Does proactive care in care homes improve survival? A quality improvement project.

BACKGROUND: NHS England's 'Enhanced Health in Care Homes' specification aims to make the healthcare of care home residents more proactive. Primary care networks (PCNs) are contracted to provide this, but approaches vary widely: challenges include frailty identification, multidisciplinary team (MDT) capability/capacity and how the process is structured and delivered. AIM: To determine whether a proactive healthcare model could improve healthcare outcomes for care home residents. DESIGN AND SETTING: Quality improvement project involving 429 residents in 40 care homes in a non-randomised crossover cohort design. The headline outcome was 2-year survival. METHOD: All care home residents had healthcare coordinated by the PCN's Older Peoples' Hub. A daily MDT managed the urgent healthcare needs of residents. Proactive healthcare, comprising information technology-assisted comprehensive geriatric assessment (i-CGA) and advanced care planning (ACP), were completed by residents, with prioritisation based on clinical needs.Time-dependent Cox regression analysis was used with patients divided into two groups:Control group: received routine and urgent (reactive) care only.Intervention group: additional proactive i-CGA and ACP. RESULTS: By 2 years, control group survival was 8.6% (n=108), compared with 48.1% in the intervention group (n=321), p<0.001. This represented a 39.6% absolute risk reduction in mortality, 70.2% relative risk reduction and the number needed to treat of 2.5, with little changes when adjusting for confounding variables. CONCLUSION: A PCN with an MDT-hub offering additional proactive care (with an i-CGA and ACP) in addition to routine and urgent/reactive care may improve the 2-year survival in older people compared with urgent/reactive care alone.

Reform and reverberation: Australian aged care policy changes and the unintended consequences for allied health.

INTRODUCTION: Allied health has a valuable role in providing services to people living in residential aged care. The recent Royal Commission into Aged Care Quality and Safety included several important recommendations relating to the nursing, personal care, and allied health workforce and the care that they provide. The purpose of this paper is to review these recommendations and the Australian Government's policy responses and explore the emerging changes in allied health service provision in residential aged care. METHODS: Data from the four available Quarterly Financial Reports from the 2022-2023 financial year were extracted and analysed in relation to staff costs and time per person per day across personal care, nursing, and allied health workers. Supplementary data sources including the 2020 Aged Care Workforce Census were accessed to provide contextual data relating to individual allied health professions, including occupational therapy. RESULTS: The analysis shows a modest increase in median registered nurse minutes per person per day, and cost per person per day, from the first to second quarter, and again in the third and fourth. By contrast, median time and cost for allied health declined. From 5.6 minutes per person per day in the first quarter, reported allied health minutes fell to 4.6 minutes per person per day in the second quarter, an 18% decrease, and by the fourth quarter was 4.3 minutes per person per day. This is just over half the Australian average of 8 minutes reported to the RCACQS in 2019. CONCLUSION: Under recent residential aged care reforms, aged care providers have regulatory incentives to concentrate their financial resources on meeting the mandated care hours for registered nurses, enrolled nurses, personal care workers, and assistants in nursing. These same reforms do not mandate minutes of allied health services. Although providers of residential aged care in Australia continue to employ and value allied health, we argue that mandating care minutes for personal and nursing care without mandating the provision of allied health creates a perverse incentive whereby access to allied health services is unintentionally reduced.

National surveillance using a clinical quality indicator for prolonged antipsychotic use among older Australians with dementia who access aged care services.

OBJECTIVES: Dementia guidelines recommend antipsychotics are only used for behavioral and psychological symptoms when non-drug interventions fail, and to regularly review use. Population-level clinical quality indicators (CQIs) for dementia care in permanent residential aged care (PRAC) typically monitor prevalence of antipsychotic use but not prolonged use. This study aimed to develop a CQI for antipsychotic use >90 days and examine trends, associated factors, and variation in CQI incidence; and examine duration of the first episode of use among individuals with dementia accessing home care packages (HCPs) or PRAC. METHODS: Retrospective cohort study, including older individuals with dementia who accessed HCPs (n = 50,257) or PRAC (n = 250,196). Trends in annual CQI incidence (2011-12 to 2015-16) and associated factors were determined using Poisson regression. Funnel plots examined geographical and facility variation. Time to antipsychotic discontinuation was estimated among new antipsychotic users accessing HCP (n = 2367) and PRAC (n = 15,597) using the cumulative incidence function. RESULTS: Between 2011-12 and 2015-16, antipsychotic use for >90 days decreased in HCP recipients from 10.7% (95% CI 10.2-11.1) to 10.1% (95% CI 9.6-10.5, adjusted incidence rate ratio (aIRR) 0.97 (95% CI 0.95-0.98)), and in PRAC residents from 24.5% (95% CI 24.2-24.7) to 21.8% (95% CI 21.5-22.0, aIRR 0.97 (95% CI 0.96-0.98)). Prior antipsychotic use (both cohorts) and being male and greater socioeconomic disadvantage (PRAC cohort) were associated with higher CQI incidence. Little geographical/facility variation was observed. Median treatment duration in HCP and PRAC was 334 (interquartile range [IQR] 108-958) and 555 (IQR 197-1239) days, respectively. CONCLUSIONS: While small decreases in antipsychotic use >90 days were observed between 2011-12 and 2015-16, findings suggest antipsychotic use among aged care recipients with dementia can be further minimized.

