April 2, 2019

To assess (1) temporal changes (2008-2015) in nursing home (NH) length of stay (LoS) in 3 Canadian health jurisdictions (Edmonton, Calgary, Winnipeg), (2) resident admission characteristics associated with LoS, and (3) temporal changes of admission characteristics in each of the 3 jurisdictions. DESIGN: Retrospective cohort study using data previously collected in Translating Research in Elder Care (TREC), a longitudinal program of applied health services research in Canadian NHs. SETTING AND PARTICIPANTS: 7817 residents admitted between January 2008 and December 2015 to a stable cohort of 18 NHs that have consistently participated in TREC since 2007. METHODS: LoS was defined as time between a resident’s first NH admission and final discharge from the NH sector. Analyses included descriptive statistics, Kaplan Meier estimates (unadjusted LoS), and Cox proportional hazard regressions (adjusted LoS), adjusted for resident characteristics (eg, age, cognitive performance, and health instability). We also controlled for NH size and ownership. RESULTS: In jurisdictions with increasing care needs, unadjusted median LoS [95% confidence interval (CI)] decreased over time (2008 and 2009 vs 2014 and 2015 admissions); in Calgary from 1.837 (95% CI 1.618, 2.275) to 1.328 (95% CI 1.185, 1.489) years and in Edmonton from 1.927 (95% CI 1.725, 2.188) to 1.073 (95% CI 0.936, 1.248) years. In Winnipeg, care needs and LoS remained constant (2.163, 95% CI 1.867, 2.494, vs 2.459, 95% CI 2.155, 2.883, years). Resident characteristics including higher physical dependency [hazard ratio (HR) 1.205, 95% CI 1.133, 1.282], higher cognitive impairment (HR 1.112, 95% CI 1.042, 1.187), or higher health instability (HR 1.333, 95% CI 1.224, 1.452) were associated with lower LoS. Adjustment for resident characteristics reduced jurisdictional LoS differences and rendered temporal LoS differences within jurisdictions statistically nonsignificant. CONCLUSIONS/IMPLICATIONS: In jurisdictions where care needs at admission have increased since 2008, resident LoS has decreased. Jurisdictional differences in care needs and LoS indicate that health policies may affect these outcomes. Variations of resident outcomes by policy environment require additional scrutiny.

The burden of pain in nursing home residents is substantial; unfortunately, many times it goes undiagnosed and is inadequately treated. To improve identification of pain in this population, we aimed to review and synthesize findings from qualitative studies that report primary barriers and facilitators to pain assessment in nursing home residents. DESIGN: This is a Cochrane-style systematic review and narrative synthesis of qualitative evidence adhering to PRISMA guidelines. Databases were searched from inception to June 2018, supplemented by hand searching of references. We assessed the quality of included studies using the Critical Appraisal Skills Program Quality Appraisal Checklist. SETTING AND PARTICIPANTS: We included studies conducted in nursing homes. Studies focused on nursing home residents, nursing home staff, or both. MEASURES: Extracted data were subject to thematic analyses and were collated and summarized into 3 groups: resident, health care provider, and health care system factors. RESULTS: Thirty-one studies met our inclusion criteria. Resident factors had 3 subthemes: physical or cognitive impairments, attitudes and beliefs, and social/cultural/demographic characteristics. Health care provider factors had 3 subthemes: knowledge and skills, attitudes and beliefs, and social/cultural/demographic characteristics. Health care system-level factors had 3 subthemes: interpersonal factors, resources, and policy. Key barriers to pain assessment included the presence of resident cognitive impairment, health care providers’ lack of knowledge, and the breakdown of communication across organizational hierarchies. Key facilitators to pain assessment included the identification of pain-related behaviors in residents, the experience and skills of health care providers, and establishing facility-level pain assessment protocols and guidelines. CONCLUSION AND IMPLICATIONS: Findings from this review identify primary barriers and facilitators to pain assessment in nursing home residents, highlighting key considerations for stakeholders, including health care providers, and health care policy decision makers. These efforts have the potential to improve the identification of pain in residents, and may ultimately improve pain management and residents’ quality of life.

What is the purpose of this tool?

Implementation researchers can use this tool to assess the utilization of one or more theory, model, or framework (TMF) in a particular project. More specifically, the tool can be used for:

Considering the characteristics of TMFs most important for the project
Presenting characteristics to stakeholders to identify their priorities
Evaluating the ways in which one or more TMF meets the needs of the project
Comparing potential TMFs to select the best fit for the project
Identifying ways in which multiple TMFs can complement one another to address all important criteria
Communicating to various stakeholders reasons why a TMF was selected
Increasing transparency related to TMF selection and use in reporting (manuscripts, grants, etc.)

To examine the current knowledge on oral health status and dental care of older persons through a systematic mapping of systematic reviews of low or moderate risk of bias. BACKGROUND: Geriatric dentistry covers all aspects of oral health and oral care of older persons. Oral health is part of general health and contributes to a person’s physical, psychological and social wellbeing. METHODS: A literature search was performed in three different databases (PubMed, The Cochrane Library and Cinahl) within 12 domains: Dental caries, periodontitis, Orofacial pain and temporomandibular joint (TMJ) pain, mucosal lesions, oral motor function, dry mouth, halitosis, interaction between oral status and other medical conditions, ability to interrelate and communicate, quality of life, ethics and organisation of dental care for older persons. Systematic reviews were identified and scrutinised, highlighting scientific knowledge and knowledge gaps. RESULTS: We included 32 systematic reviews of which 14 were judged to be of low/moderate risk of bias. Most of the domains lack systematic reviews with low or moderate risk of bias. In two of the domains evidence was identified; in institutionalised people aged 65 or older, effective oral hygiene can prevent pneumonia. Furthermore, there is an evidence of a relationship between malnutrition (protein energy-related malnutrition, PEM) and poor appetite and edentulousness. CONCLUSIONS: There is an urgent need for further research and evidence-based knowledge within most domains in geriatric dentistry and in other fields related to oral health and dental care for older persons striving for multi-disciplinary research programmes.

