[IPA in primary care: a new gateway to the healthcare system]. / L'IPA en soins primaires : une nouvelle porte d'entrée dans le système de santé.

In France, the supply of healthcare services remains insufficient to meet the growing needs of the population, which has prompted the legislator to authorize direct access to certain professionals, in particular advanced practice nurses (APNs) working in coordinated practice structures. This article details an innovative multi-professional pathway in a nursing home, where the APN takes direct charge of people without a general practitioner, with the aim of improving their access to care and reintegrating them into the healthcare system.

[Aspiration pneumonia and dementia in nursing homes: to anticipate emergency.] / Pneumonie d'aspiration en EMS et démence : anticiper l'urgence.

The care of a nursing home resident suffering from dementia and aspiration pneumonia (AP) is generally initiated by the family doctor (FD) in collaboration with the nursing home professionals. This is a holistic emergency medicine whose occurrence should be the subject of advance care planning, an AP being rarely isolated, and its risk factors are known. AP - the probable cause of half of deaths of demented individuals in nursing homes - requires essentially non-hospital care. It calls on the scientific, relational, collaborative, and ethical skills of the family doctor. This review aims to contextualize the emergency management skills of the FD in the living environment of the nursing home. The management of uncertainty linked to a probabilistic diagnosis is highlighted and care commensurate with life expectancy is provided.

La prise en soins d'un résident d'un établissement médicosocial (EMS) souffrant de démence et de pneumonie d'aspiration (PA) est en général initiée par le médecin de famille (MF) en collaboration avec les professionnels du lieu de vie de la personne. Il s'agit d'une médecine d'urgence holistique qui devrait faire l'objet d'un plan de soins anticipés, la PA étant rarement isolée et ses facteurs de risque étant connus. La PA est la cause probable de la moitié des décès de personnes démentes en EMS. Elle ne devrait en principe pas nécessiter d'hospitalisation. La PA fait appel à des compétences scientifiques, relationnelles, collaboratives et éthiques du MF. Dans cet article de revue, nous contextualisons les compétences de gestion de l'urgence du MF dans un EMS. Nous discutons également de la gestion de l'incertitude en lien avec un diagnostic probabiliste et proposons des soins en adéquation avec l'espérance de vie.

[Response to the urgent need to train family doctors in geriatrics : residency in long term care facilities]. / Réponse à l'urgence de former les médecins de famille à la gériatrie : l'assistanat en EMS.

Family doctors have to provide the geriatric cares needed by an aging population. In particular, the increased complexity of care needs in the population living in long term care facilities (LCTF) raises several challenges. One of these challenges is the adequate training of physicians working in LCTF as well as the next generation. Residency programs in LTCFs for future general practioners has demonstrated their value abroad. We describe here the creation of a residency program in LTCF for family doctors in Canton Vaud. Since its beginning in 2020, the program has not only trained young physicians but has also improved interprofessionality and strengthened the training of other healthcare professionals.

La population vieillissante requiert des soins gériatriques spécifiques auxquels le médecin de famille doit répondre. De plus, la complexification des besoins en soins de la population en établissement médicosocial (EMS) soulève de multiples défis. Un de ces défis est la formation adéquate des médecins travaillant en EMS et leur relève. A l'étranger, l'expérience de tournus des médecins de famille dans des structures similaires aux EMS a démontré sa pertinence. Nous illustrons ici le contexte et la mise en place d'une formation postgraduée en EMS pour les médecins de famille sur le canton de Vaud et présentons un aperçu des bénéfices de ce programme depuis sa mise en place en 2020 : au-delà de la formation de jeunes médecins, l'assistanat en EMS améliore la collaboration interprofessionnelle et contribue à la formation d'autres professionnels de la santé.

The impact of facility and staff characteristics on infection control of COVID-19: Perceptions of elder care home managers in Stockholm, Sweden.

