Cultivating quality awareness in corona times.

The Covid-19 pandemic is a tragedy for those who have been hard hit worldwide. At the same time, it is also a test of concepts and practices of what good care is and requires, and how quality of care can be accounted for. In this paper, we present our Care-Ethical Model of Quality Enquiry (CEMQUE) and apply it to the case of residential care for older people in the Netherlands during the Covid-19 pandemic. Instead of thinking about care in healthcare and social welfare as a set of separate care acts, we think about care as a complex practice of relational caring, crossed by other practices. Instead of thinking about professional caregivers as functionaries obeying external rules, we think about them as practically wise professionals. Instead of thinking about developing external quality criteria and systems, we think about cultivating (self-)reflective quality awareness. Instead of abstracting from societal forces that make care possible but also limit it, we acknowledge them and find ways to deal with them. Based on these critical insights, the CEMQUE model can be helpful to describe, interrogate, evaluate, and improve existing care practices. It has four entries: (i) the care receiver considered from their humanness, (ii) the caregiver considered from their solicitude, (iii) the care facility considered from its habitability and (iv) the societal, institutional and scholarly context considered from the perspective of the good life, justice and decency. The crux is enabling all these different entries with all their different aspects to be taken into account. In Corona times this turns out to be more crucial than ever.

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.

COVID-19: Opportunities for interdisciplinary research to improve care for older people in Sweden.

The emergence of COVID-19 has changed the world as we know it, arguably none more so than for older people. In Sweden, the majority of COVID-19-related fatalities have been among people aged ⩾70 years, many of whom were receiving health and social care services. The pandemic has illuminated aspects within the care continuum requiring evaluative research, such as decision-making processes, the structure and organisation of care, and interventions within the complex public-health system. This short communication highlights several key areas for future interdisciplinary and multi-sectorial collaboration to improve health and social care services in Sweden. It also underlines that a valid, reliable and experiential evidence base is the sine qua non for evaluative research and effective public-health systems.

Elementary School-Aged Children in Therapeutic Residential Care: Examining Latent Classes, Service Provision, and Outcomes.

BACKGROUND: Approximately one-third of children in residential care are elementary-school aged. Yet, little is known about the subset of younger children in residential care and the nature of these placements. OBJECTIVE: This study identified latent classes of younger children in residential care and compared the purposes for placement, treatment processes, and outcomes across classes. PARTICIPANTS AND SETTING: The sample included 216 children (ages 5-10) placed in therapeutic residential care. METHODS: A three-step latent class model was used to estimate conditional effects of class membership on impairment at discharge, length of stay, and discharge placement. A content analysis of a randomly selected sample of case records from each class was used to explore placement processes. RESULTS: There were three classes identified (class 1: child welfare/multi-problem families; class 2: mental-health/angry-oppositional; class 3: strong families/attachment). All classes experienced large improvements in functioning. Children in class 3 were in care longer (CI95% 1.72, 15.48) and experienced greater reductions in impairment (CI95% -11.17, -32.06) than class 2. Classes did not differ in rates of discharge to family-based care, however, more children in classes 1 (20.9%) and 3 (21.6%) discharged to group-based placements than class 2 (11.1%). The content analysis revealed similarities in reasons for placement and treatment processes across classes with some distinctions. Service goals were similar across classes and focused on emotional management, social skills, and developing trust. CONCLUSION: The results supported individualized approaches to facilitate discharge to stable, family-based care and reduced risks for re-entry and prolonged out-of-home care for younger children.

Palliative care delivery in residential aged care: bereaved family member experiences of the Supportive Hospice Aged Residential Exchange (SHARE) intervention.

BACKGROUND: The supportive hospice aged residential exchange (SHARE) is a new model of palliative care education that has been designed for residential aged care. The goal of SHARE is to help clinical staff improve palliative care within residential aged care facilities and to improve specialist palliative care nurses' knowledge and skill to care for frail older people. METHOD: The experiences of 18 bereaved families concerning the palliative care journey (both at the start and finish of a one-year implementation of SHARE) were explored using semi-structured interviews. RESULTS: Three themes were important to bereaved families' experience: communication with staff, systems of care, and hospice involvement. Sub-themes indicating changes in these three components of care between the start and finish of SHARE was identified. A fourth theme highlighted challenges (relationship with GP, staff shortages, and turnover) that continued across SHARE. CONCLUSION: Findings indicated that SHARE benefited families (improved communication and support) through the end of life journey of their relatives, but challenges remained.

Ageism and COVID-19: what does our society's response say about us?

