Term Care Homes Research Articles

Promoting Physical Activity With Augmented Reality Experiences

Between June 2021 and March 2023, the Centre for Innovation and Research in Aging (CIRA) evaluated the effectiveness of the 2RaceWithMe exergaming product from Centivizer Inc in two New Brunswick long term care homes. 2RaceWithMe provides physical activity, through seated exercise, for older adults. In 2RaceWithMe, exercise is motivated by the requirement that residents needs to keep pedaling in order to view scenic videos from around the world. The objective of this paper is to report on some of the qualitative results obtained in the CIRA study, and to assess some of the barriers and facilitators to the use of an exergaming product like 2RaceWithMe in long term care.

Impact of implementing the pain best practice guideline in a long-term care home using the knowledge-to-action framework

Introduction. Assessment and management of pain in older adults can be challenging, with persistent pain prevalence ranging from 25% to 80%, especially in long term care homes (LTCH), where most seniors are unable to verbalize their pain. This article describes the implementation of the Registered Nurses’ Association of Ontario (RNAO) Assessment and Management of Pain (Third Edition) best practice guideline (BPG) in a LTCH in Toronto, Canada. Methodology. Using mixed descriptive study methodology, this 391-bed home housing older adults over 80 years implemented the Pain guideline using the knowledge-to-action framework and audit procedures to evaluate the impact of implementing this guideline. Key implementation activities included educating residents, families, and staff about pain while integrating validated pain screening and assessment tools into practice. A mixed methods approach of qualitative and quantitative data was utilized to monitor improvements in clinical and organizational outcomes. Results. The impact of implementing Pain BPG is: improved utilization of pain assessment and management tools, reduced incidence of worsening pain, improved pain scores and improved resident quality of life. The structured and integrated, evidence-based approaches to pain assessment and management reflected that long-term care residents don’t have to live with pain regularly, which leads to a better quality of life and resident/family satisfaction. Discussion. In conjunction with the structured approach of the knowledge-to-action framework and the Pain BPG, the LTCH utilized tailored approaches to meet the needs of their resident population. Recognizing the unique needs of seniors in a residential setting, organizational structural facilitators, and barriers and cultural needs, the LTCH developed multi modal approaches based on a person and family centred approach. This evidence-based and resident focused approach was the key to the successful implementation and subsequent outcomes that were resultant. Conclusion. The systematic implementation of the RNAO pain BPG and the utilization of the knowledge-to-action framework was shown to improve resident outcomes, improve organizational processes and generate staff satisfaction. Participation and engagement of residents, their families and health professionals in the process was one of the greatest facilitators.

A Narrative Inquiry into Professional Quality of Life among Therapeutic Recreation Professionals Working in Long-Term Care Homes

This paper describes the findings from a study that explored Professional Quality of Life (ProQoL) among TR practitioners working in long term-care homes in Ontario, Canada. ProQoL incorporates positive (e.g., compassion satisfaction) and negative (e.g., compassion fatigue and burnout) aspects of working in healthcare (Stamm, 2010). Limited research exists exploring ProQoL from the perspective of TR practitioners working in LTC homes. To address this gap, four TR practitioners were interviewed to explore past and present experiences that contribute to ProQoL and write personal narratives that embody moments of compassion satisfaction and compassion fatigue. Narrative thematic analysis revealed three threads of ProQoL among practitioners: fueling the soul through connection and purpose, draining the TR spirit through workplace conflict and role ambiguity, and developing professional valour. Findings suggest that although practitioners derive great fulfillment from their careers, workplace culture and relational conflict are chronic challenges that erode the ProQoL of professionals. Recommendations for future research and practice are offered.

Development and Evaluation of a Nurse Practitioner Huddles Toolkit for Long Term Care Homes.

Long-term care homes (LTCHs) were disproportionately affected by the coronavirus disease (COVID-19) pandemic, creating stressful circumstances for LTCH employees, residents, and their care partners. Team huddles may improve staff outcomes and enable a supportive climate. Nurse practitioners (NPs) have a multifaceted role in LTCHs, including facilitating implementation of new practices. Informed by a community-based participatory approach to research, this mixed-methods study aimed to develop and evaluate a toolkit for implementing NP-led huddles in an LTCH. The toolkit consists of two sections. Section one describes the huddles' purpose and implementation strategies. Section two contains six scripts to guide huddle discussions. Acceptability of the intervention was evaluated using a quantitative measure (Treatment Acceptability Questionnaire) and through qualitative interviews with huddle participants. Descriptive statistics and manifest content analysis were used to analyse quantitative and qualitative data. The project team rated the toolkit as acceptable. Qualitative findings provided evidence on design quality, limitations, and recommendations for future huddles.