Evaluation of Long-Term Institutions for Older People in Brazil: an overview of regional inequalities. / Avaliação das Instituições de Longa Permanência para Idosos no Brasil: um panorama das desigualdades regionais.

This article aims to evaluate the Brazilian Long-Term Institutions for Older People (LTIE), according to the Integrated Multidimensional Theoretical Model of Quality and Service (MIQA), and compare the performance achieved between the regions of the country. Descriptive ecological study carried out with public secondary data from the LTIE participating in the 2018 Census of the Unified Social Assistance System. An Evaluation Matrix was constructed from the Census variables and the MIQA Theoretical Model. Quality parameters were used to classify the institutions' performance for each indicator as "incipient", "developing" or "desirable". The disparity index was obtained for each indicator. 1,665 institutions were analyzed. Differences were observed in the percentages of LTIE with "desirable" performance between Brazilian regions, and the need for improvement in most LTIE in relation to the proportion of caregivers of older people, the composition of the multidisciplinary team, accessibility and supply of health promotion actions. There was a need for government support for the suppression of exclusionary differentiation criteria and for the expansion of services to overcome overcrowding.

O objetivo deste artigo é avaliar as Instituições de Longa Permanência para Idosos (ILPI) brasileiras, segundo o Modelo Teórico Multidimensional Integrado de Qualidade e Atendimento (MIQA), e comparar o desempenho alcançado entre as regiões do país. Estudo ecológico descritivo realizado com dados secundários públicos das ILPI participantes do Censo do Sistema Único da Assistência Social de 2018. Uma Matriz de Avaliação foi construída a partir das variáveis do Censo e do Modelo Teórico MIQA. Parâmetros de qualidade foram empregados para classificar o desempenho das instituições para cada indicador em "incipiente", "em desenvolvimento" ou "desejável. O índice de disparidade foi obtido para cada indicador. Foram analisadas 1.665 instituições. Observaram-se diferenças nos percentuais de ILPI com desempenho "desejável" entre as regiões brasileiras, e a necessidade de aprimoramento na maioria das ILPI em relação à proporção de cuidadores de pessoas idosas, a composição da equipe multiprofissional, a acessibilidade e a oferta de ações de promoção de saúde. Verificou-se a necessidade de apoio governamental para a supressão dos critérios de diferenciações excludentes e para a expansão dos serviços para superar as superlotações.

Safety Concerns for Persons with Dementia in Senior Housing: A Qualitative Study with Korean American Caregivers in Los Angeles.

Subsidized senior housing helps many socioeconomically disadvantaged older adults pursue independent living and aging in place. However, cognitive impairment or dementia poses a critical challenge to many residents' ability to live independently and safely. Focusing on Korean American dementia caregivers, a group known to be vulnerable to caregiving burden but understudied, we explored the safety of persons with dementia in senior housing from the perspectives of caregivers. Qualitative data from nine caregivers whose care recipients were current or former residents of subsidized senior housing in Los Angeles were analyzed by the constant comparative method. Major concerns emerged were: (1) fire risks, (2) wandering, (3) physical injury (e.g., self-harm, falls), and (4) potential neglect. Caregivers also mentioned errors in the self-administration of medications, potential financial exploitation, and interpersonal conflicts. These concerns provide implications for services and programs for the safety of persons with dementia who live in senior housing.

