May 28, 2019



TREC Research highlighted by McMaster Optimal Aging Portal
Unbefriended: The tragic fate of many older adults

At some point in our life, we may become unable to assert our rights and express our wishes, and to administer our financial affairs. We may become incapacitated. There are various degrees of incapacity: it can be partial or total, temporary or permanent.

New report by Malcolm Doupe
The Health Status of Community-Dwelling Older Adults in Manitoba

Dan Chateau, Malcolm Doupe, Heather Prior, Ruth-Ann Soodeen, Joykrishna Sarkar, Roxana Dragan, Dale Stevenson, and Leanne Rajotte
This report focuses on the health status and health care use patterns for community-dwelling older adults in Manitoba (i.e., not a resident of a nursing home). Using both health system data and self-report data from the Canadian Community Health Survey, a large number of indicators were examined that addressed physical health and wellbeing, mental health status, health care use, drug use, and numerous social indicators (e.g., living in social housing, receipt of income assistance, victim of crime). The baby boom generation has started to become senior citizens, and this timely report looks at the changes they may have brought with them to the population of older adults. The youngest of the older adults (age 65-74) saw a dramatic growth in size during the study period (2005-2014), boosting the population of older adults in Manitoba by over 20,000 in just five years. Above and beyond the increased demand on services that would be expected from population growth, we can expect changes in the health status of this population, and in how older Manitobans might interact with the health care system. Results are reported by three age groups (65-74, 75-84. 85+), and at regional and sub-regional levels. This will allow planners and all Manitobans to understand what is happening at a local level, and to focus primary care resources and other services and resources to meet the changing demands of this population.

Share your perspective on the design of healthcare interventions
Recruiting KT Intervention Developers for Usability Testing on Intersectionality & KT Practice Tools

St. Michael’s Hospital
This is a research study where scientists will work with KT intervention developers and older adults to improve the way health interventions are created. Intervention developers and knowledge translation experts use frameworks when they design health interventions. Many frameworks do not adequately consider individual-level attributes (e.g., a person’s gender, ethnicity, income etc.) and how these intersect to produce various needs and experiences. The purpose of this research study is to enhance frameworks so that they include constructs on individual-level attributes. Ultimately we want to help intervention developers to think about the unique experiences of individuals from different walks of life and design interventions that will be effective for all individuals.

New article by Charlotte Berendonk and Matthias Hoben
Improving Quality of Work life for Care Providers by Fostering the Emotional well-being of Persons with Dementia: A Cluster-randomized Trial of a Nursing Intervention in German long-term Care Settings.
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C. Berendonk, R. Kaspar, M. Bar and M. Hoben.
Dementia (London) 2019 May;18(4):1286-1309
We tested the feasibility of a nursing intervention (DEMIAN) in routine care and its effects on care providers’ job satisfaction, motivation, and work strain. This cluster-randomized trial was conducted in 20 German long-term care facilities. We randomly assigned 20 facilities to an intervention group (84 care providers, 42 residents with dementia) or a control group (96 care providers, 42 residents with dementia). Intervention group providers received two training days on the intervention; 68 providers attended both training days. Sixty two providers completed both baseline and follow-up questionnaires. Trained providers created individualized mini-intervention plans for participating residents. Control group residents received ‘usual care’. Intervention group providers stated that the intervention was feasible and helped them improve emotional well-being of residents with dementia. We found significantly decreased time pressure and decreased job dissatisfaction for intervention group providers. DEMIAN is an effective and pragmatic contribution to implementing person-centred care in long-term care, with positive effects on providers’ working conditions.

New articles by Janet Squires
Attributes of context relevant to healthcare professionals’ use of research evidence in clinical practice: a multi-study analysis.
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J. E. Squires, L. D. Aloisio, J. M. Grimshaw, et al.
Implement Sci 2019 May 22;14(1):52-019-0900-8
To increase the likelihood of successful implementation of evidence-based practices, researchers, knowledge users, and healthcare professionals must consider aspects of context that promote and hinder implementation in their setting. The purpose of the current study was to identify contextual attributes and their features relevant to implementation by healthcare professionals and compare and contrast these attributes and features across different clinical settings and healthcare professional roles. METHODS: We conducted a secondary analysis of 145 semi-structured interviews comprising 11 studies (10 from Canada and one from Australia) investigating healthcare professionals’ perceived barriers and enablers to their use of research evidence in clinical practice. The data was collected using semi-structured interview guides informed by the Theoretical Domains Framework across different healthcare professional roles, settings, and practices. We analyzed these data inductively, using constant comparative analysis, to identify attributes of context and their features reported in the interviews. We compared these data by (1) setting (primary care, hospital-medical/surgical, hospital-emergency room, hospital-critical care) and (2) professional role (physicians and residents, nurses and organ donor coordinators). RESULTS: We identified 62 unique features of context, which we categorized under 14 broader attributes of context. The 14 attributes were resource access, work structure, patient characteristics, professional role, culture, facility characteristics, system features, healthcare professional characteristics, financial, collaboration, leadership, evaluation, regulatory or legislative standards, and societal influences. We found instances of the majority (n = 12, 86%) of attributes of context across multiple (n = 6 or more) clinical behaviors. We also found little variation in the 14 attributes of context by setting (primary care and hospitals) and professional role (physicians and residents, and nurses and organ donor coordinators). CONCLUSIONS: There was considerable consistency in the 14 attributes identified irrespective of the clinical behavior, setting, or professional role, supporting broad utility of the attributes of context identified in this study. There was more variation in the finer-grained features of these attributes with the most substantial variation being by setting.

Patient decision aid for contralateral prophylactic mastectomy for use in the consultation: a feasibility study.
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J. E. Squires, D. Stacey, M. Coughlin, et al.
Curr Oncol 2019 Apr;26(2):137-148


Rates of contralateral prophylactic mastectomy (cpm) continue to rise internationally despite evidence-based guidance strongly discouraging its use in most women with unilateral breast cancer. The purpose of the present study was to develop and assess the feasibility of a knowledge translation tool [a patient decision aid (da)] designed to enhance evidence-informed shared decision-making about cpm. Methods: A consultation da was developed using the Ottawa Patient Decision Aid Development eTraining in consultation with clinicians and knowledge translation experts. The final da was then assessed for feasibility with health care professionals and patients across Canada. The assessment involved a survey completed online (health care professionals) or by telephone (patients). Survey data were analyzed using descriptive statistics for closed-ended questions and qualitative content analysis for open-ended questions. Results: The 51 participants who completed the survey included 39 health care professionals and 12 patients. The da was acceptable; 88% of participants viewed it as having the right amount of information or slightly more or less information than they would like. Almost all participants (98%) felt that the da would prepare patients to make better decisions. The aid was perceived to be usable, with 73% of participants stating that they would be willing to use or share the da. Conclusions: The cpm patient da developed for the present study was viewed by health care professionals and patients across Canada to be acceptable and usable during the clinical consultation. It holds promise as a knowledge translation tool to be used by clinicians in consultation with women who have unilateral breast cancer to enhance evidence-informed and shared decision-making with respect to undergoing cpm.

New article by Susan Slaughter
Provincial Differences in Long-Term Care Menu Variety and Food Intake for Residents who Consume a Regular Texture.
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C. Lagace, N. Carrier, L. Villalon, et al.
Can J Diet Pract Res 2019 May 8:1-7
To determine regular-texture menu variety offered in Canadian long-term care (LTC) homes and its association with residents’ food intake. Methods: Twenty-nine LTC menus from Alberta, Manitoba, New Brunswick, and Ontario were analyzed. Items offered during the regular-texture menu cycle were categorized according to Eating Well with Canada’s Food Guide food groups and variety scores were calculated per day and per week. Residents’ food intake was assessed by weighing and observing intake over 3 nonconsecutive days. Diet quality was determined using a mean adequacy ratio score (MAR) for regular and soft and bite-sized consumers (n = 394). Results: Average daily and weekly menu variety scores were 24 +/- 5.8 and 78 +/- 17.2, respectively, with significantly higher scores in Ontario (29 +/- 2.7 and 102 +/- 11.7). Of all the food groups, only the variety score for the “Other” food category was positively associated with protein intake. No associations were observed between variety and energy intake or MAR score. Conclusion: This study is the first in Canada to assess LTC menu variety. Although there was variability between provinces in menu variety, this was not associated with resident diet quality or intake.

