A role description for a medical coordinator in extended and long term care facilities in British Columbia has been defined using a Delphi method. Also obtained during the study was a long term care philosophy. Three groups - nurses, administrators, and physicians took part in three rounds of the Delphi study. Thirty-five respondents were interviewed in the first round. During this interview the researcher obtained from the respondents the statements that they considered should be included in this role and philosophy description. During the second round the respondents rated the responses of the first round and in the third round those of the second round were revised after seeing the mean scores of the whole group and the three separate groups. The description of the role of a medical coordinator developed describes the role as it applies to: resident care; private physicians; planning, development and evalution of care; staffing of a facility; education; administration; and the training, experience, skills and attitude of a medical coordinator. When the description created was compared with that for the medical director in a long term care facility in the United States it was found that this study had described additional dimensions of the role, in particular the multi-disciplinary approach and the physician's knowledge, training, experience, skills and attitude. The results of the study show where there was agreement and where there were differences of opinion between the three professional groups. A long term care philosophy which was considered very important for a medical coordinator to promote, has been defined during the study. It focuses on the resident reaching his full potential, the creation of a special environment, as well as acceptance of disability, dying and death. Recommendations from the study are made for facilities which might be considering employing a medical coordinator, for planners deciding whether to provide funds for medical coordinators, for geriatric medical education and for the acceptance of a long term care philosophy in all parts of the health care system where there are long term care clients. / Medicine, Faculty of / Population and Public Health (SPPH), School of / Graduate

京都大学 / 0048 / 新制・課程博士 / 博士(社会健康医学) / 甲第22382号 / 社医博第104号 / 新制||社||医11(附属図書館) / 京都大学大学院医学研究科社会健康医学系専攻 / (主査)教授 川上 浩司, 教授 髙橋 良輔, 教授 中山 健夫 / 学位規則第4条第1項該当 / Doctor of Public Health / Kyoto University / DFAM

京都大学 / 新制・論文博士 / 博士(医学) / 乙第13426号 / 論医博第2230号 / 新制||医||1053(附属図書館) / (主査)教授 今中 雄一, 教授 森田 智視, 教授 石見 拓 / 学位規則第4条第2項該当 / Doctor of Medical Science / Kyoto University / DFAM

Objective: The transition to long-term care (LTC) of older adults receiving home care services is preceded by declining functional independence with basic and instrumental activities of daily living (ADL and IADL, respectively). These individual, and group, level time-dependent changes occur within unique provincial and regional policy contexts across Canada, which determine the amount and types of services received by home care recipients during this transition period. It is currently unknown whether activities of daily living (ADL) or IADL (instrumental activities of daily living) exhibit accelerated decline preceding transition to LTC, and if so, whether the onset and rate of decline differs for ADL versus IADL. This dissertation sets out to determine whether such change points exist within longitudinal data gathered from home care recipients in Ontario during the years of 2008 to 2015. Methods: A profile likelihood method was employed to identify the best fitting change points at which the slopes of functional decline in ADL and IADL for those who transition to LTC from home care services depart from the normative age slope of those who remain in community. Data analyzed was collected at approximately 6-month intervals using the International Residential Assessment Instrument – Home Care (RAI-HC) in Ontario, Canada, and was obtained from the Canadian Institutes for Health Information (CIHI) for the period of 2006-2015. A policy review was conducted to determine whether changes had occurred to the amount or type of home care services provided during the data collection period, and subsequently data from 2008 to 2015 were retained. IADL was measured using the 21-point IADL Involvement Scale and ADL was measured using the 28-point ADL Long Form. Best fitting change point models were first identified for ADL and IADL scores in the full sample of participants who remained in community and those who transitioned to LTC and within subgroups stratified by sex. Two additional subgroups were also examined: 1) participants without a primary or secondary caregiver living in the home, and 2) participants with a primary caregiver living in the home. Each caregiver group was also stratified by sex, resulting in a total of 9 groups in which IADL and ADL change points were estimated and compared. Results: In all groups who remained in community with home care services, age-related decline in IADL and ADL were observed. Further, IADL impairment was higher at the time of first assessment and had a greater age-related slope than ADL for those who remained in community. Both measures had discernable change points preceding discharge to LTC and the change point for IADL preceded that of ADL in all groups. Across groups, the change point for ADL had a range of 0.5 years before LTC discharge for men without a primary or secondary caregiver living in the home to 2 years for women with a primary caregiver in the home. IADL change points ranged from 2.5 years before LTC discharge for men with a primary caregiver in the home to 3.6 years for women without a primary or secondary caregiver in the home. Within the full sample, including both men and women, the onset of accelerated IADL decline for those discharged to LTC preceded the onset of home care service by 1.49 years and the time of first assessment by 1.84 years. Women in the full sample, and in both caregiver groups, experienced an earlier IADL change point relative to the availability of home care services and assessment when compared to men. Conclusions: Both IADL and ADL have discernible change points for in the years preceding discharge from home care to LTC. The change point for IADL consistently precedes that of ADL for the entire sample, for those with or without a caregiver in the home and for both men and women. The onset of accelerated IADL decline in the presence of age normative ADL decline may be an early indicator of pending transition from home care to LTC for home care recipients identified in this study. The province of Ontario has committed to providing the right care, at the right time in the right place. This study demonstrates that home care policy in Ontario during this study period, which does not provide for IADL services until after patients first qualify for ADL services, may not be achieving the provinces commitment of ensuring IADL care is provided at the right time for recipients of home care services. Opportunities for early identification and intervention may be available through early monitoring of, and intervention with, IADL function. A stepped care model holds promise for early identification and intervention of IADL impairment in community living older adults. Future research will help to confirm if accelerating decline in IADL function in the absence of appropriate rehabilitation and support services may hasten the onset of accelerated ADL impairment and subsequent admission to LTC. / Graduate / 2022-12-16

