September 13, 2022


New article by Matthias Hoben, Anna Beeber, and Ruth Anderson
A Cross-Sectional, Correlational Study Comparing Individual Characteristics of Younger and Older Nursing Home Residents Using Western Canadian Resident Assessment Instrument: Minimum Data Set (RAI-MDS) 2.0
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Shieu BM, Toles M, Hoben M, Schwartz TA, Beeber AS, Anderson RA.
Journal of the American Medical Directors Association. 2022 Sep.
ObjectiveTo compare characteristics of nursing home (NH) residents by age categories in Western Canada.

New report on dementia in Canada
Navigating the Path Forward for Dementia in Canada

Alzheimer Society Canada; 2022
In Canada, over 600,000 people from British Columbia to Nunavut to Newfoundland and Labrador are living with dementia. People who live with Alzheimer’s dementia*, vascular dementia, and other forms of dementia (including young-onset dementia) and their family and friends are all deeply affected by the cognitive decline, memory loss, changes in mood and behaviour, and loss of functional abilities that can occur. There is some hopeful news on reducing risk and delaying the onset of dementia. However, population aging in Canada means we will continue to see ongoing increases in the number of people affected by dementia. While we have made progress in the last decade to better address this brain condition, much more work needs to be done. With this report, we aim to achieve the following:
1. Clarify the path forward. The first objective of this report is to update public knowledge of dementia numbers across Canada and how we expect these counts to change over the next 30 years.
2. Improve knowledge. Dementia is a complex condition with many established risk factors. This report aims to break down the complexity and highlight key areas for risk reduction.
3. Advocate for individuals, families, care partners, and service providers. Most individuals who develop dementia do not face the challenge alone. Family, friends and neighbours often help support people living with dementia. The people contributing both formal and informal care need support and resources.
4. Create action. Inspire individuals, researchers, health-care providers, funding agencies, and the various levels of governments to support and work toward programs and policies that promote better brain health for all.
5. Push for change. There is a need for action: more dollars for research, changes to our care systems, recognizing and reducing discrimination, stigma and stereotypes, and implementing equitable solutions for the challenges that come with the onset of dementia.

New Canadian article on impact of COVID on LTC staff and managers
COVID-19 pandemic or chaos time management: first-line worker shortage – a qualitative study in three Canadian Provinces.
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Beogo I, Bationo NJC, Sia D, Collin S, Kinkumba Ramazani B, Létourneau AA, et al.
BMC Geriatr. 2022 Sep 3;22(1):727.
BACKGROUND: Over the successive waves of the COVID-19 pandemic, front-line care workers (FLCWs) -in this case, at long-term care facilities (LTCFs)- have been the backbone of the fight. The COVID-19 pandemic has disproportionately affected LTCFs in terms of the number of cases, deaths, and other morbidities, requiring managers to make rapid and profound shifts. The purpose of this study is to describe the effects of the pandemic on LTCF services offered and LTCFs staff dedicated to linguistic minorities in three Canadian provinces. METHODS: This qualitative descriptive study involved eleven managers and fourteen FLCWs, from six LTCFs of three Canadian provinces (New-Brunswick, Manitoba and Quebec). A qualitative content analysis was performed to identify key themes describing the effects of the COVID-19 pandemic on the services offered and the management of LTCFs staff. RESULTS: Based on participants’ experiences, we identified three main categories of themes. These macro-themes are as follows: (i) organization and management of staff, (ii) communication and decision-making method, and (iii) staff support. CONCLUSION: The study highlighted the tremendous impact of COVID-19 on direct care staff in terms of the high risks associated with caring for LTCFs residents, which are exacerbated by absences and resignations (sometimes up to 50% of staff), resulting in higher resident to FLCWs ratios. Team members had to support each other, they also received accolades and appreciation from the residents.. Finally, the pandemic led to the rethinking of management procedures centred on a coordinated, inclusive and more hands-on management approach.

New report on US home care workers, residential care aides, and nursing assistants in nursing homes
Direct Care Workers in the United States: Key Facts

PHI; September 6, 2022
Direct Care Workers in the United States: Key Facts provides a new annual snapshot of the direct care workforce, including its demographics, occupational roles, job quality challenges, and projected job openings. The report includes detailed overviews of three segments of this workforce: home care workers, residential care aides, and nursing assistants in nursing homes.

