Background Paratonia is a form of involuntary muscle resistance affecting virtually all individuals with late-stage dementia, causing significant morbidity, including pain, skin breakdown, and caregiver burden. Despite its near-universal prevalence, paratonia remains under-recognized, and no standardized screening tools exist within routine care assessments. Identifying care-interfering paratonia supports nonpharmacologic care, helps avoid misdirected treatments, and enables research into investigational therapies such as botulinum toxin A. Objectives To develop a preliminary Collaborative Action Plan using items from the Minimum Data Set 2.0 (MDS 2.0) to identify residents with advanced dementia whose paratonia may have progressed to care-interfering severity. Design Pilot study using nominal group technique consensus methodology combined with retrospective chart review. Setting and Participants Single-site study at a 472-bed long-term care facility in Toronto, Canada. Thirty residents with advanced dementia and confirmed care-interfering paratonia who were candidates for botulinum toxin A treatment were included. Methods An expert panel of 6 clinicians used nominal group technique to identify candidate MDS 2.0 items. Items were extracted from charts using double data entry, and frequency analysis informed final consensus on preliminary screening items. Results From 51 initially identified items across 22 MDS 2.0 sections, the panel achieved consensus on 10 preliminary items spanning activities of daily living dependency, range-of-motion limitations, medication use, pressure injuries, and resistance to care behaviors. Conclusions and Implications This pilot study represents a first step toward systematic paratonia identification in long-term care and community home care settings. The preliminary screening items require validation in larger, multisite studies before clinical implementation.

Prior research has identified gaps in the ability of hospital systems to efficiently and meaningfully characterize older adults with complex health needs. We recruited community-dwelling older adults presenting to 10 Emergency Departments (EDs) across Ontario, Quebec, and Newfoundland, Canada, from April 2017 to July 2018. We deployed a staged assessment strategy based on the interRAI Acute Care Suite to identify and characterize older adults at high risk of Alternate Level of Care designation. More than 5,700 patients underwent the ED-Screener, 53.3% of whom were not self-reliant. Subsequent focused screening and assessment identified 457 patients, 93.3% of whom were not self-reliant, and who had significant impairments in function, mobility, and cognition, as well as social vulnerability. A staged assessment approach based upon the interRAI Acute Care Suite can efficiently identify older adults with risk factors for Alternative Level of Care designation.

Specialized geriatric services care for older adults (≥ 65 years of age) with dementia and other progressive neurological disorders, frailty, and mental health conditions were provided both virtually and in person during the pandemic. The objective of this study was to implement a software-enabled standardized self-report instrument - the interRAI Check-Up Self-Report - to remotely assess patients. A convergent, mixed-methods research design was employed. Staff found the instrument easy to use and the program-level metrics helpful for planning. Most patients urgently needed a geriatrician assessment (72%) and had moderate to severe cognitive (34%) and functional impairments (34%), depressive symptoms (53%), loneliness (57%), daily pain (32%), and distressed caregivers (46%). Implementation considerations include providing ongoing support and facilitating intersectoral collaboration. The Check Up enhanced the geriatric assessment process by creating a system to track all needs for immediate and future care at both the patient and program level.

INTRODUCTION:Improving quality of life has become a priority in the long-term care (LTC) sector internationally. With development and implementation guidance, standardised quality-of-life monitoring tools based on valid, self-report surveys could be used more effectively to benefit LTC residents, families and organisations. This research will explore the potential for subjective quality-of-life indicators in the interRAI Self-Reported Quality of Life Survey for Long-Term Care Facilities (QoL-LTCF). METHODS AND ANALYSIS:Guided by the Medical Research Council Framework, this research will entail a (1) modified Delphi study, (2) feasibility study and (3) realist synthesis. In study 1, we will evaluate the importance of statements and scales in the QoL-LTCF by administering Delphi surveys and focus groups to purposively recruited resident and family advisors, researchers, and LTC clinicians, staff, and leadership from international quality improvement organisations. In study 2, we will critically examine the feasibility and implications of risk-adjusting subjective quality-of-life indicators. Specifically, we will collect expert stakeholder perspectives with interviews and apply a risk-adjustment methodology to QoL-LTCF data. In study 3, we will iteratively review and synthesise literature, and consult with expert stakeholders to explore the implementation of quality-of-life indicators. ETHICS AND DISSEMINATION:This study has received approval through a University of Waterloo Research Ethics Board and the Social and Societal Ethics Committee of KU Leuven. We will disseminate our findings in conferences, journal article publications and presentations for a variety of stakeholders.

