September 10, 2019



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Call For Input: Experience Working With Consumer Engagement In Implementation
Input required from implementation scientists

Researchers at the University of Arkansas’ Central Arkansas Veterans Healthcare System are seeking input from implementation scientists as part of a research study to develop guidelines on how to engage patients and other consumers in healthcare implementation activities. The study will assess current examples in the field and barriers participants in the survey have encountered. Consumers could include families, patients, caregivers, and are especially interested in consumers who experience health disparities. The setting is healthcare.

New article by Lars Wallin
Feasibility and usefulness of a leadership intervention to implement evidence-based falls prevention practices in residential care in Canada.
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W. Gifford, K. B. Lewis, A. C. Eldh, et al.
Pilot Feasibility Stud 2019 Aug 19;5:103-019-0485-7. eCollection 2019
Leadership is critical to supporting and facilitating the implementation of evidence-based practices in health care. Yet, little is known about how to develop leadership capacity for this purpose. The aims of this study were to explore the (1) feasibility of delivering a leadership intervention to promote implementation, (2) usefulness of the leadership intervention, and (3) participants’ engagement in leadership to implement evidence-based fall prevention practices in Canadian residential care. Methods: We conducted a mixed-method before-and-after feasibility study on two units in a Canadian residential care facility. The leadership intervention was based on the Ottawa model of implementation leadership (O-MILe) and consisted of two workshops and two individualized coaching sessions over 3 months to develop leadership capacity for implementing evidence-based fall prevention practices. Participants (n = 10) included both formal (e.g., managers) and informal (e.g., nurses and care aids leaders). Outcome measures were parameters of feasibility (e.g., number of eligible candidates who attended the workshops and coaching sessions) and usefulness of the leadership intervention (e.g., ratings, suggested modifications). We conducted semi-structured interviews guided by the Implementation Leadership Scale (ILS), a validated measure of 12-item in four subcategories (proactive, supportive, knowledgeable, and perseverant), to explore the leadership behaviors that participants used to implement fall prevention practices. We repeated the ILS in a focus group meeting to understand the collective leadership behaviors used by the intervention team. Barriers and facilitators to leading implementation were also explored. Results: Delivery of the leadership intervention was feasible. All participants (n = 10) attended the workshops and eight participated in at least one coaching session. Workshops and coaching were rated useful (>/= 3 on a 0-4 Likert scale where 4 = highly useful) by 71% and 86% of participants, respectively. Participants rated the O-MILe subcategories of supportive and perseverant leadership highest for individual leadership, whereas supportive and knowledgeable leadership were rated highest for team leadership. Conclusions: The leadership intervention was feasible to deliver, deemed useful by participants, and fostered engagement in implementation leadership activities. Study findings highlight the complexity of developing implementation leadership and modifications required to optimize impact. Future trials are now required to test the effectiveness of the leadership intervention on developing leadership for implementing evidence-based practices.

 

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Grants & Awards

SPOR Graduate Studentships (AB students only)

DEADLINE 11 October
The Alberta SPOR Graduate Studentship provides one year of funding support towards the first year of a thesis-based Master’s or Doctoral degree, consisting of a stipend of $30,000.

 

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Publications

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

KT

Designing high-quality implementation research: development, application, feasibility and preliminary evaluation of the implementation science research development (ImpRes) tool and guide.
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L. Hull, L. Goulding, Z. Khadjesari, et al.
Implement Sci 2019 Aug 14;14(1):80-019-0897-z
Designing implementation research can be a complex and daunting task, especially for applied health researchers who have not received specialist training in implementation science. We developed the Implementation Science Research Development (ImpRes) tool and supplementary guide to address this challenge and provide researchers with a systematic approach to designing implementation research. METHODS: A multi-method and multi-stage approach was employed. An international, multidisciplinary expert panel engaged in an iterative brainstorming and consensus-building process to generate core domains of the ImpRes tool, representing core implementation science principles and concepts that researchers should consider when designing implementation research. Simultaneously, an iterative process of reviewing the literature and expert input informed the development and content of the tool. Once consensus had been reached, specialist expert input was sought on involving and engaging patients/service users; and economic evaluation. ImpRes was then applied to 15 implementation and improvement science projects across the National Institute of Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) South London, a research organisation in London, UK. Researchers who applied the ImpRes tool completed an 11-item questionnaire evaluating its structure, content and usefulness. RESULTS: Consensus was reached on ten implementation science domains to be considered when designing implementation research. These include implementation theories, frameworks and models, determinants of implementation, implementation strategies, implementation outcomes and unintended consequences. Researchers who used the ImpRes tool found it useful for identifying project areas where implementation science is lacking (median 5/5, IQR 4-5) and for improving the quality of implementation research (median 4/5, IQR 4-5) and agreed that it contained the key components that should be considered when designing implementation research (median 4/5, IQR 4-4). Qualitative feedback from researchers who applied the ImpRes tool indicated that a supplementary guide was needed to facilitate use of the tool. CONCLUSIONS: We have developed a feasible and acceptable tool, and supplementary guide, to facilitate consideration and incorporation of core principles and concepts of implementation science in applied health implementation research. Future research is needed to establish whether application of the tool and guide has an effect on the quality of implementation research.

Taking an integrated knowledge translation approach in research to develop the CONSORT-Equity 2017 reporting guideline: an observational study.
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J. Jull, I. D. Graham, E. Kristjansson, et al.
BMJ Open 2019 Jul 30;9(7):e026866-2018-026866
We describe the use of an integrated knowledge translation (KT) approach in the development of the CONsolidated Standards Of Reporting Trials extension for equity (‘CONSORT-Equity 2017′), and advisory board-research team members’ (‘the team’) perceptions of the integrated KT process. DESIGN: This is an observational study to describe team processes and experience with a structured integrated KT approach to develop CONSORT-Equity 2017. Participant observation to describe team processes and a survey were used with the 38 team members. SETTING: Use of the CONSORT health research reporting guideline contributes to an evidence base for health systems decision-making, and CONSORT-Equity 2017 may improve reporting about health equity-relevant evidence. An integrated KT research approach engages knowledge users (those for whom the research is meant to be useful) with researchers to co-develop research evidence and is more likely to produce findings that are applied in practice or policy. PARTICIPANTS: Researchers adopted an integrated KT approach and invited knowledge users to form a team. RESULTS: An integrated KT approach was used in the development of CONSORT-Equity 2017 and structured replicable steps. The process for co-developing the reporting guideline involved two stages: (1) establishing guiding features for co-development and (2) research actions that supported the co-development of the reporting guideline. Stage 1 consisted of four steps: finding common ground, forming an advisory board, committing to ethical guidance and clarifying theoretical research assumptions. Bound by the stage 1 guiding features of an integrated KT approach, stage 2 consisted of five steps during which studies for consensus-based reporting guidelines were conducted. Of 38 team members, 25 (67.5%) completed a survey about their perceptions of the integrated KT approach. CONCLUSIONS: An integrated KT approach can be used to engage a team to co-develop reporting guidelines. Further study is needed to understand the use of an integrated KT approach in the development of reporting guidelines.

 

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Health Care Administration and Organization

Homelike Models in Long Term Care: A Review of Clinical Effectiveness, Cost-Effectiveness, and Guidelines
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CADTH, C. Gray, K. Farrah
2019 Jun 5
Canada’s population is rapidly aging. The percentage of Canadians aged 65 years and older increased from 12.1% to 13.2% between 1996 and 2006 – by 2016 the percentage had reached 16.5%.(1) Based on these Census data,(1) it has been forecasted that 263,000 Canadians will require long-term care by 2035.(2) Long-term care facilities offer accommodations and 24-hour care (e.g., health services, personal care, and meals) for people who are unable to live at home.(3) In Canada, long-term care is under provincial and territorial legislation, and there is wide variation in delivery and cost coverage across jurisdictions.(3) Traditional long-term care facilities are large institutions with rigid schedules that provide little autonomy for residents, and residents in these settings have reported feeling bored, lonely, and helpless.(4) Alternative models of long-term care have been developed to overcome the limitations of traditional models, with the aim of improving quality of life, quality of care, and satisfaction of residents. “Homelike models of care” broadly represent one such alternative model. In terms of the physical environment, homelike care facilities are designed to feel less like medical institutions and more like homes. Although required components are not strictly defined, common elements of homelike care models include: small group living clusters; high staff-to-patient ratios; staff wearing their own clothes instead of uniforms; comfortable, homelike furnishings; and natural elements such as plants, natural sunlight, and access to the outdoors. From a patient perspective, sense of home is determined by psychological factors (i.e., feeling acknowledged, preserving one’s habits and values, perceiving autonomy and control, and coping), social factors (interactions and relationships with staff, other residents, family, and friends; pets), and the built environment (i.e., private- and public space, personal belongings, technology, look and feel, outdoors spaces, and location).(5) The objective of the report is to summarize the evidence regarding the clinical effectiveness, cost-effectiveness, and guidelines regarding homelike models of care for residents of long-term care facilities.

