International Survey of Nursing Home Research Priorities

Dynamic changes in medication burden leading to fall and hospital readmissions in older adults: Toward a strategy for improving risk and managing costs

The majority of a health plan's performance and designated Star Rating is related to medication-related behavior, eg, medication adherence, medication review, and reconciliation, that are intricately related to adverse drug events (ADEs). Altered pharmacodynamics and pharmacokinetics owing to aging make older adults more vulnerable to ADEs like falls, fractures, hospitalizations, and mortality. Prevention of avoidable risk factors such as medication burden can help maintain quality of life. Studies of multiple populations have established drug burden index (DBI), a dose-dependent measure of anticholinergic and sedative burden, to be strongly associated with worsening vertigo, dizziness, and balance, which all predicate falls. The mean difference in DBI greater than 0.1 provides greater predictive power for adverse events, such as falls and 30-day readmission rates. Inclusion of a DBI delta metric especially on an electronic medical record has the potential to reduce fall incidence and associated health outcomes such as hospitalizations and death; this presents an opportunity to improve Centers for Medicare & Medicaid Services Star Ratings by using meaningful tools to foster engagement among informed and active Medicare beneficiaries. We believe this information is extremely relevant in real-world decision-making for health care professionals, specifically when the changes are dynamic and happen very quickly. Moreover, managed care organizations are now dedicated to eliciting a deeper understanding and mitigation of social inequalities in medication use and consequences. Among the proposed solutions includes tailoring prescription utilization management tools with DBI to decrease avoidable incidences of complications and unintended costs. Understanding the dynamic relationship between medication exposures causing ADEs and associated health care utilization and costs to third-party payments remains vital because in the United States, approximately one-third of hospital admissions in older adults occur because of ADEs. This can be achieved by emphasizing equitable therapy and tailoring quality initiatives that minimize racial disparities and avoidable costs that affect the financial burden of these patients. Importantly, this approach becomes even more critical as health care systems increasingly emphasize star ratings, which reflect the quality of care delivered to patients. By prioritizing DBI metrics in these ratings, we can ensure that care is not only clinically effective but also equitable and focused on improving patients' overall well-being. Lastly, as the future directions, the timely application of advanced technologies like artificial intelligence and machine learning in analyzing DBI metrics could enhance our ability to predict the value of DBI adjustments and their correlation with falls and other unintended ADEs. These real-world technologies can process vast amounts of data quickly and accurately, identifying patterns and potential risks that might otherwise go unnoticed.

Feasibility of Monitoring Heart and Respiratory Rates Using Nonwearable Devices and Consistency of the Measured Parameters: Pilot Feasibility Study

Background

As Japan is the world's fastest-aging society with a declining population, it is challenging to secure human resources for care providers. Therefore, the Japanese government is promoting digital transformation and the use of nursing care equipment, including nonwearable devices that monitor heart and respiratory rates. However, the feasibility of monitoring heart and respiratory rates with nonwearable devices and the consistency of the rates measured have not been reported.

Objective

In this study, we focused on a sheet-type nonwearable device (Safety Sheep Sensor) introduced in many nursing homes. We evaluated the feasibility of monitoring heart rate (HR) and respiratory rate (RR) continuously using nonwearable devices and the consistency of the HR and RR measured.

Methods

A sheet-type nonwearable device that measured HR and RR every minute through body vibrations was placed under the mattress of each participant. The participants in study 1 were healthy individuals aged 20-60 years (n=21), while those in study 2 were older adults living in multidwelling houses and required nursing care (n=20). The HR was measured using standard methods by the nurse and using the wearable device (Silmee Bar-type Lite sensor), and RR was measured by the nurse. The primary outcome was the mean difference in HR and RR between nonwearable devices and standard methods.

Results

The mean difference in HR was -0.32 (SD 3.12) in study 1 and 0.04 (SD: 3.98) in study 2; both the differences were within the predefined accepted discrepancies (<5 beats/min). The mean difference in RR was -0.98 (SD 3.01) in study 1 and -0.49 (SD 2.40) in study 2; both the differences were within the predefined accepted discrepancies (3 breaths/min).

Conclusions

HR and RR measurements obtained using the nonwearable devices and the standard method were similar. Continuous monitoring of vital signs using nonwearable devices can aid in the early detection of abnormal conditions in older people.

An ethnography of mealtime care for people living with dementia in care homes

Many people living with dementia have difficulties at mealtimes, which can result in serious complications for physical and mental health, leading to hospital admissions and even death. However, current training in mealtime care for staff working with this population has been found to be poorly reported, with variable effectiveness. It is essential that care home staff are able to provide good care at mealtimes. This study used ethnography to explore current practice in mealtime care for this population, identify good practice, and understand the factors influencing mealtime care. Approximately 28 h of mealtime observations were conducted in two UK care homes with diverse characteristics. Observations focused on interactions between care staff and residents living with dementia. Twenty-five semi-structured interviews were carried out with care home staff, family carers, and visiting health and social care professionals, to explore mealtime care from their perspectives. A constant comparative approach was taken, to probe emergent findings and explore topics in greater depth. Key thematic categories were identified, including: tensions in mealtime care; the symbolic nature of mealtime care; navigating tensions via a person-centred approach; contextual constraints on mealtime care; and teamwork in mealtime care. The findings indicated that a person-centred approach helps carers to find the right balance between apparently competing priorities, and teamwork is instrumental in overcoming contextual constraints. This evidence has contributed to development of a training intervention for care home staff. Future research should investigate the feasibility of mealtime care training in care homes.

Building a Program Theory of Implementation Using Process Evaluation of a Complex Quality Improvement Trial in Nursing Homes

BACKGROUND AND OBJECTIVES

Significant quality problems exist in long-term care (LTC). Interventions to improve care are complex and often have limited success. Implementation remains a black box. We developed a program theory explaining how implementation of a complex intervention occurs in LTC settings-examining mechanisms of impact, effects of context on implementation, and implementation outcomes such as fidelity.

