July 9, 2018


Calls for Abstracts
Grants & Awards
Publications
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News
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Announcements

New TREC article
Individual and organizational predictors of allied healthcare providers’ job satisfaction in residential long-term care
Non UofA Access

L. D. Aloisio, W. A. Gifford, K. S. McGilton, M. Lalonde, C. A. Estabrooks and J. E. Squires.
BMC Health Serv Res 2018 Jun 25;18(1):491-018-3307-3
Job satisfaction is a predictor of intention to stay and turnover among allied healthcare providers. However, there is limited research examining job satisfaction among allied health professionals, specifically in residential long-term care (LTC) settings. The purpose of this study was to identify factors (demographic, individual, and organizational) that predict job satisfaction among allied healthcare providers in residential LTC. METHODS: We conducted a secondary analysis of data from Phase 2 of the Translating Research in Elder Care program. A total of 334 allied healthcare providers from 77 residential LTC in three Western Canadian provinces were included in the analysis. Generalized estimating equation modeling was used to assess demographics, individual, and organizational context predictors of allied healthcare providers’ job satisfaction. We measured job satisfaction using the Michigan Organizational Assessment Questionnaire Job Satisfaction Subscale. RESULTS: Both individual and organizational context variables predicted job satisfaction among allied healthcare providers employed in LTC. Demographic variables did not predict job satisfaction. At the individual level, burnout (cynicism) (beta = -.113, p = .001) and the competence subscale of psychological empowerment (beta = -.224, p = < .001), were predictive of lower job satisfaction levels while higher scores on the meaning (beta = .232, p = .001), self-determination (beta = .128, p = .005), and impact (beta = .10, p = .014) subscales of psychological empowerment predicted higher job satisfaction. Organizational context variables that predicted job satisfaction included: social capital (beta = .158, p = .012), organizational slack-time (beta = .096, p = .029), and adequate orientation (beta = .088, p = .005). CONCLUSIONS: This study suggests that individual allied healthcare provider and organizational context features are both predictive of allied healthcare provider job satisfaction in residential LTC settings. Unlike demographics and structural characteristics of LTC facilities, all variables identified as important to allied healthcare providers’ job satisfaction in this study are potentially modifiable, and therefore amenable to intervention.

New article by Dr. Greta Cummings & Dr. Estabrooks
Conceptual Models of Early and Involuntary Retirement among Canadian Registered Nurses and Allied Health Professionals
Non UofA Access

S. Hewko, T. Reay, C. A. Estabrooks and G. G. Cummings.
Can J Aging 2018 Jun 25:1-15
Availability of health professionals is fundamental to population health. Multiple trends contribute to provider shortages. PURPOSE: Develop and validate conceptual models of early and involuntary retirement among registered nurses (RNs) and allied health professionals (AHPs). METHOD: A review of retirement literature (n = 23 studies). Any factor reported as predictive of early or involuntary retirement was incorporated into a model. To achieve face validity, we conducted interviews with Canadian RNs/AHPs (n = 14). RESULTS: The conceptual model of early retirement had eight categories (38 variables): workplace characteristics, socio-demographics, attitudes/beliefs, broader context, organizational factors, family, lifestyle/health, and work-related. The model of involuntary retirement had four categories (eight variables): broader context, socio-demographics, lifestyle/health, and family. Caregiving responsibilities (variable) was added based on interview data. DISCUSSION: RNs/AHPs consider many factors when contemplating retirement; some are sensitive to intercession, which generates possibilities for extending the work lives of older RNs and AHPs.

New article by Dr. Anne-Marie Boström
Job strain: a cross-sectional survey of dementia care specialists and other staff in Swedish home care services.
Non UofA Access

L. Sandberg, L. Borell, D. Edvardsson, L. Rosenberg and A. M. Bostrom.
J Multidiscip Healthc 2018 May 22;11:255-266
An increasing number of older persons worldwide live at home with various functional limitations such as dementia. So, home care staff meet older persons with extensive, complex needs. The staff’s well-being is crucial because it can affect the quality of their work, although literature on job strain among home care staff is limited. Aim: To describe perceived job strain among home care staff and to examine correlations between job strain, personal factors, and organizational factors. Methods: The study applied a cross-sectional survey design. Participants were dementia care specialists who work in home care (n=34) and other home care staff who are not specialized in dementia care (n=35). The Strain in Dementia Care Scale (SDCS) and Creative Climate Questionnaire instruments and demographic variables were used. Descriptive and inferential statistics (including regression modeling) were applied. The regional ethical review board approved the study. Results: Home care staff perceived job strain – particularly because they could not provide what they perceived to be necessary care. Dementia care specialists ranked job strain higher (m=5.71) than other staff members (m=4.71; p=0.04). Job strain (for total score and for all five SDCS factors) correlated with being a dementia care specialist. Correlations also occurred between job strain for SDCS factor 2 (difficulties understanding and interpreting) and not having Swedish as first language and SDCS factor 5 (lack of recognition) and stagnated organizational climate. Conclusion: The study indicates that home care staff and particularly dementia care specialists perceived high job strain. Future studies are needed to confirm or reject findings from this study.

New article by Dr. Whitney Berta
Towards a Community-Based Dementia Care Strategy: How Do We Get There from Here?
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F. Morton-Chang, A. P. Williams, W. Berta and A. Laporte.
Healthc Pap 2016;16(2):8-32
As recent policy reports in Ontario and elsewhere have emphasized, most older persons would prefer to age at home. This desire does not diminish for the growing numbers of persons living with dementia (PLWD). Nevertheless, many PLWD end up in residential long-term care (LTC) or in hospital beds. While LTC is valuable for PLWD with highly progressed cognitive and functional impairment requiring high-intensity care, it can be a costly and avoidable option for those who could remain at home if given early access to a coordinated mix of community-based supports. In this lead paper, we begin by exploring the “state of the art” in community-based care for PLWD, highlighting the importance of early and ongoing intervention. We then offer a brief history of dementia care policy in Ontario as an illustrative case study of the challenges faced by policy makers in all jurisdictions as they aim to re-direct healthcare systems focused on “after-the-fact” curative care towards “before-the-fact” prevention and maintenance in the community. Drawing on results from a “balance of care” study, which we conducted in South West Ontario, we examine how, in the absence of viable community-based care options, PLWD can quickly “default” to institutional care. In the final section, we draw from national and international experience to identify the following three key strategic pillars to guide action towards a community-based dementia care strategy: engage PLWD to the extent possible in decisions around their own care; acknowledge and support informal caregivers in their pivotal roles supporting PLWD and consequently the formal care; and enable “ground-up” change through policies and funding mechanisms designed to ensure early intervention across a continuum of care with the aim of maintaining PLWD and their caregivers as independently as possible, for as long as possible, “closer to home.”.

New OECD Report
Care Needed: Improving the Lives of People with Dementia

OECD, 2018
This report presents newly collected data on the quality of dementia care in OECD countries. By providing the most up-to-date and comprehensive cross-country assessment of dementia care, it can help countries to improve their care systems today, and better prepare for the challenges of tomorrow.

