Low ß-carotene bioaccessibility and bioavailability from high fat, dairy-based meal.

PURPOSE: The original aim of the study was to determine, in a double-blind 3-arm crossover human trial (n = 7), the effect of supplemental levels of iron (25 mg) and zinc (30 mg) on ß-carotene (synthetic) bioavailability (10 h postprandial). However, despite the high dose of supplemental ß-carotene (15 mg) consumed with the high fat (18 g), dairy-based breakfast test meal, there was a negligible postprandial response in plasma and triglyceride rich fraction ß-carotene concentrations. We then systematically investigated the possible reasons for this low bioavailability of ß-carotene. METHODS: We determined (1) if the supplemental ß-carotene could be micellised and absorbed by epithelial cells, using a Caco-2 cell model, (2) if the fat from the test meal was sufficiently bioavailable to facilitate ß-carotene bioavailability, (3) the extent to which the ß-carotene could have been metabolised and converted to retinoic acid/retinol and (4) the effect of the test meal matrix on the ß-carotene bioaccessibility (in vitro digestion) and Caco-2 cellular uptake. RESULTS: We found that (1) The supplemental ß-carotene could be micellised and absorbed by epithelial cells, (2) the postprandial plasma triacylglycerol response was substantial (approximately 75-100 mg dL-1 over 10 h), indicating sufficient lipid bioavailability to ensure ß-carotene absorption, (3) the high fat content of the meal (approximately 18 g) could have resulted in increased ß-carotene metabolism, (4) ß-carotene bioaccessibility from the dairy-based test meal was sixfold lower (p < 0.05) than when digested with olive oil. CONCLUSION: The low ß-carotene bioavailability is probably due to a combination of the metabolism of ß-carotene to retinol by BCMO1 and interactions of ß-carotene with the food matrix, decreasing the bioaccessibility. TRAIL REGISTRATION: The human trail was retrospectively registered (ClinicalTrail.gov ID: NCT05840848).

Intellectual and developmental disabilities in Ontario's criminal justice and forensic mental health systems: Using data to tell the story.

BACKGROUND: International studies show that adults with intellectual and developmental disabilities (IDD) are disproportionately represented in the criminal justice and forensic mental health systems; however, it is difficult to capture their involvement across systems in any one jurisdiction. AIMS: The current study aimed to estimate the prevalence of IDD across different parts of the criminal justice and forensic mental health systems in Ontario and to describe the demographic and clinical profiles of these individuals relative to their counterparts without IDD. METHODS: This project utilised administrative data to identify and describe the demographic and clinical characteristics of adults with IDD and criminal justice or forensic involvement across four sectors: federal correctional facilities, provincial correctional facilities, forensic inpatient mental health care and community mental health programmes. Questions were driven by and results were contextualised by a project advisory group and people with lived experience from the different sectors studied, resulting in a series of recommendations. RESULTS: Adults with IDD were over-represented in each of the four settings, ranging from 2.1% in federal corrections to 16.7% in forensic inpatient care. Between 20% (forensic inpatient) and 38.4% (provincial corrections) were under the age of 25 and between 34.5% (forensic inpatient) and 41.8% (provincial corrections) resided in the lowest income neighbourhoods. Medical complexity and rates of co-occurring mental health conditions were higher for people with IDD than those without IDD in federal and provincial corrections. CONCLUSIONS: Establishing a population-based understanding of people with IDD within these sectors is an essential first step towards understanding and addressing service and care needs. Building on the perspectives of people who work in and use these systems, this paper concludes with intervention recommendations before, during and after justice involvement.

Clinical factors associated with recent medical care visits in nursing homes: a multi-site cross-sectional study.

