April 14, 2014



Article recommended by Dr. Carole Estabrooks
Recommendations for reporting the results of studies of instrument and scale development and testing.
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Streiner DL, Kottner J.
Journal of advanced nursing 2014 Mar 30

Scales and instruments play an important role in health research and practice. It is important that studies that report on their psychometric properties do so in a way such that readers can understand what was done and what was found. This paper is a guide to writing articles about the development and assessment of these tools. It covers what should be in the abstract and how key words should be chosen. The article then discusses what should be in the main parts of the paper: the introduction, methods, results and discussion. In each of these parts, it suggests the statistical tests that should be used and how to report them. The emphasis throughout the paper is that reliability and validity are not fixed properties of a scale, but depend on an interaction among it, the population being evaluated and the circumstances under which the instrument is administered. © 2014 John Wiley & Sons Ltd.

New article by Drs. Jennifer Baumbush & Margaret McGregor
Emergency Department Visit Rates and Patterns in Canada’s Vancouver Coastal Health Region.
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McGregor MJ, McGrail KM, Abu-Laban RB, Ronald LA, Baumbusch J, Andrusiek D, et al.
Canadian journal on aging 2014 Apr 1:1-9

This study used administrative health data to describe emergency department (ED) visits by residents from assisted living and nursing home facilities in the Vancouver Coastal Health region, British Columbia. We compared ED visit rates, the distribution of visits per resident, and ED dispositions of the assisted living and nursing home populations over a 3-year period (2005-2008). There were 13,051 individuals in our study population. Visit rates (95% confidence interval) were 124.8 (118.1-131.7) and 64.1 (62.9-65.3) visits per 100 resident years in assisted living and nursing home facilities respectively. A smaller proportion of ED visits by assisted living residents resulted in hospital admission compared to nursing home residents (45% vs. 48%, p < .01). The ED visit rate among assisted living residents is significantly higher compared to that among nursing home residents. Future research is needed into the underlying causes for this finding.

Special Issue of Health Affairs on The Long Reach of Alzheimer’s Disease
April 2014

The Elusive Search For Solutions To Alzheimer’s
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John K. Iglehart
The Search For Effective Alzheimer’s Therapies: A Work In Progress
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Jonathan S. Bor
The Long Reach Of Alzheimer’s Disease: Patients, Practice, And Policy
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Julie P.W. Bynum
How Are We Going To Live With Alzheimer’s Disease?
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Jason Karlawish
Unintended Benefits: The Potential Economic Impact Of Addressing Risk Factors To Prevent Alzheimer’s Disease
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Pei-Jung Lin, Zhou Yang, Howard M. Fillit, Joshua T. Cohen, and Peter J. Neumann
The Alzheimer’s Study Group’s Recommendations Five Years Later: Planning Has Advanced, But Agenda Remains Unfinished
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Robert Egge
Alzheimer’s Disease Legislation And Policy—Now And In The Future
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David Hoffman
Optimizing Person-Centered Transitions In The Dementia Journey: A Comparison Of National Dementia Strategies
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Richard H. Fortinsky and Murna Downs
Obstacles And Opportunities In Alzheimer’s Clinical Trial Recruitment
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Jennifer L. Watson, Laurie Ryan, Nina Silverberg, Vicky Cahan, and Marie A. Bernard
Alzheimer’s Disease In African Americans: Risk Factors And Challenges For The Future
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Lisa L. Barnes and David A. Bennett
Translating Research Into Practice: Case Study Of A Community-Based Dementia Caregiver Intervention
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Mary S. Mittelman and Stephen J. Bartels
Estimating The Potential Cost Savings From The New York University Caregiver Intervention In Minnesota
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Kirsten Hall Long, James P. Moriarty, Mary S. Mittelman, and Steven S. Foldes
North Dakota Assistance Program For Dementia Caregivers Lowered Utilization, Produced Savings, And Increased Empowerment
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Marilyn G. Klug, Gwen Wagstrom Halaas, and Mandi-Leigh Peterson
Healthy Aging Brain Center Improved Care Coordination And Produced Net Savings
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Dustin D. French, Michael A. LaMantia, Lee R. Livin, Dorian Herceg, Catherine A. Alder, and Malaz A. Boustani
Coordinated Care Management For Dementia In A Large Academic Health System
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Zaldy S. Tan, Lee Jennings, and David Reuben
Redesigning Systems Of Care For Older Adults With Alzheimer’s Disease
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Christopher M. Callahan, Greg A. Sachs, Michael A. LaMantia, Kathleen T. Unroe, Greg Arling, and Malaz A. Boustani
Preparing The Health Care Workforce To Care For Adults With Alzheimer’s Disease And Related Dementias
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Gregg A. Warshaw and Elizabeth J. Bragg
Elder Abuse And Dementia: A Review Of The Research And Health Policy
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XinQi Dong, Ruijia Chen, and Melissa A. Simon
Alzheimer’s Disease And Nursing Homes
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Joseph E. Gaugler, Fang Yu, Heather W. Davila, and Tetyana Shippee
Dementia Prevalence And Care In Assisted Living
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Sheryl Zimmerman, Philip D. Sloane, and David Reed
Advance Directives And Nursing Home Stays Associated With Less Aggressive End-Of-Life Care For Patients With Severe Dementia
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Lauren H. Nicholas, Julie P.W. Bynum, Theodore J. Iwashyna, David R. Weir, and Kenneth M. Langa
Type Of Attending Physician Influenced Feeding Tube Insertions For Hospitalized Elderly People With Severe Dementia
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Joan Teno, David O. Meltzer, Susan L. Mitchell, Ana T. Fulton, Pedro Gozalo, and Vincent Mor
Hospital And ED Use Among Medicare Beneficiaries With Dementia Varies By Setting And Proximity To Death
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Zhanlian Feng, Laura A. Coots, Yevgeniya Kaganova, and Joshua M. Wiener
A Family Disease: Witnessing Firsthand The Toll That Dementia Takes On Caregivers
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Gary Epstein-Lubow
Lost In Translation: To Our Chinese Patient, Alzheimer’s Meant ‘Crazy And Catatonic’
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XinQi Dong and E-shien Chang

CALL FOR ABSTRACTS: Canadian Home Care Association: Home Care Summit
November 3-5 Banff AB
Deadline May 23

Presentations selected for this year’s program will be those providing insights and practical applications to support the following key priority areas:
-Client and Family-Centred Care Programs and policies that ensure clients and their family caregivers are at the centre of care provided in their home.
-Accessible Care Strategies that ensure clients / patients have equitable, appropriate, consistent access to home care, and are fully informed of the care and service options available to them.
-Accountable Care Home care is accountable to clients and their caregivers, providers, and the health care system for the provision and ongoing improvement of quality care.
-Evidence-Based Care Knowledge that is grounded in evidence is used as the foundation for effective and efficient care provision, resource allocation and innovation.
-Integrated Care Home care facilitates the integration of care across the continuum of health care and with community and social services; care is complementary, coordinated and seamless with a focus on continuity for the client.
-Sustainable Care Home care contributes to the sustainability of an integrated health system by increasing efficiency and delivering cost effective care.

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Health Care Administration and Organization
Health Care Innovation and Quality Assurance
Organizational Change
Research Practice & Methodology


What’s in a setting?: Influence of organizational culture on provider adherence to clinical guidelines for treating tobacco use.
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Hung DY, Leidig R, Shelley DR.
Health care management review 2014 Apr-Jun;39(2):154-163

Organizational culture is an important but underinvestigated feature of the work environment that can impact provider behavior, including adherence to clinical practice guidelines. There is substantial evidence that physician assistance to smokers can produce significant reductions in tobacco use. However, this evidence has not been well translated into practice, as only a small proportion of smokers receive recommended treatment during medical visits. PURPOSE: This study examines organizational culture as a contextual feature of primary care clinics and its impact on adherence to evidence-based guidelines for treating tobacco use. METHODOLOGY: Cross-sectional survey data were collected from 500 primary care providers in 60 community clinics located in New York City. Relationships between provider adherence to “5A” clinical guidelines, as recommended by the U.S. Public Health Service, and both provider and organizational covariates were described. We used hierarchical linear modeling to examine the associations between clinic culture and provider treatment patterns. FINDINGS: Providers in clinics with stronger “group/clan,” “hierarchical,” and “rational” culture types, as compared with a “developmental” culture, reported greater adherence to 5A guidelines (p < .05). System-level structures and care processes were positively associated (p < .01), whereas number of ongoing quality initiatives was negatively associated with 5A delivery (p < .05). Provider familiarity with guidelines (p < .01), confidence with cessation counseling (p < .05), and perceived effectiveness in helping smokers quit were associated with more frequent 5A intervention (p < .01). PRACTICE IMPLICATIONS: Findings suggest that organizational culture can influence provider adherence to cessation treatment guidelines, even when controlling for other factors known to affect practice patterns. Specifically, cultures that emphasize human resources and performance standards are conducive to integrating 5A guidelines into routine practice. Understanding the role of organizational culture enables healthcare managers and practitioners to be strategic when implementing, and also sustaining, use of evidence-based guidelines.