New article by Shannon Scott
Knowledge translation strategies used by healthcare professionals in child health settings: An updated systematic review.
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A. Campbell, S. Louie-Poon, L. Slater and S. D. Scott.
J Pediatr Nurs 2019 May 17;47:114-120
Strategies assisting healthcare professionals to make evidence-based decisions are crucial for quality patient care and outcomes. To date, there is one systematic review (Albrecht et al., 2016) examining knowledge translation (KT) efforts in child health settings. This systematic review aims to provide an update on current evidence identifying KT interventions implementing research into child health settings. ELIGIBILITY CRITERIA: Nine electronic databases were searched, restricted by date (2011-2018) and language (English). Eligibility included: 1) randomized controlled trials (RCT), controlled clinical trials (CCT), or controlled before-and-after (CBA) studies; 2) interventions implementing research into child health practice; and 3) outcomes were measured at the healthcare professional/process, patient, or economic level. SAMPLE: Health care professionals working in child health settings. RESULTS: 48 studies (38 RCT, 7 CBA, 3 CCT) were included. Studies employed single (n=34) and multiple (n=14) interventions. The methodological quality of studies was moderate (n=18), strong (n=16) and weak (n=14). Studies showing significant, positive effects included (n=9) RCTs, (n=3) CBAs and (n=2) CCTs. These studies employed (n=11) single KT interventions and (n=3) multiple KT interventions. Interventions included educational (n=6), reminders (n=3), computerized decision supports (n=2), multidisciplinary teams (n=2) and financial and educational interventions combined (n=1). CONCLUSIONS: Effective KT strategies used by health care professionals in child health settings were found to be online education curriculums and computerized decision supports or reminders. IMPLICATIONS: This review update serves as an up-to-date ‘state of the science’ on KT strategies used in pediatric health professionals’ clinical practice, assessed by the most rigorous research designs.


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


New perspectives on university-industry relations: an analysis of the knowledge flow within two sectors and two countries
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Gustavo Dalmarco, Willem Hulsink and Paulo A. Zawislak.
Technology Analysis & Strategic Management 2019 05/08:1-13
University–industry relations (UIR) are usually analysed by the knowledge transfer channels, but existing studies have failed to address what knowledge content is being transferred–impacting the technology output aimed by the partnership. We aim to identify the Knowledge Flow in UIR, defined by the actor responsible for initiating a partnership – direction of the flow – and the type of technology output being transferred – content of the flow. We compare the knowledge flow in innovation systems of agriculture and aerospace sectors in Brazil and the Netherlands. The cases show that the knowledge flow is influenced more by the maturity of the national and sectoral innovation system than by the technological trajectory of the sector itself. While the Dutch cases demonstrate that both sectors are part of a mature innovation system, the Brazilian cases, although expected to have a similar technological trajectory, demonstrated a more immature innovation system.

How do researchers conceptualize and plan for the sustainability of their NIH R01 implementation projects?
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A. M. Johnson, J. E. Moore, D. A. Chambers, J. Rup, C. Dinyarian and S. E. Straus.
Implement Sci 2019 May 9;14(1):50-019-0895-1
Inadequate sustainability of implementation of evidence-based interventions has led to calls for research on how sustainability can be optimized. To advance our understanding of intervention sustainability, we explored how implementation researchers conceptualized and planned for the sustainability of their implemented interventions with studies funded by the United States (US) National Institutes of Health (NIH). METHODS: We used sequential, mixed methods to explore how researchers conceptualized and planned for the sustainability of the health interventions using (1) a document review of all active and completed US NIH R01 Grants and Equivalents reviewed within the Dissemination and Implementation Research in Health (DIRH) Study Section between 2004 and 2016 and (2) a qualitative content analysis of semi-structured interviews with NIH R01 DIRH grant recipients. RESULTS: We found 277 R01 profiles within the DIRH study section listed on the US NIH RePORTER website including 84 that were eligible for screening. Of the 84 unique projects, 76 (90.5%) had primary implementation outcomes. Of the 76 implementation project profiles, 51 (67.1%) made references to sustainability and none referred to sustainability planning. In both profiles and interviews, researchers conceptualized sustainability primarily as the continued delivery of interventions, programs, or implementation strategies. Few researchers referenced frameworks with sustainability constructs and offered limited information on how they operationalized frameworks. Researchers described broad categories of approaches and strategies to promote sustainability and key factors that may influence researchers to plan for sustainability, such as personal beliefs, self-efficacy, perception of their role, and the challenges of the grant funding system. CONCLUSIONS: We explored how US NIH R01 DIRH grant recipients conceptualized and planned for the sustainability of their interventions. Our results identified the need to test, consolidate, and provide guidance on how to operationalize sustainability frameworks, and to develop strategies on how funders and researchers can advance sustainability research.


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Health Care Administration and Organization

Priorities for long-term care resource allocation in England: Actual allocation versus the views of Directors of Service and older citizens

Paul Clarkson, Sue Davies, Jane Hughes, et al.
Journal of Long-Term Care 2018(September):13-23
Decisions about resource allocation in long-term care are a perennial issue. The basis for deciding between different needs in prioritising allocation is contested. In England, this debate has crystallised with the advent of selfdirected support, where individuals’ expressed preferences drive resources. Objectives: To compare perceptions of the priority given to needs for resource allocation in long-term care of older people by two stakeholder groups, compared with actual resource allocation. Methods: Survey data, eliciting perspectives of senior service managers and older citizens, were used to rank the perceived importance of eight needs-related outcomes. Actual resource allocation from 17 local authorities was also modelled against these outcomes. A variable importance metric was used to rank the importance of these outcomes in determining actual resource allocation. Findings from each data collection were compared. Findings: Differences in prioritisation of needs emerged between stakeholders compared with actual allocation. Older citizens and actual allocation prioritised basic and instrumental activities of daily living (ADLs). Directors’ rankings were more distinct, still prioritising basic ADLs, but ranking psychological well-being higher and instrumental ADLs lower. Limitations: The model of actual allocation could not account for political and bureaucratic factors influencing resource allocation, nor the complexity of certain needs that might incur greater resources. Implications: Discretion continues to influence resource allocation, which remains a contested area. Directors must account for overall spend and other extrinsic factors to maintain sustainability, whereas older citizens prioritise instrumental ADLs, despite these being considered lower priority in eligibility decisions. Overall, ADLs remain important drivers of allocation.

Nursing Staff Time and Care Quality in Long-Term Care Facilities: A Systematic Review.
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S. Armijo-Olivo, R. Craig, P. Corabian, B. Guo, S. Souri and L. Tjosvold.
Gerontologist 2019 May 22
In long-term care (LTC) facilities, nursing staff are important contributors to resident care and well-being. Despite this, the relationships between nursing staff coverage, care hours, and quality of resident care in LTC facilities are not well understood and have implications for policy-makers. This systematic review summarizes current evidence on the relationship between nursing staff coverage, care hours, and quality of resident care in LTC facilities. RESEARCH DESIGN AND METHODS: A structured literature search was conducted using four bibliographic databases and gray literature sources. Abstracts were screened by two independent reviewers using Covidence software. Data from the included studies were summarized using a pretested extraction form. The studies were critically appraised, and their results were synthesized narratively. RESULTS: The systematic searched yielded 15,842 citations, of which 54 studies (all observational) were included for synthesis. Most studies (n = 53, 98%) investigated the effect of nursing staff time on resident care. Eleven studies addressed minimum care hours and quality of care. One study examined the association between different nursing staff coverage models and resident outcomes. Overall, the quality of the included studies was poor. DISCUSSION AND IMPLICATIONS: Because the evidence was inconsistent and of low quality, there is uncertainty about the direction and magnitude of the association between nursing staff time and type of coverage on quality of care. More rigorously designed studies are needed to test the effects of different cutoffs of care hours and different nursing coverage models on the quality of resident care in LTC facilities.

