Team Performance and Risk-Adjusted Health Outcomes in the Program of All-Inclusive Care for the Elderly (PACE)

Characterizing worker compensation claims in long-term care and examining the association between facility characteristics and severe injury: a repeated cross-sectional study from Alberta, Canada

BACKGROUND

Despite the physical demands and risks inherent to working in long-term care (LTC), little is known about workplace injuries and worker compensation claims in this setting. The purpose of this study was to characterize workplace injuries in LTC and to estimate the association between worker and organizational factors on severe injury.

METHODS

We used a repeated cross-sectional design to examine worker compensation claims between September 1, 2014 and September 30, 2018 from 25 LTC homes. Worker compensation claim data came from The Workers Compensation Board of Alberta. LTC facility data came from the Translating Research in Elder Care program. We used descriptive statistics to characterize the sample and multivariable logistic regression to estimate the association between staff, organizational, and resident characteristics and severe injury, measured as 31+ days of disability.

RESULTS

We examined 3337 compensation claims from 25 LTC facilities. Less than 10% of claims (5.1%, n = 170) resulted in severe injury and most claims did not result in any days of disability (70.9%, n = 2367). Most of the sample were women and over 40 years of age. Care aides were the largest occupational group (62.1%, n = 2072). The highest proportion of claims were made from staff working in voluntary not for profit facilities (41.9%, n = 1398) followed by public not for profit (32.9%, n = 1098), and private for profit (n = 25.2%, n = 841). Most claims identified the nature of injury as traumatic injuries to muscles, tendons, ligaments, or joints. In the multivariable logistic regression, higher staff age (50-59, aOR: 2.26, 95% CI 1.06-4.83; 60+, aOR: 2.70, 95% CI 1.20-6.08) was associated with more severe injury, controlling for resident acuity and other organizational staffing factors.

CONCLUSIONS

Most claims were made by care aides and were due to musculoskeletal injuries. In LTC, few worker compensation claims were due to severe injury. More research is needed to delve into the specific features of the LTC setting that are related to worker injury.

Minority Older Adults' Access to and Use of Programs of All-Inclusive Care for the Elderly

Programs of All-Inclusive Care for the Elderly (PACE) are an effective approach to improve care quality and delay institutional admissions especially for Black and Hispanic older adults who have seen a disproportionate rise in nursing home use. Guided by Andersen's Behavioral Model of Health Services Use and employing focus groups and one-on-one interviews, we qualitatively examined factors influencing access to and use of PACE by Black and Hispanic older adults. The study sample consisted of thirty-two PACE enrollees, six marketing-team members, and four family-caregivers from three PACE sites in a northeast urban city. Informed knowledge, cultural beliefs, and attitudes toward PACE were found to affect access. Community resources, available services, and care quality facilitated enrollment/participation. Barriers identified included poor dissemination of information and inadequate emphasis on staff's sensitivity to enrollees' cultural and disability differences. Findings will help healthcare leaders capitalize on facilitators and address barriers to enhance access and use of PACE by racial and ethnic minority older adults.

A Mixed Methods Study of Hearing Loss, Communication, and Social Engagement in a Group Care Setting for Older Adults

PURPOSE

The purpose of this study is to characterize the communication needs of older adults in group care environments and understand the factors that foster engaged communication.

METHOD

This mixed methods study provides an in-depth analysis of communication and engagement for older adults at two Program for All-inclusive Care for the Elderly (PACE) sites. Seventy-two PACE participants (M _age = 74 years) completed a hearing test, cognitive screener (MOST^™), the Institute of Medicine (IOM) Measures of Social and Behavioral Determinants of Health Questionnaire, and the UCLA Loneliness Scale. Using maximum variation sampling based on hearing status and UCLA Loneliness scores, 19 participants were invited to do (and 11 participants completed) one-on-one semi-structured interviews. In addition, 35 staff members participated in 5 focus groups. Field observations were interspersed throughout the data collection period.

RESULTS

Results suggest that communication challenges such as hearing loss, cognitive decline, and social isolation are highly prevalent in this convenience sample. Sixty-seven percent have at least a mild hearing loss in the better hearing ear. Eighty-two percent scored in the "very" or "most isolated" range of the IOM Measures of Social and Behavioral Determinants of Health questionnaire. The mean score on the MOST^™ cognitive screener was 17.6, which is below the dementia screening cutoff score of 18 points. A thematic analysis of the qualitative data suggests that the PACE programs support socialization and engagement. A conceptual framework was developed by integrating quantitative and qualitative findings to recognize what contributes to meaningful interactions or engaged communication.

CONCLUSION

Identifying communication challenges can enhance the benefits individuals can experience at care facilities and lessen the burden of the staff members trying to provide safe and effective care. In order to maximize the potential benefit of attending group-based day centers, the communication challenges and motivations of older adults need to be addressed.

Solidarity in a Community of Nursing Colleagues

Introduction

Several concepts have been used to describe the qualities of communities of nursing colleagues. Nonetheless, few studies have shed light on nursing communities by drawing on the concept of solidarity.

Objective

To explore solidarity among a community of nursing colleagues.

Methods

A qualitative research design with a reflective life world approach was selected. This study reused data from a larger Norwegian empirical study. The data from the original study consisted of qualitative interviews and follow-up interviews with 13 nurses (RNs). The research context was municipality and specialist health services. A secondary data analysis was conducted. The study was based on the SRQR reporting guidelines.

Results

The results were formulated under two themes: 1) having indispensable relationships and 2) encountering a relative absence of sympathy.