Coproduction, a collaborative model of research that includes stakeholders in the research process, has been widely advocated as a means of facilitating research use and impact. We summarise the arguments in favour of coproduction, the different approaches to establishing coproductive work and their costs, and offer some advice as to when and how to consider coproduction. DEBATE: Despite the multiplicity of reasons and incentives to coproduce, there is little consensus about what coproduction is, why we do it, what effects we are trying to achieve, or the best coproduction techniques to achieve policy, practice or population health change. Furthermore, coproduction is not free risk or cost. Tensions can arise throughout coproduced research processes between the different interests involved. We identify five types of costs associated with coproduced research affecting the research itself, the research process, professional risks for researchers and stakeholders, personal risks for researchers and stakeholders, and risks to the wider cause of scholarship. Yet, these costs are rarely referred to in the literature, which generally calls for greater inclusion of stakeholders in research processes, focusing exclusively on potential positives. There are few tools to help researchers avoid or alleviate risks to themselves and their stakeholders. CONCLUSIONS: First, we recommend identifying specific motivations for coproduction and clarifying exactly which outcomes are required for whom for any particular piece of research. Second, we suggest selecting strategies specifically designed to enable these outcomes to be achieved, and properly evaluated. Finally, in the absence of strong evidence about the impact and process of coproduction, we advise a cautious approach to coproduction. This would involve conscious and reflective research practice, evaluation of how coproduced research practices change outcomes, and exploration of the costs and benefits of coproduction. We propose some preliminary advice to help decide when coproduction is likely to be more or less useful.

The Patient and Community Engagement Training (PaCET) program aims to increase trainee capacity in conducting participatory research in projects focused on women and/or children’s health. Participatory research is a broad-based approach that involves patients, clinicians, community groups, government and/or non-government organizations (NGOs) as engaged partners in collaborative research studies that affect them and in which they have a stake. Awards of up to $1,000 per month are available for a maximum of eight months (September to April).

Audit and feedback (A&F) is a commonly used quality improvement (QI) approach. A Cochrane review indicates that A&F is generally effective and leads to modest improvements in professional practice but with considerable variation in the observed effects. While we have some understanding of factors that enhance the effects of A&F, further research needs to explore when A&F is most likely to be effective and how to optimise it. To do this, we need to move away from two-arm trials of A&F compared with control in favour of head-to-head trials of different ways of providing A&F. This paper describes implementation laboratories involving collaborations between healthcare organisations providing A&F at scale, and researchers, to embed head-to-head trials into routine QI programmes. This can improve effectiveness while producing generalisable knowledge about how to optimise A&F. We also describe an international meta-laboratory that aims to maximise cross-laboratory learning and facilitate coordination of A&F research.

Alberta is undertaking a bold and somewhat risky step overhauling its health system governance to build higher performance in quality, safety and improved health outcomes for Albertans. On the heels of having re-established a single province-wide health authority (Alberta Health Services [AHS]), provincial health system decision makers have moved to establish province-wide Strategic Clinical Networks™ (SCNs). Sixteen SCNs have been implemented, and all are constituted as teams of healthcare professionals, researchers, government stakeholders, patients and families seeking to improve delivery of healthcare across the province. SCNs were developed in part as a strategy for strengthening clinical engagement to achieve a broad range of healthcare delivery benefits including improvement of clinical care processes and reduced variations in practice, better access to care and improved patient outcomes across the province. Here, we examine the rationale and potential of this governance intervention, while also considering some of the fundamental questions around their potential impact and the ultimate need for multidimensional assessment.

The health care aide position embodies one of the most basic paradoxes of long-term care for older adults: those who have the most contact and most intensive interaction with nursing-home residents are also those having the least training, authority, and status within the system. They therefore hold one of the keys to quality care in many settings, especially nursing homes. In the absence of agreement on the position’s roles, responsibilities, and authority, it is important to examine how the position is perceived by the key members in the long-term-care framework. Objectives The current study examined and compared health care aides’ and nurses’ perceptions of the position in nursing-home settings in Israel, using a standardized tool developed for this inquiry. The comparison accounted for potential intervening factors that may help better understand the job requirements and boundaries. Design A comparative survey design. Settings 30 nursing homes (of at least 20 beds) in northern Israel. Participants We used convenience sampling to recruit 369 health care aides and 261 nurses (a total of 630 participants). Methods The main instrument of data collection was specially designed and validated for this study. It was based on a qualitative study that defined basic content units representing tasks importance, knowledge, and personal characteristics for the job. Results Participants found it difficult to prioritize the job components or to differentiate between core tasks and characteristics and the secondary aspects of their job. General care, profession-specific knowledge, and emotional abilities were endorsed the most by participants. Cleaning, communication, and safety were ranked lower (although rankings were still considerably high). However, previous experience as a health care aide undermined incumbents’ perceptions of their own responsibilities and professionalism. Incumbent health care aides rated most factors higher than nurses did, with the exception of the importance of communication. Conclusion Our results may help decision makers understand the complexity around the health care aide position, manage and develop it more effectively while setting standards (training and certification, performance appraisal, and more) for professionalization processes and better defining the division of nursing work between health care aides and nurses.

