Objective: Long-term care (LTC) homes (“nursing homes”) were challenged during the first year of the COVID-19 pandemic in Canada. The objective of this study was to measure the impact of the COVID-19 pandemic on resident admission and discharge rates, resident health attributes, treatments, and quality of care. Design: Synthesis analysis of “Quick Stats” standardized data table reports published yearly by the Canadian Institute for Health Information. These reports are a pan-Canadian scorecard of LTC services rendered, resident health characteristics, and quality indicator performance. Setting and participants: LTC home residents in Alberta, British Columbia, Manitoba, and Ontario, Canada that were assessed with the interRAI Minimum Data Set 2.0 comprehensive health assessment in fiscal years 2018/2019, 2019/2020 (pre-pandemic period), and 2020/2021 (pandemic period). Methods: Risk ratio statistics were calculated to compare admission and discharge rates, validated interRAI clinical summary scale scores, medication, therapy and treatment provision, and seventeen risk-adjusted quality indicator rates from the pandemic period relative to prior fiscal years. Results: Risk of dying in the LTC home was greater in all provinces (risk ratio [RR] range 1.06-1.18) during the pandemic. Quality of care worsened substantially on 6 of 17 quality indicators in British Columbia and Ontario, and 2 quality indicators in Manitoba and Alberta. The only quality indicator where performance worsened during the pandemic in all provinces was the percentage of residents that received antipsychotic medications without a diagnosis of psychosis (RR range 1.01-1.09) Conclusions and implications: The COVID-19 pandemic has unveiled numerous areas to strengthen LTC and ensure that resident’s physical, social, and psychological needs are addressed during public health emergencies. Except an increase in potentially inappropriate antipsychotic use, this provincial-level analysis indicates that most aspects of resident care were maintained during the first year of the COVID-19 pandemic.

that an increase in administration also occurred in the previous year among Alberta residents. Our analysis was a comparison of the pandemic period against the 2 most recent historical years and did not test for year-over-year trends. Interrupted time series analysis by Hoben et al 3 supports Dr. Quail’s argument that the inappropriate use of antipsychotic medications increased in the years leading up to the pandemic in Alberta. However, in alignment with our own findings, the rate of that increase accelerated significantly during the pandemic period. We offer supplemental analysis of pairwise comparisons back to 2013/2014 when Alberta was first included in the annual CIHI “Quick Stats” report (Figure 1). This illustrates that (1) the increase during the pandemic period was significant relative to all years since 2014/2015 and (2) the magnitude of the increase observed in recent years was largest during the pandemic period. Without question, a greater percentage of residents received inappropriate antipsychotic medications during the pandemic period.

Background In Canada, publicly-funded home care programs enable older adults to remain and be cared for in their home for as long as possible but they often differ in types of services offered, and the way services are delivered. This paper examines whether these differing approaches to care shape the pathway that home care clients will take. Older adult client pathways refer to trajectories within, and out of, the home care system (e.g., improvement, long term care (LTC) placement, death). Methods A retrospective analysis of home care assessment data (RAI-HC was linked with health administrative data, long-term care admissions and vital statistics in Nova Scotia Health (NSH) and Winnipeg Regional Health Authority (WRHA). The study cohort consists of clients age 60 + years, admitted to home care between January 1, 2011 to December 31, 2013 and up to four years from baseline. Differences in home care service use, client characteristics and their pathways were tested across the two jurisdictions overall, and among the four discharge streams within jurisdictions using t-tests and chi-square tests of significance. Results NS and WHRA clients were similar in age, sex, and marital status. NS clients had higher levels of need (ADL, cognitive impairment, CHESS) at base line and were more likely discharged to LTC (43% compared to 38% in WRHA). Caregiver distress was a factor correlated with being discharged to LTC. While a third remained as home care clients after 4 years; more than half were no longer in the community – either discharged to LTC placement or death. Such discharges occurred on average at around two years, a relatively short time period. Conclusions By following older clients over 4 years, we provide enhanced evidence of client pathways, the characteristics that influence these paths, as well as the length of time to the outcomes. This evidence is central to identification of clients at risk in the community and aids in planning for future home care servicing needs that will allow more older adults to remain living in the community.

