Utilising a 'Community of Practice' to support pharmacists to work in residential aged care: protocol for a longitudinal evaluation

INTRODUCTION

A Community of Practice is briefly defined as a group of people with a shared interest in a given area of practice who work collaboratively to grow collective knowledge. Communities of Practice have been used to facilitate knowledge exchange and improve evidence-based practice. Knowledge translation within the residential aged care sector is lacking, with barriers such as inadequate staffing and knowledge gaps commonly cited. In Australia, a Federal inquiry into residential aged care practices led to a recommendation to embed pharmacists within residential aged care facilities. Onsite practice in aged care is a new role for pharmacists in Australia. Thus, support is needed to enable pharmacists to practice in this role.The primary aim is to evaluate the processes and outcomes of a Community of Practice designed to support pharmacists to work in aged care.

METHODS AND ANALYSIS

A longitudinal, single-group, pretest-post-test design in which the intervention is a Community of Practice. The Community of Practice will be established and made available for 3 years to all Australian pharmacists interested in, new to or established in aged care roles. The Community of Practice will be hosted on online discussion platforms, with additional virtual meetings and annual symposia. The following data will be collected from all members of the Community of Practice: self-evaluation of the processes and outcomes of the Community of Practice (via the CoPeval scale) and confidence in evidence-based practice (EPIC scale), collected via online questionnaires annually; and discussion platform usage statistics and discussion transcripts. A subset of members will be invited to participate in annual semi-structured individual interviews.Data from the online questionnaire will be analysed descriptively. Discussion transcripts will be analysed using topic modelling and content analysis to identify the common topics discussed and their frequencies. Qualitative data from individual interviews will be thematically analysed to explore perceptions and experiences with the intervention for information/knowledge exchange, impact on practice, and sharing/promoting/implementing evidence-based practice.

ETHICS AND DISSEMINATION

Human ethics approval has been granted by the University of Western Australia's Human Ethics Committee (2023/ET000000). No personal information will be included in any publications and reports to funding bodies.Findings will be disseminated to all members of the Community of Practice, professional organisations, social and mass media, peer-review journals, research and professional conferences and annual reports to the funding body.

[The role of the health executive with the residents in Ehpad]

The personalized quality support for residents of residential establishments for dependent elderly people, specified in the law of January 2, 2002, is implemented through various tools and regular evaluations. The health executive, as the central link in the chain, has a key role to play in carrying out these actions, which are part of a continuous quality improvement process.

Pro-active monitoring and social interventions at community level mitigate the impact of coronavirus (COVID-19) epidemic on older adults’ mortality in Italy: A retrospective cohort analysis

Background

The COVID-19 epidemic in Italy has severely affected people aged more than 80, especially socially isolated. Aim of this paper is to assess whether a social and health program reduced mortality associated to the epidemic.

Methods

An observational retrospective cohort analysis of deaths recorded among >80 years in three Italian cities has been carried out to compare death rate of the general population and “Long Live the Elderly!” (LLE) program. Parametric and non-parametric tests have been performed to assess differences of means between the two populations. A multivariable analysis to assess the impact of covariates on weekly mortality has been carried out by setting up a linear mixed model.

Results

The total number of services delivered to the LLE population (including phone calls and home visits) was 34,528, 1 every 20 day per person on average, one every 15 days during March and April. From January to April 2019, the same population received one service every 41 days on average, without differences between January-February and March-April. The January-April 2020 cumulative crude death rate was 34.8‰ (9,718 deaths out of 279,249 individuals; CI95%: 34.1–35.5) and 28.9‰ (166 deaths out of 5,727 individuals; CI95%:24.7–33.7) for the general population and the LLE sample respectively. The general population weekly death rate increased after the 11^th calendar week that was not the case among the LLE program participants (p<0.001). The Standardized Mortality Ratio was 0.83; (CI95%: 0.71–0.97). Mortality adjusted for age, gender, COVID-19 weekly incidence and prevalence of people living in nursing homes was lower in the LLE program than in the general population (p<0.001).

Conclusions

LLE program is likely to limit mortality associated with COVID-19. Further studies are needed to establish whether it is due to the impact of social care that allows a better clients’ adherence to the recommendations of physical distancing or to an improved surveillance of older adults that prevents negative outcomes associated with COVID-19.

Multifactorial falls prevention programme compared with usual care in UK care homes for older people: multicentre cluster randomised controlled trial with economic evaluation

OBJECTIVES

To determine the clinical and cost effectiveness of a multifactorial fall prevention programme compared with usual care in long term care homes.

DESIGN

Multicentre, parallel, cluster randomised controlled trial.

SETTING

Long term care homes in the UK, registered to care for older people or those with dementia.

PARTICIPANTS

1657 consenting residents and 84 care homes. 39 were randomised to the intervention group and 45 were randomised to usual care.

INTERVENTIONS

Guide to Action for Care Homes (GtACH): a multifactorial fall prevention programme or usual care.

MAIN OUTCOME MEASURES

Primary outcome measure was fall rate at 91-180 days after randomisation. The economic evaluation measured health related quality of life using quality adjusted life years (QALYs) derived from the five domain five level version of the EuroQoL index (EQ-5D-5L) or proxy version (EQ-5D-5L-P) and the Dementia Quality of Life utility measure (DEMQOL-U), which were self-completed by competent residents and by a care home staff member proxy (DEMQOL-P-U) for all residents (in case the ability to complete changed during the study) until 12 months after randomisation. Secondary outcome measures were falls at 1-90, 181-270, and 271-360 days after randomisation, Barthel index score, and the Physical Activity Measure-Residential Care Homes (PAM-RC) score at 91, 180, 270, and 360 days after randomisation.