Conclusion

A sense of community among nursing colleagues seems to rely on solidarity: whatever affects one nurse affects another. The solidarity that arose from the content of commonalities involved maintaining indispensable relationships with nursing colleagues by supporting and aiding them and simultaneously enduring a relative absence of sympathy. Solidarity among the community in this study was not a peripheral concept of the general notion of solidarity, implying that the commonalities within the collegial relationships were ambiguous and could shift from something good to something relatively good and vice versa. Such a shift was evidenced by nurses’ experiences of their community.

Care for older adults with dementia: PACE day care or residential dementia care units?

BACKGROUND

Persons with dementia (PwD) are at greater risk for various adverse health outcomes, and the best care model remains to be determined. This study aimed to compare the physical and neurocognitive performance of PwD in the Program of All-inclusive Care for the Elderly (PACE) and residential dementia care units.

METHODS

This was a case-control study comparing outcomes between care recipients of PACE services (PC group) and residential dementia care (RC group). Demographic characteristics, underlying diseases, physical function, cognitive function, mood status, and behavioral and psychotic symptoms of dementia (BPSDs) were assessed every 3-6 months in both groups, while frailty status and Timed Up-and-Go Test (TUGT) performance were assessed every 6 months in the PC group only.

RESULTS

Overall, 96 participants (PC group: 25, RC group: 71; mean age: 86.4 ± 6.8 years) were enrolled with the median follow-up period of 43.6 weeks. Lower incidence of hospital admissions was noted in the PC group (0.52 ± 1.12 vs 1.38 ± 2.49 admissions/1,000 person-days, p=0.023), even though the PC group had higher multimorbidity and more severe BPSDs. During the study period, the PC group showed a significant improvement in body mass index, less physical dependence, better cognitive performance and reduced depressive mood. In addition, the PC group showed improvement in frailty, leisure hour activities, and TUGT results. However, participants in the PC group were more likely to experience BPSD deterioration (β coeff.: 0.193, 95% CI: 0.121- 0.265).

CONCLUSION

The PACE services significantly reduced unexpected hospital admissions of PwD, facilitated the maintenance of physical independence, and improved cognitive performance and mood status. Further randomized controlled studies are needed to determine the most appropriate care model for PwD.

What Does “Managed Long Term Care Service” Mean in the United States? A Concept Analysis From a Case Manager’s Perspective

This study aimed to examine the concept of Managed Long Term Care service from a care manager’s perspective. The Walker and Avant concept analysis approach was applied. The defining attributes include (1) chronic disease or disability, (2) coordination of care, and (3) services. Core components of Managed Long Term Care service were found to be a network of providers and capitation. A conceptual model of Managed Long Term Care service was developed with Managed Long Term Care service operationally defined as “a program with a set of services delivered to patients who have a chronic illness or disability and wish to stay safe and healthy at home in the community. The services or benefits are coordinated by a care manager who serves as a point of contact for the patient and provider(s), and are delivered by providers in the network.” Care management is a core concept of Managed Long Term Care. The triple aims of Managed Long Term Care are to deliver the right care at the right time at the right cost to Managed Long Term Care eligible patients. This paper sought to illuminate and clarify varied perspectives on the concept of Managed Long Term Care service. Without a clear understanding of a community-based service or program, delivery of nursing care may be less effective. This study was the first to examine this widely used but often imprecisely defined community health service from a case manager’s point of view.

"All for One" experiences of interprofessional team members caring for older adults: A metasynthesis

BACKGROUND

There is some evidence that healthcare professionals prefer an interprofessional approach to care and this approach is of particular importance to older people due to their complex needs and multitude of chronic conditions.

OBJECTIVE

This metasynthesis aimed to synthesise and unearth new understandings of the experiences of interprofessional team members that are caring for older people from a variety of qualitative studies.

DESIGN

This review is designed as a metasynthesis based on the method put forth by Noblit and Hare for synthesising qualitative research.

DATA SOURCES

A search for qualitative and mixed methods articles that included healthcare professionals' experiences of caring for older people as a member of an interprofessional team was conducted via an electronic database search of CINAHL, PubMed, SCOPUS and PsycINFO.

REVIEW METHODS

The inclusion criteria were as follows: (a) the method of the study was qualitative or included a qualitative component, (b) an interprofessional team cared for an older person, (c) data regarding interprofessional team members' experiences were gathered, (d) published in English and (e) between the period of 2000 and 2019. Key metaphors were extracted from the data and juxtaposed until themes emerged.

RESULTS

A total of 1807 full-text articles were retrieved and screened via their titles and abstracts. Nine studies were included in this metasynthesis based upon full-text relevance and meeting the inclusion criteria. Six themes emerged describing the experience of interprofessional team members caring for older people: All for One: Unifying the Team for a Meaningful Purpose; The Cast; A Shared Vocabulary; Collaboration and Integration; A Functional-Dysfunctional Family and Appreciate the Lifeworld. Team members appreciated this model of care.

CONCLUSIONS

The emergent themes suggest potential buy-in from interprofessional team members to this care model for older people. Nursing can assert their unique knowledge and practice into the role as the team leader to mitigate potential barriers and team conflicts.

IMPLICATIONS FOR PRACTICE

Interprofessional team members caring for older people can improve their experience. Improved experiences for interprofessional team members can lead to better care for older people. Professionals need specialized training prior to practicing interprofessionally.

