June 30, 2020

Calls for Abstracts
Events & Training Opportunities


New TREC Article
Challenges in Caring for Unbefriended Residents in Long-Term Care Homes: A Qualitative Study.
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S. A. Chamberlain, W. Duggleby, P. B. Teaster, J. Fast and C. A. Estabrooks.
J Gerontol B Psychol Sci Soc Sci 2020 Jun 12
This study examined challenges experienced by long-term care staff in caring for unbefriended residents who are incapacitated and alone. These residents often are estranged from or have no living family or live geographically distant from them and require a public guardian as their surrogate decision-maker. To date, research on unbefriended older adults has focused on those living in acute care and community settings. Little is known about those living in long-term care homes. METHODS: We conducted semi-structured interviews with 39 long-term care staff (e.g., registered nurses, care aides, social workers) and 3 public guardians. Staff were sampled from 7 long-term care homes in Alberta, Canada. We analyzed interview transcripts using content analysis and then using the theoretical framework of complex adaptive systems. RESULTS: Long-term care staff experience challenges unique to unbefriended residents. Guardians’ responsibilities did not fulfill unbefriended residents’ needs, such as shopping for personal items or accompanying residents to appointments. Consequently, the guardians rely on long-term care staff, particularly care aides, to provide increased levels of care and support. These additional responsibilities, and organizational messages dissuading staff from providing preferential care, diminish quality of work life for staff. DISCUSSION: Long-term care homes are complex adaptive systems. Within these systems, we found organizational barriers for long-term care staff providing care to unbefriended residents. These barriers may be modifiable and could improve the quality of care for unbefriended residents and quality of life of staff. Implications for practice include adjusting public guardian scope of work, improving team communication, and compensating staff for additional care.

New article by Ann Catrine Eldh and Jo Rycroft-Malone
Using Nonparticipant Observation as a Method to Understand Implementation Context in Evidence-Based Practice.
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A. C. Eldh, J. Rycroft-Malone, T. van der Zijpp, C. McMullan and C. Hawkes.
Worldviews Evid Based Nurs 2020 Jun 19
The uptake of evidence-based knowledge in practice is influenced by context. Observations are suggested as a valuable but under-used approach in implementation research for gaining a holistic understanding of contexts. AIM: The aim of this paper is to demonstrate how data from observations can provide insights about context and evidence use in implementation research. METHODS: Data were collected over 24 months in a randomised trial with an embedded realist evaluation in 24 nursing homes across four European countries; notes from 183 observations (representing 335 hours) were triangulated with interview transcripts and context survey data (from 357 staff interviews and 725 questionnaire responses, respectively). RESULTS: Although there were similarities in several elements of context within survey, interview and observation data, the observations provided additional features of the implementation context. In particular, observations demonstrated if and how the resources (staffing and supplies) and leadership (formal and informal, teamwork, and professional autonomy) affected knowledge use and implementation. Further, the observations illuminated the influence of standards and the physical nursing environment on evidence-based practice, and the dynamic interaction between different aspects of context. LINKING EVIDENCE TO ACTION: Although qualitative observations are resource-intensive, they add value when used with other data collection methods, further enlightening the understanding of the implementation context and how evidence use and sharing are influenced by context elements. Observations can enhance an understanding of the context, evidence use and knowledge-sharing triad in implementation research

New article by Alison Kitson
Interactive workshop to develop implementation framework (i-PARIHS) resources to support practice facilitation.

Sarah C. Hunter, Bo Kim and Alison L. Kitson.
Implementation Science Communications 2020 06/18;1(1):56
Practice facilitation is a method used to address the complexity associated with implementation of innovations into primary care. To provide support, we propose that the i-PARIHS (Integrated Promoting Action on Research Implementation in Health Services) framework could support practice facilitators. The i-PARIHS framework positions facilitation as a core element for successful implementation. Therefore, the aim of this study was to provide support to practice facilitators whilst simultaneously gaining feedback on what facilitators in practice need in regard to support with operationalising the i-PARIHS framework in practice.

Calls for Abstracts

Call for iKT Cases

DEADLINE 2 October
We can learn a lot about what works in integrated knowledge translation collaborations by documenting the experiences of researchers and knowledge users. The How We Work Together casebook series shines a light on what really happens in IKT projects. To continue learning about real-world researcher-knowledge user partnerships, we invite teams to write about their experiences using an IKT approach for volume 4 of the IKTRN casebook series.


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COVID-19 and Long Term Care
Health Care Administration and Organization
Health Care Innovation and Quality Assurance
Organizational Culture and Change
Research Practice and Methodology

COVID-19 and Long Term Care

Collection of articles on COVID and LTC is available here

COVID-19 and Resident Care

Dementia Care in Times of COVID-19: Experience at Fundació ACE in Barcelona, Spain.
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A. Benaque, M. J. Gurruchaga, C. Abdelnour, et al.
J Alzheimers Dis 2020 Jun 12
Fundació ACE is a non-profit organization providing care based on a holistic model to persons with cognitive disorders and their families for 25 years in Barcelona, Spain. Delivering care to this vulnerable population amidst the COVID-19 pandemic has represented a major challenge to our institution. OBJECTIVE: To share our experience in adapting our model of care to the new situation to ensure continuity of care. METHODS: We detail the sequence of events and the actions taken within Fundació ACE to swiftly adapt our face-to-face model of care to one based on telemedicine consultations. We characterize individuals under follow-up by the Memory Unit from 2017 to 2019 and compare the number of weekly visits in 2020 performed before and after the lockdown was imposed. RESULTS: The total number of individuals being actively followed by Fundació ACE Memory Unit grew from 6,928 in 2017 to 8,147 in 2019. Among those newly diagnosed in 2019, most patients had mild cognitive impairment or mild dementia (42% and 25%, respectively). Weekly visits dropped by 60% following the suspension of face-to-face activity. However, by April 24 we were able to perform 78% of the visits we averaged in the weeks before confinement began. DISCUSSION: We have shown that Fundació ACE model of care has been able to successfully adapt to a health and social critical situation as COVID-19 pandemic. Overall, we were able to guarantee the continuity of care while preserving the safety of patients, families, and professionals. We also seized the opportunity to improve our model of care.

Geriatric units at the beginning of the 2020 COVID-19 epidemic in France.
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G. Berrut, L. de Decker, J. P. Aquino, et al.
Geriatr Psychol Neuropsychiatr Vieil 2020 Jun 1;18(2):125-133
The COVID-19 epidemic that started in November in China became a national epidemic from March 16, 2020 with the declaration of population containment in order to reduce the spread of the virus in France. From March 17 to March 27, 2020, the monitoring unit of the French society of geriatrics and gerontology decided to conduct a survey to analyze the implementation of the mobilization of geriatric units, given that this epidemic had shown that it resulted in excess mortality mainly among the elderly. The survey was able to bring together the response of 34 services, nine of which were located in a high epidemic cluster zone. Dedicated acute geriatric units for patients infected with COVID-19 were present in eight facilities, only outside the cluster zones. Nine geriatric follow-up and rehabilitation services were dedicated, an additional telemedicine activity concerned 35% of the facilities, and family listening and tablet communication facilities concerned 36% of the facilities. This survey is a snapshot of an initial moment in the epidemic. It provides an opportunity to describe the context in which this epidemic occurred in terms of geriatric policy, and to assess the responsiveness and inventiveness of these services in meeting the needs of the elderly.

The coronavirus crisis and its impact on residential care homes for the elderly in Spain.
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G. R. Cabrero.
Cien Saude Colet 2020 Jun;25(6):1996-81232020256.11242020
Between March 8 and April 27, 2020, an estimated total of 23,521 people died of coronavirus in Spain. This is a provisional figure, as it is still necessary to ascertain the population that in fact died at home from coronavirus or compatible symptoms. Of this total, 15,886 were people who lived in residential care homes for the elderly and the disabled, in other words, 67% of those who died, the vast majority of whom were elderly individuals. Half of them died in Madrid and Barcelona (49.8%). This information is still provisional and as yet unconfirmed since it is reported by the 17 Autonomous Communities or regions that handle the social services. The magnitude of the impact of the pandemic on the elderly population is a dramatic event, which has affected around 3% to 4% of the population in residential care homes. It is an impact that is highly similar to that of other European countries.

Caring for Frail Older Adults During COVID-19: integrating public health ethics into clinical practice.
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J. Chase.
J Am Geriatr Soc 2020 Jun 17
During the COVID-19 pandemic, principles from both clinical and public health ethics cue clinicians and health care administrators to plan alternatives for frail older adults who prefer to avoid critical care, and for when critical care is not available due to crisis triaging. This paper will explore the COVID-19 Ethical Decision Making Framework, published in British Columbia, Canada, to familiarize clinicians and policy makers with how ethical principles can guide systems change, in the service of frail older adults. In British Columbia, the health care system has launched resources to support clinicians in proactive advance care planning discussions, and is providing enhanced supportive and palliative care options to residents of long term care facilities. If the pandemic truly overwhelms the healthcare system, frailty, but not age alone, provides a fair and evidence-based means of triaging patients for critical care and could be included into ventilator allocation frameworks. This article is protected by copyright. All rights reserved.

Clinical characteristics and prognostic factors in COVID-19 patients aged ≥80 years.
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M. Covino, G. De Matteis, M. Santoro, et al.
Geriatr Gerontol Int 2020 Jun 9
The aim of the present study was to describe the clinical presentation of patients aged ≥80 years with coronavirus disease 2019 (COVID-19), and provide insights regarding the prognostic factors and the risk stratification in this population. METHODS: This was a single-center, retrospective, observational study, carried out in a referral center for COVID-19 in central Italy. We reviewed the clinical records of patients consecutively admitted for confirmed COVID-19 over a 1-month period (1-31 March 2020). We excluded asymptomatic discharged patients. We identified risk factors for death, by a uni- and multivariate Cox regression analysis. To improve model fitting and hazard estimation, continuous parameters where dichotomized by using Youden’s index. RESULTS: Overall, 69 patients, aged 80-98 years, met the inclusion criteria and were included in the study cohort. The median age was 84 years (82-89 years is interquartile range); 37 patients (53.6%) were men. Globally, 14 patients (20.3%) presented a mild, 30 (43.5%) a severe and 25 (36.2%) a critical COVID-19 disease. A total of 23 (33.3%) patients had died at 30 days’ follow up. Multivariate Cox regression analysis showed that severe dementia, pO(2) ≤90 at admission and lactate dehydrogenase >464 U/L were independent risk factors for death. CONCLUSIONS: The present data suggest that risk of death could be not age dependent in patients aged ≥80 years, whereas severe dementia emerged is a relevant risk factor in this population. Severe COVID-19, as expressed by elevated lactate dehydrogenase and low oxygen saturation at emergency department admission, is associated with a rapid progression to death in these patients.

Dementia care and COVID-19 pandemic: a necessary digital revolution.
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L. Cuffaro, F. Di Lorenzo, S. Bonavita, G. Tedeschi, L. Leocani and L. Lavorgna.
Neurol Sci 2020 Jun 17:1-3
Due to the COVID-19 pandemic, most memory clinics have had to suspend their activities. On the other hand, international dementia experts have recommended to provide urgently worldwide support for people living with dementia. This situation urges to play out new strategies to guarantee adequate care. Telemedicine and digital technology (DT) devices, such as smartphones, can be very helpful in remote monitoring and care. Technological devices such as videoconference or smartphone apps might be used for follow-up visits and support to patients and caregivers and to acquire digital markers of clinical progression. Hopefully, this dramatic situation would facilitate the process of progressive familiarization of neurologists with telemedicine and DT approach.

The effects of ARBs, ACEIs and statins on clinical outcomes of COVID-19 infection among nursing home residents.

Anton De Spiegeleer, Antoon Bronselaer, James T. Teo, et al.
Journal of the American Medical Directors Association 2020/06
Angiotensin-converting enzyme inhibitors (ACEi), angiotensin II receptor blockers (ARB) and HMG-CoA reductase inhibitors (statins) have been hypothesised to impact COVID-19 severity. However, up till now, no studies investigating this association were conducted in the most vulnerable and affected population groups, i.e. older adults residing in nursing homes. The objective of this study has been to explore the association of ACEi/ARB and/or statins with clinical manifestations in COVID-19 infected older adults residing in nursing homes.; ObjectivesAngiotensin-converting enzyme inhibitors (ACEi), angiotensin II receptor blockers (ARB) and HMG-CoA reductase inhibitors (?statins?) have been hypothesised to impact COVID-19 severity. However, up till now, no studies investigating this association were conducted in the most vulnerable and affected population groups, i.e. older adults residing in nursing homes. The objective of this study has been to explore the association of ACEi/ARB and/or statins with clinical manifestations in COVID-19 infected older adults residing in nursing homes.

Should we deny ICU admission to the elderly? Ethical considerations in times of COVID-19.
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L. E. M. Haas, D. W. de Lange, D. van Dijk and J. J. M. van Delden.
Crit Care 2020 Jun 9;24(1):321-020-03050-x
In this article, we discuss the use of age as a criterion for ICU treatment in times of scarce ICU capacity by contrasting it with deciding under normal conditions.

Dementia in the COVID-19 Period
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A. D. Korczyn.
J Alzheimers Dis 2020;75(4):1071-1072
The effects of the COVID-19 infection on those older people who have cognitive decline (due to Alzheimer’s disease or other causes) need to be addressed. This is not restricted to those cognitively impaired people who happen to become infected by the virus. The draconic measures inflicted on the population at large impose an disproportionate burden on the elderly and particularly on those with cognitive impairment. The restrictions to move about and meet friends and family members are incomprehensible to them. The explanations given are not well understood and, in any case, soon forgotten, leading to stress on patients and caregivers.