RESULTS

Mean age of residents was 85 years. 32% were men. GtACH training was delivered to 1051/1480 staff (71%). Primary outcome data were available for 630 participants in the GtACH group and 712 in the usual care group. The unadjusted incidence rate ratio for falls between 91 and 180 days was 0.57 (95% confidence interval 0.45 to 0.71, P<0.001) in favour of the GtACH programme (GtACH: six falls/1000 residents v usual care: 10 falls/1000). Barthel activities of daily living indices and PAM-RC scores were similar between groups at all time points. The incremental cost was £108 (95% confidence interval -£271.06 to 487.58), incremental QALYs gained for EQ-5D-5L-P was 0.024 (95% confidence interval 0.004 to 0.044) and for DEMQOL-P-U was 0.005 (-0.019 to 0.03). The incremental costs per EQ-5D-5L-P and DEMQOL-P-U based QALY were £4544 and £20 889, respectively.

CONCLUSIONS

The GtACH programme was associated with a reduction in fall rate and cost effectiveness, without a decrease in activity or increase in dependency.

TRIAL REGISTRATION

ISRCTN34353836.

A systematic review of long-term care facility characteristics associated with COVID-19 outcomes

BACKGROUND/OBJECTIVES

The coronavirus disease 2019 (COVID-19) pandemic has taken a disproportionate toll on long-term care facility residents and staff. Our objective was to review the empirical evidence on facility characteristics associated with COVID-19 cases and deaths.

DESIGN

Systematic review.

SETTING

Long-term care facilities (nursing homes and assisted living communities).

PARTICIPANTS

Thirty-six empirical studies of factors associated with COVID-19 cases and deaths in long-term care facilities published between January 1, 2020 and June 15, 2021.

MEASUREMENTS

Outcomes included the probability of at least one case or death (or other defined threshold); numbers of cases and deaths, measured variably.

RESULTS

Larger, more rigorous studies were fairly consistent in their assessment of risk factors for COVID-19 outcomes in long-term care facilities. Larger bed size and location in an area with high COVID-19 prevalence were the strongest and most consistent predictors of facilities having more COVID-19 cases and deaths. Outcomes varied by facility racial composition, differences that were partially explained by facility size and community COVID-19 prevalence. More staff members were associated with a higher probability of any outbreak; however, in facilities with known cases, higher staffing was associated with fewer deaths. Other characteristics, such as Nursing Home Compare 5-star ratings, ownership, and prior infection control citations, did not have consistent associations with COVID-19 outcomes.

CONCLUSION

Given the importance of community COVID-19 prevalence and facility size, studies that failed to control for these factors were likely confounded. Better control of community COVID-19 spread would have been critical for mitigating much of the morbidity and mortality long-term care residents and staff experienced during the pandemic. Traditional quality measures such as Nursing Home Compare 5-Star ratings and past deficiencies were not consistent indicators of pandemic preparedness, likely because COVID-19 presented a novel problem requiring extensive adaptation by both long-term care providers and policymakers.

Are the Recommended Physical Activity Guidelines Practical and Realistic for Older People With Complex Medical Issues?

The world population is aging. With increased life expectancy comes increased risk of major health problems that affect the health and well-being of older adults. Adequate levels of physical activity as specified by current global guidelines can reduce the risk of health problems in older adults. However, fewer than half of older adults are sufficiently active, and thus are unlikely to achieve these health benefits. Older adults living in residential aged care are even more sedentary, with multiple health issues and comorbidities. While meeting physical activity guidelines confers the greatest benefit for physical function, the practicality of adherence to these guidelines for older people who are not healthy and have complex medical issues is questionable. This special interest paper discusses research evidence on the topic of physical activity for older people across the health spectrum, with and without multiple comorbidities. This discussion is informed by professional experience, and suggests practical recommendations to positively impact physical activity engagement in the older adult population.

The pathogenic characteristics and influencing factors of health care-associated infection in elderly care center under the mode of integration of medical care and elderly care service: A cross-sectional study

The aim of this study was to analyze the distribution of pathogenic bacteria in hospitalized patients in elderly care centers under the mode of integration of medical care and elderly care service, and explore the influencing factors to reduce the health care-associated infection rate of hospitalized patients.A total of 2597 inpatients admitted to elderly care centers from April 2018 to December 2019 were included in the study. The etiology characteristics of health care-associated infections (HCAI) was statistically analyzed, univariate analysis, and multivariate logistic regression analysis method were used to analyze the influencing factors of HCAI.A total of 98 of 2597 inpatients in the elderly care centers had HCAI, and the infection rate was 3.77%. The infection sites were mainly in the lower respiratory tract and urinary tract, accounting for 53.92% and 18.63%, respectively. A total of 53 pathogenic bacteria were isolated, 43 of which (81.13%) were Gram-negative, mainly Escherichia coli, Pseudomonas aeruginosa, and Klebsiella pneumoniae, which respectively accounted for 24.53, 16.98, and 13.21%. 9 (16.98%) strains were Gram-positive, mainly Staphylococcus aureus and Enterococcus faecium, respectively accounting for 7.55 and 5.66%. Only 1 patient (1.89%) had a fungal infection. Multivariate logistic regression analysis indicated that total hospitalization days, antibiotic agents used, days of central line catheter, use of urinary catheter and diabetes were independent risk factors of nosocomial infection in elderly care centers (P < .05).Many factors can lead to nosocomial infections in elderly care centers. Medical staff should take effective intervention measures according to the influencing factors to reduce the risk of infection in elderly care facilities.

[Evolution of COVID-19 at nursing homes from the second wave to vaccination. Description of a coordination program between Primary Care, Geriatrics and Public Health.]

