Continuing Care Settings Research Articles

A Delphi Study Using Expert Consensus to Develop a Well-Defined Vision for a Centre of Excellence for Therapeutic Recreation in Continuing Care Settings

There is an increasing demand for evidence-based practice and the demonstration of client outcome achievement in therapeutic recreation (TR). There is also an ongoing need to research TR service provision in continuing care settings. The TR profession is well-suited to improving the well-being and quality of life of individuals living in continuing care homes, however, current TR services are not standardized and vary greatly between settings and practitioners. Centres of Excellence (CoE) are organizations that endeavour to establish high standards of practice in a specific profession or area of research. A CoE could be instrumental in improving the delivery of quality TR services in continuing care settings. A Delphi expert consensus method was used to obtain a well-defined vision for a CoE for TR in continuing care settings. Three rounds of online questionnaires were completed over a period of nine weeks by an expert panel of 11 TR professionals working in continuing care settings. The participants reached the consensus that the vision of the CoE should be, “To inspire and advocate for quality TR services in continuing care settings through increased research and evidence-based practice.” The findings from this study contribute to the development of a CoE for TR in continuing care settings. They could also contribute to the development of additional CoEs for TR with other client populations—a topic that has been largely unexplored in the research literature.

A Delphi Study Using Expert Consensus to Develop a Well-Defined Vision for a Centre of Excellence for Therapeutic Recreation in Continuing Care Settings

There is an increasing demand for evidence-based practice and the demonstration of client outcome achievement in therapeutic recreation (TR). There is also an ongoing need to research TR service provision in continuing care settings. The TR profession is well-suited to improving the well-being and quality of life of individuals living in continuing care homes, however, current TR services are not standardized and vary greatly between settings and practitioners. Centres of Excellence (CoE) are organizations that endeavour to establish high standards of practice in a specific profession or area of research. A CoE could be instrumental in improving the delivery of quality TR services in continuing care settings. A Delphi expert consensus method was used to obtain a well-defined vision for a CoE for TR in continuing care settings. Three rounds of online questionnaires were completed over a period of nine weeks by an expert panel of 11 TR professionals working in continuing care settings. The participants reached the consensus that the vision of the CoE should be, “To inspire and advocate for quality TR services in continuing care settings through increased research and evidence-based practice.” The findings from this study contribute to the development of a CoE for TR in continuing care settings. They could also contribute to the development of additional CoEs for TR with other client populations—a topic that has been largely unexplored in the research literature.

Diagnostic and therapeutic pathway for pain in a Continuing Care setting: a survey at an Italian Continuing Care Service.

Law no. 38 of 15 March 2010 ensures and governs the access to the palliative care and pain management network for patients who require it. The professional roles involved in the project have been identified by the law, with the specific experience and expertise in the field of palliative care and pain management, by allocating a meaningful role to general practitioners (GPs). For this reason, an important direct training plan has been drawn up that GPs can count on for dedicated refresher courses to increase and deepen their knowledge in this specific clinical field. If the role of the GPs in the pain management and palliative care network was well-defined by the law, we cannot say the same for the Continuing Care Physician (CCP), a role that only partially overlaps that of the GP. The study observed the response of a Continuing Care Service (CCS) to the demand for services from patients with pain-related problems. The role of the CCP is, therefore, outlined in the pain therapy care network by observing the services provided to patients experiencing pain that is understood as being a non-deferrable problem. A survey was conducted at the CCSs site in Aquila, AS-01 Abruzzo. For this reason, the attending physician records the data of patients who consult the CCSs for pain-related problems on an appropriate questionnaire. The survey period covered a total of 68 days (1 January - 8 March 2020). Results. One hundred sixty five sheets were completed; females were more represented than males (57.6% v 42.4%) and the 36-65 age group appears most greatly represented (47.9%). One of the most frequent reasons for consulting the service is "musculoskeletal pain" (58.2%), followed by abdominal pain (15.8%). In the majority of patients, pain lasted from days (53.9%), with an average of approximately 3 days (3.1± 2.9), or hours in 40% of cases, with an average of over 6 hours (6.54±3.1). 88.5% of patients defined the level of pain experienced as "severe" (NRS=7-10), and the intensity of the pain associated with its repetitiveness (80.3% vs 92.6%) as "severe", with a statistically significant difference in relation to nonrepetitiveness cases (p=0.02). 66.1% of patients said that they had taken analgesics independently, with nonsteroidal anti-inflammatory drugs (NSAIDs) the most frequently taken (53.5%). Patients who turned to the CCS received a pharmacological prescription in almost all cases. NSAIDs, specifically, were the most prescribed medicines (64.8%), followed by muscle relaxants (29.7%). Tramadol was the most represented among opioids, which was prescribed in 7.9% of cases. Just 6.1% of patients were entered into the regional pain management network. The results of the survey show that a large number of patients turn to the CCS to resolve painful symptoms of various natures. The study offers some food for thought concerning the role of CCPs and the importance of providing for their inclusion in the pain therapy clinical and training pathways provided for by Law 38/2010. This would ensure its more effective implementation and, therefore, better care for patients experiencing painful pathologies.