A mixed-methods study of research dissemination across practice-based research networks.
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Lipman PD, Lange CJ, Cohen RA, Peterson KA.
The Journal of ambulatory care management 2014 Apr-Jun;37(2):179-188

Practice-based research networks may be expanding beyond research into rapid learning systems. This mixed-methods study uses Agency for Healthcare Research and Quality registry data to identify networks currently engaged in dissemination of research findings and to select a sample to participate in qualitative semistructured interviews. An adapted Diffusion of Innovations framework was used to organize concepts by characteristics of networks, dissemination activities, and mechanisms for rapid learning. Six regional networks provided detailed information about dissemination strategies, organizational context, role of practice-based research network, member involvement, and practice incentives. Strategies compatible with current practices and learning innovations that generate observable improvements may increase effectiveness of rapid learning approaches.

Development of a Simple 12-Item Theory-Based Instrument to Assess the Impact of Continuing Professional Development on Clinical Behavioral Intentions Canada-flat-icon
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Legare F, Borduas F, Freitas A, Jacques A, Godin G, Luconi F, et al.
PloS one 2014 Mar 18;9(3):e91013

Decision-makers in organizations providing continuing professional development (CPD) have identified the need for routine assessment of its impact on practice. We sought to develop a theory-based instrument for evaluating the impact of CPD activities on health professionals’ clinical behavioral intentions. METHODS AND FINDINGS: Our multipronged study had four phases. 1) We systematically reviewed the literature for instruments that used socio-cognitive theories to assess healthcare professionals’ clinically-oriented behavioral intentions and/or behaviors; we extracted items relating to the theoretical constructs of an integrated model of healthcare professionals’ behaviors and removed duplicates. 2) A committee of researchers and CPD decision-makers selected a pool of items relevant to CPD. 3) An international group of experts (n = 70) reached consensus on the most relevant items using electronic Delphi surveys. 4) We created a preliminary instrument with the items found most relevant and assessed its factorial validity, internal consistency and reliability (weighted kappa) over a two-week period among 138 physicians attending a CPD activity. Out of 72 potentially relevant instruments, 47 were analyzed. Of the 1218 items extracted from these, 16% were discarded as improperly phrased and 70% discarded as duplicates. Mapping the remaining items onto the constructs of the integrated model of healthcare professionals’ behaviors yielded a minimum of 18 and a maximum of 275 items per construct. The partnership committee retained 61 items covering all seven constructs. Two iterations of the Delphi process produced consensus on a provisional 40-item questionnaire. Exploratory factorial analysis following test-retest resulted in a 12-item questionnaire. Cronbach’s coefficients for the constructs varied from 0.77 to 0.85. CONCLUSION: A 12-item theory-based instrument for assessing the impact of CPD activities on health professionals’ clinical behavioral intentions showed adequate validity and reliability. Further studies could assess its responsiveness to behavior change following CPD activities and its capacity to predict health professionals’ clinical performance.

Measuring determinants of implementation behavior: psychometric properties of a questionnaire based on the theoretical domains framework.
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Huijg JM, Gebhardt WA, Dusseldorp E, Verheijden MW, van der Zouwe N, Middelkoop BJ, et al.
Implementation science : IS 2014 Mar 19;9(1):33-5908-9-33

To be able to design effective strategies to improve healthcare professionals’ implementation behaviors, a valid and reliable questionnaire is needed to assess potential implementation determinants. The present study describes the development of the Determinants of Implementation Behavior Questionnaire (DIBQ) and investigates the reliability and validity of this Theoretical Domains Framework (TDF)-based questionnaire. METHODS: The DIBQ was developed to measure the potential behavioral determinants of the 12-domain version of the TDF (Michie et al., 2005). We identified existing questionnaires including items assessing constructs within TDF domains and developed new items where needed. Confirmatory factor analysis was used to examine whether the predefined structure of the TDF-based questionnaire was supported by the data. Cronbach’s alpha was calculated to assess internal consistency reliability of the questionnaire, and domains’ discriminant validity was investigated. RESULTS: We developed an initial questionnaire containing 100 items assessing 12 domains. Results obtained from confirmatory factor analysis and Cronbach’s alpha resulted in the final questionnaire consisting of 93 items assessing 18 domains, explaining 63.3% of the variance, and internal consistency reliability values ranging from .68 to .93. Domains demonstrated good discriminant validity, although the domains ‘Knowledge’ and ‘Skills’ and the domains ‘Skills’ and ‘Social/professional role and identity’ were highly correlated. CONCLUSIONS: We have developed a valid and reliable questionnaire that can be used to assess potential determinants of healthcare professional implementation behavior following the theoretical domains of the TDF. The DIBQ can be used by researchers and practitioners who are interested in identifying determinants of implementation behaviors in order to be able to develop effective strategies to improve healthcare professionals’ implementation behaviors. Furthermore, the findings provide a novel validation of the TDF and indicate that the domain ‘Environmental context and resources’ might be divided into several environment-related domains.

Twitter and nursing research: how diffusion of innovation theory can help uptake. Canada-flat-icon
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Archibald MM, Clark AM.
Journal of advanced nursing 2014 Mar;70(3):e3-5.

Do nurses understand the potential benefits of Twitter? With mainstream popularity and increasing reliance in daily social life, Twitter can allow nurse researchers to connect directly, rapidly and cheaply with communities, disseminate information, and promote translation of research into practice and policy. However, nurses have not adopted to using Twitter. Perhaps, Diffusion of Innovations Theory can help.

Interagency Collaborative Team model for capacity building to scale-up evidence-based practice
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Hurlburt M, Aarons GA, Fettes D, Willging C, Gunderson L, Chaffin MJ.
Children and Youth Services Review 2014:160

System-wide scale up of evidence-based practice (EBP) is a complex process. Yet, few strategic approaches exist to support EBP implementation and sustainment across a service system. Building on the Exploration, Preparation, Implementation, and Sustainment (EPIS) implementation framework, we developed and are testing the Interagency Collaborative Team (ICT) process model to implement an evidence-based child neglect intervention (i.e., SafeCare[R]) within a large children’s service system. The ICT model emphasizes the role of local agency collaborations in creating structural supports for successful implementation.

The language of data: tools to translate evidence for nurses in clinical practice.
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Granger BB, Zhao Y, Rogers J, Miller C, Gilliss CL, Champagne M.
Journal for nurses in professional development 2013 Nov-Dec;29(6):294-300

In clinical practice, nurses are expected to understand and implement the science that supports patient care, yet they fall short of goals to implement evidence in practice. One reason is difficulty in interpreting research results. Interpretation requires an ability to read and speak a language that many nurses have never mastered-the language of data. This article presents a skill-based solution for use in nursing professional development to improve nurses’ understanding of statistics as a language.

Implementation of Sustainable Evidence-Based Practice for the Assessment and Management of Pain in Residential Aged Care Facilities.
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Savvas S, Toye C, Beattie E, Gibson SJ.
Pain management nursing 2014 Mar 25

Pain is common in residential aged care facilities (RACFs). In 2005, the Australian Pain Society developed 27 recommendations for good practice in the identification, assessment, and management of pain in these settings. This study aimed to address implementation of the standards and evaluate outcomes. Five facilities in Australia participated in a comprehensive evaluation of RACF pain practice and outcomes. Pre-existing pain management practices were compared with the 27 recommendations, before an evidence-based pain management program was introduced that included training and education for staff and revised in-house pain-management procedures. Post-implementation audits evaluated the program’s success. Aged care staff teams also were assessed on their reports of self-efficacy in pain management. The results show that before the implementation program, the RACFs demonstrated full compliance on 6 to 12 standards. By the project’s completion, RACFs demonstrated full compliance with 10 to 23 standards and major improvements toward compliance in the remaining standards. After implementation, the staff also reported better understanding of the standards (p < .001) or of facility pain management guidelines (p < .001), increased confidence in therapies for pain management (p < .001), and increased confidence in their training to assess pain (p < .001) and recognize pain in residents with dementia who are nonverbal (p = .003). The results show that improved evidence-based practice in RACFs can be achieved with appropriate training and education. Investing resources in the aged care workforce via this implementation program has shown improvements in staff self-efficacy and practice. Copyright © 2013 American Society for Pain Management Nursing. Published by Elsevier Inc. All rights reserved.

Sharing What we Know About Living a Good Life: Indigenous Approaches to Knowledge Translation Canada-flat-icon
Smylie J, Olding M, Ziegler C.
JCHLA 2014 04/01; 2014/04;35(01):16-23.

Knowledge Translation (KT), a core priority in Canadian health research, policy, and practice for the past decade, has a long and rich tradition within Indigenous communities. In Indigenous knowledge systems the processes of “knowing” and “doing” are often intertwined and indistinguishable. However, dominant KT models in health science do not typically recognize Indigenous knowledge conceptualizations, sharing systems, or protocols and will likely fall short in Indigenous contexts. There is a need to move towards KT theory and practice that embraces diverse understandings of knowledge and that recognizes, respects, and builds on pre-existing knowledge systems. This will not only result in better processes and outcomes for Indigenous communities, it will also provide rich learning for mainstream KT scholarship and practice. As professionals deeply engaged in KT work, health librarians are uniquely positioned to support the development and implementation of Indigenous KT. This article provides information that will enhance the ability of readers from diverse backgrounds to promote and support Indigenous KT efforts, including an introduction to Indigenous knowledge conceptualizations and knowledge systems; key contextual issues to consider in planning, implementing, or evaluating KT in Indigenous settings; and contemporary examples of Indigenous KT in action. The authors pose critical reflection questions throughout the article that encourage readers to connect the content with their own practices and underlying knowledge assumptions.