OBJECTIVES: We examined which resident-level clinical factors influence the provision of a recent medical care visit in nursing homes (NHs). DESIGN: Multi-site cross-sectional. SETTING AND PARTICIPANTS: We extracted data on 3,556 NH residents from 18 NH facilities in Ontario, Canada, who received at minimum, an admission and first-quarterly assessment with the Resident Assessment Instrument Minimum Data Set (MDS) 2.0 between November 1, 2009, and October 31, 2017. METHODS: We conducted a secondary analysis of routinely collected MDS 2.0 data. The provision of a recent medical care visit by a physician (or authorized clinician) was assessed in the 14-day period preceding a resident's first-quarterly MDS 2.0 assessment. We utilized best-subset multivariable logistic regression to model the adjusted associations between resident-level clinical factors and a recent medical care visit. RESULTS: Two thousand eight hundred fifty nine (80.4%) NH residents had one or more medical care visits prior to their first-quarterly MDS 2.0 assessment. Six clinically relevant factors were identified to be associated with recent medical care visits in the final model: exhibiting wandering behaviours (OR = 1.34, 95% CI 1.09 - 1.63), presence of a pressure ulcer (OR = 1.37, 95% CI 1.05 - 1.78), a urinary tract infection (UTI) (OR = 1.52, 95% CI 1.06 - 2.18), end-stage disease (OR = 9.70, 95% CI 1.32 - 71.02), new medication use (OR = 1.31, 95% CI 1.09 - 1.57), and analgesic use (OR = 1.24, 95% CI 1.03 - 1.49). CONCLUSIONS AND IMPLICATIONS: Our findings suggest that resident-level clinical factors drive the provision of medical care visits following NH admission. Clinical factors associated with medical care visits align with the minimum competencies expected of physicians in NH practice, including managing safety risks, infections, medications, and death. Ensuring that NH physicians have opportunities to acquire and strengthen these competencies may be transformative to meet the ongoing needs of NH residents.

Trophic assimilation efficiency markedly increases at higher trophic levels in four-level host-parasitoid food chain.

Trophic assimilation efficiency (conversion of resource biomass into consumer biomass) is thought to be a limiting factor for food chain length in natural communities. In host-parasitoid systems, which account for the majority of terrestrial consumer interactions, a high trophic assimilation efficiency may be expected at higher trophic levels because of the close match of resource composition of host tissue and the consumer's resource requirements, which would allow for longer food chains. We measured efficiency of biomass transfer along an aphid-primary-secondary-tertiary parasitoid food chain and used stable isotope analysis to confirm trophic levels. We show high efficiency in biomass transfer along the food chain. From the third to the fourth trophic level, the proportion of host biomass transferred was 45%, 65% and 73%, respectively, for three secondary parasitoid species. For two parasitoid species that can act at the fourth and fifth trophic levels, we show markedly increased trophic assimilation efficiencies at the higher trophic level, which increased from 45 to 63% and 73 to 93%, respectively. In common with other food chains, δ(15)N increased with trophic level, with trophic discrimination factors (Δ(15)N) 1.34 and 1.49‰ from primary parasitoids to endoparasitic and ectoparasitic secondary parasitoids, respectively, and 0.78‰ from secondary to tertiary parasitoids. Owing to the extraordinarily high efficiency of hyperparasitoids, cryptic higher trophic levels may exist in host-parasitoid communities, which could alter our understanding of the dynamics and drivers of community structure of these important systems.

Insufficient access to harm reduction measures in prisons in 5 countries (PRIDE Europe): a shared European public health concern.