Long-Term Care Facilities and the COVID-19 Pandemic: Lessons Learned in Madrid.
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J. Martinez-Peromingo and J. A. Serra-Rexach.
J Am Geriatr Soc 2020 Jun 17
We want to report our experience in Madrid, the hardest hit city by the pandemic in Spain

Potential Novel Role of COVID-19 in Alzheimer’s Disease and Preventative Mitigation Strategies.
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S. X. Naughton, U. Raval and G. M. Pasinetti.
J Alzheimers Dis 2020 Jun 12
There are a number of potential implications for the field of Alzheimer’s disease (AD) stemming from the global spread of SARS-CoV-2. Neuroinflammation is known to be a prominent feature of neurodegeneration and plays a major role in AD pathology. Immune response and excessive inflammation in COVID-19 may also accelerate the progression of brain inflammatory neurodegeneration, and elderly individuals are more susceptible to severe outcomes after SARS-CoV-2 infection. Individuals with type 2 diabetes (T2D) are at an increased risk for AD as well as severe outcomes after SARS-CoV-2 infection. Genetic and socioeconomic factors influencing the rates of T2D, AD, and COVID-19 severity may create an exceptionally high-risk profile for certain demographics such as African Americans and Hispanic Americans. Type I interferon response plays an important role in both host response to viral infection, as well as AD pathology and may be a sensible therapeutic target in both AD and COVID-19.

COVID-19 and the elderly: insights into pathogenesis and clinical decision-making.
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F. Perrotta, G. Corbi, G. Mazzeo, et al.
Aging Clin Exp Res 2020 Jun 16:1-10
The elderly may represent a specific cluster of high-risk patients for developing COVID-19 with rapidly progressive clinical deterioration. Indeed, in older individuals, immunosenescence and comorbid disorders are more likely to promote viral-induced cytokine storm resulting in life-threatening respiratory failure and multisystemic involvement. Early diagnosis and individualized therapeutic management should be developed for elderly subjects based on personal medical history and polypharmacotherapy. Our review examines the pathogenesis and clinical implications of ageing in COVID-19 patients; finally, we discuss the evidence and controversies in the management in the long-stay residential care homes and aspects of end-of-life care for elderly patients with COVID-19.

Symptoms of COVID-19 among older adults: systematic review of biomedical literature.
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G. Sacco, O. Brière, M. Asfar, O. Guérin, G. Berrut and C. Annweiler.
Geriatr Psychol Neuropsychiatr Vieil 2020 Jun 1;18(2):135-140
The COVID-19 pandemic is particularly severe in older adults. Our objective was to identify, from international literature, the most common symptoms met in older adults infected with the SARS-CoV-2 virus. This systematic review of the literature was conducted using MEDLINE from December 1, 2019 to April 13, 2020. The analysis of methodological quality used a method dedicated to case series and case reports. Out of 260 articles initially identified, only two studies were finally included in the qualitative analysis. The mean age was relatively low, between 71 and 74 years on average. The symptoms of COVID-19 were as follows: fever, dry cough, dyspnea, asthenia, anorexia, chest tightness, diarrhea, and to a lesser extent myalgia, pharyngitis, nausea, dizziness, headache, abdominal pain and finally vomiting. Lymphopenia was found in the complete blood count. In conclusion, this systematic review of the international literature reveals a lack of data about the semiology of COVID-19 in older adults, especially in the frail oldest-old ones who commonly define the geriatric population. The national survey conducted by the French Society of Geriatrics and Gerontology will help fill this semiological gap.

Allowing visitors back in the nursing home during the COVID-19 crisis – A Dutch national study into first experiences and impact on well-being.

Hilde Verbeek, Debby L. Gerritsen, Ramona Backhaus, Bram S. de Boer, Raymond T. C. M. Koopmans and Jan P. H. Hamers.
Journal of the American Medical Directors Association 2020/06
To prevent and control COVID-19 infections, nursing homes across the world have taken very restrictive measures, including a ban for visitors. These restrictive measures have an enormous impact on residents? well-being and pose dilemmas for staff, although primary data are lacking. A Dutch guideline was developed to cautiously open nursing homes for visitors during the COVID-19 pandemic. This study reports the first findings on how the guideline was applied in the local context, the compliance to local protocols and the impact on well-being of residents, their family caregivers and staff.; ObjectivesTo prevent and control COVID-19 infections, nursing homes across the world have taken very restrictive measures, including a ban for visitors. These restrictive measures have an enormous impact on residents? well-being and pose dilemmas for staff, although primary data are lacking. A Dutch guideline was developed to cautiously open nursing homes for visitors during the COVID-19 pandemic. This study reports the first findings on how the guideline was applied in the local context, the compliance to local protocols and the impact on well-being of residents, their family caregivers and staff.

COVID-19 Prevalence and Spread

Asymptomatic SARS-CoV-2 Infection in Nursing Homes, Barcelona, Spain, April 2020.
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B. Borras-Bermejo, X. Martínez-Gómez, M. G. San Miguel, et al.
Emerg Infect Dis 2020 Jun 23;26(9):10.3201/eid2609.202603
During the coronavirus disease pandemic in Spain, from April 10-24, 2020, a total of 5,869 persons were screened for severe acute respiratory syndrome coronavirus 2 at nursing homes. Among residents, 768 (23.9%) tested positive; among staff, 403 (15.2%). Of those testing positive, 69.7% of residents and 55.8% of staff were asymptomatic.

COVID-19 infections and deaths among Connecticut nursing home residents: facility correlates.
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Y. Li, H. Temkin-Greener, S. Gao and X. Cai.
J Am Geriatr Soc 2020 Jun 18
To determine the associations of nursing home registered nurse (RN) staffing, overall quality of care, and concentration of Medicaid or racial and ethnic minority residents with COVID-19 confirmed cases and deaths by April 16, 2020 among Connecticut nursing home residents. DESIGN: Cross-sectional analysis on Connecticut nursing home (n=215) COVID-19 report, linked to other nursing home files and county counts of confirmed cases and deaths. Multivariable two-part models determined the associations of key nursing home characteristics with the likelihood of at least 1 confirmed case (or death) in the facility, and with the count of cases (deaths) among facilities with at least 1 confirmed case (death). RESULTS: The average number of confirmed cases was 8 per nursing home (zero in 107 facilities), and the average number of confirmed deaths was 1.7 per nursing home (zero in 131 facilities). Among facilities with at least 1 confirmed case, every 20 minutes (per resident day) increase in RN staffing was associated with 22% fewer confirmed cases (incidence rate ratio [IRR]=0.78, 95% confidence interval [CI] 0.68-0.89, p<0.001); compared to 1- to 3-star facilities, 4- or 5-star facilities had 13% fewer confirmed cases (IRR=0.87, 95% CI 0.78-0.97, p<0.015); and facilities with high concentration of Medicaid residents (IRR=1.16, 95% CI 1.02-1.32, p=0.025) or racial/ethnic minority residents (IRR=1.15, 95% CI 1.03-1.29, p=0.026) had 16% and 15% more confirmed cases, respectively, than their counterparts. Among facilities with at least 1 death, every 20 minutes increase in RN staffing significantly predicted 26% fewer COVID-19 deaths (IRR=0.74, 95% CI 0.55-1.00, p=0.047). Other focused characteristics did not show statistically significant associations with deaths. CONCLUSIONS: Nursing homes with higher RN staffing and quality ratings have the potential to better control the spread of the novel coronavirus and reduce deaths. Nursing homes caring predominantly for Medicaid or racial and ethnic minority residents tend to have more confirmed cases.

Asymptomatic SARS-CoV-2 infection and COVID-19 mortality during an outbreak investigation in a skilled nursing facility.
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M. C. Patel, L. H. Chaisson, S. Borgetti, et al.
Clin Infect Dis 2020 Jun 16
Outbreaks of COVID-19 have been reported in nursing homes and assisted living facilities; however, the extent of asymptomatic and pre-symptomatic SARS-CoV-2 infection in this high-risk population remains unclear. METHODS: We conducted an investigation of the first known outbreak of SARS-CoV-2 at a skilled nursing facility (SNF) in Illinois on March 15, 2020 and followed residents for 30 days. We tested 126/127 residents for SARS-CoV-2 via RT-PCR and performed symptom assessments. We calculated the point prevalence of SARS-CoV-2 and assessed symptom onset over 30-day follow-up to determine: 1) the proportion of cases who were symptomatic, pre-symptomatic, and asymptomatic and 2) incidence of symptoms among those who tested negative. We used the Kaplan-Meier method to determine the 30-day probability of death for cases. RESULTS: Of 126 residents tested, 33 had confirmed SARS-CoV-2 on March 15. Nineteen (58%) had symptoms at the time of testing, 1 (3%) developed symptoms over follow-up, and 13 (39%) remained asymptomatic. Thirty-five residents who tested negative on March 15 developed symptoms over follow-up; of these, 3 were re-tested and 2 were positive. The 30-day probability of death among cases was 29%. CONCLUSIONS: SNFs are particularly vulnerable to SARS-CoV-2, and residents are at risk of severe outcomes. Attention must be paid to preventing outbreaks in these and other congregate care settings. Widespread testing and infection control are key to help prevent COVID-19 morbidity and mortality in these high-risk populations.

The Missing Pieces of the COVID-19 Puzzle.
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P. A. Rochon, W. Wu, V. Giannakeas and N. M. Stall.
J Am Geriatr Soc 2020 Jun 14
When data, such as age and sex, are presented internationally in a consistent format, we identify patterns and make connections that may not have been anticipated. We focus here on laboratory‐confirmed coronavirus disease 2019 (COVID‐19) cases and fatalities by sex, age, and the intersection of the two, because these data are fundamental and routinely collected.

Association Between Nursing Home Crowding and COVID-19 Infection and Mortality in Ontario, Canada. [Pre-Print]

Kevin A. Brown, Aaron Jones, Nick Daneman, et al.
medRxiv 2020
Nursing home residents have been disproportionately impacted by the COVID-19 epidemic. Prevention recommendations have emphasized frequent testing of healthcare personnel and residents, but additional strategies are needed to protect nursing home residents. Objective: We developed a reproducible index of nursing home crowding and determined whether crowding was associated with incidence of COVID-19 in the first months of the COVID-19 epidemic. Design, Setting, and Participants: Population-based retrospective cohort study of over 78,000 residents of 618 distinct nursing homes in Ontario, Canada from March 29 to May 20, 2020. Exposure: The nursing home crowding index equalled the average number of residents per bedroom and bathroom. Outcomes: Primary outcomes included the cumulative incidence of COVID-19 infection and mortality, per 100 residents; introduction of COVID-19 into a home (\>=1 resident case) was a negative tracer. Results: Of 623 homes in Ontario, we obtained complete information on 618 homes (99\%) housing 78,607 residents. A total of 5,218 residents (6.6\%) developed COVID-19 infection, and 1,452 (1.8\%) died with COVID-19 infection as of May 20, 2020. COVID-19 infection was distributed unevenly across nursing homes: 4,496 (86\%) of infections occurred in just 63 (10\%) of homes. The crowding index ranged across homes from 1.3 (mainly single-occupancy rooms) to 4.0 (exclusively quadruple occupancy rooms); 308 (50\%) homes had high crowding index (\>=2). Incidence in high crowding index homes was 9.7\%, versus 4.5\% in low crowding index homes (p\<0.001), while COVID-19 mortality was 2.7\%, versus 1.3\%. The likelihood of COVID-19 introduction did not differ (31.3\% vs 30.2\%, p=0.79). After adjustment for regional, nursing home, and resident covariates, the crowding index remained associated with increased risk of infection (RR=1.72, 95\% Confidence Interval [CI]: 1.11-2.65) and mortality (RR=1.72, 95\%CI: 1.03-2.86). Propensity score analysis yielded similar conclusions for infection (RR=2.06, 95\%CI: 1.34-3.17) and mortality (RR=2.09, 95\%CI: 1.30-3.38). Simulations suggested that converting all 4-bed rooms to 2-bed rooms would have averted 988 (18.9\%) infections of COVID-19 and 271 (18.7\%) deaths. Conclusions and Relevance: Crowding was associated with higher incidence of COVID-19 infection and mortality. Reducing crowding in nursing homes could prevent future COVID-19 mortality.Competing Interest StatementThe authors have declared no competing interest.Funding StatementNo external funding was received for this workAuthor 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:Research Ethics Board of the University of TorontoAll 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.YesThe data from this study is not publically available.

Administration & Organizational Issues

COVID-19 epidemic: Regional organization centered on nursing homes.
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C. Cofais, D. Veillard, C. Farges, et al.
J Am Geriatr Soc 2020 Jun 17
Description of how NH care was re-organized in France during the pandemic.

What Have We Learned about Nursing from the Coronovirus Pandemic

Barbara Resnick.
Journal of the American Medical Directors Association 2020/06.
During the current coronavirus pandemic, the focus of the accolades has gone to nurses working in the acute care sector, where “real nursing” occurs as portrayed in television or in the movies. Over the past few months there has, however, been some increased recognition of the critically important role that nurses play in long-term care. Nursing home nurses are present 24 hours a day, providing care and serving as the eyes and ears of all other providers who intermittently evaluate residents in these settings. During coronavirus pandemic quarantine they provide enhanced care, as family are not able to visit. They also facilitate telecommunication with physicians, hospital staff, and families and friends of residents. This care is consistent with the role of nurses over time, which ranges from preventing illness and promoting health to caring for the sick and comforting the dying. Their courage, dedication, and resilience is something to be admired. Never have I been prouder to be a nurse.

Establishment of a COVID-19 Recovery Unit in a Veteran Affairs (VA) Post-Acute Facility.
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L. Sohn, M. Lysaght, W. A. Schwartzman, S. R. Simon, M. B. Goetz and T. Yoshikawa.
J Am Geriatr Soc 2020 Jun 18
Coronavirus disease 19 (COVID-19) is now an epidemic of global proportion with major adverse impacts on older adults, persons with chronic diseases, and especially residents of long-term care facilities. This health catastrophe has challenged healthcare facilities’ capacity to deliver care to not only COVID-19 patients but all patients who need hospital care. We report on a novel approach of utilizing long-term care beds at a Department of Veterans Affairs healthcare facility for managing recovering COVID-19 patients.

Nursing Home Characteristics Associated with COVID-19 Deaths in Connecticut, New Jersey, and New York.