RESEARCH DESIGN AND METHODS

Concurrent process evaluation of Safer Care for Older Persons in residential Environments (SCOPE)-a frontline worker (care aide) led improvement trial in 31 Canadian LTC homes. Using a mixed-methods exploratory sequential design, qualitative data were analyzed using grounded theory to develop a conceptual model illustrating how teams implemented the intervention and how it produced change. Quantitative analyses (mixed-effects regression) tested aspects of the program theory.

RESULTS

Implementation fidelity was moderate. Implementation is facilitated by (a) care aide engagement with core intervention components; (b) supportive leadership (internal facilitation) to create positive team dynamics and help negotiate competing workplace priorities; (c) shifts in care aide role perceptions and power differentials. Mixed-effects model results suggest intervention acceptability, perceived intervention benefits, and leadership support predict implementation fidelity. When leadership support is high, fidelity is high regardless of intervention acceptability or perceived benefits.

DISCUSSION AND IMPLICATIONS

Our program theory addresses important knowledge gaps regarding implementation of complex interventions in nursing homes. Results can guide scaling of complex interventions and future research.

Unplanned Hospital Visits and Poor Oral Health With Undernutrition in Nursing Home Residents

OBJECTIVES

In 2021, the Japanese government began operating a long-term care (LTC) database called the Long-Term Care Information System for Evidence (LIFE). However, its utility has not been verified. Regarding unplanned hospital visits of nursing home residents, one of the challenges in LTC is that poor oral health with undernutrition could indicate high-risk residents. Therefore, this study examined the association between poor oral health with undernutrition assessed using the LIFE data and unplanned hospital visits of nursing home residents.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

The participants were 237 residents aged ≥65 years in 4 nursing homes in Japan. The analyses included 1041 LIFE data entries repeatedly measured for the participants every month and unplanned hospital visit data during the observation period.

METHODS

The participants' LIFE and unplanned hospital visit data were obtained from the nursing home providers. Poor oral health was defined using oral items included in the LIFE data and body mass index. Using the LIFE data, the association between poor oral health and unplanned hospital visits within 1 month after LIFE assessment entries was analyzed. The odds ratios (ORs) and 95% CIs were calculated using a generalized linear mixed model.

RESULTS

In total, 59 of 1041 LIFE data (5.7%) entries were unplanned hospital visits within 1 month after LIFE assessment. Among patient characteristics, significant differences were noted in dementia diagnosis [OR (95% CI): 2.66 (1.26-5.63)], although no significant differences were observed in other characteristics. Multivariate analysis using participant identification as a random effect confirmed that poor oral health was associated with unplanned hospital visits within 1 month [adjusted OR (95% CI): 2.63 (1.05-6.61)].

CONCLUSIONS AND IMPLICATIONS

Poor oral health assessed using the LIFE data could be used as an indicator to identify nursing home residents at high risk for unplanned hospital visits.

Nurses' and midwives' participation and utilization of health-related research in Kenya: Implications for evidence-based practice

Objective

To assess the level of participation of nurses and midwives in health-related research, determine the status of utilization of research to inform nursing and midwifery practice in Kenya, and explore perspectives of nurses and midwives about strategies to empower nurses/midwives to engage in health research in Kenya.

Methods

Data were extracted from online survey responses of 156 nurse and midwife educators, practitioners, and managers/administrators. SPSS version 26 was used to analyze quantitative data; qualitative data were analyzed using Excel to organize data into categories.

Results

Over one-third of participants reported ever publishing research (37.2%, 58/156). Participants reported using knowledge gained in nursing school to guide practice most frequently (n = 148). Utilization of research findings to guide practice was reported by 80.3% (110/137) of participants. Strategies to enhance participation in the research included research training, research forums, policy reforms, and emphasis on research in curricula.

Conclusions

There is need to intensify and prioritize proposed strategies to empower nurses/midwives to engage in health research.

A qualitative study of organisational resilience in care homes in Scotland

Providing care for the dependent older person is complex and there have been persistent concerns about care quality as well as a growing recognition of the need for systems approaches to improvement. The I-SCOPE (Improving Systems of Care for the Older person) project employed Resilient Healthcare (RHC) theory and the CARE (Concepts for Applying Resilience) Model to study how care organisations adapt to complexity in everyday work, with the aim of exploring how to support resilient performance. The project was an in-depth qualitative study across multiple sites over 24 months. There were: 68 hours of non-participant observation, shadowing care staff at work and starting broad before narrowing to observe care domains of interest; n = 33 recorded one-to-one interviews (32 care staff and one senior inspector); three focus groups (n = 19; two with inspectors and one multi-disciplinary group); and five round table discussions on emergent results at a final project workshop (n = 31). All interviews and discussion groups were recorded and transcribed verbatim. Resident and family interviews (n = 8) were facilitated through use of emotional touchpoints. Analysis using QSR NVivo 12.0 focused on a) capturing everyday work in terms of the interplay between demand and capacity, adaptations and intended and unintended outcomes and b) a higher-level thematic description (care planning and use of information; coordination of everyday care activity; providing person-centred care) which gives an overview of resilient performance and how it might be enhanced. This gives important new insight for improvement. Conclusions are that resilience can be supported through more efficient use of information, supporting flexible adaptation, coordination across care domains, design of the physical environment, and family involvement based on realistic conversations about quality of life.

The Quebec Observatory on End-of-Life Care for People with Dementia: Implementation and Preliminary Findings

Most Canadians with dementia die in long-term care (LTC) facilities. No data are routinely collected in Canada on the quality of end-of-life care provided to this vulnerable population, leading to significant knowledge gaps. The Quebec Observatory on End-of-Life Care for People with Dementia was created to address these gaps. The Observatory is a research infrastructure designed to support the collection of data needed to better understand, and subsequently enhance, care quality for residents dying with dementia. This article reports on the main steps involved in setting up the Observatory, as well as a pilot study that involved 172 residents with dementia who died between 2016 and 2018 in one of 13 participating facilities. It describes the data gathered, methodological changes that were made along the way, feedback from participating facilities, and future developments of the Observatory.

Implementation of communication routines facilitating person-centred care in long-term residential care: A pilot study

BACKGROUND

Specific routines such as the development of personal communication plans can improve the interaction between people with communication disorders and healthcare staff.

OBJECTIVE

This pilot study explores a model for implementing communication routines including personal communication plans in long-term residential care.

