Care Outcomes in Long-Term Care Facilities in British Columbia, Canada

Organizational Context and Quality Indicators in Nursing Homes: A Microsystem Look

The association of organizational context with quality of care in nursing homes is not well understood at the clinical microsystem (care unit) level. This cross-sectional study examined the associations of unit-level context with 10 unit-level quality indicators derived from the Minimum Data Set 2.0. Study settings comprised 262 care units within 91 Canadian nursing homes. We assessed context using unit-aggregated care-aide-reported scores on the 10 scales of the Alberta Context Tool. Mixed-effects regression analysis showed that structural resources were negatively associated with antipsychotics use (B = -.06; p = .001) and worsened late-loss activities of daily living (B = -.03, p = .04). Organizational slack in time was negatively associated with worsened pain (B = -.04, p = .01). Social capital was positively associated with delirium symptoms (B = .12, p = .02) and worsened depressive symptoms (B = .10, p = .01). The findings suggested that targeting interventions to modifiable contextual elements and unit-level quality improvement will be promising.

Delivering person-centred palliative care in long-term care settings: is humanism a quality of health-care employees or their organisations?

Reflecting on sustained calls for patient-centredness and culture change in long-term care, we evaluated the relative importance of personal and organisational predictors of palliative care, hypothesising the former as weaker predictors than the latter. Health-care employees (N = 184) from four Canadian long-term care homes completed a survey of person-centred care, self-efficacy, employee wellbeing and occupational characteristics. Using backward stepwise regression models, we examined the relative contributions of these variables to person-centred palliative care. Specifically, blocks of variables representing personal, organisational and occupational characteristics; palliative care self-efficacy; and employee wellbeing were simultaneously regressed on variables representing aspects of person-centred care. The change in R2 associated with the removal of each block was examined to determine each block's overall contribution to the model. We found that occupational characteristics (involvement in care planning), employee wellbeing (compassion satisfaction) and self-efficacy were reliably associated with person-centred palliative care (p < 0.05). Facility size was not associated, and facility profit status was less consistently associated. Demographic characteristics (gender, work experience, education level) and some aspects of employee wellbeing (burnout, secondary trauma) were also not reliably associated. Overall, these results raise the possibility that humanistic care is less related to intrinsic characteristics of employees, and more related to workplace factors, or to personal qualities that can be cultivated in the workplace, including meaningful role engagement, compassion and self-efficacy.

Impact of COVID-19 on Relationship-Centred Residential Dining Practices

This study describes changes in dining practices and provider perspectives on meal-related challenges due to the coronavirus disease (COVID-19) pandemic. An online survey was disseminated between July and September 2020 through stakeholder networks and social media with 1,036 respondents. Altered dining practices included residents eating in rooms (54.3%), spacing residents in common areas for meals (69.3%), and disposable dish use (44.9%). The most common mealtime challenges were reduced socializing opportunities at meals (29.3%), inadequate staffing (22.8%), reduced family/volunteer help (16.7%), and assisting residents to eat (10.5%). Many participants (72.2%) felt conflict balancing safety and relationship-centred care. Geographic region, home size, building age, respondent’s job title, pre-pandemic relationship-centred practices, and mealtime satisfaction, and some pandemic-initiated practices were associated with mealtime challenges and feeling conflicted in binary logistic regression analyses. Considering trade-offs between safety and relational aspects of mealtimes during the pandemic is crucial.

For-profit long-term care homes and the risk of COVID-19 outbreaks and resident deaths

BACKGROUND

Long-term care (LTC) homes have been the epicentre of the coronavirus disease 2019 (COVID-19) pandemic in Canada to date. Previous research shows that for-profit LTC homes deliver inferior care across a variety of outcome and process measures, raising the question of whether for-profit homes have had worse COVID-19 outcomes than nonprofit homes.

METHODS

We conducted a retrospective cohort study of all LTC homes in Ontario, Canada, from Mar. 29 to May 20, 2020, using a COVID-19 outbreak database maintained by the Ontario Ministry of Long-Term Care. We used hierarchical logistic and count-based methods to model the associations between profit status of LTC homes (for-profit, nonprofit or municipal) and COVID-19 outbreaks in LTC homes, the extent of COVID-19 outbreaks (number of residents infected), and deaths of residents from COVID-19.

RESULTS

The analysis included all 623 Ontario LTC homes, comprising 75 676 residents; 360 LTC homes (57.7%) were for profit, 162 (26.0%) were nonprofit, and 101 (16.2%) were municipal homes. There were 190 (30.5%) outbreaks of COVID-19 in LTC homes, involving 5218 residents and resulting in 1452 deaths, with an overall case fatality rate of 27.8%. The odds of a COVID-19 outbreak were associated with the incidence of COVID-19 in the public health unit region surrounding an LTC home (adjusted odds ratio [OR] 1.91, 95% confidence interval [CI] 1.19-3.05), the number of residents (adjusted OR 1.38, 95% CI 1.18-1.61), and older design standards of the home (adjusted OR 1.55, 95% CI 1.01-2.38), but not profit status. For-profit status was associated with both the extent of an outbreak in an LTC home (adjusted risk ratio [RR] 1.96, 95% CI 1.26-3.05) and the number of resident deaths (adjusted RR 1.78, 95% CI 1.03-3.07), compared with nonprofit homes. These associations were mediated by a higher prevalence of older design standards in for-profit LTC homes and chain ownership.

