Homes In Ontario Research Articles

Health Equity Implications of the COVID-19 Lockdown and Visitation Strategies in Long-Term Care Homes in Ontario: A Mixed Method Study.

The COVID-19 pandemic has negatively impacted the lives and well-being of long-term care home residents. This mixed-method study examined the health equity implications of the COVID-19 lockdown and visitation strategies in long-term care homes in Ontario. We recruited long-term care home residents, their family members and designated caregivers, as well as healthcare workers from 235 homes in Ontario, Canada. We used online surveys and virtual interviews to assess the priority, feasibility, and acceptability of visitation strategies, and to explore the lived experiences of participants under the lockdown and thereafter. A total of n = 201 participants completed a survey and a purposive sample of n = 15 long-term care home residents and their family members completed an interview. The initial lockdown deteriorated residents’ physical, mental, and cognitive well-being, and disrupted family and community ties. Transitional visitation strategies, such as virtual visits, were criticised for lack of emotional value and limited feasibility. Designated caregiver programs emerged as a prioritised and highly acceptable strategy, one that residents and family members demanded continuous and unconditional access to. Our findings suggest a series of equity implications that highlight a person-centred approach to visitation strategies and promote emotional connection between residents and their loved ones.

Greater Opioid Use Among Nursing Home Residents in Ontario, Canada During the First 2 Waves of the COVID-19 Pandemic.

ObjectivesTo examine the association between the COVID-19 pandemic and opioid use among nursing home residents followed up to March 2021, and possible variation by dementia and frailty status.DesignPopulation-based cohort study with an interrupted time series analysis.Setting and ParticipantsLinked health administrative databases for residents of all nursing homes (n = 630) in Ontario, Canada were examined. Residents were divided into consecutive weekly cohorts (first observation week was March 5 to 11, 2017 and last was March 21 to March 27, 2021).MethodsThe weekly proportion of residents dispensed an opioid was examined overall and by strata defined by the presence of dementia and frailty. Autoregressive Integrated Moving Average models with step and ramp intervention functions tested for immediate level and slope changes in weekly opioid use after the onset of the pandemic (March 1, 2020) and were fit on prepandemic data for projected trends.ResultsThe average weekly cohort ranged from 76,834 residents (prepandemic) to 69,359 (pandemic period), with a consistent distribution by sex (69% female) and age (54% age 85 + years). There was a statistically significant increased slope change in the weekly proportion of residents dispensed opioids (parameter estimate (β) = 0.035; standard error (SE) = 0.005, P < .001). Although significant for all 4 strata, the increased slope change was more pronounced among nonfrail residents (β = 0.038; SE = 0.008, P < .001) and those without dementia (β = 0.044; SE = 0.008, P < .001). The absolute difference in observed vs predicted opioid use in the last week of the pandemic period ranged from 1.25% (frail residents) to 2.28% (residents without dementia).Conclusions and ImplicationsAmong Ontario nursing home residents, there was a statistically significant increase in opioid dispensations following the onset of the pandemic that persisted up to 1 year later. Investigations of the reasons for increased use, potential for long-term use and associated health consequences for residents are warranted.

Spiritual Care in Ontario Long-Term Care: Current Staffing Realities and Recommendations.

How are spiritual needs addressed in long-term care? This quantitative study explored the level of spiritual care offered and qualifications of spiritual care providers in 177 LTC homes in Ontario. Data showed 49% of homes employ Spiritual Care Providers (SCPs), with more positions in urban and not-for-profit homes. Findings revealed SCPs bring a substantial skill set, attending to needs of residents, families and team members. More consistent staffing for spiritual care provision across the sector is recommended.

Incidence of outbreak-associated COVID-19 cases by industry in Ontario, Canada, 1 April 2020–31 March 2021

ObjectivesThe objective of our study was to estimate the rate of workplace outbreak-associated cases of COVID-19 by industry in labour market participants aged 15–69 years who reported working the majority...

InterRAI Pediatric Home Care (PEDS-HC) Assessment Tool: Evaluating Ontario Healthcare Workers' Experience.

