Sharing clinical information across care settings: the birth of an integrated assessment system

Predictors of Pain and Mood Disturbances Among Older People in Custody Using an interRAI Assessment

The population of people in federal custody in Canada is aging. Those in custody report experiencing poorer health and high rates of chronic health conditions. Two health concerns that are disproportionately higher among those in custody are mood disorders and pain. This cross-sectional study examined health indicators associated with pain and depressive symptoms among older people (50 years and above) from multiple facilities and security levels in federal custody in Canada. Participants were assessed using the interRAI Emergency Department Contact Assessment, which captures key health indicators. Chi square and logistic regression analyses were conducted to describe the population and identify health indicators associated with mood- and pain-related outcomes, respectively. Of the 1,422 participants in this study, the majority (55%) experienced pain and at least 1 out of 5 experienced depressive symptoms. Health indicators associated with depressive symptoms and/or pain were functional measures, including mobility, managing medication(s), and dyspnea. Depressive symptoms and pain are highly prevalent among older adults in federal custody. The relationship between functional health, depressive symptoms, and pain highlights the importance of interprofessional health care and biopsychosocial intervention(s).

Exploring subjective quality-of-life indicators in long-term care facilities: a mixed-methods research protocol

INTRODUCTION

Improving quality of life has become a priority in the long-term care (LTC) sector internationally. With development and implementation guidance, standardised quality-of-life monitoring tools based on valid, self-report surveys could be used more effectively to benefit LTC residents, families and organisations. This research will explore the potential for subjective quality-of-life indicators in the interRAI Self-Reported Quality of Life Survey for Long-Term Care Facilities (QoL-LTCF).

METHODS AND ANALYSIS

Guided by the Medical Research Council Framework, this research will entail a (1) modified Delphi study, (2) feasibility study and (3) realist synthesis. In study 1, we will evaluate the importance of statements and scales in the QoL-LTCF by administering Delphi surveys and focus groups to purposively recruited resident and family advisors, researchers, and LTC clinicians, staff, and leadership from international quality improvement organisations. In study 2, we will critically examine the feasibility and implications of risk-adjusting subjective quality-of-life indicators. Specifically, we will collect expert stakeholder perspectives with interviews and apply a risk-adjustment methodology to QoL-LTCF data. In study 3, we will iteratively review and synthesise literature, and consult with expert stakeholders to explore the implementation of quality-of-life indicators.

ETHICS AND DISSEMINATION

This study has received approval through a University of Waterloo Research Ethics Board and the Social and Societal Ethics Committee of KU Leuven. We will disseminate our findings in conferences, journal article publications and presentations for a variety of stakeholders.

Using interRAI Assessment for Research: Developing a National Research Agenda in Aotearoa New Zealand

interRAI provides a suite of standardized, validated instruments used to assess health and psychosocial well-being, and to inform person-centered care planning. Data obtained from these standardized tools can also be used at a population level for research and to inform policy, and interRAI is currently used in more than 40 countries globally. We present a brief overview of the use of interRAI internationally within research and policy settings, and then introduce how interRAI is used within the universal public health system in Aotearoa New Zealand (NZ), including considerations relating to Māori, the Indigenous people of NZ. In NZ, improvement in interRAI data utilization for research purposes was called for from aged care, health providers, and researchers, to better use these data for quality improvement and health advancement for New Zealanders. A national research network has been established, providing a medium for researchers to form relationships and collaborate on interRAI research with a goal of translating routinely collected interRAI data to improve clinical care, patient experience, service development, and quality improvement. In 2023, the network members met (hybrid: in-person and online) and identified research priorities. These were collated and developed into a national interRAI research agenda by the NZ interRAI Research Network Working Group. Research priorities included reviewing the interRAI assessment processes, improving methods for data linkage to national data sets, exploring how Indigenous Data Sovereignty can be upheld, as well as a variety of clinically focused research topics. Implications for Practice, Policy, and Research: This appears to be the first time national interRAI research priorities have been formally identified. Priorities identified have the potential to inform quality and clinical improvement activities and are likely of international relevance. The methodology described to cocreate the research priorities will also be of wider significance for those looking to do so in other countries.

First Evidence on the Validity of the Complexity Index Derived from the Resident Assessment Instrument for Home Care in Home Care Patients

OBJECTIVES

Recently, a Complexity Index (CI), based on the multidimensional complexity model and derived from the Resident Assessment Instrument for Home Care (interRAI HC) was proposed as a decision-support tool to help frontline health care professionals in their clinical evaluation to identify and analyze complex situations. This study aims to test the CI: (1) concurrent validity with another measure of complexity (ie, the COMID), (2) convergent validity with related constructs assessed by interRAI HC scales (eg, depression), (3) divergent validity (comparison between CI-COMID and scales-COMID correlations), and (4) predictive validity on coordination meetings.

DESIGN

A cross-sectional observational design was used for a secondary analysis of interRAI HC and COMID data collected in routine home care nursing practice (July-December 2021).

SETTING AND PARTICIPANTS

Participants were community-dwelling adults receiving home care, with full interRAI HC and COMID assessments (N = 3533).

METHODS

Correlational analyses were conducted to test the concurrent validity of the CI (with the COMID) and the convergent and divergent validity of the CI (with interRAI HCSwitzerland scales, eg, Depression Rating Scale, Method for Assigning Priority Levels, and a Frailty Index). A receiver operating characteristic (ROC) analysis was conducted to test the discriminative ability of CI on specific professional team coordination meetings.

RESULTS

Results showed that the CI correlated positively and strongly with the COMID (ρ = 0.691, P < .001, concurrent validity), positively with all the tested scales (P < .001, convergent validity), whereas the CI-COMID correlation was higher than the interRAI HC scales-COMID correlations (divergent validity). The ROC analysis showed the CI had a high area under the curve (AUC = 0.719, predictive validity).

CONCLUSIONS AND IMPLICATIONS

The CI demonstrates good validity properties with a strong correlation with the COMID and a high predictive value for coordination meeting. It is distinct from the other interRAI HC scales and has its place among them to support the clinical analysis of complex situations.

Aging of persons with schizophrenia: analysis of a national dataset

OBJECTIVES

The number of older adults suffering from schizophrenia is increasing. Despite this, less than 1% of published studies about schizophrenia focus on those older than 65 years. Research indicates these individuals may age differently from the general population due to lifestyle, medication factors, and effects of the disease itself. We aimed to analyze whether schizophrenia was associated with a younger age at first assessment for social care as a proxy measure for accelerated aging.

DESIGN

We analyzed the effect of schizophrenia diagnosis, demographics, mood, comorbidities, falls, cognition, and substance use on age at first assessment for social care using linear regression.

PARTICIPANTS

We used data from 168,780 interRAI Home Care and Long-Term Care Facility (HC; LTCF) assessments completed from July 2013 to June 2020.

RESULTS

When corrected for confounding factors, schizophrenia contributed to age at first assessment being 5.5 years younger (p = 0.0001 Cohen's D = 1.0) than in people free from schizophrenia. Its effect on age at first assessment was second only to smoking. People suffering from schizophrenia also required a higher level of care (long-term care facility rather than home care). People suffering from schizophrenia had significantly higher rates of diabetes mellitus and chronic obstructive pulmonary disease but otherwise had lower rates of comorbidity than people free from schizophrenia who required care.

CONCLUSIONS

Aging with schizophrenia is associated with needing increased social care at a younger age. This has implications for social spending and developing policies to decrease frailty in this population.

[The need for a multidimensional assessment in frail patients]

A comprehensive geriatric assessment (CGA) encompasses medical, psychosocial, and functional aspects that facilitate comprehensive treatment planning and therapy for older adults. It goes beyond a simple screening and typically includes evaluating functionality, mobility, cognition, and emotions, with additional dimensions being relevant based on specific goals. In essence, CGA is suitable for recognizing and evaluating the complexity of frailty and devising suitable interventions.CGA represents a structured way to map the complexity of frail older adults. Employing a multidimensional strategy, it enables the early identification of frailty, facilitating tailored treatment plans, risk assessment and the monitoring of changes over time. A CGA can be conducted in different settings, including acute geriatric wards, in form of a consultation in non-geriatric wards, or directly in outpatient settings and has proven effective in improving care among frail patients.A recent trend in CGA programs involves the use of virtual assessments through telemedicine. Communication occurs via telephone or electronic health records, with each evaluation being checked by a physician. The latest evidence indicates substantial research potential in automated data collection and AI-driven analysis.

Development of a Preventive Health Screening Procedure Enabling Supportive Service Planning for Home-Dwelling Older Adults (PORI75): Protocol for an Action Research Study

BACKGROUND

In Finland, at least 1 in 4 residents will be >75 years of age in 2030. The national aging policy has emphasized the need to improve supportive services to enable older people to live in their own homes for as long as possible.

OBJECTIVE

This study aimed to develop a preventive health screening procedure for home-dwelling older adults aged 75 years to enable the use of clinical patient data for purposes of strategic planning of supportive services in primary care.

METHODS

The action research method was applied to develop the health screening procedure with selected validated health measures in cooperation with the local practicing interprofessional health care teams from 10 primary care centers in the Social Security Center of Pori, Western Finland (99,485 residents, n=11,938, 12% of them >75 years). The selection of evidence-based validated health measures was based on the national guide to screen factors increasing fall risk and the national functioning measures database. The cut-off points of the selected health measures and laboratory tests were determined in consecutive consensus meetings with the local primary care physicians, with decisions based on internationally validated measures, national current care guidelines, and local policies in clinical practice.