Long-term care facilities for older people and the COVID-19 pandemic: epidemiological data and preventive measures / Instituições de longa permanência para idosos e a pandemia de COVID-19: dados epidemiológicos e medidas preventiva

Objectives: The COVID-19 pandemic has challenged society, especially residents of long-term care facilities (LTCF). This study investigated rates of infection, hospitalization, and death due to COVID-19 among LTCF residents and staff in Minas Gerais, Brazil and identified strategies to control the spread of the disease.Methods: This cross-sectional study collected data from 164 LTCF (6017 older adults). The owners or managers were invited to answer an electronic questionnaire. The questionnaire included 55 items, divided into 3 sections.Results: Of the participating LTCF, 48.7%, 39.6%, and 32.3% reported COVID-19 infections, hospitalizations, and deaths, respectively, among residents, while 68.9%, 7.3%, and 1.2% reported COVID-19 infections, hospitalizations, and deaths, respectively, among staff. Preventive measures were identified and classified as organizational, infrastructural, hygiene items/personal protective equipment, and staff training.Conclusion: The strategies used in the daily routines of LTCF during the pandemic were classified. The challenges experienced in Brazilian facilities were similar to those observed worldwide. The results highlight the importance of continuity and the need to improve protective measures for LTCF residents, especially in low- and middle-income countries

Objetivos: A pandemia da COVID-19 tem sido desafiadora para a sociedade, principalmente para aqueles que residem em Instituições de Longa Permanência (ILPI). Este estudo teve como objetivo descrever as taxas de infecção, hospitalização e óbito por COVID-19 entre idosos e funcionários de ILPI de Minas Gerais/Brasil e identificar estratégias de prevenção e controle da disseminação da doença.Metodologia: Este estudo transversal foi realizado com 164 ILPI (6.017 idosos). Os gestores ou proprietários foram convidados a responder ao questionário eletrônico. O questionário incluiu 55 itens, divididos em três seções.Resultados: Entre as ILPI estudadas, 48,7% confirmaram a infecção por COVID-19 em idosos, resultando em 39,6% de internação e 32,3% de óbito entre os infectados. Além disso, 68,9% das ILPI confirmaram infecção por COVID-19 na equipe, com 7,3% de internação e 1,2% de óbito. As medidas preventivas foram identificadas e classificadas como organizacionais, infraestrutura, itens de higiene e equipamentos de proteção individual e treinamento de pessoal contra a COVID-19.Conclusão: Essas medidas revelaram estratégias e barreiras vivenciadas no cotidiano das ILPI durante a pandemia. As ILPI no Brasil passaram por desafios semelhantes aos observados mundialmente. Os resultados destacaram a importância da continuidade e melhoria das medidas de proteção para idosos em ILPI, especialmente em países de baixa e média renda

Trends in the Use of Residential Settings Among Older Adults.

OBJECTIVES: As the U.S. population ages, the prevalence of disability and functional limitations, and demand for long-term services and supports (LTSS), will increase. This study identified the distribution of older adults across different residential settings, and how their health characteristics have changed over time. METHODS: A cross-sectional analysis of older adults residing in traditional housing, community-based residential facilities (CBRFs), and nursing facilities using 3 data sources: the Medicare Current Beneficiary Survey (MCBS), 2008 and 2013; the Health and Retirement Study (HRS), 2008 and 2014; and the National Health and Aging Trends Study, 2011 and 2015. We calculated the age-standardized prevalence of older adults by setting, functional limitations, and comorbidities and tested for health characteristics changes relative to the baseline year (2002). RESULTS: The proportion of older adults in traditional housing increased over time, relative to baseline (p < .05), while the proportion of older adults in CBRFs was unchanged. The proportion of nursing facility residents declined from 2002 to 2013 in the MCBS (p < .05). The prevalence of dementia and functional limitations among traditional housing residents increased, relative to the baseline year in the HRS and MCBS (p < .05). DISCUSSION: The proportion of older adults residing in traditional housing is increasing, while the nursing facility population is decreasing. This change may not be due to better health; rather, older adults may be relying on noninstitutional LTSS.

Identification and Critical Appraisal of Food Service Satisfaction Questionnaires for Use in Nursing Homes: A Systematic Review.

