Long-term Care Teams Research Articles

A Novel Primary Care-Based, Practice Nurse-Led Bone Health Service for People in Long Term Care

Abstract Background 11% of all Irish hip fractures originate in the long-term care (LTC) setting and LTC residents are at the highest risk of reduced bone density. Risk is poorly managed as no primary care framework exists. A novel practice nurse-prescriber-led service is described in which risk estimation directs stratification, investigation, and treatment of fragility fracture risk. Methods Baseline assessment uses FRAX (fracture risk assessment tool) to risk-stratify using NOGG (National Osteoporosis Guideline Group) risk charts and inform the need for bone mineral density (BMD) measurement. A bone health drug optimisation process ensured patients were offered treatment at appropriate intensity. Results 107 residents of mean age 86.2 were newly admitted to long-term care in 2023. 92 were included and 15 were excluded due to poor prognosis. 10 of the 92 residents included died in 2023. 91 patients were risk-stratified into NOGG categories as follows: Low 22%, n=20; intermediate, below intervention threshold 23%, n=21; intermediate, above intervention threshold 16%, n=15; high 19%, n=17; very high 20% n=18. 84% (n=77) of those in risk categories indicating anti-resorptive treatment were not prescribed a bisphosphonate at baseline and none were prescribed Denosumab. 84% (n=42) were prescribed Vitamin D either with or without supplemental calcium and 16% were prescribed nothing to improve bone health. Post-intervention, 100% (n=43) of patients at a risk level of NOGG ‘intervention threshold’ or above were prescribed either Vitamin D with or without supplemental calcium and 58% (n=25) were prescribed anti-resorptive therapy (denosumab =47%, n=20 or bisphosphonate = 9%, n=5). Discussion of treatment with the primary care and LTC team is periodic. At the time of data capture, 88% of residents were discussed and 12% were planned for discussion. Conclusion A practice nurse-prescriber led service targeting LTC residents is effective in optimising screening and prescribing. Future work could include replication in the national LTC community.

Factors associated with dietitian referrals to support long-term care residents advancing towards the end of life.

Dietitians are central members of the multidisciplinary long-term care (LTC) healthcare team. The overall aim of this current investigation is to gain a better understanding of dietitian involvement in LTC resident's end-of-life care via referrals. Retrospective chart reviews for 164 deceased residents (mean age = 88.3 ± 7.3; 61% female) in 18 LTC homes in Ontario, Canada, identified dietitian referrals and documented eating challenges recorded over 2-week periods at four time points (i.e., 6 months, 3 months, 1 month and 2 weeks) prior to death. Nutrition care plans at the beginning of these time points were also noted. Logistic mixed effects regression models identified time-varying predictors of dietitian referrals. Bivariate tests identified associations between nutrition orders and dietitian referrals that occurred in the last month of life. Nearly three-quarters (73%) of participants had at least one dietitian referral across the four observations. Referrals increased significantly with proximity to death; 45% of residents had a referral documented in the last 2 weeks of life. Dietitian referrals were associated with the number of eating challenges (odds ratio [OR] = 1.42, 95% confidence interval [CI] = 1.27, 1.58). Comfort-focused nutrition care orders were significantly more common when a dietitian was referred (25%) compared with when a dietitian was not referred (12%) in the final month of life (p = 0.04). Our findings suggest that dietitians are involved in end-of-life and comfort-focused nutrition care initiatives, yet they are not engaged consistently for this purpose. This presents a significant opportunity for dietitians to upskill and champion palliative approaches to nutrition care within the multidisciplinary LTC team.

Integration of a dental hygienist into the interprofessional long-term care team.