RESULTS

The health screening procedure for 75-year-old residents comprised 30 measures divided into three categories: (1) validated self-assessments (9 measures), (2) nurse-conducted screenings (14 measures), and (3) laboratory tests (7 measures). The procedure development process comprised the following steps: (1) inventory and selection of the validated health measures and laboratory tests, (2) training of practical nurses to perform screenings for the segment of 75-year-old residents and to guide them to possible further medical actions, (3) creation of research data from clinical patient data for secondary use purposes, (4) secondary data analysis, and (5) consensus meeting after the pilot test of the health screening procedure for 75-year-old residents procedure in 2019 based on the experiences of health care professionals and collected research data.

CONCLUSIONS

The developed preventive health screening procedure for 75-year-old residents enables the use of clinical patient data for purposes of strategic planning of supportive services in primary care if the potential bias by a low participation rate is controlled.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/48753.

The Community Rehabilitation Assessment: patient and clinician-reported outcomes in ambulatory rehabilitation

Objectives

The interRAI Community Rehabilitation Assessment (CRA) is a comprehensive health assessment designed to collect essential health and function information for rehabilitation care planning, benchmarking, and evaluation of clinic and home-based programs. A portion of the CRA is completed through patient self-report. The objective of this study was to demonstrate how the CRA can be used to describe the baseline clinical characteristics of patients participating in ambulatory rehabilitation programs and measure change across numerous domains of function, health, and wellbeing over time.

Design

Cohort study.

Setting and participants

In total, 709 patients were assessed with the CRA across 25 ambulatory clinics in Ontario, Canada between January 1st, 2018, to December 31st, 2018. We examined sub-groups of patients receiving rehabilitation following stroke (n = 82) and hip or knee total joint replacement (n = 210).

Methods

Frequency responses and means were compared between admission and discharge from the ambulatory rehabilitation programs. Measures of interest included self-reported difficulty in completing instrumental activities of daily living, locomotion, fear of falling, and pain.

Results

Significant improvement relative to at admission was detected for the overall cohort and both sub-samples on individual instrumental activities of daily living, stair difficulty, use of mobility aides, distance walked, fear of falling, and pain.

Conclusions and implications

The standardized and comparable information collected by the CRA is expected to provide clinicians, clinic, and health system administrators with essential health and function information that can be used for care planning, benchmarking, and evaluation.

The interRAI COVID-19 vulnerability screener: Results of a health surveillance initiative for vulnerable adults in the community during the COVID-19 pandemic

During the pandemic, the interRAI COVID-19 Vulnerability Screener (CVS) was used to identify community-dwelling older adults or adults with disabilities at risk of negative outcomes and facilitate triage for follow-up with health/social services. The interRAI CVS, a standardized self-report instrument administered virtually by a lay-person, includes COVID-19-related items and psychosocial and physical vulnerability. Our objective was to describe those assessed and identify sub-groups at highest risk of adverse outcomes. Seven community-based organizations in Ontario, Canada, implemented the interRAI CVS. We used descriptive statistics to report results and created a priority indicator for monitoring and/or intervention based on possible COVID-19 symptoms and psychosocial/physical vulnerabilities. We used logistic regression to examine the association between priority level and risk of poor outcomes using fair/poor self-rated health as a proxy measure. The sample included 942 adults assessed (April-November 2020; mean age=79). About 10% of individuals reported potential COVID-19 symptoms and <1% had a positive COVID-19 test/diagnosis. Of those with psychosocial/physical vulnerabilities (73.1%), most common were depressed mood (20.9%), loneliness (21.6%), and limited access to food/medications (7.5%). Overall, 45.7% had a recent doctor or nurse practitioner visit. Odds of fair/poor self-reported health were highest among those who reported both possible symptoms of COVID-19 and psychosocial/physical vulnerabilities (OR 10.9, 95% CI 5.96-20.12) compared to those with neither symptoms nor psychosocial/physical vulnerabilities. The sample represents a population largely unaffected by COVID-19 itself but with identified vulnerabilities. The interRAI CVS allows community providers to stay connected and obtain a better understanding of vulnerable individuals' needs during the pandemic.

Digital health technologies supporting the application of comprehensive geriatric assessments in long-term care settings or community care: A systematic review

Objective

To provide high-quality elderly care, digital health technologies (DHTs) can potentially assist in reaching the full capacity of comprehensive geriatric assessments (CGAs) to improve communication and data transfer on patients' medical and treatment plan information and health decision-making. This systematic review aimed to describe the evidence on the feasibility and usability, efficacy and effectiveness, and implementation outcomes of DHTs developed to facilitate the administration of CGAs for long-term care settings or community care and to describe their technical features and components.

Methods

A search strategy was conducted in three databases, targeting studies evaluating the DHTs facilitating the administration of CGAs used in long-term care settings or community care. Studies in English and Spanish published up to 5 April 2023 were considered.

Results

Four DHTs supporting the administration of the CGAs were identified. Limited information was found on the technical features and required hardware. Some of the barriers identified regarding usability can be overcome with novel technologies; however, training of health professionals on the assessments and staff knowledge regarding the purpose of the data collected are not technology related and need to be addressed.

Conclusions

Barriers regarding usability were related to experienced difficulties navigating the software, unstable network connectivity, and length of the assessment. Feasibility obstacles were associated with the lack of training to use the DHT, availability and accessibility to hardware (e.g. laptops), and lack of insight into the clinical benefits of collected data. Further research must focus on these areas to improve the implementation and usefulness of these DHTs.

Multistate Competing Risk Analysis of Transition Back to the Community Among Long-Term Care Home (LTC) Destined Patients: A Brief Report

OBJECTIVE

The demand for long-term care in community and facilitybased settings in Canada is expected to increase with population growth. The Toronto Grace Health Center piloted an intervention program that aims to support return to the community of acute hospital patients designated for LTC placement. We investigated whether this program was effective in transitioning the program patients back to their homes in the community and the factors associated with transitioning patients to different destinations.

METHOD

We performed a competing risk multi-state analysis of 111 patients enrolled into the Harbour Light (HL) transitional unit program between January 2020 and June 2023.

RESULTS

At the time of the study, 92 enrolled patients had been discharged and of those these, 48.9% (45) were successfully transitioned back to their private home in the community. The remaining 51.1% (46) were discharged to other destinations. Being a female was the only positive predictor of transitioning back home. Higher CPS scores (HR 0.53, 95% CI 0.31-0.88), PADDRS scale of 1+, and higher ADL Hierarchy scale, strongly predicted lower odds of transitioning back to the community.

CONCLUSION

Within the context of rising LTC bed demand and lengthy waiting time in Canada, with appropriate measures, this program successfully transitioned LTC home bound persons back to their homes. If replicable on a large scale, this could provide short and long-term solution to LTC bed demand in Canada.

Interrater reliability of the BelRAI Social Supplement in Flanders, Belgium: Simultaneous rating of community-dwelling adults with care needs during COVID-19

Background

The BelRAI Screener is a short-form assessment consolidating internationally validated interRAI items focusing on physical and psychological aspects of functioning and problems with activities of daily living. It was fully implemented in the Flemish home care setting as of June 2021. In a biopsychosocial model for developing a personalized and effective care plan social and contextual aspects are considered equally important to biomedical ones. Thus, a social supplement to the BelRAI Screener was collaboratively developed with stakeholders and tested to gather additional information on the social context of community-dwelling adults with care needs.

Objective and methods

To examine the interrater reliability of the BelRAI Social Supplement in Flanders, Belgium, an observational study was conducted using a convenience sample. The method of simultaneous rating was used due to strict COVID-19 guidelines at the time and to minimize assessment burden. Fifty two community-dwelling adults requesting home care support were simultaneously assessed by two independent assessors during home visits. Interrater reliability was tested on all 80 items of the BelRAI Social Supplement using observed agreement, kappa coefficients, and intraclass correlation coefficients.

Results

The kappa mean (0.74) and median (0.79) values for nominal items, show substantial agreement, while the kappa mean and median values for ordinal items were 0.81 and 0.90, which correspond to almost perfect agreement. Following the traditional cut-off points for the interpretation of the kappa statistic, reliability was almost perfect (κ &gt; 0.81) for 49% of all items, substantial (0.60 &lt; κ ≤ 0.80) for 33%, moderate (0.40 &lt; κ ≤ 0.60) for 8%, and poor (κ &lt; 0.40) for 10%. The majority of items with poor kappa value, showed a high observed agreement, reflecting homogeneity of the sample rather than poor agreement.

Conclusion

The strength of kappa agreement for the items in this version of the BelRAI Social Supplement is generally substantial to almost perfect, with high proportions of observed agreement. COVID-19 restrictions had a large impact on the planning and execution of the home visits. A final optimization of the instrument and accompanying manual according to the findings will result in an improved version ready for nation-wide implementation.

Developing the Patient Falls Risk Report: A Mixed-Methods Study on Sharing Falls-Related Clinical Information from Home Care with Primary Care Providers

If interRAI home care information were shared with primary care providers, care provision and integration could be enhanced. The objective of this study was to co-develop an interRAI-based clinical information sharing tool (i.e., the Patient Falls Risk Report) with a sample of primary care providers. This mixed-methods study employed semi-structured interviews to inform the development of the Patient Falls Risk Report and online surveys based on the System Usability Scale instrument to test its usability. Most of the interview sample (n = 9) believed that the report could support patient care by sharing relevant and actionable falls-related information. However, criticisms were identified, including insufficient detail, clarity, and support for shared care planning. After incorporating suggestions for improvement, the survey sample (n = 27) determined that the report had excellent usability with an overall usability score of 83.4 (95% CI = 78.7-88.2). By prioritizing the needs of end-users, sustainable interRAI interventions can be developed to support primary care.