AIM: To examine the perceptions of managers of elder care homes on the impact of facility and staff characteristics on infection control of COVID-19. DESIGN: Case study. METHODS: Six purposively sampled care home managers in the city of Stockholm were interviewed. Through content analysis, three categories and nine subcategories were identified. RESULTS: According to the interviewed care home managers, a home-like environment that allows for isolation of residents and possibilities for staff to get changed and store personal protective equipment outside each resident's room was considered ideal. Experienced employees were reported as invaluable when facing an infectious outbreak. A mix of permanent and temporary staff was considered essential although some thought that temporary staff who work in multiple care homes might negatively influence the spread of infection. Language barriers among staff were considered an obstacle when trying to disseminate information.

The palliative care experience in Irish nursing homes during the COVID-19 pandemic: a survey of residents, family, and staff.

BACKGROUND: Nursing homes and other long-term care services account for a disparate share of COVID-19 cases and casualties worldwide. During COVID-19 there is a distinct need to preserve a holistic view of the wellbeing of residents of nursing homes, be mindful of their rights as citizens, and to be aware of protecting residents from infection. The delivery of health and social care throughout a pandemic must remain person-centred and adhere to a human rights-based approach. METHODS: This study aimed to capture nursing home residents, their families and staff's perspective of the nursing homes residents experience, approaches of staff and the nursing home environment. An online survey was distributed via stakeholder networks and online platforms across Ireland. This study was performed and reported in line with the Consensus-Based Checklist for Reporting of Survey Studies (CROSS). RESULTS: 25 residents, 42 family members and 51 staff completed the survey (n = 118). Across the domains measured all but one aspect scored above 50% (residents get up and go to bed when they want 41.5%) with the highest score of 89.1% scored for the nursing home is comfortable and well-kept. Results highlight evidence of positive experiences and endeavours to preserve social connections, residents were in a safe place cared for by staff who did their best in a difficult position and who went above and beyond their duty of care. However, some families reported poor communication, no internet connections, not enough phones or tablets, and that staff were busy and unable at times to assist residents who needed help using phones/tablets. CONCLUSION: This study highlights the importance of human rights and how they ought to inform and shape the advancement of public health advice and policy documents. Overall, nursing home residents, their families and staff reported favourably on the study measures. However, issues pertaining to communication are essential and there is a need to address issues such as the provision of accurate timely information, communication infrastructure and resources, and inconsistencies in communications. Of note is that while healthcare professionals have a duty to uphold the rights of nursing home residents, they themselves have human rights which must also be protected and supported.

Relation between pre-existing quality management measures and prevention and containment of COVID-19 outbreaks in 159 nursing homes in Tuscany: a mixed methods study.

BACKGROUND: Nursing homes were often the focus of COVID-19 outbreaks. Many factors are known to influence the ability of a nursing home to prevent and contain a COVID-19 outbreak. The role of an organisation's quality management prior to the pandemic is not yet clear. In the Italian region of Tuscany nursing home performance indicators have been regularly collected since before the pandemic, providing the opportunity to better understand this relationship. OBJECTIVES: To test if there is a difference in the results achieved by nursing homes in Tuscany on 13 quality management indicators, when grouped by severity of COVID-19 outbreaks; and to better understand how these indicators may be related to the ability to control COVID-19 outbreaks, from the perspective of nursing homes. METHODS: We used a mixed methods sequential explanatory design. Based on regional and national databases, 159 nursing homes in Tuscany were divided into four groups by outbreak severity. We tested the significance of the differences between the groups with respect to 13 quality management indicators. The potential relation of these indicators to COVID-19 outbreaks was discussed with 29 managers and other nursing homes' staff through four group interviews. RESULTS: The quantitative analysis showed significant differences between the groups of nursing homes for 3 of the 13 indicators. From the perspective of nursing homes, the indicators might not be good at capturing important aspects of the ability to control COVID-19 outbreaks. For example, while staffing availability is seen as essential, the staff-to-bed ratio does not capture the turn-over of staff and temporary absences due to positive COVID-19 testing of staff. CONCLUSIONS: Though currently collected indicators are key for overall performance monitoring and improvement, further refinement of the set of quality management indicators is needed to clarify the relationship with nursing homes' ability to control COVID-19 outbreaks.