Mark Aaron Unruh, Hyunkyung Yun, Yongkang Zhang, Robert T. Braun and Hye-Young Jung.
Journal of the American Medical Directors Association 2020/06.
The objective of this study was to compare the characteristics 7 of nursing homes with COVID-19 deaths to other nursing homes using data from Connecticut, 8 New Jersey, and New York.

COVID-19 and Quality Improvement

COVID-19 Highlights the Need for Trained Social Workers in Nursing Homes.
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M. Bern-Klug and E. Beaulieu.
J Am Med Dir Assoc 2020 May 25
A nursing home social worker knew it was going to be a challenging day when she arrived at work to find an ambulance at the front door and a hearse at the back. Coronavirus disease 2019 (COVID-19) had struck. This spring’s pandemic has forced a new psychosocial playbook in nursing homes across the country as fears run high, emotions run hot, and distress runs rampant. Social workers are trained to run toward the emotional chaos, offering their skills to support people’s own coping process. Good psychosocial care, even in the midst of a pandemic, can help people identify and build on their natural resilience. Core features of psychosocial care in a crisis include access to information and emotional support.

Covid-19: Adapting the geriatric organisations to respond to the pandemic.
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T. Celarier, L. Lafaie, L. Goethals, et al.
Respir Med Res 2020 Jun 11;78:100774
This article reports the impact of the pandemic of Covid-19 on geriatric wards and describes the whole reorganisation implemented to be able to receive Covid patients, as to maintain the usual care of non-Covid patients. Tools already used in practice, such as the telephone hotline and hospital mobile teams have been transformed into special Covid tools to optimize the patient flow.

Ethics, care and ageing during the Covid-19 pandemic.
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F. Gzil, A. C. Clause-Verdreau, P. E. Brugeron and E. Hirsch.
Geriatr Psychol Neuropsychiatr Vieil 2020 Jun 1;18(2):151-156
At the beginning of the Covid-19 epidemic, National forum for ethical reflection on Alzheimer’s disease and neurodegenerative diseases conducted a national survey to identify the difficulties encountered by professionals working in the field of old age and autonomy, families and volunteers, and the initiatives they have implemented. Seven major difficulties were identified: the isolation induced by the prohibition of visits, the lack of protective equipment and tests, the difficulties of people with cognitive difficulties in understanding measures to avoid the spread of the epidemic, the sustainability of overwork for professionals, the concern of the families of residents, complex situations at home and difficulties in accessing care. Four initiatives are being implemented: information and training for teams, compensation for interrupted visits, consultations and exchanges between professionals, actions to benefit people living at home. The Covid-19 epidemic hit the elderly sector at a very special moment in its history, several years of effort by the sector to reinvent itself around strong values. They have been a resource during this period of crisis. An ambitious law on old age and autonomy therefore appears to be a necessity.

Is there a Link between Nursing Home Reported Quality and COVID-19 Cases? Evidence from California Skilled Nursing Facilities

Mengying He, Yumeng Li and Fang Fang.
Journal of the American Medical Directors Association 2020/06
During the COVID-19 outbreak in the U.S., nursing homes became the hotbed for the spread of COVID-19. States developed different policies to mitigate the COVID-19 risks at nursing homes, including limiting nursing home visitation and mandating staff screening. The purpose of this study is to examine whether COVID-19 cases and deaths are related to the nursing home reported quality.; ObjectivesDuring the COVID-19 outbreak in the U.S., nursing homes became the hotbed for the spread of COVID-19. States developed different policies to mitigate the COVID-19 risks at nursing homes, including limiting nursing home visitation and mandating staff screening. The purpose of this study is to examine whether COVID-19 cases and deaths are related to the nursing home reported quality.

Widespread severe acute respiratory coronavirus virus 2 (SARS-CoV-2) laboratory surveillance program to minimize asymptomatic transmission in high-risk inpatient and congregate living settings.
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L. P. Jatt, A. Winnett, C. J. Graber, J. Vallone, D. O. Beenhouwer and M. B. Goetz.
Infect Control Hosp Epidemiol 2020 Jun 16:1-4
We describe a widespread laboratory surveillance program for severe acute respiratory coronavirus virus 2 (SARS-CoV-2) at an integrated medical campus that includes a tertiary-care center, a skilled nursing facility, a rehabilitation treatment center, and temporary shelter units. We identified 22 asymptomatic cases of SARS-CoV-2 and implemented infection control measures to prevent SARS-CoV-2 transmission in congregate settings.

Symptom management and end-of-life care of residents with COVID-19 in long-term care homes.
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H. Khosravani, L. Steinberg, N. Incardona, P. Quail and G. A. Perri.
Can Fam Physician 2020 Jun;66(6):404-406
The care challenges for residents of LTCHs who test positive for COVID-19 are numerous. They include the need to provide palliative care in place with potentially fewer opportunities for transfer to other facilities. Therefore, a framework that can be used in LTCHs for symptom management including end-of-life care is needed. We present such a framework, with considerations for respiratory symptom management and provision of palliative and end-of-life care in long-term care.

Solving the COVID-19 Crisis in Post-Acute and Long-Term Care.

Christopher E. Laxton, David A. Nace and Arif Nazir.
Journal of the American Medical Directors Association 2020 06/16
Our nation’s nursing home industry has been in need of overhaul for decades – a situation made all the more evident by COVID-19. AMDA – The Society of Post-Acute and Long-Term Care Medicine is dedicated to quality in post-acute and long-term care (PALTC) process and outcomes. This special article presents five keys to solving the COVID-19 crisis in PALTC, related to policy, collaboration, individualization, leadership, and reorganization. Taking action during this crisis may prevent sinking back into the complacency and habits of our pre-COVID-19 lives.

COVID-19 highlights the need for universal adoption of standards of medical care for physicians in nursing homes in Europe.
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D. O’Neill, R. Briggs, I. Holmerová, et al.
Eur Geriatr Med 2020 Jun 17:1-6
The nursing home sector has seen a disproportionately high number of deaths as part of the COVID-19 pandemic. This reflects, in part, the frailty and vulnerability of older people living in care homes but has also, in part, been a consequence of the failure to include care homes in the systematic planning of a response to COVID, as well as a measure of neglect of standards and quality improvement in the sector. In response, the EUGMS published a set of medical standards of care developed in consultation with experts across its member national societies in 2015. The standards consisted of seven core principles of medical care for physicians working in nursing homes as a first step in developing a programme of clinical, academic and policy engagement in improving medical care for older people who are living and frequently also dying as residents in nursing homes. The gravity of the concerns arising for nursing home care from the COVID-19 pandemic, as well as emerging insights on care improvement in nursing homes indicate that an update of these medical standards is timely. This was performed by the writing group from the original 2015 guidelines and is intended as an interim measure pending a more formal review incorporating a systematic review of emerging literature and a Delphi process.

Under the Radar: States Vary in Regulating and Reporting COVID-19 in Assisted Living Facilities

Sarah True, Nancy Ochieng, Juliette Cubanski, Wyatt Koma, and Tricia Neuman
KFF Jun 16, 2020
Since the COVID-19 pandemic first surfaced in the United States, the number of cases and deaths in long-term care (LTC) facilities has been rising. As of June 4, 2020, over 43,000 COVID-19 related resident and staff deaths have been reported in nursing homes and other long-term care facilities, which is a conservative estimate because not all states publish these data. Among 41 states reporting COVID-19 LTC data at the state level, long-term care facility residents account for 50% or more of all COVID-19 deaths in 27 states. The increase in deaths among long-term care facility residents and staff has become an urgent concern for federal and state policymakers, the long-term care industry, family members of residents, residents themselves, and the general public.

Rapid Review: What is the effectiveness of cohorting virus-positive residents to shared rooms in care facilities?

National Collaborating Centre for Methods and Tools. 2020
Effective infection prevention and control measures are critical to prevent and mitigate the transmission of COVID-19 in long-term care (LTC) facilities. Cohorting of infected residents to shared rooms is a practice that has been used in the context of other infections, and its effectiveness for managing COVID-19 is of interest. This rapid review was produced to support the Public Health Agency of Canada’s response to the coronavirus disease 2019 (COVID-19) pandemic. This review seeks to identify, appraise, and summarize emerging research evidence to support evidence-informed decision making. This rapid review includes evidence available up to June 8, 2020. In this rapid review, we provide the most recent research evidence to answer the question: What is the effectiveness of cohorting virus-positive residents to shared rooms in care facilities?

The COVID-19 Outbreak at the Soldiers’ Home in Holyoke: An Independent Investigation Conducted for the Governor of Massachusetts

Mark W. Pearlstein, McDermott Will & Emery LLP
23 June 2020
The Soldiers’ Home in Holyoke is a long-term care facility operated by the Commonwealth of Massachusetts. Its residents are veterans, all of whom served this nation with honor, and in many instances were responsible for acts of heroism during wartime. The employees of the Home—some of whom are veterans themselves—are mission-driven and regard caring for the veterans as a special form of service. Prior to the COVID-19 outbreak, the care provided at the Home was generally quite good, and the veterans were treated consistent with the Home’s mission to provide “Care with Honor and Dignity.” This investigation focuses on the COVID-19 outbreak at the Home in the spring of 2020. During this tragedy, at least 76 veterans died with COVID-19, and an additional 84 veterans and over 80 staff tested positive. Governor Baker retained us to investigate the causes of this outbreak, with a goal of preventing similar tragedies in the future. We were also asked to investigate whether the Home complied with rules for timely reporting of COVID-19 infections and deaths to the Massachusetts Department of Veterans’ Services and the Executive Office of Health and Human Services (“EOHHS”)


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Implementing Microlearning in Nursing Homes: Implications for Policy and Practice in Person-Centered Dementia Care.
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J. Inker, C. Jensen, S. Barsness and M. M. Stewart.
J Appl Gerontol 2020 Jun 11:733464820929832
The aim of this study was to develop and pilot a 52-week Microlearning curriculum on person-centered dementia care in nine nursing homes. The goal was to evaluate the usability and application of Microlearning as a tool to increase staff knowledge and improve perceptions of people with dementia, thus increasing their ability to deliver person-centered care and their job satisfaction. Findings indicate that participants enjoyed the flexible, 24/7 access to training and found that the immediacy of the format encouraged them to apply their learning directly to practice. Staff knowledge and attitudes toward people with dementia were positively impacted by the training, as was job satisfaction. Further research to test the efficacy of Microlearning compared to usual training is warranted, as are coordinated policy development efforts that can guide the implementation of best practices in the use of Microlearning as an innovative training modality in nursing homes.

Implementation science in times of Covid-19.
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M. Wensing, A. Sales, R. Armstrong and P. Wilson.
Implement Sci 2020 Jun 8;15(1):42-020-01006-x
The emergence of SARS-CoV-2/Covid-19 affects all of us and is associated with rapid and massive changes in healthcare and societies. As a response, a range of interventions for patients and populations have been implemented in health and preventive settings, or need to be implemented in the short and long term. Implementation science offers a multidisciplinary perspective and systematic approach for the design, evaluation and analysis of programmes and policies to enhance implementation. The emergence of Covid-19 provides an urgent need to develop new perspectives and approaches in implementation science, such as the addition of innovative and rigorous approaches to the collection, use and analysis of ‘real-world’ data. Above all, we hope that implementation scientists will focus on what they can contribute to manage Covid-19 and its consequences for people, healthcare and society.


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Health Care Administration and Organization

Clinical Decision Support Systems in Nursing Homes: A Scoping Review.
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A. Abdellatif, J. Bouaud, D. Nghiem, C. Lafuente-Lafuente, J. Belmin and B. Seroussi.
Stud Health Technol Inform 2020 Jun 16;270:542-546
The world population is dramatically ageing, resulting in an increase of the prevalence of older dependent adults living in nursing homes (NHs). Because of insufficient resources in NHs, and nurses’ lack of time and knowledge, adverse events, most of them being preventable, are often reported. Clinical decision support systems (CDSSs) have proven to improve the quality of care in various healthcare settings such as hospitals and primary care centers. However, the use of CDSSs in NHs is still limited and little is known about their influence on nursing practices and NH residents’ clinical outcomes. We conducted a scoping review of the literature to evaluate CDSS use in NHs. Out of 1,231 retrieved papers, 15 studies were retrieved which assess 10 CDSSs applied to pressure ulcers and malnutrition prevention, drug prescription, and disease management. This review showed CDSSs could be effective in NHs for improving routine clinical practice and patient outcomes, but research is still needed to implement effective CDSSs in NHs.

An Exploration of Pain Documentation for People Living with Dementia in Aged Care Services.
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S. M. Andrews, J. F. Dipnall, R. Tichawangana, et al.
Pain Manag Nurs 2019 Oct;20(5):475-481
Pain in people with dementia is a common occurrence. Providing evidence-based pain management for people with dementia in residential aged care services is imperative to providing quality care. However, it remains unclear from current research how various aged care staff (Registered Nurses (RNs), Enrolled Nurses (ENs), Personal Care Assistants (PCAs)) engage at specific points of the pain management pathway. With structural changes to the residential aged care workforce over the past two decades, understanding the relative contributions of these aged care staff to pain management practices is crucial for future practice development. AIM: To investigate the quality and completeness of pain documentation for people living with dementia, and assess the extent to aged care staff are engaged in documentation processes. DESIGN: A three-month retrospective documentation audit. SETTING AND PARTICIPANTS: The audit was conducted on the files of 114 residents with moderate to very severe dementia, across four Australian residential aged care facilities. METHODS: Data was collected on each resident’s pain profile (n=114). One hundred and sixty-nine (169) pain episodes were audited for quality and completeness of pain documentation and the extent to which aged care staff (RNs/ENs and PCAs) were engaged in the documentation of pain management. RESULTS: Twenty-nine percent of pain episodes had no documentation about how resident pain was identified and only 22% of the episodes contained an evidence-based (E-B) assessment. At least one intervention was documented for 89% of the pain episodes, the majority (68%) being non-pharmacological. Only 8% of pain episodes had an E-B evaluation reported. Thirteen percent (13%) of episodes contained information across all four pain management domains (Identification/ problems, assessment, intervention and evaluation). Documentation by PCAs was evident at all points in the pain management pathway. PCAs were responsible for considerately more episodes of assessment (50% vs 18%) compared to nursing staff. CONCLUSION AND CLINICAL IMPLICATIONS: Despite the high prevalence of pain in people with dementia in aged care settings, current pain management documentation does not reflect best practice standards. Future capacity building initiatives must engage PCAs, as key stakeholders in pain management, with support and clinical leadership of nursing staff.

