Growing demand for Long-Term Care (LTC) services highlights the need to address systemic issues within an ethnically and culturally diverse healthcare workforce. To address such challenges in a healthcare setting, an Equity, diversity, and inclusion (EDI) program was developed. This study aimed to evaluate the implementation of the EDI program in a rural LTC facility in Nova Scotia, Canada, using the Donabedian framework. This mixed-methods study involved ninety-two LTC staff members. Participants completed a survey to assess the program relative to the Donabedian framework: Structure (resources and policies), Process (training and implementation), and Outcomes (staff satisfaction, knowledge and participation in EDI activities). Interviews (n = 4) were conducted to further explore their experiences and perceptions of the program. Descriptive and analytical analysis was employed for the survey data, while qualitative data was explored via reflexive thematic analysis. Participants reported moderate understanding and satisfaction with the program. Responses differed significantly in terms of satisfaction levels based on reported income and religious affiliation. Convergence between qualitative and quantitative data indicated the effectiveness of material facilitation, but staff availability was a limiting factor. Staff were satisfied with the EDI program; however, the results reiterate the need for sustained efforts in rural communities. Improved resources and targeted education for rural healthcare facilities are crucial, and it is essential to consider intersectionality when promoting equity, diversity, inclusion, and accessibility.

This case-based report compares two residents experiencing progressive neuromuscular diseases who transitioned from palliative care to hospice and underwent ventilator discontinuation in a rural long-term care (LTC) facility. With a focus on effective interprofessional collaboration and communication, it highlights a coordinated approach while navigating system-level barriers, process challenges, and the emotional, cultural, and ethical complexities of goal-concordant end-of-life care. In the absence of well-documented protocols, ventilator discontinuation is feasible in rural LTC settings. To improve the quality of this care option, policies are needed to support the development of standardized practice guidelines, ensure simulation-based staff education to improve coordination, and enhance access to essential resources for residents, their families, and health care clinicians in the LTC setting.

Information and communication technologies (ICTs) are increasingly recognized as valuable tools for enhancing the well-being of nursing home residents. However, residents’ perspectives on ICT usage and its implementation in rural nursing homes remain underexplored. This study investigated the role of ICT in promoting well-being from the viewpoint of residents in rural long-term care settings. A qualitative research approach was employed, using semistructured interviews with 16 residents from nursing homes in southern Illinois, USA. Thematic analysis generated five key themes: ICT as a bridge to the outside world, ICT as mental and emotional support, ICT’s role in enhancing independence and self-sufficiency, Technology remains out of reach, and ICT support and assistance. The findings highlight the significant advantages of ICT use, particularly in improving mood, reducing isolation, and alleviating symptoms of depression. Despite these benefits, ongoing barriers, such as limited resources, financial constraints, and insufficient institutional support, continue to impede effective ICT integration. These challenges underscore the need for increased investment in digital literacy programs, reliable internet access, and affordable technology solutions to maximize the benefits of ICT in rural long-term care settings.