Developing an evidence-informed model of long-term life care at home for older adults with medical, functional and/or social care needs in Ontario, Canada: a mixed methods study protocol

INTRODUCTION

The COVID-19 pandemic exacerbated existing challenges within the Canadian healthcare system and reinforced the need for long-term care (LTC) reform to prioritise building an integrated continuum of services to meet the needs of older adults. Almost all Canadians want to live, age and receive care at home, yet funding for home and community-based care and support services is limited and integration with primary care and specialised geriatric services is sparse. Optimisation of existing home and community care services would equip the healthcare system to proactively meet the needs of older Canadians and enhance capacity within the hospital and residential care sectors to facilitate access and reduce wait times for those whose needs are best served in these settings. The aim of this study is to design a model of long-term 'life care' at home (LTlifeC model) to sustainably meet the needs of a greater number of community-dwelling older adults.

METHODS AND ANALYSIS

An explanatory sequential mixed methods design will be applied across three phases. In the quantitative phase, secondary data analysis will be applied to historical Ontario Home Care data to develop unique groupings of patient needs according to known predictors of residential LTC home admission, and to define unique patient vignettes using dominant care needs. In the qualitative phase, a modified eDelphi process and focus groups will engage community-based clinicians, older adults and family caregivers in the development of needs-based home care packages. The third phase involves triangulation to determine initial model feasibility.

ETHICS AND DISSEMINATION

This study has received ethics clearance from the University of Waterloo Research Ethics Board (ORE #42182). Results of this study will be disseminated through peer-reviewed publications and local, national and international conferences. Other forms of knowledge mobilisation will include webinars, policy briefs and lay summaries to elicit support for implementation and pilot testing phases.

Changes in Urinary Continence After Admission to a Complex Care Setting: A Multistate Transition Model

OBJECTIVES

To examine changes in urinary continence for post-acute, Complex Continuing Care hospital patients from time of admission to short-term follow-up, either in hospital or after discharge to long-term care or home with services.

DESIGN

Retrospective cohort study of patients in Complex Continuing Care hospitals using clinical data collected with interRAI Minimum Data Set 2.0 and interRAI Resident Assessment Instrument Home Care.

SETTING AND PARTICIPANTS

Adults aged 18 years and older, admitted to Complex Continuing Care hospitals in Ontario, Canada, between 2009 and 2015 (n = 78,913).

METHODS

A multistate transition model was used to characterize the association between patient characteristics measured at admission and changes in urinary continence state transitions (continent, sometimes continent, and incontinent) between admission and follow-up.

RESULTS

The cohort included 27,896 patients. At admission, 9583 (34.3%) patients belonged to the continent state, 6441 (23.09%) patients belonged to the sometimes incontinent state, and the remaining 11,872 (42.6%) patients belonged to the incontinent state. For patients who were continent at admission, the majority (62.7%) remained continent at follow-up. However, nearly a quarter (23.9%) transitioned to the sometimes continent state, and an additional 13.4% became incontinent at follow-up. Several factors were associated with continence state transitions, including cognitive impairment, rehabilitation potential, stroke, Parkinson's disease, Alzheimer's disease and related dementias, and hip fracture.

CONCLUSIONS AND IMPLICATIONS

This study suggests that urinary incontinence is a prevalent problem for Complex Continuing Care hospital patients and multiple factors are associated with continence state transitions. Standardized assessment of urinary incontinence is helpful in this setting to identify patients in need of further assessment and patient-centered intervention and as a quality improvement metric to examine changes in continence from admission to discharge.

Examining the adaptability and validity of interRAI acute care quality indicators in a surgical context

Background:

Currently, the use of quality indicators in the surgical setting may be challenged by diverse patient needs, clinical complexity, and health trajectories. Therefore, the objective of this study was to examine the adaptability of existing quality indicators to a surgical context and propose new time points.

Methods:

A multi-method approach included an environmental scan of the literature, consultation with multinational experts, and analysis of surgical patient data. Quality indicators from the nurse-administered interRAI Acute Care instrument were examined within a surgical context using secondary data from a hospital in Brisbane, Australia (N = 1006 surgical cases).

Results:

A lack of relevancy of existing time points can preclude meaningful quality indicator measurement. Definitions of some quality indicators were adapted to ensure relevancy for the surgical population. As well, a surgical baseline (measured preoperative and post-injury) and a 48-h postoperative time point were added to the existing measurement timeline.

Conclusion:

Distinct measurement timelines were created for elective and non-elective surgical patients. The use of surgery-specific time points that can be embedded into an existing Acute Care measurement framework supports consistent quality indicator reporting. This study represents the first steps towards standardized quality reporting for health information systems across different care settings.

Clinical factors associated with recent medical care visits in nursing homes: a multi-site cross-sectional study

Objectives

We examined which resident-level clinical factors influence the provision of a recent medical care visit in nursing homes (NHs).

Design

Multi-site cross-sectional.

Setting and participants

We extracted data on 3,556 NH residents from 18 NH facilities in Ontario, Canada, who received at minimum, an admission and first-quarterly assessment with the Resident Assessment Instrument Minimum Data Set (MDS) 2.0 between November 1, 2009, and October 31, 2017.

Methods

We conducted a secondary analysis of routinely collected MDS 2.0 data. The provision of a recent medical care visit by a physician (or authorized clinician) was assessed in the 14-day period preceding a resident’s first-quarterly MDS 2.0 assessment. We utilized best-subset multivariable logistic regression to model the adjusted associations between resident-level clinical factors and a recent medical care visit.

Results

Two thousand eight hundred fifty nine (80.4%) NH residents had one or more medical care visits prior to their first-quarterly MDS 2.0 assessment. Six clinically relevant factors were identified to be associated with recent medical care visits in the final model: exhibiting wandering behaviours (OR = 1.34, 95% CI 1.09 – 1.63), presence of a pressure ulcer (OR = 1.37, 95% CI 1.05 – 1.78), a urinary tract infection (UTI) (OR = 1.52, 95% CI 1.06 – 2.18), end-stage disease (OR = 9.70, 95% CI 1.32 – 71.02), new medication use (OR = 1.31, 95% CI 1.09 – 1.57), and analgesic use (OR = 1.24, 95% CI 1.03 – 1.49).

Conclusions and implications

Our findings suggest that resident-level clinical factors drive the provision of medical care visits following NH admission. Clinical factors associated with medical care visits align with the minimum competencies expected of physicians in NH practice, including managing safety risks, infections, medications, and death. Ensuring that NH physicians have opportunities to acquire and strengthen these competencies may be transformative to meet the ongoing needs of NH residents.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03011-9.

An interRAI derived frailty index predicts acute hospitalizations in older adults residing in retirement villages: A prospective cohort study

Objectives

The development of frailty tools from electronically recorded healthcare data allows frailty assessments to be routinely generated, potentially beneficial for individuals and healthcare providers. We wished to assess the predictive validity of a frailty index (FI) derived from interRAI Community Health Assessment (CHA) for outcomes in older adults residing in retirement villages (RVs), elsewhere called continuing care retirement communities.

Design

Prospective cohort study.

Setting and participants

34 RVs across two district health boards in Auckland, Aotearoa New Zealand (NZ). 577 participants, mean age 81 years; 419 (73%) female; 410 (71%) NZ European, 147 (25%) other European, 8 Asian (1%), 7 Māori (1%), 1 Pasifika (<1%), 4 other (<1%).

Methods

interRAI-CHA FI tool was used to stratify participants into fit (0–0.12), mild (>0.12–0.24), moderate (>0.24–0.36) and severe (>0.36) frail groups at baseline (the latter two grouped due to low numbers of severely frail). Primary outcome was acute hospitalization; secondary outcomes included long-term care (LTC) entry and mortality. The relationship between frailty and outcomes were explored with multivariable Cox regression, estimating hazard ratios (HRs) and 95% confidence intervals (95%CIs).

Results

Over mean follow-up of 2.5 years, 33% (69/209) of fit, 58% (152/260) mildly frail and 79% (85/108) moderate-severely frail participants at baseline had at least one acute hospitalization. Compared to the fit group, significantly increased risk of acute hospitalization were identified in mildly frail (adjusted HR = 1.88, 95%CI = 1.41–2.51, p<0.001) and moderate-severely frail (adjusted HR = 3.52, 95%CI = 2.53–4.90, p<0.001) groups. Similar increased risk in moderate-severely frail participants was seen in LTC entry (adjusted HR = 5.60 95%CI = 2.47–12.72, p<0.001) and mortality (adjusted HR = 5.06, 95%CI = 1.71–15.02, p = 0.003).

Conclusions and implications

The FI derived from interRAI-CHA has robust predictive validity for acute hospitalization, LTC entry and mortality. This adds to the growing literature of use of interRAI tools in this way and may assist healthcare providers with rapid identification of frailty.

Behavioral and Cognitive Problems as Determinants of Malnutrition in Long-Term Care Facilities, a Cross-Sectional and Prospective Study

OBJECTIVES

To investigate the cross-sectional and prospective associations between behavior and cognitive problems and malnutrition in long-term care facilities (LTCF).

DESIGN

Cross-sectional and prospective routine care cohort study.

SETTING

6874 Residents in Dutch LTCFs (period 2005-2020).

PARTICIPANTS

Data were obtained from the InterRAI-LTCF instrument. Cross-sectional analyses on prevalence of malnutrition at admission included 3722 residents. Prospective analyses studied incident malnutrition during stay (total follow-up time 7104 years) and included data of 1826 residents with first measurement on admission ('newly-admitted') and n=3152 with first measurement on average ~1 year after admission ('existing').

