The Integrated Care Team: A primary care based-approach to support older adults with complex health needs.

Many older adults have complex needs and experience high rates of acute care use and institutionalization. Comprehensive Geriatric Assessment (CGA) is a specialized multidimensional interprofessional intervention to prevent such outcomes, but access to CGA in the community is limited. The Integrated Care Team (ICT) is a proactive case-finding intervention to support older adults with complex needs in primary care.

Use of an electronic wellness instrument in the integrated health and social care of older adults: a group concept mapping study.

Background: Health system fragmentation directly contributes to poor health and social outcomes for older adults with multiple chronic conditions and their care partners. Older adults often require support from primary care, multiple specialists, home care, community support services, and other health-care sectors and communication between these providers is unstructured and not standardized. Integrated and interprofessional team-based models of care are a recommended strategy to improve health service delivery to older adults with complex needs.

Comparing quality indicator rates for home care clients receiving palliative and end-of-life care before and during the Covid-19 pandemic.

Background: The consensus among Canadians with regards to end-of-life preferences is that with adequate support the majority prefer to live and die at home.

Purpose: To compare quality indicator (QI) rates for home care clients receiving palliative and end-of-life care prior to and after the onset of the COVID-19 pandemic.

Methods: A retrospective population-based cohort design was used.

Integrating a Standardized Self-Report Tool into Geriatric Medicine Practice during the COVID-19 Pandemic: A Mixed-Methods Study.

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.

The interRAI COVID-19 vulnerability screener: Results of a health surveillance initiative for vulnerable adults in the community during the COVID-19 pandemic.

During the pandemic, the interRAI COVID-19 Vulnerability Screener (CVS) was used to identify community-dwelling 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.

Older adults' experiences and perceived impacts of the Aging, Community and Health Research Unit-Community Partnership Program (ACHRU-CPP) for diabetes self-management in Canada: a qualitative descriptive study.

Objectives: To assess the experiences and perceived impacts of the Aging, Community and Health Research Unit-Community Partnership Program (ACHRU-CPP) from the perspectives of older adults with diabetes and other chronic conditions. The ACHRU-CPP is a complex 6-month self-management evidence-based intervention for community-living older adults aged 65 years or older with type 1 or type 2 diabetes and at least one other chronic condition. It includes home and phone visits, care coordination, system navigation support, caregiver support and group wellness sessions delivered by a nurse, dietitian or nutritionist, and community programme coordinator.

Care Coordination of Older Adults With Diabetes: A Scoping Review.

Objectives: Care coordination is a common intervention to support older adults with diabetes and their caregivers, and provides individualized, integrated health and social care. However, the optimal approach of care coordination is not well described. In this scoping review we synthesized evidence regarding the implementation of traditional and virtual care coordination for older adults with diabetes to inform future research and best practices.

Predictors of improvement in urinary incontinence in the postacute setting: A Canadian cohort study.

Purpose: To determine factors associated with improvement in urinary incontinence (UI) for long-stay postacute, complex continuing care (CCC) patients.

Design: A retrospective cohort investigation of patients in a CCC setting using data obtained from the Canadian Institute for Health Information's Continuing Care Reporting System collected with interRAI Minimum Data Set 2.0.

Changes in Urinary Continence After Admission to a Complex Care Setting: A Multistate Transition Model.

Objectives: To examine changes in urinary continence for post-acute, Complex Continuing Care hospital patients from time of admission to short-term follow-up, either in hospital or after discharge to long-term care or home with services.

Design: Retrospective cohort study of patients in Complex Continuing Care hospitals using clinical data collected with interRAI Minimum Data Set 2.0 and interRAI Resident Assessment Instrument Home Care.

mHealth Interventions to Support Caregivers of Older Adults: Equity-Focused Systematic Review.

Background: Informal caregivers, hereafter referred to as caregivers, provide support to older adults so that they can age safely at home. The decision to become a caregiver can be influenced by individual factors, such as personal choice, or societal factors such as social determinants of health, including household income, employment status, and culture-specific gender roles. Over time, caregivers' health can be negatively affected by their caregiving roles.

Recruitment of Community-Based Samples: Experiences and Recommendations for Optimizing Success.

Background: Recruitment in health and social science research is a critically important but often overlooked step in conducting successful research. The challenges associated with recruitment pertain to multiple factors such as enrolling groups with vulnerabilities, obtaining geographic, cultural, and ethnic representation within study samples, supporting the participation of less accessible populations such as older adults, and developing networks to support recruitment.

