A clinical trial of nurse practitioner care in residential aged care facilities

Nurse Practitioner-Sensitive Outcome Measures in Older Person Care: A Scoping Review

BACKGROUND

Nurse practitioner-sensitive outcomes (NPSOs) are critical indicators of the quality and effectiveness of nursing care provided to older adults. These outcomes, which include metrics such as falls, pressure ulcers, infection rates, frailty, delirium, length of stay, hospital readmissions, and quality of life (QoL), are essential for assessing the impact of nurse practitioners (NPs) and enhancing patient safety. Despite their importance, the current literature on NPSOs in services for older adults remains limited. This scoping review aims to address this gap by systematically mapping the existing research, identifying key themes, and uncovering areas needing further exploration. By doing so, the authors seek to provide a comprehensive overview that will inform future research directions and contribute to the enhancement of clinical practice in older person services (OPS). This review is important for healthcare providers, policymakers, and researchers who are committed to improving the quality of nursing care and outcomes for older people.

AIM

The aim of this scoping review is to map the existing research on NPSOs in services for older adults. This review seeks to identify key themes and gaps in the current literature to guide future research and enhance clinical practice in this area.

METHOD

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines were utilised to structure this scoping review.

RESULTS

From initial screening of 3593 manuscripts drawn from seven databases, 66 were deemed eligible for full screen. Five studies met the inclusion criteria and were ultimately selected for data extraction and analysis. The most common outcome measures reported were complications and comorbidities, and QoL.

CONCLUSIONS

This review highlights that the reporting of NPSOs in older person care is lacking and requires further attention.

Community Palliative Care: What are the Best Models?

OPINION STATEMENT

Palliative care seeks to address the physical, psychosocial and spiritual concerns of patients with a life limiting illness and their caregivers. Early referral to palliative care improves symptoms and is the standard of care. This paper evaluates the evidence for different models of community palliative care and looks at the effects of homecare, hospice programs and residential aged care facility (RACF) interventions on symptom management, home death rate and acute health service utilization. It also examines the impact of COVID-19, telehealth, integration and staffing models on the efficacy of community palliative care. Evidence suggests that community palliative care increases the rate of death at home and may improve satisfaction with care, but effect on symptoms and acute health care utilization are less certain. Enrolment in a hospice program may decrease hospitalizations and improve satisfaction. RACF staff training interventions to improve the quality of palliative care provided to residents show mixed results across all indicators. COVID-19 saw a relative increase in the demand for community palliative care, as people opted out of the hospital system. Models of community palliative care that facilitate integration, support primary health providers, and promote technological innovation are worthy of further research.

Enablers and barriers to nurse practitioners working in Australian aged care: A scoping review

OBJECTIVE

To identify evidence reporting on nurse practitioners working in aged care in Australia and to categorise the reported factors found to be barriers or facilitators to operation in terms of establishment, sustainability, and expansion.

INTRODUCTION

Nurse practitioners work in a variety of aged care contexts throughout Australia but are underutilised and uncommon. Despite evidence for their effectiveness, it is unclear what barriers or enabling factors contribute to the successful and sustainable implementation of nurse practitioners working in this sector.

METHODS

Based on an a-priori protocol the JBI methodology for scoping reviews was used and the review reported against the PRISMA extension for scoping reviews (PRISMA-ScR). Databases searched included MEDLINE, Embase, Emcare, Web of Science, and Scopus. Peer reviewed and grey literature describing the role of Australian nurse practitioners in aged care were included.

RESULTS

Of 2968 retrieved sources, 18 were included representing studies of a variety of designs from all Australian states and territories. Residential care and in-home care contexts as well as metropolitan, regional, and remote locations were represented. Overall, 123 individual barriers and facilitators were identified across seven inductively derived categories: staff/individual, organisational, system, operational, resource, data, and consumers/clients/residents. In many cases, factors appeared across both positive (facilitators) and negative (barriers) categories.

CONCLUSIONS

Nurse practitioners can improve the quality of care being provided to older people accessing aged care in Australia. When establishing or maintaining nurse practitioner roles in aged care knowledge users should have a comprehensive understanding of the range of factors potentially contributing to or limiting success or sustainability. As implementation is highly contextual, various types of organisational and sectoral factors as well as individual and overarching factors related to the regulation of nurse practitioners practice should be considered.

The rate, causes and predictors of ambulance call outs to residential aged care in the Australian Capital Territory: A retrospective observational cohort study

Older people in residential aged care are susceptible to acute illness or injury which may necessitate an ambulance call out, assessment/treatment by a paramedic and transfer to a hospital emergency department. Understanding the case mix of residential aged care ambulance attendances is important for prevention strategies and for planning services. A retrospective observational closed cohort study was designed to investigate the characteristics of emergency ambulance call outs to 15 residential aged care sites in the Australian Capital Territory over a 12-month period. Data were collected from the local ambulance service and the aged care sites. Case load data were analysed to determine rates, clinical characteristics, ambulance attendance outcomes and the temporal distribution of call outs. A Poisson regression model was developed to investigate demographic, morbidity and medication-related risk factors associated with the number of ambulance call outs per resident. Annual ambulance call out costs were estimated. There were 1,275 residents, with 396 (31.1%) requiring at least one ambulance call out over 12 months. Of 669 ambulance attendances, the majority (87.0%) were transported to emergency departments. Trauma (23.9%), pain (16.9%) and infections (9.4%) were the most common primary assessments by the ambulance attendees. Cases/day were similar throughout the year and on weekdays compared to weekends/public holidays. The main predictors of ambulance call out were multi-morbidity, taking regular anticholinergic medicines, being male and younger age. Estimated costs of ambulance call outs/year were $475/resident and $40,375/residential aged care site. The most frequent primary assessments (trauma, pain, infections) may constitute priorities for developing prevention strategies and for treatment initiatives within residential aged care. Strategies to reduce anticholinergic medication prescribing may also be a potential intervention to decrease ambulance call outs and hospital emergency department demand. The ambulance usage data from this study may be useful to compare with future datasets to measure the impact of the introduction of new services.