BACKGROUND:Geriatric Emergency Department (ED) Guidelines recommend optimizing transitions of care for older patients with complex needs. In this study, we investigated referral patterns to interprofessional services, including occupational therapy, physiotherapy, dietician, social work, home care, and specialized geriatric services, among older adults presenting to the ED with high-risk characteristics. METHODS:We recruited community-dwelling older adults presenting to 10 EDs across Ontario, Quebec, and Newfoundland, Canada, from April 2017 to July 2018. To observe processes of care in the ED, we deployed a two-stage high-risk case-finding and focused comprehensive assessment process based on the interRAI ED-Screener and ED Contact Assessment to identify and characterize older adults at high risk. We analyzed the secondary data using descriptive statistics and logistic regression. RESULTS:We screened 5265 individuals with the ED Screener, further assessed 1479 with the ED Contact Assessment, and analyzed data from a subset of 1055 community-dwelling older adults assessed with the ED Contact Assessment. Participants in our study sample had a mean age of 83 years, 58% were female, and many had a complex burden of cognitive and functional impairment and social needs. Over half of this high-needs sample were referred to general home care services (62.7%), occupational therapy (59.3%), and physiotherapy services (55.2%), while 16% were referred to specialized geriatric services. We also found a significant positive association between interprofessional referrals and the Assessment Urgency Algorithm and Institutional Risk Scale. The most important determinants of referral to interprofessional services were hospital province, functional, clinical, and social burden and support measures. CONCLUSIONS:The referral patterns identified suggest that patient needs and risk intensity did not always guide referral patterns in the Canadian EDs investigated. We suggest that EDs critically examine the appropriateness of their documentation and referral systems for supporting person-centered care provision.

Background: Emergency Department (ED) overcrowding, unnecessary hospitalization, and alternate level of care has been identified as a major issue in Canada and around the world. This problem especially impacts older adult populations, who are at elevated risk of functional decline and adverse events in hospital-centric systems. This study uses data from the interRAI ED Contact Assessment (ED-CA)[1], a comprehensive geriatric assessment used in the ED, to improve our understanding of ED systems of referral to community resources. Target Audience: ED staff in clinical and leadership positions interested in better understanding community referral processes to improve care for community-dwelling older adults. Methods: This study is a secondary analysis of cross-sectional Canadian data from a cohort study of elderly ED patients. The cohort of community-dwelling patients aged 65 and older presented to the ED between April 2017 and July 2018. They were screened and recruited in 10 EDs across Ontario, Quebec, and Newfoundland. The data were analyzed using frequency and logistic regression analyses, then the results were interpreted in collaboration with two geriatricians and one physiotherapist. What was done: This study explored referral patterns and identified predictors of referral from the ED to five different community health services (occupational therapy, physiotherapy, home care, social work, and/or specialized geriatric services) for supporting community-dwelling older adults. Results: We found that the sample (n=1055) was frail, with high needs and a high risk of ED revisit and institutionalization. Over half of the sample was referred to home care, occupational therapy, and/or physiotherapy, while only 16% were referred to specialized geriatric services. Most patients received multiple referrals from the ED. Province was the most impactful predictor for referral to occupational therapy or physiotherapy (OR for Ontario vs. Quebec=62.12, 95% CI [19.04, 202.70]) and home care (OR for Ontario vs. Quebec=12.09, 95% CI [5.81, 25.17]), while having an unstable condition was the most impactful predictor for social work referral (OR=5.51, 95% CI [3.78, 8.02]) and weight loss was the most impactful predictor for specialized geriatric service referral (OR=8.13, 95% CI [5.49, 12.04]). Other notable predictors included having overwhelmed family members, self-rated health, and having had a fall in the last 90 days. Key Learnings: Occupational therapy, physiotherapy, home care, social work, and specialized geriatric services are distinct services, specialized in addressing a specific set of care needs. We learned that specialized geriatric services are underutilized and may be poorly understood. Next Steps: To improve the quality of ED care, we have provided recommendations for restructuring care processes to promote shifts in clinical culture, evidence-informed decision-making, and proactive referral to community health services. References: Costa A, Hirdes JP, Ariño-Blasco S, Berg K, Boscart V, Carpenter CR, et al. interRAI Emergency Department (ED) Assessment System Manual: For use with the interRAI ED Screener (EDS) and ED Contact Assessment (ED-CA). Version 9.3. Washington, D.C.: interRAI; 2017.

