With the continued ageing of the population, the demand for long term care (LTC) beds is set to increase, where older adults have access to 24 hour/7 days a week assistance with activities of daily living and monitoring of their health. The growing demand for LTC services is not matched by the number of skilled professionals practicing in LTC as mandated by the current model of care. The majority of work is done by unregulated staff. Implementation of evidence-based interventions in LTC is complex, limited by lack of management support, structural and environmental issues, beliefs and expectations of residents, families and staff and unregulated care workers delivering care. There is a need for more rigorously designed studies to test the effects of different models of care to optimize health outcomes for residents. Resident, family and career-driven approaches have the potential to empower this vulnerable cohort. Emerging evidence supports the positive role of nurse practitioners (NPs) in reducing health service utilization, decreasing rates of transfer and admission to hospital, and decreasing length of hospital stay post-transfer for residents of LTC. NPs are recommended in other countries for the provision of primary care of residents in LTC, where current Saskatchewan legislation inhibits NPs from operating in their full scope of practice within LTC homes as they cannot independently admit, diagnose, treat or discharge in-patient residents. Other models include interventions such as increasing numbers of residents with Advance Care Planning. Primary care outreach services, hospital in the nursing home, or telephone triage may increase the capacity to treat the resident in the LTC home, avoiding transfers or admissions to the hospital. Residents may experience illness or transfer to the local emergency department (ED) for an illness which may have been avoidable or more appropriately managed within LTC. Presentation of LTC residents to the ED is common, costly and is often associated with negative outcomes. Unnecessary transfers to the ED and hospitalization for LTC residents can be disorienting, distressing and exacerbate pre-existing conditions, leaving some residents more physically and cognitively compromised. This leads to significant increases in mortality, hospital admission and death. These residents are also found to have a reduced quality of life (QoL).
Our aim is to build innovative models of care that will improve the QoL and health outcomes for residents living in long-term care in partnership with residents of LTC, family members, staff and content experts to ensure quality care in the right place, at the right time, by the right person.
The Research Questions
1. What are the structures and processes that currently underpin the care of frail older adults residing in LTC, who develop an acute medical condition and/or an acute exacerbation of a chronic condition?
2. What are the clinical, health service, and cost outcomes associated with the care of frail older adults residing in LTC, who develop an acute medical condition and/or an acute exacerbation of a chronic condition?
3. What are resident-reported QoL outcomes for frail older adults residing in LTC, who develop an acute medical condition and/or acute exacerbation of a chronic condition?
Methodologies and Data Collection
The method of this study is designed to explore research questions focused on resident QoL staff skills-mix, care processes, and the decision to transfer residents to the Emergency Department, including indicators of health including acceptability, accessibility, appropriateness, and continuity. catalyst grant will utilize patient-oriented research (POR) to mobilize knowledge gained through the foundation study. The participatory World Café method will be used to generate data through participant input, sharing of experience and wisdom, and nurturing diverse perspectives. This data will be analyzed following the principles of thematic analysis to propose innovative models of care for LTC homes. Six LTC home study sites in central Saskatchewan will be used to collect resident, staff, family, and policy data: Mennonite Nursing Home (Rosthern), Warman Mennonite Special Care Home (Warman), Bethany Pioneer Village (Middle Lake); and, Saskatoon Convalescent Home, Sunnyside Adventist Care Centre, and Porteous Lodge within Saskatoon. The homes were selected based on size, staff mix, resources, location, and no physical attachment to a primary health care centre. The lived experiences shared by patient knowledge users as family caregivers, older adults, advocates, and researchers, will guide team discussions and decisions. All team members will co-design an intervention (World Café) for each participating LTC home (6 in total). The goal of site-specific World Cafés is to prioritize QoL indicators that affect the health and wellbeing of LTC residents when they become unwell. In order to overcome the challenges of recruiting residents living with cognitive impairment, an inclusive recruitment approach will be utilized. This approach will involve actively inviting family members or care partners to co-participate with the resident living with cognitive impairment and ensuring all