Using the "Surprise Question" in Nursing Homes: A Prospective Mixed-Methods Study.

BACKGROUND: The "Surprise Question" (SQ) is often used to identify patients who may benefit from a palliative care approach. The time frame of the typical question (a 12-month prognosis) may be unsuitable for identifying residents in nursing homes since it may not be able to differentiate between those who have a more imminent risk of death within a cohort of patients with high care needs. OBJECTIVE: To examine the accuracy and acceptability of 3 versions of the SQ with shortened prognostication time frames (3 months, 6 months, and "the next season") in the nursing home setting. DESIGN: A prospective mixed-methods study. SETTING/PARTICIPANTS: Forty-seven health-care professionals completed the SQ for 313 residents from a nursing home in Ontario, Canada. A chart audit was performed to evaluate the accuracy of their responses. Focus groups and interviews were conducted to examine the participants' perspectives on the utility of the SQ. RESULTS: Of the 301 residents who were included in the analysis, 74 (24.6%) deaths were observed during our follow-up period. The probability of making an accurate prediction was highest when the seasonal SQ was used (66.7%), followed by the 6-month (58.9%) and 3-month (57.1%) versions. Despite its high accuracy, qualitative results suggest the staff felt the seasonal SQ was ambiguous and expressed discomfort with its use. CONCLUSION: The SQ with shortened prognostication periods may be useful in nursing homes and provides a mechanism to facilitate discussions on palliative care. However, a better understanding of palliative care and increasing staff's comfort with prognostication is essential to a palliative care approach.

Level of Need, Divertibility, and Outcomes of Newly Admitted Nursing Home Residents.

OBJECTIVES: To describe the level of need and divertibility of newly admitted nursing home residents, describe the factors that drive need, and describe the outcomes of residents across different levels of need. DESIGN: Retrospective cohort study. SETTING: A total of 640 publicly funded nursing homes (also known as long-term care facilities) in Ontario, Canada. PARTICIPANTS: All newly admitted residents between January 1, 2010 and March 1, 2012. MEASUREMENTS: We categorized residents into 36 groups based on different levels of (1) cognitive impairment, (2) difficulty in activities of daily living (ADL), (3) difficulty in instrumental ADLs, and (4) whether or not they had a caregiver at home. Residents were then categorized as having low, intermediate, or high needs; applying results from previous "Balance of Care" studies, we also captured the proportion who could have been cost-effectively diverted into the community. We then contrasted the characteristics of residents across the needs and divertible groupings, and compared 4 outcomes among these groups: hospital admissions, emergency department visits, mortality, and return to home. RESULTS: A population-level cohort of 64,105 incident admissions was captured. About two-thirds had great difficulty performing ADLs (65%) and had mild to severe cognitive impairment (66%); over 90% had great difficulty with instrumental ADLs. Just less than 50% of the new admissions were considered to be residents with high care needs (cognitively impaired with great ADL difficulty), while only 4.5% (2880 residents) had low care needs (cognition and ADL intact). Those with dementia (71.0%) and previous stroke (21.5%) were over-represented in the high needs group. Those that cannot be divertible to anywhere else but an institution with 24 hour nursing care comprised 41.3% (n = 26,502) of residents. Only 5.4% (n = 3483), based on community resources available, could potentially be cost-effectively diverted to the community. Those at higher needs experienced higher rates of mortality, higher total cost across all health sectors, and lower rates of return to home. CONCLUSIONS: The majority of those admitted into nursing homes have high levels of need (driven largely by dementia and stroke) and could not have their needs met cost-effectively elsewhere, suggesting that the system is at capacity. Caring for the long-term care needs of the aging population should consider the balance of investments in institution and community settings.

Research impact of systems-level long-term care research: a multiple case study.

