Stakeholder perspectives of care for people living with dementia moving from hospital to care facilities in the community: a systematic review

Access to preferred skilled nursing facilities: Transitional care pathways for patients with Alzheimer's disease and related dementias

OBJECTIVE

The study aimed to assess whether individuals with Alzheimer's disease and related dementias (ADRD) experience restricted access to hospitals' high-volume preferred skilled nursing facility (SNF) partners.

DATA SOURCES

The data source includes acute care hospital to SNF transitions identified using 100% Medicare Provider Analysis and Review files, 2017-2019.

STUDY DESIGN

We model and compare the estimated effect of facility "preferredness" on SNF choice for patients with and without ADRD. We use conditional logistic regression with a 1:1 patient sample otherwise matched on demographic and encounter characteristics.

DATA COLLECTION

Our matched sample included 58,190 patients, selected from a total observed population of 3,019,260 Medicare hospitalizations that resulted in an SNF transfer between 2017 and 2019.

PRINCIPAL FINDINGS

Overall, patients with ADRD have a lower probability of being discharged to a preferred SNF (52.0% vs. 54.4%, p < 0.001). Choice model estimation using our matched sample suggests similarly that the marginal effect of preferredness on a patient choosing a proximate SNF is 2.4 percentage points lower for patients with ADRD compared with those without (p < 0.001). The differential effect of preferredness based on ADRD status increases when considering (a) the cumulative effect of multiple SNFs in close geographic proximity, (b) the magnitude of the strength of hospital-SNF relationship, and (c) comparing patients with more versus less advanced ADRD.

CONCLUSIONS

Preferred relationships are significantly predictive of where a patient receives SNF care, but this effect is weaker for patients with ADRD. To the extent that these high-volume relationships are indicative of more targeted transitional care improvements from hospitals, ADRD patients may not be fully benefiting from these investments. Hospital leaders can leverage integrated care relationships to reduce SNFs' perceived need to engage in selection behavior (i.e., enhanced resource sharing and transparency in placement practices). Policy intervention may be needed to address selection behavior and to support hospitals in making systemic improvements that can better benefit all SNF partners (i.e., more robust information sharing systems).

Long-term care transitions during a global pandemic: Planning and decision-making of residents, care partners, and health professionals in Ontario, Canada

The COVID-19 pandemic appears to have shifted the care trajectories of many residents and care partners in Ontario who considered leaving LTC to live in the community for a portion or the duration of the pandemic. This type of care transition-from LTC to home care-was highly uncommon prior to the pandemic, therefore we know relatively little about the planning and decision-making involved. The aim of this study was to describe who was involved in LTC to home care transitions in Ontario during the COVID-19 pandemic, to what extent, and the factors that guided their decision-making. A qualitative description study involving semi-structured interviews with 32 residents, care partners and health professionals was conducted. Transition decisions were largely made by care partners, with varied input from residents or health professionals. Stakeholders considered seven factors, previously identified in a scoping review, when making their transition decisions: (a) institutional priorities and requirements; (b) resources; (c) knowledge; (d) risk; (e) group structure and dynamic; (f) health and support needs; and (g) personality preferences and beliefs. Participants' emotional responses to the pandemic also influenced the perceived need to pursue a care transition. The findings of this research provide insights towards the planning required to support LTC to home care transitions, and the many challenges that arise during decision-making.

Challenges to Systems of Long-Term Care: Mapping of the Central Concepts from an Umbrella Review

The ageing of the population poses urgent challenges to the health and social protection sectors, including the need for greater adequacy and integration of health care services provided to older people. It is considered necessary and urgent to understand the state-of-the-art of community-based models of care for older people in institutional care and at home. This study aims to map the concepts that politicians and providers need to address through an umbrella review as a review method. Articles describing the structuring aspects of care models appropriate to the needs in long-term care and systematic reviews or meta-analyses targeting people aged 65 years or more were considered. A total of 350 studies met the inclusion criteria and were included in the review. The results identified the need to contribute to effective and more efficient integration and articulation of all the stakeholders, based essentially on professional care at the patient's homes, focused on their needs using the available technologies, empowering patients and families. Eight categories emerged that addressed factors and variables involved in care models for the long-term care needs of institutionalised and home-based older people as a guarantee of accessibility to healthcare and to enhance the well-being and quality of life of patients and family caregivers.

Unique Care Needs of People with Dementia and Their Caregivers during Transitions from Skilled Nursing Facilities to Home and Assisted Living: A Qualitative Study

OBJECTIVES

The purpose of the study was to describe unique care needs of people with dementia (PWD) and their caregivers during transitions from skilled nursing facilities (SNF) to home.

DESIGN

A qualitative study using focus groups, semistructured interviews, and descriptive qualitative analysis.

