Meet the Implementation Science Teams

Promising practice: Presence of family
Jurisdictions of focus: Ottawa, Markdale, Tavistock (Ontario)

Our project focuses on giving essential care partners of long-term care (LTC) residents vital physical and psycho-social care. We aim to develop and disseminate a intervention to enable essential care partners safe access to their loved one’s 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, Health Excellence Canada (previously Canadian Foundation for Healthcare Improvement and Canadian Patient Safety Institute), three LTC homes have initiated a Designated Care Partner program. The program combines training with a commitment to follow safety protocols and use ID badges, so essential care partners can have greater access to the home.

Promising practice: Plan for COVID-19 and non-COVID-19 care
Jurisdictions of focus: Ottawa, Brampton (Ontario)

For long-term care (LTC) residents with and without COVID-19, palliative approaches to care are vital for quality care. However, the capacity of LTC homes to introduce and embed palliative care can be hindered by poor communication or information about prognosis.

In our project we will rapidly implement and evaluate the Risk Evaluation for Support: Predictions for Elder-life in the Community Tool in LTC (RESPECT–LTC), to support health and social service providers’ ongoing efforts to embed palliative approaches to care in their processes and culture.

RESPECT–LTC is a mortality-risk communication tool that accurately predicts an older adults’s six-month mortality risk as well as life expectancy, to inform health and social service providers’ decision-making regarding the initiation of palliative and/or end-of-life care. The tool was co-designed with patients and caregivers.

Promising practices: Preparation; plan for COVID-19 and non-COVID-19 care; people in the workforce
Jurisdictions of focus: Brampton (Ontario), Calgary (Alberta)
Partners: Ontario Palliative Care Network and Alberta Health Services

Palliative care is essential for long-term care (LTC) residents, whether or not they have COVID-19, with an average stay of 18 months and 25 percent dying in the first year after admission. Symptom management at end-of-life is essential to provide a comfortable death and is an excellent surrogate marker for palliative care delivery.

LTC providers may not have the expertise and/or time – especially with COVID-19 restrictions/pressures – to prescribe such essential medications. Our study aims for system-wide improvement in end-of-life care by:

• creating a new Quality Indicator for palliative/end-of-life care across all LTC homes
• improving staff through educational and other interventions
• improving pandemic response by improving low prescribers’ capacity to deal with deaths in subsequent waves of the pandemic
• improving planning for COVID-19 and non-COVID 19 care.

Promising practices: Prevention; people in the workforce
Jurisdictions of focus: Ottawa, London (Ontario)

Infection prevention and control protocols (IPAC) focused on mitigating the risks of staff-to-staff transmission may be difficult to achieve LTC homes due to the nature of shared work areas. Common design characteristics include centralized, compact and potentially crowded work and break areas; areas that are challenging to disinfect, coupled with dynamic people traffic flow.

Using a human centred design approach, we aim to support the resiliency of LTC homes by studying: how the design of staff work areas and associated patterns of use may be undermining IPAC; short and long term design interventions that may help reduce transmission risks; and the cost-effectiveness of our proposed design interventions. Through interdisciplinary and evidence-based design we hope to contribute to current pandemic efforts and inform the future design of LTC homes.

Promising practice: Plan for COVID-19 and non-COVID-19 care
Jurisdiction of focus: Montreal (Quebec)

Malnourishment and weight loss are endemic in long-term care (LTC) homes, and exacerbated during the COVID-19 pandemic. Since 2017, our team has been developing and testing a strategy called Nutrition as Medication (NAM) – prescribing small doses of an oral nutritional supplement, administered as medication in LTC homes. Preliminary results show NAM to be a promising approach to limiting, and potentially preventing, the decline in residents’ nutritional state, whether they have COVID-19 or not.

To equip LTC homes to better weather the pandemic, we are overseeing a large-scale adoption of NAM in LTC homes. We will evaluate its implementation, identify enabling and constraining factors, collect the opinions of LTC workers and caregivers/residents of the effect of NAM, and revise the NAM implementation in the context of the pandemic.

Promising practice: Preparation
Jurisdictions of focus: Abbotsford, New Westminster, Coquitlam (British Columbia)

To be effectively pandemic-prepared, long-term care (LTC) homes need rapid, comprehensive and customized implementation of promising practices and policies. Implementation can be supported through a systematic and collaborative approach to quality improvement (QI). COVID-19 restrictions mean that key QI partners, such as caregivers, care aides, nurses, healthcare professionals and managers/directors, often have to be engaged remotely.