Home is where the future is: The BrightFocus Foundation consensus panel on dementia care.
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Q. M. Samus, B. S. Black, D. Bovenkamp, et al.
Alzheimers Dement 2018 Jan;14(1):104-114
A national consensus panel was convened to develop recommendations on future directions for home-based dementia care (HBDC). METHODS: The panel summarized advantages and challenges of shifting to HBDC as the nexus of care and developed consensus-based recommendations. RESULTS: The panel developed five core recommendations: (1) HBDC should be considered the nexus of new dementia models, from diagnosis to end of life in dementia; (2) new payment models are needed to support HBDC and reward integration of care; (3) a diverse new workforce that spans the care continuum should be prepared urgently; (4) new technologies to promote communication, monitoring/safety, and symptoms management must be tested, integrated, and deployed; and (5) targeted dissemination efforts for HBDC must be employed. DISCUSSION: HBDC represents a promising paradigm shift to improve care for those living with dementia and their family caregivers: these recommendations provide a framework to chart a course forward for HBDC.

Quality dementia care: Prerequisites and relational ethics among multicultural healthcare providers.
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G. S. Sellevold, V. Egede-Nissen, R. Jakobsen and V. Sorlie.
Nurs Ethics 2019 Mar;26(2):504-514
Many nursing homes appear as multicultural workplaces where the majority of healthcare providers have an ethnic minority background. This environment creates challenges linked to communication, interaction and cultural differences. Furthermore, the healthcare providers have varied experiences and understanding of what quality care of patients with dementia involves. PURPOSE:: The aim of this study is to illuminate multi-ethnic healthcare providers’ lived experiences of their own working relationship, and its importance to quality care for people with dementia. RESEARCH DESIGN:: The study is part of a greater participatory action research project: ‘Hospice values in the care for persons with dementia’. The data material consists of extensive notes from seminars, project meetings and dialogue-based teaching. The text material was subjected to phenomenological-hermeneutical interpretation. PARTICIPANTS AND RESEARCH CONTEXT:: Participants in the project were healthcare providers working in a nursing home unit. The participants came from 15 different countries, had different formal qualifications, varied backgrounds and ethnic origins. ETHICAL CONSIDERATIONS:: The study is approved by the Norwegian Regional Ethics Committee and the Norwegian Social Science Data Services. FINDINGS:: The results show that good working relationships, characterized by understanding each other’s vulnerability and willingness to learn from each other through shared experiences, are prerequisites for quality care. The healthcare providers further described ethical challenges as uncertainty and different understandings. DISCUSSION:: The results are discussed in the light of Logstrup’s relational philosophy of ethics and the concepts of vulnerability, ethic responsibility, trust and openness of speech. CONCLUSION:: The prerequisite for quality care for persons with dementia in a multicultural working environment is to create arenas for open discussions between the healthcare providers. Leadership is of great importance.

The costs of dementia in England.
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R. Wittenberg, M. Knapp, B. Hu, et al.
Int J Geriatr Psychiatry 2019 Apr 5
This study measures the average per person and annual total costs of dementia in England in 2015. METHODS/DESIGN: Up-to-date data for England were drawn from multiple sources to identify prevalence of dementia by severity, patterns of health and social care service utilisation and their unit costs, levels of unpaid care and its economic impacts, and other costs of dementia. These data were used in a refined macrosimulation model to estimate annual per-person and aggregate costs of dementia. RESULTS: There are around 690 000 people with dementia in England, of whom 565 000 receive unpaid care or community care or live in a care home. Total annual cost of dementia in England is estimated to be pound24.2 billion in 2015, of which 42% ( pound10.1 billion) is attributable to unpaid care. Social care costs ( pound10.2 billion) are three times larger than health care costs ( pound3.8 billion). pound6.2 billion of the total social care costs are met by users themselves and their families, with pound4.0 billion (39.4%) funded by government. Total annual costs of mild, moderate, and severe dementia are pound3.2 billion, pound6.9 billion, and pound14.1 billion, respectively. Average costs of mild, moderate, and severe dementia are pound24 400, pound27 450, and pound46 050, respectively, per person per year. CONCLUSIONS: Dementia has huge economic impacts on people living with the illness, their carers, and society as a whole. Better support for people with dementia and their carers, as well as fair and efficient financing of social care services, are essential to address the current and future challenges of dementia.

Building a Culturally Competent Workforce to Care for Diverse Older Adults: Scope of the Problem and Potential Solutions.
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V. S. Periyakoil.
J Am Geriatr Soc 2019 May;67(S2):S423-S432
The population of minority older adults is going to explode over the next four decades. Older adults from racial and ethnic minorities face persistent and pervasive health disparities. Health disparities exert a huge fiscal burden on the nation. The national financial cost of health disparities for the years 2002 to 2006 was an estimated 1.23 trillion dollars. As the aging population becomes more diverse, these disparity-related costs are expected to increase. Older adults from racial and ethnic minorities face multiple barriers to accessing health and support services that will help them to age and die in place in the community. Patient-related barriers include limited English proficiency, low health literacy, varying levels of acculturation, biases about Western healthcare and medications, mistrust of clinicians, inability to navigate the complex healthcare system, and cultural beliefs and taboos. Clinician-related barriers include ageism (ie, discrimination against older people due to negative and inaccurate stereotypes), conscious and unconscious bias, being deeply entrenched in the culture of biomedicine, and the lack of training in the principles and practice of providing culturally respectful care. Health system-related barriers include lack of culturally tailored services, including access to medical interpreters. We conclude by identifying three specific strategies to facilitate culturally humble and respectful care for diverse patients.

Nurses’ perceptions regarding providing psychological care for older residents in long-term care facilities: A qualitative study.
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C. L. Kuo, S. Y. Wang, C. H. Tsai, Y. F. Pan and Y. H. Chuang.
Int J Older People Nurs 2019 May 9:e12242
To explore nurses’ perceptions regarding providing psychological health care for older residents in long-term care facilities (LTCFs). BACKGROUND: Loneliness and depressive symptoms are commonly observed among older residents living in LTCFs. Nurses are expected to provide holistic care including physical, psychological and social care for older residents in LTCFs to fulfil their needs. Therefore, understanding nurses’ feelings and thoughts regarding providing care for older residents who feel lonely, sad, unhappy or depressed is important for delivering better care. DESIGN: A qualitative research design was employed. The Standards for Reporting Qualitative Research (SRQR) was used to enhance for reporting quality. METHODS: Purposive sampling and snowball sampling were applied in Northern Taiwan. One-to-one in-depth interviews were conducted using a semi-structured interview guide. Twenty-one nurses with a mean age of 38.4 years were interviewed. Content analysis was performed for data analysis. FINDINGS: Four themes were generated from the data: “insufficient psychological healthcare competency,” “having a willing heart but not adequate support,” “families playing an essential role in residents’ mood” and “physical-oriented care model.” CONCLUSIONS: Long-term care facilitie nurses felt that they were not adequately prepared for taking care of older adults’ psychological problems before their nursing career or during their practice. Unreasonable nurse-to-resident ratios and an absence of care consensus among healthcare providers can make nurses feel that they have a willing heart but not adequate support. Family members are essential in older residents’ emotional status within the Taiwanese cultural context. Physical care evaluation indicators emphasised by LTCF accreditation resulted in the current care practice model. IMPLICATIONS FOR PRACTICE: This study provides valuable information for LTCF nurses, managers and directors to develop appropriate strategies to assist nurses in providing better psychological health care for older residents. Evaluation indicators required by LTCF accreditation in Taiwan must be re-examined at the earliest stage.