High quality pediatric homecare requires comprehensive assessment of the needs, supports, and health care challenges of children with special healthcare needs and their families. There is no standardized homecare assessment system to evaluate children’s clinical needs in the home (support services, equipment, etc.) in Ontario, Canada, which contributes to inequitable homecare service allocation. In 2017, the interRAI Pediatric Home Care assessment tool (PEDS-HC) was implemented on a pilot basis in several regions of Ontario. This qualitative descriptive study explores the experiences of homecare coordinators using the PEDS-HC, seeking to understand the utility and feasibility of this tool through focus group discussion. Four major themes were identified including: the benefits of the tool; areas for modification; challenges to use; and Clinical Assessment Protocols to develop. These themes can guide modifications to the tool to improve utility and improve pediatric home care services. The PEDS-HC is an effective tool to assess children needing homecare in a standardized and comprehensive manner. Use of the tool can improve the quality of homecare services by ensuring equity in service provision and facilitate early identification of clinical issues to prevent unexpected health deteriorations.

Evaluating the Conversation Starter Kit in Long Term Care: A Canadian Perspective

This study evaluated an advance care planning intervention, the Conversation Starter Kit (CSK) booklet, for use in long term care (LTC) homes. This study used a quasi-experimental, one group pre/post design. Quantitative surveys were administered before and after a 3-month advance care planning intervention (CSK booklet). Data were collected at three LTC homes in southern Ontario. We collected data from 55 resident who were able to make decisions on their own paired with 11 family members of these residents. We also collected data from 24 family members of residents who were not able to make decisions on their own. Quantitative surveys were administered before and after the intervention. An additional structured interview was completed at the end of the intervention period, which included both closed and open-ended questions to assess perceptions about the CSK booklet’s use or non-use. Residents reported higher engagement in advance care planning after having completed the CSK booklet than before, particularly related to asking questions to health care providers about health care decisions. Family members reported feeling very certain that they would be able to make decisions on behalf of the resident but they felt less certain after completing the CSK booklet, implying that the CSK booklet raised their awareness of the types of decisions that they might need to make, hopefully triggering them to become more prepared for these decisions in the future. The CSK appears acceptable, easy to use for residents and family members/friends in LTC, and can improve resident engagement in ACP.

Fall-Related Injury in Older Adult Home Care Recipients: A Descriptive Population Study

Canada is experiencing a growing aging population leading to an increase in the number of individuals receiving home care. More needs to be known about home care clients who experience fall-related injuries. The purpose of this study was to describe the characteristics of Ontario home care recipients (65 and older) who experienced fall-related injury, and the characteristics of those injuries. We conducted a population-based descriptive study using secondary data from the IC/ES data repository for the period of 2010-2014. Person-level characteristics were extracted from the Resident Assessment Instrument - Home Care and injury characteristics from ICD-10 CA codes for falls (W00-W19) in combination with injuries (S00-S99 or T00-T14), available from the NACRS database. Descriptive statistics and rates were calculated using R. Results show the population (N= 88,731) was primarily female (67.0%), the largest age group was 85-89 years old (25.5%) and hypertension was the most prevalent (83.0%) chronic condition. Clinical Assessment Protocols (CAPs) indicated need for support in management of IADLs (75.4%), falls (72.3%) and pain (70.3%). Most patients (55.8%) used nine or more medications. In 90 days prior to home care assessment, 39.6% experienced no falls, 32.4% fell once, and 26.1% fell two or more times. Injuries primarily took place within the home (38.2%). Factures were the predominant injury type (40.8%), followed by superficial injuries (19.7%). These findings create a foundation for fall-related injury prevention in home care and further research on risk identification, the efficacy of CAPs, and home environment adjustments.

"Let's Connect": Implementing a tablet‐based intervention for people with dementia and caregivers

AbstractBackgroundLet’s Connect training to use tablets and accessible apps with people living with dementia was implemented with staff, volunteers and family caregivers to evaluate the program impact.MethodEighty‐six staff and volunteers (18‐88 years of age) in 14 adult day programs and long‐term care homes in Ontario, Canada received training to deliver Let’s Connect groups as part of their daily or weekly programming. They were supported to deliver Let’s Connect group program for an initial eight sessions program with 118 people with dementia (56‐98 years of age). Staff and volunteers completed the Dementia Attitudes Scale (DAS) before and after the eight sessions and an exit interview, which was also completed by family caregivers who received training to support Let's Connect at home. People with dementia completed the QoL‐AD and SPS‐10 measure of social connectedness plus exit interviews.ResultThere was an improvement in staff and volunteer’s DAS score, while the people with dementia attending the adult day programs maintained their relatively high levels of social connectedness. Thematic analysis identified social interaction as a key benefit for staff, volunteers, caregivers and people with dementia. Further benefits and potential barriers were also identified.ConclusionLet’s Connect was well‐received, directly improved attitudes towards dementia and enhanced social activity. All of the sites that received training continued with the Let’s Connect group program after the research project ended. We will share our training strategy that can be applied to other tablet‐based activities.