To address poor oral health of residents in long-term care homes (LTCH), this study explored the process of integrating an educational resource and a dental hygienist on the interprofessional care team. This convergent mixed-methods study took place at a 472-bed LTCH in Toronto, Canada from February to August 2018. Nurses employed at the LTCH participated in the study. During the study period, a dental hygienist was integrated into an interprofessional LTCH team. Nurses completed an online eLearning module about using the Oral Health Assessment Tool (OHAT) when referring residents' oral health concerns to a. Pre/post knowledge quizzes, module feedback and satisfaction surveys were administered. A retrospective chart review examined OHAT use and compared nurse and dental hygienist oral health assessments. Two cycles of semi-structured interviews with five nurses explored experiences with the eLearning module, OHAT and integration of the dental hygienist into the team. Nurses scored well on the knowledge quizzes and reported comfort in using the OHAT to refer oral concerns to a dental hygienist; however, actual use was minimal. oral health issues were under-reported by nurses on the Resident Assessment Instrument-Minimum Data Set (RAI-MDS); the dental hygienist reported significantly more debris, teeth lost and carious teeth (all P < 0.0001). Qualitative analysis indicated that the nurses valued dental hygienist integration into the team. Using knowledge mobilisation practices, a new oral health referral tool was developed. This study highlights the feasibility and desirability of an oral health eLearning module, practical assessment tools and participation of a dental hygienist on the LTCH interprofessional care team.

Addressing Medications Definitively By Avoiding “Medication Management”

Addressing Medications Definitively By Avoiding “Medication Management”

Effect of a multimethod quality improvement intervention on antipsychotic medication use among residents of long-term care

BackgroundAntipsychotic medications are used to address neuropsychiatric symptoms associated with dementia. Evidence suggests that among older adults with dementia, their harms outweigh their benefits. A quality improvement initiative was conducted...

Use of Long-Term Care Facilities for Primary Care Nurse Practitioner Students.

Family and adult-gerontology primary care nurse practitioner (NP) students must obtain patient clinical hours caring for older adults. Primary care occurs in a variety of settings, including long-term care (LTC) facilities. Anecdotal reports indicate that faculty in some primary NP academic programs do not recognize the robust primary care opportunities that exist in LTC settings. This article describes a professional nursing organization's process of researching the appropriateness of designating LTC clinical hours as allowable primary care clinical experiences for NP students. The NP serves as an integral member of the LTC team, providing the same elements of primary care provided in traditional ambulatory care settings. Older adults receiving primary care in LTC settings have a variety of health care needs, including assessment and management of acute and chronic conditions. A position statement was developed for primary care NP students and endorsed by 22 professional organizations and NP programs. [J Nurs Educ. 2021;60(2):99-102.].

Toward a learning-to-performance program for interprofessional long-term care teams: Team Essentials to foster engagement, reciprocity, and meaningful, sustained practice change

ABSTRACT This paper presents the design, delivery, and preliminary evaluation of a gerontological learning-to-performance program. An interprofessional educational team sought to integrate leading clinical and educational practices into Team Essentials to engage long-term care teams in learning to improve performance. Although the association between skilled, trained staff and quality of care is well-established in research, how best to engage learners from an increasingly diverse workforce is less well understood. This paper outlines the context, framework, methods, and preliminary evaluation of the program. Data from participant surveys, interviews, and field notes suggest that program content and delivery positively impacted participants. Four major themes emerged: Enabling engagement through experiential learning; Valuing reciprocity in long-term care training; Creating meaningful change through significant learning; and, Fostering sustained practice change through leadership involvement. The paper concludes with implications for LTC workforce training.

Building Long-Term Care Staff Capacity During COVID-19 Through Just-in-Time Learning: Evaluation of a Modified ECHO Model