Pharmacist services in nursing home: A systematic review and meta-analysis.
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S. W. H. Lee, V. S. L. Mak and Y. W. Tang.
Br J Clin Pharmacol 2019 Aug 29
Pharmacists have been contributing to the care of residents in nursing homes and play a significant role in ensuring quality use of medicine. However, the changing role of pharmacist in nursing homes and their impact on residents is relatively unknown. METHODS: Six electronic databases were searched from inception until November 2018 for articles published in English examining the services offered by pharmacists in nursing homes. Studies were included if it examined the impact of interventions by pharmacists to improve the quality use of medicine in nursing homes. RESULTS: Fifty-two studies (30,376 residents) were included in the current review. Thirteen studies were randomised controlled studies, while the remainder were either pre-post, retrospective or case-control studies which pharmacists provided services such as clinical medication review in collaboration with other healthcare professionals as well as staff education. Pooled analysis found that pharmacist-led services reduced the mean number of falls (-0.50; 95%CI: -0.79 to -0.21) among residents in nursing home. Mixed results were noted on the impact of pharmacists’ services on mortality, hospitalization and admission rates among residents. The potential financial savings of such services have not been formally evaluated by any studies thus far. The strength of evidence was moderate for the outcomes of mortality and number of fallers. CONCLUSION: Pharmacists contribute substantially to patient care in nursing homes, ensuring quality use of medication, resulting in reduced fall rates. Further studies with rigorous design are needed to measure the impact of pharmacist services on the economic benefits and other patient health outcomes.

Care workers’ view on factors leading to unplanned hospitalizations of nursing home residents: A cross-sectional multicenter study.
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M. Giger, N. Voneschen, T. Brunkert and F. Zuniga.
Geriatr Nurs 2019 Aug 22
Nursing home residents have a high risk of adverse events during hospitalizations. Since up to two-thirds of hospitalizations of nursing home residents are rated as potentially preventable, this study aimed to describe factors related to unplanned hospitalizations and to describe rates of unplanned hospitalizations, comparing differences between high- and low-hospitalization nursing homes. This cross-sectional multicenter study was conducted in 19 Swiss nursing homes and used questionnaire surveys of ward supervisors (n=33) and nursing staff (n=146) and retrospectively assessed hospitalization data. The study revealed several issues regarding unplanned hospitalizations, mostly concerning limitations regarding physicians’ availability, lack of acquaintance of on-call physicians with the residents, and health professionals’ lack of knowledge about the residents’ wishes concerning therapeutic decisions. Our findings suggest that standardizing advance care planning processes and better physician availability might further reduce hospitalizations and improve quality of care in nursing homes.

Characteristics of nursing homes with comprehensive antibiotic stewardship programs: Results of a national survey.
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C. J. Fu, E. Mantell, P. W. Stone and M. Agarwal.
Am J Infect Control 2019 Aug 22
Antibiotic stewardship in nursing homes (NHs) is a high priority owing to intense antibiotic use and increased risk of adverse events. Updated Centers for Medicare and Medicaid Services regulations required NHs to establish antibiotic stewardship programs (ASPs). This study describes the current state of NH ASPs. METHODS: A nationally representative survey of NHs was conducted in 2018. ASP comprehensiveness, infection preventionist (IP) training, participation in Quality Innovation Network-Quality Improvement Organization (QIN-QIO) activities, and facility and staff characteristics were analyzed using weighted descriptive statistics and multinomial regression models. RESULTS: Of 861 NHs, 33.2% (6-7) had “comprehensive” ASP policies, 41.1% (4-5) had “moderately comprehensive” ASP policies, and 25.6% (</= 3) had “not comprehensive” ASP policies. Data collection on antibiotic use was most reported (91.4%), and restricting use of specific antibiotics was least reported (19.0%). Comprehensive ASPs were associated with QIN-QIO involvement; moderate and comprehensive ASPs were associated with IP training and high occupancy. DISCUSSION: Immediately following Centers for Medicare and Medicaid Services regulation changes, a majority of NHs had moderately comprehensive or comprehensive ASPs. Rates for each policy and infection control-trained IPs increased from previous studies. CONCLUSIONS: NH ASPs are becoming more comprehensive. Infection control training and partnerships with QIN-QIOs can support NHs to increase ASP comprehensiveness.

Professionals’ views and experiences in supporting decision-making involvement for people living with dementia.
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C. Sinclair, J. Bajic-Smith, M. Gresham, et al.
Dementia (London) 2019 Jul 26:1471301219864849.
The provision of supported decision-making for people living with disabilities is an emerging area of practice and rights-based law reform, and is required under international law. Objectives This qualitative study aimed to understand how Australian health and legal professionals conceptualised their professional roles in the practice of providing decision-making support for people living with dementia. Methods The methods were informed by grounded theory principles. In-depth, semi-structured interviews were conducted with 28 health and legal professionals involved in providing care or services for people with dementia. Interviews explored how professionals described their practice of providing support for decision-making and how they conceptualised their roles. The analysis was underpinned by the theoretical perspective of symbolic interactionism. Results Participants described providing support across a range of decision domains, some of which were specific to their professional role. Four key themes were identified: ‘establishing a basis for decision-making’, ‘the supportive toolbox’, ‘managing professional boundaries’ and ‘individualist advocacy versus relational practice’. Participants identified a range of generic and specialised techniques they used to provide support for people with dementia. These techniques were applied subject to resource limitations and perceived professional obligations and boundaries. A continuum of professional practice, ranging from ‘individualist advocacy’ to ‘relational practice’ describes the approaches adopted by different professionals. Discussion Professionals conceptualised their role in providing support for decision-making through the lens of their own profession. Differences in positioning on the continuum of ‘individualist advocacy’ through to ‘relational practice’ had practical implications for capacity assessment, engaging with persons with impaired decision-making capacity, and the inclusion of supporters and family members in decision-making processes. Further progress in implementing supported decision-making (including through law and policy reform) will require an understanding of these inter-professional differences in perceived roles relating to the practice of providing decision-making support.

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Health Care Innovation and Quality Assurance

Perceived enabling factors and barriers for the implementation of improvements in health care in order to achieve patient-centred care: A case report from Sweden.
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K. Wijk, F. Aberg Jonsson and M. Lindberg.
J Eval Clin Pract 2019 Sep 2
More knowledge is needed regarding the complex factors and perceptions that enable the implementation of change in health care. The study aimed to examine the enabling factors and barriers encountered in the implementation of improvements in health care in order to achieve patient-centred care (PCC) and to study if there was a correlation in the extent the improvements were perceived to be implemented and the preconditions that were considered to affect them. METHODS: Using a mixed method design, data were gathered via a questionnaire and individual interviews with health care personnel, clinic managers, and first-line managers. The data collection and analyses were based on the framework for Promoting Action on Research Implementation in Health Services (PARiHS). Correlations between PCC improvements and preconditions for improvements were performed. RESULTS: A high level of involvement, knowledge, and adequate resources were considered important to achieve an implementation of PCC with joint responsibility. Leadership and management need to be explicit and promote continuous follow-up and feedback. Preconditions for improvement had a linear correlation with the perceived level of implementation. Knowledge-related preconditions had greatest impact on implementation. CONCLUSIONS: The PARiHS framework was appropriate to use since the three components of evidence, context, and facilitation present different important preconditions in the implementation process. Evidence was the highest rated contributor since evidence-based practices in health care are necessary. It is vital that the important role of the context and facilitators is acknowledged in the implementation process to enable a successful implementation of change. There is a need to incorporate a clear strategy involving all levels in the organization. Furthermore, leaders play an important role in the implementation by facilitating communication and support and by having trust in facilitators and health care personnel. The results are applicable to other interventions implementing change in health care.