INTERPRETATION

For-profit status is associated with the extent of an outbreak of COVID-19 in LTC homes and the number of resident deaths, but not the likelihood of outbreaks. Differences between for-profit and nonprofit homes are largely explained by older design standards and chain ownership, which should be a focus of infection control efforts and future policy.

Long-Term Care Facility Ownership and Acute Hospital Service Use in British Columbia, Canada: A Retrospective Cohort Study

OBJECTIVE

Previous studies report higher hospitalization rates in for-profit compared with nonprofit long-term care facilities (LTCFs), but have not included staffing data, a major potential confounder. Our objective was to examine the effect of ownership on hospital admission rates, after adjusting for facility staffing levels and other facility and resident characteristics, in a large Canadian province (British Columbia).

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

Our cohort included individuals resident in a publicly funded LTCF in British Columbia at any time between April 1, 2012 and March 31, 2016.

MEASURES

Health administrative data were extracted from multiple databases, including continuing care, hospital discharge, and Minimum Data Set (MDS 2.0) assessment records. Cox extended hazards regression was used to estimate hospitalization risk associated with facility- and resident-level factors.

RESULTS

The cohort included 49,799 residents in 304 LTCF facilities (116 publicly owned and operated, 99 for-profit, and 89 nonprofit) over the study period. Hospitalization risk was higher for residents in for-profit (adjusted hazard ratio [adjHR] 1.34; 95% confidence interval [CI] 1.29-1.38) and nonprofit (adjHR 1.37; 95% CI 1.32-1.41) facilities compared with publicly owned and operated facilities, after adjustment for staffing, facility size, urban location, resident demographics, and case mix. Within subtypes, risk was highest in single-site facilities: for-profit (adjHR 1.42; 95% CI 1.36-1.48) and nonprofit (adjHR 1.38, 95% CI 1.33-1.44).

CONCLUSIONS AND IMPLICATIONS

This is the first Canadian study using linked health data from hospital discharge records, MDS 2.0, facility staffing, and ownership records to examine the adjusted effect of facility ownership characteristics on hospital use of LTCF residents. We found significantly lower adjHRs for hospital admission in publicly owned facilities compared with both for-profit and nonprofit facilities. Our finding that publicly owned facilities have lower hospital admission rates compared with for-profit and nonprofit facilities can help inform decision-makers faced with the challenge of optimizing care models in both nursing homes and hospitals as they build capacity to care for aging populations.

Do-Not-Resuscitate and Do-Not-Hospitalize Orders in Nursing Homes: Who Gets Them and Do They Make a Difference?

OBJECTIVES

To describe the rate of do-not-resuscitate (DNR) and do-not-hospitalize (DNH) orders among residents newly admitted into long-term care homes. We also assessed the association between DNR and DNH orders with hospital admissions, deaths in hospital, and survival.

DESIGN

A retrospective cohort study.

SETTING AND PARTICIPANTS

Admissions in all 640 publicly funded long-term care homes in Ontario, Canada, between January 1, 2010 and March 1, 2012 (n = 49,390).

MEASURES

We examined if a DNR and/or DNH was recorded on resident's admission assessment. All residents were followed until death, discharge, or end of study to ascertain rates of several outcomes, including death and hospitalization, controlling for resident characteristics.

RESULTS

Upon admission, 60.7% of residents were recorded to have a DNR and 14.8% a DNH order. Those who were older, female, widowed, lived in rural facilities, lived in higher income neighborhoods prior to entry, had higher health instability or cognitive impairment, and spoke English or French were more likely to receive a DNR or DNH. Survival time was only slightly shorter for those with a DNR and DNH with a mean of 145 and 133 days, respectively, vs 160 and 153 days for those without a DNR and DNH. After controlling for age, sex, rurality, neighborhood income, marital status, health instability, cognitive performance score, and multimorbidity, DNR and DNH were associated with an odds ratio of 0.57 [95% confidence interval (CI) 0.53-0.62] and 0.41 (95% CI 0.37-0.46) for dying in hospital, respectively. Those with a DNR and DNH, after adjustment, had an incidence rate ratio of 0.87 (95% CI 0.83-0.90) and 0.70 (95% CI 0.67-0.73), respectively, days spent in hospital.

CONCLUSIONS AND IMPLICATIONS

This study outlines identifiable factors influencing whether residents have a DNR and/or DNH order upon admission. Both orders led to lower rates, but not absolute avoidance, of hospitalizations near and at death.

Facility ownership and mortality among older adults residing in care homes

Background and objectives

Nursing or care home characteristics may have a long-term impact on the residents’ mortality risks that has not been studied previously. The study’s main objective was to assess the association between facility ownership and long-term, all-cause mortality.