The goal of this commentary is to highlight the ageism that has emerged during the COVID-19 pandemic. Over 20 international researchers in the field of ageing have contributed to this document. This commentary discusses how older people are misrepresented and undervalued in the current public discourse surrounding the pandemic. It points to issues in documenting the deaths of older adults, the lack of preparation for such a crisis in long-term care homes, how some 'protective' policies can be considered patronising and how the initial perception of the public was that the virus was really an older adult problem. This commentary also calls attention to important intergenerational solidarity that has occurred during this crisis to ensure support and social-inclusion of older adults, even at a distance. Our hope is that with this commentary we can contribute to the discourse on older adults during this pandemic and diminish the ageist attitudes that have circulated.

Trust in the smart home: Findings from a nationally representative survey in the UK.

Businesses in the smart home sector are actively promoting the benefits of smart home technologies for consumers, such as convenience, economy and home security. To better understand meanings of and trust in the smart home, we carried out a nationally representative survey of UK consumers designed to measure adoption and acceptability, focusing on awareness, ownership, experience, trust, satisfaction and intention to use. We analysed the results using theories of meanings and acceptability of technologies including semiotics, social construction of technology (SCOT) and sociotechnical affordance. Our findings suggest that the meaning and value proposition of the smart home have not yet achieved closure for consumers, but is already foregrounding risks to privacy and security amongst the other meaning-making possibilities it could afford. Anxiety about the likelihood of a security incident emerges as a prominent factor influencing adoption of smart home technology. This factor negatively impacts adoption. These findings underline how businesses and policymakers will need to work together to act on the sociotechnical affordances of smart home technology in order to increase consumers' trust. This intervention is necessary if barriers to adoption and acceptability of the smart home are to be addressed now and in the future.

A clinical audit of oral anticoagulant therapy in aged care residents with atrial fibrillation.

Background Atrial fibrillation (AF) is a risk factor for stroke in older people. Oral anticoagulants can reduce stroke risk but they are commonly under prescribed in the elderly, often due to concerns regarding the risk of bleeding. Prescribing in aged care residents may also be further complicated by associated geriatric conditions such as dementia and risk of falls. Systematic assessment of stroke and bleed risk can help identify people with AF expected to benefit from anticoagulant therapy and optimise prescribing. Objective The aim of this study was to assess the prescribing of anticoagulants in elderly aged care residents in accordance with Australian guideline recommendations. Setting Nineteen aged care facilities across southeast Queensland. Method A clinical audit of anticoagulant therapy in aged care residents was conducted. Main outcome measure Information was collected from the records of residents with non-valvular AF to assess the risk of stroke and bleeding and compare this prescribing to current evidence-based guidelines for anticoagulation in AF. Results A total of 1754 residents were screened with 359 (20.4%) identified to have a diagnosis of non-valvular AF. There were 356 (99.2%) residents with non-valvular AF and a sufficiently high risk of stroke to warrant the use of an anticoagulant. Of these, 172 (48.3%) were prescribed an oral anticoagulant and 40 (11.2%) residents had a documented decision not to prescribe oral anticoagulants in their records. The majority of residents prescribed anticoagulation were receiving non-vitamin K antagonists (76.8%). The prescribed dose was consistent with recommendations for 44.8% of residents prescribed oral anticoagulant therapy. Conclusion Many residents with non-valvular AF and significant risk of stroke were not receiving oral anticoagulation despite a lack of documented reason for non-prescribing. Non-vitamin K antagonists were widely prescribed but dosing of these agents could still be improved. There remains a need to improve anticoagulant prescribing for aged care residents and optimise stroke prevention in this population.

The Coronavirus and the Risks to the Elderly in Long-Term Care.

The elderly in long-term care (LTC) and their caregiving staff are at elevated risk from COVID-19. Outbreaks in LTC facilities can threaten the health care system. COVID-19 suppression should focus on testing and infection control at LTC facilities. Policies should also be developed to ensure that LTC facilities remain adequately staffed and that infection control protocols are closely followed. Family will not be able to visit LTC facilities, increasing isolation and vulnerability to abuse and neglect. To protect residents and staff, supervision of LTC facilities should remain a priority during the pandemic.

A systematic review on the causes of the transmission and control measures of outbreaks in long-term care facilities: Back to basics of infection control.

