Facility-based Long-term Care Research Articles

Trajectories of medical care expenditure in the last year of life associated with long-term care utilization in frail older adults: A retrospective cohort study.

Medical care and long-term care utilization in the last year of life of frail older adults could be a key indicator of their quality of life. This study aimed to identify the medical care expenditure (MCE) trajectories in the last year of life of frail older adults by investigating the association between MCE and long-term care utilization in each trajectory. The retrospective cohort study of three municipalities in Japan included 405 decedents (median age at death, 85 years; 189 women [46.7%]) from a cohort of 1,658 frail older adults aged ≥65 years who were newly certified as support level in the long-term care insurance program from April 2012 to March 2013. This study used long-term care and medical insurance claim data from April 2012 to March 2017. The primary outcome was MCE over the 12 months preceding death. Group-based trajectory modeling was conducted to identify the MCE trajectories. A mixed-effect model was employed to examine the association between long-term care utilization and MCE in each trajectory. Participants were stratified into four groups based on MCE trajectories over the 12 months preceding death as follows: rising (n = 159, 39.3%), persistently high (n = 143, 35.3%), minimal (n = 56, 13.8%), and descending (n = 47, 11.6%) groups. Home-based long-term care utilization was associated with increased MCE in the descending trajectory (coefficient, 1.48; 95% confidence interval [CI], 1.35-1.62). Facility-based long-term care utilization was associated with reduced MCE in the rising trajectory (coefficient, 0.59; 95% CI, 0.50-0.69). Both home-based (coefficient, 0.92; 95% CI, 0.85-0.99) and facility-based (coefficient; 0.53; 95% CI, 0.41-0.63) long-term care utilization were associated with reduced MCE in the persistently high trajectory. These findings may facilitate the integration of medical and long-term care models at the end of life in frail older adults.

WHO CARES? RETENTION STRATEGIES FOR DIRECT CARE WORKERS

Abstract More than 30 years ago the Gerontological Society sponsored a congressional briefing about a growing problem; concerns about the adequacy and quality of the direct care workforce in long-term care. In 2002 the Robert Wood Johnson Foundation sponsored the Better Jobs, Better Care demonstration, in response to this continued challenge. Today recruiting and retaining high quality workers in the long-term services system has moved beyond a challenge to an all-out crisis. The initial paper of the symposium presents recent retention and work culture data highlighting todays’ hurdles, collected from more than 80% of long-term care facilities across Ohio. The second presentation provides a comprehensive review of state-level initiatives and innovations aimed at improving recruitment and retention for direct care workers (DCWs) in both facility-based long-term care and home and community-based long-term services across the country. A third paper focuses on retention-promoting factors from the perspective of providers and DCWs working in high-performing long-term care facilities in Ohio. In-depth interviews with 37 providers and DCWs revealed an overarching theme of the importance of work culture, highlighting the modifiable, intangible aspects for promoting DCW retention. The final paper introduces a tip sheet with practical strategies for providers who are seeking to retain direct care workers. Symposium findings will include both practical implications for long-term care providers and ideas for future studies. The direct care workforce crisis is the result of an array of challenges, which means that there will not be one solution, but rather many ideas will be needed.

STATE-LEVEL INITIATIVES FOR DIRECT CARE WORKERS

Abstract As problems surrounding recruitment and retention of direct care workers continue to worsen, changes have been made at both the state and national level to accommodate for these challenges. This paper provides a literature review of various state-level initiatives and innovations aimed at improving recruitment and retention strategies for direct care workers in both facility-based long-term care and home and community-based long-term services across the country. Research revealed three themes, 1) strategies to improve wages and benefits, 2) education and training, and 3) community support. To improve wages and benefits, many states increased compensation and benefits for DCWs with the implementation of wage pass-throughs, minimum wage increases, and earmarked funds. Education and training efforts were identified as another way to enhance recruitment and retention efforts for the direct care workforce, such as through credential and certification opportunities for workers, as well as standardizing current training requirements. Lastly, increasing community support was identified through advocacy and research efforts specifically aimed at understanding and supporting DCWs. This study seeks to inform policymakers and providers of current initiatives that can be used to address the ongoing workforce crisis.

Holocaust survivors in long-term care

ABSTRACTLittle research exists on the experience of older trauma survivors in long-term care settings. This study examined the experience of Holocaust survivors in community-based and facility-based long-term care. We wished to know if Holocaust survivors had a systematically different experience in such settings compared to persons without a trauma experience in their backgrounds. Through interviews with survivors, American-born Jews in the same settings, family members, and professional staff, we learned that there were differences in certain aspects of mental health and emotional well-being and that these differences are associated with the relative lack of a network of family members as compared to American-born Jews.

