Adverse impacts in residential aged care facilities: The resident perspective.

OBJECTIVES: Inclusion of consumer perspectives is a key component to person-centred health-care approaches. While current residential aged care systems focus on recording adverse events to meet the requirements of regulatory reporting, little is known about the views of residents. The aim of this research was to explore residents' responses on the types of incidents that have an adverse impact on them and how they are affected by these incidents. METHODS: The study used a qualitative, inductive approach to derive themes from interviews with 20 permanent residents of aged care facilities in New South Wales and the Australian Capital Territory. RESULTS: Four main themes surrounding adverse incidents emerged: (i) social relationships and the adverse impacts of lack of meaningful interactions, (ii) adjustment to life in the residential aged care facility and the loss of residents' former life and self-determination, (iii) the impact of COVID-19 lockdowns which meant that residents were not able to go out or interact with others and (iv) acceptance, resignation and resilience in coping with adverse incidents. CONCLUSIONS: This research highlights the difference between health-care definition, used for incident management reporting and quality indicators, and the way residents respond when asked to describe an incident that has affected them. Resident responses discuss situations having an adverse effect on them in contrast to the way adverse events and incidents are reported and monitored. The findings suggest that within adverse event and incident management systems and resident governance systems, there is scope for incorporating periods of transitions and well-being measures that capture elements that matter to older people.

Designing an Informatics Infrastructure for a National Aged Care Medication Roundtable.

In the residential aged care sector medication management has been identified as a major area of concern contributing to poor outcomes and quality of life for residents. Monitoring medication management in residential aged care in Australia has been highly reliant on small, internal audits. The introduction of electronic medication administration systems provides new opportunities to establish improved methods for ongoing, timely and efficient monitoring of a range of medication indicators, made more meaningful by linking medication data with resident characteristics and outcomes. Benchmarking contemporary medication indicators provides a further opportunity for improvement and is most effective when indicator data are adjusted to take account of confounding factors, such as residents' characteristics and health conditions. Roundtables provide a structure for sharing and discussing indicator data in a trusted and supportive environment and encourage the identification of strategies which may be effective in improving medication management. This paper describes a new project to establish, implement and evaluate a National Aged Care Medication Roundtable.

Pharmacological intervention for irritability, aggression, and self-injury in autism spectrum disorder (ASD).