Background: Existing challenges in providing high quality care within Long-Term Care (LTC) are often compounded by mistrust and poor relationships. Ameliorating this through intentionally building trust and relationships requires focused effort and necessitates the inclusion of staff, residents, and families as valued partners who effectively contribute to improved quality of care. Approach: The People-Centred Care Strategy (PCS) Team in the Saskatchewan Health Authority (SHA) co-created and facilitated an 8-month co-designed quality improvement (QI) pilot project in a rural LTC Home in southern Saskatchewan. The primary aim was to strengthen trust and relationships between residents, families, staff, and managers through working together on a specific improvement project.The PCS team introduced the co-design concept to the Managers and broadly within the Home and asked for volunteers for a Working Group (WG) made up of residents, families, staff, and Managers. The team became external facilitators of the WG and helped the group work through initial formation issues and to build relationships through getting to know each other and learning to work together. However, all improvement decisions and actions were driven by the WG. The WG decided on two areas for improvement and split into two sub-groups that created and implemented tools to improve quality of life for residents. Although Managers were members of the WG, other staff members took the lead role within the group. Additionally, the Managers and Director of the Home received tailored leadership coaching, particularly around teamwork and communication. A pre- and post-intervention evaluation and a Realist Evaluation was conducted to develop and refine a program theory (PT) identifying key mechanisms of building trust. Results: The WG got off to a slow start and was slow to develop cohesion. Members were dissatisfied with the early pace as the PCS team intentionally spent time on building relationships and ensuring co-identification of the project. The WG wanted less talk and more action. However, the PCS team repeatedly emphasized that building trust and relationships was the focus of this project rather than simply QI. In addition, the time spent getting to know each other would speed up the later stages of project implementation. This prediction was fulfilled as differences in group dynamics became evident in later stages. The WG not only achieved results through pilot testing the improvement tools, but had fun along the way.All participants gained new insights about the work and experiences of the others. Although psychological safety is often a concern within the hierarchy of health care, we saw staff increasingly willing to push back against the opinions of others and to speak out as the central point-of-care providers. We saw a shared leadership model emerge as group members shared their ideas and questioned Managers about decisions and next steps.Preliminary data analyses confirm that top-down hierarchical approaches contribute to mistrust and frustration with staff, residents, and families and reducing this approach through co-design has a positive effect on relationships. Eight mechanisms that contribute to trust have been identified: autonomy/sense of control, transparency, shared goals/values, an expressed commitment to building relationships, optimism for change, and feeling acknowledged, valued, and respected. Implications: The practical learnings will be synthesized and used together with the PT to help other SHA LTC Homes work on building trust and relationships as the foundation for improved quality of care and quality of life for residents. Future co-design efforts will include prioritizing relationship building over initial quick actions, sharing power with key partners, ensuring shared values and goals, ensuring the organizational culture is supportive of co-design and sufficient time and resources are allocated, and having clear communication within and beyond the co-design team.

The purpose of this study was to use serum anticholinergic activity (SAA) to assess the validity of a modified version of the Clinician-Rated Anticholinergic Scale (CR-ACh-mod) in evaluating anticholinergic medication exposure. The CR-ACh-mod scale assigns a value of 0–3 (none to marked anticholinergic effects) to each drug in a subject’s regimen and sums the values to create the CR-ACh-mod score. Subjects were part of a study of delirium in elderly residents of rural long-term care facilities. The 96 subjects had a mean age of 87±7 years (range 68–106), and 82.3% were female. The mean SAA was 0.91±0.51 pmol/0.2 mL atropine equivalents (range 0.09–2.61). The mean CR-ACh-mod score was 2.8±2.3 (range 0–9). CR-ACh-mod scores were significantly associated with SAA using linear regression (t = 2.68, df = 1, P = 0.0087). However, the scores only explained 7.1% of the variance in SAA, suggesting that improvements in the CR-ACh-mod may increase its robustness as a measure of anticholinergic exposure. These findings support the validity of the CR-ACh-mod. However, unexplained variance in SAA suggests that the CR-ACh-mod could benefit from improvements. Future research will evaluate the effect of including factors such as dose and the relative anticholinergic burden from drugs at each rating level. An alternative explanation for the variance, supported by recent research, is that nondrug factors contribute to SAA. Psychopharmacology Bulletin. 2002;36(4):14-19

Retraction: \u201cEvaluating the Clinical Efficacy of an Exergame-Based Training Program for Enhancing Physical and Cognitive Functions in Older Adults With Mild Cognitive Impairment and Dementia Residing in Rural Long-Term Care Facilities: Randomized Controlled Trial\u201d