We describe the development of a nursing home information technology (IT) maturity model designed to capture stages of IT maturity. MATERIALS AND METHODS: This study had 2 phases. The purpose of phase I was to develop a preliminary nursing home IT maturity model. Phase II involved 3 rounds of questionnaires administered to a Delphi panel of expert nursing home administrators to evaluate the validity of the nursing home IT maturity model proposed in phase I. RESULTS: All participants (n = 31) completed Delphi rounds 1-3. Over the 3 Delphi rounds, the nursing home IT maturity staging model evolved from a preliminary, 5-stage model (stages 1-5) to a 7-stage model (stages 0-6). DISCUSSION: Using innovative IT to improve patient outcomes has become a broad goal across healthcare settings, including nursing homes. Understanding the relationship between IT sophistication and quality performance in nursing homes relies on recognizing the spectrum of nursing home IT maturity that exists and how IT matures over time. Currently, no universally accepted nursing home IT maturity model exists to trend IT adoption and determine the impact of increasing IT maturity on quality. CONCLUSIONS: A 7-stage nursing home IT maturity staging model was successfully developed with input from a nationally representative sample of U.S. based nursing home experts. The model incorporates 7-stages of IT maturity ranging from stage 0 (nonexistent IT solutions or electronic medical record) to stage 6 (use of data by resident or resident representative to generate clinical data and drive self-management).

The aim of the study was to assess the relationship of culture of safety dimensions and the rate of unanticipated care outcomes in long-term care facilities (LTCFs) using the Agency for Healthcare Research and Quality framework of resident safety culture. METHODS: Cross-sectional survey data were collected on 13 dimensions of culture of safety in five LTCFs from registered nurses, licensed practical nurses (LPNs), nursing assistants, administrators/managers, administrative support, and rehabilitation staff. Secondary data on falls in the five LTCFs from quarters 1 to 3 of 2014 were obtained from the Centers for Medicare and Medicaid Services in February 2015. Spearman’s rho and the Generalized Estimating Equations using a log link (Poisson distribution) were used. RESULTS: Communication and feedback about incidences reported the highest mean scores (M = 4.35, SD =0.71). Higher rate of falls was associated with a lower level of team work, lower degree of handoffs, and lower levels of organizational learning. The risk for falls increased as the number of residents per facility increased (rate ratio [RR] = 1.02; 95% confidence interval [CI] = 1.01-1.02) and as the number of LPN hours per resident increased (RR = 37.7, 95% CI = 18.5-76.50). Risk for long stay urinary tract infections increased as number of residents increased (RR =1.01, 95% CI =1.01-1.01). Increase in culture of safety score was associated with decrease in risk of falls, long stay urinary tract infections, and short stay ulcers. CONCLUSIONS: With the shortage of registered nurses in LTCFs and new reimbursement regulations, many LTCFs are hiring LPNs to have full staffing and save money. Licensed practical nurses may lack essential knowledge to decrease the rate of falls.

Retention of certified nursing assistants (CNAs) is an ongoing challenge for nursing homes. PURPOSE: To combat the effects of providing complex care needs to residents, this quality improvement project explored a 90-minute evidence-based education program on compassion fatigue awareness and multiple self-care skill strategies for CNA retention. DESIGN: A single-group pre- and posttest design, mixed-methods approach. METHOD: A preintervention demographic survey, a postexperience survey, and the ProQOL (Professional Quality of Life; Version 5) tool measured the CNAs’ level of compassion satisfaction, burnout, and secondary traumatic stress at three time points: preintervention, 1 month postintervention, and 3 months postintervention. RESULTS: Forty-five CNAs participated. After 1 month, CNA retention increased by 43%, and at the end of the fourth month, the facility’s retention rate was 100%. Forty-four percent of the full-time supplemental agency CNAs became full-time facility employees. The use of supplemental agency staff decreased to less than 5% of the total CNA hours worked. CNAs improved their compassion satisfaction, burnout, and secondary traumatic stress scores. CONCLUSION: This education program proved to be an effective, low-cost intervention. The quality improvement project highlighted the need for additional study on holistic interventions such as workplace education programs addressing compassion fatigue awareness and self-care skill strategies in this understudied group of formal caregivers.

Cross-sectional research has found that shorter and poorer sleep are associated with lower work performance and greater work-to-family conflict (WTFC). However, we know little about daily mechanisms linking sleep, work performance, and WTFC. This study tested whether previous nights’ sleep was linked to next day WTFC, mediated by work performance. DESIGN: Daily interview methodology. SETTING: US extended-care workplaces. PARTICIPANTS: One hundred seventy-one female employees with children aged 9 to 17 years. MEASUREMENTS: In telephone interviews on 8 consecutive evenings, participants reported their daily work performance (work productivity, work quality), WTFC (e.g., “how much did things you wanted to do at home not get done because of the demands your job put on you?”), and previous nights’ sleep duration (in hours) and sleep quality (1 = very badly, 4 = very well). RESULTS: Multilevel models revealed a significant association between previous night’s sleep with next-day work performance. More specifically, on days following better sleep quality than usual, participants reported better work productivity than usual. Moreover, higher work productivity was associated with less WTFC on that day. A mediation test revealed that poorer previous night’s sleep quality predicted less work productivity the next day, which, in turn, predicted more WTFC on the same day. CONCLUSION: Results provide evidence for the downward spiral of resource losses starting from poor sleep. Better quality sleep, as a replenished resource, may promote next-day productivity at work, which may bring less interference from work to the home.

Health care needs of individuals living in the community are increasing. To meet the rising need, unregulated care providers are providing more complex patient care. The aim of this review is to articulate the unregulated care provider role by identifying patient care activities offered by unregulated care providers in home care. METHODS: A scoping review was conducted. One thousand and eleven published manuscripts were identified in CINAHL, Ageline and MEDLINE. Eleven additional manuscripts were identified through hand searching. Manuscripts were screened for relevancy and data were abstracted to address the research question. RESULTS: Twenty-eight studies originating from Canada, Sweden, Belgium, UK, USA and New Zealand were included. Three categories of patient care activities provided by unregulated care providers were found: (1) personal care and core skills; (2) delegated tasks and added skills; and (3) specialty roles. CONCLUSION: Unregulated care providers predominantly provide assistance with personal care and activities of daily living. However, unregulated care providers also provide care outside their training, including care once provided by nurses. IMPLICATIONS FOR NURSING MANAGEMENT: Guidelines clearly articulating responsibilities of nurses transferring care activities to unregulated care providers should be developed. Processes and policies regarding evaluation and supervision of unregulated care providers providing added skills should be developed to ensure appropriate monitoring and support.