Barriers to implementation of a redesign of information transfer and feedback in acute care: results from a multiple case study
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van Leijen-Zeelenberg JE, van Raak AJ, Duimel-Peeters IG, Kroese ME, Brink PR, Ruwaard D, et al.
BMC health services research 2014 Apr 3;14(1):149-6963-14-149

Accurate information transfer is an important element of continuity of care and patient safety. Despite the demonstrated urge for improvement of communication in acute care, there is a lack of data on improvements of communication. This study aims to describe the barriers to implementation of a redesign of the existing model for information transfer and feedback. METHODS: A case study with six cases (i.e. acute care chains), using mixed methods was carried out in the Netherlands. The redesign was implemented in one acute care chain while the five other acute care chains served as control groups. Focus group interviews were held with members of the acute care chains and questionnaires were sent to care providers working in the acute care chains. RESULTS: Respondents reported three sets of barriers for implementation of the model: (a) existing routines for information transfer and feedback in organizations within the acute care chain; (b) barriers related to the implementation method and time period; and (c) the absence of a high ‘sense of urgency’ amongst providers in the acute care chain which would aid in improving the communication process. CONCLUSIONS: This study shows that organizational factors play an important role in the success or failure of redesigning a communication process. Organizational routines can hamper implementation of a redesign if it differs too much from the routines of care providers involved. Besides focussing on provider characteristics in the implementation of a redesigned process, specific attention should be paid to unlearning existing organizational routines.

The stages of implementation completion for evidence-based practice: protocol for a mixed methods study
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Saldana L.
Implementation science : IS 2014 Apr 5;9(1):43-5908-9-43

This protocol describes the ‘development of outcome measures and suitable methodologies for dissemination and implementation approaches,’ a priority for implementation research. Although many evidence-based practices (EBPs) have been developed, large knowledge gaps remain regarding how to routinely move EBPs into usual care. The lack of understanding of ‘what it takes’ to install EBPs has costly public health consequences, including a lack of availability of the most beneficial services, wasted efforts and resources on failed implementation attempts, and the potential for engendering reluctance to try implementing new EBPs after failed attempts.The Stages of Implementation Completion (SIC) is an eight-stage tool of implementation process and milestones, with stages spanning three implementation phases (pre-implementation, implementation, sustainability). Items delineate the date that a site completes implementation activities, yielding an assessment of duration (time to complete a stage), proportion (of stage activities completed), and a general measure of how far a site moved in the implementation process. METHODS/DESIGN: We propose to extend the SIC to EBPs operating in child service sectors (juvenile justice, schools, substance use, child welfare). Both successful and failed implementation attempts will be scrutinized using a mixed methods design. Stage costs will be measured and examined. Both retrospective data (from previous site implementation efforts) and prospective data (from newly adopting sites) will be analyzed. The influence of pre-implementation on implementation and sustainability outcomes will be examined (Aim 1). Mixed methods procedures will focus on increasing understanding of the process of implementation failure in an effort to determine if the SIC can provide early detection of sites that are unlikely to succeed (Aim 2). Study activities will include cost mapping of SIC stages and an examination of the relationship between implementation costs and implementation performance (Aim 3). DISCUSSION: This project fills a gap in the field of implementation science by addressing the measurement gap between the implementation process and the associated costs. The goal of this project is to provide tools that will help increase the uptake of EBPs, thereby increasing the availability of services to youth and decreasing wasted resources from failed implementation efforts.

Thrombolysis ImPlementation in Stroke (TIPS): evaluating the effectiveness of a strategy to increase the adoption of best evidence practice – protocol for a cluster randomised controlled trial in acute stroke care
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Paul CL, Levi CR, D Este CA, Parsons MW, Bladin CF, Lindley RI, et al.
Implementation science : IS 2014 Mar 25;9(1):38

Stroke is a leading cause of death and disability internationally. One of the three effective interventions in the acute phase of stroke care is thrombolytic therapy with tissue plasminogen activator (tPA), if given within 4.5 hours of onset to appropriate cases of ischaemic stroke.Objectives: To test the effectiveness of a multi-component multidisciplinary collaborative approach compared to usual care as a strategy for increasing thrombolysis rates for all stroke patients at intervention hospitals, while maintaining accepted benchmarks for low rates of intracranial haemorrhage and high rates of functional outcomes for both groups at three months.Methods and design: A cluster randomised controlled trial of 20 hospitals across 3 Australian states with 2 groups: multi- component multidisciplinary collaborative intervention as the experimental group and usual care as the control group. The intervention is based on behavioural theory and analysis of the steps, roles and barriers relating to rapid assessment for thrombolysis eligibility; it involves a comprehensive range of strategies addressing individual-level and system-level change at each site. The primary outcome is the difference in tPA rates between the two groups post-intervention. The secondary outcome is the proportion of tPA treated patients in both groups with good functional outcomes (modified Rankin Score (mRS 2), compared to international benchmarks. DISCUSSION: TIPS will trial a comprehensive, multi-component and multidisciplinary collaborative approach to improving thrombolysis rates at multiple sites. The trial has the potential to identify methods for optimal care which can be implemented for stroke patients during the acute phase. Study findings will include barriers and solutions to effective thrombolysis implementation and trial outcomes will be published whether significant or not.Trial registration: Australian New Zealand Clinical Trials Registry: ACTRN12613000939796.

Making sense of evidence in management decisions: the role of research-based knowledge on innovation adoption and implementation in health care (UK)
National Institute for Health Research, 2014

Our research design comprised multiple case studies with mixed methods. We investigated technology adoption and implementation in nine acute -care organisations across England. We employed structured survey questionnaires, in-depth interviews and documentary analysis. The empirical setting was infection prevention and control. Phase 1 focused on the espoused use of evidence by 126 non-clinical and clinical hybrid managers. Phase 2 explored the use of evidence by managers in specific technology examples: (1) considered for adoption; (2) successfully adopted and implemented; and (3) rejected or discontinued. Findings (1) Access to, and use of, evidence types and sources varied greatly by profession. Clinicians reported a strong preference for science-based, peer-reviewed, published evidence. All groups called upon experiential knowledge and expert opinion. Nurses overall drew upon a wider range of evidence sources and types. Non-clinical managers tended to sequentially prioritise evidence on cost from national-level sources, and local implementation trials. (2) A sizeable proportion of professionals from all groups, including experienced staff, reported difficulty in making sense of evidence. Lack of awareness of existing implementation literature, lack of knowledge on how to translate information into current practice, and lack of time and relevant skills were reported as key reasons for this. (3) Infection outbreaks, financial pressures, performance targets and trusted relationships with suppliers seemed to emphasise a pragmatic and less rigorous approach in sourcing for evidence. Trust infrastructure redevelopment projects, and a strong emphasis on patient safety and collaboration, appeared to widen scope for evidence use. (4) Evidence was continuously interpreted and (re)constructed by professional identity, organisational role, team membership, audience and organisational goals. (5) Doctors and non-clinical managers sourced evidence plausible to self. Nursing staff also sought acceptance of evidence from other groups. (6) We found diverse ‘evidence templates’ in use: ‘biomedical-scientific’, ‘practice-based’, ‘rational-policy’. These represented shared cognitive models which defined what constituted acceptable and credible evidence in decisions. Nurses drew on all diverse ‘templates’ to make sense of evidence and problems; non-clinical managers drew mainly on the practice-based and rational-policy templates; and doctors drew primarily on the biomedical-scientific template.

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Health Care Administration and Organization

Medical staff involvement in nursing homes: development of a conceptual model and research agenda.
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Shield R, Rosenthal M, Wetle T, Tyler D, Clark M, Intrator O.
Journal of applied gerontology 2014 Feb;33(1):75-96

Medical staff (physicians, nurse practitioners, physicians’ assistants) involvement in nursing homes (NH) is limited by professional guidelines, government policies, regulations, and reimbursements, creating bureaucratic burden. The conceptual NH Medical Staff Involvement Model, based on our mixed-methods research, applies the Donabedian “structure-process-outcomes” framework to the NH, identifying measures for a coordinated research agenda. Quantitative surveys and qualitative interviews conducted with medical directors, administrators and directors of nursing, other experts, residents and family members and Minimum Data Set, the Online Certification and Reporting System and Medicare Part B claims data related to NH structure, process, and outcomes were analyzed. NH control of medical staff, or structure, affects medical staff involvement in care processes and is associated with better outcomes (e.g., symptom management, appropriate transitions, satisfaction). The model identifies measures clarifying the impact of NH medical staff involvement on care processes and resident outcomes and has strong potential to inform regulatory policies.

Nurse Staffing and Quality: The Unanswered Question
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Arling G, Mueller C.
Journal of the American Medical Directors Association 2014 Apr 2

Researchers have spent decades trying to answer the question: Does more nurse staff lead to better quality of nursing home care? Many nurses, consumers, nursing home providers, and other stakeholders believe intuitively that the answer is “yes.” Yet, the research literature fails to give us a clear answer.