Engaging Caregivers in Health-Related Housing Decisions for Older Adults With Cognitive Impairment: A Cluster Randomized Trial.
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R. Adekpedjou, D. Stacey, N. Briere, et al.
Gerontologist 2019 May 16
Informal caregivers are rarely as involved as they want to be in the housing decisions of cognitively impaired older adults. Lack of awareness of available options and their benefits and risks may lead to decisions that do not reflect older adults’ preferences, and to guilt and regret. We assessed the effect of training home care teams in interprofessional shared decision-making (SDM) on the proportion of caregivers who report being active in this decision. RESEARCH DESIGN AND METHODS: In a two-arm pragmatic cluster randomized trial with home care teams working in health centers in the Province of Quebec, we randomized health centers randomized to receive training in interprofessional SDM (intervention) or not (control). Eligible caregivers had made a housing decision for a cognitively impaired adult aged 65 years or older who was receiving services from a home care team. The primary outcome was the proportion of caregivers reporting an active role in decision making. We performed intention-to-treat multilevel analysis. RESULTS: We consecutively enrolled a random group of 16 health centers and recruited 309 caregivers, among whom 296 were included in the analysis. In the intervention arm, the proportion of caregivers reporting an active role in decision making increased by 12% (95% CI -2% to 27%; p = .10). After removal of an influential cluster outlier, the proportion increased to 18% (95% CI: 7%-29%; p < .01). DISCUSSION AND IMPLICATIONS: Training home care teams in interprofessional SDM increased caregiver involvement in health-related housing decisions for cognitively impaired older adults.

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Health Care Innovation and Quality Assurance

Putting out fires: a qualitative study exploring the use of patient complaints to drive improvement at three academic hospitals

Jessica J. Liu, Leahora Rotteau, Chaim M. Bell and Kaveh G. Shojania.
BMJ Qual Saf 2019 05/23:bmjqs-2018-008801
Recent years have seen increasing calls for more proactive use of patient complaints to develop effective system-wide changes, analogous to the intended functions of incident reporting and root cause analysis (RCA) to improve patient safety. Given recent questions regarding the impact of RCAs on patient safety, we sought to explore the degree to which current patient complaints processes generate solutions to recurring quality problems.Design/setting Qualitative analysis of semistructured interviews with 21 patient relations personnel (PRP), nursing and physician leaders at three teaching hospitals (Toronto, Canada).Results Challenges to using the patient complaints process to drive hospital-wide improvement included: (1) Complaints often reflect recalcitrant system-wide issues (eg, wait times) or well-known problems which require intensive efforts to address (eg, poor communication). (2) The use of weak change strategies (eg, one-off educational sessions). (3) The handling of complaints by unit managers so they never reach the patient relations office. PRP identified giving patients a voice as their primary goal. Yet their daily work, which they described as ‘putting out fires’, focused primarily on placating patients in order to resolve complaints as quickly as possible, which may in effect suppress the patient voice.Conclusions Using patient complaints to drive improvement faces many of the challenges affecting incident reporting and RCA. The emphasis on ‘putting out fires’ may further detract from efforts to improve care for future patients. Systemically incorporating patients’ voices in clinical operations, as with co-design and other forms of authentic patient engagement, may hold greater promise for meaningful improvements in the patient experience than do RCA-like analyses of patient complaints.

Blended Facilitation as an Effective Implementation Strategy for Quality Improvement and Research in Nursing Homes.
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C. B. Pimentel, W. L. Mills, J. A. Palmer, et al.
J Nurs Care Qual 2019 Jul/Sep;34(3):210-216
Blended facilitation, which leverages the complementary skills and expertise of external and internal facilitators, is a powerful strategy that nursing stakeholders and researchers may use to improve implementation of quality improvement (QI) innovations and research performed in nursing homes. PROBLEM: Nursing homes present myriad challenges (eg, time constraints, top-down flow of communication, high staff turnover) to QI implementation and research. APPROACH: This methods article describes the theory and practical application of blended facilitation and its components (external facilitation, internal facilitation, relationship building, and skill building), using examples from a mixed QI and research intervention in Veterans Health Administration nursing homes. CONCLUSIONS: Blended facilitation invites nursing home stakeholders to be equal partners in QI and research processes. Its intentional use may overcome many existing barriers to QI and research performed in nursing homes and, by strengthening relationships between researchers and stakeholders, may accelerate implementation of innovative care practices.

Tackling the wicked problem of health networks: the design of an evaluation framework.
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F. C. Cunningham, G. Ranmuthugala, J. I. Westbrook and J. Braithwaite.
BMJ Open 2019 May 5;9(5):e024231-2018-024231
Networks are everywhere. Health systems and public health settings are experimenting with multifarious forms. Governments and providers are heavily investing in networks with an expectation that they will facilitate the delivery of better services and improve health outcomes. Yet, we lack a suitable conceptual framework to evaluate the effectiveness and sustainability of clinical and health networks. This paper aims to present such a framework to assist with rigorous research and policy analysis. The framework was designed as part of a project to evaluate the effectiveness and sustainability of health networks. We drew on systematic reviews of the literature on networks and communities of practice in health care, and on theoretical and evidence-based studies of the evaluation of health and non-health networks. Using brainstorming and mind-mapping techniques in expert advisory group sessions, we assessed existing network evaluation frameworks and considered their application to extant health networks. Feedback from stakeholders in network studies that we conducted was incorporated. The framework encompasses network goals, characteristics and relationships at member, network and community levels, and then looks at network outcomes, taking into account intervening variables. Finally, the short-term, medium-term and long-term effectiveness of the network needs to be assessed. The framework provides an overarching contribution to network evaluation. It is sufficiently comprehensive to account for many theoretical and evidence-based contributions to the literature on how networks operate and is sufficiently flexible to assess different kinds of health networks across their life-cycle at community, network and member levels. We outline the merits and limitations of the framework and discuss how it might be further tested.

Advancing Long-Term Care Science Through Using Common Data Elements: Candidate Measures for Care Outcomes of Personhood, Well-Being, and Quality of Life.
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D. Edvardsson, R. Baxter, L. Corneliusson, et al.
Gerontol Geriatr Med 2019 May 8;5:2333721419842672-Dec
To support the development of internationally comparable common data elements (CDEs) that can be used to measure essential aspects of long-term care (LTC) across low-, middle-, and high-income countries, a group of researchers in medicine, nursing, behavioral, and social sciences from 21 different countries have joined forces and launched the Worldwide Elements to Harmonize Research in LTC Living Environments (WE-THRIVE) initiative. This initiative aims to develop a common data infrastructure for international use across the domains of organizational context, workforce and staffing, person-centered care, and care outcomes, as these are critical to LTC quality, experiences, and outcomes. This article reports measurement recommendations for the care outcomes domain, focusing on previously prioritized care outcomes concepts of well-being, quality of life (QoL), and personhood for residents in LTC. Through literature review and expert ranking, we recommend nine measures of well-being, QoL, and personhood, as a basis for developing CDEs for long-term care outcomes across countries. Data in LTC have often included deficit-oriented measures; while important, reductions do not necessarily mean that residents are concurrently experiencing well-being. Enhancing measurement efforts with the inclusion of these positive LTC outcomes across countries would facilitate international LTC research and align with global shifts toward healthy aging and person-centered LTC models.

Safety and Quality of Care for Seniors Living with Dementia.
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A. Dudevich, L. Husak, T. Johnson and A. Chen.
Healthc Q 2018 Oct;21(3):12-15
The number of Canadian seniors living with dementia is increasing because of the aging population and population growth. This article highlights various aspects of safety and quality of care for seniors with dementia as described in the Dementia in Canada digital report.

Experienced Quality of Post-Acute and Long-Term Care From the Care Recipient’s Perspective-A Conceptual Framework.
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K. Y. J. Sion, R. Haex, H. Verbeek, et al.
J Am Med Dir Assoc 2019 May 9
This article aims to conceptualize experienced quality of post-acute and long-term care for older people as perceived by care recipients. An iterative literature review and consultations with stakeholders led to the development of the INDividually Experienced QUAlity of Long-term care (INDEXQUAL) framework. INDEXQUAL presents the process of an individual care experience consisting of a pre (expectations), during (experiences), and post (assessment) phase. Expectations are formed prior to an experience by personal needs, past experiences, and word-of-mouth. An experience follows, which consists of interactions between the players in the caring relationships. Lastly, this experience is assessed by addressing what happened and how it happened (perceived care services), how this influenced the care recipient’s health status (perceived care outcomes), and how this made the care recipient feel (satisfaction). INDEXQUAL can serve as a framework to select or develop methods to assess experienced quality of long-term care. It can provide a framework for quality monitoring, improvement, and transparency.

