Profiling the medical, functional, cognitive, and psychosocial care needs of adults assessed for home care in Ontario, Canada: The case for long-term 'life care' at home.

Calls to leverage routinely collected data to inform health system improvements have been made. Misalignment between home care services and client needs can result in poor client, caregiver, and system outcomes. To inform development of an integrated model of community-based home care, grounded in a holistic definition of health, comprehensive clinical profiles were created using Ontario, Canada home care assessment data. Retrospective, cross-sectional analyses of 2017-2018 Resident Assessment Instrument Home Care (RAI-HC) assessments (n = 162,523) were completed to group home care clients by service needs and generate comprehensive profiles of each group's dominant medical, functional, cognitive, and psychosocial care needs. Six unique groups were identified, with care profiles representing home care clients living with Geriatric Syndromes, Medical Complexity, Cognitive Impairment and Behaviours, Caregiver Distress and Social Frailty. Depending on group membership, between 51% and 81% of clients had identified care needs spanning four or more Positive Health dimensions, demonstrating both the heterogeneity and complexity of clients served by home care. Comprehensive clinical profiles, developed from routinely collected assessment data, support a future-focused, evidence-informed, and community-engaged approach to research and practice in integrated home-based health and social care.

Co-designing action-oriented mental health conversations between care providers and ageing Canadians in the community: a participatory mixed-methods study protocol.

INTRODUCTION: The mental health of ageing Canadians is a growing concern, particularly post-pandemic. Older adults face systemic ageism and mental health stigma as pervasive barriers to seeking needed mental health support, care and treatment within health and social care systems. These barriers are exacerbated when service providers focus on physical healthcare needs or lack the skills and confidence to talk about and/or address mental health during routine visits. This study aims to co-design and test an evidence-based approach to mental health conversations at the point-of-care in home and community settings with older adults, family and friend caregivers and health and social care providers that could facilitate help-seeking activities and care access. METHODS AND ANALYSIS: A participatory mixed-methods study design will be applied, guided by a Working Group of experts-by-experience (n=30). Phase 1 engages ageing Canadians in four online workshops (n=60) and a national survey (n=1000) to adapt an evidence-based visual model of mental health for use with older adults in home and community care. Phase 2 includes six co-design workshops with community providers (n=90) in rural and urban sites across three Canadian provinces to co-design tools, resources and processes for enabling the use of the adapted model as a conversation guide. Phase 3 involves pilot and feasibility testing the co-designed conversations with older adult clients of providers from Phase 2 (n=180). ETHICS AND DISSEMINATION: Phases 1 and 2 of this study have received ethics clearance at the University of Waterloo (ORE #44187), University of British Columbia (#H22-02306) and St. Francis Xavier University (#26075). While an overview of Phase 3 is included, details will rely on Phase 2 outcomes. Knowledge mobilisation activities will include peer-reviewed publications, conference presentations, webinars, newsletters, infographics and policy briefs. Interested audiences may include community organisations, policy and decision-makers and health and social care providers.

Policy and practices in primary care that supported the provision and receipt of care for older persons during the COVID-19 pandemic: a qualitative case study in three Canadian provinces.

BACKGROUND: The effects of the COVID-19 pandemic on older adults were felt throughout the health care system, from intensive care units through to long-term care homes. Although much attention has been paid to hospitals and long-term care homes throughout the pandemic, less attention has been paid to the impact on primary care clinics, which had to rapidly change their approach to deliver timely and effective care to older adult patients. This study examines how primary care clinics, in three Canadian provinces, cared for their older adult patients during the pandemic, while also navigating the rapidly changing health policy landscape. METHODS: A qualitative case study approach was used to gather information from nine primary care clinics, across three Canadian provinces. Interviews were conducted with primary care providers (n = 17) and older adult patients (n = 47) from October 2020 to September 2021. Analyses of the interviews were completed in the language of data collection (English or French), and then summarized in English using a coding framework. All responses that related to COVID-19 policies at any level were also examined. RESULTS: Two main themes emerged from the data: (1) navigating the noise: understanding and responding to public health orders and policies affecting health and health care, and (2) receiving and delivering care to older persons during the pandemic: policy-driven challenges & responses. Providers discussed their experiences wading through the health policy directives, while trying to provide good quality care. Older adults found the public health information overwhelming, but appreciated the approaches adapted by primary care clinics to continue providing care, even if it looked different. CONCLUSIONS: COVID-19 policy and guideline complexities obliged primary care providers to take an important role in understanding, implementing and adapting to them, and in explaining them, especially to older adults and their care partners.