BACKGROUND: Prisoners constitute a high-risk population, particularly for infectious diseases. The aim of this study was to estimate the level of infectious risk in the prisons of five different European countries by measuring to what extent the prison system adheres to WHO/UNODC recommendations. METHODS: Following the methodology used in a previous French survey, a postal/electronic questionnaire was sent to all prisons in Austria, Belgium, Denmark and Italy to collect data on the availability of several recommended HIV-HCV prevention interventions and HBV vaccination for prisoners. A score was built to compare adherence to WHO/UNODC recommendations (considered a proxy of environmental infectious risk) in those 4 countries. It ranged from 0 (no adherence) to 12 (full adherence). A second score (0 to 9) was built to include data from a previous French survey, thereby creating a 5-country comparison. RESULTS: A majority of prisons answered in Austria (100 %), France (66 %) and Denmark (58 %), half in Belgium (50 %) and few in Italy (17 %), representing 100, 74, 89, 47 and 23 % coverage of the prison populations, respectively. Availability of prevention measures was low, with median adherence scores ranging from 3.5 to 4.5 at the national level. These results were confirmed when using the second score which included France in the inter-country comparison. Overall, the adherence score was inversely associated with prison overpopulation rates (p = 0.08). CONCLUSIONS: Using a score of adherence to WHO/UNODC recommendations, the estimated environmental infectious risk remains extremely high in the prisons of the 5 European countries assessed. Public health strategies should be adjusted to comply with the principle of equivalence of care and prevention with the general community.

Focusing on Provider Quality Measurement: Continued Consensus and Feasibility Testing of Practice-Based Quality Measures for Primary Care Providers in Long-Term Care.

Medical providers in long-term care (LTC) use a unique skillset in delivering comprehensive resident care. Publicly reported quality measures (QMs) do not directly emphasize medical provider competency and their role in care. The impact of providers is understudied and to a large extent, unknown. Our objective was to define, test, and validate QMs to pragmatically measure the practice-based quality of medical providers in a pilot study. We included 7 North American LTC homes with data from practicing medical providers for LTC residents. We engaged in a 4-phased approach. In phase 1, experts rated 95 candidate QMs using 5 pragmatic-focused criteria in a RAND-modified Delphi process. Phase 2 involved specifying 37 QMs for collection (4 QMs were dropped during pilot testing). We created an abstraction manual and data collection tool for all QMs. Phase 3 involved a retrospective chart review in 7 LTC homes on 33 QMs with trained data abstractors. Data were sufficient to analyze performance for 26 QMs. Lastly, in phase 4 results and psychometric properties were reviewed with an expert panel. They ranked the tested measures for validity and feasibility for use by a nonphysician auditor to evaluate medical provider performance based on medical record review. In total, we examined data from 343 resident charts from 7 LTC homes and 49 providers. Our process yielded 10 QMs as being specified for measurement, feasible to collect, and had good test performance. This is the only study to systematically identify a subset of QMs for feasible collection from the medical record by various data collectors. This pragmatic approach to measuring practice-based quality and quantifying select medical provider competencies allows for the evaluation of individual and facility-level performance and facilitates quality improvement initiatives. Future work should perform broader testing and validate and refine operationalized QMs.

Fracture risk assessment in long-term care: a survey of long-term care physicians.

BACKGROUND: The majority of frail elderly who live in long-term care (LTC) are not treated for osteoporosis despite their high risk for fragility fractures. Clinical Practice Guidelines for the diagnosis and management of osteoporosis provide guidance for the management of individuals 50 years and older at risk for fractures, however, they cannot benefit LTC residents if physicians perceive barriers to their application. Our objectives are to explore current practices to fracture risk assessment by LTC physicians and describe barriers to applying the recently published Osteoporosis Canada practice guidelines for fracture assessment and prevention in LTC. METHODS: A cross-sectional survey was conducted with the Ontario Long-Term Care Physicians Association using an online questionnaire. The survey included questions that addressed members' attitudes, knowledge, and behaviour with respect to fracture risk assessment in LTC. Closed-ended responses were analyzed using descriptive statistics and thematic framework analysis for open-ended responses. RESULTS: We contacted 347 LTC physicians; 25% submitted completed surveys (81% men, mean age 60 (Standard Deviation [SD] 11) years, average 32 [SD 11] years in practice). Of the surveyed physicians, 87% considered prevention of fragility fractures to be important, but a minority (34%) reported using validated fracture risk assessment tools, while 33% did not use any. Clinical risk factors recommended by the OC guidelines for assessing fracture risk considered applicable included; glucocorticoid use (99%), fall history (93%), age (92%), and fracture history (91%). Recommended clinical measurements considered applicable included: weight (84%), thyroid-stimulating hormone (78%) and creatinine (73%) measurements, height (61%), and Get-Up-and-Go test (60%). Perceived barriers to assessing fracture risk included difficulty acquiring necessary information, lack of access to tests (bone mineral density, x-rays) or obtaining medical history; resource constraints, and a sentiment that assessing fracture risk is futile in this population because of short life expectancy and polypharmacy. CONCLUSION: Perceived barriers to fracture risk assessment and osteoporosis management in LTC have not changed recently, contributing in part to the ongoing care gap in osteoporosis management. Our findings highlight the importance to adapt guidelines to be applicable to the LTC environment, and to develop partnerships with stakeholders to facilitate their use in clinical practice.