New Article by Dr. Gillian Harvey
When East meets West: a qualitative study of barriers and facilitators to evidence-based practice in Hunan China.
Non UofA Access

W. Gifford, Q. Zhang, S. Chen, et al.
BMC Nurs 2018 Jun 20;17:26-018-0295-x. eCollection 2018
Research into evidence-based practice has been extensively explored in nursing and there is strong recognition that the organizational context influences implementation. A range of barriers has been identified; however, the research has predominantly taken place in Western cultures, and there is little information about factors that influence evidence-based practice in China. The purpose of this study was to explore barriers and facilitators to evidence-based practice in Hunan province, a less developed region in China. Methods: A descriptive qualitative methodology was employed. Semi-structured interviews were conducted with staff nurses, head nurses and directors (n = 13). Interviews were translated into English and verified for accuracy by two bilingual researchers. Both Chinese and English data were simultaneously analyzed for themes related to factors related to the evidence to be implemented (Innovation), nurses’ attitudes and beliefs (Potential Adopters), and the organizational setting (Practice Environment). Results: Barriers included lack of available evidence in Chinese, nurses’ lack of understanding of what evidence-based practice means, and fear that patients will be angry about receiving care that is perceived as non-traditional. Nurses believed evidence-based practice was to be used when clinical problems arose, and not as a routine way to practice. Facilitators included leadership support and the pervasiveness of web based social network services such as Baidu () for easy access to information. Conclusion: While several parallels to previous research were found, our study adds to the knowledge base about factors related to evidence-based practice in different contextual settings. Findings are important for

Calls for Abstracts

CALL FOR ABSTRACTS:
WCHRI 11th Annual Research Day

24 October 2018 Edmonton AB
DEADLINE 10 September
WCHRI’s annual Research Day is our time to celebrate our members’ successes and achievements. It brings our membership and stakeholders together to share common interests and research outputs on women and children’s health, and is a great venue for our trainees to communicate their recent work, discuss their research and network with colleagues. All of our trainees will share their research at Research Day through either a poster or oral presentation. Each presentation will be judged by two WCHRI researchers. In many cases, the poster judges will be “shadowed” by stakeholders of the Foundations that support WCHRI in our work (the Stollery Children’s Hospital Foundation and the Royal Alexandra Hospital Foundation).

CALL FOR ABSTRACTS:
AcademyHealth’s 11th Annual Conference on the Science of Dissemination and Implementation in Health

3-5 December 2018 Washington DC
DEADLINE Tuesday 24 July
The conference aims to bridge the gap between research, practice and policy by outlining priorities in the field. The theme for this year’s Dec. 3–5 conference will focus on strategies for scaling up effective interventions across communities, health systems, networks and countries, and efforts to build capacity for dissemination and implementation science. Abstract submissions are encouraged for three types of scientific sessions: individual oral presentations, panel presentations and poster presentations.

 

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Grants & Awards

PCORI Funding Announcement: Implementation of Effective Shared Decision Making Approaches in Practice Settings — Cycle 2 2018

DEADLINE Letters of Intent Tuesday 24 July 2018
This PCORI Funding Announcement (PFA) promotes the targeted implementation and systematic uptake of shared decision making (SDM) in healthcare settings, in line with PCORI’s goal of supporting patients in making informed decisions about their care. For this PFA, PCORI defines an SDM strategy as an intervention or approach that draws on and presents evidence to inform patients of available treatment options and their risks and benefits, and either engages patients in a decision-making process with their clinician or promotes their ability to engage in such a process.

 

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Publications

KT
Health Care Administration and Organization
Health Care Innovation and Quality Assurance
Organizational Culture and Change
Research Practice and Methodology
Aging

KT

Supporting the implementation of stroke quality-based procedures (QBPs): a mixed methods evaluation to identify knowledge translation activities, knowledge translation interventions, and determinants of implementation across Ontario.
Non UofA Access

J. E. Moore, C. Marquez, K. Dufresne, et al.
BMC Health Serv Res 2018 Jun 18;18(1):466-018-3220-9
In 2013, Health Quality Ontario introduced stroke quality-based procedures (QBPs) to promote use of evidence-based practices for patients with stroke in Ontario hospitals. The study purpose was to: (a) describe the knowledge translation (KT) interventions used to support stroke QBP implementation, (b) assess differences in the planned and reported KT interventions by region, and (c) explore determinants perceived to have affected outcomes. METHODS: A mixed methods approach was used to evaluate: activities, KT interventions, and determinants of stroke QBP implementation. In Phase 1, a document review of regional stroke network work plans was conducted to capture the types of KT activities planned at a regional level; these were mapped to the knowledge to action framework. In Phase 2, we surveyed Ontario hospital staff to identify the KT interventions used to support QBP implementation at an organizational level. Phase 3 involved qualitative interviews with staff to elucidate deeper understanding of survey findings. RESULTS: Of the 446 activities identified in the document review, the most common were ‘dissemination’ (24.2%; n = 108), ‘implementation’ (22.6%; n = 101), ‘implementation planning’ (15.0%; n = 67), and ‘knowledge tools’ (10.5%; n = 47). Based on survey data (n = 489), commonly reported KT interventions included: staff educational meetings (43.1%; n = 154), champions (41.5%; n = 148), and staff educational materials (40.6%; n = 145). Survey participants perceived stroke QBP implementation to be successful (median = 5/7; interquartile range = 4-6; range = 1-7; n = 335). Forty-four people (e.g., managers, senior leaders, regional stroke network representatives, and frontline staff) participated in interviews/focus groups. Perceived facilitators to QBP implementation included networks and collaborations with external organizations, leadership engagement, and hospital prioritization of stroke QBP. Perceived barriers included lack of funding, size of the hospital (i.e., too small), lack of resources (i.e., staff and time), and simultaneous implementation of other QBPs. CONCLUSIONS: Information on the types of activities and KT interventions used to support stroke QBP implementation and the key determinants influencing uptake of stroke QBPs can be used to inform future activities including the development and evaluation of interventions to address barriers and leverage facilitators.

Development and testing of the Measure of Innovation-Specific Implementation Intentions (MISII) using Rasch measurement theory
Non UofA Access

J. C. Moullin, M. G. Ehrhart and G. A. Aarons.
Implement Sci 2018 Jun 28;13(1):89-018-0782-1
Implementation is proposed to be a multiphase, multilevel process. After a period of exploration, an adoption decision is made, typically at the upper management or policy level. Nevertheless, movement through each of the subsequent phases of the implementation process involves clinicians or providers at the individual level to adopt the innovation and then change their behavior to use/deliver the innovation. Multiple behavioral change theories propose that intentions are a critical determinant of implementation behavior. However, there is a need for the development and testing of pragmatic measures of providers’ intentions to use a specific innovation or evidence-based practice (EBP). METHODS: Nine items were developed to assess providers’ intentions to use a specific innovation or EBP. Motivational interviewing was the EBP in the study. Items were administered, as part of larger survey, to 179 providers across 38 substance use disorder treatment (SUDT) programs within five agencies in California, USA. Rasch analysis was conducted using RUMM2030 software to assess the items, their overall fit to the Rasch model, the response scale used, individual item fit, differential item functioning (DIF), and person separation. RESULTS: Following a stepwise process, the scale was reduced from nine items to three items to increase the feasibility and acceptability of the scale while maintaining suitable psychometric properties. The three-item unidimensional scale showed good person separation (PSI = .872), no disordering of thresholds, and no evidence of uniform or non-uniform DIF. Rasch analysis supported the viability of the scale as a measure of implementation intentions. CONCLUSIONS: The Measure of Innovation-Specific Implementation Intentions (MISII) is a sound measure of providers’ intentions to use a specific innovation or EBP. Future evaluation of convergent, divergent, and predictive validity are needed. The study also demonstrates the value of Rasch analysis for testing the psychometric properties of pragmatic implementation measures.