Conditions and ethical challenges that could influence the implementation of technologies in nursing homes: A qualitative study.
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A. Bourbonnais, J. Rousseau, M. H. Lalonde, J. Meunier, N. Lapierre and M. P. Gagnon.
Int J Older People Nurs 2019 Sep 1:e12266
To explore the conditions that may influence the implementation of an interactive mobile application (app) and an intelligent videomonitoring system (IVS) in nursing homes (NHs) and the ethical challenges of their use. BACKGROUND: There is a lack of knowledge about implementing technologies in NHs and the ethical challenges that might arise. In past studies, nursing care teams expressed the need for technologies offering clinical support. Technologies like an IVS and an app could prove useful in NHs to prevent and manage falls and responsive behaviours. DESIGN: An exploratory qualitative study was conducted with care managers, family caregivers and formal caregivers in five NHs. METHODS: Each participant was shown a presentation of a potential app and a short video on an IVS. It was followed by an individual semi-structured interview. A conventional content analysis was performed. FINDINGS: Potential users found it would be possible to implement these technologies in NHs even if resistance could be expected. To facilitate adoption and achieve clinical benefits, the implementation of technologies should be pilot-tested, and coaching activities should be planned. Ethical risks were considered already present in NHs even without technologies, for example, risks to privacy. Strategies were proposed, for instance, to adapt the code of ethics and procedures. Some potential prejudices about the interest and abilities of older staff, nurses’ aides, and family caregivers to use technology were identified. CONCLUSIONS: Through rigorous and ethical implementation, technologies supporting clinical care processes could benefit older people living in NHs, as well as their relatives and the staff. IMPLICATIONS FOR PRACTICE: Various strategies are proposed to successfully implement technologies. Effort should be made to avoid prejudices during implementation, and procedures should be adapted to mitigate possible ethical challenges.

Five-layer border dressings as part of a quality improvement bundle to prevent pressure injuries in US skilled nursing facilities and Australian nursing homes: A cost-effectiveness analysis.
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W. V. Padula, Y. H. Chen and N. Santamaria.
Int Wound J 2019 Sep
The BORDER III trial found that five-layer silicone border dressings effectively prevented pressure injuries in long-term care, but the value of this approach is unknown. Our objective was to analyse the cost-effectiveness of preventing facility-acquired pressure injuries with a quality improvement bundle, including prophylactic five-layer dressings in US and Australian long-term care. Markov models analysed the cost utility for pressure injuries acquired during long-term care from US and Australian perspectives. Models calibrated outcomes for standard care compared with a dressing-inclusive bundle over 18 monthly cycles or until death based on BORDER III outcomes. Patients who developed a pressure injury simulated advancement through stages 1 to 4. Univariate and multivariate probabilistic sensitivity analyses tested modelling uncertainty. Costs in 2017 USD and quality-adjusted life years (QALYs) were used to calculate an incremental cost-effectiveness ratio (ICER). Dressing use yielded greater QALYs at slightly higher costs from perspectives. The US ICER was $36 652/QALY, while the Australian ICER was $15 898/QALY, both of which fell below a willingness-to-pay threshold of $100 000/QALY. Probabilistic sensitivity analysis favoured dressings as cost-effective for most simulations. A quality improvement bundle, including prophylactic five-layer dressings, is a cost-effective approach for pressure injury prevention in all US and Australia long-term care residents.

Implementing Project Extension for Community Healthcare Outcomes for Geriatric Mental Healthcare in Long-Term Care Facilities.
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M. J. Hasselberg, E. Fisher, Y. Conwell, D. Jacobowitz and J. A. Pagan.
J Am Med Dir Assoc 2019 Aug 26.
Long-term care (LTC) facilities are being incentivized to shift toward value-based reimbursement, with a focus on achieving the Triple Aim—enhanced patient experience, improved population health, and reduced costs. High staff turnover is also common in LTC settings, and occupational stress is a major challenge. Thus, achieving the Triple Aim within the LTC context may require addressing a fourth aim of improving the work life of LTC clinicians and staff.

Coroners’ recommendations for prevention of resident deaths in aged care: The role of primary care providers
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G. Aitken, A. Demosthenous, L. Bugeja, M. Willoughby, C. Young and J. E Ibrahim.
Aust J Gen Pract 2018 May;47(5):314-317
Currently, very little is known about how coroners consider a role for general practitioners (GPs) and registered nurses (RNs) in recommendations for the prevention of premature death. Involving these professions in recommendations generally directed towards government organisations or residential aged care providers and management may contribute to more successful broader policy changes. The aim of this article was to examine whether coroners’ recommendations describe a specific role for GPs and RNs in the prevention of premature death in residential aged care settings and, if so, what domains of practice were considered. METHOD: This study was part of a larger retrospective cohort study. The National Coronial Information System (NCIS) was used to extract coroners’ reports that included recommendations directed towards GPs and RNs. The following information was extracted: mechanism of death, incident location, text of coroners’ recommendations. RESULTS: Of 162 unique recommendations, 14 (8.6%) were relevant to GPs and 10 (6.2%) were relevant to RNs. Most recommendations were made in the domains of ‘applied professional knowledge and skills’, ‘organisations and legal dimensions’ and ‘provision and coordination of care’. Recommendations were primarily made in response to natural cause deaths and complications of clinical care. DISCUSSION: Coroners’ recommendations have a limited focus directed towards GPs and RNs, and recommendations focus on their roles in application of skills and knowledge, legal domains, and provision and coordination of care. Recommendations were mainly made in response to deaths due to suboptimal care or from ‘complications of clinical care’. Formulating recommendations for these health professions may increase accountability and the likelihood of a recommendation being effectively implemented.

Implementing a multidisciplinary psychotropic medication review among nursing home residents with dementia: a process evaluation.
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D. L. Gerritsen, E. de Vries, M. Smalbrugge, et al.
Int Psychogeriatr 2019 Aug 27:1-13
Before drawing conclusions on the contribution of an effective intervention to daily practice and initiating dissemination, its quality and implementation in daily practice should be optimal. The aim of this process evaluation was to study these aspects alongside a randomized controlled trial investigating the effects of a multidisciplinary biannual medication review in long-term care organizations (NTR3569). DESIGN: Process evaluation with multiple measurements. SETTING: Thirteen units for people with dementia in six long-term care organizations in the Netherlands. PARTICIPANTS: Physicians, pharmacists, and nursing staff of participating units. INTERVENTION: The PROPER intervention is a structured and biannually repeated multidisciplinary medication review supported by organizational preparation and education, evaluation, and guidance. MEASUREMENTS: Web-based questionnaires, interviews, attendance lists of education sessions, medication reviews and evaluation meetings, minutes, evaluation, and registration forms. RESULTS: Participation rates in education sessions (95%), medication reviews (95%), and evaluation meetings (82%) were high. The intervention’s relevance and feasibility and applied implementation strategies were highly rated. However, the education sessions and conversations during medication reviews were too pharmacologically oriented for several nursing staff members. Identified barriers to implementation were required time, investment, planning issues, and high staff turnover; facilitators were the positive attitude of professionals toward the intervention, the support of higher management, and the appointment of a local implementation coordinator. CONCLUSION: Implementation was successful. The commitment of both higher management and professionals was an important factor. This may partly have been due to the subject being topical; Dutch long-term-care organizations are pressed to lower inappropriate psychotropic drug use.

