Yes / An unplanned hospital admission of a nursing home resident distresses the person, their family and nursing home staff, and is costly to the NHS. Improving health care in care homes, including early detection of residents’ health changes, may reduce hospital admissions. Previously, we identified four conditions associated with avoidable hospital admissions. We noted promising ‘within-home’ complex interventions including care pathways, knowledge and skills enhancement, and implementation support. Objectives: Develop a complex intervention with implementation support [the Better Health in Residents in Care Homes with Nursing (BHiRCH-NH)] to improve early detection, assessment and treatment for the four conditions. Determine its impact on hospital admissions, test study procedures and acceptability of the intervention and implementation support, and indicate if a definitive trial was warranted. Design: A Carer Reference Panel advised on the intervention, implementation support and study documentation, and engaged in data analysis and interpretation. In workstream 1, we developed a complex intervention to reduce rates of hospitalisation from nursing homes using mixed methods, including a rapid research review, semistructured interviews and consensus workshops. The complex intervention comprised care pathways, approaches to enhance staff knowledge and skills, implementation support and clarity regarding the role of family carers. In workstream 2, we tested the complex intervention and implementation support via two work packages. In work package 1, we conducted a feasibility study of the intervention, implementation support and study procedures in two nursing homes and refined the complex intervention to comprise the Stop and Watch Early Warning Tool (S&W), condition-specific care pathways and a structured framework for nurses to communicate with primary care. The final implementation support included identifying two Practice Development Champions (PDCs) in each intervention home, and supporting them with a training workshop, practice development support group, monthly coaching calls, handbooks and web-based resources. In work package 2, we undertook a cluster randomised controlled trial to pilot test the complex intervention for acceptability and a preliminary estimate of effect. Setting: Fourteen nursing homes allocated to intervention and implementation support (n = 7) or treatment as usual (n = 7). Participants: We recruited sufficient numbers of nursing homes (n = 14), staff (n = 148), family carers (n = 95) and residents (n = 245). Two nursing homes withdrew prior to the intervention starting. Intervention: This ran from February to July 2018. Data sources: Individual-level data on nursing home residents, their family carers and staff; system-level data using nursing home records; and process-level data comprising how the intervention was implemented. Data were collected on recruitment rates, consent and the numbers of family carers who wished to be involved in the residents’ care. Completeness of outcome measures and data collection and the return rate of questionnaires were assessed. Results: The pilot trial showed no effects on hospitalisations or secondary outcomes. No home implemented the intervention tools as expected. Most staff endorsed the importance of early detection, assessment and treatment. Many reported that they ‘were already doing it’, using an early-warning tool; a detailed nursing assessment; or the situation, , assessment, recommendation communication protocol. Three homes never used the S&W and four never used care pathways. Only 16 S&W forms and eight care pathways were completed. Care records revealed little use of the intervention principles. PDCs from five of six intervention homes attended the training workshop, following which they had variable engagement with implementation support. Progression criteria regarding recruitment and data collection were met: 70% of homes were retained, the proportion of missing data was < 20% and 80% of individuallevel data were collected. Necessary rates of data collection, documentation completion and return over the 6-month study period were achieved. However, intervention tools were not fully adopted, suggesting they would not be sustainable outside the trial. Few hospitalisations for the four conditions suggest it an unsuitable primary outcome measure. Key cost components were estimated. Limitations: The study homes may already have had effective approaches to early detection, assessment and treatment for acute health changes; consistent with government policy emphasising the need for enhanced health care in homes. Alternatively, the implementation support may not have been sufficiently potent. Conclusion: A definitive trial is feasible, but the intervention is unlikely to be effective. Participant recruitment, retention, data collection and engagement with family carers can guide subsequent studies, including service evaluation and quality improvement methodologies. Future work: Intervention research should be conducted in homes which need to enhance early detection, assessment and treatment. Interventions to reduce avoidable hospital admissions may be beneficial in residential care homes, as they are not required to employ nurses. / This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 2. See the NIHR Journals Library website for further project information.

