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This paper examines the funding procedure in Ontario long-term care facilities and seeks to identify whether current resources for protecting the elderly from mistreatment is allocated fairly and effectively. The research also observes how the political economy may influence the needs-based allocation built to protect seniors from mistreatment in institutional care settings and the consequences of these resources on residents’ autonomy. The topic is also viewed through the lens of the current COVID-19 pandemic. Five experts in the area of long-term care participated in this research work including academics, scholars and institutional or agency advocates. Interviews lasting up to 60 minutes interviews were conducted, transcribed and analyzed using a political economy lens. Participants described their knowledge and experience with the funding procedure for long term-care facilities, particularly in Ontario and provided their view on areas that they felt could be improved. The analysis identified four themes including whether the issue is under-resourced, poor allocation of resources; funding according to need; the struggle to define and assess the quality of care; and general work conditions in long-term care. The result of this research will help us to better understand the resource allocation of Ontario long-term care facilities which could in turn highlight improvements that could be made to create better quality of life for residents as well as frontline workers. / Thesis / Master of Arts (MA) / This paper examines the funding procedure in Ontario long-term care facilities and seeks to identify whether current resources for protecting the elderly from mistreatment is allocated fairly and effectively. The topic is viewed through the lens of the COVID-19 pandemic. The analysis of the five expert interviews identified four themes including whether the issue is under-resourced, poor allocation of resources; funding according to need; the struggle to define and assess the quality of care; and general work conditions in long-term care. The result of this research will help us to better understand the resource allocation of Ontario long-term care facilities which could in turn highlight improvements that could be made to create better quality of life for residents as well as frontline workers.

Introduction: Long term care (LTC) residents require complete or extensive support, including 24-hour nursing and personal care. LTC residents contribute a greater number of emergency department (ED) visits when compared to community-dwelling older adults. Little is known about which resident-level characteristics at admission are predictive of LTC resident transfer to the ED. The objective of this thesis was to identify which admission characteristics are associated with ED transfers in Ontario, Canada. Methodology: I conducted a population-level retrospective cohort study using the Resident Assessment Instrument Minimum Data Set Version 2.0 (RAI-MDS). The cohort included 56,433 LTC resident admission assessments from January 1, 2017, to December 31, 2018. Logistic regression and 10-fold cross-validation were used to identify adjusted associations between characteristics routinely collected during LTC admission assessment and ED transfers. Model performance was assessed using the area under the receiver operating characteristics curve (AUC). Outcomes of interest included any ED use, potentially preventable, and low acuity ED transfers. Results: A recent change in medical orders, previous ED visitation, female sex, the presence of an indwelling catheter, and the need for oxygen therapy were informative predictors for any, potentially preventable, and low acuity ED transfers. Deterioration in cognitive status and change in behavior was influential to any ED transfers only. Urinary tract infections, pneumonia, indictors of delirium, and change in mood are unique to potentially preventable ED transfers, and antibiotic resistance is unique to low acuity ED transfers. Similar discrimination was reached for any ED use (AUC = 0.630), potentially preventable transfers (AUC = 0.659), and low acuity transfers (AUC = 0.645). Conclusion: The factors associated with ED transfers may be modifiable, and closer attention to these factors may help reduce ED transfers. Although the discriminability of the models was poor, advanced knowledge of informative characteristics can support upstream decision-making for clinicians. Future studies are required to validate these findings, derive risk scales, and demonstrate the utility of this model in health service planning. / Thesis / Master of Science (MSc) / Long term care (LTC) provides residents with 24-hour nursing and personal care. When the care or clinical needs of the resident cannot be met in the LTC facility, they may be transferred to the Emergency Department (ED). However, the ED’s are poorly situated to manage the distinct needs of older adults, given the sole focus on medical acuity rather than geriatric complexity. Unwarranted ED transfers are burdensome for LTC residents and increase their risk for adverse health events, such as nosocomial infections, delirium, and injuries. Understanding characteristics associated with ED transfers can help identify which residents may be at a risk of an ED transfer. The objective of this thesis was to identify which LTC resident characteristics at admission are associated with ED transfers in Ontario, Canada. A recent change in medical orders, previous ED visitation, female sex, the presence of an indwelling catheter, and the need for oxygen therapy were informative predictors for ED transfers.

The mass media influences our worldviews and perceptions, especially of social problems and potential solutions. Importantly, media messages, especially when repeated over time and during a crisis (real or perceived), tend to influence future public policy. Consistent with other periods of crisis and uncertainty, the COVID-19 pandemicization has led to an increased consumption of and reliance on news for accurate information and guidance on what to do and how to act amidst changing public health regulations and social norms. While the aging demographic has made media headlines before the COVID-19 pandemic was declared, the death of nearly 4,000 long-term care facility patients in Ontario alone since March 2020, most of them older adults, has increased the salience of Long-Term Care in the news (television, radio, newspapers, and digital news platforms). In this regard, many claims have been made in the media regarding older adults and their care and safety. But how are the problems leading to mass deaths in LTCFs defined and subsequent solutions presented in the mass media? In order to answer this question, this research asks: how are aging, care, and safety constructed or portrayed in newspaper coverage of LTC in Ontario during the first eight months of the COVID-19 pandemicization? Moreover, what are the implications of these portrayals for an aging population whereby nearly all of us will either need assistance at some point in our lives, provide this assistance to others, or both? Newspaper articles in the National Post on the topic of LTC from March to November 2020 were reviewed using Critical Discourse Analysis. Findings indicate event bias in reporting, journalistic ignorance on the issues in LTC and for those confined therein, dehumanization of older adult subjects, and highly medicalized notions of care and safety. / Thesis / Master of Arts (MA) / The mass media influences our perceptions, especially of societal problems and potential solutions. Consistent with other periods of uncertainty, since the declaration of the COVID-19 pandemic, consumption of and reliance on news has increased among the public. Importantly, media messaging during a crisis often influences future public policy with the potential to further exacerbate the crisis. The death of nearly 4,000 long-term care facility patients in Ontario alone since March 2020, most of them older adults, has increased the salience of Long-Term Care in the news, but toward what end? In order to deconstruct media messages during this time of tremendous upheaval, this research asks: how are age(ing), care, and safety portrayed in newspaper coverage of LTC in Ontario during the first eight months of the COVID-19 pandemic? What are the consequences of these portrayals for an aging population whereby nearly all of us will either need assistance at some point in our lives, provide this assistance to others, or both?