Research design and methods

We conducted a mortality follow-up study on a cohort of 611 nursing-home residents in the city Madrid, Spain, from their 1998–1999 baseline interviews up to September 2013. Residents lived in three types of facilities: public, subsidized and private, which were also sub-classified according to size (number of beds). Residents’ information was collected by interviewing the residents themselves, their caregivers and facility physicians. We used time-to-event multivariable models and inverse probability weighting to estimate standardized mortality risk differences.

Results

After a 3728 person-year follow-up (median/maximum of 4.8/15.2 years), 519 participants had died. In fully-adjusted models, the standardized mortality risk difference at 5 years of follow-up between medium-sized private facilities and large-sized public facilities was -18.9% (95% confidence interval [CI]: -33.4 to -4.5%), with a median survival (95% CI) of 3.6 (0.5 to 6.8) additional years. The fully-standardized 5-year mortality difference (95% CIs) between for-profit private facilities and not-for-profit public institutions was -15.1% (-31.1% to 0.9%), and the fully-standardized median survival difference (95% CIs) was 3.0 (-1.7 to 7.7) years.

Discussion and implications

These results are compatible with an association between factors related with the ownership of facilities and the long-term mortality risk of their residents. One of these factors, the facility size, could partly explain this association.

Ontario’s Retirement Homes and Long-Term Care Homes: A Comparison of Care Services and Funding Regimes

La demande croissante de lits en établissements publics subventionnés de soins de longue durée (ÉPSLD) occasionne de longues listes d’attentes en Ontario. Ces temps d’attente doivent être absorbés par les autres types d’hébergements, incluant les résidences non subventionnées (RNS). Cette étude compare les ÉPSLD et les RNS en termes de services fournis, de régimes de financement et des implications de ces sources de financement pour les personnes âgées. Des données descriptives pour les ÉPSLD et les RNS ont été collectées à partir de sources publiques et privées afin de représenter l’offre de services, leur disponibilité, leurs coûts et les sources de financement de ces types d’hébergement. Les services offerts par les ÉPSLD et les RNS se chevauchent en partie, particulièrement dans les niveaux de soins les plus élevés. Bien que les secteurs public et privé facturent des frais d’hébergement aux résidents, la plus grande partie des coûts en ÉPSLD sont couverts par des fonds publics, tandis que les résidents en RNS assument personnellement ces frais, en règle générale. Compte tenu des listes d’attente des ÉPSLD, plusieurs personnes âgées doivent se tourner vers d’autres établissements de soins, tels que les RNS. Plusieurs politiques alternatives existantes pourraient être considérées en vue d’améliorer l’équité dans l’accès aux soins en résidence pour les personnes âgées.

Financial performance, employee well-being, and client well-being in for-profit and not-for-profit nursing homes: A systematic review

BACKGROUND

Expanding the opportunities for for-profit nursing home care is a central theme in the debate on the sustainable organization of the growing nursing home sector in Western countries.

PURPOSES

We conducted a systematic review of the literature over the last 10 years in order to determine the broad impact of nursing home ownership in the United States. Our review has two main goals: (a) to find out which topics have been studied with regard to financial performance, employee well-being, and client well-being in relation to nursing home ownership and (b) to assess the conclusions related to these topics. The review results in two propositions on the interactions between financial performance, employee well-being, and client well-being as they relate to nursing home ownership.

METHODOLOGY/APPROACH

Five search strategies plus inclusion and quality assessment criteria were applied to identify and select eligible studies. As a result, 50 studies were included in the review. Relevant findings were categorized as related to financial performance (profit margins, efficiency), employee well-being (staffing levels, turnover rates, job satisfaction, job benefits), or client well-being (care quality, hospitalization rates, lawsuits/complaints) and then analyzed based on common characteristics.

FINDINGS

For-profit nursing homes tend to have better financial performance, but worse results with regard to employee well-being and client well-being, compared to not-for-profit sector homes. We argue that the better financial performance of for-profit nursing homes seems to be associated with worse employee and client well-being.

PRACTICAL IMPLICATIONS

For policy makers considering the expansion of the for-profit sector in the nursing home industry, our findings suggest the need for a broad perspective, simultaneously weighing the potential benefits and drawbacks for the organization, its employees, and its clients.

A before-after study of hospital use in two frail populations receiving different home-based services over the same time in Vancouver, Canada

Background

As individuals age, they are more likely to experience increasing frailty and more frequent use of hospital services. First, we explored whether initiating home-based primary care in a frail homebound cohort, influenced hospital use. Second, we explored whether initiating regular home care support for personal care with usual primary care, in a second somewhat less frail cohort, influenced hospital use.

Methods

This was a before-after retrospective cohort study of two frail populations in Vancouver, Canada using administrative data to assess the influence of two different services started in two different cohorts over the same time period. The participants were 246 recipients of integrated home-based primary care and 492 recipients of home care followed between July 1st, 2008 and June 30th, 2013 before and after starting their respective services. Individuals in each group were linked to their hospital emergency department visit and discharge abstract records. The main outcome measures were mean emergency department visit and hospital admission rates per 1000 patient days for 21 months before versus the period after receipt of services, and the adjusted incidence rate ratios (IRRs) on these outcomes post receipt of service.