ObjectivesThe onset of the COVID-19 pandemic significantly challenged the capacity of long-term care (LTC) homes in Canada, resulting in new, pressing priorities for leaders and health care providers (HCPs) in the care and safety of LTC residents. This study aimed to determine whether Project ECHO (Extension for Community Healthcare Outcomes) Care of the Elderly Long-Term Care (COE-LTC): COVID-19, a virtual education program, was effective at delivering just-in-time learning and best practices to support LTC teams and residents during the pandemic. DesignMixed methods evaluation. Setting and ParticipantsInterprofessional HCPs working in LTC homes or deployed to work in LTC homes primarily in Ontario, Canada, who participated in 12 weekly, 60-minute sessions. MethodsQuantitative and qualitative surveys assessing reach, satisfaction, self-efficacy, practice change, impact on resident care, and knowledge sharing. ResultsOf the 252 registrants for ECHO COE-LTC: COVID-19, 160 (63.4%) attended at least 1 weekly session. Nurses and nurse practitioners represented the largest proportion of HCPs (43.8%). Overall, both confidence and comfort level working with residents who were at risk, confirmed, or suspected of having COVID-19 increased after participating in the ECHO sessions (effect sizes ≥ 0.7, Wilcoxon signed rank P < .001). Participants also reported impact on intent to change behavior, resident care, and knowledge sharing. Conclusions and ImplicationsThe results demonstrate that ECHO COE-LTC: COVID 19 effectively delivered time-sensitive information and best practices to support LTC teams and residents. It may be a critical platform during this pandemic and in future crises to deliver just-in-time learning during periods of constantly changing information.

State Actions and Shortages of Personal Protective Equipment and Staff in U.S. Nursing Homes.

BACKGROUNDIt is crucial that nursing homes have adequate personal protective equipment (PPE) and staff to protect residents and staff from COVID‐19. Some states have taken actions to mitigate shortages of PPE and staffing in nursing homes, including creating dedicated long‐term care (LTC) teams and supporting staffing capacity.OBJECTIVETo examine whether state actions and nursing home characteristics are associated with shortages of PPE and staffing.DESIGN AND SETTINGFacility‐level data, released July 31, 2020, from the Nursing Home COVID‐19 Public File, were combined with data from other sources. Our sample was the 13,445 facilities with information about PPE and staffing shortages for each of the 5 weeks between the week ending June 21, 2020, and the week ending July 19, 2020. Associations between facility characteristics and shortages were examined using descriptive statistics and logistic regression models.MEASUREMENTSOutcome variables were whether or not a facility lacked a 1‐week supply of PPE (“PPE shortage”) and whether or not a facility had a staffing shortage during 1 or more weeks over the 5‐week study period.RESULTSOver the 5‐week study period, 27.6% of facilities reported 1 or more weeks of PPE shortage, 30.2% of facilities reported at least 1 week of staffing shortage, and 46.5% of facilities lacked PPE and/or staff. Facilities located in states in the Northeast PPE Consortium or with LTC teams were modestly less likely to have had a PPE shortage, and facilities located in states that implemented processes to match job seekers with LTC facilities were marginally significantly less likely to have had a staffing shortage.CONCLUSIONGiven that nearly half of U.S. nursing homes recently faced a shortage of PPE and/or staff, and that state budget deficits may limit further state actions, ongoing federal assistance with PPE and staffing of nursing homes is needed.

Enfermagem de reabilitação na prevenção de quedas em idosos no domicílio

Objetivo: Identificar fatores intrínsecos e extrínsecos associados ao risco de queda em idosos no domicílio; Analisar o resultado de cuidados de Enfermagem de Reabilitação na diminuição do risco de queda em idosos no domicílio. Métodos: Estudo de caso descritivo com três participantes que são utentes integrados na Equipa de Cuidados Continuados Integrados de uma Unidade de Cuidados na Comunidade, com alterações do foro neurológico e com alteração do equilíbrio, alvos de cuidados de enfermagem de reabilitação, e com potencial de recuperação. Resultados: Durante oito semanas de implementação do programa de cuidados de enfermagem de reabilitação verificou-se a diminuição de fatores de risco intrínsecos para queda, relacionados com o equilíbrio, com as transferências e com a mobilidade. Ao avaliar os resultados obtidos é possível observar que todos os participantes obtiveram ganhos. De uma forma geral, em todos os casos houve ganhos na capacidade dos participantes executarem as AVD’s (IB) em 45 pontos e um aumento do Equilíbrio (EEB) de 42 pontos. A evolução no grau de dependência ocorreu apenas em um caso, sendo que nos restantes dois manteve-se a dependência grave. Conclusão: Os cuidados de enfermagem de reabilitação indiciam produzir ganhos no equilíbrio e na capacidade de execução dos autocuidados, o que consequentemente diminui o risco de queda em idosos no domicílio. A enfermagem de reabilitação no domicílio nas fases subagudas da doença neurológica pode potencializar estes resultados. Palavras-chave: Reabilitação, Idoso, Acidentes por Quedas