BACKGROUND: The unique characteristics of long-term care facilities (LTCFs) including host factors and living conditions contribute to the spread of contagious pathogens. Control measures are essential to interrupt the transmission and to manage outbreaks effectively. AIM: The aim of this systematic review was to verify the causes and problems contributing to transmission and to identify control measures during outbreaks in LTCFs. METHODS: Four electronic databases were searched for articles published from 2007 to 2018. Articles written in English reporting outbreaks in LTCFs were included. The quality of the studies was assessed using the risk-of-bias assessment tool for nonrandomized studies. FINDINGS: A total of 37 studies were included in the qualitative synthesis. The most commonly reported single pathogen was influenza virus, followed by group A streptococcus (GAS). Of the studies that identified the cause, about half of them noted outbreaks transmitted via person-to-person. Suboptimal infection control practice including inadequate decontamination and poor hand hygiene was the most frequently raised issue propagating transmission. Especially, lapses in specific care procedures were linked with outbreaks of GAS and hepatitis B and C viruses. About 60% of the included studies reported affected cases among staff, but only a few studies implemented work restriction during outbreaks. CONCLUSIONS: This review indicates that the violation of basic infection control practice could be a major role in introducing and facilitating the spread of contagious diseases in LTCFs. It shows the need to promote compliance with basic practices of infection control to prevent outbreaks in LTCFs.

Designing clinical practice feedback reports: three steps illustrated in Veterans Health Affairs long-term care facilities and programs.

BACKGROUND: User-centered design (UCD) methods are well-established techniques for creating useful artifacts, but few studies illustrate their application to clinical feedback reports. When used as an implementation strategy, the content of feedback reports depends on a foundational audit process involving performance measures and data, but these important relationships have not been adequately described. Better guidance on UCD methods for designing feedback reports is needed. Our objective is to describe the feedback report design method for refining the content of prototype reports. METHODS: We propose a three-step feedback report design method (refinement of measures, data, and display). The three steps follow dependencies such that refinement of measures can require changes to data, which in turn may require changes to the display. We believe this method can be used effectively with a broad range of UCD techniques. RESULTS: We illustrate the three-step method as used in implementation of goals of care conversations in long-term care settings in the U.S. Veterans Health Administration. Using iterative usability testing, feedback report content evolved over cycles of the three steps. Following the steps in the proposed method through 12 iterations with 13 participants, we improved the usability of the feedback reports. CONCLUSIONS: UCD methods can improve feedback report content through an iterative process. When designing feedback reports, refining measures, data, and display may enable report designers to improve the user centeredness of feedback reports.

A Narrative Care approach for persons living with dementia in institutional care settings.

AIMS AND OBJECTIVES: We will provide insights in the theoretical background and key concepts of a Narrative Care approach, such as narrative cultures, narrative curiosity, narrative co-composition and narrative reflective practice. BACKGROUND: Care understood as narrative practice underscores the importance of experiences and how these shape identities. Important to the quality of care in institutional care settings is the ability of care providers to cope with complexities and uncertainties in older adults' stories, which can be realised by attending to ways that foster and co-compose evolving and forward-looking narratives. Recognising these ongoing co-compositions means that persons living in institutional care settings and care providers live, tell, retell and relive their experiences. A change in the current institutional culture is necessary to implement care as narrative practice. To support such a change, approaches are needed that foster a focus on experiences and relationships and make relational ethics central to care. METHODS: The proposed Narrative Care approach is the result of an iterative development process involving a literature review, interviews with, and observations of, care providers, dialogues with an advisory committee, and consultation with experts. MAIN CONTRIBUTIONS: The proposed Narrative Care approach aims to help care providers (a) to recognise the importance of curiosity in a person's verbal and embodied narratives-especially for those living with dementia; (b) to take note of individual experiences in all of their complexity and uncertainty; (c) to respect these narratives; (d) to open up spaces to co-compose new narratives; and (e) to allow care providers to engage in narrative reflective practices that shape who they are and are becoming. CONCLUSION: The introduced approach responds to the need of implementing strategies to think and work narratively in institutional care settings. IMPLICATIONS FOR PRACTICE: Narrative Care has the potential to reshape task-oriented, technical notions of care. Concepts such as embodied narratives, relational ethics, narrative co-composition and narrative reflective practice must be integrated in the education of all care providers.

The role of cognitive impairment in pain care in the emergency department for patients from residential aged care facilities: a retrospective, case-control study.

BACKGROUND: Patients with cognitive impairment are at risk of substantial delays to analgesic medication when presenting to the emergency department in pain. AIM: To identify if patients from residential aged care facilities with cognitive impairment experience the same delays to analgesic medication are reported in the general emergency department population. METHODS: This study is a retrospective case-control review of patients presenting to one emergency department with pain as a presenting complaint from residential aged care, with and without cognitive impairment. RESULTS: Patients without cognitive impairment experience delays in time to first analgesic medication (175min vs 98min, p=0.006) compared to cognitively impaired patients from residential aged care facilities. Both cohorts of patients waited more than three times the national benchmark for analgesic medication and 66% of all patients in this study did not have pain assessment completed. CONCLUSION: Patients presenting from residential caged care facilities in this study without cogitative impairment wait longer for analgesia then patients who present with cogitative impairment, contrary to previously described relationships. Pain assessment and treatment are open to cogitative bias, and in the absence of pain assessment cogitative bias may prevail leading to poor pain care and discrepancies between patients with and without cogitative impairment.