BACKGROUND: Pharmacological interventions are frequently used for people with autism spectrum disorder (ASD) to manage behaviours of concern, including irritability, aggression, and self-injury. Some pharmacological interventions might help treat some behaviours of concern, but can also have adverse effects (AEs). OBJECTIVES: To assess the effectiveness and AEs of pharmacological interventions for managing the behaviours of irritability, aggression, and self-injury in ASD. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, 11 other databases and two trials registers up to June 2022. We also searched reference lists of relevant studies, and contacted study authors, experts and pharmaceutical companies. SELECTION CRITERIA: We included randomised controlled trials of participants of any age with a clinical diagnosis of ASD, that compared any pharmacological intervention to an alternative drug, standard care, placebo, or wait-list control. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Primary outcomes were behaviours of concern in ASD, (irritability, aggression and self-injury); and AEs. Secondary outcomes were quality of life, and tolerability and acceptability. Two review authors independently assessed each study for risk of bias, and used GRADE to judge the certainty of the evidence for each outcome. MAIN RESULTS: We included 131 studies involving 7014 participants in this review. We identified 26 studies as awaiting classification and 25 as ongoing. Most studies involved children (53 studies involved only children under 13 years), children and adolescents (37 studies), adolescents only (2 studies) children and adults (16 studies), or adults only (23 studies). All included studies compared a pharmacological intervention to a placebo or to another pharmacological intervention. Atypical antipsychotics versus placebo At short-term follow-up (up to 6 months), atypical antipsychotics probably reduce irritability compared to placebo (standardised mean difference (SMD) -0.90, 95% confidence interval (CI) -1.25 to -0.55, 12 studies, 973 participants; moderate-certainty evidence), which may indicate a large effect. However, there was no clear evidence of a difference in aggression between groups (SMD -0.44, 95% CI -0.89 to 0.01; 1 study, 77 participants; very low-certainty evidence). Atypical antipsychotics may also reduce self-injury (SMD -1.43, 95% CI -2.24 to -0.61; 1 study, 30 participants; low-certainty evidence), possibly indicating a large effect. There may be higher rates of neurological AEs (dizziness, fatigue, sedation, somnolence, and tremor) in the intervention group (low-certainty evidence), but there was no clear evidence of an effect on other neurological AEs. Increased appetite may be higher in the intervention group (low-certainty evidence), but we found no clear evidence of an effect on other metabolic AEs. There was no clear evidence of differences between groups in musculoskeletal or psychological AEs. Neurohormones versus placebo At short-term follow-up, neurohormones may have minimal to no clear effect on irritability when compared to placebo (SMD -0.18, 95% CI -0.37 to -0.00; 8 studies; 466 participants; very low-certainty evidence), although the evidence is very uncertain. No data were reported for aggression or self -injury. Neurohormones may reduce the risk of headaches slightly in the intervention group, although the evidence is very uncertain. There was no clear evidence of an effect of neurohormones on any other neurological AEs, nor on any psychological, metabolic, or musculoskeletal AEs (low- and very low-certainty evidence). Attention-deficit hyperactivity disorder (ADHD)-related medications versus placebo At short-term follow-up, ADHD-related medications may reduce irritability slightly (SMD -0.20, 95% CI -0.40 to -0.01; 10 studies, 400 participants; low-certainty evidence), which may indicate a small effect. However, there was no clear evidence that ADHD-related medications have an effect on self-injury (SMD -0.62, 95% CI -1.63 to 0.39; 1 study, 16 participants; very low-certainty evidence). No data were reported for aggression. Rates of neurological AEs (drowsiness, emotional AEs, fatigue, headache, insomnia, and irritability), metabolic AEs (decreased appetite) and psychological AEs (depression) may be higher in the intervention group, although the evidence is very uncertain (very low-certainty evidence). There was no evidence of a difference between groups for any other metabolic, neurological, or psychological AEs (very low-certainty evidence). No data were reported for musculoskeletal AEs. Antidepressants versus placebo At short-term follow-up, there was no clear evidence that antidepressants have an effect on irritability (SMD -0.06, 95% CI -0.30 to 0.18; 3 studies, 267 participants; low-certainty evidence). No data for aggression or self-injury were reported or could be included in the analysis. Rates of metabolic AEs (decreased energy) may be higher in participants receiving antidepressants (very low-certainty evidence), although no other metabolic AEs showed clear evidence of a difference. Rates of neurological AEs (decreased attention) and psychological AEs (impulsive behaviour and stereotypy) may also be higher in the intervention group (very low-certainty evidence) although the evidence is very uncertain. There was no clear evidence of any difference in the other metabolic, neurological, or psychological AEs (very low-certainty evidence), nor between groups in musculoskeletal AEs (very low-certainty evidence). Risk of bias We rated most of the studies across the four comparisons at unclear overall risk of bias due to having multiple domains rated as unclear, very few rated as low across all domains, and most having at least one domain rated as high risk of bias. AUTHORS' CONCLUSIONS: Evidence suggests that atypical antipsychotics probably reduce irritability, ADHD-related medications may reduce irritability slightly, and neurohormones may have little to no effect on irritability in the short term in people with ASD. There was some evidence that atypical antipsychotics may reduce self-injury in the short term, although the evidence is uncertain. There was no clear evidence that antidepressants had an effect on irritability. There was also little to no difference in aggression between atypical antipsychotics and placebo, or self-injury between ADHD-related medications and placebo. However, there was some evidence that atypical antipsychotics may result in a large reduction in self-injury, although the evidence is uncertain. No data were reported (or could be used) for self-injury or aggression for neurohormones versus placebo. Studies reported a wide range of potential AEs. Atypical antipsychotics and ADHD-related medications in particular were associated with an increased risk of metabolic and neurological AEs, although the evidence is uncertain for atypical antipsychotics and very uncertain for ADHD-related medications. The other drug classes had minimal or no associated AEs.