Results

Before versus after starting integrated home-based primary care, emergency department visit rates per 1000 patient days (95% confidence intervals) were 4.1 (3.8, 4.4) versus 3.7 (3.3, 4.1), and hospital admissions rates were 2.3 (2.1, 2.5) versus 2.2 (1.9, 2.5). Before versus after starting home care, emergency department visit rates per 1000 patient days (95% confidence intervals) were 3.0 (2.8, 3.2) versus 4.0 (3.7, 4.3) visits and hospital admissions rates were 1.3 (1.2, 1.4) versus 1.9 (1.7, 2.1). Home-based primary care IRRs were 0.91 (0.72, 1.15) and 0.99 (0.76, 1.27) and home care IRRs were 1.34 (1.15, 1.56) and 1.46 (1.22, 1.74) for emergency department visits and hospital admissions respectively.

Conclusions

After enrollment in integrated home-based primary care, emergency department visit and hospital admission rates stabilized. After starting home care with usual primary care, emergency department visit and hospital admission rates continued to rise.

Gender Regimes in Ontario Nursing Homes: Organization, Daily Work, and Bodies

Today more men work in the long-term care sector, but men are still in the minority. Little is known about men's experiences in care work, and the dilemmas and opportunities they face because of their gender. This article focuses on men care workers' integration into the organization and flow of nursing home work as perceived by these workers and staff members. Using a rapid ethnography method in two Ontario nursing homes, we found work organization affected interpretations of gender and race, and that workers' scope for discretion affected the integration and acceptance of men as care workers. In a nursing home with a rigid work organization and little worker discretion, women workers perceived men workers as a problem, whereas at a nursing home with a more flexible work organization that stressed relational care, both women and men workers perceived men workers as a resource in the organization.

Staffing in Ontario's Long-Term Care Homes: Differences by Profit Status and Chain Ownership

Ontario has the highest proportion of for-profit nursing homes in Canada. These facilities, which are known in Ontario as long-term care (LTC) homes, offer 24-hour custodial as well as nursing care to individuals who cannot live independently. Increasingly, they are also operating as members of multi-facility chains. Using longitudinal data (1996-2011) from the Residential Care Facilities Survey (n = 627), our analysis revealed discernible differences in staffing levels by profit status and chain affiliation. We found for-profit LTC homes - especially those owned by a chain organization - provided significantly fewer hours of care, after adjusting for variation in the residents' care needs. Findings from this study offer new information on the impact of organizational structure on staffing levels in Ontario's LTC homes and have implications for other jurisdictions where a growing presence of private, chain-affiliated operators has been observed.

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

BACKGROUND

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

METHODS

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

DISCUSSION

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

TRIAL REGISTRATION

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

Patient reported outcome measures of quality of end-of-life care: A systematic review

End-of-life (EoL) care¹ is increasingly used as a generic term in preference to palliative care or terminal care, particularly with reference to individuals with chronic disease, who are resident in community and long-term care (LTC) settings. This review evaluates studies based on patient reported outcome measures (PROMS) of quality of EoL care across all health-care settings. From 1041 citations, 12 studies were extracted by searches conducted in EBSCO, Scopus, Web of Science, PubMed, Cochrane, Open Grey and Google Scholar databases. At present, the evidence base for EoL care is founded on cancer care. This review highlights the paucity of studies that evaluate quality of EoL care for patients with chronic disease outside the established cancer-acute care paradigm, particularly in LTC. This review highlights the absence of any PROMs for the estimated 60% of patients in LTC with cognitive impairment. Patient-reported outcomes (PROs) are critical to understanding how EoL care services and practices affect patients' health and EoL experience. PROMs describe the quality of care from the patient's perspective and add balance to existing clinical or proxy-derived knowledge on the quality of care and services provided.

Observational Evidence of For-Profit Delivery and Inferior Nursing Home Care: When Is There Enough Evidence for Policy Change?

Margaret McGregor and colleagues consider Bradford Hill's framework for examining causation in observational research for the association between nursing home care quality and for-profit ownership.

Private capital investments in health care provision through mergers and acquisitions: from long-term to acute care

OBJECTIVES

This work aims to test whether different segments of healthcare provision differentially attract private capital and thus offer heterogeneous opportunities for private investors' diversification strategies.

METHODS

Thomson Reuter's SDC Platinum database provided data on 2563 merger and acquisition (M&A) deals targeting healthcare providers in Western Europe between 1990 and 2010. Longitudinal trends of industrial and geographical characteristics of M&As' targets and acquirers are examined.

RESULTS

Our analyses highlight: (i) a relative decrease of long-term care facilities as targets of M&As, replaced by an increasing prominence of general hospitals, (ii) a shrinking share of long-term care facilities as targets of financial service organizations' acquisitions, in favor of general hospitals, and (iii) an absolute and relative decrease of long-term care facilities' role as target of cross-border M&As.

