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New article by Dr. Matthias Hoben
Barriers and facilitators in providing oral health care to nursing home residents, from the perspective of care aides-a systematic review protocol.
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BACKGROUND: Unregulated care aides provide up to 80 % of direct resident care in nursing homes. They have little formal training, manage high workloads, frequently experience responsive behaviours from residents, and are at high risk for burnout. This affects quality of resident care, including quality of oral health care. Poor quality of oral health care in nursing homes has severe consequences for residents and the health care system. Improving quality of oral health care requires tailoring interventions to identified barriers and facilitators if these interventions are to be effective. Identifying barriers and facilitators from the care aide’s perspective is crucial. METHODS: We will systematically search the databases MEDLINE, Embase, Evidence Based Reviews-Cochrane Central Register of Controlled Trials, CINAHL, and Web of Science. We will include qualitative and quantitative research studies and systematic reviews published in English that assess barriers and facilitators, as perceived by care aides, to providing oral health care to nursing home residents. Two reviewers will independently screen studies for eligibility. We will also search by hand the contents of key journals, publications of key authors, and reference lists of all the studies included. Two reviewers will independently assess the methodological quality of the studies included using four validated checklists appropriate for different research designs. Discrepancies at any stage of review will be resolved by consensus. We will conduct a thematic analysis of barriers and facilitators using all studies included. If quantitative studies are sufficiently homogeneous, we will conduct random-effects meta-analyses of the associations of barriers and facilitators with each other, with care aide practices in resident oral health care, and with residents’ oral health. If quantitative study results cannot be pooled, we will present a narrative synthesis of the results. Finally, we will compare quantitative findings to qualitative studies to identify hypothesized associations or effects not yet tested quantitatively. DISCUSSION: This review will advance the development of effective strategies for improving quality of oral health care and highlight gaps in research on barriers and facilitators to providing oral health care to nursing home residents, as perceived by care aides. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42015032454.
New article on PARIHS framework
PARIHS revisited: from heuristic to integrated framework for the successful implementation of knowledge into practice.
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BACKGROUND: The Promoting Action on Research Implementation in Health Services, or PARIHS framework, was first published in 1998. Since this time, work has been ongoing to further develop, refine and test it. Widely used as an organising or conceptual framework to help both explain and predict why the implementation of evidence into practice is or is not successful, PARIHS was one of the first frameworks to make explicit the multi-dimensional and complex nature of implementation as well as highlighting the central importance of context. Several critiques of the framework have also pointed out its limitations and suggested areas for improvement. DISCUSSION: Building on the published critiques and a number of empirical studies, this paper introduces a revised version of the framework, called the integrated or i-PARIHS framework. The theoretical antecedents of the framework are described as well as outlining the revised and new elements, notably, the revision of how evidence is described; how the individual and teams are incorporated; and how context is further delineated. We describe how the framework can be operationalised and draw on case study data to demonstrate the preliminary testing of the face and content validity of the revised framework. This paper is presented for deliberation and discussion within the implementation science community. Responding to a series of critiques and helpful feedback on the utility of the original PARIHS framework, we seek feedback on the proposed improvements to the framework. We believe that the i-PARIHS framework creates a more integrated approach to understand the theoretical complexity from which implementation science draws its propositions and working hypotheses; that the new framework is more coherent and comprehensive and at the same time maintains it intuitive appeal; and that the models of facilitation described enable its more effective operationalisation.
U.S. Population Aging Slower than Other Countries, Census Bureau Reports
An Aging World: 2015 International Population Reports
America’s 65-and-over population is projected to nearly double over the next three decades, ballooning from 48 million to 88 million by 2050. However, the U.S. Census Bureau projects the U.S. population will age at a slower rate compared with other countries. Worldwide, the 65-and-over population will more than double to 1.6 billion by 2050, according to An Aging World: 2015. This new report from the Census Bureau examines the continuing global aging trend and projected growth of the population age 65 and over, with an emphasis on the differences among world regions.
Grants & Awards
CIHR Gold Leaf Prizes Recognizing excellence in health research
CIHR is proud to announce its new suite of prizes, the CIHR Gold Leaf Prizes, which are among the highest honours that can be bestowed on an individual or team for excellence in health research and its translation into benefits for Canadians. Each CIHR Gold Leaf Prize has a value of $100,000. These prizes cover achievements across all pillars of research (biomedical, clinical, health services and policy, and population and public health) and will be awarded every two years.
The Wilfred and Joyce Posluns Chair in Women’s Brain Health and Aging
The specific objectives of this funding opportunity are:
-To support a leading researcher based at an Ontario institution to develop and implement the Chair with the goal of impacting and enhancing research on sex and gender differences in brain health.
-The Chair holder can be either a world-class expert in this area recruited specifically for this Chair from across Canada or abroad, or
a top researcher already established at an Ontario institution.
-To support an outstanding research program that will enhance women’s brain health through the study of cognitive aging and associated disorders.
-To build capacity for research on brain health and aging that accounts for sex and gender.
-To foster the translation of that research into gender- and sex-responsive policies and interventions that improve brain health and promote wellness in aging.
Publications
KT
Health Care Administration and Organization
Health Care Innovation and Quality Assurance
Research Practice and Methodology
Aging
KT
Translating research into prevention of high-risk behaviors in the presence of complex systems: definitions and systems frameworks
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To impact population health, it is critical to collaborate across disciplinary and practice-based silos and integrate resources, experiences, and knowledge to exert positive change. Complex systems shape both the prevention outcomes researchers, practitioners, and policymakers seek to impact and how research is translated and can either impede or support movement from basic scientific discovery to impactful and scaled-up prevention practice. Systems science methods can be used to facilitate designing translation support that is grounded in a richer understanding of the many interacting forces affecting prevention outcomes across contexts. In this paper, we illustrate how one systems science method, system dynamics, could be used to advance research, practice, and policy initiatives in each stage of translation from discovery to translation of innovation into global communities (T0-T5), with tobacco prevention as an example. System dynamics can be applied to each translational stage to integrate disciplinary knowledge and document testable hypotheses to inform translation research and practice.
Effects of a demand-led evidence briefing service on the uptake and use of research evidence by commissioners of health services: protocol for a controlled before and after study.