If interRAI home care information were shared with primary care providers, care provision and integration could be enhanced. The objective of this study was to co-develop an interRAI-based clinical information sharing tool (i.e., the Patient Falls Risk Report) with a sample of primary care providers. This mixed-methods study employed semi-structured interviews to inform the development of the Patient Falls Risk Report and online surveys based on the System Usability Scale instrument to test its usability. Most of the interview sample (n = 9) believed that the report could support patient care by sharing relevant and actionable falls-related information. However, criticisms were identified, including insufficient detail, clarity, and support for shared care planning. After incorporating suggestions for improvement, the survey sample (n = 27) determined that the report had excellent usability with an overall usability score of 83.4 (95% CI = 78.7-88.2). By prioritizing the needs of end-users, sustainable interRAI interventions can be developed to support primary care.

Background: Only 24% of Canadian primary care providers communicate with home care providers about the needs and services of patients. This service gap puts vulnerable people at risk of adverse events. One tool that may enhance communication between home care and primary care is the interRAI home care (interRAI-HC), a mandated comprehensive geriatric assessment in home care. The focus of this study was on development of a one-page document for sharing falls-related clinical information from the interRAI-HC with primary care providers (i.e., the Patient Falls Risk Report). Target audience: Primary care providers who feel siloed from the rest of the health care system. About the intervention: The Patient Falls Risk Report is a structured, one-page, faxable form that contains falls-related patient information derived from interRAI-HC assessments. The report is evidence-based and includes personalized information on future falls risk, balance, cognition, pain, foot problems, medications, and physical activity levels, as well as recommendations for falls prevention in older persons. Stakeholder engagement and other research methods: This mixed-methods intervention development study began with one-on-one stakeholder engagement via semi-structured interviews with primary care providers. We first explored their views on falls-related information sharing. Then, we tested a prototype of the Patient Falls Risk Report for usability and utility, thematically analyzing the findings to iteratively to develop the tool. The report was then evaluated again with voluntary self-report surveys based on the System Usability Scale. Results: A sample of 9 interview participants co-developed the Patient Falls Risk Report to improve its clarity and level of detail. All participants stated that they would use the report in their practices and most believed that it could support care provision due to its inclusion of relevant, actionable information. In the end, a survey sample of 27 participants determined that the report was highly usable, with an overall usability score of 83.4 (95% CI = 78.7, 88.2). However, the need for improved shared care planning and community responsibility was also emphasized. Impact: This study demonstrates that information collected from existing clinical assessments can be shared with primary care providers in a useful manner. It also highlights criteria to inform the design of future information-sharing interventions, especially those harnessing interRAI assessments. Key Learning: Primary care providers need tailored and consistent streams of communication with other health care providers so that collaboration and integration can become a reality. Next Steps: We are at a turning point in health care, where the functionality of health information systems is improving, and fax is becoming increasingly obsolete. Based on the recently published results of this study [1], we are currently collaborating with government and eHealth organizations on an implementation plan for interRAI information sharing with patients and caregivers in Ontario, Canada. 1. Nova AA, Heckman G, Giangregorio LM, Alarakhia M. Developing the Patient Falls Risk Report: A Mixed-Methods Study on Sharing Falls-Related Clinical Information from Home Care with Primary Care Providers. Canadian Journal on Aging / La Revue canadienne du vieillissement. 2022;1–14.