MEASUREMENTS

InterRAI scales for communication problems (CS), aggressive behavior (ABS), social engagement (RISE), depressive symptoms (DRS), cognitive performance (CPS) and the total number of behavior and cognitive problems were investigated as independent variables and malnutrition (ESPEN 2015 definition) as dependent variable in regression analyses. Results were stratified for gender and group 'newly-admitted' vs. 'existing'.

RESULTS

On admission, 9.5% of residents was malnourished. In men, low social engagement was associated with prevalence of malnutrition. In women, all behavior and cognitive problems except depression were associated with malnutrition in the unadjusted analyses, but this attenuated in the full model taking all problems into account. The incidence of malnutrition during stay amounted to 8.9%. No significant associations of behavior and cognitive problems with malnutrition incidence were seen in 'newly-admitted' male residents while in 'existing' male residents all determinants were significantly associated. In 'newly-admitted' female residents CS, ABS and CPS, and in 'existing' female residents CS, RISE, ABS and CPS were significantly associated with incident malnutrition. All associations slightly attenuated after adjustment. Malnutrition incidence increased with increasing number of combined behavior and cognitive problems.

CONCLUSION

Residents with behavior and cognitive problems are at an increased risk of being malnourished at admission, or becoming malnourished during stay in a LTCF, especially residents with multiple behavior and cognitive problems.

Mood Disturbances Across the Continuum of Care Based on Self-Report and Clinician Rated Measures in the interRAI Suite of Assessment Instruments

BACKGROUND

Mood disturbance is a pervasive problem affecting persons of all ages in the general population and the subset of those receiving services from different health care providers. interRAI assessment instruments comprise an integrated health information system providing a common approach to comprehensive assessment of the strengths, preferences and needs of persons with complex needs across the continuum of care.

OBJECTIVE

Our objective was to create new mood scales for use with the full suite of interRAI assessments including a composite version with both clinician-rated and self-reported items as well as a self-report only version.

METHODS

We completed a cross-sectional analysis of 511,641 interRAI assessments of Canadian adults aged 18+ in community mental health, home care, community support services, nursing homes, palliative care, acute hospital, and general population surveys to develop, test, and refine new measures of mood disturbance that combined clinician and self-rated items. We examined validity and internal consistency across diverse care settings and populations.

RESULTS

The composite scale combining both clinician and self-report ratings and the self-report only variant showed different distributions across populations and settings with most severe signs of disturbed mood in community mental health settings and lowest severity in the general population prior to the COVID-19 pandemic. The self-report and composite measures were strongly correlated with each other but differed most in populations with high rates of missing values for self-report due to cognitive impairment (e.g., nursing homes). Evidence of reliability was strong across care settings, as was convergent validity with respect to depression/mood disorder diagnoses, sleep disturbance, and self-harm indicators. In a general population survey, the correlation of the self-reported mood scale with Kessler-10 was 0.73.

CONCLUSIONS

The new interRAI mood scales provide reliable and valid mental health measures that can be applied across diverse populations and care settings. Incorporating a person-centered approach to assessment, the composite scale considers the person's perspective and clinician views to provide a sensitive and robust measure that considers mood disturbances related to dysphoria, anxiety, and anhedonia.

Factors associated with healthcare utilization and trajectories in retirement village residents

BACKGROUND

To study healthcare utilization and trajectories, and associated factors, in older adults in retirement villages (RVs), also known as continuing care retirement communities.

METHODS

Prospective cohort study of 578 cognitively intact residents from 34 RVs in Auckland, New Zealand (NZ).

MEASUREMENT

InterRAI-Community Health Assessment (includes core items that may trigger functional supplement (FS) completion in those with higher needs, and generates clinical assessment protocols (CAPs) in those with potential unmet needs).

OUTCOMES

time to acute hospitalization, long-term care (LTC), and death during average 2.5 years follow-up.

RESULTS

Three hundred seven (53%) residents had acute hospitalizations, 65 (11%) moved to LTC, and 51 (9%) died over a mean of 2.5 years. Factors associated with increased risk of acute hospitalization included CAP-falls (high risk) triggered, number of comorbidities, not having left RV in 2 weeks prior, moderate/severe hearing impairment, CAP-cardiorespiratory conditions triggered, acute hospitalization in year prior and age, with significant hazard ratios (HR) ranging between 1.03 and 2.90. Factors associated with reduced risk of hospitalization included other (non-NZ) European ethnicity (HR 0.73, 95% CI 0.55-0.98, p = 0.04), presence of on-site clinic (HR 0.62, 95% CI 0.45-0.85, p = 0.003), no influenza vaccination (HR 0.56, 95% CI 0.38-0.83, p = 0.004). Factors associated with LTC transition included FS triggered (HR 3.84, 95% CI 1.92-7.66, p < 0.001), CAP-instrumental activities of daily living (IADL) (HR 2.62, 95% CI 1.22-5.62, p = 0.01), CAP-social relationship triggered (HR 2.00, 95% CI 1.13-3.55, p = 0.02), and age (HR 1.13, 95% CI 1.07-1.18 p < 0.001). Factors associated with mortality included number of comorbidities (HR 3.75, 95% CI 1.54-9.10, p = 0.004 for 3-5 comorbidities), CAP-IADL triggered (HR 3.05, 95% CI 1.30-7.16, p = 0.01), and age (HR 1.11, 95% CI 1.05-1.18, p < 0.001).

CONCLUSION

A large proportion of cognitively intact RV residents are admitted to hospital in mean 2.5 years of follow-up. Multiple factors were associated with acute hospitalization risk. On-site clinics were associated with reduced risk and should be considered in RV development.

Minimum data and core outcomes for subacute rehabilitation: A scoping review

OBJECTIVE

In clinical practice and research, standardised sets of data and outcomes are routinely collected to facilitate data comparison, benchmarking and quality improvement. Most existing data sets are condition-specific and cannot be applied to all patients in a given clinical setting. This review aimed to determine whether the development of a minimum data set for subacute rehabilitation is feasible by collating and comparing existing rehabilitation minimum data sets and core outcome sets.

DATA SOURCES

Published literature was identified through database searches (Scopus, PubMed, EMBASE, CINAHL and the COMET Initiative) in September 2021. Additional data sets were identified through a grey literature search.

REVIEW METHODS

This review was conducted in alignment with the PRISMA-ScR recommendations. Datasets were included if they were published in English, designed for adults, and intended for use in subacute rehabilitation. Data were extracted and taxonomically organised to identify commonalities. Items present in ≥50% of data sets were considered common.

RESULTS

Twenty minimum data sets and seven core outcome sets were included. There were 29 common minimum data set domains, with 19 relating to Patient Information, seven relating to Outcomes, two relating to Service Delivery and one relating to Provider Demographics. Four common domains were identified within the Core Outcome Set analysis, which all related to Life Impact, specifically Physical Functioning (86%), Emotional Functioning/Wellbeing (57%), Social Functioning (86%) and Global Quality of Life (100%).

CONCLUSION

Common item domains in conditions requiring subacute rehabilitation have been identified, suggesting that development of a dataset for subacute rehabilitation may be feasible.

Relevance of assessment items in community paramedicine home visit programmes: results of a modified Delphi study

OBJECTIVE

Guidelines for a structured assessment in community paramedicine home visit programmes have not been established and evidence to inform their creation is lacking. We sought to investigate the relevance of assessment items to the practice of community paramedics according to a pre-established clarity-utility matrix.

DESIGN

We designed a modified-Delphi study consisting of predetermined thresholds for achieving consensus, number of rounds of for scoring items, a defined meeting and discussion process, and a sample of participants that was purposefully representative.

SETTING AND PARTICIPANTS

We established a panel of 26 community paramedics representing 20 municipal paramedic services in Ontario, Canada. The sample represented a majority of paramedic services within the province that were operating a community paramedicine home visit programme.

MEASURES

Drawing from a bank of standardised assessment items grouped according to domains aligned with the International Classification on Functioning, Disability, and Health taxonomy, 64 previously pilot-tested assessment items were scored according to their clarity (being free from ambiguity and easy to understand) and utility (being valued in care planning or case management activities). Assessment items covered a broad range of health, social and environmental domains. To conclude scoring rounds, assessment items that did not achieve consensus for relevance to assessment practices were discussed among participants with opportunities to modify assessment items for subsequent rounds of scoring.

RESULTS

Resulting from the first round of scoring, 54 assessment items were identified as being relevant to assessment practices and 3 assessment items were removed from subsequent rounds. The remaining 7 assessment items were modified, with some parts removed from the final items that achieved consensus in the final rounds of scoring.

CONCLUSION

A broadly representative panel of community paramedics identified consensus for 61 assessment items that could be included in a structured, multidomain, assessment instrument for guiding practice in community paramedicine home visit programmes.

TRAIL REGISTRATION NUMBER

ISRCTN58273216.

Changes in home care clients' characteristics and home care in five European countries from 2001 to 2014: comparison based on InterRAI - Home Care data

Background

Policymakers advocate extended residence in private homes as people age, rather than relocation to long-term care facilities. Consequently, it is expected that older people living in their own homes will be frailer and have more complex health problems over time. Therefore, community care for aging people is becoming increasingly important to facilitate prevention of decline in physical and cognitive abilities and unnecessary hospital admission and transfer to a nursing home. The aim of this study was to examine changes in the characteristic of home care clients and home care provided in five European countries between 2001 and 2014 and to explore whether home care clients who are most in need of care receive the care required.

Methods

This descriptive study used data from two European research projects, Aged in Home Care (AdHOC; 2001–2002) and Identifying best practices for care-dependent elderly by Benchmarking Costs and outcomes of Community Care (IBenC; 2014–2016). In both projects, the InterRAI-Home Care assessment tool was used to assess a random sample of home care clients 65 years and older in five European countries. These data facilitate a comparison of physical and cognitive health and the provided home care between countries and study periods.