Barriers and enablers for externally and internally driven implementation processes in healthcare: a qualitative cross-case study.

BACKGROUND: Quality in healthcare is a subject in need of continuous attention. Quality improvement (QI) programmes with the purpose of increasing service quality are therefore of priority for healthcare leaders and governments. This study explores the implementation process of two different QI programmes, one externally driven implementation and one internally driven, in Norwegian nursing homes and home care services. The aim for the study was to identify enablers and barriers for externally and internally driven implementation processes in nursing homes and homecare services, and furthermore to explore if identified enablers and barriers are different or similar across the different implementation processes. METHODS: This study is based on an exploratory qualitative methodology. The empirical data was collected through the 'Improving Quality and Safety in Primary Care - Implementing a Leadership Intervention in Nursing Homes and Homecare' (SAFE-LEAD) project. The SAFE-LEAD project is a multiple case study of two different QI programmes in primary care in Norway. A large externally driven implementation process was supplemented with a tracer project involving an internally driven implementation process to identify differences and similarities. The empirical data was inductively analysed in accordance with grounded theory. RESULTS: Enablers for both external and internal implementation processes were found to be technology and tools, dedication, and ownership. Other more implementation process specific enablers entailed continuous learning, simulation training, knowledge sharing, perceived relevance, dedication, ownership, technology and tools, a systematic approach and coordination. Only workload was identified as coincident barriers across both externally and internally implementation processes. Implementation process specific barriers included turnover, coping with given responsibilities, staff variety, challenges in coordination, technology and tools, standardizations not aligned with work, extensive documentation, lack of knowledge sharing. CONCLUSION: This study provides understanding that some enablers and barriers are present in both externally and internally driven implementation processes, while other are more implementation process specific. Dedication, engagement, technology and tools are coinciding enablers which can be drawn upon in different implementation processes, while workload acted as the main barrier in both externally and internally driven implementation processes. This means that some enablers and barriers can be expected in implementation of QI programmes in nursing homes and home care services, while others require contextual understanding of their setting and work.

The experiences and needs of older adults receiving voluntary services in Chinese nursing home organizations: a qualitative study.

BACKGROUND: Older adults living in nursing home organizations are eager to get voluntary help, however, their past experiences with voluntary services are not satisfactory enough. To better carry out voluntary services and improve the effectiveness of services, it is necessary to have a deeper understanding of the experiences and needs of older adults for voluntary services. METHODS: The purposive sampling method was used to select 14 older adults from two nursing home organizations in Hangzhou and conduct semi-structured interviews, Collaizzi's seven-step method was used to analyze the data. RESULTS: Older adults in nursing home organizations have both beneficial experiences and unpleasant service experiences in the process of receiving voluntary services; Beneficial experiences include solving problems meeting needs and feeling warmth and care, while unpleasant service experiences include the formality that makes it difficult to benefit truly, lack of organization, regularity, sustainability, and the mismatch between service provision and actual demands. The needs for voluntary services mainly focuses on emotional comfort, Cultural and recreational, and knowledge acquisition. CONCLUSION: Older adults in nursing home organizations have varied voluntary experiences, and their voluntary service needs are diversified. Voluntary service needs of older adults should be accurately assessed, and voluntary service activities should be focused upon.

Implementation of an Advance Care Planning Intervention in Nursing Homes: An International Multiple Case Study.