Strategies and interventions to reduce or manage refusals in personal care in dementia: A systematic review.
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T. Backhouse, E. Dudzinski, A. Killett and E. Mioshi.
Int J Nurs Stud 2020 May 16;109:103640
Refusals of care in dementia are common and can create difficult situations for caregivers. Little is known about the best way to manage them. AIM: To identify possible strategies and interventions to reduce or cope with refusals of care in dementia, and determine the evidence for these. METHODS: We searched MEDLINE, CINAHL, PsycINFO, EMBASE, AMED and Cochrane Central Register of Controlled Trials databases August 2018, with an updated search August 2019. An additional lateral search was conducted. Two researchers screened all records for potential eligibility and quality. Narrative synthesis was used to combine the findings. RESULTS: Out of the 5953 records identified, 36 articles, relating to 30 studies, met the eligibility criteria. Twenty-eight of the studies (93%) were set in long-term care facilities, one in a psychogeriatric unit and one with community dwelling people. Fourteen out of the 30 studies focussed on general or mixed care activities, 8 bathing, 4 mealtimes, 2 medication administration, and 2 mouth care. Strategies or interventions identified as potential ways to reduce refusals included: music interventions, interaction and communication style, caregiver approach, bathing techniques, abilities focussed approaches, distraction approaches, and video-simulated presence of a loved one. There was most evidence for music interventions and different bathing techniques, and interaction and communication styles were associated with reduced refusals. There was no evidence that slow-stroke massage (mixed care activities) or aromatherapy (mixed care activities and medication administration) reduced refusals of care. CONCLUSIONS: Some non-pharmacological interventions can reduce, but not eliminate, refusals of care, such as playing music during care or communicating positively without using elderspeak. More research evidence is needed to underpin strategies identified as encouraging such as Namaste Care or distraction techniques. Future research should address gaps identified such as, the absence of research examining non-pharmacological interventions for refusals of care in hospital settings and in community settings with home-care workers, and the limited research involving family carers. Tweetable abstract: Playing music during care and offering different bathing options can reduce refusal behaviours in dementia, whereas elderspeak and negative communication are associated with refusals.

Who lives in Scotland’s care homes? Descriptive analysis using routinely collected social care data 2012-16.
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J. K. Burton, E. Lynch, S. Love, J. Rintoul, J. M. Starr and S. D. Shenkin.
J R Coll Physicians Edinb 2019 Mar;49(1):12-22
Adults living in long-term care are a significant and complex population who are under-represented in research using traditional methodologies. METHODS: The aim of this study was to provide the first description of the adult care home population and their homes, using routinely collected data. A retrospective descriptive analysis was performed using the Scottish Care Home Census (SCHC) between 1 April 2012 and 31 March 2016. RESULTS: Data are from 1,299 care home services (79.3-89.7% completeness), including 34,399-39,311 residents per year across all regions of Scotland. A total of 68% of residents are female, with median age 84 years. 27% fund their own care. Over 85% of self-funded residents receive free personal care allowance. Around 60% require care from a registered nurse and 49% have a formal diagnosis of dementia. The majority of admissions come from hospital (46%). Between 13 and 17% of residents die annually, with a median time to death of 596-653 days. CONCLUSIONS: This study provides the most comprehensive descriptive data of UK care home residents available. There is scope to enhance the information available through linkage to other routine sources.

Challenges faced by residential aged care staff in decision-making for residents with dementia.
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N. Cameron, D. Fetherstonhaugh and M. Bauer.
Dementia (London) 2020 Jun 14:1471301220929154
Care staff in residential aged care facilities (nursing homes) in Australia are obligated, under the Australian National Framework for Action on Dementia 2015-2019, to support residents to exercise choice and make decisions. Research indicates, however, that care staff are often given little guidance regarding which residents’ decisions should be supported or how to make decisions on their behalf. This lack of guidance can result in a denial of residents’ rights and inconsistent treatment by staff, placing residents’ wellbeing at risk. Through providing an analysis of the responses of staff at RACFs in Victoria and Queensland to two case scenarios, this study seeks to provide some understanding of the difficulties staff face in supporting residents’ self-determination and their own need for greater organisational support.

How do care staff in residential aged care facilities conceptualise their non-verbal interactions with residents with dementia and what relevance has this for how residents’ preferences and capacity for decision-making are understood?
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N. Cameron, D. Fetherstonhaugh, M. Bauer and L. Tarzia.
Dementia (London) 2020 Jul;19(5):1364-1380
This paper considers the significance of how staff in residential aged care facilities interpret the non-verbal communication and behaviour of residents vis-a-vis their assessments of residents’ preferences and ability to participate in decision-making. It highlights the risks associated with staff members’ failure to interpret residents’ non-verbal communication and behaviour with reference to residents’ backgrounds and prior experiences. It also considers how non-verbal communication implemented by staff may impact residents’ emotional state and, as a consequence, decision-making abilities. Drawing on interview data with aged care staff from Queensland and Victoria, it demonstrates that care staff in residential facilities appear to rely heavily on non-verbal signals in assessing the decision-making capacity and preferences of residents with dementia. It also indicates that many staff fail to consider residents’ non-verbal communication and behaviour with due consideration of residents’ individual histories.

Autonomy Support of Nursing Home Residents With Dementia in Staff-Resident Interactions: Observations of Care.
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L. J. M. Hoek, H. Verbeek, E. de Vries, J. C. M. van Haastregt, R. Backhaus and J. P. H. Hamers.
J Am Med Dir Assoc 2020 Jun 15
People with dementia living in nursing homes benefit from a social environment that fully supports their autonomy. Yet, it is unknown to what extent this is supported in daily practice. This study aimed to explore to which extent autonomy is supported within staff-resident interactions. DESIGN: An exploratory, cross-sectional study. SETTING AND PARTICIPANTS: In total, interactions between 57 nursing home residents with dementia and staff from 9 different psychogeriatric wards in the Netherlands were observed. METHODS: Structured observations were carried out to assess the support of resident autonomy within staff-resident interactions. Observations were performed during morning care and consisted of 4 main categories: getting up, physical care, physical appearance, and breakfast. For each morning care activity, the observers consecutively scored who initiated the care activity, how staff facilitated autonomy, how residents responded to staff, and how staff reacted to residents’ responses. Each resident was observed during 3 different mornings. In addition, qualitative field notes were taken to include environment and ambience. RESULTS: In total, 1770 care interactions were observed. Results show that autonomy seemed to be supported by staff in 60% of the interactions. However, missed opportunities to engage residents in choice were frequently observed. These mainly seem to occur during interactions in which staff members took over tasks and seemed insensitive to residents’ needs and wishes. Differences between staff approach, working procedures, and physical environment were observed across nursing home locations. CONCLUSIONS AND IMPLICATIONS: The findings of this study indicate that staff members support resident autonomy in more than one-half of the cases during care interactions. Nonetheless, improvements are needed to support resident autonomy. Staff should be encouraged to share and increase knowledge in dementia care to better address residents’ individual needs. Especially for residents with severe dementia, it seems important that staff develop skills to support their autonomy.

The Nuts and Bolts of Utilizing Telemedicine in Nursing Homes – The GeriCare@North Experience.
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J. A. Low, H. J. Toh, L. L. C. Tan, J. W. K. Chia and A. T. S. Soek.
J Am Med Dir Assoc 2020 Jun 20
We examined the demographics and the clinical profile of teleconsultations conducted between an acute geriatric medicine department and 8 nursing homes over a period of 6.5 years. DESIGN: This is a prospective, descriptive study. SETTING AND PARTICIPANTS: This study was conducted in 8 nursing homes of Singapore. All nursing home patients referred to the program for teleconsultation between December 2010 and May 2017 were enrolled in the study. MEASURES: The unit observed and studied was the individual telemedicine consultation. Each unique patient contributed 1 or more observation points. The data collected included consultation dates, patient demographics, background medical comorbidities, reasons for referral, physical examination findings, primary diagnoses, and general management plans recommended by the doctors. RESULTS: There were 1673 teleconsultations conducted with 850 unique patients. Most of these patients were categorized as having moderate to severe disability. Ninety-five percent of the consultations were scheduled. The main reasons for referral were for medication review (47.6%) and behavioral problems (22.1%). The 4 commonest comorbidities were hypertension (57.0%), dementia (40.0%), diabetes (39.0%), and hyperlipidemia (38%). The most common primary diagnosis was dementia (21.6%), of which 227 of those diagnosed (62.8%) were referred for behavioral and psychological symptoms of dementia. CONCLUSIONS AND IMPLICATIONS: A telemedicine service for older patients is feasible and could be of a high quality, especially if made available in places where a high density of the latter reside, such as in the care homes and other nursing and rehabilitation facilities.

Care coordinator assistants: Job satisfaction and the importance of teamwork in delivering person-centered dementia care.
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D. Nowaskie, C. A. Carvell, C. A. Alder, et al.
Dementia (London) 2020 Jul;19(5):1560-1572
As the prevalence of persons with dementia increases, a larger, trained, and skilled healthcare workforce is needed. Attention has been given to models of person-centered care as a standard for dementia care. One promising role to deliver person-centered care is the care coordinator assistant. An inquiry about care coordinator assistant’s job satisfaction is reasonable to consider for retention and quality improvement purposes. We evaluated care coordinator assistants’ job satisfaction quantitatively and qualitatively. This study was part of a Centers for Medicare & Medicaid Services Health Care Innovation Award to the Indiana University School of Medicine. Sixteen care coordinator assistants, predominately female, African American or Caucasian, college graduates with a mean age of 43.1 years participated. Care coordinator assistants wrote quarterly case reports to share stories, lessons learned, and/or the impact of their job and completed the revised Job Satisfaction Inventory and Job in General scales during the second year of the Centers for Medicare & Medicaid Services award. For the Job Descriptive Index subscales promotion, supervision, and coworkers and Job in General, care coordinator assistants scored similar to normative means. Care coordinator assistants reported significantly higher satisfaction on the work subscale and significantly lower satisfaction on the pay subscale compared to normative data. Care coordinator assistants completed 119 quarterly case reports. Job satisfaction and teamwork were recurring themes in case reports, referenced in 47.1% and 60.5% of case reports, respectively. To address the demands of increasing dementia diagnoses, care coordinator assistants can constitute a compassionate, competent, and satisfied workforce. Training care coordinator assistants to work together in a team to address the needs of persons with dementia and caregivers provides a viable model of workforce development necessary to meet the growing demands of this population.

Appropriate Nursing Home Nurse Hours per Resident Day in Korea: A Secondary Analysis of Longitudinal Data.
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J. H. Shin.
J Nurs Scholarsh 2019 Sep;51(5):569-579
To encourage the enactment of laws about mandatory nurse staffing in nursing homes, researchers should provide evidence of concrete nurse hours per resident day (HPRD). This article estimates optimal nurse staffing HPRD to achieve increased quality-of-care outcomes for nursing home residents. DESIGN: Secondary analysis of longitudinal data. METHODS: This study used secondary analysis of longitudinal nursing home survey data. Nurse staffing HPRD and quality-of-care survey data accrued from nursing homes operating under long-term-care insurance in Korea. The collected data include a total of six quarterly base measurements on nurse staffing HPRD and 15 quality indicators from 2014 to 2017. The proposed optimization model emerged to most appropriately combine nurse staffing HPRD to increase quality-of-care outcomes for nursing home residents by 3% to 8%. Optimal outcome measures were fixed as best outcomes and compiled from 15 nursing-sensitive quality indicators. FINDINGS: Constrained nonlinear optimization was used for analysis. A 12% increase in registered nurse (RN) HPRD (from 0.168 HPRD [10 min 5 s] to 0.177 [10 min 38 s]) aligned with a 3% improvement in quality-of-care outcomes. A 20% RN HPRD increase aligned with a commensurate 5% to 8% increase in compiled quality-of-care outcomes (from 0.168 HPRD [10 min 5 s] to 0.202 HPRD [12 min 6 s]) without increasing certified nurse aide HPRD. About a 30% RN HPRD increase aligned with a commensurate 5% to 8% increase in compiled quality-of-care outcomes (from 0.168 HPRD [10 min 5 s] to 0.218 HPRD [13 min 6 s]) without increasing certified nurse aide HPRD. CONCLUSIONS: It is urgent to institute mandatory nurse HPRD for nursing homes in Korea by law. This research provides evidence that increasing nursing HPRD improved residents’ outcomes in nursing homes. CLINICAL RELEVANCE: Findings from the optimization model implied that stable care by RNs in nursing homes is a key factor in achieving acceptable quality of care for residents.

Nursing home staff’s perspective on end-of-life care of German nursing home residents: a cross-sectional survey.
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A. Strautmann, K. Allers, A. M. Fassmer and F. Hoffmann.
BMC Palliat Care 2020 Jan 3;19(1):2-019-0512-8
Nursing homes are becoming more important for end-of-life care. Within the industrialised world, Germany is among the countries with the most end-of-life hospitalizations in nursing home residents. To improve end-of-life care, investigation in the status quo is required. The objective was to gain a better understanding of the perspectives of nursing home staff on the current situation of end-of-life care in Germany. METHODS: A cross-sectional study was conducted as a postal survey among a random sample of 1069 German nursing homes in 2019. The survey was primarily addressed to nursing staff management. Data was analyzed using descriptive statistics. Staff was asked to rate different items regarding common practices and potential deficits of end-of-life care on a 5-point-Likert-scale. Estimations of the proportions of in-hospital deaths, residents with advance directives (AD), cases in which documented ADs were ignored, and most important measures for improvement of end-of-life care were requested. RESULTS: 486 (45.5%) questionnaires were returned, mostly by nursing staff managers (64.7%) and nursing home directors (29.9%). 64.4% of the respondents rated end-of-life care rather good, the remainder rated it as rather bad. The prevalence of in-hospital death was estimated by the respondents at 31.5% (SD: 19.9). Approximately a third suggested that residents receive hospital treatments too frequently. Respondents estimated that 45.9% (SD: 21.6) of the residents held ADs and that 28.4% (SD: 26.8) of available ADs are not being considered. Increased staffing, better qualification, closer involvement of general practitioners and better availability of palliative care concepts were the most important measures for improvement. CONCLUSIONS: Together with higher staffing, better availability and integration of palliative care concepts may well improve end-of-life care. Prerequisite for stronger ties between nursing home and palliative care is high-quality education of those involved in end-of-life care.

