Evaluating the impact of a national geriatric mental health ECHO educational program on healthcare providers' practice.

Project Extension for Community Healthcare Outcomes (ECHO) enables healthcare providers to share knowledge and best practices via telementoring. The ECHO model builds provider capacity and improves care for patients with a variety of health conditions. This study describes a Canada-wide National ECHO pilot project in the area of geriatric mental health and reports on the program's impact on providers' care practices. A mixed-methods approach was used to analyze surveys completed by participating healthcare providers. Program evaluation measured satisfaction, achievement of learning objectives, awareness of issues related to geriatric mental health, and comfort and self-efficacy working with older adults. The program led to a statistically significant increase in participants' awareness of issues related to support for older adults with mental illness and comfort and self-efficacy in managing these patients in their own practice. The National ECHO pilot project was successful in building healthcare providers' capacity to care for older adults with mental health issues and positively impacting their practice. These findings support using the ECHO model to provide ongoing geriatric mental health education for clinicians from across Canada and beyond.

The Aging Care 5Ms Competencies: A Modified Delphi Study to Revise Medical Student Competencies for the Care of Older Adults.

PURPOSE: To revise the 2009 Canadian Geriatrics Society (CGS) Core Competencies in the Care of Older Persons for Canadian Medical Students by applying current frameworks and using a modified Delphi process. METHOD: The working group chose the Geriatric 5Ms model and CanMEDS framework to develop and structure the competencies. National (i.e., Canadian) Delphi participants were recruited, and 3 Delphi survey rounds were conducted from 2019 to 2021. Each survey round collected quantitative data using a 7-point Likert scale (LS) and qualitative data using free-text comments. The purpose of the first round was to establish the importance of the components of the proposed competencies (categorized into 13 subsections) and identify additional themes. The second round assessed agreement with 31 proposed competencies organized into 7 themes: aging, caring for older adults, mind, mobility, medications, multicomplexity, and matters the most. The third survey-rated agreement levels after further revisions to the competencies were applied. The final 33 competencies were shared with survey participants for feedback and other stakeholders for external validation. RESULTS: Mean LSs for the importance of the 13 competency component subsections on the first survey varied from 5.11 to 6.54, with an agreement level of 73%-93%. New themes emerged from the qualitative comments. Mean LSs for the 31 competencies on the second survey ranged from 5.57 to 6.81, with an agreement level of 80%-97%. Mean LSs for the revised competencies on the third survey ranged from 5.83 to 6.65, with an agreement level of 83%-95%. CONCLUSIONS: The authors developed the 33 Aging Care 5Ms Competencies for Canadian medical students using a consensus process. The competencies fulfill an important need in medical education, and ultimately, society. The authors strongly believe that the competencies can be woven into existing undergraduate medical curricula through purposeful integration and collaboration, including with other specialties.

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.

Integration of hospital with congregate care homes in response to the COVID-19 pandemic.

Background: The coronavirus disease 2019 (COVID-19) pandemic has highlighted the need to improve the safety of the environments where we care for older adults in Canada. After providing assistance during the first wave, many Ontario hospitals formally partnered with local congregate care homes in a "hub and spoke" model during second pandemic wave onward. The objective of this article is to describe the implementation and longitudinal outcomes of residents in one hub and spoke model composed of a hospital partnered with 18 congregate care homes including four long-term care and 14 retirement or other congregate care homes. Intervention: Homes were provided continuous seven-day per week access to hospital support, including infection prevention and control (IPAC), testing, vaccine delivery and clinical support as needed. Any COVID-19 exposure or transmission triggered a same-day meeting to implement initial control measures. A minimum of weekly on-site visits occurred for long-term care homes and biweekly for other congregate care homes, with up to daily on-site presence during outbreaks. Outcomes: Case detection among residents increased following implementation in context of increased testing, then decreased post-immunization until the Omicron wave when it peaked. After adjusting for the correlation within homes, COVID-related mortality decreased following implementation (OR=0.51, 95% CI, 0.30-0.88; p=0.01). In secondary analysis, homes without pre-existing IPAC programs had higher baseline COVID-related mortality rate (OR=19.19, 95% CI, 4.66-79.02; p<0.001) and saw a larger overall decrease during implementation (3.76% to 0.37%-0.98%) as compared to homes with pre-existing IPAC programs (0.21% to 0.57%-0.90%). Conclusion: The outcomes for older adults residing in congregate care homes improved steadily throughout the COVID-19 pandemic. While this finding is multifactorial, integration with a local hospital partner supported key interventions known to protect residents.