Current situation, strengths and problems in intra- and interprofessional collaboration in German nursing homes - A holistic multiple case study

BACKGROUND

The increasing care complexity of nursing home residents living with dementia requires new care models that strengthen professional collaboration. To contribute to the sustainable implementation of new care models, it is important that they are linked to the care reality. However, little is known about intra- and interprofessional organization and provision of care in German nursing homes. Therefore, the aim of this study was to explore the current care situation, problems and strengths regarding intra- and interprofessional collaboration in the care of residents living with dementia.

METHODS

We conducted a holistic multiple case study. The individual care units in which residents living with dementia are cared for were defined as cases. The context was built by the respective nursing homes and their regional affiliation to the federal state of North Rhine-Westphalia. We used qualitative face-to-face interviews, documents and context questionnaires for data collection. The different sources of evidence served to capture complementary perspectives and to validate the findings. First, the collected qualitative data were analyzed using deductive-inductive content analysis. Second, similarities and differences between the cases were identified to elaborate case-specific and cross-case patterns and themes. The reporting followed the EQUATOR reporting guideline for organizational case studies.

RESULTS

We included four care units comprising 21 professionals (nurses, physicians, social worker, physiotherapist, pharmacist) and 14 relatives of residents living with dementia. The analysis revealed four categories to describe current intra- and interprofessional collaboration in all cases: actors and their roles, service delivery, coordination and governance, and communication channel. Moreover, we identified three categories that relate to the strengths and problems of intra- and interprofessional collaboration in all cases: role understanding, teamwork, and communication and exchange. Although we examined similar care units, we found differences in the realization of professional collaboration and resulting problems and strengths that are connected to the organizational contexts and strategies used.

CONCLUSIONS

Even though professional collaboration follows given patterns; these patterns do differ context-specifically and are perceived as problematic and fragmentary. Therefore, the identified differences and problems in collaboration need to be addressed in future research to develop and successfully implement tailored innovative care models.

Non-emergency department (ED) interventions to reduce ED utilization: a scoping review

BACKGROUND

Emergency department (ED) crowding is a global burden. Interventions to reduce ED utilization have been widely discussed in the literature, but previous reviews have mainly focused on specific interventions or patient groups within the EDs. The purpose of this scoping review was to identify, summarize, and categorize the various types of non-ED-based interventions designed to reduce unnecessary visits to EDs.

METHODS

This scoping review followed the JBI Manual for Evidence Synthesis and the PRISMA-SCR checklist. A comprehensive structured literature search was performed in the databases MEDLINE and Embase from 2008 to March 2024. The inclusion criteria covered studies reporting on interventions outside the ED that aimed to reduce ED visits. Two reviewers independently screened the records and categorized the included articles by intervention type, location, and population.

RESULTS

Among the 15,324 screened records, we included 210 studies, comprising 183 intervention studies and 27 systematic reviews. In the primary studies, care coordination/case management or other care programs were the most commonly examined out of 15 different intervention categories. The majority of interventions took place in clinics or medical centers, in patients' homes, followed by hospitals and primary care settings - and targeted patients with specific medical conditions.

CONCLUSION

A large number of studies have been published investigating interventions to mitigate the influx of patients to EDs. Many of these targeted patients with specific medical conditions, frequent users and high-risk patients. Further research is needed to address other high prevalent groups in the ED - including older adults and mental health patients (who are ill but may not need the ED). There is also room for further research on new interventions to reduce ED utilization in low-acuity patients and in the general patient population.

Models for delivery and co-ordination of primary or secondary health care (or both) to older adults living in aged care facilities

BACKGROUND

The number of older people is increasing worldwide and public expenditure on residential aged care facilities (ACFs) is expected to at least double, and possibly triple, by 2050. Co-ordinated and timely care in residential ACFs that reduces unnecessary hospital transfers may improve residents' health outcomes and increase satisfaction with care among ACF residents, their families and staff. These benefits may outweigh the resources needed to sustain the changes in care delivery and potentially lead to cost savings. Our systematic review comprehensively and systematically presents the available evidence of the effectiveness, safety and cost-effectiveness of alternative models of providing health care to ACF residents.

OBJECTIVES

Main objective To assess the effectiveness and safety of alternative models of delivering primary or secondary health care (or both) to older adults living in ACFs. Secondary objective To assess the cost-effectiveness of the alternative models.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, five other databases and two trials registers (WHO ICTRP, ClinicalTrials.gov) on 26 October 2022, together with reference checking, citation searching and contact with study authors to identify additional studies.