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BACKGROUND: Clinical Commissioning Groups (CCGs) are mandated to use research evidence effectively to ensure optimum use of resources by the National Health Service (NHS), both in accelerating innovation and in stopping the use of less effective practices and models of service delivery. We intend to evaluate whether access to a demand-led evidence service improves uptake and use of research evidence by NHS commissioners compared with less intensive and less targeted alternatives. METHODS/DESIGN: This is a controlled before and after study involving CCGs in the North of England. Participating CCGs will receive one of three interventions to support the use of research evidence in their decision-making: 1) consulting plus responsive push of tailored evidence; 2) consulting plus an unsolicited push of non-tailored evidence; or 3) standard service unsolicited push of non-tailored evidence. Our primary outcome will be changed at 12 months from baseline of a CCGs ability to acquire, assess, adapt and apply research evidence to support decision-making. Secondary outcomes will measure individual clinical leads and managers’ intentions to use research evidence in decision making. Documentary evidence of the use of the outputs of the service will be sought. A process evaluation will evaluate the nature and success of the interactions both within the sites and between commissioners and researchers delivering the service. DISCUSSION: The proposed research will generate new knowledge of direct relevance and value to the NHS. The findings will help to clarify which elements of the service are of value in promoting the use of research evidence. Those involved in NHS commissioning will be able to use the results to inform how best to build the infrastructure they need to acquire, assess, adapt and apply research evidence to support decision-making and to fulfil their statutory duties under the Health and Social Care Act.
Analysing key influences over actors’ use of evidence in developing policies and strategies in Nigeria: a retrospective study of the Integrated Maternal Newborn and Child Health strategy
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BACKGROUND: Evidence-informed policymaking has been promoted as a means of ensuring better outcomes. However, what counts as evidence in policymaking lies within a spectrum of expert knowledge and scientifically generated information. Since not all forms of evidence share an equal validity or weighting for policymakers, it is important to understand the key factors that influence their preferences for different types of evidence in policy and strategy development. METHOD: A retrospective study was carried out at the national level in Nigeria using a case-study approach to examine the Nigerian Integrated Maternal Newborn and Child Health (IMNCH) strategy. Two frameworks were used for conceptualization and data analysis, namely (1) to analyse the role of evidence in policymaking and (2) the policy triangle. They were used to explore the key contextual and participatory influences on choice of evidence in developing the IMNCH strategy. Data was collected through review of relevant national documents and in-depth interviews of purposively selected key policy and strategic decision makers. Thematic analysis was applied to generate information from collected data. RESULTS: The breadth of evidence used was wide, ranging from expert opinions to systematic reviews. The choice of different types of evidence was found to overlap across actor categories. Key influences over actors’ choice of evidence were: (1) perceived robustness of evidence – comprehensive, representative, recent, scientifically sound; (2) roles in evidence process, i.e. their degree and level of participation in evidence generation and dissemination, with regards to their role in the policy process; and (3) contextual factors such as global agenda and influence, timeline for strategy development, availability of resources for evidence generation, and lessons learnt from previous unsuccessful policies/plans. CONCLUSION: Actors’ preferences for different types of evidence for policy are influenced not only by the characteristics of evidence itself, but on actors’ roles in the evidence process, their power to influence the policy, and the context in which evidence is used.
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Health Care Administration and Organization
Towards person-centredness in aged care – exploring the impact of leadership.
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The incidence of behavioural and psychological symptoms of dementia in residential aged care facilities is high. Effective team work and knowledgeable staff are cited as important facilitators of appropriate care responses to clients with these symptoms, but to achieve this within a resource-poor workplace can be challenging. In the study reported in this paper, concept mapping was trialled to enhance multifocal person-centred assessment and care planning as well as team learning. The outcomes of team concept mapping were evaluated using a quasi-experimental design with pre- and post-testing in 11 selected Australian residential aged care facilities , including two control residential aged care facilities , over a nine-month period. It was demonstrated that use of concept mapping improved team function, measured as effectiveness of care planning, as well as enhancing learning, with increased knowledge of dementia care even amongst staff who were not directly involved with the process. It is suggested that these results may be generalizable to other countries and care settings.
Meaning making in long-term care: what do certified nursing assistants think?
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Certified nursing assistants (CNAs) provide up to 80% of the direct care to older adults in long-term care facilities. CNAs are perceived as being at the bottom of the hierarchy among healthcare professionals often negatively affecting their job satisfaction. However, many CNAs persevere in providing quality care and even reporting high levels of job satisfaction. The aim of the present investigation was to identify primary themes that may help CNAs make meaning of their chosen career; thus potentially partially explaining increases in job satisfaction among this group. Focus groups were conducted with CNAs at three long-term care facilities. Four themes emerged from the data: CNA work is good or special; CNA as relationship builder; CNA as expert; CNA as team member. These themes reflect the perceptions that these CNAs held in regard to themselves and their relationships to others in the work environment and, when present, can contribute to intrinsic job satisfaction. Our meaning-making themes support the premise that CNAs do not passively accept the evaluations of others but instead actively frame identities that validate their importance to residents and the institution.
Concept mapping to improve team work, team learning and care of the person with dementia and behavioural and psychological symptoms
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The incidence of behavioural and psychological symptoms of dementia in residential aged care facilities is high. Effective team work and knowledgeable staff are cited as important facilitators of appropriate care responses to clients with these symptoms, but to achieve this within a resource-poor workplace can be challenging. In the study reported in this paper, concept mapping was trialled to enhance multifocal person-centred assessment and care planning as well as team learning. The outcomes of team concept mapping were evaluated using a quasi-experimental design with pre- and post-testing in 11 selected Australian residential aged care facilities , including two control residential aged care facilities , over a nine-month period. It was demonstrated that use of concept mapping improved team function, measured as effectiveness of care planning, as well as enhancing learning, with increased knowledge of dementia care even amongst staff who were not directly involved with the process. It is suggested that these results may be generalizable to other countries and care settings.
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Health Care Innovation and Quality Assurance
When Patients Customize Nursing Home Ratings, Choices And Rankings Differ From The Government’s Version.
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Report cards currently published by the Centers for Medicare and Medicaid Services (CMS) offer composite (summary) quality measures based on a five-star ratings system, such as the one featured on the Nursing Home Compare website. These ratings are “one size fits all patients” measures. Nursing Home Compare Plus is an alternative that allows patients and their families to create their own composite scores based on their own preferences and medical needs. We present data from 146 patients who were discharged from the hospital to nursing homes who used Nursing Home Compare Plus. We found that the individual patient-constructed composites differed from CMS’s five-star ratings composite. Patients differed from each other and from CMS in the number of performance measures they chose to include in their composite and in their weighting of each performance measure. When comparing Nursing Home Compare Plus to Medicare’s five-star ratings, we found only minimal agreement on ranking of nursing homes. We conclude that patients might benefit if current report cards are modified to include an option for personalized ranking.
