Extreme drought impacts have been underestimated in grasslands and shrublands globally.

Climate change is increasing the frequency and severity of short-term (~1 y) drought events-the most common duration of drought-globally. Yet the impact of this intensification of drought on ecosystem functioning remains poorly resolved. This is due in part to the widely disparate approaches ecologists have employed to study drought, variation in the severity and duration of drought studied, and differences among ecosystems in vegetation, edaphic and climatic attributes that can mediate drought impacts. To overcome these problems and better identify the factors that modulate drought responses, we used a coordinated distributed experiment to quantify the impact of short-term drought on grassland and shrubland ecosystems. With a standardized approach, we imposed ~a single year of drought at 100 sites on six continents. Here we show that loss of a foundational ecosystem function-aboveground net primary production (ANPP)-was 60% greater at sites that experienced statistically extreme drought (1-in-100-y event) vs. those sites where drought was nominal (historically more common) in magnitude (35% vs. 21%, respectively). This reduction in a key carbon cycle process with a single year of extreme drought greatly exceeds previously reported losses for grasslands and shrublands. Our global experiment also revealed high variability in drought response but that relative reductions in ANPP were greater in drier ecosystems and those with fewer plant species. Overall, our results demonstrate with unprecedented rigor that the global impacts of projected increases in drought severity have been significantly underestimated and that drier and less diverse sites are likely to be most vulnerable to extreme drought.

Engagement of older adults in regional health innovation: The ECOTECH concept mapping project.

OBJECTIVES: Regional health innovation ecosystems can activate collaboration and support planning, self-management and development and commercialization of innovations. We sought to understand how older adults and their caregivers can be meaningfully engaged in regional health innovation ecosystems focused on health and aging-related technology innovation. METHODS: A six-phase concept mapping technique gathered data over six time points across Canada. Brainstorming conducted online and in person identified engagement ideas. Statements were sorted by similarity and rated by participants on importance and feasibility. Qualitative approaches and multidimensional scaling, hierarchical cluster analysis, descriptive statistics and t tests were used for analysis. RESULTS: Sixty-two unique ideas were assembled into a seven-cluster framework of priorities for engagement in regional health innovation ecosystems including public forums, co-production and partnerships, engagement, linkage and exchange, developing cultural capacity, advocacy and investment in the ecosystem. CONCLUSIONS: This study identified a framework of priorities for directions and strategies for older adult and caregiver engagement in regional health innovation ecosystems. Next steps include collaborations to develop regional health innovation ecosystems that actively engage older adults and their caregivers in health and aging-related technology innovation.

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.

A Framework for Supporting Post-acute Care Transitions of Older Patients With Hip Fracture.

OBJECTIVE: Improving care transitions is of critical importance for older patients, especially those with complex care needs. Our study examined the "Transitions of Care" (ToC) of complex, post-acute older adults at multiple time points. The objective of this article is to identify domains relevant to health care transitions of post-acute older patients with hip fracture so as to inform future ToC interventions. DESIGN: Here we conducted a framework-based synthesis of the 12 peer-reviewed manuscripts that were published from our multisite, ethnographic study. SETTING AND PARTICIPANTS: All 12 manuscripts were based on 1 study, described here. Data were collected in multiple regions, in acute and sub-acute care wards, rehabilitation programs, home care agencies, long-term care and assisted living facilities, and patients' private homes. We completed 51 interviews with 23 postoperative hip fracture patients aged ≥65 years, 24 interviews with 19 family caregivers, and 96 interviews with 92 health care providers. Interviews with patients, family caregivers, and health care providers were conducted at each transition point for a total of 171 individual interviews. RESULTS: Taken together, our framework analysis of the 12 manuscripts identified 8 themes related to ToC. Two themes, patient complexity and system constraints, are contextual factors that tend to impede ToC and may be less amenable to change. The remaining 6 themes, patient involvement and choice, family caregiver roles, strong relationships, coordination of roles, documentation, and information sharing, have the potential to support and improve ToC. CONCLUSIONS AND IMPLICATIONS: With comprehensive data from a range of stakeholders, collected at multiple transition points along the health care continuum, in our final 6 themes we identify potential points of intervention for clinicians and teams seeking to improve ToC for older complex patients.

Caring in the Information Age: Personal Online Networks to Improve Caregiver Support.

