April 30, 2019

Grants & Awards


TREC article in Calgary Herald
“Unbefriended” seniors are the forgotten population

By Stephanie Chamberlain & Carole Estabrooks, 27 April 2019
What happens when a person grows older and is no longer able to make health and financial decisions for themselves — but also does not have family or friends who can make those decisions on their behalf? Health and social services use a hard-hitting term to describe this growing population: “unbefriended.”

Canada’s Dementia Strategy Stakeholder Feedback
What We Heard Report: Informing a dementia strategy for Canada

Public Health Agency of Canada, April 2019
Beginning in June 2017, following the enactment of the National Strategy for Alzheimer’s Disease and Other Dementias Act, the Public Health Agency of Canada sought to further understand the impacts of dementia in Canada by engaging the six stakeholder groups mentioned in the Act: people living with dementia, family/friend caregivers, representatives of provincial and territorial governments, researchers, health care providers, as well as dementia advocacy groups. This report summarizes what we heard from these stakeholders and is informing the development of a dementia strategy for Canada. Given the depth and breadth of information received, this report aims to reflect the essence of the ideas and perspectives that were raised. It is not intended to imply consensus on the part of all participants. The views expressed are those of participants and should not be construed as representative of the Government of Canada’s positions or views.

UAlberta Researchers now eligible for 20% discount off Cambridge University Press Journals APC
More information

This includes the Canadian Journal on Aging
University of Alberta researchers qualify for a 20% discount on APCs in all Gold OA and Hybrid OA journals published by Cambridge University Press. The discount is applied when an author submits the article to the Copyright Clearance Center’s RightsLink service. During the APC payment process, select ‘Apply Discount’ and enter the token number for the University of Alberta: O8495Y73CVZB7I6VY7R9


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Grants & Awards

Michael Smith Foundation for Health Research: 2019 Convening & Collaborating (C2) and Reach competitions

Research knowledge is most likely to be applied when it is informed by those who will use it, whether that be community members, care providers, policy-makers, or other researchers.

To support this, and help ensure research has the maximum impact on health and the health system, MSFHR runs the C2 and Reach Programs. These programs are specifically designed to foster collaboration between researchers and research users*, support the co-development of research questions and the dissemination of research evidence.

This year we are pleased to be running the C2 and Reach competitions concurrently, with each award providing a maximum of $15,000 for up to 12 months.

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


Specifying and comparing implementation strategies across seven large implementation interventions: a practical application of theory.
Non UofA Access

C. K. Perry, L. J. Damschroder, J. R. Hemler, T. T. Woodson, S. S. Ono and D. J. Cohen.
Implement Sci 2019 Mar 21;14(1):32-019-0876-4
The use of implementation strategies is an active and purposive approach to translate research findings into routine clinical care. The Expert Recommendations for Implementing Change (ERIC) identified and defined discrete implementation strategies, and Proctor and colleagues have made recommendations for specifying operationalization of each strategy. We use empirical data to test how the ERIC taxonomy applies to a large dissemination and implementation initiative aimed at taking cardiac prevention to scale in primary care practice. METHODS: EvidenceNOW is an Agency for Healthcare Research and Quality initiative that funded seven cooperatives across seven regions in the USA. Cooperatives implemented multi-component interventions to improve heart health and build quality improvement capacity, and used a range of implementation strategies to foster practice change. We used ERIC to identify cooperatives’ implementation strategies and specified the actor, action, target, dose, temporality, justification, and expected outcome for each. We mapped and compiled a matrix of the specified ERIC strategies across the cooperatives, and used consensus to resolve mapping differences. We then grouped implementation strategies by outcomes and justifications, which led to insights regarding the use of and linkages between ERIC strategies in real-world scale-up efforts. RESULTS: Thirty-three ERIC strategies were used by cooperatives. We identified a range of revisions to the ERIC taxonomy to improve the practical application of these strategies. These proposed changes include revisions to four strategy names and 12 definitions. We suggest adding three new strategies because they encapsulate distinct actions that were not described in the existing ERIC taxonomy. In addition, we organized ERIC implementation strategies into four functional groupings based on the way we observed them being applied in practice. These groupings show how ERIC strategies are, out of necessity, interconnected, to achieve the work involved in rapidly taking evidence to scale. CONCLUSIONS: Findings of our work suggest revisions to the ERIC implementation strategies to reflect their utilization in real-work dissemination and implementation efforts. The functional groupings of the ERIC implementation strategies that emerged from on-the-ground implementers will help guide others in choosing among and linking multiple implementation strategies when planning small- and large-scale implementation efforts.

Clinical Performance Feedback Intervention Theory (CP-FIT): a new theory for designing, implementing, and evaluating feedback in health care based on a systematic review and meta-synthesis of qualitative research.
Non UofA Access

B. Brown, W. T. Gude, T. Blakeman, et al.
Implement Sci 2019 Apr 26;14(1):40-019-0883-5
Providing health professionals with quantitative summaries of their clinical performance when treating specific groups of patients (“feedback”) is a widely used quality improvement strategy, yet systematic reviews show it has varying success. Theory could help explain what factors influence feedback success, and guide approaches to enhance effectiveness. However, existing theories lack comprehensiveness and specificity to health care. To address this problem, we conducted the first systematic review and synthesis of qualitative evaluations of feedback interventions, using findings to develop a comprehensive new health care-specific feedback theory. METHODS: We searched MEDLINE, EMBASE, CINAHL, Web of Science, and Google Scholar from inception until 2016 inclusive. Data were synthesised by coding individual papers, building on pre-existing theories to formulate hypotheses, iteratively testing and improving hypotheses, assessing confidence in hypotheses using the GRADE-CERQual method, and summarising high-confidence hypotheses into a set of propositions. RESULTS: We synthesised 65 papers evaluating 73 feedback interventions from countries spanning five continents. From our synthesis we developed Clinical Performance Feedback Intervention Theory (CP-FIT), which builds on 30 pre-existing theories and has 42 high-confidence hypotheses. CP-FIT states that effective feedback works in a cycle of sequential processes; it becomes less effective if any individual process fails, thus halting progress round the cycle. Feedback’s success is influenced by several factors operating via a set of common explanatory mechanisms: the feedback method used, health professional receiving feedback, and context in which feedback takes place. CP-FIT summarises these effects in three propositions: (1) health care professionals and organisations have a finite capacity to engage with feedback, (2) these parties have strong beliefs regarding how patient care should be provided that influence their interactions with feedback, and (3) feedback that directly supports clinical behaviours is most effective. CONCLUSIONS: This is the first qualitative meta-synthesis of feedback interventions, and the first comprehensive theory of feedback designed specifically for health care. Our findings contribute new knowledge about how feedback works and factors that influence its effectiveness. Internationally, practitioners, researchers, and policy-makers can use CP-FIT to design, implement, and evaluate feedback. Doing so could improve care for large numbers of patients, reduce opportunity costs, and improve returns on financial investments. TRIAL REGISTRATION: PROSPERO, CRD42015017541.

Clinical performance comparators in audit and feedback: a review of theory and evidence.
Non UofA Access

W. T. Gude, B. Brown, S. N. van der Veer, et al.
Implement Sci 2019 Apr 24;14(1):39-019-0887-1
Audit and feedback (A&F) is a common quality improvement strategy with highly variable effects on patient care. It is unclear how A&F effectiveness can be maximised. Since the core mechanism of action of A&F depends on drawing attention to a discrepancy between actual and desired performance, we aimed to understand current and best practices in the choice of performance comparator. METHODS: We described current choices for performance comparators by conducting a secondary review of randomised trials of A&F interventions and identifying the associated mechanisms that might have implications for effective A&F by reviewing theories and empirical studies from a recent qualitative evidence synthesis. RESULTS: We found across 146 trials that feedback recipients’ performance was most frequently compared against the performance of others (benchmarks; 60.3%). Other comparators included recipients’ own performance over time (trends; 9.6%) and target standards (explicit targets; 11.0%), and 13% of trials used a combination of these options. In studies featuring benchmarks, 42% compared against mean performance. Eight (5.5%) trials provided a rationale for using a specific comparator. We distilled mechanisms of each comparator from 12 behavioural theories, 5 randomised trials, and 42 qualitative A&F studies. CONCLUSION: Clinical performance comparators in published literature were poorly informed by theory and did not explicitly account for mechanisms reported in qualitative studies. Based on our review, we argue that there is considerable opportunity to improve the design of performance comparators by (1) providing tailored comparisons rather than benchmarking everyone against the mean, (2) limiting the amount of comparators being displayed while providing more comparative information upon request to balance the feedback’s credibility and actionability, (3) providing performance trends but not trends alone, and (4) encouraging feedback recipients to set personal, explicit targets guided by relevant information.