Through development of a conceptual model and an index measure based on actual performance, this dissertation focused on clarifying what is "very good" (and "very bad") in nursing home quality. The model expanded on the traditional narrow image of nursing home quality of care, and specified four major dimensions of this broader view of quality. The dimensions (staff intervention, nutrition/food service, physical environment, and community relations) were each reduced further to two subdimensions. Factors influencing quality were also delineated. The new model was then used to tie specific measurable indicators to the overall quality construct. Quality indicators derived from standardized assessments of Medicaid residents were employed in a study of 135 intermediate care facilities in Virginia. Process variables, such as use of physical restraints, catheters, and receipt of various therapies, were analysed for 12,327 residents. Outcome variables (weight loss, increased dependencies in activities of daily living, new pressure sores) were determined through longitudinal analysis for residents with an appropriate preceding assessment (n = 9,006). Assessments were aggregated in each home to calculate a mean (percentage incidence) for each of the 14 quality indicators. A scaling system was used to clearly identify industry"norms" for each variable. Quintiles based on relative incidence were employed to assign homes to five levels of performance. Scale scores were summed to obtain a facility index measure of relative quality. Reliability and validity were evaluated. Relationships of case-mix and selected structural variables (size, ownership, location, percent Medicaid, staff ratios) to the quality measure were analysed. Results suggested better performance by non-profit and smaller homes, but proprietary and non-prof it facilities were about evenly represented among the top tenth percentile of homes. Presence of a skilled care unit appeared to negatively influence quality. Possible interactions and explanations for this finding were considered. Most significantly, the study demonstrated that resident assessments can serve as excellent information sources about what goes on in nursing homes. However, additional variables must be incorporated to make a comprehensive quality measure, based on the model. Recommendations and policy implications were discussed. / Doctor of Philosophy

Medication shortages in the Netherlands are the highest they have ever been while approximately 20% of all medication is being thrown away unused. Combined with strengthened ambitions from the Dutch government to improve the sustainability of the healthcare sector, voices have become louder to consider the redispensing of medication. In this study, the perspectives of nurses, pharmacists, and prescribers that are active in the medication chain for Dutch nursing homes have been gathered regarding this strategy to reduce the medication wastage. Semi-structured interviews were organized, transcribed, and subsequently analysed through the framework method. The aim of this study is to enable policy makers to include the perspectives of stakeholders in the medication chain for nursing homes on medication leftovers and on the strategy of redispension in their strengthened ambitions on sustainable healthcare. The results of the analysis showed that medication wastage is a multi-causal problem that is considered as a negative aspect of the current system by all stakeholders. Redispension was seen as a realistic additive to the current practices, under the condition that the quality of the medication could be assured, that the stakeholders are provided with enough information, and that the system would be financially viable. Circular strategies such as rethink, refuse and reduce are possible effective options to reduce the medication leftovers as well. Several recommendations were made for nursing homes from examples in nursing homes that were collected during the study.

This qualitative phenomenological study examined central Florida's nursing home administrators' knowledge and perception of cultural competence and how they perceive that their knowledge and perceptions impact residents, families, and healthcare. The theoretical framework for this study was explained through Campinha-Bacote's interdisciplinary model of The Process of Cultural Competence in the Delivery of Healthcare Services. The theoretical framework was used to guide research questions, and individual interview questions to obtain nursing home administrator's knowledge and perception of cultural competence. The study explored the level of cultural competence reported by nursing home administrators, their individual perception of cultural competence, their degree of confidence in cultural competence, and how nursing home administrators describe their proficiencies and skills in cultural competence. Interviews with six nursing home administrators included licensed nursing home administrators (NHA) and assistant nursing home administrators, and the director of nursing (DON). The findings identified and analyzed the diverse levels of nursing home administrator's knowledge and perception of cultural competence. Some participants demonstrated difficulty expressing their knowledge and perception of cultural competence. Findings indicate that various factors influenced participants' overall degree of confidence in their knowledge and perception of cultural competence. Nursing home administrators also had a difficult time articulating particular skills that demonstrate their ability to adapt to the diverse residents in their facilities, and how they promote cultural competence in their nursing home facilities. This study identified the need for additional research and continuing education about cultural competence in healthcare.

published_or_final_version / Public Administration / Master / Master of Public Administration

The nursing home industry has been saturated for decades with culture change initiatives in an effort to improve resident quality of care. The direct care worker (DCW) is considered a critical position to achieving nursing facility quality improvements. Understanding what leads to job satisfaction for DCWs could result in improved resident care. The relationship DCWs have with their direct supervisor or upper-level manager can impact employee satisfaction. The purpose of this research is to identify factors that are associated with DCWs satisfaction with supervisor and management support. Data was obtained from 307 DCWs who were employed at 11 North Texas nursing homes. It was expected that factors affecting satisfaction with direct supervision and upper-level management would differ. In fact, the study found that the antecedents for employee satisfaction with supervisor support were participative decision-making/empowerment, age, information exchange and feedback. Furthermore, participative decision-making/empowerment, perceived competence, staffing, information exchange and feedback were found to affect direct care workers' satisfaction with manager support. In conclusion, this research provides a starting point towards a more holistic view of employee satisfaction with supervisor support by considering the preceding factors and its subsequent effects.