SETTING AND PARTICIPANTS

The study was set in one state, in 4 SNFs where staff had experience using a standardized transitional care protocol. The sample included 22 SNF staff, 4 home health nurses, 10 older adults with dementia, and their 10 family caregivers of whom 39 participated in focus groups and/or interviews.

METHODS

Data collection included 4 focus groups with SNF staff and semistructured interviews with home health nurses, SNF staff, PWD, and their family caregivers. Standardized focus group and interview guides were used to elicit participant perceptions of transitional care. We used the framework analytic approach to qualitative analysis. A steering committee participated in interpretation of findings.

RESULTS

Participants described 4 unique care needs: (1) PWD and caregivers may not be ready to fully engage in dementia care planning while in the SNF, (2) caregivers are not prepared to manage dementia symptoms at home, (3) SNF staff have difficulty connecting PWD and caregivers to community supports, and (4) caregivers receive little support to address their own needs.

CONCLUSIONS AND IMPLICATIONS

Based on findings, recommendations are offered for adapting transitional care to address the needs of PWD and their caregivers. Further research is needed (1) to confirm these findings in larger, more diverse samples and (2) to adapt and test interventions to support successful community discharge of PWD and their caregivers.

Stakeholder involvement in care transition planning for older adults and the factors guiding their decision-making: a scoping review

OBJECTIVE

To synthesise the existing literature on care transition planning from the perspectives of older adults, caregivers and health professionals and to identify the factors that may influence these stakeholders' transition decision-making processes.

DESIGN

A scoping review guided by Arksey and O'Malley's six-step framework. A comprehensive search strategy was conducted on 7 January 2021 to identify articles in five databases (MEDLINE, Embase, CINAHL Plus, PsycINFO and AgeLine). Records were included when they described care transition planning in an institutional setting from the perspectives of the care triad (older adults, caregivers and health professionals). No date or study design restrictions were imposed.

SETTING

This review explored care transitions involving older adults from an institutional care setting to any other institutional or non-institutional care setting. Institutional care settings include communal facilities where individuals dwell for short or extended periods of time and have access to healthcare services.

PARTICIPANTS

Older adults (aged 65 or older), caregivers and health professionals.

RESULTS

39 records were included. Stakeholder involvement in transition planning varied across the studies. Transition decisions were largely made by health professionals, with limited or unclear involvement from older adults and caregivers. Seven factors appeared to guide transition planning across the stakeholder groups: (a) institutional priorities and requirements; (b) resources; (c) knowledge; (d) risk; (e) group structure and dynamic; (f) health and support needs; and (g) personality preferences and beliefs. Factors were described at microlevels, mesolevels and macrolevels.

CONCLUSIONS

This review explored stakeholder involvement in transition planning and identified seven factors that appear to influence transition decision-making. These factors may be useful in advancing the delivery of person and family-centred care by determining how individual-level, group-level and system-level values guide decision-making. Further research is needed to understand how various stakeholder groups balance these factors during transition planning in different health contexts.

The use of digital touch screen technology to deliver reminiscence therapy among people with dementia in Jordanian care homes: a mixed-method feasibility study

BACKGROUND

Using technology to deliver psychosocial interventions such as reminiscence therapy (RT) to people with dementia may improve their mental health. Yet, establishing the feasibility of digital interventions in low- to middle-income countries is still in the early stages. This study aimed to: (i) determine the feasibility of using digital touch screen technology to deliver RT among people with dementia living in Jordanian care homes; and (ii) compare study outcomes pre- and post-reminiscence sessions to investigate whether specific outcomes are sensitive to change and explore the acceptability and experiences of the intervention.

METHODS

A pragmatic mixed-method study design was implemented. Sixty residents with dementia were recruited from two Jordanian care homes (Site 1: n = 35; Site 2: n = 10). A process evaluation was conducted alongside a single-group pre-post-intervention study. The intervention involved 10 supported RT sessions of up to 1 h each, delivered over 5 weeks. Feasibility was determined by assessing the rate of recruitment, adherence, retention, data completion, implementation fidelity, and adverse events. Qualitative semi-structured interview questions were used to explore experience and acceptability, and data were thematically analysed.

RESULTS

Response rate was 100%; loss to follow up at post-intervention was 25%. Median session attendance for those who received the intervention was 80%. No serious adverse events were reported. A positive, statistically significant and clinically relevant difference was found in all outcome measures before and after reminiscence sessions. Qualitative findings suggest that digital RT intervention is generally well accepted by people with dementia who reported positive changes, including enhanced communication and cognitive abilities.

CONCLUSION

Using digital touch screen technology to deliver RT is feasible and acceptable among people with dementia in Jordanian care homes. Digital RT intervention is a promising approach to improving mental health and communication for people living with dementia.