SELECTION CRITERIA

We included individual and cluster-randomised trials, and cost/cost-effectiveness data collected alongside eligible effectiveness studies. Eligible study participants included older people who reside in an ACF as their place of permanent abode and healthcare professionals delivering or co-ordinating the delivery of healthcare at ACFs. Eligible interventions focused on either ways of delivering primary or secondary health care (or both) or ways of co-ordinating the delivery of this care. Eligible comparators included usual care or another model of care. Primary outcomes were emergency department visits, unplanned hospital admissions and adverse effects (defined as infections, falls and pressure ulcers). Secondary outcomes included adherence to clinical guideline-recommended care, health-related quality of life of residents, mortality, resource use, access to primary or specialist healthcare services, any hospital admissions, length of hospital stay, satisfaction with the health care by residents and their families, work-related satisfaction and work-related stress of ACF staff.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies for inclusion, extracted data, and assessed risk of bias and certainty of evidence using GRADE. The primary comparison was any alternative model of care versus usual care.

MAIN RESULTS

We included 40 randomised trials (21,787 participants; three studies only reported number of beds) in this review. Included trials evaluated alternative models of care aimed at either all residents of the ACF (i.e. no specific health condition; 11 studies), ACF residents with mental health conditions or behavioural problems (12 studies), ACF residents with a specific condition (e.g. residents with pressure ulcers, 13 studies) or residents requiring a specific type of care (e.g. residents after hospital discharge, four studies). Most alternative models of care focused on 'co-ordination of care' (n = 31). Three alternative models of care focused on 'who provides care' and two focused on 'where care is provided' (i.e. care provided within ACF versus outside of ACF). Four models focused on the use of information and communication technology. Usual care, the comparator in all studies, was highly heterogeneous across studies and, in most cases, was poorly reported. Most of the included trials were susceptible to some form of bias; in particular, performance (89%), reporting (66%) and detection (42%) bias. Compared to usual care, alternative models of care may make little or no difference to the proportion of residents with at least one emergency department visit (risk ratio (RR) 1.01, 95% confidence interval (CI) 0.84 to 1.20; 7 trials, 1276 participants; low-certainty evidence), but may reduce the proportion of residents with at least one unplanned hospital admission (RR 0.74, 95% CI 0.56 to 0.99, I2 = 53%; 8 trials, 1263 participants; low-certainty evidence). We are uncertain of the effect of alternative models of care on adverse events (proportion of residents with a fall: RR 1.15, 95% CI 0.83 to 1.60, I² = 74%; 3 trials, 1061 participants; very low-certainty evidence) and adherence to guideline-recommended care (proportion of residents receiving adequate antidepressant medication: RR 5.29, 95% CI 1.08 to 26.00; 1 study, 65 participants) as the certainty of the evidence is very low. Compared to usual care, alternative models of care may have little or no effect on the health-related quality of life of ACF residents (MD -0.016, 95% CI -0.036 to 0.004; I² = 23%; 12 studies, 4016 participants; low-certainty evidence) and probably make little or no difference to the number of deaths in residents of ACFs (RR 1.03, 95% CI 0.92 to 1.16, 24 trials, 3881 participants, moderate-certainty evidence). We did not pool the cost-effectiveness or cost data as the specific costs associated with the various alternative models of care were incomparable, both across models of care as well as across settings. Based on the findings of five economic evaluations (all interventions focused on co-ordination of care), we are uncertain of the cost-effectiveness of alternative models of care compared to usual care as the certainty of the evidence is very low.

AUTHORS' CONCLUSIONS

Compared to usual care, alternative models of care may make little or no difference to the number of emergency department visits but may reduce unplanned hospital admissions. We are uncertain of the effect of alternative care models on adverse events (i.e. falls, pressure ulcers, infections) and adherence to guidelines compared to usual care, as the certainty of the evidence is very low. Alternative models of care may have little or no effect on health-related quality of life and probably have no effect on mortality of ACF residents compared to usual care. Importantly, we are uncertain of the cost-effectiveness of alternative models of care due to the limited, disparate data available.

State scope of practice restrictions and nurse practitioner practice in nursing homes: 2012-2019

Increased engagement of nurse practitioners (NPs) has been recommended as a way to address care delivery challenges in settings that struggle to attract physicians, such as primary care and rural areas. Nursing homes also face such physician shortages. We evaluated the role of state scope of practice regulations on NP practice in nursing homes in 2012-2019. Using linear probability models, we estimated the proportion of NP-delivered visits to patients in nursing homes as a function of state scope of practice regulations. Control variables included county demographic, socioeconomic, and health care workforce characteristics; state fixed effects; and year indicators. The proportion of nursing home visits conducted by NPs increased from 24% in 2012 to 42% in 2019. Expanded scope of practice regulation was associated with a greater proportion and total volume of nursing home visits conducted by NPs in counties with at least 1 NP visit. These relationships were concentrated among short-stay patients in urban counties. Removing scope of practice restrictions on NPs may address clinician shortages in nursing homes in urban areas where NPs already practice in nursing homes. However, improving access to advanced clinician care for long-term care residents and for patients in rural locations may require additional interventions and resources.

Core elements and potential of nurse-led care models in residential long-term care: A scoping review

AIMS AND OBJECTIVE

To identify and summarise core elements, resident-, staff- and process-related outcomes and challenges of nurse-led care models in residential long-term care.

BACKGROUND

Due to demographic trends, the complexity of residential long-term care has increased. To address this complexity, the implementation of nurse-led care models has been recommended.

DESIGN

Scoping review.

METHODS

A systematic search was conducted of English and German articles in CINAHL via EBSCO, MEDLINE via PubMed, Cochrane Library and Scopus. Forward and backward citation tracking via reference lists and Google Scholar supplemented the search. The final update was made on 19 January 2021. To draw conclusions about the potential of nurse-led care models, evaluation studies of the described models for residents in nursing homes were included. Full texts were independently screened and assessed for methodological quality. Data were extracted and summarised in tables and synthesised for analysis. The core elements of the models were described using the Sustainable intEgrated chronic care modeLs for multimorbidity: delivery, FInancing and performancE (SELFIE) framework. The review followed the PRISMA-ScR guideline.

