The main object of the research is to analyze the effect of the clinical intervention algorithms proposed for reducing antibiotic use for older adults in long-term care facilities (LTCFs) by managing urinary tract infections (UTIs). 20 paired nursing homes were enrolled in the 12-month study. Within each pair, one was randomized to use of the intervention algorithms and the other to use of regular management. Cluster-level paired t-tests (unweighted and weighted) and regression analyses (unweighted and weighted) were used in the analysis of the data. Paired t-tests show that the algorithms did not significantly reduce the antibiotic use, the number of urine cultures or the antibiotic use for urinary infections in most months. However, they did reduce the proportion of antibiotic use for urinary infections significantly in most months. Regression analysis indicates that the difference between the control group and intervention group has no significant increasing or decreasing trend with time (month). And the algorithms significantly reduced the antibiotic use for urinary infections, number of cultures and the proportions through the 12-month study. The analyses reached a similar conclusion using nonparametric methods and weighted analysis. / Thesis / Master of Science (MS)

In this study, I explored Adult Foster Care (AFC) provider experiences. AFC is a small-setting option for community-based long-term care. This option varies considerably in accessibility and structure across states; due to the nature of the state's approach to AFC, this initial research effort focused on AFC provider experiences in North Carolina. As of 2013, there were 632 AFC facilities in North Carolina (NC DHHS, 2013). AFC homes in North Carolina are licensed by the state and allow service for 2-6 residents per home (Mollica et al., 2009). The approach to research was informed by literature on AFC, the disabilities context of AFC, and Child Foster Care (CFC). The theoretical framework guiding the study included theories of care and relational reciprocity; power, difference, and hierarchy; and intersectionality. I conducted semi-structured, guided interviews with 26 providers. As a context for grounded theory data analysis, I also relied on reflexive material stemming from my positionality as a care worker. Emergent codes related to issues of the providers' motivation for beginning work as an AFC provider; providers' personal and professional roles; perspectives on giving residents a choice; balancing "family" with business; reciprocity and how residents express their affection and care to providers; providers' values; and dialectics of power and care. Findings shed light on implications for state and organizational responsibility to the AFC system, and practice context for provider-resident relationships. / Ph. D.

Yes / Service robots with advanced intelligence capabilities can potentially transform servicescapes. However, limited attention has been given to how consumers experiencing vulnerabilities, particularly those with disabilities, envisage the characteristics of robots’ prospective integration into emotionally intense servicescapes, such as long-term care (LTC). We take an interdisciplinary approach conducting three exploratory studies with consumers with disabilities involving Community Philosophy, LEGO® Serious Play®, and Design Thinking methods. Addressing a lack of consumer-centric research, we offer a three-fold contribution by 1) developing a conceptualization of consumer-conceived value of robots in LTC, which are envisaged as a supporting resource offering consumers opportunities to realize value; 2) empirically evidencing pathogenic vulnerabilities as a potential value-destruction factor to underscore the importance of integrating service robots research with a service inclusion paradigm; and 3) providing a theoretical extension and clarification of prior characterizations of robots’ empathetic and emotion-related AI capabilities. Consumers with disabilities conceive robots able to stimulate and regulate emotions by mimicking cognitive and behavioral empathy, but unable to express affective and moral empathy, which is central to care experience. While providing support for care practices, for the foreseeable future, service robots will not, in themselves, actualize the experience of “being cared for.” / This paper originates as a result of work on a project titled “Improving Inclusivity in Robotics Design” which received funding from “Research England, via The University of Sheffield’s Higher Education Innovation Fund (HEIF)" and in-kind funding from IBM.

General acceptance of a pattern of activities of daily living (ADL) dependency has led to the use of an additive method of determining self-care dependency and need for long-term care. This traditional method of determining ADL levels is convenient, and it is practical to the extent that individuals in a long-term care population do fit a scaled pattern of dependency. This research was based on 3611 cases from the Preadmission Screening Program of the Virginia Medical Assistance Program. Tabular and staged logistic regression analyses examined: 1) characteristics of this group of long-term care elders, 2) the extent of ADL divergence in various recommended care settings, 3) the relationship between rehabilitation status and ADL divergence, 4) other factors influencing divergence from the ADL dependency hierarchy. The results of this study demonstrated that a large proportion of those screened did not match the original Index of ADL. Therefore, the justification for counting ADL dependency, based on an underlying hierarchy of ADL, was not upheld. Further research was indicated for improving eligibility and placement criteria that would reflect a fluid rather than a static system of long-term care. For example, rehabilitative trajectory could serve as an indicator of projected changes in assistance for self-care. / Ph. D. / incomplete_metadata