How to deal with context? A context-mapping tool for quality and safety in nursing homes and homecare (SAFE-LEAD Context).
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S. Wiig, K. Aase, T. Johannessen, et al.
BMC Res Notes 2019 May 10;12(1):259-019-4291-3
The objective of this paper is to develop a context-mapping tool (SAFE-LEAD Context) adapted to the nursing home and homecare setting. These two contexts represent a substantial variability, but studies focusing on the types and roles of contextual factors in quality and safety in these care settings are lacking. RESULTS: We conducted a step-wise collaborative design process consisting of mapping of key contextual factors as perceived by managers in Norwegian nursing homes and homecare, then created a draft tool discussed in a consortium workshop with co-researchers, and ran an international cross-country comparison. The SAFE-LEAD Context tool is inspired by the Consolidated Framework for Implementation Research (CFIR). The tool incorporates factors describing the outer setting of nursing homes and homecare at the national and local levels, in addition to factors describing the inner setting. The tool is flexible yet more detailed than current frameworks and capable of grading and describing the included contextual factors over time in the nursing home and homecare settings. A systematic approach using the SAFE-LEAD Context tool will support and improve the understanding and evaluation of quality and safety improvement interventions.

Supervisory relationships in long-term care facilities: A comparative case study of two facilities using complexity science.
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A. Escrig-Pinol, K. N. Corazzini, M. B. Blodgett, C. H. Chu and K. S. McGilton.
J Nurs Manag 2019 Mar;27(2):311-319
This study aims to understand the factors that contribute to supervisory nurse performance in long-term care facilities. BACKGROUND: Long-term care facilities have been faced with staffing challenges and increasing resident care needs, resulting in suboptimal quality of care. Nursing leadership has been identified as a key factor in the provision of high-quality care. METHODS: The comparative case study employed a complexity science framework to compare two facilities. The facilities were chosen based on the level of perceived supervisory support staff received from their supervisors, and 10 participants were recruited from each facility at various levels of management and staff (n = 20). Data were collected in 2015 using semi-structured interviews. FINDINGS: The quality and quantity of supervisory relationships was central to shaping the effectiveness of the supervision. Effective supervisory support was characterized by frequent and high-quality supervisor-staff interactions. Effective nurse supervisors acknowledged self-organisation as beneficial, and worked in environments that encouraged fluidity of roles. CONCLUSIONS: The findings suggest that effective nurse supervisors and supervisory support fosters improved work environments and the staff’s ability to respond to residents’ needs in a timely, effective and compassionate manner. IMPLICATIONS FOR NURSING MANAGEMENT: Nurse managers who provide effective supervisory support can improve the quality of care provided to their residents.

The improvement journey Why organisation-wide improvement in health care matters, and how to get started (UK)

The Health Foundation
May 2019
This report is a practical guide to developing an organisation-wide approach to improvement. It summarises the benefits of such an approach and outlines the key elements and steps that NHS trust leaders should adopt when pursuing this agenda.


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Research Practice and Methodology

Writing to Improve Healthcare: An Author’s Guide to Scholarly Publication
Non UofA Access

Stevens DP. First ed. Boca Raton, FL: CRC Press, Taylor & Francis Group; 2018
This new book is a ‘what and how to’ guide to writing for successful scholarly publication in the emerging fields of healthcare improvement and patient safety. While there are many useful authors’ aids for scholarly biomedical publication, none focuses explicitly on these relatively new fields. It offers practical advice that includes preparation and organization of a scholarly healthcare improvement manuscript, where to submit it to find the most likely interested editor and journal, how to take full advantage of coauthors’ working together effectively, and strategies for authors to reach a broader health professions readership.

Building the Next Generation of Implementation Science Careers to Advance Health Equity.
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C. A. Boyce, W. Barfield, J. Curry, et al.
Ethn Dis 2019 Feb 21;29(Suppl 1):77-82
Rapid advancements in translational research have produced innovative clinical discoveries and evidence-based interventions that are ready for uptake in real-world settings, creating vast opportunities and challenges for implementation science. However, there is an inadequate research workforce to study effective strategies and delivery of implementation to advance the field. Novel career development initiatives will build scholars for the next generation of implementation science to bridge research to practice for diverse populations to advance health equity, specifically with a strategic focus on heart, lung, blood and sleep diseases and conditions. Along with traditional mentoring and curricula, research training includes state-of-the-art approaches using complex methods and multi-disciplinary collaborations between researchers, practice settings, and diverse communities. Implementation science scholars strive not only to decrease the lag time between the discovery of evidence-based interventions and successful implementation but also how to advance health equity and to reduce disparities for underserved populations that suffer disproportionally.

Priorities for research in multiple conditions in later life (multi-morbidity): findings from a James Lind Alliance Priority Setting Partnership.
Non UofA Access

S. G. Parker, L. Corner, K. Laing, et al.
Age Ageing 2019 May 1;48(3):401-406
INTRODUCTION: multiple conditions in later life (multi-morbidity) is a major challenge for health and care systems worldwide, is of particular relevance for older people, but has not (until recently) received high priority as a topic for research. We have identified the top 10 research priorities from the perspective of older people, their carers, and health and social care professionals using the methods of a James Lind Alliance Priority Setting Partnership. METHODS: in total, 354 participants (162 older people and carers, 192 health professionals) completed a survey and 15 older people and carers were interviewed to produce 96 ‘unanswered questions’. These were further refined by survey and interviews to a shortlist of 21 topics, and a mix of people aged 80+ living with three or more conditions, carers and health and social care providers to prioritised the top 10. RESULTS: the key priorities were about the prevention of social isolation, the promotion of independence and physical and emotional well-being. In addition to these broad topics, the process also identified detailed priorities including the role of exercise therapy, the importance of falls (particularly fear of falling), the recognition and management of frailty and Comprehensive Geriatric Assessment. CONCLUSION: these topics provide a unique perspective on research priorities on multiple conditions in later life and complement existing UK and International recommendations about the optimisation of health and social care systems to deliver essential holistic models of care and the prevention and treatment of multiple co-existing conditions.

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“Now I write songs”: Growth and Reciprocity After Long-Term Nursing Home Placement.
Non UofA Access

T. A. Allison and A. K. Smith.
Gerontologist 2019 May 21
Nursing home residents have a need for activities that are meaningful, yet mandated scheduled activities remain poorly characterized. In order to understand how scheduled activities provide meaning for nursing home residents, we conducted a study of daily life in a nursing home with a robust activities program. RESEARCH DESIGN AND METHODS: This 2-year, longitudinal ethnographic study embedded an ethnographer into the activities department of a 430-bed, not-for-profit, faith-based nursing home. Forty-three interviews and more than 250 hr of participant-observation were conducted, with a focus on creative arts and religious activities. Thirty-two residents and 15 activities staff were followed more than 12-23 months. Data were coded concurrently, and emerging themes challenged through purposive recruitment until thematic saturation was reached. RESULTS: Scheduled activities in the nursing home offered opportunities for learning and personal growth regardless of functional or cognitive disability. Three major themes emerged. Artistic development included new self-identification as a musician, painter, or sculptor through arts programming. Intellectual and spiritual growth involved the use of activities to support ongoing practice and study. Reciprocity occurred as residents used the arts to remain contributing members of their institutional society, reciprocating with the institution that housed them. DISCUSSION AND IMPLICATIONS: Nursing home scheduled activities can facilitate the transformation of identity from resident or patient to the normalized social roles of artist, Torah scholar, and productive member of society.