We identified two overarching classifications of integrated geriatric and palliative care to maximize older people’s quality of life at the end of life. Both are oriented to person-centered care, but with differing emphasis on either function or symptoms and concerns. Policymakers should both improve access to palliative care beyond just the last months of life and increase geriatric care provision to maintain and optimize function. This would ensure that continuity and coordination for potentially complex care needs across the continuum of late life would be maintained, where the demarcation of boundaries between healthy aging and healthy dying become increasingly blurred. Our findings highlight the urgent need for health system change to improve end-of-life care as part of universal health coverage. The use of health services should be informed by the likelihood of benefits and intended outcomes rather than on prognosis. CONTEXT: In an era of unprecedented global aging, a key priority is to align health and social services for older populations in order to support the dual priorities of living well while adapting to a gradual decline in function. We aimed to provide a comprehensive synthesis of evidence regarding service delivery models that optimize the quality of life (QoL) for older people at the end of life across health, social, and welfare services worldwide. METHODS: We conducted a rapid scoping review of systematic reviews. We searched MEDLINE, CINAHL, EMBASE, and CDSR databases from 2000 to 2017 for reviews reporting the effectiveness of service models aimed at optimizing QoL for older people, more than 50% of whom were older than 60 and in the last one or two years of life. We assessed the quality of these included reviews using AMSTAR and synthesized the findings narratively. RESULTS: Of the 2,238 reviews identified, we included 72, with 20 reporting meta-analysis. Although all the World Health Organization (WHO) regions were represented, most of the reviews reported data from the Americas (52 of 72), Europe (46 of 72), and/or the Western Pacific (28 of 72). We identified two overarching classifications of service models but with different target outcomes: Integrated Geriatric Care, emphasizing physical function, and Integrated Palliative Care, focusing mainly on symptoms and concerns. Areas of synergy across the overarching classifications included person-centered care, education, and a multiprofessional workforce. The reviews assessed 117 separate outcomes. A meta-analysis demonstrated effectiveness for both classifications on QoL, including symptoms such as pain, depression, and psychological well-being. Economic analysis and its implications were poorly considered. CONCLUSIONS: Despite their different target outcomes, those service models classified as Integrated Geriatric Care or Integrated Palliative Care were effective in improving QoL for older people nearing the end of life. Both approaches highlight the imperative for integrating services across the care continuum, with service involvement triggered by the patient’s needs and likelihood of benefits. To inform the sustainability of health system change we encourage economic analyses that span health and social care and examine all sources of finance to understand contextual inequalities.

To determine the effect of multicomponent exercise on frailty and related adverse outcomes in residents of long-term nursing homes (LTNHs). DESIGN: A single-blind randomized controlled trial. SETTING: Ten LTNHs in Gipuzkoa, Spain. PARTICIPANTS: The study sample comprised 112 men and women aged 70 years or older who scored 50 or higher on the Barthel Index, 20 or higher on the MEC-35 test (an adapted and validated version of the Mini-Mental State Examination in Spanish), and who were capable of standing up and walking independently for at least 10 m. INTERVENTION: Subjects in the control group (CG) participated in routine activities. The intervention group (IG) participated in a 6-month program of individualized and progressive multicomponent exercise at moderate intensity. MEASUREMENTS: Frailty was assessed by four different scales at baseline and at 6 months. The Barthel Index was measured at baseline and at 12 months. Frailty-related adverse outcomes were recorded from 12 months before to 12 months after starting the intervention. RESULTS: A lower prevalence of frailty was observed in the IG compared with the CG according to Fried’s frailty phenotype, Short Physical Performance Battery, and Tilburg Frailty Indicator after 6 months (p .05), but during the 6-month intervention period, fewer falls were observed in the IG than the CG (p < .05). Lower overall mortality was observed 12 months after starting the intervention for the IG than the CG (1 vs 6, respectively; p = .05). CONCLUSION: Individualized and progressive multicomponent exercise at moderate intensity seems to be effective to prevent falls and reduce frailty and mortality.

A challenge for commissioners and providers of end-of-life care in dementia is to translate recommendations for good or effective care into quality indicators that inform service development and evaluation. AIM:: To identify and critically evaluate quality indicators for end-of-life care in dementia. RESULTS:: We found 8657 references, after de-duplication. In all, 19 publications describing 10 new and 3 updated sets of indicators were included in this review. Ultimately, 246 individual indicators were identified as being relevant to dementia end-of-life care and mapped against EAPC guidelines. CONCLUSIONS:: We systematically derived and assessed a set of quality indicators using a robust framework that provides clear definitions of aspects of palliative care, which are dementia specific, and strengthens the theoretical underpinning of new complex interventions in end-of-life care in dementia.

The purpose of this article is to analyse the available literature describing the economic burden of dementia and to compare costs between studies examining cost drivers. To shed light on this field, a systematic review is performed using PubMed, the Cochrane Library and Web of Science. An eight-year retrospective horizon was considered until 25 May 2018. Several papers were obtained from the database search (n = 23), being others (n = 3) identified through other sources (hand-searching) because we did not detect it through the three databases. The cost estimates were compared between three perspectives: state/publicly funded health services, third-party/private sector/not-for-profit organisations and patient and family and/or societal. The estimated total annual cost per person with dementia in Europe is on average euro32,506.73 (n = 10), whereas for the United States, it gets euro42,898.65 (n = 2). Furthermore, differences are appreciated by type of costs. Besides, differences by severity groups are also considered. Overall, the higher the severity the higher the associated costs. Dementia imposes a huge economic burden. The figures here presented provide a good framework to quantify these costs for both, economic experts and researchers, and policy decision makers.

