June 16, 2020

This article examines provincial policy influence on long-term care (LTC) professionals’ advice-seeking networks in Canada’s Maritime provinces. The effects of facility ownership, geography, and region-specific political landscapes on LTC best-practice dissemination are examined. We used sociometric statistics and network sociograms, calculated from surveys with 169 senior leaders in LTC facilities, to identify advice-seeking network structures and to select 11 follow-up interview participants. Network structures were distinguished by density, sub-group number, opinion leader, and boundary spanner distribution. Network structure was affected by ownership model in Nova Scotia and Prince Edward Island, and by regional geography in New Brunswick. Political instability within each province’s LTC system negatively affected network actors’ capabilities to enact innovation. Moreover, provincial policy variations influence advice-seeking network structures, facilitating and constraining relationship development and networking. Consequently, local policy context is essential to informing dissemination strategy design or implementation.

What have we learned from these events and how can we use these learnings to prepare for what seems to be the inevitable second wave of COVID-19, particularly in Ontario and Quebec? Our decision-makers at all levels must learn from the devastation and death of our vulnerable seniors in LTC settings and ensure there is no repeat performance of these damning statistics. Here are seven things that must happen.

The current state of evidence regarding measures that assess evidence-informed decision-making (EIDM) competence attributes (i.e., knowledge, skills, attitudes/beliefs, behaviours) among nurses is unknown. This systematic review provides a narrative synthesis of the psychometric properties and general characteristics of EIDM competence attribute measures in nursing. METHODS: The search strategy included online databases, hand searches, grey literature, and content experts. To align with the Cochrane Handbook of Systematic Reviews, psychometric outcome data (i.e., acceptability, reliability, validity) were extracted in duplicate, while all remaining data (i.e., study and measure characteristics) were extracted by one team member and checked by a second member for accuracy. Acceptability data was defined as measure completion time and overall rate of missing data. The Standards for Educational and Psychological Testing was used as the guiding framework to define reliability, and validity evidence, identified as a unified concept comprised of four validity sources: content, response process, internal structure and relationships to other variables. A narrative synthesis of measure and study characteristics, and psychometric outcomes is presented across measures and settings. RESULTS: A total of 5883 citations were screened with 103 studies and 35 unique measures included in the review. Measures were used or tested in acute care (n = 31 measures), public health (n = 4 measures), home health (n = 4 measures), and long-term care (n = 1 measure). Half of the measures assessed a single competence attribute (n = 19; 54.3%). Three measures (9%) assessed four competence attributes of knowledge, skills, attitudes/beliefs and behaviours. Regarding acceptability, overall missing data ranged from 1.6-25.6% across 11 measures and completion times ranged from 5 to 25 min (n = 4 measures). Internal consistency reliability was commonly reported (21 measures), with Cronbach’s alphas ranging from 0.45-0.98. Two measures reported four sources of validity evidence, and over half (n = 19; 54%) reported one source of validity evidence. CONCLUSIONS: This review highlights a gap in the testing and use of competence attribute measures related to evidence-informed decision making in community-based and long-term care settings. Further development of measures is needed conceptually and psychometrically, as most measures assess only a single competence attribute, and lack assessment and evidence of reliability and sources of established validity evidence. REGISTRATION: PROSPERO #CRD42018088754.

In this opinion editorial, I will briefly explore the meaning of patient engagement in LTC and provide suggestions for future research directions.

To identify the current state of knowledge about the use of the sit-to-stand intervention with older people and to identify implications for further research. BACKGROUND: Many older people experience mobility challenges which can negatively affect their well-being. Physical activities are vital to improving or maintaining mobility. Although there is evidence that mobility challenged older people benefit from the sit-to-stand intervention, there is a need to systematically examine the state of knowledge about this intervention. DESIGN: Scoping review using Arksey and O’Malley’s methodological framework. METHODS: A systematic search of three databases was completed. Abstracts were evaluated for relevance using predetermined inclusion criteria. Studies that met the inclusion criteria had data extracted and were appraised for internal and external validity. Narrative synthesis was based on methods described by Popay and colleagues. RESULTS: Of 3,041 papers, six studies met the inclusion criteria. Publications provided a range of sit-to-stand interventions with durations varying from four weeks to six months. The frequency of each intervention fluctuated from three to seven times/week with a duration of 15-45 min. Different professionals prompted the activity. Three themes were identified the following: (a) sit-to-stand activity as an intervention; (b) generalisability of findings; and (c) sustainability. CONCLUSIONS: Most of the studies reviewed indicated improvements in performance of the sit-to-stand activity and in motor function. However, issues with studies rigour do not allow us to make generalisations. Further research is needed to confirm the effectiveness of the intervention. IMPLICATIONS FOR PRACTICE: Healthcare providers are expected to offer evidence-based patient care. This review details current knowledge about the sit-to-stand intervention with older people.

Nursing home (NH) residents are often undernourished and physically inactive, which contributes to sarcopenia and frailty. The Older Person’s Exercise and Nutrition Study aimed to investigate the effects of sit-to-stand exercises (STS) integrated into daily care, combined with a protein-rich oral nutritional supplement (ONS), on physical function, nutritional status, body composition, health-related quality of life, and resource use. DESIGN: Residents in 8 NHs were randomized by NH units into an intervention group (IG) or a control group (CG) (n = 60/group). The IG was a combination of STS (4 times/day) and ONS (2 bottles/day providing 600 kcal and 36 g protein) for 12 weeks. SETTING AND PARTICIPANTS: The participants resided in NH units (dementia and somatic care), were ≥75 years of age, and able to rise from a seated position. METHODS: The 30-second Chair Stand Test was the primary outcome. Secondary outcomes were balance, walking speed, dependence in activities of daily living, nutritional status and body composition, health-related quality of life, and resource use. RESULTS: Altogether, 102 residents (age 86 ± 5 years, 62% female) completed the study. No improvement in the physical function assessments was observed in the IG, whereas body weight increased significantly (2.05 ± 3.5 kg, P = .013) vs the CG. Twenty-one (of 52) participants with high adherence to the intervention (ie, at least 40% compliance to the combined intervention) increased their fat free mass (2.12 kg (0.13, 4.26 interquartile range), P = .007 vs CG). Logistic regression analyses indicated that the odds ratio for maintained/improved 30-second Chair Stand Test was 3.5 (confidence interval 1.1, 10.9, P = .034) among the participants with high adherence compared with the CG. CONCLUSIONS/IMPLICATIONS: Twelve-week intervention of daily STS combined with ONS in NH residents did not improve physical function, but increased body weight. Subgroup analyses indicated that high adherence to the combined intervention was associated with maintained or improved physical function and a gain of fat free mass.

Research has identified inadequacies in the quality and quantity of dementia-related information, particularly end-of-life information provided to those living with dementia and their family caregivers. The purpose of this study was to identify what types of information family caregivers of persons living with dementia in nursing homes would deem useful in preparing them for their relative’s end-of-life and assist them to make decisions about care along the dementia trajectory. METHODS: The qualitative methodology of interpretive description was used to guide the study in which semi-structured interviews were conducted with nursing home staff in clinical roles (e.g., nurses, health care aides, social workers, speech language pathologists; N = 26), palliative care clinicians (N = 7), and bereaved family caregivers of persons with dementia (N = 17). Data were analyzed using thematic analysis. FINDINGS: Eight substantive categories essential to meeting family members’ needs for information and preparing them for the future were identified including: (i) dementia in general, (ii) dementia toward the end-of-life, (iii) care of persons dying with dementia, (iv) the role of family caregiver as decision maker, (v) sustaining connection, (vi) emotional impact of dementia on caregivers, (vii) relationships with staff, and (viii) general questions about life in a NH. CONCLUSION: Our findings suggest that family caregivers of nursing home residents with dementia have unique information and support needs, some disease specific, others more related to life in a nursing home in general. Health care providers need to support and encourage dementia literacy for family caregivers. A key strategy is to proactively broach these topic areas, as too often family caregivers may not recognize or value their need for information.

The COVID-19 pandemic and subsequent state of public emergency have significantly affected older adults in Canada and worldwide. It is imperative that the gerontological response be efficient and effective. In this statement, the board members of the Canadian Association on Gerontology/L’Association canadienne de gérontologie (CAG/ACG) and the Canadian Journal on Aging/La revue canadienne du vieillissement (CJA/RCV) acknowledge the contributions of CAG/ACG members and CJA/RCV readers. We also profile the complex ways that COVID-19 is affecting older adults, from individual to population levels, and advocate for the adoption of multidisciplinary collaborative teams to bring together different perspectives, areas of expertise, and methods of evaluation in the COVID-19 response.

The objective of this call is to support all industries with challenges to mitigate, and also looks for new opportunities that can be further leveraged, accelerating skills training to help many navigate an evolving job market.
FSC is seeking proposals for activities such as research, network development and innovation pilots that target sectors, regions, and populations facing pressing needs and recognize emerging opportunities that examine new insights and models across three levels of the skills ecosystem:
Support for individuals: to help inform training and career paths for workers, especially those who face barriers based on geography, background or experience.
Support for organizations: to adopt new technologies and expand the understanding of a new health and safety environment, policy development and program delivery for large and small businesses, government, educational institutions and service delivery organizations.
Systems change: to promote innovative approaches to policy and program development and re-engineering of processes in large and small businesses, government, educational institutions, or service delivery organizations.

Bedside chest ultrasound, when integrated with clinical data, is an accurate tool improving the diagnostic process of many respiratory diseases. This study aims to evaluate the feasibility of a chest ultrasound screening program in nursing homes for detecting coronavirus disease-19 (COVID-19)-related pneumonia and improving the appropriateness of hospital referral of residents.; ObjectiveBedside chest ultrasound, when integrated with clinical data, is an accurate tool improving the diagnostic process of many respiratory diseases. This study aims to evaluate the feasibility of a chest ultrasound screening program in nursing homes for detecting coronavirus disease-19 (COVID-19)-related pneumonia and improving the appropriateness of hospital referral of residents.

This letter argues that we need to pay particular attention to people with dementia during this difficult time of the COVID-19 pandemic. Social distancing rules and cocooning for people aged 70 years and over are now in place in Ireland to slow down the rate of infection and protect vulnerable older people. This letter argues that we need, more than ever, to assert the personhood of people with dementia at this difficult time. That means more person-centred care and practical support structures for family carers to allow them to continue to care at home in a safe and life-enhancing way. New public broadcasting initiatives could create information and communication channels for people with dementia and their carers, as well as demonstrating empathy and solidarity with their predicament. Government, the Department of Health, the HSE and the voluntary sector have risen to the challenge of COVID-19 in all sectors of society. So too have ordinary citizens. Now we need to unite even more to create an unyielding commitment and adherence to the principles of decency, justice and equity in the allocation of scarce health and social care resources. By doing this, we will demonstrate our caring potential and capacity in a way that reflects our shared humanity, not only in the current crisis, but into the future.

This commentary focuses on the challenge met by old age psychiatrists during the pandemic.

Many nursing home residents infected with SARS-CoV-2 fail to be identified with standard screening for the associated COVID-19 syndrome. Current nursing home COVID-19 screening guidance includes assessment for fever defined as a temperature of at least 38.0°C. The objective of this study is to describe the temperature changes before and after universal testing for SARS-CoV-2 in nursing home residents.; ObjectivesMany nursing home residents infected with SARS-CoV-2 fail to be identified with standard screening for the associated COVID-19 syndrome. Current nursing home COVID-19 screening guidance includes assessment for fever defined as a temperature of at least 38.0°C. The objective of this study is to describe the temperature changes before and after universal testing for SARS-CoV-2 in nursing home residents.

The 2020 Coronavirus pandemic is the greatest global health crisis we have had in recent decades, both by its own consequences and by the impact of the measures that have been taken by various countries to deal with it. The effect is major on Western health systems, affecting all areas of care and research, including research on Alzheimer’s disease and cognitive aging.

To appreciate these consequences, it seemed interesting to us to provide data on the activity of a Memory Clinic and Research Center, taking as an example the Alzheimer’s Disease Center of Toulouse in France, one of the European countries most affected by this outbreak.