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Health Care Administration and Organization

A Scoping Review of Dementia Care Experiences in Migrant Aged Care Workforce.
Non UofA Access

B. Adebayo, P. Nichols, K. Heslop and B. Brijnath.
Gerontologist 2019 Apr 12
In high-income countries, an increasing number of people living with dementia in residential aged care facilities are being cared for by an increasingly multicultural workforce. The purpose of this review was to investigate migrant aged care workers’ dementia care experiences and to identify enablers and challenges that influence their retention. RESEARCH DESIGN AND METHODS: Utilizing Arksey and O’ Malley’s approach, PubMed, Scopus, CINAHL, Web of Science, and EMBASE were searched for peer-reviewed studies published from 2000 to November 2018. Selection criteria were studies with original research, focusing on dementia care among migrant aged care workers, and conducted in high-income countries. RESULTS: Seventeen articles were identified incorporating 13 (76.47%) qualitative, 1 (5.88%) quantitative, and 3 (17.65%) mixed method designs. A limited understanding of dementia and experiences of dementia care were reported among some migrant care workers in residential aged care facilities. The identified enablers to retention were the availability of organization support services; professional development opportunities; reciprocity and mutual respect between migrant care workers, care recipients, and coworkers; and good working conditions. Factors such as discrimination from care recipients and coworkers and limited understanding of workplace culture were identified as barriers to migrant care workforce retention. DISCUSSION AND IMPLICATIONS: Migrant care workers are valuable contributors to the aged care workforce. It is important to consider their cultural perceptions of dementia in relation to care provision. In addition, their exposure to occupational psychosocial risk factors in conjunction with the challenges associated with resettlement and dementia care needs to be addressed.

Usability Testing of a Mobile Clinical Decision Support App for Urinary Tract Infection Diagnosis in Nursing Homes.
Non UofA Access

B. Reeder, C. Drake, M. Ozkaynak and H. L. Wald.
J Gerontol Nurs 2019 Apr 12:1-7
The aim of the current study was to conduct usability testing of a mobile clinical decision support (CDS) prototype designed for urinary tract infection (UTI) assessment by nurses in nursing homes (NHs). Usability of the UTIDecide smartphone application (app) was evaluated using cognitive walk-through and think-aloud protocol sessions with nurses (n = 6) at two NH sites. This evaluation was followed by unsupervised field tests lasting >/=1 week with nurses at one site (n = 4) and posttest interviews and administration of the System Usability Scale (SUS). Cognitive walk-through/think-aloud sessions yielded interface design recommendations that were implemented prior to field tests. All test sessions resulted in highly positive perceived usability and usefulness from participants. Average SUS score was 92.5 (n = 3), which equates to an “A” grade for usability. Design recommendations identified for future app versions are: (a) integration of the mobile CDS app with organizational information systems; and (b) expanded features to support assessment of other conditions

Intentional Rounding With Certified Nursing Assistants in Long-Term Care: A Pilot Project.
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M. Jenko, Y. Panjwani and H. G. Buck.
J Gerontol Nurs 2019 Apr 12:1-7
Intentional rounding (IR) is a strategy used by predominately acute care nursing staff to proactively address patients’ needs at regular and consistent intervals. The current project piloted the use of IR with certified nursing assistants (CNAs) on a 60-bed unit of a 120-bed skilled nursing facility (SNF). Using a pre/post intervention design and the Plan-Do-Study-Act (PDSA) framework, the authors measured knowledge of IR’s “4Ps” (potty, position, possessions, and pain) and the incidence of falls and lost possessions. Uptake of IR over 10 weeks of implementation and CNAs’ perceptions of intervention were also assessed. The pilot showed positive outcomes for each of the five aims. Data suggest that IR was well received by CNAs and changed practice patterns regarding quality, safety, and satisfaction. Based on these findings, replication of this project in other SNFs is recommended, given the current small and underpowered study.

Effects on staff outcomes from an intervention for management of neuropsychiatric symptoms in residents of young-onset dementia care units: A cluster randomised controlled trial.
Non UofA Access

J. C. L. van Duinen-van den IJssel, C. Bakker, M. Smalbrugge, et al.
Int J Nurs Stud 2019 Mar 15
Neuropsychiatric symptoms are common in nursing home residents with young-onset dementia and burdensome for nursing staff. It is known that neuropsychiatric symptoms are associated with burn-out complaints and low job satisfaction. An intervention aimed at decreasing neuropsychiatric symptoms in nursing home residents with young-onset dementia might also result in less burnout complaints and job demands and improve job satisfaction in nursing staff. OBJECTIVES: The aim was to evaluate the effect of the intervention on nursing staff burnout, job satisfaction and job demands. DESIGN: Cluster randomised controlled trial using a stepped wedge design with a total duration of 18 months, with four assessments. SETTING: Thirteen young-onset dementia special care units across the Netherlands were, by means of random allocation software, assigned to three groups crossing over at different time points. PARTICIPANTS: All nursing staff, in total 391, were invited to participate. 305 nursing staff participated during the course of the study of whom 71 participated in all assessments. INTERVENTION: An educational program followed by a structured multidisciplinary care program aimed at the management of neuropsychiatric symptoms. The care program consists of evaluation of psychotropic drug prescription followed by detection, analysis, treatment and evaluation of treatment of neuropsychiatric symptoms. METHODS: Emotional exhaustion, depersonalisation and personal accomplishment were assessed with the Utrecht Burnout Scale. Job satisfaction and job demands were assessed with subscales of the Leiden Quality of Work Questionnaire. RESULTS: The baseline burnout risk on emotional exhaustion and personal accomplishment was average, and low on depersonalisation. The mean scores for job satisfaction were above average and for job demands average. Linear mixed models showed that the intervention had no effect on emotional exhaustion (estimated effect -0.04, 95% confidence interval -1.25 to 1.16), depersonalisation (estimated effect 0.24, 95% confidence interval -0.26 to 0.74), personal accomplishment (estimated effect -0.82, 95% confidence interval -1.86 to 0.22) job satisfaction (estimated effect -0.40, 95% confidence interval -0.98 to 0.17) and job demands (estimated effect -0.04, 95% confidence interval -0.57 to 0.49). A significant difference was found between registered nurses and other nursing staff on emotional exhaustion and job satisfaction. Compared to other staff members, registered nurses’ emotional exhaustion scores slightly increased while job satisfaction slightly decreased when using the intervention. CONCLUSION: The intervention was not effective on three dimensions of burnout, job satisfaction and job demands. Staff scored positive on the outcomes of interest before implementation of the intervention, leaving little opportunity for improvement.

