Article recommended by Dr. Carole Estabrooks
Hiding in plain sight: communication theory in implementation science.
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Manojlovich M, Squires JE, Davies B, Graham ID.
Implementation science 2015 Apr 23;10(1):58
Poor communication among healthcare professionals is a pressing problem, contributing to widespread barriers to patient safety. The word “communication” means to share or make common. In the literature, two communication paradigms dominate: (1) communication as a transactional process responsible for information exchange, and (2) communication as a transformational process responsible for causing change. Implementation science has focused on information exchange attributes while largely ignoring transformational attributes of communication. In this paper, we debate the merits of encompassing both paradigms. DISCUSSION: We conducted a two-staged literature review searching for the concept of communication in implementation science to understand how communication is conceptualized. Twenty-seven theories, models, or frameworks were identified; only Rogers’ Diffusion of Innovations theory provides a definition of communication and includes both communication paradigms. Most models (notable exceptions include Diffusion of Innovations, The Ottawa Model of Research Use, and Normalization Process Theory) describe communication as a transactional process. But thinking of communication solely as information transfer or exchange misrepresents reality. We recommend that implementation science theories (1) propose and test the concept of shared understanding when describing communication, (2) acknowledge that communication is multi-layered, identify at least a few layers, and posit how identified layers might affect the development of shared understanding, (3) acknowledge that communication occurs in a social context, providing a frame of reference for both individuals and groups, (4) acknowledge the unpredictability of communication (and healthcare processes in general), and (5) engage with and draw on work done by communication theorists. Implementation science literature has conceptualized communication as a transactional process (when communication has been mentioned at all), thereby ignoring a key contributor to implementation intervention success. When conceptualized as a transformational process, the focus of communication moves to shared understanding and is grounded in human interactions and the way we go about constructing knowledge. Instead of hiding in plain sight, we suggest explicitly acknowledging the role that communication plays in our implementation efforts. By using both paradigms, we can investigate when communication facilitates implementation, when it does not, and how to improve it so that our implementation and clinical interventions are embraced by clinicians and patients alike.
New Article by Dr. Greta Cummings
Leaders’ Experiences and Perceptions Implementing Activity-Based Funding and Pay-for-Performance Hospital Funding Models: A Systematic Review
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Baxter PE, Hewko SJ, Pfaff KA, Cleghorn L, Cunningham BJ, Elston D, et al.
Providing cost-effective, accessible, high quality patient care is a challenge to governments and health care delivery systems across the globe. In response to this challenge, two types of hospital funding models have been widely implemented: 1) activity-based funding (ABF) and 2) pay-for-performance (P4P). Although health care leaders play a critical role in the implementation of these funding models, to date their perspectives have not been systematically examined. Purpose The purpose of this systematic review was to gain a better understanding of the experiences of health care leaders implementing hospital funding reforms within Organisation for Economic Cooperation and Development countries. Methods We searched literature from 1982-2013 using: Medline, EMBASE, CINAHL, Academic Search Complete, Academic Search Elite, and Business Source Complete. Two independent reviewers screened titles, abstracts and full texts using predefined criteria. We included 2 mixed methods and 12 qualitative studies. Thematic analysis was used in synthesizing results. Results Five common themes and multiple subthemes emerged. Themes include: pre-requisites for success, perceived benefits, barriers/challenges, unintended consequences, and leader recommendations. Conclusions Irrespective of which type of hospital funding reform was implemented, health care leaders described a complex process requiring the following: organizational commitment; adequate infrastructure; human, financial and information technology resources; change champions and a personal commitment to quality care.
Best practices in the management of behavioural and psychological symptoms of dementia in residents of long-term care facilities in Alberta
The Health Technology Assessment Unit, University of Calgary, 2014
Best practices in the management of behavioural and psychological symptoms of dementia (BPSD) is a heterogeneous set of complex symptoms that may require a multifaceted approach to their successful management. This evidence synthesis generally supports the recommendations within the BC guidelines. Non-pharmacological interventions are likely a viable first-line of treatment for managing BPSD with 21/40 RCTs reporting improved outcomes, and no studies reporting worsening behavior or adverse events. The evidence to support alternative pharmacological treatments such as antidepressants, cholinesterase inhibitors, mood stabilizers, anti-epileptics, benzodiazepines, and sedatives is limited. There are a small number of studies of low to moderate quality. However, these studies generally support that alternative pharmacological treatments have a similar impact on BPSD outcomes and similar short-term safety profiles. Evidence assessing modifications to the built environment to manage BPSD show small improvements or no difference in the frequency and/or severity of BPSD. The cost-effectiveness of the above mentioned alternatives to antipsychotics has not been formally assessed.
Grants & Awards
CIHR Project Scheme: 2016 1st Live Pilot
Registration Deadline: 18 January 2016
The Project Scheme is designed to capture ideas with the greatest potential to advance health-related knowledge, health research, health care, health systems, and/or health outcomes. It supports projects with a specific purpose and a defined endpoint. The best ideas may stem from new, incremental, innovative, and/or high-risk lines of inquiry or knowledge translation approaches.
The Project Scheme is expected to:
– Support a diverse portfolio of health-related research and knowledge translation projects at any stage, from discovery to application, including commercialization;
– Contribute to the creation and use of health-related knowledge;
– Promote relevant collaborations across disciplines, professions, and sectors.
*Partnered/Integrated Knowledge Translation (iKT) projects: Special consideration
CIHR Foundation Scheme: 2015 2nd Live Pilot
Registration Deadline: 27 July
The Foundation Scheme is designed to contribute to a sustainable foundation of new and established health research leaders, by providing long-term support for the pursuit of innovative and high-impact research programs.
The Foundation Scheme is expected to:
– Support a broad base of health research leaders across all career stages, areas, and health-related disciplines with a demonstrable track record of excellence and impact in their field of study;
– Develop and maintain Canadian capacity in health research and other related fields;
– Provide research leaders with the flexibility to pursue novel and innovative lines of inquiry;
– Contribute to the creation and application of health-related knowledge through a wide range of research and/or knowledge translation activities, including relevant collaborations.
*New and early-career investigators: Special consideration
On-going collaborative priority-setting for research activity: a method of capacity building to reduce the research-practice translational gap
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Cooke J, Ariss S, Smith C, Read J.
Health research policy and systems 2015 May 7;13(1):25
International policy suggests that collaborative priority setting (CPS) between researchers and end users of research should shape the research agenda, and can increase capacity to address the research-practice translational gap. There is limited research evidence to guide how this should be done to meet the needs of dynamic healthcare systems. One-off priority setting events and time-lag between decision and action prove problematic. This study illustrates the use of CPS in a UK research collaboration called Collaboration and Leadership in Applied Health Research and Care (CLAHRC). METHODS: Data were collected from a north of England CLAHRC through semi-structured interviews with 28 interviewees and a workshop of key stakeholders (n = 21) including academics, NHS clinicians, and managers. Documentary analysis of internal reports and CLAHRC annual reports for the first two and half years was also undertaken. These data were thematically coded. RESULTS: Methods of CPS linked to the developmental phase of the CLAHRC. Early methods included pre-existing historical partnerships with on-going dialogue. Later, new platforms for on-going discussions were formed. Consensus techniques with staged project development were also used. All methods demonstrated actual or potential change in practice and services. Impact was enabled through the flexibility of research and implementation work streams; ‘matched’ funding arrangements to support alignment of priorities in partner organisations; the size of the collaboration offering a resource to meet project needs; and the length of the programme providing stability and long term relationships. Difficulties included tensions between being responsive to priorities and the possibility of ‘drift’ within project work, between academics and practice, and between service providers and commissioners in the health services. Providing protected ‘matched’ time proved difficult for some NHS managers, which put increasing work pressure on them. CPS is more time consuming than traditional approaches to project development. CONCLUSIONS: CPS can produce needs-led projects that are bedded in services using a variety of methods. Contributing factors for effective CPS include flexibility in use and type of available resources, flexible work plans, and responsive leadership. The CLAHRC model provides a translational infrastructure that enables CPS that can impact on healthcare systems.
Stroke unit Nurse Managers’ views of individual and organizational factors liable to influence evidence-based practice: A survey.
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Drury P, McInnes E, Hardy J, Dale S, Middleton S.
International journal of nursing practice 2015 May 5
The uptake of evidence into practice may be impeded or facilitated by individual and organizational factors within the local context. This study investigated Nurse Managers of New South Wales, Australia, stroke units (n = 19) in their views on: leadership ability (measured by the Leadership Practices Inventory), organizational learning (measured by the Organizational Learning Survey), attitudes and beliefs towards evidence-based practice (EBP) and readiness for change. Overall Nurse Managers reported high-level leadership skills and a culture of learning. Nurse Managers’ attitude towards EBP was positive, although nursing colleague’s attitudes were perceived as less positive. Nurse Managers agreed that implementing evidence in practice places additional demands on staff; and almost half (n = 9, 47%) reported that resources were not available for evidence implementation. The findings indicate that key persons responsible for evidence implementation are not allocated sufficient time to coordinate and implement guidelines into practice. The findings suggest that barriers to evidence uptake, including insufficient resources and time constraints, identified by Nurse Managers in this study are not likely to be unique to stroke units. Furthermore, Nurse Managers may be unable to address these organizational barriers (i.e. lack of resources) and thus provide all the components necessary to implement EBP. © 2015 Wiley Publishing Asia Pty Ltd.