Virtual Fracture Care in Long-Term Care Homes Avoiding Emergency Department Visits.

Long-term care residents with suspected fractures as a result of a fall typically transfer to the emergency department (ED) for diagnostic imaging and care. During the COVID-19 pandemic, transfer to the hospital increased the risk of COVID-19 exposure and resulted in extended isolation days for the resident. A fracture care pathway was developed and implemented to provide rapid diagnostic imaging results and stabilization in the care home, reducing transportation and exposure risk to COVID-19. Eligible residents with a stable fracture would receive a referral to a designated fracture clinic for consultation; fracture care is provided in the care home by long-term care staff. Evaluation of the pathway was completed and demonstrated that 100% of residents did not transfer to the ED and 47% of the residents did not transfer to a fracture clinic for additional care.

Nurse practitioner/physician collaborative models of care: a scoping review protocol.

BACKGROUND: Before the COVID-19 pandemic, many long-term care (LTC) homes experienced difficulties in providing residents with access to primary care, typically delivered by community-based family physicians or nurse practitioners (NPs). During the pandemic, legislative changes in Ontario, Canada enabled NPs to act in the role of Medical Directors thereby empowering NPs to work to their full scope of practice. Emerging from this new context, it remains unclear how NPs and physicians will best work together as primary care providers. NP/physician collaborative models appear key to achieving optimal resident outcomes. This scoping review aims to map available evidence on existing collaborative models of care between NPs and physicians within LTC homes. METHODS: The review will be guided by the research question, "What are the structures, processes and outcomes of collaborative models of care involving NPs and Physicians in LTC homes?" This scoping review will be conducted according to the methods framework for scoping reviews outlined by Arksey and O'Malley and refined by Levac et al., Colquhoun et al., and Daudt et al., as well as the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Statement. Electronic databases (MEDLINE, Embase + Embase Classic, APA PsycInfo, Cochrane Central Register of Controlled Trials, AMED, CINAHL, Ageline, and Scopus), grey literature, and reference lists of included articles will be searched. English language studies that describe NP and physician collaborative models within the LTC setting will be included. DISCUSSION: This scoping review will consolidate what is known about existing NP/physician collaborative models of care in LTC homes. Results will be used to inform the development of a collaborative practice framework for long-term care clinical leadership.

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.

The DWQ-EMR Embedded Tool to Enhance the Family Physician-Caregiver Connection: A Pilot Case Study.

The number of family caregivers to individuals with dementia is increasing. Family physicians are often the first point of access to the health care system for individuals with dementia and their caregivers. Caregivers are at an increased risk of developing negative physical, cognitive and affective health problems themselves. Caregivers also describe having unmet needs to help them sustain care in the community. Family physicians are in a unique position to help support caregivers and individuals with dementia, but often struggle with keeping up with best practice dementia service knowledge. The Dementia Wellness Questionnaire was designed to serve as a starting point for discussions between caregivers and family physicians by empowering caregivers to communicate their needs and concerns and to enhance family physicians' access to specific dementia support information. The DWQ aims to alert physicians of caregiver and patient needs. This pilot study aimed to explore the experiences of physicians and caregivers of people using the Questionnaire in two family medicine clinics in Ontario, Canada. Interviews with physicians and caregivers collected data on their experiences using the DWQ following a 10-month data gathering period. Data was analyzed using content analysis. Results indicated that family physicians may have an improved efficacy in managing dementia by having dementia care case specific guidelines integrated within electronic medical records. By having time-efficient access to tailored supports, family physicians can better address the needs of the caregiver-patient dyad and help support family caregivers in their caregiving role. Caregivers expressed that the Questionnaire helped them remember concerns to bring up with physicians, in order to receive help in a more efficient manner.

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.

Preventing Fractures in Long-Term Care: Translating Recommendations to Clinical Practice.

