Predictors of Pain and Mood Disturbances Among Older People in Custody Using an interRAI Assessment.

The population of people in federal custody in Canada is aging. Those in custody report experiencing poorer health and high rates of chronic health conditions. Two health concerns that are disproportionately higher among those in custody are mood disorders and pain. This cross-sectional study examined health indicators associated with pain and depressive symptoms among older people (50 years and above) from multiple facilities and security levels in federal custody in Canada. Participants were assessed using the interRAI Emergency Department Contact Assessment, which captures key health indicators. Chi square and logistic regression analyses were conducted to describe the population and identify health indicators associated with mood- and pain-related outcomes, respectively. Of the 1,422 participants in this study, the majority (55%) experienced pain and at least 1 out of 5 experienced depressive symptoms. Health indicators associated with depressive symptoms and/or pain were functional measures, including mobility, managing medication(s), and dyspnea. Depressive symptoms and pain are highly prevalent among older adults in federal custody. The relationship between functional health, depressive symptoms, and pain highlights the importance of interprofessional health care and biopsychosocial intervention(s).

Impact of an intergenerational program to improve loneliness and social isolation in older adults initiated at the time of emergency department discharge: study protocol for a three-arm randomized clinical trial.

BACKGROUND: Social isolation and loneliness (SIL) worsens mortality and other outcomes among older adults as much as smoking. We previously tested the impact of the HOW R U? intervention using peer support from similar-aged volunteers and demonstrated reduced SIL among older adults discharged from the emergency department (ED). Generativity, defined as "the interest in establishing and guiding the next generation," can provide an alternative theoretical basis for reducing SIL via intergenerational programs between members of younger and older generations. The current protocol will examine the impact of younger intergenerational volunteers providing the HOW RU? METHODS: In this randomized clinical trial, we will compare the following three arms: (1) the standard same-generation peer support HOW R U? intervention, (2) HOW R U? intervention delivered by intergenerational volunteers, and (3) a common wait-list control group. Outcome assessors will be blinded to the intervention. Trained volunteers will deliver 12 weekly telephone support calls. We will recruit participants ≥ 70 years of age with baseline loneliness (six-item De Jong loneliness score of 2 or greater) from two EDs. Research staff will assess SIL, depression, quality of life, functional status, generativity, and perceived benefit at baseline, at 12 weeks, and 24 weeks post-intervention. DISCUSSION: We hypothesize participants receiving the intergenerational intervention will show improved outcomes compared to the control group and peer support HOW R U? INTERVENTION: We also hypothesize that participants with higher perceptions of generativity will have greater reductions in SIL than their lower generativity counterparts. Aging is experienced diversely, and social interventions combatting associated SIL should reflect that diversity. As part of a program of research following the Obesity-Related Behavioral Intervention Trials (ORBIT) model, the findings of this RCT will be used to define which intervention characteristics are most effective in reducing SIL. TRIAL REGISTRATION: ClinicalTrials.gov NCT05998343 Protocol ID:21-0074E. Registered on 24 July 2023.

The clinical use of personal hearing amplifiers in facilitating accessible patient-provider communication: A scoping review.

