Care Coordination Processes in Transitional Care for Patients With Heart Failure: An Integrative Review Through a Social Network Lens.

BACKGROUND: Transitional care components are well studied, but their coordination has not been systematically reviewed. Viewing transitional care through a social network framework can focus attention on processes leading to information and relationship transferal to ensure continuity and may lead to new strategies to improve transitional care. OBJECTIVE: The aim of this study was to examine care coordination processes in transitional care interventions for older adults with heart failure by integrating a social network analysis approach. METHODS: PubMed, Scopus, and CINAHL were searched to capture transitional care interventions ( a ) involving care coordination for older adults with heart failure transitioning from hospital to home and ( b ) published in the United States from 2010 to 2020. Study characteristics, intervention characteristics, and care coordination processes (ie, participants, interactions among participants, and their characteristics) were extracted. RESULTS: In 17 studies reviewed, the number of individual roles involved in care coordination varied from 3 to 32. Nurses and pharmacists were the most common interventionists. Six studies involved informal caregivers. In-person interactions were most common among individuals within settings; interactions across settings were typically assisted by technology. Despite high variability among the individuals and interactions involved, a common triadic process was found through which interventionists, patients, and primary care providers or outpatient cardiologists aimed to facilitate the transfer of information and care relationships from hospital to community. CONCLUSIONS: High variability in transitional care is likely because the processes are highly relational. Using a network analysis may help uncover the relational structures and processes underlying transitional care to inform intervention development.

Resilience in relation to older adults with multimorbidity: A scoping review.

The purpose of this scoping review is to identify conceptual and theoretical resilience models, types of resilience measures, and outcomes regarding resilience in relation to older adults with multimorbidity. PubMed, Embase, CINAHL, and PsycINFO were searched, and we identified 14 studies to July 2021. Most models operationalize resilience as dependent on the social and environmental context of older adults. Three of the five resilience measures in the included studies are used to evaluate general resilience. They are primarily psychological or psychosocial in nature, and measuring physical resilience therefore may help to better understand individuals' ability to cope with the physical challenges associated with various chronic diseases. Quality of life and physical activity were common outcomes in studies of resilience. Findings highlight the need for studies that incorporate physiological measures or physical properties of resilience and longitudinal studies that capture the dynamic process of resilience in older adults with multimorbidity.

A mixed methods study on the manifestations of behavioural symptoms of dementia among veterans with and without posttraumatic stress disorder.

AIMS: To explore how behavioural symptoms of dementia are manifested among veterans in residential long-term care settings, in the context of personal, interpersonal/social and environmental triggers and how the manifestations differ between veterans with and without posttraumatic stress disorder. DESIGN: Secondary analysis using a mixed methods approach. METHODS: We analysed text data from a stratified random sample of 66 cases derived from the programme evaluation dataset of the Staff Training in Assisted Living Residences-Veterans Health Administration (STAR-VA) intervention from 2013 to 2016, using framework analysis. The detailed behavioural assessment descriptions in this dataset are consistent with contemporary non-pharmacologic symptom management. Qualitative categories were converted to quantitative variables for two group comparisons. RESULTS: Four patterns emerged linking specific types of triggers and behavioural symptoms: (1) unmet physical needs or emotional distress triggers non-aggressive behaviours; (2) unsolicited direct care approach triggers care refusal, resistance or combativeness; (3) interpersonal interactions interfering with self-direction trigger aggressive behaviours; and (4) uncontrolled stimulation from environments trigger non-aggressive behaviours. The organisational culture of care influenced how staff conceptualised behavioural symptoms. Veterans with co-existing posttraumatic stress disorder and dementia tended to exhibit rejection of care with aggression compared to those with dementia alone. CONCLUSION: Contextualised accounts of behavioural symptoms of dementia revealed symptom heterogeneity, with different clusters of multi-level triggers arising from specific personal, interpersonal and environmental circumstances. Distinct patterns of symptom manifestations between veterans with and without posttraumatic stress disorder suggest a tailored approach is required to meet each veteran's unique biopsychosocial needs. IMPACT: Classifying behavioural symptoms with their triggers rather than solely by behaviours provides important new information for developing person-centred, non-pharmacological interventions to improve outcomes for veterans with dementia. Multi-level interventions should be considered to meet veteran's needs that account for their earlier life history and current life circumstances.

Predictors and patterns of home health care utilization among older adults in Shanghai, China.