Teleconsultation has expanded rapidly in recent years, especially during the COVID-19 pandemic, and has become standard practice among physicians. The benefits of teleconsultation, namely, improving access to care, ensuring continuity and quality of care, increasing patient satisfaction, and reducing costs and wait times, are well documented. However, its use in nursing practice, especially in long-term care settings, remains underresearched despite its significant transformative potential, particularly in resource-limited and rural settings, where it could address major challenges such as nursing shortages and access to care. This study aimed to identify barriers to and facilitators of implementing overnight nursing teleconsultation in rural residential and long-term care centers in Quebec, Canada (centres d'hébergement et de soins de longue durée [CHSLDs]), with ≤50 beds. A 6-month pilot project was rolled out sequentially in 3 rural CHSLDs in 2 administrative regions of Quebec between July 2022 and March 2023. A total of 38 semistructured interviews were conducted with managers (n=27, 71%), nursing staff members (n=9, 24%), and resident committee presidents (n=2, 5%) between February 2023 and July 2023. The study identified several barriers to the implementation of teleconsultation. The main barriers reported included union opposition (managers: 23/27, 85%), network instability (resident committee presidents: 2/2, 100%), limited technology skills (nursing staff members: 7/9, 78%), a perceived increase in workload (nursing staff members: 8/9, 89%; resident committee presidents: 2/2, 100%), and a low volume of teleconsultations (nursing staff members: 8/9, 89%). Despite the barriers, participants also identified key facilitators. These included the care setting (nursing staff members: 9/9, 100%; managers: 21/27, 78%), buy-in from senior management and managers (managers: 27/27, 100%; resident committee presidents: 2/2, 100%), collaboration between the departments (nursing staff members: 9/9, 100%), nursing staff motivation (nursing staff members: 9/9, 100%), and improvements in professional practices (nursing staff members: 8/9, 89%). Finally, the relative benefits of teleconsultation, such as enhanced mutual vision, faster assessment of clinical situations, improved resident care management quality, and greater flexibility and safety, were unanimously recognized (38/38, 100%) as contributing to its acceptability and potential for success. This study provides an in-depth understanding of the barriers to and facilitators of implementing overnight nursing teleconsultation in small rural CHSLDs. This constitutes a sound basis for developing tailored strategies aimed at overcoming identified barriers and optimizing facilitators. The results also provide practical guidelines for decision makers, highlighting the need to adapt implementation approaches to the unique context of each facility. Furthermore, this study highlights the importance of further research to broaden our knowledge on the dissemination and scale-up of health care innovations. This includes the development of learning health systems capable of responding in an agile and effective way to the needs of rural and vulnerable populations both in Quebec and elsewhere.

Expression of Concern: Evaluating the Clinical Efficacy of an Exergame-Based Training Program for Enhancing Physical and Cognitive Functions in Older Adults With Mild Cognitive Impairment and Dementia Residing in Rural Long-Term Care Facilities: Randomized Controlled Trial

Rural hospital closures since 2005 reached 194 this year, raising concerns for rural health care access. Little is known about the effects of facility closures on the local long-term care sector. This analysis models the relationship between rural hospital closure and nursing homes in the same county. We explore nursing home-level outcomes related to utilization and resident health. Centers for Medicare & Medicaid Services Healthcare Cost Report Information System, LTCFocus, and NC Rural Health Research Program hospital closure datasets are used to conduct a difference-in-differences study of closures from 2012 to 2019. We do not find evidence that hospital closure impacted non-hospital-based nursing home occupancy rate, proportion of Medicare paying residents, or average resident ADL score. However, hospitalizations per resident year declined by 0.13 following closure (95% CI: -0.24, -0.02), representing a change of 0.33 standard deviations from the grand mean. It is unclear if reduced nursing home hospitalizations reflect a reduction in emergent, urgent, or elective admissions. Our results build on the existing body of hospital closure literature by highlighting the understudied role of hospitals in rural postacute and long-term care. To our knowledge, this was the first study examining the impacts of hospital closure on nursing homes. These findings are particularly relevant in the wake of COVID-19 as rural long-term care facilities and hospitals alike navigate exacerbated workforce and funding challenges.