Frail elderly patients with multimorbidity are at high risk of serious illness and death in cases of corona virus infection. Unlike ‘normal deaths’ in nursing homes with time to prepare, the condition can change rapidly and cause organ failure. In this article we describe palliative non-invasive and invasive interventions for frail elderly patients in nursing homes who are dying due to COVID-19.

Hong Kong is a major international travel hub and a densely populated city geographically adjacent to Mainland China. Despite these risk factors, it has managed to contain the COVID-19 epidemic without a total lockdown of the city. Three months on since the outbreak, the city reported slightly more than 1,000 infected people, only four deaths and no infection in residential care homes or adult day care centers. Public health intervention and population behavioral change were credited as reasons for this success. Hong Kong’s public health intervention was developed from the lessons learned during the SARS epidemic in 2003 that killed 299 people, including 57 residential care residents. This perspective summarizes Hong Kong’s responses to the COVID-19 virus, with a specific focus on how the long-term care system contained the spread of COVID-19 into residential care homes and home and community-based services.

The outbreak of Coronavirus Disease 2019 (COVID-19) has become a global public health emergency. METHODS: 204 elderly patients (≥60 years old) diagnosed with COVID-19 in Renmin Hospital of Wuhan University from January 31(st) to February 20(th), 2020 were included in this study. Clinical endpoint was in-hospital death. RESULTS: Of the 204 patients, hypertension, diabetes, cardiovascular disease, and chronic obstructive pulmonary disease (COPD) were the most common coexisting conditions. 76 patients died in the hospital. Multivariate analysis showed that dyspnea (hazards ratio (HR) 2.2, 95% confidence interval (CI) 1.414 to 3.517;p < 0.001), older age (HR 1.1, 95% CI 1.070 to 1.123; p < 0.001), neutrophilia (HR 4.4, 95% CI 1.310 to 15.061; p = 0.017) and elevated ultrasensitive cardiac troponin I (HR 3.9, 95% CI 1.471 to 10.433; p = 0.006) were independently associated with death. CONCLUSION: Although so far the overall mortality of COVID-19 is relatively low, the mortality of elderly patients is much higher. Early diagnosis and supportive care are of great importance for the elderly patients of COVID-19.

The aim of this study was to analyze and summarize the clinical characteristics of elderly patients with coronavirus disease 2019 (COVID-19) and compare the differences of young-old patients (60-74 years old) and old-old patients (≥75 years old). METHODS: In this retrospective, multicenter study, the medical records of elderly patients who were diagnosed with COVID-19 in Hunan province, China, from January 21 to February 19, 2020 were reviewed. The characteristics of young-old patients and old-old patients were compared. RESULTS: Of the 105 elderly patients confirmed withCOVID-19, 81.0% were young-old patients, and 19.0% were old-old patients; 54.3% of elderly patients were females. Overall, 69.5% of elderly patients had underlying diseases, and the most common comorbidities included hypertension (43.8%), diabetes (25.7%), and cardiac disease (16.2%). Of the elderly patients, 22.9% were severe and 10.5% were critical severe cases. On admission, the most frequent symptoms in elderly patients included fever (66.7%), cough (64.8%), and fatigue (33.3%). Lymphopenia (31.4%), increased D-dimer (38.1%), depressed albumin (36.2%), elevated lactate dehydrogenase (41.0%), and a high level of C-reactive protein (79.0%) were common among elderly patients with COVID-19. The median prothrombin time (PT) and the activated partial thromboplastin time (APTT) were longer in old-old patients than young-old patients (PT median 12.3 vs. 13.1 s, p = 0.007; APTT median 39.0 vs. 33.5 s, p = 0.045). Young-old patients showed fewer complications (14.1%) than old-old patients (40.0%; p = 0.0014) and fewer received invasive ventilator support (3.5 vs. 25.0%, p = 0.006). As of March 11, 2020, 85.7% of elderly patients had been discharged, 3 deaths had occurred, and 11.4% were still hospitalized. CONCLUSIONS: Elderly patients usually have chronic medical illness and are likely to have a severe or critically severe condition. They could show atypical symptoms without fever or cough and multiple organ dysfunction. Old-old patients tend to have more complications than young-old patients during hospitalization. Careful nursing, observation, and systemic treatment are very important in elderly patients.

As one of the most vulnerable groups of patients during the era of coronavirus disease 2019 (COVID‐19), the geriatric population must adhere to specific guidelines to reduce their chance of contracting this potentially fatal virus. Older patients who implement measures, such as frequent handwashing and sheltering in place, benefit most from the perspective of viral infectivity; however, paradoxically, this group is also the most vulnerable to dermatologic consequences associated with these preventative measures.

Are nursing homes a priority in national COVID-19 strategies?—one remains to be convinced.

The coronavirus disease 2019 (COVID-19) pandemic has become a global public health crisis that results in a great variety of challenges to the world, and the rapidly escalating case load overwhelmed health care systems. The mortality rate of COVID-19 varied greatly between countries, but it may reach approximately 10 % in European countries. Yet, the case fatality rate may reach 20 % among people aged over 80 years, or with multimorbidity. Until now, no effective therapeutics is available, so public health approach remained to be the most important strategy for COVID-19 control, including lockdown of communities or even cities, face mask ordinances, quarantine, and cordon sanitaire, and so on. However, these public health actions may disproportionately impact vulnerable older adults in health, social, and economic dimensions. Despite that the COVID-19 pandemic remains to be a public health threat, many countries are trying to restore social and economic activities gradually. In the process of recovering from COVID-19 pandemic, resilience of older adults, communities or a country may lead to different outcomes that deserves further attentions.

The ongoing coronavirus disease 2019 (COVID‐19) pandemic is having a profound impact on people with dementia. A relevant proportion of COVID‐19–related deaths have probably occurred in patients with dementia. Thus, we sought to explore whether the clinical conditions of patients with dementia and cognitive disturbances have changed during the pandemic to gain insights on how to rearrange the provision of care in the postemergency phase.

To assess the American Testing Guidance for Nursing Homes (NHs) – updated May 19, 2020 – with a new COVID-19 case.

Hebrew Rehabilitation Center (HRC) is a 723‐bed multicampus organization that provides both long‐term care and post‐acute rehabilitation services, with 625 and 98 beds, respectively. In many ways, HRC is not a typical long‐term care organization as it operates within an integrated senior healthcare organization with a continuum of care that includes home‐ and community‐based services and assisted living and independent living units. Additionally, medical care is provided by employed clinical staff and, notably, dedicated infection control preventionists. The average age of HRC’s patients is 89 years, whose frailty and comorbidities increase their risk for worse outcomes from COVID‐19 infection, which was shown in early reports from China, revealing a 21.9% mortality rate in patients older than 80 years.1 In February 2020, after confirmed cases of COVID‐19 were reported at a Washington state nursing home, we began preparing for COVID‐19 patients. We present steps taken in our long‐term care and post‐acute rehabilitation facilities during the early surge.

The COVID-19 pandemic is devastating post-acute and long-term care (PA/LTC). As geriatricians practicing in PA/LTC and a regional academic medical center, we created this program for collaboration between academic medical centers and regional PA/LTC facilities. The mission of the geriatric engagement and resource integration in post-acute and long-term care facilities (GERI-PaL) program is to support optimal care of residents in PA/LTC facilities during the COVID-19 pandemic. There are 5 main components of our program: (1) Project ECHO; (2) Nursing liaisons; (3) Infection advisory consultation; (4) Telemedicine consultation; and (5) Resident social contact remote connections. Implementation of this program has had positive response from our local PA/LTC facilities. A key component of our program is our inter-professional team, which includes physicians, nursing, emergency response, and public health experts. With diverse professional backgrounds, our team have created a new model for academic medical centers to collaborate with local PA/LTC facilities.; The COVID-19 pandemic is devastating post-acute and long-term care (PA/LTC). As geriatricians practicing in PA/LTC and a regional academic medical center, we created this program for collaboration between academic medical centers and regional PA/LTC facilities. The mission of the geriatric engagement and resource integration in post-acute and long-term care facilities (GERI-PaL) program is to support optimal care of residents in PA/LTC facilities during the COVID-19 pandemic. There are 5 main components of our program: (1) Project ECHO; (2) Nursing liaisons; (3) Infection advisory consultation; (4) Telemedicine consultation; and (5) Resident social contact remote connections. Implementation of this program has had positive response from our local PA/LTC facilities. A key component of our program is our inter-professional team, which includes physicians, nursing, emergency response, and public health experts. With diverse professional backgrounds, our team have created a new model for academic medical centers to collaborate with local PA/LTC facilities.

Older adults have been disproportionately affected by the COVID-19 pandemic, with many outbreaks occurring in Long Term Care Facilities (LTCFs). We discuss this vulnerability among LTCF residents using an ecological framework, on levels spanning from the individual to families and caregivers, institutions, health services and systems, communities, and contextual government policies. Challenges abound for fully understanding the burden of COVID-19 in LTCF, including differences in nomenclature, data collection systems, cultural differences, varied social welfare models, and (often) under-resourcing of the LTC sector. Registration of cases and deaths may be limited by testing capacity and policy, record-keeping and reporting procedures. Hospitalization and death rates may be inaccurate depending on atypical presentations and whether or not residents’ goals of care include escalation of care and transfer to hospital. Given the important contribution of frailty, use of the Clinical Frailty Scale (CFS) is discussed as a readily implementable measure, as are lessons learned from the study of frailty in relation to influenza. Biomarkers hold emerging promise in helping to predict disease severity and address the puzzle of why some frail LTCF residents are resilient to COVID-19, either remaining test-negative despite exposure or having asymptomatic infection, while others experience the full range of illness severity including critical illness and death. Strong and coordinated surveillance and research focused on LTCFs and their frail residents is required. These efforts should include widespread assessment of frailty using feasible and readily implementable tools such as the CFS, and rigorous reporting of morbidity and mortality in LTCFs.

The coronavirus disease 2019 (COVID-19) pandemic presents unprecedented challenges to society. Behind the daily tally of deaths and cases of infection are individuals and families who are experiencing the ultimate consequence of this disease. Every aspect of our lives has been affected and these affects are amplified for those who have to cocoon and have conditions such as dementia. There is little opportunity to directly hear the experience of those ‘vulnerable adults’ who have been self-isolating for many weeks now. This letter takes the form of a reflective conversation with a person living with dementia. Honouring the principles of public and patient involvement (PPI), it is an attempt to give voice to the experience of one of the many thousands of vulnerable people during the COVID-19 pandemic. As well as describing the effect on her daily life, Helen describes what supports would help at this time. While the focus of attention at the moment is rightly on dealing with the effects of the virus in nursing homes, the many thousands of people living with dementia in the community should not be forgotten.

What services are available and where racial and ethnic minorities receive long-term services and supports (LTSS) have resulted in a lower quality of care and life for racial/ethnic minority users. These disparities are only likely to worsen during the COVID-19 pandemic, as the pandemic has disproportionately affected racial and ethnic minority communities both in the rate of infection and virus-related mortality. By examining these disparities in the context of the pandemic, we bring to light the challenges and issues faced in LTSS by minority communities with regard to this virus as well as the disparities in LTSS that have always existed.

With the COVID-19 pandemic progressing, guidance on strategies to mitigate its devastating effects in nursing facilities (NFs) is critical to preventing additional tragic outcomes. Asymptomatic spread of COVID-19 from nursing facility staff and residents is a major accelerator of infection. Facility-wide point-prevalence testing is an emerging strategy in disease mitigation. Because time is not available to await the results of randomized controlled trials before implementing strategies in this high-risk setting, an expert Delphi panel composed of experienced long-term care medicine professionals has now met to provide testing guidance for SARS-Coronavirus-2 to NFs. After many email and telephone discussions, the panel responded to a questionnaire that included six different scenarios, based on varying availability of Polymerase Chain Reaction (RT-PCR) testing and personal protective equipment (PPE). The panel endorsed facility-wide testing of staff and residents without dissent when diagnostic RT-PCR was available. While the panel recognized the limitations of RT-PCR testing, it strongly recommended this testing for both staff and residents in NFs that were either COVID-19 naive or had limited outbreaks. There was also consensus on testing residents with atypical symptoms in a scenario of limited testing capability. The panel favored testing every 1 to 2 weeks if testing was readily available, reducing the frequency to every month as community prevalence declined or as the collection of additional data further informed clinical critical thinking and decision-making. The panel recognized that frequent testing would have consequences in terms of potential staff shortages due to quarantine after positive tests and increased PPE use. However, the panel felt that not testing would allow new clusters of infection to form. The resulting high mortality rate would outweigh the potential negative consequences of testing. The panel also recognized the pandemic as a rapidly evolving crisis, and that new science and increasing experience might require an updating of its recommendations. The panel hopes that its recommendations will be of value to the long-term care industry and to policy makers as we work together to manage through this challenging and stressful time.

