The role of unregulated care providers in managing heart failure patients in long-term care facilities.

AIMS AND OBJECTIVES: Heart failure is a complex syndrome in which abnormal heart function results in clinical symptoms and signs of low cardiac output and/or pulmonary or systemic congestion. Heart failure is common among long-term care residents, and is associated with significant morbidity and acute care utilisation. Heart failure guidelines endorse standard therapies, yet long-term care residents are less likely to receive recommended treatments. The objective of this study is to understand the perceptions and potential role of unregulated care providers in contributing to better heart failure management among long-term care residents. DESIGN: Focus group interviews. METHODS: This qualitative study employed focus groups to explore perceptions from 24 unregulated care providers in three Ontario, Canada long-term care homes, about barriers to the optimal management of heart failure. RESULTS: Three overarching concepts emerged characterising unregulated care providers' experiences in caring for residents with heart failure in long-term care: (1) the complexity of providing heart failure care in a long-term care setting, (2) striving for resident-centred decision making and (3) unregulated care providers role enactment nested within an interprofessional team in long-term care. These concepts reflect the complex interplay between individual unregulated care providers and residents, and heart failure-related, socio-cultural and organisational factors that influence heart failure care processes in the long-term care system. CONCLUSIONS: Optimising the management of heart failure in long-term care is contingent on greater engagement of unregulated care providers as active partners in the interprofessional care team. Interventions to improve heart failure management in long-term care must ensure that appropriate education is provided to all long-term care staff, including unregulated care providers, and in a manner that fosters greater and more effective interprofessional collaboration. RELEVANCE TO CLINICAL PRACTICE: Active and collaborative engagement unregulated care providers has the potential to improve the management of heart failure in long-term care residents.

Physicians' perceptions of capacity building for managing chronic disease in seniors using integrated interprofessional care models.

OBJECTIVE: To explore the barriers to and facilitators of adapting and expanding a primary care memory clinic model to integrate care of additional complex chronic geriatric conditions (heart failure, falls, chronic obstructive pulmonary disease, and frailty) into care processes with the goal of improving outcomes for seniors. DESIGN: Mixed-methods study using quantitative (questionnaires) and qualitative (interviews) methods. SETTING: Ontario. PARTICIPANTS: Family physicians currently working in primary care memory clinic teams and supporting geriatric specialists. METHODS: Family physicians currently working in memory clinic teams (n = 29) and supporting geriatric specialists(n = 9) were recruited as survey participants. Interviews were conducted with memory clinic lead physicians (n = 16).Statistical analysis was done to assess differences between family physician ratings and geriatric specialist ratings related to the capacity for managing complex chronic geriatric conditions, the role of interprofessional collaboration within primary care, and funding and staffing to support geriatric care. Results from both study methods were compared to identify common findings. MAIN FINDINGS: Results indicate overall support for expanding the memory clinic model to integrate care for other complex conditions. However, the current primary care structure is challenged to support optimal management of patients with multiple comorbidities, particularly as related to limited funding and staffing resources. Structured training, interprofessional teams, and an active role of geriatric specialists within primary care were identified as important facilitators. CONCLUSION: The memory clinic model, as applied to other complex chronic geriatric conditions, has the potential to build capacity for high-quality primary care, improve health outcomes,promote efficient use of health care resources, and reduce healthcare costs.

Managing heart failure in the long-term care setting: nurses' experiences in Ontario, Canada.