BackgroundCognitive impairment is an important public health challenge among older adults, particularly in long-term care facilities (LTCFs), where prevalence is higher due to staffing shortages, limited resources, and difficulty maintaining structured exercise programs. Furthermore, older adults often lose interest in repetitive interventions. The exergame “WarioWare: Move It!” (Nintendo) offers a novel solution by combining aerobic exercise, motor coordination, balance training, and cognitive engagement into an immersive experience.ObjectiveThis study aimed to assess the clinical efficacy of an exergame-based training program delivered via “WarioWare: Move It!” in improving physical flexibility, joint range of motion, motor coordination, hand dexterity, and cognitive function in older adults living in LTCFs.MethodsThe training program was conducted across multiple rural LTCFs in Shanxi Province, China. Participants were randomly assigned to the intervention or control group. The intervention protocol encompassed two 60-minute sessions per week over 12 weeks, using motion-sensing exercises such as waving, jumping, arm swinging, rotational movements, and object-mimicking postures with Joy-Con controllers. Primary outcome measures were derived through clinical tests, including the sit and reach test, shoulder flexibility test, trunk rotation flexibility test, shoulder and elbow range of motion, figure-of-8 walk test, standing balance test, hand dexterity test, and cognitive function tests. Statistical analysis was performed using mixed ANOVA, with time as the within-participant factor and intervention group as the between-participant factor, to assess the training effects on the various outcome measures.ResultsA total of 232 participants were recruited, including 32 (13.8%) patients with mild dementia, 18 (7.8%) with moderate dementia, and 182 (78.4%) with mild cognitive impairment, all of whom completed the study. The mixed ANOVA revealed significant group × time interactions across multiple physical flexibility assessments, including the remaining distance between the hands and toes during the forward bend (F2,156=8.484; P<.001; η²=0.098), the distance between the hands clasped behind the back (F2,156=3.666; P=.04; η²=0.045), and the angle formed by trunk rotation to the left and right (F2,156=17.353; P<.001; η²=0.182). Significant group × time interactions also emerged for shoulder joint forward flexion (F2,156=17.655; P<.001; η²=0.185), abduction (F2,156=6.281; P=.004; η²=0.075), and elbow flexion (F2,156=3.298; P=.049; η²=0.041). In addition, the time to complete the figure-of-8 walk test (F2,156=11.846; P<.001; η²=0.132) and the number of blocks moved within 1 minute (F2,156=4.016; P=.02; η²=0.049) showed significant interactions. Finally, all scale-based measures exhibited statistically significant group × time interactions (all P values <.001).ConclusionsThe “WarioWare: Move It!” intervention significantly improved physical flexibility, joint range of motion, motor coordination, hand dexterity, and cognitive function among older adults with mild cognitive impairment or dementia residing in rural LTCFs. The intervention offers an innovative and feasible approach for promoting the health of older adults in resource-limited settings, demonstrating its potential for widespread application in diverse low-resource environments.Trial RegistrationClinicalTrials.gov NCT06717971; https://clinicaltrials.gov/study/NCT06717971

ABSTRACT Historically, long-term care (LTC) homes have operated under a biomedical model, with a fairly institutional atmosphere. The culture change movement has challenged this approach, advocating for person-centred care and more homelike environments. We conducted a multi-site comparative case study at three rural LTC homes to examine the role therapeutic recreation (TR) services play in contributing to culture change and in creating a homelike environment in LTC. Three factors emerged that enabled TR staff to actively contribute to LTC culture change: 1) prioritizing the value of leisure experiences for improved quality of life, 2) being valued, supported, and empowered by management, and 3) being welcomed as essential and collaborative members of the care team. We discuss the implications of these findings and conclude with several recommendations for how LTC homes can better utilize TR services to improve quality of life and advance the aims of the culture change movement.

BackgroundIn Quebec, the shortage of nurses during night shifts compromises the safety and quality of resident care, particularly in small residential and long-term care centers (“Centres d’hébergement et de soins de longue durée”; CHSLDs) located in rural areas. The need to ensure the continuous presence of nurses 24 hours a day in CHSLDs has become more pressing, forcing some facilities to implement exceptional measures such as on-call telephone services to ensure access to a nurse. In light of these challenging circumstances, the Direction nationale des soins et des services infirmiers of Quebec’s Ministère de la Santé et des Services sociaux has rolled out a teleconsultation pilot project.ObjectiveThis study aims to explore nurses’ and nursing assistants’ experience of integrating teleconsultation during night shifts in rural CHSLDs with ≤50 residents.MethodsThe 6-month pilot project was rolled out sequentially in 3 rural CHSLDs located in 2 administrative regions of Quebec between July 2022 and March 2023. A total of 18 semistructured interviews were conducted with 9 nurses and nursing assistants between February and July 2023.ResultsParticipants’ experiences revealed that teleconsultation provided significant added value by improving clinical, administrative, and organizational practices. Some practices remained unchanged, indicating stable workflows. Workflow optimization through an expanded scope of practice ensured efficient and safe continuity of care. Enhanced collaboration between nurses and nursing assistants led to improved care coordination and communication. The leadership played a significant role in clarifying professionals’ roles and in supporting effective adaptation to teleconsultation.ConclusionsThis pilot project represents a significant step forward in improving care for CHSLD residents in Quebec. Teleconsultation not only makes it possible to overcome recruitment challenges and ensure the continuous presence of nurses during night shifts but also optimizes professional practices while ensuring the safety and quality of care provided to residents.