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Health Care Innovation and Quality Assurance

How collaborative are quality improvement collaboratives: a qualitative study in stroke care
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Carter P, Ozieranski P, McNicol S, Power M, Dixon-Woods M.
Implementation science 2014 Mar 11;9(1):32

Quality improvement collaboratives (QICs) continue to be widely used, yet evidence for their effectiveness is equivocal. We sought to explain what happened in Stroke 90:10, a QIC designed to improve stroke care in 24 hospitals in the North West of England. Our study drew in part on the literature on collective action and inter-organizational collaboration. This literature has been relatively neglected in evaluations of QICs, even though they are founded on principles of co-operation and sharing. METHODS: We interviewed 32 professionals in hospitals that participated in Stroke 90:10, conducted a focus group with the QIC faculty team, and reviewed purposively sampled documents including reports and newsletters. Analysis was based on a modified form of Framework Analysis, combining sensitizing constructs derived from the literature and new, empirically derived thematic categories. RESULTS: Improvements in stroke care were attributed to QIC participation by many professionals. They described how the QIC fostered a sense of community and increased attention to stroke care within their organizations. However, participants’ experiences of the QIC varied. Starting positions were different; some organizations were achieving higher levels of performance than others before the QIC began, and some had more pre-existing experience of quality improvement methods. Some participants had more to learn, others more to teach. Some evidence of free-riding was found. Benchmarking improvement was variously experienced as friendly rivalry or as time-consuming and stressful. Participants’ competitive desire to demonstrate success sometimes conflicted with collaborative aims; some experienced competing organizational pressures or saw the QIC as duplication of effort. Experiences of inter-organizational collaboration were influenced by variations in intra-organizational support. CONCLUSIONS: Collaboration is not the only mode of behavior likely to occur within a QIC. Our study revealed a mixed picture of collaboration, free-riding and competition. QICs should learn from work on the challenges of collective action; set realistic goals; account for context; ensure sufficient time and resources are made available; and carefully manage the collaborative to mitigate the risks of collaborative inertia and unhelpful competitive or anti-cooperative behaviors. Individual organizations should assess the costs and benefits of collaboration as a means of attaining quality improvement.

Instrumental variable applications using nursing home prescribing preferences in comparative effectiveness research.
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Huybrechts KF, Gerhard T, Franklin JM, Levin R, Crystal S, Schneeweiss S.
Pharmacoepidemiology and drug safety 2014 Mar 24

Nursing home residents are of particular interest for comparative effectiveness research given their susceptibility to adverse treatment effects and systematic exclusion from trials. However, the risk of residual confounding because of unmeasured markers of declining health using conventional analytic methods is high. We evaluated the validity of instrumental variable (IV) methods based on nursing home prescribing preference to mitigate such confounding, using psychotropic medications to manage behavioral problems in dementia as a case study. METHODS: A cohort using linked data from Medicaid, Medicare, Minimum Data Set, and Online Survey, Certification and Reporting for 2001-2004 was established. Dual-eligible patients ≥65 years who initiated psychotropic medication use after admission were selected. Nursing home prescribing preference was characterized using mixed-effects logistic regression models. The plausibility of IV assumptions was explored, and the association between psychotropic medication class and 180-day mortality was estimated. RESULTS: High-prescribing and low-prescribing nursing homes differed by a factor of 2. Each preference-based IV measure described a substantial proportion of variation in psychotropic medication choice (β(IV → treatment): 0.22-0.36). Measured patient characteristics were well balanced across patient groups based on instrument status (52% average reduction in Mahalanobis distance). There was no evidence that instrument status was associated with markers of nursing home quality of care. CONCLUSION: Findings indicate that IV analyses using nursing home prescribing preference may be a useful approach in comparative effectiveness studies, and should extend naturally to analyses including untreated comparison groups, which are of great scientific interest but subject to even stronger confounding. Copyright © 2014 John Wiley & Sons, Ltd. Copyright © 2014 John Wiley & Sons, Ltd.

The limits of checklists: handoff and narrative thinking.
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Hilligoss B, Moffatt-Bruce SD.
BMJ quality & safety 2014 Apr 2

Concerns about the role of communication failures in adverse events coupled with the success of checklists in addressing safety hazards have engendered a movement to apply structured tools to a wide variety of clinical communication practices. While standardised, structured approaches are appropriate for certain activities, their usefulness diminishes considerably for practices that entail constructing rich understandings of complex situations and the handling of ambiguities and unpredictable variation. Drawing on a prominent social science theory of cognition, this article distinguishes between two radically different modes of human thought, each with its own strengths and weaknesses. The paradigmatic mode organises context-free knowledge into categorical hierarchies that emphasise member-to-category relations in order to apply universal truth conditions. The narrative mode, on the other hand, organises context-sensitive knowledge into temporal plots that emphasise part-to-whole relations in order to develop meaningful, holistic understandings of particular events or identities. Both modes are crucial to human cognition but are appropriate responses for different kinds of tasks and situations. Many communication-intensive practices in which patient cases are communicated, such as handoffs, rely heavily on the narrative mode, yet most interventions assume the paradigmatic mode. Improving the safety and effectiveness of these practices, therefore, necessitates greater attention to narrative thinking.

Antipsychotic medication use in nursing homes: a proposed measure of quality.
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Lucas JA, Chakravarty S, Bowblis JR, Gerhard T, Kalay E, Paek EK, et al.
International journal of geriatric psychiatry 2014 Mar 20

The potential misuse of antipsychotic medications (APMs) is an ongoing quality concern in nursing homes (NHs), especially given recent black box warnings and other evidence regarding the risk of APMs when used in NH populations. One mechanism regulators could use is public reporting of APM use by NHs; however, there is currently no agreed-upon measure of guideline-inconsistent APM use. In this paper, we describe a proposed measure of quality of APM use that is based on Centers for Medicare and Medicaid Services (CMS) Interpretive Guidelines, Food and Drug Administration (FDA) indications for APMs, and severity of behavioral symptoms. METHODS: The proposed measure identifies NH residents who receive an APM but do not have an approved indication for APM use. We demonstrate the feasibility of this measure using data from Medicaid-eligible long-stay residents aged 65 years and older in seven states. Using multivariable logistic regressions, we compare it to the current CMS Nursing Home Compare quality measure. RESULTS: We find that nearly 52% of residents receiving an APM lack indications approved by CMS/FDA guidelines compared with 85% for the current CMS quality measure. APM guideline-inconsistent use rates vary significantly across resident and facility characteristics, and states. Only our measure correlates with another quality indicator in that facilities with higher deficiencies have significantly higher odds of APM use. Predictors of inappropriate use are found to be consistent with other measures of NH quality, supporting the validity of our proposed measure. CONCLUSION: The proposed measure provides an important foundation to improve APM prescribing practices without penalizing NHs when there are limited alternative treatments available. Copyright © 2014 John Wiley & Sons, Ltd. Copyright © 2014 John Wiley & Sons, Ltd.

Successfully Reducing Antibiotic Prescribing in Nursing Homes.
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Zimmerman S, Sloane PD, Bertrand R, Olsho LE, Beeber A, Kistler C, et al.
Journal of the American Geriatrics Society 2014 Apr 2

To determine whether antibiotic prescribing can be reduced in nursing homes using a quality improvement (QI) program that involves providers, staff, residents, and families. DESIGN: A 9-month quasi-experimental trial of a QI program in 12 nursing homes (6 comparison, 6 intervention) conducted from March to November 2011. SETTING: Nursing homes in two regions of North Carolina, roughly half of whose residents received care from a single practice of long-term care providers. PARTICIPANTS: All residents, including 1,497 who were prescribed antibiotics. INTERVENTION: In the intervention sites, providers in the single practice and nursing home nurses received training related to prescribing guidelines, including situations for which antibiotics are generally not indicated, and nursing home residents and their families were sensitized to matters related to antibiotic prescribing. Feedback on prescribing was shared with providers and nursing home staff monthly. MEASUREMENTS: Rates of antibiotic prescribing for presumed urinary tract, skin and soft tissue, and respiratory infections. RESULTS: The QI program reduced the number of prescriptions ordered between baseline and follow-up more in intervention than in comparison nursing homes (adjusted incidence rate ratio = 0.86, 95% confidence interval = 0.79-0.95). Based on baseline prescribing rates of 12.95 prescriptions per 1,000 resident-days, this estimated adjusted incidence rate ratio implies 1.8 prescriptions avoided per 1,000 resident-days. CONCLUSION: This magnitude of effect is unusual in efforts to reduce antibiotic use in nursing homes. Outcomes could be attributed to the commitment of the providers; outreach to providers and staff; and a focus on common clinical situations in which antibiotics are generally not indicated; and suggest that similar results can be achieved on a wider scale if similar commitment is obtained and education provided. © 2014, Copyright the Authors Journal compilation © 2014, The American Geriatrics Society.

Effect of the Bathing Without a Battle Training Intervention on Bathing-Associated Physical and Verbal Outcomes in Nursing Home Residents with Dementia: A Randomized Crossover Diffusion Study.
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Gozalo P, Prakash S, Qato DM, Sloane PD, Mor V.
Journal of the American Geriatrics Society 2014 Apr 2

To evaluate the effectiveness of the Bathing Without a Battle intervention in reducing physical and verbal aggressive behaviors for nursing home residents with dementia. DESIGN: A randomized crossover diffusion study, with one group receiving the intervention after one round of baseline observations and a delayed intervention group receiving the intervention after two rounds of baseline observations. SETTING: Six nursing home facilities in the state of New York. PARTICIPANTS: Nursing home residents with dementia (N = 240). INTERVENTION: The Bathing Without a Battle educational program, designed for direct-care staff members responsible for bathing residents diagnosed with dementia and implemented through a train-the-trainer model. MEASUREMENTS: Rates of verbal and physical aggressive and agitated behaviors were measured using the Care Recipient Behavior Assessment; secondary measures of effect included bath duration, bath modality, and antipsychotic medication use. RESULTS: In spite of implementation obstacles (consent delays and change in leadership at one facility), a significant change was observed in how residents were bathed that translated into a significant reduction in the rate of aggressive and agitated behaviors, particularly verbal, during residents’ baths. The use of in-bed baths increased 17%, and average bath duration decreased significantly (average 1.5 minutes less) in the postintervention period, particularly for in-bed baths. Verbal behaviors declined 17.8% (P = .008), combined verbal and physical behaviors declined 18.6% (P = .004), and antipsychotic use declined 30% (P = .002) after the intervention. CONCLUSION: The Bathing Without a Battle educational program, delivered through a train-the-trainer format, is an effective means of improving the bathing experience of residents with dementia in nursing homes. This research supports broadly adopting this intervention, especially for nursing homes serving many residents with dementia. © 2014, Copyright the Authors Journal compilation © 2014, The American Geriatrics Society.