Nurse practitioner led implementation of huddles for staff in long term care homes during the COVID-19 pandemic

BackgroundStaff working in long-term care (LTC) homes during COVID-19 frequently reported a lack of communication, collaboration, and teamwork, all of which are associated with staff dissatisfaction, health concerns, lack of support and moral distress. Our study introduced regular huddles to support LTC staff during COVID-19, led by a Nurse Practitioner (NP). The objectives were to evaluate the process of huddle implementation and to examine differences in outcomes between categories of staff (direct care staff, allied care and support staff, and management) who attended huddles and those who did not.MethodsAll staff and management at one LTC home (< 150 beds) in Ontario, Canada were included in this pre-experimental design study. The process evaluation used a huddle observation tool and focused on the dose (duration, frequency) and fidelity (NP’s adherence to the huddle guide) of implementation. The staff attending and non-attending huddles were compared on outcomes measured at post-test: job satisfaction, physical and mental health, perception of support received, and levels of moral distress. The outcomes were assessed with validated measures and compared between categories of staff using Bayesian models.ResultsA total of 42 staff enrolled in the study (20 attending and 22 non-attending huddles). Forty-eight huddles were implemented by the NP over 15 weeks and lasted 15 min on average. Huddles were most commonly attended by direct care staff, followed by allied care/support, and management staff. All huddles adhered to the huddle guide as designed by the research team. Topics most often addressed during the huddles were related to resident care (46%) and staff well-being (34%). Differences were found between staff attending and non-attending huddles: direct care staff attending huddles reported lower levels of overall moral distress, and allied care and support staff attending huddles perceived higher levels of support from the NP.ConclusionsNP-led huddles in LTC homes may positively influence staff outcomes. The process evaluation provided some understanding of why the huddles may have been beneficial: the NP addressed resident care issues which were important to staff, encouraged a collaborative approach to solving issues on the unit, and discussed their well-being.Trial registration numberNCT05387213, registered on 24/05/2022.

Markers of community outbreak and facility type for mitigation of COVID-19 in long-term care homes in Ontario, Canada: Insights and implications from a time-series analysis

PurposeThe resident deaths among Long Term Care Home (LTCH) accounted for more than 65% of total deaths in the province of Ontario, Canada, during March 29 to June 3, 2020, yet not all LTCHs were severely affected. MethodsWe carried out a retrospective cohort study, with case control for questions for which data allowed, with LTCH COVID-19 databases obtained from Ontario’s Ministry of Long Term Care. We performed a combined temporal and spatial data analysis of COVID-19 cases and deaths among LTCH residents, identified trends, contributing factors, and early markers of LTCH outbreak severity. ResultsOur analysis shows that for-profit LTCHs had higher death-to-bed ratio, also with an average rate of increase of death-to-bed ratio higher for for-profit homes than other types of management. We find from uni- and multi-variable analyses (linear and nonlinear) that staff infection has the strongest association with death-to-bed ratio from among the descriptor variables considered, reflecting the risk of the disease in the health region/community. We also identify a delay of up to 8 days between the trends in fatalities among individuals outside LTCHs and that of LTCH residents. We did find an association between policy change to single LTCH/staff and reduction in weekly LTCH resident death, albeit with an expected time delay of about 7–10 days. ConclusionsThe association between the risk of COVID-19 in the health region and the deaths among LTCH residents, and the delay between fatality among individuals residing outside and inside LTCHs suggests that fatality in a health region could be a predictor of outbreak in LTCHs within the same health region.

The predictable crisis of covid-19 in Canada's long term care homes.

The predictable crisis of covid-19 in Canada's long term care homes.