To identify the conditions needed to implement nurse practitioners (NP) in long-term care (LTC) in Quebec, Canada. DESIGN: A qualitative descriptive study was undertaken. METHODS: Semi-structured interviews (N = 91) and socio-demographic questionnaires were completed with providers and managers from May 2016-March 2017. Nurse practitioner activity logs were compiled at three sites. Content analysis was used. RESULTS: All sites initially implemented a shared care model but not all sites successfully implemented a consultative model. The progression was influenced by physicians’ level of comfort in moving towards a consultative model. Weekly meetings with physicians and nurse managers and an office for NPs located near healthcare teams facilitated communication and improved implementation. Half-time NP positions facilitated recruitment. Improvements were noted in timely care for residents, family involvement and quality of documentation of the healthcare team. Regulatory restrictions on prescribing medications used frequently in LTC and daily physician presence at some sites limited implementation. CONCLUSION: The project fostered an understanding of the conditions needed to successfully implement NPs in LTC. An examination of the perspective of residents and families is needed.

The current study sought to obtain pilot data from a Situation, Background, Assessment, Recommendation (SBAR) communication intervention focused on the shared meaning construct of the sensemaking model and explore shared meaning in communication between nursing home (NH) nurses and physicians. The study design was an exploratory sequential mixed method with a pre/post quasi-experiment. Grounded theory was used to collect and analyze nurse and physician interviews and medical records. The Pathway to Shared Meaning model illustrating distinct processes supported use of the sensemaking model for understanding nurse-physician communication. Quantitative changes in communication were not significant. Shared meaning and training in SBAR for communication can be used to strengthen the design and use of structured communication in NHs. TARGETS: Nurses and physicians providing direct care in NHs. INTERVENTION DESCRIPTION: Stories describing nurse-physician sharing of resident information using SBAR. MECHANISM OF ACTION: Mutual understanding of one another’s perspective enhances communication. OUTCOME: Communication openness and satisfaction.

A majority of nursing home residents have dementia, and many develop neuropsychiatric symptoms. These symptoms are often caused by neuropathological changes in the brain, but modifiable factors related to quality of care also have an impact. A team-based approach to care that include comprehensive geriatric assessments to facilitate clinical decision-making and structured case conference meetings could improve quality of care and quality of life for the residents. Despite recommendations to adopt this approach, dementia care does not reach standards of evidence-based practice. Better implementation strategies are needed to improve care. A cluster randomised controlled trial with a 12-month intervention was conducted, and the experiences of staff from the intervention nursing homes were explored in a qualitative study after the trial was completed. The aim of the present study was to describe: (i) staff’s experiences with the intervention consisting of comprehensive geriatric assessments of nursing home residents and case conferencing, and (ii) enablers and barriers to implementing and sustaining the intervention. METHODS: Four focus groups with a total of 19 healthcare staff were interviewed, representing four out of eight intervention nursing homes. Thematic content analysis was used to interpret the transcribed data. RESULTS: Two major themes emerged: 1) learning experiences and 2) enablers and barriers to implementation. The participants had experienced learning both on an organisational level: improvements in care and an organisation that could adjust and facilitate change; and on an individual level: becoming more conscious of residents’ needs and acquiring skills in resident assessments. Participants described important enabling factors such as managerial support, drivers for change, and feasibility of the intervention for the local nursing home. Barriers to implementing and sustaining the intervention were time constraints, lack of staff training, unsuitable electronic patient record system for care planning and high complexities of care and instabilities that are present in nursing homes. CONCLUSIONS: Quality improvements in nursing homes are difficult to sustain. In order to offer residents high quality of care that meet their individual needs, it is important for management and nursing home staff to be aware of and understand factors that enable or constrain change.

To determine community- and individual-level correlates of administrator tenure in US residential care communities (RCCs). DESIGN: Secondary data analysis of the 2010 National Survey of Residential Care Facilities designed by the National Center for Health Statistics. Analysis was conducted using Tobit regression. SETTING AND PARTICIPANTS: A nationally representative sample of RCCs in the United States (n = 2302). MEASURES: The outcome measure for this study is RCC administrator tenure. Residential care community characteristics include chain ownership, size, occupancy rate, profit status, years of operation, if the building was purposely constructed as an RCC, Medicaid census, presence of a dementia care unit, and whether administrative staff provided care. Administrator characteristics included age, gender, race/ethnicity, and level of education. RESULTS: Over a quarter of administrators in this sample remained employed with the same RCC for 10 or more years (28%). Chain membership, community size, and presence of a dementia care unit are associated with shorter administrator tenure (P < .001). Communities with greater than 80% occupancy, administrator’s age 40+, and Hispanic race/ethnicity were associated with longer administrator tenure (P < .001). CONCLUSIONS/IMPLICATIONS: Various community and administrator characteristics are associated with shorter or longer tenure within the same community. More setting-specific research is needed to identify how RCC administrators influence care quality and what different lengths of tenure indicate in the context of RCC operations.

Long-term care ombudsmen are advocates who empower and assist residents with complaints relating to quality of care and violations of resident rights in assisted living (AL) and skilled nursing facilities (SNF). Given that long-term care residents are vulnerable to elder abuse, neglect and exploitation (ANE), and existing gaps in the literature addressing ANE in AL, more research is needed to understand the prevalence of ANE in these communities. Ombudsman complaint data (n = 140,497 complaints) in 3,171 Texas long-term care facilities were analyzed using proportion Z tests. Findings showed that SNF had higher rates of ANE per resident. For both AL and SNF, verbal/psychological abuse was the most reported type of ANE and sexual abuse was the least reported. AL residents had disproportionately high rates of financial exploitation. We explored factors that may contribute to these findings and recommend strategies for preventing ANE.

Though the world has gotten more tolerant toward people who identify as LGBTQ, significant fear and barriers still exist in the health system, particularly for LGBTQ older adults. When you couple this fear with providers ill-equipped to handle the unique needs of LGBTQ older adults, you have a health system that allows these consumers to fall through the cracks.