During the pandemic, the interRAI COVID-19 Vulnerability Screener (CVS) was used to identify communitydwelling older adults or adults with disabilities at risk of negative outcomes and facilitate triage for follow-up with health/social services. The interRAI CVS, a standardized self-report instrument administered virtually by a lay-person, includes COVID-19-related items and psychosocial and physical vulnerability. Our objective was to describe those assessed and identify sub-groups at highest risk of adverse outcomes. Seven community-based organizations in Ontario, Canada, implemented the interRAI CVS. We used descriptive statistics to report results and created a priority indicator for monitoring and/or intervention based on possible COVID-19 symptoms and psychosocial/physical vulnerabilities. We used logistic regression to examine the association between priority level and risk of poor outcomes using fair/poor self-rated health as a proxy measure. The sample included 942 adults assessed (April-November 2020; mean age=79). About 10% of individuals reported potential COVID19 symptoms and <1% had a positive COVID-19 test/diagnosis. Of those with psychosocial/physical vulnerabilities (73.1%), most common were depressed mood (20.9%), loneliness (21.6%), and limited access to food/ medications (7.5%). Overall, 45.7% had a recent doctor or nurse practitioner visit. Odds of fair/poor selfreported health were highest among those who reported both possible symptoms of COVID-19 and psychosocial/physical vulnerabilities (OR 10.9, 95% CI 5.96-20.12) compared to those with neither symptoms nor psychosocial/physical vulnerabilities. The sample represents a population largely unaffected by COVID-19 itself but with identified vulnerabilities. The interRAI CVS allows community providers to stay connected and obtain a better understanding of vulnerable individuals' needs during the pandemic.

Background: Older adults receiving home care (HC) services and living in long-term care homes (LTC) experience high levels of multimorbidity. In this project - called iCARE4OLD, we aimed first to identify and compare subgroups of care dependent individuals sharing the same patterns of chronic diseases. For these subgroups, we will identify care paths and try to make integration of services and continuity of care possible. Settings and participants: We studied 102,000 individuals 60+ years receiving HC services or living in LTC homes in Canada, Italy, Finland and New Zealand. Methods: This is a cross-sectional study including the baseline interRAI HC and LTCF assessments of older people in the period of 2014 until 2018. The project has received funding from the European Union’s Horizon 2020 research and innovation programme under Grant Agreement number 965341 and from the New Frontiers Research Fund, grant number NFRFG-2020-00500. Latent Class Analysis (LCA) was used to classify individuals according to their underlying diseases patterns starting from a list of 19 conditions. Results: Mean age of the sample was 80 years (65% females). After assessing several fit parameters, a 5-class solution was chosen as the best model for both HC and LTC. The following 5 disease patterns were identified in all countries: (1) Alzheimer/dementia; (2) psychiatric diseases; (3) cardio-pulmonary diseases; (4) stroke/hemiplegia; (5) other dementias. The distribution of sociodemographic, clinical and functional characteristics varied across the different multimorbidity patterns, with the cardio-pulmonary disease and the stroke/hemiplegia patterns showing the highest complexity and impairment. Results: Our results show that, by using a common assessment tool, it is possible to identify homogeneous morbidity patterns in older patients receiving long-term care. These may be useful to compare health status in care-dependent individuals across different settings and countries, as well as to predict health trajectories and care needs. Discussion: By applying this methodology to whole populations, care paths can be drawn for home care and residential care clients in a more evidence-based way. The goals would be to use these algorithms to design more integrated care plans for older persons, so that clients and their families are better served, and policy makers can finance the right services and offer targeted care.