‘I do it my way’: long-term care staff’s perceptions of residents’ sexual needs and suggestions for improvement in their management.
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F. Villar, R. Serrat, M. Celdrán, J. Fabà, T. Martínez and J. Twisk.
Eur J Ageing 2019 Nov 25;17(2):197-205
This study is aimed at exploring to what extent staff perceive older residents in long-term care facilities (LTCFs) as still having sexual needs, and how they think care in relation to sexual issues could be improved. The sample was self-selected and comprised 2115 staff members (including managers, technical and care assistants) employed at 152 Spanish LTCFs. Data were collected in the second half of 2016. Participants were asked to estimate the proportion of older residents who had sexual needs in their institution and, by means of open-ended questions, they were also asked about how they satisfied such needs and how to improve care in relation to sexual issues. Responses to the open-ended questions were analysed using content analysis. Differences were assessed according to participants’ work position. Results showed that most participants did not see sexual needs as being present in many (or even any) older people living in LTCFs. Masturbation was the most common way staff thought residents’ sexual needs were being satisfied. The participants mentioned a broad range of measures to improve care regarding sexual issues, including providing more training opportunities for staff, guaranteeing privacy and improving negative attitudes held by family, residents or staff members. Work position influenced participants’ responses: managers and technical staff were more likely to recognise sexual needs among residents, perceived a greater need for training, and proposed more ambitious and far-reaching improvements than care assistants.

Systematic training program for nursing home staff based on the concept of combination of medicine and care.
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L. Wang, H. Chen, L. Yang, C. Qian, D. Sun and Y. Sun.
Medicine (Baltimore) 2020 Jun 12;99(24):e20559
It is important to improve the training for nursing home staff in order to achieve better quality of life for the elderly.This study aimed to develop a systematic training program for nursing home staff based on the concept of combination of medicine and care.Thirty-four nursing staff from 2 representative nursing homes in Qiqihar City were selected as study subjects and divided into experimental and control groups. The subjects in both groups received routine training following “National Occupational Standards of Elderly Nursing Staff”. In addition, the subjects in experimental groups received systematic training at three levels based on the concept of combination of medicine and care for 4 months.After the training, the competence scores of nursing staff in experimental group increased significantly compared to control group, the living quality of the elderly in nursing homes cared by nursing staff in experimental group was significantly improved, and the satisfaction of the elderly to nursing staff in experimental group improved significantly, compared to control group (P < .05).We develop systematic training program for nursing home staff based on the concept of combination of medicine and care, which can improve nursing care for the elderly in nursing home.

The contribution of immigrants and population groups designated as visible minorities to nurse aide, orderly and patient service associate occupations

Statistics Canada, 2020
Using census data, a new study titled “The contribution of immigrants and population groups designated as visible minorities to nurse aide, orderly and patient service associate occupations” looks at the important contribution of immigrants and groups designated as visible minority groups to this group of essential workers.

The study found that at the time of the most recent census (in 2016), over one-third (36%) of nurse aides, orderlies and patient service associates in Canada were immigrants, and that the vast majority were women.

The study also found that some groups designated as visible minorities were particularly more likely to be represented among immigrants working in these professions. Specifically, about 3 in 10 immigrants working in these occupations were Black, and another 3 in 10 were Filipino.

Immigrants working as nurse aides, orderlies and patient service associates were more highly educated than their Canadian-born counterparts, with one-quarter holding at least a bachelor’s degree compared with 5% of the Canadian-born, most often in a health-related field.

There are also marked regional differences. For example, immigrants accounted for over three-quarters of the nurse aides, orderlies and patient service associates in Toronto (79%) but less than 10% in the Atlantic provinces.

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Health Care Innovation and Quality Assurance

Improving oral health in nursing home residents: A process evaluation of a shared oral care intervention.
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K. Aagaard, G. J. Meléndez-Torres and C. Overgaard.
J Clin Nurs 2020 Jun 13
Aims and objectives: To evaluate the process of implementing an oral care intervention in nursing homes in a Danish municipality. Background: Older people with aged natural dentition require preventive and curative oral health care. An intervention based on principles of situated learning was implemented to establish closer cooperation between dental and nursing staff in nursing homes, leading to improved oral hygiene in nursing home residents. Design: An embedded multiple-case study combined with principles of realist evaluation unfolded in three phases: Formulation of initial programme theory, Testing and Refining the programme theory. The COREQ checklist is followed in reporting. Methods: Observations, six group interviews and 22 face-to-face interviews with dentists, dental practitioners, nursing home managers, care professionals and residents were conducted in three nursing homes (n = 41). Results: Three main outcomes of a programme theory were identified, relating to (a) residents, in the form of new oral care routines; (b) interdisciplinary working, in the form of professional pride in performing sufficient oral care; (c) organisational level changes, in the form of increased interdisciplinary knowledge sharing. The overarching supportive mechanisms were the creation of relationships between residents, dental practitioners and care professionals as well as nursing home management taking responsibility for structure, planning and knowledge sharing. Conclusion: The situated learning perspective supported residents and care professionals’ competencies in performing sufficient oral care. The shared oral care intervention supports an individual and multidisciplinary assessment of nursing home residents’ ability to self-care concerning oral care. Contextual factors, supportive and restraining mechanisms influence the intervention’s success. Relevance to clinical practice: Understanding the complexity within interdisciplinary cooperation in primary nursing and unravelling the necessary properties to enhance nursing home residents’ oral health care are areas of improvement for care service in nursing homes. Keywords: evaluation study; interdisciplinary research; nursing homes; oral health; qualitative research.

Accessing care summaries at point-of-care: Implementation of mobile devices for personal carers in aged care.
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R. E. Brimelow, A. Gibney, S. Meakin and J. A. Wollin.
Health Informatics J 2019 Mar;25(1):126-138
Continued development of mobile technology now allows access to information at the point-of-care. This study was conducted to evaluate the use of one such tool on a mobile device, from the carer perspective. Caregivers across 12 aged-care facilities were supplied mobile devices to access a Picture Care Plan (PCP), a specific tool designed around the role of the personal carer. An anonymous questionnaire was subsequently completed by 85 carers with questions relating to participants’ experience. Perceived helpfulness of the PCP at the point-of-care was high (87%). A significant number of participants believed the use of the PCP increased resident safety and quality of care (76%). Practical components related to the carrying of the device, network speed and the requirement to maintain communication with senior members of staff to ascertain updates were also expressed by participants. Findings suggest that staff are receptive to adoption of mobile devices to access care directives at the point-of-care and that the technology is useful.

Discrepancies between Expected and Actual Implementation: The Process Evaluation of PERS Integration in Nursing Homes.
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F. Chang, A. Eriksson and B. Östlund.
Int J Environ Res Public Health 2020 Jun 14;17(12):E4245. doi: 10.3390/ijerph17124245
Recent studies prove that when implementing new technology technology-driven and one-size-fits-all approaches are problematic. This study focuses on the process of implementing personal emergency response system (PERS) at nursing homes. The aim is to understand why the implementation of PERS has not met initial expectations. Multiple methods were used in two Swedish nursing homes, including document analysis, questionnaires (n = 42), participant observation (67 h), and individual interviews (n = 12). A logic model was used to ascertain the discrepancies that emerged between expected and actual implementation, and the domestication theory was used to discuss the underlying meanings of the discrepancies. The discrepancies primarily focused on staff competence, system readiness, work routines, and implementation duration. Corresponding reasons were largely relevant to management issues regarding training, the procurement systems, individual and collective responsibilities as well as invisible work. The uptake of technology in daily practice is far more nuanced than a technology implementation plan might imply. We point out the importance of preparing for implementation, adjusting to new practices, and leaving space and time for facilitating implementation. The findings will be of use to implementers, service providers, and organizational managers to evaluate various measures in the implementation process, enabling them to perform technology implementation faster and more efficiently.

A Systematic Review of Interventions to Improve Nursing Home to Emergency Department Care Transitions.
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C. J. Gettel, N. Pertsch and E. M. Goldberg.
Ann Longterm Care 2020 Jun;28(2):e12-e19
This study aimed to identify interventions that are effective in improving the transitions of care for patients from nursing homes (NHs) to emergency departments (EDs). A total of 607 studies were identified, from which 19 studies were included for full-text review. Nine pre-post intervention studies and two retrospective cohort studies met all criteria for inclusion. In the quality assessment, two (18.2%) were assessed as good quality; seven (63.6%) were fair; and two (18.2%) were poor. Nine studies (81.2%) had a severe risk of bias, primarily due to confounding and deviation from the intended intervention. Pre-post intervention studies utilized transfer checklists/forms, web-based communication networks, and multimodal approaches to improve transitions of care. Eight studies reported significant improvement in critical NH-ED transfer information completeness after intervention implementation. Three studies assessed health care utilization after intervention implementation with two studies reporting no reduction in utilization and one study reporting decreased 30-day hospital readmission and ED revisit rates. Studies evaluating patient-centered outcomes, such as whether interventions reduced harm to patients by decreasing medical errors, hospital length of stay, or the overall number of facility transfers, are needed.

Restorative Quality Improvement: Novel Application of Six Sigma in a Skilled Nursing Facility.
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H. Johnson.
J Nurs Care Qual 2020 Jun 12
Six Sigma is a quality improvement (QI) method used in hospitals, but not typically in nursing homes (NHs), to reduce service variability and expenditures. LOCAL PROBLEM: The existing QI process for functional maintenance program (FMP) charting/auditing in an urban NH allowed variability and lost revenue. METHODS: A single-group pre/posttest design with analysis of variance and t-test analysis was used to implement Six Sigma for the FMP process. INTERVENTION: Phases of Define, Measure, Analyze, Improve, and Control addressed performance objectives of FMP capacity; staff retention; congruence between prescribed, performed, and charted FMPs; and month-end summaries of resident status on FMPs. RESULTS: With the existing staff, capability was increased by 17 residents ($200 000 revenue) and 90% to 100% charting congruence was achieved. Limited success was attributed to lack of skill diffusion, team communication, manager availability, and project prioritization. CONCLUSIONS: Six Sigma was moderately successful when applied in a single NH for QI.

Implementing e-learning and e-tools for care home staff supporting residents with dementia and challenging behaviour: A process evaluation of the ResCare study using normalisation process theory.
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J. Keenan, F. Poland, J. Manthorpe, C. Hart and E. Moniz-Cook.
Dementia (London) 2020 Jul;19(5):1604-1620
Dementia-related symptoms, sometimes termed challenging or distressing behaviour, can give rise to significant distress in care homes. Individualised formulation-led interventions show promise in reducing these behaviours. ResCare, a cluster randomised controlled trial in England, tested an online individualised intervention, comprising e-learning and decision support e-tools, designed to enable staff to better support residents with such symptoms. Normalisation process theory was used to understand the implementation processes. We analysed contextual process data for all 27 ‘intervention’ care homes and identified three implementation mechanisms. These were examined for four illustrative case study homes. Seven qualitative interviews with care home staff and one interview with two research therapists informed this understanding. The main barrier to implementation was difficulty in conveying a sustained understanding of the value of individually tailored interventions. Emphasis was placed on training rather than practice change. Implementation seemed easier in smaller homes and in those with flexible managerial styles where transfer of knowledge and skill might have been easier to achieve. Take up of e-learning and e-tools proved hard. There may be a need to continually promote ‘buy-in’ of the potential benefits of individualised formulation-led interventions, and this would have to be congruent with other priorities. Interventions within care homes need to consider organisational readiness, capacity for innovation and ongoing appraisal and adjustment to maintain changes in practice.

Inter-Rater Reliability of the Mealtime Scan+.
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H. Keller, S. Awwad, J. Morrison and H. Chaudhury.
J Nutr Health Aging 2019;23(7):623-627
The Mealtime Scan (MTS) was developed to assess the dining environment in Long Term Care (LTC). MTS has been reviewed and updated to ensure its standardization and responsiveness to changes in the dining environment. The objectives of this paper are to provide an overview of the changes made in the new MTS+ tool and to describe its inter-rater reliability. RESEARCH DESIGN AND METHODS: The observational and scoring methods used to evaluate the physical, social, and relational-centered dining environments in LTC homes were reviewed and updated into MTS+ and an overall quality of dining rating derived. Two trained assessors were evaluated for the inter-rater reliability. Nine dining rooms in three LTC homes at different meals were observed for a total of 45 observations. Interclass Correlation Coefficient (ICC) was used to assess reliability. RESULTS: MTS+ demonstrated good reliability on the orientation cues, social environment, and relationship-centered activities (orientation cues ICC: 0.75, social ICC: 0.78, relational ICC: 0.78). However, the tool’s reliability was poor for the physical environment, ICC: 0.48 and moderate for the overall rating of the quality of the dining environment, ICC: 0.67. Discussion and Implications: Although deemed more effective and practical for use in intervention studies, MTS+ has some limitations with respect to its reliability, particularly in assessing the physical environment. It is hypothesized that more extensive training of the assessors may lead to improvements in the reliability of MTS+. MTS+ can be used in intervention research when one assessor completes repeat observations of a dining area.