BACKGROUND: Food service provision in nursing homes is a complex, adaptive system through which multiple stakeholders interface. Organizational stakeholders include staff involved in preparing and delivering meals. Consumer stakeholders are the end users including residents and family. Questionnaires can be an economical and efficient method of measuring food service satisfaction in nursing homes and a powerful quality improvement tool. OBJECTIVE: (1) To identify questionnaires that measure food service satisfaction of various stakeholders in a nursing homes and (2) to critically appraise the psychometric properties of identified questionnaires. METHODS: Five electronic databases were searched (Cumulative Index to Nursing and Allied Health Literature, Medline, ProQuest, Scopus, and Cochrane) in April 2020. Data from the eligible studies were extracted, and the psychometric properties were critically appraised using the Consensus-Based Standards for the Selection of Health Measurement Instruments. RESULTS: This review identified 129 studies that used a questionnaire to measure food service satisfaction in nursing homes. Of those, 107 studies representing 75 unique general nursing home satisfaction questionnaires were excluded for failing to adequately explore aspects related to food service. From the remaining 22 studies, 7 food service satisfaction questionnaires were identified; 5 intended for consumers (residents) and 2 intended for organizational stakeholders (staff). Using the Consensus-Based Standards for the Selection of Health Measurement Instruments quality criteria, most questionnaires had flaws in content validity and construct validity, primarily due to small sample sizes. No questionnaires explored food service satisfaction from the family perspective. CONCLUSIONS: Nursing homes collect satisfaction information for accreditation, marketing, benchmarking, and quality improvement. Although questionnaires are easy to administer, the quality of the data they collect is impacted by the validity and reliability of the questionnaires used. Using unreliable satisfaction data may mean that nursing homes are not accurately able to understand the impact of changes in the system on stakeholder satisfaction.

"It's Been a Whole New World": Staff Perceptions of Implementing a Person-Centered Communication Intervention During the COVID-19 Pandemic.

The coronavirus disease 2019 (COVID-19) has challenged the way nursing homes deliver person-centered care (PCC). Preferences for Activity and Leisure (PAL) Cards are a tool to communicate residents' important preferences to staff. Monthly interviews (N = 32) were conducted with champions who were conducting a PAL Card quality improvement project in Tennessee nursing homes (N = 11) between March and August 2020. Three major themes emerged: Structural Changes (e.g., halting admissions, adding an isolation unit), Resident Burden (e.g., physical isolation, loneliness), and Provider Burnout (e.g., increased workload, mental exhaustion). Further, providers expressed the benefits to using PAL Cards, specifically in regard to blunting the negative impact of each theme. Results showed the overall negative impact of COVID-19 on nursing home communities. Nursing staff experienced greater burden than other staff, reflecting their prominent role in providing direct care to residents with COVID-19. Staff reported that PAL Cards helped promote PCC. [Journal of Gerontological Nursing, 47(5), 9-13.].

ADVANCE: Methodology of a qualitative study.

BACKGROUND/OBJECTIVES: Quantitative studies have documented persistent regional, facility, and racial differences in the intensity of care provided to nursing home (NH) residents with advanced dementia including, greater intensity in the Southeastern United States, among black residents, and wide variation among NHs in the same hospital referral region (HRR). The reasons for these differences are poorly understood, and the appropriate way to study them is poorly described. DESIGN: Assessment of Disparities and Variation for Alzheimer's disease Nursing home Care at End of life (ADVANCE) is a large qualitative study to elucidate factors related to NH organizational culture and proxy perspectives contributing to differences in the intensity of advanced dementia care. Using nationwide 2016-2017 Minimum DataSet information, four HRRs were identified in which the relative intensity of advanced dementia care was high (N = 2 HRRs) and low (N = 2 HRRs) based on hospital transfer and tube-feeding rates among residents with this condition. Within those HRRs, we identified facilities providing high (N = 2 NHs) and low (N = 2 NHs) intensity care relative to all NHs in that HRR (N = 16 total facilities; 4 facilities/HRR). RESULTS/CONCLUSIONS: To date, the research team conducted 275 h of observation in 13 NHs and interviewed 158 NH providers from varied disciplines to assess physical environment, care processes, decision-making processes, and values. We interviewed 44 proxies (black, N = 19; white, N = 25) about their perceptions of advance care planning, decision-making, values, communication, support, trust, literacy, beliefs about death, and spirituality. This report describes ADVANCE study design and the facilitators and challenges of its implementation, providing a template for the successful application of large qualitative studies focused on quality care in NHs.

The Rights of Elders in Ireland during COVID-19.