Team functioning as a predictor of patient outcomes in early medical home implementation

BACKGROUND

New models of patient-centered primary care such as the patient-centered medical home (PCMH) depend on high levels of interdisciplinary primary care team functioning to achieve improved outcomes. A few studies have qualitatively assessed barriers and facilitators to optimal team functioning; however, we know of no prior study that assesses PCMH team functioning in relationship to patient health outcomes.

PURPOSE

The aim of the study was to assess the relationships between primary care team functioning, patients' use of acute care, and mortality.

METHODOLOGY/APPROACH

Retrospective longitudinal cohort analysis of patient outcomes measured at two time points (2012 and 2013) after PCMH implementation began in Veterans Health Administration practices. Multilevel models examined practice-level measures of team functioning in relationship to patient outcomes (all-cause and ambulatory care-sensitive condition-related hospitalizations, emergency department visits, and mortality). We controlled for practice-level factors likely to affect team functioning, including leadership support, provider and staff burnout, and staffing sufficiency, as well as for individual patient characteristics. We also tested the model among a subgroup of vulnerable patients (homeless, mentally ill, or with dementia).

RESULTS

In adjusted analyses, higher team functioning was associated with lower mortality (OR = 0.92, p = .04) among all patients and with fewer all-cause admissions (incidence rate ratio [IRR] = 0.90, p < 0.01), ambulatory care-sensitive condition-related admissions (IRR = 0.91, p = .04), and emergency department visits (IRR = 0.91, p = .03) in the vulnerable patient subgroup.

CONCLUSION

These early findings give support for the importance of team functioning within PCMH models for achieving improved patient outcomes.

PRACTICE IMPLICATIONS

A focus on team functioning is important especially in the early implementation of team-based primary care models.

Perceived Effectiveness of Home-Based Primary Care Teams in Veterans Health Administration

Background and Objectives

Previous studies have shown that staff perception of team effectiveness is related to better health outcomes in various care settings. This study focused on the Veterans Health Administration’s Home-Based Primary Care (HBPC) program. We examined variations in HBPC interdisciplinary teamwork (IDT) and identified modifiable team and program characteristics that may influence staff perceptions of team effectiveness.

Research Design

We used a broadly validated survey instrument to measure perceived team effectiveness, workplace conditions/resources, group culture, and respondents’ characteristics. Surveys were initiated in January and completed in July, 2016.

Methods

Team membership rosters (n = 249) included 2,852 IDT members. The final analytical data set included 1,403 surveys (49%) from 221 (89%) teams. A generalized estimating equation model with logit link function, weighted by survey response rates, was used to examine factors associated with perceived team effectiveness.

Results

Respondents who served as primary care providers (PCPs) were 8% more likely (p = .0044) to view team’s performance as highly effective compared to other team members. Teams with nurse practitioners serving as team leader reported 6% higher likelihood of high-perceived team effectiveness (p = .0234). High team effectiveness was 13% more likely in sites where the predominant culture was characterized as group/developmental, and 7%–8% more likely in sites with lower environmental stress and better resources and staffing, respectively.

Conclusions and Implications

Team effectiveness is an important indirect measure of HBPC teams’ function. HBPC teams should examine their predominant culture, workplace stress, resources and staffing, and PCP leadership model as part of their quality improvement efforts.

Measuring nurses' perception of work environment: a scoping review of questionnaires

Background

Nurses’ work environment has been shown to be associated with quality of care and organizational outcomes. In order to monitor the work environment, it is useful for all stakeholders to know the questionnaires that assess or evaluate conditions for delivering nursing care. The aim of this article is: to review the literature for assessed survey questionnaires that measure nurses’ perception of their work environment, make a brief assessment, and map the content domains included in a selection of questionnaires.

Methods

The search included electronic databases of internationally published literature, international websites, and hand searches of reference lists. Eligible papers describing a questionnaire had to be; a) suitable for nurses working in direct care in general hospitals, nursing homes or home healthcare settings; and b) constructed to measure work environment characteristics that are amenable to change and related to patient and organizational outcomes; and c) presented along with an assessment of their measurement properties.

Results

The search yielded 5077 unique articles. For the final synthesis, 65 articles met inclusion criteria, consisting of 34 questionnaires measuring nursing work environments in different settings. Most of the questionnaires that we found were developed, and tested, for registered nurses in a general hospital setting. Six questionnaires were developed specifically for use in nursing home settings and one for home healthcare. The content domains covered by the questionnaires were both overlapping and unique and the terminology in use was inconsistent. The most common content domains in the work environment questionnaires were supportive managers, collaborative relationships with peers, busyness, professional practice and autonomy.

Conclusions

The findings from this review enhance the understanding of how “work environment” can be measured by an overview of existing questionnaires and domains. Our results indicate that there are very many work environment questionnaires with varying content.

Electronic supplementary material

The online version of this article (10.1186/s12912-017-0256-9) contains supplementary material, which is available to authorized users.

What works in implementation of integrated care programs for older adults with complex needs? A realist review

PURPOSE

A realist review of the evaluative evidence was conducted on integrated care (IC) programs for older adults to identify key processes that lead to the success or failure of these programs in achieving outcomes such as reduced healthcare utilization, improved patient health, and improved patient and caregiver experience.

DATA SOURCES

International academic literature was searched in 12 indexed, electronic databases and gray literature through internet searches, to identify evaluative studies.

STUDY SELECTION

Inclusion criteria included evaluative literature on integrated, long-stay health and social care programs, published between January 1980 and July 2015, in English.