Thirty-Year Trends in Nursing Home Composition and Quality Since the Passage of the Omnibus Reconciliation Act.
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S. A. Fashaw, K. S. Thomas, E. McCreedy and V. Mor.
J Am Med Dir Assoc 2019 Aug 23
In 1987, the Omnibus Reconciliation Act (OBRA) called for a dramatic overhaul of the nursing home (NH) quality assurance system. This study examines trends in facility, resident, and quality characteristics since passage of that legislation. METHODS: We conducted univariate analyses of national data on US NHs from 3 sources: (1) the 1985 National Nursing Home Survey (NNHS), (2) the 1992-2015 Online Survey Certification and Reporting (OSCAR) Data, and (3) LTCfocUS data for 2000-2015. We examined changes in NH characteristics, resident composition, and quality. SETTING AND PARTICIPANTS: US NH facilities and residents between 1985 and 2015. RESULTS: The proportion of NHs that are Medicare and Medicaid certified, members of chains, and operating not-for-profit has increased over the past 30 years. There have also been reductions in occupancy and increases in the share of residents who are racial or ethnic minorities, admitted for post-acute care, in need of physical assistance with daily activities, primarily supported by Medicare, and diagnosed with a psychiatric condition such as schizophrenia. With regard to NH quality, direct care staffing levels have increased. The proportion of residents physically restrained has decreased dramatically, coupled with changes in inappropriate antipsychotic (chemical restraint) use. CONCLUSIONS AND IMPLICATIONS: Together with changes in the long-term care market, the NHs of today look very different from NHs 30 years ago. The 30th anniversary of OBRA provides a unique opportunity to reflect, consider what we have learned, and think about the future of this and other sectors of long-term care.

Why the Discretion Mix Matters: Understanding the Transformation of Long-term Care Services.
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Y. J. Choi and H. Choi.
Inquiry 2019 Jan-Dec;56:46958019871821
This study aims to extend the concept of discretion, ie, a certain degree of freedom in crucial decisions left to specific actors, to understand and examine the transformation of social care services in the era of aging and austerity. Although previous studies have reviewed and analyzed changes in care provision, they have been less concerned with who has the authority to make care decisions in the implementation process. We propose a new theoretical concept, the discretion mix, to understand the realignment of social care services beyond simply tracking institutional changes. Using a case study approach, this research investigates how the discretion mix of the Korean long-term care system has changed and the consequences of these changes; in addition, it discusses why the discretion mix can be a useful concept for analyzing the changing landscape of social care services.

Nutrition care quality indicators in hospitals and nursing homes: A systematic literature review and critical appraisal of current evidence.
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S. Moick, J. Simon and M. Hiesmayr.
Clin Nutr 2019 Aug 7
Quality indicators (QIs) can be used to assess and improve the quality of care in health care institutions. Although QIs about nutrition care in hospitals and nursing homes have been used in studies, no systematic catalogue exists to date. This systematic literature review identifies nutrition care QIs in hospitals and nursing homes and maps them according to QI type, stakeholder level and nutrition care theme. We also assess the level of consensus between studies and critically appraise the QIs presented therein based on two conceptual frameworks. METHODS: Ovid, Scopus and grey literature were searched from 1995 to 2016 including studies in English and German. Papers were considered if they presented, developed, assessed, rated or applied nutrition care QIs in hospitals or nursing homes. We used Donabedian’s framework to define structure, process and outcome indicators, the WHO (World Health Organization) definition to describe stakeholder levels, and a structured table to map indicators within themes. Further, we used the Institute of Medicine (IOM) and the Organisation for Economic Cooperation and Development (OECD) frameworks’ key dimensions to measure the conceptual quality of the QIs. Results are summarised and presented tabulated and narratively. RESULTS: From 536 identified studies, 46 were included. Eight hundred and twenty-two QIs were extracted and mapped into 19 themes and 151 sub-themes. Half were process indicators (49%) and about a quarter were outcome (28%) and structure (23%) indicators, respectively. The vast majority (71%) targeted micro level, while 28% meso level and only 1% macro level information. The nutrition themes meals/mealtimes (12%), treatment (adherence) (12%), nutrition screening (7%), assessment (7%) and monitoring (7%) were most frequently covered. 69% of indicators were cited by more than one study. Most frequent framework dimensions were patient-centeredness (33%), timeliness (30%), validity (30%) and actionability/feasibility (30%). CONCLUSION: The large number of nutrition care QIs in hospitals and nursing homes indicates the high interest in and importance of better nutrition care provision in institutions. However, the great variability indicates little consensus of the nutrition community on how to best assess and measure the quality of nutrition care. The limited methodological and conceptual validity of presented QIs and the low representation of QIs at macro and meso levels make international consensus finding complicated. Increased efforts including all stakeholder levels and using conceptual frameworks to define a limited number of key QIs with high methodological validity, actionability and stakeholder relevance are needed. Registration in clinicaltrials.gov: Identifier: NCT02820246.

Assessing quality of care in nursing homes using discrete choice experiments: How does the level of cognitive functioning impact upon older people’s preferences?
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R. Milte, E. Huynh and J. Ratcliffe.
Soc Sci Med 2019 Aug 8;238:112466
Traditionally older people with mild to moderate cognitive impairment have been excluded from preference elicitation studies in health economics. We assessed the impact of the level of cognitive functioning on preference and scale heterogeneity in a discrete choice experiment undertaken with 126 older people living in residential aged care homes in Australia between January 2015 and February 2016. Data was analysed using conditional logit models for sub-groups of participants with mild to moderate cognitive impairment (N=52) and without cognitive impairment (N=74), and for the entire study sample using a heteroscedastic conditional logit regression model allowing for scale heterogeneity. The Swait-Louviere test was undertaken to formally test for differences in preference and scale between the two groups. Cognitive impairment was not significant in the scale function of the heteroscedastic conditional logit model (beta=-0.403, SE=0.341, p=0.237). There were no statistical differences in estimated vector of preference parameters based on the presence or absence of cognitive impairment (Chi-squared=13, 25 df, p=0.976). Although there was evidence of a small increase in response variability with increasing cognitive impairment this did not reach statistical significance, and we were able to combine responses for people with and without cognitive impairment. Overall, the findings provide support for the more widespread inclusion of older people with mild to moderate cognitive impairment in such studies.

Exposing the mechanisms underlying successful animal-assisted interventions for people with dementia: A realistic evaluation of the Dementia Dog Project.
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L. Ritchie, S. Quinn, D. Tolson, N. Jenkins and B. Sharp.
Dementia (London) 2019 Jul 23:1471301219864505.
There is increasing recognition of animal-assisted interventions as a promising area of practice within health and social care for people living with dementia. However, much of the research focuses on benefits for those living in care homes and not in their own homes. The Dementia Dog Project is an innovative project that aims to support people with dementia to engage with dogs and to promote the use of dogs in dementia care in the community. The pilot project introduced a dementia assistance dog to four couples where one person had a diagnosis of dementia. The aim of this paper is to explore the mechanisms that can successfully expose the benefits of integrating dogs into dementia care by drawing on the findings of a realistic evaluation of the pilot phase of the Dementia Dog Project (2013–2015). A realistic evaluation, with its focus on context, mechanisms and outcomes illuminates why an approach may work in some situations but not in others. This makes it especially appropriate to the unique, complex experience of living with dementia and the early development stage of the programme. The analysis triangulated data from a range of primary and secondary sources including interviews with the project team, case reports, team meeting notes and transcripts of interviews with participants. The findings identified three mechanisms that help to unlock the most positive outcomes for both the participants and the dogs. These were (1) the human–animal bond, (2) relationship dynamics and (3) responsibility of caring. The findings presented within this paper provide essential information to inform and advance the planning for the use of assistance dogs for people with dementia.

