An image of a map of Canada showing the location of the 14 Implementation Science Teams.

Host institution: McMaster University

Research project:

Implementing and scaling up the long-term care palliative toolkit during COVID

Jurisdictions of Focus:

Saint John (New Brunswick), Hamilton (Ontario), Battleford (Saskatchewan)

Promising practices:

Presence of family; preparation, people in the workforce, planning for COVID-19 and non-COVID-19 care

Prior to COVID-19, our Strengthening a Palliative Approach in LTC (SPA-LTC) work highlighted how residents and families were faced with making critical and emotional end-of-life decisions without any preparatory discussions, resulting in stress and conflict. Most recently, the SPA-LTC team has developed a long-term care (LTC) palliative toolkit that can address the immediate LTC homes’ needs in response to COVID-19.

The research questions/objectives are to:

  1. Conduct a scale-up assessment of the new LTC palliative toolkit in three provinces 
  2. Identify ways to adapt the LTC palliative toolkit for diverse regions and contexts
  3. Document lessons learned from implementation in diverse settings
  4. Evaluate the implementation and effectiveness of the toolkit in participating LTC homes during COVID-19.

Host institution: Toronto Rehab, University Health Network

Research project:

Dementia Isolation Toolkit (DIT)

Jurisdictions of Focus:

Toronto, Petrolia, Sarnia (Ontario)

Promising practices:

Prevention, people in the workplace, plan for COVID and non-COVID care, presence of Family

The Dementia Isolation Toolkit (DIT) was designed and developed with LTC stakeholders to:

  1. To support the compassionate, safe and effective isolation and quarantine of residents of LTC during the COVID-19 pandemic
  2. To support the moral resilience of LTC staff.

In this project, we will evaluate the effectiveness of the DIT implementation program (DITi) and measure its impact on achieving effective, safe, and compassionate isolation, as well as reducing the moral distress of LTC staff. We will explore the impact of the DIT and DITi on other relevant outcomes arising out of a developmental evaluation and the Common Measurement Framework.

The impact of this project will include the development of evidence-informed implementation approaches and materials to facilitate the spread and sustainability of promising practices in person-centered isolation care and in supporting the moral resilience of staff across the LTC sector.

Host institution: Université Laval

Research project:

Préserver le lien des résidents en ESLD atteints de troubles cognitifs avec leurs proches en contexte de pandémie: évaluation de la mise en œuvre et des effets d’interventions virtuelles et en personnes

Common Measurement Framework:

This team will be leading the Common Measurement Framework for the Implementation Science Teams - Strengthening Pandemic Preparedness in Long-Term Care initiative.

Jurisdictions of Focus:

Saint-Jean-Port-Joli, Sainte-Marie, Thetford Mines, Saint-Augustin-de-Desmaures (Quebec)

Promising practices:

Presence of family

In Quebec, nearly 70% of the people who died of COVID-19-related complications were living in long-term care (LTC) homes. The restrictions imposed to curb the transmission of the virus have harmful effects on elderly people, as well as consequences for their informal caregivers. Several strategies are used to mitigate these negative effects in order to allow seniors to maintain contact with their loved ones and, in turn, to preserve their mental and physical health. However, evaluation research on the implementation and effects of innovative initiatives aimed at elderly people with cognitive disorders during the pandemic has yet to be done in Canada.

The project, conducted in collaboration with five partner LTC homes, aims to evaluate the implementation, feasibility and acceptability of initiatives to promote the presence of caregivers (either in person or virtually), as well as their effects on residents and caregivers and the associated costs. We will work with an evaluation research design. A multiple case study will be used to describe the reality of the institutions and the actors in the project, understand the complex relationships between a variety of factors, and document the degree and variability of the implementation between different institutions, as well as initiative outcomes. Residents with cognitive disorders, their caregivers and members of the care team will be recruited at each institution.

Initiatives to preserve resident contact with their caregivers that are encouraged by the person’s residential setting may mitigate the effects of isolation and have a considerable impact on anxiety, on cognitive symptoms and behaviours and on quality of life. We will document acceptability by collecting the opinions of the elderly, their caregivers and the care staff in order to argue that adapted initiatives with a human focus are viable and relevant in the context of LTC homes.