DESIGN, SETTING AND PARTICIPANTS

This multiple case study includes two residential care facilities that differ in size and the number of languages spoken. Intervention or main variables studied implementation strategies involved workshops, individual coaching and follow-up visits. Main outcome measure implementation was assessed using goal attainment measurements, and the staff's views about facilitators and barriers to implementation were explored through structured interviews using the Theoretical Domains Framework.

RESULTS

The overall implementation success rate for the facilities was moderate, and one of the facilities showed promising results related to personal communication plans. Both facilities experienced barriers to implementation, including management problems and a lack of reminders. However, the two facilities seem to have different motivations for change.

DISCUSSION AND CONCLUSIONS

Regardless of the features of the facility, successful implementation requires stable and committed leadership. Moreover, experiences with language diversity may motivate staff to implement communication routines.

PATIENT OR PUBLIC CONTRIBUTION

The content of the implementation model used (i.e., choice of specific routines and implementation strategies) was coproduced by staff, managers and the researchers involved in this project. The staff and managers were responsible for the implementation of the new routines under the supervision of the researchers.

Improvement of quality of life and postural balance of institutionalized elderly people undergoing to a treadmill walking training

INTRODUCTION

Institutionalized older adults have fewer opportunities to participate in daily living activities and tasks in an independent manner, with greater deleterious effects on the physiological losses inherent to aging and with increased gait and balance impairment compared to community-dwelling older adults. The use of a treadmill for rehabilitation, with or without partial weight support, has been studied in different groups, but not on institutionalized older adults.

OBJECTIVES

To assess the effects of a treadmill walking program on the postural balance and quality of life of institutionalized older adults.

METHODS

Thirty-seven institutionalized older adults: intervention group (n = 23, 75.7 ± 7.8 years) and control group (n = 14, 78.9 ± 10.2 years). A total of 10 weeks of treadmill walking, twice a week (intervention group) vs. no training (control group). Postural balance was assessed by the Tinetti test, 6-min walk test (6MWT), and 10-m walk test and Quality of life with the WHOQOL-Bref questionnaire.

RESULTS

Significant improvement was observed in balance parameters (6MWT distance: p < 0.001; gait speed 6MWT: p < 0.001; gait speed 10MWT: p < 0.001; Tinetti scale: p = 0.001), and in the physical (p = 0.01), psychological (p = 0.002), self-assessed quality of life (p = 0.01) and overall quality of life domains (p = 0.002).

CONCLUSIONS

Treadmill walking program had positive effects on the postural balance and quality of life of institutionalized older adults.

Designing Acceptable Robots for Assisting Older Adults: A Pilot Study on the Willingness to Interact

The aim of this paper was to explore the psychosocial determinants that lead to acceptability and willingness to interact with a service robot, starting with an analysis of older users' behaviors toward the Robot-Era platform, in order to provide strategies for the promotion of social assistive robotics. A mixed-method approach was used to collect information on acceptability, usability, and human-robot interaction, by analyzing nonverbal behaviors, emotional expressions, and verbal communication. The study involved 35 older adults. Twenty-two were women and thirteen were men, aged 73.8 (±6) years old. Video interaction analysis was conducted to capture the users' gestures, statements, and expressions. A coded scheme was designed on the basis of the literature in the field. Percentages of time and frequency of the selected events are reported. The statements of the users were collected and analyzed. The results of the behavioral analysis reveal a largely positive attitude, inferred from nonverbal clues and nonverbal emotional expressions. The results highlight the need to provide robotic solutions that respect the tasks they offer to the users It is necessary to give older consumers dedicated training in technological literacy to guarantee proper, long-lasting, and successful use.

Translation and validation of the Alberta Context Tool for use in Norwegian nursing homes

PURPOSE

Organizational context is recognized as important for facilitating evidence-based practice and improving patient outcomes. Organizational context is a complex construct to measure and appropriate instruments that can quantify and measure context are needed. The aim of this study was to translate and cross-culturally adapt the Alberta Context Tool (ACT) to Norwegian, and to test the reliability and structural validity among registered nurses (RNs) and licenced practice nurses (LPNs) working in nursing homes.

METHODS

This study was a validation study utilizing a cross-sectional design. The sample consisted of n = 956 healthcare personnel from 28 nursing homes from a municipality in Norway. In the first stage, the ACT was translated before being administered in 28 nursing homes. In the second stage, internal consistency and structural validity were explored using Cronbach's alpha and confirmatory factor analysis.

RESULTS

A rigorous forward-and-back translation process was performed including a team of academics, experts, professional translators and the copyright holders, before an acceptable version of the ACT was piloted and finalized. The Norwegian version of the ACT showed good internal consistency with Chronbachs alpha above .75 for all concepts except for Formal interactions where the alpha was .69. Structural validity was acceptable for both RNs and LPNs with factors loadings more than .4 for most items.

CONCLUSIONS

The Norwegian version of the ACT is a valid measure of organizational context in Norwegian nursing homes among RNs and LPNs.

Optimizing mealtime care for people with dementia from the perspective of formal caregivers: A systematic review of qualitative research

BACKGROUND

As dementia progresses, people with dementia experience many problems during mealtimes that seriously affect their physical, psychological, and social health and quality of life. Formal caregivers play an important role in optimizing mealtime care.

OBJECTIVE

To systematically review and synthesise relevant qualitative studies exploring the experience and perceptions of formal caregivers regarding optimizing mealtime care for people with dementia.

DESIGN

A systematic review of qualitative research.

DATA SOURCES

The PubMed, Web of Science, Cochrane Library, Embase, CINAHL, CNKI, WanFang and Vip databases were systematically searched.

REVIEW METHODS

Two reviewers independently screened the titles and abstracts, extracted the data and performed critical appraisals of each included study. The data synthesis was conducted using thematic analysis.

FINDINGS

A total of 10 studies were included. The formal caregivers included nursing assistants, nurses, speech and language therapists, nursing students, dietitians, a social worker, a professional educator, physiotherapists, health care aides, kitchen staff, diversional therapy assistants and other unidentified care staff. The findings were synthesised into the following 3 analytical themes: (1) tailored rather than standardized; (2) emotional nurturance; and (3) beyond the individual level.

