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 impact of the COVID-19 pandemic on transfers between long-term care and emergency departments across Alberta.

BACKGROUND: Long-term care (LTC) was overwhelmingly impacted by COVID-19 and unnecessary transfer to emergency departments (ED) can have negative health outcomes. This study aimed to explore how the COVID-19 pandemic impacted LTC to ED transfers and hospitalizations, utilization of community paramedics and facilitated conversations between LTC and ED physicians during the first four waves of the pandemic in Alberta, Canada. METHODS: In this retrospective population-based study, administrative databases were linked to identify episodes of care for LTC residents who resided in facilities in Alberta, Canada. This study included data from January 1, 2018 to December 31, 2021 to capture outcomes prior to the onset of the pandemic and across the first four waves. Individuals were included if they visited an emergency department, received care from a community paramedic or whose care involved a facilitated conversation between LTC and ED physicians during this time period. RESULTS: Transfers to ED and hospitalizations from LTC have been gradually declining since 2018 with a sharp decline seen during wave 1 of the pandemic that was greatest in the lowest-priority triage classification (CTAS 5). Community paramedic visits were highest during the first two waves of the pandemic before declining in subsequent waves; facilitated calls between LTC and ED physicians increased during the waves. CONCLUSIONS: There was a reduction in number of transfers from LTC to EDs and in hospitalizations during the first four waves of the pandemic. This was supported by increased conversations between LTC and ED physicians, but was not associated with increased community paramedic visits. Additional work is needed to explore how programs such as community paramedics and facilitated conversations between LTC and ED providers can help to reduce unnecessary transfers to hospital.

Barriers and Facilitators to the Use of Personal Protective Equipment in Long-Term Care: A Scoping Review.

OBJECTIVE: To review existing literature evaluating barriers and facilitators to the use of personal protective equipment (PPE) by health care workers in long-term care (LTC). DESIGN: Scoping review. SETTING AND PARTICIPANTS: Health care workers in LTC settings. METHODS: Several online databases were searched and a gray literature search was conducted. Study inclusion criteria were (1) conducted in nursing homes or LTC settings, (2) focused on LTC health care workers as the study population, and (3) identified barriers and/or facilitators to PPE use. The Theoretical Domains Framework (TDF), which assesses barriers to implementation across 14 behavioral change domains, was used to extract and organize data about barriers and facilitators to appropriate use of PPE from the included studies. RESULTS: A total of 5216 references were screened for eligibility and 10 studies were included in this review. Eight of the 10 studies were conducted during the COVID-19 pandemic. Several barriers and facilitators to PPE use were identified. The most common TDF domain identified was environmental context and resources, which was observed in 9 of the 10 studies. Common barriers to PPE use included supply issues (n = 7 studies), the cost of acquisition (n = 3 studies), unclear guidelines on appropriate use of PPE (n = 2 studies), difficulty providing care (n = 2 studies), and anxiety about frightening patients (n = 2 studies). Having PPE readily available facilitated the use of PPE (n = 2 studies). CONCLUSIONS AND IMPLICATIONS: Further research is necessary to identify barriers and facilitators more extensively across behavior change domains to develop effective strategies to improve PPE use and prevent infection transmission within LTC.

Efficacy of virtual interventions for reducing symptoms of depression in community-dwelling older adults: a systematic review.

BACKGROUND: Older adults experience symptoms of depression, leading to suffering and increased morbidity and mortality. Although we have effective depression therapies, physical distancing and other public health measures have severely limited access to in-person interventions. OBJECTIVE: To describe the efficacy of virtual interventions for reducing symptoms of depression in community-dwelling older adults. DESIGN: Systematic review. SETTING: We searched MEDLINE, EMBASE, Cochrane Libraries, PsycINFO, and gray literature from inception to July 5, 2021. PARTICIPANTS AND INTERVENTIONS: We included randomized trials (RCTs) comparing the efficacy of virtual interventions to any other virtual intervention or usual care in community-dwelling adults ≥60 years old experiencing symptoms of depression or depression as an outcome. MEASUREMENTS: The primary outcome was change in symptoms of depression measured by any depression scale. RESULTS: We screened 12,290 abstracts and 830 full text papers. We included 15 RCTs (3100 participants). Five RCTs examined persons with depression symptoms at baseline and ten examined depression as an outcome only. Included studies demonstrated feasibility of interventions such as internet or telephone cognitive behavioral therapy with some papers showing statistically significant improvement in depressive symptoms. CONCLUSIONS: There is a paucity of studies examining virtual interventions in older adults with depression. Given difficulty in accessing in-person therapies in a pandemic and poor access for people living in rural and remote regions, there is an urgent need to explore efficacy, effectiveness, and implementation of virtual therapies.