BACKGROUND: Older adults with hearing loss struggle to communicate with care providers and experience higher mortality rates when hospitalized (Genther et al., 2015), even after controlling for age and comorbidities. Personal hearing amplifiers (PHAs), (e.g., Pocketalkers™), can improve communication with older patients. METHODS: We conducted a scoping review to identify research gaps and summarize findings on the clinical use of PHAs with patients with hearing loss. After refining search terms relating to hearing loss and PHAs, we searched MEDLINE, Embase, PsycINFO, Cochrane Library, CINAHL Complete, Web of Science Core Collection, ERIC (Proquest), PubMed, ClinicalTrials.gov, International Clinical Trials Registry Platform, and the International Standard Randomised Controlled Trial Number Registry. We identified articles published in English between 1980 and 2022 that reported empirical outcomes relating to PHA use in clinical settings. Two reviewers independently extracted data from articles. We then organized data into an evidence map, and a narrative review summarizing outcomes. RESULTS: From 4234 initially identified titles and abstracts, 12 met our criteria as full texts. These included three surveys on clinicians' awareness and use of PHAs, one evaluation of the acoustic output of a PHA, and eight interventions wherein PHAs were provided to patients with hearing loss. These papers used 10 different terms for PHAs and largely did not cite one another. Results showed high levels of satisfaction with PHAs, and consistently improved speech understanding. Despite this, care providers used devices inconsistently, with challenges around provider awareness, and device maintenance and location tracking. CONCLUSIONS: PHAs have a consistent positive effect on patients' ability to understand their care providers despite hearing loss. Barriers and facilitators to their use in clinical settings should be further explored.

Transitions of care for older adults discharged home from the emergency department: an inductive thematic content analysis of patient comments.

OBJECTIVE: Improving care transitions for older adults can reduce emergency department (ED) visits, adverse events, and empower community autonomy. We conducted an inductive qualitative content analysis to identify themes emerging from comments to better understand ED care transitions. METHODS: The LEARNING WISDOM prospective longitudinal observational cohort includes older adults (≥ 65 years) who experienced a care transition after an ED visit from both before and during COVID-19. Their comments on this transition were collected via phone interview and transcribed. We conducted an inductive qualitative content analysis with randomly selected comments until saturation. Themes that arose from comments were coded and organized into frequencies and proportions. We followed the Standards for Reporting Qualitative Research (SRQR). RESULTS: Comments from 690 patients (339 pre-COVID, 351 during COVID) composed of 351 women (50.9%) and 339 men (49.1%) were analyzed. Patients were satisfied with acute emergency care, and the proportion of patients with positive acute care experiences increased with the COVID-19 pandemic. Negative patient comments were most often related to communication between health providers across the care continuum and the professionalism of personnel in the ED. Comments concerning home care became more neutral with the COVID-19 pandemic. CONCLUSION: Patients were satisfied overall with acute care but reported gaps in professionalism and follow-up communication between providers. Comments may have changed in tone from positive to neutral regarding home care over the COVID-19 pandemic due to service slowdowns. Addressing these concerns may improve the quality of care transitions and provide future pandemic mitigation strategies.

Impact of a peer-support programme to improve loneliness and social isolation due to COVID-19: does adding a secure, user friendly video-conference solution work better than telephone support alone? Protocol for a three-arm randomised clinical trial.

INTRODUCTION: The COVID-19 pandemic has forced the implementation of physical distancing and self-isolation strategies worldwide. However, these measures have significant potential to increase social isolation and loneliness. Among older people, loneliness has increased from 40% to 70% during COVID-19. Previous research indicates loneliness is strongly associated with increased mortality. Thus, strategies to mitigate the unintended consequences of social isolation and loneliness are urgently needed. Following the Obesity-Related Behavioural Intervention Trials model for complex behavioural interventions, we describe a protocol for a three-arm randomised clinical trial to reduce social isolation and loneliness. METHODS AND ANALYSIS: A multicentre, outcome assessor blinded, three-arm randomised controlled trial comparing 12 weeks of: (1) the HOspitals WoRking in Unity ('HOW R U?') weekly volunteer-peer support telephone intervention; (2) 'HOW R U?' deliver using a video-conferencing solution and (3) a standard care group. The study will follow Consolidated Standard of Reporting Trials guidelines.We will recruit 24-26 volunteers who will receive a previously tested half day lay-training session that emphasises a strength-based approach and safety procedures. We will recruit 141 participants ≥70 years of age discharged from two participating emergency departments or referred from hospital family medicine, geriatric or geriatric psychiatry clinics. Eligible participants will have probable baseline loneliness (score ≥2 on the de Jong six-item loneliness scale). We will measure change in loneliness, social isolation (Lubben social network scale), mood (Geriatric Depression Score) and quality of life (EQ-5D-5L) at 12-14 weeks postintervention initiation and again at 24-26 weeks. ETHICS AND DISSEMINATION: Approval has been granted by the participating research ethics boards. Participants randomised to standard care will be offered their choice of telephone or video-conferencing interventions after 12 weeks. Results will be disseminated through journal publications, conference presentations, social media and through the International Federation of Emergency Medicine. TRIAL REGISTRATION NUMBER: NCT05228782.