CONCLUSIONS

Mealtimes involve complex physiological and psychological processes. Formal caregivers should develop tailored care practices based on individual patients' preferences and needs. Emotional connection plays a key role and has a positive impact on the mealtime experience. Further research is needed to explore the specific effects of emotional connections on optimizing mealtime care.

How, why and under what circumstances does a quality improvement collaborative build knowledge and skills in clinicians working with people with dementia? A realist informed process evaluation

In increasingly constrained health and aged care services, strategies are needed to improve quality and translate evidence into practice. In dementia care, recent failures in quality and safety have led the WHO to prioritise the translation of known evidence into practice. While quality improvement collaboratives have been widely used in healthcare, there are few examples in dementia care.

We describe a recent quality improvement collaborative to improve dementia care across Australia and assess the implementation outcomes of acceptability and feasibility of this strategy to translate known evidence into practice. A realist-informed process evaluation was used to analyse how, why and under what circumstances a quality improvement collaborative built knowledge and skills in clinicians working in dementia care.

This realist-informed process evaluation developed, tested and refined the programme theory of a quality improvement collaborative. Data were collected pre-intervention and post-intervention using surveys and interviews with participants (n=28). A combined inductive and deductive data analysis process integrated three frameworks to examine the context and mechanisms of knowledge and skill building in participant clinicians.

A refined program theory showed how and why clinicians built knowledge and skills in quality improvement in dementia care. Six mechanisms were identified: motivation, accountability, identity, collective learning, credibility and reflective practice. These mechanisms, in combination, operated to overcome constraints, role boundaries and pessimism about improved practice in dementia care.

A quality improvement collaborative designed for clinicians in different contexts and roles was acceptable and feasible in building knowledge, skills and confidence of clinicians to improve dementia care. Supportive reflective practice and a credible, flexible and collaborative process optimised quality improvement knowledge and skills in clinicians working with people with dementia.

Trial registration number

ACTRN12618000268246.

Is it possible to influence ability, willingness and understanding among nursing home care staff to implement nutritional guidelines? A comparison of a facilitated and an educational strategy

BACKGROUND

Translating nutrition knowledge into care practice is challenging since multiple factors can affect the implementation process. This study examined the impact of two implementation strategies, that is external facilitation (EF) and educational outreach visits (EOVs), on the organisational context and individual factors when implementing nutritional guidelines in a nursing home (NH) setting.

METHODS

The EF strategy was a one-year, multifaceted (including support, guidance, a practice audit and feedback) intervention given to four NH units. The EOV strategy was a three-hour lecture about the nutritional guidelines given to four other NH units. Both strategies were directed at selected NH teams, consisting of a unit manager, a nurse and 5-10 care staff. A questionnaire was distributed, before and after the interventions, to evaluate the prerequisites for the staff to use the guidelines. Three conditions were used to examine the organisational context and the individual factors: the staff's ability and willingness to implement the nutritional guidelines and their understanding of them. Confirmatory factor analysis and structural equation models were used for the data analysis.

RESULTS

The results indicated that on average, there was a significant increase in the staff's ability to implement the nutritional guidelines in the EF group. The staff exposed to the EF strategy experienced better resources to implement the guidelines in terms of time, tools and support from leadership and a clearer assignment of responsibility regarding nutrition procedures. There was no change in staff's willingness and understanding of the guidelines in the EF group. On average, no significant changes were observed for the staff's ability, willingness or understanding in the EOV group.

CONCLUSIONS

A long-term, active and flexible implementation strategy (i.e. EF) affected the care staff's ability to implement the nutritional guidelines in an NH setting. No such impact was observed for the more passive, educational approach (i.e. EOV).

Prevalence and Associated Factors of Polypharmacy in Nursing Home Residents: A Cross-Sectional Study

In Spain, there has been a progressive increase in aging. Specifically, Leon has been one of the Spanish provinces with the highest aging index. Polypharmacy is highly prevalent among the elderly, with significant consequences for safety. The aim of this study was to assess the consumption of drugs in a nursing home in the province of Leon and establish the relationship between polypharmacy and the most common comorbid diseases. A descriptive, observational, and cross-sectional study design was used. Residents' information and treatments were collected by reviewing on medical charts, completed with clinical information obtained from the physician of the nursing home. The mean age of residents was 86.8 years, and 63.8% were female. Mean medical consumption amounted to 7.02 prescriptions. Polypharmacy was observed in 54.9% of residents, and excessive polypharmacy in 22.1%. The most commonly used medications (ATC classification) were those acting on the cardiovascular system (84.4%) and the nervous system (82.8%). A high-level of drug consumption was observed in the nursing home. Interventions should focus on those residents hospitalized the last year and with recent contact with a general practitioner. There is a need to develop a comprehensive monitoring system to assess the quality of prescriptions for nursing home residents.

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.

Prevalence of Malnutrition and Depression in Older Adults Living in Nursing Homes in Mexico City

This study evaluated the association between nutritional status, depressive symptoms, and the number of prescription drugs taken by older adults living in nursing homes in Mexico City. In a cross-sectional study, 262 participants were subjected to anthropometric and nutritional (Mini Nutritional Assessment (MNA)) evaluations; additionally, their depression (Geriatric Depression Scale (GDS)) and functional status were assessed. Multiple logistic regression was used for identifying factors associated with the risk of malnutrition/malnourishment. The mean age of participants was 83.1 ± 8.6 years. A total of 59.9% and 21.1% were at risk of malnutrition and malnourished, respectively. With respect to depression, 27.9% of the participants had mild depression, while 11.4% showed severe depression. An inverse correlation between MNA evaluations and depression scores was found (Spearman's ρ = -0.4624, p < 0.001); residents with a better nutritional status had lower depression scores. Individuals with depressive symptoms were approximately five times more likely to be at risk of malnutrition or malnourished (OR = 5.82, 95% CI = 2.27-14.89) than individuals without depression. Residents taking three or more prescription drugs daily (OR = 1.83, 95% CI = 1.27-2.63, p < 0.001) were more likely to be at risk of malnutrition or malnourished. In summary, poor nutritional status was associated with depression, while the intake of numerous prescription drugs was associated with being at risk of malnutrition or malnourished.