OBJECTIVE

Nursing homes have suffered in a particularly pronounced way from the effects of COVID-19 so it is very convenient to know the evolution in them of the disease and the impact of SARS-CoV2 vaccination The objective of this study was to analyze COVID-19 pandemic evolution from the start of the second wave to the end of the vaccination campaign at the nursing homes. A coordination program between Primary Care and Geriatrics and Public Health services was activated.

METHODS

2,668 seniors were followed at 39 nursing homes. Data from new cases, active cases, mortality and place of treatment of COVID-19 were collected. A descriptive analysis was performed with the measurement of the absolute number of positive SARS-CoV-2 cases and the frequency distribution.

RESULTS

Between August 7^th 2020 and February 26^th 2021, 30 outbreaks occurred at 21 nursing homes. 300 people tested positive for SARS-CoV-2 (11% of total residents). The daily average of active cases was 27,166 were hospitalized (55%). 66 patients died (22% of those infected), 54 of them (78%) at the hospital. 1,984 PCR tests were performed. The temporary profile of new cases did not follow a distribution "in waves" as in the community. Thirty-seven days after the start of the second dose of vaccination, there were no active cases until March 1^st, when new cases were under study for possible vaccine leakage.

CONCLUSIONS

The incidence of COVID-19 at nursing homes after the first wave of the pandemic has apparently been lower. The transmission in these centers has followed a different distribution than at community. Mass vaccination has achieved the practical disappearance of the disease.

[Liaison geriatrics with nursing homes in COVID time. A new coordination model arrived to stay]

Older people living in nursing homes fulfil the criteria to be considered as geriatric patients, but they often do not have met their health care needs. Current deficits appeared as a result of COVID-19 pandemic. The need to improve the coordination between hospitals and nursing homes emerged, and in Madrid it materialized with the implantation of Liaison Geriatrics teams or units at public hospitals. The Sociedad Española de Geriatría y Gerontología has defined the role of the geriatricians in the COVID-19 pandemic and they have given guidelines about prevention, early detection, isolation and sectorization, training, care homes classification, patient referral coordination, and the role of the different care settings, among others. These units and teams also must undertake other care activities that have a shortfall currently, like nursing homes-hospital coordination, geriatricians visits to the homes, telemedicine sessions, geriatric assessment in emergency rooms, and primary care and public health services coordination. This paper describes the concept of Liaison Geriatrics and its implementation at the Autonomous Community of Madrid hospitals as a result of COVID-19 pandemic. Activity data from a unit at a hospital with a huge number of nursing homes in its catchment area are reported. The objective is to understand the need of this activity in order to avoid the current fragmentation of care between hospitals and nursing homes. This activity should be consolidated in the future.

[Collaboration experience between hospitals and long-term care facilities for the care of COVID-19 patients.]

OBJECTIVE

The disease produced by SARS-CoV-2 has led to severe situations and mortality in elderly people. The objective of this study was to describe the collaboration between hospital professionals and nursing homes when applying preventive measures for the transmission of COVID-19 and in the assistance of institutionalized patients.

METHODS

A descriptive study was carried out in 4 centers with information collected by researchers in two moments of the COVID-19 pandemic. The information collected was related to the resources and knowledge of infection prevention, details about face-to-face and telematic assistance from the hospital team, as well as material, drugs provided, and clinical results. The variables studied were described by means of percentages, absolute frequencies and ratios; statistical chi-square tests and McNemar'test were used.

RESULTS

The study was conducted in 4 centers with a total of 640 residents and an initial occupancy between 62% and 85%. Differences were found regarding the ratio of staff and knowledge of preventive measures of the transmission of SARS-CoV-2 infection, which was improved in the second period of the study. The number of face-to-face visits (from 5 to 22) and telematic visits (between 42 and 109 patients) were different in the 4 nursing homes, as well as the material provided, adapted to the needs of each center. The percentage of infected patients ranged from 6.1% to 90.2%, and the accumulated mortality in the second period ranged from 15.38% to 38.35% of the residents at the beginning of the pandemic.

CONCLUSIONS

The collaboration between the professionals of healthcare centers and the hospital, adapted to the needs of each center, has allowed to improve the assistance to the residents and the coordination between the professionals, optimizing the available resources.

A recommended management plan for coronavirus disease 2019-positive geriatric patients based in South African old age homes

The coronavirus disease 2019 (COVID-19) pandemic has had a profound impact on elderly patients, and thus, adequate treatment plans are essential. This qualitative report provides recommendations for the supportive care and treatment of residents in long-term care facilities (LTCF) with COVID-19. A treatment protocol was developed in response to an outbreak of COVID-19 in an LTCF based in Johannesburg and was implemented over a 3-month period.

The Resident and the Spouse and the Lover and the Ethicist: Considerations and Challenges in Nursing Home Romance

The level of impairment shown by the 1.3 million residents of nursing homes in the United States varies significantly, and this raises considerable challenges for how to address the sexual and romantic interests and needs of these diverse individuals. Unfortunately, bright-line rules and a one-size-fits-all approach are often taken when addressing these challenges. This article proposes a novel taxonomy for classifying the potential sexual and romantic relationships of cognitively impaired nursing home residents that includes relationships between unmarried residents, relationships between residents and their own spouses, and adulterous relationships. We explore the ethical and logistical challenges distinctive to each category of relationship.