BACKGROUND: Implementation of heart failure guidelines in long-term care (LTC) settings is challenging. Understanding the conditions of nursing practice can improve management, reduce suffering, and prevent hospital admission of LTC residents living with heart failure. OBJECTIVE: The aim of the study was to understand the experiences of LTC nurses managing care for residents with heart failure. METHODS: This was a descriptive qualitative study nested in Phase 2 of a three-phase mixed methods project designed to investigate barriers and solutions to implementing the Canadian Cardiovascular Society heart failure guidelines into LTC homes. Five focus groups totaling 33 nurses working in LTC settings in Ontario, Canada, were audiorecorded, then transcribed verbatim, and entered into NVivo9. A complex adaptive systems framework informed this analysis. Thematic content analysis was conducted by the research team. Triangulation, rigorous discussion, and a search for negative cases were conducted. Data were collected between May and July 2010. RESULTS: Nurses characterized their experiences managing heart failure in relation to many influences on their capacity for decision-making in LTC settings: (a) a reactive versus proactive approach to chronic illness; (b) ability to interpret heart failure signs, symptoms, and acuity; (c) compromised information flow; (d) access to resources; and (e) moral distress. DISCUSSION: Heart failure guideline implementation reflects multiple dynamic influences. Leadership that addresses these factors is required to optimize the conditions of heart failure care and related nursing practice.

Personalized Tablets for Residents in Long-Term Care to Support Recreation and Mitigate Isolation.

OBJECTIVES: There is a digital divide in long-term care homes (LTCHs), with few residents having regular access to internet-connected devices. In this study, we provided long-term care residents with personalized and adapted tablets. We aimed to understand what factors influenced tablet use and the impact of tablet access on opportunities for social connection and recreation. DESIGN: A pragmatic, mixed-methods multicenter, open-label, uncontrolled interventional study with assessment of outcomes at baseline and 3 months. SETTING AND PARTICIPANTS: A total of 58 resident-care partner dyads were recruited across 7 LTCHs in Ontario, Canada. The main inclusion criterion was having a care partner willing to participate, and we excluded residents who already had an internet-connected device. METHODS: Resident demographics, functional status assessments, and recreational engagement were captured using items from the Resident Assessment Instrument/Minimum Data Set. Care partners completed a questionnaire about relational closeness and site leads assessed resident quality of life before and approximately 3 months after tablet distribution. Interviews with 23 care partners and 7 residents post-implementation were completed and analyzed. RESULTS: The median tablet use by participants was 7 minutes (interquartile range 27) per day on average over the study period. Predictors of higher tablet use were younger age, higher cognitive functioning, absence of hearing impairment, and having a care partner who lives farther away. There was no improvement on quantitative measures of quality of life, recreation, or relational closeness. In interviews, participants identified many different opportunities afforded by access to personalized tablets. CONCLUSIONS AND IMPLICATIONS: Some LTCH residents without current access to the internet benefit from being provided a personal tablet and use it in a variety of ways to enrich their lives. There is a critical need to bridge the digital divide for this population.

Living and dying with heart failure in long-term care: experiences of residents and their family members.

The purpose of this study was to explore the experiences of long-term care (LTC) residents living and dying with heart failure (HF)and their family members. An exploratory descriptive design was used to collect data from seven LTC residents and seven family members. The data was analysed using thematic content analysis. The main themes that emerged from the data were: limited understanding of the HF diagnosis, living with restrictions and other comorbidities, making decisions about transitioning to end-of-life care, and learning and negotiating the lines of communication. Residents and family members communicated with many health-care providers about managing the HF symptoms but most often worked through the nurse when problems arose or decisions about care needed to be made. The findings from this study contribute to our understanding of residents' and family members' experiences in managing residents' HF in LTC.

Implementation of participatory organizational change in long term care to improve safety.