Impact of training and structured medication review on medication appropriateness and patient-related outcomes in nursing homes: results from the interventional study InTherAKT.
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A. Mahlknecht, L. Krisch, N. Nestler, et al.
BMC Geriatr 2019 Sep 18;19(1):257-019-1263-3
Uncoordinated interprofessional communication in nursing homes increases the risk of polypharmacy and inappropriate medication use. This may lead to augmented frequency of adverse drug events, hospitalizations and mortality. The aims of this study were (1) to improve interprofessional communication and medication safety using a combined intervention and thus, (2) to improve medication appropriateness and health-related outcomes of the included residents. METHODS: The single-arm interventional study (2014-2017) was conducted in Muenster, Germany and involved healthcare professionals and residents of nursing homes. The intervention consisted of systematic education of participating healthcare professionals and of a structured interprofessional medication review which was performed via an online communication platform. The primary endpoint was assessed using the Medication Appropriateness Index MAI. Secondary endpoints were: cognitive performance, delirium, agitation, mobility, number of drugs, number of severe drug-drug interactions and appropriateness of analgesics. Outcomes were measured before, during and after the intervention. Data were analyzed using descriptive and inference-statistical methods. RESULTS: Fourteen general practitioners, 11 pharmacists, 9 nursing homes and 120 residents (n = 83 at all testing times) participated. Overall MAI sum-score decreased significantly over time (mean reduction: -7.1, CI(95%) -11.4 – - 2.8; median = - 3.0; d(Cohen) = 0.39), especially in cases with baseline sum-score ≥ 24 points (mean reduction: -17.4, CI(95%) -27.6 – - 7.2; median = - 15.0; d(Cohen) = 0.86). MAI sum-score of analgesics also decreased (d(Cohen) = 0.45). Mean number of severe drug-drug interactions rose slightly over time (d(Cohen) = 0.17). The proportion of residents showing agitated behavior diminished from 83.9 to 67.8%. Remaining secondary outcomes were without substantial change. CONCLUSION: Medication appropriateness increased particularly in residents with high baseline MAI sum-scores. Cognitive decline of participating residents was seemingly decelerated when compared with epidemiologic studies. A controlled trial is required to confirm these effects. Interprofessional interaction was structured and performance of medication reviews was facilitated as the online communication platform provided unlimited and consistent access to all relevant and updated information. TRIAL REGISTRATION: DRKS Data Management, ID: DRKS00007900 , date of registration: 2015-09-02 (retrospectively registered i.e. 6 weeks after commencement of the first data collection).

Two Decades of Nursing Home Compare: What Have We Learned?
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R. Tamara Konetzka, K. Yan and R. M. Werner.
Med Care Res Rev 2020 Jun 13:1077558720931652
Approximately two decades ago, federally mandated public reporting began for U.S. nursing homes through a system now known as Nursing Home Compare. The goals were to provide information to enable consumers to choose higher quality nursing homes and to incent providers to improve the quality of care delivered. We conduct a systematic review of the literature on responses to Nursing Home Compare and its effectiveness in meeting these goals. We find evidence of modest but meaningful response by both consumers and providers. However, we also find evidence that some improvement in scores does not reflect true quality improvement, that disparities by race and income have increased, that risk-adjustment of the measures is likely inadequate, and that several key domains of quality are not represented. Our results support moderate success of Nursing Home Compare in achieving intended goals but also reveal the need for continued refinement.

Health system decision-makers at the helm of implementation research: development of a framework to evaluate the processes and effectiveness of embedded approaches.
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N. I. Varallyay, E. V. Langlois, N. Tran, V. Elias and L. Reveiz.
Health Res Policy Syst 2020 Jun 10;18(1):64-020-00579-9
Embedded approaches to implementation research (IR), whereby health system decision-makers participate actively in the research process, are gaining traction as effective approaches to optimise the delivery of health programmes and policies. However, the evidence base on the processes and effectiveness of such collaborative research remains inchoate. Standardised approaches to evaluate these initiatives are needed to identify core elements of ’embeddedness’, unveil the underlying pathways of change, and assess contribution to evidence uptake in decision-making and overall outcomes of effect. The framework presented in this paper responds to this need, designed to guide the systematic evaluation of embedded IR. METHODS: This evaluation framework for embedded IR approaches is based on the experience of a joint initiative by the Pan American Health Organization/Alliance for Health Policy and Systems Research, which has supported 19 IR grants in 10 Latin American and Caribbean countries from 2014 to 2017. The conceptualisation of this framework drew on various sources of information, including empirical evidence and conceptual insights from the literature, interviews with content experts, and a prospective evaluation of the 2016 cohort that included semi-structured key informant interviews, document analysis, and a research team survey to examine key aspects of embedded research. RESULTS: We developed a widely applicable conceptual framework to guide the evaluation of embedded IR in various contexts. Focused on uncovering how this collaborative research approach influences programme improvement, it outlines expected processes and intermediate outcomes. It also highlights constructs with which to assess ’embeddedness’ as well as critical contextual factors. The framework is intended to provide a structure by which to systematically examine such embedded research initiatives, proposing three key stages of evidence-informed decision-making – co-production of evidence, engagement with research, and enactment of programme changes. CONCLUSION: Rigorous evaluation of embedded IR is needed to build the evidence on its processes and effectiveness in influencing decision-making. The evaluation framework presented here addresses this gap with consideration of the complexity of such efforts. Its applicability to similar initiatives is bolstered by virtue of being founded on real-world experience; its potential to contribute to a nuanced understanding of embedded IR is significant.

Quality of Nursing Homes and Admission of Residents With Alzheimer’s Disease and Related Dementias: The Potential Influence of Market Factors and State Policies.
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D. Yan, S. Wang, H. Temkin-Greener and S. Cai.
J Am Med Dir Assoc 2020 Jun 18
This study aimed to examine the associations between nursing home (NH) quality and prevalence of newly admitted NH residents with Alzheimer’s disease and related dementias (ADRD), and to assess the extent to which market-level wages for certified nursing assistants (CNAs) and state Medicaid behavioral and mental health add-on policy may influence such associations. DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: The analytical sample included 2777 NHs with either high or low quality, located in urban areas of 41 states from 2011 to 2014. METHODS: The outcome variable was the prevalence of ADRD among newly admitted NH residents. NH quality was defined as dichotomous, based on the Nursing Home Compare (NHC) star rating system. We considered an NH with 5-star rating as having high quality and with 1-star rating as having low quality. Information on county-level CNA wages and state Medicaid behavioral and mental health add-on policies was included. Linear regression models with NH random effects and robust standard errors were estimated. A set of sensitivity analyses were performed. RESULTS: After accounting for NH-level aggregated resident characteristics and market/state-level factors, the prevalence of ADRD among newly admitted residents was 3% lower in high-quality NHs compared with low-quality NHs (P < .01). A 1-dollar increase in CNA hourly wage was associated with a 0.9-percentage point decrease in the prevalence of ADRD among newly admitted residents (P < .01). State Medicaid behavioral and mental health add-on policy was associated with a 2.5-percentage point increase in the prevalence of ADRD in high-quality NHs (P < .05), but not in low-quality NHs. CONCLUSIONS AND IMPLICATIONS: Our findings suggest that high-quality NHs are less likely to admit residents with ADRD. The effect size of this relationship is modest and may be influenced by state Medicaid behavioral and mental health add-on policies. Future studies are needed to better understand reasons leading to these associations so that effective interventions can be developed to incentivize high-quality NHs to more readily serve residents with ADRD.


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Organizational Culture and Change

Qualitative Comparative Analysis: A Mixed-Method Tool for Complex Implementation Questions.
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L. G. Hill, B. R. Cooper and L. A. Parker.
J Prim Prev 2019 Feb;40(1):69-87
The translation and scale-up of evidence-based programs require new methods to guide implementation decisions across varying contexts. As programs are translated to real-world settings, variability is introduced. Some program components may have minor roles to play in producing positive outcomes, and some may have major roles, but only if adapted to meet different contextual demands. While some sources of variability are likely to improve program outcomes, we currently lack methods that allow us to determine the critical components or combinations of components that serve as causal pathways to a desired outcome and then to advise practitioners accordingly. In this paper, we introduce a promising tool for this purpose and illustrate its use in a translational research context. Qualitative Comparative Analysis (QCA) is often used to examine causality in situations that have complex, multiply-determined outcomes. The basic premise of QCA is that different sets of causal conditions, or causal pathways, may lead to a single outcome (the principle of equifinality). We applied QCA to a selection of the highest- and lowest-performing programs from a multi-year two-state dissemination of The Strengthening Families Program for Parents and Adolescents 10-14 to determine which components or combinations of components at the implementation, program delivery, and participant levels produced desired participant outcomes. In particular, we examined which components were necessary (i.e., in the absence of these factors, the outcome didnot occur), and which were sufficient (i.e., in the presence of these factors, the outcome always occurred). Results demonstrated that certain conditions were necessary for program success. In addition, given those necessary conditions, there were two sets of conditions sufficient to produce success, regardless of the presence or absence of any of the others. QCA, not previously used in prevention science research, helps to illuminate causal pathways, leading to concrete, evidence-based implementation decisions that facilitate generalization and scale-up.

Contracting as a bridging factor linking outer and inner contexts during EBP implementation and sustainment: a prospective study across multiple U.S. public sector service systems.
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R. Lengnick-Hall, C. Willging, M. Hurlburt, K. Fenwick and G. A. Aarons.
Implement Sci 2020 Jun 11;15(1):43-020-00999-9
Bridging factors are relational ties (e.g. partnerships), formal arrangements (e.g. contracts or polices) and processes (e.g. data sharing agreements) linking outer and inner contexts and are a recent evolution of the Exploration-Preparation-Implementation-Sustainment (EPIS) framework. Bridging factor research can elucidate ways that service systems may influence and/or be influenced by organizations providing health services. This study used the EPIS framework and open systems and resource dependence theoretical approaches to examine contracting arrangements in U.S. public sector systems. Contracting arrangements function as bridging factors through which systems communicate, interact, and exchange resources with the organizations operating within them. METHODS: The sample included 17 community-based organizations in eight service systems. Longitudinal data is derived from 113 contract documents and 88 qualitative interviews and focus groups involving system and organizational stakeholders. Analyses consisted of a document review using content analysis and focused coding of transcripts from the interviews and focus groups. A multiple case study analysis was conducted to identify patterns across service systems and organizations. The dataset represented service systems that had sustained the same EBP for between 2 and 10 years, which allowed for observation of bridging factors and outer-inner context interactions over time. RESULTS: Service systems and organizations influenced each other in a number of ways through contracting arrangements. Service systems influenced organizations when contracting arrangements resulted in changes to organizational functioning, required organizational responses to insufficient funding, and altered interorganizational network relationships. Organizations influenced service systems when contract arrangements prompted organization-driven contract negotiation/tailoring, changes to system-level processes, and interorganizational collaboration. Service systems and organizations were dependent on each other as implementation progressed. Resources beyond funding emerged, including adequate numbers of eligible clients, expertise in the evidence-based practice, and training and coaching capacity. CONCLUSION: This study advances implementation science by expanding the range and definition of bridging factors and illustrating specific bi-directional influences between outer context service systems and inner context organizations. This study also identifies bi-directional dependencies over the course of implementation and sustainment. An analysis of influence, dependencies, and resources exchanged through bridging factors has direct implications for selecting and tailoring implementation strategies, especially those that require system-level coordination and change.

The Changing Adoption of Culture Change Practices in U.S. Nursing Homes.
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J. C. Lima, M. L. Schwartz, M. A. Clark and S. C. Miller.
Innov Aging 2020 Jun 5;4(3):igaa012
The study aimed to: (i) describe whether culture change (CC) practice implementation related to physical environment, resident-centered care, and staff empowerment increased within the same nursing homes (NHs) over time; and (ii) identify factors associated with observed increases. RESEARCH DESIGN AND METHODS: This was a nationally representative panel study of 1,584 U.S. NHs surveyed in 2009/2010 and 2016/2017. Survey data were merged with administrative, NH, and market-level data. Physical environment, staff empowerment, and resident-centered care domain scores were calculated at both time points. Multivariate logistic regression models examined factors associated with domain score increases. RESULTS: Overall, 22% of NHs increased their physical environment scores over time, 32% their staff empowerment scores, and 44% their resident-centered care scores. However, 32%-68% of NHs with below median baseline scores improved their domain scores over time compared with only 11%-21% of NHs with baseline scores at or above the median. Overall, NHs in states with Medicaid pay-for-performance (with CC components), in community care retirement communities, with special care units and higher occupancy had significantly higher odds of increases in physical environment scores. Only baseline domain scores were associated with increases in staff empowerment and resident-centered care scores. DISCUSSION AND IMPLICATIONS: This is the first nationally representative panel study to assess NH CC adoption. Many NHs increased their CC practices, though numerous others did not. While financial incentives and indicators of financial resources were associated with increase in physical environment scores, factors associated with staff empowerment and resident-centered care improvements remain unclear. Studies are needed to assess whether the observed increases in CC adoption are associated with greater quality of life and care gains for residents and whether there is a threshold effect beyond which the efficacy of additional practice implementation may be less impactful.

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Research Practice and Methodology

Cutting edge or blunt instrument: how to decide if a stepped wedge design is right for you.
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R. Hooper and S. M. Eldridge.
BMJ Qual Saf 2020 Jun 16
The vast majority of stepped wedge trials are cluster randomised, and when people refer to stepped wedge designs this is usually what they have in mind. A cluster randomised trial is a trial in which all the participants at the same site or ‘cluster’ are allocated to the same intervention.