In February 2020, the US outbreak of novel coronavirus disease 2019 (COVID-19) began with a cluster of cases at a long-term care (LTC) facility in Washington State. Since then, 34 of the 40 states with available data report that at least 40% of COVID-19-related deaths in those states have occurred in LTC facilities, which provide ideal conditions for rapid spread of severe acute respiratory syndrome coronavirus (SARS-CoV-2). Although the populations in these facilities bear a significant burden of the pandemic, mathematical models that contribute to US national or state policy do not account for residents of LTC facilities separately from surrounding populations in their calculations.2 This Viewpoint explores why it is important to separate projections for residents of LTC facilities and the general population.

Taiwan is highly successful in the initial rapid containment of COVID-19 pandemic. As of May 14th, 2020, there have been 440 total confirmed cases in Taiwan, and only 55 cases internal cases. In April, 17th, LSE researchers published an analysis of 7 official national data, including Australia, Singapore, Belgium, Canada, France, Ireland and Norway, and the reported share of care home residents whose deaths are linked to COVID-19 were from 14% to 64%. Therefore, it is worth reporting that Taiwan has no cluster infection in the total of 62,651 beds at 1091 care institutions. Only one single case (No. 156) was related to a nursing home RN among a total of 27,513 employees.

The proportion of COVID-19 deaths in LTCFs continues to increase on the downside of the surge.

Estimated overall mortality among patients with COVID-19 is 10% in France but reaches up to 30% in LTCFs. There are, however, substantial differences in mortality rates between the different LTCFs. What explains these differences?

The Covid-19 pandemic is currently a major global public health problem. We know that the elderly and people with chronic diseases contract the infection more easily and they develop clinically more serious and often lethal forms. To date, the reasons for this have been generically attributed to old age and underlying diseases. Most Covid-19 deaths occurred in long-term care facilities because the residents are elderly people with chronic illness living in close contact. Therefore, facilities have become epidemic outbreaks. Forensic knowledge is very limited because an autopsy is rarely performed. Post-mortem investigations can help increase knowledge about Covid-19 and identify any undiagnosed pathologies in life. Therefore, forensic investigations play a role in protecting a frail population. Autopsies should be encouraged on elderly people who died of Covid-19.

On May 15, 2020, the UK Office for National Statistics (ONS) released provisional figures on deaths involving COVID-19 in the care sector in England and Wales. From March 2 to May 1, 2020, COVID-19 was confirmed or suspected in the deaths of 12 526 individuals living in care homes in the two nations. Worrying as these figures are, they only capture official notifications; when taking account of excess mortality, the situation appears even worse. In an average year, the care sector in England and Wales sees roughly 20 000 fewer deaths during March and April than have been recorded in 2020.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection can spread rapidly within skilled nursing facilities. After identification of a case of Covid-19 in a skilled nursing facility, we assessed transmission and evaluated the adequacy of symptom-based screening to identify infections in residents. METHODS: We conducted two serial point-prevalence surveys, 1 week apart, in which assenting residents of the facility underwent nasopharyngeal and oropharyngeal testing for SARS-CoV-2, including real-time reverse-transcriptase polymerase chain reaction (rRT-PCR), viral culture, and sequencing. Symptoms that had been present during the preceding 14 days were recorded. Asymptomatic residents who tested positive were reassessed 7 days later. Residents with SARS-CoV-2 infection were categorized as symptomatic with typical symptoms (fever, cough, or shortness of breath), symptomatic with only atypical symptoms, presymptomatic, or asymptomatic. RESULTS: Twenty-three days after the first positive test result in a resident at this skilled nursing facility, 57 of 89 residents (64%) tested positive for SARS-CoV-2. Among 76 residents who participated in point-prevalence surveys, 48 (63%) tested positive. Of these 48 residents, 27 (56%) were asymptomatic at the time of testing; 24 subsequently developed symptoms (median time to onset, 4 days). Samples from these 24 presymptomatic residents had a median rRT-PCR cycle threshold value of 23.1, and viable virus was recovered from 17 residents. As of April 3, of the 57 residents with SARS-CoV-2 infection, 11 had been hospitalized (3 in the intensive care unit) and 15 had died (mortality, 26%). Of the 34 residents whose specimens were sequenced, 27 (79%) had sequences that fit into two clusters with a difference of one nucleotide. CONCLUSIONS: Rapid and widespread transmission of SARS-CoV-2 was demonstrated in this skilled nursing facility. More than half of residents with positive test results were asymptomatic at the time of testing and most likely contributed to transmission. Infection-control strategies focused solely on symptomatic residents were not sufficient to prevent transmission after SARS-CoV-2 introduction into this facility.

In Israel, NHs and assisted living facilities were some of the hardest hit by COVID-19. Henceforth, a national task force appointed by the Israeli Prime minister named “Shield of Fathers and Mothers”, was appointed. In order to aid the task force, we devised a novel, interactive, real-time, dashboard-based heat map tool based on COVID-19 outbreak analytic metrics as well as spatiotemporal data analytics (http://covid19maps.org/). We developed a novel platform, focused on assisted living facilities and NHs, providing the Israeli Ministry of Health (MOH) policymakers with a national graphical representation of all institutes (passkey protected to secure privacy issues).

This point-prevalence investigation of all residents at a single nursing home found a 54% infection rate in this reportedly asymptomatic population. Prior to testing no confirmed or suspected cases had been reported.; This point-prevalence investigation of all residents at a single nursing home found a 54% infection rate in this reportedly asymptomatic population. Prior to testing no confirmed or suspected cases had been reported.

During the novel coronavirus disease 2019 (COVID-19) pandemic, older adults are a particularly vulnerable group with higher mortality. In long-term care facilities (LTCFs), the risk of serious outbreaks is great given a higher prevalence of dementia and potential poor resident compliance with infection control measures such as hand hygiene and wearing of surgical masks. Transmission from infected health care workers in LCTFs have led to disastrous outbreaks. Hong Kong recorded its first confirmed case of COVID-19 on January 23, 2020. Up to the point of writing (16th 11 May 2020), there has been no LTCF resident (~74000 in 940 LTCF) infected with COVID-19 in Hong Kong. We believe that the following measures have contributed to this favorable outcome.

COVID-19 has been documented in a large share of nursing homes throughout the United States. This has led to high rates of mortality for residents. In order to understand how to prevent and mitigate future outbreaks, it is imperative that we understand which nursing homes are more likely to experience COVID-19 cases. OBJECTIVE: To examine the characteristics of nursing homes with documented COVID-19 cases in 30 states reporting individual facilities affected. DESIGN AND SETTING: We constructed a database of nursing homes with verified COVID-19 cases as of May 11, 2020 via correspondence with and publicly available reports from state departments of health. We linked this information to nursing home characteristics and used regression analysis to examine association between these characteristics and the likelihood of having a documented COVID-19 case. RESULTS: Of 9,395 nursing homes in our sample, 2,949 (31.4%) had a documented COVID-19 case. Larger facility size, urban location, greater percentage of African American residents, non-chain status, and state were significantly (p<0.05) related to increased probability of having a COVID-19 case. Five-star rating, prior infection violation, Medicaid dependency, and ownership were not significantly related. CONCLUSIONS: COVID-19 cases in nursing homes are related to facility location and size and not traditional quality metrics such as star rating and prior infection control citations. This article is protected by copyright. All rights reserved.

SARS-CoV-2 has disproportionately affected nursing home (NH) residents. In Ireland, the first NH case of COVID-19 occurred on 16/03/2020. A national point-prevalence testing program of all NH residents and staff took place from 18/04/2020-05/05/2020. Aims: To examine characteristics of NHs across three Community Health Organisations (CHOs) in Ireland, proportions with COVID-19 outbreaks, staff and resident, symptom-profile and resident case-fatality. Methods: Forty-five NHs surveyed across three CHOs requesting details on occupancy, size, COVID-19 outbreak, timing of outbreak, total symptomatic/asymptomatic cases, and outcomes for residents from 29/02/2020-22/05/2020. Results: Surveys were returned from (62.2\%, 28/45) of NHs (2043 residents, 2303 beds). Three-quarters (21/28) had COVID-19 outbreaks (1741 residents, 1972 beds). Median time from first case of COVID-19 in Ireland to first case in these NHs was 27.0 days. Resident COVID-19 incidence was (43.9\%, 764/1741): laboratory-confirmed (40.1\%, 710/1741) with (27.2\%, 193/710 asymptomatic), and clinically-suspected (3.1\%, 54/1741). Resident case-fatality was (27.6\%, 211/764) for combined laboratory-confirmed/clinically-suspected COVID-19. Similar proportions of residents in NH with an early outbreak (\<28days) versus a later outbreak developed confirmed/suspected COVID-19. A lower proportion of residents in NHs with early outbreaks had recovered compared to those with late outbreaks (37.4\% vs 61.7\%; X2=56.9, p\<0.001). Among 675 NH staff across twenty-four sites who had confirmed/suspected COVID-19 (23.6\%, 159/675) were asymptomatic. There was a significant correlation between the proportion of staff with symptomatic COVID-19 and resident numbers with confirmed/suspected COVID-19 (Spearmans rho=0.81, p\<0.001). Conclusion: This study demonstrates COVID-19 impact on NH residents and staff. High infection rates lead to challenges in care provision.Competing Interest StatementThe authors have declared no competing interest.Funding StatementNot applicableAuthor DeclarationsI confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.YesThe details of the IRB/oversight body that provided approval or exemption for the research described are given below:Tallaght University Hospital and St James Hospital ethics committeeAll necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived.YesI understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).Yes I have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable.YesAnonymous dataset available on request.

SARS-CoV-2 emerged in 2019 and has become a major global pathogen in an astonishingly short period of time. The emergence of SARS-CoV-2 also has been notable due to its impacts on individuals residing within skilled nursing facilities (SNFs) such as rehabilitation centers and nursing homes. SNF residents tend to possess several risk factors for the most severe outcomes of SARS-CoV-2 infection, including advanced age and the presence of multiple comorbidities. Indeed, residents of long-term care facilities represent approximately 40 percent of US SARS-CoV-2 deaths. To assess the prevalence and incidence of SARS-CoV-2 among SNF workers, determine the extent of asymptomatic infection by SARS-CoV-2, and provide information on the genomic epidemiology of the virus within these unique care settings, we sampled workers weekly at five SNFs in Colorado using nasopharyngeal swabs, determined the presence of viral RNA and infectious virus among these workers, and sequenced 48 nearly complete genomes. This manuscript reports results from the first five to six weeks of observation. Our data reveal a strikingly high degree of asymptomatic infection, a strong correlation between RNA detection and the presence of infectious virus in NP swabs, persistent RNA in a subset of individuals, and declining incidence over time. Our data suggests that asymptomatic individuals infected by SARS-CoV-2 may contribute to virus transmission within the workplace.Competing Interest StatementThe authors have declared no competing interest.Funding StatementThis work was supported by funds donated by the Colorado State University Colleges of Health and Human Sciences, Veterinary Medicine and Biomedical Sciences, Natural Sciences, and Walter Scott, Jr. College of Engineering, and the Colorado State University Columbine Health Systems Center for Healthy Aging. KQ was supported by a fellowship from the National Institute of Allergy and Infectious Diseases, National Institutes of Health under grant number F32AI150123-01. None of the authors received payment from a third party not disclosed above.Author DeclarationsI confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.YesThe details of the IRB/oversight body that provided approval or exemption for the research described are given below:This study was reviewed and approved by the Colorado State University IRB under protocol number 20-10057H. Participants provided consent to participate in the study and were promptly informed of test results.All necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived.YesI understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).Yes I have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable.YesN/A. Sequence data will be deposited and made publicly available once it is completed. Files in their current state are available from the authors upon request.

