Malcolm Doupe

Background: Transfers from nursing homes (NHs) to emergency care facilities (ECFs) are often questioned, as many residents are terminally ill and may have access to on-site qualified care from staff. We sought to investigate the association between nursing home staff characteristics (e.g., time since graduation, turnover, sick leave) and residents’ risk of a first acute care transfer after accounting for the competing risk of resident mortality. Methods: A semi-Markov irreversible illness-death model was used to assess the association between NH staff characteristics and residents’ risk of initial ECF transfer in a retrospective, register-based longitudinal cohort study. Analyses were stratified by NH resident sex. Resident age, comorbidity, NH number of residents (occupancy), and proximity of next of-kin were used as additional predictors in the model. Data on staff characteristics at 851 NHs between 2016 and 2022 were linked to each resident’s NH admission date. Data on NH staff and residents was obtained from Statistics Norway (SSB), the Norwegian Registry for Primary Health Care (NRPHC), the Norwegian Control and Payment of Health Reimbursements Database (KUHR), and the Norwegian Patient Registry (NPR). Results: Analyses were conducted on 76,140 NH residents, aged 65 and older, who entered long-term care in Norway between 2017 and 2022, of whom 46% ( n = 34,899) underwent an emergency transfer to an ECF, and 66% ( n = 50,548) died before the end of follow-up on 2022-12-31. Residents had a lower estimated ECF transfer risk in NHs where staff had more experience (longer average time since graduation). Specifically, for every additional decade of NH staff time since graduation, the estimated hazard ratio was 0.95 [95% CI: 0.93–0.98, p < 0.001] for males and 0.94 [95% CI: 0.91–0.97, p < 0.001] for females. Female residents had a higher estimated risk of transfer in NHs that had higher staff turnover rates, with an estimated hazard ratio of 1.01 [95% CI: 1.00–1.03, p = 0.035] for each additional increase of 10% points of yearly turnover. NH staff sick leave was not statistically significantly associated with transfer risk for either reported sex. Conclusions: Higher average staff experience in nursing homes is associated with a reduced risk of residents’ initial transfer to emergency care facilities. Accumulated knowledge among NH staff and acute care decision outcomes should be further investigated, and this study underscores the need for NH administrators and policymakers to prioritize staff retention.

Continuums of care (e.g., home-based services, assisted living, nursing homes) deliver essential health and social services for older people and are organized differently across healthcare settings. Informed by academic research and consensus-building sessions with policymakers and older people from two Canadian provinces, this article presents a typology of 12 dimensions that define how care continuums are organized and operationalized. Dimensions define the care provided by different services , including how they are accessed and their recipients; paid staffing , illustrating provider type, volume, and employment practices; funding , showing how care is paid for and additional client costs; and central governance , defining regulatory procedures, audits, standards, and data monitoring systems. This typology supports systematic comparisons across two Canadian provinces and helps to identify promising practices, care gaps, and reform ideas in each jurisdiction. Further application, expansion, and refinement of this tool is required to assess its value in other Canadian and international settings.