New report on features that can facilitate more successful early interventions
What successful early intervention looks like across the service system

Centre for Evidence and Implementation
Prepared for the Victorian Department of Treasury & Finance.2020.
In this paper, we explore the features of successful early intervention systems and ways in which the Early Intervention Investment Framework can be leveraged or strengthened to foster these features in the Victorian early intervention system. We conclude that to transition to a more balanced service system there’s a need for the early intervention system to be expanded and strengthened. We identify seven measures that are necessary for this to be achieved. These are:
-Funding that enables collective early intervention across the system
-Sourcing evidence on ‘what works’ in early intervention
-Guidance and capacity to implement ‘what works’
-Practices and support to de-implement what does not work
-Person-centred approaches that drive service innovation
-Integrated cross-government data systems to drive investment, and
-Embedded data systems that enable quality outcome measurement and evaluation.

New model on scaling up EBP
Intensification of implementation strategies: Developing a model of foundational and enhanced implementation approaches to support national adoption and scale-up.
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Hughes JM, Zullig LL, Choate AL, Decosimo KP, Wang V, Van Houtven CH, et al.
Gerontologist. 2022 Aug 27;gnac130.
Implementation strategies are activities to support integration of evidence-based programs (EBPs) into routine care. Comprised of 170+ facilities, the Veterans Affairs (VA) Healthcare System is conducive to evaluating feasibility and scalability of implementation strategies on a national level. In previous work evaluating implementation of three EBPs for older Veterans (hospital-based walking, caregiver skills training, group physical therapy), we found facilities varied in their need for implementation support, with some needing minimal guidance and others requiring intensive support. Committed to national scalability, our team developed an implementation intensification model consisting of foundational (low-touch) and enhanced (high-touch) implementation support. This Forum article describes our multi-level and multi-step process to develop and evaluate implementation intensification. Steps included: (1) Review completed trial data; (2) Conduct listening sessions; (3) Review literature; (4) Draft foundational and enhanced implementation support packages; (5) Iteratively refine packages; and, (6) Devise an evaluation plan. Our model of implementation intensification may be relevant to other healthcare systems seeking strategies that can adapt to diverse delivery settings, optimize resources, help build capacity, and ultimately enhance implementation outcomes. As more healthcare systems focus on spread of EBPs into routine care, identifying scalable and effective implementation strategies will be critical.

New article on readiness and implementation
Readiness as a precursor of early implementation outcomes: an exploratory study in specialty clinics.
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Livet M, Blanchard C, Richard C.
Implement Sci Commun. 2022 Sep 3;3(1):94.
BACKGROUND: Readiness has been identified as an essential precursor of successful implementation. However, evidence supporting its value is sparse. Empirical studies exploring the relationship between the application of readiness interventions, readiness levels, and implementation outcomes are lacking. The purpose of this study was twofold: (1) to evaluate the effectiveness of a readiness intervention (based on increases in readiness levels, changes in early implementation outcomes (i.e., acceptability, appropriateness, feasibility, and intent to adopt), and qualitative insights into the types of perceived outcomes) and (2) to assess the role of readiness as a predictor of these early implementation outcomes. METHODS: Seven healthcare specialty clinics engaged in a structured process to assess and build readiness for implementing a comprehensive medication management (CMM) service over a 10-month period. A mixed methods approach, which included surveys with healthcare stakeholders at each clinic (N = 27) and interviews with the lead pharmacists (N = 7), was used to evaluate the effectiveness of the readiness intervention (aim 1). Survey data were also used to conduct multiple regression models to assess the role of readiness as a predictor of early acceptability, appropriateness, feasibility, and intent to adopt CMM (aim 2). RESULTS: Significantly higher readiness levels, as well as higher scores on acceptability, appropriateness, feasibility, and intent to adopt, were reported as a result of engaging in the readiness intervention. However, upon closer examination, the direction of this association seemed to be dependent on the type of clinic. Qualitative data on the types of perceived outcomes resulting from engaging in the readiness intervention provided further insights into the potential reasons for these findings. Furthermore, post-readiness levels predicted between 44 and 68% of the variance in the early implementation outcomes. When accounting for clinic membership, readiness remained critical for service acceptability, feasibility, and intent to adopt but not for appropriateness. CONCLUSION: These findings provide insights into the relationship between use of a readiness intervention, readiness levels, and early implementation outcomes. Engaging healthcare settings in a readiness intervention was beneficial in ways more complex than a simple positive linear relationship, highlighting the opportunity to broaden its purpose and expand definitions of readiness success. In addition, the importance of readiness levels in predicting early implementation outcomes, while critical, also seems to be highly dependent on context, particularly for appropriateness (fit).