Falling through the care cracks: younger people in long-term care homes

The COVID-19 casualties in long-term care homes (nursing homes) around the world are usually described as our collective failure in care towards older adults. The plight of younger long-term care residents appears to be forgotten in the midst of long-term care tragedies. This article summarises a small number of key informant interviews (conducted in 2017) that shed light on why younger adults reside in long-term care homes in Ontario, Canada. To put it simply, the younger residents have nowhere to go. Diverting younger people with disabilities from long-term care will help alleviate pressures on long-term care systems as respective governments race to reform them.

Development of communication tool for resident- and family-led care discussions in long-term care through patient and family engagement.

BackgroundEffective communication between residents (older adults), families, and the healthcare team supports person‐centred care. However, communication breakdowns can occur that can impact care and outcomes. The aim of this paper is to describe a feedback approach to developing a communication tool for residents and families to guide information sharing during care discussions with the healthcare team in long‐term care.MethodsDevelopment of the communication tool included consultation with key stakeholders for their feedback and input. Following initial development of the tool template by our research team, we invited feedback from our study collaborators. Next, individual interviews and a focus group were conducted with family members, followed by individual interviews with selected residents from two long‐term care homes in Ontario, Canada. Participants were asked to provide input and feedback on the tool's content and usability and to share ideas for improving the tool. Content analysis was used to analyse the interview data.ResultsFeedback from residents and family included suggestions to enhance the tool's content and use of plain language, and suggestions for potential application of the tool.ConclusionFeedback highlighted the value of engaging residents and family members in the development of a communication tool. The communication tool offers a structured format to support participation of residents and families in information sharing for care discussions with the healthcare team.

Using Patient Simulation to Promote Best Practices in Fall Prevention and Postfall Assessment in Nursing Homes.

Background:Fall-related injuries rise with age and are of particular concern for frail populations living in nursing homes.Local Problem:The Perley and Rideau Veterans' Health Centre is a large nursing home in Ontario, Canada. In 2019, we conducted internal audits of our Falls Prevention Program and identified notable variations in staff's response to a resident fall.Interventions:We developed an in situ patient simulation program of a resident fall.Methods:This was a mixed-methods evaluation of participants' perspectives of a simulation-based interprofessional education program for fall prevention.Results:Participants indicated high-level support for simulation-based learning, with more than 80% of the participants expressing that they will apply these skills in the future when caring for a resident who falls.Conclusions:Our findings indicate that simulation-based training is well received by frontline workers in a nursing home setting and can be conducted as part of a typical shift with minimal disruption to resident care.

Predictors of mortality among long-term care residents with SARS-CoV-2 infection.

While individuals living in long-term care (LTC) homes have experienced adverse outcomes of SARS-CoV-2 infection, few studies have examined a broad range of predictors of 30-day mortality in this population. We studied residents living in LTC homes in Ontario, Canada, who underwent PCR testing for SARS-CoV-2 infection from January 1 to August 31, 2020, and examined predictors of all-cause death within 30 days after a positive test for SARS-CoV-2. We examined a broad range of risk factor categories including demographics, comorbidities, functional status, laboratory tests, and characteristics of the LTC facility and surrounding community were examined. In total, 304 potential predictors were evaluated for their association with mortality using machine learning (Random Forest). A total of 64,733 residents of LTC, median age 86 (78, 91) years (31.8% men), underwent SARS-CoV-2 testing, of whom 5029 (7.8%) tested positive. Thirty-day mortality rates were 28.7% (1442 deaths) after a positive test. Of 59,702 residents who tested negative, 2652 (4.4%) died within 30 days of testing. Predictors of mortality after SARS-CoV-2 infection included age, functional status (e.g., activity of daily living score and pressure ulcer risk), male sex, undernutrition, dehydration risk, prior hospital contacts for respiratory illness, and duration of comorbidities (e.g., heart failure, COPD). Lower GFR, hemoglobin concentration, lymphocyte count, and serum albumin were associated with higher mortality. After combining all covariates to generate a risk index, mortality rate in the highest risk quartile was 48.3% compared with 7% in the first quartile (odds ratio 12.42, 95%CI: 6.67, 22.80, p < 0.001). Deaths continued to increase rapidly for 15 days after the positive test. LTC residents, particularly those with reduced functional status, comorbidities, and abnormalities on routine laboratory tests, are at high risk for mortality after SARS-CoV-2 infection. Recognizing high-risk residents in LTC may enhance institution of appropriate preventative measures.

