Does proactive care in care homes improve survival? A quality improvement project.

BACKGROUND: NHS England's 'Enhanced Health in Care Homes' specification aims to make the healthcare of care home residents more proactive. Primary care networks (PCNs) are contracted to provide this, but approaches vary widely: challenges include frailty identification, multidisciplinary team (MDT) capability/capacity and how the process is structured and delivered. AIM: To determine whether a proactive healthcare model could improve healthcare outcomes for care home residents. DESIGN AND SETTING: Quality improvement project involving 429 residents in 40 care homes in a non-randomised crossover cohort design. The headline outcome was 2-year survival. METHOD: All care home residents had healthcare coordinated by the PCN's Older Peoples' Hub. A daily MDT managed the urgent healthcare needs of residents. Proactive healthcare, comprising information technology-assisted comprehensive geriatric assessment (i-CGA) and advanced care planning (ACP), were completed by residents, with prioritisation based on clinical needs.Time-dependent Cox regression analysis was used with patients divided into two groups:Control group: received routine and urgent (reactive) care only.Intervention group: additional proactive i-CGA and ACP. RESULTS: By 2 years, control group survival was 8.6% (n=108), compared with 48.1% in the intervention group (n=321), p<0.001. This represented a 39.6% absolute risk reduction in mortality, 70.2% relative risk reduction and the number needed to treat of 2.5, with little changes when adjusting for confounding variables. CONCLUSION: A PCN with an MDT-hub offering additional proactive care (with an i-CGA and ACP) in addition to routine and urgent/reactive care may improve the 2-year survival in older people compared with urgent/reactive care alone.

Abuse in Canadian long-term care homes: a mixed methods study.

OBJECTIVE: To examine reported cases of abuse in long-term care (LTC) homes in the province of Ontario, Canada, to determine the extent and nature of abuse experienced by residents between 2019 and 2022. DESIGN: A qualitative mixed methods study was conducted using document analysis and descriptive statistics. Three data sources were analysed: LTC legislation, inspection reports from a publicly available provincial government administrative database and articles published by major Canadian newspapers. A data extraction tool was developed that included variables such as the date of inspection, the type of inspection, findings and the section of legislation cited. Descriptive analyses, including counts and percentages, were calculated to identify the number of incidents and the type of abuse reported. RESULTS: According to legislation, LTC homes are required to protect residents from physical, sexual, emotional, verbal or financial abuse. The review of legislation revealed that inspectors are responsible for ensuring homes comply with this requirement. An analysis of their reports identified that 9% (781) of overall inspections included findings of abuse. Physical abuse was the most common type (37%). Differences between the frequency of abuse across type of ownership, location and size of the home were found. There were 385 LTC homes with at least one reported case of abuse, and 55% of these homes had repeated incidents. The analysis of newspaper articles corroborated the findings of abuse in the inspection reports and provided resident and family perspectives. CONCLUSIONS: There are substantial differences between legislation intended to protect LTC residents from abuse and the abuse occurring in LTC homes. Strategies such as establishing a climate of trust, investing in staff and leadership, providing standardised education and training and implementing a quality and safety framework could improve the care and well-being of LTC residents.

Adherence to Legionella control regulations and guidelines in Norwegian nursing homes: a cross-sectional survey.

BACKGROUND: Infection by Legionella bacteria is a risk to elderly individuals in health care facilities and should be managed by preventing bacterial proliferation in internal water systems. Norwegian legislation calls for a mandatory Legionella-specific risk assessment with the subsequent introduction of an adapted water management programme. The present study investigates adherence to legislation and guidelines on Legionella control and prevention in Norwegian nursing homes. METHODS: A cross-sectional survey was distributed to Norwegian municipalities to investigate the status of Legionella specific risk assessments of internal water distribution systems and the introduction of water management programmes in nursing homes. RESULTS: A total of 55.1% (n = 228) of the participating nursing homes had performed Legionella-specific risk assessments, of which 55.3% (n = 126) stated that they had updated the risk assessment within the last year. 96.5% introduced a water management programme following a risk assessment, whereas 59.6% of the ones without a risk assessment did the same. Nursing homes with risk assessments were more likely to monitor Legionella levels than those without (61.2% vs 38.8%), to remove dead legs (44.7% vs 16.5%), and to select biocidal preventive treatment over hot water flushing (35.5% vs 4.6%). CONCLUSIONS: This study presents novel insight into Legionella control in Norway, suggesting that adherence to mandatory risk assessment in nursing homes is moderate-low. Once performed, the risk assessment seems to be advantageous as an introduction to future Legionella prevention in terms of the scope and contents of the water management programme.