Did the Long-Term Care Physician Workforce Change During the Pandemic? Describing MRP Trends in Ontario, Canada.

OBJECTIVES: To examine the practice patterns and trends of long-term care (LTC) physicians between 2019 and 2021 in Ontario, Canada. DESIGN: Population-level descriptive time trend study. SETTING AND PARTICIPANTS: Most responsible physicians (MRPs) of LTC residents of publicly funded LTC homes in Ontario, Canada, from September 2019 to December 2021. METHODS: We examined the number of MRPs in publicly regulated Ontario LTC homes before and during the COVID-19 pandemic using population-level administrative databases. Characteristics of MRPs and practice patterns were generated at baseline and across distinct time periods of the pandemic in descriptive tables. We created a Sankey diagram to visualize MRP practice changes over time. RESULTS: More than one-quarter of pre-pandemic MRPs were no longer MRPs by the end of 2021, although most continued to practice in non-LTC settings. There was a decrease from 1444 to 1266 MRPs over time. Other characteristics of MRPs remained stable over the pandemic time periods. At baseline, LTC physicians were MRP for an average of 57.3 residents. By the end of 2021, this caseload decreased to 53.3 residents per MRP. MRPs increasingly billed monthly management compensation fees over the fee-for-service model across the pandemic time periods. The number of MRPs working in an LTC home shifted to fewer MRPs per home. CONCLUSIONS AND IMPLICATIONS: MRP demographic characteristics did not change over the course of the pandemic. The observed shifts in practice patterns showed a reduction in the overall LTC MRP workforce, who delivered care to fewer residents on average in LTC homes with fewer colleagues to rely on. Future work can study how changes to LTC MRPs' practice patterns impact physician coverage, access and continuity of care, and health services and quality outcomes among residents.

Physician Practice in Ontario Nursing Homes: Defining Physician Commitment.

OBJECTIVES: To characterize the practice profile of nursing home (NH) physicians in Ontario, Canada. DESIGN: Population-based cross-sectional study. SETTING AND PARTICIPANTS: A total of 1527 most responsible physicians (MRPs) across 626 NHs in Ontario, Canada, for the calendar year, 2017. METHODS: We examined physician services within all publicly regulated and funded NH facilities. Descriptive summaries were generated to characterize MRPs and their practice patterns by the physician's primary practice location, the NH facility size, and the proportion of physician billings that occurred within NHs. Community sizes were classified into quintiles based on population size and assigned as urban or rural. The number of ministry-designated NH beds were assessed by quintiles to examine physician services by facility size. We also assessed the proportion of physician billings within NHs by quintiles. RESULTS: MRPs tended to be older, male, and practice family medicine. The majority of MRPs practiced in communities with populations exceeding 100,000 residents, although physicians with greater NH billings tended to practice in rural locations. The mean number of NH residents that a physician was MRP for was positively associated with the community size. Physicians provided care for more NH residents than they were assigned most responsible. Fifty-one percent of physicians were MRP for 90% of all NH residents. CONCLUSIONS AND IMPLICATIONS: Our work provides an exemplar for characterizing physician commitment in NHs, using 2 approaches, according to the NH specialist model. We demonstrated the medical practice characteristics, locations, and billing patterns of physicians within Ontario NHs. Future work can investigate the association between physician commitment and the quality of care provided to NH residents. A greater understanding of physician commitment may lead to the development of quality metrics based on physician practice patterns.