As the Canadian population continues to age efforts have been focussed on finding innovative strategies to promote active aging throughout the aging process and well into long-term care (LTC). The increased use of innovative technologies has been identified as a leading strategy to promote participation in health activities among older adults in LTC. However, technology use by older adults remains a challenge and participatory design (PD) frameworks must be used to design user-centered technologies with favourable acceptance and uptake. Hence, this thesis aimed to identify design requirements for an augmented reality health activity gaming platform for use in LTC. A participatory design framework was used with the objectives of (1) exploring the current attitudes, usage, benefits and challenges regarding the use of technology, (2) gathering preliminary data on the attitudes of older adults and staff in LTC regarding the inclusion of an augmented reality health activity platform and (3) reflecting on the process of employing a PD approach with older adults and other stakeholders in the context of LTC. Focus group data was used to perform qualitative inductive thematic analysis on older adult and staff discussions. The findings of the research included a current understanding of technological needs and uses within LTC, facilitators and barriers to technology uptake as well as the integration process of technology in LTC. In addition, findings included pragmatic design requirements for the augmented reality health activity platform at the selected LTC facility. This thesis research addresses the need to engage in PD activities to create a platform anchored in person-driven design rather than technology-driven design. This research ultimately builds the foundation for which future technology design teams should involve relevant stakeholders in the ideation, prototyping and evaluation of novel technologies for LTC.

An evidence-based clinical practice guideline was developed to prevent and manage constipation in the long-term care (LTC) resident. Constipation is a prevalent condition in the LTC resident. Guidelines do not address this vulnerable population. Constipation may result in poor nutritional status, quality of life along with increased health care costs and hospitalizations. A literature review was completed and evidence was evaluated and included into the initial draft recommendations. The guideline was reviewed for content validity using a Delphi Committee of clinical experts in gastroenterology, geriatrics, and pharmacy. The updated guidelines were presented to an interdisciplinary team of long-term care residents. Participants were asked to review and complete a survey regarding clinical applicability of the guideline. Thirty-one interdisciplinary members participated in the education session and 30 surveys were received. Overall, the interdisciplinary team members agreed or strongly agreed the guideline was clinically applicable. Finally, the guideline was evaluated by a group of doctoral prepared practicing nurse practitioners using the AGREE II instrument. The scores were >80% in every domain, with an overall score of 91%, indicating the guideline is high in quality. Development of this guideline signifies an initial step in the management and prevention of constipation in the LTC resident.