To determine the association between frailty and short-term mortality in older adults hospitalized for coronavirus disease 2019 (COVID-19).; Objectives To determine the association between frailty and short-term mortality in older adults hospitalized for coronavirus disease 2019 (COVID-19).

As the COVID-19-related mortality rate of nursing home residents continues to rise, so too will the rates of mortality and morbidity of staff who care for them, a problem we must address now to avoid another health care crisis once this pandemic recedes. Currently, a significant proportion of deaths are attributed to persons living in nursing homes, ranging from 42-57% in European countries reporting data to as high as 82% in several U.S. states and in Canada reporting data. However, there is a concern that many countries are not including nursing home deaths in the death toll. While not reported globally experts predict, the majority of health care workers who will die from COVID-19 are nursing staff (nurses and nursing assistants) working in nursing homes.

This rapid review shows that there is no direct evidence of the effects of healthcare personnel in nursing homes wearing facemasks for primary prevention of COVID-19.

With the nation’s goodwill directed at hospitals during the coronavirus disease 2019 (COVID-19) pandemic, nursing homes became caught in a critical catch-22. Their initial pleas for personal protective equipment (PPE), diagnostic tests, and staffing support went largely ignored. Months into the crisis, as some facilities still scrounged for supplies and staff, the federal government announced phased guidance for reopening nursing homes that hinges on the very resources they don’t have.

This perspective addresses the challenges that assisted living (AL) providers face concerning federal guidelines to prevent increased spread of COVID-19. These challenges include restriction of family visitation, use of third-party providers as essential workers, staffing guidelines, transfer policies, and rural AL hospitalizations. To meet these challenges we recommend that AL providers incorporate digital technology to maintain family-resident communication. We also recommend that states adopt protocols that limit the number of AL communities visited by home health care workers in a 14-day period, appeal to the federal government for hazard pay for direct care workers, and to extend the personal care attendant program to AL. It is further recommended that states work with AL communities to implement COVID-19 comprehensive emergency management plans that are well-coordinated with local emergency operation centers to assist with transfers to COVID-19 specific locations and to assist in rural areas with hospital transfers. Together, these recommendations to AL providers and state and federal agencies address the unique structure and needs of AL and would enable AL communities to be better prepared to care for and reduce those infected with COVID-19.

During the COVID-19 pandemic, we face an exacerbation of ageism as well as a flourish of intergenerational solidarity. The use of chronological age is an unjustified threshold for the creation of public policies to control the spreading of the virus; doing so reinforces intrapersonal and interpersonal negative age stereotypes and violates older persons’ human rights to autonomy, proper care treatment, work, and equality. By overlooking differences within age groups, measures formulated solely on the basis of age are unable to target beneficiaries’ needs. Concurrently, several initiatives are trying to overcome ageist practices by providing different types of assistance to older adults on the basis of need rather than chronological age. The Marie Skłodowska-Curie Innovative Training Network EuroAgeism calls on policymakers to refrain from ageist practices and language, as they exacerbate our ability to meet the COVID-19 crisis and future emergencies.

Residents in long-term care facilities (LTCF) are a vulnerable population group. Coronavirus disease (COVID-19)-related deaths in LTCF residents represent 30-60% of all COVID-19 deaths in many European countries. This situation demands that countries implement local and national testing, infection prevention and control, and monitoring programmes for COVID-19 in LTCF in order to identify clusters early, decrease the spread within and between facilities and reduce the size and severity of outbreaks.

Can we expect residents to give up ever again feeling a human touch, seeing family members, joining in a song or attending a religious service? In return, that resident could expect to live a little longer before dying of COVID-19 or something else. Many nursing home residents and their families might prefer to take their risks with COVID-19  rather than enduring a barren, but longer, survival. At the least, we should be asking residents and their families for their well-informed preferences before imposing severe isolation measures indefinitely.

To provide policy recommendations for managing COVID-19 in Skilled Nursing Facilities (SNFs), a group of certified medical directors from several facilities in New York state with experience managing the disease used email, phone, and video conferencing to develop consensus recommendations. The resulting document provides recommendations on screening, and protection of staff, screening of residents, management of COVID-19 positive and presumed positive cases, communication during an outbreak, management of admissions and readmissions, and providing emotional support for staff. These consensus guidelines have been endorsed by the Executive Board of the New York Medical Directors Association and the Board of the Metropolitan Area Geriatrics Society.; To provide policy recommendations for managing COVID-19 in Skilled Nursing Facilities (SNFs), a group of certified medical directors from several facilities in New York state with experience managing the disease used email, phone, and video conferencing to develop consensus recommendations. The resulting document provides recommendations on screening, and protection of staff, screening of residents, management of COVID-19 positive and presumed positive cases, communication during an outbreak, management of admissions and readmissions, and providing emotional support for staff. These consensus guidelines have been endorsed by the Executive Board of the New York Medical Directors Association and the Board of the Metropolitan Area Geriatrics Society.

The risk of developing severe illness from COVID-19 and of dying from it increases with age. This statistical association has led to numerous highly problematic policy suggestions and comments revealing underlying ageist attitudes and promoting age discrimination. Such attitudes are based on negative stereotypes on the health and functioning of older adults. As a result, the lives of older people are disvalued, including in possible triage situations and in the potential limitation of some measures against the spread of the pandemic to older adults. These outcomes are unjustified and unethical. We develop six propositions against the ageism underlying these suggestions to spur a more adequate response to the current pandemic in which the needs and dignity of older people are respected.

As of May 2020, nursing home residents account for a staggering one-third of the more than 80,000 deaths due to COVID-19 in the U.S. This pandemic has resulted in unprecedented threats to achieving and sustaining care quality even in the best nursing homes, requiring active engagement of nursing home leaders in developing solutions responsive to the unprecedented threats to quality standards of care delivery during the pandemic. This perspective offers a framework, designed with the input of nursing home leaders, to facilitate internal and external decision-making and collective action to address these threats. Policy options focus on assuring a shared understanding among nursing home leaders and government agencies of changes in the operational status of nursing homes throughout the crisis, improving access to additional essential resources needed to mitigate the crisis’ impact, and promoting shared accountability for consistently achieving accepted standards in core quality domains.

In order to reduce the spread of COVID-19, we emphasise the need to follow infection control guide-lines, such as hand hygiene, wearing masks, and safe social distancing. While the susceptibility of the elderly to the virus because of close quarters in urban areas and in long term care facilities (LTCFs) has been well described,3, 4less attention has been paid to the effect of the pandemic on, and the difficulty of protecting, patients with dementia or cognitive impairment regardless of their living conditions.

Oliver rightly reports that care homes are in trouble.1 Covid-19 has laid bare weaknesses of support from the NHS, public health, regulators, and local government, showing once more that care homes and their residents don’t fit traditional healthcare or social care paradigms.

Residents in long-term care settings are particularly vulnerable to COVID-19 infections and, compared to younger adults, are at higher risk of poor outcomes and death. Given the poor prognosis of resuscitation outcomes for COVID-19 in general, the specter of COVID-19 in long-term care residents should prompt revisiting goals of care. Visitor restriction policies enacted to reduce the risk of transmission of COVID-19 to long-term care residents requires advance care planning discussions to be conducted remotely. A structured approach can help guide discussions regarding the diagnosis, expected course, and care of individuals with COVID-19 in long-term care settings. Information should be shared in a transparent and comprehensive manner to allay the increased anxiety that families may feel during this time. To achieve this, we propose an evidence-based COVID-19 Communication and Care Planning Tool that allows for an informed consent process and shared decision making between the clinician, resident and their family.; Residents in long-term care settings are particularly vulnerable to COVID-19 infections and, compared to younger adults, are at higher risk of poor outcomes and death. Given the poor prognosis of resuscitation outcomes for COVID-19 in general, the specter of COVID-19 in long-term care residents should prompt revisiting goals of care. Visitor restriction policies enacted to reduce the risk of transmission of COVID-19 to long-term care residents requires advance care planning discussions to be conducted remotely. A structured approach can help guide discussions regarding the diagnosis, expected course, and care of individuals with COVID-19 in long-term care settings. Information should be shared in a transparent and comprehensive manner to allay the increased anxiety that families may feel during this time. To achieve this, we propose an evidence-based COVID-19 Communication and Care Planning Tool that allows for an informed consent process and shared decision making between the clinician, resident and their family.

The C.D. Howe Institute has initiated a special project to provide rapid expert insights to help Canadians and Canadian policymakers navigate the COVID-19 crisis. The Working Group on Public Health and Emergency Measures is Co-Chaired by Janet Davidson, Chair of the Board of the Canadian Institute for Health Information and former Deputy Minister of Health (AB) and Tom Closson, Co-Chair of the C.D. Howe Institute Health Policy Council. The membership of the group includes health academics, professionals and business leaders. Meeting weekly, this group discusses policy ideas for addressing various aspects of the COVID-19 crisis, and publicly communicates the results of its discussions via Communiqués. The most recent meetings of the Public Health and Emergency Measures Working Group have focussed on healthcare for the elderly population in the context of COVID-19. In particular, the group discussed high mortality rates in institutional care settings and some of the underlying causes. Provinces have implemented different policies related to long-term care and retirement homes which has resulted in some faring much better than others. In general, however, Canada has not done well at protecting the elderly population living in an institutional care setting from COVID-19 infection and mortality compared to many other countries.

In the last decade, there is an increasing focus on detecting and compiling lists of low-value nursing procedures. However, less is known about effective de-implementation strategies for these procedures. Therefore, the aim of this systematic review was to summarize the evidence of effective strategies to de-implement low-value nursing procedures. METHODS: PubMed, Embase, Emcare, CINAHL, PsycINFO, Cochrane Central Register of Controlled Trials, Web of Science, and Google Scholar were searched till January 2020. Additionally, reference lists and citations of the included studies were searched. Studies were included that described de-implementation of low-value nursing procedures, i.e., procedures, test, or drug orders by nurses or nurse practitioners. PRISMA guideline was followed, and the ‘Cochrane Effective Practice and Organisation of Care’ (EPOC) taxonomy was used to categorize de-implementation strategies. A meta-analysis was performed for the volume of low-value nursing procedures in controlled studies, and Mantel-Haenszel risk ratios (95% CI) were calculated using a random effects model. RESULTS: Twenty-seven studies were included in this review. Studies used a (cluster) randomized design (n = 10), controlled before-after design (n = 5), and an uncontrolled before-after design (n = 12). Low-value nursing procedures performed by nurses and/or nurse specialists that were found in this study were restraint use (n = 20), inappropriate antibiotic prescribing (n = 3), indwelling or unnecessary urinary catheters use (n = 2), ordering unnecessary liver function tests (n = 1), and unnecessary antipsychotic prescribing (n = 1). Fourteen studies showed a significant reduction in low-value nursing procedures. Thirteen of these 14 studies included an educational component within their de-implementation strategy. Twelve controlled studies were included in the meta-analysis. Subgroup analyses for study design showed no statistically significant subgroup effect for the volume of low-value nursing procedures (p = 0.20). CONCLUSIONS: The majority of the studies with a positive significant effect used a de-implementation strategy with an educational component. Unfortunately, no conclusions can be drawn about which strategy is most effective for reducing low-value nursing care due to a high level of heterogeneity and a lack of studies. We recommend that future studies better report the effects of de-implementation strategies and perform a process evaluation to determine to which extent the strategy has been used. TRIAL REGISTRATION: The review is registered in Prospero (CRD42018105100).

