Resilience for working in Ontario home and community care: registered practical nurses need the support of themselves, family and clients, and employers.

BACKGROUND: The context of practice is often not explicit in the discourse around the personal and professional resilience of nurses. The unique factors related to providing nursing care in home and community care may provide novel insight into the resilience of this health workforce. Therefore, this research addressed how nurses build and maintain resilience working in the home and community care sector. METHOD: A qualitative study was conducted between November 2022 to August 2023 using 36 in-depth interviews (29 registered practical nurses [RPNs], five supervisors of RPNs, two family/care partners (FCPs) of clients receiving home and community care services). Analysis was consistent with a grounded theory approach including coding and comparative methods. RESULTS: The factors of personal and professional resilience were not distinct but rather mixed together in the experience of nurses having resilience working in the home and community care sector. The process of building and maintaining resilience as home and community care nurses was informed by three categories: (1) The conditions of working in HCC; (2) The rapport RPNs held with FCPs; and (3) The nurses' ability for supporting the 'self'. Multiple components to inform these categories were identified and illustrated by the words of the nurse participants. CONCLUSION: The process of building and maintaining resilience by RPNs working in the home and community care sector was guided by the day-to-day experiences of providing care for clients and the conditions of being a mobile health care provider. However, nurses may sense when they need to support their 'self' and must be empowered to request and receive support to do so.

Sustaining a Workforce: Reflections on Work from Home and Community Care Nurses Transitioning out of the COVID-19 Pandemic.

Introduction: The COVID-19 pandemic has had an unprecedented impact on nurses' well-being and desire to practice; however, the experience of Canadian home and community care nurses remains less well understood. As the health human resources crisis in this sector persists, understanding these nurses' experiences may be vital in creating more effective retention strategies. Objective: The aim of this study was to explore how the COVID-19 pandemic shaped the working experiences, motivations, and attitudes of home and community care nurses in the Greater Toronto Area. Methods: Using an exploratory, descriptive, qualitative approach, 16 home and community care nurses participated in semistructured interviews. Data were analyzed using collaborative thematic analysis. Participants shared their reflections on work by detailing their experiences prepandemic, during crisis, transitioning out of crisis, and regarding pandemic recovery. Results: During the COVID-19 pandemic inadequate staffing resources during and beyond the crisis period disrupted many desirable facets of work for home and community care nurses such as stable, balanced, and flexible work conditions, and exacerbated the unfavorable aspects such as isolation and inconsistent support. Many nurses were reevaluating their careers: for some, this meant stronger professional attachment and for others, it meant intentions to leave. Improved sector preparedness, wages, and workplace support were identified as strategies to sustain this workforce beyond the pandemic. Conclusion: Home care organizations must consider ways to address the root cause of concerns expressed by nurses who wish to practice in a supportive environment that is sufficiently staffed and sensitive to workload expectations.

Factors influencing self-reported facial-protective equipment adherence among home care nurses and personal support workers: A multisite cross-sectional study.

BACKGROUND: Facial-protective equipment (FPE) use increased during the SARS-CoV-2 pandemic. This study explored factors influencing home care personal support workers' (PSWs) and nurses' self-reported adherence to FPE. METHODS: A cross-sectional, electronic, survey was distributed to PSWs and nurses (1,108 complete responses) at 3 home care agencies in Ontario, Canada, in May to June 2022. Descriptive, bivariate, and multivariable analysis were used to assess individual, environmental, and organizational factors influencing adherence. RESULTS: Among participants (786 PSWs, 322 nurses), 64% reported being adherent to both respiratory and eye FPE (Respiratory: 96%, Eye: 64%). Higher adherence was associated with facility-based work; better knowledge of FPE; prepandemic FPE use; good availability and convenient access; strong organizational support for health and safety; and Caribbean identity. Lower adherence was found for men; nurses with 2-year diplomas; shorter length of employment; communal transportation; and experiencing negative mental health effects from workplace infectious disease exposure. DISCUSSION: Agencies should prioritize increasing providers' knowledge of FPE, supporting mental well-being, fostering a supportive culture, and ensuring availability of FPE. The influences of gender, ethnicity, and role require further exploration. CONCLUSIONS: FPE adherence may be improved by addressing modifiable factors and developing population-specific strategies.