Understanding immigrants’ use and preferences for health care services is essential to be able to shape a health care system that is equitable. Without doing so, we risk population health deterioration that can be both costly for immigrants and society. Given the bidirectional relationship between income and health, it also becomes important to understand how immigrants respond economically to health shocks. With this understanding, the objectives of this thesis are as follows: 1) investigate whether neighbourhood immigrant concentration influences the relationship between immigrant status and mental health problems and mental health service use among youth and children in Ontario, 2) assess the impacts of a cerebrovascular or cardiovascular health shock on income variables (i.e., employment income, governmental income, total income, and household income) in heterogenous immigrant populations in Canada, and 3) explore preferences for home care and long-term care among older adults in Ontario. Novel findings from each of the studies include: 1) immigrants show lower odds of having elevated mental health problems and using mental health services compared to non-immigrants. The probability of using mental health services among immigrants is lower in immigrant-concentrated neighbourhoods, 2) a cardiovascular or cerebrovascular health shock does not cause a significant reduction in employment income. Also, the impact of a cardiovascular or cerebrovascular health shock on income variables is not significantly different than the impact of other types of health shocks, and 3) individuals are willing to pay approximately $4000 extra per month for home care compared to long-term care. Other attributes preferred include having a private room, living at a short distance to family/friends, and having culturally adapted care. This program of research advances intersectoral research on immigrant health and health care use. / Dissertation / Doctor of Philosophy (PhD) / Immigrants in Canada are a highly diverse group, differing in language, ethnicity, and income levels. Not only are some immigrant groups at high risk for developing certain health conditions, they face unique challenges in using health care services. There is a need to better understand the prevalence of health conditions among immigrants as well as immigrants’ use and preferences for health care services. This thesis, divided in three independent chapters, 1) investigates whether the mental health and mental health service use of children and youth in immigrant households are influenced by neighbourhood immigrant density, 2) investigates what impact heart attacks and strokes have on income variables in immigrants who work, and 3) explores preferences for home care and long-term care among immigrant and non-immigrant older adults in Ontario.

No / Objectives: The aim of this study is to explore the extent to which staff–resident interactions address or undermine residents’ psychological needs and how such interactions are associated with residents’ well-being. Method: Data on staff–resident interactions and residents’ well-being were collected for 51 residents from nine long-term care settings using dementia care mapping (DCM). DCM yields a count and detailed description of staff–resident interactions that either address (personal enhancers – PEs) or undermine (personal detractions – PDs) residents’ psychological needs, and every 5-minute scores for each resident's mood and engagement (ME-value). The relationship between PEs and PDs and well-being was analysed by studying residents’ ME-values before and three time frames after a PE or PD occurred. Results: A total of 76 PEs and 33 PDs were observed. The most common PEs were those addressing psychological needs for comfort and occupation. However residents’ well-being increased most often after PEs that addressed residents’ need for identity, attachment and inclusion. The most common PDs were those which undermined the need for comfort, inclusion and occupation. Residents’ well-being decreased most often after PDs that undermined the need for comfort. Conclusion: Increasing interactions which address residents’ need for attachment, identity and inclusion and eliminating interactions which undermine residents’ need for comfort may be particularly important in achieving residents’ well-being. In the long run, residents’ well-being could be achieved by staff availing of the opportunities to empower and facilitate residents, thus meeting their needs for occupation. These findings provide directions for training in person-centred care.

No / The journey for people with Alzheimer’s disease or another dementia involves the need for increasing levels of support, with transitions across care settings. Although transitional care has received increasing attention in the health care arena, no widely accepted transitions typology exists for the dementia journey. At the same time, national dementia strategies are proliferating. We developed a typology containing six transitions that cover the dementia journey from symptom recognition to end-of-life care. We then critically evaluated whether and how the national dementia strategies of Australia, England, France, the Netherlands, Norway, Scotland, and the United States addressed each transition. Adopting a person-centered perspective, we found that most or all of the national strategies adequately address earlier transitions in the journey, but fewer strategies address the later transitions. We recommend that next-generation national dementia strategies focus on later transitions, specify how care coordination and workforce training should make transitions more person centered, and use person-centered outcomes in evaluating the success of the strategies’ implementation and dissemination.

No / In the UK, one third of the 850,000 people with dementia live in care homes. This article explores the process of carrying out research in nursing homes, identifying barriers and enabling factors, and making recommendations for researchers. The authors’ experiences derive from an ongoing study investigating the effect of educational interventions to promote and embed person-centred care, designed for nurses caring for the people with dementia in nursing homes. Design issues arose from the need to use cluster randomisation which requires a large sample size, implementation fidelity, poor compliance and high numbers of participants lost to follow up. Further difficulties included gaining ethical approval, recruitment, raising concerns and the practicalities of participant retention. There are many benefits of conducting research in care homes, for the homes themselves, their staff and residents. These include training and education, networking and empowerment of staff and subsequent improved standards of care. For the research team, benefits include opportunities to contribute to an underserved setting, to advance care standards and improve nurses’ working lives. / The authors would like to acknowledge the Burdett Trust for Nursing who funded the study