Going above and beyond for implementation: the development and validity testing of the Implementation Citizenship Behavior Scale (ICBS).
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Ehrhart MG, Aarons GA, Farahnak LR.
Implementation science 2015 May 7;10(1):65
In line with recent research on the role of the inner context of organizations in implementation effectiveness, this study extends research on organizational citizenship behavior (OCB) to the domain of evidence-based practice (EBP) implementation. OCB encompasses those behaviors that go beyond what is required for a given job that contribute to greater organizational effectiveness. The goal of this study was to develop and test a measure of implementation citizenship behavior (ICB) or those behaviors that employees perform that go above and beyond what is required in order to support EBP implementation. METHODS: The primary participants were 68 supervisors from ten mental health agencies throughout California. Items measuring ICB were developed based on past research on OCB and in consultation with experts on EBP implementation in mental health settings. Supervisors rated 357 of their subordinates on ICB and implementation success. In addition, 292 of the subordinates provided data on self-rated performance, attitudes towards EBPs, work experience, and full-time status. The supervisor sample was randomly split, with half used for exploratory factor analyses and the other half for confirmatory factor analyses. The entire sample of supervisors and subordinates was utilized for analyses assessing the reliability and construct validity of the measure. RESULTS: Exploratory factor analyses supported the proposed two-factor structure of the Implementation Citizenship Behavior Scale (ICBS): (1) Helping Others and (2) Keeping Informed. Confirmatory factor analyses with the other half of the sample supported the factor structure. Additional analyses supported the reliability and construct validity for the ICBS. CONCLUSIONS: The ICBS is a pragmatic brief measure (six items) that captures critical behaviors employees perform to go above and beyond the call of duty to support EBP implementation, including helping their fellow employees on implementation-related activities and keeping informed about issues related to EBP and implementation efforts. The ICBS can be used by researchers to better understand the outcomes of improved organizational support for implementation (i.e., implementation climate) and the proximal predictors of implementation effectiveness. The ICBS can also provide insight for organizations, practitioners, and managers by focusing on key employee behaviors that should increase the probability of implementation success.
An organizational readiness intervention and randomized controlled trial to test strategies for implementing substance use disorder treatment into primary care: SUMMIT study protocol.
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Ober AJ, Watkins KE, Hunter SB, Lamp K, Lind M, Setodji CM.
Implementation science 2015 May 8;10(1):66-015-0256-7
Millions of people who need treatment for substance use disorders (SUD) do not receive it. Evidence-based practices for treating SUD exist, and some are appropriate for delivery outside of specialty care settings. Primary care is an opportune setting in which to deliver SUD treatment because many individuals see their primary care providers at least once a year. Further, the Patient Protection and Affordable Care Act (PPACA) increases coverage for SUD treatment and is increasing the number of individuals seeking primary care services. In this article, we present the protocol for a study testing the effects of an organizational readiness and service delivery intervention on increasing the uptake of SUD treatment in primary care and on patient outcomes. METHODS/DESIGN: In a randomized controlled trial, we test the combined effects of an organizational readiness intervention consisting of implementation tools and activities and an integrated collaborative care service delivery intervention based on the Chronic Care Model on service system (patient-centered care, utilization of substance use disorder treatment, utilization of health care services and adoption and sustainability of evidence-based practices) and patient (substance use, consequences of use, health and mental health, and satisfaction with care) outcomes. We also use a repeated measures design to test organizational changes throughout the study, such as acceptability, appropriateness and feasibility of the practices to providers, and provider intention to adopt the practices. We use provider focus groups, provider and patient surveys, and administrative data to measure outcomes. DISCUSSION: The present study responds to critical gaps in health care services for people with substance use disorders, including the need for greater access to SUD treatment and greater uptake of evidence-based practices in primary care. We designed a multi-level study that combines implementation tools to increase organizational readiness to adopt and sustain evidence-based practices (EBPs) and tests the effectiveness of a service delivery intervention on service system and patient outcomes related to SUD services. TRIAL REGISTRATION: Current controlled trials: NCT01810159.
Successful knowledge translation intervention in long-term care: final results from the vitamin D and osteoporosis study (ViDOS) pilot cluster randomized controlled trial.
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Kennedy CC, Ioannidis G, Thabane L, Adachi JD, Marr S, Giangregorio LM, et al.
Trials 2015 May 12;16(1):214-015-0720-3
Few studies have systematically examined whether knowledge translation (KT) strategies can be successfully implemented within the long-term care (LTC) setting. In this study, we examined the effectiveness of a multifaceted, interdisciplinary KT intervention for improving the prescribing of vitamin D, calcium and osteoporosis medications over 12-months. METHODS: We conducted a pilot, cluster randomized controlled trial in 40 LTC homes (21 control; 19 intervention) in Ontario, Canada. LTC homes were eligible if they had more than one prescribing physician and received services from a large pharmacy provider. Participants were interdisciplinary care teams (physicians, nurses, consultant pharmacists, and other staff) who met quarterly. Intervention homes participated in three educational meetings over 12 months, including a standardized presentation led by expert opinion leaders, action planning for quality improvement, and audit and feedback review. Control homes did not receive any additional intervention. Resident-level prescribing and clinical outcomes were collected from the pharmacy database; data collectors and analysts were blinded. In addition to feasibility measures, study outcomes were the proportion of residents taking vitamin D (≥800 IU/daily; primary), calcium ≥500 mg/day and osteoporosis medications (high-risk residents) over 12 months. Data were analyzed using the generalized estimating equations technique accounting for clustering within the LTC homes. RESULTS: At baseline, 5,478 residents, mean age 84.4 (standard deviation (SD) 10.9), 71% female, resided in 40 LTC homes, mean size = 137 beds (SD 76.7). In the intention-to-treat analysis (21 control; 19 intervention clusters), the intervention resulted in a significantly greater increase in prescribing from baseline to 12 months between intervention versus control arms for vitamin D (odds ratio (OR) 1.82, 95% confidence interval (CI): 1.12, 2.96) and calcium (OR 1.33, 95% CI: 1.01, 1.74), but not for osteoporosis medications (OR 1.17, 95% CI: 0.91, 1.51). In secondary analyses, excluding seven nonparticipating intervention homes, ORs were 3.06 (95% CI: 2.18, 4.29), 1.57 (95% CI: 1.12, 2.21), 1.20 (95% CI: 0.90, 1.60) for vitamin D, calcium and osteoporosis medications, respectively. CONCLUSIONS: Our KT intervention significantly improved the prescribing of vitamin D and calcium and is a model that could potentially be applied to other areas requiring quality improvement. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01398527
Key components of external facilitation in an acute stroke quality improvement collaborative in the Veterans Health Administration
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Bidassie B, Williams LS, Woodward-Hagg H, Matthias MS, Damush TM.
Implementation science 2015 May 14;10(1):69
Facilitation is a key component for successful implementation in several implementation frameworks; however, there is a paucity of research specifying this component. As part of a stroke quality improvement intervention in the Veterans Health Administration (VHA), facilitation plus data feedback was compared to data feedback alone in 11 VA medical facilities. The objective of this study was to elucidate upon the facilitation components of the stroke quality improvement. Methods We conducted a secondary evaluation of external facilitation using semi-structured interviews. Five facilitators and two program directors were interviewed. Qualitative analysis was performed on transcribed interviews to gain an understanding of the role and activities of external facilitators during the on-site and telephone facilitation. Quantitative frequencies were calculated from the self-reported time spent in facilitation tasks by facilitators. Results The external facilitators saw their role as empowering the clinical teams to take ownership of the process changes at the clinical sites to improve their performance quality. To fulfill this role, they reported engaging in a number of core tasks during telephone and on-site visits including: assessing the context in which the teams were currently operating, guiding the clinical teams through their planned changes and use of process improvement tools, identifying resources and making referrals, holding teams accountable for plan implementation with on-site visits, and providing support and encouragement to the teams. Time spent in facilitation activities changed across time from guiding change (early) to supporting efforts made by the clinical teams (later). Facilitation activity transitioned to more monitoring, problem solving, and intentional work to hand over the clinical improvement process to the site teams with the coach’s role being increasingly that of a more distant consultant. Overall, this study demonstrated that external facilitation is not an event but rather a process where relationships and responsibilities evolve over time. Conclusions This study shows that external facilitation involves core elements related to communication, relationship building, methods training, monitoring performance over time, and facilitating team-based problem solving. Importantly, this work demonstrates the fluid nature of external facilitation over time, as teams learn, grow, change, and experience changing contexts.
Health Care Administration and Organization
Provision of NHS generalist and specialist services to care homes in England: review of surveys.
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Iliffe S, Davies SL, Gordon AL, Schneider J, Dening T, Bowman C, et al.