Factors influencing nursing professionals' adherence to facial protective equipment usage: A comprehensive review.

BACKGROUND: Facial protective equipment (FPE) adherence is necessary for the health and safety of nursing professionals. This review was conducted to synthesize predisposing, enabling, and reinforcing factors that influence FPE adherence, and thus inform efforts to promote adherence. METHODS: Articles were collected using Cumulated Index to Nursing and Allied Health Literature and MEDLINE and screened for inclusion. Included articles were original studies focused on FPE adherence by nurses to prevent respiratory infection which contained occupation-specific data from at least 10 individuals and were published in English between January 2005 and February 2022. RESULTS: Thirty articles were included, 21 of which reported adherence rates. Adherence ranged from 33% to 100% for respiratory protection and 22% to 100% for eye protection. Predisposing demographic factors influencing adherence included tenure and occupation, while modifiable predisposing factors included knowledge and perception of FPE, infection transmission, and risk. Enabling factors included geography, care settings, and FPE availability. Reinforcing factors included organizational support for health and safety, clear policies, and training. CONCLUSIONS: The identified demographic factors suggest populations that may benefit from targeted interventions, while modifiable factors suggest opportunities to enhance education as well as operational processes and supports. Interventions that target these areas have the potential to promote adherence and thereby improve the occupational safety of nurses.

Shifting the Safety Culture: Evaluation of a Novel Approach to Understanding and Responding to Workplace Harassment and Violence Experienced by Homecare Workers.

BACKGROUND: Workplace violence and harassment are commonplace for healthcare workers and most incidents are unreported. Normalization of these experiences, lack of confidence in reporting systems, and fear of the consequences of reporting contribute to the invisibility of these experiences. Challenges are exacerbated in homecare settings and for precarious workforces including Personal Support Workers (PSWs). We created, piloted, and evaluated an intervention to enhance safety culture and encourage reporting of workplace violence and harassment. METHODS: A multi-stakeholder steering committee designed an intervention combining policy changes, a pre-visit screening tool, education, and brief end-of-visit reporting. This was piloted with a PSW care team which provided >55,000 client visits during the 32-week intervention. Operational metrics characterized screening, education, and reporting uptake. Pre- and post-intervention surveys characterized PSWs' experiences with workplace violence and harassment, reporting experiences, training history and intervention feedback. FINDINGS: PSWs reported increased comfort discussing workplace violence and harassment, and increased confidence managing client-to-worker incidents. The screening went smoothly with most clients in private homes. Most PSWs (75%) engaged at least once with end-of-visit reporting and nearly half submitted reports regularly. During the pilot, 21% of PSWs reported incidents and 52% of reports shared client-specific strategies for managing these situations. APPLICATION TO PRACTICE: Changes in comfort and behavior with reporting indicated a shift toward a more open culture surrounding workplace violence and harassment. Tools created for this intervention and lessons for implementation are shared for consideration by occupational health practitioners throughout the homecare sector.

Developing and Retaining Homecare Nurses Through Employer-Based Tuition Assistance Programs: A Mixed Methods Study.