Background: Canada has an aging population. With increased life expectancy, older adults become at higher risk of developing chronic disease. Therefore, the need and demand for long-term care (LTC) is expected to continue to increase. LTC homes provide 24-hour nursing care, personal care, and assistance with activities of daily living (Government of Ontario, 2014). Health information technology (IT) presents opportunities to support staff, residents, and their families in LTC environments. This has been particularly emphasized during the latest COVID19 pandemic in light of the challenges that have been observed in LTC homes (e.g., social isolation, limited integration of information, shortage of human resources etc.). Yet, LTC homes still lag significantly behind other areas in healthcare in relation to the adoption of health IT, and little information is available on the factors that affect the decision-making related to health IT solutions in these settings. Objectives and Research Question: This research aims to explore and examine the most relevant and important factors that managers consider when making decisions on the adoption of health IT in LTC homes. Therefore, the research question is: “What are the factors that affect and can inform the decision-making of managers in relation to health IT adoption in LTC homes?” Methods: This research uses an exploratory data-driven Delphi method that consists of a survey of a panel of 19 experts who are decision-makers in their respective LTC homes in Ontario. The Delphi survey is an exploratory approach that elicits the opinion of a panel of experts through iterative feedback consisting of three rounds (brainstorming, narrowing down, and ranking). In this research, the panelists were asked to identify and describe the most important and relevant factors that affect and inform their decision-making regarding health IT solutions in LTC. Then, they were asked to narrow down and rank the list, and a final coefficient of agreement was calculated based on their rankings. Results: The panelists were mostly female, 40-49 years old, and had an average of 9.7 years of experience in their current LTC organization. In addition, participants had an average of 10.5 years of experience in making decisions related to health IT adoption. In the brainstorming round, the panelists provided a total of 102 key factors, which were consolidated into a list of 27 items that varied across 5 general categories: availability of resources, social factors, organizational factors, regulatory requirements, and technical factors of the health IT solution. Fourteen panelists reported key factors related to the cost of technology and ease of use, which were the two key factors that were reported most often by participants. Two items were dropped from the list of key factors in the narrowing down round (i.e., comfort and social environment and vendor reputation) as only items with a rating of 5 out of 7 or greater were retained for the ranking round. In the ranking round, the consensus level was W=0.341. The top 5 factors that were identified and ranked by managers in LTC homes as important in influencing their decisions on the adoption of health IT were (in order of importance): availability of funding, impact on workload and efficiency, value proposition, ease of use, and impact on residents’ outcomes. Contributions: This Delphi survey provides an authoritative list of 25 key factors (and their description) that influence and affect managers’ decisions in LTC homes in relation to the adoption of health IT. This is a first step towards understanding what is happening in the LTC context in relation to health IT decision-making. From a LTC managers’ perspective, the findings provide benchmarking to understand what other LTC homes are doing and the factors that influence their decision-making on health IT solutions. Particular importance should be placed on the highly ranked factors, as they are identified as the factors that are most relevant and most important in facilitating or hindering the decision of LTC managers to adopt health IT solutions. In addition, the results of this thesis may help inform future planning and policies aimed at advancing the use of technology to support the care provided to older adults and the work of health care professionals in LTC. Future studies can use the results of this thesis to develop surveys that assess and monitor the evolution of these factors in broader and more representative samples of LTC managers.

京都大学 / 新制・論文博士 / 博士(社会健康医学) / 乙第13455号 / 論社医博第17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 長尾 美紀, 教授 近藤 尚己, 教授 中川 一路 / 学位規則第4条第2項該当 / Doctor of Public Health / Kyoto University / DFAM

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Healthcare managers face an incredible challenge today; understanding and implementing financially and economically sound decisions in the complex healthcare environment of the United States. The pressure to be profitable managers is greater than ever. Considering current research, past studies, and articles focused on the demands of healthcare managers will illuminate the state of health care administration, and the importance of real world application of accounting and economics in healthcare. This thesis will explore and examine research about industry standards, and the need for preparedness in healthcare finance management. It will also examine the important and complex role of accounting and economics in healthcare administration by answering the three following questions: What do administrators, according to studies and literature available, believe is essential to becoming and remaining effective managers? What financial and economic concepts are understood and implemented by healthcare managers? What changes, if any, are necessary to adequately train and educate future healthcare administrators for successful financial management? The answers to these questions will highlight the impact of the economic, political, and social changes on administrators, as well as the best ways to succeed despite the difficulties often faced by those in this field.

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