Redesigning acute care for cognitively impaired older adults: Optimizing health care services

Simulation learning to train healthcare students in person-centered dementia care

In coming decades, healthcare providers will treat a greater number of individuals living with Alzheimer's Disease and related dementias than ever. Simulation-based learning provides experiential learning opportunities to enhance clinical training, but little is known about how dementia simulation training improves understanding of dementia or how it changes in participants' ability to deliver high-quality healthcare to individuals living with dementia. In this study, we examine how a simulation training program may prepare healthcare trainees to treat individuals living with dementia. We conducted eight in-depth, one-on-one interviews with healthcare trainees who participated in the Virtual Dementia Tour (VDT) program and faculty who added VDT to their curricula, and also examined 20 reflection papers from students following participation in VDT. A thematic analysis of qualitative data led us to three themes: 1) dementia simulation complements and enhances traditional teaching methods, 2) dementia simulation helps students to understand the experiences of people living with dementia, and 3) experiential learning inspired students to reflect on actions they would take as clinicians and leaders to support individuals living with dementia and their families. Based on these findings, we propose a modified transformative learning process for dementia simulation training with healthcare students.

Understanding and improving experiences of care in hospital for people living with dementia, their carers and staff: three systematic reviews

Background

Being in hospital can be particularly confusing and challenging not only for people living with dementia, but also for their carers and the staff who care for them. Improving the experience of care for people living with dementia in hospital has been recognised as a priority.

Objectives

To understand the experience of care in hospital for people living with dementia, their carers and the staff who care for them and to assess what we know about improving the experience of care.

Review methods

We undertook three systematic reviews: (1) the experience of care in hospital, (2) the experience of interventions to improve care in hospital and (3) the effectiveness and cost-effectiveness of interventions to improve the experience of care. Reviews 1 and 2 sought primary qualitative studies and were analysed using meta-ethnography. Review 3 sought comparative studies and economic evaluations of interventions to improve experience of care. An interweaving approach to overarching synthesis was used to integrate the findings across the reviews.

Data sources

Sixteen electronic databases were searched. Forwards and backwards citation chasing, author contact and grey literature searches were undertaken. Screening of title and abstracts and full texts was performed by two reviewers independently. A quality appraisal of all included studies was undertaken.

Results

Sixty-three studies (reported in 82 papers) were included in review 1, 14 studies (reported in 16 papers) were included in review 2, and 25 studies (reported in 26 papers) were included in review 3. A synthesis of review 1 studies found that when staff were delivering more person-centred care, people living with dementia, carers and staff all experienced this as better care. The line of argument, which represents the conceptual findings as a whole, was that ‘a change of hospital culture is needed before person-centred care can become routine’. From reviews 2 and 3, there was some evidence of improvements in experience of care from activities, staff training, added capacity and inclusion of carers. In consultation with internal and external stakeholders, the findings from the three reviews and overarching synthesis were developed into 12 DEMENTIA CARE pointers for service change: key institutional and environmental practices and processes that could help improve experience of care for people living with dementia in hospital.

Limitations

Few of the studies explored experience from the perspectives of people living with dementia. The measurement of experience of care across the studies was not consistent. Methodological variability and the small number of intervention studies limited the ability to draw conclusions on effectiveness.

Conclusions

The evidence suggests that, to improve the experience of care in hospital for people living with dementia, a transformation of organisational and ward cultures is needed that supports person-centred care and values the status of dementia care. Changes need to cut across hierarchies and training systems to facilitate working patterns and interactions that enable both physical and emotional care of people living with dementia in hospital. Future research needs to identify how such changes can be implemented, and how they can be maintained in the long term. To do this, well-designed controlled studies with improved reporting of methods and intervention details to elevate the quality of available evidence and facilitate comparisons across different interventions are required.

Study registration

This study is registered as PROSPERO CRD42018086013.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 43. See the NIHR Journals Library website for further project information. Additional funding was provided by the NIHR Collaboration for Leadership in Applied Health Research and Care South West Peninsula.

The experiences of hospital staff who provide care for people living with dementia: A systematic review and synthesis of qualitative studies

AIMS AND OBJECTIVES

To systematically review and synthesise qualitative data from studies exploring the experiences of hospital staff who care for people living with dementia (Plwd).

BACKGROUND

In hospital, the number of Plwd continues to rise; however, their experiences of care remain problematic. Negative experiences of care are likely to contribute to poorer mental and physical health outcomes for Plwd while in hospital and after discharge. Experiences of the hospital staff who care for Plwd can also be poor or unrewarding. It is important to understand the experiences of staff in order to improve staff well-being and ultimately the experience of care for Plwd while in hospital.

DESIGN

Systematic review and evidence synthesis of qualitative research.

DATA SOURCES

We searched 16 electronic databases in March 2018 and completed forward and backward citation chasing.

METHODS

Eligible studies explored the experiences of paid and unpaid staff providing care in hospital for Plwd. Study selection was undertaken independently by two reviewers, and quality appraisal was conducted. We prioritised included studies according to richness of text, methodological rigour and conceptual contribution. We adopted approaches of meta-ethnography to analyse study findings, creating a conceptual model to represent the line of argument.

FINDINGS

Forty-five studies reported in 58 papers met the inclusion criteria, and of these, we prioritised 19 studies reported in 24 papers. The line of argument was that Institutions can improve staff experiences of care for Plwd by fostering person-centred care (PCC). PCC aligned with staff perceptions of 'good care'; however, staff often felt prevented from providing PCC because of care cultures that prioritised tasks, routines and physical health. Staff experienced conflict over the care they wanted to give versus the care they were able to give, and this caused moral distress. When staff were able to provide PCC, this increased experiences of job satisfaction and emotional well-being.