Although a great deal is known about the etiology of falls in elderly individuals, fall accidents continue to represent a significant burden to elders residing in long-term care facilities. It has been stated that 75% of deaths due to falls in the United States occur in the 13% of the population age 65 and over. The first objective of the study was to identify which fall-predictor variables acknowledged in the research literature are associated with increased fall frequency with the older population. Identifying specific predictor variables related to a high occurrence of falls in long-term care setting can assist in the redesign of tools and programs aimed to recognize fall risk, and prevent fall-related accidents and fatalities in the geriatric population. The second objective of the study was to identify which combination of predictor variables could better predict the frequency of falls. A history of falls variable was the only predictive variable that differed significantly between groups of residents who had sustained subsequent falls and those who had not. Other variables including age, mental status, day number of stay, elimination, visual impairment, confinement, blood pressure drop, gait and balance, and medication were found to not be statistically significant between groups of fallers and non-fallers. In this setting, the current design of the tool had limited accuracy and exhibited an inability to effectively discriminate between resident populations at risk of falling and those not at risk of falling. Consequently, the current fall risk assessment tool is not adequate for assessing fall risk in this clinical setting. / Master of Science

Despite the benefits of physical activity for older adults, many residents living in long-term care homes (LTC) are relatively inactive. Previous research has revealed barriers to physical activity at the resident-level, organizational, and environmental level. However, little attention has been paid to other factors influencing physical activity within the broader institutional complex. The goal of this study was to uncover how the work of personal support workers (PSWs) related to the promotion of physical activity was socially organized. Institutional Ethnography (IE), developed by Dorothy Smith, guided this study. Smith proposed that peoples’ everyday experiences in local settings are organized, often unknowingly, by the actions of people located outside of the local setting and that this organization is textually-mediated. Two LTC homes in Ontario participated in this study. I began data collection by observing PSWs as they went about their work. Next, I interviewed PSWs and other people located inside (e.g. nurses, managers) and outside the LTC homes (e.g. representatives from the Ministry of Health and Long-Term Care (MOHLTC). Lastly, I collected texts that organized the PSWs’ work, such as Ministry standards. The findings revealed that although the MOHLTC standards were viewed as producing something “good” for the residents, some of the standards disrupted the PSWs’ work, which made it challenging for them to support daily physical activity. The promotion of physical activity was seen as an additional program that happened a few times per week and it was parceled out as a professional activity that was socially organized “out” of the PSW role. The findings suggest that local solutions are needed. A good starting point would be to go and talk to PSWs and residents to determine what type of assignments would permit the incorporation of physical activity into daily care. To embed the promotion of physical activity into daily care, a major rethink and reorganization of PSWs work will be needed, including a greater investment in human and material supports for PSWs.

Anticoagulation risks in older adult, long-term care patients are known to be high, especially in those with frequent transitions between care environments. Introduction of collaborative practice agreements (CPA) in specific settings is encouraged in the United States and has provided an additional option for the care of medically challenging patients. The aim of this study was to investigate the time in therapeutic range (TTR) in a Medicare Part A sponsored long-term care environment managed by pharmacists through a collaborative practice agreement in South-Central Appalachia. A retrospective review of all warfarin patient admissions from a large long-term care pharmacy’s anticoagulant clinic was conducted for residents over an 18-month period. For all patients (n = 104), the overall TTR was 46.7% (INR 43% in range). Average management duration was 19.5 days per patient. Further studies are required to optimize CPA and transition strategies for complex, advanced age warfarin patients.

The Centers for Medicare and Medicaid are requiring long-term care facilities (LTCFs) to implement antibiotic stewardship programs (ASPs) to alleviate overuse of antibiotics in the nursing home population. Current research shows that the benefits of ASPs include improved patient outcomes, reduced adverse events related to Clostridium difficile (C-diff) infection, improvement in rates of antibiotic susceptibilities, and optimized resource utilization. This project addressed the problem of antibiotic overuse and misuse in the geriatric population and whether the implementation of an ASP reduced the overuse of antibiotics, C-diff infection, and resistance rates in the LTCF. Application of the Johns Hopkins nursing model and Centers for Disease Control framework informed this project. An ASP was implemented by the organization. This project evaluated the program preASP and postASP over a 10-month period. A descriptive analysis was used to compare the number of new antibiotic starts, C-diff cases, and resistant cases before and after ASP implementation. The total number of cases of resistance declined from 12 to 10 cases after the ASP was implemented, which was a 16.67% decline. The number of monthly new antibiotic orders for the time period evaluated declined from 120 to 110 respectively, which was an 8.3% change. There was no change in the number of C-diff infections. The results demonstrated that implementing the ASP led to a decline in antibiotic misuse, overuse, and resistance cases. This project supports social change by expanding the healthcare team's knowledge regarding the project problem and informing future interventions to be implemented to help reduce antibiotic overuse and misuse in the geriatric population.