To help address some of these barriers, we have put together a new issue brief, authored by staff members at SAGE, about the importance of training aging service providers on the unique needs of LGBTQ older adults and on meeting those needs in a culturally competent manner. This brief describes SAGE’s cultural competency training program and shares a case study of how this training helped one large provider organization, Visiting Nurse Service of New York (VNSNY).

Resident safety and welfare in long-term care (LTC) is being redefined as the focus shifts to promoting an optimal quality of life especially in LTC. Achieving this requires contemporary practice to improve the organization and staff’s ability in identifying, communicating, documenting, and managing the risks that arise from the choices a person makes in pursuit of a better quality of life. This article is a narrative realist style review examining the issues of how to manage risks for older residents living in LTC. The issues are examined in six stages: context, identifying, communicating, documenting, enacting, reviewing and reflecting on how choices are made and risks managed. It is important for individuals to be supported in making an informed choice – this requires identifying, providing, and communicating the available options and the potential consequences. Documenting consent, perhaps with formal risk agreements, provides clarity for all involved and assists in determining how and who is responsible for enacting choices. Reviewing and reflecting upon the decisions and actions to enact choices are familiar to prudent LTC managers who implement and monitor robust governance systems. Learning from these experiences is essential to better meet individual resident, staff, organizational, and community expectations. Improving practice at each of the six steps should reduce adverse professional and legal repercussions and enable the resident, families, and staff to better cope with respecting choices when a known harmful outcome eventuates.

Hospitalisations are very common among nursing home residents and many of these are deemed inappropriate or preventable. Little is known about whether clinical care quality is related to hospitalisation, especially potentially preventable hospitalisations (PPHs). Among the few studies that have been conducted, the findings have been inconsistent. The objective of this study was to examine the relationship between quality indicators and overall and PPHs among Medicaid beneficiaries aged 65 years and older receiving care at nursing homes in Minnesota. METHODS: 23 risk-adjusted quality indicators were used to assess nursing home quality of care. Quality indicators and other facility-level variables from the Minnesota Nursing Home Report Card were merged with resident-level variables from the Minimum Data Set. These merged data were linked with Medicaid claims to obtain hospitalisation rates during the 2011-2012 period. The sample consisted of a cohort of 20 518 Medicaid beneficiaries aged 65 years and older who resided in 345 Minnesota nursing homes. The analyses controlled for resident and facility characteristics using the generalised linear mixed model. RESULTS: The results showed that about 44 % of hospitalisations were PPHs. Available quality indicators were not strongly or consistently associated with the risk of hospitalisation (neither overall nor PPH). Among these 23 quality indicators, five quality indicators (antipsychotics without a diagnosis of psychosis, unexplained weight loss, pressures sores, bladder continence and activities of daily living [ADL] dependence) were related significantly to hospitalisation and only four quality indicators (antipsychotics without a diagnosis of psychosis, unexplained weight loss, ADL dependence and urinary tract infections) were related to PPH. CONCLUSION: Although general quality indicators can be informative about overall nursing home performance, only selected quality indicators appear to tap dimensions of clinical quality directly related to hospitalisations.

The relevance of context in implementation science is reflected in the numerous theories, frameworks, models and taxonomies that have been proposed to analyse determinants of implementation (in this paper referred to as determinant frameworks). This scoping review aimed to investigate and map how determinant frameworks used in implementation science were developed, what terms are used for contextual determinants for implementation, how the context is conceptualized, and which context dimensions that can be discerned. METHODS: A scoping review was conducted. MEDLINE and EMBASE were searched from inception to October 2017, and supplemented with implementation science text books and known published overviews. Publications in English that described a determinant framework (theory, model, taxonomy or checklist), of which context was one determinant, were eligible. Screening and inclusion were done in duplicate. Extracted data were analysed to address the study aims. A qualitative content analysis with an inductive approach was carried out concerning the development and core context dimensions of the frameworks. The review is reported according to the PRISMA guidelines. RESULTS: The database searches yielded a total of 1113 publications, of which 67 were considered potentially relevant based on the predetermined eligibility criteria, and retrieved in full text. Seventeen unique determinant frameworks were identified and included. Most were developed based on the literature and/or the developers’ implementation experiences. Six of the frameworks explicitly referred to “context”, but only four frameworks provided a specific definition of the concept. Instead, context was defined indirectly by description of various categories and sub-categories that together made up the context. Twelve context dimensions were identified, pertaining to different aggregation levels. The most widely addressed context dimensions were organizational support, financial resources, social relations and support, and leadership. CONCLUSIONS: The findings suggest variation with regard to how the frameworks were developed and considerable inconsistency in terms used for contextual determinants, how context is conceptualized, and which contextual determinants are accounted for in frameworks used in implementation science. Common context dimensions were identified, which can facilitate research that incorporates a theory of context, i.e. assumptions about how different dimensions may influence each other and affect implementation outcomes. A thoughtful application of the concept and a more consistent terminology would enhance transparency, simplify communication among researchers, and facilitate comparison across studies.

The behavior of people with dementia has been a focus of both research and dementia care for decades, particularly behavior that is considered “challenging.” As we will discuss below, this challenging behavior has appeared difficult to demarcate and define, resulting in many approaches and views about what it comprises, which consequently has resulted in many different measurement instruments. The striking consequence is that the field now has been provided with a pool of research results that are hard to interpret and combine into knowledge that really moves it forward.