Background:Falls are a growing concern in Canada. Primary care providers are well positioned to address falls risk, but international literature suggests that best-practice guidelines are rarely followed. The objective of this study is to explore the perspectives of Canadian primary care providers around falls prevention and identify solutions.Methods:We conducted one-on-one qualitative interviews with a maximum variation sample of nine primary care providers in Ontario (n=8) and Alberta (n=1) in Canada. Data were collected over telephone and in-person at the location of participants choosing. Audio recordings of the interviews were transcribed, then coded and analyzed with the Behaviour Change Wheel theoretical framework.Results:Most participants reported relying on patient self-report, intuition, and reactive approaches to identifying falls risk. Reported barriers to falls prevention included low capability to gather information on patient history, context, and community resources; limited opportunity to manage patient complexity due to time constraints; and challenges with motivating patients to engage in care plans. Reported facilitators included team-based interprofessional care and provider motivation.Conclusions:This study has found that Canadian primary care providers face barriers to identifying and managing falls risk. These barriers may be rooted in primary care culture, structure, and tradition.

Background: The interRAI home care (interRAI-HC) instrument is valid, reliable, and capable of enhancing integration across health settings. However, its uptake has been met with criticism. If interRAI-HC information were shared with primary care providers in a useable, actionable, and context-appropriate manner, evidence suggests that its implementation could enhance care provision and integration between these providers. The objective of this study was to co-develop an information sharing tool with primary care providers for sharing clinical information from the interRAI-HC (named the Patient Falls Risk Report). Methods: This mixed-methods study, conducted from December 2019 to May 2020, employed qualitative and quantitative methods to develop and test the usability of the Patient Falls Risk Report. After recruiting primary care providers via snowball and maximum variation sampling, we employed semi-structured interviews in-person and over the telephone. The interview transcripts were analyzed through iterative thematic analysis and informed development of the report. Next, online surveys based on the System Usability Scale instrument were completed by a voluntary response sample of primary care providers and residents and descriptively analyzed to test the usability of the report. Results: Of the interview sample (n=9), we found that most believed that the Patient Falls Risk Report could support patient care by sharing relevant and actionable falls-related information. However, criticisms were identified including insufficient detail, lack of clarity, and limited support for shared care planning. After incorporating participants’ suggestions for improvement, a sample of primary care providers and primary care residents (n=27) determined that the report had excellent usability with an overall usability score of 83.4 (95% CI = 78.7, 88.2). Conclusions: By emphasizing usability and utility, and prioritizing the needs of end-users, sustainable interRAI-HC interventions can be developed and implemented to support care planning in primary care.

Acid mine drainage (AMD) sludge is by-product from AMD treatment that formed by iron deposition. This sludge has a potential to be used as an active adsorbent to remove phosphate from domestic wastewater. The adsorbent that was used in this research is AMD sludge from PT Bukit Asam Tbk., Tanjung Enim that majorly composed of Si, Fe and Al compound (determined by the XRD test). Phosphate adsorption was done by AMD sludge and MD sludge that was activated by hydrogen peroxide. Activation process by hydrogen peroxide affected the chemical and physic characteristic of sludge and it showed from the results that the concentration of Si, Fe and Al were shifted by 7.33%, 7.03%, and 1.49%, respectively. Meanwhile for the physical characteristic; specific surface area, pore volume, and pore size were shifted by 19.51 m2/g, 0.0635 cm3/g, and 142.694 nm, respectively. Phosphate removal by AMD sludge has a greater result than activated sludge. Adsorption capacity of AMD sludge was well described by Freundlich isotherm model, which is equal to 6.358 mg P/g. Meanwhile, adsorption capacity of activated sludge was well described by Langmuir isotherm model, which is equal to 0.48 mg P/g. Results in this study indicated that the activation process with hydrogen peroxide affects the ability of phosphate adsorption that was showed by the difference of removal percentage.