RESULTS

We included 13 studies of 12 nurse-led care models. The different models comprised many of the core elements suggested in the SELFIE framework, particularly in the components service delivery, workforce, and leadership and governance. The studies reported a broad range of resident-, staff- and process-related outcomes and challenges considered relevant to the success of the models.

CONCLUSIONS

Studies evaluating nurse-led care models in nursing homes are limited and of moderate quality. This review demonstrates that nurse-led care models include many elements for care coordination and could improve resident-, staff- and process-related outcomes.

RELEVANCE TO CLINICAL PRACTICE

This review highlights that nurse-led care models share common core elements despite their heterogeneity. It also shows that highly qualified nurses in nurse-led care models can advance nursing practice in nursing homes.

Physician Practice Characteristics Influencing Nurse Practitioner and Physician Assistant Care in Nursing Homes: A Scoping Review

OBJECTIVES

Physicians, nurse practitioners (NPs), and physician assistants (PAs) are key to the effective delivery of medical care in nursing homes (NHs). Although several studies have reported on the relationship between the care delivered by a given discipline and specific clinical outcomes, the mediating effect of physician practice characteristics is unknown. A scoping review was conducted to determine whether studies examining the impact of NP and PA care in NHs have accounted for both the collaborative relationship between themselves and physicians as well as physician practice size and type.

DESIGN

Scoping review.

SETTINGS AND PARTICIPANTS

NH and NH residents.

METHODS

Papers eligible for review included peer-reviewed studies written in English and that were quantitative in nature. Inclusion criteria required that more than 1 NH and more than a single NP or PA be included for the analysis. Further, the size of the NH studied must have equaled or exceeded 100 residents and more than 1 clinical outcome reported. Databases searched included Ovid MEDLINE, Cochrane Library, Web of Science; CINAHL, and AgeLine.

RESULTS

A total of 1878 studies underwent abstract review of which 1719 were excluded. A full-text review of the remaining articles was completed (n = 157, as 2 articles could not be retrieved), of which 16 met eligibility criteria. The study designs were generally retrospective and quasi-experimental in nature. No randomized controlled studies were identified. Physician practice variables such as number of physicians, total practice case load, case mix, and the nature of the collaborative practice between NP/PA and MD were infrequently specified. In no reports was the type of physician practice characterized and no physician practice variables were adjusted for with regard to outcomes.

CONCLUSIONS

None of the studies included in the review were found to have incorporated any physician variables into their outcome analyses. Before purporting equivalency between medical provider disciplines in NHs, future studies must, at the very least, consider the mediating effect of physician practice characteristics.

Taxonomy of Interventions to Reduce Acute Care Transfers From Long-term Care Homes: A Systematic Scoping Review

OBJECTIVE

To develop a taxonomy of interventions aimed at reducing emergency department (ED) transfers and/or hospitalizations from long-term care (LTC) homes.

DESIGN

A systematic scoping review.

SETTING AND PARTICIPANTS

Permanent LTC home residents.

METHODS

Experimental and comparative observational studies were searched in MEDLINE, CINAHL, Embase Classic + Embase, the Cochrane Library, PsycINFO, Social Work Abstracts, AMED, Global Health, Health and Psychosocial Instruments, Joanna Briggs Institute EBP Database, Ovid Healthstar, and Web of Science Core Collection from inception until March 2020. Forward/backward citation tracking and gray literature searches strengthened comprehensiveness. The Mixed Methods Appraisal Tool was used to assess study quality. Intervention categories and components were identified using an inductive-deductive thematic analysis. Categories were informed by 3 intervention dimensions: (1) "when/at what point(s)" on the continuum of care they occur, (2) "for whom" (ie, intervention target resident populations), and (3) "how" these interventions effect change. Components were informed by the logistical elements of the interventions having the potential to influence outcomes. All interventions were mapped to the developed taxonomy based on their categories, components, and outcomes. Distributions of components by category and study year were graphically presented.

RESULTS

Ninety studies (25 randomized, 23 high quality) were included. Six intervention categories were identified: advance care planning; palliative and end-of-life care; onsite care for acute, subacute, or uncontrolled chronic conditions; transitional care; enhanced usual care (most prevalent, 31% of 90 interventions); and comprehensive care. Four components were identified: increasing human resource capacity (most prevalent, 93%), training or reorganization of existing staff, technology, and standardized tools. The use of technology increased over time. Potentially avoidable ED transfers and/or hospitalizations were measured infrequently as primary outcomes.

CONCLUSIONS AND IMPLICATIONS

This proposed taxonomy can guide future intervention designs. It can also facilitate systematic reviews and precise effect size estimations for homogenous interventions when outcomes are comparable.

Which interventions are effective at decreasing or increasing emergency department attendances or hospital admissions from long-term care facilities? A systematic review

OBJECTIVE

UK long-term care facility residents account for 185 000 emergency hospital admissions each year. Avoidance of unnecessary hospital transfers benefits residents, reduces demand on the healthcare systems but is difficult to implement. We synthesised evidence on interventions that influence unplanned hospital admissions or attendances by long-term care facility residents.