Understanding Music Care in Canadian Facility-Based Long Term Care

Understanding Music Care in Canadian Facility-Based Long Term CareAbstractMusic has been used in Canadian long-term care (LTC) facilities which, for decades, have relied on programs, technology and music therapy to deliver live music through a variety of forums. Current confluences in long term care (LTC), in particular, a change in demographic and a shift in philosophy towards person-centered care, call for a renewed understanding of music in LTC and specifically how it is delivered. In this mixed method study, 7 emergent factors influence music care delivery from a Phase one qualitative study in 5 Ontario LTC homes form the basis of a Phase two; a pan-Canadian survey in 50 LTC homes. Results illustrate several key aspects of understanding music care in Canadian LTC facilities as well as illuminate some of the incongruencies of music care delivery in the Canadian LTC context. Recommendations to LTC leadership for imminent next steps are posited.Keywords: long term care, culture change, quality of care, quality of life, music careSpanishMúsica se ha venido utilizando durante décadas en Residencias para personas mayores y asistidas canadienses, que han utilizado distintos programas tecnológicos y musicoterapéuticos para ofrecer música en vivo en distintas oportunidades. La situación actual en cuanto a cambio demográfico y enfoque de los cuidados centrados en la persona, nos obliga a repensar el rol de la música en estas residencias y específicamente cómo se ofrece. Esta investigación analiza 7 factores emergentes que influyen en cómo se ejecutan estos programas: fase 1 consite en un estudio cualitativo en 5 residencias en Ontario;fase 2 consiste en una encuesta en 50 residencias a lo largo de Canadá. Los resultados ilustran varios aspectos clave para entender la el tratamiento con música en residencias canadienses, e iluminan algunas de sus incongruencias en este contexto. Finalmente, se ofrecen recomendaciones a tener en cuenta. Palabras clave: Residencias de personas asistidas, cambio cultural, calidad en los cuidados, calidad de vida, atención con músicaFrenchCompréhension du soin par la musique dans les soins de longue durée canadiens RésuméLa musique a été utilisée dans les soins de longue durée (SLD) canadiens, qui se sont appuyés, des décénnies durant, sur des programmes, sur la technologie et la musicothérapie pour apporter de la musique vivante à travers une diversité de formes. Les tendances actuelles dans le soin longue durée (SLD), en particulier, le changement démographique et le changement de paradigme philosophique envers le soin centré sur la personne, appellent à une nouvelle compréhension de la musique utilisée dans les soins longue durée, et plus specialement de la manière dont elle est adressée. Dans cette méthode de recherche mixte, 7 facteurs émergents influençant l’apport du soin par la musique, issus d’une première phase d’étude qualitative réalisée dans 5 maisons de soins de longue durée en Ontario ont constitué la base d’une deuxième phase : une étude pancanadienne dans 50 unités de soins de longue durée. Les résultats illustrent plusieurs aspects clés de la compréhension du soin par la musique dans les maisons de soins de longue durée canadien, ainsi qu’ils éclairent certaines incongruités dans l’apport de soin par la musique dans ce même contexte. Des recommandations à l’attention du personnel encadrant des services de SLD ont été présentées pour une prochaine étape.Mots clés : soins de longue durée, changement de culture, qualité des oisn, qualité de vie, soin par la musiqueGermanMusik in der stationären Langzeitpflege in Canada.Abstract:Musik wird in Langzeitversorgungseinrichtungen (LTD) genutzt, die seit Jahrzehnten auf Programme, Technologie und Musiktherapie vertrauen, um Live-Musik in verschiedenen Foren zu übermitteln. Der gegenwärtige Zustrom von Mensche in die Langzeitpflege (LTD), insbesondere die demographische Veränderung und die in der Philosophie der personenzentrierten Pflege, erfordern ein verändertes Verständnis von Musik in den LTDs, und da vor allem wie diese übermittelt wird. In dieser mixed-method Studie zeigten sich 7 Faktoren, die die musikalische Versorgung beeinflussen: ausgehend von einer 1 qualitativen Studie in 5 LTC Einrichtungen in Ontario gab es eine 2. Studie: einen landesweiten Überblick über 50 canadische LTC Einrichtungen. Die Ergebnisse zeigen ebenso mehrere grundlegende Aspekte, Musikversorgung in canadischen LTC Einrichtungen zu verstehen als auch einige Unstimmigkeiten in der Musikversorgung im canadischen LTC Kontext. Es folgen Vorschläge an die Verantwortlichen der LTC für wichtige nächste Schritte.Keywords: Langzeitpflege, kultureller Wechsel, Versorgungsqualität, Lebensqualität, Versorgung mit MusikJapanese要旨音楽は、カナダの長期ケア施設（ＬＴＣ）において活用されており、数十年もの間、音楽プログラムやテクノロジー、そして音楽療法が様々な形態を通じて生の音楽を定常してきた。現在の長期ケア施設における潮流、特に人口年齢の変容とパーソンセンタード理論へのシフトによって、長期ケア施設における音楽の理解が見直されており、具体的にどの活用法について注目されている。本研究は方法を混合させたもので、第1段階ではオンタリオの５施設における質的研究から7つの要素が出現した。さらに第2段階では、前段階を基に汎カナダ的な調査を50の長期ケア施設にて行った。結果として、カナダの長期ケア施設における音楽的ケアを理解するためのいくつかの重要な要素を検証することができた。また同時に、カナダの施設状況において音楽的ケアを行うことの不適合な点についても調査することができた。今後の展望として、長期的ケアにおいては、差し迫ったリーダーシップが求められている、ということが推察される。キーワード：長期ケア、文化的変容、ケアの質、生活の質（ＱＯＬ）音楽的ケア Chinese音樂的使用在加拿大長期照護(LTC)機構裡已有數十年的時間，透過音樂節目、現代科技及音樂治療來提供現場音樂。目前長期照護的主流在人口結構的改變及以人為本的照護理念趨勢之下，對於音樂如何在長期照護機構裡被運用有了新的認識。在這個混合方法研究中，研究者首先在五個安大略省長期照護之家進行第一階段的質性研究，並生成7項影響音樂照護運用的因素，接著在50間泛加拿大長期照護之家進行調查。結果顯示出對加拿大長期照護機構裡的音樂照護狀況的了解，同時也闡明了一些不一致的關鍵層面，並對長期照護領導者的下一步提出緊迫的建議。