The Ontario Osteoporosis Strategy for long-term care (LTC) aims to support fracture risk-reduction. LTC specific recommendations for fracture prevention were developed in 2015. This article describes the use of the Knowledge-to Action framework to guide the development and application of research evidence on fracture prevention in older adults. Knowledge translation activities highlighted fractures as a significant source of morbidity in LTC, significant gaps in fracture risk assessment and treatment, and barriers and facilitators to guideline implementation. Multifaceted knowledge translation strategies, targeting staff in LTC homes in Ontario, Canada to support fracture guideline implementation have included education, audit and feedback, team-based action planning, and engagement of LTC residents, their families, and health professionals. Provincial administrative databases were accessed to monitor fracture rates between 2005 and 2015. Our research has identified enablers and barriers to knowledge use such as limited knowledge of osteoporosis, fracture risk, and prevention. Province-wide over a 10-year period, hip fracture rates in LTC decreased from 2.3% to 1.9%, and any fracture rates decreased from 4% to 3.6%. This body of work suggests that multifaceted knowledge translation initiatives are feasible to implement in LTC and can improve the uptake of clinical recommendations for fracture prevention. A key aspect of our fracture prevention knowledge translation activities has been the full engagement of key stakeholders to assist in the co-development and design of knowledge translation products.

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.

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.

Canadian Guidelines on Opioid Use Disorder Among Older Adults.

BACKGROUND: In Canada, rates of hospital admission from opioid overdose are higher for older adults (≥ 65) than younger adults, and opioid use disorder (OUD) is a growing concern. In response, Health Canada commissioned the Canadian Coalition of Seniors' Mental Health to create guidelines for the prevention, screening, assessment, and treatment of OUD in older adults. METHODS: A systematic review of English language literature from 2008-2018 regarding OUD in adults was conducted. Previously published guidelines were evaluated using AGREE II, and key guidelines updated using ADAPTE method, by drawing on current literature. Recommendations were created and assessed using the GRADE method. RESULTS: Thirty-two recommendations were created. Prevention recommendations: it is key to prioritize non-pharmacological and non-opioid strategies to treat acute and chronic noncancer pain. Assessment recommendations: a comprehensive assessment is important to help discern contributions of other medical conditions. Treatment recommendations: buprenorphine is first line for both withdrawal management and maintenance therapy, while methadone, slow-release oral morphine, or naltrexone can be used as alternatives under certain circumstances; non-pharmacological treatments should be offered as an integrated part of care. CONCLUSION: These guidelines provide practical and timely clinical recommendations on the prevention, assessment, and treatment of OUD in older adults within the Canadian context.

Importance of Team Functioning as a Target of Quality Improvement Initiatives in Nursing Homes: A Qualitative Process Evaluation.

INTRODUCTION: Quality improvement interventions demonstrate variable degrees of effectiveness. The aim of this work was to (1) qualitatively explore whether, how, and why an academic detailing intervention could improve evidence uptake and (2) identify perceived changes that occurred to inform outcomes appropriate for quantitative evaluation. METHODS: A qualitative process evaluation was conducted involving semistructured interviews with nursing home staff. Interviews were analyzed inductively using the framework method. RESULTS: A total of 29 interviews were conducted across 13 nursing homes. Standard processes to reduce falls are well-known but not fully implemented due to a range of mostly postintentional factors that influence staff behavior. Conflicting expectations around professional roles impeded evidence uptake; physicians report a disconnection between the information they would like to receive and the information communicated; and a high proportion of casual and part-time staff creates challenges for those looking to effect change. These factors are amenable to change in the context of an active, tailored intervention such as academic detailing. This seems especially true when the entire care team is actively engaged and when the intervention can be tailored to the varied determinants of behaviors across different team members. DISCUSSION: Interventions aiming to increase evidence-based practice in the nursing home sector need to move beyond education to explicitly address team functioning and communication. Variability in team functioning requires a flexible intervention with the ability to tailor to individual- and home-level needs. Evaluations in this setting may benefit from measuring changes in team functioning as an early indicator of success.

Quality Indicators of Primary Care Provider Engagement in Nursing Home Care.