Pressure ulcer is a frequent complication in patients hospitalized in nursing homes and has a serious impact on quality of life and overall health. Moreover, ulcer treatment is highly expensive. Several studies have shown that pressure ulcer prevention is cost-effective. Audit and feedback programmes can help improve professional practices in pressure ulcer prevention and thus reduce their occurrence. The aim of this study was to analyze, with a prospective longitudinal study, the effectiveness of an audit and feedback programme at 1- and 2-year follow-up for reducing pressure ulcer prevalence and enhancing adherence to preventive practices in nursing homes. METHODS: Pressure ulcer point prevalence and preventive practices were measured in 2015, 2016 and 2017 in nursing homes of the Canton of Geneva (Switzerland). Oral and written feedback was provided 2 months after every survey to nursing home reference nurses. RESULTS: A total of 27 nursing homes participated in the programme in 2015 and 2016 (4607 patients) and 15 continued in 2017 (1357 patients). Patients were mostly females, with mean age > 86 years and median length of stay about 2 years. The programme significantly improved two preventive measures: patient repositioning and anti-decubitus bed or mattress. It also reduced acquired pressure ulcers prevalence in nursing homes that participated during all 3 years (from 4.5% in 2015 to 2.9% in 2017, p 0.035), especially in those with more patients with pressure ulcers. CONCLUSION: Audit and feedback is relatively easy to implement at the regional level in nursing homes and can enhance adherence to preventive measures and reduce pressure ulcers prevalence in the homes.

RE-AIM is a widely adopted, robust implementation science (IS) framework used to inform intervention and implementation design, planning, and evaluation, as well as to address short-term maintenance. In recent years, there has been growing focus on the longer-term sustainability of evidence-based programs, policies and practices (EBIs). In particular, investigators have conceptualized sustainability as the continued health impact and delivery of EBIs over a longer period of time (e.g., years after initial implementation) and incorporated the complex and evolving nature of context. We propose a reconsideration of RE-AIM to integrate recent conceptualizations of sustainability with a focus on addressing dynamic context and promoting health equity. In this Perspective, we present an extension of the RE-AIM framework to guide planning, measurement/evaluation, and adaptations focused on enhancing sustainability. We recommend consideration of: (1) extension of “maintenance” within RE-AIM to include recent conceptualizations of dynamic, longer-term intervention sustainability and “evolvability” across the life cycle of EBIs, including adaptation and potential de-implementation in light of changing and evolving evidence, contexts, and population needs; (2) iterative application of RE-AIM assessments to guide adaptations and enhance long-term sustainability; (3) explicit consideration of equity and cost as fundamental, driving forces that need to be addressed across RE-AIM dimensions to enhance sustainability; and (4) use or integration of RE-AIM with other existing frameworks that address key contextual factors and examine multi-level determinants of sustainability. Finally, we provide testable hypotheses and detailed research questions to inform future research in these areas.

Social isolation (the objective state of having few social relationships or infrequent social contact with others) and loneliness (a subjective feeling of being isolated) are serious yet underappreciated public health risks that affect a significant portion of the adult population. Social isolation is a risk factor for development of loneliness, but some persons enjoy it (eg, hermits). Conversely, having social relationships does not ensure that loneliness will not develop, because the social relationship has to be meaningful. Many people feel lonely under the best of circumstances. Approximately one-quarter (24%) of community-dwelling Americans aged 65 and older are considered to be socially isolated, and a significant proportion of adults in the United States report feeling lonely (35% of adults aged 45 and older and 43% of adults aged 60 and older). Loneliness is even more common in long-term care institutions.

Across Ontario, since the year 2006 various knowledge translation (KT) interventions designed to improve the quality of rectal cancer surgery have been implemented by the provincial cancer agency or by individual researchers. Ontario is divided administratively into 14 health regions. We piloted a method to audit and score for each region of the province the KT interventions implemented to improve the quality of rectal cancer surgery. METHODS: We interviewed stakeholders to audit KT interventions used in respective regions over years 2006 to 2014. Results were summarized into narrative and visual forms. Using a modified Delphi approach, KT experts reviewed these data and then, for each region, scored implementation of KT interventions using a 20-item KT Signature Assessment Tool. Scores could range from 20 to 100 with higher scores commensurate with greater KT intervention implementation. RESULTS: There were thirty interviews. KT experts produced scores for each region that were bimodally distributed, with an average score for 2 regions of 78 (range 73-83) and for 12 regions of 30.5 (range 22-38). CONCLUSION: Our methods efficiently identified two groups with similar KT Signature scores. Two regions had relatively high scores reflecting numerous KT interventions and the use of sustained iterative approaches in addition to those encouraged by the provincial cancer agency, while 12 regions had relatively low scores reflecting minimal activities outside of those encouraged by the provincial cancer agency. These groupings will be used for future comparative quantitative analyses to help determine if higher KT signature scores correlate with improved measures for quality of rectal cancer surgery.

The purpose of this study is to examine the effects of managers’ authentic leadership, person–job match in the six areas of worklife (AWLs) and emotional exhaustion on long-term care registered nurses’ job satisfaction.Design/methodology/approach A secondary analysis of baseline data from a national survey of 1,410 Canadian registered nurses from various work settings was used in this study, which yielded a subsample of 78 nurses working in direct care roles in long-term care settings. Hayes’ PROCESS macro for mediation analysis in SPSS was used to test the hypothesized model.Findings Findings showed that authentic leadership significantly predicted job satisfaction directly and indirectly through AWLs and emotional exhaustion.Practical implications Authentic leadership may provide guidance to long-term care managers about promoting nurses’ job satisfaction, which is essential to recruiting and retaining nurses to meet the care needs of an aging population.Originality/value As demand for care of the aged is increasing and creating challenges to ensuring a sufficient and sustainable nursing workforce, it is important to understand factors that promote long-term care nurses’ job satisfaction. Findings contribute to knowledge of long-term care nurses by suggesting that managers’ authentic leadership can positively affect nurses’ job satisfaction directly and indirectly through positive perceptions of AWLs and lower emotional exhaustion.

The aim of the study was to describe omitted or delayed nursing care (i.e., missed nursing care [MNC]) in a sample of Italian nursing homes (NHs). METHODS: Nurses from 50 NHs located in Northern Italy selected the 20 most dependent residents in their care and reported instances of MNC for three to five consecutive shifts. They described the type of MNC, its cause(s), management, recurrence, and severity of possible consequences for the resident. Information on the residents and the NH was also collected. The instances of MNC were classified as potentially avoidable/preventable or not. RESULTS: Overall, 266 (85.3%) of 312 nurses participated and 1000 residents were observed during 381 shifts (164 mornings, 164 afternoons, and 53 nights); 101 (38%) nurses reported 223 instances of MNC among 175 residents (17.5%). Ninety-seven omissions and 109 delays occurred during the day shift (56 omissions were delegated to the next shift). The most frequent MNC was drug administration (n = 71, 34.5%). In 24 (44.4%) of 54 instances of delayed drug administration, the delay was less than 30 minutes. Nurses rated approximately 20% of MNC (n = 41) as highly severe because of the discomfort caused to the resident, the clinical impact, or the repetitiveness of the situation. Nurses ascribed almost half of MNC (n = 100, 48.5%) to inadequate staffing, and they categorized 26 (11.6%) instances of MNC as unavoidable. CONCLUSIONS: The number of nurse-reported instances of MNC we reported was much lower than that previously collected with available instruments. Most MNC did not impact the comfort and safety of residents. A certain proportion of MNC was unavoidable.

In order to optimize interventions and services in the community, it is important to identify the profile of persons who are able to stay at home and of those who are being admitted into residential care. Understanding their needs and their use of resources is essential. The main objective of the study is to identify persons who are likely to enter residential care based upon their needs and resource utilization, so that care providers can plan interventions effectively and optimize services and resources to meet the persons’ needs. METHODS: This is a longitudinal quasi-experimental study. The data consists of primary data from the community setting collected every six months during the period of 2010-2016. Interventions had the goal of keeping older people longer at home. Participants were at least 65 years old and were living in the community. The interRAI Resource Utilization Group system (RUG-III) was used to calculate the case-mix indexes (CMI) of all participants. Comparisons were made between the case-mix of those who were still living at home and those who were admitted into residential care at follow-up. RESULTS: A total of 10,289 older persons participated in the study (81.2 ± 7.1 yrs., 69.1% female). From this population, 853 participants (8.3%) were admitted into residential care. The CMI of the persons receiving night care at home were the highest (1.6 at baseline and 1.7 at the entry point of residential care), followed by persons receiving occupational therapy (1.5 at baseline and 1.6 at the entry point of residential care) and persons enrolled in case management interventions with rehabilitation (1.4 at baseline and 1.6 at the entry point of residential care). The CMIs at follow-up were significantly higher than at baseline and the linear regression model showed that admission to residential care was a significant factor in the model. CONCLUSIONS: The study showed that the RUG-III system offers possibilities for identifying persons at risk of institutionalization. Interventions designed to avoid early nursing home admission can make use of the RUG-III system to optimize care planning and the allocation of services and resources. Based on the RUG-III case-mix, resources can be allocated to keep older persons at home longer, bearing in mind the complexity of care and the availability of services in the community.

This study aimed to explore the effects of person-centered care on their job productivity, job satisfaction, and organizational commitment among employees in long-term care facilities. BACKGROUND: Person-centered care has been regarded as the best caregiving model for long-term care facilities. Few studies tested the impact of person-centered care on employee performance. DESIGN: A cross-sectional study was employed. METHODS: This study sent 373 samples with self-report questionnaires to the employees of sixteen long-term care facilities in Taiwan. A total of 366 valid samples were collected. A 33-item person-centered care questionnaire with Likert scale responses was developed to assess the extent of person-centered care. We adopted hierarchical multiple regression analysis to test the impact of person-centered care on employee performance. We adopted the STROBE guidelines. RESULTS: Friendly environment level and personalized care respectively scored the highest with a mean of 4.19 among five dimensions of person-centered care. Personalized care, residents’ self-realization and relationships, and organizational support had significantly positive correlations with job productivity. Friendly environment level and organizational support had significantly correlations with job satisfaction. Friendly environment level, residents’ self-realization and relationships, and organizational support had significantly correlations with organizational commitment. CONCLUSION: Person-centered care has beneficial impact on job satisfaction, job productivity, and organizational commitment of employees in long-term care facilities. RELEVANCE TO CLINICAL PRACTICE: Person-centered care appears to be a crucial factor of employee performance in long-term care facilities. The five-dimensional person-centered care questionnaire in this study can serve as an important management tool for improving the effectiveness of person-centered care.

Nursing home (NH) adoption of culture change practices has substantially increased in recent decades. We examined how increasing adoption of culture change practices impacted the prevalence of health, severe health, and quality of life (QoL) deficiencies. RESEARCH DESIGN AND METHODS: Novel data on culture change practice adoption from a nationally representative NH panel (N=1,585) surveyed in 2009/2010 and 2016/2017 were used to calculate change in practice adoption scores in three culture change domains (resident-centered care, staff empowerment, physical environment). These data were linked to data on health, severe health, and QoL deficiencies and facility-level covariates. Multinomial logistic regression models, with survey weights and inverse probability of treatment weighting, examined how increased culture change practice adoption related to change in deficiencies. RESULTS: We generally observed less increase in deficiencies when culture change practices increased. However, after weighting and controlling for baseline deficiencies and culture change scores, we found few statistically significant effects. Still, results show increased physical environment practices resulted in a higher likelihood of decreases or no change (versus increases) in QoL deficiencies; increased resident-centered care practices resulted in decreases or no change (versus increases) in health deficiencies; and increased staff empowerment practices resulted in higher a likelihood of no change (versus increases) in severe health deficiencies. DISCUSSION AND IMPLICATIONS: This study provides some evidence that culture change practices can help reduce the risk of increasing some types of deficiencies, but the impact of increases in each culture change domain related differently to different types of deficiencies.