Primary health care research & development 2015 May 5:1-16
The number of beds in care homes (with and without nurses) in the United Kingdom is three times greater than the number of beds in National Health Service (NHS) hospitals. Care homes are predominantly owned by a range of commercial, not-for-profit or charitable providers and their residents have high levels of disability, frailty and co-morbidity. NHS support for care home residents is very variable, and it is unclear what models of clinical support work and are cost-effective. OBJECTIVES: To critically evaluate how the NHS works with care homes. METHODS: A review of surveys of NHS services provided to care homes that had been completed since 2008. It included published national surveys, local surveys commissioned by Primary Care organisations, studies from charities and academic centres, grey literature identified across the nine government regions, and information from care home, primary care and other research networks. Data extraction captured forms of NHS service provision for care homes in England in terms of frequency, location, focus and purpose. RESULTS: Five surveys focused primarily on general practitioner services, and 10 on specialist services to care home. Working relationships between the NHS and care homes lack structure and purpose and have generally evolved locally. There are wide variations in provision of both generalist and specialist healthcare services to care homes. Larger care home chains may take a systematic approach to both organising access to NHS generalist and specialist services, and to supplementing gaps with in-house provision. Access to dental care for care home residents appears to be particularly deficient. CONCLUSIONS: Historical differences in innovation and provision of NHS services, the complexities of collaborating across different sectors (private and public, health and social care, general and mental health), and variable levels of organisation of care homes, all lead to persistent and embedded inequity in the distribution of NHS resources to this population. Clinical commissioners seeking to improve the quality of care of care home residents need to consider how best to provide fair access to health care for older people living in a care home, and to establish a specification for service delivery to this vulnerable population.
Affective Organizational Commitment in Swiss Nursing Homes: A Cross-Sectional Study
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Graf E, Cignacco E, Zimmermann K, Zúñiga F.
The Gerontologist 2015 05/01
This substudy of the Swiss Nursing Homes Human Resources Project (SHURP) explored the relationships between affective organizational commitment (AOC) levels and organizational, situational, and care personnel characteristics, and between AOC and care personnel outcomes. Designs and Methods: SHURP was a representative national cross-sectional study in 163 Swiss nursing homes. Its data sources were: (a) a care personnel questionnaire, (b) a facility questionnaire, (c) a unit questionnaire, and (d) administrative resident data. Generalized estimating equations (GEEs) were applied to examine AOC’s relationships with selected antecedents and care personnel outcomes. Results: Data were collected from 5,323 care personnel in 163 nursing homes (return rate: 76%). On a scale from 1 to 5, the mean level of AOC was 3.86 (standard deviation = 0.81). Variations in AOC regarding care personnel characteristics (age, education, and experience in nursing home) and organizational characteristics (size, profit status) were statistically significant with minimal effect sizes. The main factors positively related to AOC were leadership, job satisfaction, quality of care, and collaboration with the nursing home director. Care personnel outcomes significantly related to higher AOC were reduced intention to leave, health complaints, presenteeism, and absenteeism. Implications: As leadership is a crucial factor of AOC, its development might improve care personnel outcomes such as intention to leave or absenteeism.
Relationships, expertise, incentives, and governance: supporting care home residents’ access to health care. An interview study from England.
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Goodman C, Davies SL, Gordon AL, Meyer J, Dening T, Gladman JR, et al.
Journal of the American Medical Directors Association 2015 May 1;16(5):427-432
To explore what commissioners of care, regulators, providers, and care home residents in England identify as the key mechanisms or components of different service delivery models that support the provision of National Health Service (NHS) provision to independent care homes. METHODS: Qualitative, semistructured interviews with a purposive sample of people with direct experience of commissioning, providing, and regulating health care provision in care homes and care home residents. Data from interviews were augmented by a secondary analysis of previous interviews with care home residents on their personal experience of and priorities for access to health care. Analysis was framed by the assumptions of realist evaluation and drew on the constant comparative method to identify key themes about what is required to achieve quality health care provision to care homes and resident health. RESULTS: Participants identified 3 overlapping approaches to the provision of NHS that they believed supported access to health care for older people in care homes: (1) Investment in relational working that fostered continuity and shared learning between visiting NHS staff and care home staff, (2) the provision of age-appropriate clinical services, and (3) governance arrangements that used contractual and financial incentives to specify a minimum service that care homes should receive. CONCLUSION: The 3 approaches, and how they were typified as working, provide a rich picture of the stakeholder perspectives and the underlying assumptions about how service delivery models should work with care homes. The findings inform how evidence on effective working in care homes will be interrogated to identify how different approaches, or specifically key elements of those approaches, achieve different health-related outcomes in different situations for residents and associated health and social care organizations. Copyright © 2015 AMDA
Foreign-born care givers in Washington state nursing homes: characteristics, associations with quality of care, and views of administrators.
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Acker K, Pletz AM, Katz A, Hagopian A.
Journal of aging and health 2015 Jun;27(4):650-669
Following national trends, Washington State relies heavily on foreign-born workers to provide long-term care. Our study assesses state nursing facility characteristics, quality ratings, and the views of facility administrators about the implications of an increasing number of foreign-born employees. METHODS: We used independently available data to supplement a survey of nursing home administrators. RESULTS: Nearly half of the administrators reported difficulty hiring U.S.-born job applicants. Three in four administrators reported problems related to language differences, and just more than a third reported challenges related to cultural and/or religious differences. Nonetheless, the proportion of foreign-born employees was positively associated with independent facility quality ratings. Almost half of the administrators reported discrimination by patients/clients toward their foreign-born workers. Quality ratings were negatively associated with for-profit, chain, or multi-ownership status. DISCUSSION: The proportion of foreign-born employees in nursing facilities may be associated with improved performance. © The Author(s) 2014.
Cluster Randomized Controlled Trial of An Aged Care Specific Leadership and Management Program to Improve Work Environment, Staff Turnover, and Care Quality.
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Jeon YH, Simpson JM, Li Z, Cunich MM, Thomas TH, Chenoweth L, et al.
Journal of the American Medical Directors Association 2015 May 8
To evaluate the effectiveness of a leadership and management program in aged care. DESIGN: Double-blind cluster randomized controlled trial. SETTING: Twelve residential and community-aged care sites in Australia. PARTICIPANTS: All care staff employed for 6 months or longer at the aged care sites were invited to participate in the surveys at 3 time points: baseline (time 1), 9 months from baseline (time 2), and 9 months after completion of time 2 (time 3) from 2011 to 2013. At each time point, at least 500 care staff completed a survey. At baseline (N = 503) the largest age group was 45 to 54 years (37%), and the majority of care staff were born in Australia (70%), spoke English (94%), and had at least completed secondary education (57%). INTERVENTION: A 12-month Clinical Leadership in Aged Care (CLiAC) program for middle managers, which aimed to further develop their leadership and management skills in creating positive workplace relationships and in enabling person-centered, evidence-based care. MAIN OUTCOME MEASURES: The primary outcomes were care staff ratings of the work environment, care quality and safety, and staff turnover rates. Secondary outcomes were care staff’s intention to leave their employer and profession, workplace stress, job satisfaction, and cost-effectiveness of implementing the program. Absenteeism was excluded due to difficulty in obtaining reliable data. Managers’ self-rated knowledge and skills in leadership and management are not included in this article, which focuses on care staff perceptions only. RESULTS: At 6 months after its completion, the CLiAC program was effective in improving care staff’s perception of management support [mean difference 0.61, 95% confidence interval (CI) 0.04-1.18; P = .04]. Compared with the control sites, care staff at the intervention sites perceived their managers’ leadership styles as more transformational (mean difference 0.30, 95% CI 0.09-0.51; P = .005), transactional (mean difference 0.22, 95% CI 0.05-0.39; P = .01), and less passive avoidant (mean difference 0.30, 95% CI 0.07-0.52; P = .01); and were rated higher on the overall leadership outcomes (mean difference 0.35, 95% CI 0.13-0.56; P = .001) as well as individual manager outcomes: extra effort (P = .004), effectiveness (P = .001), and satisfaction (P = .01). There was no evidence that CLiAC was effective in reducing staff turnover, or improving patient care quality and safety. CONCLUSIONS: While the CLiAC leadership program had direct impact on the primary process outcomes (management support, leadership actions, behaviors, and effects), this was insufficient to change the systems required to support care service quality and client safety. Nevertheless, the findings send a strong message that leadership and management skills in aged care managers can be nurtured and used to change leadership behaviors at a reasonable cost. Copyright © 2015 AMDA
Health Care Innovation and Quality Assurance
I-RREACH: an engagement and assessment tool for improving implementation readiness of researchers, organizations and communities in complex interventions.
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Maar M, Yeates K, Barron M, Hua D, Liu P, Lum-Kwong MM, et al.