Simple rules for evidence translation in complex systems: A qualitative study.
Non UofA Access

J. E. Reed, C. Howe, C. Doyle and D. Bell.
BMC Med 2018 Jun 20;16(1):92-018-1076-9
Ensuring patients benefit from the latest medical and technical advances remains a major challenge, with rational-linear and reductionist approaches to translating evidence into practice proving inefficient and ineffective. Complexity thinking, which emphasises interconnectedness and unpredictability, offers insights to inform evidence translation theories and strategies. Drawing on detailed insights into complex micro-systems, this research aimed to advance empirical and theoretical understanding of the reality of making and sustaining improvements in complex healthcare systems. METHODS: Using analytical auto-ethnography, including documentary analysis and literature review, we assimilated learning from 5 years of observation of 22 evidence translation projects (UK). We used a grounded theory approach to develop substantive theory and a conceptual framework. Results were interpreted using complexity theory and ‘simple rules’ were identified reflecting the practical strategies that enhanced project progress. RESULTS: The framework for Successful Healthcare Improvement From Translating Evidence in complex systems (SHIFT-Evidence) positions the challenge of evidence translation within the dynamic context of the health system. SHIFT-Evidence is summarised by three strategic principles, namely (1) ‘act scientifically and pragmatically’ – knowledge of existing evidence needs to be combined with knowledge of the unique initial conditions of a system, and interventions need to adapt as the complex system responds and learning emerges about unpredictable effects; (2) ’embrace complexity’ – evidence-based interventions only work if related practices and processes of care within the complex system are functional, and evidence-translation efforts need to identify and address any problems with usual care, recognising that this typically includes a range of interdependent parts of the system; and (3) ‘engage and empower’ – evidence translation and system navigation requires commitment and insights from staff and patients with experience of the local system, and changes need to align with their motivations and concerns. Twelve associated ‘simple rules’ are presented to provide actionable guidance to support evidence translation and improvement in complex systems. CONCLUSION: By recognising how agency, interconnectedness and unpredictability influences evidence translation in complex systems, SHIFT-Evidence provides a tool to guide practice and research. The ‘simple rules’ have potential to provide a common platform for academics, practitioners, patients and policymakers to collaborate when intervening to achieve improvements in healthcare.

 

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Health Care Administration and Organization

Exploration of dynamics in a complex person-centred intervention process based on health professionals’ perspectives.
Non UofA Access

F. Friberg, C. Wallengren, C. Hakanson, et al.
BMC Health Serv Res 2018 Jun 13;18(1):441-018-3218-3
The assessment and evaluation of practical and sustainable development of health care has become a major focus of investigation in health services research. A key challenge for researchers as well as decision-makers in health care is to understand mechanisms influencing how complex interventions work and become embedded in practice, which is significant for both evaluation and later implementation. In this study, we explored nurses’ and surgeons’ perspectives on performing and participating in a complex multi-centre person-centred intervention process that aimed to support patients diagnosed with colorectal cancer to feel prepared for surgery, discharge and recovery. METHOD: Data consisted of retrospective interviews with 20 professionals after the intervention, supplemented with prospective conversational data and field notes from workshops and follow-up meetings (n = 51). The data were analysed to construct patterns in line with interpretive description. RESULTS: Although the participants highly valued components of the intervention, the results reveal influencing mechanisms underlying the functioning of the intervention, including multiple objectives, unclear mandates and competing professional logics. The results also reveal variations in processing the intervention focused on differences in using and talking about intervention components. CONCLUSIONS: The study indicates there are significant areas of ambiguity in understanding how theory-based complex clinical interventions work and in how interventions are socially constructed and co-created by professionals’ experiences, assumptions about own professional practice, contextual conditions and the researchers’ intentions. This process evaluation reveals insights into reasons for success or failure and contextual aspects associated with variations in outcomes. Thus, there is a need for further interpretive inquiry, and not only descriptive studies, of the multifaceted characters of complex clinical interventions and how the intervention components are actually shaped in constantly shifting contexts.

Reflecting on our perceptions of the worth, status and rewards of working in nursing homes.
Non UofA Access

D. O’Neill.
Age Ageing 2018 Apr 24.
The quality of healthcare provision in nursing homes across the globe is not routinely congruent with the complexity of care needs of residents or the advances of modern geriatric medicine and gerontological nursing. Even within these disciplines, the degree of research and reflection has been modest and relatively recent, perhaps indicating the challenge of prioritising the many diverse health needs of an ageing population across the spectrum of health services, or possibly a professional echo of the low political salience of quality of care in nursing homes.

Higher Level of Obesity Is Associated with Intensive Personal Care Assistance in the Nursing Home.
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C. M. Kosar, K. S. Thomas, P. L. Gozalo and V. Mor.
J Am Med Dir Assoc 2018 Jun 20
To examine whether higher obesity level was associated with extensive staffing assistance (from 2 or more persons) for completing activities of daily living (ADL) among older nursing home residents. DESIGN: Retrospective cross-sectional study. SETTING: US government-certified nursing homes. PARTICIPANTS: Medicare beneficiaries residing in a nursing home on April 1, 2015. Exclusion criteria were age less than 65 years and body mass index (BMI) below 18.5 (underweight). MEASURES: Residents were divided by obesity level according to established BMI cutoffs, as follows: nonobese (BMI = 18.5-29.9) or mild (BMI = 30.0-34.9), moderate (BMI = 35.0-39.9), or severe (BMI >/=40) obesity. Level of staffing assistance for completing each of 10 ADL (bed mobility, transfer, walking in room, walking in corridor, on- and off-unit locomotion, dressing, eating, toileting, and personal hygiene) was dichotomized as below 2 and 2 or more. Robust Poisson regression was used to test whether obesity conferred excess risk for needing 2 or more staff to complete each ADL. Adjusted models included individual-level covariates and nursing home fixed effects. RESULTS: A total of 1,063,383 nursing home residents were identified, including 309,263 (29.0%) with obesity. Adjusted relative risks (95% confidence intervals) for 2-person assistance with bed mobility associated with mild, moderate, and severe obesity were 1.17 (1.15, 1.18), 1.28 (1.25, 1.31), and 1.40 (1.36, 1.43), respectively. Adjusted relative risks for 2-person assistance with transferring associated with mild, moderate, and severe obesity were 1.15 (1.13, 1.17), 1.24 (1.22, 1.27), and 1.36 (1.33, 1.39), respectively. Obesity was associated with 2-person assistance for all other ADL except for eating. CONCLUSIONS: Higher obesity level was significantly associated with assistance from 2 or more staff for completing 9 of 10 ADL. Given increasing obesity rates in nursing homes, payment mechanisms that do not adjust for obesity or comprehensively account for excess ADL assistance may need revision to prevent adverse impacts on the long-term care system.

Do care homes deliver person-centred care? A cross-sectional survey of staff-reported abusive and positive behaviours towards residents from the MARQUE (Managing Agitation and Raising Quality of Life) English national care home survey.
Non UofA Access

C. Cooper, L. Marston, J. Barber, et al.
PLoS One 2018 Mar 21;13(3):e0193399
There are widespread concerns about abuse of care home residents. We report, in the largest care home survey, prevalence of staff anonymously-reported, perpetrated/witnessed abusive behaviours towards care home residents over 3 months. We also report positive care behaviours. METHODS: 1544 staff in 92 English care home units completed the revised Modified Conflict Tactics Scale and Maslach Burnout Inventory. OUTCOMES: Most staff reported positive care behaviours, but specific person-centred activities were sometimes infrequent. Many care home staff were never or almost never aware of a resident being taken out of the home for their enjoyment (34%, n = 520); or an activity planned around a resident’s interests (15%, n = 234). 763 (51%; 95% Confidence Interval (CI) 47% to 54%) of care home staff reported carrying out or observing potentially abusive or neglectful behaviours at least sometimes in the preceding 3 months; some abuse was reported as happening “at least sometimes” in 91/92 care homes. Neglect was most frequently reported: making a resident wait for care (n = 399, 26%), avoiding a resident with challenging behaviour (n = 391, 25%), giving residents insufficient time for food (n = 297, 19%), and taking insufficient care when moving residents (n = 169, 11%). 1.1% of staff reported physical and 5% verbal abuse. More staff reported abusive/neglectful behaviour in homes with higher staff burnout-depersonalisation scores (adjusted odds ratio 1.191, CI 1.052-1.349). INTERPRETATION: Staff anonymous reports of abusive behaviour and neglect could be used to monitor care quality, as cases currently reported are probably tip of the iceberg, and be an outcome in intervention studies.