Implementation of the Acute Care for Elders Strategy to Improve the Quality of Care Transitions in Quebec and Ontario: a Retrospective Multiple Case Study.

Background: In 2016, two Canadian hospitals participated in a quality improvement (QI) program, the International Acute Care for Elders (ACE) Collaborative, and sought to adapt and implement a transition coach intervention (TCI). Both hospitals were challenged to provide optimal continuity of care for an increasing number of older adults. The two hospitals received initial funding, coaching, educational materials, and tools to adapt the TCI to their local contexts, but the QI project teams achieved different results. We aimed to compare the implementation of the ACE TCI in these two Canadian hospitals to identify the factors influencing the adaptation of the intervention to the local contexts and to understand their different results. Methods: We conducted a retrospective multiple case study, including documentary analysis, 21 semi-structured individual interviews, and two focus groups. We performed thematic analysis using a hybrid inductive-deductive approach. Results: Both hospitals met initial organizational goals to varying degrees. Our qualitative analysis highlighted certain factors that were critical to the effective implementation and achievement of the QI project goals: the magnitude of changes and adaptations to the initial intervention; the organizational approaches to the QI project implementation, management, and monitoring; the organizational context; the change management strategies; the ongoing health system reform and organizational restructuring. Our study also identified other key factors for successful care transition QI projects: minimal adaptation to the original evidence-based intervention; use of a collaborative, bottom-up approach; use of a theoretical model to support sustainability; support from clinical and organizational leadership; a strong organizational culture for QI; access to timely quality measures; financial support; use of a knowledge management platform; and involvement of an integrated research team and expert guidance. Conclusion: Many of the lessons learned and strategies identified from our analysis will help clinicians, managers, and policymakers better address the issues and challenges of adapting evidence-based innovations in care transitions for older adults to local contexts.

Commentary: Minding the Gap - Why Wage Parity Is Crucial for the Care of Older Canadians.

Zagrodney and colleagues (2023) have highlighted the pay differences that exist between those working in the home and community care (HCC) sector and other healthcare sectors. The authors argue that achieving wage parity could significantly mitigate the current HCC human resource crisis, support the overall sustainability of Ontario's healthcare system and improve patient outcomes. We build on their argument by highlighting issues that have contributed to wage disparities within healthcare systems and discuss how addressing them can create more equitable systems for both those receiving and those providing care. We further note how other healthcare systems that have wage parity have demonstrated that it is not a "nice to have" but an essential element of establishing a sustainable health human resources strategy. Finally, the new 10-year bilateral healthcare funding agreements that the federal, provincial and territorial governments are currently announcing will not only provide significant new funding but also an opportunity to decisively address the long-standing issue of wage parity in Canada, once and for all.

Rates of Hospital-Based Care among Older Adults in the Community and Residential Care Facilities: A Repeated Cross-Sectional Study.