Abstract Background The Hospital Frailty Risk Score (HFRS) is scored using ICD-10 diagnostic codes in administrative hospital records. Home care clients in Canada are routinely assessed with Resident Assessment Instrument-Home Care (RAI-HC) which can calculate the Clinical Frailty Scale (CFS) and the Frailty Index (FI). Objective Measure the correlation between the HFRS, CFS and FI and compare prognostic utility for frailty-related outcomes. Design Retrospective cohort study. Setting Alberta, British Columbia and Ontario, Canada. Subjects Home care clients aged 65+ admitted to hospital within 180 days (median 65 days) of a RAI-HC assessment (n = 167,316). Methods Correlation between the HFRS, CFS and FI was measured using the Spearman correlation coefficient. Prognostic utility of each measure was assessed by comparing measures of association, discrimination and calibration for mortality (30 days), prolonged hospital stay (10+ days), unplanned hospital readmission (30 days) and long-term care admission (1 year). Results The HFRS was weakly correlated with the FI (ρ 0.21) and CFS (ρ 0.28). Unlike the FI and CFS, the HFRS was unable to discriminate for 30-day mortality (area under the receiver operator characteristic curve (AUC) 0.506; confidence interval (CI) 0.502–0.511). It was the only measure that could discriminate for prolonged hospital stay (AUC 0.666; CI 0.661–0.673). The HFRS operated like the FI and CFI when predicting unplanned readmission (AUC 0.530 CI 0.526–0.536) and long-term care admission (AUC 0.600; CI 0.593–0.606). Conclusions The HFRS identifies a different subset of older adult home care clients as frail than the CFS and FI. It has prognostic utility for several frailty-related outcomes in this population, except short-term mortality.

Abstract The public home care (PHC) system in Canada is heavily reliant on family caregivers to enable clients to stay in the community. When caregivers are present, there are concerns formal home care aide (HCA) services are less available. Using data from the Resident Assessment Instrument for Home Care (RAI-HC), we examined caregiver and client characteristics in relation to HCA service amounts. Our cohorts were individuals aged 60+ receiving an initial RAI-HC assessment in 2011-2013, and one subsequent assessment in two provincial jurisdictions: the Winnipeg Regional Health Authority (n=5,251) and Nova Scotia Health (n=5291). We measured weekly HCA hours and constructed a predictive model for hours of care controlling for client need. To identify the most underserved client population, we calculated the ratio between predicted to actual received hours of care ascertaining the lowest client quintile. In both jurisdictions, the odds of being underserviced were higher when the client co-resided or had a spouse. Clients living alone at initial intake were least likely to be underserved. Caregiver characteristics increasing the risk of being underserved in Winnipeg included providing IADLs/ADLs support, caring more than 14 hours per week and being unable to continue. Rurality increased risk of underservice in Nova Scotia. These findings contribute to the debate: is PHC a supplement or substitution for family care? PHC as a supplement to family care was more pronounced in Winnipeg and in rural Nova Scotia. Implications for greater equity across regions is explored using an Equity, Diversity and Inclusion lens.