Nurses' Shared Subjectivity on Person-Centered Care for Behavioral and Psychological Symptoms of Dementia in Nursing Homes.

BACKGROUND: Person-centered care (PCC), an approach to healthcare that focuses on the individual needs, preferences, and values of patients, is particularly important in the context of caring for residents of nursing homes (NHs) with the behavioral and psychological symptoms of dementia (BPSD). However, implementing PCC in NHs varies widely due to individual staff, NH environment, and country factors, leading to heterogeneity in person-centered approaches. PURPOSE: This study was designed to explore and gain insight into the shared subjective perspectives of nurses on providing PCC to manage BPSD in NHs in order to elicit a deeper understanding of how nurses interpret and approach the provision of PCC. METHODS: Q methodology was applied to explore the subjective perspectives of nurses. Twenty-nine NH nurses with more than 3 years of experience in managing BPSD completed a Q-sorting task, categorizing 43 Q-samples into a normal distribution shape. Postsorting interviews were conducted after the participants had completed this task. The collected data were analyzed using centroid factor analysis and varimax rotation run within the PQMethod 2.35 program. Interpretation of the resulting factors was based on factor arrays, field notes, and interview data. RESULTS: Four factors from the shared subjective perspectives of nurses related to PCC were identified, including (a) sharing information focused on details to update care strategies, (b) monitoring until the true needs of residents are identified, (c) awareness of interactive cues in relationships, and (d) connecting an individual's life pattern to their current care. CONCLUSIONS/IMPLICATIONS FOR PRACTICE: The findings highlight that a one-size-fits-all approach may not be suitable for all nurses and interventions, indicating that nurses should consider the applicable subjective frames to ensure the effectiveness of planned interventions. A need for PCC education that specifically addresses BPSD management is suggested, with the findings implying that a strong organizational climate with respect to PCC in managing BPSD should promote higher job satisfaction and commitment and reduce turnover rates among nurses in NHs. Facilitating the development of PCC interventions appropriate for BPSD management that encompass the various categories and ranges of NH settings and nursing phenomena is thus recommended.

[Response to the urgent need to train family doctors in geriatrics : residency in long term care facilities]. / Réponse à l'urgence de former les médecins de famille à la gériatrie : l'assistanat en EMS.

Family doctors have to provide the geriatric cares needed by an aging population. In particular, the increased complexity of care needs in the population living in long term care facilities (LCTF) raises several challenges. One of these challenges is the adequate training of physicians working in LCTF as well as the next generation. Residency programs in LTCFs for future general practioners has demonstrated their value abroad. We describe here the creation of a residency program in LTCF for family doctors in Canton Vaud. Since its beginning in 2020, the program has not only trained young physicians but has also improved interprofessionality and strengthened the training of other healthcare professionals.

La population vieillissante requiert des soins gériatriques spécifiques auxquels le médecin de famille doit répondre. De plus, la complexification des besoins en soins de la population en établissement médicosocial (EMS) soulève de multiples défis. Un de ces défis est la formation adéquate des médecins travaillant en EMS et leur relève. A l'étranger, l'expérience de tournus des médecins de famille dans des structures similaires aux EMS a démontré sa pertinence. Nous illustrons ici le contexte et la mise en place d'une formation postgraduée en EMS pour les médecins de famille sur le canton de Vaud et présentons un aperçu des bénéfices de ce programme depuis sa mise en place en 2020 : au-delà de la formation de jeunes médecins, l'assistanat en EMS améliore la collaboration interprofessionnelle et contribue à la formation d'autres professionnels de la santé.