METHODS

This is a systematic review of randomised controlled trials. PubMed, MEDLINE, EMBASE, ISI Web of Science, CINAHL and the Cochrane Library were searched from 2012 to 2022, building on a review published in 2013. We included randomised controlled trials that evaluated interventions that influence (decrease or increase) acute hospital admissions or attendances of long-term care facility residents. Risk of bias and evidence quality were assessed using Cochrane Risk Of Bias-2 and Grading of Recommendations Assessment, Development and Evaluation.

RESULTS

Forty-three randomised studies were included in this review. A narrative synthesis was conducted and the weight of evidence described with vote counting. Advance care planning and goals of care setting appear to be effective at reducing hospitalisations from long-term care facilities. Other effective interventions, in order of increasing risk of bias, were: nurse practitioner/specialist input, palliative care intervention, influenza vaccination and enhancing access to intravenous therapies in long-term care facilities.

CONCLUSIONS

Factors that affect hospitalisation and emergency department attendances of long-term care facility residents are complex. This review supports the already established use of advance care planning and influenza vaccination to reduce unscheduled hospital attendances. It is likely that more than one intervention will be needed to impact on healthcare usage across the long-term care facility population. The findings of this review are useful to identify effective interventions that can be combined, as well as highlighting interventions that either need evaluation or are not effective at decreasing healthcare usage.

PROSPERO REGISTRATION NUMBER

CRD42020169604.

Emergency department transfers from residential aged care: what can we learn from secondary qualitative analysis of Australian Royal Commission data?

OBJECTIVES

To use publicly available submissions and evidence from the Australian Royal Commission into Aged Care Quality and Safety as data for secondary qualitative analysis. By investigating the topic of emergency department transfer from the perspective of residents, family members and healthcare professionals, we aimed to identify modifiable factors to reduce transfer rates and improve quality of care.

DESIGN

The Australian Royal Commission into Aged Care Quality and Safety has made over 7000 documents publicly available. We used the documents as a large data corpus from which we extracted a data set specific to our topic using keywords. The analysis focused on submissions and hearing transcripts (including exhibits). Qualitative thematic analysis was used to interrogate the text to determine what could be learnt about transfer events from a scholarly perspective.

RESULTS

Three overarching themes were identified: shortfalls and failings, reluctance and misunderstanding, and discovery and exposure.

CONCLUSIONS

The results speak to workforce inadequacies that have been central to problems in the Australian aged care sector to date. We identified issues around clinical and pain assessment, lack of consideration to advance care directives and poor communication among all parties. We also highlighted the role that emergency departments play in identifying unmet clinical needs, substandard care and neglect. Given the inadequate clinical care available in some residential aged care facilities, transferring residents to a hospital emergency department may be making the best of a bad situation. If the objective of reducing unnecessary transfers to emergency departments is to be achieved, then access to appropriate clinical care is the first step.

Detecting Acute Deterioration in Older Adults Living in Residential Aged Care: A Scoping Review

OBJECTIVES

To explore models, processes, or tools implemented in residential aged care (RAC) to support registered nurses (RNs) to identify and respond to the acute deterioration of residents.

DESIGN

Scoping literature review of English Language articles published in peer reviewed journals.

SETTINGS AND PARTICIPANTS

Studies were conducted in RAC facilities providing long-term 24-hour medical, nursing, and social care for people age 65 years or older with age-related disability.

METHODS

We completed a MESH term and key word search of MEDLINE, Embase, CINAHL, PubMed, and Google Scholar. Included studies had (1) part of the intervention based in RAC; (2) had a direct impact on RAC day to day practice; and (3) contained or provided access to the detail of the intervention. Data was charted by author, date, country, study design and the components, genesis, and efficacy of the methods used to identify and respond to acute deterioration.

RESULTS

We found 46 studies detailing models of care, clinical patterns of acute deterioration, and deterioration detection tools. It was not possible to determine which element of the models care had the greatest impact on RN decision making. The clinical patterns of acute deterioration painted a picture of acute deterioration in the frail. There was limited evidence to support the use of existing deterioration detection tools in the RAC population.

CONCLUSION AND IMPLICATIONS

We found no straight forward systematic method to support RAC RNs to identify and respond to the acute deterioration of residents. This is an important practice gap. The clinical pattern of acute deterioration described in the literature has the potential to be used for the development of a tool to support RAC RNs to identify and respond to the acute deterioration of residents.

Impact of relational continuity of primary care in aged care: a systematic review

Background

Greater continuity of care has been associated with lower hospital admissions and patient mortality. This systematic review aims to examine the impact of relational continuity between primary care professionals and older people receiving aged care services, in residential or home care settings, on health care resource use and person-centred outcomes.

Methods

Systematic review of five databases, four trial registries and three grey literature sources to October 2020. Included studies (a) aimed to increase relational continuity with a primary care professional, (b) focused on older people receiving aged care services (c) included a comparator and (d) reported outcomes of health care resource use, quality of life, activities of daily living, mortality, falls or satisfaction. Cochrane Collaboration or Joanna Briggs Institute criteria were used to assess risk of bias and GRADE criteria to rate confidence in evidence and conclusions.

Results

Heterogeneity in study cohorts, settings and outcome measurement in the five included studies (one randomised) precluded meta-analysis. None examined relational continuity exclusively with non-physician providers. Higher relational continuity with a primary care physician probably reduces hospital admissions (moderate certainty evidence; high versus low continuity hazard ratio (HR) 0.94; 95% confidence interval (CI) 0.92–0.96, n = 178,686; incidence rate ratio (IRR) 0.99, 95%CI 0.76–1.27, n = 246) and emergency department (ED) presentations (moderate certainty evidence; high versus low continuity HR 0.90, 95%CI 0.89–0.92, n = 178,686; IRR 0.91, 95%CI 0.72–1.15, n = 246) for older community-dwelling aged care recipients. The benefit of providing on-site primary care for relational continuity in residential settings is uncertain (low certainty evidence, 2 studies, n = 2,468 plus 15 care homes); whilst there are probably lower hospitalisations and may be fewer ED presentations, there may also be an increase in reported mortality and falls. The benefit of general practitioners’ visits during hospital admission is uncertain (very low certainty evidence, 1 study, n = 335).