Applying the Advancing Excellence in America’s Nursing Homes Circle of Success to improving and sustaining quality.
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Bakerjian D, Zisberg A.
Geriatric nursing (New York, N.Y.) 2013 Sep-Oct;34(5):402-411

Looking forward to the Quality Assurance Performance Improvement (QAPI) program to be implemented and required in 2014, and as nursing home staff provide care for residents with increasingly complex health issues, knowledge of how to implement quality improvement (QI) is imperative. The nursing home administrator and director of nursing (DON) provide overall leadership, but it is the primary responsibility of the DON and other registered nurse staff to implement and manage the day to day QI process. This article describes potential roles of nursing leaders and key components of a QI project using a pressure ulcer case study exemplar to illustrate a quality improvement process. The authors suggest specific methods that RN leaders can employ using the Advancing Excellence Campaign Circle of Success as an organizing framework along with evidence-based resources. Nursing home leaders could use this article as a guideline for implementing any clinical quality improvement process. Copyright © 2013 Mosby, Inc. All rights reserved.

Effectiveness of supervised implementation of an oral health care guideline in care homes; a single-blinded cluster randomized controlled trial.
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van der Putten GJ, Mulder J, de Baat C, De Visschere LM, Vanobbergen JN, Schols JM.
Clinical oral investigations 2013 May;17(4):1143-1153

The objective of this study was to assess the effectiveness of a supervised implementation of the “Oral health care Guideline for Older people in Long-term care Institutions” (OGOLI) in The Netherlands. MATERIALS AND METHODS: A sample of 12 care homes in the Netherlands was allocated randomly to an intervention or control group. While the residents in the control group received oral health care as before, the intervention consisted of a supervised implementation of the OGOLI. RESULTS: At baseline, the overall random sample comprised 342 residents, 52 % in the intervention group and 48 % in the control group. At 6 months, significant differences were observed between the intervention and the control group for mean dental as well as denture plaque, with a beneficial effect for the intervention group. The multilevel mixed-model analyses conducted with the plaque scores at 6 months as outcome variables showed that the reduction by the intervention was only significant for denture plaque. CONCLUSIONS: Supervised implementation of the OGOLI was more effective than non-supervised implementation in terms of reducing mean plaque scores at 6 months. However, the multilevel mixed-model analysis could not exclusively explain the reduction of mean dental plaque scores by the intervention. CLINICAL RELEVANCE: A supervised implementation of an oral health care guideline improves oral health of care home residents.

Expert Recommendations for Implementing Change (ERIC): protocol for a mixed methods study.
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Waltz TJ, Powell BJ, Chinman MJ, Smith JL, Matthieu MM, Proctor EK, et al.
Implementation science 2014 Mar 26;9:39-5908-9-39

Identifying feasible and effective implementation strategies that are contextually appropriate is a challenge for researchers and implementers, exacerbated by the lack of conceptual clarity surrounding terms and definitions for implementation strategies, as well as a literature that provides imperfect guidance regarding how one might select strategies for a given healthcare quality improvement effort. In this study, we will engage an Expert Panel comprising implementation scientists and mental health clinical managers to: establish consensus on a common nomenclature for implementation strategy terms, definitions and categories; and develop recommendations to enhance the match between implementation strategies selected to facilitate the use of evidence-based programs and the context of certain service settings, in this case the U.S. Department of Veterans Affairs (VA) mental health services. METHODS/DESIGN: This study will use purposive sampling to recruit an Expert Panel comprising implementation science experts and VA mental health clinical managers. A novel, four-stage sequential mixed methods design will be employed. During Stage 1, the Expert Panel will participate in a modified Delphi process in which a published taxonomy of implementation strategies will be used to establish consensus on terms and definitions for implementation strategies. In Stage 2, the panelists will complete a concept mapping task, which will yield conceptually distinct categories of implementation strategies as well as ratings of the feasibility and effectiveness of each strategy. Utilizing the common nomenclature developed in Stages 1 and 2, panelists will complete an innovative menu-based choice task in Stage 3 that involves matching implementation strategies to hypothetical implementation scenarios with varying contexts. This allows for quantitative characterizations of the relative necessity of each implementation strategy for a given scenario. In Stage 4, a live web-based facilitated expert recommendation process will be employed to establish expert recommendations about which implementations strategies are essential for each phase of implementation in each scenario. DISCUSSION: Using a novel method of selecting implementation strategies for use within specific contexts, this study contributes to our understanding of implementation science and practice by sharpening conceptual distinctions among a comprehensive collection of implementation strategies.

The effects of contextual and structural factors on patient safety in nursing units.
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Hung CC, Hsu SC, Lee LL, Huang CM.
The journal of nursing research : JNR 2013 Sep;21(3):225-233

Because of limited research on patient safety from a macrolevel perspective, our understanding of how to reduce the risk of system failures that impact patient safety outcomes in Taiwanese healthcare organizations is limited. PURPOSE: We conducted this study to explore the relationships between macrolevel factors and patient safety outcomes. METHODS: Structural contingency theory was used as the framework for the study. A cross-sectional design was used, and data were collected from self-administered questionnaires. Head nurses and registered nurses working in 64 in-patient nursing units at three hospitals participated in the study. A tailored design method was used for data collation, and the data collection lasted 3 weeks during the winter of 2010. Data were aggregated from the individual to the unit level, and path analysis was used to examine the hypothesized model. RESULTS: Sixty-two head nurses (96.8%) and 977 staff nurses (72%) completed and returned the questionnaire. Eta-squared coefficient (η), interitem consistency (rwg), and F ratio results showed that data at the individual level are appropriate for aggregating to the unit level. These findings show that nursing units with high degrees of professional autonomy, comparatively higher proportions of nursing experts, and relatively large unit sizes tend to have higher rates of medication errors. In addition, we found high degrees of unit technology associated with higher rates of medication errors and patient falls. CONCLUSIONS/IMPLICATIONS FOR PRACTICE: These findings suggest a link between macrolevel factors and patient safety outcomes. This study shows that redesigning continuing education programs encourages nurses to participate in patient safety training and understand the nursing unit characteristics that enhance patient safety outcomes to improve the patient safety of nursing units.

New Toolkit to Measure Quality of Person-Centered Care: Development and Pilot Evaluation With Nursing Home Communities
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Van Haitsma K, Crespy S, Humes S, Elliot A, Mihelic A, Scott C, et al.
Journal of the American Medical Directors Association 2014 Apr 7

Increasingly, nursing home (NH) providers are adopting a person-centered care (PCC) philosophy; yet, they currently lack methods to measure their progress toward this goal. Few PCC tools meet criteria for ease of use and feasibility in NHs. The purpose of this article is to report on the development of the concept and measurement of preference congruence among NH residents (phase 1), its refinement into a set of quality indicators by Advancing Excellence in America’s Nursing Homes (phase 2), and its pilot evaluation in a sample of 12 early adopting NHs prior to national rollout (phase 3). The recommended toolkit for providers to use to measure PCC consists of (1) interview materials for 16 personal care and activity preferences from Minimum Data Set 3.0, plus follow-up questions that ask residents how satisfied they are with fulfillment of important preferences; and (2) an easy to use Excel spreadsheet that calculates graphic displays of quality measures of preference congruence and care conference attendance for an individual, household or NH. Twelve NHs interviewed residents (N = 146) using the toolkit; 10 also completed a follow-up survey and 9 took part in an interview evaluating their experience. RESULTS: NH staff gave strong positive ratings to the toolkit. All would recommend it to other NHs. Staff reported that the toolkit helped them identify opportunities to improve PCC (100%), and found that the Excel tool was comprehensive (100%), easy to use (90%), and provided high quality information (100%). Providers anticipated using the toolkit to strengthen staff training as well as to enhance care planning, programming and quality improvement. CONCLUSIONS: The no-cost PCC toolkit provides a new means to measure the quality of PCC delivery. As of February 2014, over 700 nursing homes have selected the Advancing Excellence in America’s Nursing Homes PCC goal as a focus for quality improvement. The toolkit enables providers to incorporate quality improvement by moving beyond anecdote, and advancing more systematically toward honoring resident preferences. Copyright © 2014 American Medical Directors Association, Inc. Published by Elsevier Inc. All rights reserved.

