:319-329. [PMID: 36192147 DOI: 10.1136/bmjqs-2021-014384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 08/29/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Healthcare quality measurement systems, which use aggregated patient-level quality measures to assess organisational performance, have been introduced widely. Yet, their usefulness in practice has received scant attention. Using Minnesota nursing home quality indicators (QIs) as a case example, we demonstrate an approach for systematically evaluating QIs in practice based on: (a) parsimony and relevance, (b) usability in discriminating between facilities, (c) actionability and (d) construct validity. METHODS We analysed 19 risk-adjusted, facility-level QIs over the 2012-2019 period. Parsimony and relevance of QIs were evaluated using scatter plots, Pearson correlations, literature review and expert opinions. Discrimination between facilities was assessed by examining facility QI distributions and the impact of the distributions on scoring. Actionability of QIs was assessed through QI trends over time. Construct validity was assessed through exploratory factor analysis of domain structure for grouping the QIs. RESULTS Correlation analysis and qualitative assessment led to redefining one QI, adding one improvement-focused QI, and combining two highly correlated QIs to improve parsimony and clinical relevance. Ten of the QIs displayed normal distributions which discriminated well between the best and worst performers. The other nine QIs displayed poor discrimination; they had skewed distributions with ceiling or floor effects. We recommended scoring approaches tailored to these distributions. One QI displaying substantial improvement over time was recommended for retirement (physical restraint use). Based on factor analysis, we grouped the 18 final QIs into four domains: incontinence (4 QIs), physical functioning (4 QIs), psychosocial care (4 QIs) and care for specific conditions (6 QIs). CONCLUSION We demonstrated a systematic approach for evaluating QIs in practice by arriving at parsimonious and relevant QIs, tailored scoring to different QI distributions and a meaningful domain structure. This approach could be applied in evaluating quality measures in other health or long-term care settings.
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Affiliation(s)
- Dongjuan Xu
- School of Nursing, Purdue University, West Lafayette, Indiana, USA
| | - Teresa Lewis
- Nursing Facility Rates and Policy Division, Minnesota Department of Human Services, Saint Paul, Minnesota, USA
| | - Marissa Rurka
- Department of Sociology, Purdue University, West Lafayette, Indiana, USA
| | - Greg Arling
- School of Nursing, Purdue University, West Lafayette, Indiana, USA
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Cohen-Mansfield J, Golander H. Predictors of Quality-of-Care Provided by Migrant Live-In Caregivers of Frail older Persons: A Cross-Sectional Study. J Appl Gerontol 2022; 41:2167-2179. [PMID: 35857434 DOI: 10.1177/07334648221107616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
We examined the association between employment-related characteristics and the quality-of-care migrant live-in caregivers provide to older care-recipients. Structured interviews were conducted with 115 migrant live-in caregivers, 72 older care-recipients, and 117 relatives of care-recipients. We conducted correlations among dependent (quality-of-care), independent (quality of relationship between caregiver and informant, caregiver perception of work, and problematic employment conditions), and demographic variables, and performed a path analysis by conducting a series of multiple regressions. Quality-of-care was most highly correlated with quality of relationship between informant and caregiver. Quality of relationship was predicted by caregiver perceptions of work, which was negatively predicted by problematic employment conditions. In the relatives-based model, quality of relationship was significantly better when the care-receiver was female and the care-recipient needed more assistance with activities of daily living. The study clarifies the role of caregiver work characteristics for quality-of-care and highlights the crucial role of the relationship with the care-recipient.