Cognitive job crafting as mediator between behavioral job crafting and quality of care in residential homes for the elderly

Extending previous studies on job crafting, the aim of the present study is to analyze the effect of job crafting on quality of care in residential homes for elderly people in two European countries (Spain and Sweden). We hypothesize that cognitive crafting could be a consequence of behavioral crafting and that it will mediate the relationship between behavioral crafting and the perception of quality of care. A correlational design was used, with two-waves approximately 12 months apart (n = 226). Our results indicate that behavioral job crafting at T1 had an effect on cognitive job crafting at T2, relational job crafting at T1 increases quality of care at T2, and the mediation effect of cognitive job crafting. These results indicate that we must differentiate between the two forms of crafting (behavioral and cognitive), not as indicators of the same latent construct, but as aggregates. Additionally, we point out two main implications for managerial practice. First, as relational job crafting has a direct effect on quality of care, it is important to assure an organizational culture oriented towards employees. Secondly, due to the mediation effect of cognitive job crafting, managers should facilitate meaningful work environments. To do so, jobs should be re-designed, increasing skills variety, identity and significance.

[COVID-19, impact on residents and caregivers]

Following the COVID-19's entry into France, in order to protect the residents, the doors of the accommodation facilities for dependent elderly have been closed and a complete reorganization has been necessary. This confinement and restructuring behind closed doors has many consequences both for the residents and for the staff who accompany them on a daily basis. For the resident, the physical and/or psychological impact will be different depending on his degree of autonomy. The staff fear for their health, their families health, and the one of the elderly they accompany.

The balancing act of dementia care: an ethnographic study of everyday life and relatives' experiences in a Danish nursing home for people living with advanced dementia

PURPOSE

The purpose of this study was to explore how everyday life was organized in a Danish nursing home for people living with advanced dementia and how relatives experienced their family members' everyday lives.

METHODS

Field notes from participant observations (approximately 160 hours) and transcripts from ethnographic interviews with relatives (9) were analysed thematically in accordance with ethnographic principles.

RESULTS

The analysis revealed one main theme, 'Enabling a meaningful everyday life in the nursing home' with two corresponding sub-themes: (1) Structures of daily life: Balancing collective and individual activities and (2) Physical togetherness: Balancing being together and being alone.

CONCLUSIONS

The findings showed that everyday life in the nursing home was organized to support a meaningful life for the residents by providing activities and togetherness on a daily basis. While relatives generally appreciated the everyday life experienced in the nursing home, challenges were encountered in connection with the provision of an appropriate balance between levels and types of activities and togetherness for all residents.

[Medicalization of nursing facilities as a real alternative to hospitalization during the COVID-19 pandemic.]

OBJECTIVE

Nursing homes are high-risk environments for the transmission of the SARS-CoV-2 coronavirus, as they are a closed environment, with patients who present atypical manifestations of the disease, high risk of unfavorable evolution, and staff who frequently present a high mobility in relation to their jobs. On the other hand, in a pandemic situation, numerous hospitals have suffered periods of great healthcare pressure. The objective of this work was to present an experience of medicalization of a residence where almost 50% of the residents contracted the disease.

METHODS

A multidisciplinary intervention was carried out in a publicly owned nursing home with 99 residents. Specialists from Internal Medicine, Primary Care and health technicians worked together, in close collaboration with the residence workers. The presence of nursing personnel 24 hours a day and medical personnel with daily visits was enabled. The center was provided with the necessary means to administer the medication (oral and intravenous) and oxygen therapy necessary to care for patients with the disease. Analytical results were available within 24 hours. For data analysis, the percentages were calculated and the mean was used as a measure of central tendency.

RESULTS

Forty-eight residents (48.5%) and fifteen workers contracted the disease. The total number of deaths during that period was thirteen (13.1%), seven of them diagnosed with COVID-19 (mean age 84.4 years), with a fatality rate of 14.6%. Eleven patients (22%) diagnosed with COVID-19 were hospitalized, two of whom died during admission.

CONCLUSIONS

The medicalization of nursing homes can help to reduce the pressure on care in hospitals and optimize care for these vulnerable people with more humanized care, which can ultimately lead to better health outcomes.

Structure and agency attributes of residents' use of dining space during mealtimes in care homes for older people

Research stresses that mealtimes in care homes for older people are vital social events in residents' lives. Mealtimes have great importance for residents as they provide a sense of normality, reinforce individuals' identities and orientate their routines. This ethnographic study aimed to understand residents' use of dining spaces during mealtimes, specifically examining residents' table assignment processes. Data were collected in summer 2015 in three care homes located in England. The research settings looked after residents aged 65+, each having a distinct profile: a nursing home, a residential home for older people and a residential home for those with advanced dementia. Analyses revealed a two-stage table assignment process: 1. Allocation - where staff exert control by determining residents' seating. Allocation is inherently part of the care provided by the homes and reflects the structural element of living in an institution. This study identified three strategies for allocation adopted by the staff: (a) personal compatibilities; (b) according to gender and (c) 'continual allocation'. 2. Appropriation - it consists of residents routinely and willingly occupying the same space in the dining room. Appropriation helps residents to create and maintain their daily routines and it is an expression of their agency. The findings demonstrate the mechanisms of residents' table assignment and its importance for their routines, contributing towards a potentially more self-fulfilling life. These findings have implications for policy and care practices in residential and nursing homes.

Consumer expectations of self-managing aged home care packages in Australia

This study investigated the expectations of older people who chose to participate in a self-management trial of home aged care packages conducted by COTA Australia. Empowerment theory is used to interpret the findings. All Australian home aged care support packages are delivered using a consumer directed care (CDC) model, and most are managed by an aged care provider. The COTA Australia trial gave older people the opportunity to self-manage their package and have more control over spending and less constraints on its use. This study examined three questions: (a) what motivated the older person, or an informal carer acting on their behalf, to participate in the self-managing trial; (b) what outcomes they expected (c) and what was their attitude towards risk. The trial was conducted over 9 months in 2018-2019. Seven registered home aged care providers from six Australian states and territories recruited 103 consumers to the trial, with having an informal carer act on their behalf. Online questionnaires with consumers (n = 103) and informal carers (n = 66), and 18 semi-structured interviews showed that older consumers and their informal carers had high expectations that self-management would result in: increased choice and control and more flexible use of funds; lower administration fees and more money to spend on services and supports; improved relations with service providers and the opportunity to select support staff. Participants wanted clear information and guidelines and support from their provider. While wanting to have more control and be empowered, few respondents noted concerns about possible risks. This finding raises questions about consumers' awareness of risks that are documented in the literature, and it challenges providers to balance risk management with facilitating independence and autonomy.