What lies beneath: a retrospective, population-based cohort study investigating clinical and resource-use characteristics of institutionalized older people in Catalonia

Background

Planning population care in a specific health care setting requires deep knowledge of the clinical characteristics of the target care recipients, which tend to be country specific. Our area virtually lacks any descriptive, far-reaching publications about institutionalized older people (IOP). We aimed to investigate the demographic and clinical characteristics of institutionalized older people (IOP) ≥65 years old and compare them with those of the rest of the population of the same age.

Methods

Retrospective analysis (total cohort approach) of clinical and resource-use characteristics of IOP and non-IOP older than 65 years in Catalonia (North-East Spain). Variables analysed included age and sex, diagnoses, morbidity burden—using Adjusted Morbidity Groups (GMA, Grupos de Morbilidad Ajustada)—, mortality, use of resources, and medications taken. All data were obtained from the administrative database of the local healthcare system.

Results

This study included 93,038, 78,458, 68,545 and 67,456 IOP from 2011, 2013, 2015 and 2017, respectively. In this interval, an increase in median age (83 vs. 87 years), in women (68.64% vs. 72.11%) and in annual mortality (11.74% vs. 20.46%) was observed. Compared with non-IOP (p < 0.001 in all comparisons), IOP showed a higher annual mortality (20.46% vs. 3.13%), a larger number of chronic diseases (specially dementia: 46.47% vs. 4.58%), higher multimorbidity (15.2% vs. 4.2% with GMA of maximum complexity), and annual admissions to acute care (47.6% vs. 27.7%) and skilled nursing facilities (27.8% vs. 7.4%), mean length of hospital stay (10.0 vs. 7.2 days) and mean of medications taken (11.7 vs. 8.0).

Conclusions

There is a growing gap between the clinical and demographic characteristics of age-matched IOP and non-IOP, which overlaps with a higher mortality rate of IOP. The profile of resources utilization of IOP compared with non-IOP strongly suggests a deficiency of preventive actions and stresses the need to rethink the care model for IOP from a social and health care perspective.

Citizen and stakeholder led priority setting for long-term care research: identifying research priorities within the Translating Research in Elder Care (TREC) Program

BACKGROUND

The Translating Research in Elder Care (TREC) program is a longitudinal partnered program of research in Western Canada that aims to improve the quality of care and quality of life for residents and quality of worklife for staff in long-term care settings. This program of research includes researchers, citizens (persons living with dementia and caregivers of persons living in long-term care), and stakeholders (representatives from provincial and regional health authorities, owner-operators of long-term care homes). The aim of this paper is to describe how we used priority setting methods with citizens and stakeholders to identify ten priorities for research using the TREC data.

METHODS

We adapted the James Lind Alliance Priority Setting Partnership method to ensure our citizens and stakeholders could identify priorities within the existing TREC data. We administered an online survey to our citizen and stakeholder partners. An in-person priority setting workshop was held in March 2019 in Alberta, Canada to establish consensus on ten research priorities. The in-person workshop used a nominal group technique and involved two rounds of small group prioritization and one final full group ranking.

RESULTS

We received 72 online survey respondents and 19 persons (citizens, stakeholders) attended the in-person priority setting workshop. The workshop resulted in an unranked list of their ten research priorities for the TREC program. These priorities encompassed a range of non-clinical topics, including: influence of staffing (ratios, type of care provider) on residents and staff work life, influence of the work environment on resident outcomes, and the impact of quality improvement activities on residents and staff.

CONCLUSIONS

This modified priority setting approach provided citizens and stakeholders with an opportunity to identify their own research priorities within the TREC program, without the external pressures of researchers. These priorities will inform the secondary analyses of the TREC data and the development of new projects. This modified priority setting may be a useful approach for research teams trying to engage their non-academic partners and to identify areas for future research.

Nursing research priorities based on CINAHL database: A scoping review

Aim

To analyse nursing research based on the CINAHL database to identify research priorities for nursing.

Design

A scoping literature review was conducted. The CINAHL Plus (EBSCO) Full Text was searched between 2012-2018.

Methods

Out of 1522 original publications, 91 fulfilled the inclusion criteria. The Joanna Briggs Institute critical appraisal tools were applied. Data were analysed by a thematic analysis method.

Results

A strong emphasis should be put on development and evaluation of nursing theories and, in addition, randomized controlled trial studies, meta-synthesis, experimental and intervention studies are needed in nursing research. Development of competencies and skills in the nursing profession ought to be studied more extensively and research should be focused on variety fields of nursing practice.

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.

Effectiveness of a Treadmill Training Programme in Improving the Postural Balance on Institutionalized Older Adults

Background

Institutionalized older adults have increased gait and balance impairment compared with community-dwelling older adults. The use of the treadmill for the rehabilitation process has been studied in different groups, but not in the institutionalized elderly.

Objectives

The objective of this study was to assess the effects of a treadmill walking workout program on the postural balance of institutionalized older adults.

Methods

Postural balance was assessed by the Berg Balance Scale (BBS), Short Physical Performance Battery (SPPB), gait speed, and Timed Up and Go Test (TUG) on 37 institutionalized older adults (23 in the intervention group and 14 in the control group). Training consisted of a 20-minute treadmill walking workout carried out twice a week for 10 weeks. Measurements were obtained before and after 10 weeks and with 1 month of follow-up for the intervention group. For the control group, the data were obtained before and after the training period.

Results

Significant improvement occurred in all motor function parameters (BBS: p < 0.01; gait speed: p < 0.01; gait speed: p < 0.01; gait speed: p < 0.01; gait speed:

Conclusions

The present results permit us to conclude that a treadmill walking program had positive effects on the postural balance of institutionalized older adults.