INTRODUCTION: Long Term Care (LTC) facilities are fast-paced, demanding environments placing workers at significant risk for injuries. Health and safety interventions to address hazards in LTC are challenging to implement. The study assessed a participatory organizational change intervention implementation and impacts. METHODS: This was a mixed methods implementation study with a concurrent control, conducted from 2017 to 2019 in four non-profit LTC facilities in Ontario, Canada. Study participants were managers and frontline staff. Intervention sites implemented a participatory organizational change program, control sites distributed one-page health and safety pamphlets. Program impact data were collected via Survey (self-efficacy, control over work, pain and general health) and observation (Quick Exposure Checklist). Interviews/focus groups were used to collect program implementation data. RESULTS: Participants described program impacts (hazard controls through equipment purchase/modification, practice changes, and education/training) and positive changes in culture, communication and collaboration. There was a statistically significant difference in manager self-efficacy for musculoskeletal disorder (MSD) hazards between the control and intervention sites over time but no other statistical differences were found. Key program implementation challenges included LTC hazards, staff shortage/turnover, safety culture, staff time to participate, and communication. Facilitators included frontline staff involvement during implementation, management support, focusing on a single unit, training, and involving an external program facilitator. CONCLUSION: A participatory program can have positive impacts on identifying and reducing MSD hazards. Key to success is involving frontline staff in identifying hazards and creating solutions and management encouragement on a unit working together. High turnover rates, staffing shortages, and time constraints were barriers as they are for all organizational change efforts in LTC. The implementation findings are likely applicable in any jurisdiction. Practical Application: Implementing a participatory organizational change program to reduce MSD hazards is feasible in LTC and can improve communication and aid in identification and control of hazards.

Process evaluation of a participatory organizational change program to reduce musculoskeletal and slip, trip and fall injuries.

BACKGROUND: Long-term care (LTC) workers are at significant risk for occupational-related injuries. Our objective was to evaluate the implementation process of a participatory change program to reduce risk. METHODS: A process evaluation was conducted in three LTC sites using a qualitative approach employing structured interviews, consultant logs and a focus group. RESULTS: Findings revealed recruitment/reach themes of being "voluntold", using established methods, and challenges related to work schedules. Additional themes about dose were related to communication, iterative solution development, participation and engagement. For program fidelity and satisfaction, themes emerged around engagement, capacity building and time demands. CONCLUSION: Process evaluation revealed idiosyncratic approaches to recruitment and related challenges of reaching staff. Solutions to prioritized hazards were developed and implemented, despite time challenges. The iterative solution development approach was embraced. Program fidelity was considered good despite early program time demands. Post implementation reports revealed sustained hazard identification and solution development.

Managing Heart Failure in Long-Term Care: Recommendations from an Interprofessional Stakeholder Consultation.

Heart failure (HF) affects up to 20 per cent of residents in long-term care (LTC) and is associated with substantial morbidity, mortality, and health service utilization. Our study objective was to formulate recommendations on implementing HF care processes in LTC. A three-phase and iterative stakeholder consultation process, guided by expert panel input, was employed to develop recommendations on implementing care processes for HF in LTC. This article presents the results of the third phase, which consisted of a series of interdisciplinary workshops. We developed 17 recommendations. Key elements of these recommendations focus on improving interprofessional communication and improving HF-related knowledge among all LTC stakeholders. Engaging frontline staff, including personal support workers, was stated as an essential component of all recommendations. System-level recommendations include improving communication between LTC homes and acute care and other external health service providers, and developing facility-wide interventions to reduce dietary sodium intake and increase physical activity.

Perspectives of Primary-Care Providers on Heart Failure in Long-Term Care Homes.

Heart failure (HF) is common among long-term care (LTC) residents, and may account for 40 per cent of acute-care transfers. Canadian Cardiovascular Society HF guidelines endorse standard therapies; yet LTC residents are less likely to receive treatment. This qualitative study employed focus groups to explore perceptions, from 18 physicians and nurse practitioners in three Ontario homes, on HF care practices and challenges. For example, participants reported challenges with HF diagnostic skills and procedural knowledge. They also identified the need for interprofessional collaboration and role clarification to improve HF care and outcomes. To address these challenges, multimodal interventions and bedside teaching are required. Leadership was viewed as essential to improve HF care. Several concerns arose regarding knowledge gaps and clinical deficits among primary-care providers who manage heart failure in LTC residents. Multimodal, clinically focused educational and interprofessional solutions are needed to improve HF care in long-term care.