CONCLUSIONS

We explain the decreasing interest of private investors towards long-term care facilities along three lines of reasoning, which take into account the saturation of the long-term care market and the liberalization of acute care provision across Western European countries, regulatory interventions aimed at reducing private ownership to ensure resident outcomes and new cultural developments in favor of small-sized facilities, which strengthen the fragmentation of the sector. These findings advance the literature investigating the effect of private ownership on health outcomes in long-term facilities. Market, policy and cultural forces have emerged over two decades to jointly regulate the presence of privately owned, large-sized long-term care providers, seemingly contributing to safeguard residents' well-being. Copyright © 2016 John Wiley & Sons, Ltd.

Dancing the Two-Step in Ontario's Long-term Care Sector: More Deterrence-oriented Regulation = Ownership and Management Consolidation

This paper explores shifts in public and private delivery over time through an analysis of Ontario's approach to LTC funding and regulation in relation to other jurisdictions in Canada and abroad. The case of Ontario's long-term care (LTC) policy evolution - from the 1940s until early 2013 -- shows how moving from compliance to deterrence oriented regulation can support consolidation of commercial providers' ownership and increase the likelihood of non-profit and public providers outsourcing their management.

Increasing fluid intake and reducing dehydration risk in older people living in long-term care: a systematic review

OBJECTIVE

To assess the efficacy of interventions and environmental factors on increasing fluid intake or reducing dehydration risk in older people living in long-term care facilities.

DESIGN

Systematic review of intervention and observational studies.

DATA SOURCES

Thirteen electronic databases were searched from inception until September 2013 in all languages. References of included papers and reviews were checked.

ELIGIBILITY CRITERIA

Intervention and observational studies investigating modifiable factors to increase fluid intake and/or reduce dehydration risk in older people (≥65 years) living in long-term care facilities who could drink orally.

REVIEW METHODS

Two reviewers independently screened, selected, abstracted data, and assessed risk of bias from included studies; narrative synthesis was performed.

RESULTS

A total of 4328 titles and abstracts were identified, 325 full-text articles were obtained and 23 were included in the review. Nineteen intervention and 4 observational studies from 7 countries investigated factors at the resident, institutional, or policy level. Overall, the studies were at high risk of bias due to selection and attrition bias and lack of valid outcome measures of fluid intake and dehydration assessment. Reported findings from 6 of the 9 intervention studies investigating the effect of multicomponent strategies on fluid intake or dehydration described a positive effect. Components included greater choice and availability of beverages, increased staff awareness, and increased staff assistance with drinking and toileting. Implementation of the US Resident Assessment Instrument reduced dehydration prevalence from 3% to 1%, P = .01. Two smaller studies reported positive effects: one on fluid intake in 9 men with Alzheimer disease using high-contrast red cups, the other involved supplementing 13 mildly dehydrated residents with oral hydration solution over 5 days to reduce dehydration. Modifications to the dining environment, advice to residents, presentation of beverages, and mode of delivery (straw vs beaker; prethickened drinks vs those thickened at the bedside) were inconclusive. Two large observational studies with good internal validity investigated effects of ownership; in Canada, for-profit ownership was associated with increased hospital admissions for dehydration; no difference was seen in dehydration prevalence between US for-profit and not-for-profit homes, although chain facilities were associated with lower odds of dehydration. This US study did not suggest any effect of staffing levels on dehydration prevalence.

CONCLUSIONS

A wide range of interventions and exposures were identified, but the efficacy of many strategies remains unproven due to the high risk of bias present in many studies. Reducing dehydration prevalence in long-term care facilities is likely to require multiple strategies involving policymakers, management, and care staff, but these require further investigation using more robust study methodologies. The review protocol was registered with the International Prospective Register of Systematic Reviews (http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42012003100).

Nursing home characteristics associated with resident transfers to emergency departments

This study examined how nursing home facility ownership and organizational characteristics relate to emergency department (ED) transfer rates. The sample included a retrospective cohort of nursing home residents in the Vancouver Coastal Health region (n = 13,140). Rates of ED transfers were compared between nursing home ownership types. Administrative data were further linked to survey-derived data of facility organizational characteristics for exploratory analysis. Crude ED transfer rates (transfers/100 resident years) were 69, 70, and 51, respectively, in for-profit, non-profit, and publicly owned facilities. Controlling for sex and age, public ownership was associated with lower ED transfer rates compared to for-profit and non-profit ownership. Results showed that higher total direct-care nursing hours per resident day, and presence of allied health staff--disproportionately present in publicly owned facilities--were associated with lower transfer rates. A number of other facility organizational characteristics--unrelated to ownership--were also associated with transfer rates.

Contributions of environment, comorbidity, and stage of dementia to the onset of walking and eating disability in long-term care residents

OBJECTIVES

To estimate the relative effects of environment, comorbidities, stage of dementia and other variables on disability onset.

DESIGN

A 1-year prospective cohort study was conducted in which the walking and eating abilities of long-term care residents were observed fortnightly. Structural equation modeling was used to assess the contributions of individual and environmental factors to the onset of disability.