Success in the Face of Reform

We hear repeatedly that health reform will dramatically affect the way postacute and long-term care (PA/LTC) will participate in the U.S. health care system. New models of care delivery include accountable care organization, medical homes, and demonstration projects that combine Medicare and Medicaid dollars. All have core principles of accountability, integration of care, emphasis on long-term health outcomes, and better transitions. So, where do physicians look for guidance in the postreform world? Many of us immediately think of innovative centers such as the Cleveland Clinic and the Mayo Clinics. There is certainly much to learn from them, but how transferable are their practices? How dependent are their models on concentrated populations and resources? What do they offer to rural or suburban practices? At the same time, some independent physician practices are trying to chart their own paths through the changing environment without sacrificing physician leadership. One such model is Chappel Health and Wellness in central Florida. It's led by Chris Chappel, MD, CMD, and includes three other physicians and six physician assistants. They operate three clinics and provide medical direction to 25 PA/LTC facilities in the three counties around Orlando. What makes Dr. Chappel's practice model unusual is that it incorporates “discharge clinics” in cooperation with local hospitals. These clinics streamline transitions from the acute setting by giving patients on-site access to a pharmacy, a home health agency, and a durable medical equipment provider. The discharge clinics also set the immediate follow-up appointments with primary care physicians and specialists. The pharmacy's presence alone mitigates what is a major contributor to hospital readmissions, medication errors. Each Chappell clinic also has a wellness program incorporating diet and exercise coaching in a 5,500 square-foot gym. In a final twist, Chappel Health and Wellness has a clinical research arm staffed by a pharmacist and two physicians. Dr. Chappel has been working with Florida's Quality Improvement Organization on a project to reduce hospital readmissions. The collaboration includes four nursing homes, two home health agencies, and a patient-advocacy and coaching organization. The project targets seven of the leading readmission diagnoses, including heart failure, chronic obstructive pulmonary disease, and sepsis. The linchpins of the project are two: immediately offering a health coach to a patient at hospital discharge and use of the Interventions to Reduce Acute Care Transfers (INTERACT) program for improving long-term care transitions. The results have been dramatic. Nursing homes have become more comfortable treating patients with complex diagnoses and talking with family members about care-setting choice. Hospital admission rates of residents in the four nursing homes have decreased from 26% to 17% and are still falling. Thus, Chappel Health and Wellness is firmly planted in both community-based and facility-based long-term care. Dr. Chappel describes the model as a medical village concept within a clinic. He and his colleagues strive to follow the Institute of Medicine's advice on how to give appropriate and affordable care: “Deliver the right care at the right time by the right provider in the right setting.” Is Dr. Chappel naïve in trying to go it alone in the post–health reform world? He says that he is striving to let primary care do what it does best and eliminate or reduce the need for the administrative middle man of an accountable care organization (ACO), for instance. “I think we are years away from bundled payments for physician services in the outpatient world. If it happens sooner, our concept will be ready for it and will have a track record, especially when it comes to decreasing 30-day readmits,” Dr. Chappel said. Maybe he's not naïve. He says that physician groups partnering with hospitals, nursing homes, insurance companies, and other entities is inevitable. “We are starting small to work out the bugs, then expanding in whatever direction it takes us.” The handwriting is on the wall. Governmental payers, employers, and health insurance companies are all pushing for more integrated health care systems, where physicians and hospitals are held accountable for the overall cost and quality of care. It is likely that all physicians will need to participate in systems requiring more communication, care coordination, and quality-data reporting. The Chappel Health and Wellness model strives for coordinated services that are rooted deeply in a profound respect for patients. In Dr. Chappel's view, hospitals, LTC facilities, and physicians' practices can and must work together effectively.