OBjeCTIVe: Long-term care (LTC) homes (“nursing homes”) were challenged during the first year of the COVID-19 pandemic in Canada. The objective of this study was to measure the impact of the COVID-19 pandemic on resident admission and discharge rates, resident health attributes, treatments, and quality of care. DeSIgn: Synthesis analysis of “Quick Stats” standardized data table reports published yearly by the Canadian Institute for Health Information. These reports are a pan-Canadian scorecard of LTC services rendered, resident health characteristics, and quality indicator performance. SeTTIng AnD PARTICIPAnTS: LTC home residents in Alberta, British Columbia, Manitoba, and Ontario, Canada that were assessed with the interRAI Minimum Data Set 2.0 comprehensive health assessment in fiscal years 2018/2019, 2019/2020 (pre-pandemic period), and 2020/2021 (pandemic period). MeTHODS: Risk ratio statistics were calculated to compare admission and discharge rates, validated interRAI clinical summary scale scores, medication, therapy and treatment provision, and seventeen risk-adjusted quality indicator rates from the pandemic period relative to prior fiscal years. ReSuLTS: Risk of dying in the LTC home was greater in all provinces (risk ratio [RR] range 1.10 to 1.29) during the pandemic. Quality of care worsened substantially on 6 of 17 quality indicators in British Columbia and Ontario, and 2 quality indicators in Manitoba and Alberta. The only quality indicator where performance worsened during the pandemic in all provinces was the percentage of residents that received antipsychotic medications without a diagnosis of psychosis (RR range 1.02 - 1.16). COnCLuSIOnS AnD IMPLICATIOnS: The COVID-19 pandemic has unveiled numerous areas to strengthen LTC and ensure that resident’s physical, social, and psychological needs are addressed during public health emergencies. Except an increase in potentially inappropriate antipsychotic use, this provincial-level analysis indicates that most aspects of resident care were maintained during the first year of the COVID-19 pandemic.

Publicly funded home care in Canada supports older adults in the community to delay institutional care, which results in complex care populations with multimorbidity that includes mental health problems. The purpose of this study is to examine prevalence of psychiatric diagnoses and other mental health symptoms among older clients in two publicly funded Home Care (HC) Programs and their psychiatry service utilization (psychiatrist visits) after being admitted to home care. This retrospective cohort study examines clients age 60 years and older in the two Canadian provinces of Manitoba (MB), specifically the Winnipeg Regional Health Authority (WRHA) ( n = 5,278), and Nova Scotia (NS) ( n = 5,323). Clients were admitted between 2011 and 2013 and followed up to 4 years. Linked data sources include the InterRAI Resident Assessment Instrument for Home Care (RAI-HC), physician visit/billing data and hospital admission data. Both regions had similar proportions (53%) of home care clients with one or more psychiatric diagnoses. However, we observed over 10 times the volume of psychiatry visits in the WRHA cohort (8,246 visits vs. 792 visits in NS); this translated into a 4-fold increased likelihood of receiving psychiatry visits (17.2% of WRHA clients vs. 4.2% of NS clients) and 2.5 times more visits on average per client (9.1 avg. visits in MB vs. 3.6 avg. visits in NS). The location of psychiatry services varied, with a greater number of psychiatry visits occurring while in hospital for WRHA HC clients compared to more visits in the community for NS HC clients. Younger age, psychotropic medication use, depressive symptoms, dementia, and having an unstable health condition were significantly associated with receipt of psychiatry visits in both cohorts. Access to psychiatric care differed between the cohorts despite little to no difference in need. We conclude that many home care clients who could have benefitted from psychiatrist visits did not receive them. This is particularly true for rural areas of NS. By linking the RAI-HC with other health data, our study raises important questions about differential access to psychiatry services by site of care (hospital vs. community), by geographical location (MB vs. NS and urban vs. rural) and by age. This has implications for staff training and mental health resources in home care to properly support the mental health needs of clients in care. Study results suggest the need for a mental health strategy within public home care services.

Objective: The main objective was to develop a decision-support tool to assess the risk of caregiver burden, the Caregiver Risk Evaluation (CaRE) algorithm. Methods: Home care clients were assessed using the Resident Assessment Instrument for Home Care (RAI-HC). Their caregiver completed the 12-item Zarit Burden Interview (ZBI), the main dependent measure, which was linked to the RAI-HC. Results: In the sample (n = 344), 48% were aged 85+ years and 61.6% were female. The algorithm can be collapsed into four categories (low, moderate, high, and very high risk). Relative to the low-risk group, clients in the very high-risk group had an odds ratio of 5.16 (95% confidence interval: [2.05, 12.9]) for long-term care admission, after adjusting for client age, sex, and regional health authority. Discussion: The CaRE algorithm represents a new tool to be used by home care clinicians as they proactively plan for the needs of clients and their caregivers.