Results

In most participating countries, both cognitive (measured on the Cognitive Performance Scale) and functional ability (measured on the Activities of Daily Living Hierarchy scale) of home care clients deteriorated over a 10-year period. Home care provided increased between the studies. Home care clients who scored high on the physical and cognitive scales also received home care for a significantly higher duration than those who scored low.

Conclusion

Older people in several European countries remain living in their own homes despite deteriorating physical and cognitive skills. Home care services to this group have increased. This indicates that the government policy of long-term residence at own home among older people, even in increased frailty, has been realised.

Learning from a multidisciplinary randomized controlled intervention in retirement village residents

BACKGROUND

Retirement villages (RVs), also known as continuing care retirement communities, are an increasingly popular housing choice for older adults. The RV population has significant health needs, possibly representing a group with needs in between community-dwelling older adults and those in long-term residential care (LTC). Our previous work shows Gerontology Nurse Specialist (GNS)-facilitated multidisciplinary team (MDT) interventions may reduce hospitalizations from LTC. This study tested whether a similar intervention reduced hospitalizations in RV residents.

METHODS

Open-label randomized controlled trial in which 412 older residents of 33 RVs were randomized (1:1) to an MDT intervention or usual care.

SETTING

RVs across two District Health Boards in Auckland, New Zealand. Residents were eligible if considered high risk of health/functional decline (triggering ≥3 interRAI Clinical Assessment Protocols or needing special consideration identified by GNS).

INTERVENTION

GNS-facilitated MDT intervention, including geriatrician/nurse practitioner and clinical pharmacist, versus usual care. Primary outcome was time from randomization to first acute hospitalization. Secondary outcomes were rate of acute hospitalizations, LTC admission, and mortality. Twelve residents died before randomization; all others (n = 400: MDT intervention = 199; usual care = 201) were included in intention-to-treat analyses.

RESULTS

Mean (SD) age was 82.2 (6.9) years, 302 (75.5%) were women, and 378 (94.5%) were European. Over median 1.5 years follow-up, no difference was found in hazard of acute hospitalization between the MDT intervention (51.8%) and usual care (49.3%) groups (Hazard ratio [HR] = 1.01, 95% CI = 0.77-1.34). No difference was found in the incidence rate of acute hospitalizations between the MDT intervention (0.69 per person-year) and usual care (0.86 per person-year) groups (incidence rate ratio = 0.81, 95% CI = 0.59-1.10). Similar results were seen for the proportion of residents with LTC transition (HR = 1.18, 95% CI = 0.65-2.11) and mortality (HR = 0.70, 95% CI = 0.36-1.35).

CONCLUSION

Further studies are needed to assess the effects of other patient-centered interventions and outcomes with adequate primary care integration.

Psychometric Properties, Feasibility, and Acceptability of the Self-Reported interRAI Check-Up Assessment

OBJECTIVES

To assess the feasibility, acceptability, and psychometric properties of the self-report version of the interRAI Check-Up (CUSR).

DESIGN

Cross-sectional study of participant ratings of item content and difficulty completing the CUSR. Participants were also randomly assigned to complete the assessment by themselves or with help from a lay interviewer.

SETTINGS AND PARTICIPANTS

A total of 184 older adults from diverse backgrounds, served by 6 Canadian organizations in Ontario and Nova Scotia were recruited. Settings ranged from retirement communities for healthy older adults to assisted living facilities.

MEASURES/METHODS

Time to complete the interRAI CUSR was tracked automatically. Participants self-reported on what items they wanted to have modified, added, or deleted. The also rated whether items were embarrassing or difficult to complete. Psychometric properties were examined between the 2 approaches to completion and were benchmarked against existing reports on psychometric properties of clinician-led home care assessments.

RESULTS

The interRAI CUSR takes about 28 minutes to complete with both self-administered and lay interviewer approaches. The convergent validity and reliability of CUSR is comparable to those of clinician-based assessments like the Resident Assessment Instrument-Home Care. Most participants had no difficulty completing the assessment, and none rated the task as very difficult. Poor self-rated health and difficulty with phone use were predictive of any difficult in completing the assessment in a multivariate logistic regression. Most participants reported that CUSR adequately described their health needs, but arthritis, hypertension, and mental health issues were identified as items to be added by participants.

CONCLUSIONS AND IMPLICATIONS

The CUSR is an appropriate, feasible assessment system with good psychometric properties for use with general populations, including primary care, community services, and patient-reported outcome measurement studies. Interoperability with other interRAI assessments makes it an ideal system to use to obtain a longitudinal view of the person's needs over time.

Towards a standardized approach of assessing social context of persons receiving home care in Flanders, Belgium: the development and test of a social supplement to the interRAI instruments

BACKGROUND

Apart from a person's physical functioning, the early identification of social context indicators which affect patient outcomes - such as environmental and psychosocial issues - is key for high quality and comprehensive care at home. During a home care assessment, a person's biomedical and functional problems are typically considered. Harder to define concepts, such as psychosocial well-being or living arrangements, are not routinely documented, even though research shows they also affect functioning and health outcomes. The purpose of this study is to develop and test a concise, integrated assessment (BelRAI Social Supplement) that evaluates these social context indicators for persons receiving home care to complement existing interRAI- instruments.

METHODS

The development of the BelRAI Social Supplement is a multi-stage process, based upon the revised MRC-framework, involving both qualitative and quantitative research with stakeholders such as; clients, informal caregivers, care professionals and policy makers. The developmental process encompasses four stages: (I) item generation based on multiple methods and content validation by a panel of stakeholders (II) assessing feasibility and piloting methods, (III) early evaluation, and (IV) final evaluation. Stage II and III are covered in this paper.

RESULTS

During Stages I and II, a testable version of the BelRAI Social Supplement was developed in an iterative process. In Stage III, 100 care professionals assessed 743 individuals receiving home care in Flanders between December 2018 and December 2019. Using inter-item correlation matrixes, frequency distributions and regular feedback from the participants, the BelRAI Social Supplement was improved and prepared for Stage IV. The updated version of the instrument consists of four main sections: (1) environmental assessment; (2) civic engagement; (3) psychosocial well-being; and (4) informal care and support. In total, the BelRAI Social Supplement contains a maximum of 76 items.

CONCLUSIONS

The BelRAI Social Supplement was reviewed and shortened in close collaboration with care professionals and other experts in Flanders. This study resulted in an instrument that documents need-to-know social context determinants of home dwelling adults.

The prevalence and prescribing patterns of benzodiazepines and Z-drugs in older nursing home residents in different European countries and Israel: retrospective results from the EU SHELTER study

Background

Benzodiazepines (BZDs) and Z-drugs have high potential for developing frequent adverse drug events in older adults (e.g., psychomotor sedation, drug-related dementia, deliria, drug dependence, etc.). Knowledge of the prevalence and patterns of the use of BZDs/Z-drugs in vulnerable older patients is important in order to prevent and reduce the burden caused by their drug-related complications. Our study focused on international comparisons of the prevalence, country-specific prescribing patterns and risk factors of regular BZD/Z-drug use in nursing home (NH) residents.

Methods

This cross-sectional study retrospectively analysed data of 4156 NH residents, prospectively assessed in the Services and Health in the Elderly in Long TERm care (SHELTER) project conducted from 2009 to 2014. Residents aged 65+ in 57 NHs in 7 European countries and Israel were assessed by the InterRAI Long-Term Care Facilities instrument. Descriptive statistics and multiple logistic regression models were used to describe the country-specific prevalence, patterns and risk factors of BZD/Z-drug use.

Results

The mean age of the participants was 83.4 ± 9.4 years, 73% were female and 27.7% used BZDs/Z-drugs. The prevalence of BZD/Z-drug use differed significantly across countries, ranging from 44.1% in Israel to 14.5% in Germany. The most frequently prescribed were zopiclone (17.8%), lorazepam (17.1%) and oxazepam (16.3%). Lorazepam, oxazepam and diazepam were used in most of the countries. Brotizolam, temazepam and zolpidem showed highest prevalence in Israel (99.4% of all regular users of this medication in the sample), the Netherlands (72.6%) and France (50.0%), respectively. Residing in Israel was the most significant factor associated with the use of BZDs/Z-drugs or BZDs only (odds ratio [OR] 6.7; 95% confidence interval [CI] 4.8–9.2 and OR 9.7, 95%CI 6.5–14.5, respectively). The use of Z-drugs only was most significantly associated with residing in France (OR 21.0, 95%CI 9.0–48.9).

Conclusions

Despite global recommendations and warnings, the preference for and extent of use of individual BZDs and Z-drugs in vulnerable NH residents differ significantly across countries. The strong association with country of residence compared to clinical and functional factors denotes that prescribing habits, social, cultural, behavioural, and regulatory factors still play an important role in the current diverse use of these medications.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02213-x.

Do premorbid characteristics of home care clients predict delayed discharges in acute care hospitals: a retrospective cohort study in Ontario and British Columbia, Canada

BACKGROUND

Improved identification of patients with complex needs early during hospitalisation may help target individuals at risk of delayed discharge with interventions to prevent iatrogenic complications, reduce length of stay and increase the likelihood of a successful discharge home.

METHODS

In this retrospective cohort study, we linked home care assessment records based on the Resident Assessment Instrument for Home Care (RAI-HC) of 210 931 hospitalised patients with their Discharge Abstract Database records. We then undertook multivariable logistic regression analyses to identify preadmission predictive factors for delayed discharge from hospital.