Allied health assistants (AHAs) are support staff who complete clinical and non-clinical tasks under the supervision and delegation of an allied health professional. The effect of allied health professional delegation of clinical tasks to AHAs on patient and healthcare organisational outcomes is unknown. The purpose of this systematic review was to investigate the effect of allied health professional delegation of therapy to AHAs on patient and organisational outcomes. METHODS: A systematic review and meta-analysis was conducted. Databases MEDLINE (Ovid), Embase (Ovid), Informit (all databases), Emcare (Ovid), PsycINFO (Ovid), Cumulative Index to Nursing and Allied Health Literature [CINAHL] (EbscoHost) and the Cochrane Database of Systematic Reviews were searched from earliest date available. Additional studies were identified by searching reference lists and citation tracking. Two reviewers independently applied inclusion and exclusion criteria. The quality of the study was rated using internal validity items from the Downs and Black checklist. Risk ratios (RR) and mean differences (MD) were calculated for patient and organisational outcomes. Meta-analyses were conducted using the inverse variance method and random-effects model. RESULTS: Twenty-two studies met the inclusion criteria. Results of meta-analysis provided low quality evidence that AHA supervised exercise in addition to usual care improved the likelihood of patients discharging home (RR 1.28, 95%CI 1.03 to 1.59, I(2) = 60%) and reduced length of stay (MD 0.28 days, 95%CI 0.03 to 0.54, I(2) = 0%) in an acute hospital setting. There was preliminary evidence from one high quality randomised controlled trial that AHA provision of nutritional supplements and assistance with feeding reduced the risk of patient mortality after hip fracture (RR 0.41, 95%CI 0.16 to 1.00). In a small number of studies (n = 6) there was no significant difference in patient and organisational outcomes when AHA therapy was substituted for therapy delivered by an allied health professional. CONCLUSION: We found preliminary evidence to suggest that the use of AHAs to provide additional therapy may be effective for improving some patient and organisational outcomes. REVIEW REGISTRATION: CRD42019127449.

To explore the variables related to the quality of work life and the self-care of nursing professionals working with high emotional demand. METHOD: Qualitative, according to the constructivist paradigm. It combines the phenomenological-hermeneutic/interpretative method with the use of semi-structured interviews. Information was analyzed with Maxqda 11. Interviews included professionals from the Valencian healthcare system, with typical profiles of nurses working in surgical units, emergencies, oncology, home care, and cooperation. RESULTS: Organizational factors were reported as a barrier to self-care, affecting healthcare activity. Working with patients was highlighted as a protective factor, based on the satisfaction derived from helping in situations of serious illness and suffering. The quality of work life manifested was assessed as not being what they would desire and deficient. The factors that affected the professionals most were the type of working day and work schedules (shifts, nights, holidays, on call…). The physical, mental and social dimensions of self-care can attenuate the negative effects of this situation. CONCLUSIONS: It is necessary to examine in depth the construct of self-care, to counteract emotionally stressful problems and situations, to propose intervention strategies, training plans and greater involvement of health institutions in the improvement of nurses’ quality of work life.

The Great Recession substantially affected most developed countries. How countries responded to the Great Recession varied greatly, especially in terms of public spending. We examine the impact of the Great Recession on long-term services and supports (LTSS) in the United States and England. Financing for LTSS in these two countries differs in important ways; by examining the two countries’ financing and program structures, we learn how these factors influenced each country’s response to this common external stimulus. We find that between 2006 and 2013, LTSS increased in the United States in terms of spending (17%) and number of people served; in contrast, over the same period, LTSS in England decreased in terms of spending (6%) and people served. We find that the use of earmarked LTSS funding in the United States, compared to non-earmarked funding in England, contributed to different trajectories for LTSS in the two countries. Other contributing factors included differences in service entitlements, variations in ability of state and local governments to tax, and larger macroeconomic strategies implemented to combat the recession. We analyze the implications of our findings, especially as related to the potential shift to Medicaid block grant LTSS funding in the United States.

Despite efforts to implement learner competencies in gerontological nursing, a significant knowledge-attitude disassociation remains, with few students interested in pursuing careers in the care of older adults. One reason may be the lack of well-qualified faculty who can design engaging learning experiences with older adults and serve as positive role models for aging care. In response, the National Hartford Center of Gerontological Nursing Excellence commissioned the development of core competencies and a recognition program for educators in gerontological nursing. The goal of these competencies is to promote quality instruction in the care of older adults by describing a set of preferred skills characterizing faculty teaching gerontological content to nursing and interprofessional learners. These educator-focused competencies can guide individual career development for new and current educators who specialize in teaching about the care of older adults. They provide direction for selecting well-prepared individuals for gerontological nursing teaching positions and evaluating educator role performance. This paper describes the development of seven core competencies for nurse educators who teach in academic and professional development programs, as well as criteria for their recognition. An iterative development process was used to define the core competencies, along with descriptions and exemplars of each domain.

While stakeholder mapping is common in public policy, social sciences, and business management, this tool has not often been used in healthcare settings. We developed a new method of healthcare stakeholder mapping, which we call Contextual and Organizational Support Mapping of Stakeholders (COSMOS), to identify and assess key stakeholders in an implementation project. Stakeholder mapping allows the implementation team to assess and visually display all relevant stakeholders, their support for the project, and their ability to facilitate—or hinder—project implementation.

This study aimed to identify risk factors associated with adverse events in residential aged care facilities in China. Patients and Methods: After compiling a list of risk factors for adverse events generated from in-depth interviews with managers of residential aged care facilities, a three-round Delphi method was used to reach consensus. The synthesized risk factors were presented on a Likert scale to the expert panelists three times to validate their responses. Results: The list identified 67 items as risk factors for adverse events, attached to four firstlevel indexes (ie, environmental facility, nursing staff, older adults’ characteristics, and management factors). The experts’ authority coefficient was 0.87. The positive coefficients were 82.76%, 91.67%, and 100%, and the coordination coefficients were 0.154, 0.297, and 0.313 in the first, second, and third rounds, respectively. Conclusion: Using a Delphi method, this study established a consensus on risk factors contributing to adverse events and developed a risk assessment grade for use in future aged care practice and research. The resulting list is useful in prioritizing risk-reduction activities and assessing intervention or education strategies for preventing adverse events in residential aged care facilities. Impact: This study fills the gap in risk identification in the Chinese residential aged care system to ensure provision of best-practice care to this vulnerable population. Nursing staff and management factors at the top of the list are not only the most common causes of adverse events but also the core elements in creating a secure and error-free environment. This list was intended to support predictive and prevention-oriented decision-making by managers and nursing supervisors to reduce preventable adverse events.

Polypharmacy is prevalent among long-term care residents in Canada, with 48.4% receiving ten or more different medications and 40.7% chronically prescribed potentially inappropriate medications. Objective We implemented a pharmacist-administered deprescribing program in a long-term care facility to determine if the number of medications taken per resident could be reduced. SETTING: A long-term care facility in Newfoundland and Labrador, Canada from February 2017 to February 2018. METHOD: Residents were randomized to receive either a deprescribing-focused medication review by a pharmacist or usual care. Main outcome measure Change in the number of medications at 3 and 6 months. Results Forty-five residents enrolled in the study (n = 22 intervention, n = 23 control). Seventy-eight deprescribing recommendations were made, and 85.1% were successfully implemented. The average number of medications taken by residents in the intervention group was 2.68 less than the control group (p < 0.02; 95% CI – 4.284, – 1.071) at 3 months and 2.88 less (p = 0.02, 95% CI – 4.543, – 1.112) at 6 months. In 14.9% of cases, a medication had to be restarted after deprescribing was attempted because symptoms returned. CONCLUSION: A pharmacist-led deprescribing intervention can reduce the number of unnecessary and potentially harmful medications taken by LTC residents.

To examine the effect of an intervention comprising professional support by a geriatrician engaged in a quality care indicators’ audit for nursing home (NH) staff on reducing polypharmacy. METHODS: Of a total of 3709 NH residents, 90 NHs (2026 residents) were allocated to a light intervention and 85 NHs (1683 residents) to a strong intervention group. RESULTS: Mixed-effect linear model found no significant variation in the total number of medications over time (β-coefficient for interaction 0.007, 95% CI - 0.15, 0.16). Within-group-adjusted mean differences showed a statistical decline in the psychotropic medication class (- 0.04 SE 0.02 p 0.03 for the strong intervention group and - 0.06 SE 0.02 p 0.001 for the light intervention group) and a statistically significant increase in the analgesics use. CONCLUSION: The possibility that a simple audit intervention might reduce psychotropic prescriptions deserves further investigation.

To evaluate the impact of a multicenter intervention to reduce potentially inappropriate antipsychotic use in Canadian nursing homes at the individual and facility levels. DESIGN: Longitudinal, population-based cohort study to evaluate the Canadian Foundation for Healthcare Improvement’s Spreading Healthcare Innovations Initiative to reduce potentially inappropriate antipsychotic use in 6 provinces/territories. SETTING AND PARTICIPANTS: Adults in nursing homes in 6 provinces/territories in Canada between 2014 and 2016. The sample involved 4927 residents in 45 intervention homes and 122,570 residents in 1193 control homes in the first quarter of the study. MEASURES: Assessment data based on the Resident Assessment Instrument 2.0 were used in both settings to track antipsychotic use and to obtain risk-adjusters for a quality indicator on potentially inappropriate use. INTERVENTION: Quality improvement teams in participating organizations were provided with education, training, and support to implement localized strategies intended to reduce antipsychotic medication use in residents without diagnosis of psychosis. RESULTS: At the resident level, we found that the odds of remaining on potentially inappropriate antipsychotics were 0.75 in intervention compared with control homes after adjusting for age, sex, aggressive behavior, and cognition. These findings were evident within the pooled Canadian data as well as within provinces. At the facility level, the intervention homes had greater improvements in risk-adjusted quality indicator performance than the control homes, and this was true for the worst, median, and best-performing homes at baseline. There was no major change in the quality indicator for worsening of behavior symptoms. CONCLUSIONS/IMPLICATIONS: The Canadian Foundation for Healthcare Improvement intervention was associated with a reduction in potentially inappropriate antipsychotic use at both the individual and facility levels of analysis. This improvement in performance was independent of secular trends toward reduced antipsychotic use in participating provinces. This suggests that substantial improvements in medication use may be achieved through targeted, collaborative quality improvement initiatives in long-term care.

Teamwork is important in the design and delivery of initiatives in complex healthcare systems but the specifics of quality improvement (QI) teams are not well studied. OBJECTIVE: To explain the functioning of front-line healthcare teams working on patient-centred QI using Bourdieu’s sociological construct of capital. METHODS: One medical ward from each of six NHS Trusts in England participated in the study, purposively selected for a range of performance levels on patient experience metrics. Three ethnographers conducted focused ethnography for 1 year, using interviews and observations to explore the organisation, management and delivery of patient-centred QI projects by the six front-line teams. Data were analysed using Bourdieu’s typology of the four forms of capital: economic, social, symbolic and cultural. RESULTS: While all teams implemented some QI activities to improve patient experience, progress was greater where teams included staff from a broad range of disciplines and levels of seniority. Teams containing both clinical and non-clinical staff, including staff on lower grades such as healthcare assistants and clerks, engaged more confidently with patient experience data than unidisciplinary teams, and implemented a more ambitious set of projects. We explain these findings in terms of ‘team capital’. CONCLUSION: Teams that chose to restrict membership to particular disciplines appeared to limit their capital, whereas more varied teams were able to draw on multiple resources, skills, networks and alliances to overcome challenges. Staff of varying levels of seniority also shared and valued a broader range of insights into patient experience, including informal knowledge from daily practice. The construct of ‘team capital’ has the potential to enrich understanding of the mechanism of teamwork in QI work.

In 2012, the University of Missouri Sinclair School of Nursing was one of 7 sites across the United States selected for their evidence-based model called the Missouri Quality Initiative (MOQI), based on the nationally recognized Quality Improvement Program of Missouri (QIPMO). The goal of the MOQI was to work with 16 nursing homes in the Midwestern United States who had higher than national averages of hospitalization rates to change their systems of care delivery so that reduced hospital transfers could be achieved.6 Since 2012, the MOQI has achieved a 30% reduction in all-cause admissions following full implementation.