Spread tools: a systematic review of components, uptake, and effectiveness of quality improvement toolkits.
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S. Hempel, C. O’Hanlon, Y. W. Lim, M. Danz, J. Larkin and L. Rubenstein.
Implement Sci 2019 Aug 19;14(1):83-019-0929-8
The objective was to conduct a systematic review of toolkit evaluations intended to spread interventions to improve healthcare quality. We aimed to determine the components, uptake, and effectiveness of publicly available toolkits. METHODS: We searched PubMed, CINAHL, and the Web of Science from 2005 to May 2018 for evaluations of publicly available toolkits, used a forward search of known toolkits, screened references, and contacted topic experts. Two independent reviewers screened publications for inclusion. One reviewer abstracted data and appraised the studies, checked by a second reviewer; reviewers resolved disagreements through discussion. Findings, summarized in comprehensive evidence tables and narrative synthesis addressed the uptake and utility, procedural and organizational outcomes, provider outcomes, and patient outcomes. RESULTS: In total, 77 studies evaluating 72 toolkits met inclusion criteria. Toolkits addressed a variety of quality improvement approaches and focused on clinical topics such as weight management, fall prevention, vaccination, hospital-acquired infections, pain management, and patient safety. Most toolkits included introductory and implementation material (e.g., research summaries) and healthcare provider tools (e.g., care plans), and two-thirds included material for patients (e.g., information leaflets). Pre-post studies were most common (55%); 10% were single hospital evaluations and the number of participating staff ranged from 17 to 704. Uptake data were limited and toolkit uptake was highly variable. Studies generally indicated high satisfaction with toolkits, but the perceived usefulness of individual tools varied. Across studies, 57% reported on adherence to clinical procedures and toolkit effects were positive. Provider data were reported in 40% of studies but were primarily self-reported changes. Only 29% reported patient data and, overall, results from robust study designs are missing from the evidence base. CONCLUSIONS: The review documents publicly available toolkits and their components. Available uptake data are limited but indicate variability. High satisfaction with toolkits can be achieved but the usefulness of individual tools may vary. The existing evidence base on the effectiveness of toolkits remains limited. While emerging evidence indicates positive effects on clinical processes, more research on toolkit value and what affects it is needed, including linking toolkits to objective provider behavior measures and patient outcomes. TRIAL REGISTRATION: PROSPERO registration number: PROSPERO 2014: CRD42014013930

 

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Research Practice and Methodology

Effects of age and cognitive function on data quality of standardized surveys in nursing home populations.
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P. Kutschar, M. Weichbold and J. Osterbrink.
BMC Geriatr 2019 Sep 3;19(1):244-019-1258-0
Data quality is of special concern when it comes to survey research in nursing homes. Very little is known about specifics of cognitively impaired elderly in responding to survey questions. This study examines effects of cognitive impairment, age, gender, and interview duration on the data quality in a sample of 659 nursing home residents (NHR). METHODS: Within a cross-sectional design, survey methodology was used to evaluate the pain situation in 13 nursing homes. Residents were stratified into NHR with no/mild (Mini-Mental State Examination MMSE: 18-30) and NHR with moderate (MMSE: 10-17) cognitive impairment. Data quality is measured by item nonresponse (INR). Correlation analyses, ANCOVA, linear and logistic regression models are applied. RESULTS: Neither interview duration nor gender have effects on item nonresponse. Age accounts for higher INR (beta = 0.12, p 5% for residents with moderate cognitive impairment is 3.8-times (p < 0.001) of that for those with no/mild impairment. CONCLUSIONS: Surveys are adequate for residents with no/mild cognitive impairment but data quality is threatened in residents with moderate impairments. Precision and validity of responses from NHR with progressed cognitive impairment are potentially limited and results may be biased. The results clearly do support the need for a multidisciplinary ‘general theory’ of the question-/answer-process which has to be also inclusive for cognitively impaired elderly persons.

Collecting self-report research data with people with dementia within care home clinical trials: Benefits, challenges and best practice.
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D. Perfect, A. W. Griffiths, M. Vasconcelos Da Silva, N. Lemos Dekker, J. McDermid and C. A. Surr.
Dementia (London) 2019 Aug 29:1471301219871168.
One-third of people with dementia live in care home settings and in order to deliver better evidence-based care, robust research including clinical trials is required. Concerns have been raised by researchers about the capacity of care home residents with dementia to participate in clinical trials. This includes self-report measures, completion of which researchers have suggested may be unreliable or impossible and may cause distress for residents. Many trials, therefore, utilise only proxy completed outcome measures. This is despite evidence that individuals with mild through to advanced dementia can reliably report on outcomes, if appropriate measures and approaches to data collection are used. However, little has been written about best practice in data collection with this group. This study aimed to explore the experiences of researchers working on dementia trials in care homes and identify best practices to assist design of future trials. Thirty-three researchers completed an online, qualitative questionnaire outlining their experiences and the perceived benefits and challenges of data collection with people with dementia. We identified five main benefits: (1) improving the delivery of person-centred care, (2) hearing the voice of people with dementia, (3) residents spending time with researchers, (4) improving researcher understanding, and (5) having an evidence base from multiple sources. We also identified five main challenges: (1) effective communication, (2) fluctuating capacity, (3) causing distress to residents, (4) time pressures, and (5) staff availability. Researchers also made suggestions about how these can be overcome. We recommend that the challenges identified could be overcome using appropriate methods for collecting data. Thorough training for researchers on data collection with people with dementia was identified as important for ensuring successful data collection.

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Aging

Impaired Mobility and Urinary Incontinence in Nursing Home Residents: A Multicenter Study.
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D. E. Jachan, U. Muller-Werdan and N. A. Lahmann.
J Wound Ostomy Continence Nurs 2019 Aug 30
The purpose of this study was to evaluate associations among use of walking aids, mobility status, and occurrence of urinary incontinence (UI) in geriatric patients residing in nursing homes, and to examine associations between UI severity (frequency and amount) and its impact on health-related quality of life (QoL). DESIGN: Multicenter descriptive cross-sectional prevalence study. SUBJECTS AND SETTING: A total of 2044 patients from nursing homes were included in the study. A majority were female (72.0%), the mean age of participants was 82.1 years (SD 11.2), their mean body mass index was 26.1 (SD 5.4), and their mean Care Dependency Scale score was 46.0 (SD 18.2), indicating a medium to high care dependency. The study setting was 30 nursing homes throughout Germany from 2014 to 2015. METHODS: Data were collected by trained nurses using a standardized data collection form to collect information about demographic characteristics, health conditions, mobility status measured according to the Elderly Mobility Scale (EMS), UI, and QoL measured using the International Consultation of Incontinence Questionnaire Short Form (ICIQ-SF). RESULTS: The prevalence of UI was 69.7% (n = 1804). Analysis of variance showed that, in 1659 nursing home residents with information on UI, 572 reported a medium amount of leakage with a mean impact on health-related QoL of 2.2 (SD 2.2, P < .001) on a scale from 0 (no impact) to 10 (very high impact). The mean of the impact on QoL in 235 residents who reported a large amount of leakage was 2.4 (SD 3.0, P < .001). In 1741 residents with information on the frequency of UI, 637 reported being urinary incontinent more than once a day with a mean impact on QoL of 2.2 (SD 2.1, P < .001) and 359 residents with permanent UI stated a mean impact on QoL of 2.1 (SD 2.8, P < .001). According to the bivariate association of UI with use of walking aids, the highest prevalence of UI (61.2%) was in patients who did not use any walking aids. The Chi-square Automatic Interaction Detector (CHAID) of the relationship between mobility according to the EMS and UI indicated that 71.1% of all patients with UI did not use any walking aids, although their mobility status had been reduced. CONCLUSIONS: Findings indicate a significant association between impaired mobility and UI in nursing home residents. Chronic, severe urinary incontinence exerted the greatest impact on health-related QoL. Therefore, we recommend measures to preserve or regain mobility to minimize or prevent UI in geriatric residents and patients and, thus, increase their health-related QoL.