A Scoping Review: Characteristics and Outcomes of Residents Who Experience Involuntary Relocation.
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R. H. Weaver, K. A. Roberto and N. Brossoie.
Gerontologist 2019 May 21
Relocation to a residential care facility has been described as the most significant relocation affecting older adults, yet subsequent relocations, like in the case of a facility closure, have received minimal attention in the scholarly research literature. This paper reviews the published literature on involuntary relocation, focusing on the experiences of residents, families, and staff and the effects of involuntary relocation on nursing home residents’ health. RESEARCH DESIGN AND METHODS: We conducted a scoping review to identify peer-reviewed studies reporting on involuntary relocation of nursing home residents. A total of 28 quantitative, qualitative, and mixed-method articles met inclusion criteria. RESULTS: Researchers mostly relied on longitudinal designs and quantitative indicators of functional health, cognitive status, psychological and emotional well-being, environment, and relocation context to examine residents’ mortality risk and health outcomes associated with involuntary relocation. Inclusion of qualitative and mixed-method approaches was infrequent, as were indicators of social engagement and perceptions of relocation. Residents’ awareness of and preparation for involuntary relocation positively influenced their health and well-being. Family involvement was frequently hindered by communication challenges with facilities. Staff expressed concern about residents, experienced increased workload demands, and acknowledged challenges with planning and communication. DISCUSSION AND IMPLICATIONS: Based on the collective findings, we propose a conceptual model of critical factors at play during relocation for consideration for guiding future research and developing provisions to current policies guiding relocation processes. Facilities and policymakers need to consider procedures that enhance planning efforts and decision-making among this vulnerable population and their families.

Factors Associated with the Quality of Life of People with Dementia and with Quality of Life-Improving Interventions: Scoping Review.
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A. Holopainen, H. Siltanen, A. Pohjanvuori, M. Makisalo-Ropponen and E. Okkonen.
Dementia (London) 2019 May;18(4):1507-1537
To synthesise current research exploring the factors and interventions associated with the quality of life of people with dementia. BACKGROUND: Dementia is a progressive condition affecting an estimated 40 million people worldwide. The illness has a significant impact on the lives of the persons affected and their loved ones, and may thus impair the quality of life of both. As it progresses, dementia weakens the patients’ ability to express their own views about their quality of life and the factors associated with it. DESIGN: Scoping review. DATA SOURCES: Electronic database search of MEDLINE, CINAHL, PsycINFO, Joanna Briggs Institute Library, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects (DARE), EMBASE, Medic published up to March 2016; and incremental hand search. Review method: Systematic or other kinds of reviews and single studies were included for the review if they met the inclusion criteria. Results: A total of 20 reviews and 7 primary studies were retained for synthesis. Key findings were abstracted and a themes matrix was generated to identify patterns of meaning. The factors associated with the quality of life of people with dementia were sociodemographic factors, factors related to dementia and social and caring environment. Interventions supporting quality of life focused on the activation of people with dementia. Conclusions: This scoping review identified a large body of knowledge exploring the factors and interventions associated with the quality of life of people with dementia. The interventions were heterogeneous and the sample sizes small, which is why more research is needed.

Enhancing the decision-making process when considering artificial nutrition in advanced dementia care.
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D. De and C. Thomas.
Int J Palliat Nurs 2019 May 2;25(5):216-223
Nutritional problems often manifest during late-stage dementia, and some families may request to instigate artificial nutrition and hydration (ANH) therapies. In the US, an estimated one-third of nursing home patients with a severe cognitive impairment have artificial feeding tubes inserted. Fear that a relative could experience extreme hunger or thirst if they are not mechanically fed tends to be the main driver behind family’s requests to implement artificial or enteral feeding methods. In contrast, artificial hydration is rarely given to older people with dementia in the UK and this practice of non-intervention tends to apply across all healthcare and hospice type environments. AIM: This literature review aims to evaluate the evidence to support the use and non-use of ANH. METHOD: A literature review was undertaken to examine the evidence around ANH for patients with dementia to offer support to families or carers contemplating feeding choices. CONCLUSION: This paper challenges the implementation of invasive ANH worldwide. It highlights how resorting to ANH does not necessarily lead to improvements in comfort, survival or wound healing. The risk of aspiration does not appear to significantly alter either.

Relationships Between Residential Care Community Characteristics and Overnight Hospital Stays and Readmissions: Results From the National Study of Long-Term Care Providers.
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C. Caffrey, L. Harris-Kojetin, V. Rome and L. Schwartz.
Seniors Hous Care J 2018 Nov;26(1):38-49
Hospitalizations and subsequent readmissions can produce significant challenges when trying to reduce costs and improve quality of care. This study describes hospitalizations and readmissions using residential care community data from the 2012 National Study of Long-Term Care Providers. The Resolution: About 61.0% of residential care communities had hospitalizations, and among these communities, 39.3% had readmissions. Residential care communities in the Northeast were more likely to have had hospitalizations and readmissions. Residential care communities located in a continuing care retirement community (CCRC) had a lower likelihood of hospitalizations, and communities that provided therapeutic services had a lower likelihood of readmissions. Tips for Success: An association with a CCRC and provision of therapeutic services were found to be protective against hospitalizations and readmissions, respectively.

Evaluating a smartwatch notification system in a simulated nursing home.
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H. Ali and H. Li.
Int J Older People Nurs 2019 May 17:e12241
This paper evaluates a high-fidelity prototype of a smartwatch-based communication system for nursing homes. The system could improve communication between residents and caregivers, thus reducing staff response time and improving residents’ safety. BACKGROUND: Across the country, nursing homes are often cited as having serious quality and safety issues. Deficiencies in the communication systems that connect residents with caregivers significantly impact the quality of care. Most nursing homes still use traditional call light systems, that give visual and auditory cues to caregivers, who may or may not be in proximity to the system. This study evaluates a smartwatch communication system developed to quickly relay a resident’s requests for assistance to staff anywhere in the nursing home. METHOD: Certified Nursing Assistants (CNAs) employed by nursing homes were recruited to perform routine tasks using both a traditional system and a smart system. Response time to call lights, staff performance and outcomes were measured through direct and recorded observations and through the surveys of participants. RESULTS: The smartwatch system reduced staff response time to call lights from bedrooms by 40%, from bathrooms by 58% and from bed exit alarms by 29%. The smartwatch system also reduced perceived workload by about 50% and was highly accepted by the CNAs. CONCLUSION: A smartwatch-based notification system may increase staff performance and decrease workload, thus leading to greater staff and patient satisfaction, which could ultimately lead to better quality of care and patient safety. RELEVANCE TO CLINICAL PRACTICE: This study provides empirical evidence for the usefulness of smartwatches in facilitating the notification and communication processes in healthcare settings and is also among the first to actually examine a smartwatch system in a healthcare setting.

Neighborhood Environment, Residential Satisfaction, and Depressive Symptoms Among Older Adults in Residential Care Homes.
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S. Liu, Z. Ouyang, A. M. Chong and H. Wang.
Int J Aging Hum Dev 2018 Oct;87(3):268-288
Burgeoning evidence has shown that neighborhood environments are related to depressive symptoms in the older population. Older adults living in residential care homes may be more vulnerable to environmental characteristics. The current study sought to understand how institutionalized older adults relate to environmental factors and residential satisfaction in terms of depressive symptoms. Data were collected from a cross-sectional national survey of 1,429 Chinese elders living in residential care homes. The findings reveal that 46.1% of the older Chinese residents living in residential care homes suffered from mild to severe depression. In addition, the current study finds that both environmental factors (e.g., geographic position, air quality, and transportation) and residential satisfaction are negatively associated with depressive symptoms. The findings support that residential satisfaction partially mediate the relationship between exterior environmental characteristics and depressive symptoms.

Challenges of improving oral health for adults in care homes.
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V. Elliot.
Nurs Older People 2017 Aug 31;29(7):21-26
In 2016 the National Institute for Health and Care Excellence (NICE) published a guideline on oral health for adults in care homes in England. The author was a co-opted member of the NICE oral health for adults in care homes public health advisory committee. This article reviews the NICE guideline as it applies to care homes, and relates it to the results of a survey of oral care practice undertaken in a large care home organisation and the available research literature from the past 20 years. The literature and survey results suggest that, if translated into practice, the NICE guideline could do much to improve oral health for adults in care homes. The survey highlighted that 85% of residents required support from carers to undertake mouth care. It also found that care homes experienced significant difficulties in accessing dental services for residents. The author concludes that providers need to equip staff with the necessary knowledge and skills to undertake mouth care and to give this area of personal care greater priority. Finally, the author suggests that the Care Quality Commission could ensure that the NICE guideline is translated into practice in care homes.