Implementation science 2015 May 4;10(1):64
Non-communicable chronic diseases are the leading causes of mortality globally, and nearly 80% of these deaths occur in low- and middle-income countries (LMICs). In high-income countries (HICs), inequitable distribution of resources affects poorer and otherwise disadvantaged groups including Aboriginal peoples. Cardiovascular mortality in high-income countries has recently begun to fall; however, these improvements are not realized among citizens in LMICs or those subgroups in high-income countries who are disadvantaged in the social determinants of health including Aboriginal people. It is critical to develop multi-faceted, affordable and realistic health interventions in collaboration with groups who experience health inequalities. Based on community-based participatory research (CBPR), we aimed to develop implementation tools to guide complex interventions to ensure that health gains can be realized in low-resource environments. METHODS: We developed the I-RREACH (Intervention and Research Readiness Engagement and Assessment of Community Health Care) tool to guide implementation of interventions in low-resource environments. We employed CBPR and a consensus methodology to (1) develop the theoretical basis of the tool and (2) to identify key implementation factor domains; then, we (3) collected participant evaluation data to validate the tool during implementation. RESULTS: The I-RREACH tool was successfully developed using a community-based consensus method and is rooted in participatory principles, equalizing the importance of the knowledge and perspectives of researchers and community stakeholders while encouraging respectful dialogue. The I-RREACH tool consists of three phases: fact finding, stakeholder dialogue and community member/ patient dialogue. The evaluation for our first implementation of I-RREACH by participants was overwhelmingly positive, with 95% or more of participants indicating comfort with and support for the process and the dialogue it creates. CONCLUSIONS: The I-RREACH tool was designed to (1) pinpoint key domains required for dialogue between the community and the research team to facilitate implementation of complex health interventions and research projects and (2) to identify existing strengths and areas requiring further development for effective implementation. I-RREACH has been found to be easily adaptable to diverse geographical and cultural settings and can be further adapted to other complex interventions. Further research should include the potential use of the I-RREACH tool in the development of blue prints for scale-up of successful interventions, particularly in low-resource environments.
What works to prevent falls in older adults dwelling in long term care facilities and hospitals? An umbrella review of meta-analyses of randomised controlled trials.
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Stubbs B, Denkinger MD, Brefka S, Dallmeier D.
Maturitas 2015 Apr 14
Preventing falls in long term care facilities (LTCF) and hospitals is an international priority. Many interventions have been investigated and summarised in meta-analyses (MA) and there is a need to synthesise the top of the hierarchy of evidence in one place. Therefore we conducted an umbrella review of MA of randomised controlled trials (RCTs) of falls prevention interventions LTCF and hospitals. Two independent reviewers searched major electronic databases from inception till October 2014 for MA containing ≥3 RCTs investigating any intervention to prevent falls in LTCF or hospitals in older adults aged ≥60 years. Methodological quality was assessed by the AMSTAR tool and data were narratively synthesised. The methodological quality of the MA was moderate to high across the 10 included MA. Nine MA provided data for LTCF and only two considered hospital settings. Only one MA defined a fall and two reported adverse events (although minor). Consistent evidence suggests that multifactorial interventions reduce falls (including the rate, risk and odds of falling) in LTCF and hospitals. Inconsistent evidence exists for exercise and vitamin D as single interventions in LTCF, whilst no MA has investigated this in hospitals. No evidence exists for hip protectors and medication review on falls in LTCF. In conclusion, multifactorial interventions appear to be the most effective interventions to prevent falls in LTCF and hospital settings. This is not without limitations and more high quality RCTs are needed in hospital settings in particular. Future RCTs and MA should clearly report adverse events. Copyright © 2015 Elsevier Ireland Ltd.
Medicare and Medicaid Reimbursement Rates for Nursing Homes Motivate Select Culture Change Practices But Not Comprehensive Culture Change.
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Lepore MJ, Shield RR, Looze J, Tyler D, Mor V, Miller SC.
Journal of aging & social policy 2015 May 5
Components of nursing home (NH) culture change include resident-centeredness, empowerment, and home likeness, but practices reflective of these components may be found in both traditional and “culture change” NHs. We use mixed methods to examine the presence of culture change practices in the context of a NH’s payer sources. Qualitative data show how higher pay from Medicare versus Medicaid influences implementation of select culture change practices; and, quantitative data show NHs with higher proportions of Medicare residents have significantly higher (measured) environmental culture change implementation. Findings indicate that heightened coordination of Medicare and Medicaid could influence NH implementation of reform practices.
Nursing home 5-star rating system exacerbates disparities in quality, by payer source.
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Tamara Konetzka R, Grabowski DC, Perraillon MC, Werner RM.
Health affairs (Project Hope) 2015 May 1;34(5):819-827
Market-based reforms in health care, such as public reporting of quality, may inadvertently exacerbate disparities. We examined how the Centers for Medicare and Medicare Services’ five-star rating system for nursing homes has affected residents who are dually enrolled in Medicare and Medicaid (“dual eligibles”), a particularly vulnerable and disadvantaged population. Specifically, we assessed the extent to which dual eligibles and non-dual eligibles avoided the lowest-rated nursing homes and chose the highest-rated homes once the five-star rating system began, in late 2008. We found that both populations resided in better-quality homes over time but that by 2010 the increased likelihood of choosing the highest-rated homes was substantially smaller for dual eligibles than for non-dual eligibles. Thus, the gap in quality, as measured by a nursing home’s star rating, grew over time. Furthermore, we found that the benefit of the five-star system to dual eligibles was largely due to providers’ improving their ratings, not to consumers’ choosing different providers. We present evidence suggesting that supply constraints play a role in limiting dual eligibles’ responses to quality ratings, since high-quality providers tend to be located close to relatively affluent areas. Increases in Medicaid payment rates for nursing home services may be the only long-term solution.
Experiences of nursing staff using dementia-specific case conferences in nursing homes.
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Holle D, Kruger C, Halek M, Sirsch E, Bartholomeyczik S.
American Journal of Alzheimer’s Disease and Other Dementias 2015 May;30(3):228-237
Dementia specific-case conferences with the Innovative dementia oriented assessment tool (CC-IdA) could be an important tool with which to analyze and manage challenging behavior. The study gives an insight into nursing staff’ experiences using CC-IdA in dementia care. METHODS: Qualitative interviews were conducted with 18 nursing teams from 12 nursing homes alongside a quasi-experimental study. In addition, observational field notes were taken. Interviews and observational field notes were analyzed using the thematic content analysis. RESULTS: CC-IdA contributed to a reflective handling of challenging behavior, to changes in the communication with residents and to the identification of potentially triggers of challenging behavior. Factors influencing the implementation of CC-IdA were among others a lack of moderation skills, limited knowledge of dementia, a lack of biographical information and a lack of involvement by other professionals. CONCLUSIONS: CC-IdA represents an important tool in the management of challenging behavior of people with dementia. For the successful implementation of these case conferences, both structural and personal resources are needed. © The Author(s) 2014.
Impact of the organisational culture on primary care staff members’ intention to engage in research and development.
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Mortenius H, Baigi A, Palm L, Fridlund B, Bjorkelund C, Hedberg B.
Journal of health organization and management 2015;29(2):234-251
The purpose of this paper is to understand how organisational culture influences the intentions of primary care staff members (PCSM) to engage in research and development (R&D). Design/methodology/approach – The participants (n=30) were PCSM employed in a care centre in south-western Sweden. The study had an observational design with an ethnographic approach. The data were collected by means of observations, interviews and analysis of documents. Findings – The results revealed the perceptions of PCSM in two domains, research and clinical practice, both of which existed at three different cultural levels: visible (structures and policy), semi-visible (norms and values) and invisible (taken-for-granted attitudes). Research limitations/implications – It is difficult to conduct a purely objective ethnographic study because the investigation is controlled by its context. However, it is necessary to highlight and discuss the invisible level to improve understanding of negative attitudes and preconceptions related to the implementation of R&D in the clinical setting. Practical implications – By highlighting the invisible level of culture, the management of an organisation has the opportunity to initiate discussion of issues related to concealed norms and values as well as attitudes towards new thinking and change in the primary health context. Originality/value – This paper is one of the very few studies to investigate the influence of organisational culture on the intentions of PCSM to engage in R&D.
Person-centredness in direct care workers caring for residents with dementia: Effects of a psycho-educational intervention.
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Barbosa A, Nolan M, Sousa L, Figueiredo D.
Dementia (London, England) 2015 May 12
This study assessed the effects of a psycho-educational intervention on direct care workers’ person-centredness during morning care to residents with dementia. A controlled pretest-posttest study was conducted in four aged-care facilities with 56 direct care workers (female, mean age 44.72 ± 9.02). Two experimental facilities received a psycho-educational intervention comprising person-centred care competences and stress management skills; control facilities received an education-only intervention, without stress support. In total, 112 video-recorded morning care sessions were coded using the Global Behaviour Scale. Both groups reported significantly higher scores on eight of 11 items of the Global Behaviour Scale and on the Global Behaviour Scale total score at posttest (F=10.59; p=0.02). Global Behaviour Scale total score improvements were higher for the experimental group, with values close to significance (F=3.90; p=0.054). The findings suggest that a psycho-educational intervention may increase care workers’ person-centredness. Further research is needed to explore the long-term sustainability and extent of its benefits on workers and residents. © The Author(s) 2015
Increasing enjoyable activities to treat depression in nursing home residents with dementia: A pilot study
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Dementia (London, England) 2015 May 12
This pilot study aimed to assess the feasibility and acceptability of a behavioral activities intervention (BE-ACTIV) in Australian nursing homes. BE-ACTIV was developed by researchers at the University of Louisville, USA, to improve mood and quality of life (QOL) in nursing home residents with mild to moderate dementia. An eight-week trial was conducted and 10 residents with mild to moderate dementia received the BE-ACTIV intervention while eight residents received a Walking and Talking intervention. Measures of depression (GDS-12R) and QOL (QOL-AD-NH) were administered prior to and following the interventions. Qualitative feedback indicated residents benefited from BE-ACTIV, evident by improved mood, although no statistically significant treatment effect was found. Moreover, the intervention was found to be feasible and acceptable to Australian nursing home staff and our findings highlight the importance of individualizing activities for people with dementia, of which 1:1 staff attention was a key component. © The Author(s)
Computerised clinical decision support systems to improve medication safety in long-term care homes: a systematic review.