Conclusion

Greater relational continuity with a primary care physician probably reduces hospitalisations and ED presentations for community-dwelling aged care recipients, thus policy initiatives that increase continuity may have cost offsets. Further studies of approaches to increase relational continuity of primary care within aged care, particularly in residential settings, are needed.

Review registration

CRD42021215698.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03131-2.

Graduating nurse students' interest in older people nursing-A cross-sectional survey in six European countries

BACKGROUND

Countries vary in the number of qualified nurses employed in older adult services. Moreover, students' views of older people nursing as a career differ internationally. Studying future nurses and their career intentions for the field is warranted to meet the increased nurse workforce expectations in terms of quantity and competence.

AIM

To analyse graduating nurse students' interest in older people nursing and the factors associated with it.

METHODS

A cross-sectional multicountry survey design was applied. Data were collected between May 2018 and March 2019 from several educational institutions in Finland, Germany, Iceland, Ireland, Lithuania and Spain. Non-probability convenience sampling was used to recruit graduating nurse students (n = 1796). The data were collected with a structured questionnaire comprising background factors and the Willingness sub-scale (six items) of the Students' Interest in Nursing Older People Scale. Data were analysed using a linear mixed model including relevant background variables.

RESULTS

Overall, students' interest in older people nursing was low (score 20.5, on a 0-100 scale). Among the studied countries, Spanish students scored the highest (38.8) and German students the lowest (3.6). Students' interest in older people nursing was associated with country (p < .001), the length of work experience (p = .006), plans for further study (p = .007), competence (p < .001) and the extent that nursing is valued by society (p < .001). The students who were most interested in older people nursing had higher self-reported competence level (p < .001).

CONCLUSION

In the studied sample of future nurse professionals, interest in older people nursing is low at a time when the field suffers from workforce shortage. As for quality workforce, it was promising that the students who considered working in the field also evaluated themselves as competent.

IMPLICATIONS FOR PRACTICE

Multidimensional actions are required to promote interest in the field, including continued development of competence in both undergraduate education and workplaces, and investing in various career pathways to envisage potential opportunities.

Hospital admissions and place of death of residents of care homes receiving specialist healthcare services: A systematic review without meta-analysis

AIM

To synthesize evidence on the ability of specialist care home support services to prevent hospital admission of older care home residents, including at end of life.

DESIGN

Systematic review, without meta-analysis, with vote counting based on direction of effect.

DATA SOURCES

Fourteen electronic databases were searched from January 2010 to January 2019. Reference lists of identified reviews, study protocols and included documents were scrutinized for further studies.

REVIEW METHODS

Papers on the provision of specialist care home support that addressed older, long-term care home residents' physical health needs and provided comparative data on hospital admissions were included. Two reviewers undertook study selection and quality appraisal independently. Vote counting by direction of effect and binomial tests determined service effectiveness.

RESULTS

Electronic searches identified 79 relevant references. Combined with 19 citations from an earlier review, this gave 98 individual references relating to 92 studies. Most were from the UK (22), USA (22) and Australia (19). Twenty studies were randomized controlled trials and six clinical controlled trials. The review suggested interventions addressing residents' general health needs (p < .001), assessment and management services (p < .0001) and non-training initiatives involving medical staff (p < .0001) can reduce hospital admissions, while there was also promising evidence for services targeting residents at imminent risk of hospital entry or post-hospital discharge and training-only initiatives. End-of-life care services may enable residents to remain in the home at end of life (p < .001), but the high number of weak-rated studies undermined confidence in this result.

CONCLUSION

This review suggests specialist care home support services can reduce hospital admissions. More robust studies of services for residents at end of life are urgently needed.

IMPACT

The review addressed the policy imperative to reduce the avoidable hospital admission of older care home residents and provides important evidence to inform service design. The findings are of relevance to commissioners, providers and residents.

Models of provider care in long-term care: A rapid scoping review

INTRODUCTION

One of the current challenges in long-term care homes (LTCH) is to identify the optimal model of care, which may include specialty physicians, nursing staff, person support workers, among others. There is currently no consensus on the complement or scope of care delivered by these providers, nor is there a repository of studies that evaluate the various models of care. We conducted a rapid scoping review to identify and map what care provider models and interventions in LTCH have been evaluated to improve quality of life, quality of care, and health outcomes of residents.

METHODS

We conducted this review over 10-weeks of English language, peer-reviewed studies published from 2010 onward. Search strategies for databases (e.g., MEDLINE) were run on July 9, 2020. Studies that evaluated models of provider care (e.g., direct patient care), or interventions delivered to facility, staff, and residents of LTCH were included. Study selection was performed independently, in duplicate. Mapping was performed by two reviewers, and data were extracted by one reviewer, with partial verification by a second reviewer.

RESULTS

A total of 7,574 citations were screened based on the title/abstract, 836 were reviewed at full text, and 366 studies were included. Studies were classified according to two main categories: healthcare service delivery (n = 92) and implementation strategies (n = 274). The condition/ focus of the intervention was used to further classify the interventions into subcategories. The complex nature of the interventions may have led to a study being classified in more than one category/subcategory.