Costs of potentially inappropriate medication use in residential aged care facilities.
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S. L. Harrison, L. Kouladjian O’Donnell, R. Milte, et al.
BMC Geriatr 2018 Jan 11;18(1):9-018-0704-8
The potential harms of some medications may outweigh their potential benefits (inappropriate medication use). Despite recommendations to avoid the use of potentially inappropriate medications (PIMs) in older adults, the prevalence of PIM use is high in different settings including residential aged care. However, it remains unclear what the costs of these medications are in this setting. The main objective of this study was to determine the costs of PIMs in older adults living in residential care. A secondary objective was to examine if there was a difference in costs of PIMs in a home-like model of residential care compared to an Australian standard model of care. METHODS: Participants included 541 participants from the Investigation Services Provided in the Residential Environment for Dementia (INSPIRED) Study. The INSPIRED study is a cross-sectional study of 17 residential aged care facilities in Australia. 12 month medication costs were determined for the participants and PIMs were identified using the 2015 updated Beers Criteria for older adults. RESULTS: Of all of the medications dispensed in 1 year, 15.9% were PIMs and 81.4% of the participants had been exposed to a PIM. Log-linear models showed exposure to a PIM was associated with higher total medication costs (Adjusted beta = 0.307, 95% CI 0.235 to 0.379, p < 0.001). The mean proportion (+/-SD) of medication costs that were spent on PIMs in 1 year was 17.5% (+/-17.8) (AUD$410.89 +/- 479.45 per participant exposed to a PIM). The largest PIM costs arose from proton-pump inhibitors (34.4%), antipsychotics (21.0%) and benzodiazepines (18.7%). The odds of incurring costs from PIMs were 52% lower for those residing in a home-like model of care compared to a standard model of care. CONCLUSIONS: The use of PIMs for older adults in residential care facilities is high and these medications represent a substantial cost which has the potential to be lowered. Further research should investigate whether medication reviews in this population could lead to potential cost savings and improvement in clinical outcomes. Adopting a home-like model of residential care may be associated with reduced prevalence and costs of PIMs.

Nursing home staff perspectives on adoption of an innovation in goals of care communication.
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L. Chisholm, S. Zimmerman, C. Rosemond, et al.
Geriatr Nurs 2018 Mar – Apr;39(2):157-161
Nursing homes (NH) are important settings for end-of-life care, but limited implementation may impede goals of care discussions. The purpose of this study was to understand NH staff perceptions of adoption and sustainability of the Goals of Care video decision aid for families of residents with advanced dementia. Study design was a cross-sectional survey of staff at 11 NHs in North Carolina who participated in the Goals of Care (GOC) cluster randomized clinical trial. Staff perceived the GOC decision aid intervention as a positive innovation; it was perceived as more compatible with current practices by male staff, nurses, and more experienced NH staff. Perceptions were correlated with experience, implying that experience with an innovative approach may help to promote improved GOC communication in nursing homes. Nurses and social work staff could be effective champions for implementing a communication technique, like the GOC intervention.

The Need for Electronic Health Records in Long-Term Care.
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S. Tharmalingam, S. Hagens and S. English.
Stud Health Technol Inform 2017;234:315-320
Long-term care (LTC) settings serve an important proportion of seniors and vulnerable populations that require 24-hour nursing care. Deployment of interoperable electronic health records (iEHRs) to these settings lag. There is little evidence on the availability of patient information from across the continuum of care. To fill this knowledge gap this study examines the prevalence and nature of information gaps experienced in LTC during patient encounters (n=1050). Overall, more than one-third (34%) of all LTC patient encounters were missing at least one item of information that was needed for the encounter. Approximately 59% of missing information during patient encounters was documented or ordered by a clinician external to the LTC facility; 41% were within the LTC facility itself. These information gaps have an adverse consequence for nearly 3 out of every 10 (31%) patient encounters in LTC. Extending iEHRs to LTC has the potential to support timely, appropriate, and better quality of patient care and improve provider experience.

Implementing montessori methods for dementia in Ontario long-term care homes: Recreation staff and multidisciplinary consultants’ perceptions of policy and practice issues
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K. Ducak, M. Denton and G. Elliot.
Dementia (London) 2018 Jan;17(1):5-33
Montessori-based activities use a person-centred approach to benefit persons living with dementia by increasing their participation in, and enjoyment of, daily life. This study investigated recreation staff and multidisciplinary consultants’ perceptions of factors that affected implementing Montessori Methods for Dementia in long-term care homes in Ontario, Canada. Qualitative data were obtained during semi-structured telephone interviews with 17 participants who worked in these homes. A political economy of aging perspective guided thematic data analysis. Barriers such as insufficient funding and negative attitudes towards activities reinforced a task-oriented biomedical model of care. Various forms of support and understanding helped put Montessori Methods for Dementia into practice as a person-centred care program, thus reportedly improving the quality of life of residents living with dementia, staff and family members. These results demonstrate that when Montessori Methods for Dementia approaches are learned and understood by staff they can be used as practical interventions for long-term care residents living with dementia.

Primary Care Physicians’ Perceived Barriers to Optimal Dementia Care: A Systematic Review.
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E. Mansfield, N. Noble, R. Sanson-Fisher, D. Mazza and J. Bryant.
Gerontologist 2018 Jun 25
Primary care physicians (PCPs) have a key role in providing care for people with dementia and their carers, however, a range of barriers prevent them from delivering optimal care. We reviewed studies on PCPs’ perceptions of barriers to providing optimal dementia care, including their methodological quality, whether they focused on barriers related to diagnosis and/or management, and the patient-, provider-, and system-level barriers identified. Research Design and Methods: Studies were included if they were quantitative studies published since 2006 which reported on PCPs’ perceptions of the barriers to providing dementia care. The methodological quality of identified studies was assessed using an adapted version of accepted rating criteria for quantitative studies. Data were extracted from studies which were rated as “moderate” or “strong” quality. Results: A total of 20 studies were identified, 16 of which were rated as “moderate” or “strong” methodological quality. Patient-related barriers included a reluctance to acknowledge cognitive decline and patient nonadherence to management plans. Provider-related barriers included a lack of training and confidence. System-related barriers included a lack of time during consultations and lack of support services. Discussion and Implications: This review highlights a range of barriers to dementia diagnosis and management from studies rated as being methodologically adequate. Future studies should also utilize theory-driven approaches to exploring a comprehensive range of barriers to optimal dementia care across the care trajectory.

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Health Care Innovation and Quality Assurance

Description of an advance care planning intervention in nursing homes: outcomes of the process evaluation.
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I. Aasmul, B. S. Husebo and E. Flo.
BMC Geriatr 2018 Jan 25;18(1):26-018-0713-7
Advance Care Planning (ACP) is the repeated communication and decision-making process between the patient, family, and healthcare professionals. This study describes an ACP intervention in nursing homes and evaluates the outcomes of the implementation process. METHODS: The ACP intervention was part of a 4-month complex, cluster randomized controlled trial (COSMOS). 37 Norwegian nursing homes with 72 units (1 cluster = 1 unit) and 765 patients were invited to participate and eligible units were randomised to the intervention group or control. Nursing home staff in the intervention group was offered a standardized education programme to learn early and repeated communication with patients and families and to implement ACP in their units. We used a train-the-trainer approach to educate staff in the units, supported by regular telephone calls and a midway seminar after two months. Individual patient logs consisting of different communication deliverables were used to evaluate the implementation process. Supported by Qualitative Content Analyses, we identified facilitators and barriers of the ACP implementation based on feedback during midway seminars and individual patient logs. RESULTS: The ACP intervention was conducted in 36 NH units (n = 297); 105 healthcare providers participated at the education seminar prior to the study, and 3-4 employees from each unit participated in the midway seminar. NH staff reported the educational material relevant for the implementation strategy. The patient logs showed that ACP was successfully implemented in 62% (n = 183) of the patients using our predefined implementation criteria. The staff emphasized the clear communication of the relevance of ACP addressed to leaders and staff as important facilitators, along with the clearly defined routines, roles and responsibilities. Identified barriers included lack of competence, perceived lack of time, and conflicting culture and staff opinions. CONCLUSION: Monthly communication with the family was the most frequently conducted communication, and the predefined criteria of successfully implemented ACP were largely achieved. Nursing home routines and engagement of leaders and staff were crucial facilitators, whereas lack of time and competence reduced the implementation success. TRIAL REGISTRATION: The COSMOS-trial was registered in the ClinicalTrials.gov ( NCT02238652 ) July 7th, 2014.