An Evaluation of the Communication at End-of-Life Education Program for Personal Support Workers in Long-Term Care.

Background: Communication skills are crucial for personal support workers (PSWs) to foster therapeutic relationships with the residents and their families in the long-term care (LTC) setting. Aim: To evaluate the impact of the Communication at End-of-Life (CEoL) Education Program on the competency and confidence of PSWs working in LTC to communicate about palliative and end-of-life care, and factors affecting their involvement in palliative and end-of-life care. Setting/Participants: PSWs from 35 LTC homes in Ontario, Canada, who participated in the CEoL Education Program between January and March 2019. Design: Mixed-methods evaluation using pre- (n = 178) and post-workshop (n = 113) surveys capturing the attitudes and beliefs toward death and dying; relationships with residents and families; and PSWs' participation in end-of-life care. Follow-up interviews were conducted between February and March 2019 with 21 PSWs to examine facilitators and barriers that affected their confidence in engaging in palliative care. Results: We observed significant improvements in all three domains, with the greatest increase (11%, p < 0.001) in the proportion of participants who responded "Often" or "Always" in the participation in end-of-life care domain. Specifically, we observed PSWs' elevated confidence in speaking with families of the residents about end-of-life, discussing goals and plans with the residents, and realizing that a "good death" is possible. Time constraints and staff shortages were recurrent themes that hindered many participants' ability to provide resident-centered care. Conclusions: This evaluation demonstrates that CEoL Education Program was associated with improved PSW competency and confidence in supporting palliative and end-of-life care in LTC settings.

Association Between Dementia Care Programs in Assisted Living Facilities and Transitions to Nursing Homes in Ontario, Canada: A Population-Based Cohort Study

ObjectiveWe investigate whether older adults who were newly diagnosed with dementia (severity unspecified) and resided in an assisted living facility that offered a dementia care program had a lower rate of transition to a nursing home, compared to those who resided in an assisted living facility without such a program. DesignPopulation-based retrospective cohort study. Setting and ParticipantsLinked, person-level health system administrative data on older adults who were newly diagnosed with dementia and resided in an assisted living facility in Ontario, Canada, from 2014 to 2019 (n = 977). MethodsAccess to a dementia care program in an assisted living facility (n = 57) was examined. Multivariable Cox proportional hazards regression with robust standard errors clustered on the assisted living facility was used to model the time to transition to a nursing home from the new dementia diagnosis. ResultsThere were 11.8 transitions to a nursing home per 100 person-years among older adults who resided in an assisted living facility with a dementia care program, compared with 20.5 transitions to a nursing home per 100 person-years among older adults who resided in an assisted living facility without a dementia care program. After adjustment for relevant characteristics at baseline, older adults who resided in an assisted living facility with a dementia care program had a 40% lower rate of transition to a nursing home (hazard ratio 0.60, 95% confidence interval 0.44, 0.81), compared with those in an assisted living facility without such a program at any point during the follow-up period. Conclusions and ImplicationsThe rate of transition to a nursing home was significantly lower among older adults who resided in an assisted living facility that offered a dementia care program. These findings support the expansion of dementia care programs in assisted living facilities.