[COVID pandemic in accommodation facilities for dependent elderly]

During the coronavirus outbreak, accommodation facilities for dependent elderly (Ehpad) had to adapt quickly to an unknown and dangerous situation for residents, putting all the resources of these places to the test. Caregivers faced clinical and organizational emergencies with the coordinating doctors and nurse, going through different individual and collective phases. The directors, who are legally responsible for Ehpad, had to make room for the "we", anticipate, apprehend and evaluate the crisis but also deal with paradoxical recommendations.

Designing residential aged care for people at risk of, or experiencing, homelessness: An exploratory Australian study

The number of older people experiencing or at risk of homelessness, both long-term and first-time homelessness, is increasing. The proportion of women facing homelessness within that cohort is also increasing. When combined with complex health needs, appropriate long-term care options remain limited. This qualitative study conducted in Sydney, Australia, aimed to explore the care needs of older people with comorbid health issues who are facing homelessness and, from this assessment, derive a preferred model of residential aged care. Interviews and focus groups were conducted with 29 participants from providers in the aged care and homelessness sectors. Data were analysed using a grounded theory approach. Causal and contextual factors, and consequences surrounding the experience of homelessness, informed the wide range of care needs of this group (model of care), and the organisational resources required to deliver them (management issues and staff). A trauma-informed approach to care consistently applied by all staff to all processes throughout the care home was recommended. Such an approach would further strengthen existing models of care and take into account both health needs (such as mental health, substance dependence and acquired brain injury) and significant losses through the life course of this vulnerable population.

COVID-19 highlights the need for universal adoption of standards of medical care for physicians in nursing homes in Europe

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

Older Adults and Covid 19: Social Justice, Disparities, and Social Work Practice

The Covid- 19 pandemic has brought immense challenges to almost every country as it spreads throughout their populations. Foremost among these challenges is the heightened awareness of inequalities in society and the immense toll that the virus has on the most vulnerable. Globally, older people are the most at risk of getting the virus and dying from the it. Yet, although age is a significant contributor, it is its interaction with other factors, chronic conditions, poverty, and race that makes it a strong determinant. These factors reflect disparities and systemic social injustices that interact to increase the vulnerability of older adults. This paper discusses the many roles that social work, with its focus on social change, injustice, and vulnerable groups can intervene at many levels of practice and with specific groups to alleviate these fundamental disparities.

Older Adults and Covid-19: The Most Vulnerable, the Hardest Hit

Older adults in the United States have been the age group hardest hit by the Covid pandemic. They have suffered a disproportionate number of deaths; Covid patients eighty years or older on ventilators had fatality rates higher than 90 percent. How could we have better protected older adults? Both the popular press and government entities blamed nursing homes, labeling them "snake pits" and imposing harsh fines and arduous new regulations. We argue that this approach is unlikely to improve protections for older adults. Rather than focusing exclusively on acute and critical resources, including ventilators, a plan that respected the best interests of older adults would have also supported nursing homes, a critical part of the health care system. Better access to protective equipment for staff members, early testing of staff members and patients, and enhanced means of communication with families were what was needed. These preventive measures would have offered greater benefit to the oldest members of our population than the exclusive focus on acute care.

Allowing Visitors Back in the Nursing Home During the COVID-19 Crisis: A Dutch National Study Into First Experiences and Impact on Well-Being

OBJECTIVES

To prevent and control COVID-19 infections, nursing homes across the world have taken very restrictive measures, including a ban for visitors. These restrictive measures have an enormous impact on residents' well-being and pose dilemmas for staff, although primary data are lacking. A Dutch guideline was developed to cautiously open nursing homes for visitors during the COVID-19 pandemic. This study reports the first findings on how the guideline was applied in the local context; the compliance to local protocols; and the impact on well-being of residents, their family caregivers, and staff.

DESIGN

A mixed-methods cross-sectional study was conducted.

SETTING AND PARTICIPANTS

In total, 26 nursing homes were permitted to enlarge their possibilities for allowing visitors in their facility. These nursing homes were proportionally representative of the Netherlands as they were selected by their local Area Health Authority for participation. At each nursing home, a contact person was selected for participation in the current study.

METHODS

A mixed-methods cross-sectional study was conducted, consisting of questionnaire, telephone interviews, analyses of documentation (ie, local visiting protocols), and a WhatsApp group.

RESULTS

Variation in local protocols was observed, for example, related to the use of personal protective equipment, location, and supervision of visits. In general, experiences were very positive. All nursing homes recognized the added value of real and personal contact between residents and their loved ones and indicated a positive impact on well-being. Compliance with local guidelines was sufficient to good. No new COVID-19 infections were reported during this time.

CONCLUSIONS AND IMPLICATIONS

These results indicate the value of family visitation in nursing homes and positive impact of visits. Based on these results, the Dutch government has decided to allow all nursing homes in the Netherlands to cautiously open their homes using the guidelines. More research is needed on impact and long-term compliance.