BACKGROUND Older people are the fastest-growing segment of the population in all developed countries, and in part due to this trend, nursing homes (NHs) are now reserved for people with extensive comorbid physical, cognitive, and social needs. While the challenges related to NH care are well known, strategies are needed to more effectively bridge the transactional gap between what we know from research and what we do in practice. OBJECTIVE This protocol paper describes how we designed, implemented, and evaluated an innovation called SHIFT (Supporting Healthcare Improvement through Facilitated Training) that helps front-line NH providers incorporate formal quality improvement techniques (e.g., Plan-Do-Study-Act, PDSA cycles) into their everyday care routines. Our goal was to understand how providers received this facilitated support and implemented their quality improvement ideas, assess their ability to use more structured care improvement processes, examine the facilitators and barriers to their success, and describe how SHIFT impacted resident quality of care and staff-related outcomes. METHODS SHIFT is a sequential mixed-methods clinical trial guided by key implementation science frameworks and lessons learned from the Translating Research in Elder Care (TREC) research program. It consists of a core module based on the Institute for Healthcare Improvement (IHI) Breakthrough Series framework (e.g., learning congresses interspersed with action periods, various forms of facilitation). From TREC learnings, we added to this core module (i) readiness-for-change activities to help identify suitable intervention environments and team members with requisite skills, and (ii) a leadership program that provides person-level coaching to boost internal facilitation. SHIFT and its components were examined using a suite of quantitative (e.g., team member surveys) and qualitative (e.g., focus groups, quality advisor field notes, research observations) data. Our primary goal was to assess implementation strategies and secondarily measure intervention effectiveness. RESULTS Ten NH sites involving 65 team members have participated in SHIFT. Recruitment occurred in February 2024, and the study concluded in July 2024. As of January 2026, all data have been analyzed, and four manuscripts are in preparation that discuss participant perspectives on (i) SHIFT team implementation and intervention effectiveness, (ii) the value of R4C and leadership activities and how they impacted innovation success, (iii) challenges teams encountered specific to SHIFT fidelity, and (iv) future innovation directions based on participant input (e.g., creating more targeted quality advisor training sessions, increasing the number of these sessions with fewer cross-team learning congress workshops). CONCLUSIONS SHIFT investigates strategies that help NH front-line care teams embed, with support, quality improvement methodology into their daily care routines. This innovation is positioned as the first in a series of iterative collaborations that aim to achieve this goal while balancing best evidence with the everyday complexities of NH care. CLINICALTRIAL ClinicalTrials.gov NCT06106087; https://clinicaltrials.gov/study/NCT06106087

Background: Readiness for change (R4C) is an important antecedent of care practice change and is linked to a range of implementation and effectiveness outcomes. We describe the creation, piloting, and evaluation of R4C activities intended to help nursing home (NH) teams implement a quality improvement intervention. Methods: We developed and operationalized a R4C module with activities conducted with NH leaders during intervention recruitment. An implementation pilot was conducted in three NHs and evaluated using a mixed methods process evaluation guided by Proctor’s (2011) implementation outcomes framework. Results: R4C activities were feasible, acceptable, and delivered with fidelity. The approach promoted readiness among senior leaders, but not among front-line teams. Results also showed (1) R4C activities are closely tied to other variables (e.g., NH leadership facilitation) that influence implementation, and (2) core R4C components (i.e., change efficacy) can emerge during an intervention, pending teams’ perceived success Discussion: We suggest conducting R4C activities with all of those involved across an organization who have a role to play in change implementation. Findings also reveal challenges associated with isolating the effects of ‘pre-intervention’ R4C activities on intervention implementation and success. Pilot results will inform a larger-scale quality improvement study. Trial registration: Registered at ClinicalTrials.gov (ID NCT03426072 ) on July 18, 2022. KEY MESSAGES REGARDING FEASIBILITY: What uncertainties existed regarding the feasibility? While ‘readiness for change’ has been identified as an important lever for implementation of evidence-informed practice change, there is little in the published literature regarding how to operationalize of R4C to promote uptake of practice change initiatives. There is also uncertainty regarding ‘implementability’ (feasibility, acceptability, appropriateness, fidelity) of R4C activities in complex care settings What are the key feasibility findings? Up-front activities requiring a few hours of a facility leader’s time, designed to gauge and also operationalize and promote readiness for change were both feasible and acceptable and were delivered with fidelity. Facility leaders showed less fidelity enacting the intervention support and communication roles targeted by the R4C activities. A ‘broken telephone’ scenario existed where senior leaders did not convey to unit leaders what their project roles entailed. What are the implications of the feasibility findings for the design of the main study? Our results suggest that it is necessary to actively target R4C activities directly to all organizational members involved in the practice change initiative. Failure to promote linkages and role clarity across participants at different levels of an organization makes it likely that change actors will remain unsure of their role in the change initiative. The design of the main study ultimately included two additional R4C focused meetings (one to bring senior and team sponsors together, one to bring team sponsors and team members together) to promote greater role clarity and enhanced project preparation.