Towards healthy settings for people with intellectual disabilities.

People with intellectual disabilities (ID) depend on their environment for support to live healthily. The characteristics of healthy settings for people with ID are unknown. This study aims to conceptualize healthy settings for people with ID by conducting an international and multidisciplinary concept mapping study. As theoretical framework the settings approach, an ecological model with a whole system focus toward health promotion, was used. The integrative mixed-methods approach of this study involved concept mapping with researchers specialized in healthcare for people with ID and researchers specialized in healthy settings. The 41 participants generated statements that were later sorted and rated. Findings encompass 13 clusters relating to the social environment, the physical environment and societal preconditions. Specific factors of healthy settings for people with ID include: (i) universal design of the physical environment, (ii) the role of care professionals in the social environment to empower people with ID, (iii) possibilities for care providers to contribute to a health-promoting setting and (iv) preconditions that allow people to engage in society. These factors can be used in strategies to apply the approach in practice and give directions to put in place policies on developing enabling environments and decreasing health inequities.

Resident Challenges With Pain and Functional Limitations in Chinese Residential Care Facilities.

BACKGROUND AND OBJECTIVES: Pain and functional limitations can severely impede older adults' quality of life. In Chinese residential care facilities, limited research suggests that residents potentially have significant unmet care needs with pain and related functional limitations. Therefore, we aimed to explore residents' challenges and self-management strategies in these two areas. This knowledge is essential to developing care interventions to improve quality of care and quality of life in Chinese residential care facilities. RESEARCH DESIGN AND METHODS: We conducted semi-structured open-ended interviews with residents (n = 21) in two facilities in eastern and central China and assessed their pain and functional status using self-report measures from Minimum Data Set 3.0. We applied descriptive statistics to the self-reported data and analyzed the interview data using thematic analysis by drawing on the Adaptive Leadership Framework. This framework proposes that individuals living with chronic conditions need to engage in work to address their complex health concerns and that they need support from the environment to facilitate problem-solving. RESULTS: Residents described significant unmet care needs with pain and functional limitations. To address these care needs, they adopted a substantial number of self-management strategies. While doing so, they faced significant barriers, including service gaps and inadequate direct care. DISCUSSION AND IMPLICATIONS: The findings suggest further research to explore long-term care policy change that is needed to provide comprehensive health and medical services and adequate direct care in these facilities. The importance of establishing various types of long-term care facilities is also highlighted.

Hyderabad Ocular Morbidity in Elderly Study (HOMES) - Rationale, Study Design and Methodology.

Purpose: To describe the study design, interobserver variability of the questionnaires and clinical procedures of Hyderabad Ocular Morbidity in Elderly Study (HOMES) designed to, (a) to investigate the prevalence, causes and risk factors for visual impairment, and (b) to assess the impact of dispensing spectacles and cataract surgery on visual functions, fear of falls (FOF) and depression among the elderly in India.Methods: Individuals aged ≥60 years are considered elderly. The non-clinical protocol was administered by two trained investigators and included collection of personal, sociodemographic information, ocular and systemic history, Indian Visual Function Questionnaire (IND-VFQ33), Patient Health Questionnaire (PHQ9), Mini-Mental State Examination (MMSE) questionnaire, Hearing Handicap Inventory for the Elderly Screening (HHIE), Short Falls Efficacy Scale (SFES) questionnaire. The eye examination was conducted by a trained optometrist and vision technicians in clinics set-up in the homes and included visual acuity (VA) assessment for distance and near, anterior segment examination and fundus examination, and imaging. The reliability assessments were carried out among 138 participants.Result: The intraclass correlation (ICC) coefficients for MMSE, PHQ9, HHIE, SFES was 0.73 (95% CI: 0.62-0.81), 0.67 (95% CI: 0.54-0.77), 0.63 (95% CI: 0.48-0.74) and 0.70 (95% CI: 0.58-0.79) respectively. The ICC for INDVFQ domains ranged from 0.66 (95% CI: 0.55-0.74) for Psychosocial Impact to 0.88 (95% CI: 0.84-0.91) for activity limitation. The ICC for VA was 0.94 (95% CI: 0.92-0.96).Conclusion: All questionnaires demonstrated acceptable reliability and can be applied in the main study. HOMES is expected to provide data that will help plan strategies to contribute towards 'healthy aging' in India.