BACKGROUND AND OBJECTIVES: The inability of individuals in the advanced stage of dementia to communicate about preferences in care at the end-of-life poses a challenge for healthcare professionals and family carers. The proven effective Family Carer Decision Support intervention has been designed to inform family carers about end-of-life care options available to a person living with advanced dementia. The objectives of the mySupport study were to adapt the application of the intervention for use in different countries, assess impact on family satisfaction and decision-making, and identify costs and supportive conditions for the implementation of the intervention. RESEARCH DESIGN AND METHODS: A multiple-case study design was chosen where the nursing home was the case. Nursing homes were enrolled from six countries: Canada, Czech Republic, Italy, Netherlands, Republic of Ireland, and United Kingdom. RESULTS: Seventeen cases (nursing homes) participated, with a total of 296 interviews completed including family carers, nursing home staff, and health providers. Five themes relevant to the implementation of the intervention were identified: supportive relationships; committed staff; perceived value of the intervention; the influence of external factors on the nursing home; and resource impact of delivery. DISCUSSION AND IMPLICATIONS: There is a commonality of facilitators and barriers across countries when introducing practice innovation. A key learning point was the importance of implementation being accompanied by committed and supported nursing home leadership. The nursing home context is dynamic and multiple factors influence implementation at different points of time.

Skin care types, frequencies and products: A cross-sectional study in German institutional long-term care.

AIM: The aim of the study was to describe types and frequencies of skin care interventions and products provided in institutional long-term care. MATERIALS AND METHODS: Baseline data from a cluster randomized controlled trial conducted in nursing homes in Berlin, Germany was collected before randomization. Numbers, proportions and frequencies of washing, showering and bathing, and the application of leave-on products were calculated. Product labels were iteratively and inductively categorized into overarching terms and concepts. RESULTS: A total of n = 314 residents participated in the study. In the majority, washing of the whole body was done once daily, and showering was performed once per week or more rarely. The majority received leave-on products daily on the face and once per week on the whole body. Most of the skin care interventions were delivered by nurses. There was marked heterogeneity in terms of product names, whereas the product names reveal little about the ingredients or composition. CONCLUSION: Personal hygiene and cleansing interventions are major parts of clinical practice in long-term care. Daily washing is a standard practice at the moment. In contrast, leave-on products are used infrequently. To what extent the provided care promotes skin integrity is unclear. Due to the heterogeneity and partly misleading labels of skin care products, informed decision making is difficult to implement at present. GOV IDENTIFIER: NCT03824886.

Designing a virtual course for essential care partners (ECPs) in long-term care (LTC): a pre-implementation study.

Objectives: We describe our co-design process aimed at supporting the reintegration of essential care partners into long-term care homes during the COVID-19 pandemic.Methods: More specifically, using a co-design process, we describe the pre-design, generative, and evaluative phases of developing a virtual infection prevention and control course for essential care partners at our partnering long-term care home. For the evaluative phase, we also provide an overview of our findings from interviews conducted with essential care partners on the expected barriers and facilitators associated with this virtual course.Results: Results from these interviews indicated that the virtual course was viewed as comprehensive, detailed, engaging, refreshing, and reliable, and that its successful implementation would require appropriate resources and support to ensure its sustainability and sustainment. Findings from this study provide guidance for the post-design phase of our co-design process.Conclusion: Our careful documentation of our co-design process also facilitates its replication for other technological interventions and in different healthcare settings. Limitations of the present study and implications for co-designing in the context of emergent public health emergencies are explored in the discussion.

Psychological and Structural Burdens and Nursing Home Administrator Turnover Intentions During the COVID-19 Pandemic.

The COVID-19 pandemic created challenges for U. S. nursing home administrators (NHA) and staff. This study explored organizational and psychological factors associated with NHA stress, dissatisfaction, and turnover intent (TI) during the third year of the pandemic. Results from a nationwide, cross-sectional survey of 1139 NHAs were merged with Centers for Medicare and Medicaid Services nursing home survey deficiency, staffing, complaint, and other operations data. A hierarchical, generalized estimating equations model with ordered logit link found that NHAs with higher COVID stress (AOR = 1.65, 95% CI = 1.22, 2.23), higher use of agency/contract staff (AOR = 1.50, 95% CI = 1.08.2.09) and higher role conflict were more likely to indicate TI. NHAs with higher job satisfaction in workload, work content, and rewards were less likely to hold TI. Industry leaders should create strategies to reduce NHA's job stress and role conflicts and provide opportunities for improving staff recruitment and retention, reducing reliance on agency staffing.