The palliative care experience in Irish nursing homes during the COVID-19 pandemic: a survey of residents, family, and staff.

BACKGROUND: Nursing homes and other long-term care services account for a disparate share of COVID-19 cases and casualties worldwide. During COVID-19 there is a distinct need to preserve a holistic view of the wellbeing of residents of nursing homes, be mindful of their rights as citizens, and to be aware of protecting residents from infection. The delivery of health and social care throughout a pandemic must remain person-centred and adhere to a human rights-based approach. METHODS: This study aimed to capture nursing home residents, their families and staff's perspective of the nursing homes residents experience, approaches of staff and the nursing home environment. An online survey was distributed via stakeholder networks and online platforms across Ireland. This study was performed and reported in line with the Consensus-Based Checklist for Reporting of Survey Studies (CROSS). RESULTS: 25 residents, 42 family members and 51 staff completed the survey (n = 118). Across the domains measured all but one aspect scored above 50% (residents get up and go to bed when they want 41.5%) with the highest score of 89.1% scored for the nursing home is comfortable and well-kept. Results highlight evidence of positive experiences and endeavours to preserve social connections, residents were in a safe place cared for by staff who did their best in a difficult position and who went above and beyond their duty of care. However, some families reported poor communication, no internet connections, not enough phones or tablets, and that staff were busy and unable at times to assist residents who needed help using phones/tablets. CONCLUSION: This study highlights the importance of human rights and how they ought to inform and shape the advancement of public health advice and policy documents. Overall, nursing home residents, their families and staff reported favourably on the study measures. However, issues pertaining to communication are essential and there is a need to address issues such as the provision of accurate timely information, communication infrastructure and resources, and inconsistencies in communications. Of note is that while healthcare professionals have a duty to uphold the rights of nursing home residents, they themselves have human rights which must also be protected and supported.

Long term care facilities in England during the COVID-19 pandemic-a scoping review of guidelines, policy and recommendations.

BACKGROUND: The disproportionate effect of COVID-19 on long term care facility (LTCF) residents has highlighted the need for clear, consistent guidance on the management of pandemics in such settings. As research exploring the experiences of LTCFs during the pandemic and the implications of mass hospital discharge, restricting staff movement, and limiting visitation from relatives are emerging, an in-depth review of policies, guidance and recommendations issued during this time could facilitate wider understanding in this area. AIMS: To identify policies, guidance, and recommendations related to LTCF staff and residents, in England issued by the government during the COVID-19 pandemic, developing a timeline of key events and synthesizing the policy aims, recommendations, implementation and intended outcomes. METHOD: A scoping review of publicly available policy documents, guidance, and recommendations related to COVID-19 in LTCFs in England, identified using systematic searches of UK government websites. The main aims, recommendations, implementation and intended outcomes reported in included documents were extracted. Data was analysed using thematic synthesis following a three-stage approach: coding the text, grouping codes into descriptive themes, and development of analytical themes. RESULTS: Thirty-three key policy documents were included in the review. Six areas of recommendations were identified: infection prevention and control, hospital discharge, testing and vaccination, staffing, visitation and continuing routine care. Seven areas of implementation were identified: funding, collaborative working, monitoring and data collection, reducing workload, decision making and leadership, training and technology, and communication. DISCUSSION: LTCFs remain complex settings, and it is imperative that lessons are learned from the experiences during COVID-19 to ensure that future pandemics are managed appropriately. This review has synthesized the policies issued during this time, however, the extent to which such guidance was communicated to LTCFs, and subsequently implemented, in addition to being effective, requires further research. In particular, understanding the secondary effects of such policies and how they can be introduced within the existing challenges inherent to adult social care, need addressing.

Reducing Hospitalizations and Multidrug-Resistant Organisms via Regional Decolonization in Hospitals and Nursing Homes.