Family Satisfaction With Nursing Home Care: Findings and Implications From Two State Comparison

Family satisfaction, while recognized as important, is frequently missing from validated measures of long-term care quality. This is the first study to compare family satisfaction across two states using validated measures and to compare the organizational and structural factors associated with higher family satisfaction with nursing home care. Data sources are family satisfaction surveys from Minnesota (MN) and Ohio (OH), linked to facility characteristics from Certification and Survey Provider Enhanced Reports (CASPER) for both states (N = 378 facilities for MN; N = 926 facilities for OH). Activities and food were among lowest rated items in both states. Relationships with staff were the highest rated domain. Higher occupancy rates, smaller facility size, and non-profit ownership consistently predicted better satisfaction in both states. Our findings show consistent organizational factors associated with family satisfaction and provide further evidence to the validity of family satisfaction as a person-centered measure of quality. This lays the foundation for tool development on the national level.

Effects of Whole-Body Vibration Training on the Physical Function of the Frail Elderly: An Open, Randomized Controlled Trial

OBJECTIVE

To investigate the feasibility and benefits of whole-body vibration (WBV) exercise as a safe and effective training tool for countering sarcopenia and age-related declines in mobility and function in the frail elderly.

DESIGN

An open, randomized controlled trial.

SETTING

Residential care facilities.

PARTICIPANTS

Male and female volunteers (N=117; 82.5±7.9y).

INTERVENTIONS

After prescreening for contraindications, participants were randomly allocated to a control, simulated WBV (SIM), or WBV exercise group. All participants received regular care, whereas WBV and SIM participants also underwent thrice-weekly exercise sessions for 16 weeks. Delivered by overload principle, WBV training began with 5 × 1-minute bouts at 6 Hz/2 mm (1:1 min exercise:rest), progressing to 10 × 1 minute at up to 26 Hz/4 mm, maintaining knee flexion. Training for SIM participants mimicked WBV exercise stance and duration only.

MAIN OUTCOME MEASURES

The timed Up and Go, Parallel Walk, and 10-m Timed Walk (10mTW) tests performance were assessed, in addition to the Barthel Index Questionnaire, at baseline, 8, and 16 weeks of exercise, and 3, 6, and 12 months postexercise.

RESULTS

High levels of compliance were reported in SIM (89%) and WBV training (93%), with ease of use and no adverse effects. In comparison to baseline levels, WBV training elicited clinically important treatment effects in all parameters compared to SIM and control groups. Treatment effects remained apparent up to 12 months postintervention for Parallel Walk Test and 6 months for 10mTW Test. Functional test performance declined during and postintervention in non-WBV groups.

CONCLUSIONS

Findings indicate that 16 weeks of low-level WBV exercise provides easily accessible, adequate stimulus for the frail elderly to attain improved levels of physical functionality.

Development of an education integrated design framework for the physical space of nursing homes in relation to life expectancy of the older people

The purpose of this research is to find design variables effective on education integration with physical spaces of nursing homes in association with life expectancy of older people. Delphi technique was used to obtain the design variables by which the education integration with physical spaces of nursing homes can be achieved. Subsequently, in order to investigate the modifying effect of education integrated physical space on life expectancy of the elderly, questionnaires were sent to 50 local researchers and experts in the field of ageing. Results showed a significant and positive correlation between education integrated physical space and life expectancy indicators (p < .05). The results suggest that as per expert opinions, designing a physical space integrated with education could increase the life expectancy of older people.

An Australian study on the benefits of pastoral care to aged care residents in Christian affiliated homes

This study aimed to understand the experience of pastoral care (PC), that is, the provision of support, comfort and spiritual counselling, from the perspective of Australian aged care residents. A survey research design captured feedback on participants' PC experience. Outcomes were reported by 575 residents (aged 53-102) across 41 sites. The majority perceived that they received a high quality of care (92%) and benefited from their meeting with the pastoral practitioner (80%), 'often' or 'all of the time'. A few significant differences were found based on participants' gender, spirituality (i.e. connection and meaning), religiosity (i.e. faith beliefs and religious practices) and well-being. Females and participants who identified as both religious and spiritual were more likely to feel that their faiths/beliefs were valued. Those with greater psychological well-being, as defined by the World Health Organisation (1998), were more likely to report receiving a high quality of care and greater benefits from receiving PC than those with poorer well-being. Three overarching themes and eight subthemes were identified from the open-ended responses: 1) personal qualities of the pastoral practitioner; caring, supportive, understanding and empathetic; 2) pastoral practitioner met specific needs; spiritual and religious, friendship and company and assistance, advice and help; and 3) positive impact on the participant; feeling listened to, peaceful and valued, accepted and respected. The qualitative findings resonate with Maslow's Hierarchy of Needs, to feel safe, belong and have self-esteem. There was a synergy between what participants desire in the care they receive, as expressed in the open-ended questions, and what the pastoral practitioners provide, as indicated in the quantitative findings. A study strength was its mixed-method, multi-site and cross-organisational context, enabling PC to be explored across a diverse sample. Future research should consider a pre- and post-test survey to more comprehensively capture the impact and benefits of PC.

'You have got to stick to your times': Care workers and managers' experiences of working in extra care housing

Extra care housing (ECH) has been lauded as an innovative model of housing with care for older people that promotes and supports independent living. The study used a qualitative design to explore how care is delivered in four extra care settings in England over 20 months during 2016-2017. This paper reports findings from semi-structured interviews with 20 care workers and seven managers. The article argues that, despite being heralded as a new model, care workers in ECH face similar organisational pressures as those working in more conventional settings and, in turn, the care which they are able to provide to residents mimics traditional forms of care.

Systematic Dementia Screening by Multidisciplinary Team Meetings in Nursing Homes for Reducing Emergency Department Transfers: The IDEM Cluster Randomized Clinical Trial

IMPORTANCE

Dementia is often underdiagnosed in nursing homes (NHs). This potentially results in inappropriate care, and high rates of emergency department (ED) transfers in particular.

