Long-term care funding in Canada: a policy mosaic

Integrating Technology Adoption Models Into Implementation Science Methodologies: A Mixed-Methods Preimplementation Study

BACKGROUND AND OBJECTIVES

Sustainable implementation of patient-oriented technologies in health care settings is challenging. Preimplementation studies guided by the Consolidated Framework for Implementation Research (CFIR) can provide opportunities to address barriers and leverage facilitators that can maximize the likelihood of successful implementation. When looking to implement patient-oriented technologies, preimplementation studies may also benefit from guidance from a conceptual framework specific to technology adoption such as the Unified Theory of Acceptance and Use of Technology. This study was, therefore, aimed at identifying determinants for the successful implementation of a patient-oriented technology (i.e., automated pain behavior monitoring [APBM] system) within a health care setting (i.e., long-term care [LTC] facility).

RESEARCH DESIGN AND METHODS

Using a mixed-methods study design, 164 LTC nurses completed a set of questionnaires and 68 LTC staff participated in individual interviews involving their perceptions of an APBM system in LTC environments. Quantitative data were analyzed using a series of mediation analyses and narrative responses were examined using directed content analysis.

RESULTS

Performance expectancy and effort expectancy partially and fully mediated the influence of implementation, readiness for organizational change, and technology readiness constructs on behavioral intentions to use the APBM system in LTC environments. Findings from the qualitative portion of this study provide guidance for the development of an intervention that is grounded in the CFIR.

DISCUSSION AND IMPLICATIONS

Based on our results, we offer recommendations for the implementation of patient-oriented technologies in health care settings.

Expanding the breadth of Medicare: learning from Australia

The design of Australia’s Medicare programme was based on the Canadian scheme, adapted somewhat to take account of differences in the constitutional division of powers in the two countries and differences in history. The key elements are very similar: access to hospital services without charge being the core similarity, universal coverage for necessary medical services, albeit with a variable co-payment in Australia, the other. But there are significant differences between the two countries in health programmes – whether or not they are labelled as ‘Medicare’. This paper discusses four areas where Canada could potentially learn from Australia in a positive way. First, Australia has had a national Pharmaceutical Benefits Scheme for almost 70 years. Second, there have been hesitant extensions to Australia’s Medicare to address the increasing prevalence of people with chronic conditions – extensions which include some payments for allied health professionals, ‘care coordination’ payments, and exploration of ‘health care homes’. Third, Australia has a much more extensive system of support for older people to live in their homes or to move into supported residential care. Fourth, Australia has gone further in driving efficiency in the hospital sector than has Canada. Finally, the paper examines aspects of the Australian health care system that Canada should avoid, including the very high level of out-of-pocket costs, and the role of private acute inpatient provision.

Contemplating case mix: A primer on case mix classification and management

Case mix classifications are the frameworks that underlie many healthcare funding schemes, including the so-called activity-based funding. Now more than ever, Canadian healthcare administrators are evaluating case mix-based funding and deciphering how they will influence their organization. Case mix is a topic fraught with technical jargon and largely relegated to government agencies or private industries. This article provides an abridged review of case mix classification as well as its implications for management in healthcare.

Exploring the ecology of Canada's publicly funded residential long-term care bed supply

Despite Canada's increasing population of seniors and the varying long-term care (LTC) strategies that provinces have implemented, little research has focused on understanding the extent to which publicly funded residential LTC bed supply varies across provinces, or the factors influencing this variation. Our study involved an analysis in which we examined the association of three select jurisdictional characteristics with LTC bed supply: population age demographics, provincial wealth, and provincial investments in home care. No significant cross-jurisdictional "ecology" or inter-relatedness was found between the variation in LTC bed supply and any of the examined variables. Interprovincial variation in bed supply also did not statistically influence alternate level of care days specific to LTC waits, suggesting that these days were not influenced simply by differences in LTC bed supply and that other provincial-level factors were in play.