BACKGROUND: It is becoming increasingly important to find ways for caregivers and service providers to collaborate. This study explored the potential for improving care and social support through shared online network use by family caregivers and service providers in home care. METHODS: This qualitative study was guided by Rogers' Theory of Diffusion of Innovations [NY: Free Press; 1995], and involved focus group and individual interviews of service providers (n = 31) and family caregivers (n = 4). Interview transcriptions were analyzed using descriptive, topic, and analytic coding, followed by thematic analysis. RESULTS: The network was identified as presenting an opportunity to fill communication gaps presented by other modes of communication and further enhance engagement with families. Barriers included time limitations and policy-related restrictions, privacy, security, and information ownership. CONCLUSION: Online networks may help address longstanding home-care issues around communication and information-sharing. The success of online networks in home care requires support from care partners. Future research should pilot the use of online networks in home care using barrier and facilitator considerations from this study.

Asymmetric responses of primary productivity to precipitation extremes: A synthesis of grassland precipitation manipulation experiments.

Climatic changes are altering Earth's hydrological cycle, resulting in altered precipitation amounts, increased interannual variability of precipitation, and more frequent extreme precipitation events. These trends will likely continue into the future, having substantial impacts on net primary productivity (NPP) and associated ecosystem services such as food production and carbon sequestration. Frequently, experimental manipulations of precipitation have linked altered precipitation regimes to changes in NPP. Yet, findings have been diverse and substantial uncertainty still surrounds generalities describing patterns of ecosystem sensitivity to altered precipitation. Additionally, we do not know whether previously observed correlations between NPP and precipitation remain accurate when precipitation changes become extreme. We synthesized results from 83 case studies of experimental precipitation manipulations in grasslands worldwide. We used meta-analytical techniques to search for generalities and asymmetries of aboveground NPP (ANPP) and belowground NPP (BNPP) responses to both the direction and magnitude of precipitation change. Sensitivity (i.e., productivity response standardized by the amount of precipitation change) of BNPP was similar under precipitation additions and reductions, but ANPP was more sensitive to precipitation additions than reductions; this was especially evident in drier ecosystems. Additionally, overall relationships between the magnitude of productivity responses and the magnitude of precipitation change were saturating in form. The saturating form of this relationship was likely driven by ANPP responses to very extreme precipitation increases, although there were limited studies imposing extreme precipitation change, and there was considerable variation among experiments. This highlights the importance of incorporating gradients of manipulations, ranging from extreme drought to extreme precipitation increases into future climate change experiments. Additionally, policy and land management decisions related to global change scenarios should consider how ANPP and BNPP responses may differ, and that ecosystem responses to extreme events might not be predicted from relationships found under moderate environmental changes.

Home support workers perceptions of family members of their older clients: a qualitative study.

BACKGROUND: Health care discourse is replete with references to building partnerships between formal and informal care systems of support, particularly in community and home based health care. Little work has been done to examine the relationship between home health care workers and family caregivers of older clients. The purpose of this study is to examine home support workers' (HSWs) perceptions of their interactions with their clients' family members. The goal of this research is to improve client care and better connect formal and informal care systems. METHODS: A qualitative study, using in-depth interviews was conducted with 118 home support workers in British Columbia, Canada. Framework analysis was used and a number of strategies were employed to ensure rigor including: memo writing and analysis meetings. Interviews were transcribed verbatim and sent to a professional transcription agency. Nvivo 10 software was used to manage the data. RESULTS: Interactions between HSWs and family members are characterized in terms both of complementary labour (family members providing informational and instrumental support to HSWs), and disrupted labour (family members creating emotion work and additional instrumental work for HSWs). Two factors, the care plan and empathic awareness, further impact the relationship between HSWs and family caregivers. CONCLUSIONS: HSWs and family members work to support one another instrumentally and emotionally through interdependent interactions and empathic awareness. Organizational Care Plans that are too rigid or limited in their scope are key factors constraining interactions.

"When Things Are Really Complicated, We Call the Social Worker": Post-Hip-Fracture Care Transitions for Older People.

Social workers play a key role in the delivery of interdisciplinary health care. However, in the past decade, concerns have been raised about social work's sustainability and contributions in a changing health care sector. These changes come at a time when older patients are more complex and vulnerable than ever before. In this article, using a strengths-based approach, the authors examine the key contributions made by social workers working with older patients with hip fracture as they strive to achieve successful care transitions. Twenty-five interviews with health care professionals (HCPs) were conducted and then analyzed using an analytical coding framework. Although social workers are vital, they are often underused and overlooked in the care of hip fracture patients. The authors sketch the important contributions that social workers make to care transitions after hip fracture, specifically informational continuity; patient-HCP relational continuity; conflict resolution; mediation among family, patient, and HCP (for example, doctors and nurses); collaboration with family caregivers and community supports; and relocation counseling.

The role of documentation and inter-provider information exchange in care continuity for older hip fracture patients.