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Organizational Change

A conceptual model for culture change evaluation in nursing homes.
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Hartmann CW, Snow AL, Allen RS, Parmelee PA, Palmer JA, Berlowitz D.
Geriatric nursing (New York, N.Y.) 2013 Sep-Oct;34(5):388-394

This article describes the development and particulars of a new, comprehensive model of nursing home culture change, the Nursing Home Integrated Model for Producing and Assessing Cultural Transformation (Nursing Home IMPACT). This model is structured into four categories, “meta constructs,” “care practices,” “workplace practices,” and “environment of care,” with multiple domains under each. It includes detailed, triangulated assessment methods capturing various stakeholder perspectives for each of the model’s domains. It is hoped that this model will serve two functions: first, to help practitioners guide improvements in resident care by identifying particular areas in which culture change is having positive effects, as well as areas that could benefit from modification; and second, to emphasize the importance in culture change of the innumerable perspectives of residents, family members, staff, management, and leadership. Published by Mosby, Inc.

A meta-ethnography of organisational culture in primary care medical practice
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Grant S, Guthrie B, Entwistle V, Williams B.
Journal of Health, Organisation and Management 2014;28(1):21-40

Over the past decade, there has been growing international interest in shaping local organisational cultures in primary healthcare. However, the contextual relevance of extant culture assessment instruments to the primary care context has been questioned. The aim of this paper is to derive a new contextually appropriate understanding of the key dimensions of primary care medical practice organisational culture and their inter-relationship through a synthesis of published qualitative research. Design/methodology/approach: A systematic search of six electronic databases followed by a synthesis using techniques of meta-ethnography involving translation and re-interpretation. Findings: A total of 16 papers were included in the meta-ethnography from the UK, the USA, Canada, Australia and New Zealand that fell into two related groups: those focused on practice organisational characteristics and narratives of practice individuality; and those focused on sub-practice variation across professional, managerial and administrative lines. It was found that primary care organisational culture was characterised by four key dimensions, i.e. responsiveness, team hierarchy, care philosophy and communication. These dimensions are multi-level and inter-professional in nature, spanning both practice and sub-practice levels. Research limitations/implications: The research contributes to organisational culture theory development. The four new cultural dimensions provide a synthesized conceptual framework for researchers to evaluate and understand primary care cultural and sub-cultural levels. Practical implications: The synthesised cultural dimensions present a framework for practitioners to understand and change organisational culture in primary care teams. Originality/value: The research uses an innovative research methodology to synthesise the existing qualitative research and is one of the first to develop systematically a qualitative conceptual framing of primary care organisational culture. © Emerald Group Publishing Limited.

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Research Practice & Methodology

Developing a checklist for research proposals to help describe health service interventions in UK research programmes: a mixed methods study.
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Dorling H, White D, Turner S, Campbell K, Lamont T.
Health research policy and systems 2014 Mar 4;12(1):12-4505-12-12

One of the most common reasons for rejecting research proposals in the National Institute for Health Research (NIHR) Health Services and Delivery Research (HS&DR) Programme is the failure to adequately specify the intervention or context in research proposals. Examples of failed research proposals include projects to assess integrated care models, use of generic caseworkers, or new specialist nurse services. These are all important service developments which need evaluation, but the lack of clarity about the intervention and context prevented these research proposals from obtaining funding. The purpose of the research presented herein was to develop a checklist, with key service intervention and contextual features, for use by applicants to the NIHR HS&DR Programme to potentially enhance the quality of research proposals. METHODS: The study used mixed methods to identify the need for and develop and test a checklist. Firstly, this included assessing existing checklists in peer-reviewed literature relevant to organisational health research. Building on existing work, a new checklist was piloted. Two reviewers used a small sample (n = 16) of research proposals to independently assess the relevance of the checklist to the proposal and the degree of overlap or gaps between the constructs. The next two stages externally validated the revised checklist by collecting qualitative feedback from researchers and experts in the field. RESULTS: The initial checklist was developed from existing checklists which included domains of intervention and context. The constructs and background to each were developed through review of existing literature. Eight researchers provided feedback on the checklist, which was generally positive. This iterative process resulted in changes to the checklist, collapsing two constructs and providing more prompts for others; the final checklist includes six constructs. CONCLUSIONS: Features relating to intervention and context should be well described to increase the quality of research proposals and enhance the chances of the research receiving funding. Existing checklists do not have enough focus on areas relevant to research proposals in complex health service interventions, such as workforce. A formative checklist has been developed, and tested by end users. Tentative findings suggest usefulness and acceptability of such a tool but further work is needed for full validation.

International Survey of Nursing Home Research Priorities
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Morley JE, Caplan G, Cesari M, Dong B, Flaherty JH, Grossberg GT, et al.
Journal of the American Medical Directors Association 2014 Apr 2

This article reports the findings of a policy survey designed to establish research priorities to inform future research strategy and advance nursing home practice. The survey was administered in 2 rounds during 2013, and involved a combination of open questions and ranking exercises to move toward consensus on the research priorities. A key finding was the prioritization of research to underpin the care of people with cognitive impairment/dementia and of the management of the behavioral and psychological symptoms of dementia within the nursing home. Other important areas were end-of-life care, nutrition, polypharmacy, and developing new approaches to putting evidence-based practices into routine practice in nursing homes. It explores possible innovative educational approaches, reasons why best practices are difficult to implement, and challenges faced in developing high-quality nursing home research. Copyright © 2014 American Medical Directors Association, Inc. All rights reserved. Published by Elsevier Inc. All rights reserved.

Challenges and strategies pertaining to recruitment and retention of frail elderly in research studies: a systematic review
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Provencher V, Mortenson WB, Tanguay-Garneau L, Belanger K, Dagenais M.
Archives of Gerontology and Geriatrics

To identify challenges and strategies pertaining to recruitment and retention of frail elderly in research studies. Methods A systematic review was conducted. Four databases (MEDLINE, CINAHL, AgeLine, Embase) were searched from January 1992 to December 2012. Empirical studies were included if they explored barriers to or strategies for recruitment or retention of adults aged 60-plus who were identified as frail, vulnerable or housebound. Two researchers independently determined the eligibility of each abstract reviewed and assessed the level of evidence presented. Data concerning challenges encountered (type and impact) and strategies used (type and impact) were abstracted. Results Of 916 articles identified in the searches, 15 met the inclusion criteria. The level of evidence of the studies retained varied from poor to good. Lack of perceived benefit, distrust of research staff, poor health and mobility problems were identified as common challenges. The most frequently reported strategies used were to establish a partnership with staff that participants knew and trusted, and be flexible about the time and place of the study. However, few studies performed analyses to compare the impact of specific challenges and strategies on refusal or drop-out rates. Conclusions This review highlights the need to improve knowledge about the impact of barriers and strategies on recruitment and retention of frail older adults. This knowledge will help to develop innovative and cost-effective ways to increase and maintain participation, which may improve the generalizability of research findings to this population.

Enabling research in care homes: an evaluation of a national network of research ready care homes.
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Davies SL, Goodman C, Manthorpe J, Smith A, Carrick N, Iliffe S.
BMC medical research methodology 2014 Apr 5;14(1):47

In the UK care homes are one of the main providers of long term care for older people with dementia. Despite the recent increase in care home research, residents with dementia are often excluded from studies. Care home research networks have been recommended by the Ministerial Advisory Group on Dementia Research (MAGDR) as a way of increasing research opportunities for residents with dementia. This paper reports on an evaluation of the feasibility and early impact of an initiative to increase care home participation in research. METHODS: A two phase, mixed methods approach was used; phase 1 established a baseline of current and recent studies including the National Institute for Health Research portfolio. To explore the experiences of recruiting care homes and research participation, interviews were conducted with researchers working for the Dementia and Neurodegenerative Diseases Research Network (DeNDRoN) and care home managers. In phase 2, four DeNDRoN area offices recruited care homes to a care home networks for their region. The care home networks were separate from the DeNDRoN research network. Diaries were used to document and cost recruitment; DeNDRoN staff were interviewed to understand the barriers, facilitators and impact of the care home networks. RESULTS: Thirty three current or recent studies were identified as involving care homes as care home specific studies or those which included residents. Further details of care home recruitment were obtained on 20 studies by contacting study teams. Care home managers were keen to be involved in research that provided staff support, benefits for residents and minimal disruptive. In phase 2, 141 care homes were recruited to the care home research networks, through corporate engagement and individual invitation. Pre-existing relationships with care homes facilitated recruitment. Sites with minimal experience of working with care homes identified the need for care home training for researchers. CONCLUSIONS: Phase 1 review revealed a small but increasing number of studies involving care homes. Phase 2 demonstrated the feasibility of care home research networks, their potential to increase recruitment to research and develop partnerships between health services and care homes, but highlighted the need for care home training for researchers.

Research excellence in UK universities
Department for Business, Innovation & Skills, UK April 2014

This report aims to understand what UK universities do to improve research excellence, excluding funding levels. It includes a literature review and a survey of 51 academics in 12 leading UK universities. It identifies 6 important factors contributing to research excellence:
recruitment practices
mentoring and appraisal
research strategies
securing a mix of funding
The report finds that the UK’s successful research performance relies on a number of subtle factors besides funding levels. As such, increasing R&D expenditure in other countries is not enough in itself to replicate the UK’s research success.