Criteria for evaluating transferability of health interventions: a systematic review and thematic synthesis
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T. Schloemer and P. Schroder-Back.
Implement Sci 2018 Jun 26;13(1):88-018-0751-8
Improving the public’s health in different countries requires the consideration of diverse health care systems and settings. For evidence-based public health, decision-makers need to consider the transferability of effective health interventions from a primary context to their specific target context. The aim of this systematic review was to develop a model for the assessment of transferability of health interventions through identification and systematization of influencing criteria, including facilitators and barriers. METHODS: A systematic literature search was performed in the databases PubMed, Embase, CINAHL, and PsycINFO. Articles were eligible if they were published in English or German and provided a description of transferability criteria. Included articles were ranked based on their thematic relevance and methodological support of transferability criteria. Using a qualitative approach, a thematic synthesis was conducted. RESULTS: Thirty-seven articles were included in the review. The thematic synthesis revealed 44 criteria, covered by 4 overarching themes, which influence transferability of health interventions: The population (P), the intervention (I), and the environment (E) represent 30 conditional transferability criteria, and the transfer of the intervention (T) represents 14 process criteria for transferring the intervention to the target context. Transferability (-T) depends on the dynamic interaction of conditional criteria in the primary and target context as well as on the process of transfer. The description of facilitators and barriers deepens the understanding of the criteria. The synthesis resulted in two related models: the conceptual PIET-T model explains the underlying mechanism of transferability of health interventions and the PIET-T process model provides practical guidance for a transferability assessment. CONCLUSIONS: Transferability of health interventions is a complex concept, which needs systematic consideration of the primary and target context. It should be anticipated before and evaluated after an intervention is implemented in the target context. Therefore, decision-makers need systematic and practically relevant knowledge on transferability. The synthesized PIET-T conceptual and process models with systematized criteria, facilitators, and barriers are intended as a theoretical basis to determine transferability of health interventions. Further research is needed to develop a practical tool for the PIET-T models and to evaluate the tool’s usefulness for decision-making processes and intervention transfer.

The principal-agent problem and owner-managers: An instrumental variables application to nursing home quality.
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S. S. Huang and J. R. Bowblis.
Health Econ 2018 Jul 2
The literature on provider ownership has primarily focused broadly on for-profits compared with nonprofits and chains versus nonchains. However, the understanding of more nuanced ownership arrangements within individual facilities is limited. Utilizing the principal-agent and managerial control frameworks, we study the role of managerial ownership and its relationship to quality among for-profit nursing homes (NHs). We identify NH administrators with more than 5% ownership (owner-manager) from Ohio Medicaid Cost Reports (2005-2010) and link these data to long-stay resident records in the Minimum Data Set. Using differential distance to the nearest NHs with a salaried manager relative to an owner-manager, we address the differential selection into these two types of NHs. After instrumenting for admissions to owner-managed NHs, quality among long-stay residents at owner-managed NHs is generally better than NHs with salaried managers. We find suggestive evidence that the magnitudes of quality difference are larger when the principal-agent problem is likely more pronounced, such as when NHs that are part of a multifacility chain and located in more concentrated markets.

Improving quality and safety of care in nursing homes by team support for strengths use: A survey study.
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M. Buljac-Samardzic and M. van Woerkom.
PLoS One 2018 Jul 2;13(7):e0200065
Growing evidence suggests that workload has an adverse effect on quality of care and patient safety in nursing homes. A novel job resource that may improve quality of care and patient safety and alleviate the negative effect of workload in nursing homes is team support for strengths use. This refers to team members’ beliefs concerning the extent to which the team they work in actively supports them in applying their individual strengths at work. The objective was to investigate the relationships between workload, team support for strengths use, quality of care, and patient safety in nursing homes. We collected (cross-sectional) survey data from 497 caregivers from 74 teams in seven different nursing homes. The survey included measures on perceived workload, team support for strengths use, caregivers’ perception of the quality of care provided by the team and four safety incidents (i.e. fall incidents, medication errors, pressure ulcers, incidents of aggression). After controlling for age, team size, team tenure, organizational tenure, and nursing home, multilevel regression analyses (i.e. individual and team level) showed that perceived workload was not significantly related to perceived team-based quality of care and the frequency of safety incidents. Team support for strengths use was positively related to perceived team-based quality of care, negatively related to medication errors, but not significantly related to fall incidents, pressure ulcers, and aggression incidents. Finally, we found that perceived workload had a negative effect on perceived team-based quality of care when team support for strengths use is low and no significant effect on perceived team-based quality of care when team support for strengths use is high. This study provides promising evidence for a novel avenue for promoting team-based quality of care in nursing homes.

Lessons from Changing CARE: The Discovery Phase of Experience-Based Co-Design

The Change Foundation, 2018
Lessons from Changing CARE: The Discovery Phase of Experience-Based Co-Design focuses on our four teams’ first year of listening and learning from, and co-designing with the family caregivers and healthcare providers in their communities. As the first in a series of reports focused on learnings and lessons from Changing CARE, this paper describes what the Changing CARE projects have learned during the discovery phase of their experienced-based co-design. The report features 40 practical tips that are organized in five sections: project planning engagement planning recruitment for engagement engagement post engagement

 

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Organizational Culture and Change

Linking molar organizational climate and strategic implementation climate to clinicians’ use of evidence-based psychotherapy techniques: cross-sectional and lagged analyses from a 2-year observational study.
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N. J. Williams, M. G. Ehrhart, G. A. Aarons, S. C. Marcus and R. S. Beidas.
Implement Sci 2018 Jun 25;13(1):85-018-0781-2
Behavioral health organizations are characterized by multiple organizational climates, including molar climate, which encompasses clinicians’ shared perceptions of how the work environment impacts their personal well-being, and strategic implementation climate, which includes clinicians’ shared perceptions of the extent to which evidence-based practice implementation is expected, supported, and rewarded by the organization. Theory suggests these climates have joint, cross-level effects on clinicians’ implementation of evidence-based practice and that these effects may be long term (i.e., up to 2 years); however, no empirical studies have tested these relationships. We hypothesize that molar climate moderates implementation climate’s concurrent and long-term relationships with clinicians’ use of evidence-based practice such that strategic implementation climate will have its most positive effects when it is accompanied by a positive molar climate. METHODS: Hypotheses were tested using data collected from 235 clinicians in 20 behavioral health organizations. At baseline, clinicians reported on molar climate and implementation climate. At baseline and at a 2-year follow-up, all clinicians who were present in the organizations reported on their use of cognitive-behavioral psychotherapy techniques, an evidence-based practice for youth psychiatric disorders. Two-level mixed-effects regression models tested whether baseline molar climate and implementation climate interacted in predicting clinicians’ evidence-based practice use at baseline and at 2-year follow-up. RESULTS: In organizations with more positive molar climates at baseline, higher levels of implementation climate predicted increased evidence-based practice use among clinicians who were present at baseline and among clinicians who were present in the organizations at 2-year follow-up; however, in organizations with less positive molar climates, implementation climate was not related to clinicians’ use of evidence-based practice at either time point. CONCLUSIONS: Optimizing clinicians’ implementation of evidence-based practice in behavioral health requires attention to both molar climate and strategic implementation climate. Strategies that focus exclusively on implementation climate may not be effective levers for behavior change if the organization does not also engender a positive molar climate. These findings have implications for the development of implementation theory and effective implementation strategies.