CONCLUSIONS

Person-centred care not only has the potential to improve the experience of care for Plwd and their carers, but can also improve the experiences of hospital staff caring for Plwd. However, without institutional-level changes, hospital staff are often unable to provide PCC even when they have the experience and knowledge to do so.

IMPLICATIONS FOR PRACTICE

Institutional-level areas for change include the following: training; performance indicators and ward cultures that prioritise psychological needs alongside physical needs; adequate staffing levels; inclusive approaches to carers; physical environments that promote familiarisation, social interaction and occupation; systems of documentation about individual needs of Plwd; and cultures of sharing knowledge across hierarchies.

Systems Delivery Innovation for Alzheimer Disease

OBJECTIVE

The authors describe a comprehensive care model for Alzheimer disease (AD) that improves value within 1-3 years after implementation by leveraging targeted outpatient chronic care management, cognitively protective acute care, and timely caregiver support.

METHODS

Using current best evidence, expert opinion, and macroeconomic modeling, the authors designed a comprehensive care model for AD that improves the quality of care while reducing total per capita healthcare spending by more than 15%. Cost savings were measured as reduced spending by payers. Cost estimates were derived from medical literature and national databases, including both public and private U.S. payers. All estimates reflect the value in 2015 dollars using a consumer price index inflation calculator. Outcome estimates were determined at year 2, accounting for implementation and steady-state intervention costs.

RESULTS

After accounting for implementation and recurring operating costs of approximately $9.5 billion, estimated net cost savings of between $13 and $41 billion can be accomplished concurrently with improvements in quality and experience of coordinated chronic care ($0.01-$6.8 billion), cognitively protective acute care ($8.7-$26.6 billion), timely caregiver support ($4.3-$7.5 billion), and caregiver efficiency ($4.1-$7.2 billion).

CONCLUSION

A high-value care model for AD may improve the experience of patients with AD while significantly lowering costs.

A Multicomponent Model to Improve Hospital Care of Older Adults with Cognitive Impairment: A Propensity Score-Matched Analysis

OBJECTIVES

To determine whether a multicomponent intervention improves care in hospitalized older adults with cognitive impairment.

DESIGN

One-year retrospective chart review with propensity score matching on critical demographic and clinical variables was used to compare individauls with cognitive impairmenet on intervention and nonintervention units.

SETTING

Large tertiary medical center.

PARTICIPANTS

All hospitalized individuals age 65 and older with cognitive impairment admitted to medicine who required constant or enhanced observation for behavioral and psychological symptoms.

INTERVENTION

Multicomponent intervention (geographic unit cohorting, multidisciplinary approach, patient engagement specialists (PES), staff education) or usual care.

MEASUREMENTS

In-hospital mortality, length of stay, readmission, management of behavioral disturbances.

RESULTS

After propensity score matching, 476 of the 712 intervention visits were pair-matched with 476 of the 558 usual care visits. Matching was successful in balancing baseline covariates between intervention and usual care units. Individuals admitted to the intervention unit had lower in-hospital mortality (1.1% vs 2.9%, p=0.05) and shorter stays (5.0 vs 5.8 days, p=0.04). There was no difference in discharge home (p=0.90) or 30-day readmission rates (p=0.44). Individuals on the intervention unit were less likely than those receivng usual care to have an order for constant (12.0% vs 45.8%, p<0.01) or enhanced (22.1% vs 79.6%, p<0.01) observation, to be taking benzodiazepines (26.3% vs 38.0%, p<0.01), to be taking nothing by mouth (29.6% vs 40.8%, p=0.01), to be on bedrest (17.0% vs 25.8%, p=0.01), to be taking antipsychotics (41.2% vs 54.0%, p<0.01), or to have restraints (3.2% vs 6.9%, p=.01).

CONCLUSION

A multicomponent intervention of geographic cohorting, multidisciplinary approach, PES, and staff education may offer a new paradigm in the management of hospitalized older adults with cognitive impairment.

'Dementia-friendly communities' and being dementia friendly in healthcare settings

PURPOSE OF REVIEW

This review discusses the concept of 'dementia-friendly communities' and summarizes the latest research and practice around such communities. This review also highlights important topic areas to be considered to promote dementia friendliness in healthcare settings.

RECENT FINDINGS

Definitions of 'dementia-friendly communities' reflect the contemporary thinking of living with dementia (e.g., dementia as a disability, equal human rights, a sense of meaning). Existing research has covered a wide range of topic areas relevant to 'dementia-friendly communities'. However, these studies remain qualitative and exploratory by nature and do not evaluate how dementia-friendly communities impact health and quality of life of people living with dementia and their caregivers. In healthcare settings, being dementia friendly can mean the inclusion of people with dementia in treatment discussion and decision-making, as well as the provision of first, adequate and appropriate service to people with dementia at an equivalent standard of any patient, second, person-centered care, and third, a physical environment following dementia-friendly design guidelines.

SUMMARY

Research incorporating more robust study designs to evaluate dementia-friendly communities is needed. Being dementia-friendly in healthcare settings requires improvement in multiple areas - some may be achieved by environmental modifications while others may be improved by staff education.

Communication in dementia care

Dementia is a progressive neurodegenerative illness that affects a growing number of older adults in our country. We discuss ways to improve the management of persons with dementia within current healthcare models. Specifically, we argue that structured communication at regular intervals is essential for dementia care at all phases of illness. We emphasize the need for a single healthcare provider to take on a central role in organizing communication between patient, family and other healthcare providers in the outpatient setting. We also emphasize the need for healthcare providers to begin conversations about prognosis, care transitions and end of life early while balancing these difficult conversations with a hopeful attitude of realistic optimism that the disease can be managed.