DATA EXTRACTION

Data were extracted on the study purpose, period, setting, design, population, sample size, outcomes, and study results, as well as explanations of mechanisms and contextual factors influencing outcomes.

RESULTS OF DATA SYNTHESIS

A total of 65 articles, representing 28 IC programs, were included in the review. Two context-mechanism-outcome configurations (CMOcs) were identified: (i) trusting multidisciplinary team relationships and (ii) provider commitment to and understanding of the model. Contextual factors such as strong leadership that sets clear goals and establishes an organizational culture in support of the program, along with joint governance structures, supported team collaboration and subsequent successful implementation. Furthermore, time to build an infrastructure to implement and flexibility in implementation, emerged as key processes instrumental to success of these programs.

CONCLUSIONS

This review included a wide range of international evidence, and identified key processes for successful implementation of IC programs that should be considered by program planners, leaders and evaluators.

Effect of interprofessional clinical education programme length on students' attitudes towards teamwork

This article reports on a study involving a range of health professions students who participated in similar one-semester (short) or two-semester (long) interprofessional clinical education programmes that focused on clinical assessment of senior citizens living independently in the community. Students' attitudes towards teamwork skills and perceptions of their own teamwork skills both before and after the programmes were assessed using two validated scales. Osteopathic medical student participants reported no significant changes in attitudes towards interprofessional healthcare teamwork skills or their perceptions of their own interprofessional teamwork skills after either the one- or two-semester programmes. For athletic training, speech-language pathology, exercise sciences, public health, and nursing students, though, attitudes towards teamwork skills significantly improved (p < .05) after the one-semester programme; and perceptions of their own team skills significantly improved (p < .05) after both the one- and two-semester programmes. Overall, this study provides some support for interprofessional teamwork attitude change, but with a significant difference between medical as compared to nursing, allied health, and public health students.

Toward a mediation model for nurses' well-being and psychological distress effects of quality of leadership and social support at work

Given the lack of active nurses in industrialized countries throughout the world, in combination with demographic changes, it is of utmost importance to protect nurses' well-being and to prevent psychological distress, because of their strong association with premature occupational leave. The aim of this study was to investigate the effects of quality of leadership and social support at work on well-being and psychological distress of nurses and to determine whether nurses' overcommitment mediates the relationship between the abovementioned determinants and the outcomes. A cross-sectional survey design was used to gather our data. This study utilized part of the database of the Nurses' Early Exit Study. A total of 34,771 nurses (covering all nurse qualifications) working in hospitals, nursing homes, and home-care institutions in 8 European countries filled out a questionnaire (response rate = 51.4%). For all model variables (job satisfaction, satisfaction with salary, positive affectivity, personal burnout, negative affectivity, quality of leadership, social support from immediate supervisor, social support from near colleagues, and overcommitment), psychometrically sound, that is, valid and reliable measures were used. Outcomes from testing a structural equation mediation model indicated that, respectively, positive and negative influences of leadership quality and social support from supervisor and colleagues on nurses' well-being and psychological distress are partially mediated, that is, reduced, by nurses' overcommitment. Social work environment is highly important in relation to nurses' well-being and psychological distress.

Falls prevention education: Interprofessional training to enhance collaborative practice

The gap between the complex health care needs of older adults and the availability of geriatrics-trained health care professionals is widening. Interprofessional education offers an opportunity to engage multiple professions in interactive learning and clinically relevant problem solving to achieve high-quality patient-centered care. This article describes a project that engaged an interprofessional teaching team to support interprofessional practice teams to reduce falls in older adults via implementation of evidence-based practice guidelines. Ninety-five participants from 25 teams were trained on multiple strategies to decrease the risk of falls in older adults. The intervention facilitated increases in knowledge, confidence in skill performance, and team commitment to change practice patterns to support the health and safety of older adults. Findings suggest that community-based practices can successfully support the training of interprofessional teams and that training may lead to improved care processes and outcomes for older adults.

Navigating Poorly Charted Territory

American health care is complex, fragmented, and arcane rather than being patient centered. Many patients have considerable difficulty navigating this system. As a result, care is less timely, safe, effective, and efficient. Since navigation problems are more likely for those who are sicker and less educated, they contribute to inequity. Early solutions proposed for this problem focused on the use of yet another specialized professional, the “navigator,” to help individuals find their way through the system so they get the care they need. The author defines the patient navigation problem and its probable consequences and argues that research and action are needed to (a) document the problem empirically, (b) identify underlying organizational structures and behaviors that can make navigation easy or difficult, and (c) assess whether and how policies, regulations, and improvement strategies can influence these structures and behaviors.

Team learning, team performance and safe team climate in elder care nursing

Purpose

This study aims to determine whether elder care nurses engage in knowledge sharing and reflection within their teams and if these team-learning activities influence an elder care nursing team’s performance. Furthermore, the authors investigated the relation between elder care nurses' estimation of the team climate as being safe and team-learning activities.

Design/methodology/approach

For this research, a questionnaire survey of 30 elder care nursing teams (N = 30, n = 149) working in 17 different retirement homes was conducted.

Findings

Structural equation model showed significant positive relations between knowledge sharing and team performance, and between reflection and knowledge sharing. A safe team climate had a significantly positive influence on reflection.

Originality/value

Little is known about the performance of elder care nursing teams, how to measure team performance in this domain and how performance is influenced by learning activities. This study fills these gaps by providing an insight into the relationship between team-learning activities and team performance. Team performance was measured by the estimation of the team members and by using performance assessments from an independent institution.

