Browsing by Author "Hirdes, John"

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Application of interRAI Assessments in Disaster Management: Identifying Vulnerable Persons in the Community
(University of Waterloo, 2016-09-02) Van Solm, Alexandra; Hirdes, John
Background: Several studies have shown the increased vulnerability and disproportionate mortality rate among frail community dwelling older adults as a result of disasters. Parallel to an escalating number of disasters, Canada is faced with an aging demographic and a policy shift emphasizing aging at home. This results in a greater vulnerability of this group of high needs community dwelling individuals to the effects of events that lead to interruption of home health care services and/or displacement. Despite the growing vulnerability it has proven to be difficult to identify those most vulnerable older adults and their characteristics. This makes it challenging for emergency managers, first responders and health care providers to develop targeted preparedness, response and recovery strategies aimed at the most vulnerable older adults living at home. Relatively recent developments in electronic health records provide an unprecedented opportunity to use comprehensive assessment information collected as part of routine clinical practice in the home care sector to identify vulnerable community dwelling older adults. In Ontario, the Resident Assessment Instrument for Home Care (RAI-HC) is the mandated primary assessment tool for long-stay home care clients. Objective: The three specific objectives of this dissertation are to examine: 1. The application of the New Zealand Priority Algorithm used during the Christchurch earthquake to the Ontario Home Care Client database. 2. Determinants of Emergency Response Level (ERL) designation within CCACs. 3. The person-level factors that contribute to increased vulnerability of home care clients to power interruptions through examining the health effects of the power outage that occurred as a result of the December 2013 Ice Storm including emergency department (ED) visits, hospitalization and service utilization. Conceptual Framework: The person-environment fit model is used as the conceptual framework for this dissertation. This model views individual vulnerability as a product of the interaction between individual competence, adaptive behavior and the strength of the environmental stress (the emergency or disaster). Where the demands of an emergency or disaster exceed the ability of the older adult to cope, a person- environment misfit may lead to negative health outcomes. Methodology: All research questions were addressed using RAI-HC datasets in combination with other datasets. Chapter three used the RAI-HC database by selecting unique home care clients with assessments closest to December 31st 2014 (N=275,797). For chapter four Emergency Response Level (ERL) codes were provided by the Hamilton Niagara Haldimand Brant (HNHB) and Toronto Central (TC) Community Care Access Centre (CCAC) and matched with a RAI-HC assessment in both CCACs (N=70,292 and N=8,996 respectively). In addition, linkages were made with data regarding death, hospitalization and long term care (LTC) admission. Lastly, chapter five uses information on Toronto Hydro power outages and an estimation of outage areas based on outage mapping in addition to the HC database. The exposure group (N=10,748) was compared to two comparison groups. Group one included clients with HC assessments in the same period and receiving services during the same week but were unaffected by the hydro outage (N=12,072). The second comparison group was comprised of clients residing in the same area as the hydro outage one year prior to the storm (N=10,886). Service utilization was collected from the Client Health Related Information System (CHRIS). Statistical analyses were done using SAS version 9.4 and methods used include frequency tabulation, bivariate logistic regression, multivariate logistic regression as well as Kaplan-Meier survival plotting and Cox proportional hazards ratios calculations. Results: When comparing four decision support algorithms (University of Waterloo, Canterbury, Vulnerable Persons at Risk (VPR) and VPR Plus) to identify high priority clients, the VPR and VPR Plus were most predictive of mortality, LTC admission and hospitalization. The high priority groups were significantly more impaired than lower priority clients with both the VPR and VPR Plus. They had higher levels of health instability, experienced more falls, required more assistance with Activities of Daily Living (ADL), were more cognitively impaired and had higher levels of depression ratings. When comparing the chosen algorithms, the VPR and VPR Plus, with ERL levels assigned by care coordinators the analysis showed considerable overlap in predictive variables. The ERL was highly predictive of mortality and LTC admission, but less predictive of hospitalization. C-stats of logistic regression modeling with ERL and VPR/VPR Plus in predicting mortality showed that the VPR and VPR Plus models were a better or equal fit as models with the ERL. Finally, when examining the characteristics of clients that were affected by the 2013 power outage with the two comparison groups, a significant difference was found for the non-exposed group in the year of the outage in relation to numbers of nursing and personal support worker (PSW) visits, hospital admission and emergency department (ED) visits as well as mortality, LTC admission and hospitalization rates. The analysis showed that clients in the non-affected areas in the year of the outage were more likely to decline in Depression Rating Scale (DRS), Changes in Health, End-Stage Disease, Signs and Symptoms Scale (CHESS) and Instrumental Activities of Daily Living (IADL). This is consistent with the higher rates of LTC admission and hospitalization within six months after the outage for non-exposed clients as well as higher frequency of nursing and PSW visits during and 30 days after the outage. In contrast to the expectation that exposed clients would do worse during and after the outage, the analysis showed that exposed clients showed in fact less health decline than non-exposed clients. However, when looking at those clients that would have been considered high and medium risk clients based on the VPR and VPR Plus, the analysis showed that those clients in areas with hydro outages were more likely to die and to be admitted to long term care (LTC) than the high and medium risk clients living in unaffected areas. Conclusions: The analyses in this dissertation have shown the usefulness of information collected as routine clinical practice using interRAI assessment tools. The current system of designating Emergency Response Levels (ERL) by care coordinators is highly dependent on consistent updating of the ERLs in the system whenever a new home care assessment is completed. The analyses showed that this is not consistently done, and may render the ERL code obsolete overtime. The VPR and VPR Plus have been shown to be valid and reliable alternatives to ERL codes and they are kept up to date as new assessments are completed on home care clients. Incorporating these decision support algorithms into the RAI-HC assessment system software enables an automatic and up to date vulnerability assessment of clients. This can make it possible for emergency managers, first responders and health care providers to use a comprehensive priority system before, during and after emergency, ultimately preventing unnecessary death or health deterioration.