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BMJ open 2015 May 12;5(5):e006539-2014-006539
Computerised clinical decision support systems (CCDSS) are used to improve the quality of care in various healthcare settings. This systematic review evaluated the impact of CCDSS on improving medication safety in long-term care homes (LTC). Medication safety in older populations is an important health concern as inappropriate medication use can elevate the risk of potentially severe outcomes (ie, adverse drug reactions, ADR). With an increasing ageing population, greater use of LTC by the growing ageing population and increasing number of medication-related health issues in LTC, strategies to improve medication safety are essential. METHODS: Databases searched included MEDLINE, EMBASE, Scopus and Cochrane Library. Three groups of keywords were combined: those relating to LTC, medication safety and CCDSS. One reviewer undertook screening and quality assessment. RESULTS: Overall findings suggest that CCDSS in LTC improved the quality of prescribing decisions (ie, appropriate medication orders), detected ADR, triggered warning messages (ie, related to central nervous system side effects, drug-associated constipation, renal insufficiency) and reduced injury risk among older adults. CONCLUSIONS: CCDSS have received little attention in LTC, as attested by the limited published literature. With an increasing ageing population, greater use of LTC by the ageing population and increased workload for health professionals, merely relying on physicians’ judgement on medication safety would not be sufficient. CCDSS to improve medication safety and enhance the quality of prescribing decisions are essential. Analysis of review findings indicates that CCDSS are beneficial, effective and have potential to improve medication safety in LTC; however, the use of CCDSS in LTC is scarce. Careful assessment on the impact of CCDSS on medication safety and further modifications to existing CCDSS are recommended for wider acceptance. Due to scant evidence in the current literature, further research on implementation and effectiveness of CCDSS is required.
Pain Management in Long-Term Care Communities: A Quality Improvement Initiative.
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Reid C, O’Neil KW, Dancy J, Berry CA, Stowell SA.
The annals of long-term care 2015 Feb;23(2)
Pain is underrecognized and undertreated in the long-term care (LTC) setting. To improve the management of pain for LTC residents, the authors implemented a quality improvement (QI) initiative at one LTC facility. They conducted a needs assessment to identify areas for improvement and designed a 2-hour educational workshop for facility staff and local clinicians. Participants were asked to complete a survey before and after the workshop, which showed significant improvement in their knowledge of pain management and confidence in their ability to recognize and manage residents’ pain. To measure the effectiveness of the QI initiative, the authors performed a chart review at baseline and at 3 and 8 months after the workshop and evaluated relevant indicators of adequate pain assessment and management. The post-workshop chart reviews showed significant improvement in how consistently employees documented pain characteristics (ie, location, intensity, duration) in resident charts and in their use of targeted pain assessments for residents with cognitive dysfunction. The proportion of charts that included a documented plan for pain assessment was high at baseline and remained stable throughout the study. Overall, the findings suggest a QI initiative is an effective way to improve pain care practices in the LTC setting.
The effect of using high facilitation when implementing the Gold Standards Framework in Care Homes programme: a cluster randomised controlled trial.
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Kinley J, Stone L, Dewey M, Levy J, Stewart R, McCrone P, et al.
Palliative medicine 2014 Oct;28(9):1099-1109
The provision of quality end-of-life care is increasingly on the national agenda in many countries. In the United Kingdom, the Gold Standards Framework for Care Homes programme has been promoted as a national framework for improving end-of-life care. While its implementation is recommended, there are no national guidelines for facilitators to follow to undertake this role. AIM: It was hypothesised that action learning alongside high facilitation when implementing the Gold Standards Framework for Care Homes programme will result in a reduced proportion of hospital deaths for residents and improvement in the care home staff ability to facilitate good end-of-life care. DESIGN: A cluster randomised controlled trial where 24 nursing homes received high facilitation to enable them to implement the Gold Standards Framework for Care Homes programme. The managers of 12 nursing homes additionally took part in action learning sets. A third group (14 nursing homes) received the ‘standard’ Gold Standards Framework for Care Homes facilitation available in their locality. SETTING/PARTICIPANTS: In total, 38 nursing homes providing care for frail older people, their deceased residents and their nurse managers. RESULTS: A greater proportion of residents died in those nursing homes receiving high facilitation and action learning but not significantly so. There was a significant association between the level of facilitation and nursing homes completing the Gold Standards Framework for Care Homes programme through to accreditation. Year-on-year change occurred across all outcome measures. CONCLUSION: There is a danger that without national guidelines, facilitation of the Gold Standards Framework for Care Homes programme will vary and consequently so will its implementation. The nurse manager of a care home must be actively engaged when implementing the Gold Standards Framework for Care Homes programme.
Research Practice and Methodology
Evidence-informed recommendations to reduce dissemination bias in clinical research: conclusions from the OPEN (Overcome failure to Publish nEgative fiNdings) project based on an international consensus meeting.
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Meerpohl JJ, Schell LK, Bassler D, Gallus S, Kleijnen J, Kulig M, et al.
BMJ open 2015 May 5;5(5):e006666-2014-006666
Dissemination bias in clinical research severely impedes informed decision-making not only for healthcare professionals and patients, but also for funders, research ethics committees, regulatory bodies and other stakeholder groups that make health-related decisions. Decisions based on incomplete and biased evidence cannot only harm people, but may also have huge financial implications by wasting resources on ineffective or harmful diagnostic and therapeutic measures, and unnecessary research. Owing to involvement of multiple stakeholders, it remains easy for any single group to assign responsibility for resolving the problem to others. OBJECTIVE: To develop evidence-informed general and targeted recommendations addressing the various stakeholders involved in knowledge generation and dissemination to help overcome the problem of dissemination bias on the basis of previously collated evidence. METHODS: Based on findings from systematic reviews, document analyses and surveys, we developed general and targeted draft recommendations. During a 2-day workshop in summer 2013, these draft recommendations were discussed with external experts and key stakeholders, and refined following a rigorous and transparent methodological approach. RESULTS: Four general, overarching recommendations applicable to all or most stakeholder groups were formulated, addressing (1) awareness raising, (2) implementation of targeted recommendations, (3) trial registration and results posting, and (4) systematic approaches to evidence synthesis. These general recommendations are complemented and specified by 47 targeted recommendations tailored towards funding agencies, pharmaceutical and device companies, research institutions, researchers (systematic reviewers and trialists), research ethics committees, trial registries, journal editors and publishers, regulatory agencies, benefit (health technology) assessment institutions and legislators. CONCLUSIONS: Despite various recent examples of dissemination bias and several initiatives to reduce it, the problem of dissemination bias has not been resolved. Tailored recommendations based on a comprehensive approach will hopefully help increase transparency in biomedical research by overcoming the failure to disseminate negative findings.
Developing a Research Agenda on Resident-to-Resident Aggression: Recommendations From a Consensus Conference.
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McDonald L, Hitzig SL, Pillemer KA, Lachs MS Md M, Beaulieu M, Brownell P, et al.
Journal of Elder Abuse & Neglect 2015 Mar-May;27(2):146-167
This article provides an overview of the development of a research agenda on resident-to-resident aggression (RRA) in long-term care facilities by an expert panel of researchers and practitioners. A 1-day consensus-building workshop using a modified Delphi approach was held to gain consensus on nomenclature and an operational definition for RRA, to identify RRA research priorities, and to develop a roadmap for future research on these priorities. Among the six identified terms in the literature, RRA was selected. The top five priorities were: (a) developing/assessing RRA environmental interventions; (b) identification of the environmental factors triggering RRA; (c) incidence/prevalence of RRA; (d) developing/assessing staff RRA education interventions; and (e) identification of RRA perpetrator and victim characteristics. Given the significant harm RRA poses for long-term care residents, this meeting is an important milestone, as it is the first organized effort to mobilize knowledge on this under-studied topic at the research, clinical, and policy levels.
Pan-Canadian Vision and Strategy for Health Services and Policy Research 2014–2019
CIHR Institute of Health Services and Policy Research, 2014
Under the leadership of the Canadian Institutes of Health Research-Institute of Health Services and Policy Research (CIHR-IHSPR), the National Alliance of Provincial Health Research Organizations (NAPHRO) and health charities, a strategic framework was developed to capture the core functions of a HSPR enterprise. It includes fund research, conduct research, foster the use of research to inform health policy and practice decision-making, train researchers and build capacity (educate) and support the production and use of research.