Use Of Nursing Home Compare Website Appears Limited By Lack Of Awareness And Initial Mistrust Of The Data.
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In December 2008 the Centers for Medicare and Medicaid Services (CMS) launched a five-star rating system of nursing homes as part of Nursing Home Compare, a web-based report card detailing quality of care at all CMS-certified nursing homes. Questions remain, however, as to how well consumers use this rating system as well as other sources of information in choosing nursing home placement. We used a qualitative assessment of how consumers select nursing homes and of the role of information about quality, using semistructured interviews of people who recently placed a family member or friend in a nursing home. We found that consumers were receptive to using Internet-based information about quality as one source of information but that choice was limited by the need for specialized services, proximity to family or health care providers, and availability of Medicaid beds. Consumers had a positive reaction when shown Nursing Home Compare; however, its use appeared to be limited by lack of awareness and, to some extent, initial lack of trust of the data. Our findings suggest that efforts to expand the use of Nursing Home Compare should focus on awareness and trust. Useful additions to Nursing Home Compare might include measures of the availability of activities, information about cost, and consumer satisfaction.
CNA Training Requirements and Resident Care Outcomes in Nursing Homes.
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PURPOSE OF THE STUDY: To examine the relationship between certified nursing assistant (CNA) training requirements and resident outcomes in U.S. nursing homes (NHs). The number and type of training hours vary by state since many U.S. states have chosen to require additional hours over the federal minimums, presumably to keep pace with the increasing complexity of care. Yet little is known about the impact of the type and amount of training CNAs are required to have on resident outcomes. DESIGN AND METHODS: Compiled data on 2010 state regulatory requirements for CNA training (clinical, total initial training, in-service, ratio of clinical to didactic hours) were linked to 2010 resident outcomes data from 15,508 NHs. Outcomes included the following NH Compare Quality Indicators (QIs) (Minimum Data Set 3.0): pain, antipsychotic use, falls with injury, depression, weight loss and pressure ulcers. Facility-level QIs were regressed on training indicators using generalized linear models with the Huber-White correction, to account for clustering of NHs within states. Models were stratified by facility size and adjusted for case-mix, ownership status, percentage of Medicaid-certified beds and urban-rural status. RESULTS: A higher ratio of clinical to didactic hours was related to better resident outcomes. NHs in states requiring clinical training hours above federal minimums (i.e., >16hr) had significantly lower odds of adverse outcomes, particularly pain falls with injury, and depression. Total and in-service training hours also were related to outcomes. IMPLICATIONS: Additional training providing clinical experiences may aid in identifying residents at risk. This study provides empirical evidence supporting the importance of increased requirements for CNA training to improve quality of care.
Assessing the physical environment of older people’s residential care facilities: development of the Swedish version of the Sheffield Care Environment Assessment Matrix (S-SCEAM).
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BACKGROUND: There is emerging evidence that the physical environment is important for health, quality of life and care, but there is a lack of valid instruments to assess health care environments. The Sheffield Care Environment Assessment Matrix (SCEAM), developed in the United Kingdom, provides a comprehensive assessment of the physical environment of residential care facilities for older people. This paper reports on the translation and adaptation of SCEAM for use in Swedish residential care facilities for older people, including information on its validity and reliability. METHODS: SCEAM was translated into Swedish and back-translated into English, and assessed for its relevance by experts using content validity index (CVI) together with qualitative data. After modification, the validity assessments were repeated and followed by test-retest and inter-rater reliability tests in six units within a Swedish residential care facility that varied in terms of their environmental characteristics. RESULTS: Translation and back translation identified linguistic and semantic related issues. The results of the first content validity analysis showed that more than one third of the items had item-CVI (I-CVI) values less than the critical value of 0.78. After modifying the instrument, the second content validation analysis resulted in I-CVI scores above 0.78, the suggested criteria for excellent content validity. Test-retest reliability showed high stability (96% and 95% for two independent raters respectively), and inter-rater reliability demonstrated high levels of agreement (95% and 94% on two separate rating occasions). Kappa values were very good for test-retest (kappa = 0.903 and 0.869) and inter-rater reliability (kappa = 0.851 and 0.832). CONCLUSIONS: Adapting an instrument to a domestic context is a complex and time-consuming process, requiring an understanding of the culture where the instrument was developed and where it is to be used. A team, including the instrument’s developers, translators, and researchers is necessary to ensure a valid translation and adaption. This study showed preliminary validity and reliability evidence for the Swedish version (S-SCEAM) when used in a Swedish context. Further, we believe that the S-SCEAM has improved compared to the original instrument and suggest that it can be used as a foundation for future developments of the SCEAM model.
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Research Practice and Methodology
Team Science Approach to Developing Consensus on Research Good Practices for Practice-Based Research Networks: A Case Study.
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Using peer learning strategies, seven experienced PBRNs working in collaborative teams articulated procedures for PBRN Research Good Practices (PRGPs). The PRGPs is a PBRN-specific resource to facilitate PBRN management and staff training, to promote adherence to study protocols, and to increase validity and generalizability of study findings. This paper describes the team science processes which culminated in the PRGPs. Skilled facilitators used team science strategies and methods from the Technology of Participation (ToP(R)), and the Consensus Workshop Method to support teams to codify diverse research expertise in practice-based research. The participatory nature of “sense-making” moved through identifiable stages. Lessons learned include (1) team input into the scope of the final outcome proved vital to project relevance; (2) PBRNs with diverse domains of research expertise contributed broad knowledge on each topic; and (3) ToP(R) structured facilitation techniques were critical for establishing trust and clarifying the “sense-making” process.