Dying in long-term care facilities in Europe: the PACE epidemiological study of deceased residents in six countries.
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E. Honinx, N. van Dop, T. Smets, et al.
BMC Public Health 2019 Aug 30;19(1):1199-019-7532-4
By 2030, 30% of the European population will be aged 60 or over and those aged 80 and above will be the fastest growing cohort. An increasing number of people will die at an advanced age with multiple chronic diseases. In Europe at present, between 12 and 38% of the oldest people die in a long-term care facility. The lack of nationally representative empirical data, either demographic or clinical, about people who die in long-term care facilities makes appropriate policy responses more difficult. Additionally, there is a lack of comparable cross-country data; the opportunity to compare and contrast data internationally would allow for a better understanding of both common issues and country-specific challenges and could help generate hypotheses about different options regarding policy, health care organization and provision. The objectives of this study are to describe the demographic, facility stay and clinical characteristics of residents dying in long-term care facilities and the differences between countries. METHODS: Epidemiological study (2015) in a proportionally stratified random sample of 322 facilities in Belgium, Finland, Italy, the Netherlands, Poland and England. The final sample included 1384 deceased residents. The sampled facilities received a letter introducing the project and asking for voluntary participation. Facility manager, nursing staff member and treating physician completed structured questionnaires for all deaths in the preceding 3 months. RESULTS: Of 1384 residents the average age at death ranged from 81 (Poland) to 87 (Belgium, England) (p < 0.001) and length of stay from 6 months (Poland, Italy) to 2 years (Belgium) (p < 0.05); 47% (the Netherlands) to 74% (Italy) had more than two morbidities and 60% (England) to 83% (Finland) dementia, with a significant difference between countries (p < 0.001). Italy and Poland had the highest percentages with poor functional and cognitive status 1 month before death (BANS-S score of 21.8 and 21.9 respectively). Clinical complications occurred often during the final month (51.9% England, 66.4% Finland and Poland). CONCLUSIONS: The population dying in long-term care facilities is complex, displaying multiple diseases with cognitive and functional impairment and high levels of dementia. We recommend future policy should include integration of high-quality palliative and dementia care.

Identifying Sarcopenia in Female Long-Term Care Residents: A Comparison of Current Guidelines.
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M. P. Kotlarczyk, S. Perera, D. A. Nace, N. M. Resnick and S. L. Greenspan.
J Am Geriatr Soc 2018 Feb;66(2):316-320
To establish the prevalence of sarcopenia in a long-term care population, assess agreement among different consensus sarcopenia diagnostic criteria, and examine agreement of a self-reported questionnaire with consensus guidelines. DESIGN: Cross-sectional secondary analysis. SETTING: Long-term care communities in the greater Pittsburgh, Pennsylvania, area. PARTICIPANTS: Women aged 65 and older (mean 83.6) undergoing eligibility screening for a fracture reduction trial (N = 141). MEASUREMENTS: We measured appendicular lean muscle mass using dual-energy X-ray absorptiometry. Hand grip strength and usual gait speed were also evaluated. Sarcopenia status was determined according to European Working Group on Sarcopenia in Older People (EWGSOP) and the Foundation for the National Institutes of Health (FNIH) Sarcopenia Project criteria and the SARC-F questionnaire. RESULTS: Eleven participants were sarcopenic (7.8%) according to the EWGSOP criteria, six (4.3%) according to FNIH conservative cut-point guidelines, and 32.6% (n = 46) according to FNIH intermediate cut-points. Only 2 of 141 participants met criteria for sarcopenia according to all three guidelines. Sarcopenia was identified in 30 (21.3%) participants according to the SARC-F questionnaire. Sensitivity of the SARC-F with consensus panel definitions ranged from 18.2% to 33.3%. Specificity ranged from 78.7% to 81.1%. CONCLUSION: Current consensus criteria from the EWGSOP and FNIH Sarcopenia Project do not agree and have little overlap in older female long-term care residents. The SARC-F questionnaire is a simple tool that could be implemented in long-term care, but it has low sensitivity compared with current consensus guidelines in the identification of sarcopenic individuals.

Living Well With Dementia: Factors Associated With Nursing Home Residents’ Affect Balance.
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A. Kolanowski, L. Behrens, E. Lehman, et al.
Res Gerontol Nurs 2019 Aug 27:1-10
Well-being is an important outcome for people with dementia. The current study is a secondary analysis of baseline data from an ongoing pragmatic trial. Affect balance, the ratio of positive to negative affect, was used as a measure of well-being, and factors related to it were examined in a sample of 325 nursing home residents. Measures of staff interaction during caregiving, staff knowledge of person-centered approaches for dementia care, staff hours of care, the physical environment, person-centered policies, resident function, and quality of life were obtained using direct observation, staff interview, and medical chart review. The results of the quantile multivariable regression analysis indicated that positive staff interaction and higher resident function were significantly associated with higher affect balance after controlling for other variables. The findings have heuristic value for the development of conceptual frameworks that focus on meaningful outcomes for residents with dementia and future research.

Pain Management in Nursing Home Residents: Findings from a Pilot Effectiveness-Implementation Study.
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T. Brunkert, M. Simon, W. Ruppen and F. Zuniga.
J Am Geriatr Soc 2019 Aug 27
To evaluate the effectiveness and implementation of a multilevel pain management intervention in nursing homes (NHs) comprising a pain management guideline, care worker training, and pain champions. DESIGN: An implementation science pilot study using a quasi-experimental effectiveness-implementation (hybrid II) design. SETTING: Four NHs in Switzerland. PARTICIPANTS: All consenting long-term residents aged 65 years and older with pain at baseline (N = 62) and all registered and licensed practical nurses (N = 61). INTERVENTION: Implementation of a contextually adapted pain management guideline, interactive training workshops for all care workers, and specifically trained pain champions. MEASUREMENTS: Interference from pain, worst and average pain intensity over the previous 24 hours; proxy ratings of pain with the Pain Assessment in Advanced Dementia scale; and care workers’ appraisal of the guideline’s reach, acceptability, and adoption. RESULTS: Pain-related outcomes improved for self-reporting residents (n = 43) and residents with proxy rating (n = 19). Significant improvements of average pain from baseline to T1 (P = .006), and in worst pain from baseline to T1 (P = .003) and T2 (P = .004). No significant changes in interference from pain (P = .18). With regard to the implementation efforts, about 76% of care workers indicated they were familiar with the guideline; 70.4% agreed that the guideline is practical and matches their ideas of good pain assessment (75.9%) and treatment (79.7%). CONCLUSION: Implementation of a multilevel pain management intervention did significantly improve average and worst pain intensity in NH residents. However, to effect clinical meaningful changes in interference from pain, a more comprehensive approach involving other disciplines may be necessary.

Clinical and cost-effectiveness of the Managing Agitation and Raising Quality of Life (MARQUE) intervention for agitation in people with dementia in care homes: a single-blind, cluster-randomised controlled trial.
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G. Livingston, J. Barber, L. Marston, et al.
Lancet Psychiatry 2019 Apr;6(4):293-304
Many people with dementia living in care homes have distressing and costly agitation symptoms. Interventions should be efficacious, scalable, and feasible. METHODS: We did a parallel-group, cluster-randomised controlled trial in 20 care homes across England. Care homes were eligible if they had 17 residents or more with dementia, agreed to mandatory training for all eligible staff and the implementation of plans, and more than 60% of eligible staff agreed to participate. Staff were eligible if they worked during the day providing face-to-face care for residents with dementia. Residents were eligible if they had a known dementia diagnosis or scored positive on screening with the Noticeable Problems Checklist. A statistician independent of the study randomised care homes (1:1) to the Managing Agitation and Raising Quality of Life (MARQUE) intervention or treatment as usual (TAU) using computer-generated randomisation in blocks of two, stratified by type of home (residential or nursing). Care home staff were not masked to the intervention but were asked not to inform assessors. Residents with dementia, family carers, outcome assessors, statisticians, and health economists were masked to allocation until the data were analysed. MARQUE is an evidence-based manualised intervention, delivered by supervised graduate psychologists to staff in six interactive sessions. The primary outcome was agitation score at 8 months, measured using the Cohen-Mansfield Agitation Inventory (CMAI). Analysis of the primary outcome was done in the modified intention-to-treat population, which included all randomly assigned residents for whom CMAI data was available at 8 months. Mortality was assessed in all randomly assigned residents. This study is registered with the ISRCTN registry, number ISRCTN96745365. FINDINGS: Between June 14, 2016, and July 4, 2017, we randomised ten care homes (189 residents) to the MARQUE intervention and ten care homes (215 residents) to TAU. At 8 months, primary outcome data were available for 155 residents in the MARQUE group and 163 residents in the TAU group. At 8 months, no significant differences in mean CMAI scores were identified between the MARQUE and TAU groups (adjusted difference -0.40 [95% CI -3.89 to 3.09; p=0.8226]). In the intervention care homes, 84% of all eligible staff completed all sessions. The mean difference in cost between the MARQUE and TAU groups was pound204 (-215 to 623; p=0.320) and mean difference in quality-adjusted life-years was 0.015 (95% CI -0.004 to 0.034; p=0.127). At 8 months, 27 (14%) of 189 residents in the MARQUE group and 41 (19%) of 215 residents in the TAU group had died. The prescription of antipsychotic drugs was not significantly different between the MARQUE group and the TAU group (odds ratio 0.66; 95% CI 0.26 to 1.69, p=0.3880). INTERPRETATION: The MARQUE intervention was not efficacious for agitation although feasible and cost-effective in terms of quality of life. Addressing agitation in care homes might require resourcing for delivery by professional staff of a more intensive intervention, implementing social and activity times, and a longer time to implement change. FUNDING: UK Economic and Social Research Council and the National Institute of Health Research.