Importance: Infections due to multidrug-resistant organisms (MDROs) are associated with increased morbidity, mortality, length of hospitalization, and health care costs. Regional interventions may be advantageous in mitigating MDROs and associated infections. Objective: To evaluate whether implementation of a decolonization collaborative is associated with reduced regional MDRO prevalence, incident clinical cultures, infection-related hospitalizations, costs, and deaths. Design, Setting, and Participants: This quality improvement study was conducted from July 1, 2017, to July 31, 2019, across 35 health care facilities in Orange County, California. Exposures: Chlorhexidine bathing and nasal iodophor antisepsis for residents in long-term care and hospitalized patients in contact precautions (CP). Main Outcomes and Measures: Baseline and end of intervention MDRO point prevalence among participating facilities; incident MDRO (nonscreening) clinical cultures among participating and nonparticipating facilities; and infection-related hospitalizations and associated costs and deaths among residents in participating and nonparticipating nursing homes (NHs). Results: Thirty-five facilities (16 hospitals, 16 NHs, 3 long-term acute care hospitals [LTACHs]) adopted the intervention. Comparing decolonization with baseline periods among participating facilities, the mean (SD) MDRO prevalence decreased from 63.9% (12.2%) to 49.9% (11.3%) among NHs, from 80.0% (7.2%) to 53.3% (13.3%) among LTACHs (odds ratio [OR] for NHs and LTACHs, 0.48; 95% CI, 0.40-0.57), and from 64.1% (8.5%) to 55.4% (13.8%) (OR, 0.75; 95% CI, 0.60-0.93) among hospitalized patients in CP. When comparing decolonization with baseline among NHs, the mean (SD) monthly incident MDRO clinical cultures changed from 2.7 (1.9) to 1.7 (1.1) among participating NHs, from 1.7 (1.4) to 1.5 (1.1) among nonparticipating NHs (group × period interaction reduction, 30.4%; 95% CI, 16.4%-42.1%), from 25.5 (18.6) to 25.0 (15.9) among participating hospitals, from 12.5 (10.1) to 14.3 (10.2) among nonparticipating hospitals (group × period interaction reduction, 12.9%; 95% CI, 3.3%-21.5%), and from 14.8 (8.6) to 8.2 (6.1) among LTACHs (all facilities participating; 22.5% reduction; 95% CI, 4.4%-37.1%). For NHs, the rate of infection-related hospitalizations per 1000 resident-days changed from 2.31 during baseline to 1.94 during intervention among participating NHs, and from 1.90 to 2.03 among nonparticipating NHs (group × period interaction reduction, 26.7%; 95% CI, 19.0%-34.5%). Associated hospitalization costs per 1000 resident-days changed from $64 651 to $55 149 among participating NHs and from $55 151 to $59 327 among nonparticipating NHs (group × period interaction reduction, 26.8%; 95% CI, 26.7%-26.9%). Associated hospitalization deaths per 1000 resident-days changed from 0.29 to 0.25 among participating NHs and from 0.23 to 0.24 among nonparticipating NHs (group × period interaction reduction, 23.7%; 95% CI, 4.5%-43.0%). Conclusions and Relevance: A regional collaborative involving universal decolonization in long-term care facilities and targeted decolonization among hospital patients in CP was associated with lower MDRO carriage, infections, hospitalizations, costs, and deaths.

Relation between pre-existing quality management measures and prevention and containment of COVID-19 outbreaks in 159 nursing homes in Tuscany: a mixed methods study.