What makes it work? Exploring experiences of patient research partners and researchers involved in a long-term co-creative research collaboration.
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E. Hovén, L. Eriksson, Å. Månsson D’Souza, et al.
Res Involv Engagem 2020 Jun 19;6:33-020-00207-4. eCollection 2020
Exchanging experiences of patient and public involvement (PPI) can bring insights into why, how and when PPI is most effective. The aim of this study was to explore the experiences of patient research partners (PRPs) and researchers engaged in a co-creative long-term collaboration in cancer research. METHODS: The aim and procedures of this study were jointly decided upon by PRPs and researchers. The PRPs included former patients treated for cancer and significant others of the same target group. The participants (11 PRPs, 6 researchers) took part in semi-structured telephone interviews. The interviews were analysed using qualitative content analysis by a researcher who had no prior relationships with the participants. RESULTS: Five overarching categories were identified: Reasons for investing in a long-term collaboration, Benefits of participating, Improving the research, Elements of success and Challenges and ways to improve. Reasons for investing in the collaboration included the desire to improve cancer care and to make use of own negative experiences. Benefits of participating included a positive impact on the PRPs’ psychosocial adjustment to the illness. Moreover, the researchers highlighted that working together with the PRPs made the research feel more meaningful. The participants reported that the collaboration improved the relevance and acceptability of the research. Having a shared goal, a clear but yet accommodating structure, as well as an open and trustful working atmosphere were recognised as elements of success. The PRPs furthermore emphasized the importance of seeing that their input mattered. Among the few challenges raised were the distance to the meeting venues for some PRPs and a limited diversity among participants. CONCLUSIONS: This study identified factors essential to researchers and clinicians attempting to engage the public in research. Our results suggest that for successful patient involvement, the purpose and format of the collaboration should be clear to both PRPs and researchers. A clear but yet accommodating structure and keen leadership emerged as key factors to create a sense of stability and a trustful atmosphere. Furthermore, providing regular feedback on how PRPs input is implemented is important for PRPs to stay committed over time.

Blending Research, Journalism, and Community Expertise: A Case Study of Coproduction in Research Communication.
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Stephen MacGregor and Amanda Cooper.
Science Communication 2020 06/01; 2020/06;42(3):340-368
The patterns of practice characterizing coproduction as an approach to research communication are explored through semistructured interviews with researchers (N = 6), journalists (N = 6), a community liaison (N = 1), and editorial staff (N = 2) who participated in the coproduction of podcasts. Despite various challenges encountered by participants, coproduction was a primarily positive experience that motivated the reexamination of taken-for-granted perceptions about each stakeholder?s role in research communication. Key questions are raised for future research about coproduction in research communication as well as suggestions for stakeholders planning or engaging in coproduction.

A Mixed Methods–Grounded Theory Design for Producing More Refined Theoretical Models.
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Minjung Shim, Burke Johnson, Joke Bradt and Susan Gasson.
Journal of Mixed Methods Research 2020 06/08; 2020/06:1558689820932311
Current literature lacks explication of how traditional grounded theory and mixed methods?grounded theory (MM-GT) are similar/different and specific explication of how to construct MM-GT designs?our purpose is to do this. We illustrate the design process using a published study. Exploratory Phase 1 involves creation of a formative?theoretical model based on multiple implicit or explicit models identified in the literature, which are then combined into a single model using metamodeling integration. Also, in Phase 1, a traditional grounded theory is developed ?independently? using interview data. These two models are integrated into a combined/metamodel at the end of Phase 1. Confirmatory Phase 2 involves testing of the final Phase 1 metamodel using a mixed methods experiment. In Phase 3, the Phase 1 and Phase 2 results are integrated, producing the ?final? metamodel. This article contributes to the field of mixed methods research by showing how to design an MM-GT study that is focused on theory development and testing.

Conducting a Mixed-Methods Study with Older Adults in Five Languages: Lessons from the Field.
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Catherine E. Tong and Joanie Sims-Gould.
Canadian Journal on Aging / La Revue canadienne du vieillissement 2020:1-10
One third of older adults in Canada are foreign-born, yet there is a dearth of literature on this population. When our team set out to engage in a mixed-methods study on the physical activity and mobility of foreign-born older adults (FBOAs), we found limited guidance. The objective of this Research Note is to share the lessons that we learned in implementing a mixed-methods study in five languages, with 49 visible minority FBOAs from diverse ethno-cultural groups. With an emphasis on practical implementation, here we share our reflections on early community engagement, linguistic accessibility and literacy considerations, facilitating communication with the research team, creating a support role for multilingual family members, organisational suggestions, and working with interpreters and monolingual transcribers. The older Canadian population is projected to become increasingly diverse in the coming decades, and it is our hope that this note will further facilitate research in this understudied area.

Building Research Capacity in Nursing Academia in 2020: Is the Road Less Perilous?
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J. E. Tranmer, J. Almost, P. C. Plazas, et al.
Can J Nurs Res 2020 Jun 10:844562120929558
Building research capacity in nursing academic units continues to be a challenge. There are a number of external contextual factors and internal factors that influence individual faculty as well as the collective to engage successfully in research. PURPOSE: The overall aim of this opinion article is to provide an overview of the current external and internal, processes and structures, relevant to capacity of nursing faculty to engage in research. METHODS: To inform the external context, we reviewed national research funding trends for nursing. To inform the internal context, we provided an exemplar of the internal processes and structures designed to support research capacity building within our academic unit. RESULTS: Canadian Institutes of Health Research funding trends for research grants led by nurse principal applicants increased between 2010 and 2013, followed by a steady decline. In 2017 to 2018, there were only 24 research grants led by nurse principal applicants. These external challenges coupled with the traditional internal barriers, such as the imbalance between teaching and research time, threaten research capacity for nursing academics. CONCLUSION: Organizational strategies to promote research capacity within academic nursing units are a necessary requirement to move forward.

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Timely Psychosocial Interventions in Dementia Care
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Jill Manthorpe, Esme Moniz-Cook, and Helen Rochford-Brennan
This new edited volume seeks to meet the growing need for ways to support people with dementia across the whole course and trajectory of dementia care, with a wide scope of expertise.

The book addresses how professionals, carers and families can apply psychosocial interventions – which take into consideration the individual, social and environmental aspects of a person’s life – across this trajectory, right from the earliest stages through to practice in care home settings.

Divided into four sections, each covers a different context in which people with dementia can be supported: at home; in community settings; family and carer support; and those in care homes and hospitals. In addition, there is a distinct focus throughout on evidence-based practice and its implementation in real-world settings. This book is essential reading for any professional, carer or family member wanting to support people with dementia.

Rehabilitation After Hip Fracture for Nursing Home Residents: A Controlled Feasibility Trial.
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L. A. Beaupre, J. S. Magaziner, C. A. Jones, et al.
J Gerontol A Biol Sci Med Sci 2019 Aug 16;74(9):1518-1525
This study compared functional outcomes at 3 months after hip fracture surgery between nursing home residents participating in a 10-week outreach rehabilitation program and those receiving usual care. Function, health-related quality of life, and mortality were also compared over 12 months, and outreach program feasibility was assessed. METHODS: A feasibility trial was undertaken in Canadian nursing homes; of 77 participants, 46 were allocated to Outreach and 31 to Control prior to assessing function or cognition. Outreach participants received 10 weeks of rehabilitation (30 sessions), and Control participants received usual posthospital fracture care in their nursing homes. The primary outcome was the Functional Independence Measure Physical Domain (FIMphysical) score 3 months post-fracture; we also explored FIM Locomotion and Mobility. Secondary outcomes were FIM scores, EQ-5D-3L scores, and mortality over 12 months. Program feasibility was also evaluated. RESULTS: The mean age was 88.7 ± 7.0 years, 55 (71%) were female, and 58 (75%) had severe cognitive impairment with no significant group differences (p > .14). Outreach participants had significantly higher FIM Locomotion than usual care (p = .02), but no significant group differences were seen in FIMphysical or FIM Mobility score 3 months post-fracture. In adjusted analyses, Outreach participants reported significant improvements in all FIM and EQ-5D-3L scores compared with Control participants over 12 months (p < .05). Mortality did not differ by group (p = .80). Thirty (65%) Outreach participants completed the program. CONCLUSIONS: Our feasibility trial demonstrated that Outreach participants achieved better locomotion by 3 months post-fracture compared with participants receiving usual postfracture care; benefits were sustained to 12 months post-fracture. In adjusted analyses, Outreach participants also showed sustained benefits in physical function and health-related quality of life.

Can cognitive-motor training improve physical functioning and psychosocial wellbeing in nursing home residents? A randomized controlled feasibility study as part of the PROCARE project.
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L. L. Bischoff, T. Cordes, C. Meixner, D. Schoene, C. Voelcker-Rehage and B. Wollesen.
Aging Clin Exp Res 2020 Jun 14
A multi-component training program holds promises for the elderly, but still has to be tested on its feasibility and effect in nursing homes. AIMS: The aim of this study was (1) to design a multi-component training program which improves physical functioning and psychosocial wellbeing and (2) to evaluate the feasibility of this intervention in nursing home residents. METHODS: This study is a two-arm, stratified-randomized controlled feasibility trail. Twenty-four nursing home residents (aged 83.7 ± 6.4, 21 women) were divided into an intervention and a waiting-list control group. The intervention group completed a multi-component training (including dual-task, dynamic balance, endurance and strength exercises) for 16 weeks (twice per week for 45-60 min). Primary outcomes were lower extremity functionality (SPPB), gait performance (GAITRite), health-related quality of life (SF-12) as well as life satisfaction (SWLS). RESULTS: Life satisfaction (SWLS) and physical functioning (SPPB) increased in the intervention group after training whereas the control group showed a decrease. Gait parameters could only be analyzed for n = 5 participants of the intervention group and n = 2 of the control group and showed no time differences for the intervention group. The mean number of participants was 12.5 ± 1.9 per session (attendance ranged between 66% and 90%). CONCLUSION: A multi-component training seems (1) to lead to clinically relevant improvements in physical functioning as well as in psychosocial wellbeing and (2) to be feasible and well accepted in nursing home residents. Nevertheless, the complexity and progression of the program as well as the testing protocol have to be adapted. Further research should test the effectiveness of this adapted program in a larger sample size.

Is music-with-movement intervention better than music listening and social activities in alleviating agitation of people with moderate dementia? A randomized controlled trial.
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D. S. K. Cheung, C. K. Y. Lai, F. K. Y. Wong and M. C. P. Leung.
Dementia (London) 2020 Jul;19(5):1413-1425
Interactive music intervention is generally perceived as more effective on clinical outcomes than a receptive approach because it can better engage the people with dementia. The aim of this study is to compare the effects of the 6-week music-with-movement intervention on agitation of people with moderate dementia, music listening and social activity. METHODS: A multi-centre randomized controlled trial was conducted on 165 nursing home residents with moderate dementia. The participants were randomly allocated into three groups: music-with-movement, music listening or social activities groups. Participants in the music-with-movement group listened to preferred music and moved their body parts for 45 minutes, twice a week for 6 weeks. While the participants in the music listening group only listened to their preferred music and social activity group chatted with the other group members. The agitation level was examined with the Chinese Cohen-Mansfield Agitation Inventory – Nursing Home version. Total scores and sub-scores (physically aggressive, physical non-aggressive, verbal aggressive and verbal non-aggressive) were compared at baseline, at post-intervention and 6 weeks post-intervention. RESULTS: The results showed that there are no significant differences in agitation among three groups. Repeated measures univariate analyses revealed that all three groups yielded significant improvement in agitation from baseline to post-intervention, of which music-with-movement presented the largest effect size. CONCLUSION: This study showed that interactive or receptive type of music intervention or social activities may be helpful in managing agitation although there is no statistically significant difference among them.

Effects of non-facilitated meaningful activities for people with dementia in long-term care facilities: A systematic review.
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C. Jones, D. F. Liu, M. J. Murfield and P. W. Moyle.
Geriatr Nurs 2020 Jun 20
This systematic review sought to evaluate the effectiveness of non-facilitated meaningful activities for older people with dementia in long-term care facilities. Searches were conducted in PubMed; CINAHL; EMBASE; Web of science; PsycINFO; Cochrane; ProQuest; and ClinicalTrials.gov to identify articles published between January 2004 and October 2019. A total of six studies were included. Results implied that current randomised controlled trials or controlled trials about non-facilitated meaningful activities for people with living dementia in long-term care facilitates are limited, but those included in this review were of adequate methodological quality. Meaningful non-facilitated activities, such as music, stimulated family presence, animal-like social robot PARO/plush toy and lifelike dolls, may have beneficial effects on agitation, emotional well-being, feelings of pleasure, engagement, and sleep quality. However, there remains a lack of conclusive and robust evidence to support these psychological and physiological effects of non-facilitated meaningful activities for older people with dementia living in long-term care facilities by care staff.

Becoming or Remaining Agitated: The Course of Agitation in People with Dementia Living in Care Homes. The English Longitudinal Managing Agitation and Raising Quality of Life (MARQUE) Study.
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L. Marston, G. Livingston, A. Laybourne and C. Cooper.
J Alzheimers Dis 2020 Jun 8
Care home residents with dementia often have accompanying agitation. We investigated agitation’s course at 5 time-points in 1,424 people with dementia over 16 months in 86 English care homes. We categorized baseline agitation symptoms on the Cohen-Mansfield Agitation Inventory (CMAI) into none (CMAI = 29; 15%), subclinical (CMAI = 30-45; 45%), or clinically-significant (CMAI > 45; 40%). 88% of those with no agitation at baseline remained free of clinically-significant agitation at all follow-ups. Seventy percent of those exhibiting clinically-significant agitation at baseline had clinically-significant agitation at some follow-ups. Over a 16-month observation period, this study finds many care home residents with dementia never develop clinically significant agitation and interventions should be for treatment not prevention.

High Prevalence of Multidrug-Resistant Organism Colonization in 28 Nursing Homes: An “Iceberg Effect”.
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J. A. McKinnell, L. G. Miller, R. D. Singh, et al.
J Am Med Dir Assoc 2020 Jun 15
Determine the prevalence of methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus spp. (VRE), extended-spectrum beta-lactamase producing organisms (ESBLs), and carbapenem-resistant Enterobacteriaceae (CRE) among residents and in the environment of nursing homes (NHs). DESIGN: Point prevalence sampling of residents and environmental sampling of high-touch objects in resident rooms and common areas. SETTING: Twenty-eight NHs in Southern California from 2016 to 2017. PARTICIPANTS: NH participants in Project PROTECT, a cluster-randomized trial of enhanced bathing and decolonization vs routine care. METHODS: Fifty residents were randomly sampled per NH. Twenty objects were sampled, including 5 common room objects plus 5 objects in each of 3 rooms (ambulatory, total care, and dementia care residents). RESULTS: A total of 2797 swabs were obtained from 1400 residents in 28 NHs. Median prevalence of multidrug-resistant organism (MDRO) carriage per NH was 50% (range: 24%-70%). Median prevalence of specific MDROs were as follows: MRSA, 36% (range: 20%-54%); ESBL, 16% (range: 2%-34%); VRE, 5% (range: 0%-30%); and CRE, 0% (range: 0%-8%). A median of 45% of residents (range: 24%-67%) harbored an MDRO without a known MDRO history. Environmental MDRO contamination was found in 74% of resident rooms and 93% of common areas. CONCLUSIONS AND IMPLICATIONS: In more than half of the NHs, more than 50% of residents were colonized with MDROs of clinical and public health significance, most commonly MRSA and ESBL. Additionally, the vast majority of resident rooms and common areas were MDRO contaminated. The unknown submerged portion of the iceberg of MDRO carriers in NHs may warrant changes to infection prevention and control practices, particularly high-fidelity adoption of universal strategies such as hand hygiene, environmental cleaning, and decolonization.