Persistent geographic variations in availability and quality of nursing home care in the United States: 1996 to 2016.
Non UofA Access

Y. Wang, Q. Zhang, E. S. Spatz, et al.
BMC Geriatr 2019 Apr 11;19(1):103-019-1117-z
Availability of nursing home care has declined and national efforts have been initiated to improve the quality of nursing home care in the U.S. Yet, data are limited on whether there are geographic variations in declines of availability and quality of nursing home care, and whether variations persist over time. We sought to assess geographic variation in availability and quality of nursing home care. METHODS: Retrospective study using Medicaid/Medicare-certified nursing home data from the Centers for Medicare & Medicaid Services, 1996-2016. Outcomes were 1) availability of all nursing home care (1996-2016), measured by the number of Medicaid/Medicare-certified beds for a given county per 100,000 population aged >/=65 years, regardless of nursing home star rating; 2) availability of 5-star nursing home care, measured by the number of Medicaid/Medicare-certified beds provided by 5-star nursing homes; and 3) utilization of nursing home beds, defined as the rate of occupied Medicaid/Medicare-certified beds among the total Medicaid/Medicare-certified beds. RESULTS: From 1999 to 2016, availability of all nursing home care declined from 4882 (standard deviation: 931) to 3480 (912) beds, per 100,000 population aged >/=65 years. Persistent geographic variation in availability of nursing home care was observed; the correlation coefficient of county-specific availabilities from 1996 to 2016 was 0.78 (95% CI 0.77-0.79). From 2011 to 2016, availability of 5-star nursing home beds increased from 658 (303) to 895 (661) per 100,000 population aged >/=65 years. The correlation coefficient for county-specific availabilities from 2011 to 2016 was 0.54 (95% CI 0.51-0.56). Availability and quality of nursing home care were not highly correlated. In 2016, the correlation coefficient for county-specific availabilities between all nursing home and 5-star nursing home beds was 0.33 (95% CI 0.30-0.36). From 1996 to 2016, the utilization of certified beds declined from 78.5 to 72.2%. This decline was consistent across all census divisions, but most pronounced in the Mountain division and less in the South-Atlantic division. CONCLUSION: We observed persistent geographic variations in availability and quality of nursing home care. Availability of all nursing home care declined but availability of 5-star nursing home care increased. Availability and quality of nursing home care were not highly correlated.

Problematizing Sexual Harassment in Residential Long-Term Care: The Need for a More Ethical Prevention Strategy.
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A. Grigorovich and P. Kontos.
Can J Aging 2019 Apr 17:1-11
Supporting sexual rights in residential long-term care is ethically complex. The well-being of care workers and residents is inextricably linked, and increasingly recognized empirically, yet public policy in Canada generally continues to exclusively focus on either the well-being of residents or workers. The consequences of this are particularly evident when we consider how to prevent sexual harassment towards workers without unjustly restricting the freedom of sexual expression for residents living with dementia. Employing Carol Bacchi’s “What’s the Problem Represented to be?” approach, we critically analysed a recent Canadian action plan to prevent sexual violence and harassment. Our analysis suggests that this policy is less than promising and may reproduce the very phenomenon it is intended to redress. The need to refocus prevention efforts on the structural factors implicated in this phenomenon is urgent if we are to support the sexual rights of both care workers and residents.

The integration of new nurse practitioners into care of older adults: A survey study.
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S. H. Henni, M. Kirkevold, K. Antypas and C. Foss.
J Clin Nurs 2019 Apr 24
To assess Norwegian advanced geriatric nurses’ (AGNs) use of their knowledge and skills, and factors that may influence AGNs’ opportunities to use their knowledge and skills to reach their full potential. BACKGROUND: Despite the need for nurses with advanced knowledge and skill in the care of older adults, the introduction of new advanced nursing roles has been challenging. Countries in the process of establishing advanced roles need to monitor and identify possible implementation issues. DESIGN: A cross-sectional descriptive survey. METHODS: We invited the total population of AGNs in Norway (n = 26) and some of their colleagues (n = 465) to answer an online questionnaire. Twenty-three (88.5%) of the AGNs and 195 (42.0%) of the invited colleagues completed and submitted the questionnaires. The data were analysed with descriptive statistics. STROBE guidelines were used in reporting this study. RESULTS: Of the AGNs, 16 (69.6%) used their knowledge and skills to their full potential when providing direct care. However, a minority used their knowledge and skills to their full potential when proving indirect care (n = 11, 47.8%), teaching/supervision (n = 11, 47.8%) and coordination (n = 5, 21.8%). A total of 47 (24.1%) colleagues experienced the AGNs’ scope of practice as completely clear and 52 (26.6%) collaborated with the AGNs several times a week. Of the colleagues, 131 (67.2%) considered the AGNs’ role and scope of practice contributed positively to a high degree to health service for older adults. CONCLUSION: The results indicate the need for greater focus on organisational adjustment for the AGNs to utilise their knowledge and skills to their full potential. RELEVANCE TO CLINICAL PRACTICE: There is a need for greater focus on organisational adjustment to integrate AGNs at the workplace, as complete integration may improve the AGNs’ use of their knowledge and skills.

Diabetes, Care Homes, and the Influence of Technology on Practice and Care Delivery in Care Homes: Systematic Review and Qualitative Synthesis.
Non UofA Access

R. Mathews, C. O’Malley, J. M. Hall, L. Macaden and S. MacRury.
JMIR Diabetes 2019 Apr 22;4(2):e11526
Diabetes is increasing in prevalence and complexity in the care home setting, affecting up to a quarter of care home residents. Health outcomes for these residents are impacted by management of the disease, health care professionals (HCPs)’ decision-making skills within the care home setting, and access to specialist services. The use of technology has the potential to recognize opportunities for early intervention that enables efficient responsive care, taking a fundamental role in linking the care home community to wider multidisciplinary teams for support. OBJECTIVE: The aim of this paper was to identify evidence that explores factors relevant to the use of technology in and around the care home setting to aid in the management of diabetes. METHODS: Databases searched using a structured prespecified approach included: PubMed, CINAHL (Cumulative Index to Nursing and Allied Health Literature), OVID Nursing database, Scopus, MEDLINE, the Cochrane Library, and the King’s Fund from 2012 to 2017: handsearching was undertaken additionally for any gray literature. Preferred Reporting Items for Systematic review and Meta-Analysis Protocol was used as protocol with Risk of Bias in Systematic reviews a tool to assess the risk of bias across studies. Studies had to include interventions that combined technology to or from the care home setting to support residents living with diabetes. RESULTS: The combined search strategy identified a total of 493 electronic records. Of these, 171 papers were screened for eligibility, 66 full papers were accessed, and 13 have been included in this study. Qualitative synthesis has identified different strands of research evidence in what and how technology is currently being used in and around care homes to enhance diabetes management. New initiatives and implementations of technology and emerging models of care that included the use of technology have also been included. CONCLUSIONS: By triangulating the perspectives of HCPs, practitioners, specialists, and members of the care home community, the authors anticipate that this review will represent an up-to-date, evidence-based overview of the potential for using technology within the care home setting for diabetes management as well as stimulate research in this area.

“They Don’t Trust Us”: The Influence of Perceptions of Inadequate Nursing Home Care on Emergency Department Transfers and the Potential Role for Telehealth.
Non UofA Access

C. E. Stephens, E. Halifax, D. David, et al.
Clin Nurs Res 2019 Apr 21:1054773819835015
In this descriptive, qualitative study, we conducted eight focus groups with diverse informal and formal caregivers to explore their experiences/challenges with nursing home (NH) to emergency department (ED) transfers and whether telehealth might be able to mitigate some of those concerns. Interviews were transcribed and analyzed using a grounded theory approach. Transfers were commonly viewed as being influenced by a perceived lack of trust in NH care/capabilities and driven by four main factors: questioning the quality of NH nurses’ assessments, perceptions that physicians were absent from the NH, misunderstandings of the capabilities of NHs and EDs, and perceptions that responses to medical needs were inadequate. Participants believed technology could provide “the power of the visual” permitting virtual assessment for the off-site physician, validation of nursing assessment, “real time” assurance to residents and families, better goals of care discussions with multiple parties in different locations, and family ability to say goodbye.

Recognition of the complexity facing residential care homes: a practitioner inquiry.
Non UofA Access

J. Dudman, J. Meyer, C. Holman and W. Moyle.
Prim Health Care Res Dev 2018 Nov;19(6):584-590
To explore the experiences and challenges for residential care home staff when managing the healthcare needs of their residents, in particular those living with dementia. BACKGROUND: Increasing number of older people, with complex health and social care needs are living in residential care homes. Yet there is limited appreciation of why staff sometimes struggle to manage residents’ healthcare needs, or understanding of their working relationship with district nurses (DNs), whose responsibility it is to provide nursing support. METHODS: This PhD study, in a metropolitan area in the United Kingdom, was conducted by an experienced DN and involved three phases. This paper focuses on the first two phases. Phase 1 data included: semi-structured interviews (n=8), reflective field notes based on non-participant observation, documentary analysis of policies, procedures and assessment tools and other contextual data from one care home (case study site). The practitioner researcher reflected on the findings from the case study, in relation to her own knowledge and experience as a DN, focusing in particular on findings that were familiar, or which surprised. In Phase 2 she fed these findings back to other care homes (n=11) to check whether the findings from the single case study were unique or resonated with others. She gathered their feedback through semi-structured interviews with senior care staff (n=14). Data were analysed using thematic data analysis.FindingsFindings highlight the complexity facing residential care homes: high levels of healthcare needs amongst residents, the demands of caring for residents living with dementia, variations in the knowledge and skill set of care staff, inequity in the level of healthcare support, the challenges of building a good relationship with DNs, and funding pressures facing care homes.ImplicationsAny, or all of these factors can prevent care home staff from managing the healthcare needs of their residents.