Developing an in-depth understanding of patient and caregiver engagement across care transitions from hospital: protocol for a qualitative study exploring experiences in Canada.

INTRODUCTION: Patient and caregiver engagement is critical, and often compromised, at points of transition between care settings, which are more common, and more challenging, for patients with complex medical problems. The consequences of poor care transitions are well-documented, both for patients and caregivers, and for the healthcare system. With an ageing population, there is greater need to focus on care transition experiences of older adults, who are often more medically complex, and more likely to require care from multiple providers across settings. The overall goal of this study is to understand what factors facilitate or hinder patient and caregiver engagement through transitions in care, and how these current engagement practices align with a previously developed engagement framework (CHOICE Framework). This study also aims to co-develop resources needed to support engagement and identify how these resources and materials should be implemented in practice. METHODS AND ANALYSIS: This study uses ethnographic approaches to explore the dynamics of patient and caregiver engagement, or lack thereof, during care transitions across three regions within Ontario. With the help of a front-line champion, patients (n=18-24), caregivers (n=18-24) and healthcare providers (n=36-54) are recruited from an acute care hospital unit (or similar) and followed through their care journey. Data are collected using in-depth semi-structured interviews. Workshops will be held to co-develop strategies and a plan for future implementation of resources and materials. Analysis of the data will use inductive and deductive coding techniques. ETHICS AND DISSEMINATION: Ethics clearance was obtained through the Western University Research Ethics Board, University of Windsor Research Ethics Board and the University of Waterloo Office of Research Ethics. The findings from this study are intended to contribute valuable evidence to further bridge the knowledge to practice gap in patient and caregiver engagement through care transitions. Findings will be disseminated through publications, conference presentations and reports.

The Reflection Room®: Moving from Death-Avoiding to Death-Discussing.

We developed, implemented, and evaluated a participatory arts-based storytelling initiative called the Reflection Room project. Our aim was to investigate if visiting a Reflection Room, (1) creates opportunities for disclosing emotions and processing thoughts, (2) increases comfort discussing dying and death, and (3) supports advance care planning (ACP), conversations. In the pilot phase of the Reflection Room project, a Reflection Room was installed in 25 sites across Canada from 2016-2017. Data collection included reflection cards (n = 463), and surveys completed by visitors upon exiting a room (n = 271) and 3 months later (n = 50). Analysis involved theoretically driven coding, inductive content analysis, and descriptive statistics. We found reflections contained both emotional disclosures and reflective processing. Survey data indicated visiting a Reflection Room increased comfort in thinking and talking about dying and death as well as the likelihood of engaging in ACP. In the future, we will explore the extent to which the project fosters social connections and well-being.

Developing an evidence-informed model of long-term life care at home for older adults with medical, functional and/or social care needs in Ontario, Canada: a mixed methods study protocol.

INTRODUCTION: The COVID-19 pandemic exacerbated existing challenges within the Canadian healthcare system and reinforced the need for long-term care (LTC) reform to prioritise building an integrated continuum of services to meet the needs of older adults. Almost all Canadians want to live, age and receive care at home, yet funding for home and community-based care and support services is limited and integration with primary care and specialised geriatric services is sparse. Optimisation of existing home and community care services would equip the healthcare system to proactively meet the needs of older Canadians and enhance capacity within the hospital and residential care sectors to facilitate access and reduce wait times for those whose needs are best served in these settings. The aim of this study is to design a model of long-term 'life care' at home (LTlifeC model) to sustainably meet the needs of a greater number of community-dwelling older adults. METHODS AND ANALYSIS: An explanatory sequential mixed methods design will be applied across three phases. In the quantitative phase, secondary data analysis will be applied to historical Ontario Home Care data to develop unique groupings of patient needs according to known predictors of residential LTC home admission, and to define unique patient vignettes using dominant care needs. In the qualitative phase, a modified eDelphi process and focus groups will engage community-based clinicians, older adults and family caregivers in the development of needs-based home care packages. The third phase involves triangulation to determine initial model feasibility. ETHICS AND DISSEMINATION: This study has received ethics clearance from the University of Waterloo Research Ethics Board (ORE #42182). Results of this study will be disseminated through peer-reviewed publications and local, national and international conferences. Other forms of knowledge mobilisation will include webinars, policy briefs and lay summaries to elicit support for implementation and pilot testing phases.