Following the 2012 launch of the National Partnership to Improve Dementia Care in Nursing Homes (the National Partnership), the use of antipsychotics has declined. However, little is known about the impact of this effort on quality of care and outcomes for nursing home (NH) residents with Alzheimer’s disease and related dementia (ADRD). The objective of this study is to examine changes in hospitalizations for NH long-stay residents with ADRD after the launch of the National Partnership. DESIGN: Observational cross-sectional study. SETTING/PARTICIPANTS: NH residents who were newly admitted into NHs and became long-stay residents between January 2011 and March 2015 (n = 565,885). METHODS: We estimated linear probability models to explore the relationship between the National Partnership and the likelihood of NH-originated hospitalizations for NH long-stay residents with ADRD, accounting for facility fixed effect, individual covariates, and concurrent changes in hospitalizations among residents without ADRD. We further stratified the analysis by NHs according to their prevalence of antipsychotic use at baseline (ie, prior to the National Partnership). RESULTS: We detected a 0.7-percentage point relative increase (P value <.01) in risk-adjusted probabilities of hospitalizations among residents with ADRD compared with non-ADRD residents in the post-Partnership period. In the stratified analysis, we detected a 1.2-percentage point increase (P = .037) in the probability of hospitalizations among ADRD residents in NHs with high antipsychotic use at baseline but no significant change among those in NHs with low antipsychotic use. CONCLUSIONS AND IMPLICATIONS: Although the National Partnership may have reduced exposure to antipsychotics, our findings suggest this was related to an increase in hospitalization risk for residents with ADRD. Further research is needed to elucidate the reasons behind the observed relationship and to examine the impact of the National Partnership on other health outcomes.

A case study of the Pathway to Excellence in Long-Term Care model.

A growing body of literature suggests combining organizational ethnography and case study design as a new methodology for investigating complex organizational phenomena in health care contexts. However, the arguments supporting the potential of organizational ethnographic case studies to improve the process and increase the impact of qualitative research in health care is currently underdeveloped. In this article, we aim to explore the methodological potentialities and limitations of combining organizational ethnography and case study to conduct in-depth empirical health care research. We conducted a scoping review, systematically investigating seven bibliographic databases to search, screen, and select empirical articles that employed organizational ethnographic case study to explore organizational phenomena in health care contexts. We screened 573 papers, then completed full-text review of 74 papers identified as relevant based on title and abstract. A total of 18 papers were retained for analysis. Data were extracted and synthesized using a two-phase descriptive and inductive thematic analysis. We then developed a methodological matrix that positions how the impact, contextualization, credibility, and depth of this combined methodology interact to increase the generative power of in-depth qualitative empirical research in health care. Our review reveals that organizational ethnographic case studies have their own distinct methodological identity in the wider domain of qualitative health care research. We argue that by accelerating the research process, enabling various sources of reflexivity, and spreading the depth and contextualization possibilities of empirical investigation of complex organizational phenomena, this combined methodology may stimulate greater academic dynamism and increase the impact of research. Organizational ethnographic case studies appear as a new in-depth qualitative methodology that both challenges and improves the conventional ways we study the lives of organizations and the experiences of actors within the interconnected realms of health care.

With the increasing double burden of communicable and non-communicable diseases (NCDs) in sub-Saharan Africa, health systems require new approaches to organise and deliver services for patients requiring long-term care. There is increasing recognition of the need to integrate health services, with evidence supporting integration of HIV and NCD services through the reorganisation of health system inputs, across system levels. This study investigates current practices of delivering and implementing integrated care for chronically-ill patients in rural Malawi, focusing on the primary level. METHODS: A qualitative study on chronic care in Phalombe district conducted between April 2016 and May 2017, with a sub-analysis performed on the data following a document analysis to understand the policy context and how integration is conceptualised in Malawi; structured observations in five of the 15 district health facilities, selected purposively to represent different levels of care (primary and secondary), and ownership (private and public). Fifteen interviews with healthcare providers and managers, purposively selected from the above facilities. Meetings with five non-governmental organisations to study their projects and support towards chronic care in Phalombe. Data were analysed using a thematic approach and managed in NVivo. RESULTS: Our study found that, while policies supported integration of various disease-specific programmes at point of care, integration efforts on the ground were severely hampered by human and health resource challenges e.g. inadequate consultation rooms, erratic supplies especially for NCDs, and an overstretched health workforce. There were notable achievements, though most prominent at the secondary level e.g. the establishment of a combined NCD clinic, initiating NCD screening within HIV services, and initiatives for integrated information systems. CONCLUSION: In rural Malawi, major impediments to integrated care provision for chronically-ill patients include the frail state of primary healthcare services and sub-optimal NCD care at the lowest healthcare level. In pursuit of integrative strategies, opportunities lie in utilising and expanding community-based outreach strategies offering multi-disease screening and care with strong referral linkages; careful task delegation and role realignment among care teams supported with proper training and incentive mechanisms; and collaborative partnership between public and private sector actors to expand the resource-base and promoting cross-programme initiatives.

Due to an increasingly elderly population, a higher incidence of chronic diseases and higher expectations regarding public service provision, healthcare services are under increasing strain to cut costs while maintaining quality. The importance of promoting systems of co-produced health between stakeholders has gained considerable traction both in the literature and in public sector policy debates. This study provides a comprehensive map of the extant literature and identifies the main themes and future research needs. METHODS: A quantitative bibliometric analysis was carried out consisting of a performance analysis, science mapping, and a scientific collaboration analysis. Web of Science (WoS) was chosen to extract the dataset; the search was refined by language, i.e. English, and type of publication, i.e. journal academic articles and reviews. No time limitation was selected. RESULTS: The dataset is made up of 295 papers ranging from 1994 to May 2019. The analysis highlighted an annual percentage growth rate in the topic of co-production of about 25%. The articles retrieved are split between 1225 authors and 148 sources. This fragmentation was confirmed by the collaboration analysis, which revealed very few long-lasting collaborations. The scientific production is geographically polarised within the EU and Anglo-Saxon countries, with the United Kingdom playing a central role. The intellectual structure consists of three main areas: public administration and management, service management and knowledge translation literature. The co-word analysis confirms the relatively low scientific maturity of co-production applied to health services. It shows few well-developed and central terms, which refer to traditional areas of co-production (e.g. public health, social care), and some emerging themes related to social and health phenomena (e.g. the elderly and chronic diseases), the use of technologies, and the recent patient-centred approach to care (patient involvement/engagement). CONCLUSIONS: The field is still far from being mature. Empirical practices, especially regarding co-delivery and co-management as well as the evaluation of their real impacts on providers and on patients are lacking and should be more widely investigated.

Although participatory research is known to have advantages, it is unclear how participatory research can best be performed. This study aims to report on lessons learned in collaboration with service users involved as co-researchers in three participatory teams in long-term care. METHODS: A multiple case study design was chosen to explore the collaboration in three teams, each covering one specific client group receiving long-term care: physically or mentally frail elderly people, people with mental health problems or people with intellectual disabilities. RESULTS: A good working environment and a good collaboration were found to be crucial requirements for participatory research. A good working environment was developed by discussing reasons for engagement and wishes, formulating basic rules, organizing training sessions, offering financial appreciation, and the availability of the researcher to give travel support. The actual collaboration was established by developing a bond and equal positioning, deciding on the role division, holding on to transparency and a clear structure, and have sufficient time for the collaboration. Moreover, the motivations and unique contributions of the co-researchers and differences between the teams were reported. The motivations of co-researchers ranged from individual goals – such as personal development, creating a new social identity and belonging to a social group – to more external goals, such as being valuable for other service users and increasing the quality of care. An inclusive collaboration required valuing the individual contributions of co-researchers and adjustment to team differences. CONCLUSIONS: The results showed the importance of developing a good working environment and establishing a good collaboration for participatory research. Furthermore, the study shows that individual and team differences should be taken into account. These results can be used by researchers for designing and shaping future research projects in long-term care in collaboration with co-researchers.

Objectives: Assess the potential benefits of identifying drug-gene interactions in nursing home (NH) residents on multiple medications. Reduce the use of high-risk medications for residents with reduced drug metabolism.

To describe general practitioners’ (GPs) perspectives on end-of-life care of nursing home residents. METHODS: We carried out a cross-sectional study. A questionnaire was sent to a random sample of 1121 GPs in the German federal states of Bremen and Lower Saxony in 2018. Data were compared between GPs with a qualification in palliative medicine and those without such qualifications, and multivariable logistic regression was performed. RESULTS: Overall, 375 questionnaires were returned (response rate 34%). The majority of GPs (71%) agreed that nursing home residents are treated too often in hospitals at the end of life, and more than half rated end-of-life care in nursing homes as “rather poor” (54%). For both questions, GPs with a qualification in palliative medicine showed higher agreements. In the multivariable analysis, a prior qualification in palliative medicine was also strongly associated with rating end-of-life care as “rather poor” (OR 1.89, 95% CI 1.10-3.23). Respondents cited higher staffing ratios and better trained nursing staff as the most important measures to improve end-of-life care. Furthermore, it was estimated that just 37% of residents have an advance directive, with only one-third including valid information on end-of-life hospitalizations. CONCLUSIONS: This study showed that GPs tend to be critical regarding end-of-life care in nursing homes. To improve end-of-life care, better training in palliative care for nursing staff and GPs might be warranted. In addition, advance care planning can help to ensure that residents’ wishes are respected. Geriatr Gerontol Int 2020; 20: 25-30.

Pain can have a critical negative impact on the quality of life of institutionalized older people. This study aimed to examine the characteristics of pain and associated factors among older people at nursing homes in Korea. METHODS: A nationwide survey was carried out on the functional status of 1444 older residents at 91 nursing homes using the interRAI Long-Term Care Facilities instrument. The frequency, intensity, severity and consistency of pain were assessed, and data on potential attributes at the resident and facility levels were collected. Multivariate and multilevel regression analysis models were developed. RESULTS: More than one-third (36.7%) of older residents had pain. Pain prevalence differed by several sociodemographic and clinical factors, including sex, depressive symptoms, cognition, or whether or not the resident was a Medical Aid beneficiary. Pain prevalence also varied according to nursing home size and location. In the multivariate, multilevel regression analyses, both having severe pain and having consistent pain were positively associated with depressive symptoms, and the pain experience was significantly lower among older residents in nursing homes that met the nursing staffing standard. CONCLUSIONS: This is the most comprehensive study on pain assessment in long-term care facilities in Korea using a representative sample so far. Pain is prevalent among nursing home residents in Korea. Besides individual factors, facility characteristics – in particular, meeting the staffing standard – were important to pain control, which implies there is room for improving pain assessment and management through advancing quality of care policies. Geriatr Gerontol Int 2020; 20: 118-124.

This study was carried out to investigate the effect of therapeutic touch on sleep quality in the elderly people living in the nursing homes. The study is a randomized controlled experimental study (pretest-posttest control group). The sample of the research consisted of 25 elderly people. As a result of the study, although there was a significant increase (p  0.05). Therapeutic touch is an effective method of improving the sleep quality of the elders living at a nursing home.

This paper provides evidence-based and, when appropriate, expert reviewed recommendations for long-stay residents who are prescribed texture-modified diets (TMDs), with the consideration that these residents are at high risk of worsening oropharyngeal dysphagia (OD), malnutrition, dehydration, aspiration pneumonia, and OD-associated mortality, poorer quality of life and high costs. DESIGN: Nestlé Health Science funded an initial virtual meeting attended by all authors, in which the unmet needs and subsequent recommendations for OD management were discussed. The opinions, results, and recommendations detailed in this paper are those of the authors, and are independent of funding sources. SETTING: OD is common in nursing home (NH) residents, and is defined as the inability to initiate and perform safe swallowing. The long-stay NH resident population has specific characteristics marked by a shorter life expectancy relative to community-dwelling older adults, high prevalence of multimorbidity with a high rate of complications, dementia, frailty, disability, and often polypharmacy. As a result, OD is associated with malnutrition, dehydration, aspiration pneumonia, functional decline, and death. Complications of OD can potentially be prevented with the use of TMDs. RESULTS: This report presents expert opinion and evidence-informed recommendations for best practice on the nutritional management of OD. It aims to highlight the practice gaps between the evidence-based management of OD and real-world patterns, including inadequate dietary provision and insufficient staff training. In addition, the unmet need for OD screening and improvements in therapeutic diets are explored and discussed. CONCLUSION: There is currently limited empirical evidence to guide practice in OD management. Given the complex and heterogeneous population of long-stay NH residents, some ‘best practice’ approaches and interventions require extensive efficacy testing before further changes in policy can be implemented.