SETTING

Fifteen nursing homes in western Canada.

PARTICIPANTS

One hundred twenty residents with middle-stage Alzheimer disease or related dementia.

MEASUREMENTS

Environmental quality was assessed using the Professional Environmental Assessment Protocol, comorbidity using the Charlson Comorbidity Index, and stage of dementia using the Global Deterioration Scale.

RESULTS

More-advanced baseline dementia had a direct effect on onset of walking and eating disability (standardized maximum likelihood estimate (SMLE) = 0.24, P = .006). Resident environment (SMLE = -0.25, P = .007) and comorbidities (SMLE = 0.32, P < .001) influenced disability onset approximately as strongly as stage of dementia. Smaller and publicly owned facilities provided superior environmental quality, which indirectly contributed to a delay in onset of walking and eating disability.

CONCLUSION

Environmental quality and extent of comorbidity are at least as important as progression of dementia in initiating or delaying the onset of disability.

Mobility of Vulnerable Elders (MOVE): study protocol to evaluate the implementation and outcomes of a mobility intervention in long-term care facilities

Background

Almost 90% of residents living in long-term care facilities have limited mobility which is associated with a loss of ability in activities of daily living, falls, increased risk of serious medical problems such as pressure ulcers, incontinence and a significant decline in health-related quality of life. For health workers caring for residents it may also increase the risk of injury. The effectiveness of rehabilitation to facilitate mobility has been studied with dedicated research assistants or extensively trained staff caregivers; however, few investigators have examined the effectiveness of techniques to encourage mobility by usual caregivers in long-term care facilities.

Methods/Design

This longitudinal, quasi-experimental study is designed to demonstrate the effect of the sit-to-stand activity carried out by residents in the context of daily care with health care aides. In three intervention facilities health care aides will prompt residents to repeat the sit-to-stand action on two separate occasions during each day and each evening shift as part of daily care routines. In three control facilities residents will receive usual care. Intervention and control facilities are matched on the ownership model (public, private for-profit, voluntary not-for-profit) and facility size. The dose of the mobility intervention is assessed through the use of daily documentation flowsheets in the health record. Resident outcome measures include: 1) the 30-second sit-to-stand test; 2) the Functional Independence Measure; 3) the Health Utilities Index Mark 2 and 3; and, 4) the Quality of Life - Alzheimer's Disease.

Discussion

There are several compelling reasons for this study: the widespread prevalence of limited mobility in this population; the rapid decline in mobility after admission to a long-term care facility; the importance of mobility to quality of life; the increased time (and therefore cost) required to care for residents with limited mobility; and, the increased risk of injury for health workers caring for residents who are unable to stand. The importance of these issues is magnified when considering the increasing number of people living in long-term care facilities and an aging population.

Trial Registration

This clinical trial is registered with ClinicalTrials.gov (trial registration number: NCT01474616).

A Survey of Nursing Home Organizational Characteristics Associated with Potentially Avoidable Hospital Transfers and Care Quality in One Large British Columbia Health Region

L’hospitalisation des résidents en maisons de soins infirmiers peut être futile aussi bien que coûteux, et il y a maintenant des preuves qui indiquent que le traitement des résidents des maisons de soins infirmiers en place donne de meilleurs résultats pour certaines conditions. Nous avons examiné les caractéristiques organisationnelles des installations que des récherches précédentes ont montré sont associées à des transferts de l’hôpital potentiellement évitables et avec une meilleure qualité de soins. En conséquence, nous avons mené une enquête transversale de l’administration des maisons de soins infirmiers dans Vancouver Coastal Health, une grande région sanitaire en la Colombie-Britannique. Le sondage portait sur les niveaux de dotation de personnel et l’organisation, l’accès aux médecins, les soins au fin de vie, et les facteurs influençant transferts de l’installation à l’hôpital. Un bon nombre des caractéristiques organisationnels modifiables, associés dans la littérature avec les transferts hospitaliers potentiellement évitables, et de meilleure qualité de soins, sont présents dans les maisons de soins infirmiers en la Colombie-Britannique. Cependant, leur présence n’est pas universelle, et certaines fonctionnalités sont particulièrement en défaut, en particulier l’organisation des soins médicaux et le planification et les services pour la fin de vie.

Complaints in for-profit, non-profit and public nursing homes in two Canadian provinces

BACKGROUND

Nursing homes provide long-term housing, support and nursing care to frail elders who are no longer able to function independently. Although studies conducted in the United States have demonstrated an association between for-profit ownership and inferior quality, relatively few Canadian studies have made performance comparisons with reference to type of ownership. Complaints are one proxy measure of performance in the nursing home setting. Our study goal was to determine whether there is an association between facility ownership and the frequency of nursing home complaints.

METHODS

We analyzed publicly available data on complaints, regulatory measures, facility ownership and size for 604 facilities in Ontario over 1 year (2007/08) and 62 facilities in British Columbia (Fraser Health region) over 4 years (2004-2008). All analyses were carried out at the facility level. Negative binomial regression analysis was used to assess the association between type of facility ownership and frequency of complaints.