In our study, we will use a virtual QI collaborative of LTC homes to investigate:

• Using Slack to facilitate a systematic QI approach to implement promising practices, to comprehensively address gaps in pandemic preparedness
• How this virtual collaboration tool can be used to scale-up and spread promising practices and policies for pandemic preparedness across multiple homes through a QI collaborative.

Promising practices: People in the workforce, plan for COVID-19 and non-COVID-19 care
Jurisdictions of focus: Waterloo, Sarnia (Ontario)

We need to urgently address the ongoing challenges facing the long-term care (LTC) sector which have been uncovered by the COVID-19 pandemic. Our team has developed recommendations to support staff during COVID-19 and improve infection control practices in LTC homes.

From our ongoing work with Nurse Practitioners (NPs), we have convincing evidence that NPs are well positioned to disseminate and implement these recommendations in LTC homes. Our study will determine the steps and resources needed to adapt our guidelines and effectively implement them in two LTC homes. We anticipate the uptake of these guidelines will significantly impact LTC staff job satisfaction, reduce mortality and hospital admission rates and make a profound contribution to ensuring LTC residents receive the best care possible.

Promising practice: Plan for COVID-19 and non-COVID-19 care
Jurisdictions of focus: Toronto, Ottawa (Ontario)

To optimize care for people living in long-term care (LTC) during the COVID-19 pandemic (and beyond), a multi-pronged approach to care, such as comprehensive medication management, is urgently needed

MedSafer is an electronic decision support tool for medication management. It interfaces with electronic medical records (EMRs) to cross-reference a patient's medical conditions with their medications and provide a personalized report in the EMR. While research shows that MedSafer is useful in typical settings, whether this is the case during a pandemic is unknown. Our study will examine the process and outcomes of providing integrated MedSafer reports in the PointClickCare EMR to augment usual quarterly medication reviews.

During a pandemic, medication management with MedSafer may help LTC residents and staff by: minimizing pill burden; increasing health and social service provider efficiency; decreasing adverse drug events (ADEs); and preventing ADE-associated escalation of care.

Promising practices: Presence of family; preparation; people in the workforce; plan for COVID-19 and non-COVID-19 care
Jurisdictions of focus: Saint John (New Brunswick), Hamilton (Ontario), Battleford (Saskatchewan)

Long-term care (LTC) residents and families are often faced with making critical and emotional end-of-life decisions without any preparatory discussions, resulting in stress and conflict. We have developed a toolkit, Strengthening a Palliative Approach in LTC (SPA-LTC), to support the needs of residents, their loved ones and LTC homes.

SPA-LTC includes tools and practices to: engage residents and families across disease trajectories; develop workforce capacity through online education modules; reduce stress and improve psychological health; and develop organizational structures and processes to promote a palliative approach to care.

We will evaluate the toolkit’s implementation and effectiveness in LTC homes during COVID-19, assess scalability across the three provinces and identify ways to adapt the toolkit for diverse regions and contexts.

Promising practice: Presence of family
Jurisdictions of focus: Carbonear; St John’s; Placentia; Wabana, Bell Island; Clarenville; Bonavista; Grand Bank; St. Lawrence (Newfoundland and Labrador)

Our research focuses on long-term care (LTC) residents and family-centered care interventions – with the potential to change the way older adult care is provided in the province. Our aims include accelerating the availability of high-quality evidence to inform Canada’s rapid response to the COVID-19 pandemic; iterative testing to enhance local collaborative efforts and help reorient the existing research infrastructure; and providing evidence on older adults’ care for decision-making and planning throughout Canada.

The interventions will include: e-visits and electronic messaging; virtual mental health support; residents’ integrated COVID and non-COVID care plans including virtual care; and infection control and prevention training among LTC leadership.

Our findings will be relevant to all Canadian provinces with a population living in rural communities and small towns, and other settings that have similarities to those LTC homes in this province.

Promising practice: Presence of family
Jurisdictions of focus: Digby, Sydney, Debert, Halifax (Nova Scotia), Charlottetown, Summerside (Prince Edward Island)

Prolonged separation from family members during the first wave of the COVID-19 pandemic had a huge negative impact on long-term care (LTC) residents’ well-being and quality of life. Family play a critical role in LTC, often helping with their loved one’s feeding, grooming and mobility. Our project focus is the implementation and sustainability of public health directives to increase the presence of family (and friends) in LTC homes through “support visitations” during the pandemic.

As public health restrictions fluctuate in response to the pandemic, it is important to understand the implementation process for support visitations, including how family has been engaged/represented; factors that support sustainability; and outcomes of support visitations for residents, family and staff.