Who receives rehabilitation in Canadian long-term care facilities? A cross-sectional study.
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McArthur C, Hirdes J, Berg K, Giangregorio L.
Physiotherapy Canada 2015 Spring;67(2):113-121
To describe the proportion of residents receiving occupational therapy (OT) and physical therapy (PT) and the factors associated with receiving PT in long-term care (LTC) facilities across five provinces and one territory in Canada. METHODS: Using a population-based, retrospective analysis of cross-sectional data, the proportion of LTC facility residents in each province or territory receiving three different amounts (time and frequency) of PT, OT, or both before July 1, 2013, was calculated according to the Resource Utilization Groups-III rehabilitation classifications. Twenty-three variables from the Resident Assessment Instrument 2.0, such as age and cognition, were examined as correlates; those significant at p
Nursing home practices following resident death: The experience of Certified Nursing Assistants.
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Barooah A, Boerner K, van Riesenbeck I, Burack OR.
Geriatric nursing (New York, N.Y.) 2015 Mar-Apr;36(2):120-125
This study examined certified nursing assistants’ (CNAs) experiences of nursing home practices following resident death. Participants were 140 CNAs who had experienced recent resident death. In semi-structured, in-person interviews, CNAs were asked about their experiences with the removal of the resident’s body, filling the bed with a new resident, and how they were notified about the death. The facilities’ practice of filling the bed quickly was most often experienced as negative. Responses to body removal and staff notification varied, but negative experiences were reported by a substantial minority. Being notified prior to returning to work was associated with a more positive experience. Learning about the death by walking into a room to find the bed empty or already filled was the most negative experience. Study findings suggest that more mindful approaches to the transitions related to resident deaths would be valued by CNAs and could improve their work experience. Copyright © 2015 Elsevier Inc. All rights reserved.
Caring for people with dementia in residential aged care: Successes with a composite person-centered care model featuring Montessori-based activities.
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Roberts G, Morley C, Walters W, Malta S, Doyle C.
Geriatric nursing (New York, N.Y.) 2015 Mar-Apr;36(2):106-110
Person-centered models of dementia care commonly merge aspects of existing models with additional influences from published and unpublished evidence and existing government policy. This study reports on the development and evaluation of one such composite model of person-centered dementia care, the ABLE model. The model was based on building the capacity and ability of residents living with dementia, using environmental changes, staff education and organizational and community engagement. Montessori principles were also used. The evaluation of the model employed mixed methods. Significant behavior changes were evident among residents of the dementia care Unit after the model was introduced, as were reductions in anti-psychotic and sedative medication. Staff reported increased knowledge about meeting the needs of people with dementia, and experienced organizational culture change that supported the ABLE model of care. Families were very satisfied with the changes. Copyright © 2015 Elsevier Inc. All rights reserved.
Hospital-associated functional decline: the role of hospitalization processes beyond individual risk factors.
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Zisberg A, Shadmi E, Gur-Yaish N, Tonkikh O, Sinoff G.
Journal of the American Geriatrics Society 2015 Jan;63(1):55-62
To investigate the combined contribution of processes of hospitalization and preadmission individual risk factors in explaining functional decline at discharge and at 1-month follow-up in older adults with nondisabling conditions. DESIGN: Prospective cohort study. SETTING: Internal medicine wards in two Israeli medical centers. PARTICIPANTS: Six hundred eighty-four individuals aged 70 and older admitted for a nondisabling problem. MEASUREMENTS: Functional decline was measured according to change in modified Barthel Index from premorbid to discharge and from premorbid to 1 month after discharge. In-hospital mobility, continence care, sleep medication consumption, satisfaction with hospital environment, and nutrition intake were assessed using previously tested self-report instruments. RESULTS: Two hundred eighty-two participants (41.2%) reported functional decline at discharge and 317 (46.3%) at 1 month after discharge. Path analysis indicated that in-hospital mobility (standardized maximum likelihood estimate (SMLE) = -0.48, P < .001), continence care (SMLE = -0.12, P < .001), and length of stay (LOS) (SMLE = 0.06, P < .001) were directly related to functional decline at discharge and, together with personal risk factors, explained 64% of variance. In-hospital mobility, continence care, and LOS were indirectly related to functional decline at 1 month after discharge through functional decline at discharge (SMLE = 0.45, P < .001). Nutrition consumption (SMLE = -0.07, P < .001) was significantly related to functional decline at 1 month after discharge, explaining, together with other risk factors, 32% of variance. CONCLUSION: In-hospital low mobility, suboptimal continence care, and poor nutrition account for immediate and 1-month posthospitalization functional decline. These are potentially modifiable hospitalization risk factors for which practice and policy should be targeted in efforts to curb the posthospitalization functional decline trajectory. © 2015, Copyright the Authors Journal compilation
Predictive & concurrent validity of the Braden scale in long-term care: Meta-analysis.
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Wilchesky M, Lungu O.
Wound repair and regeneration 2015 Jan;23(1):44-56
Pressure ulcer prevention is an important long-term care (LTC) quality indicator. While the Braden Scale is a recommended risk assessment tool, there is a paucity of information specifically pertaining to its validity within the LTC setting. We, therefore, undertook a systematic review and meta-analysis comparing Braden Scale predictive and concurrent validity within this context. We searched the Medline, EMBASE, PsychINFO and PubMed databases from 1985-2014 for studies containing the requisite information to analyze tool validity. Our initial search yielded 3,773 articles. Eleven datasets emanating from nine published studies describing 40,361 residents met all meta-analysis inclusion criteria and were analyzed using random effects models. Pooled sensitivity, specificity, positive predictive value (PPV), and negative predictive values were 86%, 38%, 28%, and 93%, respectively. Specificity was poorer in concurrent samples as compared with predictive samples (38% vs. 72%), while PPV was low in both sample types (25 and 37%). Though random effects model results showed that the Scale had good overall predictive ability [RR, 4.33; 95% CI, 3.28-5.72], none of the concurrent samples were found to have “optimal” sensitivity and specificity. In conclusion, the appropriateness of the Braden Scale in LTC is questionable given its low specificity and PPV, in particular in concurrent validity studies. Future studies should further explore the extent to which the apparent low validity of the Scale in LTC is due to the choice of cutoff point and/or preventive strategies implemented by LTC staff as a matter of course. © 2015 by the Wound Healing Society.
Examining trends in the administration of “as needed” medications to inpatients with behavioral and psychological symptoms of dementia.
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Neumann RD, Faris P, Klassen R.
American Journal of Alzheimer’s Disease and Other Dementias 2015 May;30(3):247-256
The use of “pro re nata” (PRN) medication in patients with behavioral and psychological symptoms of dementia (BPSD) is common but may be a source of inappropriate medication administration. OBJECTIVE: To identify trends in the administration of PRN medications to inpatients with BPSD. METHODS: Retrospective chart audits were completed on inpatients with dementia who had PRN medications prescribed for aggression, agitation, or insomnia. Data collected included age, sex, time of day, day of week, medication used, and dementia diagnosis. Additionally, data regarding administration of ranged doses and concurrent use with regularly prescribed medications of the same class were collected. RESULTS: A total of 170 inpatients with dementia were included. Over 50 346 bed days, 4000 PRNs were administered. Individuals were more likely to receive a PRN if they were younger, shortly after shift change, in the evening, or during the weekend. If a ranged dose is provided they are more likely to receive the higher dose. If they are receiving regularly scheduled medication from the same class, there is risk of double dosing. © The Author(s) 2015.
Experience of burden in carers of people with dementia on the margins of long-term care.
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Sutcliffe CL, Giebel CM, Jolley D, Challis DJ.
International journal of geriatric psychiatry 2015 May 11
This study aimed to identify the factors determining carer burden in a group of carers supporting people with dementia (PwD) deemed to be at high risk of moving to long-term residential or nursing home care. DESIGN: National data collected as part of the European RightTimePlaceCare project were analysed. This included 81 dyads of community-dwelling people with dementia and their informal carers. METHODS: Structured face-to-face interviews were conducted in North West England between June 2011 and April 2012. Interviews collected data relating to the person with dementia (cognitive functioning, activities of daily living, neuropsychiatric symptoms and formal and informal dementia care resource use) and carers’ level of burden (22-item Zarit Burden Index), hours spent caring and availability of additional informal support. RESULTS: Logistic regression analysis identified five factors associated with high carer burden: neuropsychiatric symptomatology in the PwD, intensive supervision of the PwD by the carer, being a female carer, being an adult-child carer and absence of informal carer support. Use of home care or day care services was unrelated to burden. CONCLUSION: Support programmes focusing on challenging behaviours and risk management may be of benefit to carers. More individually tailored interventions for specific carer groups including female or younger carers may be warranted. The implementation of peer support networks could be beneficial to carers who lack additional family support. Copyright © 2015 John Wiley & Sons, Ltd. Copyright © 2015 John Wiley & Sons, Ltd.