Person- and family-centred goal-setting for older adults in Canadian home care: A solution-focused approach.

Goal-setting with older adults in home care is often inhibited by a lack of structure to support person- and family-centred care planning, paternalistic decision-making and task-oriented delivery models. The objective of this research study was to determine how goal-setting practices for older adults could be re-oriented around individuals' self-perceived goals, needs and preferences. Solution-focused semi-structured key informant interviews were conducted with older adult home care clients aged 65 years and older (n = 13) and their family/friend caregivers (n = 12) to explore changes, solutions and strategies for person- and family-centred goal-setting. Participants were recruited through community advertisement in a single region of Ontario, Canada between July and October of 2017. Interviews were conducted in-person and were audio-recorded and transcribed verbatim. Thematic analysis was guided by a multi-step framework method. Four themes emerged from the data: (1) seeing beyond age enables respect and dignity; (2) relational communication involves two-way information sharing; (3) doing 'with' instead of doing 'for' promotes participation and (4) collaboration is easier when older adults and caregivers lead the way. Older adults and caregivers want to be actively engaged in dialogue during care planning to ensure their preferences are included. The findings from this study add the direct perspectives of older adults and their caregivers to literature on solutions to address ageism, improve communication, enhance information sharing and promote collaboration in geriatric care. Next steps for this work could involve testing the changes, solutions and strategies that emerged to determine the effect on person- and family-centred home care delivery.

Transforming primary care for older Canadians living with frailty: mixed methods study protocol for a complex primary care intervention.

INTRODUCTION: Older Canadians living with frailty are high users of healthcare services; however, the healthcare system is not well designed to meet the complex needs of many older adults. Older persons look to their primary care practitioners to assess their needs and coordinate their care. They may need care from a variety of providers and services, but often this care is not well coordinated. Older adults and their family caregivers are the experts in their own needs and preferences, but often do not have a chance to participate fully in treatment decisions or care planning. As a result, older adults may have health problems that are not properly assessed, managed or treated, resulting in poorer health outcomes and higher economic and social costs. We will be implementing enhanced primary healthcare approaches for older patients, including risk screening, patient engagement and shared decision making and care coordination. These interventions will be tailored to the needs and circumstances of the primary care study sites. In this article, we describe our study protocol for implementing and testing these approaches. METHODS AND ANALYSIS: Nine primary care sites in three Canadian provinces will participate in a multi-phase mixed methods study. In phase 1, baseline information will be collected through questionnaires and interviews with patients and healthcare providers (HCPs). In phase 2, HCPs and patients will be consulted to tailor the evidence-based interventions to site-specific needs and circumstances. In phase 3, sites will implement the tailored care model. Evaluation of the care model will include measures of patient and provider experience, a quality of life measure, qualitative interviews and economic evaluation. ETHICS AND DISSEMINATION: This study has received ethics clearance from the host academic institutions: University of Calgary (REB17-0617), University of Waterloo (ORE#22446) and Université Laval (#MP-13-2019-1500 and 2017-2018-12-MP). Results will be disseminated through traditional means, including peer-reviewed publications and conferences and through an extensive network of knowledge user partners. TRIAL REGISTRATION NUMBER: NCT03442426;Pre-results.

Development and testing of the Geriatric Care Assessment Practices (G-CAP) survey.

BACKGROUND: While the Resident Assessment Instrument-Home Care (RAI-HC) tool was designed to support comprehensive geriatric assessment in home care, it is more often used for service allocation and little is known about how point-of-care providers collect the information they need to plan and provide care. The purpose of this pilot study was to develop and test a survey to explore the geriatric care assessment practices of nurses, occupational therapists (OTs) and physiotherapists (PTs) in home care. METHODS: Literature review and expert consultation informed the development of the Geriatric Care Assessment Practices (G-CAP) survey-a 33 question, online, self-report tool exploring assessment and information-sharing methods, attitudes, knowledge, experience and demographic information. The survey was pilot tested at a single home care agency in Ontario, Canada (N = 27). Test-retest reliability (N = 20) and construct validity were explored. RESULTS: The subscales of the G-CAP survey showed fair to good test-retest reliability within a population of interdisciplinary home care providers [ICC2 (A,1) (M ICC = 0.58) for continuous items; weighted kappa (M kappa = 0.63) for categorical items]. Statistically significant differences between OT, PT and nurse responses [M t = 3.0; M p = 0.01] and moderate correlations between predicted related items [M r = |0.39|] provide preliminary support for our hypotheses around survey construct validity in this population. Pilot participants indicated that they use their clinical judgment far more often than standardized assessment tools. Client input was indicated to be the most important source of information for goal-setting. Most pilot participants had heard of the RAI-HC; however, few used it. Pilot participants agreed they could use assessment information from others but also said they must conduct their own assessments and only sometimes share and rarely receive information from other providers. CONCLUSIONS: The G-CAP survey shows promise as a measure of the geriatric care assessment practices of interdisciplinary home care providers. Findings from the survey have the potential to inform improvements to integrated care planning. Next steps include making adaptations to the G-CAP survey to further improve the reliability and validity of the tool and a broad administration of the survey in Ontario home care.