Funders, policy-makers and research organizations increasingly expect health researchers in the UK to involve patients and members of the public in research. It has been stated that it makes research “more effective, more credible and often more cost efficient.” However, the evidence base for this assertion is evolving and can be limited. There has been little research into how health researchers feel about involving people, how they go about it, how they manage formal policy rhetoric, and what happens in practice. OBJECTIVE: To explore researchers’ experiences and perceptions of patient and public involvement (PPI). METHODS: Semi-structured interview study of 36 health researchers (both clinical and non-clinical), with data collection and thematic analysis informed by the theoretical domains framework. RESULTS: In the course of our analysis, we developed four themes that encapsulate the participants’ experiences and perceptions of PPI. Participants expressed ambivalence, cynicism and enthusiasm about PPI, an activity that creates emotional labour, which is both rewarding and burdensome and requires practical and social support. It is operationalized in an academic context influenced by power and incentives. DISCUSSION AND CONCLUSIONS: Researchers’ experiences and attitudes towards patient and public involvement are a key factor in the successful embedding of involvement within the wider research culture. We call for a culture change that supports the development of effective organizational approach to support involvement.

Cognitive Stimulation Therapy is a well-established, cognition-based intervention for people with mild to moderate dementia. However, it can be difficult for older people with dementia, particularly those living alone, to access Cognitive Stimulation Therapy groups in the community. Television offers familiar technology with potential to transmit material similar to that used in Cognitive Stimulation Therapy groups. Consequently, an interactive pilot television episode of Cognitive Stimulation Therapy was devised that adheres to the key principles and session themes of group Cognitive Stimulation Therapy. Consideration was given to the suitability of resources, on-screen visual cues, time given for the person with dementia viewing to process, consider and answer questions, possible interactions with the audience, and the grading of activities. The aim of the pilot episode was to be accessible in the home of the person with dementia, by themselves or with a caregiver, with the potential for enjoyment and cognitive stimulation similar to that seen in group Cognitive Stimulation Therapy.

Having contact with nature can be beneficial for health and wellbeing, but many older adults face barriers with getting outdoors. We conducted a systematic review of quantitative studies on health and wellbeing impacts of indoor forms of nature (both real and simulated/artificial), for older adults in residential settings. RESEARCH DESIGN AND METHODS: Search terms relating to older adults and indoor nature were run in 13 scientific databases (MEDLINE, CINAHL, AgeLine, Environment Complete, AMED, PsychINFO, EMBASE, HMIC, PsychARTICLES, Global Health, Web of Knowledge, Dissertations and Theses Global, and ASSIA). We also pursued grey literature, global clinical trials registries, and a range of supplementary methods. RESULTS: Of 6,131 articles screened against eligibility criteria, 26 studies were accepted into the review, and were quality-appraised using the Effective Public Health Practice Project (EPHPP) tool. The participants were 930 adults aged over 60. Nature interventions and health/wellbeing outcomes were heterogeneous, which necessitated a narrative synthesis. The evidence base was generally weak, with 18 of 26 studies having a high risk of bias. However, several higher-quality studies found indoor gardening and horticulture programs were effective for cognition, psychological wellbeing, social outcomes, and life satisfaction. DISCUSSION AND IMPLICATIONS: There is inconsistent evidence that indoor nature exposures are beneficial for older care residents. We expect that successful interventions were, at least partly, facilitating social interaction, supporting feelings of autonomy/control, and promoting skill development, that is, factors not necessarily associated with nature per se. Higher-quality studies with improved reporting standards are needed to further elucidate these mechanisms.

Neuropsychiatric behaviors of persons with dementia, including agitation, aggression, and rejection of care, are almost universal; occur throughout the disease process; and have negative consequences for both persons with dementia and their caregivers. Nonpharmacological approaches are now recognized as first-line treatment to address these behaviors. One promising approach is activity tailored to the person’s interests, abilities, and physical and social environment. An evidence-based program, New Ways for Better Days: Tailoring Activities for Persons With Dementia and Their Caregivers (TAP), draws on occupational therapy principles (person-environment-occupation fit, activity analysis) to meaningfully engage persons with dementia. OBJECTIVE: This case report describes the TAP protocol and clinical reasoning processes underlying use of tailored activities as a therapeutic modality to address dementia-related neuropsychiatric behaviors. DESIGN: This is a case study of an African-American woman in her 60s caring for her father, age 92, who has severe dementia and multiple behaviors. OUTCOMES AND MEASURES: Primary outcomes in this case report include the person with dementia’s engagement in an activity and the reported neuropsychiatric behaviors. In addition, the caregiver’s confidence in using activities is reported. These and other measures from the TAP protocol are described in full. RESULTS: After working with an occupational therapist for eight sessions, the person with dementia’s engagement in activity increased by 50% and his frequency of vocal disturbance decreased, and the caregiver felt more confident in using activities with her father. CONCLUSION AND RELEVANCE: This case report illustrates how occupational therapists working with families of persons with dementia can use the TAP protocol to help them manage neuropsychiatric behaviors by tailoring activities. WHAT THIS ARTICLE ADDS: Occupational therapists are uniquely qualified to systematically assess the cognitive functioning of persons with dementia, caregivers, and home environments and to integrate this information to derive and implement activities tailored to the person’s capacities and context, thereby reducing neuropsychiatric behaviors and increasing engagement in meaningful activity.

Vision impairments are prevalent, but underdiagnosed in individuals with dementia living in long term care (LTC). Effective screening tools could identify remediable vision problems. This scoping review was conducted to identify vision screening tests used with individuals with dementia and assesses their suitability for administration by nurses in LTC. A literature search using the Arksey and O’Malley (2005) method included research articles, conference proceedings, and dissertations. Data was included from participants over 65 years of age with a diagnosis of probable dementia. A panel of vision experts evaluated the suitability of the candidate vision tests. The search yielded 179 publications that met the inclusion criteria. Of 134 vision tests that were identified, 19 were deemed suitable for screening by nurses in LTC. Tests screened for acuity (12), visual field (1), anatomy (2), color vision (2), and general visual abilities (2). Tests were excluded because of complexity of interpretation (90), need for specialized training (83), use in research only (57), need for specialized equipment (54), not assessing visual function (44), long test duration (21), uncommonness (13), and needing an act reserved for specialists (7). Psychometric properties were not often reported for tests. Few of the tests we identified had been validated for use with individuals with dementia. Based on our review, few tests were deemed suitable for use by nurses to assess this population in LTC. Identifying appropriate tools to screen vision in individuals with dementia is a necessary first step to interventions that could potentially improve functioning and quality of life.