BACKGROUND: Nursing homes were often the focus of COVID-19 outbreaks. Many factors are known to influence the ability of a nursing home to prevent and contain a COVID-19 outbreak. The role of an organisation's quality management prior to the pandemic is not yet clear. In the Italian region of Tuscany nursing home performance indicators have been regularly collected since before the pandemic, providing the opportunity to better understand this relationship. OBJECTIVES: To test if there is a difference in the results achieved by nursing homes in Tuscany on 13 quality management indicators, when grouped by severity of COVID-19 outbreaks; and to better understand how these indicators may be related to the ability to control COVID-19 outbreaks, from the perspective of nursing homes. METHODS: We used a mixed methods sequential explanatory design. Based on regional and national databases, 159 nursing homes in Tuscany were divided into four groups by outbreak severity. We tested the significance of the differences between the groups with respect to 13 quality management indicators. The potential relation of these indicators to COVID-19 outbreaks was discussed with 29 managers and other nursing homes' staff through four group interviews. RESULTS: The quantitative analysis showed significant differences between the groups of nursing homes for 3 of the 13 indicators. From the perspective of nursing homes, the indicators might not be good at capturing important aspects of the ability to control COVID-19 outbreaks. For example, while staffing availability is seen as essential, the staff-to-bed ratio does not capture the turn-over of staff and temporary absences due to positive COVID-19 testing of staff. CONCLUSIONS: Though currently collected indicators are key for overall performance monitoring and improvement, further refinement of the set of quality management indicators is needed to clarify the relationship with nursing homes' ability to control COVID-19 outbreaks.

Barriers and enablers for externally and internally driven implementation processes in healthcare: a qualitative cross-case study.

BACKGROUND: Quality in healthcare is a subject in need of continuous attention. Quality improvement (QI) programmes with the purpose of increasing service quality are therefore of priority for healthcare leaders and governments. This study explores the implementation process of two different QI programmes, one externally driven implementation and one internally driven, in Norwegian nursing homes and home care services. The aim for the study was to identify enablers and barriers for externally and internally driven implementation processes in nursing homes and homecare services, and furthermore to explore if identified enablers and barriers are different or similar across the different implementation processes. METHODS: This study is based on an exploratory qualitative methodology. The empirical data was collected through the 'Improving Quality and Safety in Primary Care - Implementing a Leadership Intervention in Nursing Homes and Homecare' (SAFE-LEAD) project. The SAFE-LEAD project is a multiple case study of two different QI programmes in primary care in Norway. A large externally driven implementation process was supplemented with a tracer project involving an internally driven implementation process to identify differences and similarities. The empirical data was inductively analysed in accordance with grounded theory. RESULTS: Enablers for both external and internal implementation processes were found to be technology and tools, dedication, and ownership. Other more implementation process specific enablers entailed continuous learning, simulation training, knowledge sharing, perceived relevance, dedication, ownership, technology and tools, a systematic approach and coordination. Only workload was identified as coincident barriers across both externally and internally implementation processes. Implementation process specific barriers included turnover, coping with given responsibilities, staff variety, challenges in coordination, technology and tools, standardizations not aligned with work, extensive documentation, lack of knowledge sharing. CONCLUSION: This study provides understanding that some enablers and barriers are present in both externally and internally driven implementation processes, while other are more implementation process specific. Dedication, engagement, technology and tools are coinciding enablers which can be drawn upon in different implementation processes, while workload acted as the main barrier in both externally and internally driven implementation processes. This means that some enablers and barriers can be expected in implementation of QI programmes in nursing homes and home care services, while others require contextual understanding of their setting and work.

Skin care types, frequencies and products: A cross-sectional study in German institutional long-term care.

AIM: The aim of the study was to describe types and frequencies of skin care interventions and products provided in institutional long-term care. MATERIALS AND METHODS: Baseline data from a cluster randomized controlled trial conducted in nursing homes in Berlin, Germany was collected before randomization. Numbers, proportions and frequencies of washing, showering and bathing, and the application of leave-on products were calculated. Product labels were iteratively and inductively categorized into overarching terms and concepts. RESULTS: A total of n = 314 residents participated in the study. In the majority, washing of the whole body was done once daily, and showering was performed once per week or more rarely. The majority received leave-on products daily on the face and once per week on the whole body. Most of the skin care interventions were delivered by nurses. There was marked heterogeneity in terms of product names, whereas the product names reveal little about the ingredients or composition. CONCLUSION: Personal hygiene and cleansing interventions are major parts of clinical practice in long-term care. Daily washing is a standard practice at the moment. In contrast, leave-on products are used infrequently. To what extent the provided care promotes skin integrity is unclear. Due to the heterogeneity and partly misleading labels of skin care products, informed decision making is difficult to implement at present. GOV IDENTIFIER: NCT03824886.