Caring Difficulties and Coping Strategies for Pediatric Organ Transplant Recipients and Their Families During Dark Recovery Experiences in the Hospital: Perspective of Health Professionals in Taiwan

BackgroundThis study explored caring difficulties and the reliable coping strategies for pediatric organ transplant recipients (POTR) and their families during their dark recovery experiences (DRE) in the hospital from the perspectives of Taiwan organ transplant health professionals (OTHP) in Taiwan. MethodsA qualitative design was used with a purposive sample of OT surgeons (OTS) and nurses. Data were collected by face-to-face in-depth interviews and analyzed by content analysis. ResultsFifty-five subjects (39 females, 16 males) participated in this project. They included 15 OTS and 40 nurses. The nurses included registered nurses (n = 27), nurse practitioners (n = 5), and assistant or head nurses (n = 8). Their ages ranged from 25 to 66 (M = 38.4) years old. Thirty-eight (69%) had a college education and 17 (31%) had a graduate education. Their OT careers ranged from between 3 to 40 (M = 23.8) years for OTS, and 0.5 to 15 (M = 4.10) years for the OT nursing group. Six types of coping strategies for caring difficulties were reported: (a) implementing humanistic care training programs, (b) developing clinical paths for complex multiple OT cases, (c) holding case conferences for successful and failed cases, (d) developing OT expert training programs for interdisciplinary team members, (e) integrating acute and long-term care teams for difficult OT cases and families, and (f) inviting assistance from social workers. ConclusionsThis research identifies important care difficulties and provides coping strategies that help to empower OTHP to care for POTR and their families during DRE, including increasing the manpower of experienced OT staff, conducting systematic in-service training, building teamwork between OTHP, and establishing a good pediatric OTHP team with consensus and good communication channels so as to effectively deal with the difficulties faced when caring for the POTR, and further to effectively enhance the overall quality of clinical care of POTR.

A pathway from long-term care to adoption: findings from an Australian permanency programme

Children who hope to be adopted from the care system frequently experience delays, unproductive disruption in attachments and difficulties locating new families. This article seeks to contribute to the search for effective adoption practice by exploring an approach developed in Australia, whereby restoration and ‘long-term foster care with the view to adoption’ are undertaken intensively but sequentially. When the child cannot return home, adoption is one of the options considered but no decision is made until a long-term foster family is well established. While planning happens concurrently, placements never have dual purposes and are therefore different from what is known as concurrent planning. This study is based on an internal agency examination of adoption records over a 10-year period. Open adoptions were ultimately achieved for one-third of those who entered long-term care, and the children had a wide range of ages and included sibling groups and those with behavioural difficulties. Adoption took, on average, 4.4 years to finalise but there was wide variation in timeframes, with younger children being adopted more quickly. Perhaps most significantly, a permanent placement was found relatively soon for children of all ages, as they did not have to wait for a family willing to commit to adoption or endure lengthy legal proceedings. The adoption was most timely when both restoration and long-term care teams were managed within one agency (albeit in separate programmes). Furthermore, permanent families were located for children for whom adoption ultimately proved to be inappropriate.

Caring Dilemmas and Coping Strategies for Organ Transplant Recipients and Their Families: Perspective of Health Professionals in Taiwan