Comparison of Medication Prescribing Before and After the COVID-19 Pandemic Among Nursing Home Residents in Ontario, Canada

COVID-19 has had devastating effects on the health and well-being of older adult residents and health care professionals in nursing homes. Uncertainty about the associated consequences of these adverse effects on the use of medications common to this care setting remains. To examine the association between the COVID-19 pandemic and prescription medication changes among nursing home residents. This population-based cohort study with an interrupted time-series analysis used linked health administrative data bases for residents of all nursing homes (N = 630) in Ontario, Canada. During the observation period, residents were divided into consecutive weekly cohorts. The first observation week was March 5 to 11, 2017; the last observation week was September 20 to 26, 2020. Onset of the COVID-19 pandemic on March 1, 2020. Weekly proportion of residents dispensed antipsychotics, benzodiazepines, antidepressants, anticonvulsants, opioids, antibiotics, angiotensin receptor blockers (ARBs), and angiotensin-converting enzyme (ACE) inhibitors. Autoregressive integrated moving average models with step and ramp intervention functions tested for level and slope changes in weekly medication use after the onset of the pandemic and were fit on prepandemic data for projected trends. Across study years, the annual cohort size ranged from 75 850 to 76 549 residents (mean [SD] age, 83.4 [10.8] years; mean proportion of women, 68.9%). A significant increased slope change in the weekly proportion of residents who were dispensed antipsychotics (parameter estimate [β] = 0.051; standard error [SE] = 0.010; P < .001), benzodiazepines (β = 0.026; SE = 0.003; P < .001), antidepressants (β = 0.046; SE = 0.013; P < .001), trazodone hydrochloride (β = 0.033; SE = 0.010; P < .001), anticonvulsants (β = 0.014; SE = 0.006; P = .03), and opioids (β = 0.038; SE = 0.007; P < .001) was observed. The absolute difference in observed vs estimated use in the last week of the pandemic period ranged from 0.48% (for anticonvulsants) to 1.52% (for antipsychotics). No significant level or slope changes were found for antibiotics, ARBs, or ACE inhibitors. In this population-based cohort study, statistically significant increases in the use of antipsychotics, benzodiazepines, antidepressants, anticonvulsants, and opioids followed the onset of the COVID-19 pandemic, although absolute differences were small. There were no significant changes for antibiotics, ARBs, or ACE inhibitors. Studies are needed to monitor whether changes in pharmacotherapy persist, regress, or accelerate during the course of the pandemic and how these changes affect resident-level outcomes.

Challenges of diversity and inclusion in defence emergency management and preparedness during the COVID-19 pandemic

LAY SUMMARY The Canadian military’s recent mission in support of long-term-care homes in Ontario, and the alleged abuses reported, demonstrates the urgent need to address challenges associated with diversity and inclusion in defence emergency management and preparedness during the COVID-19 pandemic. This article reviews the social and health impacts of the COVID-19 pandemic on diverse groups within the Canadian Defence Team and across Canada, with a particular focus on visible minorities, Indigenous people, women, older adults, persons with disabilities, and lesbian, gay, bisexual, transgender, queer or questioning, and two-spirit communities. The review indicates that the pandemic widened the existing physical and mental health disparities and socio-economic inequities affecting these groups. To address these challenges, and to better understand the needs of diverse groups in the pandemic context, several recommendations for the Defence Team are proposed to incorporate into daily encounters with diverse groups and communities affected by COVID-19. The recommendations are designed to enable the Defence Team to establish positive and sustainable relations with diverse communities and to increase community resilience and defence emergency operational readiness.

Policy and Practice Note: Policy, Safety, and Regulation with Regard to Ontario Home Care Clients and Personal Support Workers.

In light of COVID-19 and elevated concerns for the health of older Canadians receiving care, this Policy and Practice Note explores the confluence of the current home care policy landscape and the organisation of personal support worker (PSW) work, and highlights the need to consider governance of PSW work generally, and in-home and community care especially. PSWs are currently not professionally regulated, nor is there a central site documenting location, education, or any form of verification of the PSW workforce. Home care PSWs often provide physical care in isolated settings with no in-person supervision. In home and community health care, complaints about PSWs can be scattered among different service providers or client files not linked to or searchable by PSW name. This policy note explores how these factors and the currently unregulated status of PSWs affect home care safety in general as well as in the context of COVID-19, Ontario's decentralised home care system, and efforts towards professional regulation.

Qualitative Insights into the Working Conditions of Personal Support Workers in Long-Term Care in the Context of a Person-Centered Communication Training Intervention.