This article reflects on COVID-19 restrictions imposed on elders in Ireland through the lens of the right to private and family life (Article 8 ECHR), focusing on stay at home orders and recommendations advising elders to avoid social contact. Furthermore, we examine restrictions on visiting nursing homes given the high death toll in that setting. In our analysis, we zero in on the principles of foreseeability and proportionality, highlighting areas of concern and aspects that we submit should be considered in a proportionality assessment. Ultimately, we argue that it is a mistake to view the COVID-19 pandemic solely as an emergency. In this manner, the solutions suggested through the law - restrictions on movement and visitation bans - are too narrow and fail to address the underlying structures, such as, issues in the healthcare system, the limited home help for elderly and poor conditions in nursing homes.

Federal requirements for nursing homes to include certified nursing assistants in resident care planning and interdisciplinary teams: A policy analysis.

Starting in 2016, Centers for Medicare and Medicaid Services implemented the first phase of a 3-year multi-phase plan revising the manner in which nursing homes are regulated. In this revision, attention was placed on the importance of certified nursing assistants (CNAs) to resident care and the need to empower these frontline workers. Phase II mandates that CNAs be included as members of the nursing home interdisciplinary team that develops care plans for the resident that are person-centered and comprehensive and reviews and revises these care plans after each resident assessment. While these efforts are laudable, there are no direct guidelines for how to integrate CNAs in the interdisciplinary team. We recommend the inclusion of direct guidelines, in which this policy revision clarifies the expected contributions from CNAs, their responsibilities, their role as members of the interdisciplinary team, and the expected patterns of communication between CNAs and other members of the interdisciplinary team.

Ethical care during COVID-19 for care home residents with dementia.

The COVID-19 pandemic has had a devastating impact on care homes in the United Kingdom, particularly for those residents living with dementia. The impetus for this article comes from a recent review conducted by the authors. That review, a qualitative media analysis of news and academic articles published during the first few months of the outbreak, identified ethical care as a key theme warranting further investigation within the context of the crisis. To explore ethical care further, a set of salient ethical values for delivering care to care home residents living with dementia during the pandemic was derived from a synthesis of relevant ethical standards, codes and philosophical approaches. The ethical values identified were caring, non-maleficence, beneficence, procedural justice, dignity in death and dying, well-being, safety, and personhood. Using these ethical values as a framework, alongside examples from contemporaneous media and academic sources, this article discusses the delivery of ethical care to care home residents with dementia within the context of COVID-19. The analysis identifies positive examples of ethical values displayed by care home staff, care sector organisations, healthcare professionals and third sector advocacy organisations. However, concerns relating to the death rates, dignity, safety, well-being and personhood - of residents and staff - are also evident. These shortcomings are attributable to negligent government strategy, which resulted in delayed guidance, lack of resources and Personal Protective Equipment, unclear data, and inconsistent testing. Consequently, this review demonstrates the ways in which care homes are underfunded, under resourced and undervalued.

COVID-19 Infection Prevention and Control Adherence in Long-Term Care Facilities, Atlanta, Georgia.

BACKGROUND/OBJECTIVE: Recommendations for infection prevention and control (IPC) of COVID-19 in long-term care settings were developed based on limited understanding of COVID-19 and should be evaluated to determine their efficacy in reducing transmission among high-risk populations. DESIGN AND SETTING: Site visits to 24 long-term care facilities (LTCFs) in Fulton County, Georgia, were conducted between June and July 2020 to assess adherence to current guidelines, provide real-time feedback on potential weaknesses, and identify specific indicators whose implementation or lack thereof was associated with higher or lower prevalence of COVID-19. PARTICIPANTS: Twenty-four LTCFs were visited, representing 2,580 LTCF residents, among whom 1,004 (39%) were infected with COVID-19. MEASUREMENTS: Overall IPC adherence in LTCFs was analyzed for 33 key indicators across five categories: Hand Hygiene, Disinfection, Social Distancing, PPE, and Symptom Screening. Facilities were divided into Higher- and Lower-prevalence groups based on cumulative COVID-19 infection prevalence to determine differences in IPC implementation. RESULTS: IPC implementation was lowest in the Disinfection category (32%) and highest in the Symptom Screening category (74%). Significant differences in IPC implementation between the Higher- and Lower-prevalence groups were observed in the Social Distancing category (Higher-prevalence group 54% vs Lower-prevalence group 74%, P < .01) and the PPE category (Higher-prevalence group 41% vs Lower-prevalence group 72%, P < .01). CONCLUSION: LTCFs with lower COVID-19 prevalence among residents had significantly greater implementation of IPC recommendations compared to those with higher COVID-19 prevalence, suggesting the utility in adhering to current guidelines to reduce transmission in this vulnerable population.