The Role of the Medical Director in Ontario Long-Term Care Homes: Impact of COVID-19.

OBJECTIVES: The pandemic has uncovered a broad lack of understanding of the role of the Medical Director in Canadian Long-Term Care (LTC) Homes. Our objectives were to identify the current demographics and practices of LTC Medical Directors, discover how the pandemic affected their practice habits, and inform the content of the Ontario Long-Term Care Clinicians Medical Director Course, to ensure that Medical Directors have the requisite knowledge of the responsibilities of their role. DESIGN: Email survey. SETTING AND PARTICIPANTS: Medical directors in Ontario long-term care homes. METHODS: Responses to open-ended, close-ended, multiple-choice, and free-text questions. RESULTS: A total of 156 medical directors (approximately 24%) completed the survey. Ninety-four percent were family physicians. Approximately 40% of participants had been a medical director for fewer than 5 years, whereas more than 11% have been in the role for greater than 30 years. More than 60% spend fewer than 2 hours per week in their administrative role, with fewer than 23% completing formal evaluations of the attending clinicians. Greater than 75% are either satisfied or extremely satisfied in their medical director role, citing excellent engagement and collaboration with team members. Feelings of dissatisfaction were associated with pandemic stress, increased hours and responsibility, inadequate remuneration, lack of ability to make decisions and lack of acknowledgement that physicians add value to the interdisciplinary team. CONCLUSION AND IMPLICATIONS: It is clear that medical directors are in a unique position to impact the care of residents within LTC. It is imperative to engage medical directors as integral members of the LTC health care team. This can be achieved by acknowledging their medical expertise for improving outcomes, providing them with the authority for decision making, compensating them appropriately, and clearly defining the role. By making these changes, we can ensure that there is a higher likelihood to sustain effective medical leadership in LTC.

CCCDTD5 recommendations on the deprescribing of cognitive enhancers in dementia.

INTRODUCTION: Cognitive enhancers (ie, cholinesterase inhibitors and memantine) can provide symptomatic benefit for some individuals with dementia; however, there are circumstances in which the risks of continuing treatment may potentially outweigh benefits. The decision to deprescribe cognitive enhancers must consider each patient's preferences, treatment indications, current clinical status and symptoms, prognosis, and dementia type. METHODS: The 5th Canadian Consensus Conference on the Diagnosis and Treatment of Dementia (CCCDTD5) established a subcommittee of experts to review current evidence on the deprescribing of cognitive enhancers. The questions answered by this group included: When should cognitive enhancers be deprescribed in persons with dementia and mild cognitive impairment? How should cognitive enhancers be deprescribed? And, what clinical factors should be considered when deprescribing cognitive enhancers? RESULTS: Patient and care-partner preferences should be incorporated into all decisions to deprescribe cognitive enhancers. Cognitive enhancers should be discontinued in individuals without ongoing evidence of benefit or when the indication for cognitive enhancer use was inappropriate (eg, mild cognitive impairment). Deprescribing should occur gradually and cognitive enhancers should be reinitiated if patients' cognition or function deteriorates. Cognitive enhancers should be continued in individuals whose neuropsychiatric symptoms improve in response to treatment. Clinicians should not deprescribe cognitive enhancers in individuals with significant neuropsychiatric symptoms until symptoms have stabilized. CONCLUSION: CCCDTD5 deprescribing recommendations provide evidence-informed recommendations related to cognitive enhancer deprescribing that will facilitate shared decision making among patients, care partners, and clinicians.