'Environments of concern': reframing challenging behaviour within a human rights approach.

While disability is recognised by the United Nations Convention on the Rights of Persons with Disabilities (CRPD) as an evolving concept, the language of positive behaviour support has not kept pace with the current human rights-based approach. The widely-used terms 'challenging behaviour' and 'behaviours that challenge' imply that the behaviour is inherent in a person with disability. Words have power in shaping practice: when the behaviour of the person with disability is framed as the problem, this leads to a pathologisation or labelling that can provide a rationale to medicate and restrain as a way of 'managing the challenging behaviour'. Many behaviours seen as being challenging could be better understood as 'adaptive behaviours to maladaptive environments', or legitimate responses to difficult environments and situations. In this paper, we argue that the language and implementation of positive behaviour support should better take into account the CRPD and contemporary evidence on behaviour change interventions, which support a shift away from focusing on individuals' behaviours towards putting environments front and centre. We outline how the social-ecological model could be used as a framework to more explicitly address 'environments of concern' in developing tailored and system-wide responses to behaviour support needs. We argue there is an urgency for this paradigm shift to better reflect the views of people with disability and improve outcomes.

Staff perceptions following a training programme about reducing psychotropic medication use in adults with intellectual disability: The need for a realistic professional practice framework.

BACKGROUND: Adults with intellectual disability are at higher risk of being administered psychotropic medications. The UK-developed SPECTROM (Short-term PsychoEducation for Carers To Reduce Over Medication of people with intellectual disabilities) training programme educates disability support workers on psychotropic medications and alternatives to these medications. METHOD: Interviews were conducted with 10 participants who took part in the pilot SPECTROM training programme to elicit their views on the programme and its appropriateness in an Australian context. RESULTS: The key theme was 'Need for a psychotropic medication practice framework'. Four sub-themes were Broad satisfaction with the SPECTROM training programme; Disability support workers acknowledging the limitations of their scope of practice; Empowering training through prescriptive and reflective methods and; Need for future mentoring from Multi-Disciplinary Team members in the application of new knowledge. CONCLUSIONS: Participants felt that whilst they could improve their knowledge and attitudes surrounding psychotropic medication administration for behaviours of concern through SPECTROM training, a national practice framework is needed to execute its goals at scale.

Quality indicators for home- and community-based aged care: A critical literature review to inform policy directions.

OBJECTIVES: Australia is lagging behind other countries in implementing quality indicators (QIs) in home- and community-based aged care. This research aimed to identify and appraise home care QI sets used internationally for older adults, to inform the future development and utilisation of QIs in the Australian context. METHODS: A systematic search of eligible studies outlining the development and validation of home care QI sets for older adults was undertaken. QIs were categorised using the Donabedian model to identify potential gaps in coverage of key areas of care quality. Each QI was classified as potentially "derivable" or not from existing national routinely collected datasets. Methodological quality was determined using the Appraisal of Indicators through Research and Evaluation instrument. RESULTS: Three sets of home care QIs developed and used internationally for older adults were identified. Two of the QI sets focused predominantly on clinical and functional aspects of care. Of 45 unique QIs, the majority were outcome measures (93%), with only three QIs measuring care processes (7%), and zero indicators measuring quality in terms of the structure of care (e.g., waiting time to access services). Nearly half of the individual indicators identified would require Australian home care providers to undertake additional data collection. There were significant methodological limitations in the development of QI sets, particularly in the scientific evidence domain. CONCLUSIONS: This review identified important gaps in existing QI sets, which should be considered by policymakers, researchers, and other stakeholders when developing and applying QIs in the Australian setting.

The use of predictive fall models for older adults receiving aged care, using routinely collected electronic health record data: a systematic review.