Tailored lighting intervention improves measures of sleep, depression, and agitation in persons with Alzheimer’s disease and related dementia living in long-term care facilities.
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Figueiro MG, Plitnick BA, Lok A, Jones GE, Higgins P, Hornick TR, et al.
Clinical interventions in aging 2014 Sep 12;9:1527-1537
Light therapy has shown great promise as a nonpharmacological method to improve symptoms associated with Alzheimer’s disease and related dementias (ADRD), with preliminary studies demonstrating that appropriately timed light exposure can improve nighttime sleep efficiency, reduce nocturnal wandering, and alleviate evening agitation. Since the human circadian system is maximally sensitive to short-wavelength (blue) light, lower, more targeted lighting interventions for therapeutic purposes, can be used. METHODS: The present study investigated the effectiveness of a tailored lighting intervention for individuals with ADRD living in nursing homes. Low-level “bluish-white” lighting designed to deliver high circadian stimulation during the daytime was installed in 14 nursing home resident rooms for a period of 4 weeks. Light-dark and rest-activity patterns were collected using a Daysimeter. Sleep time and sleep efficiency measures were obtained using the rest-activity data. Measures of sleep quality, depression, and agitation were collected using standardized questionnaires, at baseline, at the end of the 4-week lighting intervention, and 4 weeks after the lighting intervention was removed. RESULTS: The lighting intervention significantly (P<0.05) decreased global sleep scores from the Pittsburgh Sleep Quality Index, and increased total sleep time and sleep efficiency. The lighting intervention also increased phasor magnitude, a measure of the 24-hour resonance between light-dark and rest-activity patterns, suggesting an increase in circadian entrainment. The lighting intervention significantly (P<0.05) reduced depression scores from the Cornell Scale for Depression in Dementia and agitation scores from the Cohen-Mansfield Agitation Inventory. CONCLUSION: A lighting intervention, tailored to increase daytime circadian stimulation, can be used to increase sleep quality and improve behavior in patients with ADRD. The present field study, while promising for application, should be replicated using a larger sample size and perhaps using longer treatment duration.
Exploration of the meaning of connectedness for older people in long-term care in context of their quality of life: a review and commentary.
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Cooney A, Dowling M, Gannon ME, Dempsey L, Murphy K.
International journal of older people nursing 2014 Sep;9(3):192-199
A link between ‘quality of life’ and ‘connectedness’ is emerging in the literature. However, there has been little debate on what ‘connectedness’ means and how it can be fostered in long-term care settings. This review examines the meaning of ‘connectedness’ in long-term care. AIM: This paper critically examines the meaning of ‘connectedness’ in the context of its contribution to the quality of life of older people living in long-term care settings. METHOD: Key databases (CINAHL, PsychInfo and Medline) were searched systematically. Fourteen papers and two book chapters met the inclusion criterion of papers exploring ‘connectedness for older people in residential care’. CONCLUSIONS: The experience of connectedness for older people in long-term care settings is linked with quality of life and successful ageing. Fundamental prerequisites of connectedness for older people are: self-awareness, meaningful relationships with family and friends, involvement in meaningful activities and connections with wider society. However, barriers to these prerequisites are evident for many residents in long-term care settings. IMPLICATIONS FOR PRACTICE: Register and Herman (Advances in Nursing Science, 33, 2010, 53) identify six connections that combine to generate connectedness for older people. These connections are representative of the factors associated with increased quality of life for residents living in long-term care settings. The six connections are helpful in identifying areas to focus on when planning person-centred care. © 2013 Blackwell Publishing Ltd.
Pain reports and pain medication treatment in nursing home residents with and without dementia.
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Monroe TB, Misra SK, Habermann RC, Dietrich MS, Cowan RL, Simmons SF.
Geriatrics & gerontology international 2014 Jul;14(3):541-548
The purpose of this pilot study was to determine if a diagnosis of dementia influenced pain self-reports and pain medication use in a group of verbally communicative nursing home (NH) residents. METHODS: The study design was a between groups, cross-sectional chart audit and a seven-question structured pain interview comparing outcomes in residents with and without a diagnosis of dementia. The study was carried out at a large metropolitan NH in the southern USA. The participants consisted of 52 long-stay NH residents capable of self-consent with at least one order for pain medication (opioid or non-narcotic) either pro re nata, scheduled or both. Approximately 40% (n = 20) had a diagnosis of dementia. RESULTS: Although each group had similar pain-related diagnoses, residents without a dementia diagnosis were significantly more likely to have a medication order for an opioid (OR 4.37,95% CI 1.29-14.73, P = 0.018). Based on self-reported pain interview responses, no statistically significant differences were identified between the groups for chronic pain symptoms. However, among residents who reported current pain, those with a dementia diagnosis reported greater pain intensity (based on a 0-10 numeric rating scale) than did those without dementia (median 8.0 vs 6.0, respectively; P = 0.010). CONCLUSIONS: Verbally communicative NH residents with mild and moderate cognitive impairment can report their pain symptoms and pain intensity. Nurses in long-term care might assume that residents with dementia cannot reliably self-report their pain; however, suffering from untreated severe pain could exacerbate cognitive impairment, worsen functional impairment and severely impair sleep. A brief, focused pain interview might be one method for increasing the detection of moderate to severe pain in verbally communicative NH residents with dementia. © 2013 Japan Geriatrics Society.
Creating a Comprehensive Care System for Frail Elders in “Age Boom” America
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Lynn J, Montgomery A.
The Gerontologist 2015 04/01;55(2):278-285
Current options being discussed by policymakers cannot yield the highly reliable, highly efficient service delivery system—inclusive of both health care and community-based supportive services—that the nation’s upcoming and transformative “age wave” will require. More far-reaching and rapid innovations in policy and health care delivery are essential. The MediCaring Accountable Care Community initiative is a comprehensive model that can deliver higher quality care for frail elderly Medicare beneficiaries at a lower per capita cost. The savings generated by adhering to established geriatric principles in the delivery of medical care would help fund community-based long-term services and supports (LTSS), using a modified Accountable Care Organization (ACO) known as an Accountable Care Community (ACC). A Community Board would monitor the quality and supply of services for frail elders, the most expensive phase of most lives. The constellation of improvements that form the basis of this model are congruent with the goal of improving access to LTSS, which is one of the 4 areas targeted by the Sixth White House Conference on Aging.
Re-Imagining Long-Term Services and Supports: Towards Livable Environments, Service Capacity, and Enhanced Community Integration, Choice, and Quality of Life for Seniors
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Kane RA, Cutler LJ.
The Gerontologist 2015 04/01;55(2):286-295
In the half century since enactment of the 1965 Great Society programs, accomplishments were gradually made to improve access to and quality of long-term services and supports (LTSS), including: mitigation of financial and care abuses in nursing facilities (NFs); substantial rebalancing of LTSS towards consumer-preferred home-and-community-based services (HCBS); increasing flexible consumer-centered HCBS including payment to family caregivers; and more assisted-living and housing options for seniors with heavy care needs. A unified planning and advocacy agenda across age and disability type and greater consumer transparency fueled progress. Nonetheless, LTSS is a broken system; persistent problems interfere with substantial and necessary change. These include; over-emphasis on safety for LTSS consumers; inattention to physical environments in all settings; regulatory and professional rigidity; and poor communication and information. Our recommendations are aimed at builders and designers, LTSS professionals, regulators, and educators/trainers; the last may be crucial in forging new consensus and over-coming entrenched beliefs. Policy recommendations include relatively narrow steps—for example, requiring single occupancy in all NFs and assisted living settings financed with public dollars—to broad reworking of the prerequisites for livable age-friendly (and dementia-friendly) communities and for a capable, flexible LTSS workforce.
This article argues for a fresh look at how we provide long-term care (LTC) for older persons. Essentially, LTC offers a compensatory service that responds to frailty. Policy debate around LTC centers on costs, but we are paying for something we really don’t want. Building societal enthusiasm (or even support) for LTC will require re-inventing and re-branding. LTC has three basic components: personal care, housing, and health care (primarily chronic disease management). They can be delivered in a variety of settings. It is rare to find all three done well simultaneously. Personal care (PC) needs to be both competent and compassionate. Housing must provide at least minimal amenities and foster autonomy; when travel time for PC raises costs dramatically, some form of clustered housing may be needed. Health care must be proactive, aimed at preventing exacerbations of chronic disease and resultant hospitalizations. Enhancing preferences means allowing taking informed risks. Payment incentives should reward both quality of care and quality of life, but positive outcomes must be defined as slowing decline. Paying for services but not for housing under Medicaid would automatically level the playing field between nursing homes (NH) and community-based services. Regulations should achieve greater parity between NH and community care and include both positive and negative feedback. Providing post-acute care should be separate from LTC. Using the tripartite LTC framework, we can create innovative flexible approaches to providing needed services for frail older persons in formats that are both desirable and affordable. Such care will be more socially desirable and hence worth paying for.
This Rapid Response report summarizes four guidelines on the topic of dehydration prevention in long-term care that were identified as being evidence-based. This Rapid Response document was completed in July 2014 and includes summaries of guidelines from the last five years only. From this report you are also able to full-text of the guidelines that are summarized.
