Shifting the narrative from living at risk to living with risk: validating and pilot-testing a clinical decision support tool: a mixed methods study.

BACKGROUND: When there are safety concerns, healthcare professionals (HCPs) may disregard older adults' wishes to return or remain at home. A paradigm shift is needed for HCPs to move from labelling older adults as living at risk to helping them live with risk. The Living with Risk: Decision Support Tool (LwR:DST) was developed to support older adults and HCPs with difficult decision-making regarding living with risk. The study objectives were to: (1) validate, and (2) pilot-test the LwR:DST in hospital and community settings. METHODS: The study was conducted across Canada during the pandemic. The LwR:DST's content was validated with quantitative and qualitative data by: (1) 71 HCPs from hospital and community settings using the Delphi method, and (2) 17 older adults and caregivers using focus groups. HCPs provided feedback on the LwR:DST's content, format and instruction manual while older adults provided feedback on the LwR:DST's communication step. The revised LwR:DST was pilot-tested by 14 HCPs in one hospital and one community setting, and 17 older adults and caregivers described their experience of HCPs using this approach with them. Descriptive and thematic analysis were performed. RESULTS: The LwR:DST underwent two iterations incorporating qualitative and quantitative data provided by HCPs, older adults and caregivers. The quantitative Delphi method data validated the content and the process of the LwR:DST, while the qualitative data provided practical improvements. The pilot-testing results suggest that using the LwR:DST broadens HCPs' clinical thinking, structures their decision-making, improves their communication and increases their competence and comfort with risk assessment and management. Our findings also suggest that the LwR:DST improves older adults' healthcare experience by feeling heard, understood and involved. CONCLUSIONS: This revised LwR:DST should help HCPs systematically identify frail older adults' risks when they remain at or return home and find acceptable ways to mitigate these risks. The LwR:DST induces a paradigm shift by acknowledging that risks are inherent in everyday living and that risk-taking has positive and negative consequences. The challenges involved in integrating the LwR:DST into practice, i.e., when, how and with whom to use it, will be addressed in future research.

ECHO Care of the Elderly: Innovative Learning to Build Capacity in Long-term Care.

BACKGROUND: Older adults are entering long-term care (LTC) homes with more complex care needs than in previous decades, resulting in demands on point-of-care staff to provide additional and specialty services. This study evaluated whether Project ECHO® (Extension for Community Healthcare Outcomes) Care of the Elderly Long-Term Care (COE-LTC)-a case-based online education program-is an effective capacity-building program among interprofessional health-care teams caring for LTC residents. METHODS: A mixed-method, pre-and-post study comprised of satisfaction, knowledge, and self-efficacy surveys and exploration of experience via semi-structured interviews. Participants were interprofessional health-care providers from LTC homes across Ontario. RESULTS: From January-March 2019, 69 providers, nurses/nurse practitioners (42.0%), administrators (26.1%), physicians (24.6%), and allied health professionals (7.3%) participated in 10 weekly, 60-minute online sessions. Overall, weekly session and post-ECHO satisfaction were high across all domains. Both knowledge scores and self-efficacy ratings increased post-ECHO, 3.9% (p = .02) and 9.7 points (p < .001), respectively. Interview findings highlighted participants' appreciation of access to specialists, recognition of educational needs specific to LTC, and reduction of professional isolation. CONCLUSION: We demonstrated that ECHO COE-LTC can be a successful capacity-building educational model for interprofessional health-care providers in LTC, and may alleviate pressures on the health system in delivering care for residents.

Context matters when implementing patient centred rehabilitation models for persons with cognitive impairment: a case study.

BACKGROUND: There is a growing number of older adults with cognitive impairment (CI) that require inpatient rehabilitation, and as such patient centred rehabilitation models have been developed. However, implementing evidence-based models without attending to the fit of the model to the new context could lead to an unsuccessful outcome. Researchers collaborated with administrators and staff in one rural site to adapt a patient centred rehabilitation model of care in the Canadian province of Ontario. This paper reports on the contextual factors that influenced the implementation of the model of care. METHODS: The study takes a case study approach. One rural facility was purposefully selected for its interest in offering rehabilitation to persons with CI. Four focus group discussions were conducted to explore healthcare professionals' perceptions on the contextual factors that could affect the implementation of the rehabilitation model of care in the facility. Twenty-seven professionals with various backgrounds were purposively sampled using a maximum diversity sampling strategy. A hybrid inductive-deductive approach was used to analyze the data using the Context and Implementation of Complex Interventions (CICI) Framework. RESULTS: Across the domains of the CICI framework, three domains (political, epidemiological, and geographical) and seven corresponding sub-domains of the context were found to have a major influence on the implementation process. Key elements within the political domain included effective teamwork, facilitation, adequate resources, effective communication strategies, and a vision for change. Within the epidemiological domain, a key element was knowing how to tailor rehabilitation approaches for persons with CI. Infrastructure, an aspect of the geographical domain, focused on the facility's physical layout that required attention. CONCLUSIONS: The CICI framework was a useful guide to identify key factors within the context that existed and were required to fully support the implementation of the model of care in a new environment. The findings suggest that when implementing a new program of care, strong consideration should be paid to the political, epidemiological, and geographical domains of the context and how they interact and influence one another.

Building Long-Term Care Staff Capacity During COVID-19 Through Just-in-Time Learning: Evaluation of a Modified ECHO Model.

OBJECTIVES: The onset of the COVID-19 pandemic significantly challenged the capacity of long-term care (LTC) homes in Canada, resulting in new, pressing priorities for leaders and health care providers (HCPs) in the care and safety of LTC residents. This study aimed to determine whether Project ECHO (Extension for Community Healthcare Outcomes) Care of the Elderly Long-Term Care (COE-LTC): COVID-19, a virtual education program, was effective at delivering just-in-time learning and best practices to support LTC teams and residents during the pandemic. DESIGN: Mixed methods evaluation. SETTING AND PARTICIPANTS: Interprofessional HCPs working in LTC homes or deployed to work in LTC homes primarily in Ontario, Canada, who participated in 12 weekly, 60-minute sessions. METHODS: Quantitative and qualitative surveys assessing reach, satisfaction, self-efficacy, practice change, impact on resident care, and knowledge sharing. RESULTS: Of the 252 registrants for ECHO COE-LTC: COVID-19, 160 (63.4%) attended at least 1 weekly session. Nurses and nurse practitioners represented the largest proportion of HCPs (43.8%). Overall, both confidence and comfort level working with residents who were at risk, confirmed, or suspected of having COVID-19 increased after participating in the ECHO sessions (effect sizes ≥ 0.7, Wilcoxon signed rank P < .001). Participants also reported impact on intent to change behavior, resident care, and knowledge sharing. CONCLUSIONS AND IMPLICATIONS: The results demonstrate that ECHO COE-LTC: COVID 19 effectively delivered time-sensitive information and best practices to support LTC teams and residents. It may be a critical platform during this pandemic and in future crises to deliver just-in-time learning during periods of constantly changing information.