Residents transitioning between hospital and care homes: protocol for codesigning a systems-level response to safety issues (SafeST study)

INTRODUCTION

The aim of this study is to develop a better understanding of incident reporting in relation to transitions in care between hospital and care home, and to codesign a systems-level response to safety issues for patients transitioning between hospital and care home.

METHODS AND ANALYSIS

Two workstreams (W) will run in parallel. W1 will aim to develop a taxonomy of incident reporting in care homes, underpinned by structured interviews (N=150) with care home representatives, scoping review of care home incident reporting systems, and a review of incident reporting policy related to care homes. The taxonomy will be developed using a standardised approach to taxonomy development. W2 will be structured in three phases (P). P1a will consist of ≤40 interviews with care home staff to develop a better understanding of their specific internal systems for reporting incidents, and P1b will include ≤30 interviews with others involved in transitions between hospital and care home. P1a and P1b will also examine the impact of the SARS-CoV-2 pandemic on safe transitions. P2 will consist of a retrospective documentary analysis of care home data relating to resident transitions, with data size and sampling determined based on data sources identified in P1a. A validated data extraction form will be adapted before use. P3 will consist of four validation and codesign workshops to develop a service specification using National Health Service Improvement's service specification framework, which will then be mapped against existing systems and recommendations produced. Framework analysis informed by the heuristic of systemic risk factors will be the primary mode of analysis, with content analysis used for analysing incident reports.

ETHICS AND DISSEMINATION

The study has received university ethical approval and Health Research Authority approval. Findings will be disseminated to commissioners, providers and regulators who will be able to use the codesigned service specification to improve integrated care.

Discharge Communication of Dementia-Related Neuropsychiatric Symptoms and Care Management Strategies During Hospital to Skilled Nursing Facility Transitions

Provided the complexity of managing dementia-related neuropsychiatric symptoms (NPS), accurate communication about these symptoms at hospital discharge is critical to facilitating safe and effective transitions, particularly transitions from hospitals to skilled nursing facilities (SNF), which are often poorly managed. Skilled nursing facilities providers have cited undercommunication regarding NPS as a major challenge that contributes to poor outcomes including rehospitalization. This multisite retrospective cohort study identified omission rates for NPS and associated management strategies in discharge communication as compared to medical record documentation in the 72 hours preceding discharge among hospitalized patients with dementia. High rates of omission were found across NPS and management strategies: anxiety (94%), agitation/aggression (77%), hallucinations (85%), 1:1 supervision (90%), high fall risk (89%), use of restraints (91%). Omission rate for new or modified antipsychotic medication was 12.9%. Findings underscore the need for additional research on cross-setting communication regarding care needs of patients with dementia-who often cannot communicate these needs on their own-in facilitating high-quality transitions.

Health care transitions for persons living with dementia and their caregivers

BACKGROUND

Persons with dementia are likely to require care from various health care providers in multiple care settings, necessitating navigation through an often-fragmented care system. This study aimed to create a better understanding of care transition experiences from the perspectives of persons living with dementia and their caregivers in Ontario, Canada, through the development of a theoretical framework.

METHODS

Constructivist grounded theory guided the study. Seventeen individual caregiver interviews, and 12 dyad interviews including persons with dementia and their caregivers, were recorded and transcribed verbatim. The data were coded using NVivo 10 software; analysis occurred iteratively until saturation was reached.

RESULTS

A theoretical framework outlining the context, processes, and influencing factors of care transitions was developed and refined. Gaining an in-depth understanding of the complex care transitions of individuals with dementia and their caregivers is an important step in improving the quality of care and life for this population.

CONCLUSION

The framework developed in this study provides a focal point for efforts to improve the health care transitions of persons living with dementia.

Hearing and vision care provided to older people residing in care homes: a cross-sectional survey of care home staff

Background

Hearing and vision loss in older people has been proven to affect physical and mental health and increase the speed of cognitive decline. Studies have demonstrated that certain practices and improved staff knowledge increase the effective care of residents’ ears and eyes, yet it is not known which practices are being implemented in care homes. This study aimed to identify the gaps in staff knowledge regarding hearing and vision difficulties in older residents, and which practices known to improve ear and eye care in older care home residents are not commonly implemented in care homes in England.

Methods

This study used a cross-sectional survey design. Survey questions were informed by the existing literature and were focused on practices, staff knowledge, and other aspects that have shown to affect residents’ hearing and vision care. A convenience sample of care home staff were recruited from care homes across England between November 2018 and February 2019 via email and in paper format. Descriptive statistics and Chi-Square analysis were applied to identify the factors influencing the care being provided to care home residents.