Background Enhancing non-clinical home care supports and services for older adults to live well is a strategic priority in developed countries, including Canada. Underpinning these supports and services are structures of care that are reflected in home care policies, programs and practices within jurisdictions. These approaches to care exist at multiple levels and inform interactions, perceptions, and care assessment, planning and provision, ultimately shaping the supports that are delivered. Jurisdictional differences in approaches to care mean that pathways through home care systems may differ, depending on where one lives. The goal of this study is to understand how approaches to care shape the pathways of older adult home care clients with chronic and long term conditions in two Canadian health jurisdictions. Methods This longitudinal mixed-methods study has three interrelated research streams informed by aspects of the socio-ecological framework. We will examine client pathways using a retrospective analysis of home care assessment data (Resident Assessment Instrument- Home Care) in two health authorities (Client/Service Data Stream). We will analyze interview data from older adult home care clients and a cluster of each client’s family or friend caregiver(s), home support worker(s), care/case coordinator(s) and potentially other professionals at up to three points over 18 months using a prospective qualitative comparative case study design (Constellation Data Stream). We will review home care policies relevant to both health authorities and interview key informants regarding the creation and implementation of policies (Policy Stream). Our study will apply an integrated knowledge translation (iKT) approach that engages knowledge users in research design, analysis and interpretation to facilitate relevancy of results. Discussion Applying a mixed-method research design to understand approaches to care within and between two jurisdictions will contribute to the evidence base on older adult home care client pathways. Study results will identify how potential differences are experienced by clients and their families. An understanding of the policies will help to contextualize these findings. The iKT model will ensure that findings are useful for strategic planning and decision-making, and supporting changes in care practice.

OBJECTIVES:To evaluate the impact of a multicenter intervention to reduce potentially inappropriate antipsychotic use in Canadian nursing homes at the individual and facility levels.DESIGN:Longitudinal, population-based cohort study to evaluate the Canadian Foundation for Healthcare Improvement's Spreading Healthcare Innovations Initiative to reduce potentially inappropriate antipsychotic use in 6 provinces/territories.SETTING AND PARTICIPANTS:Adults in nursing homes in 6 provinces/territories in Canada between 2014 and 2016. The sample involved 4927 residents in 45 intervention homes and 122,570 residents in 1193 control homes in the first quarter of the study.MEASURES:Assessment data based on the Resident Assessment Instrument 2.0 were used in both settings to track antipsychotic use and to obtain risk-adjusters for a quality indicator on potentially inappropriate use.INTERVENTION:Quality improvement teams in participating organizations were provided with education, training, and support to implement localized strategies intended to reduce antipsychotic medication use in residents without diagnosis of psychosis.RESULTS:At the resident level, we found that the odds of remaining on potentially inappropriate antipsychotics were 0.75 in intervention compared with control homes after adjusting for age, sex, aggressive behavior, and cognition. These findings were evident within the pooled Canadian data as well as within provinces. At the facility level, the intervention homes had greater improvements in risk-adjusted quality indicator performance than the control homes, and this was true for the worst, median, and best-performing homes at baseline. There was no major change in the quality indicator for worsening of behavior symptoms.CONCLUSIONS/IMPLICATIONS:The Canadian Foundation for Healthcare Improvement intervention was associated with a reduction in potentially inappropriate antipsychotic use at both the individual and facility levels of analysis. This improvement in performance was independent of secular trends toward reduced antipsychotic use in participating provinces. This suggests that substantial improvements in medication use may be achieved through targeted, collaborative quality improvement initiatives in long-term care.