A Novel Collaborative Care Program to Augment Nursing Home Care During and After the COVID-19 Pandemic.

The 2019 novel coronavirus (COVID-19) pandemic created an immediate need to enhance current efforts to reduce transfers of nursing home (NH) residents to acute care. Long-Term Care Plus (LTC+), a collaborative care program developed and implemented during the COVID-19 pandemic, aimed to enhance care in the NH setting while also decreasing unnecessary acute care transfers. Using a hub-and-spoke model, LTC+ was implemented in 6 hospitals serving as central hubs to 54 geographically associated NHs with 9574 beds in Toronto, Canada. LTC+ provided NHs with the following: (1) virtual general internal medicine (GIM) consultations; (2) nursing navigator support; (3) rapid access to laboratory and diagnostic imaging services; and (4) educational resources. From April 2020 to June 2021, LTC+ provided 381 GIM consultations that addressed abnormal bloodwork (15%), cardiac problems (13%), and unexplained fever (11%) as the most common reasons for consultation. Sixty-five nurse navigator calls addressed requests for non-GIM specialist consultations (34%), wound care assessments (14%), and system navigation (12%). One hundred seventy-seven (46%, 95% CI 41%-52%) consults addressed care concerns sufficiently to avoid the need for acute care transfer. All 36 primary care physicians who consulted the LTC+ program reported strong satisfaction with the advice provided. Early results demonstrate the feasibility and acceptability of an integrated care model that enhances care delivery for NH residents where they reside and has the potential to positively impact the long-term care sector by ensuring equitable and timely access to care for people living in NHs. It represents an important step toward health system integration that values the expertise within the long-term care sector.

Medical Care Delivery in U.S. Nursing Homes: Current and Future Practice.

The delivery of medical care services in U.S. nursing homes (NHs) is dependent on a workforce that comprises physicians, nurse practitioners, and physician assistants. Each of these disciplines operates under a unique regulatory framework while adhering to common standards of care. NH provider characteristics and their roles in NH care can illuminate potential links to clinical outcomes and overall quality of care with important policy and cost implications. This perspective provides an overview of what is currently known about medical provider practice in NH and organizational models of practice. Links to quality, both conceptual and established, are presented as is a research and policy agenda that addresses the gaps in the evidence base within the context of our ever-changing health care landscape.

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.

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.

Proceedings from an International Virtual Townhall: Reflecting on the COVID-19 Pandemic: Themes from Long-Term Care.

Residents of long-term care (LTC) homes have suffered disproportionately during the COVID-19 pandemic, from the virus itself and often from the imposition of lockdown measures. Provincial Geriatrics Leadership Ontario, in collaboration with interRAI and the International Federation on Aging, hosted a virtual Town Hall on September 25, 2020. The purpose of this event was to bring together international perspectives from researchers, clinicians, and policy experts to address important themes potentially amenable to timely policy interventions. This article summarizes these themes and the ensuing discussions among 130 attendees from 5 continents. The disproportionate impact of the COVID-19 pandemic on frail residents of LTC homes reflects a systematic lack of equitable prioritization by health system decision makers around the world. The primary risk factors for an outbreak in an LTC home were outbreaks in the surrounding community, high staff and visitor traffic in large facilities, and crowding of residents in ageing buildings. Infection control measures must be prioritized in LTC homes, though care must be taken to protect frail and vulnerable residents from their overly blunt application that deprives residents from appropriate physical and psychosocial support. Staffing, in terms of overall numbers, training, and leadership skills, was inadequate. The built environment of LTC homes can be configured for both optimal resident well-being and infection control. Infection control and resident wellness need not be mutually exclusive. Improving outcomes for LTC residents requires more staffing with proper training and interprofessional leadership. All these initiatives must be underpinned by an effective quality assurance system based on standardized, comprehensive, accessible, and clinically relevant data, and which can support broad communities of practice capable of effecting real and meaningful change for frail older persons, wherever they chose to reside.