RESULTS

Characteristics that predicted delayed discharge included advanced age (OR: 2.72, 95% CI 2.55 to 2.90), social vulnerability (OR: 1.27, 95% CI 1.08 to 1.49), Parkinsonism (OR: 1.34, 95% CI 1.28 to 1.41) Alzheimer's disease and related dementias (OR: 1.27, 95% CI 1.23 to 1.31), need for long-term care facility services (OR: 2.08, 95% CI 1.96 to 2.21), difficulty in performing activities of daily living and instrumental activities of daily living, falls (OR: 1.16, 95% CI 1.12 to 1.19) and problematic behaviours such as wandering (OR: 1.29, 95% CI 1.22 to 1.38).

CONCLUSION

Predicting delayed discharge prior to or on admission is possible. Characteristics associated with delayed discharge and inability to return home are easily identified using existing interRAI home care assessments, which can then facilitate the targeting of pre-emptive interventions immediately on hospital admission.

Implementation and Evaluation of a Standardized Nurse-Administered Assessment of Functional and Psychosocial Issues for Patients in Acute Care

BACKGROUND

Increasingly, adults presenting to healthcare facilities have multiple morbidities that impact medical management and require initial and ongoing assessment. The interRAI Acute Care (AC), one of a suite of instruments used for integrated care, is a nurse-administered standardized assessment of functional and psychosocial domains that contribute to complexity of patients admitted to acute care.

AIM

This study aimed to implement and evaluate the interRAI AC assessment system using a multi-strategy approach based on the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework.

METHODS

This nurse-led quality improvement study was piloted in a 200-bed public hospital in Brisbane, Australia, over the period 2017 to 2018. The interRAI AC is a set of clinical observations of functional and psychosocial domains, supported by software to derive diagnostic and risk screeners, scales to measure and monitor severity, and alerts to assist in care planning. Empirical data, surveys, and qualitative feedback were used to measure process and impact outcomes using the RE-AIM evaluation framework (Reach, Efficacy, Adoption, Implementation, and Maintenance).

RESULTS

In comparison to usual practice, the interRAI assessment system and supporting software was able to improve the integrity and compliance of nurse assessments, identifying key risk domains to facilitate management of care. Pre-implementation documentation (630 items in 45 patient admissions) had 39% missing data compared with 1% missing data during the interRAI implementation phase (9,030 items in 645 patient admissions). Qualitative feedback from nurses in relation to staff engagement and behavioral intention to use the new technology was mixed.

LINKING EVIDENCE TO ACTION

Despite challenges to implementing a system-wide change, evaluation results demonstrated considerable efficiency gains in the nursing assessment system. For successful implementation of the interRAI AC, study findings suggest the need for interoperability with other information systems, access to training, and continued leadership support.

Risk factors of readmission after geriatric hospital care: An interRAI-based cohort study in Finland

PURPOSE

To identify risk factors for readmission after geriatric hospital care.

METHODS

A retrospective cohort study of 1,167 community-dwelling patients aged ≥70 years who were hospitalised in two geriatric hospitals and discharged to their homes over a three-year period. We combined the results of the interRAI-post acute care instrument (interRAI-PAC) with hospital discharge records. Factors associated with readmissions within 90 days following discharge were analysed using logistic regression analysis.

RESULTS

The patients' mean age was 84.5 (SD 6.2) years, and 71% (n = 827) were women. The 90-day readmission rate was 29.5%. The risk factors associated with readmission in the univariate analysis were as follows: age, admission from home vs. acute care hospital, Alzheimer's disease, unsteady gait, fatigue, unstable conditions, Activities of Daily Living Hierarchy Scale (ADLH) score, Cognitive Performance Scale (CPS) score, body mass index (BMI), frailty index, bowel incontinence, hearing difficulties, and poor self-rated health. In the multivariable analysis, age of ≥90 years, ADLH ≥1, unsteady gait, BMI <25 or ≥30 kg/m 2 , and frailty remained as risk factors for readmission. Surgical operation during the treatment period was associated with a lower readmission risk.

CONCLUSIONS AND IMPLICATIONS

InterRAI-PAC performed upon admission to geriatric hospitals revealed patient-related risk factors for readmission. Based on the identified risk factors, we recommend that the patient's functional ability, activities of daily living (ADL) needs, and individual factors underlying ADL disability, as well as nutritional and mobility problems should be carefully addressed and managed during hospitalization to diminish the risk for readmission.

Hearing Screening for Residents in Long-Term Care Homes Who Live with Dementia: A Scoping Review

BACKGROUND

Hearing loss is highly prevalent in older adults, particularly among those living with dementia and residing in long-term care homes (LTCHs). Sensory declines can have deleterious effects on functioning and contribute to frailty, but the hearing needs of residents are often unrecognized or unaddressed.

OBJECTIVE

To identify valid and reliable screening measures that are effective for the identification of hearing loss and are suitable for use by nursing staff providing care to residents with dementia in LTCHs.

METHODS

Electronic databases (Embase, Medline, PsycINFO, CENTRAL, and CINAHL) were searched using comprehensive search strategies, and a stepwise approach based on Arksey & O'Malley's scoping review and appraisal process was followed.

RESULTS

There were 193 scientific papers included in the review. Pure-tone audiometry was the most frequently reported measure to test hearing in older adults living with dementia. However, measures including self- or other-reports and questionnaires, review of medical records, otoscopy, and the whisper test were found to be most suitable for use by nurses working with older adults living with dementia in LTCHs.

CONCLUSION

Although frequently used, the suitability of pure-tone audiometry for use by nursing staff in LTCHs is limited, as standardized audiometry presents challenges for many residents, and specific training is needed to successfully adapt test administration procedures and interpret results. The whisper test was considered to be more suitable for use by staff in LTCH; however, it yields a limited characterization of hearing loss. There remains an urgent need to develop new approaches to screen hearing in LTCHs.

Evaluating the Effect of COVID-19 Pandemic Lockdown on Long-Term Care Residents' Mental Health: A Data-Driven Approach in New Brunswick

Long-term care (LTC) residents, isolated because of the COVID-19 pandemic, are at increased risk for negative mental health outcomes. The purpose of our article is to demonstrate how the interRAI LTC facility (LTCF) assessment can inform clinical care and evaluate the effect of strategies to mitigate worsening mental health outcomes during the COVID-19 pandemic. We present a supporting analysis of the effects of lockdown in homes without COVID-19 outbreaks on depression, delirium, and behavior problems in a network of 7 LTC homes in New Brunswick, Canada, where mitigative strategies were deployed to minimize poor mental health outcomes (eg, virtual visits and increased student volunteers). This network meets regularly to review performance on risk-adjusted quality of care indicators from the interRAI LTCF and share learning through a community of practice model. We included 4209 assessments from 765 LTC residents between January 2017 to June 2020 and modeled the change within and between residents for depression, delirium, and behavioral problems over time with longitudinal generalized estimating equations. Though the number of residents who had in-person visits with family decreased from 73.2% before to 17.9% during lockdown (chi square, P < .001), the number of residents experiencing delirium (4.5%-3.5%, P = .51) and behavioral problems (35.5%-30.2%, P = .19) did not change. The proportion of residents with indications of depression decreased from 19.9% before to 11.5% during lockdown (P < .002). The final multivariate models indicate that the effect of lockdown was not statistically significant on depression, delirium, or behavioral problems. Our analyses demonstrate that poor mental health outcomes associated with lockdown can be mitigated with thoughtful intervention and ongoing evaluation with clinical information systems. Policy makers can use outputs to guide resource deployment, and researchers can examine the data to identify better management strategies for when pandemic strikes again.

Drug related problems in older adults living with dementia

BACKGROUND

Compared with those without dementia, older patients with dementia admitted to acute care settings are at higher risk for triad combination of polypharmacy (PP), potentially inappropriate medication (PIM), and drug-drug interaction (DDI), which may consequently result in detrimental health. The aims of this research were to assess risk factors associated with triad combination of PP, PIM and DDI among hospitalized older patients with dementia, and to assess prevalence and characteristics of PP, PIM and DDI in this population.

METHODS

In this retrospective cross-sectional study, 416 older inpatients diagnosed with dementia and referred for specialist geriatric consultation at a tertiary hospital in Brisbane, Australia during 2006-2016 were enrolled. Patients were categorized into two groups according to their exposure to the combination of PP, PIM and DDI: 'triad combination' and 'non-triad combination'. Data were collected using the interRAI Acute Care (AC) assessment instrument. Independent risk factors of exposure to the triad combination were evaluated using bivariate and multivariate logistic regression analyses.

RESULTS

Overall, 181 (43.5%) were classified as triad combination group. The majority of the population took at least 1 PIM (56%) or experienced at least one potential DDI (76%). Over 75% of the participants were exposed to polypharmacy. The most common prescribed PIMs were antipsychotics, followed by benzodiazepines. The independent risk factors of the triad combination were the presence of atrial fibrillation diagnosis and higher medications use in cardiac therapy, psycholeptics and psychoanaleptics.

CONCLUSIONS

The exposure to triad combination of PP, PIM and DDI are common among people with dementia as a result of their vulnerable conditions and the greater risks of adverse events from medications use. This study identified the use of cardiac therapy, psycholeptics and psychoanaleptics as predictors of exposure to PP, PIM and DDI. Therefore, use of these medications should be carefully considered and closely monitored. Furthermore, comprehensive medication reviews to optimize medication prescribing should be initiated and continually implemented for this vulnerable population.