In many areas of rural Greece there exist remnants of traditional stereotypes that were socially constructed in closed societies where the institution of the patriarchal family previously reigned and are regenerated by the dominant culture. These stereotypes have shaped over time the perception that long-term care for older adults should be provided within the family structure and exclusively by family members. Notably, it was previously considered a disgrace in Greek rural society if children moved their parents to a residential or nursing home. Public or other care facilities for older people emerged just two decades ago, except a few led by the church. However, these attitudes have been softened in recent years. European and National funded programmes have shaped different notions towards long-term care in these areas. This was facilitated by the structural changes that occurred in the Greek countryside in combination with the existing low birth rate in these areas and the presence of concrete migratory flows. The present study explores the business environment that is being formed and its potential to unleash the productive forces that have pinned down the relevant residual stereotypes. It also examines the socio-economic impact of the above enterprises on rural areas. Qualitative interviews were conducted with eight entrepreneurs who have invested in rural long-term care settings for older persons and eight elected chairpersons of local councils. Our findings indicate that regardless of financial support towards private care entities for older people, in order for the services offered to take a more prominent social role, the development of local consensus and innovative interventions is required in tandem. If achieved, such care providers can contribute to the socio-economic development of rural areas. This study provides international literature with further evidence on the crucial role of such enterprises on supportiveness towards inhabitants’ quality of life improvement while results can be useful for Greek and European decision-making centers as well as potential rural entrepreneurs.

Frailty and sarcopenia are geriatric syndromes of increasing concern and are associated with adverse health outcomes. They are more prevalent among long-term care facility (LTCF) users than among community dwellers. Exercise, especially multicomponent and progressive resistance training, is essential for managing these conditions. However, LTCFs, particularly in rural areas, face challenges in implementing structured exercise programs due to health care professional shortages. Moreover, older adults often become bored with repetitive exercise training and may lose interest over time. The Nintendo Switch Ring Fit Adventure (RFA) exergame is a novel exergame that combines resistance, aerobic, and balance exercises and offers a potential solution by boosting motivation in an immersive manner and reducing staff intervention needs. We aimed to evaluate the clinical effectiveness of an exergame-based exercise training program delivered via RFA (exergame-RFA) in improving muscle mass and functional performance among older adult LTCF users. This was a randomized controlled trial conducted from August 2022 to September 2023 and involved older adult LTCF users (aged ≥60 y) in rural southern Taiwan. Participants were randomized into an intervention group (exergame-RFA plus standard care) or a control group (standard care alone). The intervention, conducted seated with arm fit skills and trunk control exercises using the RFA, lasted 30 minutes twice weekly over 12 weeks. The primary outcomes measured were the Study of Osteoporotic Fractures index (serving as an indicator of frailty status) and the diagnostic criteria for sarcopenia (appendicular skeletal muscle mass index, handgrip strength, and gait speed). The secondary outcomes included functional performance (box and block test as well as maximum voluntary isometric contraction of the dominant upper extremity), muscle condition (muscle thickness measured using ultrasonography), activities of daily living (Kihon checklist), health-related quality of life (Short Form Health Survey-36), and cognitive function (brain health test). We used an intention-to-treat analysis, incorporating a simple imputation technique in statistical analysis. A mixed ANOVA, with time as a within-participant factor and intervention as a between-participant factor, was used to compare the training effects on outcomes. We recruited 96 individuals, of whom 60 (62%) underwent randomization. Of these 60 participants, 55 (92%) completed the study. Significant group×time interactions were observed in the intervention group in all primary outcomes (all P<.001, except P=.01 for handgrip strength) and most secondary outcomes, including maximum voluntary isometric contraction of the biceps (P=.004) and triceps brachii (P<.001) muscles, biceps muscle thickness measured using ultrasonography (P<.001), box and block test (P<.001), Kihon checklist (physical function: P=.01, mood status: P=.003, and total: P=.003), and brain health test (P<.001). The exergame-RFA intervention significantly improved muscle mass, strength, and functional performance among older adult users of rural LTCFs, offering a novel approach to addressing frailty and sarcopenia. ClinicalTrials.gov NCT05360667; https://clinicaltrials.gov/study/NCT05360667. RR2-10.3389/fmed.2022.1071409.