OBJECTIVE: We examine annual rates of emergency department (ED) visits, hospital admissions, and alternate levels of care (ALC) days (ie, the number of days that an older adult remained in hospital when they could not be safely discharged to an appropriate setting in their community) among older adults. DESIGN: Repeated cross-sectional study. SETTING AND PARTICIPANTS: Linked, individual-level health system administrative data on community-dwelling persons, home care recipients, residents of assisted living facilities, and residents of nursing homes aged 65 years and older in Ontario, Canada, from January 1, 2013, to December 31, 2019. METHODS: We calculated rates of ED visits, hospital admissions, and ALC days per 1000 individuals per older adult population per year. We used a generalized linear model with a gaussian distribution, log link, and year fixed effects to obtain rate ratios. RESULTS: There were 1,655,656 older adults in the community, 237,574 home care recipients, 42,600 older adults in assisted living facilities, and 94,055 older adults in nursing homes in 2013; there were 2,129,690 older adults in the community, 281,028 home care recipients, 56,975 older adults in assisted living facilities, and 95,925 older adults in nursing homes in 2019. Residents of assisted living facilities had the highest rates of ED visits (1260.692019 vs 1174.912013), hospital admissions (482.632019 vs 480.192013), and ALC days (1905.572019 vs 1443.032013) per 1000 individuals. Residents of assisted living facilities also had significantly higher rates of ED visits [rate ratio (RR) 3.30, 95% CI 3.20, 3.41), hospital admissions (RR 6.24, 95% CI 6.01, 6.47), and ALC days (RR 25.68, 95% CI 23.27, 28.35) relative to community-dwelling older adults. CONCLUSIONS AND IMPLICATIONS: The disproportionate use of ED visits, hospital admissions, and ALC days among residents of assisted living facilities may be attributed to the characteristics of the population and fragmented licensing and regulation of the sector, including variable models of care. The implementation of interdisciplinary, after-hours, team-based approaches to home and primary care in assisted living facilities may reduce the potentially avoidable use of ED visits, hospital admissions, and ALC days among this population and optimize resource allocation in health care systems.

Clinical Comorbidities and Transitions Between Care Settings Among Residents of Assisted Living Facilities: A Repeated Cross-Sectional Study.

OBJECTIVE: We investigate the changes in the sociodemographic characteristics, clinical comorbidities, and transitions between care settings among residents of assisted living facilities. DESIGN: Repeated cross-sectional study. SETTING AND PARTICIPANTS: Linked, individual-level health system administrative data on residents of assisted living facilities in Ontario, Canada, from January 1, 2013, to December 31, 2019. METHODS: Counts and proportions were calculated to describe the sociodemographic characteristics and clinical comorbidities. Relative changes and trend tests were calculated to quantify the longitudinal changes in the characteristics of residents of assisted living facilities between 2013 and 2019. A Sankey plot was graphed to display transitions between different care settings (ie, hospital admission, nursing home admission, died, or remained in the assisted living facility) each year from 2013 to 2019. RESULTS: There was a 34% relative increase in the resident population size of assisted living facilities (56,9752019 vs 42,6002013). These older adults had a mean age of 87 years, and women accounted for nearly two-thirds of the population across all years. The 5 clinical comorbidities that had the highest relative increases were renal disease (24.3%), other mental health conditions (16.8%), cardiac arrhythmias (9.6%), diabetes (8.5%), and cancer (6.9%). Nearly 20% of the original cohort from 2013 remained in an assisted living facility at the end of 2019, and approximately 10% of that cohort transitioned to a nursing home in any year from 2013 to 2019. CONCLUSIONS AND IMPLICATIONS: Residents of assisted living facilities are an important older adult population that has progressively increased in clinical complexity within less than a decade. Clinicians and policy makers should advocate for the implementation of on-site medical care that is aligned with the needs of these older adults.

Exacerbated inequalities: A scoping review of the experiences of older persons during conflict situations.