CONCLUSION

Many healthcare service interventions have been evaluated in the literature in the last decade. Well represented interventions (e.g., dementia care, exercise/mobility, optimal/appropriate medication) may present opportunities for future systematic reviews. Areas with less research (e.g., hearing care, vision care, foot care) have the potential to have an impact on balance, falls, subsequent acute care hospitalization.

Effects of Staff Training on Nursing Home Residents' End-Of-Life Care: A Randomized Controlled Trial

OBJECTIVES

This trial examines the effects of end-of-life training on long-term care facility (LTCF) residents' health-related quality of life (HRQoL) and use and costs of hospital services.

DESIGN

A single-blind, cluster randomized (at facility level) controlled trial (RCT). Our training intervention included 4 small-group 4-hour educational sessions on the principles of palliative and end-of-life care (advance care planning, adverse effects of hospitalizations, symptom management, communication, supporting proxies, challenging situations). Training was provided to all members of staff. Education was based on constructive learning methods and included resident cases, role-plays, and small-group discussions.

SETTING AND PARTICIPANTS

We recruited 324 residents with possible need for end-of-life care due to advanced illness from 20 LTCF wards in Helsinki.

METHODS

Primary outcome measures were HRQoL and hospital inpatient days per person-year during a 2-year follow-up. Secondary outcomes were number of emergency department visits and cost of all hospital services.

RESULTS

HRQoL according to the 15-Dimensional Health-Related Quality-of-Life Instrument declined in both groups, and no difference was present in the changes between the groups (P for group .75, adjusted for age, sex, do-not-resuscitate orders, need for help, and clustering). Neither the number of hospital inpatient days (1.87 vs 0.81 per person-year) nor the number of emergency department visits differed significantly between intervention and control groups (P for group .41). The total hospital costs were similar in the intervention and control groups.

CONCLUSIONS AND IMPLICATIONS

Our rigorous RCT on end-of-life care training intervention demonstrated no effects on residents' HRQoL or their use of hospitals. Unsupported training interventions alone might be insufficient to produce meaningful care quality improvements.

Medical Care Delivery in U.S. Nursing Homes: Current and Future Practice

The delivery of medical care services in U.S. nursing homes (NHs) is dependent on a workforce that comprises physicians, nurse practitioners, and physician assistants. Each of these disciplines operates under a unique regulatory framework while adhering to common standards of care. NH provider characteristics and their roles in NH care can illuminate potential links to clinical outcomes and overall quality of care with important policy and cost implications. This perspective provides an overview of what is currently known about medical provider practice in NH and organizational models of practice. Links to quality, both conceptual and established, are presented as is a research and policy agenda that addresses the gaps in the evidence base within the context of our ever-changing health care landscape.

"… darum rufe ich jetzt den Rettungsdienst!"

"… that's why I call the ambulance!" - A qualitative study of emergency scenarios in nursing homes Abstract. Background: In nursing homes, emergencies lead to frequent utilisation of emergency medical services (EMS) and emergency department visits. A broad interprofessional perspective of involved practitioners on emergencies in nursing homes has been little studied so far. Aim: Characterization, identification and prioritization of emergency scenarios by relevance and frequency in nursing homes. Methods: We conducted two multi-method, interprofessional group discussions with a total of 18 participants from nursing, medicine and science in January and February 2020. Group discussions were recorded, transcribed and analyzed using qualitative content analysis according to Mayring. Results: Emergency scenarios in nursing homes arise from interactions between person-related aspects and contextual conditions. The following person-related aspects were named as relevant: Falls, unstable vital signs, abnormal behavior, neurological symptoms and lifelessness. Contextual conditions are classified into organizational-structural, political-legal and ethical aspects. The following were considered to be most relevant: lack of communication between the actors, uncertainties among staff, absent living wills and increasing workload in nursing. Conclusions: Emergencies in nursing homes turn out to be complex emergency scenarios. Contextual conditions are important for dealing with emergency scenarios in nursing homes. Recommended actions should be based on the perspective of involved practitioners on emergencies and take greater account of the contextual conditions.

Development of a Toolkit to support sustainable culture change in residential aged care

OBJECTIVE

This study aimed to develop and evaluate a Toolkit to support implementation of the Towards Organisational Culture Change (TOrCCh) intervention, with minimal external facilitation, in aged care facilities, to implement long-lasting organisational change.

METHODS

Eight residential aged care facilities across two Australian states participated. A Toolkit was drafted iteratively, engaging staff from participating sites and a reference group. Participating facilities undertook two change projects utilising the Toolkit. Qualitative data were collected from site project sponsors, work teams and other care staff, and analysed thematically.

RESULTS

The intervention was perceived to provide a generic approach that could be applied to solve agreed challenges in the workplace generating useful outcomes including staff development, increased communication, teamwork and leadership. The role of a project sponsor, and organisational support, was perceived as important for sustainability.

CONCLUSION

Aged care facility staff teams report they can work together effectively for sustainable improvements when provided with a Toolkit.

Reducing preventable patient transfers from long-term care facilities to emergency departments: a scoping review

BACKGROUND

In Canada, there were over 60,000 long-term care facility patient transfers to emergency departments (EDs) in 2014, with up to a quarter of them being potentially preventable. Each preventable transfer exposes the patient to transport- and hospital-related complications, contributes to ED crowding, and adds significant costs to the health care system. There have been many proposed and studied interventions aimed at alleviating the issue, but few attempts to assess and evaluate different interventions across institutions.