Promising practice: Presence of family
Jurisdictions of focus: Toronto, Ottawa (Ontario)

In early 2020 when COVID-19 outbreaks and deaths intensified in long-term care (LTC) homes in Canada, provinces across the country implemented strict blanket “no visitor” policies. These policies completely shut out family caregivers, resulting in countless LTC residents experiencing severe and potentially avoidable physical, cognitive and psychological harm.

Following the re-opening of LTC homes to family caregivers/visitors, our team is working to accelerate the availability of high-quality, real-time, actionable evidence for LTC homes and policy-makers grappling with finding a balance between visitor/family caregiver access and infection prevention and control. We will:

• Update provincial data collection tools to capture metrics on caregiver/visitor access to LTC homes, LTC resident absences, and their relationship with COVID-19 outbreaks in LTC homes
• Analyse data on caregiver and visitor access including the barriers and facilitators to implementing family presence

Execute and study a family presence implementation strategy and create a learning collaborative.

Promising practices: Prevention; people in the workplace; plan for COVID-19 and non-COVID-19 care; presence of family
Jurisdictions of focus: Toronto, Petrolia, Sarnia (Ontario)

The Dementia Isolation Toolkit (DIT) was designed and developed with people working and living in long-term care (LTC) to support:

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

In our project, we will evaluate the effectiveness of the DIT implementation program (DITi) and measure its impact. We will also explore the impact of the DIT and DITi on other relevant outcomes arising out of a developmental evaluation and the Common Measurement Framework.

Through our project, we will develop evidence-informed implementation approaches and materials so we can facilitate the spread and sustainability of promising practices in person-centered isolation care, across the LTC sector.

Promising practice: People in the workforce
Jurisdictions of focus: Vancouver, Richmond, Mission (British Columbia)

To stop COVID-19 spread in long-term care (LTC) homes, and to ensure the health and safety of staff, residents and their families, the Public Health Agency of Canada introduced various measures including strict visitation and “one high risk site” policies. We will focus on the “one high risk site” policy that prohibits LTC staff from working in more than one LTC home.

We will use the Consolidated Framework for Implementation Research to describe this policy’s implementation at each LTC partner site. This will include any influence on the psychological health and safety of administrators, staff, family and LTC residents; whether sex and gender influences or context have influenced enactment; and implementation barriers and facilitators.

Our research will generate a roadmap to effectively implement future policies in response to COVID-19 in LTC homes and best practice guidelines for team-based research in LTC.

Promising practices: Presence of family; prevention, people in the workforce
Jurisdictions of focus: Quebec City, Lameque (Quebec), Winnipeg, Sainte Anne (Manitoba), Moncton (New Brunswick)

In Canada, 81 percent of those who died in the first wave of COVID-19 lived in long-term care (LTC) homes. Reduced contact with professionals, families and caregivers arising from COVID-19 public health measures has led to unanticipated collateral effects – heightened isolation and loneliness for older adults, especially those belonging to minorities, and thus increased vulnerability.

In Quebec, a fifth of COVID-19 infections have involved healthcare workers. LTC homes are shorthanded, with exhausted staff afraid of infection. The vast majority have not optimally integrated computer technology. No one was prepared for the challenge of COVID-19, but innovations implemented so far have shown islands of success, and winning practices that our project will compile, with a focus on cultural-linguistic minorities.

Our project aims to identify and implement promising and best practices, create a community of practice to reduce isolation and loneliness in LTC residents, and ensure quality and safe care in LTC homes. Our focus is on older adults in linguistic and cultural minorities. Because of the very limited number of LTC homes dedicated to these populations, loved ones are often geographically distant, making digital solutions particularly useful.

Promising practice: People in the workforce
Jurisdictions of focus: Edmonton, Calgary, Okotoks (Alberta)

Long-term care (LTC) workers – including nurses, physical/occupational/recreation therapists, and food service, laundry, maintenance and housekeeping workers – face pronounced risk of occupational stress related injuries, including moral injury, during the COVID-19 pandemic.

For 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 with gloves on. Compared to individually focused occupational stress concepts such as burnout, moral injury locates the source of problems in the structures and processes in which workers are immersed.

We will investigate how to support LTC workers to maintain good mental health and avoid moral injury, and create and disseminate a mental health support/moral injury prevention toolkit tailored to pandemic conditions.

Promising practices: Preparation, plan for COVID-19 and non-COVID-19 care
Jurisdictions of focus: Calgary (Alberta), Burnaby (British Columbia)

The COVID-19 pandemic has highlighted the urgent need to improve palliative care for frail long-term care (LTC) residents. Frailty in LTC residents is under-diagnosed and is often unpredictable in its presentation and progression.