Access to Psychiatrist Services for Older Adults in Long-Term Care: A Population-Based Study.
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C. Perlman, J. Kirkham, C. Velkers, R. H. Leung, M. Whitehead and D. Seitz.
J Am Med Dir Assoc 2019 Feb 28
Although mental health disorders are common among older adults in long-term care (LTC), little is known about access to psychiatric services in LTC. We described the need for psychiatric services in LTC settings and identified variables associated with receipt of psychiatric services. DESIGN: Population-based retrospective cohort study. SETTING AND PARTICIPANTS: All adults aged 66 years and older who resided in LTC homes in Ontario, Canada, between 2015 and 2016. Individuals were included in the study at the time of LTC admission or first annual reassessment. MEASURES: We determined the percentage of LTC residents who received any psychiatric service within 90 days. We then compared the characteristics of individuals who did and did not receive any psychiatric service to determine variables associated with receipt of psychiatric services. Multivariate logistic regression was used to determine independent variables associated with receipt of psychiatric services. RESULTS: A total of 67,165 unique participants were included in the study sample, 27,650 (41.2%) of whom had identified psychiatric need. Overall, 3175 (4.7%) individuals received any psychiatric service within 90 days following cohort entry. After adjustment for potential confounders, receipt of psychiatric services was positively associated with younger age, male gender, history of major mental disorders, previous receipt of psychiatric services, indicators of psychiatric need, residence in larger LTC homes, and health region of residence. CONCLUSIONS/IMPLICATIONS: Receiving psychiatric services in Ontario LTC homes is limited when compared to the high need for services. Several factors other than patient need symptoms are associated with receipt of services, which suggests inequities in access to care. Improving the distribution of psychiatric services may help address these inequities, and additional psychiatric resources are also likely required to meet these needs. Our results directly apply to a Canadian context and have implications for other comparable countries, including the United States.

Ontario’s Retirement Homes and Long-Term Care Homes: A Comparison of Care Services and Funding Regimes.
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B. Roblin, R. Deber, K. Kuluski and M. P. Silver.
Can J Aging 2019 Jun;38(2):155-167
Growing demand for beds in government-subsidized long-term care (LTC) homes in Ontario is causing long waitlists, which must be absorbed by other residential alternatives, including unsubsidized retirement homes. This study compares Ontario’s LTC homes and retirement homes for care services provided, funding regimes, and implications of differential funding for seniors. Descriptive data for both types of homes were collected from public and proprietary sources regarding service offerings, availability, costs, and funding. Overlaps exist in the services of both LTC and retirement homes, particularly at higher levels of care. Although both sectors charge residents for accommodation, most care costs in LTC homes are publicly funded, whereas residents in retirement homes generally cover these expenses personally. Given waitlists in Ontario’s LTC homes, many seniors must find residential care elsewhere, including in retirement homes. Several policy alternatives exist that may serve to improve equity of access to seniors’ residential care.

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Health Care Innovation and Quality Assurance

Do Incentive Payments Reward The Wrong Providers? A Study Of Primary Care Reform In Ontario, Canada

Richard H. Glazier, Michael E. Green, Eliot Frymire, et al.
Health Aff 2019 04/01; 2019/04;38(4):624-632
Primary care payment reform in the US and elsewhere usually involves capitation, often combined with bonuses and incentives. In capitation systems, providing care within the practice group is needed to contain costs and ensure continuity of care, yet this is challenging in settings that allow patient choice in access to services. We used linked population-based administrative databases in Ontario, Canada, to examine a substantial payment called the “access bonus” designed to incentivize primary care access and to minimize primary care visits outside of capitation practices. We found that the access bonus flowed disproportionately to physicians outside large cities and to those whose patients made fewer primary care visits, received less after-hours care, made more emergency department visits, and had higher adjusted ambulatory costs. Our findings indicate a lack of alignment between these payments and their intended purpose. Financial incentives should be prospectively evaluated and frequently revisited to ensure relevance, alignment with system goals, efficiency, and equity.

A systematic review and critical appraisal of quality indicators to assess optimal palliative care for older people with dementia.
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S. Amador, E. L. Sampson, C. Goodman, L. Robinson and SEED Research Team.
Palliat Med 2019 Apr;33(4):415-429
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.

Evolving quality improvement support strategies to improve Plan-Do-Study-Act cycle fidelity: a retrospective mixed-methods study.
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C. McNicholas, L. Lennox, T. Woodcock, D. Bell and J. E. Reed.
BMJ Qual Saf 2019 May;28(5):356-365
Although widely recommended as an effective approach to quality improvement (QI), the Plan-Do-Study-Act (PDSA) cycle method can be challenging to use, and low fidelity of published accounts of the method has been reported. There is little evidence on the fidelity of PDSA cycles used by front-line teams, nor how to support and improve the method’s use. Data collected from 39 front-line improvement teams provided an opportunity to retrospectively investigate PDSA cycle use and how strategies were modified to help improve this over time. METHODS: The fidelity of 421 PDSA cycles was reviewed using a predefined framework and statistical analysis examined whether fidelity changed over three annual rounds of projects. The experiences of project teams and QI support staff were investigated through document analysis and interviews. RESULTS: Although modest, statistically significant improvements in PDSA fidelity occurred; however, overall fidelity remained low. Challenges to achieving greater fidelity reflected problems with understanding the PDSA methodology, intention to use and application in practice. These problems were exacerbated by assumptions made in the original QI training and support strategies: that PDSA was easy to understand; that teams would be motivated and willing to use PDSA; and that PDSA is easy to apply. QI strategies that evolved to overcome these challenges included project selection process, redesign of training, increased hands-on support and investment in training QI support staff. CONCLUSION: This study identifies support strategies that may help improve PDSA cycle fidelity. It provides an approach to assess minimum standards of fidelity which can be replicated elsewhere. The findings suggest achieving high PDSA fidelity requires a gradual and negotiated process to explore different perspectives and encourage new ways of working.

Evaluating the design and implementation of the whole systems integrated care programme in North West London: why commissioning proved (again) to be the weakest link.
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J. Smith, G. Wistow, H. Holder and M. Gaskins.
BMC Health Serv Res 2019 Apr 15;19(1):228-019-4013-5
Commissioning is a term used in the English National Health Service (NHS) to refer to what most health systems call health planning or strategic purchasing. Drawing on research from a recent in-depth mixed methods study of a major integrated care initiative in North West London, we examine the role of commissioning in attempts to secure large-scale change within and between health and social care services to support the delivery of integrated care for people living with complex long-term conditions. METHODS: We analysed data collected in semi-structured interviews, surveys, workshops and non-participant observations using a thematic framework derived both deductively from the literature on commissioning and integrated care, as well as inductively from our coding and analysis of interview data. RESULTS: Our findings indicate that commissioning has significant limitations in enabling large-scale change in health services, particularly in engaging providers, supporting implementation, and attending to both its transactional and relational dimensions. CONCLUSIONS: Our study highlights the consequences of giving insufficient attention to implementation, and especially the need for commissioners to enable, support and performance manage the delivery of procured services, while working closely with providers at all times. We propose a revised version of Ovretveit’s cycle of commissioning that gives greater emphasis to embedding effective implementation processes within models of commissioning large-scale change.