BACKGROUND: Falls in older adults remain a pressing health concern. With advancements in data analytics and increasing uptake of electronic health records, developing comprehensive predictive models for fall risk is now possible. We aimed to systematically identify studies involving the development and implementation of predictive falls models which used routinely collected electronic health record data in home-based, community and residential aged care settings. METHODS: A systematic search of entries in Cochrane Library, CINAHL, MEDLINE, Scopus, and Web of Science was conducted in July 2020 using search terms relevant to aged care, prediction, and falls. Selection criteria included English-language studies, published in peer-reviewed journals, had an outcome of falls, and involved fall risk modelling using routinely collected electronic health record data. Screening, data extraction and quality appraisal using the Critical Appraisal Skills Program for Clinical Prediction Rule Studies were conducted. Study content was synthesised and reported narratively. RESULTS: From 7,329 unique entries, four relevant studies were identified. All predictive models were built using different statistical techniques. Predictors across seven categories were used: demographics, assessments of care, fall history, medication use, health conditions, physical abilities, and environmental factors. Only one of the four studies had been validated externally. Three studies reported on the performance of the models. CONCLUSIONS: Adopting predictive modelling in aged care services for adverse events, such as falls, is in its infancy. The increased availability of electronic health record data and the potential of predictive modelling to document fall risk and inform appropriate interventions is making use of such models achievable. Having a dynamic prediction model that reflects the changing status of an aged care client is key to this moving forward for fall prevention interventions.

'I go home with a happy heart'. Enhancing community aged care services to sustain togetherness: Perspectives from Australian staff and clients.

Social participation is critical to the health and well-being of older adults, however, participation often declines with age. Research has identified that personal and environmental factors such as high socioeconomic status and accessible transportation are associated with higher levels of social participation. However, the barriers and facilitators to social participation experienced by older adults receiving community aged care services remains largely unexplored. This qualitative study aimed to generate context-rich data and identify the barriers and facilitators to effective community care services that can support older adults' participation in the community and contribute to individual well-being. Semi-structured focus groups were conducted with 40 community aged care clients and 21 staff members between January to July 2018 and thematic analysis was undertaken. Environmental factors, such as availability and accessibility of transportation services emerged as the most important factors influencing participation. Older age, self-attitude towards one's own functional ability and limited social networks were important personal factors affecting participation. Proactive aged care services (e.g., engaged staff, tailored activities) were reported to assist with continual engagement in aged care services. In contrast, the type, location and accessibility of the activity, associated costs and limited options for accessible transportation were key barriers to older adults' social participation. Pathways contributing to positive engagement were complex and variable, but personal well-being and local community resources emerged as important factors encouraging higher social participation. These findings are discussed in the context of the ongoing pandemic and implications for future aged care services are provided.

Characteristics of older Australian community aged care clients who fall: Incidents reported by care staff.

Falls are the leading cause of injury and hospitalisation for older adults (aged 65 years or older) worldwide. Data collected by community aged care providers are an underutilised source of information about precipitating risk factors and consequences of falls for older adults living in the community. The objective of this longitudinal, observational study was to describe and compare the characteristics of older Australians who did and did not have falls reported by community aged care staff. We analysed 19 months of routinely collected care management and incident data for 1,596 older clients from a large Australian community care provider. Differences in sociodemographic characteristics, care needs and community care service use were compared between those who had one or more reported falls and those who had none. Fall-related outcomes (injuries, hospitalisations, relocation to residential aged care) were examined. The average age of clients was 82 years and most were women (66%). Seventy-seven (4.8%) clients had one or more reported falls over the study period (total falls = 92). Clients who had falls reported by care staff were more likely to be older adults, male and use more hours of community care services per week. There were 38 falls-related injuries, 5 falls-related hospitalisations and 20 clients relocated to residential aged care after a reported fall. This study demonstrates the potential for using routinely collected community aged care data to understand risk factors and monitor longitudinal outcomes for a population at high risk of falls.

Incidence of adverse incidents in residential aged care.