The science of recovery capital: where do we go from here?

The concept of recovery capital (RC) has emerged in studies and discussions of the addiction recovery process and as a potential metric and marker for recovery gains. Although conceptual and applied development of the concept in the 20 years since the term was coined has increased, there remains insufficient clarity of key domains, factors and best practice research and applications for populations experiencing addiction. We aimed to review progress around the conceptualisation and operationalisation of RC and to consider future directions for a science of recovery capital. We provided a brief overview of theoretical foundations and advances, empirical measurement and application in treatment and continuing care settings. We next introduced four primary areas for addiction science to address, namely: (i) conceptual development (e.g. how RC domains are unique, but interrelated entities, valence of RC), (ii) empirical testing, adequacy of measurement and analysis, (iii) directions for novel application in treatment and recovery settings and (iv) dissemination and communication to policy, practice and lived experience groups. In this review, we also focussed on some of the challenges that must be addressed for a science of RC, which could produce long-term impact in treatment and policy. Despite burgeoning empirical work on RC, its application and translation has been unsystematic. The field currently relies on self-report questionnaires for the development of the theory and quantification of RC. Therefore, there is an urgent need for rigorous and systematic conceptual and empirical development of RC. A formal collaboration between scholars, practitioners and experts by experience worldwide would move recovery capital forward in an empirically driven and culturally appropriate manner, as would testing its applicability at individual, organisational and societal levels.

Quality Indicators for Older Persons' Transitions in Care: A Systematic Review and Delphi Process.

We identified quality indicators (QIs) for care during transitions of older persons (≥ 65 years of age). Through systematic literature review, we catalogued QIs related to older persons' transitions in care among continuing care settings and between continuing care and acute care settings and back. Through two Delphi survey rounds, experts ranked relevance, feasibility, and scientific soundness of QIs. A steering committee reviewed QIs for their feasible capture in Canadian administrative databases. Our search yielded 326 QIs from 53 sources. A final set of 38 feasible indicators to measure in current practice was included. The highest proportions of indicators were for the emergency department (47%) and the Institute of Medicine (IOM) quality domain of effectiveness (39.5%). Most feasible indicators were outcome indicators. Our work highlights a lack of standardized transition QI development in practice, and the limitations of current free-text documentation systems in capturing relevant and consistent data.

Profiling the Characteristics of People Who Are Comatose in Long-term and Complex Continuing Care Settings

ObjectivesTo describe the sociodemographic, clinical, and treatment characteristics of people who are comatose in Canadian complex continuing care (CCC) and long-term care (LTC) settings, and to make recommendations to promote comprehensive care planning for this population. DesignRetrospective, cross-sectional analysis of population data. Setting and participantsAll residents in the Canadian provinces of Alberta, Ontario, British Columbia, Manitoba, Nova Scotia, Newfoundland, Saskatchewan, and the territory of Yukon with data available from the fiscal year 2015 (April 1, 2015, to March 31, 2016). MeasuresDemographic, clinical, and treatment variables were extracted from the Resident Assessment Instrument–Minimum Data Set (MDS 2.0) and were reported using descriptive statistics. ResultsOf the LTC and CCC populations, 0.07% and 3.5% were identified as comatose, respectively. Overall, people who are comatose in both CCC or LTC settings are younger and have a longer length of stay than those who are not comatose. A higher proportion of people who are comatose experience active infections and irregular bowel elimination patterns, and those who are comatose were more likely to have a feeding tube and require oxygen therapy or suctioning than those who were not comatose. However, a lower proportion of people who were comatose had documented pain. In LTC, one-quarter of people who are comatose are expected to die within 6 months. Conclusion/ImplicationsAlthough the prevalence of people who are comatose in LTC and CCC settings is low, this population is complex and has significant care needs that require comprehensive assessment and care planning.