RESULTS

The mean (standard deviation) number of verified/substantiated complaints per 100 beds per year in Ontario and Fraser Health was 0.45 (1.10) and 0.78 (1.63) respectively. Most complaints related to resident care. Complaints were more frequent in facilities with more citations, i.e., violations of the legislation or regulations governing a home, (Ontario) and inspection violations (Fraser Health). Compared with Ontario's for-profit chain facilities, adjusted incident rate ratios and 95% confidence intervals of verified complaints were 0.56 (0.27-1.16), 0.58 (0.34-1.00), 0.43 (0.21- 0.88), and 0.50 (0.30- 0.84) for for-profit single-site, non-profit, charitable, and public facilities respectively. In Fraser Health, the adjusted incident rate ratio of substantiated complaints in non-profit facilities compared with for-profit facilities was 0.18 (0.07-0.45).

INTERPRETATION

Compared with for-profit chain facilities, non-profit, charitable and public facilities had significantly lower rates of complaints in Ontario. Likewise, in British Columbia's Fraser Health region, non-profit owned facilities had significantly lower rates of complaints compared with for-profit owned facilities.

Hospitalization rates of nursing home residents and community-dwelling seniors in British Columbia

The overall use of acute care services by nursing home (NH) residents in Canada has not been well documented. Our objectives were to identify the major causes of hospitalization among NH facility residents and to compare rates to those of community-dwelling seniors. A retrospective cohort was defined using population-level health administrative data, including all individuals aged 65 years and older living in a British Columbia NH facility between April 1996 and March 1999. Hospitalization rates of NH residents were compared to estimated rates for community-dwelling seniors, using age- and sex-adjusted standardized incidence ratios (SIRs): SIR = 2.81 (95%CI: 2.71, 2.91) for femoral fractures, 1.96 (1.88, 2.04) for pneumonia, 0.73 (0.70, 0.76) for other heart disease, and 1.01 (0.99, 1.02) for all causes. NH residents have disproportionately higher rates of hospitalization for femoral fractures and pneumonia, with NH residents accounting for approximately one quarter of all femoral fracture hospitalizations of BC seniors.

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

Institutionalization of the Elderly in Canada suggested that efforts to address the underlying causes of age-related declines in health might negate the need for nursing homes. However, the prevalence of chronic disease has increased, and conditions like dementia mean that nursing homes are likely to remain important features of the Canadian health care system. A fundamental problem limiting the ability to understand how nursing homes may change to better meet the needs of an aging population was the lack of person-level clinical information. The introduction of interRAI assessment instruments to most Canadian provinces/territories and the establishment of the national Continuing Care Reporting System represent important steps in our capacity to understand nursing home care in Canada. Evidence from eight provinces and territories shows that the needs of persons in long-term care are highly complex, resource allocations do not always correspond to needs, and quality varies substantially between and within provinces.

Lifting the ‘Violence Veil’: Examining Working Conditions in Long-term Care Facilities Using Iterative Mixed Methods

Le présent document se concentre sur les méthodes mixtes nous avons utilisé pour comprendre conditions de travail de leur travailleurs dans les établissements de soins de longue durée. Nous avons mené une enquête auprès des syndiqués travailleurs de santé en Ontario (n= 917), et une autre enquête dans trois provinces (n= 948) et quatre pays Scandinaves (n= 1625). Neuf groupes de discussion avec les Canadiens ont eu lieu; les répondants ont été présentés avec des questions du sondage et aussi descriptive des résultats statistiques et ont été demandé: “Est-ce le reflet de votre expérience?” Les contraintes de temps pour les travailleurs et la fréquence des expériences des travailleurs de la violence physique et attentions sexuelles non désirées sont signalés. Nous discutons comment de le façon dont nous utilisé des méthodes qualitatives et quantitatives étè itératif. Nous avons trouvé pas seulement la cohérence des données mais aussi la divergence des données qui montrent comment une culture de la violence dans les établissements de soins de longue durée est acceptée par les travailleurs comme d’habitude. Comment le constat de la violence structurelle vu le jour et la signification profonde, le contexte et les idées qui proviennent de la combinaison de nos méthodes itératives sont discutées.

Disability management outcomes in the Ontario long-term care sector

INTRODUCTION

Optimal disability management practices supporting early and safe return-to-work involve the workplace adoption of formal policies and procedures to ensure the quality of disability management outcomes. In the Canadian province of Ontario, there are approximately 60,000 health care workers in 600 licensed facilities providing long-term residential care to approximately 75,000 elderly residents. Workers in this sector are exposed to high biomechanical demands arising from care-giving tasks and have a substantial risk of work-related disability. Over the period 2000-2006, many long-term care facilities in Ontario adopted disability management practices that encourage modified work arrangements. The objective of this study was to describe differences in modified work arrangements and disability outcomes in long-term care facilities in Ontario.

METHODS

Measures of disability episode outcomes are described for a representative sample of 32 Ontario long-term care facilities for two consecutive years 2005 and 2006. Data were obtained from a questionnaire survey of facilities, a survey of a representative sample of caregivers and administrative records from the provincial workers' compensation agency.