Objective Adverse incident research within residential aged care facilities (RACFs) is increasing and there is growing awareness of safety and quality issues. However, large-scale evidence identifying specific areas of need and at-risk residents is lacking. This study used routinely collected incident management system data to quantify the types and rates of adverse incidents experienced by residents of RACFs. Methods A concurrent mixed-methods design was used to examine 3 years of incident management report data from 72 RACFs in New South Wales and the Australian Capital Territory. Qualitative thematic analysis of free-text incident descriptions was undertaken to group adverse incidents into categories. The rates and types of adverse incidents based on these categories were calculated and then compared using incidence rate ratios (IRRs). Results Deidentified records of 11 987 permanent residents (aged ≥65 years; mean (±s.d.) age 84 ± 8 years) from the facilities were included. Of the 60 268 adverse incidents, falls were the most common event (36%), followed by behaviour-related events (33%), other impacts and injuries (22%) and medication errors (9%). The number of adverse incidents per resident ranged from 0 (42%) to 171, with a median of 2. Women (IRR 0.804; P P Conclusion This study demonstrates that data already collected within electronic management systems can provide crucial baseline information about the risk levels that adverse incidents pose to older Australians living in RACFs. What is known about the topic? To date, research into aged care adverse incidents has typically focused on single incident types in small studies involving mitigation strategies. Little has been published quantifying the multiple adverse incidents experienced by residents of aged care facilities or reporting organisation-wide rates of adverse incidents. What does this paper add? This paper adds to the growing breadth of Australian aged care research by providing baseline information on the rates and types of adverse incidents in RACFs across a large and representative provider. What are the implications for practitioners? This research demonstrates that the wealth of data captured by aged care facilities' incident management information systems can be used to provide insight into areas of commonly occurring adverse incidents. Better use of this information could greatly enhance strategic planning of quality improvement activities and the care provided to residents.

A comprehensive overview of social network measures for older adults: A systematic review.

OBJECTIVES: The size and type of older adults' social networks is associated with health, mental and social outcomes. Investigators within many disciplines are now measuring social networks, but it is not always clear what they are assessing, or which measures may best meet their objectives. To undertake a systematic review to identify (i) social network measures used for older adults, (ii) variety of social network dimensions and (iii) how measures have developed over time. MATERIALS AND METHODS: The MEDLINE, EMBASE, CINAHL, PsycInfo and Cochrane Library databases were systematically searched to identify social network instruments, followed by categorization of the domains into quantitative, qualitative and alter domains. RESULTS: A total of 229 studies and 21 social network measures were included, with 11 quantitative dimensions (e.g., size, frequency), 5 qualitative dimensions (e.g., support satisfaction, emotional bond) and 7 alter members (e.g., family, neighbours) of social networks identified. Measures commonly clustered on quantifiable network size (n = 19), availability of supportive networks (n = 14) and presence of family ties (n = 21). The period between 1985 and 1995 produced the greatest number of newly developed social network measures (n = 10) with a stronger focus on qualitative features. DISCUSSION AND IMPLICATIONS: This review provides researchers with an organized summary of measures and dimensions for consideration when appraising social connections in older adults. This can enable better study design through providing information that makes explicit inevitable trade-offs between survey length, comprehensiveness of dimension coverage, and utilization of the measure for researchers. PROSPERO Registration number: CRD42016043089.

Transforming routinely collected residential aged care provider data into timely information: Current and future directions.

Electronic information systems are becoming increasingly common in residential aged care in Australia. These systems contain valuable data generated during day-to-day care delivery for older adults. These data (termed 'routinely collected residential aged care provider data') are currently underutilised, however have potential significant benefits for both care delivery and research purposes. Routinely collected residential aged care provider data are more readily accessible, contain up-to-date information and can be linked to existing national or state-based administrative data sets, while providing more granular details about care delivered at the coalface. The aim of this paper is to provide clinicians, researchers, policymakers and providers with an understanding of the strengths of these types of data, as well as identifying areas that require future development to maximise their potential to drive improvements in resident care and outcomes. These considerations include data quality, data standardisation and models for data governance, consent and consumer involvement.

Co-designing a dashboard of predictive analytics and decision support to drive care quality and client outcomes in aged care: a mixed-method study protocol.