Development of a consumer experience reporting questionnaire for residential aged care homes in Australia.
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Development of a consumer experience reporting questionnaire for residential aged care homes in Australia.
Y. Wells, D. Fetherstonhaugh and K. N. Solly.
Australas J Ageing 2019 Apr 23
To develop and pilot a short interview tool to be implemented by the Australian Aged Care Quality Agency (AACQA) in residential aged care, to inform prospective consumers about the quality of care and services received-the consumer experience report (CER). METHODS: Twenty-four questions addressing the four Aged Care Quality Standards were piloted with 140 residents and 48 representatives (including 27 resident-representative pairs). A method for approximating random selection was also trialled. Fifty-two residents were interviewed twice, one week apart, and each question’s usability was rated by 11 surveyors and two interpreters. Selection criteria for questions included consumer preference, test-retest reliability, resident-representative agreement, usability and low missing data. RESULTS: Nineteen questions performed well on missing data, 16 on test-retest, 17 on resident-representative agreement and 12 on usability. Ten quantitative and two open-ended questions were selected. CONCLUSIONS: The CER questions proved suitable to collect data systematically on consumer experience in residential aged care. AACQA (now the Aged Care Quality and Safety Commission) uses the CER interview to support their audit process, and aggregated results are published online.

Implementation of a multicomponent intervention to prevent physical restraints in nursing homes (IMPRINT): A pragmatic cluster randomized controlled trial.
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J. Abraham, R. Kupfer, A. Behncke, et al.
Int J Nurs Stud 2019 Apr 4
Despite clear evidence for the lack of effectiveness and safety, physical restraints are frequently applied in nursing homes. Multicomponent interventions addressing nurses’ attitudes and organizational culture have been effective in reducing physical restraints. OBJECTIVE: To evaluate the effectiveness of two versions of a guideline and theory-based multicomponent intervention to reduce physical restraints in nursing homes. DESIGN: Pragmatic cluster randomized controlled trial. SETTING: The study was conducted in 120 nursing homes in four regions in Germany. PARTICIPANTS: All residents living in the participating nursing home during follow-up, newly admitted residents were also included. A total of 12,245 residents included in the primary analysis (4126 and 3547 residents in intervention group 1 and 2 and 4572 residents in the control group). METHODS: Intervention group 1 received an updated version of a successfully tested guideline-based multicomponent intervention (comprising brief education for the nursing staff, intensive training of nominated key nurses in each cluster, introduction of a least-restraint policy and supportive material), intervention group 2 received a concise version of the original program and the control group received optimized usual care (i.e. supportive materials only). Primary outcome was physical restraint prevalence at twelve months, assessed through direct observation by blinded investigators. Intervention and control groups were compared using baseline-adjusted linear regression on cluster level, Bonferroni-adjusted for double testing. Secondary outcomes included falls, fall-related fractures, and quality of life. We also described intervention costs and performed a comprehensive process analysis. RESULTS: At baseline, mean physical restraint prevalence was 17.4% and 19.6% in intervention groups 1 and 2, and 18.8% in the control group. After twelve months, mean prevalence was 14.6%, 15.7%, and 17.6%. Baseline-adjusted differences between mean prevalences were 2.0% (97.5% CI, -5.8 to 1.9) lower in intervention group 1 and 2.5% (97.5% CI, -6.4 to 1.4) lower in intervention group 2 compared to controls. Physical restraint prevalence showed a pronounced variation between the different clusters in all study groups. We found no significant differences in the secondary outcomes. According to the process evaluation, the intervention was mainly implemented as planned, but the expected change towards a least restraint culture of care was not achieved in all clusters. CONCLUSIONS: Neither intervention showed a clear advantage compared to control. The pronounced center variation in physical restraint prevalence indicates that other approaches like governmental policies are needed to sustainably change physical restraint practice and reduce center variations in nursing homes. TRIAL REGISTRATION: ClinicalTrials.gov : NCT02341898.

Initiating Aha moments when implementing person-centered care in nursing homes: a multi-arm, pre-post intervention.
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L. J. Cornelison, L. Hermer, M. L. Syme and G. Doll.
BMC Geriatr 2019 Apr 23;19(1):115-019-1121-3
Comprehensive adoption of culture change via person-centered care (PCC) practices in nursing homes has been slow. Change such as this, requires transformation of organizational culture, frequently generating resistance and slow moving change. This study examined how nursing homes perceive their adoption of PCC practices across seven domains and how these perceptions change in response to an educational intervention embedded in a statewide program, Promoting Excellent Alternatives in Kansas nursing homes (PEAK 2.0). Given perception is an important feature of the change process, it was hypothesized that pre-adopters engaging in PEAK 2.0’s initial Foundation year (level 0) would have lower perceived PCC adoption following a year of education and exposure to PCC, whereas adopters (PEAK 2.0 level 1-5 homes) would have higher perceived PCC adoption following a year of participation in their respective level in the program. METHODS: A multi-arm, pre/post intervention study was conducted during the 2014 and 2015 years of the PEAK 2.0 program comparing pre-PCC adopters to adopters. Outcomes were self-ratings of perceived PCC implementation across seven domains of PCC at the beginning and end of the 2014-15 program year, after pre-adopters had received PCC education and adopters had implemented a year of PCC. Paired t-tests and mixed repeated-measures linear models, controlling for potential confounders, were employed to test the study hypotheses. RESULTS: Across all seven domains of PCC, pre-adopters rated their PCC implementation as significantly higher on pre-test (2014) than on post-test (2015). In contrast, adopters rated their PCC achievement as higher on post-test (2015) than on pre-test (2014). CONCLUSIONS: Pre-adopters’ lower score following a year of education and exposure to PCC may reflect a shift in perceptions of PCC as a concept or a deeper conceptualization of PCC. Since perceptions or assumptions can serve as a source of resistance to change, redefinition or “unlearning” to make way for more accurate definitions of PCC could aid in reducing organizational resistance to implementation of PCC and thus improve the rate of adoption.

Professional Pride: a qualitative descriptive study of nursing home staff’s experiences of how a quality development project influenced their work.
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S. Vikstrom and K. Johansson.
J Clin Nurs 2019 Apr 18
This study explores and describes how daily work at a nursing home had been influenced by a quality improvement project, from the perspective of direct care staff. BACKGROUND: Deficiencies in nursing home care are widely reported, often with a focus on lack of competence among direct care staff. The present trend in quality development in nursing homes brings direct care staff’s perspectives into focus through participatory action research approaches. Still little is known about how staff experience the impact of such projects on their everyday work. DESIGN: The study was designed as an interpretive descriptive study, based on interviews with nursing home staff. The methods were conducted in accordance with the SRQR guidelines. RESULTS: The analysis revealed that the participants reasoned on whether the improvement project contributed to their possibilities perform their work at the unit for the benefit of the residents. This was strongly connected to their professional pride. The participants reflected on this through three changes generated by the project: a) Participating in project activities – Supporting or threatening daily work at the unit, b) From performing individual duties towards a shared responsibility, and c) confirming and strengthening competence that brings the everyday situation of residents into focus. CONCLUSION: The importance of professional pride identified in this study points towards a need for reducing barriers for direct care staff to express and develop competences they regard as part of their professional identity. The findings also shed some light on competence that brings the everyday situation of residents into focus as a driving forces behind lack of compliance and resistance to change. RELEVANCE TO CLINICAL PRACTICE: The findings indicate a call for quality development designs to reduce barriers for care staff to express and develop knowledge that they regard as part of their professional identity.

Social media ratings of nursing homes associated with experience of care and “Nursing Home Compare” quality measures.
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Y. Li, X. Cai and M. Wang.
BMC Health Serv Res 2019 Apr 27;19(1):260-019-4100-7
Social media platforms offer unique opportunities for patients and families to provide real-time feedback on their healthcare experiences. Consumer-generated social media ratings of hospitals tend to reflect the more subjective aspects of inpatient care experiences; however, evidence on nursing home care is extremely limited. METHODS: We collected consumer-reported 5-star ratings of Maryland nursing homes posted from July 2015 to July 2017 on 4 popular social media or online review sites (Facebook, Yelp, Google Consumer Reviews, and Caring.com). We determined if the average score of social media ratings was associated with experience-of-care ratings derived from survey of family members or other responsible parties of nursing home residents, and with “Nursing Home Compare” (NHC) 5-star ratings and individual quality measures. RESULTS: One hundred ninety-six out of 206 nursing homes in Maryland were reviewed on at least one site and thus had one or more star ratings posted. The overall ratings were 3.11 on average on these sites and 3.03 on the NHC website, with a Pearson correlation of 0.41 (p < 0.001) between the 2 sets of ratings. The correlations between the social media rating and survey-based experience-of-care ratings ranged from 0.40 to 0.60, and the correlations between the social media rating and individual NHC quality measures of citations, nurse staffing, and complaints were about 0.35 (in absolute values). The social media rating also predicted well NHC and experience-of-care measures after adjusting for nursing home covariates and market competition. CONCLUSIONS: The 5-star ratings collected from 4 social networking sites was correlated with and predictive of the NHC and survey-based experience-of-care measures for Maryland nursing homes.