The aim of this study was to understand how evaluations are implemented and used in procured nursing homes for elderly. Our methodological approach consisted of a single-case study research. The case in this study was Växjö municipality. Three procured nursing homes for elderly were chosen in the municipality as examples of implementation and use of evaluation. The method for retrieving empirical data and the analyzing of it was based on triangulation. The empirical data was retrieved by semi-structured interviews with representatives from Växjö municipality and the suppliers. Empirical data was also retrieved from documents concerning the procurements and the evaluation process present in this study. The empirical data was analyzed on the basis of the neo-institutional theory and previous research that explain the implementation and use of evaluations. The result shows that evaluations are used as audit to control the suppliers and occur at three different levels in the municipality. The result also shows that the context and legitimacy of an organization affects the implementation and use of the evaluations. The result has made us question the use of evaluation at the overall level in view of the political debate at this level. The source of our doubts lies in that there are ideological differences in how politicians value procurement that may influence the use of evaluation. The ways the municipality implements and uses evaluations appear to be institutionalized.

Background: Drugs are one of the cornerstones in the management of many diseases. In general, drugs are used for diagnosis, prevention, mitigation of symptoms, and, sometimes, to cure disease. However, drug treatment in elderly people, especially those with dementia and cognitive impairments, may involve significant risk of adverse drug events.  The aim of this thesis was to identify the extent of potentially inappropriate drug treatment among people with dementia and cognitive impairment and to assess the occurrence and character of drug-related problems that lead to acute hospital admissions. Another aim was to assess the potential impact of a comprehensive medication review conducted by clinical pharmacists as part of a health care team on quality of patients’ drug therapy and drug-related hospital readmission rates. Method: Long-term use of antipsychotic/psychotropic drugs and associated factors were investigated among 344 and 278 people respectively with dementia living in specialized care units. Trends in the prescribing of potentially inappropriate drugs between 2007 and 2013, comprising 2772 and 1902 people, living in nursing homes in the county of Västerbotten, were assessed using six national quality indicators. Data on drug use, function in the activities of daily living, cognitive function and behavioral and psychological symptoms were collected using the Multi-Dimensional Dementia Assessment Scale. Further, an investigation of a separate corresponding population from 2012 was done, where potentially inappropriate drug use was measured before and after a total of 895 medication reviews. Finally, a randomized, controlled trial was carried out among people 65 years or older with dementia or cognitive impairment in internal medicine and orthopedic wards at two hospitals in northern Sweden. The proportion of hospital admissions that were drug-related were estimated, and also whether comprehensive medication reviews conducted by clinical pharmacists as part of a health care team could affect the risk of drug-related hospital readmissions. Results: Antipsychotic and other psychotropic drugs were frequently prescribed to people with dementia living in specialized care units for prolonged periods. Associations were found between behavioral and psychological symptoms and different psychotropic drugs. The extent of potentially inappropriate drug use declined between 2007 and 2013. In the separate corresponding population from 2012, the frequency of potentially inappropriate drug use was significantly reduced among people who underwent medication reviews. Hospitalizations due to drug-related problems among old people with dementia or cognitive impairment were prevalent. We found that inclusion of a clinical pharmacist in the health care team significantly reduced the risk of drug-related 30-day and 180-day readmissions. However, in a subset of patients with concomitant heart failure no effect was seen. Conclusion: Among patients with dementia or cognitive impairment long-term treatment with antipsychotic and other psychotropic drugs is common. The results indicate that these drugs are prescribed to treat behavioral and psychological symptoms among cognitively impaired individuals, despite limited evidence of their efficacy and the high risk of adverse effects. Drug-related problems, such as adverse drug reactions, constituted a major cause of hospital admissions. By reducing potentially inappropriate drug use and optimizing overall drug therapy, inclusion of clinical pharmacists in a health care team might improve the quality of patient care and reduce the risk of hospital readmissions among people with dementia.

published_or_final_version / Social Work / Master / Master of Social Work

Äldres ensamhet har uppmärksammats kontinuerligt i media senaste åren vilket bidrog till intresset att undersöka äldres ensamhet på äldreboende. Syftet med denna studie var att undersöka hur ensamhet hos de äldre kan uppfattas och vilka vägar det kan finnas för att hantera ensamheten från de äldres, anhörigas och vårdpersonalens perspektiv. Denna studie är utformad utifrån Skellefteå kommuns önskemål. Studien baserar sig på tre individuella intervjuer med vårdtagare och en gruppintervju med var och en av grupperna vårdpersonal och äldre. Studien resulterade i en beskrivning av hur äldres ensamhet kan erfaras av den äldre själv, anhöriga och vårdpersonal samt vilka strategier äldre, anhöriga och vårdpersonal har för att motverka ensamhetskänslor hos äldre. Slutsatser av studien är att äldre upplever ensamheten individuellt och har därmed olika strategier för att hantera den.