INTRODUCTION: There is a clear need for improved care quality and quality monitoring in aged care. Aged care providers collect an abundance of data, yet rarely are these data integrated and transformed in real-time into actionable information to support evidence-based care, nor are they shared with older people and informal caregivers. This protocol describes the co-design and testing of a dashboard in residential aged care facilities (nursing or care homes) and community-based aged care settings (formal care provided at home or in the community). The dashboard will comprise integrated data to provide an 'at-a-glance' overview of aged care clients, indicators to identify clients at risk of fall-related hospitalisations and poor quality of life, and evidence-based decision support to minimise these risks. Longer term plans for dashboard implementation and evaluation are also outlined. METHODS: This mixed-method study will involve (1) co-designing dashboard features with aged care staff, clients, informal caregivers and general practitioners (GPs), (2) integrating aged care data silos and developing risk models, and (3) testing dashboard prototypes with users. The dashboard features will be informed by direct observations of routine work, interviews, focus groups and co-design groups with users, and a community forum. Multivariable discrete time survival models will be used to develop risk indicators, using predictors from linked historical aged care and hospital data. Dashboard prototype testing will comprise interviews, focus groups and walk-through scenarios using a think-aloud approach with staff members, clients and informal caregivers, and a GP workshop. ETHICS AND DISSEMINATION: This study has received ethical approval from the New South Wales (NSW) Population & Health Services Research Ethics Committee and Macquarie University's Human Research Ethics Committee. The research findings will be presented to the aged care provider who will share results with staff members, clients, residents and informal caregivers. Findings will be disseminated as peer-reviewed journal articles, policy briefs and conference presentations.

Quality of life measurement in community-based aged care - understanding variation between clients and between care service providers.

BACKGROUND: Measuring person-centred outcomes and using this information to improve service delivery is a challenge for many care providers. We aimed to identify predictors of QoL among older adults receiving community-based aged care services and examine variation across different community care service outlets. METHODS: A retrospective sample of 1141 Australians aged ≥60 years receiving community-based care services from a large service provider within 19 service outlets. Clients' QoL was captured using the ICEpop CAPability Index. QoL scores and predictors of QoL (i.e. sociodemographic, social participation and service use) were extracted from clients' electronic records and examined using multivariable regression. Funnel plots were used to examine variation in risk-adjusted QoL scores across service outlets. RESULTS: Mean age was 81.5 years (SD = 8) and 75.5% were women. Clients had a mean QoL score of 0.81 (range 0-1, SD = 0.15). After accounting for other factors, being older (p < 0.01), having lower-level care needs (p < 0.01), receiving services which met needs for assistance with activities of daily living (p < 0.01), and having higher levels of social participation (p < 0.001) were associated with higher QoL scores. Of the 19 service outlets, 21% (n = 4) had lower mean risk-adjusted QoL scores than expected (< 95% control limits) and 16% (n = 3) had higher mean scores than expected. CONCLUSION: Using QoL as an indicator to compare care quality may be feasible, with appropriate risk adjustment. Implementing QoL tools allows providers to measure and monitor their performance and service outcomes, as well as identify clients with poor quality of life who may need extra support. TRIAL REGISTRATION: Australian and New Zealand clinical trial registry number: ACTRN12617001212347 . Registered 18/08/2017.

A mixed-methods study evaluating the impact of an excursion-based social group on quality of life of older adults.

BACKGROUND: Social isolation is an increasing concern for older adults who live in the community. Despite some availability of social support programs to address social isolation, their effectiveness is not routinely measured. This study aimed to evaluate an innovative excursion-based program offering unique social experiences to older adults receiving aged care services. METHODS: This six-month before and after mixed-methods study evaluated the outcomes of an Australian excursion-based program which offered social and physical outings to bring older adults receiving aged care services into the wider community. The study combined two parts: Part 1 was a pre-post survey assessing the quality of life of older adults who received the excursion-based program for 6 months (n = 56; two time-points, analysed using signed rank test) and Part 2 involved qualitative in-depth, semi-structured interviews (n = 24 aged care staff, older adults and carers; analysed using thematic analysis). RESULTS: Older adults experienced a significant increase in quality of life scores (p < 0.001) between baseline and 6 months. Interviews confirmed these observations and suggested that benefits of participation included increased opportunities for social participation, psychological wellbeing, physical function, and carer respite. Interviews also revealed being in a group setting, having tailored, convenient and accessible activities, alongside supportive staff were key drivers in improving the wellbeing of participants. CONCLUSIONS: Participating in an excursion-based community program may improve wellbeing in older adults. Aging policy should focus on prioritizing initiatives that promote social connectivity with the wider community and assist in improving outcomes for older adults.