A qualitative exploration of family carer’s understandings of people with dementia’s expectations for the future.
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S. T. Read, C. Toye and D. Wynaden.
Dementia (London) 2020 Jun 17:1471301220929543
There is little evidence that outlines how family carers understand the person with dementia’s perspective, values and anticipated future needs. Whilst people with dementia should be consulted about their own quality of life and care values, carers – otherwise known as care partners – require such understandings to ensure that the support the person receives into the future upholds their quality of life and is consistent with what they desire. AIM: This research aimed to explore and describe family carers’ experience of supporting the person with dementia to maintain their quality of life by understanding how carers developed an awareness and understanding of the person with dementia’s expectations for the future and what they believed was important for the person to whom they provided care. METHOD: Using an application of the grounded theory method, data were collected from 21 carers during semi structured interviews and analysed using constant comparative analysis. FINDINGS: Four categories emerged from the data: Knowing the person, Process of decision making, Maintaining normalcy and quality of life and Out of their control. DISCUSSION: This study provides insights into how carers developed awareness of the expectations of people with dementia. Findings also illuminate carers’ perspectives of the changing nature of decision making during the dementia trajectory. CONCLUSION: Understanding the perspective of the person living with dementia is essential to facilitate advocacy and support that is ‘person centred’ now and into the future. Assisting carers to incorporate this perspective into caring has the potential to be better facilitated by health professionals and merits further investigation.

Self-Feeding Ability as a Predictor of Mortality Japanese Nursing Home Residents: A Two-Year Longitudinal Study.
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M. Sakamoto, Y. Watanabe, A. Edahiro, et al.
J Nutr Health Aging 2019;23(2):157-164
To examine the ability of different elements of the Self-Feeding Assessment Tool for Elderly with Dementia (SFED) to predict mortality risk in nursing home residents. DESIGN AND SETTING: Data from 387 residents in five nursing homes for the elderly in Japan were obtained using a baseline survey. This measure’s ability to predict mortality risk was examined over a two-year observation period. Participants and Measurement: Demographic information (sex, age, height, weight, medical history) on 387 initial participants was gathered. A total of 10 individuals were excluded from the analysis because of the inability to eat by mouth at baseline, while 36 were excluded owing to missing mortality data during the observation period. The resulting 341 residents were divided into a death group or survival group according to whether they were still alive after two-year observation period. In addition to basic information and the SFED, the baseline survey included the Barthel Index (BI), Clinical Dementia Rating (CDR), and Mini Nutritional Assessment-Short Form (MNA®-SF). The ability of SFED to predict time-to-event mortality was examined using Cox proportional hazards regression analysis, including other measures associated with mortality as confounding variables. RESULTS: In total, 129 participants (37.8%) died during the observation period, and their mean SFED score was significantly lower than that of surviving ones (11.1 ± 6.7 vs. 15.0 ± 5.6, P<0.001). SFED score was significantly associated with two-year mortality in the Cox proportional hazards regression analysis after adjusting for sex, age, medical history, BI, CDR, and MNA®-SF (hazard ratio = 0.941, 95% confidence interval = 0.898-0.985, P = 0.010). Additionally, three SFED categories were significantly associated with mortality risk: movement (“able to eat without dropping food”), concentration (“able to maintain attention to meal”), and safety (“able to swallow without choking, with no change in vocal quality after eating”). CONCLUSIONS: Self-feeding ability as measured by SFED score was associated with long-term mortality in elderly living in nursing homes. Accordingly, adjusting feeding assistance based on regular SFED-based assessments may help maintain self-feeding ability and enhance quality of life in this population, as well as providing evidence for end-of-life care options and greatly improving care quality.

Does Living in a Higher Proportion Minority Facility Improve Quality of Life for Racial/Ethnic Minority Residents in Nursing Homes?
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T. P. Shippee, W. Ng and J. R. Bowblis.
Innov Aging 2020 Jun 5;4(3):igaa014
The proportion of racial/ethnic minority older adults in nursing homes (NHs) has increased dramatically and will surpass the proportion of white adults by 2030.Yet, little is known about minority groups’ experiences related to the quality of life (QOL). QOL is a person-centered measure, capturing multiple aspects of well-being. NH quality has been commonly measured using clinical care indicators, but there is growing recognition for the need to include QOL. This study examines the role of individual race/ethnicity, facility racial/ethnic composition, and the interaction of both for NH resident QOL. RESEARCH DESIGN AND METHODS: We used a unique state-level data set that includes self-reported QOL surveys with a random sample of long-stay Minnesota NH residents, using a multidimensional measure of QOL. These surveys were linked to resident clinical data from the Minimum Dataset 3.0 and facility-level characteristics. Minnesota is one of the two states in the nation that collects validated QOL measures, linked to data on resident and detailed facility characteristics. We used mixed-effects models, with random intercepts to model summary QOL score and individual domains. RESULTS: We identified significant racial disparities in NH resident QOL. Minority residents report significantly lower QOL scores than white residents, and NHs with higher proportion minority residents have significantly lower QOL scores. Minority residents have significantly lower adjusted QOL than white residents, whether they are in low- or high-minority facilities, indicating a remaining gap in individual care needs. DISCUSSION AND IMPLICATIONS: The findings highlight system-level racial disparities in NH residents QOL, with residents who live in high-proportion minority NHs facing the greatest threats to their QOL. Efforts need to focus on reducing racial/ethnic disparities in QOL, including potential public reporting (similar to quality of care) and resources and attention to provision of culturally sensitive care in NHs to address residents’ unique needs.

Oral Health in Nursing Homes: what we Know and what we Need to Know.
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A. M. F. Sifuentes and K. L. Lapane.
J Nurs Home Res Sci 2020;6:1-5
A “silent epidemic” of oral diseases is afflicting older adults. Older adults develop coronal caries at “approximately one new cavity per year”. Despite the rapidly growing older adult population, no recent data exist for adults aged ≥ 75 years. Oral disease impacts physical, psychological, and social well-being through pain, diminished function, and reduced quality of life. People of color disproportionately experience oral disease, yet little is known about racial/ethnic disparities in older adults. In the United States, the Health and Human Services Oral Health Strategic Framework proposed concrete steps to eliminate oral health disparities. Notably absent from this strategic plan is explicit consideration of nursing home residents. In the United States, federal regulations require nursing homes to evaluate oral health needs and facilitate access to dental care. Compliance to the regulations is unknown. Data are urgently required to provide essential information for program planning and evaluation on “racial and ethnic minorities, rural populations, and the frail elderly”.

Well-being in elderly long-term care residents with chronic mental disorder: a systematic review.
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E. van der Wolf, S. A. H. van Hooren, W. Waterink and L. Lechner.
Aging Ment Health 2019 Mar;23(3):287-296
One of the most important objectives of care for older long-term care residents with chronic mental disorders is to facilitate well-being. This review provides an overview of research literature on well-being in this population. METHOD: A systematic review was conducted using Pubmed, PsycINFO and PsycARTICLES for all studies up until March 2016. Three reviewers independently assessed the eligibility of the publications and made a selection. RESULTS: From a total of 720 unique search results, ten studies were deemed eligible. Specialized care, specifically the presence of mental health-workers was associated with increased well-being outcomes. Perceived amount of personal freedom was also related to higher well-being, whereas stigmatization and depression were related to reduced well-being. Size of residence, single or group-accommodation or moving to another locationdid not, however, seem to have an impact on well-being. CONCLUSION: Specialized care, aimed at psychiatric disorders and extra attention for depressed residents are useful tools to promote well-being. Additionally, themes like personal freedom and stigmatization should be taken into consideration in the care for older long-term care residents with chronic mental disorder. However, as very little research has been conducted on this topic, conclusions should be interpreted with caution. More research is highly desirable.

Assessment of changes in place of death of older adults who died from dementia in the United States, 2000-2014: a time-series cross-sectional analysis.
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W. Xu, C. Wu and J. Fletcher.
BMC Public Health 2020 Jun 11;20(1):765-020-08894-0
As the mortality attributable to dementia-related diseases in the United States escalates, providing quality and equitable end-of-life care for dementia patients across care settings has become a major public health challenge. Previous research suggests that place of death may be an indicator of quality of end-of-life care. This study aims to examine the geographical variations and temporal trends in place of death of dementia decedents in the US and the relationships between place of death of dementia decedents and broad structural determinants. METHODS: Using nationwide death certificates between 2000 and 2014, we described the changes in place of death of dementia decedents across states and over time. Chi-square test for trend in proportions was used to test significant linear trend in the proportion of dementia decedents at difference places. State fixed effects models were estimated to assess the relationships between the proportion of dementia decedents at difference places and state-level factors, particularly availability of care facility resources and public health insurance expenditures. RESULTS: Dementia decedents were more likely to die at home and other places and less likely to die at institutional settings over the study period. There was wide inter-state and temporal variability in the proportions of deaths at different places. Among state-level factors, availability of nursing home beds was positively associated with rates of nursing home/long term care deaths and negatively associated with rates of home deaths. Medicaid expenditure on institutional long term supports and services was positively associated with rates of nursing home/long term care deaths and negatively associated with rates of home deaths. Medicaid expenditure on home and community based services, however, had a positive association with rates of home deaths. CONCLUSIONS: There was a persistent shift in the place of death of dementia decedents from institutions to homes and communities. Increased investments in home and community based health services may help dementia patients to die at their homes. As home becomes an increasingly common place of death of dementia patients, it is critical to monitor the quality of end-of-life care at this setting.


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Events & Training Opportunities

Identifying reproductive health priorities and factors promoting women’s satisfaction with HIV care in Canada: Fuzzy Cognitive Maps as an Integrated Knowledge Translation tool
Engaging patient and public partners in a scoping review on the science and practice of James Lind Alliance Priority Setting Partnerships (2 presentations)

Thursday 9 July 10:00-11:00
Presenters: Lisa Knisley & Amanda Wurz
Learning objectives:
By the end of this presentation the audience will be able to:
1. Describe the basic properties of Fuzzy Cognitive Maps,
2. Describe the process of stakeholder engagement using Fuzzy Cognitive Maps,
3. Explain the role of Fuzzy Cognitive Maps in Integrated Knowledge Translation.

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Charting a course for team success: the team charter

Tips for Ombudsman Program Communication with Residents, Long-Term Care Facilities, Families, and the Public During COVID-19

How to collaborate using only email

What Hollywood can teach researchers about scientific storytelling
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CMS Announces Membership of Independent Coronavirus Commission on Safety and Quality in Nursing Homes

Is Canada ready for the second wave of COVID-19?

The Quest to Solve Problems Before They Happen

Using Research to Enhance Knowledge of Nursing Home Quality and Safety

Women and minority researchers have more original ideas, but white men are rewarded faster. How many trailblazers have been sidelined?

81% of COVID-19 deaths in Canada were in long-term care – nearly double OECD average

Pandemic exposes need to overhaul funding of hospice care

Confinement and toxic boredom plagued long-term care before COVID-19

Ontario to Resume Family Visits in Long-Term Care Homes, Retirement Homes, and Other Residential Care Setting

The Lancet’s editor: ‘The UK response to coronavirus is the greatest science policy failure for a generation’

The Pandemic Claims New Victims: Prestigious Medical Journals

Mary Ito moved into a seniors’ home to care for her parents. Within days they died, and she too had COVID-19

Older Adults May Be Left Out of Some Covid-19 Trials

‘They Just Dumped Him Like Trash’: Nursing Homes Evict Vulnerable Residents

Covid-19 and lack of linked datasets for care homes

Pandemic lockdown holding back female academics, data show

Increasing Middle Managers’ Commitment to Innovation Implementation: An Agenda for Research

If Not Now, When? the Role of Geriatric Leadership as Covid-19 Brings the World to Its Knees
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Research Associate for a rapid realist review of community pharmacy support for the public health agenda during the COVID-19 pandemic and future health emergencies

Aston University Main Campus, Birmingham UK
This is an exciting opportunity for someone with experience of applied health research to join an interdisciplinary team working on an externally funded (by a major UK funder) realist review. The review, aims to understand how community pharmacy can support the public health agenda during the COVID-19 pandemic and other similar future health emergencies. Members of the team have unrivalled expertise in realist approaches and so the successful applicant stands to gain unparalleled experience in this novel and increasingly used approach.

Health Data Research Network Canada – Public Advisory Committee

HDRN Canada is committed to including members of the public in decisions about health data through its Public Advisory Council (PAC). We are currently inviting people to apply to be part of the 12-15 person PAC. Our objective is to establish a council of members with diverse experiences related to geography, age, gender identity, occupation, language, culture, ethnicity and other characteristics.

HDRN Canada is a network of leading federal, provincial and territorial organizations that hold and manage health data. HDRN Canada was created to connect individuals and organizations across the country to increase the ways that health data are used for public benefit, while protecting privacy and ensuring research is aligned with public values and Indigenous data sovereignty.

The PAC will meet at least 5 times per year, with the opportunity to participate in additional work. If selected to be a member of the PAC, your responsibilities would include:

Advising HDRN Canada about public perspectives on short-term, medium-term, and long-term priorities
Identifying and discussing potential new datasets that, from the perspective of members of the public, may be priorities for HDRN Canada
Helping HDRN Canada communicate and engage with members of the public outside of the PAC

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