"Establishing the criterion validity of the interRAI Check-Up Self-Report instrument"

Background

Low and middle-income countries have growing older populations and could benefit from the use of multi-domain geriatric assessments in overcoming the challenge of providing quality health services to older persons. This paper reports on the outcomes of a study carried out in Cape Town, South Africa on the validity of the interRAI Check-Up Self-Report instrument, a multi-domain assessment instrument designed to screen older persons in primary health settings. This is the first criterion validity study of the instrument. The instrument is designed to identify specific health problems and needs, including psychosocial or cognition problems and issues related to functional decline. The interRAI Check-Up Self-Report is designed to be compatible with the clinician administered instruments in the interRAI suite of assessments, but the validity of the instrument against clinician ratings has not yet been established. We therefore sought to establish whether community health workers, rather than trained healthcare professionals could reliably administer the self-report instrument to older persons.

Methods

We evaluated the criterion validity of the self-report instrument through comparison to assessments completed by a clinician assessor. A total of 112 participants, aged 60 or older were recruited from 7 seniors clubs in Khayelitsha, Cape Town. Each participant was assessed by one of two previously untrained, non-healthcare personnel using the Check-Up Self-report version and again by a trained assessor using the clinician version of the interRAI Check-Up within 48 h. Our analyses focused on the degree of agreement between the self-reported and clinician-rated versions of the Check-Up based on the simple or weighted kappa values for the two types of ratings. Binary variables used simple kappas, and ordinal variables with three or more levels were examined using weighted kappas with Fleiss-Cohen weights.

Results

Based on Cohen’s Kappa values, we were able to establish that high levels of agreement existed between clinical assessors and lay interviewers, indicating that the instrument can be validly administered by community health workers without formal healthcare training. 13% of items had kappa values ranging between 0.10 and 0.39; 51% of items had kappa values between 0.4 and 0.69; and 36% of items had values of between 0.70 and 1.00.

Conclusion

Our findings indicate that there is potential for the Check-Up Self-Report instrument to be implemented in under-resourced health systems such as South Africa’s.

The Changes in Medication Prescribing Among the Older People with Cognitive Impairment in the Acute Care Setting

PURPOSE

Most older people with cognitive impairment usually have multiple comorbidities. In the last decade, the guidelines for the management of chronic diseases have been changed, leading to changes in the patterns of medication prescribing and in the prevalence of drug-related problems (DRPs). The main objectives were to explore the changes in medication use and in the prevalence of polypharmacy (PP), the use of potentially inappropriate medications (PIMs) and drug-drug interactions (DDIs) among older hospitalized adults with cognitive impairment in a 5-year period.

PATIENTS AND METHODS

Older hospitalized patients with cognitive impairment diagnosed by cognitive performance scale (CPS) score of 2 or more at tertiary hospital in Brisbane, Australia in 2009 and 2015 to 2016 were enrolled. Prescribed medication use, and exposures to PP, PIM and/or DDI were evaluated at two time points. The associated factors with patients exposed to >1 criteria of PP, PIM or DDI were analyzed by using logistic regression analyses.

RESULTS

The median number of prescribed medications was not significantly different between the two periods. The number of medications use as dermatological agents and analgesics substantially increased over 5 years. In contrast, there was a decrease in prescription of drugs for acid-related disorders, drugs used in diabetes, and mineral supplements. Most of the participants were exposed to at least one of PP, PIM or DDI. In multivariate regression analysis, the presence of diabetes diagnosis was a risk factor associated with increased exposure to >1 criteria of PP, PIM or DDI.

CONCLUSION

The patterns of many prescribed medications use have altered in a 5-year period. The present study confirms that the majority of older adults with cognitive impairment admitted in an acute care setting are prone to PP, PIM and DDI. Comprehensive medication reviews should be undertaken in clinical care of older patients with cognitive impairment.

Frailty Index and functional level upon admission predict hospital outcomes: an interRAI-based cohort study of older patients in post-acute care hospitals

BACKGROUND

Geriatric assessment upon admission may reveal factors that contribute to adverse outcomes in hospitalized older patients. The purposes of this study were to derive a Frailty Index (FI-PAC) from the interRAI Post-Acute Care instrument (interRAI-PAC) and to analyse the predictive ability of the FI-PAC and interRAI scales for hospital outcomes.

METHODS

This retrospective cohort study was conducted by combining patient data from interRAI-PAC with discharge records from two post-acute care hospitals. The FI-PAC was derived from 57 variables that fulfilled the Frailty Index criteria. Associations of the FI-PAC and interRAI-PAC scales (ADLH for activities of daily living, CPS for cognition, DRS for mood, and CHESS for stability of health status) with hospital outcomes (prolonged hospital stay ≥90 days, emergency department admission during the stay, and in-hospital mortality) were analysed using logistic regression and ROC curves.

RESULTS

The cohort included 2188 patients (mean age (SD) 84.7 (6.3) years) who were hospitalized in two post-acute care hospitals. Most patients (n = 1691, 77%) were discharged and sent home. Their median length of stay was 35 days (interquartile range 18-87 days), and 409 patients (24%) had a prolonged hospital stay. During their stay, 204 patients (9%) were admitted to the emergency department and 231 patients (11%) died. The FI-PAC was normally distributed (mean (SD) 0.34 (0.15)). Each increase of 0.1 point in the FI-PAC increased the likelihood of prolonged hospital stay (odds ratio [95% CI] 1.91 [1.73─2.09]), emergency admission (1.24 [1.11─1.37]), and in-hospital death (1.82 [1.63─2.03]). The best instruments for predicting prolonged hospital stay and in-hospital mortality were the FI-PAC and the ADLH scale (AUC 0.75 vs 0.72 and 0.73 vs 0.73, respectively). There were no differences in the predictive abilities of interRAI scales and the FI-PAC for emergency department admission.

CONCLUSIONS

The Frailty Index derived from interRAI-PAC predicts adverse hospital outcomes. Its predictive ability was similar to that of the ADLH scale, whereas other interRAI-PAC scales had less predictive value. In clinical practice, assessment of functional ability is a simple way to assess a patient's prognosis.

"We've got the home care data, what do we do with it?": understanding data use in decision making and quality improvement

BACKGROUND

In the past decade the provision of home care services in Canada has doubled; with this increase there has been a growing interest in improving quality and safety. National-level data are captured in the Home Care Reporting System (HCRS), using the interRAI-HC tools. Data in the HCRS provide decision-makers and administrators with actionable evidence to inform quality and safety improvement initiatives. The objective of this study was to determine how providers and administrators were using these data, and if there were any opportunities to enhance their use.

METHODS

We collaborated with the Canadian Patient Safety Institute to conduct this qualitative study. To understand data use in home care, we recruited participants in management and/or data analysis roles from home care organizations across Canada. We conducted three individual interviews and three focus group interviews with a total of eleven participants from five Canadian provinces. Individual and focus group interviews were audio recorded, transcribed, and analysed using a combination of emergent coding and thematic analysis.

RESULTS

Several participants provided powerful examples of how interRAI data have been used to guide patient safety and quality improvement initiatives; however, all participants recognized challenges in using these data. Leveraging interRAI data in the complex home care environment is limited by several factors: the general "newness" of these data in many jurisdictions; the sheer volume of data; limited capacity and resources to interpret and analyse the data; and connectivity issues in rural areas. Participants recognized and appreciated the training that has been provided, and made several recommendations for additional training.

CONCLUSIONS

Mandated clinical datasets, such as the suite of interRAI tools, have the potential to improve quality and inform decision-making. However, in order to utilize these data, home care agencies require additional education, personnel and supports. Additional training and resources for these organizations could improve the use of available data by home care agencies, as well as outcomes for individuals receiving home care services.

The interRAI Suite of Mental Health Assessment Instruments: An Integrated System for the Continuum of Care

The lives of persons living with mental illness are affected by psychological, biological, social, economic, and environmental factors over the life course. It is therefore unlikely that simple preventive strategies, clinical treatments, therapeutic interventions, or policy options will succeed as singular solutions for the challenges of mental illness. Persons living with mental illness receive services and supports in multiple settings across the health care continuum that are often fragmented, uncoordinated, and inadequately responsive. Appropriate assessment is an important tool that health systems must deploy to respond to the strengths, preferences, and needs of persons with mental illness. However, standard approaches are often focused on measurement of psychiatric symptoms without taking a broader perspective to address issues like growth, development, and aging; physical health and disability; social relationships; economic resources; housing; substance use; involvement with criminal justice; stigma; and recovery. Using conglomerations of instruments to cover more domains is impractical, inconsistent, and incomplete while posing considerable assessment burden. interRAI mental health instruments were developed by a network of over 100 researchers, clinicians, and policy experts from over 35 nations. This includes assessment systems for adults in inpatient psychiatry, community mental health, emergency departments, mobile crisis teams, and long-term care settings, as well as a screening system for police officers. A similar set of instruments is available for child/youth mental health. The instruments form an integrated mental health information system because they share a common assessment language, conceptual basis, clinical emphasis, data collection approach, data elements, and care planning protocols. The key applications of these instruments include care planning, outcome measurement, quality improvement, and resource allocation. The composition of these instruments and psychometric properties are reviewed, and examples related to homeless are used to illustrate the various applications of these assessment systems.

Risk of Hospitalization in Long-Term Care Residents Living with Heart Failure: a Retrospective Cohort Study

BACKGROUND

Older adults living with heart failure (HF) in long-term care (LTC) experience frequent hospitalization. Using routinely available clinical information, we examined resident-level factors that precipitate hospitalization within 90 days of admission to LTC.

METHODS

This was a retrospective cohort study of older adults diagnosed with HF, who were admitted to LTC in Ontario, Canada, between 2011 and 2013. Multivariate logistic regression models using generalized estimating equations were developed to determine predictors of hospitalization in residents with HF.