Infectious Diseases in Older Adults of Long-Term Care Facilities: Update on Approach to Diagnosis and Management.
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R. L. P. Jump, C. J. Crnich, L. Mody, S. F. Bradley, L. E. Nicolle and T. T. Yoshikawa.
J Am Geriatr Soc 2018 Apr;66(4):789-803
The diagnosis, treatment, and prevention of infectious diseases in older adults in long-term care facilities (LTCFs), particularly nursing facilities, remains a challenge for all health providers who care for this population. This review provides updated information on the currently most important challenges of infectious diseases in LTCFs. With the increasing prescribing of antibiotics in older adults, particularly in LTCFs, the topic of antibiotic stewardship is presented in this review. Following this discussion, salient points on clinical relevance, clinical presentation, diagnostic approach, therapy, and prevention are discussed for skin and soft tissue infections, infectious diarrhea (Clostridium difficile and norovirus infections), bacterial pneumonia, and urinary tract infection, as well as some of the newer approaches to preventive interventions in the LTCF setting.

The impact of group activities and their content on persons with dementia attending them.
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J. Cohen-Mansfield.
Alzheimers Res Ther 2018 Apr 5;10(1):37-018-0357-z
Individuals suffering from dementia and residing in nursing homes often feel lonely and bored. This study examined the engagement and mood of people with dementia in group activities, and how personal characteristics, such as cognitive function, may impact on an individual’s responses to group activities. METHODS: The study included 102 participants, who took part in group activities while their mood and engagement levels were observed. Participants were invited to attend 10 different types of group activities, each of which was offered twice. RESULTS: Results found improved engagement and mood during group activities as compared to control no-group times. Significant relationships between the type of activity and ratings of engagement and mood were also found. Although participants with higher levels of cognitive functioning manifested greater responsiveness to groups, the pattern of response to different contents did not differ by cognitive function. CONCLUSIONS: This study shows the potential utility of group activities for improving quality of life of persons with dementia and demonstrates a methodology that can be used for quality improvement to optimize group contents. Future research should expand the range of contents of group activities in order to enhance the options for improving mood and engagement of individuals with dementia.

Economic Evaluation of a Catheter-Associated Urinary Tract Infection Prevention Program in Nursing Homes.
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D. W. Hutton, S. L. Krein, S. Saint, et al.
J Am Geriatr Soc 2018 Apr;66(4):742-747
To assess the economic effect and cost effectiveness of a targeted catheter-associated urinary tract infection (CAUTI) prevention intervention in the nursing home (NH) setting. DESIGN: Randomized clinical trial. SETTING: Community-based NHs (N=12). PARTICIPANTS: NH residents with indwelling urinary catheters (N=418). INTERVENTION: Standard care versus infection prevention program involving barrier precautions, active surveillance, and NH staff education. MEASUREMENTS: Costs of the intervention, costs of disease, and health outcomes were used to calculate an incremental cost-effectiveness ratio for the intervention. Data came from intervention results and the literature and outcomes were analyzed over one year. RESULTS: A 120-bed NH would have program costs of $20,279/year. The cost of disease treatment would be reduced by $54,316 per year, resulting in a $34,037 net cost savings. Most of this savings would come from fewer CAUTI hospitalizations ($39,180), with $15,136 in savings from CAUTI care within the NH. The intervention also yielded a gain of 0.197 quality-adjusted life-years (QALYs). Taking into account uncertainty in all parameters suggests there is an 85% chance that the intervention is cost-saving. CONCLUSIONS: The CAUTI prevention program is expected to benefit payers by reducing costs and improving health outcomes. Because the savings accrue to payers and not to NHs, payers such as Medicare and private insurers may want to provide incentives for NHs to implement such programs. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01062841.

Quality of Hospice Care at Home Versus in an Assisted Living Facility or Nursing Home.
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K. T. Unroe, T. E. Stump, S. Effler, W. Tu and C. M. Callahan.
J Am Geriatr Soc 2018 Apr;66(4):687-692
To describe differences in perceived quality of hospice care for individuals living at home or in a nursing home (NH) or assisted living facility (ALF) through analysis of after-death surveys of family members. DESIGN: Retrospective cohort study using hospice medical record data and Family Evaluation of Hospice Care (FEHC) survey data. SETTING: Large, national hospice provider. PARTICIPANTS: Individuals who died while receiving routine hospice care and family caregivers who completed after-death quality-of-care surveys. MEASUREMENTS: Survey results for 7,510 individuals were analyzed using analysis of variance and chi-square tests. Logistic regression was used to assess relationship between location of care and overall service quality. RESULTS: The overall survey response rate was 27%; 34.5% of families of individuals in ALFs in hospice, 27.4% of those at home, and 22.9% of those in NHs returned the survey (P < .001). Differences in return rate according to primary diagnosis were significant, although differences were not large. Most (84.3%) respondents reported that hospice referral had occurred at the right time, and 63.4% rated service quality as excellent. Hospice care in the NH was less likely to be perceived as excellent. CONCLUSION: There were significant differences in characteristics of individuals whose family members did and did not return surveys, which has implications for use of after-death surveys to evaluate hospice quality. Lower perceived quality of hospice care in NHs may be related to general dissatisfaction with receiving care in this setting. Survey results have the potential to set priorities for quality improvement, choice of provider, and potentially reimbursement. Underlying causes of differences of perceived quality in different settings of care should be examined.

Pain interference and depressive symptoms in communicative people with Alzheimer’s disease: a pilot study.
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J. Wang, M. S. Dietrich, S. F. Simmons, R. L. Cowan and T. B. Monroe.
Aging Ment Health 2018 Jun;22(6):808-812
To examine pain interference in verbally communicative older adults with mild to moderate Alzheimer’s disease (AD) and to examine the association of pain interference with cognitive function and depressive symptoms. METHOD: For this pilot study, we used a cross-sectional design to examine pain interference (Brief Pain Inventory-Short Form), cognitive function (Mini-Mental State Exam), and depressive symptoms (15-item Geriatric Depression Scale) in 52 older (>/=65) communicative adults with AD who reported being free from chronic pain requiring daily analgesics. RESULTS: Pain was reported to interfere with general activity (13.5%), mood (13.5%), walking ability (13.5%), normal work (11.5%), enjoyment of life (11.5%), relationships with other people (9.6%), and sleep (9.6%). Pain interference was significantly positively correlated with both cognitive function (rs = 0.46, p = 0.001) and depressive symptomology (rs = 0.45, p = 0.001), indicating that greater reported pain interference was associated with better cognitive function and more depressive symptoms. CONCLUSION: Among older people with AD who report being free from chronic pain requiring daily analgesics, 2 in 10 are at risk of pain interference and depressive symptoms. Those with better cognitive function reported more pain interference and depressive symptoms, meaning pain is likely to be under-reported as AD progresses. Clinicians should regularly assess pain interference and depressive symptoms in older persons with AD to identify pain that might be otherwise overlooked.