Nurse Practitioners’ Experiences of Moral Distress in the Continuing Care Setting

This article describes a qualitative study designed to understand nurse practitioners’ (NPs) experiences with moral distress in the continuing care setting. The findings confirm that NPs in this setting experience moral distress. These experiences are in response to tensions that arise when factors interfere with their ability to provide “good” patient care. Five themes emerged as important factors: patients, perceptions, physicians, palliation, and policies. Moral distress is a substantial issue for NPs in the continuing care setting. Further research is required to examine NP’s experience with moral distress in other settings and identify solutions to resolve and respond to this distress.

Nurses’ Understanding of Spirituality and the Spirituality of Older People with Dementia in the Continuing Care Setting

This research paper was presented at the Third International Spirituality in Healthcare Conference 2017—‘Creating Space for Spirituality in Healthcare’ at Trinity College Dublin, The University of Dublin. 22 June 2017. The number of older people living with dementia in Ireland is rising. Dementia is prevalent among those residing in the continuing care setting. Nurses have a professional obligation to provide person centred, holistic care, to which spiritual care is a core element, yet often do not. As there are no guidelines in Ireland for spiritual care provision it is open to personal interpretation and application. This study was the first in Ireland to explore how spiritual care is understood by nurses in the context of older people living with dementia in a public, rural, continuing care setting. A qualitative descriptive design was utilized. Following purposive sampling, eight semi structured interviews were conducted in a rural Irish community hospital among registered nurses caring for older people living with dementia. A conceptual framework developed from the findings of a literature review, as well as this research study’s aim and objectives framed the interview schedule and data analysis. Data analysis utilized Newell and Burnard (2011) Thematic Content Analysis. Ethical approval was granted by the Health Service Executive (HSE) and the University of Dublin, Trinity College Dublin (TCD). Six key themes emerged from the study—1. Understandings of Spirituality, 2. Assessing spiritual need, 3. Providing spiritual care, 4. The impact of spirituality on quality of life, 5. Barriers to spiritual care and how these are addressed, and finally 6. The needs of staff. This paper presents and discusses the findings of the first theme ‘Understandings of Spirituality’ and its two sub-themes, 1. ‘The nurse’s own understanding of spirituality’ and 2. ‘The nurses’ understanding of spirituality and older people living with dementia.’ It is evident from the findings that there exists a variety of responses with regards to the nurses’ own understanding of the concept spirituality and spirituality for older people living with dementia. Participants placed emphasis on person-centred approaches to understanding and providing for the needs of care recipients’ in this area of care. Most participants acknowledged the positive impact of spiritual care on quality of life for older people living with dementia. Indications for practice suggest the need to develop suitable evidence based professional, person-centred frameworks, guidelines and educational standards for nurses which better equip them to understand spirituality and how this area of need can be properly assessed in partnership with the recipient of nursing practice in the continuing care setting to ensure comprehensive holistic, person-centred practice.

Comparing the care needs of people living with and without HIV in Canadian home and long-term care settings.

With the advent of highly active antiretroviral therapy (HAART), HIV has become a manageable chronic infection and individuals with it are living longer. Older individuals with HIV will begin to seek services across the continuum of health care. Whether their care needs differ from those who are HIV negative has not been well-characterized. To compare the demographic characteristics, chronic conditions, presence of infections, and mental health issues among HIV-positive versus HIV-negative individuals in home care, long-term care and complex continuing care settings across Canada. This cross-sectional study used interRAI data to compare characteristics of HIV-positive and HIV-negative individuals in long-term care, complex continuing care and home care settings. Chi-square analyses explored differences between groups on co-infections, chronic disease and mental health issues. Data from 1,200,073 people were analyzed of whom 1,608 (0.13%) had HIV. Overall, HIV-positive individuals had more co-infections but fewer chronic diseases than their HIV-negative counterparts. Depression, social isolation and the use of psychotropic medications were generally more prevalent in the HIV-positive cohort. People living with HIV make up a small cohort of people with complex needs in home care and institutional settings and their care needs differ from those who are HIV negative. As HIV-positive people age, a better understanding of the context in which these issues are experienced will support appropriate interventions.