No / While awareness among people with mild to moderate dementia residing in the community has been extensively studied, little evidence has been presented regarding the extent to which people with moderate to severe dementia living in residential care show awareness of their own situation and functioning. The present study aimed to explore how differing degrees of awareness are manifested in the conversations and interactions of people with dementia living in residential care settings, and to identify theoretical and practical implications. Transcripts of 304 conversations with 80 individuals with dementia living in residential care homes in England and Wales were analysed using a grounded theory approach. All 80 participants demonstrated a degree of retained awareness, and there was considerable evidence of retained awareness throughout the conversations, expressed in relation to the three domains of self, relationship, and the environmental context. Two-thirds of participants also demonstrated at least one instance of unawareness, although demonstrations of retained awareness outweighed indications of unawareness. Unawareness was evident in relation to appraisal of functioning and the meaning ascribed to the situation. A grounded theory model of awareness in people with moderate to severe dementia who still communicate verbally proposes that demonstration of awareness involves a set of analytic and behavioural processes, a scope or timescale, and a focus. Awareness is demonstrated in relation to a given focus and scope through the involvement of cognitive processes of varying degrees of complexity, ranging from registering through appraising and interpreting to reflection. Unawareness may be demonstrated in relation to some elements of process, focus or scope, while other aspects remain unaffected. Understanding more about the capacity for retained awareness and the specific ways in which awareness can be compromised may assist care staff in responding effectively to residents' needs.

Over the past decade, efforts led by the U.S. Department of Health and Human Services (HHS) have reduced healthcare-associated infections in acute care settings nationally. In 2013, HHS identified that the next phase of these healthcare-associated infection reduction initiatives would target long-term care facilities through the publication of a new chapter in the National Action Plan to Prevent Health Care Associated Infections devoted to this setting. Long-term care facilities are nursing facilities that provide “medical, skilled nursing and rehabilitative services on an inpatient basis to individuals who need assistance preforming activities of daily living, such as bathing and dressing”. These facilities are the primary residence for 2.5 million, predominantly elderly Americans and represented $143 billion nationally in healthcare costs as of 2010. Accordingly, it is a national priority to reduce healthcare-associated infections in this setting and protect this vulnerable population. Healthcare-associated infections caused by multidrug-resistant organisms (MDROs) are a particular burden in the long-term care population. These pathogens, usually bacteria, are defined as being resistant to one or more classes of antimicrobial agents. However, MDROs frequently exhibit resistance to nearly all antimicrobial drugs. Clinical infection control guidelines recommend isolation precautions to prevent MDRO transmission, based on evidence collected in acute care settings. However, the limited evidence that is available from studies in long-term care facilities suggests that isolation precautions may not be effective in this setting. Given that the reduction of antibiotic resistant infections is a priority of the HHS, The White House, Healthy People 2020, and the World Health Organization, it is necessary to confirm and support the appropriate use of isolation precautions for MDROs with evidence specific to long-term care facilities. Therefore, this dissertation describes the current evidence for and use of isolation precautions in long-term care facilities for MDROs. Further, it offers the most comprehensive descriptions of both isolation precautions use and predictors of MDRO infection in nursing homes (NHs), a specific type of long-term care residential setting. To assist the reader, Chapter 1 will provide background for these studies including context for current infection control and prevention practices in long-term care facilities, the importance of MDRO infections and the need for new evidence regarding isolation precautions in long-term care. It will also discuss the aims and significance of this dissertation in context of a conceptual framework, gaps in the literature and potential to improve clinical practice. Next, Chapters 2 and 3 of this dissertation systematically review the current evidence regarding effectiveness of isolation precautions against MDROs and the cost of infection prevention and control in this setting, respectively. These chapters outline how publications focused on long-term care are lacking in quality and quantity and offer suggestions for improvement in future research. Chapter 4 qualitatively describes decision-making process regarding use of isolation-based infection prevention techniques in NHs, which depends on four key considerations: perceived risk of transmission, conflict with quality of life goals, resource availability and lack of understanding. Chapter 5 builds on this qualitative analysis by quantitatively examining predictors of isolation precautions use for MDRO infection in a large, national dataset. This analysis confirms that isolation is rarely used and there is variation across NHs’ practice. However, NH staff may be tailoring infection prevention and control practice to the needs of specific residents, as would be expected based on the results of the qualitative analysis. Chapter 6 presents an analysis of MDRO infection predictors among elderly NH residents across the U.S. This study confirms concepts associated with MDRO infection in previous studies (e.g., low functionality) and provides more specificity in operationalization of these concepts than has been previously determined (e.g., needing support with locomotion), which can inform future use of isolation precautions in NHs. Finally, Chapter 7 contains a synthesis and discussion of these findings, as well as recommendations for health policy and future research regarding contact isolation precautions against MDROs in NHs.