A qualitative systematic review of experiences of persons with dementia regarding transition to long-term care.
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J. A. Young, C. Lind and J. B. Orange.
Dementia (London) 2019 Jul 23:1471301219862439.
The current qualitative systematic review identified and examined critically the literature on how persons with dementia experience transitions to long-term care. Results are intended to help develop guidelines for future care and research. Method A search was conducted of OvidSP, SCOPUS, Web of Science, ProQuest, PsycINFO, CINAHL, AgeLine and Informit databases. In total, 4705 articles were reviewed (published 1954–2018). A textual narrative approach was used to synthesise the findings of the included articles. Results Seven articles met inclusion criteria (five using data collected from interviews with persons with dementia and two using reports from a proxy). Overall, the findings showed that transition to long-term care possesses varied meanings for persons with dementia, is often not the decision of the persons with dementia, and is a process throughout which social connections remain important. Discussion Accounts of the experiences of persons with dementia regarding transitions from community to long-term care show that they and their families should be supported: with respect to their individual contexts, to share the positives and negatives of the transition experiences, to make decisions together, and to maintain old and establish new social connections.

Digging into the experiences of therapeutic gardening for people with dementia: An interpretative phenomenological analysis.
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T. A. Smith-Carrier, L. Beres, K. Johnson, C. Blake and J. Howard.
Dementia (London) 2019 Aug 19:1471301219869121.
Gardening programmes aim to promote improved engagement and quality of life in persons with dementia. Although a substantial literature has amassed documenting the overall positive outcomes associated with therapeutic gardening and horticulture for persons with dementia, little is known about the specific aspects of the gardening process that engender these benefits, and how and why they are important. The purpose of this research was to explore, using interpretative phenomenological analysis, the experiences of therapeutic gardening for persons with dementia, and their perspectives on the senses and emotions elicited in the gardening process that promote well-being. The themes that emerged in our analysis are to varying degrees substantiated in the literature: the usefulness of activating the senses, particularly those of touch and smell; the significance of being occupied in meaningful, productive work; the importance of cultivating a sense of curiosity, wonder, and learning; the positive gains derived from socialization in a group context; the peace and hope derived from being ‘in the moment’; and the positive mental and physical well-being derived from participating in the outdoor garden. Our findings support the integration of therapeutic gardening as a valuable practice for people with dementia.

The thriving of older people assessment scale: Psychometric evaluation and short-form development.
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R. Baxter, H. Lovheim, S. Bjork, et al.
J Adv Nurs 2019 Aug 23
To evaluate the psychometric properties and performance of the 32-item Thriving of Older People Assessment Scale (TOPAS) and to explore reduction into a short-form. BACKGROUND: The 32-item TOPAS has been used in studies of place-related well-being as a positive measure in long-term care to assess nursing home resident thriving; however, item redundancy has not previously been explored. DESIGN: Cross-sectional study. METHOD: Staff members completed the 32-item TOPAS as proxy raters for a random sample of Swedish nursing home residents (N = 4,831) between November 2013 – September 2014. Reliability analysis, exploratory factor analysis and item response theory-based analysis were undertaken. Items were systematically identified for reduction using statistical and theoretical analysis. Correlation testing, means comparison and model fit evaluation confirmed scale equivalence. RESULTS: Psychometric properties of the 32-item TOPAS were satisfactory and several items were identified for scale reduction. The proposed short-form TOPAS exhibited a high level of internal consistency (alpha = 0.90) and strong correlation (r = 0.98) to the original scale, while also retaining diversity among items in terms of factor structure and item difficulties. CONCLUSION: The 32-item and short-form TOPAS’ indicated sound validity and reliability to measure resident thriving in the nursing home context. IMPACT: There is a lack of positive life-world measures for use in nursing homes. The short-form TOPAS indicated sound validity and reliability to measure resident thriving, providing a feasible measure with enhanced functionality for use in aged care research, assessments and care planning for health-promoting purposes in nursing homes.

The Pattern of Hospital Admissions Prior to Care Home Placement in People With Parkinson’s Disease: Evidence of a Period of Crisis for Patients and Carers.
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J. Klaptocz, W. K. Gray, S. Marwood, et al.
J Aging Health 2019 Oct;31(9):1616-1630
We hypothesized that the number and length of hospital admissions in people with Parkinson’s disease (PD) would increase immediately prior to admission to a care home relative to those who were able to continue living at home or who died. Method: PD patients at Hoehn and Yahr Stages III to V were followed-up over two and a half years with deaths and care home placements recorded. Hospital admissions data were collected over this period. Results: Of 286 patients included in the study, 7.3% entered a care home and 28.3% died. In the final 120 days prior to the study exit point (care home placement, death, or continued living at home), longer hospital stay was significantly associated with care home placement, after adjusting for the competing risk of death. Conclusion: Our data provide evidence that, for many people with PD, a period of crisis is reached immediately prior to care home placement.

 

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Events

KT Canada Seminar Series The Improving Wisely Project: Use of KT Strategies to mitigate healthcare overuse, underuse and misuse (Online)

Thursday 12 September 10:00-11:00 MT
Presenter: Christine Fahim
Learning objectives:
1. Describe the principles of the Improving Wisely project,
2. Describe audit and feedback best practices,
3. Discuss the limitations of using available datasets to create appropriateness metrics.

Is there one best model for long-term residential care? (Online)

Wednesday 18 September 10:00-11:00 MT
Presenter: Pat Armstrong
The Butterfly Model for long-term residential care has received a great deal of attention recently, especially in the Toronto media.

Based on 10 years of international, interdisciplinary research and on a recent study conducted for the City of Toronto, this webinar will consider the central principles in popular models for care, the evidence that supports them and recommendations related to them.

Gerontological Nursing Certification (Online)

Beginning September 5, 2019 and running every Thursday for 9 weeks, the sessions are one hour in length and will include both content review and practice questions.
The per session cost is $20 for CGNA members and $30 for non-members. CGNA members also receive access to archived webinars, housed in the ‘Members Only’ section of the CGNA website.

CGNA members are also entitled to a 20% discount voucher for writing a CNA certification exam or renewing their certification!

Webinar sessions are open to all CGNA members, with a special welcome to PN members writing in the inaugural cycle for CNA PN Certification!

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Resources

The Restraint Reduction Network Training Standards 2019

The Restraint Reduction Network Training Standards 2019 have been written for training services delivered to education, health and social care services that support people with autism, learning disabilities, dementia and mental health conditions across the UK

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Announcing: Implementation Science Communications

What are Implementation Science Labs?

On the Job, 24 Hours a Day, 27 Days a Month

Leading medical journal commits to greater diversity. Will others follow?

Diversity is indispensable to excellence: The Canada
Research Chairs program

Quality to the Core

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Labrador nursing home breakfast program gives residents ‘enhanced culinary experience’

Long-term care cuts harming seniors in Ontario

Dementia advocates keep up pressure

Forget-Me-Not train service for people with dementia

Innovative dementia care models show the way forward
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Opportunities

Research Impact Canada (RIC) Network Manager, Future Skills Centre

Toronto, ON
DEADLINE: Open until filled
Broadly focused on dissemination and capacity building for knowledge mobilization, the Manager will collaborate with Research Impact Canada (RIC) member institutions as well as the Conference Board of Canada (CBoC) to operationalize RIC’s commitments to knowledge mobilization for the Future Skills Centre (FSC) ensuring results of skills research and projects are disseminated to Canadians with a focus on youth and marginalized populations . Under the direction of the Executive Director, Research & Innovation Services at York University, the RIC Network Manager for Future Skills will oversee effective RIC network operations as well as dissemination and capacity building activities for FSC.

Recruitment for Cohort Three of the Knowledge Broker Mentoring Program is Now Open

The National Collaborating Centre for Methods and Tools (NCCMT)
The National Collaborating Centre for Methods and Tools (NCCMT) launched the Knowledge Broker (KB) Mentoring Program in 2014 to advance the uptake and use of evidence-informed decision making (EIDM) in Canada within the public health sector. It combines in-person and online support to train public health practitioners to develop knowledge and capacity in the theory and practice of EIDM.

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