Exploration of pressure ulcer and related skin problems across the spectrum of health care settings in Ontario using administrative data.

This is a prospective cohort study using population-level administrative data to describe the scope of pressure ulcers in terms of its prevalence, incidence risk, associating factors and the extent to which best practices were applied across a spectrum of health care settings. The data for this study includes the information of Ontario residents who were admitted to acute care, home care, long term care or continuing care and whose health care data is contained in the resident assessment instrument-minimum data set (RAI-MDS) and the health outcomes for better information and care (HOBIC) database from 2010 to 2013. The analysis included 203 035 unique patients. The overall prevalence of pressure ulcers was approximately 13% and highest in the complex continuing care setting. Over 25% of pressure ulcers in long-term care developed one week after discharge from acute care hospitalisation. Individuals with cardiovascular disease, dementia, bed mobility problems, bowel incontinence, end-stage diseases, daily pain, weight loss and shortness of breath were more likely to develop pressure ulcers. While there were a number of evidence-based interventions implemented to treat pressure ulcers, only half of the patients received nutritional interventions.

Automated monitoring: a potential solution for achieving sustainable improvement in hand hygiene practices.

Adequate hand hygiene is often considered as the most effective method of reducing the rates of hospital-acquired infections, which are one of the major causes of increased cost, morbidity, and mortality in healthcare. Electronic monitoring technologies provide a promising direction for achieving sustainable hand hygiene improvement by introducing the elements of automated feedback and creating the possibility to automatically collect individual hand hygiene performance data. The results of the multiphase testing of an automated hand hygiene reminding and monitoring system installed in a complex continuing care setting are presented. The study included a baseline Phase 1, with the system performing automated data collection only, a preintervention Phase 2 with hand hygiene status indicator enabled, two intervention Phases 3 and 4 with the system generating hand hygiene reminding signals and periodic performance feedback sessions provided, and a postintervention Phase 5 with only hand hygiene status indicator enabled and no feedback sessions provided. A significant increase in hand hygiene performance observed during the first intervention Phase 3 was sustained over the second intervention Phase 4, with the postintervention phase also indicating higher hand hygiene activity rates compared with the preintervention and baseline phases. The overall trends observed during the multiphase testing, the factors affecting acceptability of the automated hand hygiene monitoring system, and various strategies of technology deployment are discussed.

Psychotropic drug prescribing survey in a Canadian rehabilitation and complex care facility.

To describe rates of inpatient prescribing of psychotropic drugs in a rehabilitation and complex continuing care setting. Cross-sectional, observational study. Providence Healthcare, Toronto, Ontario, Canada. Inpatients registered in the hospital on each of four annual audit dates. An audit of medication profiles for the presence of psychotropic prescriptions, done yearly on a single day in May 2007, 2008, 2010, and 2011. The percentage of inpatients prescribed at least one antidepressant, antipsychotic, benzodiazepine, or zopiclone. The percentage of inpatients with at least one prescription for each class of psychotropic drug (ranging from the lowest to highest audit-year results) were as follows: any psychotropic (55% to 63%), benzodiazepines or zopiclone (31% to 40%), antidepressants (24% to 32%), antipsychotics (7% to 13%). Rates of polypharmacy within classes was highest with antidepressants, followed by benzodiazepines (including zopiclone), then antipsychotics. Despite the limitations associated with cross-sectional, observational data, rates of prescribing of psychotropic medication, apart from antipsychotics, were high. Future research will be performed to assess appropriateness of prescribing and adverse events.