Older adults in a Modern World

Editorial Older adults in a Modern WorldBy L.F. Carver, Editor-in-Chief Stereotypes that suggest older adults are resistant to technology may have had some accuracy in the 1980s but are now outdated and inaccurate. Technology has been evolving quickly over the past century, and older adults have been adapting to these changes just as quickly. Telephones went from a single wall mounted phone in the home to cordless handsets and cellphones, changes driven by the buying habits of people who are now older adults. The consumers who enthusiastically embraced home computers, then laptops and finally tablets are now middle aged or older adults.(Geron)technologies are those technologies that support aging adults – but these do not need to be limited to health-related devices. Older adults generally report feeling much younger inside than their chronological age and buy technology that supports them to engage in hobbies and activities that they did in their twenties and thirties. These technologies often mirror those chosen by their younger counterparts.Governments are recognizing the importance of AgeTech with investments in the development of these industries. For example, in late 2022/early 2023 the Canadian government announced a $47 million dollar investment (via the Strategic Innovation Fund) and the American National Institute on Aging (a2 Pilot Awards) unveiled $40 million for AgeTech over five years. Given the inaccuracies of traditional ageist stereotypes it is important to avoid surveillance and communal residential settings (e.g., long term care homes) as the focus for AgeTech, especially given most older adults are uninterested in living these facilities and technology that violates their privacy.Modern older adults are interested in technologies that enable them maintain independence, aging gracefully in place, in their own homes. However, they tend to reject technologies that impinge on privacy – especially those that involve 24/7 surveillance. Ambient assisted living, which generally involves cameras and pressure plates that record, and report, movement and activity are a favourite among caregivers and concerned family but are generally repudiated by older adults.Finally, older adults who refuse certain technologies are not ‘resistant’ to tech, they just don’t want technology to try to fool them or replace reality. If they enjoy travel, they want technology that allows them to continue to travel as long as possible, not virtual reality goggles. Older animal lovers don’t want a robot pet, they want technology to support them to continue to care for their non-human companions as long as possible.The most important thing for policy makers, technology companies and younger adults to remember is that older adults share many of the same consumer interests when it comes to technology as younger adults. In fact, instead of considering older adults as something different or ‘other’ than their younger counterparts, we need to remember that they are the same people as they were when they were younger, they just have more mileage.

Weight Loss and Weight Gain: Multi-Level Determinants Associated with Resident 3-Month Weight Change in Long-Term Care

This study examined factors associated with weight change in 535 residents in 32 long term care homes where 3-month weight records were available. Trained researchers and standardized measures (e.g., nutrition status, food intake, home characteristics) were used to collect data; weight change was defined as ±2.5%. Just over 25% of the sample lost and 21% gained weight. Weight stability was compared to loss or gain. Weight loss was associated with being male, malnourished (MNA-SF or BMI <25), energy and protein intake and oral nutritional supplement use, while weight gain was associated with being female, and a physically (e.g., less noise) and socially supportive dining room. Weight stability was associated with better cognition. A high proportion of residents had a significant weight change in 3 months. Modifiable factors associated with weight stability or gain suggest focusing interventions that promote food intake and improve the mealtime environment.

Factors Associated with Falls in Canadian Long Term Care Homes: a Retrospective Cohort Study.

Half of Canadians living in long-term care (LTC) homes will fall each year resulting in consequences to independence, quality of life, and health. The objective in this study was to analyze factors that contribute to, or are protective against, falls in Canadian LTC homes. We analyzed of a retrospective cohort of a stratified random sample of Canadian LTC homes in Western Canada from 2011-2017. We accessed variables from the RAI-MDS 2.0 to assess the association of the dependent variable "fall within the last 31-180 days" with multiple independent factors, using generalized estimating equation models. A total of 28,878 LTC residents were analyzed. Factors found to increase the odds of falling were other fractures (OR 3.64 [95% confidence interval; CI 3.27, 4.05]), hip fractures (OR 3.58 [3.27, 3.93]), moderately impaired cognitive skills (OR 2.45 [2.28, 2.64]), partial support to balance standing (OR 2.44 [2.30, 2.57]), wandering (OR 2.31 [2.18, 2.44]). A range of factors identified were associated with falls for people living in LTC homes. Individual physical ability represented the largest group of independent factors contributing to falls. Residents who experience any fracture or an acute change in behaviour, mobility, or activities of daily living (ADL) should be considered at increased risk of falls.

The Impact of COVID-19 on the Quality of Life and Happiness of Care Home Residents in Croatia: A Cross-Sectional Study.

Care/nursing homes globally have been severely affected by the COVID-19 pandemic and have disproportionately experienced a high rate of mortality which led to the introduction of strict isolation policies. However, while there are studies on the mortality, epidemiology, staffing challenges, and mismanagement in long-term care homes as a result of COVID-19, there appears to be a paucity of information regarding the Quality of Life (QoL), happiness, and associated well-being of the elderly residents of these homes. Therefore, we examined if COVID-19 affected the happiness level, QoL, and financial condition of long-term care home residents in Croatia. To achieve this, a survey of 308 participants in eight long term care homes was conducted. Descriptive analysis was performed to describe the mean of all responses and the Bayesian Integrated Nested Laplace Approximation (INLA) was used to provide a detailed quantitative analysis of the results. We found that the QoL and happiness of residents remained relatively stable during the COVID-19 pandemic. However, the income level, financial outlook, marital status, and vaccination positivity influenced the QoL and happiness of care home residents to a considerable degree. We recommend that policy makers pay attention to these underlying factors.