PURPOSE: This study describes how an employer-based tuition-assistance program for homecare workers at one Canadian homecare organization enabled nursing career advancement and retention. DESIGN: A convergent parallel mixed-methods design. METHODS: We reviewed existing administrative data and concurrently conducted semi-structured interviews. Descriptive statistics were used on quantitative data and qualitative data was analyzed using thematic analysis. A joint data display was developed to integrate findings from both quantitative and qualitative data together. FINDINGS: Tuition assistance reduced financial barriers to career advancement; 83% of recipients remained with their employer for at least 1-year post-studies but only 29% experienced career advancement. Psychosocial supports, career navigation and coaching to ease the licensing and role transition processes were identified as opportunities to support learners. CONCLUSION: Employer-based tuition assistance programs are impactful in helping to develop skilled employees. Practical enhancements to further support career transitions may maximize retention to address urgent homecare staffing challenges. CLINICAL EVIDENCE: Employer-based tuition assistance can be a useful strategy to support nursing career growth and staff retention.

How Might We Have Known? Using Administrative Data to Predict 30-Day Hospital Readmission in Clients Receiving Home Care Services from 2018 to 2021.

Background: Reducing hospital readmissions can improve individual health outcomes and lower system-level costs. This study aimed to understand the characteristics of home care Personal Support clients who experienced a hospital admission (ie, hospital hold) and to identify factors that predict hospital readmission within 30 days of resuming home care Personal Support services. Methods: We conducted a retrospective cohort study using client administrative data from a home healthcare provider organization (2018-2021). The sample included clients (⩾18 years) who received publicly funded Personal Support services and experienced a hospital hold. Descriptive statistics and a binary logistic regression model analyzed the relationship between demographics, hospital service utilization, home care service utilization, and contextual factors on the outcome of 30-day hospital readmission. Results: Approximately 17% (n = 662) of all clients with a hospital hold (n = 3992) were readmitted to hospital within 30 days. Compared with non-readmitted clients, those with greater home care Personal Support service intensity after the index hospital hold were less likely to experience a hospital 30-day readmission. In contrast, those with greater acuity, higher assessed care needs, more hospital holds overall, more extended hospital stays (⩾2 weeks), and lower social support had a higher likelihood of 30-day hospital readmission. Conclusion: The findings from this study provide a greater understanding of factors associated with home care clients' risk of hospital readmission within 30 days and can be used to inform targeted, evidence-based support to reduce home care clients' hospital readmissions.

Why Did Home Care Personal Support Service Volumes Drop During the COVID-19 Pandemic? The Contributions of Client Choice and Personal Support Worker Availability.

Home care personal support service delivery decreased during the COVID-19 pandemic, and qualitative studies have suggested many potential contributors to these reductions. This paper provides insight into the source (client or provider) of reductions in home care service volumes early in the pandemic through analysis of a retrospective administrative dataset from a large provider organization. The percentage of authorized services not delivered was 17.2% in Wave 1, 12.6% in Wave 2 and 10.5% in Wave 3, nearing the pre-pandemic baseline of 8.9%. The dominant contribution to reduced home care service volumes was client-initiated holds and cancellations, collectively accounting for 99.3% of the service volume; missed care visits by the provider accounted for 0.7%. Worker availability also declined due to long-term absences (which increased 5-fold early in Wave 1 and remained 4× above baseline in Waves 2 and 3); short-term absences rose sharply for 6 early-pandemic weeks, then dropped below the pre-pandemic baseline. These data reveal that service volume reductions were primarily driven by client-initiated holds and cancellations; despite unprecedented decreases in Personal Support Worker availability, missed care did not increase, indicating that the decrease in demand was more substantial and occurred earlier than the decrease in worker availability.

A Good Investment: Expanding Capacity to Care for Older Adults in the Home and Community Care Sector Through Increased Personal Support Worker Wages.

Most older adults prefer to age in place, which for many will require home and community care (HCC) support. Unfortunately, HCC capacity is insufficient to meet demand due in part to low wages, particularly for personal support workers (PSWs) who provide the majority of paid care. Using Ontario as a case study, this paper estimates the cost and capacity impacts of implementing wage parity between PSWs employed in HCC and institutional long-term care (ILTC). Specifically, we consider the cost of increased HCC PSW wages versus expected savings from avoiding unnecessary ILTC placement for those accommodated by HCC capacity growth. The expected increase in HCC PSW retention would create HCC capacity for approximately 160,000 people, reduce annual health system costs by approximately $7 billion, and provide an 88 per cent return on investment. Updating wage structures to reduce turnover and enable HCC capacity growth is a cost-efficient option for expanding health system capacity.