[Palliative and Hospice Care in Nursing Homes: Discrepancies Between Theoretical Framework and Everyday Practice]. / Palliativversorgung und hospizliche Begleitung in der stationären Pflege zwischen theoretischem Konzept und Praxisalltag.

OBJECTIVES: Despite the existence of a legislative framework, palliative care and hospice support in nursing homes vary widely. Although most nursing homes have palliative care concepts by now, they are rarely integrated into everyday practice. This study aims to examine differences in palliative and hospice care and to determine the causes of discrepancies between theoretical framework and everyday practice. METHODS: Based on a pilot project, in depth structural and process analyses of two nursing homes in urban and rural areas in North Rhine-Westphalia were conducted. In addition, three nursing homes of an extended group of providers as well as an expert advisory board was included to minimize (provider-) specific characteristics and to expand findings. RESULTS: Although the proportion of palliative residents and their average age was comparable, analyses revealed significant differences between the nursing homes regarding the palliative length of stay (213.2 days vs. 88.6 days) as well as the mortality rate of palliative residents among all death cases (26% vs. 63.6%). Furthermore, internal processes within the nursing homes differed vastly despite similar concepts and procedural instructions. As a result, palliative care formally started at an earlier stage in nursing home X. Besides that, the identification of palliative care situations, as well as communication, organizational processes and the inclusion of cooperation partners, took place without fixed structures and was based on the subjective handling of staff members in both facilities. CONCLUSIONS: It turns out to be challenging for nursing homes to implement theoretical framework into everyday practice. To facilitate this process, aside from practicable assessments, defined responsibilities and organizational support, financing concepts at health policy level need to be established.

Professionals´ readiness for change to knowledge-based palliative care at nursing homes: a qualitative follow-up study after an educational intervention.

BACKGROUND: There has been a global increase in the number of people who are dying of old age. This development implies a need for good palliative care among older persons at the end of life. Here nursing homes have an important role to play. However, the principles of palliative care have not been sufficiently applied in nursing homes, and there is a need to increase the implementation of palliative care in these settings. Therefore the project named Implementation of Knowledge-Based Palliative Care in Nursing Homes (the KUPA project, to use its Swedish acronym) was started as a contribution to filling this knowledge gap. The aim of the present study was to investigate the professionals' experiences of readiness for change to knowledge-based palliative care at nursing homes after the educational intervention within the KUPA project. METHODS: The focus group method was used to interview 39 health-care professionals with the aid of semistructured questions based on the Organizational Readiness for Change theoretical framework. Six focus groups were formed at six nursing homes in two counties in southern Sweden. The groups included different types of professionals: assistant nurses, nurses, occupational therapists, physiotherapists and social workers. The analysis was conducted with an abductive approach and included deductive and inductive content analysis. RESULTS: The analysis revealed one overarching theme: hopeful readiness for change in palliative care despite remaining barriers. The main categories were increased knowledge facilitating development, enhanced team spirit, uncertainty about future plans connected with hopeful readiness and remaining organizational barriers. CONCLUSIONS: This study adds knowledge and understanding concerning professionals' readiness for change palliative care in nursing homes and shows how ready nursing home settings undertake these changes in practice. The Organizational Readiness for Change theory proved suitable for application in nursing homes to assess the professionals' experiences and to evaluate educational interventions regardless of the organization's readiness for change. TRIAL REGISTRATION: ClinicalTrials NCT02708498 , first registration 15/03/2016.

Advancing Clinical Trials in Nursing Homes: A Proposed Roadmap to Success.