Patient Safety Challenges in the Pandemic: Applying Human Factors Principles to Embed Patient Safety and Experience at the Clinical Front Line

The COVID-19 pandemic has amplified systemic gaps in patient safety, including social frailty for vulnerable populations such as older adults (Briguglio et al., 2020). Public health measures, such as prolonged and frequent lockdowns, restricted access to visitors and support networks and in extreme cases led to confinement within a single room, The negative impact of these restrictions has focused new attention on social frailty, which has hitherto been a somewhat neglected patient safety issue. Since social frailty is a multifaceted construct, it needs to be considered in a variety of settings and from a range of disciplinary perspectives. This practitioner-led panel consisting of an internist, a human factors engineer, an occupational therapist, and an implementation scientist, examines the impact of the pandemic on social interaction, and social frailty amongst older people in three different settings (hospital, long term care home, community). Through a set of case studies, the panelists provided applied experiences and perspectives on the impact of the pandemic on patient safety and on social frailty in particular. The panel covered theory, and real-world application of human factors principles. The question of how to design safety into the healthcare system were also explored. In this paper we review the problem of social frailty, list some brief case studies and discuss possible intervention strategies.

Preparation for Working in Long Term Care Homes: Recommendations on Therapeutic Recreation Curricula from Recreation Therapists and Staff in Ontario

As our population ages, more seniors will require care in long term care (LTC) homes, including care from recreation therapists and staff. This study examined recreation therapists and staff’s retrospective views of what would make them better prepared for working in LTC homes. A questionnaire distributed to 290 LTC homes in Ontario was completed by 487 recreation therapists and staff. Data were analyzed using ANOVAS and frequencies. Participants ranked experience as the most important and education as the least important factor for preparing them to work in LTC. Participants indicated increased practicum experience and knowledge of charting and documentation would help prepare them to work in LTC. The results of our study suggest the need for further training in gerontological competences for TR students, such as incorporating interprofessional collaboration and experience into TR curricula. TR practitioners can also enhance their learning by collaborating with others through communities of practice.

The predictive utility of functional status at discharge: a population-level cohort analysis

BackgroundFunctional status is a patient-important, patient-centered measurement. The utility of functional status measures to inform post-discharge patient needs is unknown. We sought to examine the utility of routinely collected functional status measures gathered from older hospitalized patients to predict a panel of post-discharge outcomes.MethodsIn this population-based retrospective cohort study, Adults 65+ discharged from an acute hospitalization between 4 November 2008 and 18 March 2016 in Ontario, Canada and received an assessment of functional status at discharge using the Health Outcomes for Better Information and Care tool were included. Multivariable regression analysis was used to determine the relationship between functional status and emergency department (ED) re-presentation, hospital readmission, long term care facility (LTCF) admission or wait listing (‘LTCF readiness’), and death at 180 days from discharge.ResultsA total of 80 020 discharges were included. 38 928 (48.6%) re-presented to the ED, 24 222 (30.3%) were re-admitted, 5 037 (6.3%) were LTCF ready, and 9 047 (11.3%) died at 180 days. Beyond age, diminished functional status at discharge was the factor most associated with LTCF readiness (adjusted Odds Ratio [OR] 4.11 for those who are completely dependent for activities of daily living compared to those who are independent; 95% Confidence Interval [CI]: 3.70-4.57) and death (OR 3.99; 95% CI: 3.67-4.35). Functional status also had a graded relationship with each outcome and improved the discriminability of the models predicting death and LTCF readiness (p<0.01) but not ED re-presentation or hospital re-admission.ConclusionRoutinely collected functional status at discharge meaningfully improves the prediction of long term care home readiness and death. The routine assessment of functional status can inform post-discharge care and planning for older adults.

Unsupervised Deep Learning to Detect Agitation From Videos in People With Dementia

Behavioural symptoms of dementia present a significant risk within Long Term Care (LTC) homes, which face difficulties supporting residents and monitoring their safety with limited staffing resources. Many LTC facilities have installed video surveillance systems in common areas that can help staff to observe residents; however, typically these video streams are not monitored. In this paper, we present the development of a computer vision algorithm to use these video streams to detect episodes of clinically important agitation in people with dementia. Given that episodes of agitation are rare in comparison to normal behaviours, we formulated this as an anomaly detection problem. This involves using the video camera to monitor the scene rather than tracking individuals. We developed a customized spatio-temporal convolution autoencoder that is trained on the normal behaviours and then identified agitation during testing as anomalous behaviour. We present a proof-of-concept using video data collected from a specialized dementia unit and annotated for agitation events. We trained the unsupervised neural network on approximately 24 hours of normal activities and tested on 11 hours of videos containing both normal activities and agitation events, and obtained an area under the curve of the receiver operating characteristic curve of 0.754. This research paves the way for leveraging existing surveillance infrastructure in LTC and other mental health settings to detect agitation or aggression, with the potential for improved health and safety.