BACKGROUND: We conducted the first known comprehensive literature review to (1) identify, categorize, and summarize the existing knowledge about the experiences of older persons and their caregivers during conflict situations; (2) identify the support needs of older persons and their caregivers, and; (3) identify gaps in the literature and understanding that may inform future research. METHODS: A scoping review methodology of academic peer-reviewed and gray English language literature was employed using six academic literature databases and one gray literature database. We further performed comprehensive searches of relevant search engines and organization websites and bibliographic hand searches to identify additional academic and gray literature. Two authors screened for eligibility of identified studies and documents. One reviewer extracted data regarding authors, article type, geographic origin, key participant characteristics, aims, study design and data collection method, results, conclusions and limitations. Data were analyzed thematically. RESULTS: 83 documents met this review's inclusion criteria, including 21 academic documents and 62 from the gray literature. Thematic analysis revealed that conflict situations exacerbate existing inequalities experienced by older persons. Within this overarching theme were three interconnected sub-themes: (1) Older adults are particularly vulnerable during conflict situations; (2) Older persons are inadequately supported in conflict situations; (3) In the face of great challenges, many older adults still manage to endure through conflict situations. We identified 15 recommendations from the reviewed documents to better support older adults in conflict situations. CONCLUSIONS: Existing inequalities, such as ageism and ableism, targeted discrimination, and poor health outcomes, become exacerbated during conflict situations, resulting in older persons being less able to flee and meet their daily needs with sufficient access to necessities and healthcare. Little is known of the experiences and needs of family caregivers during conflict situations. We identified several opportunities to improve the experience and support of older persons in conflict situations.

Cost-utility analysis of a multispecialty interprofessional team dementia care model in Ontario, Canada.

OBJECTIVES: To examine the cost-effectiveness of Multi-specialty INterprofessional Team (MINT) Memory Clinic care in comparison to the provision of usual care. DESIGN: Using a Markov-based state transition model, we performed a cost-utility (costs and quality-adjusted life years, QALY) analysis of MINT Memory Clinic care and usual care not involving MINT Memory Clinics. SETTING: A primary care-based Memory Clinic in Ontario, Canada. PARTICIPANTS: The analysis included data from a sample of 229 patients assessed in the MINT Memory Clinic between January 2019 and January 2021. PRIMARY OUTCOME MEASURES: Effectiveness as measured in QALY, costs (in Canadian dollars) and the incremental cost-effectiveness ratio calculated as the incremental cost per QALY gained between MINT Memory Clinics versus usual care. RESULTS: MINT Memory Clinics were found to be less expensive ($C51 496 (95% Crl $C4806 to $C119 367) while slightly improving quality of life (+0.43 (95 Crl 0.01 to 1.24) QALY) compared with usual care. The probabilistic analysis showed that MINT Memory Clinics were the superior treatment compared with usual care 98% of the time. Variation in age was found to have the greatest impact on cost-effectiveness as patients may benefit from the MINT Memory Clinics more if they receive care beginning at a younger age. CONCLUSION: Multispecialty interprofessional memory clinic care is less costly and more effective compared with usual care and early access to care significantly reduces care costs over time. The results of this economic evaluation can inform decision-making and improvements to health system design, resource allocation and care experience for persons living with dementia. Specifically, widespread scaling of MINT Memory Clinics into existing primary care systems may assist with improving quality and access to memory care services while decreasing the growing economic and social burden of dementia.

Agreement and prognostic accuracy of three ED vulnerability screeners: findings from a prospective multi-site cohort study.