BACKGROUND:Health instability, measured with the Changes in Health and End-Stage Disease Signs and Symptoms (CHESS) scale, predicts hospitalizations and mortality in home-care clients. Heart failure (HF) is also common among home-care clients. We seek to understand how HF contributes to the odds of death, hospitalization, or worsening health among new home-care clients, depending on admission health instability.METHODS:We undertook a retrospective cohort study of home-care clients, aged 65 years and older, between January 1, 2010, and March 31, 2015 from Alberta, British Columbia, Ontario, and the Yukon, Canada. We used multistate Markov models to derive adjusted odds ratios (ORs) for transitions to different health instability states, hospitalization, and death. We examined the role of HF and CHESS at 6 months after home-care admission.RESULTS:The sample included 286,232 clients. Those with HF had greater odds of worsening health instability than those without HF. At low-to-moderate admission health instability (CHESS 0-2), clients with HF had greater odds of hospitalization and death than those without HF. Clients with HF and high health instability (CHESS≥3) had slightly greater odds of hospitalization (OR, 1.08; 95% confidence interval (CI), 1.02-1.13) but similar odds of death (OR, 1.024; 95% CI, 0.937-1.120) compared with clients without HF.CONCLUSIONS:Among new home-care clients, a diagnosis of HF predicts death, hospitalization, and worsening health, predominantly among those with low-to-moderate admission health instability. A diagnosis of HF and admission CHESS score provide complementary information to support care planning in this population.

Use of a system-wide standardized clinical assessment to facilitate information-sharing is an essential component of an integrated healthcare system. 1 Heckman G.A. Hillier L. Manderson B. McKinnon-Wilson J. Developing an integrated system of care for frail seniors in Waterloo-Wellington: results of a consultation process to identify system strengths and gaps. Waterloo Wellington Local Health Integration Network, Waterloo, ON2011: 200-208 Google Scholar The Resident Assessment Instrument for Home Care (interRAI-HC) is a standardized clinical assessment and decision support instrument used to assess complex and vulnerable clients in home care. 2 Heckman G. Gray L.C. Hirdes J. Addressing health care needs for frail seniors in Canada: Role of interRAI instruments. CGS J CME. 2013; 3: 9 Google Scholar It provides reliable and valid screeners, risk stratification algorithms, outcome measures, and clinical recommendations for common and important conditions. 2 Heckman G. Gray L.C. Hirdes J. Addressing health care needs for frail seniors in Canada: Role of interRAI instruments. CGS J CME. 2013; 3: 9 Google Scholar Use of the interRAI-HC results in positive outcomes, such as improved care planning, greater collaboration among providers, lower hospitalization rates, and reduced client morbidity. 3 Landi F. Onder G. Tua E. et al. Impact of a new assessment system, the MDS-HC, on function and hospitalization of homebound older people: A controlled clinical trial. J Am Geriatr Soc. 2001; 49: 1288-1293 Crossref PubMed Scopus (53) Google Scholar Thus, the interRAI-HC can be used by primary care physicians to support clinical decision making, reduce duplicate testing, and improve quality of healthcare delivery overall. 2 Heckman G. Gray L.C. Hirdes J. Addressing health care needs for frail seniors in Canada: Role of interRAI instruments. CGS J CME. 2013; 3: 9 Google Scholar ,4 Garg A.X. Adhikari N.K.J. McDonald H. et al. Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: A systematic review. JAMA. 2005; 293: 1223-1238 Crossref PubMed Scopus (2160) Google Scholar ,5 Moja L. Kwag K.H. Lytras T. et al. Effectiveness of computerized decision support systems linked to electronic health records: A systematic review and meta-analysis. Am J Public Health. 2014; 104: e12-e22 Crossref PubMed Scopus (150) Google Scholar Less understood is how information from the interRAI-HC can be presented to support primary care practices. This report aims to explore physician views on the interRAI-HC as an information sharing tool.

Healthcare in Canada has been described as inefficient, fragmented, and physician-centered. 1 Heckman G.A. Hillier L. Manderson B. et al. Developing an integrated system of care for frail seniors. Healthc Manage Forum. 2013; 26: 200-208 Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar By providing computerized decision support systems (CDSS) to healthcare providers, improvements in quality of care, continuity of care, efficiency, communication, identification of risk factors, and adherence with best-practice guidelines are expected. 2 Garg A.X. Adhikari N.K.J. McDonald H. et al. Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: A systematic review. JAMA. 2005; 293: 1223-1238 Crossref PubMed Scopus (2160) Google Scholar Less understood are physicians' perspectives on if and how a CDSS should be developed. The aim of this study is to address this gap and inform the development of an effective CDSS for use by physicians.