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Affiliation(s)
- Jiska Cohen-Mansfield
- Minerva Center for the Interdisciplinary Study of End of Life, Tel Aviv University, Tel Aviv, Israel.,Igor Orenstein Chair for the Study of Geriatrics, Tel Aviv, Israel.,Department of Health Promotion, School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hava Golander
- Department of Nursing, the Stanley Steyer School of Health Professions, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Northwood M, Turcotte LA, McArthur C, Egbujie BA, Berg K, Boscart VM, Heckman GA, Hirdes JP, Wagg AS. Changes in Urinary Continence After Admission to a Complex Care Setting: A Multistate Transition Model. J Am Med Dir Assoc 2022; 23:1683-1690.e2. [PMID: 35870485 DOI: 10.1016/j.jamda.2022.06.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 06/14/2022] [Accepted: 06/18/2022] [Indexed: 10/17/2022]
Abstract
OBJECTIVES To examine changes in urinary continence for post-acute, Complex Continuing Care hospital patients from time of admission to short-term follow-up, either in hospital or after discharge to long-term care or home with services. DESIGN Retrospective cohort study of patients in Complex Continuing Care hospitals using clinical data collected with interRAI Minimum Data Set 2.0 and interRAI Resident Assessment Instrument Home Care. SETTING AND PARTICIPANTS Adults aged 18 years and older, admitted to Complex Continuing Care hospitals in Ontario, Canada, between 2009 and 2015 (n = 78,913). METHODS A multistate transition model was used to characterize the association between patient characteristics measured at admission and changes in urinary continence state transitions (continent, sometimes continent, and incontinent) between admission and follow-up. RESULTS The cohort included 27,896 patients. At admission, 9583 (34.3%) patients belonged to the continent state, 6441 (23.09%) patients belonged to the sometimes incontinent state, and the remaining 11,872 (42.6%) patients belonged to the incontinent state. For patients who were continent at admission, the majority (62.7%) remained continent at follow-up. However, nearly a quarter (23.9%) transitioned to the sometimes continent state, and an additional 13.4% became incontinent at follow-up. Several factors were associated with continence state transitions, including cognitive impairment, rehabilitation potential, stroke, Parkinson's disease, Alzheimer's disease and related dementias, and hip fracture. CONCLUSIONS AND IMPLICATIONS This study suggests that urinary incontinence is a prevalent problem for Complex Continuing Care hospital patients and multiple factors are associated with continence state transitions. Standardized assessment of urinary incontinence is helpful in this setting to identify patients in need of further assessment and patient-centered intervention and as a quality improvement metric to examine changes in continence from admission to discharge.
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Affiliation(s)
| | - Luke A Turcotte
- School of Public Health Sciences, University of Waterloo, Waterloo, Ontario, Canada
| | - Caitlin McArthur
- School of Physiotherapy, Dalhousie University, Halifax, Nova Scotia, Canada
| | | | - Katherine Berg
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | | | - George A Heckman
- School of Public Health Sciences, University of Waterloo, Waterloo, Ontario, Canada; Schlegel Research Chair in Geriatric Medicine, Schlegel-University of Waterloo Research Institute for Aging, Waterloo, Ontario, Canada
| | - John P Hirdes
- School of Public Health Sciences, University of Waterloo, Waterloo, Ontario, Canada
| | - Adrian S Wagg
- Department of Medicine, Division of Geriatric Medicine, University of Alberta, Edmonton, Alberta, Canada
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Correia RH, Mowbray FI, Dash D, Katz PR, Moser A, Strum RP, Jones A, von Schlegell A, Costa AP. Clinical factors associated with recent medical care visits in nursing homes: a multi-site cross-sectional study. BMC Geriatr 2022; 22:320. [PMID: 35413884 PMCID: PMC9003172 DOI: 10.1186/s12877-022-03011-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 03/29/2022] [Indexed: 11/10/2022] Open
Abstract
Objectives We examined which resident-level clinical factors influence the provision of a recent medical care visit in nursing homes (NHs). Design Multi-site cross-sectional. Setting and participants We extracted data on 3,556 NH residents from 18 NH facilities in Ontario, Canada, who received at minimum, an admission and first-quarterly assessment with the Resident Assessment Instrument Minimum Data Set (MDS) 2.0 between November 1, 2009, and October 31, 2017. Methods We conducted a secondary analysis of routinely collected MDS 2.0 data. The provision of a recent medical care visit by a physician (or authorized clinician) was assessed in the 14-day period preceding a resident’s first-quarterly MDS 2.0 assessment. We utilized best-subset multivariable logistic regression to model the adjusted associations between resident-level clinical factors and a recent medical care visit. Results Two thousand eight hundred fifty nine (80.4%) NH residents had one or more medical care visits prior to their first-quarterly MDS 2.0 assessment. Six clinically relevant factors were identified to be associated with recent medical care visits in the final model: exhibiting wandering behaviours (OR = 1.34, 95% CI 1.09 – 1.63), presence of a pressure ulcer (OR = 1.37, 95% CI 1.05 – 1.78), a urinary tract infection (UTI) (OR = 1.52, 95% CI 1.06 – 2.18), end-stage disease (OR = 9.70, 95% CI 1.32 – 71.02), new medication use (OR = 1.31, 95% CI 1.09 – 1.57), and analgesic use (OR = 1.24, 95% CI 1.03 – 1.49). Conclusions and implications Our findings suggest that resident-level clinical factors drive the provision of medical care visits following NH admission. Clinical factors associated with medical care visits align with the minimum competencies expected of physicians in NH practice, including managing safety risks, infections, medications, and death. Ensuring that NH physicians have opportunities to acquire and strengthen these competencies may be transformative to meet the ongoing needs of NH residents. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-022-03011-9.