The aim of this study was to develop a Minimum Data Set for Incontinence-Associated Dermatitis (MDS-IAD), to psychometrically evaluate and pilot test the instrument in nursing homes. Comparable to the MDS for pressure ulcers, the MDS-IAD aims to collect epidemiological data and evaluate the quality of care. MATERIALS AND METHODS: After designing and content/face validation by experts and clinicians, staff nurses assessed 108 residents (75.9% female, 77.8% double incontinent) in a convenience sample of five wards. A second nurse independently assessed fifteen residents to calculate inter-rater agreement (p0) and reliability [Cohen’s Kappa (k)]. RESULTS: The k-value for ‘urinary incontinence’ was 0.68 [95% confidence interval (CI) 0.37-0.99] and 0.55 (95% CI 0.27-0.82) for ‘faecal incontinence’. The p0 for severity categorisation according to the Ghent Global IAD Categorisation Tool (GLOBIAD) was 0.60. IAD was diagnosed in 21.3% of the residents. IAD management mainly involved the application of a leave-on product (66.7%), no-rinse foams (49.1%), toilet paper (47.9%), and water and soap (38.8%). Fully adequate prevention or treatment was provided to respectively 3.6% and 8.7% of the residents. CONCLUSION: This instrument provides valuable insights in IAD prevalence at organisational level, will allow benchmarking between organisations, and will support policy makers. Future testing in other healthcare settings is recommended.

This study evaluated the preliminary effect of laughter therapy on the level of loneliness and death anxiety of older adults. METHODS: This was a quasi-experimental study with a nonequivalent control group pretest-posttest design. The study participants were older adults living in two nursing homes set up by foundations located in the capital of Turkey. A total of 50 older adults formed the intervention group (n = 20) and control group (n = 30). The intervention group received laughter therapy twice a week for 5 weeks. The control group received no intervention. Data were collected using a socio-demographic form, the De Jong Gierveld Loneliness Scale (DJGLS) and the Turkish Death Anxiety Scale (TDAS). RESULTS: After laughter therapy, the DJGLS total and subscale (emotional and social loneliness) scores decreased among older adults in the intervention group (p < 0.005). While there were no significant differences for overall TDAS, death uncertainty and pain subscales scores between the intervention and control group after laughter therapy, there was a significant decrease in TDAS exposure subscale scores of the intervention group (p < 0.005). DISCUSSION: The results suggest that laughter therapy can be used to decrease levels of loneliness and death anxiety among older adults living in nursing homes. IMPLICATIONS FOR PRACTICE: Anxiety regarding death and loneliness are important issues that affect quality of life in older adults. This first pilot study demonstrates the beneficial effects of laughter therapy on loneliness and death anxiety in nursing home residents. Nurses can incorporate laughter therapy into routine programmes in nursing homes.

This report provides an overview of the research findings from the collaborative research project between Aston Research Centre for Healthy Ageing (ARCHA) and the ExtraCare Charitable Trust, collated by Professor Carol Holland, Centre for Ageing Research (C4AR), Lancaster University. This report extends the findings of the 2015 report, covering the period from 2012 to 2018. Throughout the report, the focus is on the benefits to residents generated through ExtraCare villages and schemes, including sustained improvements in markers of health and well-being for residents and subsequent cost implications for the NHS.

In this webcast from AHRQ, speakers will provide an overview of one strategy to improve patients’ experience with primary care: nurse care coordination. They will then discuss the role of staff’s creative ideas in improving patient care experiences generally, the challenges for organizations that these ideas entail, and ways to address these challenges.

Learning objectives:
1. Identify everyday ethical considerations in patient-oriented knowledge translation
2. Describe a case example illustrating ethical considerations in patient partner-researcher relationships
3. Reflect on practical implications of ethical considerations arising in the case example

To help you develop your EoG KT plan, the KT Program offers the End of Grant Knowledge Translation (EoG KT) course. This online, self-directed course provides a flexible way for you to not only learn why and how to develop an effective KT plan for your grant application, but also provides the optional opportunity for you to receive feedback on your EoG KT plan from KT experts. Upon completion of the course, participants will be able to:
Develop an end of grant KT plan
Develop an approach to help tell the story about your research using media and social media
Assess impact of research publication and how to use and interpret bibliometrics and altmetrics

This 11-week online course, held from September 16-December 1, will provide students with an introduction to the emerging field of implementation research through lectures from global health leaders and opportunities to apply lessons learned on topics of global health importance. Participants may attend as an independent participant or as part of a local site. To be admitted to the course you must have a master’s degree in a health-related field or in the social sciences, or equivalent professional experience

This comprehensive, 5-day program is designed to prepare health sciences researchers, clinicians, librarians, graduate students and other individuals involved in quality and practice portfolios to develop, conduct and report systematic reviews of evidence.

This app is designed to help patients be more engaged in their health care. The Agency for Healthcare Research and Quality (AHRQ) has launched a new mobile app for smartphones, tablets, and laptop computers to help patients be more engaged in their health care. Research has demonstrated that outcomes are best when patients are active members of the healthcare team. The AHRQ Question Builder app – available at no charge from iTunes and Google Play – helps patients prepare and organize questions and other helpful information prior to medical visits.
The web version of the AHRQ Question Builder, which allows patients to create and print a list of questions they want to ask at their medical appointment, is still available online

If you want your research to have an impact, a good place to start is working out who might benefit from your work. In this short guide and accompanying video, I will explain how to do a publics/stakeholder analysis using a simple template, so you know who to target in your grant application and who to reach out to first as you attempt to generate impact from your research.