Achieving a High-Quality Cancer Care Delivery System for Older Adults: Innovative Models of Care

OBJECTIVES

To examine innovative models and other research-based interventions that hold potential to assure high-quality care for the growing older adult population living with cancer as one of multiple chronic conditions. Evidence from these care delivery approaches provides a roadmap for the development of future care models.

DATA SOURCES

Published peer-reviewed literature, policy analyses, and web-based resources.

CONCLUSION

Available evidence suggests the need for models that engage patients and their family caregivers, focus on patient's functional capacities, emphasize palliative care, and maximize the contributions of all team members.

IMPLICATIONS FOR NURSING PRACTICE

Nurses are uniquely positioned to lead or play a major role in the evolution and implementation of care models targeting older adults with cancer, but must increase their knowledge and skills related to both oncology and geriatrics to maximize their contributions.

The common characteristics and outcomes of multidisciplinary collaboration in primary health care: a systematic literature review

INTRODUCTION

Research on collaboration in primary care focuses on specific diseases or types of collaboration. We investigate the effects of such collaboration by bringing together the results of scientific studies.

THEORY AND METHODS

We conducted a systematic literature review of PubMed, CINAHL, Cochrane and EMBASE. The review was restricted to publications that test outcomes of multidisciplinary collaboration in primary care in high-income countries. A conceptual model is used to structure the analysis.

RESULTS

Fifty-one studies comply with the selection criteria about collaboration in primary care. Approximately half of the 139 outcomes in these studies is non-significant. Studies among older patients, in particular, report non-significant outcomes (p < .05). By contrast, a higher proportion of significant results were found in studies that report on clinical outcomes.

CONCLUSIONS AND DISCUSSION

This review shows a large diversity in the types of collaboration in primary care; and also thus a large proportion of outcomes do not seem to be positively affected by collaboration. Both the characteristics of the structure of the collaboration and the collaboration processes themselves affect the outcomes. More research is necessary to understand the mechanism behind the success of collaboration, especially on the exact nature of collaboration and the context in which collaboration takes place.

A comparative evaluation of patient satisfaction outcomes in an interprofessional student-run free clinic

As the evidence supporting the value of well-coordinated healthcare teams continues to grow, so to do the calls from medical educators and policy makers for the development of meaningful interprofessional educational experiences for health professions students. The student-run clinic has emerged as a unique venue for such experiential interprofessional learning experiences, with over 100 such clinics now in operation across North America. As the number and variety of these clinics rises, it has become increasingly important to understand the quality of care which they deliver. Here, patient satisfaction data from an interprofessional student-run free clinic are described, and these results are quantitatively compared to similar data obtained from a non-interprofessional, non-student-run clinic in a post-experience only, non-equivalent groups design. Student-run free clinic patients reported high levels of satisfaction with the patient care team and the facility quality, and lower levels of satisfaction with waiting times. When compared to the non-student-run clinic, there was no significant difference in the high levels of patient satisfaction with the patient care teams between the clinics. Student-run free clinic patients did, however, report significantly lower levels of satisfaction with the accessibility of care and with the perceived privacy of protected health information. Overall, this report provides evidence that an interprofessional student-run free clinic is capable of performing at the level of an experienced free clinic across many domains of patient satisfaction, while also identifying notable areas for improvement within the domains of clinic accessibility and the perception of the privacy of protected health information.

Analyzing the Interprofessional Working of a Home-Based Primary Care Team

De plus en plus, les équipes interprofessionnelles sont chargées de fournir la prestation de services de soins de santé intégrés. Cependant, les équipes efficaces ne sont pas le fruit du hasard, mais nécessitent une planification minutieuse et une attention soutenue au processus de développer l’équipe. Basée sur une étude de cas portant sur des entretiens, l’observation participante, et une enquête, nous avons identifié les attributs clés pour le travail interprofessionnel efficace (TIE) dans le cadre de soins primaires à domicile (SPD). Reconnaissant l’importance d’un modèle théorique qui reflète la nature multi-dimensionnelle de la recherche sur l’efficacité de l’équipe, nous avons utilisé le modèle de l’efficacité de l’équipe integrée pour analyser nos résultats. Ces résultats indiquaient qu’une vision commune, des objectifs communs, le respect et la confiance entre les membres de l’équipe—ainsi que la communication continue, la direction efficace et des mécanismes de résolution des conflits—sont essentiels pour le développement d’une equipe de TIE qui fonctionne très bien. L’ambiguité et l’incertitude qui entoure le cadre de la prestation de services (à domicile), ainsi que la négociation des relations extérieures dans le domaine SPD, nécessitent la recherche plus approfondie.

Perceived quality of interprofessional interactions between physicians and nurses in oncology outpatient clinics

PURPOSE

To evaluate the perceived quality of interactions between nurses and physicians in oncology outpatient clinics.

METHODS

A cross-sectional, observational survey involving 250 physicians and nurses was conducted at oncology outpatient clinics at two regional cancer centres in the province of Ontario, Canada. Eligible participants were identified by administrators and invited to complete a one-time survey questionnaire. Quality of interactions was assessed using a seven-item survey of relational coordination, which measures two factors of interaction: supportive relationships and quality communication. Descriptive analyses and multivariate analyses of variance (MANOVA) were conducted to assess potential differences between the two study sites and the two professional groups.