Gender differences in home care clients and admission to long-term care in Ontario, Canada: a population-based retrospective cohort study

Background

Home care is integral to enabling older adults to delay or avoid long-term care (LTC) admission. To date, there is little population-based data about gender differences in home care users and their subsequent outcomes. Our objectives were to quantify differences between women and men who used home care in Ontario, Canada and to determine if there were subsequent differences in LTC admission.

Methods

This is a population-based retrospective cohort study. We identified all adults aged 76+ years living in Ontario and receiving home care on April 1, 2007 (baseline). Using the Resident Assessment Instrument – Home Care (RAI-HC) linked to other databases, we characterized the cohort by living condition, health and functioning, and identified all acute care and LTC use in the year following baseline.

Results

The cohort consisted of 51,201 women and 20,102 men. Women were older, more likely to live alone, and more likely to rely on a child or child-in-law for caregiver support. Men most frequently identified a spouse as caregiver and their caregivers reported distress twice as often as women’s caregivers. Men had higher rates of most chronic conditions and were more likely to experience impairment. Men were more likely to be admitted to hospital, to have longer stays in hospital, and to be admitted to LTC.

Conclusions

Understanding who uses home care and why is critical to ensuring that these programs effectively reduce LTC use. We found that women outnumbered men but that men presented with higher levels of need. This detailed gender analysis highlights how needs differ between older women, men, and their respective caregivers.

An evaluation of data quality in Canada's Continuing Care Reporting System (CCRS): secondary analyses of Ontario data submitted between 1996 and 2011

Background

Evidence informed decision making in health policy development and clinical practice depends on the availability of valid and reliable data. The introduction of interRAI assessment systems in many countries has provided valuable new information that can be used to support case mix based payment systems, quality monitoring, outcome measurement and care planning. The Continuing Care Reporting System (CCRS) managed by the Canadian Institute for Health Information has served as a data repository supporting national implementation of the Resident Assessment Instrument (RAI 2.0) in Canada for more than 15 years. The present paper aims to evaluate data quality for the CCRS using an approach that may be generalizable to comparable data holdings internationally.

Methods

Data from the RAI 2.0 implementation in Complex Continuing Care (CCC) hospitals/units and Long Term Care (LTC) homes in Ontario were analyzed using various statistical techniques that provide evidence for trends in validity, reliability, and population attributes. Time series comparisons included evaluations of scale reliability, patterns of associations between items and scales that provide evidence about convergent validity, and measures of changes in population characteristics over time.

Results

Data quality with respect to reliability, validity, completeness and freedom from logical coding errors was consistently high for the CCRS in both CCC and LTC settings. The addition of logic checks further improved data quality in both settings. The only notable change of concern was a substantial inflation in the percentage of long term care home residents qualifying for the Special Rehabilitation level of the Resource Utilization Groups (RUG-III) case mix system after the adoption of that system as part of the payment system for LTC.

Conclusions

The CCRS provides a robust, high quality data source that may be used to inform policy, clinical practice and service delivery in Ontario. Only one area of concern was noted, and the statistical techniques employed here may be readily used to target organizations with data quality problems in that (or any other) area. There was also evidence that data quality was good in both CCC and LTC settings from the outset of implementation, meaning data may be used from the entire time series. The methods employed here may continue to be used to monitor data quality in this province over time and they provide a benchmark for comparisons with other jurisdictions implementing the RAI 2.0 in similar populations.

Unregulated provider perceptions of audit and feedback reports in long-term care: cross-sectional survey findings from a quality improvement intervention

BACKGROUND

Audit with feedback is a moderately effective approach for improving professional practice in other health care settings. Although unregulated caregivers give the majority of direct care in long-term care settings, little is known about how they understand and perceive feedback reports because unregulated providers have not been directly targeted to receive audit with feedback in quality improvement interventions in long-term care. The purpose of this paper is to describe unregulated care providers' perceptions of usefulness of a feedback report in four Canadian long-term care facilities.