 

Host institution: University of Regina

Research project:

Presence of family and other informal caregivers in long-term care during COVID-19: A pragmatic cluster randomized trial

Jurisdictions of Focus:

Saint John (New Brunswick), Hamilton (Ontario), Regina (Saskatchewan)

Promising practices:

Presence of Family

Our Implementation Science Team is partnering with six long-term care and retirement home units in Saskatchewan, Ontario and New Brunswick to support the reintegration of family caregivers. Our team is also supporting the reintegration of other informal caregivers who play an important social role for residents who have no or less involved family caregivers. 

Using a pragmatic cluster randomized controlled trial, we will compare outcomes from three of the units that will focus on the reintegration of family caregivers alone and outcomes from the remaining three units that will focus on the reintegration of both family and other informal caregivers. 

Components of the intervention will include the identification of caregivers and a point of contact for caregivers, development of a consistent screening process and safety protocols for caregivers, establishment of a rapid appeals process, pre-entry preparation of caregivers through supportive education, and staff education to understand the essential roles of caregivers. Resident, caregiver and staff outcomes related to loneliness, social support, resilience, and burnout will be measured before, during, and after the implementation of the interventions.

 

Host institution: University of Calgary

Research project:

Development and Implementation of a Clinical Care Pathway for Frail Older Adults in Long-Term Care

Jurisdictions of Focus:

Calgary (Alberta), Burnaby (British Columbia)

Promising practices:

Preparation, planning for COVID-19 and non-COVID-19 care

The COVID pandemic has highlighted the urgent need to improve palliative care that is specific to long-term care (LTC) residents with frailty, and effective and practical care strategies for this complex care setting must be developed. We are developing a clinical pathway that focuses on frailty and early palliative care for LTC residents, leading to improved care planning and outcomes. 

Our overarching goal is to develop an evidence-based care pathway for early recognition of frailty plus initiation of early palliative care for LTC residents appropriate to degree of frailty. 

 

Host institution: University of Calgary

Research project:

Supporting mental health and preventing moral injury among long term care workers

Jurisdictions of Focus:

Edmonton, Calgary, Okotoks (Alberta)

Promising practices:

People in the workforce

For long-term care (LTC) workers, moral injury may occur from experiences such as guilt over being required to “police” end of life visits, where family members are only permitted to touch dying loved ones through gloved hands. The concept of moral injury is being newly and necessarily applied to understand occupational stress of healthcare workers during COVID-19. Compared to individually focused concepts such as burnout, moral injury locates the source of problems in the structures and processes in which individuals are immersed. 

Our research question is: how do we support mental health and help prevent moral injury among LTC workers? 

 

Host institution: Bruyère Research Institute

Research project:

Presence of Family: (re)Integrating Family Caregivers

Jurisdictions of Focus:

Ottawa, Markdale, Tavistock (Ontario)

Promising practices:

Presence of Family

The Presence of Family: (Re)Integrating Essential Care Partners in Ontario’s LTC Homes project will help develop and disseminate a promising practice intervention concerning the presence of family members in long-term care (LTC). Our work will help essential care partners, who are chosen by the resident and who provide them with vital physical/psycho-social care, to have safe access to the LTC home. 

Drawing on existing approaches and tools supported by The Change Foundation, Ontario Caregiver Organization, Ontario Centres for Learning, Research and Innovation in Long-Term Care, and the Canadian Foundation for Healthcare Improvement, three homes have initiated a Designated Care Partner program that combines training with a commitment to follow safety protocols and use ID badges, facilitating greater access for essential care partners to the home. 

We will use developmental evaluation and a rapid scoping review to support the homes as they implement the intervention. 

 

Host institution: Mount Saint Vincent University

Research project:

Implementation of policies that support and hinder families as partners in care during COVID-19 pandemic

Jurisdictions of Focus:

Digby, Sydney, Debert, Halifax (Nova Scotia), Charlottetown, Summerside (Prince Edward Island)

Promising practices:

Presence of family

This work aligns with practices that enhance the presence of family in long-term care (LTC) and the growing body of research that confirms family plays a critical role in LTC. 