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.

Multifactorial falls prevention programme compared with usual care in UK care homes for older people: multicentre cluster randomised controlled trial with economic evaluation

ObjectivesTo determine the clinical and cost effectiveness of a multifactorial fall prevention programme compared with usual care in long term care homes.DesignMulticentre, parallel, cluster randomised controlled trial.SettingLong term care homes...

804. Infection Control and Clinical Support in Long-Term Care Homes During the COVID-19 Pandemic in North Toronto: A Quasi-Experimental Study

BackgroundWave one of the COVID-19 pandemic in Ontario, Canada, resulted in significant institutional outbreaks associated with high case fatality among older adults. Our hospital formally partnered with congregate care homes in north Toronto to support infection control and clinical management before wave two of the COVID-19 pandemic. Our aim was to evaluate the impact of this program on resident and healthcare worker (HCW) outcomes. MethodsA multicentre quasi-experimental study was conducted comparing outcomes between wave one (March-June, 2020) and wave two (October-December, 2020) among 17 congregate care homes (4 long term care homes and 13 residential homes). During wave two, weekly meetings and 42 on-site visits were conducted along with on-site daily hospital presence for all COVID-19 outbreaks to support infection control and resident management. The primary outcomes included COVID-19-case fatality rate as well as overall resident fatality including COVID-19 and non-COVID-19 related causes. Secondary outcomes included healthcare worker COVID-19 infections, and infection control practices among homes with paired audits (n=6), including hand hygiene, use of personal protective equipment, environmental cleaning and physical distancing practices. ResultsAmong 2203 residents during wave one and 2287 residents during wave two, there was reduction in COVID-19 case fatality rate (38.1% vs. 13.4%; p< 0.01), overall COVID-19-related fatality (2.3% vs. 1.0%; p< 0.01) and non COVID-19 related fatality (8.3% vs. 3.5%; p< 0.01). Weekly staff testing and increased syndromic surveillance was implemented during wave two. Among 2590 staff, there were 2.6% vs.4.2% staff who tested positive for COVID-19 during wave one and two, respectively. Changes in infection control practice were observed in regard to directly observed hand hygiene (83.3% vs. 100%), use of personal protective equipment (16.7% vs. 83.3%), environmental cleaning (66.7% vs. 100%) and physical distancing (66.7% vs. 83.3%). ConclusionIntegration of hospital with community congregate care homes was associated with improvements in resident outcomes during wave two of the pandemic. Further longitudinal support and evaluation is needed to ensure sustainability. Disclosures All Authors: No reported disclosures

Depression and Functional Mobility Decline in Long Term Care Home Residents with Dementia: a Prospective Cohort Study.

ObjectiveAssess the association between depression among new long-term care residents (<3 months stay) with dementia and functional mobility decline.MethodsA multi-site prospective cohort study was carried out among 26 participants diagnosed with dementia. Functional mobility was measured by Timed-Up-and-Go (TUG) and 2-Minute walk test (2MWT) at baseline, and 60-day post-baseline while participants received usual care. Linear mixed models were applied to examine the association between depression and functional mobility decline.ResultsResidents experienced a statistically significant decline in functional mobility in as soon as 60 days. Each additional year of age was associated with a 2% increase in TUG. The interaction between depression and time spent in LTC was statistically significant. Age and time living in LTC were significantly associated with functional mobility decline in new residents with dementia.DiscussionFurther work determining why residents with dementia experience decline in functional mobility at an accelerated rate is needed.

The Subtle and Silent Issue in Older Adult Care

The treatment of elders in the community and ageism in our society has been an issue often underlooked. However, since the onset of the COVID-19 pandemic, poor treatment of elders in the community and long term care homes has been brought to light. During the beginning of the pandemic, long term care homes in Canada accounted for around 80% of all COVID-19 related mortalities [1]. This situation is due to an amalgamation of factors leading towards the ultimate neglect of the elderly population, including the governance of long term care homes in Canada, the stigma against the elderly population, and the commonly misconceived clinical picture of a ‘frail’ senior by the medical community.