Background: Leadership is a critical lever for supporting implementation of practice change ideas intended to improve care. We need evidence-based leadership programs to help front-line providers meaningfully implement practice change in complex care settings. Part of the SHIFT intervention, this paper describes and pilot tests a leadership program module (LeaderSHIFT) that provides training and implementation coaching to front-line leaders, as one of several integrated facilitated supports designed to help front-line care teams meaningfully enact practice change. Methods: The LeaderSHIFT program module was developed based on empirical work, relevant facilitation and transformational leadership theories, and principles of stakeholder co-design and feasible engagement. A pilot implementation study was conducted that examined several of Proctor’s (2011) implementation outcomes. Results: LeaderSHIFT includes four interactive workshops plus two one-on-one coaching sessions designed to develop capacity in four areas of implementation leadership: (1) Self-awareness, (2) Motivate and inspire, (3) Facilitate learning capacity, and (4 ) Support ‘team-oriented processes’. Pilot results suggest it can be successfully implemented (it was acceptable, adopted, appropriate, feasible). Fidelity (LeaderSHIFT role enactment) varied across pilot teams. Conclusions: With a strong theoretical and empirical base, LeaderSHIFT highlights important, often overlooked, relational and socio-cultural aspects of successful implementation leadership. As such, the LeaderSHIFT program module has the potential to improve implementation of practice change interventions in nursing homes and other institutional care settings. Trial registration: Registered at ClinicalTrials.gov (ID NCT03426072 ) on July 18, 2022. KEY MESSAGES REGARDING FEASIBILITY: What uncertainties existed regarding the feasibility? While leadership is known to be a critical lever for implementation of evidence-informed practice change, there are few leadership training programs that have a relational focus designed to support broader team-based practice change initiatives; and uncertainty remains regarding implementability (feasibility, acceptability, appropriateness, fidelity) of this type of leadership module in complex care settings What are the key feasibility findings? The LeaderSHIFT module performed well on several key implementation outcomes (module acceptability, feasibility, appropriateness). Fidelity to implementation leadership was successful for managers who were able to enact relational aspects of the role. What are the implications of the feasibility findings for the design of the main study? Findings confirmed the value of one-to-one coaching for enhancing leaders’ relational competencies and prompted training overlap for senior and front-line leaders to ensure there is a common understanding of respective roles in intervention implementation.

Aim: To identify the experiences, expectations, and preferred transitional care expressed by nursing home residents and close family, thus mapping perceived barriers and facilitators to improve this identification process. Design: In this study, a qualitative design was employed. Methods: Individual, semistructured interviews were conducted. Data Sources: Interviews of 12 participants (3 residents and 9 close family) were conducted. The data were analyzed using thematic analysis to identify underlying themes. Results: The following three themes were identified: (1) changes in life situations, (2) dimensions of transfer quality, and (3) interactions with staff. Conclusion: Nursing home residents and close family emphasize that proper medical care is necessary. However, this is insufficient without addressing multiple ongoing life changes of individuals transitioning between nursing homes and emergency departments. Yet, this effort to manage life changes is significantly insufficient without the support of healthcare professionals.