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Affiliation(s)
- Rebecca H Correia
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.
| | - Fabrice I Mowbray
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Darly Dash
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Paul R Katz
- Department of Geriatrics, Florida State University College of Medicine, Tallahassee, FL, USA
| | - Andrea Moser
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Ryan P Strum
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Aaron Jones
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Ahmad von Schlegell
- Trillium Health Partners, Mississauga, ON, Canada.,Schlegel Villages, Kitchener, ON, Canada.,DeGroote School of Business, McMaster University, Hamilton, ON, Canada
| | - Andrew P Costa
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
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Aryal K, Mowbray F, Gruneir A, Griffith LE, Howard M, Jabbar A, Jones A, Tanuseputro P, Lapointe-Shaw L, Costa AP. Nursing Home Resident Admission Characteristics and Potentially Preventable Emergency Department Transfers. J Am Med Dir Assoc 2021; 23:1291-1296. [PMID: 34919839 DOI: 10.1016/j.jamda.2021.11.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 11/12/2021] [Accepted: 11/16/2021] [Indexed: 01/15/2023]
Abstract
OBJECTIVES To determine which nursing home (NH) resident-level admission characteristics are associated with potentially preventable emergency department (PPED) transfers. DESIGN We conducted a population-level retrospective cohort study on NH resident data collected using the Resident Assessment Instrument-Minimum Data Set Version 2.0 and linked to the National Ambulatory Care Reporting System for ED transfers. SETTING We used all NH resident admission assessments from January 1, 2017, to December 31, 2018, in Ontario. PARTICIPANTS The cohort included the admission assessment of 56,433 NH residents. METHODS PPED transfers were defined based on the International Classification of Disease, Version 10 (Canadian) We used logistic regression with 10-fold cross-validation and computed average marginal effects to identify the association between resident characteristics at NH admission and PPED transfers within 92 days after admission. RESULTS Overall, 6.2% of residents had at least 1 PPED transfer within 92 days of NH admission. After adjustment, variables that had a prevalence of 10% or more that were associated with a 1% or more absolute increase in the risk of a PPED transfer included polypharmacy [of cohort (OC) 84.4%, risk difference (RD) 2.0%], congestive heart failure (OC 29.0%, RD 3.0%), and renal failure (OC 11.6%, RD 1.2%). Female sex (OC 63.2%, RD -1.3%), a do not hospitalize directive (OC 24.4%, RD -2.6%), change in mood (OC 66.9%, RD -1.2%), and Alzheimer's or dementia (OC 62.1%, RD -1.2%) were more than 10% prevalent and associated with a 1% or more absolute decrease in the risk of a PPED. CONCLUSIONS AND IMPLICATIONS Though many routinely collected resident characteristics were associated with a PPED transfer, the absence of sufficiently discriminating characteristics suggests that emergency department visits by NH residents are multifactorial and difficult to predict. Future studies should assess the clinical utility of risk factor identification to prevent transfers.