Profile of Patients with Amyotrophic Lateral Sclerosis Across Continuum of Care

This study describes the socio-demographic and clinical profile of persons with amyotrophic lateral sclerosis (ALS) in home care, nursing homes and complex continuing care settings in several Canadian jurisdictions. A cross-sectional study was conducted using available Resident Assessment Instrument (RAI 2.0 and RAI Home Care) national databases from 1996- 2011. The profile of ALS patients was compared with patients without pre-specified neurological conditions. There were 2,092 ALS patients identified in these settings. Persons with ALS were more likely than those in the comparison group to suffer from health instability (25.4%) and minor to major depressive symptoms (27.2%) , to experience falls (44.0%) and weight loss (22.9%), to require extensive assistance in activities of daily living (54.9%), and to receive rehabilitation services: physical (23.9%), speech language pathology (8.9%), and occupational therapy 43.3%). The ALS population in this study are greatly affected by a number of health issues. They are more likely than the comparison group to require therapies, medical interventions, and psychotropic drug use. While persons with ALS have a poor prognosis, a great deal could be done to enhance their quality of life and the quality of care they receive.

Sustaining Transfers through Affordable Research Translation (START): study protocol to assess knowledge translation interventions in continuing care settings

BackgroundBridging the research-practice gap is an important research focus in continuing care facilities, because the population of older adults (aged 65 years and over) requiring continuing care services is the fastest growing demographic among countries in the Organisation for Economic Co-operation and Development (OECD). Unlicensed practitioners, known as health care aides, provide the majority of care for residents living in continuing care facilities. However, little research examines how to sustain health care aide behavior change following initial adoption of current research evidence.Methods/DesignWe will conduct a phase III, multicentre, cluster randomized controlled trial (RCT) using a stratified 2 × 2 additive factorial design, including an embedded process evaluation, in 24 supportive living facilities within the health zone of Edmonton, AB, Canada. We will determine which combination of frequency and intensity of reminders most effectively sustains the completion of the sit-to-stand activity by health care aides with residents. Frequency refers to how often a reminder is implemented; intensity refers to whether a reminder is social or paper-based. We will compare monthly reminders with reminders implemented every 3 months, and we will compare low intensity, paper-based reminders and high intensity reminders provided by a health care aide peer.Using interviews, questionnaires, and observations, Sustaining Transfers through Affordable Research Translation (START) will evaluate the processes that inhibit or promote the mobility innovation’s sustainability among health care aides in daily practice. We will examine how the reminders are implemented and perceived by health care aides and licensed practical nurses, as well as how health care aides providing peer reminders are identified, received by their peers, and supported by their supervisors.DiscussionSTART will connect up-to-date innovation research with the practice of health care aides providing direct care to a growing population of older Albertans. The project’s reach extends to both supportive living and long-term care settings. Furthermore, START has the potential to introduce and sustain a broad range of innovations in various care areas, such as dementia care, wound care, and pain management – domains where the uptake and sustainability of innovations also encounter significant challenges. By identifying the optimal frequency and intensity of knowledge translation interventions, we hope to enable continuing care organizations to efficiently integrate care innovations into the day-to-day care of residents.Trial registrationClinicalTrials.gov, NCT01746459

Rehabilitation in Patients with Dementia Following Hip Fracture: A Systematic Review

Best rehabilitation practices after hip fracture for people with dementia have not been established. A systematic review was conducted to determine current evidence for rehabilitation in this population, including residents in continuing care. Standardized review methodology was used to search eight databases for literature on hip-fracture rehabilitation for people with dementia. Eligible studies included participants with dementia who had a hip fracture; performed a rehabilitation intervention; and evaluated one or more of function, ambulation, discharge location, or falls. The Newcastle-Ottawa Scale was used to assess validity. A total of 13 studies were included: five randomized controlled trials (RCTs), seven prospective cohort series, and one retrospective cohort study. Average quality ratings for RCTs and cohort studies were good and fair respectively. Participants with mild to moderate dementia receiving rehabilitation showed similar relative gains in function to those without dementia. Only one study examined the effect of rehabilitation among residents in continuing care. People with mild or moderate dementia may show improved function and ambulation and decreased fall risk after rehabilitation post hip fracture, similar to gains achieved by those without dementia. More research is required to ascertain the effect of rehabilitation in people with moderate to severe dementia, including those residing in continuing-care settings.