Results

A total of 400 care home staff responded from 74 care homes. The results revealed that less than half of staff respondents reported to use screening tools to identify hearing (46%) and vision impairments (43.8%); that care homes rarely have access to other assistive devices for hearing (16%) and vision loss (23.8%), and that audiology services do not regularly assess care home residents (46.8%). A majority of staff who responded were not confident in ear and eye care. Responses were found to be influenced by the respondents’ job role, length of time working in care homes and also the care home type. Findings confirmed a lack of standardised practice and the importance of shared communication for promulgation of best practice.

Conclusion

This study has identified that some practices known to facilitate ear and eye care are not commonly applied in a sample of English care homes. It has also shown that care home staff knowledge of ear and eye care is inconsistent. The information derived from this survey can be used to inform guidelines for best practice and inform needs for future research.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-020-01959-0.

Information Sharing Practices Between US Hospitals and Skilled Nursing Facilities to Support Care Transitions

IMPORTANCE

Patient transitions from hospitals to skilled nursing facilities (SNFs) require robust information sharing. After a decade of investment in health information technology infrastructure and new incentives to promote hospital-SNF coordination in the US, the current state of information sharing at this critical transition is unknown.

OBJECTIVE

To measure the completeness, timeliness, and usability of information shared by hospitals when discharging patients to SNFs, and to identify relational and structural characteristics associated with better hospital-SNF information sharing.

DESIGN, SETTING, AND PARTICIPANTS

Survey of 500 SNFs from a US nationally representative sample (265 respondents representing 471 hospital-SNF pairs; response rate of 53.0%) that collected detailed data on information sharing that supports care transitions from each of the 2 hospitals from which they receive the largest volume of patient referrals. Survey administration occurred between January 2019 and March 2020.

MAIN OUTCOMES AND MEASURES

Overall assessment of information completeness, timeliness, and usability using 5-point Likert scales. Detailed measures, including (1) completeness-routine sharing of 23 specific information types; (2) timeliness-how often information arrived after the patient; and (3) usability-whether information was duplicative, extraneous, or not tailored to SNF needs. In addition, 8 relational characteristics (eg, shared staffing, collaborative meetings, and referral volume) and 10 structural characteristics (eg, size, ownership, and staffing) were assessed as potential factors associated with better information sharing.

RESULTS

Of 471 hospital-SNF pairs, 64 (13.5%) reported excellent performance on all 3 dimensions of information sharing, whereas 141 (30.0%) were at or below the mean performance on all dimensions. Social status (missing in 309 pairs [65.7%]) and behavioral status (missing in 319 pairs [67.7%]) were the most common types of missing information. Receipt of hospital information was delayed, sometimes (159 pairs [33.8%]) or often (77 pairs [16.4%]) arriving after the patient. In total, 358 pairs [76.0%] reported at least 1 usability shortcoming. Having a hospital clinician on site at the SNF was associated in multivariate analysis with more complete (odds ratio, 1.72; 95% CI, 1.07-2.78; P = .03), timely (odds ratio, 1.76; 95% CI, 1.08-2.88; P = .02), and usable (odds ratio, 1.64; 95% CI, 1.02-2.63; P = .04) information sharing. Hospital accountable care organization participation was associated with more timely information sharing (odds ratio, 1.88; 95% CI, 1.13-3.14; P = .02).

CONCLUSIONS AND RELEVANCE

In this study, US SNFs reported significant shortcomings in the completeness, timeliness, and usability of information provided by hospitals to support patient transitions. These shortcomings are likely associated with a suboptimal transition experience. Shared clinicians represent a potential strategy to improve information sharing but are costly. New payment models such as accountable care organizations may offer a more scalable approach but were only associated with more timely sharing.

Transitional 'hospital to home' care of older patients: healthcare professionals' perspectives

BACKGROUND

Transitional care is a key area of care provision to older people with chronic and complex health conditions and is associated with the quality of care delivered in the healthcare system.

AIMS

This study aimed to explore the perspectives of healthcare providers, including nurses and physicians, regarding transitional care from hospital to home in an urban area of Turkey.

METHODS

A qualitative study using a thematic analysis method was carried out. In-depth semi-structured interviews were held with eight clinical nurses and five general physicians involved in the provision of healthcare services to older patients in the transitional care process from hospital to home.

FINDINGS

The thematic analysis of in-depth semi-structured interviews with 13 healthcare professionals led to the development of the following themes: 'uninterrupted chain of care transfer', 'commitment to meet patient's needs' and 'support and removing ambiguities'.

CONCLUSIONS

Key factors impacting on the quality and safety of transitional care and continuity of healthcare are communication and collaboration between healthcare staff and settings, and older patients' as well as family caregivers' awareness and their feelings of responsibility towards the continuity of care at home.