The objective of this study is to explore the predictors and patterns of home health care among older adults in Shanghai, China. A cross-sectional survey was conducted in the Yangpu and Pudong Districts of Shanghai from August to September of 2015. A total of 982 eligible seniors were chosen for interviews based on a stratified random sample. Four home health care patterns were identified through an exploratory factor analysis: daily living care, skilled nursing care, chronic care, and episodic care. Findings suggest that need factors have more influence on home health care use than predisposing factors.

Supervisory relationships in long-term care facilities: A comparative case study of two facilities using complexity science.

AIMS: This study aims to understand the factors that contribute to supervisory nurse performance in long-term care facilities. BACKGROUND: Long-term care facilities have been faced with staffing challenges and increasing resident care needs, resulting in suboptimal quality of care. Nursing leadership has been identified as a key factor in the provision of high-quality care. METHODS: The comparative case study employed a complexity science framework to compare two facilities. The facilities were chosen based on the level of perceived supervisory support staff received from their supervisors, and 10 participants were recruited from each facility at various levels of management and staff (n = 20). Data were collected in 2015 using semi-structured interviews. FINDINGS: The quality and quantity of supervisory relationships was central to shaping the effectiveness of the supervision. Effective supervisory support was characterized by frequent and high-quality supervisor-staff interactions. Effective nurse supervisors acknowledged self-organisation as beneficial, and worked in environments that encouraged fluidity of roles. CONCLUSIONS: The findings suggest that effective nurse supervisors and supervisory support fosters improved work environments and the staff's ability to respond to residents' needs in a timely, effective and compassionate manner. IMPLICATIONS FOR NURSING MANAGEMENT: Nurse managers who provide effective supervisory support can improve the quality of care provided to their residents.

Resident challenges with daily life in Chinese long-term care facilities: A qualitative pilot study.

As traditional family-based care in China declines, the demand for residential care increases. Knowledge of residents' experiences with long-term care (LTC) facilities is essential to improving quality of care. This pilot study aimed to describe residents' experiences in LTC facilities, particularly as it related to physical function. Semi-structured open-ended interviews were conducted in two facilities with residents stratified by three functional levels (n = 5). Directed content analysis was guided by the Adaptive Leadership Framework. A two-cycle coding approach was used with a first-cycle descriptive coding and second-cycle dramaturgical coding. Interviews provided examples of challenges faced by residents in meeting their daily care needs. Five themes emerged: staff care, care from family members, physical environment, other residents in the facility, and personal strategies. Findings demonstrate the significance of organizational context for care quality and reveal foci for future research.

Adaptive leadership and person-centered care: a new approach to solving problems.

Successfully transitioning to person-centered care in nursing homes requires a new approach to solving care issues. The adaptive leadership framework suggests that expert providers must support frontline caregivers in their efforts to develop high-quality, person-centered solutions.

Licensed practical nurse scope of practice and quality of nursing home care.

BACKGROUND: Although higher levels of registered nurse (RN) staffing in nursing homes are related to better care quality, licensed practical nurses (LPNs) provide most licensed-nursing care; prior research is mixed regarding how this influences quality. The nature of LPN practice, and RN direction of that practice, follows in part from state nurse practice acts (NPAs). OBJECTIVE: Among the 50 states and the District of Columbia, the aims of this study were to describe regulatory differences in how LPNs contribute to nursing assessment, care planning, delegation and supervision, and RN practice in these domains and to explore how these regulatory differences relate to quality of care in nursing homes. METHODS: The study design was a sequential explanatory mixed-methods design of NPAs and Centers for Medicare and Medicaid quality measures of long-stay nursing home residents. In the qualitative strand, 51 NPAs and related administrative code were analyzed to classify guidance on RN and LPN practice; then, the coded data were transformed to quantitative indicators of specificity regarding LPN and RN scope of practice. In the quantitative strand, state NPA data were linked to facility-level Centers for Medicare and Medicaid staffing and quality measures (N = 12,698 facilities) for cross-sectional, quantitative analyses. RESULTS: States varied considerably in how NPAs guided LPN and RN scope of practice. NPA differences were related to quality indicators of resident pain, catheter use, weight loss, and restraints, even when accounting for nursing home staff mix. DISCUSSION: Care quality was better in states where the NPA clearly described LPN scope, but only when there was also greater RN availability (p < .05). Classifying scope of nursing practice regulations moves beyond traditional staffing measures to inform understanding of the effects of the RN-to-LPN staffing ratio on quality of care in nursing homes.

Pain medication management in nursing homes and nursing scope of practice.

