Lynnette Chenoweth

Health professional perspectives on systems failures in transitional care for patients with dementia and their carers: a qualitative descriptive study.

BackgroundHealthcare professionals engage in discharge planning of people with dementia during hospitalisation, however plans for transitioning the person into community services can be patchy and ineffective. The aim of this study was to report acute, community and residential care health professionals’ (HP) perspectives on the discharge process and transitional care arrangements for people with dementia and their carers.MethodsA qualitative descriptive study design and purposive sampling was used to recruit HPs from four groups: Nurses and allied health practitioners involved in discharge planning in the acute setting, junior medical officers in acute care, general practitioners (GPs) and Residential Aged Care Facility (RACF) staff in a regional area in NSW, Australia. Focus group discussions were conducted using a semi-structured schedule. Content analysis was used to understand the discharge process and transitional care arrangements for people with dementia (PWD) and their carers.ResultsThere were 33 participants in four focus groups, who described discharge planning and transitional care as a complex process with multiple contributors and components.Two main themes with belonging sub-themes derived from the analysis were:Barriers to effective discharge planning for PWD and their carers - the acute care perspective: managing PWD in the acute care setting, demand for post discharge services exceeds availability of services, pressure to discharge patients and incomplete discharge documentation.Transitional care process failures and associated outcomes for PWD – the community HP perspective: failures in delivery of services to PWD; inadequate discharge notification and negative patient outcomes; discharge-related adverse events, readmission and carer stress; and issues with medication discharge orders and outcomes for PWD.ConclusionsAlthough acute care HPs do engage in required discharge planning for people with dementia, participants identified critical issues: pressure on acute care health professionals to discharge PWD early, the requirement for JMOs to complete discharge summaries, the demand for post discharge services for PWD exceeding supply, the need to modify post discharge medication prescriptions for PWD, the need for improved coordination with RACF, and the need for routine provision of medication dose decision aids and home medicine reviews post discharge for PWD and their carers.

Effects of facilitated family case conferencing for advanced dementia: A cluster randomised clinical trial.

Background Palliative care planning for nursing home residents with advanced dementia is often suboptimal. This study compared effects of facilitated case conferencing (FCC) with usual care (UC) on end-of-life care. Methods A two arm parallel cluster randomised controlled trial was conducted. The sample included people with advanced dementia from 20 Australian nursing homes and their families and professional caregivers. In each intervention nursing home (n = 10), Palliative Care Planning Coordinators (PCPCs) facilitated family case conferences and trained staff in person-centred palliative care for 16 hours per week over 18 months. The primary outcome was family-rated quality of end-of-life care (End-of-Life Dementia [EOLD] Scales). Secondary outcomes included nurse-rated EOLD scales, resident quality of life (Quality of Life in Late-stage Dementia [QUALID]) and quality of care over the last month of life (pharmacological/non-pharmacological palliative strategies, hospitalization or inappropriate interventions). Results Two-hundred-eighty-six people with advanced dementia took part but only 131 died (64 in UC and 67 in FCC which was fewer than anticipated), rendering the primary analysis under-powered with no group effect seen in EOLD scales. Significant differences in pharmacological (P < 0.01) and non-pharmacological (P < 0.05) palliative management in last month of life were seen. Intercurrent illness was associated with lower family-rated EOLD Satisfaction with Care (coefficient 2.97, P < 0.05) and lower staff-rated EOLD Comfort Assessment with Dying (coefficient 4.37, P < 0.01). Per protocol analyses showed positive relationships between EOLD and staff hours to bed ratios, proportion of residents with dementia and staff attitudes. Conclusion FCC facilitates a palliative approach to care. Future trials of case conferencing should consider outcomes and processes regarding decision making and planning for anticipated events and acute illness. Trial registration Australian New Zealand Clinical Trial Registry ACTRN12612001164886

Potential benefits to staff from humor therapy with nursing home residents.