RESULTS

Entry to LTC from a hospital was the strongest predictor of future hospitalization (OR: 8.1, 95% CI: 7.1-9.3), followed by a score of three or greater on the Changes in Health, End-stage Signs and Symptoms scale, a measure of moderate to severe medical instability (O.R 4.2, 95% CI: 3.1-5.9). Other variables that increased the likelihood of hospitalization included being flagged as a high risk for falls, two or more physician visits, and increased monitoring for acute medical illness within 14 days of admission.

CONCLUSION

Our findings highlight that health instability and transitions from acute to LTC will increase the likelihood of transitioning back into the hospital setting. The identified predisposing factors suggest the need for targeted prevention strategies for those in high-risk groups.

Examining consensus for a standardised patient assessment in community paramedicine home visits: a RAND/UCLA-modified Delphi Study

OBJECTIVE

Community paramedicine programme are often designed to address repeated and non-urgent use of paramedic services by providing patients with alternatives to the traditional 'treat and transport' ambulance model of care. We sought to investigate the level of consensus that could be found by a panel of experts regarding appropriate health, social and environmental domains that should be assessed in community paramedicine home visit programme.

DESIGN

We applied the RAND/UCLA Appropriateness Method in a modified Delphi method to investigate the level of consensus on assessment domains for use in community paramedicine home visit programme.

SETTING AND PARTICIPANTS

We included a multi-national panel of 17 experts on community paramedicine and in-home assessment from multiple settings (paramedicine, primary care, mental health, home and community care, geriatric care).

MEASURES

A list of potential assessment categories was established after a targeted literature review and confirmed by panel members. Over multiple rounds, panel members scored the appropriateness of 48 assessment domains on a Likert scale from 0 (not appropriate) to 5 (very appropriate). Scores were then reviewed at an in-person meeting and a finalised list of assessment domains was generated.

RESULTS

After the preliminary round of scoring, all 48 assessment domains had scores that demonstrated consensus. Nine assessment domains (18.8%) demonstrated a wider range of rated appropriateness. No domains were found to be not appropriate. Achieving consensus about the appropriateness of assessment domains on the first round of scoring negated the need for subsequent rounds of scoring. The in-person meeting resulted in re-grouping assessment domains and adding an additional domain about urinary continence.

CONCLUSION

An international panel of experts with knowledge about in-home assessment by community paramedics demonstrated a high level of agreement on appropriate patient assessment domains for community paramedicine home visit programme. Community paramedicine home visit programme are likely to have similar patient populations. A standardised assessment instrument may be viable in multiple settings.

Protocol of a case-control longitudinal study (fraXity) assessing frailty and complexity among Swiss home service recipients using interRAI-HC assessments

BACKGROUND

The early screening of frail individuals and of patients with complex care needs are challenges that countries witnessing population aging face. Homecare nurses are actors of choice in meeting these challenges, yet they need means of identifying frail and complex patients in their routine practice. The fraXity study's aim is to fill this gap by (1) proposing frailty and complexity computation algorithms derived from the interRAI-HC; (2) assessing the predictive validity of the proposed indices with respect to adverse health outcomes; and (3) identifying subgroups of the aged population for whom the early screening of frailty and complexity appears to be most relevant.

METHODS

The study will rely on a prospective observational case-control longitudinal study. Three samples of individuals aged 65 or older living in the community will be considered: recipients of formal home care (case 1), of formal home assistance (case 2) and individuals free of formal home services (controls). All participants will receive interRAI-HC assessments at three measurement occasions, separated by six-month intervals. Baseline assessments will serve to derive frailty and complexity scores. Follow-ups will serve to assess the predictive validity of the proposed indices and to estimate the intra-individual change in frailty and complexity. Group comparisons will serve to identify subgroups of the population for whom the screening of frailty and complexity appears to be the most relevant.

DISCUSSION

The expected results of the fraXity study are a) reliable computation algorithms for frailty and complexity scores derived from the interRAI-HC and b) clinical assessment protocols for use by homecare nurses. These outcomes should contribute to outfitting key actors of the health system with means of enhancing their part in a collective endeavor targeting the best care and quality of life for aged citizens.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03883425 , registered on March 20, 2019.

Clinical predictors of protracted length of stay in Ontario Complex Continuing Care hospitals

Background

Post-acute care hospitals are often subject to patient flow pressures because of their intermediary position along the continuum of care between acute care hospitals and community care or residential long-term care settings. The purpose of this study was to identify patient attributes associated with a prolonged length of stay in Complex Continuing Care hospitals.

Methods

Using information collected using the interRAI Resident Assessment Instrument Minimum Data Set 2.0 (MDS 2.0), a sample of 91,113 episodes of care for patients admitted to Complex Continuing Care hospitals between March 31, 2001 and March 31, 2013 was established. All patients in the sample were either discharged to a residential long-term care facility (e.g., nursing home) or to the community. Long-stay patients for each discharge destination were identified based on a length of stay in the 95th percentile. A series of multivariate logistic regression models predicting long-stay patient status for each discharge destination pathway were fit to characterize the association between demographic factors, residential history, health severity measures, and service utilization on prolonged length of stay in post-acute care.

Results

Risk factors for prolonged length of stay in the adjusted models included functional and cognitive impairment, greater pressure ulcer risk, paralysis, antibiotic resistant and HIV infection need for a feeding tube, dialysis, tracheostomy, ventilator or a respirator, and psychological therapy. Protective factors included advanced age, medical instability, a greater number of recent hospital and emergency department visits, cancer diagnosis, pneumonia, unsteady gait, a desire to return to the community, and a support person who is positive towards discharge. Aggressive behaviour was only a risk factor for patients discharged to residential long-term care facilities. Cancer diagnosis, antibiotic resistant and HIV infection, and pneumonia were only significant factors for patients discharged to the community.

Conclusions

This study identified several patient attributes and process of care variables that are predictors of prolonged length of stay in post-acute care hospitals. This is valuable information for care planners and health system administrators working to improve patient flow in Complex Continuing Care and other post-acute care settings such as skilled nursing and inpatient rehabilitation facilities.

Resource Intensity for Children and Youth: The Development of an Algorithm to Identify High Service Users in Children's Mental Health

Children’s mental health care plays a vital role in many social, health care, and education systems, but there is evidence that appropriate targeting strategies are needed to allocate limited mental health care resources effectively. The aim of this study was to develop and validate a methodology for identifying children who require access to more intense facility-based or community resources. Ontario data based on the interRAI Child and Youth Mental Health instruments were analysed to identify predictors of service complexity in children’s mental health. The Resource Intensity for Children and Youth (RIChY) algorithm was a good predictor of service complexity in the derivation sample. The algorithm was validated with additional data from 61 agencies. The RIChY algorithm provides a psychometrically sound decision-support tool that may be used to inform the choices related to allocation of children’s mental health resources and prioritisation of clients needing community- and facility-based resources.

An Overview of International Staff Time Measurement Validation Studies of the RUG-III Case-mix System

The RUG-III case-mix system is a method of grouping patients in long-term and post-acute care settings. RUG-III groups patients by relative per diem resource consumption and may be used as the basis for prospective payment systems to ensure that facility reimbursement is commensurate with patient acuity. Since RUG-III's development in 1994, more than a dozen international staff time measurement studies have been published to evaluate the utility of the case-mix system in a variety of diverse health care environments around the world. This overview of the literature summarizes the results of these RUG-III validation studies and compares the performance of the algorithm across countries, patient populations, and health care environments. Limitations of the RUG-III validation literature are discussed for the benefit of health system administrators who are considering implementing RUG-III and next-generation resource utilization group case-mix systems.

Predicting Future Health Transitions Among Newly Admitted Nursing Home Residents With Heart Failure

OBJECTIVES

To understand how a heart failure diagnosis and admission health instability predict health transitions and outcomes among newly admitted nursing home residents.

DESIGN

Retrospective cohort study of linked administrative data, including the Continuing Care Report System MDS 2.0 for nursing homes, the Discharge Abstract Database for hospitalized patients, and National Ambulatory Care Reporting System to track emergency department visits.

SETTING AND PARTICIPANTS

Older adults, aged 65 years and above, admitted to nursing homes in Ontario, Alberta, and British Columbia, Canada, from 2010 to 2016.

MEASURES

Mortality and hospitalization were plotted over 1 year. Multistate Markov models were used to estimate adjusted odds ratios (ORs) for transitions to different states of health in stability, hospitalization, and death, stratified by heart failure diagnosis and by interRAI Changes in Health and End-stage disease Signs and Symptoms (CHESS) score, at 90 days following admission to a nursing home.

RESULTS

The final sample included 143,067 residents. Adverse events were most common in the first 90 days. A diagnosis of heart failure predicted worsening health instability, hospitalizations, and mortality. The effect of heart failure on hospitalizations and death was strongest for low baseline health instability (CHESS = 0; OR 1.63, 95% confidence interval (CI) 1.58-1.68, and OR 1.71, 95% CI 1.57-1.86, respectively), versus moderate instability (CHESS = 1-2; OR 1.36, 95% CI 1.32-1.39, and OR 1.48, 95% CI 1.41-1.55), versus high instability (CHESS = 3; OR 1.12, 95% CI 1.03-1.23, and OR 1.21, 95% CI 1.11-1.32). The magnitude of the impact of a heart failure diagnosis was greatest for lower baseline health instability. Residents with the highest degree of health instability were also most likely to die in hospital.

CONCLUSIONS AND IMPLICATIONS

A diagnosis of heart failure and health instability provide complementary information to predict transfers, deaths, and adverse outcomes. Clearly identifying these at-risk patients may be useful in targeting interventions in nursing homes.