Inadequate pain medication management is pervasive in nursing homes (NHs). Licensed practical nurses (LPNs) deliver the majority of licensed nursing care, but LPNs are neither trained nor licensed to provide comprehensive pain assessment and medication management. In this study, we describe how pain medication management occurs in NHs by exploring LPNs' management approaches, while considering scope-of-practice differences between RNs and LPNs. Using comparative case studies of 10 NHs in North Carolina and Minnesota, we found practice variations in pain detection, assessment, and medication administration. Differences clustered in three areas: (a) the extent to which RNs and LPNs connected formally and informally to provide pain care, (b) the degree to which RNs and LPNs were considered interchangeable with one another, and (c) the RN-to-LPN ratio. Results highlight quality issues and suggest ways to improve pain medication management in NHs.

COPD-Related Fatigue: A Scoping Review.

Millions of people worldwide have chronic obstructive pulmonary disease (COPD), and one of the most common and troublesome symptoms that must be managed is fatigue. While there are existing interventions to address COPD-related fatigue, not all patients experience benefit. A better understanding of the factors associated with COPD-fatigue could elucidate new approaches to address COPD-related fatigue, thereby offering relief to a greater number of patients. The purpose of this review was to identify the physiologic, psychologic, and situational factors associated with COPD-related fatigue. A total of four databases, PubMed, CINAHL, Scopus, and Google Scholar, were searched. Those that were peer reviewed, in English, and published between 2000 and 2021, were included in the review. A total of 25 articles were included in this scoping review. The following factors were related to fatigue in COPD: dyspnea, pain, anxiety, depression, and sleep. Fatigue is a debilitating symptom with factors influential to the symptom and outcomes. Research is indicated to explore targeted and personalized interventions addressing the factors related to fatigue to mitigate this widespread symptom.

Factors Related to Fatigue and Physical Function in COPD: A Secondary Analysis Using National Survey Data.

Fatigue in chronic obstructive pulmonary disease (COPD) is debilitating and associated with considerable morbidity. The aim of this study is to present a model based on the Theory of Unpleasant Symptoms of physiologic, psychologic, and situational factors with COPD-related fatigue and the relationship with physical functioning. This study used data collected from Wave 2 (2010-2011) of the National Social, Health, and Aging Project (NSHAP). A total of 518 adults with self-reported COPD were included in this study. Path analysis was used for hypothesis testing. Depression was the only psychologic factor found to have a direct relation to both fatigue (ß = 0.158, p < .001) and physical function (ß = -0.131, p = .001). Factors related to physical function included fatigue, depression, sleep, loneliness, and pain. Additionally, fatigue was indirectly associated with physical function via depression (ß = -0.064, p = .012). These findings suggest avenues for future research on predictors of COPD-related fatigue in relation to physical functioning.

Jurisdiction over nursing care systems in nursing homes: latent class analysis.

BACKGROUND: In the context of declining registered nurse (RN) staffing levels in nursing homes, professional nursing jurisdiction over nursing care systems may erode. OBJECTIVE: The aim of this study was to develop a typology of professional nursing jurisdiction in nursing homes in relation to characteristics of RN staffing, drawing upon Abbott's tasks and jurisdictions framework. METHODS: The study was a cross-sectional, observational study using the 2004 National Nursing Home Survey (n = 1,120 nursing homes). Latent class analysis was used to test whether RN staffing indicators differentiated facilities in a typology of RN jurisdiction and compared classes on key organizational environment characteristics. Multiple logistic regression analysis related the emergent classes to presence or absence of specialty care programs in eight clinical areas. RESULTS: Three classes of capacity for jurisdiction were identified, including low capacity (41% of homes) with low probabilities of having any indicators of RN jurisdiction, mixed capacity (26% of homes) with moderate to high probabilities of having higher RN education and staffing levels, and high capacity (32% of homes) with moderate to high probabilities of having almost all indicators of RN jurisdiction. High-capacity homes were more likely to have specialty care programs relative to low-capacity homes; such homes were less likely to be chain-owned and more likely to be larger, provide higher technical levels of patient care, have unionized nursing assistants, have a lower ratio of licensed practical nurses to RNs, and have an administrator with higher education level. DISCUSSION: Findings provide preliminary support for the theoretical framework as a starting point to move beyond extensive reliance on staffing levels and mix as indicators of quality. Furthermore, findings indicate the importance of RN specialty certification.

Care rejection and aggression among veterans with dementia with and without posttraumatic stress disorder: A multi-group analysis.