People with dementia in nursing home research: a methodological review of the definition and identification of the study population
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BACKGROUND: There are various definitions and diagnostic criteria for dementia, leading to discrepancies in case ascertainment in both clinical practice and research. We reviewed the different definitions, approaches and measurements used to operationalize dementia in health care studies in German nursing homes with the aim of discussing the implications of different approaches. METHODS: We conducted a systematic search of the MEDLINE and CINAHL databases to identify pre-2016 studies conducted in German nursing homes that focused on residents with dementia or cognitive impairment. In- or exclusion of studies were consented by all authors; data extraction was independently carried out by 2 authors (RP, SJ). The studies’ sampling methods were compared with respect to their inclusion criteria, assessment tools and methods used to identify the study population. RESULTS: We summarized case ascertainment methods from 64 studies. Study participants were identified based on a diagnosis that was evaluated during the study, or a recorded medical dementia diagnosis, or a recorded medical diagnosis either with additional cognitive screenings or using screening tests exclusively. The descriptions of the diagnostics that were applied to assess a diagnosis of dementia were not fully transparent in most of the studies with respect to either a clear reference definition of dementia or applied diagnostic criteria. If reported, various neuropsychological tests were used, mostly without a clear rationale for their selection. CONCLUSION: Pragmatic considerations often determine the sampling strategy; they also may explain the variances we detected in the different studies. Variations in sampling methods impede the comparability of study results. There is a need to consent case ascertainment strategies in dementia studies in health service research in nursing homes. These strategies should consider resource constraints and ethical issues that are related to the vulnerable population of nursing home residents. Additionally, reporting about dementia studies in nursing homes need to be improved. If a diagnosis cannot be evaluated based on either ICD or DSM criteria, the study population may not be reported as having dementia. If a diagnosis is evaluated based on ICD or DSM criteria within the study, there is a need for more transparency of the diagnostic process.
Explanation and elaboration of the SQUIRE (Standards for Quality Improvement Reporting Excellence) Guidelines, V.2.0: examples of SQUIRE elements in the healthcare improvement literature
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Since its publication in 2008, SQUIRE (Standards for Quality Improvement Reporting Excellence) has contributed to the completeness and transparency of reporting of quality improvement work, providing guidance to authors and reviewers of reports on healthcare improvement work. In the interim, enormous growth has occurred in understanding factors that influence the success, and failure, of healthcare improvement efforts. Progress has been particularly strong in three areas: the understanding of the theoretical basis for improvement work; the impact of contextual factors on outcomes; and the development of methodologies for studying improvement work. Consequently, there is now a need to revise the original publication guidelines. To reflect the breadth of knowledge and experience in the field, we solicited input from a wide variety of authors, editors and improvement professionals during the guideline revision process. This Explanation and Elaboration document (E&E) is a companion to the revised SQUIRE guidelines, SQUIRE 2.0. The product of collaboration by an international and interprofessional group of authors, this document provides examples from the published literature, and an explanation of how each reflects the intent of a specific item in SQUIRE. The purpose of the guidelines is to assist authors in writing clearly, precisely and completely about systematic efforts to improve the quality, safety and value of healthcare services. Authors can explore the SQUIRE statement, this E&E and related documents in detail athttp://www.squire-statement.org.
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Aging
How older adults with mild cognitive impairment relate to technology as part of present and future everyday life: a qualitative study.
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BACKGROUND: Existing everyday technology as well as potential future technology may offer both challenges and possibilities in the everyday occupations of persons with cognitive decline. To meet their wishes and needs, the perspective of the persons themselves is an important starting point in intervention planning involving technology. The aim of this study was to explore how persons with mild cognitive impairment relate to technology as a part of and as potential support in everyday life – both present and future. METHODS: Qualitative in-depth interviews with six participants aged 61-86 were conducted and analyzed, using a grounded theory approach. RESULTS: The findings describe the participants’ different ways of relating to existing and potential future technology in everyday occupations as a continuum of downsizing, retaining, and updating. Multiple conditions in different combinations affected both their actions taken and assumptions made towards technology in this continuum. Both when downsizing doing and technology use to achieve simplicity in everyday life and when striving for or struggling with updating, trade-offs between desired and adverse outcomes were made, challenging take-off runs were endured, and negotiations of the price worth paying took place. CONCLUSIONS: Our findings suggest that persons with mild cognitive impairment may relate to technology in various ways to meet needs of downsized doing, but are reluctant to adopt video-based monitoring technology intended to support valued occupations. Feasibility testing of using already-incorporated everyday technologies such as smartphones and tablets as platforms for future technology support in everyday occupations is suggested.
A Communication Intervention to Reduce Resistiveness in Dementia Care: A Cluster Randomized Controlled Trial.
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PURPOSE OF THE STUDY: Nursing home (NH) residents with dementia exhibit challenging behaviors or resistiveness to care (RTC) that increase staff time, stress, and NH costs. RTC is linked to elderspeak communication. Communication training (Changing Talk [CHAT]) was provided to staff to reduce their use of elderspeak. We hypothesized that CHAT would improve staff communication and subsequently reduce RTC. METHODS: Thirteen NHs were randomized to intervention and control groups. Dyads (n = 42) including 29 staff and 27 persons with dementia were videorecorded during care before and/or after the intervention and at a 3-month follow-up. Videos were behaviorally coded for (a) staff communication (normal, elderspeak, or silence) and (b) resident behaviors (cooperative or RTC). Linear mixed modeling was used to evaluate training effects. RESULTS: On average, elderspeak declined from 34.6% (SD = 18.7) at baseline by 13.6% points (SD = 20.00) post intervention and 12.2% points (SD = 22.0) at 3-month follow-up. RTC declined from 35.7% (SD = 23.2) by 15.3% points (SD = 32.4) post intervention and 13.4% points (SD = 33.7) at 3 months. Linear mixed modeling determined that change in elderspeak was predicted by the intervention (b = -12.20, p = .028) and baseline elderspeak (b = -0.65, p < .001), whereas RTC change was predicted by elderspeak change (b = 0.43, p < .001); baseline RTC (b = -0.58, p < .001); and covariates. IMPLICATIONS: A brief intervention can improve communication and reduce RTC, providing an effective nonpharmacological intervention to manage behavior and improve the quality of dementia care. No adverse events occurred.
A protocol for a pragmatic randomized controlled trial using the Health Teams Advancing Patient Experience: Strengthening Quality (Health TAPESTRY) platform approach to promote person-focused primary healthcare for older adults.