Life in residential care can be challenging for residents and staff. Bringing humor into this setting may benefit residents, creating a more productive, enjoyable work environment for staff. The potential effect of exposure to humor therapy on staff, both as active and incidental participants, as part of a randomized controlled trial of the effect of humor therapy for aged care residents was investigated in the Sydney Multisite Intervention of LaughterBosses and ElderClowns (SMILE). The intervention involved a humor program with professional performers (ElderClowns) and trained facility staff (LaughterBosses) for a minimum of nine 2-hour sessions over 12 weeks. Methods included a staff survey at three time points, interviews with LaughterBosses, and a satisfaction rating by facility managers. There were significant positive findings for some staff subgroups, including assistants in nursing/personal care assistants and staff older than 45. LaughterBoss interviews and intervention group manager ratings of staff work enthusiasm were positive.

A facilitated approach to family case conferencing for people with advanced dementia living in nursing homes: perceptions of palliative care planning coordinators and other health professionals in the IDEAL study.

BACKGROUND Palliative care for nursing home residents with advanced dementia is often sub-optimal due to poor communication and limited care planning. In a cluster randomized controlled trial, registered nurses (RNs) from 10 nursing homes were trained and funded to work as Palliative Care Planning Coordinators (PCPCs) to organize family case conferences and mentor staff. This qualitative sub-study aimed to explore PCPC and health professional perceptions of the benefits of facilitated case conferencing and identify factors influencing implementation. METHOD Semi-structured interviews were conducted with the RNs in the PCPC role, other members of nursing home staff, and physicians who participated in case conferences. Analysis was conducted by two researchers using a thematic framework approach. RESULTS Interviews were conducted with 11 PCPCs, 18 other nurses, eight allied health workers, and three physicians. Perceived benefits of facilitated case conferencing included better communication between staff and families, greater multi-disciplinary involvement in case conferences and care planning, and improved staff attitudes and capabilities for dementia palliative care. Key factors influencing implementation included: staffing levels and time; support from management, staff and physicians; and positive family feedback. CONCLUSION The facilitated approach explored in this study addressed known barriers to case conferencing. However, current business models in the sector make it difficult for case conferencing to receive the required levels of nursing qualification, training, and time. A collaborative nursing home culture and ongoing relationships with health professionals are also prerequisites for success. Further studies should document resident and family perceptions to harness consumer advocacy.

Psychosocial changes following transition to an aged care home: qualitative findings from Iran

AIMS AND OBJECTIVES The study explored the psychosocial effects of transitioning from home to an aged care home for older Iranian people. BACKGROUND Moving from ones own home to a communal aged care home is challenging for older people and may give rise to numerous psychosocial responses. The extent and intensity of such changes have rarely been explored in Middle Eastern countries. DESIGN Data were collected through purposive sampling by in-depth semi-structured interviews with 20 participants (17 people living in aged care homes and three formal caregivers). All the interviews were recorded and typed, and conventional qualitative content analysis was used, eliciting common themes. RESULTS There were four common themes: communication isolation, resource change, monotone institutional life and negative emotional response. Participants lost their previous support systems when transitioning to an aged care home and were not able to establish new ones. Routine care was provided by formal caregivers with little attention to individual needs, and minimal support was given to help maintain the older persons independence. These losses gave rise to negative emotions in some of the participants, depending on their previous lifestyle and accommodation arrangements. CONCLUSIONS The extent and intensity of psychosocial changes occurring in most of the participants following their transition to an aged care home indicates the need for a review of Iranian aged care services. IMPLICATIONS FOR PRACTICE To assist older Iranian people adapt more readily when making the transition to aged care home and to meet their unique psychosocial needs, a family-centred approach to service delivery is recommended.

An evaluation of discharge documentation for people with dementia discharged home from hospital – A cross-sectional pilot study

This study evaluated discharge documentation for people with dementia who were discharged home, against expected discharge criteria and determined relationships between compliance scores and outcomes. This cross-sectional study audited discharge documentation and conducted a post discharge survey of carers. There were 73 eligible discharges and clinically significant documentation deficits for people with dementia included: risk assessments of confusion (48%), falls and pressure injury (56%); provision of medication dose-decision aids (53%), provision of contact information for patient support groups (6%) and advance care planning (9%). There was no significant relationship between compliance scores and outcomes. Carer strain was reported to be high for many carers. People with dementia and their carers are more vulnerable and at higher risk of poor outcomes after discharge. There are opportunities for improved provision of medications and risk assessment for people with dementia, provision of information for patient support groups and advanced care planning.