METHODS

A systematic search of MEDLINE, CINAHL, and EMBASE for studies describing the impact of interventions aimed at reducing preventable transfers from long-term care facilities to EDs on ED transfer rate. Two independent reviewers screened the studies for inclusion and completed a quality assessment. A tabular and narrative synthesis was then completed. This study adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Extension for Scoping Reviews (PRISMA-ScR) guidelines.

RESULTS

A total of 26 studies were included (Cohen's k = 0.68). One was of low quality (Cohen's k = 0.58). Studies were summarized into five themes based on intervention type: Telemedicine, Outreach Teams, Interdisciplinary Care, Integrated Approaches, and Other. Effective interventions reported reductions in ED transfer rates post intervention ranging from 10 to 70%. Interdisciplinary health care teams staffed within long-term care facilities were the most effective interventions.

CONCLUSION

There are several promising interventions that have successfully reduced the number of preventable transfers from long-term care facilities to EDs in a variety of health care settings. Widespread implementation of these interventions has the potential to reduce ED crowding in Canada.

Staff Training Interventions to Improve End-of-Life Care of Nursing Home Residents: A Systematic Review

OBJECTIVES

The aim was to review evidence from all randomized controlled trials (RCTs) using palliative care education or staff training as an intervention to improve nursing home residents' quality of life (QOL) or quality of dying (QOD) or to reduce burdensome hospitalizations.

DESIGN

A systematic review with a narrative summary.

SETTING AND PARTICIPANTS

Residents in nursing homes and other long-term care facilities.

METHODS

We searched MEDLINE, CINAHL, PsycINFO, the Cochrane Library, Scopus, and Google Scholar, references of known articles, previous reviews, and recent volumes of key journals. RCTs were included in the review. Methodologic quality was assessed.

RESULTS

The search yielded 932 articles after removing the duplicates. Of them, 16 cluster RCTs fulfilled inclusion criteria for analysis. There was a great variety in the interventions with respect to learning methods, intensity, complexity, and length of staff training. Most interventions featured other elements besides staff training. In the 6 high-quality trials, only 1 showed a reduction in hospitalizations, whereas among 6 moderate-quality trials 2 suggested a reduction in hospitalizations. None of the high-quality trials showed effects on residents' QOL or QOD. Staff reported an improved QOD in 1 moderate-quality trial.

CONCLUSIONS AND IMPLICATIONS

Irrespective of the means of staff training, there were surprisingly few effects of education on residents' QOL, QOD, or burdensome hospitalizations. Further studies are needed to explore the reasons behind these findings.

The Impact of Nurse Practitioners on Hospitalizations and Discharges from Long-term Nursing Facilities: A Systematic Review

The objective of this study was to increase the understanding of the role a nurse practitioner (NP) has in reducing the risk of hospitalizations and improving quality outcomes among nursing facility residents. This was explored by the research team conducting a systematic literature review via Cumulative Index of Nursing and Allied Health Literature, PubMed (MEDLINE), and Academic Search Ultimate. This is of concern because of the increased rate of hospital readmissions from skilled nursing facilities. The study found that utilization of NPs as primary care providers resulted in decreased unnecessary hospitalizations, increased access to healthcare, and improved health outcomes. NPs are fundamental in building relationships with residents and families and providing them information for decision making. The utilization of NPs in a long-term care setting should be encouraged to improve access to care, decrease hospitalizations, and enhance quality of care. States with reduced or restrictive scope of practice for NPs should revisit the regulations to provide unrestricted scope of practice for NPs.

Setting Priorities to Inform Assessment of Care Homes' Readiness to Participate in Healthcare Innovation: A Systematic Mapping Review and Consensus Process

Organisational context is known to impact on the successful implementation of healthcare initiatives in care homes. We undertook a systematic mapping review to examine whether researchers have considered organisational context when planning, conducting, and reporting the implementation of healthcare innovations in care homes. Review data were mapped against the Alberta Context Tool, which was designed to assess organizational context in care homes. The review included 56 papers. No studies involved a systematic assessment of organisational context prior to implementation, but many provided post hoc explanations of how organisational context affected the success or otherwise of the innovation. Factors identified to explain a lack of success included poor senior staff engagement, non-alignment with care home culture, limited staff capacity to engage, and low levels of participation from health professionals such as general practitioners (GPs). Thirty-five stakeholders participated in workshops to discuss findings and develop questions for assessing care home readiness to participate in innovations. Ten questions were developed to initiate conversations between innovators and care home staff to support research and implementation. This framework can help researchers initiate discussions about health-related innovation. This will begin to address the gap between implementation theory and practice.

Development of a Gerontology Graduate Certificate in Post-Acute and Long-Term Care

Nurse practitioners (NPs) can provide safe, effective, quality care to older adults in post-acute and long-term care (PALTC) settings. However, there is a paucity of exposure to PALTC settings in most NP educational programs. Therefore, the current authors developed an elective graduate certificate in gerontology with an emphasis in PALTC for NP students. The graduate certificate curriculum was developed by faculty with expertise in nursing and gerontology education. The PALTC certificate comprises 15 credit hours of online didactic courses, 80 leadership hours, 200 clinical hours, and a scholarly project dedicated to PALTC. Completion of a graduate certificate in PALTC is a novel model for preparing NP students for practice in PALTC settings. The current article serves as a framework for other programs to reference as they develop individualized graduate certificate PALTC programs in their academic institutions. [Journal of Gerontological Nursing, 45(10), 47-52.].