The current study reports on qualitative insights into the working conditions of personal support workers (PSWs) in long-term care (LTC) homes within the context of a person-centered communication training intervention. PSWs (N = 39) employed at one of four LTC homes in southwestern Ontario, Canada, participated in a series of 1-hour focus groups before, during, and after a 2-week person-centered communication training program for formal caregivers of persons living with dementia (PLWD). Textual data from focus group conversations were coded and organized into themes following an interpretive description research design. Three overarching themes emerged related to the working conditions of PSWs in LTC: (1) dementia care is complex, (2) there is a lack of trained staff to provide person-centered dementia care, and (3) residents' families are not appropriately situated in residents' care circles. Four overarching themes emerged related to the impact of those working conditions: (a) PSW occupational burnout, (b) poor resident care, (c) frustrated and disengaged families, and (d) PSW job attrition. These findings offer LTC employers and administrators opportunities to ameliorate working conditions to better support person-centered dementia care. [Research in Gerontological Nursing, 14(5), 245-253.].

Beyond flu: Trends in respiratory infection outbreaks in Ontario healthcare settings from 2007 to 2017, and implications for non-influenza outbreak management.

Outbreaks cause significant morbidity and mortality in healthcare settings. Current testing methods can identify specific viral respiratory pathogens, yet the approach to outbreak management remains general. Our aim was to examine pathogen-specific trends in respiratory outbreaks, including how attack rates, case fatality rates and outbreak duration differ by pathogen between hospitals and long-term care (LTC) and retirement homes (RH) in Ontario. Confirmed respiratory outbreaks in Ontario hospitals and LTC/RH reported between September 1, 2007, and August 31, 2017, were extracted from the integrated Public Health Information System (iPHIS). Median attack rates and outbreak duration and overall case fatality rates of pathogen-specific outbreaks were compared in both settings. Over the 10-year surveillance period, 9,870 confirmed respiratory outbreaks were reported in Ontario hospitals and LTC/RH. Influenza was responsible for most outbreaks (32% in LTC/RH, 51% in hospitals), but these outbreaks were shorter and had lower attack rates than most non-influenza outbreaks in either setting. Human metapneumovirus, while uncommon (<4% of outbreaks) had high case fatality rates in both settings. Attack rates and case fatality rates varied by pathogen, as did outbreak duration. Development of specific outbreak management guidance that takes into account pathogen and healthcare setting may be useful to limit the burden of respiratory outbreaks.

Risk factors for outbreaks of SARS-CoV-2 infection at retirement homes in Ontario, Canada: a population-level cohort study.

BACKGROUND:The epidemiology of SARS-CoV-2 infection in retirement homes (also known as assisted living facilities) is largely unknown. We examined the association between home-and community-level characteristics and the risk of outbreaks of SARS-CoV-2 infection in retirement homes since the beginning of the first wave of the COVID-19 pandemic.METHODS:We conducted a population-based, retrospective cohort study of licensed retirement homes in Ontario, Canada, from Mar. 1 to Dec. 18, 2020. Our primary outcome was an outbreak of SARS-CoV-2 infection (≥ 1 resident or staff case confirmed by validated nucleic acid amplification assay). We used time-dependent proportional hazards methods to model the associations between retirement home– and community-level characteristics and outbreaks of SARS-CoV-2 infection.RESULTS:Our cohort included all 770 licensed retirement homes in Ontario, which housed 56 491 residents. There were 273 (35.5%) retirement homes with 1 or more outbreaks of SARS-CoV-2 infection, involving 1944 (3.5%) residents and 1101 staff (3.0%). Cases of SARS-CoV-2 infection were distributed unevenly across retirement homes, with 2487 (81.7%) resident and staff cases occurring in 77 (10%) homes. The adjusted hazard of an outbreak of SARS-CoV-2 infection in a retirement home was positively associated with homes that had a large resident capacity, were co-located with a long-term care facility, were part of larger chains, offered many services onsite, saw increases in regional incidence of SARS-CoV-2 infection, and were located in a region with a higher community-level ethnic concentration.INTERPRETATION:Readily identifiable characteristics of retirement homes are independently associated with outbreaks of SARS-CoV-2 infection and can support risk identification and priority for vaccination.