Dominant discourses surrounding dementia tend to focus on narratives of loss and decline. Simultaneously, individuals living with dementia are vulnerable to being dispossessed of personal narratives supportive of identity and well-being. How older people with dementia story their experiences of resilience in this context has not previously been investigated. In response, this qualitative study utilised a narrative approach to understand lived experiences of resilience shared by eight older people living with dementia. Structural analyses indicated that participants’ personal narratives regarding resilience in living with dementia contained distinct and common phases (The Diagnosis, Initial Tasks, ‘The High Point’, Reflecting on Limitations and Focusing on Today) as well as a variety of dynamic characters. Overarching themes within participants’ narratives included sense of self/identity, being connected to others, sense of agency and having positive attitudes. Participants narrated richer, more active personal stories than those typically represented in dominant social discourses surrounding dementia. As such, their narratives depict lived experiences of resilience that unfolded over time in response to adversity and uncertainty and involved a dialectical process in relation to adjustment and well-being. The findings have important implications for the way resilience in living with dementia is framed and supported.

Systematic, in-depth exploration of news media coverage of aggression and older adults remains sparse, with little attention to how and why particular frames manifest in coverage across differing settings and relationships. Frame analysis was used to analyze 141 English-language Canadian news media articles published between 2008 and 2019. Existing coverage tended towards stigmatizing, fear-inducing, and biomedical framings of aggression, yet also reflected and reinforced ambiguity, most notably around key differences between settings and relations of care. Mainstream news coverage reflects tensions in public understandings of aggression and older adults (e.g., as a medical or criminal issue), reinforced in particular ways because of the nature of news reporting. More nuanced coverage would advance understanding of differences among settings, relationships, and types of actions, and of the need for multifaceted prevention and policy responses based on these differences.

There is a growing interest in using technology to provide meaningful activities for people living with dementia. The aim of this systematic review was to identify and explore the different types of digital technologies used in creating individualized, meaningful activities for people living with dementia. From 1414 articles identified from searches in four databases, 29 articles were included in the review. The inclusion criteria were the study used digital technology to deliver an individually tailored activity to participants with dementia, the process of individualization was described, and findings relating to the mental, physical, social, and/or emotional well-being of the participant were reported. Data extracted from the included studies included participant demographics, aims, methods, and outcomes. The following information on the technology was also extracted: purpose, type, training, facilitation, and the individualization process. A narrative synthesis of the results grouped the various technologies into four main purposes: reminiscence/memory support, behavior management, stimulating engagement, and conversation/communication support. A broad range of technologies were studied, with varying methods of evaluation implemented to assess their effect. Overall, the use of technology in creating individualized, meaningful activities seems to be promising in terms of improving behavior and promoting relationships with others. Furthermore, most studies in this review involved the person with dementia in the individualization process of the technology, indicating that research in this area is adopting a more co-creative and inclusive approach. However, sample sizes of the included studies were small, and there was a lack of standardized outcome measures. Future studies should aim to build a more concrete evidence base by improving the methodological quality of research in this area. Findings from the review indicate that there is also a need for more evidence concerning the feasibility of implementing these technologies into care environments.

Older adults account for a significant portion of Canadian immigrants, yet characteristics and health outcomes of older immigrants in nursing homes have not been studied. We aimed to describe the prevalence of immigrants living in nursing homes, their characteristics, and their hospitalization and mortality rates compared to long-term residents in the first year of entry to nursing homes.; ObjectiveOlder adults account for a significant portion of Canadian immigrants, yet characteristics and health outcomes of older immigrants in nursing homes have not been studied. We aimed to describe the prevalence of immigrants living in nursing homes, their characteristics, and their hospitalization and mortality rates compared to long-term residents in the first year of entry to nursing homes.

Meeting individual preferences for long-term services and supports (LTSS) is a policy priority that has implications for quality of care. Evidence regarding preferences is sparse. In addition, little is known regarding whether preferences and care arrangements match for those receiving care, and implications for quality of life. RESEARCH DESIGN AND METHODS: A random sample (n = 1,783 in 2012) of National Health and Aging Trends Study participants were asked the best care option for someone 80+ who needs help with personal care and mobility. Analyses examine variations in care preferences, the relationship of preferences to care arrangements, and the association of matched preference and care arrangements to quality of life indicators. RESULTS: Care preferences vary by demographics. Equal proportions (3 in 10) of older adults chose assisted living or continuing care retirement communities (CCRC), care in own home with family help, and care in own home with paid help, as the best options. Persons in assisted living/CCRC settings were significantly more likely to choose this option as best. Only 1 in 3 older persons receiving care are in arrangements that match preferences. No association with quality of life indicators was found. DISCUSSION AND IMPLICATIONS: Aging in place remains the care preference of a majority, but close to one-third chose assisted living/CCRC, suggesting preferences are evolving. Aligning care preferences and arrangements is a policy goal, but many do not achieve a match and there remain gaps in understanding trajectories in preferences and care arrangements and implications for quality of life.

To characterize the burden of eye disease and the utility of teleophthalmology in nursing home patients, a population with ophthalmic needs not commensurate with care received. PATIENTS AND METHODS: Informed consent was obtained from 78 California Bay Area skilled nursing facility patients. Near visual acuity (VA) and anterior/posterior segment photographs were taken with a smartphone-based VA app and ophthalmic camera system. The Nursing Home Vision-Targeted Health-Related Quality of Life questionnaire was also administered. Risk factors for visual impairment were assessed. Institutional review board approval was obtained from Stanford University. RESULTS: Cataracts (51%), diabetic retinopathy (DR) (12%), optic neuropathy (12%), and age-related macular degeneration (AMD) (10%) were common findings; 11.7% had other referral-warranted findings. AMD and DR correlated with a higher risk of poor VA, with adjusted odds ratios of 22 (P = .01) and 43 (P = .004). CONCLUSIONS: This study demonstrated a high prevalence of poor VA and ophthalmic disease in the nursing home population impacting quality of life. Smartphone-based teleophthalmology platforms have the potential to increase access to eye care for nursing home patients. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:262-270.].

The number of older people admitted to nursing homes has continued to rise with the recent expansion of the Republic of Korea’s long-term care system. Maintaining ego integrity is a major task for older people approaching the end of life. As efforts to maintain ego integrity include the final stages of life, this concept is critically important for older people in nursing homes. This study was designed to assess issues related to ego integrity in the nursing home environment to determine how nurses should play a key role in managing this important life task. PURPOSE: The management by nurses of the ego integrity of residents of nursing homes is a new phenomenon that is central to promoting long-term, quality care. This study was designed to clarify and conceptualize this management phenomenon in the context of nursing homes. METHODS: A hybrid model of concept development was used to analyze the ways in which nurses manage the ego integrity of residents of nursing homes. In the theoretical phase, a working definition of the management by nurses of residents’ ego integrity is developed using a literature review. In the fieldwork phase, in-depth interviews are conducted with eight nurses from six nursing homes in Seoul and three other provinces. Finally, in the final analytical phase, the theoretical and fieldwork findings are interpreted and compared. RESULTS: Two components, assessment and intervention, of the approach by nurses to managing the ego integrity of residents of nursing homes were identified. Assessment incorporates 10 attributes in the following three dimensions: “identifying the extent to which residents’ basic needs are being fulfilled,” “determining how residents achieve friendly relationships with others,” and “determining how each resident creates a harmonious view of his or her life.” Intervention incorporates nine attributes in the following two dimensions: “helping residents develop a positive view of life” and “helping residents make the best use of their remaining functional abilities.” CONCLUSIONS/IMPLICATIONS FOR PRACTICE: By managing the ego integrity of residents, nurses have a significant influence on residents’ sociopsychological adaptation, especially in the challenging environment of a nursing home. This study supports that managing the ego integrity of residents of nursing homes is an important and practical component of the role played by nurses and of the aid and care they provide. Furthermore, the findings verify the effectiveness of intervention studies in examining assessment tools and developing guidelines for ego-integrity management.

Although qualitative studies have been conducted to identify barriers and facilitators that influence the pain management of older adults with dementia, as far as we know, only a very recent study (Andrews et al., 2019) has used participatory action research (PAR) as a methodology for studying pain management. It allows nurses to examine and improve their practice based on their realities and within their context. AIM: To reflect on nursing practice and identify facilitators and barriers in the management of pain in older adults with dementia and to propose actions for improvement. DESIGN: We used qualitative participatory action research. PARTICIPANTS/SETTINGS: Ten nurses from the geriatric acute care unit of a university hospital in Spain were recruited through convenience sampling. METHODS: Data were generated through a written questionnaire and three focus groups. RESULTS: One of the main facilitators the participants identified was professional experience. The main barriers they identified were lack of knowledge and skills and lack of time. The participants proposed two main improvements: (1) a training program consisting of three courses (pain evaluation and management, dementia and pain, and pharmacology) and (2) the creation of a specific register for nurses to record patients’ pain. CONCLUSIONS: Involving nurses directly in research on their practices can result in precise proposals for improvements based on their needs and oriented toward improving the quality of care. Moreover, our results confirm previous findings in other countries.

This study aimed to examine associations between health status and care needs of nursing home residents and risk of death from suicide compared to other causes through a retrospective data linkage cohort study examining nursing home resident deaths in Australia between 2000 and 2013. Data linkage was performed between aged care assessment tools-Resident Classification System and Aged Care Funding Instrument-and the National Coronial Information System. A competing risks survival analysis was performed to determine the association between care assessment variables (activities of daily living (ADL), behavior, and complex health care) and the risk of death from suicide and any other cause. Of the 146 nursing home residents who died from suicide, 130 (89%) were matched to their assessment data, with comparable information available for 95 residents (65%). Residents who required high levels of care with ADL, physical health care, and cognitive and behavioral issues had a higher risk of dying from all other causes, yet lower risk of dying from suicide. The study findings demonstrate the feasibility and value of linking these two data sets; highlight a need for improved data collection processes; and support a person-centered care approach for prevention of suicide among nursing home residents.

Dementia guidelines propose the use of nonpharmacological interventions for sleep disturbances for older people. Based on available reviews, it seems most likely that multicomponent interventions have the strongest potential to be effective in improving sleep. However, a detailed description of multicomponent interventions is missing. This systematic review aims to identify, describe, and summarize multicomponent, nonpharmacological interventions to reduce or avoid sleep disturbances in nursing home residents. METHODS: This review followed established methodological frameworks for systematic evidence syntheses. A computerized search was conducted in December 2018, using the databases PubMed, CINAHL, Scopus, and Cochrane Library. Two independent reviewers assessed all search results to identify eligible studies and assessed studies’ methodological quality following the Cochrane Risk of Bias methodology for randomized controlled trials and the CASP Appraisal Checklist for controlled trials.Evaluation studies of any design investigating multicomponent interventions were included, except case studies. Components of included intervention programs were analyzed applying the TIDieR and CReDECI 2 criteria. RESULTS: A total of 2056 studies were identified through the database search; ten publications about nine interventions met the inclusion criteria and were included in the review. The identified interventions can be summarized assigned to the categories “daytime activities,” “nighttime activities,” “staff training,” and “light exposure.” The approaches showed similarities and differences in procedures, materials, modes of delivery, intervention provider, and intervention period. None of the studies described any intended interactions between components or considered context characteristics in intervention modeling as well as internal and external facilitators or barriers influencing delivery of intervention. We identified positive or mixed positive effects for sleep-related outcomes for the mentioned categories. CONCLUSIONS: The analysis of included interventions demonstrates somehow promising results, although findings are difficult to interpret as interventions were not well described, and the challenges of developing and evaluating complex interventions were not sufficiently acknowledged.

This webinar aims to deliver insights for policymakers and practitioners who work with evidence, who look to implement good evidence into widespread practice, and who commission evaluation globally.

Please join Dr. Geoffrey Curran and interviewer Dr. Robyn Mildon, Executive Director of the Centre for Evidence and Implementation, as they explore the methods and design landscape, considering the importance of innovation, experimentation and methods, and contemplating hybrid designs in particular.

The COVID-19 pandemic has disproportionately affected older persons with comorbidities, with a high fatality rate in this group.

In this webinar, we will review the basics of SARS-CoV-2 (the virus that causes COVID-19); what is known so far about its effects on the body and on the brain; and on outcomes when infection occurs in persons living with dementia. We will discuss the ethics of allocating scarce medical resources during a pandemic, and the effects it may have on access to care for persons with dementia.