Maintaining continuity of patient care can be difficult during transitions between care settings, when quality of care and patient safety are at risk. We sought to understand the role of inter-provider documentation and information exchange across successive care settings for complex, older patients. Data were gathered as part of a multi-site ethnographic study that followed 23 older post-surgical hip fracture patients across multiple care transitions. Documentation and information exchange help build a "picture" of complex patients, but care continuity is challenged by late, missing or unnecessary information, duplicated assessments and lack of interoperability of electronic systems. This study demonstrates the importance of appropriate documentation in the transition process, but points to the need for comprehensive system-level solutions which standardize information collection and sharing along the continuum of care.

'Trying to find information is like hating yourself every day': the collision of electronic information systems in transition with patients in transition.

The consequences of parallel paper and electronic medical records (EMR) and their impact on informational continuity are examined. An interdisciplinary team conducted a multi-site, ethnographic field study and retrospective documentation review from January 2010 to December 2010. Three case studies from the sample of older patients with hip fractures who were transitioning across care settings were selected for examination. Analysis of data from interviews with care providers in each setting, field observation notes, and reviews of medical records yielded two themes. First, the lack of interoperability between electronic information systems has complicated, not eased providers' ability to communicate with others. Second, rather than transforming the system, digital records have sustained health care's 'culture of documentation'. While some information is more accessible and communications streamlined, parallel paper and electronic systems have added to front line providers' burden, not lessened it. Implementation of truly interoperable electronic health information systems need to be expedited to improve care continuity for patients with complex health-care needs, such as older patients with hip fractures.

Can the past predict the future? Experimental tests of historically based population models.

A frequently advocated approach for forecasting the population-level impacts of climate change is to project models based on historical, observational relationships between climate and demographic rates. Despite the potential pitfalls of this approach, few historically based population models have been experimentally validated. We conducted a precipitation manipulation experiment to test population models fit to observational data collected from the 1930s to the 1970s for six prairie forb species. We used the historical population models to predict experimental responses to the precipitation manipulations, and compared these predictions to ones generated by a statistical model fit directly to the experimental data. For three species, a sensitivity analysis of the effects of precipitation and grass cover on forb population growth showed consistent results for the historical population models and the contemporary statistical models. Furthermore, the historical population models predicted population growth rates in the experimental plots as well or better than the statistical models, ignoring variation explained by spatial random effects and local density-dependence. However, for the remaining three species, the sensitivity analyses showed that the historical and statistical models predicted opposite effects of precipitation on population growth, and the historical models were very poor predictors of experimental responses. For these species, historical observations were not well replicated in space, and for two of them the historical precipitation-demography correlations were weak. Our results highlight the strengths and weaknesses of observational and experimental approaches, and increase our confidence in extrapolating historical relationships to predict population responses to climate change, at least when the historical correlations are strong and based on well-replicated observations.

Workers' experiences of crises in the delivery of home support services to older clients: a qualitative study.

In the provision of care to older clients, home support workers regularly confront, avert, and manage crises. Semistructured interviews were conducted to explore the nature, type, and management of crises from the perspective of home support workers (N = 118) of older persons in British Columbia, Canada. The delivery of home health care occurs within a context of unpredictability related to scheduling, time constraints, variability of client need, and changing work environments. These events are experienced by 91% of home support workers and range from a serious medical incident (e.g., fall, death) to an interpersonal dilemma (e.g., client refusal of service, argument between worker and family member). Home support workers use a variety of strategies to manage these incidents. The analysis of crises enables us to better understand how agency and care policies may be more responsive to circumstances that challenge care work in home health settings.

Types and patterns of safety concerns in home care: staff perspectives.

BACKGROUND: Quality health care in the home is dependent on having a safe environment to provide care. This analysis is based on the data from a larger study aimed at understanding key issues in the delivery and receipt of home support services from the perspectives of home support workers (HSWs), older adult clients and family members. This analysis focuses on HSWs perspectives of safety. OBJECTIVE: To explore the types and patterns of safety concerns staff encountered in home care settings. DESIGN: In-depth, semi-structured interviews were conducted with HSWs. The analysis included topic and analytical coding of workers' verbatim accounts. SETTING: Interviews were completed in British Columbia, Canada. PARTICIPANTS: A total of 115 HSWs participated. The average age was 50 years, and the average tenure in this sector was 11.5 years. Fully, 71% of workers had completed at least some college-level education, and 69% of workers were born outside of Canada. RESULTS: Workers identified four types of safety concerns: physical, spatial, interpersonal and temporal. We developed a conceptual model of HSW safety that demonstrates the: types of safety concerns; the multi-dimensional and intersectional nature of safety concerns and the factors that intensify or mitigate safety concerns. CONCLUSIONS: Our study identifies numerous HSW safety concerns, each requiring tailored interventions and strategies. Where multiple concerns intersect, the complexity and precarious nature of the home care workspace is revealed. The identification of mitigating and intensifying factors points to future interventions.