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BACKGROUND: Healthcare systems are not well designed to help people maintain or improve their health. They are generally not person-focused or well-coordinated. The objective of this study is to evaluate the effectiveness of the Health Teams Advancing Patient Experience: Strengthening Quality (Health TAPESTRY) approach in older adults. The overarching hypothesis is that using the Health TAPESTRY approach to achieve better integration of the health and social care systems into a person’s life that centers on meeting a person’s health goals and needs will result in optimal aging. METHODS/DESIGN: This is a 12-month delayed intervention pragmatic randomized controlled trial. The study will be performed in Hamilton, Ontario, Canada in the two-site McMaster Family Health Team. Participants will include 316 patients who are 70 years of age or older. Participants will be randomized to the Health TAPESTRY approach or control group. The Health TAPESTRY approach includes intentional, proactive conversations about a person’s life and health goals and health risks and then initiation of congruent tailored interventions that support achievement of those goals and addressing of risks through (1) trained volunteers visiting clients in their homes to serve as a link between the primary care team and the client; (2) the use of novel technology including a personal health record from the home to link directly with the primary healthcare team; and (3) improved processes for connections, system navigation, and care delivery among interprofessional primary care teams, community service providers, and informal caregivers. The primary outcome will be the goal attainment scaling score. Secondary outcomes include self-efficacy for managing chronic disease, quality of life, the participant perspective on their own aging, social support, access to health services, comprehensiveness of care, patient empowerment, patient-centeredness, caregiver strain, satisfaction with care, healthcare resource utilization, and cost-effectiveness. Implementation processes will also be evaluated. The main comparative analysis will take place at 6 months. DISCUSSION: Evidence of the individual elements of the Health TAPESTRY platform has been shown in isolation in the previous research. However, this study will better understand how to best integrate them to maximize the system’s transformation of person-focused, primary care for older adults. TRIAL REGISTRATION: ClinicalTrials.gov NCT02283723.
Living Alone with Dementia: Prevalence Correlates and the Utilization of Health and Nursing Care Services.
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BACKGROUND: Little is known about the proportion and the characteristics of community-dwelling people with dementia (PWD) living alone in Germany. OBJECTIVES: To analyze the prevalence of PWD living alone (with and without the support of an informal caregiver) and socio-demographical and clinical characteristics as well as health and nursing care utilization associated with living alone. METHODS: DelpHi-MV (Dementia: Life- and person-centered help in Mecklenburg-Western Pomerania) is a general practitioner-based, randomized controlled intervention trial. The present analyses are based on baseline data of 511 patients (>/=70 years, community-dwelling) who had screened positive for dementia (DemTect <9). RESULTS: N = 251 (51%) of the patients lived alone. PWD living alone were statistically significantly more often female, older, and more often widowed than those not living alone. About 9% of the patients (n = 24) were not supported by any informal caregiver. Regarding the clinical variables (cognitive and functional impairment, depression, falls, number of drug-related problems, malnutrition, quality of life), there were no statistically significant group differences. Patients living alone utilized professional services such as home care, help with medication, home-delivered meals, or housekeeping assistance significantly more often. Multivariate analyses confirmed these findings. CONCLUSION: Our results reveal the high proportion of PWD living alone in Germany. PWD living alone did not seem to be at an increased health risk. Our findings indicate that living alone with dementia is possible. In order to ensure the sufficient provision of health and nursing care services for PWD living alone, providers should consider the present results for future planning.
Implementation of a baby doll therapy protocol for people with dementia: Innovative practice.
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Dementia is exhibited by both emotional and physical states such as agitation. Chemical restraints, often used for agitated behaviors, are not always effective and produce untoward effects. Baby doll therapy is a nonpharmacologic therapy that can affect agitated behavior in dementia patients, yet a protocol for the therapy did not exist. An implementation protocol for doll therapy for those with dementia was developed and implemented with 16 residents in a dementia care center. Outcomes were measurements of the impact of the dolls on six areas of the resident’s behavior and their reactions to the doll. Participants had an increase in level of happiness, activity/liveliness, interaction with staff and others, and ease of giving care. There was also a reduction in the level of anxiety. The increase in happiness was a statistically significant outcome. Baby doll therapy is an effective nonpharmacological approach for improving the well-being of patients with moderate to severe dementia.
Quality of dying in nursing home residents dying with dementia: does advanced care planning matter? A nationwide postmortem study.
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BACKGROUND: Advance care planning is considered a central component of good quality palliative care and especially relevant for people who lose the capacity to make decisions at the end of life, which is the case for many nursing home residents with dementia. We set out to investigate to what extent (1) advance care planning in the form of written advance patient directives and verbal communication with patient and/or relatives about future care and (2) the existence of written advance general practitioner orders are related to the quality of dying of nursing home residents with dementia. METHODS: Cross-sectional study of deaths (2010) using random cluster-sampling. Representative sample of nursing homes in Flanders, Belgium. Deaths of residents with dementia in a three-month period were reported; for each the nurse most involved in care, GP and closest relative completed structured questionnaires. FINDINGS: We identified 101 deaths of residents with dementia in 69 nursing homes (58% response rate). A written advance patient directive was present for 17.5%, GP-orders for 56.7%. Controlling for socio-demographic/clinical characteristics in multivariate regression analyses, chances of having a higher mean rating of emotional well-being (less fear and anxiety) on the Comfort Assessment in Dying with Dementia scale were three times higher with a written advance patient directive and more specifically when having a do-not-resuscitate order (AOR 3.45; CI,1.1-11) than for those without either (AOR 2.99; CI,1.1-8.3). We found no association between verbal communication or having a GP order and quality of dying. CONCLUSION: For nursing home residents with dementia there is a strong association between having a written advance directive and quality of dying. Where wishes are written, relatives report lower levels of emotional distress at the end of life. These results underpin the importance of advance care planning for people with dementia and beginning this process as early as possible.
The relative impact of chronic conditions and multimorbidity on health-related quality of life in Ontario long-stay home care clients. 
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PURPOSE: To examine the relative impact of 16 common chronic conditions and increasing morbidity on health-related quality of life (HRQL) in a population-based sample of home care clients in Ontario, Canada. METHODS: Participants were adult clients assessed with the Resident Assessment Instrument for Home Care (RAI-HC) between January and June 2009 and diagnosed with one (or more) of 16 common chronic conditions. HRQL was evaluated using the Minimum Data Set-Health Status Index (MDS-HSI), a preference-based measure derived from items captured in the RAI-HC. Multivariable linear regression models assessed the relative impact of each condition, and increasing number of diagnoses, on MDS-HSI scores. RESULTS: Mean (SD) MDS-HSI score in the study population (n = 106,159) was 0.524 (0.213). Multivariable analysis revealed a statistically significant (p /= 0.03) decrease in MDS-HSI scores associated with stroke (-0.056), osteoarthritis (-0.036), rheumatoid arthritis (-0.033) and congestive heart failure (CHF, -0.030). Differences by age and sex were observed; most notably, the negative impact associated with dementia was greater among men (-0.043) than among women (-0.019). Further, HRQL decreased incrementally with additional diagnoses. In all models, chronic conditions and number of diagnoses accounted for a relatively small proportion of the variance observed in MDS-HSI. CONCLUSION: Clinically important negative effects on HRQL were observed for clients with a previous diagnosis of stroke, osteo- and rheumatoid arthritis, or CHF, as well as with increasing levels of multimorbidity. Findings provide baseline preference-based HRQL scores for home care clients with different diagnoses and may be useful for identifying, targeting and evaluating care strategies toward populations with significant HRQL impairments.