BACKGROUND: In residential long-term care, military service veterans with co-occurring posttraumatic stress disorder (PTSD) and dementia encounter a range of physical and social stimuli that may serve as triggers of trauma-related distress that manifests as care rejection or aggression. Yet, PTSD rarely has been examined in research to understand behaviors of care rejection and aggression in veterans with dementia. OBJECTIVES: Guided by the need-driven dementia-compromised behavior model, we examined the moderation effect of PTSD on pathways from background factors and interpersonal triggers to rejection of care and aggression among veterans with dementia with and without co-occurring PTSD. DESIGN: Secondary data analysis of the Staff Training in Assisted Living Residences-Veterans Health Administration (STAR-VA) intervention evaluation by the U.S. Veterans Health Administration healthcare system. SETTING: 76 Veterans Health Administration-operated nursing homes. PARTICIPANTS: 315 veterans with dementia who participated in STAR-VA. METHODS: We converted text data on the occurrence of care rejection and aggression to binary variables, combined them with data on sociodemographic and PTSD status obtained using medical chart review, and measured anxiety, cognition, depression, and function using validated instruments. A multi-group structural equation modeling analysis was then conducted to test the moderating effect of PTSD on rejection of care and aggression. RESULTS: Although multi-group structural equation modeling did not support the hypothesis of overall moderation by PTSD, distinct patterns between the two groups were observed with respect to how background factors and interpersonal triggers related to care rejection and aggression. The magnitude of the direct effects of interpersonal triggers on rejection of care was greater in veterans with PTSD (ß = 0.42, p = .014 compared to those without ß = 0.29, p = .008). Depression had a statistically significant indirect effect on rejection of care via interpersonal triggers only in veterans with PTSD (ß = 0.09, p = .009). Functional status had a statistically significant direct effect on aggression only in the PTSD group (ß = 0.28, p = .044). CONCLUSIONS: Our study identified similar and distinct patterns of relationships among background factors, interpersonal triggers, and rejection of care and aggression between veterans with dementia with and without PTSD. The indirect effect of depression on care rejection via interpersonal triggers has implications for developing targeted interventions that focus on interpersonal triggers for veterans with dementia with PTSD who have greater depressive symptoms. This study underscores the importance of an enhanced focus on trauma-informed care for veterans with dementia and PTSD.

Using Technology to Measure Older Adults' Social Networks for Health and Well-Being: A Scoping Review.

BACKGROUND AND OBJECTIVES: Social networks affect the health and well-being of older adults. Advancements in technology (e.g., digital devices and mHealth) enrich our ability to collect social networks and health data. The purpose of this scoping review was to identify and map the use of technology in measuring older adults' social networks for health and social care. RESEARCH DESIGN AND METHODS: The Joanna Briggs Institute methodology was followed. PubMed (MEDLINE), Sociological Abstracts, SocINDEX, CINAHL, and Web of Science were searched for relevant articles. Conference abstracts and proceedings were searched via Conference Papers Index, the American Sociological Society, and The Gerontological Society of America. Studies published in English from January 2004 to March 2020 that aimed to improve health or social care for older adults and used technology to measure social networks were included. Data were extracted by 2 independent reviewers using an a priori extraction tool. RESULTS: The majority of the 18 reviewed studies were pilot or simulation research conducted in Europe that focused on older adults living in the community. The various types of technologies used can be categorized as environment-based, person-based, and data-based. DISCUSSION AND IMPLICATIONS: Technology facilitates objective and longitudinal data collection on the social interactions and activities of older adults. The use of technology to measure older adults' social networks, however, is primarily in an exploratory phase. Multidisciplinary collaborations are needed to overcome operational, analytical, and implementation challenges. Future studies should leverage technologies for addressing social isolation and care for older adults, especially during the coronavirus disease 2019 pandemic.

Relational processes in heart failure care transitions: A data-driven case report.

BACKGROUND: Effective patient care transitions require consideration of social and clinical context, yet how these factors and relational processes in care coordination relate remains poorly described. This case report aims to describe provider networks and the clinical care and social context involved during longitudinal care transitions across settings. CASE: We examined the utilization and provider networks of an oldest old woman with heart failure (HF) before and after her first hospitalization for HF. She used primary care for care management and had insurance, strong caregiver support, and comprehensive discharge planning; however, after the hospitalization, Mrs. A's ambulatory provider networks were more diverse yet sparser and less strongly connected. CONCLUSIONS: Turbulence in care transition can result from sources other than transitioning between settings. The data-driven case report approach using electronic health records uncovered relational processes important for care coordination and may inform patient-centered approaches to improve care for patients with HF.

