Residential long-term care: public solutions to access and quality problems

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.

Long-Term Care Facility Workers' Perceptions of the Impact of Subcontracting on their Conditions of Work and the Quality of Care: A Qualitative Study in British Columbia

Subcontracting long-term care (LTC), whereby facilities contracted with third party agencies to provide care to residents, became widespread in British Columbia after 2002. This qualitative study aimed to understand the impact of subcontracting from the perspective of care workers. We interviewed 11 care workers employed in subcontracted facilities to explore their perceptions of caring and working under these conditions. Our overarching finding was one of loss. Care workers lost wages, benefits, security, and voice. Their working conditions worsened, with workload and turnover increasing, resulting in a loss of experienced staff and a loss of time to provide care. These findings call into question the promises of quality and flexibility that legitimated policies permitting subcontracting, while adding to the mounting evidence that subcontracting LTC harms both workers and residents.

Using Normalization Process Theory to Evaluate the Implementation of Montessori-Based Volunteer Visits Within a Canadian Long-Term Care Home

BACKGROUND AND OBJECTIVES

Montessori-based interventions (MBIs) have potential to improve the life quality of long-term care residents with dementia. In this study, we aimed to understand the processes by which staff integrated a volunteer-led MBI into practice within a special dementia care unit, and to explore staff members ' perceptions of associated strengths and limitations.

RESEARCH DESIGN AND METHODS

This study relied on a qualitative descriptive design. Following a 3-month period of volunteer involvement, we conducted 21 interviews with staff members to document perceptions of the new program and subjected interview transcripts to qualitative content analysis, guided by normalization process theory.

RESULTS

During the implementation of the volunteer-led MBI, staff members developed a shared understanding of the intervention, a sense of commitment, practical ways to support the intervention, and opinions about the value of the residents. Overall, we found that the volunteer-led MBI was quickly and successfully integrated into practice and was perceived to support both residents and staff members in meaningful ways. Nevertheless, some limitations were also identified.

DISCUSSION AND IMPLICATIONS

Volunteer-delivered MBIs are a useful adjunct to practice within a special dementia care unit. This article raises attention to some strengths and limitations associated with this approach.

A mixed methods quality improvement study to implement nurse practitioner roles and improve care for residents in long-term care facilities

BACKGROUND

To better meet long-term care (LTC) residents' (patients in LTC) needs, nurse practitioners (NPs) were proposed as part of a quality improvement initiative. No research has been conducted in LTC in Québec Canada, where NP roles are new. We collected provider interviews, field notes and resident outcomes to identify how NPs in LTC influence care quality and inform the wider implementation of these roles in Québec. This paper reports on resident outcomes and field notes.

METHODS

Research Design: This mixed methods quality improvement study included a prospective cohort study in six LTC facilities in Québec. Participants: Data were collected from September 2015-August 2016. The cohort consisted of all residents (n = 538) followed by the nurse practitioners. Nurse practitioner interventions (n = 3798) related to medications, polypharmacy, falls, restraint use, transfers to acute care and pressure ulcers were monitored. Analysis: Bivariate analyses and survival analysis of occurrence of events over time were conducted. Content analysis was used for the qualitative data.

RESULTS

Nurse practitioners (n = 6) worked half-time in LTC with an average caseload ranging from 42 to 80 residents. Sites developed either a shared care or a consultative model. The average age of residents was 82, and two thirds were women. The most common diagnosis on admission was dementia (62%, n = 331). The number of interventions/resident (range: 2.2-16.3) depended on the care model. The average number of medications/resident decreased by 12% overall or 10% for each 30-day period over 12 months. The incidence of polypharmacy, falls, restraint use, and transfers to acute care decreased, and very few pressure ulcers were identified.

CONCLUSIONS

The implementation of NPs in LTC in Québec can improve care quality for residents. Results show that the average number of medications per day per resident, the incidence of polypharmacy, falls, restraint use, and transfers to acute care all decreased during the study, suggesting that a wider implementation of NP roles in LTC is a useful strategy to improve resident care. Although additional studies are needed, the implementation of a consultative model should be favoured as our project provides preliminary evidence of the contributions of these new roles in LTC in Québec.

Importance of Team Functioning as a Target of Quality Improvement Initiatives in Nursing Homes: A Qualitative Process Evaluation

INTRODUCTION

Quality improvement interventions demonstrate variable degrees of effectiveness. The aim of this work was to (1) qualitatively explore whether, how, and why an academic detailing intervention could improve evidence uptake and (2) identify perceived changes that occurred to inform outcomes appropriate for quantitative evaluation.

METHODS

A qualitative process evaluation was conducted involving semistructured interviews with nursing home staff. Interviews were analyzed inductively using the framework method.