IntroductionHome care clients are increasingly medically complex, have limited access to effective chronic disease management and have very high emergency department (ED) visitation rates. There is a need for more appropriate and targeted supportive chronic disease management for home care clients. We aim to evaluate the effectiveness and preliminary cost effectiveness of a targeted, person-centred cardiorespiratory management model.Methods and analysisThe Detection of Indicators and Vulnerabilities of Emergency Room Trips (DIVERT) — Collaboration Action Research and Evaluation (CARE) trial is a pragmatic, cluster-randomised, multicentre superiority trial of a flexible multicomponent cardiorespiratory management model based on the best practice guidelines. The trial will be conducted in partnership with three regional, public-sector, home care providers across Canada. The primary outcome of the trial is the difference in time to first unplanned ED visit (hazard rate) within 6 months. Additional secondary outcomes are to identify changes in patient activation, changes in cardiorespiratory symptom frequencies and cost effectiveness over 6 months. We will also investigate the difference in the number of unplanned ED visits, number of inpatient hospitalisations and changes in health-related quality of life. Multilevel proportional hazard and generalised linear models will be used to test the primary and secondary hypotheses. Sample size simulations indicate that enrolling 1100 home care clients across 36 clusters (home care caseloads) will yield a power of 81% given an HR of 0.75.Ethics and disseminationEthics approval was obtained from the Hamilton Integrated Research Ethics Board as well as each participating site’s ethics board. Results will be submitted for publication in peer-reviewed journals and for presentation at relevant conferences. Home care service partners will also be informed of the study’s results. The results will be used to inform future support strategies for older adults receiving home care services.Trial registration numberNCT03012256.

Objective: To determine whether a Comprehensive Unit-based Safety Program could be used to enhance a culture of patient safety and improvemedication safety at 1 pilot site. Methods: The Canadian Patient Safety Culture Survey tool was used to assess the culture of patient safety and drill down on the key factors contributing to medication errors. Based on staff input and site improvement team investigations, solutions were developed to address medication safety issues. The main outcome measure was pre-/postintervention Canadian Patient Safety Culture scores. Change in frequency of occurrence reporting and staff's overall project experience were also measured. Results: Overall perceptions of patient safety culture improved from 70% preintervention to 76.8% postintervention, representing a 9.7% change. Volume of occurrence reporting showed a marked increase postintervention. The project was well received by staff, with 84% rating their experience as "Good" to "Excellent." Finally 100% of participants reported that they learned something new and that this information could be applied to improve their day-to-day work. Conclusion: Implementing a Comprehensive Unit-based Safety Program improved staff's perceptions of patient safety, contributing to improved medication safety. To our knowledge, this is the first application of Comprehensive Unit-based Safety Program to successfully enhance patient safety in the home care setting.

Following the publication of this article [1], the authors noticed that the results presented in the results section of the article were erroneously reported in the results section of the abstract.

This article discusses key findings from a preliminary review of a nursing care delivery model implemented in Winnipeg, Manitoba, by the Winnipeg Regional Health Authority Home Care Program in 2014. Results suggest that the model is generally seen positively by staff but challenging to implement, given established administrative practices. To meet future demands on the healthcare system, home care programs need policies and procedures that empower nurses to perform as true community health nurses.

OBJECTIVES:To develop and validate a prognostic case finding tool that classifies the risk of emergency department (ED) use in an older home care population. DESIGN:Population-based retrospective cohort study using routinely collected data from home care clinical assessments linked prospectively to ED records. SETTING:Ontario and the Winnipeg Regional Health Authority, Canada. PARTICIPANTS:Older adults living at home and expected to receive in-home services for at least 60 days (N = 361,942). MEASUREMENTS:One or more ED visits within 6 months after an in-home clinical assessment was used as the main dependent measure. Ninety-five person-level risk measures from a clinical assessment instrument were selected as potential independent variables. The Detection of Indicators and Vulnerabilities for Emergency Room Trips (DIVERT) Scale was derived using recursive partitioning analyses informed by a multinational clinical panel. RESULTS:Overall, 41.2% had one or more ED visits within 6 months of their in-home assessment. Previous ED use and cardiorespiratory symptoms, cardiac conditions, and specific geriatric syndromes were predictors within the six-level DIVERT Scale. The scale provided adequate risk differentiation for case finding, with an area under the receiver operating characteristic curve of 0.62 (95% confidence interval = 0.61-0.62) and distinct risk gradients between risk scores. The multilevel validation demonstrated consistent performance across geographic and participant clusters. CONCLUSION:The DIVERT Scale is a valid case-finding tool for ED use in older home care clients. It may be suitable for preemptively and systematically risk-stratifying individuals or groups for additional assessment, case management, and preventative interventions. It may also be suitable for the stratification and adjustment of performance metrics.