Social Participation Among Older Adults Receiving Community Care Services.

Aged care services have the potential to support social participation for the growing number of adults aging at home, but little is known about the types of social activities older adults in community care are engaged in. We used cluster analysis to examine the current profiles of social participation across seven domains in 1,114 older Australians, and chi-square analyses to explore between-group differences in social participation and sociodemographic and community care service use. Two distinct participation profiles were identified: (a) connected, capable, older rural women and (b) isolated, high-needs, urban-dwelling men. The first group had higher levels of engagement across six social participation domains compared with the second group. Social participation among older adults receiving community care services varies by gender, age, individual care needs, and geographical location. More targeted service provision at both the individual and community levels may assist older adults to access social participation opportunities.

Unmet Needs for Transdermal Patch Management in Electronic Medication Administration Records: An Analysis of Data from 66 Aged Care Facilities.

BACKGROUND: Transdermal medication patches have caused serious adverse events in residential aged care facilities (RACFs). Preliminary research suggests that facilities are using a workaround consisting of manually entered reminders in their electronic medication administration records (eMARs) to prompt staff to check and remove patches, because the eMAR does not support these tasks. However, the prevalence and factors associated with use of this workaround among facilities is unknown. OBJECTIVES: The objectives of this study were to (1) examine the frequency and consistency with which manual reminders to check and remove transdermal patches were used in facility eMARs, and (2) identify resident and facility factors associated with reminder use, to inform eMAR redesign. METHODS: This was a retrospective cross-sectional analysis of eMAR data from 66 Australian RACFs including 4,787 permanent residents, aged ≥65 years in January 2017. Prevalence of the use of reminders to check and remove patches, and consistency in their application within facilities were examined. Generalized estimating equations were used to determine factors associated with use of manual reminders. RESULTS: One in five (n = 937) residents used a patch, and 83.6% of patches contained opioids, a high-risk medicine. 56.9% of facilities implemented manually entered check patch reminders in the eMAR, and 72.3% implemented remove reminders. The reminders were applied inconsistently, with only half of these facilities having reminders for all residents with patches. Residents in facilities in regional areas were more likely to have a check reminder compared with those in major cities (adjusted odds ratio = 4.72 [95% confidence interval: 1.69-13.20]). CONCLUSION: Transdermal patches containing high-risk medicines are frequently used in RACFs, but their safe administration is not supported by a widely implemented eMAR. The frequent, but inconsistent use of a workaround to manually enter reminders indicates an unmet need for new eMAR functionality to improve safety.

Understanding the work of case managers in Australian community aged care: a longitudinal time and motion study.