Economic Evidence for Home and Community Care Investment: The Case for Ontario Personal Support Workers' Wage Parity.

The home and community care (HCC) sector is in a health human resource crisis. Particularly concerning is the shortage of personal support workers (PSWs) who provide the majority of HCC. This paper outlines a strategy to mitigate the HCC PSW shortage by applying appropriate funding to HCC and focusing on equal pay between HCC and institutional long-term care facilities' PSWs. Using publicly available data, our calculations estimate substantial government cost-savings from investing in HCC PSWs to increase HCC capacity. Beyond the economic evidence, how such investments would benefit those seeking care are also highlighted.

"You Have to Be Careful About Every Detail" How the COVID-19 Pandemic Shaped the Experiences of Canadian Personal Support Workers Working in Home Care.

OBJECTIVES: Personal support workers (PSWs) are an essential but vulnerable workforce supporting the home care sector in Canada. Given the impact COVID-19 has had on healthcare workers globally, understanding how PSWs have been impacted is vital. METHODS: We conducted a qualitative descriptive study to understand the working experiences of PSWs over the COVID-19 pandemic. Nineteen semistructured interviews were conducted, and analysis was guided by the collaborative DEPICT framework. RESULTS: Personal support workers are motivated by an intrinsic duty to work and their longstanding client relationships despite feeling vulnerable to transmission and infection. They experienced co-occurring occupational stressors and worsening work conditions, which impacted their overall well-being. CONCLUSIONS: Pandemic conditions have contributed to increased occupational stress among PSWs. Employers must implement proactive strategies that promote and protect the well-being of their workforce while advocating for sector improvements.

Determinants of nurse's and personal support worker's adherence to facial protective equipment in a community setting during the COVID-19 pandemic in Ontario, Canada: A pilot study.

BACKGROUND: Appropriate and consistent facial protective equipment (FPE) use is critical for preventing respiratory illness transmission. Little is known about FPE adherence by home care providers. The purpose of this study is to adapt an existing facial protection questionnaire and use it to develop an initial understanding of factors influencing home care providers' adherence to FPE during the COVID-19 pandemic. METHODS: A survey was shared with home care providers during Wave 2 of the COVID-19 pandemic in Ontario. Descriptive statistics and logistic regression by FPE adherence were conducted across individual, organizational, and environmental factors. RESULTS: Of the 199 respondents (140 personal support workers; 59 nurses), 71% reported that they always used FPE as required, with greater adherence to masks (89%) than eye protection (73%). The always-adherent reported greater perceived FPE efficacy, knowledge of recommended use and perceived occupational risk, lower education, and not experiencing personal barriers (including difficulty seeing, discomfort, communication challenges). DISCUSSION: Adherence rates were relatively high. In this context, with participants reporting high levels of organizational support, individual-level factors were the significant predictors of adherence. CONCLUSIONS: Initiatives addressing perceived FPE efficacy, knowledge of recommended use, perception of at-work risk, and personal barriers to use may improve FPE adherence.

Navigating the Grey Zone of Physiotherapy Assistant Autonomy in Home Care: Perspectives of Physiotherapists and Physiotherapy Assistants.