Home care demand in Canada has more than doubled in recent years. While research related to safety in home care is growing, it lags behind that of patient safety in institutional settings. One of the gaps in the literature is the study of the perceptions of home care triads (clients, their unpaid caregivers, and paid providers). Thus, the objectives of this qualitative study were to describe the safety challenges of home care triads and to further understand the multiple dimensions of safety that contribute to or reduce safety concerns for these triads. Findings indicate that clients, unpaid caregivers, and providers struggle in the home care system. Home care models that are client centered need to be considered to provide seamless, quality, sustainable home care.

Background: Persons with certain neurological conditions have higher mortality rates than the population without neurological conditions, but the risk factors for increased mortality within diagnostic groups are less well understood. The interRAI CHESS scale has been shown to be a strong predictor of mortality in the overall population of persons receiving health care in community and institutional settings. This study examines the performance of CHESS as a predictor of mortality among persons with 11 different neurological conditions.Methods: Survival analyses were done with interRAI assessments linked to mortality data among persons in home care (n = 359,940), complex continuing care hospitals/units (n = 88,721), and nursing homes (n = 185,309) in seven Canadian provinces/territories.Results: CHESS was a significant predictor of mortality in all 3 care settings for the 11 neurological diagnostic groups considered after adjusting for age and sex. The distribution of CHESS scores varied between diagnostic groups and within diagnostic groups in different care settings.Conclusions: CHESS is a valid predictor of mortality in neurological populations in community and institutional care. It may prove useful for several clinical, administrative, policy-development, evaluation and research purposes. Because it is routinely gathered as part of normal clinical practice in jurisdictions (like Canada) that have implemented interRAI assessment instruments, CHESS can be derived without additional need for data collection.

Objectives The objectives of this study were to document the incidence rate and types of adverse events (AEs) among home care (HC) clients in Canada; identify factors contributing to these AEs; and determine to what extent evidence of completion of incident reports were documented in charts where AEs were found.Methods This was a retrospective cohort study based on expert chart review of a random sample of 1200 charts of clients discharged in fiscal year 2009-2010 from publicly funded HC programmes in Manitoba, Quebec and Nova Scotia, Canada.Results The results show that 4.2% (95% CI 3.0% to 5.4%) of HC patients discharged in a 12-month period experienced an AE. Adjusting to account for clients with lengths of stay in HC of less than 1year, the AE incidence rate per client-year was 10.1% (95% CI 8.4% to 11.8%); 56% of AEs were judged preventable. The most frequent AEs were injuries from falls, wound infections, psychosocial, behavioural or mental health problems and adverse outcomes from medication errors. More comorbid conditions (OR 1.15; 95% CI 1.05 to 1.26) and a lower instrumental activities of daily living score (OR 1.54; 95% CI 1.16 to 2.04) were associated with a higher risk of experiencing an AE. Clients' decisions or actions contributed to 48.4% of AEs, informal caregivers 20.4% of AEs, and healthcare personnel 46.2% of AEs. Only 17.3% of charts with an AE contained documentation that indicated an incident report was completed, while 4.8% of charts without an AE had such documentation.Conclusions Client safety is an important issue in HC, as it is in institutionalised care. HC includes the planned delivery of self-care by clients and care provision by family, friends and other individuals often described as informal' caregivers. As clients and these caregivers can contribute to the occurrence of AEs, their involvement in the delivery of healthcare interventions at home must be considered when planning strategies to improve HC safety.