OBJECTIVES: To evaluate the agreement between three emergency department (ED) vulnerability screeners, including the InterRAI ED Screener, ER2, and PRISMA-7. Our secondary objective was to evaluate the discriminative accuracy of screeners in predicting discharge home and extended ED lengths-of-stay (> 24 h). METHODS: We conducted a nested sub-group study using data from a prospective multi-site cohort study evaluating frailty in older ED patients presenting to four Quebec hospitals. Research nurses assessed patients consecutively with the three screeners. We employed Cohen's Kappa to determine agreement, with high-risk cut-offs of three and four for the PRISMA-7, six for the ER2, and five for the interRAI ED Screener. We used logistic regression to evaluate the discriminative accuracy of instruments, testing them in their dichotomous, full, and adjusted forms (adjusting for age, sex, and hospital academic status). RESULTS: We evaluated 1855 older ED patients across the four hospital sites. The mean age of our sample was 84 years. Agreement between the interRAI ED Screener and the ER2 was fair (K = 0.37; 95% CI 0.33-0.40); agreement between the PRISMA-7 and ER2 was also fair (K = 0.39; 95% CI = 0.36-0.43). Agreement between interRAI ED Screener and PRISMA-7 was poor (K = 0.19; 95% CI 0.16-0.22). Using a cut-off of four for PRISMA-7 improved agreement with the ER2 (K = 0.55; 95% CI 0.51-0.59) and the ED Screener (K = 0.32; 95% CI 0.2-0.36). When predicting discharge home, the concordance statistics among models were similar in their dichotomous (c = 0.57-0.61), full (c = 0.61-0.64), and adjusted forms (c = 0.63-0.65), and poor for all models when predicting extended length-of-stay. CONCLUSION: ED vulnerability scores from the three instruments had a fair agreement and were associated with important patient outcomes. The interRAI ED Screener best identifies older ED patients at greatest risk, while the PRISMA-7 and ER2 are more sensitive instruments.

RéSUMé: OBJECTIFS: Évaluer la concordance entre trois outils de dépistage de la vulnérabilité des urgences, notamment l'InterRAI ED Screener, ER2 et PRISMA-7. Notre objectif secondaire était d'évaluer la précision discriminative des agents de dépistage dans la prédiction de la sortie à domicile et des durées de séjour prolongées à l'urgence (> 24 heures). MéTHODES: Nous avons mené une étude de sous-groupe emboîtée à partir des données d'une étude de cohorte prospective multi-sites évaluant la fragilité chez les patients plus âgés se présentant aux urgences de quatre hôpitaux québécois. Les infirmières de recherche ont évalué les patients consécutivement avec les trois dépisteurs. Nous avons utilisé le Kappa de Cohen pour déterminer la concordance, avec des seuils de risque élevé de trois et quatre pour le PRISMA-7, de six pour l'ER2 et de cinq pour l' interRAI ED Screener. Nous avons utilisé la régression logistique pour évaluer la précision discriminante des instruments, en les testant dans leur forme dichotomique, complète et ajustée (en ajustant pour l'âge, le sexe et le statut académique). RéSULTATS: Nous avons évalué 1 855 patients âgés aux urgences dans les quatre sites hospitaliers. L'âge moyen de notre échantillon était de 84 ans. La concordance entre l'interRAI ED Screener et l'ER2 était équitable (K =0,37 ; IC à 95 % =0,33-0,40) ; la concordance entre le PRISMA-7 et l'ER2 était également équitable (K = 0,39 ; IC à 95 % =0,36-0,43). La concordance entre interRAI ED Screener et PRISMA-7 était faible (K = 0,19 ; IC à 95 % = 0,16-0,22). L'utilisation d'un seuil de quatre pour PRISMA-7 a amélioré la concordance avec l'ER2 (K =0,55 ; IC à 95% =0,51-0,59) et l'ED Screener (K =0,32 ; IC à 95 % =0,2-0,36). En ce qui concerne la prédiction du retour à domicile, les statistiques de concordance entre les modèles étaient similaires dans leurs formes dichotomiques (c = 0,57-0,61), complètes (c =0,61-0,64) et ajustées (c =0,63-0,65), et faibles pour tous les modèles en ce qui concerne la prédiction de la durée de séjour prolongée. CONCLUSION: Les scores de vulnérabilité aux urgences des trois instruments concordaient assez bien et étaient associés à des résultats importants pour les patients.

Development and validation of a hospital frailty risk measure using Canadian clinical administrative data.