Care Perceptions among Residents of LTC Facilities Purporting to Offer Person-Centred Care
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This study explored qualitatively how residents of long-term care (LTC) facilities feel about and adapt to the care they receive. We interviewed and observed a purposeful selection of elderly residents in seven facilities purporting to provide person-centred care. Interpretative descriptions from 43 personal interviews with 23 participants answered the question: How do residents perceive the care rendered in LTC facilities purporting to offer person-centred care? Three themes emerged: (1) the caring environment; (2) preservation of dignity; and (3) maintenance of personal autonomy. Participants were sympathetic to the nursing staff’s workload, but felt distant from the staff. Participants gave examples of poor care and lack of empathy, human indignities, and violations of personal autonomy caused by institutional policies they felt inhibited their ability to receive care based on their preferences. Overall, they challenged the claims of person-centred care, but adapted to cope with an environment that threatened their dignity and autonomy.
Exploring psychosocial interventions for people with dementia that enhance personhood and relate to legacy- an integrative review.
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BACKGROUND: Epidemiological predictions suggest that dementia will continue to rise and that this will have social and economic ramifications. Effective interventions, beyond pharmacological management are needed. Psychosocial interventions have largely been investigated in relation to carers of people with dementia, or with regards to their ability to manage dementia symptoms, improve cognition, and reduce challenging behaviour. However, since dementia is a life-limiting illness and people with dementia are at risk of having their personhood compromised, psychosocial interventions should seek to enhance personhood, and offer the potential for the person to leave a legacy. METHODS: An integrative review was carried out to identify, assess, appraise and synthesise studies featuring interventions, which relate to both personhood and legacy. Search strategies were developed in key databases: MEDLINE; PsycINFO; Embase; Joanna Briggs Institute; CINAHL; Cochrane Database of Systematic Reviews; ASSIA. Grey literature was also identified through free-text searches. RESULTS: Thirty six articles were included in the final review, these were tabulated and were assessed based on how the intervention related to personhood and legacy. Classification resulted in three themes being identified: Offering aspects of legacy; Acknowledging the person behind the patient; Facilitating meaningful engagement. Generally, personhood aspects of interventions were well reported, but further research is required to explore legacy potential of psychosocial interventions for people with dementia. CONCLUSION: The integrative review provides an overview and exploration of an under-researched area, and provides directions for future research, which will help expand the evidence base and ultimately help improve patient care for people with dementia and their families.
Prescribing of Psychoactive Drugs for Older People in Nursing Homes: An Analysis of Treatment Culture.
Non UofA Access
BACKGROUND: There is increasing interest in how culture may affect the quality of healthcare services, and previous research has shown that ‘treatment culture’-of which there are three categories (resident centred, ambiguous and traditional)-in a nursing home may influence prescribing of psychoactive medications. OBJECTIVE: The objective of this study was to explore and understand treatment culture in prescribing of psychoactive medications for older people with dementia in nursing homes. METHOD: Six nursing homes-two from each treatment culture category-participated in this study. Qualitative data were collected through semi-structured interviews with nursing home staff and general practitioners (GPs), which sought to determine participants’ views on prescribing and administration of psychoactive medication, and their understanding of treatment culture and its potential influence on prescribing of psychoactive drugs. Following verbatim transcription, the data were analysed and themes were identified, facilitated by NVivo(R) and discussion within the research team. RESULTS: Interviews took place with five managers, seven nurses, 13 care assistants and two GPs. Four themes emerged: the characteristics of the setting, the characteristics of the individual, relationships and decision making. The characteristics of the setting were exemplified by views of the setting, daily routines and staff training. The characteristics of the individual were demonstrated by views on the personhood of residents and staff attitudes. Relationships varied between staff within and outside the home. These relationships appeared to influence decision making about prescribing of medications. The data analysis found that each home exhibited traits that were indicative of its respective assigned treatment culture. CONCLUSION: Nursing home treatment culture appeared to be influenced by four main themes. Modification of these factors may lead to a shift in culture towards a more flexible, resident-centred culture and a reduction in prescribing and use of psychoactive medication.
The association between aspects of daily life and quality of life of people with dementia living in long-term care facilities: a momentary assessment study.
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BACKGROUND: To improve the quality of life (QoL) of people with dementia (PwD) living in long-term care facilities, insight into the association between QoL and how people spend their daily lives is urgently needed. This study investigated which aspects of daily life are related to QoL in dementia. METHODS: An observational study was conducted. Daily life was assessed with the tablet-based Maastricht Electronic Daily Life Observation-tool (MEDLO-tool). Aspects included activity, engagement in the activity, social interaction, physical effort, mood, and agitation. QoL was assessed by formal nursing caregivers using the Quality of Life-Alzheimer’s Disease scale (QoL-AD). A total of 9,660 momentary assessments were conducted. RESULTS: The mean age of the 115 participants was 84 years and most (75%) were women. Bivariate analyses showed that residents with a higher QoL carried out less passive/purposeless activities (25% vs. 38%), were more engaged in active, expressive, and social activities, (40% vs. 27%), had more social interaction (34% vs. 22%), and had better mood scores (scale 1-7, 5.0 vs. 4.8), compared with residents with a lower QoL (all p-values < 0.001). Multivariate analyses showed that having more social interaction and a positive mood are related to a higher QoL. CONCLUSIONS: The results underline the importance of social interaction and a positive mood for a higher QoL. Future research should investigate the importance of engagement in activities in more detail.
Team-Based Models for End-of-Life Care: An Evidence-Based Analysis.