Our aims are:

  1. To explore and identify the contextual attributes of settings where support visitations have been adopted to articulate successful implementation processes
  2. To understand facilitators that support the implementation of support visitations as COVID-19 remains present in LTC and broader community settings
  3. To understand how family has been engaged/represented in the implementation process
  4. To assess the outcomes and impacts of support visitations on residents, family and staff
  5. To obtain insights into implementation and sustainability factors from other jurisdictions adopting similar support visitations practice.
 

Host institution: University of Ottawa

Research project:

Making “non-essential” family/volunteer caregiving essential in LTC

Jurisdictions of Focus:

Ottawa, Welland, Vanier, Nepean (Ontario)

Promising practices:

Presence of family, people in the workforce

The “no-visitor policies” put in place because of COVID-19 have resulted in substantial negative outcomes for residents, families, caregivers, volunteers, and health care professionals. This project will provide rigorous data to address the following implementation questions: 

  1. Can new procedures to distinguish between family/volunteers/caregivers who are essential partners in care and those who are not be implemented successfully and sustained over time?
  2. If family/volunteers/caregivers are not permitted in the home, can alternate initiatives for ensuring virtual contact be successfully implemented and what impact do those have on family, resident and healthcare professional outcomes?
 

Host institution: Centre de recherche de l'Institut universitaire de gériatrie de Montréal

Research project:

Nutrition as Medication: de la recherche à l’implantation

Jurisdictions of Focus:

Montreal (Quebec)

Promising practices:

Planning for COVID-19 and non-COVID-19 care

Malnourishment and weight loss are endemic in LTC homes, and they have dire consequences, including a greater risk of mortality and morbidity such as pressure sores and respiratory infections. This problem has been exacerbated during the pandemic. LTC home workers report that they have seen a rapid decline in the nutritional state of people suffering from COVID-19. At the same time, residents who did not contract the virus also had significant, undesirable weight loss. Weight loss prevention strategies must aim to increase energy and encourage protein intake. While oral nutritional supplements are a common way to achieve this goal, actual consumption levels for these products remain relatively low.  
Since 2017, an intervention strategy called Nutrition as Medication (NAM) has been developed and tested in LCT homes by our team. NAM consists in prescribing small doses (30 or 60 ml) of an oral nutritional supplement, administered as medication. 

The efficacy of NAM has been studied, and the preliminary results show a high rate of administration (90%–95%), a significant improvement in residents’ nutritional state, and a decrease in pressure sores. A guide was written based on these outcomes, describing NAM and its principles and suggesting a strategy to implement it successfully in LTC homes. 

NAM appears to be a promising approach to limiting, and maybe even preventing, the decline in residents’ nutritional state, whether they have COVID-19 or not. The practice was, however, studied before the pandemic, and the guide does not account for this context. Therefore, in a bid to equip LTC homes to better weather the second wave of the pandemic, our team is proposing the large-scale adoption of NAM in LTC homes. More specifically, we will: 

  1. Follow the implementation of NAM in Montréal’s LTC homes
  2. Evaluate the implementation of NAM in terms of the prescription and administration of the treatment
  3. Identify the enabling and constraining factors that affect the implementation of NAM
  4. Identify the effect of NAM as perceived by LTC workers and caregivers/residents
  5. Revise the NAM implementation material 

Host institution: Ryerson University

Research project:

Finding a Better Balance: Implementing Family Presence in Ontario LTC Homes

Jurisdictions of Focus:

Toronto, Ottawa (Ontario)

Promising practices:

Presence of family

Between March and April of 2020 when outbreaks and deaths intensified in Canadian long-term care (LTC) homes, provinces across the country implemented strict blanket “no visitor” policies as part of their LTC infection prevention and control (IPAC) strategies. These policies completely shut out family caregivers who provide direct care for many complex LTC home residents, resulting in countless LTC residents experiencing severe and potentially avoidable harms, including declines in physical, cognitive, psychological and functional status. This led to increasing concerns about ongoing “visitor” restrictions in LTC homes and worries that the risks of harm associated with these policies may outweigh their benefits related to preventing COVID-19 outbreaks. 