Differential Association of Aggression With Sadness for People With Moderate and Severe Dementia

Little is known about how individual behavioral and psychological symptoms of dementia (BPSD) impact the person with dementia. This cross-sectional, retrospective study examined the association between one BPSD, aggressive behavior, and a patient-identified outcome, sadness, among people with moderate and severe dementia (n = 5001) using clinical administrative Resident Assessment Instrument 2.0 data. For people with moderate or severe cognitive impairment, the odds of sadness were significantly higher if verbal aggression was exhibited 4 to 6 (adjusted odds ratio [aOR] = 2.85, P < .001) or 1 to 3 (aOR = 2.28, P < .001) times per week, or daily (aOR = 1.77, P = .003). People with severe cognitive impairment and who displayed physical aggression either daily (OR = 2.16, P = .002) or 1 to 3 times per week (OR = 1.45, P = .023) also had an increased odds of sadness. Aggression may harm the person with dementia's mental well-being, depending on the level of cognitive impairment, and type and frequency of aggression. Prospective studies can build on these correlational findings.

Prevalence of Malnutrition or Risk in Residents in Long Term Care: Comparison of Four Tools

The ideal tool for determination of malnutrition risk or malnutrition in long term care (LTC) is elusive. This study compares prevalence, association with resident risk factors and sensitivity (SE) and specificity (SP) of malnutrition or risk categorization in 638 residents from 32 LTC homes in Canada using four tools: the Mini-Nutritional Assessment Short Form (MNA-SF); Patient-Generated Subjective Global Assessment (PG-SGA) Global Category Rating and the Pt-Global webtool; and the interRAI Long Term Care Facility undernutrition trigger. Prevalence was most common with MNA-SF (53.7%) and lowest with InterRAI (28.9%), while the PG-SGA Global Category Rating (44%) was higher than the Pt-Global webtool (33.4%). Tools were consistently associated with resident covariates with few exceptions. The PG-SGA Global Category Rating demonstrated the best sensitivity and specificity when compared to all other tools. Further work to determine the predictive validity of this tool in LTC residents is required.

Research Priorities in Post-acute and Long-term Care: Results of a Stakeholder Needs Assessment

OBJECTIVES

Conduct a needs assessment among post-acute and long-term care (PA-LTC) stakeholder groups to identify (1) research topics of highest priority and (2) perspectives on research, including concerns/barriers to conducting research in the PA-LTC setting.

DESIGN

Mixed methods multistakeholder engagement process. Needs assessment conducted with tailored strategies per stakeholder group: interview, survey, and focus group.

SETTING AND PARTICIPANTS

Four stakeholder groups-medical directors/providers (n = 89), administrative leadership (n = 5), frontline staff (n = 17), and family members of residents and residents themselves (n = 11)-were recruited from the Colorado PA-LTC community through an academic-community partnership between the University of Colorado and Colorado Medical Directors Association.

MAIN OUTCOME(S)

Stakeholder perspectives on research and high priority PA-LTC research topics.

RESULTS

Research priorities common across stakeholder groups included polypharmacy (overuse of medication generally and overuse of antibiotics specifically), care transitions, mental health (including dementia, Alzheimer's disease, behaviors), chronic pain, urinary tract infection, and quality of life issues. Providers specifically prioritized heart failure, Parkinson's, and other chronic illnesses. Administrators and directors of nurses emphasized hospitalizations. Staff prioritized medication/therapy compliance. Families/residents prioritized neurologic disease. Concerns included staff burden, consenting process, privacy, and family involvement.

CONCLUSIONS/IMPLICATIONS

PA-LTC patients have a lot to offer as participants and decision makers in research, frontline staff are enthusiastic about participation, family members want to be involved, and providers value research findings in their practice but need a more supportive environment to produce and participate in research.

Research priorities in residential aged care services: A statewide survey

OBJECTIVES

To ascertain the research priorities of staff working in Victorian residential aged care services (RACS).

METHOD

In October 2016, all 754 Victorian RACS were asked to list three most important research priorities in a confidential postal survey. Descriptive statistics and content analysis were used to analyse the data.

RESULTS

One hundred and sixty-two (21.5%) RACS participated. Research priorities, in order of importance, were grouped thematically as workforce issues, strategies to manage residents with dementia and funding to the sector. Staffing numbers and mix, particularly nurse-to-resident ratios, dominated workforce issues. The management of responsive behaviours was highlighted as a pressing clinical issue, and insufficient funding to the sector impacted on most issues reported.

CONCLUSIONS

The research priorities identified were inter-related. Some were already well researched, suggesting RACS staff have little time and/or limited access to research evidence to inform the care and management of residents, possibly because of inadequate staffing and funding.

Malnutrition among older adults living in Portuguese nursing homes: the PEN-3S study

OBJECTIVE

To characterise the nutritional status and to identify malnutrition-associated variables of older adults living in Portuguese nursing homes.

DESIGN

Cross-sectional study. Data on demographic and socio-economic characteristics, self-reported morbidity, eating-related problems, nutritional status, cognitive function, depression symptoms, loneliness feelings and functional status were collected by trained nutritionists through a computer-assisted face-to-face structured interview followed by standardised anthropometric measurements. Logistic regression was used to identify factors associated with being at risk of malnutrition/malnourished.

SETTING

Portuguese nursing homes.

SUBJECTS

Nationally representative sample of the Portuguese population aged 65 years or over living in nursing homes.

RESULTS

A total of 1186 individuals (mean age 83·4 years; 72·8 % women) accepted to participate. According to the Mini Nutritional Assessment, 4·8 (95 % CI 3·2, 7·3) % were identified as malnourished and 38·7 (95 % CI 33·5, 44·2) % were at risk of malnutrition. These percentages increased with age and were significantly higher for women. Logistic regression showed (OR; 95 % CI) that older adults reporting no or little appetite (6·5; 2·7, 15·3), those revealing symptoms of depression (2·6; 1·6, 4·2) and those who were more dependent in their daily living activities (4·7; 2·0, 11·1) were also at higher odds of being malnourished or at risk of malnutrition.

CONCLUSIONS

Malnutrition and risk of malnutrition are prevalent among nursing home residents in Portugal. It is crucial to routinely screen for nutritional disorders, as well as risk factors such as symptoms of depression and lower functional status, to prevent and treat malnutrition.

Nurse-identified patient care and health services research priorities in the United Arab Emirates: a Delphi study

BACKGROUND

The need for improved research on ill health has been recognized internationally and locally in the United Arab Emirates (UAE). The UAE Nursing and Midwifery Council recently committed to enhancing the status and contributions of nursing in healthcare research across the UAE by establishing a National Committee for Research Development. This study using a Delphi method to identify research priorities from the perspective of nurses delivering frontline healthcare.