Post-acute stroke patient outcomes in Ontario, Canada complex continuing care settings

Purpose. In this study, Outcomes are described for patients receiving ‘slow stream’ rehabilitation care (called low tolerance long duration rehabilitation in Ontario, Canada consisting of approximately 5 h of rehabilitation weekly) for patients recovering from stroke in Ontario complex continuing care (CCC) (chronic) healthcare settings.Method. In 2006–2007, 81 post-acute stroke patients recovering in six Ontario, Canada CCC settings were studied. Both primary and secondary data sources were used to calculate six clinical characteristics of study patients and three outcomes: patient satisfaction with care, discharge location, and length of CCC stay. In addition, descriptive statistics, tests of difference were employed to examine differences in clinical characteristics and outcomes for patients across facilities.Results. Mean patient age was 74 years, 59% were females, 51% were married, and 34.6% lived alone prior to hospitalization. Patient data on six clinical characteristics is described. Almost half of patients were discharged to independent or semi-independent living. Mean length of stay (LOS) was 112.8 days. Mean scores for patient-reported satisfaction with care were 71 (out of 100). There were statistically significant differences in all outcomes across facilities.Conclusions. Slower paced and less intensive rehabilitation was successful in transitioning the majority of patients to independent living or to a healthcare setting providing less intensive care. Opportunities exist to promote increased patient satisfaction with care.

Telepsychiatry appointments in a continuing care setting: kept, cancelled and no-shows

We reviewed the appointment data for a psychiatry service in California that provided consultations and also therapy through telepsychiatry. Over an 18-month period, there were 7523 telepsychiatry appointments and 115,148 conventional (face-to-face) appointments. A higher proportion of the telepsychiatry appointments was kept (92% telepsychiatry vs. 87% non-telepsychiatry). Also, telepsychiatry appointments were significantly less likely to be cancelled by patients (3.5% vs. 4.8%) and significantly less likely to be no-shows (4.2% vs. 7.8%). These findings were similar in three of the four counties where the service was delivered. However, one county was different, and further examination suggested that the morale of the staff and patients may have contributed to the unenthusiastic acceptance of telepsychiatry. We conclude that telepsychiatry can be used effectively in continuing care settings as well as in evaluation settings, and that staff and patient morale are important factors in successful telepsychiatry.

Falls among Top Reasons for Transfers from Continuing Care to Acute Care Hospitals in Canada

There are limited data on the quality and safety of care for residents in continuing care settings. An analysis of the main reasons why residents, 75 and older, of continuing care facilities are transferred to acute care demonstrates that two of the top three reasons for transfers result from potentially avoidable events.

Supporting Relationships Between Family and Staff in Continuing Care Settings

In this Canadian study, a participatory action research approach was used to examine the relationships between families of residents of traditional continuing care facilities and the health care team. The objectives were to (a) explore the formation and maintenance of family-staff relationships, with attention paid to the relational elements of engagement and mutual respect; (b) explore family and staff perspectives of environmental supports and constraints; and (c) identify practical ways to support and enhance these relationships. Results indicate that the resource-constrained context of continuing care has directly impacted family and staff relationships. The nature of these relationships are discussed using the themes of "Everybody Knows Your Name," "Loss and Laundry," "It's the Little Things That Count," and "The Chasm of Us Versus Them." Families' and staff's ideas of behaviors that support or undermine relationships are identified, as are concrete suggestions for improving family- staff relationships in traditional continuing care settings in Canada.

Valuing the person’s story: Use of life story books in a continuing care setting

There is an increasing focus on promoting person-centred systems across continuing care settings, emphasizing the need to enhance the quality of life of older adults. Life story books (LSB) can provide a holistic view of older adults, promote relationship-centred care and enhance person-centred care. The process of developing LSB involve collecting and recording aspects of a person's life both past and present. The purpose of this study was to engage residents in developing life story books in a nursing home setting and then to explore the narratives and documented life story books with residents and their families. A qualitative descriptive exploratory design was utilized for the study. Five residents and three family carers participated. Focus groups were tape recorded and thematically analyzed and a review of the LSB was conducted. The central themes from the data analysis related to the social construction of people's lives, social roles and religious values, relationships and loss, and sense of self.