RESULTS

A total of 28,747 days of disability attributed to work-related conditions were experienced by 3,271 full-time equivalent staff in 2005 (28,034 days in 2006). Average total disability days were 922 per 100 full-time equivalent staff in 2005 and 889 per 100 full-time equivalent staff in 2006. Disability compensation expenditures, measured as wage replacement benefits received by disabled workers, were estimated to be $72,332 per 100 full-time equivalent staff in 2005 and $64,619 per 100 full-time equivalent staff in 2006. On average, approximately 60% of all disability days were managed by modified duty arrangements and the proportion of total disability days managed by modified duty arrangements for each facility was correlated between the two observation years.

CONCLUSIONS

Across facilities, there was no evidence that modified duty arrangements were associated with lower disability compensation expenditures and there was mixed evidence that modified duty was associated with a lower burden of disability. In this setting, disability days managed by modified duty arrangements were not accurately documented in worker's compensation claim records.

The influence of facility ownership structure on individual responding to stress: a multilevel model

Few studies have investigated the effect of health-care facility ownership on the relationship between patient stressors and coping strategies. The purpose of this study was to investigate whether haemodialysis (HD) patient stressors and coping strategies differ by type of health-care facility ownership, and whether such ownership has a cross-level moderating effect between stressors and coping strategies. We used the Haemodialysis Stressor Scale and the Jalowiec Coping Scale; primary data were collected by interviewing 2642 HD patients 15 years or older on dialysis for at least three months from 27 HD centres. One-way analysis of variance and hierarchical linear modelling were used to attain the research purposes. HD patients from religious-based hospitals had higher stress related to their physical symptoms, dependency on medical staff, role ambiguity and blood vessel problems than those differently owned facilities. Patients in veterans and army (VA) hospitals had higher stress related to food and fluid restriction and dependency on medical staff than private centres. Patients in religious-based hospitals had significantly higher coping scores, followed by VA and private HD centres. Religion-based ownership might serve as a cross-level moderator for patients perceiving role ambiguity stress and using problem-oriented, support seeking and isolated thought-coping strategies.

Intervention research in highly unstable environments

This article highlights issues and presents strategies for conducting intervention research in highly unstable environments such as schools, critical care units, and long-term care facilities. The authors draw on their own experiences to discuss the challenges that may be encountered in highly unstable settings. The concept of validity provides a framework for understanding the value of addressing the many methodological issues that can emerge in settings characterized by instability. We explain unstable environments by elaborating on knowable elements that contribute to instability. Strategies are provided for improving success of intervention research in unstable settings by carrying out an environmental assessment prior to beginning a study.

Hospitalizations at the end of life among long-term care residents

BACKGROUND

Concerns have been raised over transfers into acute care hospitals at the end of life. The objective of this study was to examine (a) the extent of and (b) factors related to hospitalization in the last 180 days before death among long-term care (LTC) residents.

METHODS

The study included all LTC residents from 60 facilities in the province of Manitoba, Canada, who died in 2003/04 (N = 2,379), with data derived from administrative health care records. Multilevel regression analyses were conducted to examine the relationship between resident and facility characteristics and the following: location of death (in hospital vs the LTC facility); whether individuals were hospitalized in the last 180 days before death; and number of hospital days in the last 180 days.

RESULTS

Overall, 19.1% of LTC residents died in hospital; however, 40.7% were hospitalized at least once in the last 6 months before death. Several resident characteristics (age, trajectory group, and level of care) were related to the outcome measures. Living in a not-for-profit LTC facility decreased the odds of dying in hospital (adjusted odds ratio [OR] = 0.589; 95% confidence interval [CI] = 0.402-0.863) or being hospitalized (adjusted OR = 0.647; 95% CI = 0.452-0.926).

CONCLUSIONS

Hospitalization at the end of life is common among LTC residents, and the likelihood of hospital transfers is increased for residents who are younger, have organ failure, lower care level needs, as well as among those who live in for-profit facilities. Particular emphasis should, therefore, be placed on targeting these groups to determine the appropriateness of hospital admission and possible ways of reducing transfers.

Predictors of nursing home hospitalization: a review of the literature

Hospitalization of nursing home residents is costly and potentially exposes residents to iatrogenic disease and psychological harm. This article critically reviews the association between the decision to hospitalize and factors related to the residents' welfare and preferences, the providers' attitudes, and the financial implications of hospitalization. Regarding the resident's welfare, factors associated with hospitalization included sociodemographics, health characteristics, nurse staffing, the presence of ancillary services, and the use of hospices. Patient preferences (e.g., advance directives) and provider attitudes (e.g., overburdening of staff) were also associated with increased hospitalization. Finally, financial variables related to hospitalization included nursing home ownership status and state Medicaid policies, such as nursing home payment rates and bed-hold requirements. Most studies relied on potentially confounded research designs, which leave open the issue of selection bias. Nevertheless, the existing literature asserts that nursing home hospitalizations are frequent, often preventable, and related to facility practices and state Medicaid policies.