BackgroundOrgan transplant health professionals (OTHP) are challenged by more and more sophisticated caring dilemmas raised by organ transplant recipients (OTR) and their families. The purposes of this study were to explore caring dilemmas and the reliable coping strategies applied by OTHPs in Taiwan. MethodsA qualitative design was used with a purposive sample of OT surgeons and nurses. Data were collected by face-to-face in-depth interviews and analyzed by content analysis. ResultsSixty subjects (43 females, 17 male) participated in this project. They were 16 OT surgeons and 44 nurses, including RNs (n = 29), nurse practitioners (NP, n = 6), and assistant/head nurses (n = 9). Their ages ranged from 25 to 66 (mean = 38.2) years old. Their OT careers ranged from 3 to 40 (mean = 24.7) years for OT surgeons and 0.5 to 15 (years = 4.3) years for the nursing group. Five types of coping strategies for caring dilemmas were reported: (1) developing clinical paths for complex multiple-OT cases, (2) developing OT-expert training programs for interdisciplinary team members, (3) integrating acute and long-term care teams for difficult OT cases and families, (4) holding case conferences for successful and failed cases, and (5) implementing humanistic care training programs. ConclusionsThe findings of this research provide important coping strategies that can help empower OTHPs to care for complex multiple-OT cases with humanitarian expressions. More discussion about cultivation of interdisciplinary OT experts programs, and integration of caring resources are needed in the near future.

Postacute and Long-Term Care Teams Increasingly Participate in Cancer Care

Postacute and Long-Term Care Teams Increasingly Participate in Cancer Care

A Nurse-Led Interdisciplinary Leadership Approach Targeting Pressure Ulcer Prevention in Long-term Care

Mounting evidence suggests that the quality of outcomes in long-term care can be improved by strengthening the leadership behaviors of nurses. Consequently, a reduction in the prevalence and incidence of pressure ulcers (PUs) is thought to be possible through a nurse-led, team-based approach. The purposes of this article were to (1) advocate for greater nurse-led interdisciplinary teamwork focusing on PU prevention and (2) describe how a transformational and practice-based framework can be used to guide the long-term care team to improve PU quality care outcomes. Application of nurse-led, team-conceptualized strategies enables interdisciplinary workers to partner and more effectively participate in PU prevention programs, thus deepening engagement in the organization's overall approach to achieving quality outcomes.

An interdisciplinary knowledge translation intervention in long-term care: study protocol for the vitamin D and osteoporosis study (ViDOS) pilot cluster randomized controlled trial.

BackgroundKnowledge translation (KT) research in long-term care (LTC) is still in its early stages. This protocol describes the evaluation of a multifaceted, interdisciplinary KT intervention aimed at integrating evidence-based osteoporosis and fracture prevention strategies into LTC care processes.Methods and designThe Vitamin D and Osteoporosis Study (ViDOS) is underway in 40 LTC homes (n = 19 intervention, n = 21 control) across Ontario, Canada. The primary objectives of this study are to assess the feasibility of delivering the KT intervention, and clinically, to increase the percent of LTC residents prescribed ≥800 IU of vitamin D daily. Eligibility criteria are LTC homes that are serviced by our partner pharmacy provider and have more than one prescribing physician. The target audience within each LTC home is the Professional Advisory Committee (PAC), an interdisciplinary team who meets quarterly. The key elements of the intervention are three interactive educational sessions led by an expert opinion leader, action planning using a quality improvement cycle, audit and feedback reports, nominated internal champions, and reminders/point-of-care tools. Control homes do not receive any intervention, however both intervention and control homes received educational materials as part of the Ontario Osteoporosis Strategy. Primary outcomes are feasibility measures (recruitment, retention, attendance at educational sessions, action plan items identified and initiated, internal champions identified, performance reports provided and reviewed), and vitamin D (≥800 IU/daily) prescribing at 6 and 12 months. Secondary outcomes include the proportion of residents prescribed calcium supplements and osteoporosis medications, and falls and fractures. Qualitative methods will examine the experience of the LTC team with the KT intervention. Homes are centrally randomized to intervention and control groups in blocks of variable size using a computer generated allocation sequence. Randomization is stratified by home size and profit/nonprofit status. Prescribing data retrieval and analysis are performed by blinded personnel.DiscussionOur study will contribute to an improved understanding of the feasibility and acceptability of a multifaceted intervention aimed at translating knowledge to LTC practitioners. Lessons learned from this study will be valuable in guiding future research and understanding the complexities of translating knowledge in LTC.Trial registrationClinicalTrials.gov NCT01398527.