BACKGROUND: Accessible measures specific to the Canadian context are needed to support health system planning for older adults living with frailty. We sought to develop and validate the Canadian Institute for Health Information (CIHI) Hospital Frailty Risk Measure (HFRM). METHODS: Using CIHI administrative data, we conducted a retrospective cohort study involving patients aged 65 years and older who were discharged from Canadian hospitals from Apr. 1, 2018, to Mar. 31, 2019. We used a 2-phase approach to develop and validate the CIHI HFRM. The first phase, construction of the measure, was based on the deficit accumulation approach (identification of age-related conditions using a 2-year look-back). The second phase involved refinement into 3 formats (continuous risk score, 8 risk groups and binary risk measure), with assessment of their predictive validity for several frailty-related adverse outcomes using data to 2019/20. We assessed convergent validity with the United Kingdom Hospital Frailty Risk Score. RESULTS: The cohort consisted of 788 701 patients. The CIHI HFRM included 36 deficit categories and 595 diagnosis codes that cover morbidity, function, sensory loss, cognition and mood. The median continuous risk score was 0.111 (interquartile range 0.056-0.194, equivalent to 2-7 deficits); 35.1% (n = 277 000) of the cohort were found at risk of frailty (≥ 6 deficits). The CIHI HFRM showed satisfactory predictive validity and reasonable goodness-of-fit. For the continuous risk score format (unit = 0.1), the hazard ratio (HR) for 1-year risk of death was 1.39 (95% confidence interval [CI] 1.38-1.41), with a C-statistic of 0.717 (95% CI 0.715-0.720); the odds ratio for high users of hospital beds was 1.85 (95% CI 1.82-1.88), with a C-statistic of 0.709 (95% CI 0.704-0.714), and the HR of 90-day admission to long-term care was 1.91 (95% CI 1.88-1.93), with a C-statistic of 0.810 (95% CI 0.808-0.813). Compared with the continuous risk score, using a format of 8 risk groups had similar discriminatory ability and the binary risk measure had slightly weaker performance. INTERPRETATION: The CIHI HFRM is a valid tool showing good discriminatory power for several adverse outcomes. The tool can be used by decision-makers and researchers by providing information on hospital-level prevalence of frailty to support system-level capacity planning for Canada's aging population.

Characteristics and practice patterns of family physicians who provide home visits in Ontario, Canada: a cross-sectional study.

BACKGROUND: Physician home visits are essential for populations who cannot easily access office-based primary care. The objective of this study was to describe the characteristics, practice patterns and physician-level patient characteristics of Ontario physicians who provide home visits. METHODS: This was a retrospective cross-sectional study, based on health administrative data, of Ontario physicians who provided home visits and their patients, between Jan. 1, 2019, and Dec. 31, 2019. We selected family physicians who had at least 1 home visit in 2019. Physician demographic characteristics, practice patterns and aggregated patient characteristics were compared between high-volume home visit physicians (the top 5%) and low-volume home visit physicians (bottom 95%). RESULTS: A total of 6572 family physicians had at least 1 home visit in 2019. The top 5% of home visit physicians (n = 330) performed 58.6% of all home visits (n = 227 321 out of 387 139). Compared with low-volume home visit physicians (n = 6242), the top 5% were more likely to be male and practise in large urban areas, and rarely saw patients who were enrolled to them (median 4% v. 87.5%, standardized mean difference 1.12). High-volume physicians' home visit patients were younger, had greater levels of health care resource utilization, resided in lower-income and large urban neighbourhoods, and were less likely to have a medical home. INTERPRETATION: A small subset of home visit physicians provided a large proportion of home visits in Ontario. These home visits may be addressing a gap in access to primary care for certain patients, but could be contributing to lower continuity of care.

Report on fraying resilience among the Ontario Registered Practical Nurse Workforce in long-term care homes during COVID-19.