Goal-oriented cognitive rehabilitation for early-stage Alzheimer’s and related dementias: the GREAT RCT.
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L. Clare, A. Kudlicka, J. R. Oyebode, et al.
Health Technol Assess 2019 Mar;23(10):1-242
Cognitive rehabilitation (CR) is an individualised, person-centred intervention for people with mild to moderate dementia that addresses the impact of cognitive impairment on everyday functioning. OBJECTIVES: To determine whether or not CR is a clinically effective and cost-effective intervention for people with mild to moderate Alzheimer’s disease or vascular or mixed dementia, and their carers. DESIGN: This multicentre randomised controlled trial compared CR with treatment as usual (TAU). Following a baseline assessment and goal-setting to identify areas of everyday functioning that could be improved or better managed, participants were randomised (1 : 1) via secure web access to an independent randomisation centre to receive either TAU or CR and followed up at 3 and 9 months post randomisation. SETTING: Community. PARTICIPANTS: Participants had an International Classification of Diseases, Tenth Edition, diagnosis of Alzheimer’s disease or vascular or mixed dementia, had mild to moderate cognitive impairment (Mini Mental State Examination score of >/= 18 points), were stable on medication if prescribed, and had a family carer who was willing to contribute. The exclusion criteria were people with a history of brain injury or other neurological disorder and an inability to speak English. To achieve adequate power, we needed 350 people to complete the trial, with 175 people in each trial arm. INTERVENTION: Cognitive rehabilitation consisted of 10 therapy sessions over 3 months, followed by four maintenance sessions over 6 months, delivered in participants’ homes. The therapists were nine occupational therapists and one nurse. OUTCOME MEASURES: The primary outcome was self-reported goal attainment at 3 months. Goal attainment was also assessed at 9 months. Carers provided independent ratings of goal attainment at both time points. The secondary outcomes were participant quality of life, mood, self-efficacy and cognition, and carer stress, health status and quality of life. The assessments at 3 and 9 months were conducted by researchers who were blind to the participants’ group allocation. RESULTS: A total of 475 participants were randomised (CR arm, n = 239; TAU arm, n = 236), 427 participants (90%) completed the trial and 426 participants were analysed (CR arm, n = 208, TAU arm, n = 218). At 3 months, there were statistically significant large positive effects for participant-rated goal attainment [mean change in the CR arm: 2.57; mean change in the TAU arm: 0.86; Cohen’sd = 0.97, 95% confidence interval (CI) 0.75 to 1.19], corroborated by carer ratings (Cohen’sd = 1.11, 95% CI 0.89 to 1.34). These effects were maintained at 9 months for both the participant ratings (Cohen’s d = 0.94, 95% CI 0.71 to 1.17) and the carer ratings (Cohen’s d = 0.96, 95% CI 0.73 to 1.20). There were no significant differences in the secondary outcomes. In the cost-utility analyses, there was no evidence of cost-effectiveness in terms of gains in the quality-adjusted life-years (QALYs) of the person with dementia (measured using the DEMentia Quality Of Life questionnaire utility score) or the QALYs of the carer (measured using the EuroQol-5 Dimensions, three-level version) from either cost perspective. In the cost-effectiveness analyses, by reference to the primary outcome of participant-rated goal attainment, CR was cost-effective from both the health and social care perspective and the societal perspective at willingness-to-pay values of pound2500 and above for improvement in the goal attainment measure. There was no evidence on the cost-effectiveness of the self-efficacy measure (the Generalized Self-Efficacy Scale) from either cost perspective. LIMITATIONS: Possible limitations arose from the non-feasibility of using observational outcome measures, the lack of a general measure of functional ability and the exclusion of people without a carer or with rarer forms of dementia. CONCLUSIONS: Cognitive rehabilitation is clinically effective in enabling people with early-stage dementia to improve their everyday functioning in relation to individual goals targeted in the therapy sessions. FUTURE WORK: Next steps will focus on the implementation of CR into NHS and social care services and on extending the approach to people with rarer forms of dementia. TRIAL REGISTRATION: Current Controlled Trials ISRCTN21027481. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 10. See the NIHR Journals Library website for further project information.; BACKGROUND: Cognitive rehabilitation (CR) is a personalised intervention to help people with early-stage dementia to manage everyday activities. This individualised therapy is conducted in people’s own homes over several sessions. A therapist works with the person and the carer to identify realistic and relevant goals, plan how to tackle these and support people in achieving them. Previous small studies suggested that CR could be beneficial. METHODS: The Goal-oriented cognitive Rehabilitation in Early-stage Alzheimer’s and related dementias: multicentre single-blind randomised controlled Trial (GREAT) was run in eight centres to find out whether or not CR improves everyday functioning. Participants were in the early stages of having Alzheimer’s disease, vascular dementia or mixed dementia, with a family carer involved. At the first assessment, participants identified areas in which they would like to see improvements, and set goals. Participants and carers rated how well participants were currently doing in relation to these goals and completed questionnaires, for example about mood and quality of life. Participants were then randomly selected to either receive CR or continue with treatment as usual (TAU). CR consisted of 10 weekly sessions with the therapist over 3 months, followed by four sessions over the next 6 months. Participants were reassessed after 3 and 9 months. RESULTS: We included 475 participants, and 427 participants (90%) completed the trial (209 participants in the CR arm and 218 participants in the TAU arm). After 3 months, the ratings by both participants and carers in the CR group showed that participants were doing significantly better in relation to their goals, and this was maintained 6 months later. Ratings for the TAU-arm participants did not improve significantly. There were no other differences between the groups. There was a strong economic case for CR. CONCLUSIONS: Cognitive rehabilitation is effective in enabling people with early-stage dementia to improve their everyday functioning in relation to individual goals targeted in the therapy sessions. Next steps will focus on the implementation of CR into NHS and social care services.

Hospital readmission in persons with dementia: A systematic review.
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C. Ma, S. Bao, P. Dull, B. Wu and F. Yu.
Int J Geriatr Psychiatry 2019 May 13
Hospital readmission in persons with dementia is becoming a critical safety and cost issue. The purpose of this review is to systematically assess published evidence on hospital readmissions in persons with dementia, including rate, clinical reasons, risk factors, and prevention programs. METHODS: A systematic review of relevant literature was conducted. Literature were searched in PubMed, CINAHL, PsycINFO, and Embase as well as hand searching. Quality of reviewed studies were assessed independently by reviewers using quality assessment checklists. RESULTS: Nineteen studies met the inclusion criteria and were reviewed. In persons with dementia, all-cause 30-day readmission rate was most frequently reported and ranged from 7% to 35%. Compared with those without dementia, persons with dementia had significantly higher rate of readmission. Reported risk factors of readmission varied across studies from patient sociodemographic and clinical status, history of health care utilization, to family caregivers. Reasons for readmission were rarely documented. Programs of home-based individualized care and interdisciplinary team care were used for preventing readmissions. Findings from some of the studies were limited by small sample sizes, single data source, and other methodologic flaws. CONCLUSIONS: Persons with dementia are at high risk for hospital readmission, but many of the readmissions are potentially preventable. Multiple strategies such like identifying high-risk individuals and the clinical reasons for index admission and readmission and implementing home-based individualized care by interdisciplinary team can reduce preventable hospital readmissions. Future studies should use multiple national data sources and advanced methodology to identify risk factors and clinical reasons of hospital readmissions.