Other challenges to providing this type of palliative care include barriers to discussing end-of-life within Canadian culture, and limited palliative care knowledge and skills among LTC staff, combined with excessive workloads.

We are developing an evidence-informed care pathway for early recognition of frailty and the initiation of early palliative care for LTC residents depending on their degree of frailty, which will support improved care planning and outcomes. The steps include restructuring the physical setting, engaging families, education and skills training, integration of care and broadening the meaning of frailty.

Promising practice: Presence of family
Jurisdictions of focus: Saint-Jean-Port-Joli, Sainte-Marie, Thetford Mines, Saint-Augustin-de-Desmaures, Québec (Quebec)

In Quebec, nearly 70 percent of the people who have died of COVID-19-related complications were living in long-term care (LTC) homes. Finding a balance between the restrictions imposed to curb virus transmission and the negative impact of these restrictions on LTC residents and their informal caregivers is challenging. Evaluating initiatives that mitigate this negative impact on older adults with cognitive disorders during the pandemic has yet to be done in Canada.

Maintaining contact with caregivers can help LTC residents’ anxiety, their cognitive symptoms and behaviours and support their quality of life. Our project will evaluate the implementation, feasibility and acceptability of initiatives to promote the presence of caregivers (either in person or virtually) in LTC homes, as well as their effects on residents and caregivers, and the associated costs.

Promising practices: Presence of family, people in the workforce
Jurisdictions of focus: Ottawa, Welland, Vanier, Nepean (Ontario)

The no-visitor policies put in place in long-term care (LTC) homes because of COVID-19 have resulted in substantial negative outcomes for residents, families, caregivers, volunteers and healthcare professionals. Our project seeks to answer the following questions:

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

Our key aims include understanding the safety, efficacy, effectiveness and ethics of current COVID-19 policies about family presence; increasing the evidence of the impact of reduced family presence on the emotional and psycho-social well-being of residents, caregivers and healthcare professionals; and identifying and addressing barriers and enablers to the uptake of interventions and policy changes.

Promising practices: Preparation; prevention; people in the workforce; pandemic response and surge capacity; plan for COVID-19 and non-COVID-19 care; presence of family
Jurisdictions of focus: Chatham, Sarnia (Ontario)
Co-applicants:  UBC/Canadian Gerontological Nurses Association; Western Registered Practical Nurses Association of Ontario (WeRPN); PIECES Canada; Ontario Supporting Patient-Oriented Research Support unit; McMaster University; Canadian Gerontological Nursing Association; Sinai Health Systems.
Collaborators: National Institute on Ageing and Behavioural Supports Ontario

COVID-19 restrictions in the pandemic’s first wave resulted in profound isolation for older adults in long-term care (LTC) homes, which exacerbated their other needs. The mental and physical health of the LTC workforce was also badly impacted. Future COVID-19 outbreaks could coincide with flu season, so LTC staff, residents and families need a clear strategy in place to better manage resident care, and the safe, effective practice and resilience of Registered Practical Nurses (RPNs) and staff.

In our project, residents and families, interdisciplinary professionals, RPNs, LTC leaders and staff will adapt and implement P.I.E.C.E.S.™ (PIECES: a holistic person-centered care team approach) to enable team collaboration, family involvement and communication. The PIECES intervention will use PHIPA-approved Zoom within our partner LTC homes to enable a “virtual team huddle” with family off-site, the resident and RPNs on-site, and other healthcare team members to create an integrated resident care plan.

Promising practice: Plan for COVID and non-COVID care
Jurisdiction of focus: Toronto (Ontario)

In the COVID-19 pandemic’s first wave, we developed and rapidly implemented a multi-institutional model of collaborative virtual care that provides long-term care (LTC) homes in the Greater Toronto Area with rapid access to specialists and diagnostic services. Our program, GTA-LTC+, initially focused on preventing avoidable hospital transfers, reflecting the perceived priority at the time. However, the need already existed pre-COVID-19 for more coordinated access to specialist care, ideally consolidated in a single partner hospital for any given LTC home.

GTA-LTC+ is useful in improving care even without the problems posed by COVID-19, with additional value in ensuring residents can continue to receive high quality, person-centered specialized care during future outbreaks. Our program uses a hub and spoke design, where six hospital hubs provide rapid access to a suite of virtual and in-person clinical and diagnostic services to geographically associated LTC homes in two of the five Ontario Health Regions (Toronto and Central).