RESULTS

Overall, nurses and physicians at both study sites rated their interactions highly (mean = 4.32 and 4.51 out of 5 for supportive relationships and quality communication, respectively). No difference in either factor was reported between physicians and nurses at either study site, but the two study sites differed significantly in both factors [F(2, 245) = 7.54, p < 0.001].

CONCLUSIONS

Overall, oncology nurses and oncologists at outpatient clinics rated their levels of interprofessional interaction highly. Contextual factors may have contributed to the high interaction scores and different ratings between the two cancer centres. The finding that nurses and physicians reported similar levels of perceived interactions suggests that relationships in these outpatient cancer clinics are highly collaborative and collegial.

Simulation in healthcare education: a best evidence practical guide. AMEE Guide No. 82

Over the past two decades, there has been an exponential and enthusiastic adoption of simulation in healthcare education internationally. Medicine has learned much from professions that have established programs in simulation for training, such as aviation, the military and space exploration. Increased demands on training hours, limited patient encounters, and a focus on patient safety have led to a new paradigm of education in healthcare that increasingly involves technology and innovative ways to provide a standardized curriculum. A robust body of literature is growing, seeking to answer the question of how best to use simulation in healthcare education. Building on the groundwork of the Best Evidence in Medical Education (BEME) Guide on the features of simulators that lead to effective learning, this current Guide provides practical guidance to aid educators in effectively using simulation for training. It is a selective review to describe best practices and illustrative case studies. This Guide is the second part of a two-part AMEE Guide on simulation in healthcare education. The first Guide focuses on building a simulation program, and discusses more operational topics such as types of simulators, simulation center structure and set-up, fidelity management, and scenario engineering, as well as faculty preparation. This Guide will focus on the educational principles that lead to effective learning, and include topics such as feedback and debriefing, deliberate practice, and curriculum integration - all central to simulation efficacy. The important subjects of mastery learning, range of difficulty, capturing clinical variation, and individualized learning are also examined. Finally, we discuss approaches to team training and suggest future directions. Each section follows a framework of background and definition, its importance to effective use of simulation, practical points with examples, and challenges generally encountered. Simulation-based healthcare education has great potential for use throughout the healthcare education continuum, from undergraduate to continuing education. It can also be used to train a variety of healthcare providers in different disciplines from novices to experts. This Guide aims to equip healthcare educators with the tools to use this learning modality to its full capability.

Multiple Chronic Conditions and the Aging of America

Background: As the United States population ages, chronic conditions are becoming more prevalent and our healthcare system is faced with increasing costs. This aging population with increased multiple chronic conditions coupled with increased burden of disease will provide a challenge to primary care physicians to provide quality care that is cost-effective. Therefore, we examined national data to study the impact of chronic conditions, age and caregiving on lifestyle burden. Methods: Cross-sectional data from the 2009 Behavioral Risk Factor Surveillance System were analyzed for the presence of 9 chronic health conditions, including angina/coronary heart disease (CHD), arthritis, asthma, cancer, diabetes, heart attack, hypertension, obesity, and stroke, and average number of chronic conditions among persons 50 years of age and older. Lifestyle burden, measured by activity limitation, required use of assistive devices, and/or serving in a caregiving capacity was measured and stratified by number of chronic conditions. Results: All conditions except obesity and asthma increased with each age category. By age 70, the majority of adults had hypertension (60.7%) and arthritis (55.0%). Prevalence of activity limitations and use of assistive devices increased as did the numbers of chronic conditions. Discussion: These findings point to a changing population of patients for primary care physicians that will require treatment of multiple chronic conditions as well as increased burden of disease. As this population grows, workloads for primary care physicians will increase and could likely lead to inefficient care and possibly inadequate payment for the required level of management. Therefore, the current challenge facing our healthcare system is to evaluate existing models of care for older patients and to develop new models that are cost-effective while at the same time providing fair reimbursement for increased management.

Elderly hispanics more likely to reside in poor-quality nursing homes

The proportion of Hispanics age sixty-five and older who are living in nursing homes rose from 5 percent in 2000 to 6.4 percent in 2005. Although segregation in nursing homes seems to have declined slightly, elderly Hispanics are more likely than their non-Hispanic white peers to reside in nursing homes that are characterized by severe deficiencies in performance, understaffing, and poor care.

SCOPE: Safer care for older persons (in residential) environments: a study protocol

BACKGROUND

The current profile of residents living in Canadian nursing homes includes elder persons with complex physical and social needs. High resident acuity can result in increased staff workload and decreased quality of work life.

AIMS

Safer Care for Older Persons [in residential] Environments is a two year (2010 to 2012) proof-of-principle pilot study conducted in seven nursing homes in western Canada. The purpose of the study is to evaluate the feasibility of engaging front line staff to use quality improvement methods to integrate best practices into resident care. The goals of the study are to improve the quality of work life for staff, in particular healthcare aides, and to improve residents' quality of life.

METHODS/DESIGN

The study has parallel research and quality improvement intervention arms. It includes an education and support intervention for direct caregivers to improve the safety and quality of their care delivery. We hypothesize that this intervention will improve not only the care provided to residents but also the quality of work life for healthcare aides. The study employs tools adapted from the Institute for Healthcare Improvement's Breakthrough Series: Collaborative Model and Canada's Safer Healthcare Now! improvement campaign. Local improvement teams in each nursing home (1 to 2 per facility) are led by healthcare aides (non-regulated caregivers) and focus on the management of specific areas of resident care. Critical elements of the program include local measurement, virtual and face-to-face learning sessions involving change management, quality improvement methods and clinical expertise, ongoing virtual and in person support, and networking.