Purpose: To explore perspectives and experiences regarding the autonomy of physiotherapist assistants (PTAs) among physiotherapists and PTAs providing home care services in Ontario since the introduction of PTAs into home care rehabilitation teams. Method: For this qualitative study, we conducted semi-structured interviews with 10 physiotherapists and 5 PTAs working in home care. We analyzed interview transcripts using the DEPICT model. Results: Participants described navigating a grey zone characterized by a lack of clarity about acceptable levels of PTA autonomy. Four interrelating factors shaped the extent to which PTAs practised with autonomy: system influences (number of physiotherapy visits, professional guidelines), patient complexity (status, comorbidities), perceived PTA competence (skills, training), and the physiotherapist-PTA relationship (trust, communication). Conclusions: New practice models in home care have impacted the role of both physiotherapists and PTAs. Home care agencies should facilitate emerging professional relationships and address autonomy-related challenges, such as trust and competence, to promote high-quality client-centred care.

Objectif : explorer les perspectives et les expériences relatives à l'autonomie des assistants-physiothérapeutes (APT) chez les physiothérapeutes et les APT qui donnent des soins à domicile en Ontario depuis que les APT ont été intégrés aux équipes de réadaptation à domicile. Méthodologie : dans le cadre de cette étude qualitative, les auteurs ont réalisé des entrevues semi-structurées auprès de dix physiothérapeutes et de cinq APT en soins à domicile. Ils ont analysé les transcriptions d'entrevue au moyen du modèle DEPICT. Résultats : les participants ont décrit qu'ils évoluaient dans une zone grise caractérisée par l'absence de clarté quant aux taux d'autonomie acceptables pour les APT. Quatre facteurs interreliés déterminaient les limites de l'autonomie des APT : les influences des systèmes (nombre de visites en physiothérapie, directives professionnelles), complexité des patients (état, autres maladies), perception des compétences des APT (habiletés, formation) et relation entre le physiothérapeute et l'APT (confiance, communication). Conclusions : les nouveaux modèles d'exercice en soins à domicile ont des répercussions sur le rôle des physiothérapeutes tout autant que des APT. Les agences de soins à domicile devraient faciliter les relations professionnelles émergentes et aborder les problèmes liés à l'autonomie, comme la confiance et la compétence, pour promouvoir des soins de qualité axés sur le patient.

Consumer-Grade Wearable Device for Predicting Frailty in Canadian Home Care Service Clients: Prospective Observational Proof-of-Concept Study.

BACKGROUND: Frailty has detrimental health impacts on older home care clients and is associated with increased hospitalization and long-term care admission. The prevalence of frailty among home care clients is poorly understood and ranges from 4.0% to 59.1%. Although frailty screening tools exist, their inconsistent use in practice calls for more innovative and easier-to-use tools. Owing to increases in the capacity of wearable devices, as well as in technology literacy and adoption in Canadian older adults, wearable devices are emerging as a viable tool to assess frailty in this population. OBJECTIVE: The objective of this study was to prove that using a wearable device for assessing frailty in older home care clients could be possible. METHODS: From June 2018 to September 2019, we recruited home care clients aged 55 years and older to be monitored over a minimum of 8 days using a wearable device. Detailed sociodemographic information and patient assessments including degree of comorbidity and activities of daily living were collected. Frailty was measured using the Fried Frailty Index. Data collected from the wearable device were used to derive variables including daily step count, total sleep time, deep sleep time, light sleep time, awake time, sleep quality, heart rate, and heart rate standard deviation. Using both wearable and conventional assessment data, multiple logistic regression models were fitted via a sequential stepwise feature selection to predict frailty. RESULTS: A total of 37 older home care clients completed the study. The mean age was 82.27 (SD 10.84) years, and 76% (28/37) were female; 13 participants were frail, significantly older (P<.01), utilized more home care service (P=.01), walked less (P=.04), slept longer (P=.01), and had longer deep sleep time (P<.01). Total sleep time (r=0.41, P=.01) and deep sleep time (r=0.53, P<.01) were moderately correlated with frailty. The logistic regression model fitted with deep sleep time, step count, age, and education level yielded the best predictive performance with an area under the receiver operating characteristics curve value of 0.90 (Hosmer-Lemeshow P=.88). CONCLUSIONS: We proved that a wearable device could be used to assess frailty for older home care clients. Wearable data complemented the existing assessments and enhanced predictive power. Wearable technology can be used to identify vulnerable older adults who may benefit from additional home care services.