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Affiliation(s)
- Komal Aryal
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; ICES, Toronto, Ontario, Canada
| | - Fabrice Mowbray
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; ICES, Toronto, Ontario, Canada
| | - Andrea Gruneir
- ICES, Toronto, Ontario, Canada; Department of Family Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Lauren E Griffith
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Michelle Howard
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Amina Jabbar
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; Trillium Health Partners, Toronto, Ontario, Canada
| | - Aaron Jones
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; ICES, Toronto, Ontario, Canada
| | - Peter Tanuseputro
- ICES, Toronto, Ontario, Canada; Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada; Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Lauren Lapointe-Shaw
- ICES, Toronto, Ontario, Canada; Departments of Medicine, University of Toronto and University Health Network, Toronto, Ontario, Canada
| | - Andrew P Costa
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; ICES, Toronto, Ontario, Canada.
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Proceedings from an International Virtual Townhall: Reflecting on the COVID-19 Pandemic: Themes from Long-Term Care. J Am Med Dir Assoc 2021; 22:1128-1132. [PMID: 33932351 PMCID: PMC8030741 DOI: 10.1016/j.jamda.2021.03.029] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 03/29/2021] [Accepted: 03/29/2021] [Indexed: 11/24/2022]
Abstract
Residents of long-term care (LTC) homes have suffered disproportionately during the COVID-19 pandemic, from the virus itself and often from the imposition of lockdown measures. Provincial Geriatrics Leadership Ontario, in collaboration with interRAI and the International Federation on Aging, hosted a virtual Town Hall on September 25, 2020. The purpose of this event was to bring together international perspectives from researchers, clinicians, and policy experts to address important themes potentially amenable to timely policy interventions. This article summarizes these themes and the ensuing discussions among 130 attendees from 5 continents. The disproportionate impact of the COVID-19 pandemic on frail residents of LTC homes reflects a systematic lack of equitable prioritization by health system decision makers around the world. The primary risk factors for an outbreak in an LTC home were outbreaks in the surrounding community, high staff and visitor traffic in large facilities, and crowding of residents in ageing buildings. Infection control measures must be prioritized in LTC homes, though care must be taken to protect frail and vulnerable residents from their overly blunt application that deprives residents from appropriate physical and psychosocial support. Staffing, in terms of overall numbers, training, and leadership skills, was inadequate. The built environment of LTC homes can be configured for both optimal resident well-being and infection control. Infection control and resident wellness need not be mutually exclusive. Improving outcomes for LTC residents requires more staffing with proper training and interprofessional leadership. All these initiatives must be underpinned by an effective quality assurance system based on standardized, comprehensive, accessible, and clinically relevant data, and which can support broad communities of practice capable of effecting real and meaningful change for frail older persons, wherever they chose to reside.
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Cheung G, Mah TM, Barak Y, Hirdes JP. Determinants of Non-emergency Use of Control Interventions in Older Canadian Psychiatric Inpatients: Analysizing the InterRAI Mental Health Electronic Health Records. Front Psychiatry 2021; 12:744341. [PMID: 34616324 PMCID: PMC8488129 DOI: 10.3389/fpsyt.2021.744341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 08/24/2021] [Indexed: 11/13/2022] Open
Abstract
Background: The use of control interventions (CIs; acute control medications, physical/mechanical restraint) is associated with negative physical and psychological outcomes, particularly in older adults who are physically vulnerable. The aims of this study were to: (i) report the rates of CI use in older psychiatric inpatients (age 65 - 84 and age 85+), and compare them with younger age groups (18 - 44, age 45 - 64); and (ii) identify the factors associated with non-emergency CI use in older psychiatric inpatients. Methods: Routinely collected interRAI Mental Health assessments from 2005 - 2018 in Ontario, Canada, were analyzed to determine the rates of CI use. Logistic regression models were used to examine the