OECD: Unleashing the Power of Big Data for Alzheimer’s Disease and Dementia Research
March 2014

More than 35 million people worldwide had dementia in 2010, when annual costs were estimated at USD 604 billion; the number of people with dementia is expected to exceed 115 million by 2050. Alzheimer’s disease is today considered the prototype problem for the Grand Global Challenge in healthcare. Despite decades of intensive research, the causal chain of mechanisms behind Alzheimer’s has remained elusive as reflected in recent failures of well-designed clinical trials on promising investigational new drugs. The multi-factorial nature of the disease requires the collection, storage and processing of increasingly large and very heterogeneous datasets (behavioural, genetic, environmental, epigenetic, clinical data, brain imaging, etc.). No one nation has all the assets to pursue this type of research independently. In an effort to tackle this huge challenge, the OECD held a consultation on “Unlocking Global Collaboration to Accelerate Innovation for Alzheimer’s Disease and Dementia” which looked at ways to harness developments in life sciences and information technologies to accelerate innovation in the prevention and treatment of the disease. This paper reports on the opportunities offered by the informatics revolution and big data. Creating and using big data to change the future of Alzheimer’s and dementia requires careful planning and multi-stakeholder collaboration. Numerous technical, administrative, regulatory, infrastructure and financial obstacles emerge and will need to be hurdled to make this vision a reality.

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The relationship between apathy and participation in therapeutic activities in nursing home residents with dementia: Evidence for an association and directions for further research
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Ellis JM, Doyle CJ, Selvarajah S.
Dementia (London, England) 2014 Mar 31

Apathy is one of the most frequent and early symptoms of dementia. Because apathy is characterised by lack of initiative and motivation, it leads to considerable burden being placed on carers to ensure that the person living with dementia has a reasonable quality of life. The aim of this study was to investigate the relationship between apathy and participation in therapeutic activities for older people with dementia living in nursing homes. Ninety residents were recruited into the study, and apathy was measured by nursing home staff using the Apathy Evaluation Scale Clinician version. Staff also compiled data on each resident’s involvement in therapeutic activities. Among this sample, the mean age was 84.8 years, and mean length of stay in the nursing home was 1.8 years. The mean apathy score was 50.4, indicating that on average the residents had a moderate level of apathy. Overall, residents participated in six activities per week and those residents who were involved in the most activities had the lowest levels of apathy. This paper provides evidence that residents involved in therapeutic activities have lower levels of apathy. Further research should be conducted on the direction of causality, whether apathy levels can be changed through participation in therapeutic activities, the relationship between dementia severity and modifiability of apathy, and the intensity of therapeutic activities required to maintain functioning.

BE-ACTIV for Depression in Nursing Homes: Primary Outcomes of a Randomized Clinical Trial.
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Meeks S, Van Haitsma K, Schoenbachler B, Looney SW.
The journals of gerontology.Series B, Psychological sciences and social sciences 2014 Apr 1

To report the primary outcomes of a cluster randomized clinical trial of Behavioral Activities Intervention (BE-ACTIV), a behavioral intervention for depression in nursing homes.Method.Twenty-three nursing homes randomized to BE-ACTIV or treatment as usual (TAU); 82 depressed long-term care residents recruited from these nursing homes. BE-ACTIV participants received 10 weeks of individual therapy after a 2-week baseline. TAU participants received weekly research visits. Follow-up assessments occurred at 3- and 6-month posttreatment. RESULTS: BE-ACTIV group participants showed better diagnostic recovery at posttreatment in intent-to-treat analyses adjusted for clustering. They were more likely to be remitted than TAU participants at posttreatment and at 3-month posttreatment but not at 6 months. Self-reported depressive symptoms and functioning improved in both groups, but there were no significant treatment by time interactions in these variables.Discussion.BE-ACTIV was superior to TAU in moving residents to full remission from depression. The treatment was well received by nursing home staff and accepted by residents. A large proportion of participants remained symptomatic at posttreatment, despite taking one or more antidepressants. The results illustrate the potential power of an attentional intervention to improve self-reported mood and functioning, but also the difficulties related to both studying and implementing effective treatments in nursing homes.

Change and predictors of change in social skills of nursing home residents with dementia. Canada-flat-icon
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Chappell NL, Kadlec H, Reid C.
American Journal of Alzheimer’s Disease and Other Dementias 2014 Feb;29(1):23-31

Social skills are of primary importance for those with dementia and their care providers, yet we know little about the extent to which basic social skills can be maintained over time and the predictors of change. METHODS: A total of 18 nursing homes with 149 newly admitted residents with moderate to severe dementia, 195 direct care staff, and 135 family members, in British Columbia, Canada, contributed data on change in social skills from admission to 6 months and 1 year later. RESULTS: Three-quarters of residents maintained or improved their basic social skills during both the time periods. Decline was explained primarily by cognitive status at the time of admission, notably present orientation. However, staff-to-resident communication becomes more important over time. CONCLUSIONS: Social skills appear to present an opportunity to maintain interaction with these residents. The findings also suggest that a focus on the present orientation before and following admission and on staff-to-resident communication may be beneficial.

Secure surveillance of antimicrobial resistant organism colonization or infection in Ontario long term care homes. Canada-flat-icon
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El Emam K, Arbuckle L, Essex A, Samet S, Eze B, Middleton G, et al.
PloS one 2014 Apr 8;9(4):e93285

There is stigma attached to the identification of residents carrying antimicrobial resistant organisms (ARO) in long term care homes, yet there is a need to collect data about their prevalence for public health surveillance and intervention purposes. OBJECTIVE: We conducted a point prevalence study to assess ARO rates in long term care homes in Ontario using a secure data collection system. METHODS: All long term care homes in the province were asked to provide colonization or infection counts for methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and extended-spectrum beta-lactamase (ESBL) as recorded in their electronic medical records, and the number of current residents. Data was collected online during the October-November 2011 period using a Paillier cryptosystem that allows computation on encrypted data. RESULTS: A provably secure data collection system was implemented. Overall, 82% of the homes in the province responded. MRSA was the most frequent ARO identified at 3 cases per 100 residents, followed by ESBL at 0.83 per 100 residents, and VRE at 0.56 per 100 residents. The microbiological findings and their distribution were consistent with available provincial laboratory data reporting test results for AROs in hospitals. CONCLUSIONS: We describe an ARO point prevalence study which demonstrated the feasibility of collecting data from long term care homes securely across the province and providing strong privacy and confidentiality assurances, while obtaining high response rates.

Medication monitoring for people with dementia in care homes: the feasibility and clinical impact of nurse-led monitoring.
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Jordan S, Gabe M, Newson L, Snelgrove S, Panes G, Picek A, et al.
TheScientificWorldJournal 2014 Feb 23;2014:843621

People with dementia are susceptible to adverse effects of medicines. However, they are not always closely monitored. We explored (1) feasibility and (2) clinical impact of nurse-led medication monitoring. Design. Feasibility “before-and-after” intervention study. Setting. Three care homes in Wales. Participants. Eleven service users diagnosed with dementia, taking at least one antipsychotic, antidepressant, or antiepileptic medicine. Intervention. West Wales Adverse Drug Reaction (ADR) Profile for Mental Health Medicines. Outcome Measures. (1) Feasibility: recruitment, retention, and implementation. (2) Clinical impact: previously undocumented problems identified and ameliorated, as recorded in participants’ records before and after introduction of the profile, and one month later. Results. Nurses recruited and retained 11 of 29 eligible service users. The profile took 20-25 minutes to implement, caused no harm, and supplemented usual care. Initially, the profile identified previously undocumented problems for all participants (mean 12.7 (SD 4.7)). One month later, some problems had been ameliorated (mean 4.9 (3.6)). Clinical gains included new prescriptions to manage pain (2 participants), psoriasis (1), Parkinsonian symptoms (1), rash (1), dose reduction of benzodiazepines (1), new care plans for oral hygiene, skin problems, and constipation. Conclusions. Participants benefited from structured nurse-led medication monitoring. Clinical trials of our ADR Profile are feasible and necessary.

Repositioning for pressure ulcer prevention in adults.
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Gillespie BM, Chaboyer WP, McInnes E, Kent B, Whitty JA, Thalib L.
The Cochrane database of systematic reviews 2014 Apr 3;4:CD009958

The objectives of this review were to:1) assess the effects of repositioning on the prevention of PUs in adults, regardless of risk or in-patient setting;2) ascertain the most effective repositioning schedules for preventing PUs in adults; and3) ascertain the incremental resource consequences and costs associated with implementing different repositioning regimens compared with alternate schedules or standard practice. We included three RCTs and one economic study representing a total of 502 randomised participants from acute and long-term care settings. Two trials compared the 30º and 90º tilt positions using similar repositioning frequencies (there was a small difference in frequency of overnight repositioning in the 90º tilt groups between the trials). The third RCT compared alternative repositioning frequencies.All three studies reported the proportion of patients developing PU of any grade, stage or category. None of the trials reported on pain, or quality of life, and only one reported on cost. All three trials were at high risk of bias.The two trials of 30º tilt vs. 90º were pooled using a random effects model (I² = 69%) (252 participants). The risk ratio for developing a PU in the 30º tilt and the standard 90º position was very imprecise (pooled RR 0.62, 95% CI 0.10 to 3.97, P=0.62, very low quality evidence). This comparison is underpowered and at risk of a Type 2 error (only 21 events).In the third study, a cluster randomised trial, participants were randomised between 2-hourly and 3-hourly repositioning on standard hospital mattresses and 4 hourly and 6 hourly repositioning on viscoelastic foam mattresses. This study was also underpowered and at high risk of bias. The risk ratio for pressure ulcers (any category) with 2-hourly repositioning compared with 3-hourly repositioning on a standard mattress was imprecise (RR 0.90, 95% CI 0.69 to 1.16, very low quality evidence). The risk ratio for pressure ulcers (any category) was compatible with a large reduction and no difference between 4-hourly repositioning and 6-hourly repositioning on viscoelastic foam (RR 0.73, 95% CI 0.53 to 1.02, very low quality evidence).A cost-effectiveness analysis based on data derived from one of the included parallel RCTs compared 3-hourly repositioning using the 30º tilt overnight with standard care consisting of 6-hourly repositioning using the 90º lateral rotation overnight. In this evaluation the only included cost was nursing time. The intervention was reported to be cost saving compared with standard care (nurse time cost per patient €206.6 vs €253.1, incremental difference €-46.5; 95%CI: €-1.25 to €-74.60).