Background: Adult day programs provide critical supports to older adults and their family or friend caregivers. High-quality care in the community for as long as possible and minimizing facility-based continuing care are key priorities of older adults, their caregivers, and health care systems. While most older adults in need of care live in the community, about 10% of newly admitted care home residents have relatively low care needs that could be met in the community with the right supports. However, research on the effects of day programs is inconsistent. The methodological quality of studies is poor, and we especially lack robust, longitudinal research. Objective: Our research objectives are to (1) compare patterns of day program use (including nonuse) by province (Alberta, British Columbia, and Manitoba) and time; (2) compare characteristics of older adults by day program use pattern (including nonuse), province, and time; and (3) assess effects of day programs on attendees, compared with a propensity score–matched cohort of older nonattendees in the community. Methods: In this population-based retrospective cohort study, we will use clinical and health administrative data of older adults (65+ years of age) who received publicly funded continuing care in the community in the Canadian provinces of Alberta, British Columbia, and Manitoba between January 1, 2012, and December 31, 2024. We will compare patterns of day program use between provinces and assess changes over time. We will then compare characteristics of older adults (eg, age, sex, physical or cognitive disability, area-based deprivation indices, and caregiver availability or distress) by pattern of day program use or nonuse, province, and time. Finally, we will create a propensity score–matched comparison group of older adults in the community, who have not attended a day program. Using time-to-event models and general estimating equations, we will assess whether day program attendees compared with nonattendees enter care homes later; use emergency, acute, or primary care less frequently; experience less cognitive and physical decline; and have better mental health. Results: This will be a 3-year study (July 1, 2024, to June 30, 2027). We received ethics approvals from the relevant ethics boards. Starting on July 1, 2024, we will work with the 3 provincial health systems on data access and linkage, and we expect data analyses to start in early 2025. Conclusions: This study will generate robust Canadian evidence on the question whether day programs have positive, negative, or no effects on various older adult and caregiver outcomes. This will be a prerequisite to improving the quality of care provided to older adults in day programs, ultimately improving the quality of life of older adults and their caregivers. Trial Registration: ClinicalTrials.gov NCT06440447; https://clinicaltrials.gov/study/NCT06440447 International Registered Report Identifier (IRRID): PRR1-10.2196/60896

BACKGROUND Adult day programs provide critical supports to older adults and their family or friend caregivers. High-quality care in the community for as long as possible and minimizing facility-based continuing care are key priorities of older adults, their caregivers, and health care systems. While most older adults in need of care live in the community, about 10% of newly admitted care home residents have relatively low care needs that could be met in the community with the right supports. However, research on the effects of day programs is inconsistent. The methodological quality of studies is poor, and we especially lack robust, longitudinal research. OBJECTIVE Our research objectives are to (1) compare patterns of day program use (including nonuse) by province (Alberta, British Columbia, and Manitoba) and time; (2) compare characteristics of older adults by day program use pattern (including nonuse), province, and time; and (3) assess effects of day programs on attendees, compared with a propensity score–matched cohort of older nonattendees in the community. METHODS In this population-based retrospective cohort study, we will use clinical and health administrative data of older adults (65+ years of age) who received publicly funded continuing care in the community in the Canadian provinces of Alberta, British Columbia, and Manitoba between January 1, 2012, and December 31, 2024. We will compare patterns of day program use between provinces and assess changes over time. We will then compare characteristics of older adults (eg, age, sex, physical or cognitive disability, area-based deprivation indices, and caregiver availability or distress) by pattern of day program use or nonuse, province, and time. Finally, we will create a propensity score–matched comparison group of older adults in the community, who have not attended a day program. Using time-to-event models and general estimating equations, we will assess whether day program attendees compared with nonattendees enter care homes later; use emergency, acute, or primary care less frequently; experience less cognitive and physical decline; and have better mental health. RESULTS This will be a 3-year study (July 1, 2024, to June 30, 2027). We received ethics approvals from the relevant ethics boards. Starting on July 1, 2024, we will work with the 3 provincial health systems on data access and linkage, and we expect data analyses to start in early 2025. CONCLUSIONS This study will generate robust Canadian evidence on the question whether day programs have positive, negative, or no effects on various older adult and caregiver outcomes. This will be a prerequisite to improving the quality of care provided to older adults in day programs, ultimately improving the quality of life of older adults and their caregivers. CLINICALTRIAL ClinicalTrials.gov NCT06440447; https://clinicaltrials.gov/study/NCT06440447 INTERNATIONAL REGISTERED REPORT PRR1-10.2196/60896