New article on facilitation
Facilitation as a component of evidence implementation: a multinational perspective
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Lizarondo L, McArthur A, Moola S, Albornos-Muñoz L, Badeaux J, Bennett M, et al.
JBI Evidence Implementation 2022;20(3).
Background: Facilitation is a key component of JBI’s approach to evidence implementation along with context analysis and evaluation of process and outcomes. Although the role of facilitation is recognized as a critical component of evidence implementation, what constitutes effective facilitation is poorly understood. Aim: This article presents a descriptive exploration of facilitation as it occurs in evidence implementation initiatives conducted in various healthcare and geographical contexts. All projects used the JBI approach to evidence implementation. Methods: To provide a multinational perspective on how facilitation was operationalized to promote positive changes in clinical practice and health outcomes, five case studies of evidence implementation projects are presented. Results: The cases highlighted that facilitation is a multifaceted process that can be met through a variety of roles that address aspects of education and capacity building, partnerships, action planning, problem solving and evaluation. Facilitation in all cases appeared to be collaborative, with multiple ‘players’ within and outside of the health organization being involved in the process. Although there are similarities in activities, facilitation involved some level of local contextualization where there were unique or additional activities performed to accommodate the local needs and requirements of the health organization involved in each case. Numerous contextual factors influenced the success of the implementation initiative. Conclusion: The cases emphasized the complex nature of facilitation as a strategy for evidence implementation, indicating that contextual attributes and features define the range of knowledge, skills, and activities that should take place in order for facilitation to be effective. Although there appears to be some core components, tailoring and adaptation of the facilitation process (or roles) is required.

New article on the emotional experience of QI
Quality improvement as a primary approach to change in healthcare: a precarious, self-limiting choice?
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Mandel KE, Cady SH.
BMJ Qual Saf. 2022 Jul 28;bmjqs-2021-014447.
Total quality management activities have produced undeniable positive results. However, I predict that the way these activities are implemented will lead to the programs becoming self-limiting…seeds for the deterioration of total quality management lie in the very practices that today produce successful outcomes. (Chris Argyris, professor of organizational behavior, Harvard Business School). Argyris’s contention above begs the question: Is quality improvement as a primary approach to change in healthcare potentially self-limiting? Our viewpoint is yes, particularly when fundamental underpinnings and mental models are not continually surfaced and challenged. We propose two imbalances underlie why quality improvement as a primary approach to change in healthcare can become self-limiting: prioritising performance (improving organisational-level quality measures) over participants’ (improvement leaders, facilitators, team members) emotional experience, and privileging process-technical over sociobehavioural design elements. Contributing to these imbalances are performance-driven cultures (eg, ‘zero-harm’ goals), pacesetting leadership styles, and environmental and organisational pressures for rapid, substantial improvement.

New Canadian article on violence in NHs
Conceptualizing violence in nursing home policy: A citizenship perspective
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Novek S, Herron RV, Funk L, Aubrecht K, Spencer D, Luo Y (Isabelle).
Journal of Aging Studies. 2022;63:101064.
Violence is a pervasive, yet often hidden, issue within nursing homes, affecting residents, family members and care workers. Critical exploration of embedded understandings of violence within public policies can provide important insights into how violence is viewed and addressed in nursing home environments as well as the implications of violence for different groups and alternative ways of framing and addressing violence. To this end, this study explored how violence is conceptualized within 45 nursing home policy texts from two Canadian provinces – Manitoba and Nova Scotia. Using a critical policy analysis approach and a citizenship lens, we identified four dominant constructions of policy ‘targets’ associated with specific rights and conceptualizations of violence. Policy documents construct residents as either vulnerable and in need of protection or as challenging and requiring behavior management. Care workers are constructed as either clinical risk managers, responsible for mitigating violence, or as employees with rights and responsibilities. Overall, violence prevention policies governing nursing homes are fragmented and convey conflicting conceptualizations of violence, associated with divergent rights and responsibilities. Our findings highlight the need for comprehensive violence prevention policies that affirm the rights of nursing home residents and care workers alike.