Non UofA Access
BACKGROUND: End of life refers to the period when people are living with advanced illness that will not stabilize and from which they will not recover and will eventually die. It is not limited to the period immediately before death. Multiple services are required to support people and their families during this time period. The model of care used to deliver these services can affect the quality of the care they receive. OBJECTIVES: Our objective was to determine whether an optimal team-based model of care exists for service delivery at end of life. In systematically reviewing such models, we considered their core components: team membership, services offered, modes of patient contact, and setting. DATA SOURCES: A literature search was performed on October 14, 2013, using Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid Embase, EBSCO Cumulative Index to Nursing & Allied Health Literature (CINAHL), and EBM Reviews, for studies published from January 1, 2000, to October 14, 2013. REVIEW METHODS: Abstracts were reviewed by a single reviewer and full-text articles were obtained that met the inclusion criteria. Studies were included if they evaluated a team model of care compared with usual care in an end-of-life adult population. A team was defined as having at least 2 health care disciplines represented. Studies were limited to English publications. A meta-analysis was completed to obtain pooled effect estimates where data permitted. The GRADE quality of the evidence was evaluated. RESULTS: Our literature search located 10 randomized controlled trials which, among them, evaluated the following 6 team-based models of care: *hospital, direct contact *home, direct contact *home, indirect contact *comprehensive, indirect contact *comprehensive, direct contact *comprehensive, direct, and early contact Direct contact is when team members see the patient; indirect contact is when they advise another health care practitioner (e.g., a family doctor) who sees the patient. A “comprehensive” model is one that provides continuity of service across inpatient and outpatient settings, e.g., in hospital and then at home. All teams consisted of a nurse and physician at minimum, at least one of whom had a specialty in end-of-life health care. More than 50% of the teams offered services that included symptom management, psychosocial care, development of patient care plans, end-of-life care planning, and coordination of care. We found moderate-quality evidence that the use of a comprehensive direct contact model initiated up to 9 months before death improved informal caregiver satisfaction and the odds of having a home death, and decreased the odds of dying in a nursing home. We found moderate-quality evidence that the use of a comprehensive, direct, and early (up to 24 months before death) contact model improved patient quality of life, symptom management, and patient satisfaction. We did not find that using a comprehensive team-based model had an impact on hospital admissions or length of stay. We found low-quality evidence that the use of a home team-based model increased the odds of having a home death. LIMITATIONS: Heterogeneity in data reporting across studies limited the ability to complete a meta-analysis on many of the outcome measures. Missing data was not managed well within the studies. CONCLUSIONS: Moderate-quality evidence shows that a comprehensive, direct-contact, team-based model of care provides the following benefits for end-of-life patients with an estimated survival of up to 9 months: it improves caregiver satisfaction and increases the odds of dying at home while decreasing the odds of dying in a nursing home. Moderate-quality evidence also shows that improvement in patient quality of life, symptom management, and patient satisfaction occur when end-of-life care via this model is provided early (up to 24 months before death). However, using this model to deliver end-of-life care does not impact hospital admissions or hospital length of stay. Team membership includes at minimum a physician and nurse, with at least one having specialist training and/or experience in end-of-life care. Team services include symptom management, psychosocial care, development of patient care plans, end-of-life care planning, and coordination of care.
The Determinants of Place of Death: An Evidence-Based Analysis.
Non UofA Access
BACKGROUND: According to a conceptual model described in this analysis, place of death is determined by an interplay of factors associated with the illness, the individual, and the environment. OBJECTIVES: Our objective was to evaluate the determinants of place of death for adult patients who have been diagnosed with an advanced, life-limiting condition and are not expected to stabilize or improve. DATA SOURCES: A literature search was performed using Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid Embase, EBSCO Cumulative Index to Nursing & Allied Health Literature (CINAHL), and EBM Reviews, for studies published from January 1, 2004, to September 24, 2013. REVIEW METHODS: Different places of death are considered in this analysis-home, nursing home, inpatient hospice, and inpatient palliative care unit, compared with hospital. We selected factors to evaluate from a list of possible predictors-i.e., determinants-of death. We extracted the adjusted odds ratios and 95% confidence intervals of each determinant, performed a meta-analysis if appropriate, and conducted a stratified analysis if substantial heterogeneity was observed. RESULTS: From a literature search yielding 5,899 citations, we included 2 systematic reviews and 29 observational studies. Factors that increased the likelihood of home death included multidisciplinary home palliative care, patient preference, having an informal caregiver, and the caregiver’s ability to cope. Factors increasing the likelihood of a nursing home death included the availability of palliative care in the nursing home and the existence of advance directives. A cancer diagnosis and the involvement of home care services increased the likelihood of dying in an inpatient palliative care unit. A cancer diagnosis and a longer time between referral to palliative care and death increased the likelihood of inpatient hospice death. The quality of the evidence was considered low. LIMITATIONS: Our results are based on those of retrospective observational studies. CONCLUSIONS: The results obtained were consistent with previously published systematic reviews. The analysis identified several factors that are associated with place of death.
Effect of horticultural therapy on wellbeing among dementia day care programme participants: A mixed-methods study
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Fourteen people attending an adult day programme were recruited to a structured horticultural therapy programme which took place over 10 weeks. The effects were assessed using Dementia Care Mapping and questionnaires completed by family carers. High levels of wellbeing were observed while the participants were engaged in horticultural therapy, and these were sustained once the programme was completed. This study adds to the growing evidence on the benefits of horticultural therapy for people with dementia who have enjoyed gardening in the past.
The challenges of implementing and evaluating a pilot music and movement intervention for people with dementia
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This paper reports on the challenges associated with implementing and evaluating an innovative pilot music and movement project. The evaluation documents that participants enjoyed the sessions and that they created the opportunity for social engagement although there is little to suggest this is unique to this particular type of intervention. Difficulties included matching the programme to the needs of participants, communicating effectively, and over burdensome paperwork. The paper also comments on the challenges associated with last minute, limited funding opportunities for both the organisation commissioning a project and the team evaluating it. In this case, the evaluation team found that many of the more difficult issues associated with the pilot could have been resolved with more time for planning and preparation.
RemoDem: Delivering support for people with dementia in remote areas
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RemoDem aimed to develop, test and evaluate services for people with dementia in remote areas of the Faroe Islands, Greenland, Sweden and Scotland. Formative and summative evaluation used a flexible research design including collection of baseline data, interviews and focus groups with key informants and data relating to service users, i.e. people with dementia and their carers. Challenges for service providers included organisational difficulties, lack of clear information about their populations with dementia and lack of knowledge in local communities. Test sites which developed services building on their particular local starting points adopted both specialist and ‘off the shelf’ technologies and found that these were generally helpful for people with significant support needs. The flexible research design was found to be essential in the real world conditions of the service development and evaluation. Services were more successful where more mature and less experimental technologies were used. The new services promised to address effectively challenges of remoteness including distance, communication and workforce deployment issues.