residents have an equal opportunity to register as participants. Purposeful and snowball sampling drawing on existing contacts between the LTC homes and the community will be used to recruit participants living with early dementia in the community. Their engagement in the World Café will provide an opportunity to explore their anticipated needs and understanding of QoL, for their future care if or when they need LTC. The discussion questions will be co-developed by patient knowledge users, in consultation with stakeholders, to collect meaningful data to inform care practices in LTC to improve QoL for residents. In consultation with stakeholders, the data gathered in the first sessions will be used to propose innovative models of care through a prioritization process to be trialled in the LTC home sites. Participants will then be invited to suggest modes for knowledge translation. Particular consideration will be paid to sex and gender throughout data collection, cognizant of the gendering of care roles within LTC and the high prevalence of female LTC residents. The research team is selected to similarly include males, females, and members of the LGBTQ2S+ community. Patient knowledge users will assist to maintain participant safety, rights, inclusion, well-being and dignity throughout the discussions. Finally, research team members and collaborators will thematically analyze the data generated from the World Café’s and present the preliminary findings from aggregated data to the stakeholders, including interested persons from the community, for feedback to inform the final draft. Knowledge gained from this study, the foundation study findings and current literature will be used to design an intervention and evaluation plan for the trial implementation of innovative care models in LTC homes.
To address Research Question 1, we will conduct: a) an audit of organizational policies related to regulated and unregulated staffing, access to medical care for residents, care during acute illness, and transfer to ED; b) review of organizational documentation to identify resources available for acute illness care, physical structures, staffing levels, skill mix, and staff turnover, over a 12-month period; c) review of health records to describe prevalence of Sudden Illness/Sudden Collapse documentation completion (i.e., as related to advance care planning and ED transfer) and the provision of service by GPs and other primary health professionals to residents, over a 12-mongh period; d) interviews with staff related to structures and processes currently used to provide care to residents with an acute illness; and e) interviews with residents and their family members about their experiences of care when the resident is experiencing an acute illness.
To address Research Question 2, we will focus on all residents of the study site LTC homes presenting to the EDs of Royal University Hospital, Saskatoon City Hospital, St. Paul’s Hospital, Humboldt District Health Complex, and Rosthern Union Hospital, in the 12-month period. At the end of the 12-month study period, for all residents transferred from the study LTCs to ED, retrospective data will be provided by the hospitals. Descriptive statistics will be presented for all indicators, including cost.
To address Research Question 3, we will collect data on resident-reported QoL outcomes. Data will be collected in all six LTC homes in the SHA-Saskatoon area. Resident/family partners will co-lead this phase of the study design and will be trained in the use of the selected tool and conduct the surveys.
Using a co-production approach, resident/family partners, knowledge users, and LTC Advisory Group will ensure participant safety, rights, well-being and dignity are guaranteed throughout the study. The study questions were co-developed by resident/family partners to collect meaningful data to inform care practices in LTC. Ethics approval. Resident/family partners will co-author the requisite ethics applications, participant information documents, and consent forms. Data collection and analysis. Resident/family partners will be involved in the development and trial of selected tools to assess readability and comprehensibility of the content; engage in data collection (i.e., recruitment strategies, distribution of questionnaires, conducting interviews); develop strategies to troubleshoot problems (i.e., recruitment of participants, lack of depth in participant responses, difficulties interpreting data) to encourage transparency; involvement and inclusion of their feedback; and, collaboratively analyze data to identify key themes and report core outcomes. End-of-grant knowledge translation will involve resident/family partners and knowledge users to identify outcomes and key research questions to inform future studies relating to LTC care practices; presentations at provincial and national conferences; and, provide plain language summaries and dissemination of outcomes through informal and formal networks, which will increase advocacy for policy and practice change at local, national, and international levels.
Research Funded By
This research was funded by:
The following organizations contributed to this project.
Page last updated April 14, 2020