METHODS

A two-phase Delphi design was implemented with 1032 nurses participating in phase one of the study and 1339 in phase two.

RESULTS

The most important priority was patient safety and healthcare professionals' awareness of international patient safety goals (including staffing levels and shift length) and potential effects on patient safety. Other important priorities were infection control practices and management of communicable diseases.

CONCLUSIONS

These priorities may inform nursing research programs to improve patient care and health outcomes in the UAE and similar contexts worldwide.

Dietary Intake and Associated Factors in Long-Term Care Homes in Southeast Spain

Diet is a key modifiable factor in the management of malnutrition and age-related diseases such as sarcopenia, an important issue in long-term care homes. The objectives of this study were to evaluate the dietary intake of residents, define dietary patterns, and analyze their association with sex, diet texture, nutritional status, and the presence of sarcopenia. Intake was assessed by the precise weighing method, dietary patterns were defined a posteriori by cluster analysis, and nutritional status and sarcopenia were evaluated by applying the MNA-SF test and EWGSOP algorithm, respectively. A regular diet was consumed by 63% of participants; 56% were at risk of malnutrition and 63% were diagnosed with sarcopenia. Intake of potassium, magnesium, zinc, iodine, vitamin D, E, folic acid, and fiber was low in >80% of participants. Protein intake was <1 g/kg/day in 56% of participants and <25 g/meal in 100%. Two dietary patterns were identified, but neither fully met recommendations. The risk of a poorer diet was higher in females and residents with sarcopenia and was lower in those consuming regular diets. In conclusion, action is required to improve the inadequate nutritional intake of long-term care residents.

Priority issues for pressure injury research: An Australian consensus study

Pressure injuries are a significant health concern in all clinical settings. The current body of research on pressure injuries reported in the literature presents primarily low level evidence. The purpose of the current study was to identify and prioritize pressure injury research issues. The approach entailed evidence scoping and implementing a formal consensus process using a modified nominal group technique based on the Research and Development/University of California at Los Angeles appropriateness method. Sixteen Australian pressure injury experts participated in five consensus voting rounds in May to June 2015. From 60 initial research issues, the experts reached agreement that 26 issues are a priority for future pressure injury research. The highest priorities were strategies to assess skin and tissues, appropriate outcome measures for indicators of pressure injury healing and recurrence, heel pressure off-loading and shear reduction strategies, economic cost of pressure injuries and their management and effectiveness of skin moisturizers and barrier products. Developing a prioritized research agenda, informed by clinical and academic pressure injury experts, can assist in reducing the burden of pressure injuries by identifying topics of the highest need for further research. A web-based nominal group voting process was successful in engaging expert decision-making and has wide-reaching international appeal in facilitating cost-effective consensus methodologies. The priority list generated from this research is currently used in Australia to inform government investment in pressure injury research.

Stated preferences for long-term care: a literature review

Person-centred provision of long-term care (LTC) requires information on how individuals value respective LTC services. The literature on LTC preferences has not been comprehensively reviewed, existing summaries are contradictory. An explorative, scoping review was conducted to provide a thorough methodological description and results synthesis of studies that empirically investigated LTC preference outcomes based on respondents’ statements. A wide search strategy, with 18 key terms relating to ‘LTC’ and 31 to ‘preferences’, was developed. Database searches in PubMed, Ovid and ScienceDirect were conducted in February 2016. The 59 studies meeting the inclusion criteria were grouped and methodically described based on preference elicitation techniques and methods. Despite substantial methodological heterogeneity between studies, certain findings consistently emerged for the investigated LTC preference outcomes. The large majority of respondents preferred to receive LTC in their known physical and social environment when care needs were moderate, but residential care when care needs were extensive. Preferences were found to depend on a variety of personal, environmental, social and cultural aspects. Dependent individuals aspired to preserve their personal and social identity, self-image, independence, autonomy, control and dignity, which suggests that LTC preferences are a function of the perceived ability of a specific LTC arrangement to satisfy peoples’ basic physiological and mental/social needs. Research on LTC preferences would greatly profit from a standardisation of respective concepts and methods.

SCOPEOUT: sustainability and spread of quality improvement activities in long-term care- a mixed methods approach

BACKGROUND

Interventions to improve quality of care for residents of long-term care facilities, and to examine the sustainability and spread of such initiatives, remain a top research priority. The purpose of this exploratory study was to assess the extent to which activities initiated in a quality improvement (QI) collaborative study using care aide led teams were sustained or spread following cessation of the initial project and to identify factors that led to its success.

METHODS

This study used an exploratory mixed methods study design and was conducted in seven residential long-term care facilities in two Canadian provinces. Sustainability and spread of QI activities were assessed by a questionnaire over five time points for 18 months following the collaborative study with staff from both intervention with non-intervention units. Semi-structured interviews were conducted with care managers at six and 12 months. QI team success in applying the QI model was ranked as high, medium, or low using criteria developed by the research team. Descriptive statistics, bivariate analyses, and General Estimating Equations were used to analyze the data. Interview data were analyzed using thematic analysis.

RESULTS

In total, 683 surveys were received over the five time periods from 476 unique individuals on a facility unit. Seven managers were interviewed. A total of 533 surveys were analyzed. While both intervention and non-intervention units experienced a decline over time in all outcome measures, this decline was significantly less pronounced on intervention units. Facilities with medium and high success ranking had significantly higher scores in all four outcomes than facilities with a low success ranking. Care aides reported significantly less involvement of others in QI activities, less empowerment and less satisfaction with the quality of their work life than regulated care providers. Manager interviews provided evidence of sustainability of QI activities on the intervention units in four of the seven facilities up to 18 months following the intervention and demonstrated the need for continued staff and leadership engagement.

CONCLUSION

Sustainability of a QI project which empowers and engages care aides is possible and achievable, but requires ongoing staff and leadership engagement.