Improving care for residents in long term care facilities experiencing an acute change in health status.

BACKGROUND: Long term care (LTC) facilities provide health services and assist residents with daily care. At times residents may require transfer to emergency departments (ED), depending on the severity of their change in health status, their goals of care, and the ability of the facility to care for medically unstable residents. However, many transfers from LTC to ED are unnecessary, and expose residents to discontinuity in care and iatrogenic harms. This knowledge translation project aims to implement a standardized LTC-ED care and referral pathway for LTC facilities seeking transfer to ED, which optimizes the use of resources both within the LTC facility and surrounding community. METHODS/DESIGN: We will use a quasi-experimental randomized stepped-wedge design in the implementation and evaluation of the pathway within the Calgary zone of Alberta Health Services (AHS), Canada. Specifically, the intervention will be implemented in 38 LTC facilities. The intervention will involve a standardized LTC-ED care and referral pathway, along with targeted INTERACT® tools. The implementation strategies will be adapted to the local context of each facility and to address potential implementation barriers identified through a staff completed barriers assessment tool. The evaluation will use a mixed-methods approach. The primary outcome will be any change in the rate of transfers to ED from LTC facilities adjusted by resident-days. Secondary outcomes will include a post-implementation qualitative assessment of the pathway. Comparative cost-analysis will be undertaken from the perspective of publicly funded health care. DISCUSSION: This study will integrate current resources in the LTC-ED pathway in a manner that will better coordinate and optimize the care for LTC residents experiencing an acute change in health status.

Keeping Long-Term Care Patients Out of Hospital During Acute Medical Illness: Proposal for Common Elements of an Integrated Healthcare Delivery System for Long-Term Care.

Integration of acute and palliative care services for long-term care (LTC) residents reduces the morbidity and mortality associated with avoidable hospitalizations while contributing to healthcare system sustainability. This paper explores patient, provider and system factors contributing to potentially avoidable emergency room visits from LTC homes, based on our clinical and quality improvement work in the Greater Toronto Area and Calgary, as well as reviews the existing literature. Commonalities are used to identify key elements for developing an integrated healthcare delivery system to manage acute medical changes in LTC residents and minimize the need for in-patient hospitalization.

Aging at Home: A Portrait of Home-Based Primary Care Across Canada.

Older adults and their families often struggle in navigating an increasingly fragmented healthcare system when it becomes increasingly difficult to receive care beyond their homes in the face of advanced illness, frailty and complex care needs. The provision of integrated home-based primary care has demonstrated improved patient and caregiver experiences and reduced healthcare costs when primary care providers collaborate in delivering care as part of larger interprofessional teams. In this trans-Canada portrait of five urban home-based primary care programs, their core features are highlighted to provide a roadmap on how to integrate this form of care into a Patient's Medical Home in partnership with acute and home-care providers.

A controlled quality improvement trial to reduce the use of physical restraints in older hospitalized adults.

OBJECTIVES: To implement and evaluate an evidence-informed multicomponent strategy to reduce physical restraint use in older adults admitted to acute care medical units. DESIGN: Stepped-wedge trial. SETTING: Four acute care medical units in Calgary, Alberta, over a 4-month time period. PARTICIPANTS: Data were collected from individuals aged 65 and older present on the study units during monthly restraint audits. INTERVENTION: Development of opinion leaders among the nursing leadership, education and training of physicians and unit nurses, and implementation of least restraint rounds. MEASUREMENTS: The primary outcome was rate of restraint use as determined from walk-around audits. Secondary outcomes included number of physician orders for physical restraints on the electronic medical record and fall reports. RESULTS: Thirteen percent to 27% of individuals were being restrained on the medical units before the intervention, with the vast majority of restraints being bed rails. This decreased to 7% to 14% after the intervention. The intervention resulted in a statistically significant reduction in restraint use measured in the early mornings (P = .01), and this trend continued after adjusting for unit and month (P = .06). Similarly, the rate of restraint use trended down at all other measured time periods but was not statistically significant. A limited number of individuals had an order for physical restraint within their electronic medical record (3% before, 2% after the intervention). The median number of monthly fall reports did not change (three before, three after; P = .60). CONCLUSION: A multicomponent team-focused quality improvement intervention has the potential to decrease the use of physical restraints in older hospitalized adults.