DISCUSSION

There are two sustainability challenges in this study: ongoing staff and leadership engagement, and organizational infrastructure. Addressing these challenges will require strategic planning with input from key stakeholders for sustaining quality improvement initiatives in the long-term care sector.

Evaluation of the impact of interdisciplinarity in cancer care

BACKGROUND

Teamwork is a key component of the health care renewal strategy emphasized in Quebec, elsewhere in Canada and in other countries to enhance the quality of oncology services. While this innovation would appear beneficial in theory, empirical evidences of its impact are limited. Current efforts in Quebec to encourage the development of local interdisciplinary teams in all hospitals offer a unique opportunity to assess the anticipated benefits. These teams working in hospital outpatient clinics are responsible for treatment, follow-up and patient support. The study objective is to assess the impact of interdisciplinarity on cancer patients and health professionals.

METHODS/DESIGN

This is a quasi-experimental study with three comparison groups distinguished by intensity of interdisciplinarity: strong, moderate and weak. The study will use a random sample of 12 local teams in Quebec, stratified by intensity of interdisciplinarity. The instrument to measure the intensity of the interdisciplinarity, developed in collaboration with experts, encompasses five dimensions referring to aspects of team structure and process. Self-administered questionnaires will be used to measure the impact of interdisciplinarity on patients (health care utilization, continuity of care and cancer services responsiveness) and on professionals (professional well-being, assessment of teamwork and perception of teamwork climate). Approximately 100 health professionals working on the selected teams and 2000 patients will be recruited. Statistical analyses will include descriptive statistics and comparative analysis of the impact observed according to the strata of interdisciplinarity. Fixed and random multivariate statistical models (multilevel analyses) will also be used.

DISCUSSION

This study will pinpoint to what extent interdisciplinarity is linked to quality of care and meets the complex and varied needs of cancer patients. It will ascertain to what extent interdisciplinary teamwork facilitated the work of professionals. Such findings are important given the growing prevalence of cancer and the importance of attracting and retaining health professionals to work with cancer patients.

Diseño, implementación y evaluación de un programa de educación para la salud con personas mayores

OBJETIVO: Desde el análisis de los hábitos que perjudican la salud de las personas mayores de 65 años, diseñar, implementar y evaluar un programa de educación para la salud. MÉTODOS: Se abordó una investigación evaluativa desde un estudio de casos múltiples en tres centros de salud del Noroeste de España combinando el enfoque cuantitativo con el cualitativo. Los instrumentos de recogida de información utilizados fueron el cuestionario y la entrevista. RESULTADOS: El consumo de medicamentos en los mayores es elevado así como la automedicación. Un pequeño grupo fuma y consume alcohol. Más de la cuarta parte son sedentarios y su índice de masa corporal medio es de 30,55. La implementación del programa ha repercutido de forma significativa sobre su calidad de vida. Las personas mayores tienen arraigadas prácticas malsanas. El logro de contenidos educativos alcanzado mejoró gratamente su calidad de vida. Con todo, presentan reticencia para asumir nuevos hábitos de salud aunque les favorezcan.

Program of all-inclusive care (PACE): past, present, and future

From modest beginnings in 1973 to over 60 programs nationwide, the PACE concept has proven the value of integrated, interdisciplinary-based care for frail older adults. The evolution of PACE and its regulatory and reimbursement model have changed over time, but the principals of care have remained unchanged. Nationally PACE programs are dealing with some of the same challenges they had 30 years ago and yet PACE programs continue to expand and provide care to an ever wider distribution of populations. The looming issue of ever-growing health care expenditures represents another opportunity for PACE to demonstrate its value while providing a level of quality beyond what could normally be provided by typical Medicare and Medicaid payments for similar conditions and patient characteristics. The future for PACE includes a number of possibilities including flexibility in financing and reimbursement, design changes to work with community-based physicians, potential eligibility adjustments, and growth of rural PACE. The PACE model has clearly demonstrated that in a debilitated, frail population in whom health care expenses would be expect to be high, a combination of team care, managed health care services, and care coordination can lead to both improved health outcomes and reduced expenses over time.

Cost implications of organizing nursing home workforce in teams

OBJECTIVE

To estimate the costs associated with formal and self-managed daily practice teams in nursing homes.

DATA SOURCES/STUDY SETTING

Medicaid cost reports for 135 nursing homes in New York State in 2006 and survey data for 6,137 direct care workers.

STUDY DESIGN

A retrospective statistical analysis: We estimated hybrid cost functions that include team penetration variables. Inference was based on robust standard errors.

DATA COLLECTION

Formal and self-managed team penetration (i.e., percent of staff working in a team) were calculated from survey responses. Annual variable costs, beds, case mix-adjusted days, admissions, home care visits, outpatient clinic visits, day care days, wages, and ownership were calculated from the cost reports.

PRINCIPAL FINDINGS

Formal team penetration was significantly associated with costs, while self-managed teams penetration was not. Costs declined with increasing penetration up to 13 percent of formal teams, and increased above this level. Formal teams in nursing homes in the upward sloping range of the curve were more diverse, with a larger number of participating disciplines and more likely to include physicians.

CONCLUSIONS

Organization of workforce in formal teams may offer nursing homes a cost-saving strategy. More research is required to understand the relationship between team composition and costs.