In response, members of our implementation science team (IST) published National Institute on Ageing (NIA) guidance in July 2020 on the reopening of Canadian LTC homes to family caregivers and visitors during the COVID-19 pandemic. This guidance was widely disseminated, and led to several provinces updating their visitor policies, including Ontario’s Ministry of Long-Term Care (MLTC) which now allows residents or their substitute decision makers to designate up to two family caregivers who can “visit” at any time and without restriction. In spite of this policy change, reports from residents and family caregivers collated by our team suggest an inconsistent and incomplete implementation of this updated family presence policy. Many LTC homes have voiced concerns about the lack of data being collected on the policy change, uncertainty regarding the safety of the policy in terms of elevated risk for COVID-19 outbreaks, and inadequate resourcing to support the full implementation of the policy. 

To address this gap, our IST will work to accelerate the availability of high quality, real-time, actionable evidence for LTC homes and policymakers grappling with finding a balance between visitor and family caregiver access to LTC homes and infection prevention and control during the COVID-19 pandemic. Our multiphase project will accomplish the following objectives: 

  1. Update provincial data collection tools to capture metrics on caregiver and visitor access to LTC homes and LTC resident absences and their relation to relationship with COVID-19 outbreaks in LTC homes
  2. Conduct an analysis of provincial quantitative data on caregiver and visitor access and qualitative LTC home data on the barriers and facilitators to implementing family presence
  3. Execute and study an implementation strategy at our partner LTC homes, and create a learning collaborative on the implementation of family presence in LTC homes across the province.
 

Host institution: University Health Network – Toronto Rehabilitation Institute (KITE)

Research project:

Nurse Practitioner Led Implementation of Health Workforce Recommendations In Long Term Care Homes During a Pandemic - IST/p>

Jurisdictions of Focus:

Waterloo, Sarnia (Ontario)

Promising practices:

People in the Workforce, planning for COVID-19 and non-COVID-19 care

There is an urgency to respond to the ongoing challenges facing the long-term care (LTC) sector which have been uncovered by the COVID-19 pandemic. To address these challenges and contribute to mitigating the effects of any future outbreaks, members of our team along with their international colleagues have developed recommendations to support staff during COVID-19 (e.g. provide clear direction and guidance, keep staff healthy, promote effective human resource policies, implement new clinical practices) and improve infection control practices in nursing homes (McGilton et al., 2020, JAMDA).  

Preliminary findings from our ongoing work with Nurse Practitioners (NPs) have provided convincing evidence that NPs are well positioned to disseminate and implement these recommendations in LTC homes. This implementation study will determine the steps and resources that are necessary to adapt the guidelines to the context of and to effectively implement them in two homes.

The focus of the grant is to: 

  1. Adapt the recommendations to the context of the two homes (phase 1)
  2. Pilot test and evaluate the adaptation of the recommendations by focusing on feasibility, fidelity, cost and sustainability of implementing them per each LTCH context (phase 2).  

 

Host institution: University of British Columbia

Research project:

Implementation of the “one high risk site only” policy

Jurisdictions of Focus:

Vancouver, Richmond, Mission (British Columbia)

Promising practices:

People in the workforce

To stop the virus spread in long-term care (LTC), and to ensure health and safety of staff, residents and their families, the Public Health Agency of Canada instituted a number of evidence-based rapid redesign and resource redeployment practices, including strict visitation and “one high risk site” staffing policies. 

In this proposal we focus on the “one high risk site” staffing policy, prohibiting LTC staff from employment in more than one facility. Our research is guided by the Consolidated Framework for Implementation Research (CFIR). We will use the CFIR framework domains and their associated constructs to describe “one high risk site” policy implementation at each LTC partner site.  

Host Institution: Fraser Health Authority

Research project:

A Resident/Family-Centered, Team-Based Quality Improvement Collaborative Approach to Comprehensive PAndemic Preparedness in LOng-term Care Homes (PAPLOC study)

Jurisdiction of Focus:

Abbotsford, New Westminster, Coquitlam (British Columbia)

Promising Practice: 

Preparation

To stop the virus spread in long-term care (LTC), and to ensure health and safety of staff, residents and their families, the Public Health Agency of Canada instituted a number of evidence-based rapid redesign and resource redeployment practices, including strict visitation and “one high risk site” staffing policies. In this proposal we focus on the “one high risk site” staffing policy, prohibiting LTC staff from employment in more than one facility. We currently have four LTC partner facilities. We will use the CFIR framework domains and their associated constructs to describe “one high risk site” policy implementation at each LTC partner site.