New article on the conditions necessary for workplace learning in LTC
How to establish workplace learning in long-term care: results from a World Café dialogue.
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van Lierop MEA, Meijers JMM, van Rossum E, Rutten JER, Thoma-Lürken T, Zwakhalen SMG.
BMC Nurs. 2022 Aug 29;21(1):241.
BACKGROUND: As long-term care continues to change, the traditional way of learning for work purposes is no longer sufficient. Long-term care organisations need to become ‘learning organisations’ and facilitate workplace learning for nursing staff teams. Therefore, insight is needed into what conditions are important for establishing workplace learning. The aim and objective of this article is to gain insight into necessary individual, team and organisational conditions for nursing staff to enhance workplace learning in long-term care settings. METHODS: This study is a qualitative explorative study. A World Café method was used to host group dialogues in which participants (n = 42) discussed certain questions. Group dialogues were held for the nursing home and community care setting separately due to organisational differences. Nursing staff, experts in workplace learning, educational staff, client representatives and experts in the field of work and organisation in healthcare organisations were invited to a Dutch long-term care organisation to discuss questions of interest. Data were analysed using theme-based content analysis. RESULTS: Overall themes concerning individual, team and organisational conditions for workplace learning included: facilitating characteristics (e.g. to be given time and room for [team] development); behavioural characteristics (e.g. an open attitude); context and culture (e.g. feeling safe); cooperation and communication (e.g. giving/receiving feedback); and knowledge and skills (e.g. acquiring knowledge from each other). No major differences were found between settings. CONCLUSIONS: By assessing the themes at the individual, team and organisational level regarding nursing staff, the current workplace learning situation, and its possible improvements, can be detected.

Article on how profit vs non-profit Ontario LTC homes fared during COVID
Does the Profit Motive Matter? COVID-19 Prevention and Management in Ontario Long-Term-Care Homes.
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Pue K, Westlake D, Jansen A.
Can Public Policy. 2021 Sep 1;47(3):421–38.
We introduce evidence that for-profit long-term-care providers are associated with less successful outcomes in coronavirus disease 2019 outbreak management. We introduce two sets of theoretical arguments that predict variation in service quality by provider type: those that deal with the institution of contracting (innovative competition vs. erosive competition) and those that address organizational features of for-profit, non-profit, and government actors (profit seeking, cross-subsidization, and future investment). We contextualize these arguments through a discussion of how contracting operates in Ontario long-term care. That discussion leads us to exclude the institutional arguments while retaining the arguments about organizational features as our three hypotheses. Using outbreak data as of February 2021, we find that government-run long-term-care homes surpassed for-profit and non-profit homes in outbreak management, consistent with an earlier finding from Stall et al. (2020). Non-profit homes outperform for-profit homes but are outperformed by government-run homes. These results are consistent with the expectations derived from two theoretical arguments-profit seeking and cross-subsidization-and inconsistent with a third-capacity for future investment.