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Research Practice and Methodology

Research Priorities in Post-acute and Long-term Care: Results of a Stakeholder Needs Assessment.
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C. Drake, H. L. Wald, L. B. Eber, J. I. Trojanowski, K. A. Nearing and R. S. Boxer.
J Am Med Dir Assoc 2019 Apr 11
Conduct a needs assessment among post-acute and long-term care (PA-LTC) stakeholder groups to identify (1) research topics of highest priority and (2) perspectives on research, including concerns/barriers to conducting research in the PA-LTC setting. DESIGN: Mixed methods multistakeholder engagement process. Needs assessment conducted with tailored strategies per stakeholder group: interview, survey, and focus group. SETTING AND PARTICIPANTS: Four stakeholder groups-medical directors/providers (n = 89), administrative leadership (n = 5), frontline staff (n = 17), and family members of residents and residents themselves (n = 11)-were recruited from the Colorado PA-LTC community through an academic-community partnership between the University of Colorado and Colorado Medical Directors Association. MAIN OUTCOME(S): Stakeholder perspectives on research and high priority PA-LTC research topics. RESULTS: Research priorities common across stakeholder groups included polypharmacy (overuse of medication generally and overuse of antibiotics specifically), care transitions, mental health (including dementia, Alzheimer’s disease, behaviors), chronic pain, urinary tract infection, and quality of life issues. Providers specifically prioritized heart failure, Parkinson’s, and other chronic illnesses. Administrators and directors of nurses emphasized hospitalizations. Staff prioritized medication/therapy compliance. Families/residents prioritized neurologic disease. Concerns included staff burden, consenting process, privacy, and family involvement. CONCLUSIONS/IMPLICATIONS: PA-LTC patients have a lot to offer as participants and decision makers in research, frontline staff are enthusiastic about participation, family members want to be involved, and providers value research findings in their practice but need a more supportive environment to produce and participate in research.

Frameworks for supporting patient and public involvement in research: Systematic review and co‐design pilot
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T. Greenhalgh, L. Hinton, T. Finlay, et al.
Health Expect 2019 Apr 22
Numerous frameworks for supporting, evaluating and reporting patient and public involvement in research exist. The literature is diverse and theoretically heterogeneous. OBJECTIVES: To identify and synthesize published frameworks, consider whether and how these have been used, and apply design principles to improve usability. SEARCH STRATEGY: Keyword search of six databases; hand search of eight journals; ancestry and snowball search; requests to experts. INCLUSION CRITERIA: Published, systematic approaches (frameworks) designed to support, evaluate or report on patient or public involvement in health-related research. DATA EXTRACTION AND SYNTHESIS: Data were extracted on provenance; collaborators and sponsors; theoretical basis; lay input; intended user(s) and use(s); topics covered; examples of use; critiques; and updates. We used the Canadian Centre for Excellence on Partnerships with Patients and Public (CEPPP) evaluation tool and hermeneutic methodology to grade and synthesize the frameworks. In five co-design workshops, we tested evidence-based resources based on the review findings. RESULTS: Our final data set consisted of 65 frameworks, most of which scored highly on the CEPPP tool. They had different provenances, intended purposes, strengths and limitations. We grouped them into five categories: power-focused; priority-setting; study-focused; report-focused; and partnership-focused. Frameworks were used mainly by the groups who developed them. The empirical component of our study generated a structured format and evidence-based facilitator notes for a “build your own framework” co-design workshop. CONCLUSION: The plethora of frameworks combined with evidence of limited transferability suggests that a single, off-the-shelf framework may be less useful than a menu of evidence-based resources which stakeholders can use to co-design their own frameworks.

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Impact of Coexisting Overactive Bladder in Medicare Patients With Dementia on Clinical and Economic Outcomes.
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E. O. Caplan, I. M. Abbass, B. T. Suehs, D. B. Ng, K. Gooch and D. van Amerongen.
Am J Alzheimers Dis Other Demen 2019 Apr 9:1533317519841164
Patients with dementia commonly suffer from symptoms of overactive bladder (OAB); however, limited research exists on the clinical impact of coexisting OAB among patients with dementia. As such, the objective of this study was to examine the impact of OAB on clinical outcomes, health-care resource use, and associated costs among patients with dementia. METHODS: We conducted a retrospective cohort analysis of patients with dementia using 3861 matched pairs of patients with and without OAB. Analyses were based on administrative claims data from January 1, 2007, to September 30, 2015, and compared clinical outcomes, health services use, and associated costs. RESULTS: Patients with dementia and OAB were more likely than those without OAB to have least one fall (incidence rate ratio [IRR]: 1.43, 95% confidence interval [CI], 1.22-1.68, P < .001), fracture (IRR: 1.23, 95% CI, 1.05-1.44, P = .008), combined fall/fracture (IRR: 1.25, 95% CI, 1.11-1.42, P < .001), or urinary tract infection (IRR: 2.75, 95% CI, 2.55-2.96, P < .001). Patients with dementia and OAB demonstrated greater utilization of all-cause encounter types compared to similar patients without coexisting OAB ( P < .01). All-cause and dementia-related total health-care costs were approximately 23% (95% CI, 0.19-0.28, P < .001) and 13% (95% CI, 0.05-0.20, P = .001), respectively, greater than similar patients without coexisting OAB. CONCLUSION: Coexisting OAB was associated with impacts on clinical outcomes, health-care resource utilization, and costs in patients with dementia.

Do-Not-Resuscitate and Do-Not-Hospitalize Orders in Nursing Homes: Who Gets Them and Do They Make a Difference?
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P. Tanuseputro, A. Hsu, M. Chalifoux, et al.
J Am Med Dir Assoc 2019 Apr 8
To describe the rate of do-not-resuscitate (DNR) and do-not-hospitalize (DNH) orders among residents newly admitted into long-term care homes. We also assessed the association between DNR and DNH orders with hospital admissions, deaths in hospital, and survival. DESIGN: A retrospective cohort study. SETTING AND PARTICIPANTS: Admissions in all 640 publicly funded long-term care homes in Ontario, Canada, between January 1, 2010 and March 1, 2012 (n = 49,390). MEASURES: We examined if a DNR and/or DNH was recorded on resident’s admission assessment. All residents were followed until death, discharge, or end of study to ascertain rates of several outcomes, including death and hospitalization, controlling for resident characteristics. RESULTS: Upon admission, 60.7% of residents were recorded to have a DNR and 14.8% a DNH order. Those who were older, female, widowed, lived in rural facilities, lived in higher income neighborhoods prior to entry, had higher health instability or cognitive impairment, and spoke English or French were more likely to receive a DNR or DNH. Survival time was only slightly shorter for those with a DNR and DNH with a mean of 145 and 133 days, respectively, vs 160 and 153 days for those without a DNR and DNH. After controlling for age, sex, rurality, neighborhood income, marital status, health instability, cognitive performance score, and multimorbidity, DNR and DNH were associated with an odds ratio of 0.57 [95% confidence interval (CI) 0.53-0.62] and 0.41 (95% CI 0.37-0.46) for dying in hospital, respectively. Those with a DNR and DNH, after adjustment, had an incidence rate ratio of 0.87 (95% CI 0.83-0.90) and 0.70 (95% CI 0.67-0.73), respectively, days spent in hospital. CONCLUSIONS AND IMPLICATIONS: This study outlines identifiable factors influencing whether residents have a DNR and/or DNH order upon admission. Both orders led to lower rates, but not absolute avoidance, of hospitalizations near and at death.