BACKGROUND: Traditional reporting of research outcomes and impacts, which tends to focus on research product publications and grant success, does not capture the value, some contributions, or the complexity of research projects. The purpose of this study was to understand the contributions of five systems-level research projects as they were unfolding at the Bruyère Centre for Learning, Research and Innovation (CLRI) in long-term care (LTC) in Ottawa, Ontario, Canada. The research questions were, (1) How are partnerships with research end-users (policymakers, administrators and other public/private organisations) characterised? (2) How have interactions with the CLRI Management Committee and Steering Committee influenced the development of research products? (3) In what way have other activities, processes, unlinked actors or organisations been influenced by the research project activities? METHODS: The study was guided by Kok and Schuit's concept of research impacts, using a multiple case study design. Data were collected through focus groups and interviews with research teams, a management and a steering committee, research user partners, and unlinked actors. Documents were collected and analysed for contextual background. RESULTS: Cross-case analysis revealed four major themes: (1) Benefits and Perceived Tensions: Working with Partners; (2) Speaking with the LTC Community: Interactions with the CLRI Steering Committee; (3) The Knowledge Broker: Interactions with the Management Committee; and (4) All Forms of Research Contributions. CONCLUSIONS: Most contributions were focused on interactions with networks and stimulating important conversations in the province about LTC issues. These contributions were well-supported by the Steering and Management Committees' research-to-action platform, which can be seen as a type of knowledge brokering model. It was also clear that researcher-user partnerships were beneficial and important.

Designated specialized units: How Ontario's long-term care homes fill a gap in care.

Ontario has eight designated Specialized Units (SUs) located in Long-Term Care (LTC) homes. Each unit serves a well-defined group of residents whose needs go beyond what regular LTC homes can offer but do not require the complexity and range of care provided in hospitals. An applied qualitative research project looked at the realities of designated SUs, explored their role in health system capacity planning, and created a tool kit to help stakeholders navigate the designation process. Results outline the benefits and challenges experienced by the existing SUs that provide care to clients with severe responsive behaviours or dialysis needs and the units' potential to address current and future healthcare system gaps. More systematic data collection, robust evaluations, and cost-benefit analyses are needed to fully understand how effectively and efficiently the SUs fulfill the outcomes desired by residents and their families, as well as how they contribute to health system efficiencies.

Barriers and facilitators to recruitment of physicians and practices for primary care health services research at one centre.

BACKGROUND: While some research has been conducted examining recruitment methods to engage physicians and practices in primary care research, further research is needed on recruitment methodology as it remains a recurrent challenge and plays a crucial role in primary care research. This paper reviews recruitment strategies, common challenges, and innovative practices from five recent primary care health services research studies in Ontario, Canada. METHODS: We used mixed qualitative and quantitative methods to gather data from investigators and/or project staff from five research teams. Team members were interviewed and asked to fill out a brief survey on recruitment methods, results, and challenges encountered during a recent or ongoing project involving primary care practices or physicians. Data analysis included qualitative analysis of interview notes and descriptive statistics generated for each study. RESULTS: Recruitment rates varied markedly across the projects despite similar initial strategies. Common challenges and creative solutions were reported by many of the research teams, including building a sampling frame, developing front-office rapport, adapting recruitment strategies, promoting buy-in and interest in the research question, and training a staff recruiter. CONCLUSIONS: Investigators must continue to find effective ways of reaching and involving diverse and representative samples of primary care providers and practices by building personal connections with, and buy-in from, potential participants. Flexible recruitment strategies and an understanding of the needs and interests of potential participants may also facilitate recruitment.

Riding the wave of primary care research: development of a primary health care research centre.

PROBLEM BEING ADDRESSED: Family medicine departments and primary health care research centres across the country are growing in size and complexity and therefore require increasingly sophisticated management strategies. Conducting effective and relevant research relies on a stable and efficient organization. OBJECTIVE OF THE PROGRAM To focus on the needs of individuals, teams, and the organization in order to ensure the success of research projects. PROGRAM DESCRIPTION: In order to ensure the success of research projects, the C.T. Lamont Primary Health Care Research Centre (CTLC) in Ottawa, Ont, used the following strategies: ensuring organizational support (ie, protected time for research and sustained funding for some investigators); arranging financial and infrastructure support; building skills and confidence (eg, education sessions); organizing linkages and collaborations (eg, forums among staff members); creating appropriate dissemination (eg, newsletter, website); and providing continuity and sustainability. CONCLUSION: In order to ensure progress in primary health care research, the CTLC created solutions that focused on the individual, team, and organizational levels. With its management strategies, the CTLC was successful in maintaining a high-functioning team and a well-organized research organization.