The initiative described here aims to identify quality indicators (QIs) germane to the international practice of primary care providers (PCP) in post-acute and long-term care in order to demonstrate the added value of medical providers in nursing homes (NHs). A 7-member international team identified and adapted existing QIs to the AMDA competencies for medical providers. QI sources included the ACOVE 3 Quality Indicators (2007), NH Quality Indicators (2004), NH Residential Care Quality Indicators (2002), and AGS Choosing Wisely (2014). We recruited a technical expert panel (TEP) consisting of 11 panelists from the US, Canada, and the European Union, selected for their knowledge and leadership in post-acute and long-term care. The TEP, using a RAND Modified Delphi approach, provided pre-meeting ratings, discussed items in-person for clarification, and re-rated items following discussion. When panelists rated more than 1 option for a particular QI as valid and feasible, the most stringent option was selected for inclusion in the final candidate set of QIs. Panelists confidentially rated an initial 103 items on validity and feasibility of implementation. During the meeting, panelists added 18 QIs and modified 18. In post-meeting analysis, we eliminated 7 QIs rated not valid and 9 QIs for which a more stringent QI was rated valid and feasible. This resulted in a final set of 97 QIs rated valid and feasible and 8 rated valid but not feasible. This set of QIs for PCPs in the NH identified practices in which provider engagement adds value through expertise in geriatric syndromes, employing evidence-based practice, advocating for residents, delivering person-centered care, facilitating advance care planning, and communicating effectively to coordinate care. Next steps include pilot testing and evaluating the association between adherence to QIs, PCP staffing models, and better outcomes.

The Prevalence of Burnout Among Nursing Home Physicians: An International Perspective.

Physician burnout is a critical factor influencing the quality of care delivered in various healthcare settings. Although the prevalence and consequences of burnout have been well documented for physicians in various jurisdictions, no studies to date have reported on burnout in the postacute and long-term care setting. In this exploratory study, we sought to quantify the prevalence of burnout among 3 cohorts of physicians, each practicing in nursing homes in the United States (US), Canada, or The Netherlands. International comparisons were solicited to highlight cultural and health system factors potentially impacting burnout levels. Using standard survey techniques, a total of 721 physicians were solicited to participate (Canada 393; US 110; The Netherlands 218). Physicians agreeing to participate were asked to complete the "Maslach Burnout Inventory" using the Survey Monkey platform. A total of 118 surveys were completed from The Netherlands, 59 from Canada, and 65 from the US for response rates of 54%, 15%, and 59%, respectively. While US physicians demonstrated more negative scores in the emotional exhaustion subscale compared with their counterparts in Canada and The Netherlands, there were no meaningful differences on the depersonalization and personal accomplishments subscales. Factors explaining these differences are explored as well as approaches to future research on physician burnout in postacute and long-term care.

Brain Function Is Linked to LDL Cholesterol in Older Adults with Cardiovascular Risk.

OBJECTIVES: To determine how cardiovascular risk is associated with working memory task performance and task-related suppression of default-mode network (DMN) activity in cognitively intact older adults. DESIGN: A cross-sectional functional magnetic resonance imaging study of older adults with cardiovascular risk factors. SETTING: Rotman Research Institute, Baycrest Health Sciences. PARTICIPANTS: Thirty older adults with cardiovascular risk factors. MEASUREMENTS: Participants provided health information and a blood sample, and underwent functional magnetic resonance imaging during a working memory task and during a breath-hold task to assess cerebrovascular reactivity. RESULTS: Higher plasma low-density lipoprotein cholesterol (LDL-C) was associated with poorer working memory task performance (P = 0.008) and reduced task-related DMN suppression (P = 0.005). A composite index of cardiovascular risk, the Framingham General Cardiovascular Risk Profile, showed no associations with task performance or task-related DMN suppression. These findings were independent of white matter burden and cerebrovascular reactivity and thus cannot be accounted for by individual differences in neurovascular health. CONCLUSION: These findings suggest a deleterious effect of elevated LDL-C on working memory task performance and task-related DMN suppression in older adults with cardiovascular risk. The relations between the Framingham General Cardiovascular Risk Profile, cognitive task performance, and DMN function require further study.

Implementation of Mental Health Huddles on Dementia Care Units.

Client-responsive behaviours occur commonly among residents in long-term care (LTC) settings; direct-care staff, however, receive little education, support, or opportunities to discuss and collaborate on managing such behaviours. Our participatory action project introduced mental health huddles to support staff in discussing and managing client-responsive behaviours in long-term care. This research project engaged direct-care staff (e.g., personal support workers, registered practical nurses, housekeeping staff, and registered nurses) in learning how to use these huddles. Staff workers used huddles as a forum to stay informed, review work, problem solve, and develop person-centered action plans. Fifty-six huddles occurred over a 12-week period; two to seven direct-care staff participated in each huddle. Focus groups indicated improved staff collaboration, teamwork, support, and communication when discussing specific responsive behaviours. Huddles provided LTC staff with the opportunity to collaborate and discuss strategies to optimize resident care. Further research on how huddles affect resident care outcomes is needed.