The Role of Community-Based Care Capacity in Shaping Risk of Long-Term Care Facility Placement

Across the developed world, wait lists for facility-based long-term care (LTC) beds continue to grow. Wait lists are primarily driven by the needs of aging populations (demand-side factors). Less attention has been given to system capacity to provide community alternatives to LTC (supply-side factors). We examine the role of both demand- and supply-side factors by comparing the characteristics of individuals who have been assessed and deemed eligible for LTC in urban and rural/underserviced parts of northwestern Ontario, Canada. Home care assessment data were analyzed for all individuals waiting for LTC in northwestern Ontario as of March 2008 (n=858). For the analysis, the sample was separated into urban and rural groups to account for geographical differences in wait list location. Characteristics between these two groups were compared. Individuals on LTC wait lists in the rural areas were significantly less impaired in activities of daily living and cognition than their counterparts in the urban area. However, in both areas, impairments in lighter-care activities appeared to be a key wait list driver, and few people had an informal caregiver living in the home. Our data suggest that LTC wait lists reflect, at least to some extent, insufficient community capacity, not just need for LTC.

Home care or long-term care? Setting the balance of care in urban and rural Northwestern Ontario, Canada

The objective of the study was to determine the extent to which community care packages could be provided at a lower cost than facility-based long-term care (LTC) for 864 individuals on the LTC waiting list in urban and rural parts of Northwestern Ontario, Canada. A sequential mixed methods design was used entailing a retrospective chart review, the formation of case vignettes, the creation of community care packages with an 'expert panel' of care managers, the costing of care packages and the calculation of potential diversion rates from LTC. Data collection took place in Northwestern Ontario between the months of March and June 2008. Eight per cent of individuals in the urban area and 50% of individuals from the rural areas could potentially be safely diverted to the community and provided with a community care package at a cost lower than facility-based LTC. There is potential for home and community care to substitute for more costly long-term care, but doing so requires building capacity in this sector, particularly in rural areas, which are currently underserviced. Reconfiguring the 'balance of care' may lead to long-term cost efficiencies for an ageing population.

What Does Quality Look Like to the Resident?

In her thought-provoking and well-researched paper, Irene Jansen presents some of the main challenges within the facility-based long-term care (LTC) sector and advocates for three major policy changes and investments. But her aim in writing the paper is to start the conversation. I am happy to oblige Jansen's call to tackle other critical issues and thank the editors of Healthcare Papers for the opportunity to briefly express my views. I concur that the federal government is not adequately fulfilling its stewardship role in helping to ensure - along with the provinces and territories - that the facility-based LTC system has the ways and means to meet the legitimate needs of LTC residents and the people who care for them. A national dialogue should be convened with an emphasis on what quality looks like to the resident, not to LTC ministries or funding authorities. The resident is the nucleus around which all else revolves. The challenges in the areas of supply and demand, the patchwork of services and health human resources are huge. But additional staffing and more beds will not add real value to the system unless they are closely linked to the principles of culture change - the journey to improving living and working conditions in LTC across the Canadian landscape. And it is here where I make my prime contribution to the conversation.