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Research Practice and Methodology

Priority-setting in public health research funding organisations: an exploratory qualitative study among five high-profile funders.
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Y. Cartier, M. I. Creatore, S. J. Hoffman and L. Potvin.
Health Res Policy Syst 2018 Jun 22;16(1):53-018-0335-8
Priority-driven funding streams for population and public health are an important part of the health research landscape and contribute to orienting future scholarship in the field. While research priorities are often made public through targeted calls for research, less is known about how research funding organisations arrive at said priorities. Our objective was to explore how public health research funding organisations develop priorities for strategic extramural research funding programmes. METHODS: Content analysis of published academic and grey literature and key informant interviews for five public and private funders of public health research in the United Kingdom, Australia, the United States and France were performed. RESULTS: We found important distinctions in how funding organisations processed potential research priorities through four non-sequential phases, namely idea generation, idea analysis, idea socialisation and idea selection. Funders generally involved the public health research community and public health decision-makers in idea generation and socialisation, but other groups of stakeholders (e.g. the public, advocacy organisations) were not as frequently included. CONCLUSIONS: Priority-setting for strategic funding programmes in public health research involves consultation mainly with researchers in the early phase of the process. There is an opportunity for greater breadth of participation and more transparency in priority-setting mechanisms for strategic funding programmes in population and public health research.

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Aging

Seniors in Transition: Exploring Pathways Across the Care Continuum
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Kim Nuernberger, Steve Atkinson,and Georgina MacDonald
Healthcare Quarterly 2018 04/30;21(1):10-12
The next 20 years will see unprecedented growth in Canada’s senior population, with higher demands and changing expectations challenging long-term care systems. The Canadian Institute for Health Information (CIHI) linked long-term and acute care data for over 59,000 seniors across six provinces and territories to analyze the pathways and transition patterns of seniors receiving long-term care services. The analysis revealed factors related to residential care entry and identified profiles of seniors admitted into residential care before it may be clinically necessary. This work provides critical information for health system decision-makers to ensure that our long-term care systems are responsive, effective and sustainable.

Occurrence of oral health problems and planned measures in dependent older people in nursing care.
Non UofA Access

V. Rantzow, P. Andersson and U. Lindmark.
J Clin Nurs 2018 Jun 26
The aim of the study was to describe oral health problems and planned measures in older people receiving nursing care. BACKGROUND: Poor oral health conditions have a negative impact on the quality of life of older people. Therefore, oral care is an important task in daily nursing activities. METHODS: Data were obtained from the web-based Swedish national quality register Senior Alert. Data regarding oral health status and planned measures in individuals >/=65 years from one county in Sweden between July 2014 and June 2015 were included. The Revised Oral Assessment Guide – the Jonkoping (ROAG-J), was used routinely by nursing staff in nursing care facilities to measure oral health status. RESULTS: Oral assessments were made on 2567 individuals (65.7% women). The most common oral health problem was related to “Teeth” (43.0%), which indicates deficient oral hygiene and/or broken teeth. At least one measure was planned in all the participants. The most common planned measures were “Moistening of the mouth” (16.6%), followed by “Brushing – assistance or complete help” (13.5%). CONCLUSION: Oral health problems were common, and planned measures did not seem to be sufficient to address the identified problems. The results indicate that greater priority should be given to the oral health care of older people in nursing care. RELEVANCE TO CLINICAL PRACTICE: The study highlights the importance of not only identifying oral health problems but also having knowledge and strategies for oral health care. Collaboration is needed to support nurses in caring for the oral health care of older people in nursing homes. This article is protected by copyright. All rights reserved.

A review of coronial investigations into medication-related deaths in Australian residential aged care.
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N. Jokanovic, N. Ferrah, J. J. Lovell, et al.
Res Social Adm Pharm 2018 Jun 12
Residential aged care is a complex and challenging clinical setting where medication errors continue to occur despite efforts to improve medication safety. No studies have sought to review and synthesize coronial investigations into medication-related deaths in Australian residential aged care facilities (RACFs). OBJECTIVE: To review coronial investigations into medication-related deaths in Australian RACFs. METHODS: A national review of medication-related deaths between July 2000 and July 2013 reported to Australian Coroners was performed. Data were extracted from the National Coronial Information System and errors categorized according to stages of the medication management cycle. RESULTS: The database search identified thirty coronial investigations into deaths. Single medication classes were implicated in 22 deaths; including opioids (n=7), antipsychotics (n=4) and antidepressants (n=3). Eight deaths resulted from two or more medication classes. Thirteen deaths reported stages of medication errors, including administration (n=9) and monitoring (n=4). Coroners made recommendations following three deaths; including education and training on dose administration aids, regulation of personal care workers, and protocol-based renal function monitoring for residents taking digoxin. CONCLUSIONS: Deaths involving high-risk medications occurred primarily at the stages of administration and monitoring. Few investigations resulted in specific recommendations, however it is unknown whether these were implemented. f

Advance care planning in dementia: recommendations for healthcare professionals.
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R. Piers, G. Albers, J. Gilissen, et al.
BMC Palliat Care 2018 Jun 21;17(1):88-018-0332-2
Advance care planning (ACP) is a continuous, dynamic process of reflection and dialogue between an individual, those close to them and their healthcare professionals, concerning the individual’s preferences and values concerning future treatment and care, including end-of-life care. Despite universal recognition of the importance of ACP for people with dementia, who gradually lose their ability to make informed decisions themselves, ACP still only happens infrequently, and evidence-based recommendations on when and how to perform this complex process are lacking. We aimed to develop evidence-based clinical recommendations to guide professionals across settings in the practical application of ACP in dementia care. METHODS: Following the Belgian Centre for Evidence-Based Medicine’s procedures, we 1) performed an extensive literature search to identify international guidelines, articles reporting heterogeneous study designs and grey literature, 2) developed recommendations based on the available evidence and expert opinion of the author group, and 3) performed a validation process using written feedback from experts, a survey for end users (healthcare professionals across settings), and two peer-review groups (with geriatricians and general practitioners). RESULTS: Based on 67 publications and validation from ten experts, 51 end users and two peer-review groups (24 participants) we developed 32 recommendations covering eight domains: initiation of ACP, evaluation of mental capacity, holding ACP conversations, the role and importance of those close to the person with dementia, ACP with people who find it difficult or impossible to communicate verbally, documentation of wishes and preferences, including information transfer, end-of-life decision-making, and preconditions for optimal implementation of ACP. Almost all recommendations received a grading representing low to very low-quality evidence. CONCLUSION: No high-quality guidelines are available for ACP in dementia care. By combining evidence with expert and user opinions, we have defined a unique set of recommendations for ACP in people living with dementia. These recommendations form a valuable tool for educating healthcare professionals on how to perform ACP across settings.