AIM: Registered Practical Nurses (RPNs) are frontline healthcare providers in Ontario long-term care (LTC) homes. Throughout COVID-19, RPNs working in LTC homes experienced prolonged lockdowns, challenging working conditions, and inadequate resource allocation. This study aimed to describe the personal and professional resilience of RPNs working in LTC during the COVID-19 pandemic. DESIGN: An open cross-sectional online survey containing the Connor-Davidson Resilience Scale, Resilience at Work Scale®, and Resilience at Work Team Scale®. METHODS: The survey was distributed by the RPN Association of Ontario (WeRPN) to approximately 5000 registered members working in Ontario LTC homes. RESULTS: A total of 434 respondents participated in the survey (completion rate = 88.0%). Study respondents scored low on measures of resilience and reported extreme levels of job (54.5%) and personal (37.8%) stress. Resources to support self-care and work-life balance, build capacity for team-based care practice(s) are needed.

Examining the utility and accuracy of the interRAI Emergency Department Screener in identifying high-risk older emergency department patients: A Canadian multiprovince prospective cohort study.

Objectives: We set out to determine the accuracy of the interRAI Emergency Department (ED) Screener in predicting the need for detailed geriatric assessment in the ED. Our secondary objective was to determine the discriminative ability of the interRAI ED Screener for predicting the odds of discharge home and extended ED length of stay (>24 hours). Methods: We conducted a multiprovince prospective cohort study in Canada. The need for detailed geriatric assessment was determined using the interRAI ED Screener and the interRAI ED Contact Assessment as the reference standard. A score of ≥5 was used to classify high-risk patients. Assessments were conducted by emergency and research nurses. We calculated the sensitivity, positive predictive value, and false discovery rate of the interRAI ED Screener. We employed logistic regression to predict ED outcomes while adjusting for age, sex, academic status, and the province of care. Results: A total of 5629 older ED patients across 11 ED sites were evaluated using the interRAI ED Screener and 1061 were evaluated with the interRAI ED Contact Assessment. Approximately one-third of patients were discharged home or experienced an extended ED length of stay. The interRAI ED Screener had a sensitivity of 93%, a positive predictive value of 82%, and a false discovery rate of 18%. The interRAI ED Screener predicted discharge home and extended ED length of stay with fair accuracy. Conclusion: The interRAI ED Screener is able to accurately and rapidly identify individuals with medical complexity. The interRAI ED Screener predicts patient-important health outcomes in older ED patients, highlighting its value for vulnerability screening.

Identifying the areas of low self-reported confidence of internal medicine residents in geriatrics: a descriptive study of findings from a structured geriatrics skills assessment survey.

BACKGROUND: Currently, no standardized methods exist to assess the geriatric skills and training needs of internal medicine trainees to enable them to become confident in caring for older patients. This study aimed to describe the self-reported confidence and training requirements in core geriatric skills amongst internal medicine residents in Toronto, Ontario using a standardized assessment tool. METHODS: This study used a novel self-rating instrument, known as the Geriatric Skills Assessment Tool (GSAT), among incoming and current internal medicine residents at the University of Toronto, to describe self-reported confidence in performing, teaching and interest in further training with regard to 15 core geriatric skills previously identified by the American Board of Internal Medicine. RESULTS: 190 (75.1%) out of 253 eligible incoming (Year 0) and current internal medicine residents (Years 1-3) completed the GSAT. Year 1-3 internal medicine residents who had completed a geriatric rotation reported being significantly more confident in performing 13/15 (P < 0.001 to P = 0.04) and in teaching 9/15 GSAT skills (P < 0.001 to P = 0.04). Overall, the residents surveyed identified their highest confidence in administering the Mini-Mental Status Examination and lowest confidence in assessing fall risk using a gait and balance tool, and in evaluating and managing chronic pain. CONCLUSION: A structured needs assessment like the GSAT can be valuable in identifying the geriatric training needs of internal medicine trainees based on their reported levels of self-confidence. Residents in internal medicine could further benefit from completing a mandatory geriatric rotation early in their training, since this may improve their overall confidence in providing care for the mostly older patients they will work with during their residency and beyond.