Long-Term Care as Part of the Continuum

Long-term care (LTC) is but one piece of a continuum of care that stretches from living at home completely independently to the 24-hour supervision and care provided in LTC facilities. People want to stay at home as long as possible and to retain as much independence as they can, and they are often aided in doing so with informal care provided by family and friends. These realities should inform the debates around the construction of the continuum of care. Canada's spending on facility-based long-term care puts us in the middle of the pack among OECD countries; if we consider the whole of continuing care, combining LTC, supportive housing/assisted living and home-based healthcare, Canada stands out as spending the highest proportion (among the 15 countries compared) on facility-based care. Predicting the number of new long-term care beds needed in the future is difficult because of shifting needs and changes in service delivery - new stops on the continuum of care. It is quite possible to organize a system of care that includes a continuum from home-based care to supportive housing and assisted living to LTC that de-emphasizes this last step. The increasing elderly population in Canada will not bring an apocalypse to the healthcare system, but caring for this population will require a redistribution of resources to increase the emphasis on home and community-based services. Our planning for just how many (if any) new long-term care beds are needed and our assessment of reasonable access to those beds need to rest on a vision for the full spectrum of care and attention to the desires of the population we are trying to serve.

Assembly-line care: Ancillary care work in post-Fordist economies

In the United States, health care aid is one of the fastest growing jobs. This trend is observed in many other Western countries experiencing increased demands for home and facility-based long-term care. However, the recruitment and retention of workers is difficult. The goal of this research is to provide a sound conceptual analysis of paid ancillary care as a better understanding of this type of labour can help improve the delivery and quality of services as well as the retention of workers. The activities of paid ancillary care are analysed using Marx's analysis of labour and Habermas's distinction of action types. Studies on care workers as well as the manner in which the provision of care is structured by agencies are examined in order to highlight how care work is perceived. Although care labour is situated in a post-Fordist economy, it is, nonetheless organised as assembly-line work reminiscent of Fordist labour. This is in part a consequence of the reduction of care to a commodity. The commodification of care erases the relational component intrinsic to adequate caring. It is suggested that care labour should be structured to support the complex activities that comprise this type of labour.

For the record

Canada should consider creating a mandatory social insurance scheme for long-term care, similar to the Canada Pension Plan, the Canadian Healthcare Association urges in a comprehensive review of facility-based long-term care services across the country. A publicly administered insurance plan,

Stroke Care in Long-Term Care Facilities in Southwestern Ontario

Purpose: This study describes the current state of stroke care and rehabilitation in facility-based long-term care (LTC).Method: LTC representatives, community partners (including physiotherapists and occupational therapists), stroke survivors, and family members were interviewed about stroke care provided in LTC facilities. Results: Limitations of the current system were identified including inadequate provision of therapy, unequal access to specialized rehabilitation, lack of staff training to care for the specialized needs of residents with stroke, and the lack of coordinated and consistent care. Conclusion: This study identified challenges and barriers to providing optimal stroke care in LTC facilities. Recommendations for enhancing stroke care are suggested.

Stroke Care in Long-Term Care Facilities in Southwestern Ontario

Purpose: This study describes the current state of stroke care and rehabilitation in facility-based long-term care (LTC).Method: LTC representatives, community partners (including physiotherapists and occupational therapists), stroke survivors, and family members were interviewed about stroke care provided in LTC facilities. Results: Limitations of the current system were identified including inadequate provision of therapy, unequal access to specialized rehabilitation, lack of staff training to care for the specialized needs of residents with stroke, and the lack of coordinated and consistent care. Conclusion: This study identified challenges and barriers to providing optimal stroke care in LTC facilities. Recommendations for enhancing stroke care are suggested.

Interprovincial Comparisons of Public and Private Sector Long-Term Care Facilities for the Elderly in Canada

Long-term care services for the elderly in Canada have evolved into a vast array of types of facilities, levels and types of care and organizational arrangements, and are best characterized as operating within ten individual provincial systems. This study was undertaken in an effort to more fully understand the organization and financing of facility-based long-term care across the provinces. The wide degree of variability across systems renders interprovincial comparisons problematic and, to mitigate this, a reconciliation process was undertaken whereby facilities and beds were classified into four Categories of Care. While a few general patterns emerged, the results also serve to highlight the dissimilarities between, and within, systems. The article concludes by examining the potential value of such data to health planners and policy-makers.