A multi-site study of the feasibility and clinical utility of Goal Attainment Scaling in geriatric day hospitals.

BACKGROUND: Goal Attainment Scaling (GAS) is an individualized goal-setting and measurement approach that is useful for patients with multiple, individualized health problems, such as those served by geriatric day hospitals (GDHs) and other specialized geriatric programmes. PURPOSE: To assess the feasibility and utility of GAS in a multi-site study of six GDH affiliated with the Regional Geriatric Programmes of Ontario. METHOD: Individualized GAS guides were developed for 15 consecutively admitted patients at each site [total n = 90; mean age: 76.2 SD 8.3; 58.9% female; mean attendances: 24.0 SD 10.3]. Staff members (n = 39) were surveyed on their experience with GAS. RESULTS: Mean goals/patient ranged across sites from 2.1 to 4.3. Mean GAS discharge score was 52.3 SD 8.7, close to the theoretically expected values of 50 SD 10. Common goals included mobility, community reintegration, basic and instrumental activities of daily living, medical issues, cognition/communication, and home safety. Estimated mean time to develop a GAS guide ranged across sites from 15.3 to 43.8 min. CONCLUSION: Clients were often involved in goal setting; family involvement was less frequent. The staff survey identified challenges and benefits regarding the use of GAS. Study results are being used to inform a more consistent approach to the clinical and research use of GAS in GDH.

Examining "success" in post-hip fracture care transitions: a strengths-based approach.

Transitions between health care settings are a high-risk period for care quality and patient safety (Coleman, 2003; Picker Institute, 1999), particularly for older patients - such as those with hip fracture - who have complex needs and may undergo multiple care transitions. We sought to understand the key elements of "success" in care transition. Using a strengths-based perspective (Rapp, 1998; Saleebey, 2006), we focused on interprofessional health care providers' perspectives of what constitutes a "good" care transition for elderly hip fracture patients. As part of a larger ethnographic field study, semi-structured interviews were conducted with 17 health providers across a number of disciplines employed across the continuum of post-hip fracture management in British Columbia, Canada. We found two hallmarks of "success" in care transitions: a focus on process - information gathering and communication, and a focus on outcomes - autonomy and care pathways. Strategies for promoting and improving success, such as using practitioner-driven ground-up solutions to address challenges in care transitions, are highlighted.

"I'm satisfied but": clients' and families' contingent responses about home care.

Home care service organizations need a means of gaining useful feedback about satisfaction with care from clients and their families. Interviews were conducted with 82 older adult clients and 52 family members about their satisfaction with home care. A subgroup of participants (n = 39) provided "contingent" satisfaction responses. Contingent responses reflect the duality of perceptions that clients and families convey about services. Three themes emerged as critical to understanding these types of responses: adept versus inept staff, predictable versus precarious scheduling, and responsive versus restrictive care plans. Understanding the reasons for contingent responses could help home care agencies to target quality improvement initiatives for individual clients and families.

Care transition experiences of spousal caregivers: from a geriatric rehabilitation unit to home.

The purpose of this study was to develop a theoretical framework about caregivers' experiences and the processes in which they engaged during their spouses' transition from a geriatric rehabilitation unit to home. We used a constructivist grounded theory methodology approach. Forty-five interviews were conducted across three points in time with 18 older adult spousal caregivers. A theoretical framework was developed within which reconciling in response to fluctuating needs emerged as the basic social process. Reconciling included three subprocesses (i.e., navigating, safekeeping, and repositioning), and highlighted how caregivers responded to the fluctuating needs of their spouse, to their own needs, and to those of the marital dyad. Reconciling was situated within a context shaped by a trajectory of prior care transitions and intertwined life events experienced by caregivers. Findings serve as a resource for scientists, rehabilitation clinicians, educators, and decision makers toward improving transitional care for spousal caregivers.

Why I became a home support worker: recruitment in the home health sector.

Home care is considered an essential pillar of the health care systems in many industrialized countries. With an increased demand for home health workers, there has been growing interest in examining recruitment and retention of these workers. With a focus on recruitment of home support workers, in this study we draw on data from interviews with 57 home support workers in three Canadian provinces, to examine the factors that attract individuals to employment in this sector. These factors include: previous experience, financial considerations, and enjoying working with people. Understanding these overlapping factors can aide in the recruitment of future workers.