New Canadian article on building a virtual community of practice
Building a virtual community of practice: experience from the Canadian foundation for healthcare improvement’s policy circle.
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Sibbald SL, Burnet ML, Callery B, Mitchell JI.
Health Res Policy Syst. 2022 Sep 1;20(1):95.
BACKGROUND: Communities of Practice are formed by people who interact regularly to engage in collective learning in a shared domain of human endeavor. Virtual Communities of Practice (VCoP) are online communities that use the internet to connect people who share a common concern or passion. VCoPs provide a platform to share and enhance knowledge. The Policy Circle is a VCoP that connects mid-career professionals from across Canada who are committed to improving healthcare policy and practice. We wanted to understand the perceived value of the VCoP. METHODS: We used qualitative and quantitative survey research to explore past and current Policy Circle members’ thoughts, feelings, and behaviours related to the program. Our research was guided by the Value Creation Framework proposed by Wenger and colleagues. Three surveys were created in collaboration with stakeholders. Data were analyzed within cohort and in aggregate across cohorts. Qualitative data was analyzed thematically, and quantitative data was analyzed using descriptive statistics (means of ranked and scaled responses). RESULTS: Survey participation was high among members (Cohort 1: 67%, Cohort 2: 64%). Participants came from a variety of disciplines including medicine, health policy, allied health, and nursing, with most members having a direct role in health services research or practice. The program was successful in helping participants make connections (mean = 2.43 on a scale from 1 to 5: 1 = yes, significantly, 5 = not at all); variances in both qualitative and quantitative data indicated that levels of enthusiasm within the program varied among individuals. Members appreciated the access to resources; quarterly meetings (n = 11/11), and a curated reading list (n = 8/11) were the most valued resources. Participants reported the development of a sense of belonging (mean = 2.29) and facilitated knowledge exchange (mean = 2.43). At the time of this study, participants felt the program had minor impact on their work (mean = 3.5), however a majority of participants (50%) from Cohort 2 planned to acknowledge the program in their professional or academic endeavours. Through reflective responses, participants expressed a desire for continued and deeper professional network development. CONCLUSIONS: The Policy Circle was successful in facilitating knowledge exchange by creating a community that promoted trust, a sense of belonging and a supportive environment. Members were satisfied with the program; to promote further value, the Policy Circle should implement strategies that will continue member participation and networking after the program is finished.

New article by Adrian Wagg
Predictors of improvement in urinary incontinence in the postacute setting: A Canadian cohort study.
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Egbujie BA, Northwood M, Turcotte LA, McArthur C, Berg K, Heckman GA, et al.
Neurourol Urodyn. 2022 Aug 30.
PURPOSE: To determine factors associated with improvement in urinary incontinence (UI) for long-stay postacute, complex continuing care (CCC) patients. DESIGN: A retrospective cohort investigation of patients in a CCC setting using data obtained from the Canadian Institute for Health Information’s Continuing Care Reporting System collected with interRAI Minimum Data Set 2.0. SETTING AND PARTICIPANTS: Individuals aged 18 years and older, were admitted to CCC hospitals in Ontario, Canada, between 2010 and 2018. METHODS: Multivariable logistic regression was used to determine the independent effects of predictors on UI improvement, for patients who were somewhat or completely incontinent on admission and therefore had the potential for improvement. RESULTS: The study cohort consisted of 18 584 patients, 74% (13 779) of which were somewhat or completely incontinent upon admission. Among those patients with potential for improvement, receiving bladder training, starting a new medication 90 days prior (odds ratio, OR: 1.54 [95% confidence interval, CI: 1.36-1.75]), and triggering the interRAI Urinary Incontinence Clinical Assessment Protocol to facilitate improvement (OR: 1.36 [95% CI: 1.08-1.71]) or to prevent decline (OR: 1.32 [95% CI: 1.13-1.53]) were the strongest predictors of improvement. Conversely, being totally dependent on others for transfer (OR: 0.62 [95% CI: 0.42-0.92]), is rarely or never understood (OR: 0.65 [95% CI: 0.50-0.85]), having a major comorbidity count of ≥3 (OR: 0.72 [95% CI: 0.59-0.88]), Parkinson’s disease, OR: 0.77 (95% CI: 0.62-0.95), Alzheimer/other dementia, OR: 0.83 (95% CI: 0.74-0.93), and respiratory infections, OR: 0.57 (95% CI: 0.39-0.85) independently predicted less likelihood of improvement in UI. CONCLUSIONS AND IMPLICATIONS: Findings of this study suggest that improving physical function, including bed mobility, and providing bladder retraining have strong positive impacts on improvement in UI for postacute care patients. Evidence generated from this study provides useful care planning information for care providers in identifying patients and targeting the care that may lead to better success with the management of UI.

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