A Model for Collaborative Quality Improvement in Rural Nursing Homes

Introduction/Objective: Quality improvement learning collaboratives (QILC) are commonly used in acute care settings as an approach for performance improvement. In contrast, long-term care teams have only recently begun to adopt this approach. Rural communities are geographically isolated and on average have greater utilization of nursing home (NH) services with lower quality of care than metropolitan settings. The potential power of QILCs to spread learning of QI methods and improvement ideas across rural NHs is illustrated by the Greater Rochester Nursing Home Quality Consortium (GRNHQC).

A team-based approach to warfarin management in long term care: A feasibility study of the MEDeINR electronic decision support system

BackgroundPrevious studies in long-term care (LTC) have demonstrated that warfarin management is suboptimal with preventable adverse events often occurring as a result of poor International Normalized Ratio (INR) control. To assist LTC teams with the challenge of maintaining residents on warfarin in the therapeutic range (INR of 2.0 to 3.0), we developed an electronic decision support system that was based on a validated algorithm for warfarin dosing. We evaluated the MEDeINR system in a pre-post implementation design by examining the impact on INR control, testing frequency, and experiences of staff in using the system.MethodsFor this feasibility study, we piloted the MEDeINR system in six LTC homes in Ontario, Canada. All128 residents (without a prosthetic valve) who were taking warfarin were included. Three-months of INR data prior to MEDeINR was collected via a retrospective chart audit, and three-months of INR data after implementation of MEDeINR was captured in the central computer database. The primary outcomes compared in a pre-post design were time in therapeutic range (TTR) and time in sub/supratherapeutic ranges based on all INR measures for every resident on warfarin. Secondary measures included the number of monthly INR tests/resident and survey/focus-group feedback from the LTC teams.ResultsLTC homes in our study had TTR's that were higher than past reports prior to the intervention. Overall, the TTR increased during the MEDeINR phase (65 to 69%), but was only significantly increased for one home (62% to 71%, p < 0.05). The percentage of time in supratherapeutic decreased from 14% to 11%, p = 0.08); there was little change for the subtherapeutic range (21% to 20%, p = 0.66). Overall, the average number of INR tests/30 days decreased from 4.2 to 3.1 (p < 0.0001) per resident after implementation of MEDeINR. Feedback received from LTC clinicians and staff was that the program decreased the work-load, improved confidence in management and decisions, and was generally easy to use.ConclusionAlthough LTC homes in our sample had TTR's that were relatively high prior to the intervention, the MEDeINR program represented a useful tool to promote optimal TTR, decrease INR venipunctures, streamline processes, and increase nurse and physician confidence around warfarin management. We have demonstrated that MEDeINR was a practical, usable clinical information system that can be incorporated into the LTC environment.

The nurse practitioner role in pain management in long‐term care

This paper is a report of a study exploring the perceptions of long-term care team members and nurse managers about barriers and facilitators to optimal use of nurse practitioners to manage residents' pain in long-term care settings. Considering the high rates of pain in long-term care, research is needed to explore innovations in health-services delivery, including the emerging nurse practitioner role. For this study, an exploratory descriptive design was used to collect data in spring 2007 from five focus groups of nurses and 14 individual interviews with other healthcare team members and nurse managers. Data were analysed using thematic content analysis. Five pain management activities performed by nurse practitioners were identified, including assessing pain, prescribing pain medications, monitoring pain levels and side effects of pain medications, consulting and advocating for staff and patients, and leading and educating staff related to pain management. Factors that influenced the implementation of the nurse practitioner role included the availability of the nurse practitioner, scope of practice, role clarity, perceived added value of nurse practitioner role, terms of employment, nurse practitioner-physician relationship. Perceived outcomes of the nurse practitioner role were also described. The findings from this study contribute to our understanding of how the nurse practitioner role is perceived by other healthcare professionals, particularly in pain management. Stronger interprofessional collaborative relationships need to be facilitated within a model of care that includes a nurse practitioner, with the ultimate goal of improving pain management services in long-term care.

Diabetes Management Demands Flexibility

Diabetes Management Demands Flexibility