Using the “Surprise Question” in Nursing Homes: A Prospective Mixed-Methods Study.
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J. Rice, L. Hunter, A. T. Hsu, et al.
J Palliat Care 2018 Jan;33(1):9-18
The “Surprise Question” (SQ) is often used to identify patients who may benefit from a palliative care approach. The time frame of the typical question (a 12-month prognosis) may be unsuitable for identifying residents in nursing homes since it may not be able to differentiate between those who have a more imminent risk of death within a cohort of patients with high care needs. OBJECTIVE: To examine the accuracy and acceptability of 3 versions of the SQ with shortened prognostication time frames (3 months, 6 months, and “the next season”) in the nursing home setting. DESIGN: A prospective mixed-methods study. SETTING/PARTICIPANTS: Forty-seven health-care professionals completed the SQ for 313 residents from a nursing home in Ontario, Canada. A chart audit was performed to evaluate the accuracy of their responses. Focus groups and interviews were conducted to examine the participants’ perspectives on the utility of the SQ. RESULTS: Of the 301 residents who were included in the analysis, 74 (24.6%) deaths were observed during our follow-up period. The probability of making an accurate prediction was highest when the seasonal SQ was used (66.7%), followed by the 6-month (58.9%) and 3-month (57.1%) versions. Despite its high accuracy, qualitative results suggest the staff felt the seasonal SQ was ambiguous and expressed discomfort with its use. CONCLUSION: The SQ with shortened prognostication periods may be useful in nursing homes and provides a mechanism to facilitate discussions on palliative care. However, a better understanding of palliative care and increasing staff’s comfort with prognostication is essential to a palliative care approach.

Evaluating Mobility in Advanced Dementia: A Scoping Review and Feasibility Analysis
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Karen Van Ooteghem, Kristin Musselman, David Gold, et al.
Gerontologist 2018 07/05:gny068-gny068
Mobility decline is a symptom of advanced dementia that affects function, safety, caregiving, and quality of life. Monitoring mobility status is essential for initiating timely and targeted interventions aimed at preventing excess disability in people with dementia (PWD). The physical, cognitive, and behavioral symptoms of dementia however, present unique challenges for mobility assessment. The goals of this review were to (a) identify and describe measures of mobility used for PWD and (b) assess measures’ feasibility for use in people with advanced dementia; a group whose degree of cognitive impairment results in severe functional deficits.Research Design and MethodsElectronic searches of Medline, Embase, CINAHL, and PsychInfo databases were conducted using keywords related to dementia, mobility, measurement, and validation. Descriptive characteristics were extracted and measures coded for mobility components. Tools were also evaluated for feasibility of use in advanced dementia and those deemed feasible, screened for psychometric strength.ResultsThirty-eight measures were included and 68% of these tools were performance-based. Elements of mobility evaluated were walking (53% of measures), postural transitions (42%), standing (40%), mobility-related behavioral/psychological symptoms (24%), transfers (10%), bed mobility (5%), and wheeled mobility (3%). 36% of studies included people with advanced dementia. Only 18% of tools received high scores for feasibility.Discussion and ImplicationsExisting measures provide only partial information regarding mobility and few target elements that become relevant as dementia progresses. Most measures are not feasible for people with advanced dementia, and the psychometric evaluation of these measures is limited. Further research is needed to develop a comprehensive, dementia-specific, mobility assessment tool.

New Book: Wash, wear, and care: clothing and laundry in long-term residential care
Non UofA Access

Armstrong P, Day S.
Clothing and appearance are steeped in social and personal significance, conveying individuals’ gender, class, culture, and occupation. In the communal setting of long-term residential care, where residents’ autonomy and mobility are often limited but their dignity and identity are paramount, clothes have become crucial issues and the source of tension for residents, their families, and staff.

Prevalence of skin tears among frail older adults living in Canadian long-term care facilities.
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K. Woo and K. LeBlanc.
Int J Palliat Nurs 2018 Jun 2;24(6):288-294
To explore the prevalence of skin tears in the Canadian long-term care (LTC) population. SUBJECTS AND SETTING: The setting included 678 residents residing in four LTC facilities in western Canada. DESIGN: A cross-sectional prevalence study to establish the prevalence of skin tears in four LTC facilities in Canada. RESULTS: The prevalence of skin tears was 14.7%. Primary associated risk factors included advanced age, being male and having an increased pressure ulcer risk. CONCLUSION: This study was an important step in establishing the burden of skin tears in the Canadian LTC population. Findings supported the International Skin Tear Advisory Panel (ISTAP) risk reduction programme’s claim that increases in age and being of the male sex increase the risk for skin tears. The results support a possible link between skin tear risk factors and risk factors associated with pressure ulcers.

Age and sex differences in emergency department visits of nursing home residents: a systematic review.
Non UofA Access

A. Brucksch, F. Hoffmann and K. Allers.
BMC Geriatr 2018 Jul 3;18(1):151-018-0848-6
Nursing home residents (NHRs) are often transferred to emergency departments (EDs). A great proportion of ED visits is considered inappropriate. There is evidence that male NHRs are more often hospitalised, but this is less clear for ED visits. It is unclear, which influence age has on ED visits. We aimed to study the epidemiology of ED visits in NHRs focusing on age- and sex-specific differences. METHODS: A systematic review was carried out based on articles found in MEDLINE (via PubMed), CINAHL and Scopus. Articles published on or before Aug 31, 2017 were eligible. Two reviewers independently identified articles for inclusion. The quality of studies was assessed by the Joanna Briggs Institute critical appraisal tool for prevalence studies. RESULTS: Out of 1192 references, we found seven studies meeting our inclusion criteria. Six studies were conducted in the USA or Canada. Overall, 29-62% of NHRs had at least one ED visit over the course of 1 year. Most studies assessing the influence of sex found that male residents visited EDs more frequently. All but one of the five studies with multivariable analyses reported a statistically significant positive association (with odds or rate ratios of 1.05-1.38). All studies assessed the influence of age. There was no clear pattern with some studies showing no association between ED visits and age and other studies reporting decreasing ED visits with increasing age or increasing proportions followed by a decrease in the highest age group. Studies used 85+ or 86+ years as the highest age category. Hospital admission rate ranged from 36.4 to 48.7%. There was no study reporting stratified analyses by age and sex. Only one study reported main diagnoses leading to ED visits stratified by sex. CONCLUSION: Male NHRs visit EDs more often than females, but there is no evidence on reasons. The association with age is unclear. Any future study on acute care of NHRs should assess the influence of age and sex. These studies should include large sample sizes to provide a more differentiated age categorisation. TRIAL REGISTRATION: PROSPERO CRD42017074845

Cost analysis of improving emergency care for aged care residents under a Hospital in the Nursing Home program in Australia.
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L. Fan, B. Lukin, J. Zhao, et al.
PLoS One 2018 Jul 3;13(7):e0199879
This study aims to examine the costs associated with a Hospital in the Nursing Home (HiNH) program in Queensland Australia directed at patients from residential aged care facilities (RACFs) with emergency care needs. METHODS: A cost analysis was undertaken comparing the costs under the HiNH program and the current practice, in parallel with a pre-post controlled study design. The study was conducted in two Queensland public hospitals: the Royal Brisbane and Women’s Hospital (intervention hospital) and the Logan Hospital (control hospital). Main outcome measures were the associated incremental costs or savings concerning the HiNH program provision and the acute hospital care utilisation over one year after intervention. RESULTS: The initial deterministic analysis calculated the total induced mean costs associated with providing the HiNH program over one year as AU$488,116, and the total induced savings relating to acute hospital care service utilisation of AU$8,659,788. The total net costs to the health service providers were thus calculated at -AU$8,171,671 per annum. Results from the probabilistic sensitivity analysis (based on 10,000 simulations) showed the mean and median annual net costs associated with the HiNH program implementation were -AU$8,444,512 and-AU$8,202,676, and a standard deviation of 2,955,346. There was 95% certainty that the values of net costs would fall within the range from -AU$15,018,055 to -AU$3,358,820. CONCLUSIONS: The costs relating to implementing the HiNH program appear to be much less than the savings in terms of associated decreases in acute hospital service utilisation. The HiNH service model is likely to have the cost-saving potential while improving the emergency care provision for RACF residents.