RESULTS

A total of 29 interviews were conducted across 13 nursing homes. Standard processes to reduce falls are well-known but not fully implemented due to a range of mostly postintentional factors that influence staff behavior. Conflicting expectations around professional roles impeded evidence uptake; physicians report a disconnection between the information they would like to receive and the information communicated; and a high proportion of casual and part-time staff creates challenges for those looking to effect change. These factors are amenable to change in the context of an active, tailored intervention such as academic detailing. This seems especially true when the entire care team is actively engaged and when the intervention can be tailored to the varied determinants of behaviors across different team members.

DISCUSSION

Interventions aiming to increase evidence-based practice in the nursing home sector need to move beyond education to explicitly address team functioning and communication. Variability in team functioning requires a flexible intervention with the ability to tailor to individual- and home-level needs. Evaluations in this setting may benefit from measuring changes in team functioning as an early indicator of success.

How well does the minimum data set measure healthcare use? a validation study

Background

To improve care, planners require accurate information about nursing home (NH) residents and their healthcare use. We evaluated how accurately measures of resident user status and healthcare use were captured in the Minimum Data Set (MDS) versus administrative data.

Methods

This retrospective observational cohort study was conducted on all NH residents (N = 8832) from Winnipeg, Manitoba, Canada, between April 1, 2011 and March 31, 2013. Six study measures exist. NH user status (newly admitted NH residents, those who transferred from one NH to another, and those who died) was measured using both MDS and administrative data. Rates of in-patient hospitalizations, emergency department (ED) visits without subsequent hospitalization, and physician examinations were also measured in each data source. We calculated the sensitivity, specificity, positive and negative predictive values (PPV, NPV), and overall agreement (kappa, κ) of each measure as captured by MDS using administrative data as the reference source. Also for each measure, logistic regression tested if the level of disagreement between data systems was associated with resident age and sex plus NH owner-operator status.

Results

MDS accurately identified newly admitted residents (κ = 0.97), those who transferred between NHs (κ = 0.90), and those who died (κ = 0.95). Measures of healthcare use were captured less accurately by MDS, with high levels of both under-reporting and false positives (e.g., for in-patient hospitalizations sensitivity = 0.58, PPV = 0.45), and moderate overall agreement levels (e.g., κ = 0.39 for ED visits). Disagreement was sometimes greater for younger males, and for residents living in for-profit NHs.

Conclusions

MDS can be used as a stand-alone tool to accurately capture basic measures of NH use (admission, transfer, and death), and by proxy NH length of stay. As compared to administrative data, MDS does not accurately capture NH resident healthcare use. Research investigating these and other healthcare transitions by NH residents requires a combination of the MDS and administrative data systems.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3089-7) contains supplementary material, which is available to authorized users.

Stranded: causes and effects of discharge delays involving non-acute in-patients requiring maintenance care in a tertiary hospital general medicine service

Objectives The aims of the present study were to identify causes of prolonged discharge delays among non-acute in-patients admitted to a tertiary general medicine service, quantify occupied bed days (OBDs) and propose strategies for eliminating avoidable delays. Methods A retrospective study was performed of patients admitted between 1 January 2012 and 31 May 2015 and discharged as non-acute cases requiring maintenance care and who incurred a total non-acute length of stay (LOS) >7 days and total hospital LOS >14 days. Long-stay patients with non-acute LOS ≥28 days were subject to chart review in ascertaining serial causes of discharge delay and their attributable OBDs. Literature reviews and staff feedback identified potential strategies for minimising delays. Results Of the 406 patients included in the present study, 131 incurred long-stays; for these 131 patients, delays were identified that accounted for 5420 of 6033 (90%) non-acute OBDs. Lack of available residential care beds was most frequent, accounting for 44% of OBDs. Waits for outcomes of guardianship applications accounted for 13%, whereas guardian appointments, Public Trustee applications and funding decisions for equipment or care packages each consumed between 4% and 5% of OBDs. Family and/or carer refusal of care accounted for 7%. Waits for aged care assessment team (ACAT) assessments, social worker reports, geriatrician or psychiatrist reviews and confirmation of enduring power of attorney each accounted for between 1% and 3% of OBDs. Of 30 proposed remedial strategies, those rated as high priority were: greater access to interim care or respite care beds or supported accommodation, especially for patients with special needs; dedicated agency officers for hospital guardianship applications and greater interagency collaboration and harmonisation of assessment and decision processes; and formal requests from hospital administrators to patients and family to accept care options and attend mediation meetings. Conclusions Delayed discharge of non-acute maintenance care patients results principally from impaired access to residential care, administrative delays involving external agencies and patient or family refusal of care. Proposed remedial actions require concerted interjurisdictional advocacy. What is known about this topic? Delays in discharge of non-acute patients requiring maintenance care can occur for many reasons and incur inordinately long hospital stays. What does this paper add? The present detailed chart review of 131 long-stay non-acute patients identified causes of serial discharge delays and quantified their prevalence and attributable bed days. Waits for residential care accounted for less than half the bed days, administrative delays involving decisions by agencies external to the hospital accounted for one-quarter and patient or family refusal of care options accounted for one-tenth. Strategies are proposed that may minimise these delays. What are the implications for practitioners? Delayed discharge of non-acute patients requiring maintenance care threatens to consume an ever-increasing proportion of acute hospital bed days. Remedial action is required from stakeholders both within and outside hospitals to reverse this trend.