Objective The aim of this study was to quantify the work activities of community aged care case managers and assess changes following consumer-directed policy reforms. Methods A longitudinal, time and motion study was performed, with direct observation (n=339h) of case managers undertaking work in the office or in the community. We compared the distribution of proportions of time spent across seven broad work task categories during May-August 2014 (P1) and May-October 2016 (P2). Results Office time was primarily consumed by communication (43.7%) and documentation (33.3%) tasks. Documentation increased substantially from P1 to P2 (29.4% vs 37.0% respectively; P<0.001), with more time spent on the subtask of recording information (18.0% vs 24.5% respectively; P=0.039). Travel (45.9%) and communication (41.0%) accounted for most community time. Time in communication increased from P1 to P2 (37.3% vs 48.4% respectively; P=0.047), with more time allocated to client communication (14.6% vs 31.7%; P<0.001). Case managers spent 33.6% of community time in clients' homes (median 25.2min per client; 22.8 vs 30.1min in P1 and P2 respectively) and visited a median of two clients per day (3 vs 1 visits per day in P1 and P2 respectively). Conclusions This study provides the first quantification of task-time distribution among this workforce and how work patterns have changed during a time of significant policy reform and operational changes within the community aged care sector. What is known about the topic? Early qualitative studies gauging case managers' perceptions of the effect of consumer-directed care reforms on their work activities indicate an increase in time spent working directly with aged care clients. However, there is no existing quantitative evidence examining changes to case managers' work activities. What does this paper add? By capturing timed, multidimensional data, this study provides new quantitative evidence of how case managers distribute their time on work activities in office and community settings. Further, the results provide an indication of changes in work task-time distribution over a 2-year period when significant policy reforms and operational changes occurred. Amid a changing aged care landscape, how and with whom case managers spend their time was found to shift, with an increase in time spent recording information and communicating with clients identified. What are the implications for practitioners? This study demonstrates that direct observational studies provide important evidence of the ways in which policy and organisational changes affect community aged care case managers' work activities in practice. Triangulating this quantitative evidence with existing qualitative accounts of policy impact can further allow assessment of how complex reforms may affect everyday work. For policy makers and aged care organisations, such evidence can help discern whether policies and changes are having their desired effects, as well as providing insights as to why or why not.

Measuring the prevalence of 60 health conditions in older Australians in residential aged care with electronic health records: a retrospective dynamic cohort study.

BACKGROUND: The number of older Australians using aged care services is increasing, yet there is an absence of reliable data on their health. Multimorbidity in this population has not been well described. A clear picture of the health status of people using aged care is essential for informing health practice and policy to support evidence-based, equitable, high-quality care. Our objective was to describe the health status of older Australians living in residential aged care facilities (RACFs) and develop a model for monitoring health conditions using data from electronic health record systems. METHODS: Using a dynamic retrospective cohort of 9436 RACF residents living in 68 RACFs in New South Wales and the Australian Capital Territory from 2014 to 2017, we developed an algorithm to identify residents' conditions using aged care funding assessments, medications administered, and clinical notes from their facility electronic health record (EHR). We generated age- and sex-specific prevalence estimates for 60 health conditions. Agreement between conditions recorded in aged care funding assessments and those documented in residents' EHRs was evaluated using Cohen's kappa. Cluster analysis was used to describe combinations of health conditions (multimorbidity) occurring among residents. RESULTS: Using all data sources, 93% of residents had some form of circulatory disease, with hypertension the most common (62%). Most residents (93%) had a mental or behavioural disorder, including dementia (58%) or depression (54%). For most conditions, EHR data identified approximately twice the number of people with the condition compared to aged care funding assessments. Agreement between data sources was highest for multiple sclerosis, Huntington's disease, and dementia. The cluster analysis identified seven groups with distinct combinations of health conditions and demographic characteristics and found that the most complex cluster represented a group of residents that had on average the longest lengths of stay in residential care. CONCLUSIONS: The prevalence of many health conditions among RACF residents in Australia is underestimated in previous reports. Aged care EHR data have the potential to be used to better understand the complex health needs of this vulnerable population and can help fill the information gaps needed for population health surveillance and quality monitoring.

HealthPathways: a detailed analysis of utilisation trends in the northern Sydney region.

This study developed a model for using Google Analytics (GA) data to evaluate utilisation trends of the Sydney North HealthPathways portal. HealthPathways GA data merged with dates of page localisations and promotional events from March 2017 through June 2018 were analysed to evaluate engagement and use of HealthPathways, integration into clinical practice and how HealthPathways is used. Descriptive statistics and plots were generated for each clinical stream and page for the number of users per month (total, new and return users), mean time on page, navigation and search terms. The number of page views, new users and return users increased during the study period. Each clinical stream had between 26 and 2508 views, with a median of 199 views (interquartile range 84-461 views). Individual pages had 0-12388 total views. Return users visited seven times on average. Most usage occurred between mid-morning and mid-afternoon. Diabetes was the most frequently viewed and searched clinical stream, followed by palliative care. These streams had the greatest number of promotional events. Increasing use of and interaction with HealthPathways suggests that it is a useful tool to support clinical practice among northern Sydney primary care providers.