Let's Get Real about Person- and Family-Centred Geriatric Home Care: A Realist Synthesis.

Cette étude a examiné les mécanismes complexes intervenant lors de la prestation de soins axés sur la personne et la famille (SAPF) par des équipes de soins gériatriques à domicile. Une approche par synthèse réaliste a été utilisée pour élaborer un cadre d'évaluation qui a inclus 159 références provenant de la littérature scientifique, des consultations d'experts canadiens en SAPF, des recherches ciblées dans les bases PubMed/MEDLINE® et CINAHL, et des recensions de la littérature grise canadienne. Les références ont été sélectionnées par deux personnes, selon une approche consensuelle avec évaluation de la qualité. Les données ont été extraites et synthétisées en tenant compte du contexte, des mécanismes et des configurations des résultats dans un cadre théorique de SAPF d'équipe pour les soins gériatriques à domicile. Le cadre présente les contributions spécifiques prédominantes des infirmières, des ergothérapeutes et des physiothérapeutes, leurs apports collectifs impliquant des communications pour des équipes virtuelles, ainsi que le soutien du système nécessité pour la prestation de SAPF d'équipe complets. Les résultats de cette étude pourraient contribuer à l'amélioration de l'éducation sur les SAPF et des lignes directrices sur les pratiques exemplaires, en vue d'assurer une prestation plus intégrée des SAPF dans les soins gériatriques offerts à domicile ou dans d'autres milieux comportant des équipes de soins.This study investigated the complex mechanisms underlying team-based delivery of person- and family-centred care (PFCC) in geriatric home care. Using a realist synthesis approach, an evaluative framework was developed and populated with 159 references from scoping the literature, consulting Canadian experts in PFCC, purposive searching in PubMed/MEDLINE® and Cumulative Index to Nursing and Allied Health Literature (CINAHL), and reviewing grey literature within Canada. References were selected using a two-person review and/or consensus approach and quality appraisal. Data were extracted and synthesized using context, mechanism, and outcome configurations into a theoretical framework of team-based PFCC in geriatric home care. The framework details the predominant discipline-specific contributions of nurses, occupational therapists, and physiotherapists, their collective contributions through communication in the context of a virtual team, and the system-level support required for comprehensive team-based PFCC delivery. Findings from this study could inform improvements to PFCC education, best practice guidelines, and more integrated delivery of PFCC in geriatric home care and other team-based care environments.

An examination of family caregiver experiences during care transitions of older adults.

This study explored informal family caregiver experiences in supporting care transitions between hospital and home for medically complex older adults. Using a qualitative, grounded-theory approach, in-depth semi-structured interviews were conducted with community and resource case managers, as well as with informal caregivers of older hip-fracture and stroke patients, and of those recovering from hip replacement surgery. Six properties characterizing caregiver needs in successfully transitioning care between hospital and home were integrated into a theory addressing both a transitional care timeline and the emotional journey. The six properties were (1) assessment of unique family situation; (2) practical information, education, and training; (3) involvement in planning process; (4) agreement between formal and informal caregivers; (5) time to make arrangements in personal life; and (6) emotional readiness. This work will support research and clinical efforts to develop more well-informed and relevant interventions to most appropriately support patients and families during transitional care.

Caregiving is not a disease: moving from reactive to proactive supports for family caregivers across the healthcare system.

Saint Elizabeth partnered directly with family caregivers in a study to develop promising practices and indicators of effective caregiver education and support. Researchers heard that caregivers want and need proactive supports to help them thrive and equip them with tools and resources to protect their capacity to care and prevent distress; however, the current system of support is heavily focused on a reactive, medical approach to managing and treating caregiver "burden." Saint Elizabeth is dedicated to promoting a philosophical shift in thinking about caregiver education and support and is actively re-designing support services to reflect what caregivers say they need.