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The impact of nurse staffing and nurses’ working conditions on patient outcomes
Wednesday 23 April 12:00-13:30 ECHA 1-182

This lecture by Dr. Jack Needleman is sponsored by FoN’s Health Systems Area of Excellence.

Why is it so difficult to make and sustain change in hospital care?
Friday 25 April ECHA L1-490

This lecture by Dr. Jack Needleman is sponsored by FoN’s Health Systems Area of Excellence.


AHRQ Improving Patient Safety in Long-Term Care Facilities

These new educational materials are intended for use in training front-line personnel in nursing homes and other long-term care facilities. The materials were developed for the Agency for Healthcare Research and Quality (AHRQ) under a contract to the RAND Corporation. They are organized into three modules:
Module 1: Detecting Change in a Resident’s Condition.
Module 2: Communicating Change in a Resident’s Condition.
Module 3: Falls Prevention and Management.

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Statistical workshop on indirect and mixed treatment comparisons
26 June University of York, UK Cost: £250 (plus VAT)

Indirect and mixed treatment comparisons are increasingly used in health technology assessment. They are statistical techniques to synthesise available direct and indirect evidence. They provide information on the comparative effectiveness of a range of competing interventions. Developing indirect (ITC) and mixed treatment comparisons (MTC) are often the end product of systematic reviews and the data produced is often used to inform economic models. Deciding on the suitability of conducting these analyses and undertaking them require a range of specialist skills including statistical skills. These analyses also significantly benefit from appropriate scoping and advanced planning. This new training course provides an introduction to ITC and MTC for project managers, research commissioners and others new to these techniques, who are seeking a better understanding of how to plan, commission and assess such comparisons.

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For People with Dementia, Does It Take a Village?

A community in the Netherlands has become a model for how to help people feel at home even after they’ve lost their memory.

End of 2004 Canada Health Accord calls out need for strategy on seniors’ health care Canada-flat-icon

Canadians and their governments must realize that no amount of spending — and no amount of cost cutting — will meet this challenge unless our governments learn to work together again for the benefit of Canadians’ health and wellness. This means Ottawa, as the fifth largest provider/purchaser of health care services, must take a central role.

CIHI announces David O’Toole as new president and CEO Canada-flat-icon

The Board of Directors of the Canadian Institute for Health Information is pleased to announce that after a thorough search and interview process, David O’Toole has been selected as the new president and CEO of CIHI, effective May 12, 2014.

Latest issue of AHRQ’s Health Care Innovations Exchange is on Policy Innovations in Long-Term Care

Featured Innovations:
• Long-Term Care Facilities Cede Control of Immunization Policies to Regional Pharmacy, Significantly Increasing Influenza Vaccination Rates Among Workers
• State Uses Financial Incentives To Fund Nursing Home–Initiated Quality Improvement Projects Through Competitive Bidding Process, Leading to Better Care
Featured QualityTools:
• Guide to Long Term Care for Veterans
Developed by U.S. Department of Veterans Affairs
• Improving Outcomes for an Aging Population: Alzheimer’s Treatment in Long-Term Care
Developed by Academy for Continued Healthcare Learning (ACHL); Indiana University School of Medicine
• On-Time Quality Improvement Manual for Long-Term Care Facilities
Developed by Health Management Strategies, Inc.; International Severity Information Systems, Inc.
Featured Articles:
• States Turn to Managed Care To Constrain Medicaid Long-Term Care Costs

Call for Research Participants Involved in Health Sciences Research at the University of Alberta

If you are researcher involved in health science related work, I would like to invite you to participate in a research study about the impact of data sharing practices, norms, policies, and infrastructure in your field. Interviews will take approximately one hour of your time. Researchers at all stages of their career are encouraged to participate (graduate, postdoc, faculty and other positions involved directly in the research process). The goal of this study is to document and contribute to interdisciplinary knowledge about the impact of emergent research practices and forms of data governance. If you would like to participate or find out more about this project, please contact the principal investigator Kendall Roark, roark@ualberta.ca This research project has been approved by the University of Alberta Research Ethics Board and is being conducted as part of a CLIR/DLF Postdoctoral Fellowship project in Data Curation with the University of Alberta Libraries.

UofA’s Faculty of Nursing becomes the first school outside of the US to join the National Hartford Centers of Gerontological Nursing Excellence (NHCGNE)

Only schools of nursing that have demonstrated a commitment to the field of gerontological nursing and share a vision of optimal health and quality of life for older adults are invited to apply for membership. NHCGNE members must have both current experience and future potential to build the next generation of gerontological nurses and manifest leadership that transcends their own institution.

New BBC series shows the increasing difficulties in caring for older people

Protecting our Parents reveals multiple issues with the fragmented systems of health and social care

Overprescribed? Anti-psychotic drugs used too commonly on dementia patients, some say Canada-flat-icon

Lalita Figueredo’s husband, Allan, has been taking anti-psychotic drugs for a decade. But he’s not psychotic. The drugs were prescribed to control his behaviour after his diagnosis of early onset Alzheimer’s disease in 2003. That sort of “off-label” use of antipsychotics is common. In the Champlain Local Health Integration Network (LHIN), which includes Ottawa and much of Eastern Ontario, 31.7 per cent of the region’s 7,500 long-term care home residents are on antipsychotics with no diagnosis of psychosis. The ratio is similar elsewhere in Canada. The Canadian Institute for Health Information considers that a “potentially inappropriate” use of medication.

How far along are we in making hospitals more ‘senior friendly’? Canada-flat-icon

Being hospitalized can have dramatic impacts on seniors’ wellness, and time spent in hospital contributes to loss of important functions such as strength and mobility – critical to their independence and wellbeing. Camilla Wong, a geriatrician at St. Michael’s Hospital in Toronto says “hospitalization robs us of the things that are really important for older people.”

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CRECS’ Ten Minute Window

The CRECS’ Ten Minute Window (TMW) is an open-source serial publication sponsored by the Centre for Research on Educational and Community Services (CRECS), University of Ottawa. The TMW provides a platform through which researchers, within the space of no more than 10 minutes, may disseminate encapsulated summaries of their research findings or conceptual contributions. Content may range from findings associated with a specific study or a research program more broadly defined. Submissions are welcome from researchers working in the education sector, community services and social and health sciences whose contributions align well with CRECS’ mission

Ontario Health System Documents Portal Canada-flat-icon

The Ontario Health System Documents Portal is a continuously updated repository of policy-relevant documents that address health system strengthening in Ontario, with a focus on 10 government-identified priority areas: community-based care; health system performance and sustainability; healthy living, with a focus on tobacco control; mental health and addictions; nursing research; primary care reform; quality improvement and safety; seniors’ care; vulnerable and special health needs populations; and women’s health.

Guide on late-life depression Canada-flat-icon

This resource guide from Baycrest in Ontario provides the following information on late life depression: signs & symptoms, causes, types, and treatment.

PC P.E.A.R.L.S.™ 7 key elements of person-centred care of people with dementia in long-term care homes Canada-flat-icon

Through research, the Alzheimers Society of Canada learned about seven common key elements to begin and sustain a culture change to provide person-centred care. These elements are outlined and explained in seven information sheets entitled PC P.E.A.R.L.S.™, under the following headings: 1 Person and Family Engagement 2 Care 3 Processes 4 Environment 5 Activity & Recreation 6 Leadership 7 Staffing The approaches adopted and practices implemented by the six homes studied are real-life, credible, effective choices that can be duplicated in most other homes and the lessons learned can be applied in various situations and settings. ASC encourages long-term care homes to put the PC P.E.A.R.L.S.™ into practice to improve the experience of people with dementia, caregivers and staff. The ultimate goal of ASC is to make person-centred care the norm rather than the exception in Canada, and many long-term care homes already share our vision.

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Fully funded PhD studentship
University of Lincoln, Lincoln UK

The School of Architecture and The Lincoln Institute of Health in University of Lincoln is inviting applications for fully funded studentships from outstanding, highly-motivated students to join a thriving research environment based in one of the world’s great small cities.

Scientific Director, CIHR Institute of Gender and Health Canada-flat-icon

As the leader of CIHR-IGH, and under the authority of CIHR’s Governing Council, the Scientific Director will foster:
-leadership in gender, sex and health research and its translation into new policies, products, services and systems that support better health for all Canadians; and
-partnership, collaboration and capacity building to ensure the continued growth and impact of Canada’s gender, sex and health research community.
As a member of Science Council, the Scientific Director, in collaboration with colleagues from the other CIHR Institutes, will be involved in setting and implementing CIHR’s strategic agenda and deciding upon the resultant research spending.

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