Quality of Life and Pain Medication Use in Persons With Advanced Dementia Living in Long-Term Care Facilities.
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P. H. van Dam, M. A. A. Caljouw, D. D. Slettebo, W. P. Achterberg and B. S. Husebo.
J Am Med Dir Assoc 2019 Apr 11
In residents with dementia living in a long-term care facility (LTCF), un(der)treated pain may trigger behavioral disturbances, mood syndromes, and deterioration of physical functioning and self-maintenance. Because these factors can have considerable impact on the quality of life (QoL), this study aimed to (1) compare characteristics of persons with advanced dementia living in LTCFs with and without pain medication; (2) compare QoL in these persons with and without pain, stratified by type of pain medication use; and (3) explore associations between the use of paracetamol and QoL in persons with advanced dementia living in LTCFs. DESIGN AND SETTING: This study analyzed baseline data from the Communication, Systematic Assessment and Treatment of Pain, Medication Review, Occupational Therapy, and Safety Study; a multicenter, cluster-randomized effectiveness-implementation clinical hybrid trial in 67 Norwegian LTCF clusters. PARTICIPANTS: In total, 407 LTCF residents (rural and urban areas) aged >/=65 years, with Functional Assessment Staging scores of 5-7 (ie, moderate to advanced dementia). MAIN OUTCOME MEASURE: QoL as assessed by the 6 QUALIDEM (validated questionnaire to measure QoL in persons with dementia living in LTCF) domains applicable to persons with moderate to severe dementia. The association between QoL and paracetamol was estimated using linear mixed-effect models, adjusting for confounding variables. RESULTS: 62.0% used pain medication (paracetamol, opioids, or both). QoL was lower in residents using pain medication, compared with those without pain medication [mean QUALIDEM score 68.8 (standard deviation 17.4 vs) 75.5 (standard deviation 14.6), respectively, P < .001). Multilevel analysis showed that paracetamol use was not associated with QoL. CONCLUSIONS AND IMPLICATIONS: Persons with advanced dementia living in LTCF using pain medication have a lower QoL compared with those not using pain medication. These results are of key importance for the clinician because they stress the need for regular medication review and pain management. When measured cross-sectionally, use of paracetamol is not associated with increased QoL.

Review of Programs for Persons Facing Death with Dementia.
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L. Volicer.
Healthcare (Basel) 2019 Apr 15;7(2):10.3390/healthcare7020062
Persons with advanced dementia cannot initiate activities because of the executive dysfunction. The lack of activities was identified as one of the most important factors contributing to behavioral problems of these persons. The unmet needs were boredom/sensory deprivation, loneliness/need for social interaction, and need for meaningful activities. There is a need for activities designed specifically for residents with advanced dementia. OBJECTIVE: A description of patient’s needs and of programs that intend to maintain quality of life for people with dementia and facing death. DATA SOURCES: A literature review of programs used for persons with advanced dementia and residing in long-term facilities, using the PubMed data base and collateral sources. RESULTS: Since palliative care is appropriate for persons with advanced dementia, attention has to be paid to three following important aspects of care: Medical issues, behavioral symptoms, and meaningful activities. Medical interventions should be limited to those which have more benefits than burdens, behavioral symptoms should be distinguished according to the context in which they occur, and treated by non-pharmacological interventions that involve meaningful activities. This review describes four programs that may promote the quality of life in persons with advanced dementia and facing death. They are designed for persons with advanced dementia, taking into account their functional impairments. Most of these programs involve short infrequent sessions. In contrast, Namaste Care is a daily extended program of enhanced nursing care that can provide quality of life until the last breath. CONCLUSIONS: It is possible to maintain quality life for people with advanced dementia if a special program of activities is available.

Interventions for preventing delirium in older people in institutional long-term care.
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R. Woodhouse, J. K. Burton, N. Rana, Y. L. Pang, J. E. Lister and N. Siddiqi.
Cochrane Database Syst Rev 2019 Apr 23;4:CD009537
Delirium is a common and distressing mental disorder. It is often caused by a combination of stressor events in susceptible people, particularly older people living with frailty and dementia. Adults living in institutional long-term care (LTC) are at particularly high risk of delirium. An episode of delirium increases risks of admission to hospital, development or worsening of dementia and death. Multicomponent interventions can reduce the incidence of delirium by a third in the hospital setting. However, it is currently unclear whether interventions to prevent delirium in LTC are effective. This is an update of a Cochrane Review first published in 2014. OBJECTIVES: To assess the effectiveness of interventions for preventing delirium in older people in institutional long-term care settings. SEARCH METHODS: We searched ALOIS (www.medicine.ox.ac.uk/alois), the Cochrane Dementia and Cognitive Improvement Group (CDCIG) ‘s Specialised Register of dementia trials (dementia.cochrane.org/our-trials-register), to 27 February 2019. The search was sufficiently sensitive to identify all studies relating to delirium. We ran additional separate searches in the Cochrane Central Register of Controlled Trials (CENTRAL), major healthcare databases, trial registers and grey literature sources to ensure that the search was comprehensive. SELECTION CRITERIA: We included randomised controlled trials (RCTs) and cluster-randomised controlled trials (cluster-RCTs) of single and multicomponent, non-pharmacological and pharmacological interventions for preventing delirium in older people (aged 65 years and over) in permanent LTC residence. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. Primary outcomes were prevalence, incidence and severity of delirium; and mortality. Secondary outcomes included falls, hospital admissions and other adverse events; cognitive function; new diagnoses of dementia; activities of daily living; quality of life; and cost-related outcomes. We used risk ratios (RRs) as measures of treatment effect for dichotomous outcomes, hazard ratios (HR) for time-to-event outcomes and mean difference (MD) for continuous outcomes. For each outcome, we assessed the overall certainty of the evidence using GRADE methods. MAIN RESULTS: We included three trials with 3851 participants. All three were cluster-RCTs. Two of the trials were of complex, single-component, non-pharmacological interventions and one trial was a feasibility trial of a complex, multicomponent, non-pharmacological intervention. Risk of bias ratings were mixed across the three trials. Due to the heterogeneous nature of the interventions, we did not combine the results statistically, but produced a narrative summary.It was not possible to determine the effect of a hydration-based intervention on delirium incidence (RR 0.85, 95% confidence interval (CI) 0.18 to 4.00; 1 study, 98 participants; very low-certainty evidence downgraded for risk of bias and very serious imprecision). This study did not assess delirium prevalence, severity or mortality.The introduction of a computerised system to identify medications that may contribute to delirium risk and trigger a medication review was probably associated with a reduction in delirium incidence (12-month HR 0.42, CI 0.34 to 0.51; 1 study, 7311 participant-months; moderate-certainty evidence downgraded for risk of bias) but probably had little or no effect on mortality (HR 0.88, CI 0.66 to 1.17; 1 study, 9412 participant-months; moderate-certainty evidence downgraded for imprecision), hospital admissions (HR 0.89, CI 0.72 to 1.10; 1 study, 7599 participant-months; moderate-certainty evidence downgraded for imprecision) or falls (HR 1.03, CI 0.92 to 1.15; 1 study, 2275 participant-months; low-certainty evidence downgraded for imprecision and risk of bias). Delirium prevalence and severity were not assessed.In the enhanced educational intervention study, aimed at changing practice to address key delirium risk factors, it was not possible to determine the effect of the intervention on delirium incidence (RR 0.62, 95% CI 0.16 to 2.39; 1 study, 137 resident months; very low-certainty evidence downgraded for risk of bias and serious imprecision) or delirium prevalence (RR 0.57, 95% CI 0.15 to 2.19; 1 study, 160 participants; very low-certainty evidence downgraded for risk of bias and serious imprecision). There was probably little or no effect on mortality (RR 0.82, CI 0.50 to 1.34; 1 study, 215 participants; moderate-certainty evidence downgraded for imprecision). The intervention was probably associated with a reduction in hospital admissions (RR 0.67, CI 0.57 to 0.79; 1 study, 494 participants; moderate-certainty evidence downgraded due to indirectness). AUTHORS’ CONCLUSIONS: Our review identified limited evidence on interventions for preventing delirium in older people in LTC. A software-based intervention to identify medications that could contribute to delirium risk and trigger a pharmacist-led medication review, probably reduces incidence of delirium in older people in institutional LTC. This is based on one large RCT in the US and may not be practical in other countries or settings which do not have comparable information technology services available in care homes. In the educational intervention aimed at identifying risk factors for delirium and developing bespoke solutions within care homes, it was not possible to determine the effect of the intervention on delirium incidence, prevalence or mortality. This evidence is based on a small feasibility trial. Our review identified three ongoing trials of multicomponent delirium prevention interventions. We identified no trials of pharmacological agents. Future trials of multicomponent non-pharmacological delirium prevention interventions for older people in LTC are needed to help inform the provision of evidence-based care for this vulnerable group.