OBJECTIVE

To assess whether systematic dementia screening of NH residents combined with multidisciplinary team meetings resulted in a lower rate of ED transfer at 12 months compared with usual care.

DESIGN, SETTING, AND PARTICIPANTS

Multicenter, cluster randomized trial with NHs as the unit of randomization. The IDEM (Impact of Systematic Tracking of Dementia Cases on the Rate of Hospitalization in Emergency Care Units) trial took place at 64 public and private NHs in France. Recruitment started on May 1, 2010, and was completed on March 31, 2012. Residents who were aged 60 years or older, had no diagnosed or documented dementia, were not bedridden, had lived in the NH for at least 1 month at inclusion, and had a life expectancy greater than 12 months were included. The residents were followed up for 18 months. The main study analyses were completed on October 14, 2016.

INTERVENTION

Two parallel groups were compared: an intervention group consisting of NHs that set up 2 multidisciplinary team meetings to identify residents with dementia and to discuss an appropriate care plan, and a control group consisting of NHs that continued their usual practice. During the inclusion period of 23 months, all residents of participating NHs who met eligibility criteria were included in the study.

MAIN OUTCOMES AND MEASURES

The primary end point (ED transfer) was analyzed at 12 months, but the residents included were followed up for 18 months.

RESULTS

A total of 64 NHs participated in the study and enrolled 1428 residents (mean [SD] age, 84.7 [8.1] years; 1019 [71.3%] female): 599 in the intervention group (32 NHs) and 829 in the control group (32 NHs). The final study visit was completed by 1042 residents (73.0%). The main reason for early discontinuation was death (318 residents [22.7%]). The intervention did not reduce the risk of ED transfers during the 12-month follow-up: the proportion of residents transferred at least once to an ED during the 12-month follow-up was 16.2% in the intervention group vs 12.8% in the control group (odds ratio, 1.32; 95% CI, 0.83-2.09; P = .24).

CONCLUSIONS AND RELEVANCE

This study failed to demonstrate that systematic screening for dementia in NHs resulted in fewer ED transfers. The findings do not support implementation of multidisciplinary team meetings for systematic dementia screening of all NH residents, beyond the national recommendations for dementia diagnosis, to reduce ED transfers.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01569997.

Is greenery associated with mental health among residents of aged care facilities? A systematic search and narrative review

Objectives: Older adults living in residential aged care facilities (RACFs) may be vulnerable to mental health issues. Evidence suggests greenery is beneficial for adults' mental health in community settings. This review aims to summarise evidence of associations between greenery in RACFs and residents' mental health.Method: Six databases were searched with three sets of terms related to: (1) exposure (e.g. garden, green); (2) outcome (e.g. mental health, well-being); and (3) setting (e.g. aged care, nursing home). The inclusion criteria were peer-reviewed journal articles published in English up to 2017, reporting quantitative/qualitative associations between greenery and mental health in RACFs.Results: Of the nine articles identified, seven reported positive associations between greenery (in particular, garden use) at RACFs and some aspect of residents' mental well-being (e.g. quality of life); however, four out of seven studies used observations and perceptions of staff and relatives. One study examined depression and reported reduction in depression following garden use, while one examined physiological indicators of stress (blood pressure, heart rate) and found no association with garden use. Seven studies examined garden use and four examined the presence of greenery (two examined both exposures).Conclusion: Exposure to greenery and use of greenspace in RACFs show promise for promoting mental health. However, the findings relied mainly on non-validated measures of mental health. More robust evidence based on valid and reliable mental health measures is needed. Future studies also need to examine the effect of visual exposure to greenery and the effect of greenery on stress reduction.

Improved patient participation through advance care planning in nursing homes-A cluster randomized clinical trial

OBJECTIVE

To improve patient participation in advance care planning in nursing homes where most patients have some degree of cognitive impairment.

METHODS

This was a pair-matched cluster randomized clinical trial with eight wards in eight Norwegian nursing homes. We randomized one ward from each of the matched pairs to the intervention group. We included all patients above 70. The primary outcome was prevalence of documented patient participation in end-of-life treatment conversations. The intervention included implementation support using a whole-ward approach where regular staff perform advance care planning and invite all patients and next of kin to participate.

RESULTS

In intervention group wards the patients participated more often in end-of-life treatment conversations (p < 0.001). Moreover, the patient's preferences, hopes AND worries (p = 0,006) were more often documented, and concordance between provided TREATMENT and patient preferences (p = 0,037) and next of kin participation in advance care planning with the patient (p = 0,056) increased.

CONCLUSION

Improved patient participation - also when cognitively impaired - is achievable through advance care planning in nursing homes using a whole-ward approach.

PRACTICE IMPLICATIONS

Patients with cognitive impairment should be included in advance care planning supported by next of kin. A whole-ward approach may be used to implement advance care planning.

TRIAL REGISTRATION

ISRCTN registry (ID ISRCTN69571462) - retrospectively registered.

Small is beautiful? Explaining resident satisfaction in Swedish nursing home care

BACKGROUND

Resident satisfaction is an important aspect of nursing home quality. Despite this, few studies have systematically investigated what aspects of nursing home care are most strongly associated with satisfaction. In Sweden, a large number of processual and structural measures are collected to describe the quality of nursing home care, though the impact of these measures on outcomes including resident satisfaction is poorly understood.

METHODS

A cross-sectional analysis of data collected in two nationally representative surveys of Swedish eldercare quality using multi-level models to account for geographic differences.

RESULTS

Of the factors examined, nursing home size was found to be the most important predictor of resident satisfaction, followed by the amount of exercise and activities offered by the nursing home. Measures of individualized care processes, ownership status, staffing ratios, and staff education levels were also weakly associated with resident satisfaction. Contrary to previous research, we found no clear differences between processual and structural variables in terms of their association with resident satisfaction.