The Canadian Frailty Priority Setting Partnership: Research Priorities for Older Adults Living with Frailty.

BACKGROUND: Patient engagement in research priority-setting is intended to democratize research and increase impact. The objectives of the Canadian Frailty Priority Setting Partnership (PSP) were to engage people with lived or clinical experience of frailty, and produce a list of research priorities related to care, support, and treatment of older adults living with frailty. METHODS: The Canadian Frailty PSP was supported by the Canadian Frailty Network, coordinated by researchers in Toronto, Ontario and followed the methods of the James Lind Alliance, which included establishing a Steering Group, inviting partner organizations, gathering questions related to care, support and treatment of older adults living with frailty, processing the data and prioritizing the questions. RESULTS: In the initial survey, 799 submissions were provided by 389 individuals and groups. The 647 questions that were within scope were categorized, merged, and summarized, then checked against research evidence, creating a list of 41 unanswered questions. Prioritization took place in two stages: first, 146 individuals and groups participated in survey and their responses short-listed 22 questions; and second, an in-person workshop was held on September 26, 2017 in Toronto, Ontario where these 22 questions were discussed and ranked. CONCLUSION: Researchers and research funders can use these results to inform their agendas for research on frailty. Strategies are needed for involving those with lived experience of frailty in research.

Home-based diabetes self-management coaching delivered by paraprofessionals: A randomized controlled trial.

This study evaluated paraprofessional-led diabetes self-management coaching (DSMC) among 94 clients with type 2 diabetes recruited from a Community Care Access Centre in Ontario, Canada. Subjects were randomized to standard care or standard care plus coaching. Measures included the Diabetes Self-Efficacy Scale (DSES), Insulin Management Diabetes Self-Efficacy Scale (IMDSES), and Hospital Anxiety and Depression Scale (HADS). Both groups showed improvement in DSES (6.6 + 1.5 vs. 7.2 + 1.5, p < .001) and IMDSES (113.5 + 20.6 vs. 125.7 + 22.3, p < .001); there were no between-groups differences. There were no between-groups differences in anxiety (p > .05 for all) or depression scores (p > .05 for all), or anxiety (p > .05 for all) or depression (p > .05 for all) categories at baseline, postintervention, or follow-up. While all subjects demonstrated significant improvements in self-efficacy measures, there is no evidence to support paraprofessional-led DSMC as an intervention which conveys additional benefits over standard care.

Footwear width and balance-recovery reactions: A new approach to improving lateral stability in older adults.

BACKGROUND: Age-related difficulty in controlling lateral stability is of crucial importance because lateral falls increase risk of debilitating hip-fracture injury. This study examined whether a small increase in footwear sole width can improve ability of older adults to regain lateral stability subsequent to balance perturbation. METHODS: The study involved sixteen healthy, ambulatory, community-dwelling older adults (aged 65-78). Widened base-of-support (WBOS) footwear was simulated by affixing polystyrene-foam blocks (20mm wide) on the medial and lateral sides of rubber overshoes; unaltered overshoes were worn in normal (NBOS) trials. Balance perturbations were applied using a motion platform. RESULTS: Gait, mobility and agility tests revealed no adverse effects of wearing the WBOS footwear. Lateral-perturbation tests showed that the WBOS footwear improved ability to stabilize the body without stepping (p=0.002). Depending on the perturbation magnitude, the frequency of stepping was reduced by up to 25% (64% of NBOS trials vs 39% of WBOS trials). In addition, the WBOS footwear appeared to improve ability to maintain lateral stability during forward-step reactions, as evidenced by reduced incidence of additional lateral steps (p=0.04) after stepping over an obstacle in response to a forward-fall perturbation. CONCLUSIONS: A small increase in sole width can improve certain aspects of lateral stability in older adults, without compromising mobility and agility. This finding supports the viability of WBOS footwear as an intervention to improve balance. Further research is needed to test populations with more severe balance impairments, examine user compliance, and determine if WBOS footwear actually reduces falling risk in daily life.