The influence of individual and organizational factors on person-centred dementia care

OBJECTIVES

Although some individual and organizational contributors to person-centred care or quality of care have been studied, they have rarely been examined together. Our goal was to investigate the association of personal and organizational-environmental characteristics with self-reported person-centred behaviours in long-term residential care settings.

METHOD

We asked 109 long-term care staff from two Canadian long-term care homes to complete scales assessing self-reported person-centred care, organizational support for person-centred care, beliefs about personhood in dementia, and burnout. Independent variables included four employee background characteristics (age, gender, occupation, and years of education), beliefs about personhood in dementia, burnout, and three aspects of organizational support for person-centred care (the physical environment of residents, collaboration on care, and support from management). Dependent variables included five aspects of person-centred care: autonomy, personhood, knowing the person, comfort care, and support for relationships .We used multiple linear regression analysis and changes in R(2) to test variable associations.

RESULTS

Including organizational variables in regression models resulted in statistically significant (p < .05) changes in R(2) for each of the five dependent variables. Including personal variables resulted in statistically significant changes in R(2) for some dependent variables, but not others. In particular, including employee background characteristics resulted in a statistically significant change in R(2) for comfort care, and including beliefs about personhood and burnout resulted in statistically significant changes in R(2) for personhood but not for other dependent variables.

CONCLUSION

Organizational characteristics are associated with several aspects of person-centred dementia care. Individual characteristics, including gender, beliefs about personhood, and burnout, appear to be more important to some aspects of person-centred dementia care (e.g., respect for personhood and comfort care) than others.

Cost-effectiveness of a nurse practitioner-family physician model of care in a nursing home: controlled before and after study

AIMS

To examine the cost-effectiveness of a nurse practitioner-family physician model of care compared with family physician-only care in a Canadian nursing home.

BACKGROUND

As demand for long-term care increases, alternative care models including nurse practitioners are being explored.

DESIGN

Cost-effectiveness analysis using a controlled before-after design.

METHODS

The study included an 18-month 'before' period (2005-2006) and a 21-month 'after' time period (2007-2009). Data were abstracted from charts from 2008-2010. We calculated incremental cost-effectiveness ratios comparing the intervention (nurse practitioner-family physician model; n = 45) to internal (n = 65), external (n = 70) and combined internal/external family physician-only control groups, measured as the change in healthcare costs divided by the change in emergency department transfers/person-month. We assessed joint uncertainty around costs and effects using non-parametric bootstrapping and cost-effectiveness acceptability curves.

RESULTS

Point estimates of the incremental cost-effectiveness ratio demonstrated the nurse practitioner-family physician model dominated the internal and combined control groups (i.e. was associated with smaller increases in costs and emergency department transfers/person-month). Compared with the external control, the intervention resulted in a smaller increase in costs and larger increase in emergency department transfers. Using a willingness-to-pay threshold of $1000 CAD/emergency department transfer, the probability the intervention was cost-effective compared with the internal, external and combined control groups was 26%, 21% and 25%.

CONCLUSION

Due to uncertainty around the distribution of costs and effects, we were unable to make a definitive conclusion regarding the cost-effectiveness of the nurse practitioner-family physician model; however, these results suggest benefits that could be confirmed in a larger study.

Does regulating private long-term care facilities lead to better care? A study from Quebec, Canada

OBJECTIVE

In the province of Quebec, Canada, long-term residential care is provided by two types of facilities: publicly funded accredited facilities and privately owned facilities in which care is privately financed and delivered. Following evidence that private facilities were delivering inadequate care, the provincial government decided to regulate this industry. We assessed the impact of regulation on care quality by comparing quality assessments made before and after regulation. In both periods, public facilities served as a comparison group.

DESIGN

A cross-sectional study conducted in 2010-12 that incorporates data collected in 1995-2000.

SETTINGS

Random samples of private and public facilities from two regions of Quebec.

PARTICIPANTS

Random samples of disabled residents aged 65 years and over. In total, 451 residents from 145 care settings assessed in 1995-2000 were compared with 329 residents from 102 care settings assessed in 2010-12.

INTERVENTION

Regulation introduced by the province in 2005, effective February 2007.

MAIN OUTCOME MEASURE

Quality of care measured with the QUALCARE Scale.

RESULTS

After regulation, fewer small-size facilities were in operation in the private market. Between the two study periods, the proportion of residents with severe disabilities decreased in private facilities whereas it remained >80% in their public counterparts. Meanwhile, quality of care improved significantly in private facilities, while worsening in their public counterparts, even after controlling for confounding.

CONCLUSIONS

The private industry now provides better care to its residents. Improvement in care quality likely results in part from the closure of small homes and change in resident case-mix.