Life-story work in long-term care facilities for older people: An integrative review.
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C. Doran, M. Noonan and O. Doody.
J Clin Nurs 2019 Apr;28(7-8):1070-1084
To systematically review the literature regarding the experience of older people, families and staff using life-story work in residential care facilities for older people. BACKGROUND: Life-story work has been promoted as an approach to enhance care provided and involves collecting memories and moments that are important to the person assisting them to regain their sense of self. DESIGN: An integrative review utilising the PRISMA reporting guidelines where seven databases, Scopus, EMBASE, CINAHL, MEDLINE, PsychInfo, PsychARTICLES, and Cochrane, were searched within the timeframe; 1 January 2006 to 14 March 2016. Data were reviewed using Whittemore and Knalf’s (Journal of Advanced Nursing, 2005, 52:546) methodological approach for integrative reviews. Analysis was conducted utilising Braun and Clarke’s (Qualitative Research in Psychology, 2006, 3:77) six phases to identify, analyse and record themes within the data. RESULTS: Thirteen articles were reviewed, and the review found that life-story work has been introduced using a range of different approaches, with no common approach. Thematic analysis identified two: maintaining identity and building and maintaining relationships. CONCLUSION: The review extends the current evidence on the experience of using life-story work in long-term aged care facilities for older people. Life-story work has the potential to enhance person-centred care in long-term care. However, improving the process of implementation of life-story work will require education, time and resources and a commitment from service providers and managers. RELEVANCE TO CLINICAL PRACTICE: Staff who undertake life-story work with residents need to be equipped with the skills to recognise and manage the challenges and issues that may potentially arise. Further research into the successful implementation of life-story work and how it can be resourced is required.

The Meaning of a Visual Arts Program for Older Adults in Complex Residential Care.
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L. M. Rodrigues, A. P. Smith, D. J. Sheets and J. Hemond.
Can J Aging 2019 Jun;38(2):143-154
This qualitative study explores the experiences of older adults participating in a creative visual arts program at a residential care facility in Victoria, British Columbia. A narrative inquiry approach was used to conduct face-to-face interviews with 10 residents and three program staff in addition to the systematic observations of program activities and an arts exhibit. The findings reveal the program fostered a sense of community among participants and enhanced their sense of self-worth as artists. A public art exhibition at a community centre underlined the value of residents’ artwork and gave meaning and purpose to their involvement in the program. Findings show the importance of arts programs in fostering creativity in later life and illustrate how people living in institutions can experience multiple dimensions of the self through artistic forms of expression. This study highlights the need to increase access to arts programs for individuals living in residential care.


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Evaluating Complex Community-Based Initiatives: Emerging Practices

3 June 17:00-19:00 MT Art Gallery of Alberta Edmonton
Presenter: Mark Cabaj
The University of Alberta: Faculty of Extension will be hosting a public keynote lecture on the evening of June 3 featuring Mark Cabaj, President of Here to There Edmonton & Fellow of Tamarack Institute.

Getting on the same page: the difference between data for improvement, data for research, and data for accountability (QI Power Hour)

Available on demand
Have you ever worked on developing a measurement plan with your quality improvement team and experienced disagreement on the types of measures needed, how much data is needed, and how often to collect it? This session will help to answer some common questions experienced when selecting measures, as well as understand perspectives that team members may be bringing to your measurement discussion.

brainXchange webinar Human rights and dementia

Thursday 16 May 10:00-11:00 MT
Presenter: Stéfanie Fréel
This webinar will provide:
•An overview of the relevant international commitments and developments related to human rights and dementia, including a definition of human rights and human rights violations according to international law.
•Highlight how the World Health Organization (WHO) has integrated, and is addressing, human rights into its Global action plan on the public health response to dementia 2017-2025 and other dementia activities and tools.
•Identify what is meant by a rights-based approach to health, including core principles of a human-rights-based approach to health and social care for dementia.


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University of Alberta: Faculty of Extension Patient-Oriented Research Credit Course

12-17 May Cost is subsidized by Alberta Sport Support unit
The School of Public Health at the University of Alberta, in collaboration with the Alberta SPOR SUPPORT unit, is offering a graduate credit course in patient-oriented research and is open to all Alberta graduate students.

The Fundamentals of Patient-Oriented Research course (SPH 566 Special Seminar) will be held May 12-17, 2019. The course will incorporate the annual Summer Institute in Patient-Oriented Research (May 13-15 in Edmonton) as part of the course content. Students who are enrolled in the course will benefit from the Summer Institute’s keynote speakers, workshops and presentations. Students will also attend a one-day in-class orientation on the day prior and two days of in-class training post-event.

GREAT NEWS! The cost of attending the Summer Institute will be subsidized by the Alberta SPOR SUPPORT Unit Career Development Platform.

Contact Donna Pressick for more information: dpressick@ualberta.ca.

Scale Up: Take Successful Improvements to the Next Level

IHI Begins 8 May $750 per team
​If you’re struggling with how to implement and sustain improvements across your hospital, health system, or community, the Institute for Healthcare Improvement (IHI) has developed an approach that includes a cohesive and balanced set of steps for achieving — and sustaining — system-wide change.

Get a team together for this Virtual Expedition and learn how to use these steps as a guide to achieve your scale-up goals.

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Adapt films – providing support for people newly diagnosed

YoungDementia UK is launching three films to help educate and inform people about young onset dementia. We hope our Adapt films will be of particular use and interest to people who have been newly diagnosed and those who support them.

Providing Person & Family Centred Care within Behavioural Support Transition Units (BSTU): The Critical Elements

The purpose of the four page Welcome document is to:
Identify and explain the philosophy of person and family-centred care and how it is provided and experienced within a BSTU.
Communicate to family members that they are part of the care team and decision making, and that their relative will be cared for an individualized way.
Help the organization communicate their commitment to person and family-centered care.
BSTU teams across Ontario have been invited to provide this document to family members when their relative is moving into a BSTU (ideally prior to moving in or soon after). The BSTU Collaborative has also set up a feedback process with BSTU team members and family members regarding the value of the document.

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Leadership Survey: Organizational Culture Is the Key to Better Health Care

Strengthening the Patient Voice in the Review Process

Measuring outcomes in quality improvement education: success is in the eye of the beholder

Parental leave for scientific group leaders – changes needed

Importance of Social Support Within the Nursing Staff on Agitation in Residents With Dementia

5 Tips for Guiding Improvement with Visual Data

Health database that crosses provincial borders to launch
with federal funding

CFHI Strategic Plan 2019-2021

No One Cares When Planes Don’t Crash: The Message for Long-term Care

Quality measurement and nursing homes: measuring what matters.

How this Lafayette nursing home uses nostalgic field trips to trigger memories for residents

After unanimous vote, Toronto council to plan for emotion-focused care in all city-run nursing homes

Only half of needed LPNs and PCAs hired ahead of summer season

Workplaces launch help for employees struggling with caring for elder relatives

Do authors comply when funders enforce open access to research?

Ageism: A ‘Prevalent and Insidious’ Health Threat
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Postdoctoral Scholar – The Department of Medicine in the Cumming School of Medicine at the University of Calgary

Calgary AB
Support the implementation and evaluation of a pathway targeted at the early detection and management of acute issues among residents living within long-term care (LTC), including optimizing the use of community paramedicine and emergency department transfers. This project is funded as a PRIHS (Partnership for Research and Innovation in the Health System) grant.

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