Independence at home: community-based care for older adults with severe chronic illness

By most clinical and economic measures, our health care system is not providing effective or affordable care to Medicare beneficiaries with severe chronic illness. Two million elders, constituting most of the 5% who account for nearly half of Medicare costs, have multiple chronic conditions, functional disability, and average per capita costs of over $50,000 per year. Prior reforms aimed at this population did not change the flawed delivery system, which remains centered in the doctor's office, hospitals, and nursing homes. This article describes a model of coordinated home-based medical care, called Independence at Home (IAH), which operates on a limited basis in many US communities and in the Veterans Affairs system. IAH-type teams deliver a full range of medical and social services at home to seriously ill elders and thereby reduce overall health care costs. We review the evidence that this approach can lower total costs by 25 percent or more while improving patient satisfaction and outcomes. We discuss funding for the new model, which also produces net savings for Medicare. A Medicare reform bill, called the Independence at Home Act, was introduced in the US House and Senate in 2008 to promote replication of this mobile elder care model.

Measuring work environment and performance in nursing homes

BACKGROUND

Qualitative studies of the nursing home work environment have long suggested that attributes such as leadership and communication may be related to nursing home performance, including residents' outcomes. However, empirical studies examining these relationships have been scant.

OBJECTIVES

This study is designed to develop an instrument for measuring nursing home work environment and perceived work effectiveness; test the reliability and validity of the instrument; and identify individual and facility-level factors associated with better facility performance.

RESEARCH DESIGN AND METHODS

The analysis was based on survey responses provided by managers (N = 308) and direct care workers (N = 7418) employed in 162 facilities throughout New York State. Exploratory factor analysis, Cronbach's alphas, analysis of variance, and regression models were used to assess instrument reliability and validity. Multivariate regression models, with fixed facility effects, were used to examine factors associated with work effectiveness.

RESULTS

The reliability and the validity of the survey instrument for measuring work environment and perceived work effectiveness have been demonstrated. Several individual (eg, occupation, race) and facility characteristics (eg, management style, workplace conditions, staffing) that are significant predictors of perceived work effectiveness were identified.

CONCLUSIONS

The organizational performance model used in this study recognizes the multidimensionality of the work environment in nursing homes. Our findings suggest that efforts at improving work effectiveness must also be multifaceted. Empirical findings from such a line of research may provide insights for improving the quality of the work environment and ultimately the quality of residents' care.

Daily practice teams in nursing homes: evidence from New York state

PURPOSE

Most health care organizations, including nursing homes, report having teams. However, little is known about everyday practice teams among staff providing direct resident care. We assess the prevalence of such teams in nursing homes as reported by direct care staff and administrators, and examine characteristics of facilities that foster these teams.

DESIGN AND METHODS

The analytical model is based on 149 nursing homes. Data sources include surveys of administrators (n = 292) and direct care staff (n = 6,867), and Online Survey Certification and Reporting System. Linear regression with robust standard errors and sampling probability weights is used to examine the relationship between daily practice teams and facility characteristics.

RESULTS

On average, 16% of workers per facility report practicing in formal multidisciplinary teams providing daily resident care. Team prevalence is 3.3% higher when managers view teams as very important for clinical care quality, 2.6% higher when the directors of nursing report formally organized teams, 2.5% higher for each 10% increase in workers' involvement in teams other than the daily practice teams, and 1.95% higher for each 1-hr increase in nursing hours.

IMPLICATIONS

Our study shows that multidisciplinary daily practice teams can be found in most facilities in our large sample, but their penetration within nursing homes is far from pervasive; in 72% of facilities, staff report team prevalence of less than 25%. Given that the majority of managers report teamwork as very important to their facilities' operations, we discuss why only a relatively small proportion of daily care is provided in this fashion.

Community and in-home models

PACE and state-based payment for in-home supportive services.

Advancing the evidence base for social work in long-term care: the disconnect between practice and research

This article reviews the research literature relative to social work practice in geriatric long-term care (LTC) settings with the aim of determining the state of the evidence base for practice. Overall, this body of research supports the efficacy of social work services within the context of community-based case management and interdisciplinary models of geriatric intervention; however, there is less evidence of a discipline-specific contribution, particularly in institutional health care settings (e.g., nursing homes and hospitals) where a great number of gerontological social workers are employed. Implications of this review include the need to prioritize research within gerontological social work in order to enhance best practice knowledge and skills in settings where it is most needed.

Program characteristics and enrollees' outcomes in the Program of All-Inclusive Care for the Elderly (PACE)

The Program of All-Inclusive Care for the Elderly (PACE) is a unique program providing a full spectrum of health care services, from primary to acute to long-term care for frail elderly individuals certified to require nursing home care. The objective of this article is to identify program characteristics associated with better risk-adjusted health outcomes: mortality, functional status, and self-assessed health. The article examines statistical analyses of information combining DataPACE (individual-level clinical data), a survey of direct care staff about team performance, and interviews with management in twenty-three PACE programs. Several program characteristics were associated with better functional outcomes. Fewer were associated with long-term self-assessed health, and only one with mortality. These findings offer strategies that may lead to better care.

Art therapy: Using the creative process for healing and hope among African American older adults

This article provides an introduction to the field of art therapy and the potential it can offer to address the emotional needs of the frail elderly. Two case studies are discussed, and examples of artwork are provided. The case studies and artwork were created under the guidance of an art therapist at a Program of All-Inclusive Care for the Elderly (PACE) site in an urban African American community. This article explores how art making addresses the specific developmental tasks of the elderly in a culturally competent manner. Included are practical considerations in the choice of art media and directives for working with elderly clients, as well as resources for further information on the use of art in therapy.