sociodemographic and clinical determinants of non-emergency and any CI use. Results: There were 226,119 (female: 48.6%) interRAI assessments, and 85% of those assessed were under 65 years of age. The rates of non-emergency CI use in the four age groups were: 18 - 44 = 9.4%, 45 - 64 = 8.3%, 65 - 84 = 9.9%, 85+ = 13.2%. The most significant determinants of non-emergency CI use in older adults were highest impairments in activities of daily living (ADL Short Form score 8-16: OR = 2.72, 95% CI = 2.42 - 3.06), highest levels of aggression (Aggressive Behavior Scale score 4 - 6: OR = 1.76, 95% CI = 1.57 - 1.98), and highest levels of positive psychotic symptoms (Positive Symptoms Scale score 9+: OR = 1.65, 95% CI = 1.43 - 1.90). Delirium, cognitive disorder diagnosis, cognitive impairment, and falls were also associated with increased CI use odds, as were having the reasons for admission be danger to self, danger to others or inability to care for self. Females were less likely to have non-emergency CI use (OR = 0.84, 95% CI = 0.73 - 0.95). Patients admitted from long-term care homes had significantly greater odds of non-emergency CI use compared with community admissions (OR = 1.18; 95% CI = 1.07 - 1.29). Conclusion: The higher rates of non-emergency CI use in older psychiatric inpatients is concerning. Alternative non-pharmacological and person-centered management strategies should be considered to support older psychiatric inpatients with functional impairment, positive symptoms, aggressive behavior, cognitive impairment and delirium. The use of CIs could be incorporated as a quality improvement activity to monitor changes at various service provision levels.
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Affiliation(s)
- Gary Cheung
- Department of Psychological Medicine, School of Medicine, University of Auckland, Auckland, New Zealand
| | - Tina M Mah
- Schlegel-University of Waterloo Research Institute for Aging, Waterloo, ON, Canada.,School of Public Health Sciences, University of Waterloo, Waterloo, ON, Canada
| | - Yoram Barak
- Department of Psychological Medicine, School of Medicine, University of Otago, Dunedin, New Zealand
| | - John P Hirdes
- School of Public Health Sciences, University of Waterloo, Waterloo, ON, Canada
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Evaluating the Effect of COVID-19 Pandemic Lockdown on Long-Term Care Residents' Mental Health: A Data-Driven Approach in New Brunswick. J Am Med Dir Assoc 2020; 22:187-192. [PMID: 33232682 PMCID: PMC7587131 DOI: 10.1016/j.jamda.2020.10.028] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 10/06/2020] [Accepted: 10/20/2020] [Indexed: 01/29/2023]
Abstract
Long-term care (LTC) residents, isolated because of the COVID-19 pandemic, are at increased risk for negative mental health outcomes. The purpose of our article is to demonstrate how the interRAI LTC facility (LTCF) assessment can inform clinical care and evaluate the effect of strategies to mitigate worsening mental health outcomes during the COVID-19 pandemic. We present a supporting analysis of the effects of lockdown in homes without COVID-19 outbreaks on depression, delirium, and behavior problems in a network of 7 LTC homes in New Brunswick, Canada, where mitigative strategies were deployed to minimize poor mental health outcomes (eg, virtual visits and increased student volunteers). This network meets regularly to review performance on risk-adjusted quality of care indicators from the interRAI LTCF and share learning through a community of practice model. We included 4209 assessments from 765 LTC residents between January 2017 to June 2020 and modeled the change within and between residents for depression, delirium, and behavioral problems over time with longitudinal generalized estimating equations. Though the number of residents who had in-person visits with family decreased from 73.2% before to 17.9% during lockdown (chi square, P < .001), the number of residents experiencing delirium (4.5%-3.5%, P = .51) and behavioral problems (35.5%-30.2%, P = .19) did not change. The proportion of residents with indications of depression decreased from 19.9% before to 11.5% during lockdown (P < .002). The final multivariate models indicate that the effect of lockdown was not statistically significant on depression, delirium, or behavioral problems. Our analyses demonstrate that poor mental health outcomes associated with lockdown can be mitigated with thoughtful intervention and ongoing evaluation with clinical information systems. Policy makers can use outputs to guide resource deployment, and researchers can examine the data to identify better management strategies for when pandemic strikes again.
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