Testing the evidence integration triangle for implementation of interventions to manage behavioral and psychological symptoms associated with dementia: Protocol for a pragmatic trial

Behavioral and psychological symptoms of dementia (BPSD) include aggression, agitation, resistiveness to care, depression, anxiety, apathy, and hallucinations. BPSD are common in nursing home residents and can be ameliorated using person-centered approaches. Despite regulatory requirements, less than 2% of nursing homes consistently implement person-centered behavioral approaches. In a National Institute of Nursing Research-funded research protocol, we are implementing a pragmatic cluster randomized clinical trial designed to enable staff in nursing homes to reduce BPSD using behavioral approaches while optimizing function, preventing adverse events, and improving quality of life of residents. The implementation is based on use of the Evidence Integration Triangle (EIT), a parsimonious, community-engaged participatory framework that is well suited to the complexity and variability in the nursing home environment. A total of 50 nursing home communities will be randomized to EIT-4-BPSD or education only. Primary Aim 1 is to determine if communities exposed to EIT-4-BPSD demonstrate evidence of implementation evaluated by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) criteria. Primary Aim 2 is to evaluate the feasibility, utility, and cost of the EIT approach in EIT-4-BPSD communities.

Clinical Update on Nursing Home Medicine: 2017

This is the 11th annual Clinical Update from the AMDA meeting article. This year the topics covered are hypertension after the Systolic Blood Pressure Intervention Trial; chronic obstructive pulmonary disease risk factors, diagnosis and management including end-of-life planning, and the difficulties with exacerbations such as breathlessness; diagnosis and treatment of cognitive impairment and dementia; and wound care and pressure ulcer management.

Hearing the Voice of the Resident in Long-Term Care Facilities-An Internationally Based Approach to Assessing Quality of Life

OBJECTIVES

interRAI launched this study to introduce a set of standardized self-report measures through which residents of long-term care facilities (LTCFs) could describe their quality of life and services. This article reports on the international development effort, describing measures relative to privacy, food, security, comfort, autonomy, respect, staff responsiveness, relationships with staff, friendships, and activities. First, we evaluated these items individually and then combined them in summary scales. Second, we examined how the summary scales related to whether the residents did or did not say that the LTCFs in which they lived felt like home.

DESIGN

Cross-sectional self-report surveys by residents of LTCFs regarding their quality of life and services.

SETTING/PARTICIPANTS

Resident self-report data came from 16,017 individuals who resided in 355 LTCFs. Of this total, 7113 were from the Flanders region of Belgium, 5143 residents were from Canada, and 3358 residents were from the eastern and mid-western United States. Smaller data sets were collected from facilities in Australia (20), the Czech Republic (72), Estonia (103), Poland (118), and South Africa (87).

MEASUREMENTS

The interRAI Self-Report Quality of Life Survey for LTCFs was used to assess residents' quality of life and services. It includes 49 items. Each area of inquiry (eg, autonomy) is represented by multiple items; the item sets have been designed to elicit resident responses that could range from highly positive to highly negative. Each item has a 5-item response set that ranges from "never" to "always."

RESULTS

Typically, we scored individual items scored based on the 2 most positive categories: "sometimes" and "always." When these 2 categories were aggregated, among the more positive items were: being alone when wished (83%); decide what clothes to wear (85%); get needed services (87%); and treated with dignity by staff (88%). Areas with a less positive response included: staff knows resident's life story (30%); resident has enjoyable things to do on weekends (32%); resident has people to do things with (33%); and resident has friendly conversation with staff (45%). We identified 5 reliable scales; these scales were positively associated with the resident statement that the LTCF felt like home. Finally, international score standards were established for the items and scales.

CONCLUSIONS

This study establishes a set of standardized, self-report items and scales with which to assess the quality of life and services for residents in LTCFs. The study also demonstrates that these scales are significantly related to resident perception of the home-like quality of the facilities.

Optimal NHS service delivery to care homes: a realist evaluation of the features and mechanisms that support effective working for the continuing care of older people in residential settings

Background

Care homes are the institutional providers of long-term care for older people. The OPTIMAL study argued that it is probable that there are key activities within different models of health-care provision that are important for residents’ health care.

Objectives

To understand ‘what works, for whom, why and in what circumstances?’. Study questions focused on how different mechanisms within the various models of service delivery act as the ‘active ingredients’ associated with positive health-related outcomes for care home residents.

Methods

Using realist methods we focused on five outcomes: (1) medication use and review; (2) use of out-of-hours services; (3) hospital admissions, including emergency department attendances and length of hospital stay; (4) resource use; and (5) user satisfaction. Phase 1: interviewed stakeholders and reviewed the evidence to develop an explanatory theory of what supported good health-care provision for further testing in phase 2. Phase 2 developed a minimum data set of resident characteristics and tracked their care for 12 months. We also interviewed residents, family and staff receiving and providing health care to residents. The 12 study care homes were located on the south coast, the Midlands and the east of England. Health-care provision to care homes was distinctive in each site.

Findings

Phase 1 found that health-care provision to care homes is reactive and inequitable. The realist review argued that incentives or sanctions, agreed protocols, clinical expertise and structured approaches to assessment and care planning could support improved health-related outcomes; however, to achieve change NHS professionals and care home staff needed to work together from the outset to identify, co-design and implement agreed approaches to health care. Phase 2 tested this further and found that, although there were few differences between the sites in residents’ use of resources, the differences in service integration between the NHS and care homes did reflect how these institutions approached activities that supported relational working. Key to this was how much time NHS staff and care home staff had had to learn how to work together and if the work was seen as legitimate, requiring ongoing investment by commissioners and engagement from practitioners. Residents appreciated the general practitioner (GP) input and, when supported by other care home-specific NHS services, GPs reported that it was sustainable and valued work. Access to dementia expertise, ongoing training and support was essential to ensure that both NHS and care home staff were equipped to provide appropriate care.

Limitations

Findings were constrained by the numbers of residents recruited and retained in phase 2 for the 12 months of data collection.

Conclusions

NHS services work well with care homes when payments and role specification endorse the importance of this work at an institutional level as well as with individual residents. GP involvement is important but needs additional support from other services to be sustainable. A focus on strategies that promote co-design-based approaches between the NHS and care homes has the potential to improve residents’ access to and experience of health care.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.