Nathan M. Stall

Background: Advances in antiretroviral therapy have transformed HIV into a chronic condition, leading to a growing population of adults aged 50 years and older living with HIV in Canada and globally. These individuals experience higher rates of multimorbidity, frailty, cognitive changes, and polypharmacy than their HIV-negative peers, and many rely on caregivers for emotional and practical support. Caregiving often occurs within chosen families of partners, friends, and community members, yet these caregivers remain largely unrecognized in policies that prioritize bio-legal family structures. Existing person- and family-centered care (PFCC) models in HIV focus mainly on pediatric and adolescent populations, leaving a critical gap in guidance for older adults and their diverse caregivers. Objective: This study aims to co-design Canada’s first equity-informed person- and family-centered care model tailored to older adults living with HIV and their biological, bio-legal, and chosen family caregivers. The objectives are to (1) examine experiences of accessing and providing caregiving support, including gendered and intersectional differences; (2) identify key components of a PFCC model to improve access and care experiences; and (3) develop a context-sensitive implementation strategy to support uptake across care settings. Methods: This multiphase study uses an equity-informed Experience-Based Co-Design methodology guided by the UK Design Council’s Double Diamond framework. An advisory committee of knowledge users, clinicians, and older adults living with HIV will provide ongoing input. Phase 1 involves approximately 45 semistructured interviews with older adults living with HIV, caregivers, and health care professionals, analyzed using reflexive thematic analysis. Phase 2 includes 2 co-design workshops with about 45 participants to collaboratively develop model components. Phase 3 includes 3 to 4 focus groups (approximately 30 participants) guided by the Consolidated Framework for Implementation Research to refine an implementation strategy. Equity will be operationalized using the Culturally-Competent Research Criteria for Methodological Areas and monitored using PROGRESS-Plus (place of residence, race/ethnicity, occupation, gender, religion, education, socioeconomic status, social capital, plus additional factors) indicators to support intersectional analysis. Results: The study was funded on July 17, 2025. Data collection for phase 1 is scheduled to begin in January 2027, with subsequent co-design workshops (phase 2) planned for fall 2027 and evaluation activities (phase 3) anticipated in winter-spring 2028. Completion of data analysis is expected by mid-2028, with dissemination of findings anticipated later in 2028. Conclusions: This study will generate a rigorously developed, equity-informed PFCC model grounded in lived experience. Findings will inform policy, program planning, and service delivery to better support older adults living with HIV and their diverse caregivers while offering a replicable framework for co-designing inclusive care models in other chronic or stigmatized conditions.

Importance: Extreme heat poses a serious health risk to older adults because they are generally more susceptible to heat-related mortality. Many nursing homes in the US and elsewhere lack air conditioning (AC). Ecological studies have evaluated the protective role of AC against mortality on extreme heat days in prisons and large urban settings; however, the nursing home setting remains understudied. Objective: To assess mortality rates during extreme heat days in nursing homes with AC compared to those without AC. Design, Setting, and Participants: This was a case-crossover study conducted in Ontario, Canada, to determine the odds of mortality associated with extreme days separated for nursing homes with and without AC using conditional logistic regression. Nursing home residents who died during the warm months (June to September) from 2010 to 2023 were included. Data were analyzed from June 2024 to April 2025. Exposures: An extreme heat day was defined as any day in the ≥90th percentile of the heat index (ambient temperature and relative humidity) for any given nursing home location during the study period. Main Outcomes and Measures: All-cause mortality during extreme heat days, by AC status of nursing homes. Results: Of the 73 578 deaths of nursing home residents from 2010 to 2023, 40 255 residents (mean [SD] age, 86.8 [8.8] years; 65.6% women) died at 276 homes with AC and 33 323 residents (mean [SD] age, 87.2 [8.7] years; 64.8% women) at 339 homes without AC. Before the AC mandate was announced in July 2020, nursing homes without AC (55.1%) were predominantly investor owned (ie, for profit; standardized mean difference [SMD], 0.47), were built to older design standards (SMD, 0.57), and had more residents per room (SMD, 0.58) compared with nursing homes with AC. Overall, 4889 deaths (13.8%) in nursing homes without AC occurred on extreme heat days compared with 4611 deaths (12.1%) in those with AC. Extreme heat was associated with significantly increased odds of mortality in nursing homes without AC (odds ratio [OR], 1.11; 95% CI, 1.06-1.16) but not in those with AC (OR, 1.03; 95% CI, 0.98-1.07). Compared to nursing homes with AC, those without AC were associated with significantly higher relative odds of mortality on extreme heat days (relative OR, 1.08; 95% CI, 1.01-1.15). Lagged analyses suggest that the associated effects of extreme heat persisted for 3 days beyond the initial exposure. Conclusion and Relevance: In this case-crossover study, mortality was lower during extreme heat days in nursing homes with AC compared to those without AC. These findings suggest that AC provision in nursing homes and other congregate care settings may be important for preventing mortality among older adults during extreme heat days.