Living With Cognitive Impairment in China: Exploring Dyadic Experiences Through a Person-Centered Care Lens.

China has experienced a substantial increase in the number of older adults with dementia and milder forms of cognitive impairment. Being spouses of Persons with cognitive impairment (PWCI) and living with them for several decades does not necessarily mean that it is easier for them to provide person-centered care and maintain a valued and healthy relationship. The current study explored how elements of PCC, as operationalized by the Senses Framework, operate or fail to operate in the dyadic experiences of PWCI and their spousal care partners within the socio-cultural context of China. Our findings suggest that PWCI and their spouses experience the six senses through the person-centeredness in their daily interactions with each other. It also indicated successes and challenges to being person-centered early in the disease and identified their unmet needs as well as barriers and facilitators to improve their well-being.

Delegation in Long-term Care: Scope of practice or job description?

This study is a qualitative, descriptive study of how registered nurses (RNs) (N=33) in leadership roles in institutionalized long-term care settings delegate care, including their strategies and processes for delegating care, and their perceptions of barriers to effective delegation and potential benefits of delegation. Findings indicate two key approaches to delegation, including the "follow the job description" approach, emphasizing adherence to facility-level roles and job descriptions, and the "consider the scope of practice" approach, emphasizing consideration of multiple aspects of scope of practice and licensure, and the context of care. While the former resulted in more clarity and certainty for the RN, the latter facilitated a focus on quality of resident care outcomes as linked to the delegation process. Barriers to effective delegation were comparable among RNs using either approach to delegation, and almost all RNs could describe benefits of delegation for long-term care.

Resident Challenges With Pain and Functional Limitations in Chinese Residential Care Facilities.

BACKGROUND AND OBJECTIVES: Pain and functional limitations can severely impede older adults' quality of life. In Chinese residential care facilities, limited research suggests that residents potentially have significant unmet care needs with pain and related functional limitations. Therefore, we aimed to explore residents' challenges and self-management strategies in these two areas. This knowledge is essential to developing care interventions to improve quality of care and quality of life in Chinese residential care facilities. RESEARCH DESIGN AND METHODS: We conducted semi-structured open-ended interviews with residents (n = 21) in two facilities in eastern and central China and assessed their pain and functional status using self-report measures from Minimum Data Set 3.0. We applied descriptive statistics to the self-reported data and analyzed the interview data using thematic analysis by drawing on the Adaptive Leadership Framework. This framework proposes that individuals living with chronic conditions need to engage in work to address their complex health concerns and that they need support from the environment to facilitate problem-solving. RESULTS: Residents described significant unmet care needs with pain and functional limitations. To address these care needs, they adopted a substantial number of self-management strategies. While doing so, they faced significant barriers, including service gaps and inadequate direct care. DISCUSSION AND IMPLICATIONS: The findings suggest further research to explore long-term care policy change that is needed to provide comprehensive health and medical services and adequate direct care in these facilities. The importance of establishing various types of long-term care facilities is also highlighted.

Measurement of older adults' social networks using technologies in the context of health and social care: a scoping review protocol.

OBJECTIVE: This scoping review aims to identify and map the use of technology in measuring and analyzing older adults' social networks in the context of health and social care. INTRODUCTION: Research has shown that social networks impact the health and well-being of older adults. Advancements in the internet, electronic and digital devices, social media, and healthcare technology enhance our ability to collect social network and health data. These rapidly evolving technologies present opportunities to overcome limitations in social network measurement and promote improved understanding of the impact of social networks on the health and well-being of older adults. INCLUSION CRITERIA: This scoping review will include studies of older adults that measured social networks using technology and were related to health or health and social care. Studies published in English from 2004 to the present will be included. Books, editorials, letters, and commentaries will be excluded. METHODS: PubMed (MEDLINE), Sociological Abstracts, SocINDEX, CINAHL, and Web of Science will be searched for related articles. Gray literature will be included by searching conference abstracts via Conference Papers Index and hand-searching conference proceedings from the American Sociological Society and the Gerontological Society of America. Data will be extracted by two independent reviewers using an a priori data extraction tool. Tables and summary narratives will be used to map and synthesize existing approaches to measuring social networks using technology, the settings for measurement development or testing, and the use of approaches in discovery science, implementation science, or clinical care.