Access to Care For Supported Residents (Aus)
Government of Australia, 2015
The Aged Care Financing Authority (ACFA) is an independent statutory committee whose role is to provide independent, transparent advice to the Australian Government on financing and funding issues in the aged care sector. ACFA considers issues in the context of maintaining a viable, accessible and sustainable aged care industry that balances the needs of consumers, providers, the workforce, taxpayers, investors and financiers.
Policies in Support of Caregivers
Caledon Institute of Social Policy May 2015
More than one in four Canadian adults provide care that complements our health care and social service systems. But only limited and inconsistent supports are available to these caregivers. The lack of supports places a burden on the economy and negatively affects the physical, emotional and financial health of both caregivers and care receivers. POLICY OBJECTIVE The policy objective is to ensure a set of linked measures that recognize the vital role of informal caregivers in the health care and social service systems. These linked actions would directly address the needs of caregivers and care receivers through community supports, financial assistance and workplace provisions
This inaugural Cardus Health report builds on the 2011 parliamentary report “Not to be Forgotten: Care of Vulnerable Canadians.” Many recommendations have been published by many organizations since 2011, and this report evaluates these proposals while looking through three lenses:
1. Natural Death: We need to build a social system that supports the desire of Canadians for a natural death, which we understand to mean dying of natural causes in our natural environment surrounded by our natural caregivers.
2. Social Architecture: We need to think of this system in terms of more than health, recognizing that not only the patient but also the natural caregivers need to be the focus of support, and thus the full range of social institutions best equipped for natural deaths need to be made more available to more Canadians.
3. Continuum of Care: We need to think of the delivery of care not as a series of alternatives to be chosen between, but rather as a continuum of care in which there is a seamless continuity of end-of-life care supports and settings as our fellow Canadians and their loved ones travel the journey through to the end of their natural lives.
Cardus aims to build on the good work done by the 2011 Parliamentary Committee and the hundreds of good organizations in this field, toward the common goal of bringing the best care to some of the most vulnerable among us.
In this debate each side will make an argument about whether or not citation based metrics such as Journal Impact Factor or h-indices are the best representation of nursing research impact. Alex Clark will be arguing for the resolution. Thane Chambers (that’s me) will be arguing against the resolution.
Control Chart Workshop
Wednesday 3 June
This is a TREC workshop for anyone interested in using control charts (SPC) to understand variation in data collected over time.
Geriatric Medicine 2015: Getting Evidence into Practice
Saturday 6 June Lister Conference Centre
This is a day long conference covering many aspects of geriatric medicine including incontinence, dementia, sleep, and skin issues.
CFHI Webinar Connecting the Dots: Social Network Analysis (SNA) as a Quality Improvement Measurement Tool
Wednesday 27 May 10:00-11:00 MT
How can quality improvement (QI) relationships and networks be visualized and measured? How can QI teams know they have engaged the right people and organizations, as well as identified key people who can help with the uptake and spread of a QI initiative? How can QI uptake and spread be measured? Social network analysis (SNA) is a method that models and measures relationships between people and groups, and it can help answer these questions. This webinar will provide an introduction to SNA – including how to collect data and interpret a basic social network map. Demonstrating the application of SNA in QI work, CFHI will provide an overview of how this method is being applied as an evaluative tool within a regional collaboration, including early results from the Atlantic Healthcare Collaboration.
All That Glitters Is Not Gold – Are Systematic Reviews Fool’s Gold?
CADTH Lecture Series – Speaker: Jon Brassey
Monday 25 May 11:00-12:30 MT Free
Systematic reviews hold a special place in the “evidence-based” world — seen as the best way to assess the “worth” of an intervention. This view is outdated and needs to be challenged. The current techniques are caught between two stools: not quick enough and not robust enough. Join Jon Brassey for a thought-provoking presentation that will focus on the problems of systematic reviews, the rise of the rapid review, and the potential role of automation. The presentation will conclude with the author’s work in improving search to ensure all the wonderful reviews are findable.
Dr. Sharon Straus will present “Use of theory in implementation research; Pragmatic application and scientific advancement of the knowledge-to-action (KTA) cycle”. In follow up to our January session, “Applying Models and Frameworks to D&I Research: An Overview & Analysis” we have developed a suite of webinars that will delve deeper into popular D&I frameworks, operationalization, and specific examples where they have been used. May’s seminar will introduce the knowledge-to-action cycle and its application in a series of studies highlighting its use to guide data collection, analyses and its potential for syntheses and to guide tailoring of implementation strategies.
UofA credit course that may be of interest:
STAT 590 Statistical Consulting
6 July-12 August, Monday to Friday 10:30-11:40
Data analysis, problem solving, oral communication with clients, issues in planning experiments and collecting data; practical aspects of consulting and report writing.
All NHS staff – from porters to surgeons – are required to undergo training in dementia care
For the reference year April 1, 2013 to March 31, 2014, there were 1,519 long-term care facilities in Canada serving 149,488 residents. During this time, the industry generated revenues of $10.9 billion and expenses of $10.8 billion, of which $7.2 billion were wages and salaries. This corresponded to a profit margin of $154.2 million or 1.4% of total revenues.
A misguided attempt to improve healthcare has led some hospitals to focus on making people happy, rather than making them well.
Recent news about a scientific journal that appeared to reject a paper by two women partly for sexist reasons highlights why editors and reviewers need to be held more accountable.
The provincial government has unveiled a new and progressive policy to calculate the cost of nursing home care in New Brunswick. Under the new formula, many seniors – especially low and middle income earners – will see their contributions to the cost of total care drop, leaving them more money for necessities and partners or dependents that remain at home.
Compassion and extra care go a long way to make people with dementia comfortable at the dentist
The National Institutes of Health released recommendations today that provide a framework for a bold and transformative Alzheimer’s disease research agenda. Developed at the recent Alzheimer’s Disease Research Summit 2015: Path to Treatment and Prevention, the highly anticipated recommendations provide the wider Alzheimer’s research community with a strategy for speeding the development of effective interventions for Alzheimer’s and related dementias. These recommendations call for a change in how the academic, biopharmaceutical and government sectors participating in Alzheimer’s research and therapy generate, share and use knowledge to propel the development of critically needed therapies.
The number of older carers in England is rising, with signs the pressures of looking after loved ones is damaging their health, research suggests.
For the last eleven years Dr. Jenny Basran, Saskatchewan’s only Royal College certified geriatrician, has dedicated her life to ensuring this province’s growing population of older adults receives optimal care that meets their increasingly complex needs. In recognition of her remarkable work, she has been named the Saskatchewan Medical Association’s 2015 Physician of the Year.
Psychiatric drugs do more harm than good and the use of most antidepressants and dementia drugs could be virtually stopped without causing harm, an expert on clinical trials argues in a leading medical journal. But other experts disagree.
89 percent of British Columbians view health and medical research as making important contributions to the Canadian health-care system. And three quarters of British Columbians say health and medical research makes important contributions to the Canadian economy.
Ontario patients and family caregivers will get more control over the types of home and community care services they can access under a new “self-directed” funding program.
Nursing homes and special care home operators are welcoming a new initiative from the provincial government to post inspection reports of their facilities online.
Albertans now have information about palliative care and end-of-life care at their fingertips with the launch of a new provincial online resource.
Dementia Language Guidelines
Suggested language guidelines have been produced in Australia, to encourage a more inclusive and non-stigmatising use of words when talking and writing about dementia. This guidance will be particularly of interest for health professionals, service providers and others working in the field when talking to / about people diagnosed with dementia (and their families / carers). It may also, in the broader context of social change towards the development of more dementia-friendly communities and dementia-friendly discourse generally, influence researchers, writers and commentators in the media.
Care Improvement Works (UK)
Social Care Institute for Excellence (SCIE); Skills for Care; Think Local, Act Personal (TLAP).
Free, reliable guides, learning tools and resources for providers of adult social care in England. These are mapped to the Care Quality Commission’s inspection questions and key lines of enquiries (KLOEs). Care Improvement Works aims to give managers, owners and care staff the confidence to challenge and change practice. They can use the online resource before and after inspection, or at any time, to identify products that will support improvement in areas where they may have concerns, or to review their current practice against recognised good practice.
The aim of this guide is to support carers plan activities with their loved ones using practical and straightforward tips.
Tips for better pureed foods
Agri-Food for Healthy Aging
Agri-Food for Healthy Aging has developed a preliminary set of recommendations for LTC facilities for better pureed foods that provides examples for different types of food, as well as a checklist to ensure standardized texture outcomes.
Senior Consultant: Systematic Reviews
York Health Economics Consortium, York UK
DEADLINE 8 June
The primary purpose of the role is to undertake systematic reviews and other review activity on a wide range of project types.
Consultant: Systematic Reviews
York Health Economics Consortium, York UK
DEADLINE 8 June
The primary purpose of the role is to undertake systematic reviews and other review activity on a wide range of project types.
Consultant: Trainee Reviewer
York Health Economics Consortium, York UK
DEADLINE 15 June
The primary purpose of the role is to provide research support to a team of systematic reviewers who carry out a wide range of project types.