Objectives: To measure the association between initiating palliative care using the combined criteria of short survival expectations and increased care needs with acute healthcare utilization among community‐dwelling people living with dementia. Design: A population‐level propensity‐based overlap‐weighted cohort study. Setting: Ontario, Canada. Participants: 50,961 community‐dwelling people living with dementia between 2010 and 2023, with 1‐year follow‐up until 2024. We used moderate to severe dementia and the initiation of homecare services as proxies for short survival expectations and increased care needs, respectively. We used linked health administrative data with propensity‐based overlap weighting on sociodemographic and clinical factors to address confounding by the indication to receive palliative care. Exposures: Receipt of home‐based palliative care within 30 days of homecare initiation. Main Outcome Measures: Individual 1‐year cause‐specific hazards of emergency department (ED) use, hospitalization, and intensive care unit (ICU) admission. Results: Palliative care was associated with a higher risk of hospitalization in the first 90 days (e.g., hazard ratio (HR) 1.43 at 30 days; 95% confidence interval (CI) 1.25–1.64), which was driven predominantly by hospitalization with palliative intent, but was no longer significantly different beyond 180 days, compared to not receiving palliative care. [Correction added on 31 January 2026, after first online publication: The preceding sentence has been revised in this version.] At 90 days, the cumulative incidence of hospitalization, death, or admission to a nursing home was approximately 20% among those receiving palliative care, compared to 15% in those not receiving palliative care. Although the overall absolute rate of ICU admission was low (0.01 ± 0.1 admissions per month), palliative care initiation was associated with a 186% higher risk in the first 30 days ( HR 2.86; 95% CI 1.75–4.69) but not beyond 90 days. Palliative care was not associated with ED use over the following year ( HR 1.02; 95% CI 0.72–1.45). Conclusions: The current approach to delivering palliative care services for community‐dwelling people living with dementia in Canada may paradoxically increase early acute care use, likely reflecting system gaps and unmet needs. Given the high prevalence of dementia, there is an urgent need to re‐examine homecare delivery models.

Introduction: The delivery of medical services by primary care physicians (PCPs) in long-term care (LTC) homes lacks consistency. There is no Canadian standard for PCP commitment in the LTC home setting, which can influence the quality of care delivered and resident health outcomes. The PCP’s commitment to LTC practice is theorised as the proportion of a physician’s practice dedicated to LTC, the number of residents for whom they provide care and the time spent on individual resident encounters. We aim to establish consensus on expectations concerning PCP commitment in Canadian LTC homes. Methods and analysis: We describe a protocol for a two-round modified e-Delphi study assessing the consensus of an expert panel, guided by the RAND methodological guidance for conducting Delphi panels and the ACcurate COnsensus Reporting Document (ACCORD) guideline for healthcare-based consensus studies. We will recruit pan-Canadian experts who demonstrate extensive knowledge and experience in medical care delivery and medical practice models in the Canadian LTC sector. A literature review will generate a candidate list of statements constituting PCP commitment. The first round evaluates the relevance and feasibility of candidate statements through an online questionnaire. Panellists may also write open-ended, qualitative responses to add rationales, suggest alternatives and share new ideas. We will then host a virtual synchronous meeting to have an in-depth discussion about the results from round one. A second questionnaire will be distributed to evaluate the remaining statements that have not reached consensus, and any new statements added based on the same criteria. Ethics and dissemination: The Hamilton Integrated Research Ethics Board (Project ID #17321) approved our study. The findings will be disseminated through manuscripts, presentations, and the lead author’s thesis. Trial registration number: The ISRCTN Registry: #35125526.