CONCLUSIONS

The results suggest that of the investigated aspects of nursing home care, the size of the nursing home and the amount activities offered to residents were the strongest predictors of satisfaction. Investigation of the mechanisms behind the higher levels of satisfaction found at smaller nursing homes may be a fruitful avenue for further research.

A nurse-led model of care within an emergency department reduces representation rates for frail aged care residents

BACKGROUND

Hospital Emergency Departments (EDs) experience high presentation rates from older adults residing in Aged Care Facilities (ACFs), yet very few intervention studies have addressed the care needs of this population group. We designed and implemented a nurse-led model of care for older adults from ACFs, and determined its impact on patient outcomes.

METHODS

This 12-month pre-post intervention study was conducted during 2013-2014, with follow-up during 2015-2016. Participants included all older adults presenting from ACFs to the ED of Mater Hospital Brisbane (MHB), Australia. Frailty status was determined using the Clinical Frailty Scale (CFS).

RESULTS

All participants were frail (n = 1130), with 19% severely frail, 55% very-severely frail, and 26% terminally ill. The intervention resulted in several improvements in patient outcomes, including significant reductions in ward admissions and 28-day representation rates.

CONCLUSION

Significant improvements can be achieved by integration of an acute frail older person service into an ED.

Behavioural activation in nursing homes to treat depression (BAN-Dep): study protocol for a pragmatic randomised controlled trial

INTRODUCTION

Depression is a common disorder among older people living in residential aged care facilities. Several trials have demonstrated the effectiveness of behavioural therapies in treating depressive symptoms in older adults living in the community and in residential aged care. Behavioural Activation is demonstrably effective even when delivered by non-specialists (staff without formal psychological training), although strategies for adapting its use in residential aged care facilities are yet to be explored. This study will determine whether training residential care staff in the use of a structured Behavioural Activation programme is more effective at decreasing depressive symptoms among older residents than internet-based training about depression recognition and management alone.

METHOD AND ANALYSIS

The behavioural activation in nursing homes to treat depression (BAN-Dep) trial is a pragmatic two-arm parallel clustered randomised controlled trial. It will recruit 666 residents aged 60 or older from 100 residential aged care facilities, which will be randomly assigned to the Behavioural Activation or control intervention. Staff in both treatment groups will be encouraged to complete the Beyondblue Professional Education to Aged Care e-learning programme to improve their recognition of and ability to respond to depression in older adults. Selected staff from intervention facilities will undergo additional training to deliver an 8-module Behavioural Activation programme to residents with subthreshold symptoms of depression-they will receive ongoing Mental support from trained Behavioural Activation therapists. Outcome measures will be collected by blind research officer at baseline and after 3, 6 and 12 months. The Patient Health Questionnaire-9 is the primary outcome measure of the study.

ETHICS AND DISSEMINATION

The trial will comply with the principles of the Declaration of Helsinki for Human Rights and is overseen by the University of Western Australia (reference RA/4/20/4234) and Melbourne Health (reference number HREC/18/MH/47) Ethics Committees. The results of this research project will be disseminated through publications and/or presentations in a variety of media to health professionals, academics, clinicians and the public. Only de-identified group data will be presented.

TRIAL REGISTRATION

ACTRN12618000634279.

Rural Dementia Caregivers in Southwest Texas: An Exploratory Study of Advance Directives and End-of-Life Proxy Decision Making

For a growing number of persons with dementia (PWDs), advance care planning (ACP) can help families make important end-of-life (EOL) care decisions that reflect PWDs' values and preferences. The current exploratory study aimed to understand advance directive planning and decision making among PWDs and caregivers. A survey was conducted with a convenience sample of 47 ethnically diverse PWD caregivers recruited from rural health care facilities in Southwest Texas. Sixty-eight percent of PWDs and caregivers were Hispanic. The majority of PWDs had completed an advance directive (60%) and preferred equally shared decision making between family (including the PWD) and physicians (57%). Under a hypothetical EOL scenario for PWDs, caregivers chose comfort (40%) and palliative care treatment (55%) more than other goals and treatment options. In this scenario, Hispanic PWDs were less likely than non-Hispanic White counterparts to complete an advance directive (48% vs. 81%, p < 0.05) and to choose only pain and symptom management (46% vs. 81%, p < 0.05). Although the overall ACP rates among rural PWDs may be comparable to those for the general PWD population, ethnic differences exist. More culturally competent education efforts are needed to promote ACP among PWDs in culturally diverse rural communities. [Journal of Gerontological Nursing, 45(9), 11-17.].

The "Violent Resident": A Critical Exploration of the Ethics of Resident-to-Resident Aggression

Resident-to-resident aggression is quite prevalent in long-term care settings. Within popular and empirical accounts, this form of aggression is most commonly attributed to the actions of an aberrant individual living with dementia characterized as the "violent resident." It is often a medical diagnosis of dementia that is highlighted as the ultimate cause of aggression. This neglects the fact that acts of aggression are influenced by broader structural conditions. This has ethical implications in that the emphasis on individual aberration informs public policy strategies for prevention with a focus on restricting the freedom of individuals using behavioural modification, drugs, or other restraints with the intent to protect others from harm. A more ethical approach requires attention to the structural conditions of long-term care that both foster aggression and constrain prevention efforts. To this end, we turn to a model of relational citizenship that offers a theory of embodied selfhood and relationality as essential to human dignity, thus entailing human rights protections. The application of an ethic based on this model offers a more holistic prevention strategy for resident-to-resident aggression by drawing attention to the critical need and obligation to promote human flourishing through system level efforts.