Purpose: This paper presents the experiences of two early career researchers in recruiting community-based samples of older adults, their caregivers, and associated health providers.

Home-Care Nurses' Experiences of Caring for Older Adults With Type 2 Diabetes Mellitus and Urinary Incontinence: An Interpretive Description Study.

Introduction: A third of older adults with diabetes receiving home-care services have daily urinary incontinence. Despite this high prevalence of urinary incontinence, the condition is typically not recognized as a complication and thereby not detected or treated. Diabetes and urinary incontinence in older adults are associated with poorer functional status and lower quality of life.

The Complexity of Living with Diabetes and Urinary Incontinence for Older Adults with Multiple Chronic Conditions Receiving Home Care Services: An Interpretive Description Study.

Over 40% of older adults with diabetes receiving home-care services experience urinary incontinence. However, experiential knowledge is lacking on how these older adults live with diabetes and incontinence. Interpretive description methodology was used to explore the experiences of 18 older adults with diabetes and urinary incontinence receiving home-care services in Ontario, Canada.

Cross-sectional Study of Prevalence and Correlates of Urinary Incontinence in Older Home-Care Clients With Type 2 Diabetes in Ontario, Canada.

Objectives: Urinary incontinence (UI) is a burdensome condition for older adults with diabetes receiving home-care services, yet little is known about the prevalence and correlates of UI in this population. The objective of this cross-sectional study, informed by a complexity model, was to determine the prevalence and correlates of UI in older adults with diabetes receiving home care in Ontario, Canada.

Methods: In this study, we analyzed population-level data of the most recently completed Resident Assessment Instrument for Home Care from 2011 to 2016 for older (≥65 years) home-care clients with diabetes.

Capacity development among academic trainees in community-based primary health care research: The Aging, Community and Health Research Unit Experience.

Health care system capacity and sustainability to address the needs of an aging population are a challenge worldwide. An aging population has brought attention to the limitations associated with existing health systems, specifically the heavy emphasis on costly acute care and insufficient investments in comprehensive primary health care (PHC). Health system reform demands capacity building of academic trainees in PHC research to meet this challenge.

Profiling the Characteristics of People Who Are Comatose in Long-term and Complex Continuing Care Settings.

Objectives: To describe the sociodemographic, clinical, and treatment characteristics of people who are comatose in Canadian complex continuing care (CCC) and long-term care (LTC) settings, and to make recommendations to promote comprehensive care planning for this population.

Design: Retrospective, cross-sectional analysis of population data.

Setting And Participants: All residents in the Canadian provinces of Alberta, Ontario, British Columbia, Manitoba, Nova Scotia, Newfoundland, Saskatchewan, and the territory of Yukon with data available from the fiscal year 2015 (April 1, 2015, to March 31, 2016).

Caregivers of older adults with dementia and multiple chronic conditions: Exploring their experiences with significant changes.

Family caregiving is considered a social transition as changes in the health of the care recipient create a process of transition for the caregiver when they are more vulnerable to threats to their own health. Family and friend caregivers take on many responsibilities and experience high levels of burden when caring for community-dwelling older adults living with dementia and multiple chronic conditions. However, little is known about the changes they experience in their caring roles or how they cope with these changes.

A Sustainability Oriented and Mentored Approach to Implementing a Fall Prevention Guideline in Acute Care Over 2 Years.

The purpose of this study was to assess the impact of a mentored guideline implementation (Registered Nurses' Association of Ontario Prevention of Falls and Falls Injuries in the Older Adult Best Practice Guideline) focused on enhancing sustainability in reducing fall rates and number of serious falls and the experience of staff in three acute care hospitals. The National Health Service (NHS) Sustainability Model was used to guide the study. Interviews and focus groups were held with 82 point-of-care professional staff, support staff, volunteers, project leaders, clinical leaders, and senior leaders.

Integrative review of the social determinants of health in older adults with multimorbidity.

Aim: To examine how the social determinants of health have been considered in conceptualizations of multimorbidity in older adults in the literature and to identify implications for nursing practice, research and healthcare planning and policy.

Background: The common conceptualization of multimorbidity is the presence of multiple chronic conditions where one is not more central than others.

Design: The integrative review methodology of Whittemore and Knafl was employed.