METHODS

We delivered monthly feedback reports to unregulated care providers for 13 months in 2009-2010. The feedback reports described a unit's performance in relation to falls, depression, and pain as compared to eight other units in the study. Follow-up surveys captured participant perceptions of the feedback report. We conducted descriptive analyses of the variables related to participant perceptions and multivariable logistic regression to assess the association between perceived usefulness of the feedback report and a set of independent variables.

RESULTS

The vast majority (80%) of unregulated care providers (n = 171) who responded said they understood the reports. Those who discussed the report with others and were interested in other forms of data were more likely to find the feedback report useful for making changes in resident care.

CONCLUSIONS

This work suggests that unregulated care providers can understand and feel positively about using audit with feedback reports to make changes to resident care. Further research should explore ways to promote fuller engagement of unregulated care providers in decision-making to improve quality of care in long-term care settings.

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

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

A protocol for determining differences in consistency and depth of palliative care service provision across community sites

Numerous accounts document the difficulty in obtaining accurate data regarding the extent and composition of palliative care services. Compounding the problem is the lack of standardisation regarding categorisation and reporting across jurisdictions. In this study, we gathered both quantitative and spatial--or geographical--data to develop a composite picture that captures the extent, composition and depth of palliative care in the Canadian province of British Columbia (BC). The province is intensely urban in the southwest and is rural or remote in most of the remainder. For this study, we conducted a detailed telephone survey of all palliative care home care teams and facilities hosting designated beds in BC. We used geographic information systems to geocode locations of all hospice and hospital facilities. In-home care data was obtained individually from each of five BC regional health authorities. In addition, we purchased accurate road travel time data to determine service areas around palliative facilities and to determine populations outside of a 1-hour travel time to a facility. With this data, we were able to calculate three critical metrics: (i) the population served within 1 hour of palliative care facilities--and more critically those not served; (ii) a matrix that determines access to in-home palliative care measured by both diversity of professionals as well as population served per palliative team member; and (iii) a ranking of palliative care services across the province based on physical accessibility as well as the extent of in-home care. In combination, these metrics provide the basis for identifying areas of vulnerability with respect to not meeting potential palliative care need. In addition, the ranking provides a basis for rural/urban comparisons. Finally, the protocol introduced can be used in other areas and provides a means of comparing palliative care service provision amongst multiple jurisdictions.

Long-term care in the St. John's region: impact of single entry and prediction of bed need

In 1996, the St. John's region had a population of 8,435 > or = 75 years, with 996 nursing home (NH) beds and 550 supervised care (SC) beds. A single entry system to these institutions was implemented in 1995. To determine the impact of the single entry system, the demographic and clinical characteristics of NH residents were assessed in 1997 (N = 1,044) and in 2003 (N = 963). To determine the efficiency of placement and the need for long-term care beds, two incident cohorts requesting placement were studied in 1995/96 (N = 467) and in 1999/2000 (N = 464). Degree of disability was determined using the Residents Utilization Groups III classification (RUG-III) and the Alberta Resident Classification Score (ARCS), and time to placement and to death was measured. In prevalent NH residents, the percentage without RUGS-III disability decreased from 18.5% in 1997 and to 9.9% in 2003. The proportion recommended for NH was 75% in 1995/96 and 72% in 1999/2000, despite the fact that the proportion with RUGS-III disability was 64% in both periods. Using a decision tree, optimal placement for the 1999/2000 cohort was 36% to SC, 20% to SC for the cognitively impaired, and 44% to NH. Predicted need for long-term care beds in 2004 matched poorly with current provision of NH and SC beds, and the mismatch will be worse in 2014. It was concluded that the single entry system was associated with improved appropriateness of NH bed utilization. However, there was a mismatch in need for and provision of institutional long-term care. Investment in the reconfiguration of long-term care beds by case mix and by geography is necessary.