Wellness in Early Onset Familial Alzheimer Disease: Experiences of the Tahltan First Nation
This report summarizes community perspectives of the Tahltan First Nation and their experiences with early onset familial Alzheimer disease (EOFAD). The report also provides information about EOFAD for dialogue within and across Tahltan communities.
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Events
UofA
Film and panel discussion: Human Harvest
Special Guests:
David Kilgour, Former Edmonton MP, Nobel Peace Prize Nominee
Charl Els, MD, Associate Clinical Professor, Advisory Board DAFOH (Nominee: 2016 Nobel Peace Prize)
Film Logline: “Nobel Peace Prize nominees David Matas and David Kilgour investigate the organ harvesting trade in China and uncover one of the world’s worst crimes against humanity”
Non-beneficial treatment in ICU
Visiting Speaker, Dr. James Downar Critical Care and Palliative Care Physician, University Health Network, Toronto
Online
The imperative of person-centered care requires that the voices of palliative older adults and their families are represented at all levels of health care decision making. Routine assessments of perceived healthcare needs and quality of life (QOL) can make patient and family caregiver concerns more visible to healthcare professionals, so they can be effectively monitored and addressed. These assessments involve asking people about symptoms, physical, psychological and social wellbeing, and their experiences with healthcare.
News
Quality improvement must be part of training, say experts (UK)
All doctors should have access to training in quality improvement, which should be made “part of the mindset” of all health and social care staff, experts have said.
New Brunswick Appropriate Use of Antipsychotics Collaborative
The Canadian Foundation for Healthcare Improvement and the New Brunswick Association of Nursing Homes (NBANH) are working together, with funding support from the Government of New Brunswick, to improve dementia care through the appropriate use of antipsychotic medications in New Brunswick nursing homes.
Stirling collaborates to develop dementia activity toolkit (UK)
The University of Stirling is supporting the development of an innovative activity toolkit to encourage creative activities among people living with dementia.
Here you will be able to find information on KT rounds, the scientific meeting, view past newsletters, etc.
Finding a suitable home for your research program – Part 1, reviewing the offer
The chair of the search committee has now made it clear that they are prepared to offer you a faculty position in their department and would like to begin negotiating the details of your appointment. Now what . . .
Finding a suitable home for your research program – part 2, budgeting and resources
The chair of the search committee has now made it clear that they are prepared to offer you a faculty position in their department and would like to begin negotiating the details of your appointment. What about the money???
What are the most important skills PhDs need upon graduation?
Successful graduates of a Ph.D. program are armed with the skills that will enhance their future success, regardless of chosen career path. Included among the most important of these skills are scientific writing, critical thinking, and the construction of solid logical arguments combined with a plan for rigorous testing. Despite the importance of these skills, specific formalized training geared at acquiring them is typically limited, often quite variable, and commonly dependent on individual thesis advisors or the voluntary efforts of a small subset of faculty members.
Caregivers Often Give Up Necessities to Cover Alzheimer’s Costs (US)
Many skip food and health care, cut back work hours or quit jobs to care for loved ones, survey shows.
Not Just a Death, a System Failure
On the day before my mother died, she gave my father a list of demands. He wrote them on the back of an envelope and showed them to me as he left the intensive care unit. There, in his clear block handwriting, it read: CREAM; WHISKEY; HEROIN.
Milestones in Quality Improvement Measurement
Quality teams need to go beyond the common measures used in the past and identify initiatives that address the current emphasis on effective and efficient care.
Innovations in End-of-Life Care: Where the Chart Meets the Heart
It can be daunting to make improving end-of-life care a high priority with all the challenges of the current health care environment. But there are many reasons to do so.
New Models for Elder Care: Three Ways Norway Inspired Me
In Norway, as in many countries, the population is aging and the burden of disease is increasing. Elder care will need new designs and new models. Here are three things that most inspired me on my trip to Norway.
Three Things Scholarly Publishers Should Know About Researchers
A couple of recent posts on this blog have been aimed at increasing researchers’ understanding of publishing and publishers. As it happens, around the time they were posted, I was in the middle of a series of interviews with researchers, and they in turn were flagging challenges that they wished publishers understood better.
If you’re working with a writing partner, or a group, there’ll come a time when you want to give each other feedback. And you’ll want that feedback to be affirming not debilitating, and helpfully critical and not crushingly negative.
B.C. Health Minister orders review of staffing guidelines in long-term care homes for seniors
Health Minister Terry Lake has ordered a review of staffing guidelines in government-funded long-term care homes for seniors after a report from the province’s seniors advocate.
A homelike feel to new dementia assessment unit
As the door of the new dementia assessment unit at the Wascana Rehabilitation Centre closes, a mural of sunflowers against a bright blue sky emerges for patients to see.
Resources
Practice Guideline: Older people with social care needs and multiple long-term conditions (UK)
Guideline Objective(s)
-To consider how person-centred social care and support for older people with multiple long-term conditions should be planned and delivered
-To address how those responsible for commissioning, managing and providing care for people with multiple long-term conditions should work together to deliver safe, high-quality services that promote independence, choice and control
The Mind Thief: A Kid’s Guide to Alzheimer’s Disease
This comic book explains Alzheimer’s Disease from a First Nations perspective.
How to Ask Faculty for a Favor
Although I have many questions that I could use your help with, the one foremost in my mind right now is: How do I write an email to someone I don’t know, asking them for something? Be it a research paper, an interview, or the opportunity to collaborate in their research, I am struggling with how to reach out to people I don’t know and ask them for favors. How much do I tell them about myself, so that they are interested in me and want to help? Should I just get to the point? Any recommendations in this regard would be truly appreciated.
Practice Guideline: Recommendations on screening for cognitive impairment in older adults.
This guideline objective is to provide evidence-based recommendations on screening for cognitive impairment in adults
The prospect of laboriously crafting an online image is probably somewhat off-putting. It’s certainly a recurrent theme in critiques of social media and the digital narcissism it is said to engender. However it doesn’t have to be a time-consuming process. Reflecting on how to present yourself online is helpful because it’s the most immediate way of addressing broader issues of online identity.
Narrative matters on long-term care
Narrative Matters is a popular section within Health Affairs that focuses on personal accounts of individuals’ encounters with the health care system. These sometimes heart-breaking, often familiar experiences with being a patient or health care professional (or both!) are sure to captivate and inform you. And, they reveal how health policy touches lives in a very real way. In this book, real life accounts from patient and caregivers explore the challenges of living with long-term needs and of dying.