Facilitators and barriers to implementation of telemedicine in nursing homes: A qualitative systematic review and meta-aggregation.

BACKGROUND: Telemedicine is an effective way to provide nursing home residents ease of access to consultations with healthcare professionals. It is safe, effective, and time- and cost-efficient, and can be used when there are movement restrictions, such as during the COVID-19 pandemic. This literature focuses only on healthcare professionals' experiences and perspectives on the use of telemedicine in long-term care facilities. OBJECTIVES: This review concentrated on telemedicine programs that did not involve remote monitoring. It aimed to comprehensively appraise existing literature examining the facilitators and barriers in implementing telemedicine services in nursing homes. METHODS: A systematic qualitative review was conducted with content analysis. Database searching was conducted in PubMed, Embase, Cochrane, Scopus, and CINAHL. Hand searching for gray literature and reference lists of included papers was also performed. Qualitative studies or mixed-method studies with a qualitative analysis addressing implementation of telemedicine in any long-term care facilities were included. The Critical Appraisal Skills Programme qualitative checklist was used to assess the quality of the included studies. The data were extracted and cross-checked between two reviewers. A third reviewer was consulted for any disagreements. Meta-aggregation was used to synthesize the results. RESULTS: Eighty-one findings were extracted, which informed 16 categories and 13 synthesized findings. The synthesized findings were related to the innovation domain, infrastructure, work processes, individuals, and implementation processes. LINKING EVIDENCE TO ACTION: This review highlighted factors that affect the successful implementation of a telemedicine service in nursing homes. These findings provide evidence to support the future utilization of this service in the nursing home setting. Further research should explore the best approach to address these barriers and facilitators.

Longitudinal Evaluation of a Statewide Quality Improvement Program for Nursing Homes.

OBJECTIVES: The National Academies of Sciences, Engineering, and Medicine (NASEM) Nursing Home Quality report recommends that states "develop and operate state-based…technical assistance programs…to help nursing homes…improve care and…operations." The Quality Improvement Program for Missouri (QIPMO) is one such program. This longitudinal evaluation examined and compared differences in quality measures (QMs) and nursing home (NH) characteristics based on intensity of QIPMO services used. DESIGN: A descriptive study compared key QMs of clinical care, facility-level characteristics, and differing QIPMO service intensity use. QIPMO services include on-site clinical consultation by expert nurses; evidence-based practice information; teaching NHs use of quality improvement (QI) methods; and guiding their use of Centers for Medicare and Medicaid Services (CMS)-prepared QM comparative feedback reports to improve care. SETTING AND PARTICIPANTS: All Missouri NHs (n = 510) have access to QIPMO services at no charge. All used some level of service during the study, 2020-2022. METHODS: QM data were drawn from CMS's publicly available website (Refresh April 2023) and NH characteristics data from other public websites. Service intensity was calculated using data from facility contacts (on-site visits, phone calls, texts, emails, webinars). NHs were divided into quartiles based on service intensity. RESULTS: All groups had different beginning QM scores and improved ending scores. Group 2, moderate resource intensity use, started with "worse" overall score and improved to best performing by the end. Group 4, most resource intensity use, improved least but required highest service intensity. CONCLUSIONS AND IMPLICATIONS: This longitudinal evaluation of QIPMO, a statewide QI technical assistance and support program, provides evidence of programmatic stimulation of statewide NH quality improvements. It provides insight into intensity of services needed to help facilities improve. Other states should consider QIPMO success and develop their own programs, as recommended by the NASEM report so their NHs can embrace QI and "initiate fundamental change" for better care for our nation's older adults.