“She doesn’t want to go to hospital. That’s one thing she hates”: Collective performativity in avoidable nursing home to hospital transfers.
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P. Makela.
J Eval Clin Pract 2018 Jul 3
Older people who live with a combination of conditions experience fluctuations over time, which others may interpret as a need for medical attention. For some nursing home residents, this results in transitions in and out of hospital. Such transfers may be arranged without expectation of improved quality of life, can be associated with significant morbidity and mortality, and may preclude end-of-life preferences. Factors affecting avoidable hospitalization for nursing home residents are not well understood. I aim to explore potential drivers, moving beyond deficit explanations relating to funding, training, and resources. I use a framework of analysis that firstly considers medicalization of frailty, as a state of vulnerability that provides focus for others’ action. I then draw on Judith Butler’s theory of performativity, to explore nursing homes as sites of identity work for staff, residents and families. I consider ways subjectivities can be effected through reiterative practice that is compelled by normative conventions. Trouble may arise when citational practice of health care staff, and performative acquiescence of residents and families, culminates in an inevitability of hospitalization when navigating grey areas of assumed clinical risk. Principles of coproduction could present a disruptive opening, to rework power asymmetries, and move toward aspirations for residents and their relatives to be at the centre of decisions about care.

An Iceberg Phenomenon in Dementia: Pain.
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A. Agit, C. Balci, B. B. Yavuz, et al.
J Geriatr Psychiatry Neurol 2018 Jan 1:891988718785765
Pain is one of the most frequent symptoms in older adults. It severely impairs quality of life, increases delirium risk, and may lead to progression of dementia. Assessment of pain performed by taking anamnesis from the patient is not reliable in patients with dementia due to cooperation and communication problems. The aim of this study was to assess pain and its consequences in patients with dementia. METHODS: Seventy-five nursing home residents with dementia were enrolled. After comprehensive geriatric assessment, presence of pain was asked to patients, and Pain Assessment in Advanced Dementia (PAINAD), Discomfort Scale for Dementia of the Alzheimer’s Type (DS-DAT), Pain Assessment for the Dementing Elderly (PADE), Wong-Baker Faces Pain Rating Scale, and Numeric Rating Scale tests were performed. RESULTS: Mean age was 81.1 (7.0), and 46.7% (n = 35) were female. Thirty-two percent of the patients were at early stage, 24% at moderate stage, and 44% at severe stage. Although the number of patients declaring pain was lower in moderate and severe stage, scores of PADE, PAINAD, and DS-DAT were significantly higher in severe stage showing the presence of pain ( P < .001). Furthermore, scores of PADE, PAINAD, and DS-DAT were negatively correlated with comprehensive geriatric assessment test scores. CONCLUSION: These results demonstrate that pain is not rare in patients with dementia, but they are not usually capable of expressing it, especially in the severe stage. Therefore, objective pain assessment scales developed for patients with dementia should be routinely used and management of pain should be done regarding the association of pain with other geriatric syndromes.

Prognostic Models Associated with 6-Month Survival of Patients Admitted to Nursing Homes.
Non UofA Access

A. A. Esteban-Burgos, J. El Mansouri-Yachou, R. Munoz-Ramirez, C. Hueso-Montoro, M. P. Garcia-Caro and R. Montoya-Juarez.
Gerontology 2018 Jun 29:1-5
Health status and the needs presented by people admitted to nursing homes make it necessary to contemplate aspects such as prognosis to offer quality palliative care. OBJECTIVE: To compare the prognostic utility in nursing homes of two prognostic models of 6-month survival based on the Palliative Prognostic Index (PPI) or Palliative Performance Status (PPS) instruments and palliative needs indicators. METHODS: A longitudinal prospective observational and analytical cohort study of survival and prognostic models in 88 patients with palliative needs (assessed by the NECPAL-ICO-CCOMS(c)) from an Andalusian (Spain) nursing home was performed. Sociodemographic and clinical variables were assessed, and 6 months later, in September 2017, survival was checked. Multiple logistic regression analysis was performed using the R-Commander program (version 3.2.2). RESULTS: Two models of the logistic regression analysis met the fit criteria. The two models combined the Surprise Question, the presence of persistent symptoms, and the clinical indicators of severity from the NECPAL tool, in addition to the Charlson Comorbidity Index, and varied only in terms of the latter variable, including the PPI in the first model and the PPS in the second. In the first model, significant associations were identified between 6-month survival and the persistent symptoms variable (OR = 7.78, p = 0.025, 95% CI = 1.45-60.92) and PPI (OR = 1.94, p < 0.001, 95% CI = 1.21). In the second model, 6-month survival was also significantly associated with the persistent symptoms variable (OR = 4.57, p = 0.045, 95% CI = 1.07-22.41) and the PPS (OR = 0.93, p = 0.001, 95% CI = 0.88-0.96). CONCLUSIONS: Prognostic models such as ours that include variables commonly included in clinical assessments can help nursing home professionals prioritize and ensure adequate mobilization of palliative care resources, which are very limited in these institutions.

Review of Nutrition Screening and Assessment Practices for Long-Term Care Residents.
Non UofA Access

S. Johnson, R. Nasser, K. Rustad, et al.
J Nutr Gerontol Geriatr 2018 Jun 28:1-14
The older adult population in Canada is growing, creating a greater demand for long-term care (LTC) facilities. Seniors living in LTC are more vulnerable to malnutrition, making it important to implement nutrition screening tools on a routine basis. The purpose of this study was to explore the practices of Registered Dietitians (RDs) related to nutritional screening, nutritional assessment, and follow-ups conducted within LTC facilities. This study also explored possible barriers hindering the application of these practices. Nine RDs from two health regions in Southern Saskatchewan completed a phone interview to address nutrition care practices/policies and barriers in LTC facilities. Results showed a considerable amount of variability in nutrition care practices for screening and assessment with lack of time identified as the greatest barrier. These findings highlight the importance of having consistent policies and a sufficient amount of RDs available in LTC facilities to provide the expected level of nutrition care for residents.

Management of Diabetes in Long-Term Care Facilities: Guidelines

CADTH, June 2018
Rapid Response reports are organized so that the higher quality evidence is presented first. Normally, health technology assessment reports, systematic reviews, and meta-analyses are presented first; however in reports where guidelines are primarily sought, the aforementioned evidence types are presented in the appendix. One evidence-based guideline was identified regarding the management of patients with diabetes in long-term care facilities. Additional references of potential interest are provided in the appendix

 

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Courses

Scientist Knowledge Translation Training September 2018

SickKids Toronto ON 13-14 September 2018
A well-developed knowledge translation (KT) plan is often a proposal requirement for health research funding agencies in Canada and abroad. In addition, various sectors are demonstrating greater attention to the utilization and impact of research. The Scientist Knowledge Translation Training (SKTT™) workshop was developed on the premise that scientists, and increasingly, other practitioners and educators, are agents of change in creating research impact, promoting research utilization, and ensuring that research findings reach the appropriate audiences. This course was designed to teach the unique skillset that surrounds KT practice.

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News

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When dementia patients commit crimes: Can Canada’s justice system handle the ‘grey wave’?

Almost half of caregivers of loved ones with dementia experience distress, report says

Is it safe? 5 questions when looking for long term care

How to win at academic presentations: top tips on what to say and how to say it.

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Opportunities

Scientific Director Michael Smith Foundation for Health Research (MSFHR),

Vancouver BC
MSFHR is seeking an experienced research leader to fill the newly created position of Scientific Director. With a minimum 10-year track record as a researcher, the Scientific Director is excited to turn their attention to the “science of research funding” – an increasingly important focus for funders committed to understanding and responding to the ecosystem in which they work.

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