Pressure Injury Prevention: Outcomes and Challenges to Use of Resident Monitoring Technology in a Nursing Home.
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T. L. Yap, S. M. Kennerly and K. Ly.
J Wound Ostomy Continence Nurs 2019 May/Jun;46(3):207-213
We examined the usability, user perceptions, and nursing occupational subculture associated with introduction of a patient monitoring system to facilitate nursing staff implementation of standard care for pressure ulcer/injury prevention in the nursing home setting. DESIGN: Mixed methods, pre-/posttest design. SUBJECTS AND SETTING: Resident (n = 44) and staff (n = 38) participants were recruited from a 120-bed nursing home in the Southeast United States. METHODS: Digital data on frequency and position of residents were transmitted wirelessly from sensors worn on each resident’s anterior chest to estimate nursing staff compliance with repositioning standard of care before and after visual monitors were activated to cue staff. The validated Nursing Culture Assessment Tool was used to determine changes in nursing culture. Benefits and challenges of implementation were assessed by 2 focus groups composed of 8 and 5 female members of the nursing staff (RN, LPN, CNA), respectively, and led by the three authors. Descriptive statistics were used for all quantitative variables, and inferential statistics were applied to categorical variables (chi test or Fisher exact test) and continuous variables (analyses of variance or equivalent nonparametric tests), respectively, where a 2-sided P value of <.05 was considered statistically significant. RESULTS: System use significantly (P = .0003) improved compliance with every 2-hour repositioning standards. The nursing culture normative ranking percentage increased from 30.9% to 58.2%; this difference was not statistically significant. Focus groups expressed satisfaction with the monitoring system and recommended improvements to support adaptation and use of technology. CONCLUSIONS: Study findings support the usability of the patient monitoring system to facilitate repositioning. Implementation of multiple strategies for training, supplies, and communication may enhance uptake and effectiveness.

Measuring health-related quality of life of care home residents: comparison of self-report with staff proxy responses.
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A. Usman, S. Lewis, K. Hinsliff-Smith, et al.
Age Ageing 2019 May 1;48(3):407-413
Care home residents are often unable to complete health-related quality of life questionnaires for themselves because of prevalent cognitive impairment. This study compared care home resident and staff proxy responses for two measures, the EQ-5D-5L and HowRU. METHODS: a prospective cohort study recruited residents >/=60 years across 24 care homes who were not receiving short stay, respite or terminal care. Resident and staff proxy EQ-5D-5L and HowRu responses were collected monthly for 3 months. Weighted kappa statistics and intra-class correlation coefficients (ICCs) adjusted for clustering at the care home level were used to measure agreement between resident and proxies for each time point. The effect of staff and resident baseline variables on agreement was considered using a multilevel mixed effect regression model. RESULTS: 117, 109 and 104 matched pairs completed the questionnaires at 1, 2 and 3 months, respectively. When clustering was controlled for, agreement between resident and staff proxy EQ-5D-5L responses was fair for mobility (ICC: 0.29) and slight for all other domains (ICC </= 0.20). EQ-5D Index and Quality-Adjusted Life Year scores (proxy scores higher than residents) showed better agreement than EQ-5D-VAS (residents scores higher than proxy). HowRU showed only slight agreement (ICC </= 0.20) between residents and proxies. Staff and resident characteristics did not influence level of agreement for either index. DISCUSSION: the levels of agreement for EQ-5D-5L and HowRU raise questions about their validity in this population.

Goal-setting can help people with early-stage dementia improve function

NIHR, 2019
Cognitive rehabilitation (CR) is a personalised intervention to help people with early-stage dementia to manage everyday activities. This individualised therapy is conducted in people’s own homes over several sessions. A therapist works with the person and the carer to identify realistic and relevant goals, plan how to tackle these and support people in achieving them. Previous small studies suggested that CR could be beneficial.The Goal-oriented cognitive Rehabilitation in Early-stage Alzheimer’s and related dementias: multicentre single-blind randomised controlled Trial (GREAT) was run in eight centres to find out whether or not CR improves everyday functioning. Participants were in the early stages of having Alzheimer’s disease, vascular dementia or mixed dementia, with a family carer involved. At the first assessment, participants identified areas in which they would like to see improvements, and set goals. Participants and carers rated how well participants were currently doing in relation to these goals and completed questionnaires, for example about mood and quality of life. Participants were then randomly selected to either receive CR or continue with treatment as usual (TAU). CR consisted of 10 weekly sessions with the therapist over 3 months, followed by four sessions over the next 6 months. Participants were reassessed after 3 and 9 months.We included 475 participants, and 427 participants (90%) completed the trial (209 participants in the CR arm and 218 participants in the TAU arm). After 3 months, the ratings by both participants and carers in the CR group showed that participants were doing significantly better in relation to their goals, and this was maintained 6 months later. Ratings for the TAU-arm participants did not improve significantly. There were no other differences between the groups. There was a strong economic case for CR.Cognitive rehabilitation is effective in enabling people with early-stage dementia to improve their everyday functioning in relation to individual goals targeted in the therapy sessions. Next steps will focus on the implementation of CR into NHS and social care services.


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“Revolutionizing Dementia Care” Documentary

“Revolutionizing Dementia Care” reveals how people living with dementia can still live a full and meaningful life based on their abilities, not their disabilities. Innovative approaches in memory care communities have shown improvements in the well-being of residents as they’re included, engaged and supported in social gatherings, clubs and everyday activities. A revolution is here where people living with dementia get the individual heart-felt care they need.

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First the worst? Lead authors ‘should take misconduct blame’

Fix Dementia Care (UK)

Frail elderly ‘failed by care deserts’ (UK)

How to cut your dementia risk, according to WHO

The Time is Now. We must consider longer term policy changes for LTC in Ontario

Spreading and scaling up innovation and improvement

The ludicrous idea of a provincial intellectual property framework

New report shows big increase in demand for mental health support among higher education staff (UK)

Age and Ageing issues special collection on longitudinal studies of ageing

Support staff at Quebec universities struggle with psychological distress

The Changing Face Of Aging In Canada: Veronica Boscart

Neuroscientist and expert in Alzheimer research, Dr. Jane Rylett, named Scientific Director of the CIHR Institute of Aging

Physician Visits at the Nursing Home: Does More Mean Better Care?

The power of hidden teams The most-engaged employees work together in ways companies don’t even realize.

The impossible case of assisted death for people with dementia

Living in a remote location is associated with avoidable death. Why is that?

Staff shortages ‘abusing good will of nurses’ (UK)

What we know about designing an effective improvement intervention (but too often fail to put into practice)

StaRI Aims to Overcome Knowledge Translation Inertia: The Standards for Reporting Implementation Studies Guidelines

A Daughter’s Portrait of Her Mother Through Dementia

The death of the literature review and the rise of the dynamic knowledge map

Measuring Inequality – Creating an indicator to assess gender bias in universities

Getting past the senior stereotypes: U of A researcher says attitudes need to mature

‘It’s cut-throat’: half of UK academics stressed and 40% thinking of leaving

Cannula sleeves: ‘Simple solution for dementia patients’

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Dissemination & Implementation Scientist – Assistant or Associate Professor

University of Colorado – School of Medicine, Denver, CO
The University of Colorado School of Medicine (CU SOM) seeks an experienced Dissemination and Implementation (D&I) Scientist at the advanced assistant or associate professor level to collaborate with and help lead an active and growing D&I research, training and consultation program.

This position will be predominantly or solely research, although some clinical work or teaching is possible depending upon candidate background and interests. The position will involve partnership with diverse programs, departments and disciplines across the CU SOM and other community and academic partner organizations. It will be housed within the D&I Science Program of the CU Denver Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS).

Assistant Or Associate Professor In Implementation Science

Simon Fraser University; Burnaby, BC
DEADLINE: Open until Filled
The Faculty of Health Sciences (FHS) at Simon Fraser University seeks applications from early and mid-career scientists or scientist-practitioners with an outstanding research record to be appointed as a tenure -track Assistant or Associate Professor in Implementation Science. They are seeking a scholar who has a PhD in a relevant field, and who has demonstrated strengths in combining theory and methods to study the implementation or scale-up of interventions or the adaptation of interventions among settings, regions, genders, or conditions to improve population and public health.

Cochrane seeks KT Projects Officer

Flexible Location
This role is an exciting opportunity to use your experience as a Projects Officer to make a difference in the field of health care research.

This new role, as part of Cochrane’s Knowledge Translation (KT) department, will be responsible for supporting the delivery of specific KT activities and implementation projects; and to assist colleagues across Cochrane’s global community by providing training, tools and guidance in order for them to implement their KT activities and wider strategic plans.

The successful applicant will work across a range of project areas within the KT department that includes: supporting and coordinating the work of the KT Working Groups, support to external and internal communications, multi-lingual strategies, partnerships and advocacy, brand marketing and events, and KT training requirements.

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