Effect of Achilles tendon vibration on posture in children.

This study investigated the effect of unilateral Achilles tendon vibration on postural response in children and young adults during standing. Thirty healthy subjects participated in this study including ten 6-year-old children (YC group), ten 10-year-old children (OC group), and ten young adults (YA group). Eight-second vibration was elicited in each trial from a small vibrator attached above the right Achilles tendon when participants stood barefoot on a force platform. Three 40-s trials were collected under both eyes-open and eyes-closed conditions. Center of pressure (COP) was calculated to examine postural response during the pre-vibration, vibration and post-vibration phases. Results show that both the YC and OC groups had a greater COP average velocity than the YA group in all three phases. Tendon vibration induced a directionally specific postural response in all three groups such that the onset of vibration induced a posterior and medial COP shift during the vibration phase, and the offset of vibration induced an anterior and lateral COP shift during the post-vibration phase. Timing of the maximal COP shift was comparable among three groups in both anterior-posterior (AP) and medial-lateral (ML) directions. However, only the OC group showed an adult-like magnitude of the maximal COP shift during the post-vibration phase in the AP direction. These results suggest that 6-year-old children may start showing an adult-like directionally specific response and temporal parameter to tendon vibration during standing; however, the development of an adult-like spatial postural response to tendon vibration may take more than 10 years.

Effects of uni- and multimodal cueing on handrail grasping and associated gaze behavior in older adults.

INTRODUCTION: It appears that age-related changes in visual attention may impair ability to acquire the visuospatial information needed to grasp a handrail effectively in response to sudden loss of balance. This, in turn, may increase risk of falling. To counter this problem, we developed a proximity-triggered cueing system that provides a visual cue (flashing lights) and/or verbal cue ("attention use the handrail") to attract attention to the handrail. This study examined the effect of handrail cueing on grasping of the rail and associated gaze behavior in a large cohort (n=160) of independent and ambulatory older adults (age 64-80). METHODS: The handrail and cueing system was mounted on a large (2 m×6 m) motion platform configured to simulate a real-life environment. Subjects performed a daily-life task that required walking to the end of the platform, which was triggered to perturb balance by moving suddenly when they were adjacent to the rail. To prevent adaptation, each subject performed only one trial, and a deception was used to ensure that the perturbation was truly unexpected. Each subject was assigned to one of four cue conditions: visual, verbal, multimodal (visual-plus-verbal) or no cue. RESULTS: Verbal cueing attracted overt visual attention to the handrail and markedly increased proactive grasping (prior to the onset of the balance perturbation) particularly when delivered unimodally. Subjects were otherwise much more likely to grasp the rail in reaction to the perturbation. A possible trend for visual cueing to improve the accuracy of these reactions was offset by adverse effects on reaction speed and on frequency of proactive grasping. CONCLUSIONS: The results support the viability of using unimodal verbal cueing to reduce fall risk by increasing proactive handrail use. Conversely, they do not strongly support use of visual cueing (either alone or in combination with verbal cueing) and suggest that it may even have adverse effects. Further study is needed to evaluate effects of handrail cueing in a wide range of populations and real-life settings.

Hoarding in the home: a toolkit for the home healthcare provider.

Hoarding is a mental health disorder characterized by difficulties with discarding possessions, yielding cluttered and chaotic home environments that can pose significant safety concerns, impairment to functioning, and distress for those who live in and encounter these situations. Understanding the condition and the strategies available to support individuals who hoard are important skills for the home care provider and are described here in the context of one community organization's response via the development of a Community Clutter and Hoarding Toolkit.