An effective clinical research effort in nursing homes to address prevention and treatment of COVID-19 faced overwhelming challenges. Under the Health Care Systems Research Network-Older Americans Independence Centers AGING Initiative, a multidisciplinary Stakeholder Advisory Panel was convened to develop recommendations to improve the capability of the clinical research enterprise in US nursing homes. The Panel considered the nursing home as a setting for clinical trials, reviewed the current state of clinical trials in nursing homes, and ultimately developed recommendations for the establishment of a nursing home clinical trials research network that would be centrally supported and administered. This report summarizes the Panel's recommendations, which were developed in alignment with the following core principles: build on available research infrastructure where appropriate; leverage existing productive partnerships of researchers with groups of nursing homes and nursing home corporations; encompass both efficacy and effectiveness clinical trials; be responsive to a broad range of stakeholders including nursing home residents and their care partners; be relevant to an expansive range of clinical and health care delivery research questions; be able to pivot as necessary to changing research priorities and circumstances; create a pathway for industry-sponsored research as appropriate; invest in strategies to increase diversity in study populations and the research workforce; and foster the development of the next generation of nursing home researchers.

Leadership and Staff Perceptions on Long-term Care Staffing Challenges Related to Certified Nursing Assistant Retention.

OBJECTIVE: This study investigates practices that may help retain certified nursing assistants (CNAs) and address the staffing challenges faced in long-term care. BACKGROUND: CNAs are critical to quality care and retention has never been more challenging. To solve this staffing crisis, understanding the unique perspective of CNAs is imperative. METHODS: In semistructured interviews, 5 nursing assistants, the director of nursing, and the nursing home administrator at 59 long-term care facilities answered 4 questions, providing multiple perspectives about causes and solutions to CNA staffing challenges. RESULTS: Key responses for each stakeholder group were identified. CNAs highlighted the nature of the job as a bigger challenge than leadership recognized. Although pay is a top concern, emotional support, training, relationship-building, communication, and the work culture can be equally important in reducing turnover. CONCLUSION: When organizational leaders understand how to meet the needs and interests of CNAs, they can reduce turnover.

Pro-active monitoring and social interventions at community level mitigate the impact of coronavirus (COVID-19) epidemic on older adults' mortality in Italy: A retrospective cohort analysis.

BACKGROUND: The COVID-19 epidemic in Italy has severely affected people aged more than 80, especially socially isolated. Aim of this paper is to assess whether a social and health program reduced mortality associated to the epidemic. METHODS: An observational retrospective cohort analysis of deaths recorded among >80 years in three Italian cities has been carried out to compare death rate of the general population and "Long Live the Elderly!" (LLE) program. Parametric and non-parametric tests have been performed to assess differences of means between the two populations. A multivariable analysis to assess the impact of covariates on weekly mortality has been carried out by setting up a linear mixed model. RESULTS: The total number of services delivered to the LLE population (including phone calls and home visits) was 34,528, 1 every 20 day per person on average, one every 15 days during March and April. From January to April 2019, the same population received one service every 41 days on average, without differences between January-February and March-April. The January-April 2020 cumulative crude death rate was 34.8‰ (9,718 deaths out of 279,249 individuals; CI95%: 34.1-35.5) and 28.9‰ (166 deaths out of 5,727 individuals; CI95%:24.7-33.7) for the general population and the LLE sample respectively. The general population weekly death rate increased after the 11th calendar week that was not the case among the LLE program participants (p<0.001). The Standardized Mortality Ratio was 0.83; (CI95%: 0.71-0.97). Mortality adjusted for age, gender, COVID-19 weekly incidence and prevalence of people living in nursing homes was lower in the LLE program than in the general population (p<0.001). CONCLUSIONS: LLE program is likely to limit mortality associated with COVID-19. Further studies are needed to establish whether it is due to the impact of social care that allows a better clients' adherence to the recommendations of physical distancing or to an improved surveillance of older adults that prevents negative outcomes associated with COVID-19.