Most individuals prefer to spend their final moments of life outside a hospital setting. This study compares the places of care and death of long-term care (LTC) home residents in Ontario in the last 90 days of life, according to LTC home rurality. This retrospective cohort study was conducted using health administrative data from ICES (formerly known as the Institute for Clinical Evaluative Sciences). The study population, which was identified through algorithms, included all Ontario LTC home residents with a dementia diagnosis who died between April 1, 2014, and March 31, 2019. The location of death was categorized as in an acute care hospital, an LTC home, a subacute care facility, or the community. Places of care included emergency department visits and hospitalizations in the last 90 days of life. Statistical tests were used to evaluate differences in location of death and places of care by rurality. Of the 65,375 LTC home residents with dementia, 49,432 (75.6%) died in an LTC home. Residents of LTC homes in the most urban areas were less likely to die in an LTC home than those in more rural homes (adjusted relative risk: 0.84; 95% confidence interval: 0.83 to 0.85). A higher proportion of residents of the most urban LTC homes had at least one hospitalization in the last 90 days of life compared with rural residents (23.7% versus 9.9% palliative hospitalizations and 28.3% versus 15.9% non-palliative hospitalizations [p ⟨ 0.001]). Individuals with dementia residing in urban LTC homes are more likely to receive care in the hospital and to die outside a LTC home than their counterparts living in rural LTC homes. The findings of this work will inform efforts to improve end-of-life care for older adults with dementia living in LTC homes.

Compassionate Ventilator Withdrawal for Residents in a Rural Long-term Care Setting: A Case-Based Review

ABSTRACT This study examines age differences in the association of psychological resilience with mental health among older Tekun (socially and economically vulnerable) men. It analyzed the 2019 data from 718 Tekun men (≥60 years) residing in rural long-term care (LTC) facilities in Anhui Province, China. Results indicated that the oldest-old (≥80 years) reported significantly lower levels of psychological resilience than the other age groups (the young-old: 60–69 years and the middle-old: 70–79 years). Hierarchical logistic regression analyses revealed a significant negative association between psychological resilience and poor mental health among the middle-old (OR = 0.95, 95% CI: 0.93–0.98) and the oldest-old (OR = 0.93, 95% CI: 0.88–0.98) groups. Psychological resilience plays a more crucial role in maintaining mental health among the oldest-old participants compared to the young-old and middle-old participants. Implications for social work practice were discussed.

We need a radical change to take place now´–The potential of integrated healthcare for rural long-term care facilities

BackgroundDuring the COVID-19 pandemic, governments across the world implemented processes and policies to limit the spread of COVID-19, especially in long-term care (LTC) homes. This led to changes in technology use for persons living in LTC homes, their families and friends, as well as the paid workforce dedicated to caring for them.ObjectiveThe study describes the role of technology and its impact on the experiences of LTC staff working in northern and rural areas in Western Canada during COVID-19.MethodsA secondary analysis of semi-structured interviews with 52 LTC staff was conducted. Qualitative data was analysed thematically using Braun and Clarke's thematic analysis approach.ResultsAnalysis of the study data revealed that new and innovative uses of technology emerged in the LTC setting during COVID-19, including technologies to support communication and collaboration with medical and health care professionals external to the LTC homes. Video-conferencing technology were rapidly implemented to facilitate virtual visits for LTC residents to connect to their families, further new streaming services were introduced to support recreational activities, including live music and spiritual services. LTC residents required significant support from staff to participate in virtual activities. Inadequate Internet infrastructure and scheduling difficulties in the context of severe staff shortages created challenges in technology adoption.ConclusionsThis research provides insight into how technology can support LTC teams in northern and rural communities, as well as supports needed for LTC residents and staff to integrate technology effectively. The study informs actionable insights for those working in rural LTC settings.

Acute Health Care Provision in Rural Long-Term Care Facilities: AScoping Review of Integrated Care Models.