Assessing the feasibility of an integrated collection of education modules for fall and fracture prevention (iCARE) for healthcare providers in long term care: A longitudinal study
(Public Library of Science (PLOS), 2024) Rodrigues, Isabel B.; Ioannidis, George; Kane, Lauren L.; Hillier, Loretta M.; Adachi, Jonathan; Heckman, George; Hirdes, John; Holroyd-Leduc, Jayna; Jaglal, Susan; Kaasalainen, Sharon; Marr, Sharon; McArthur, Caitlin; Straus, Sharon; Tarride, Jean-Eric; Abbas, Momina; Costa, Andrew P.; Lau, Arthur N.; Thabane, Lehana; Papaioannou, Alexandra
Falls and hip fractures are a major health concern among older adults in long term care (LTC) with almost 50% of residents experiencing a fall annually. Hip fractures are one of the most important and frequent fall-related injuries in LTC. There is moderate to strong certainty evidence that multifactorial interventions may reduce the risk of falls and fractures; however, there is little evidence to support its implementation. The purpose of this study was to determine the feasibility (recruitment rate and adaptations) with a subobjective to understand facilitators to and barriers of implementing the PREVENT (Person-centred Routine Fracture PreEVENTion) model in practice. The model includes a multifactorial intervention on diet, exercise, environmental adaptations, hip protectors, medications (including calcium and vitamin D), and medication reviews to treat residents at high risk of fracture. Our secondary outcomes were to determine if there was a change in knowledge uptake of the guidelines among healthcare providers and in the proportion of fracture prevention prescriptions post-intervention. We conducted a mixed-methods longitudinal cohort study in three LTC homes across southern Ontario. A local champion was selected to help guide the implementation of the model and promote best practices. We reported recruitment rates using descriptive statistics and challenges to implementation using content analysis. We reported changes in knowledge uptake and in the proportion of fracture prevention medications using the McNemar's test. We recruited three LTC homes and identified one local champion for each home. We required two months to identify and train the local champion over three, 1.5-hour train-the-trainer sessions, and the local champion required three months to deliver the intervention to a team of healthcare professionals. We identified several facilitators, barriers, and adaptations to PREVENT. Benefits of the model include easy access to the Fracture Risk Scale (FRS), clear and succinct educational material catered to each healthcare professional, and an accredited Continuing Medical Educational module for physicians and nurses. Challenges included misperceptions between the differences in fall and fracture prevention strategies, fear of perceived side effects associated with fracture prevention medications, and time barriers with completing the audit report. Our study found an increase knowledge uptake of the guidelines and an increase in the proportion of fracture prevention prescriptions post-intervention.
Caregivers in distress: Using interRAI assessments to target and evaluate community based interventions
(University of Waterloo, 2017-01-19) Betini, Raquel; Hirdes, John
Background: Informal caregivers have a fundamental role in our society with the provision of unpaid care for family members or friends that may otherwise be unable to live in their homes. However, caregivers may jeopardize their own physical and mental health leaving them unable to continue caring for older persons with complex health needs. Objectives: Data from interRAI instruments and other sources were used to: a) develop and evaluate a caregiver survey; b) develop a screener to identify caregivers at risk of adverse outcomes; c) examine caregiver and care recipient predictors of long term care home admission and d) evaluate a respite intervention for distressed caregivers. The model of caregiver distress proposed by Pearlin et al. (1990) was used as a conceptual framework for this research study. Methods: interRAI assessments serve as either the main or the secondary dataset used for analysis. In chapter three, the psychometric properties of the caregiver survey were examined using factor and frequency analysis and a reliability test. Information on the caregiver survey was used to develop and evaluate a caregiver screener using frequency analysis and logistic regression models in chapter four. In the next chapter, survival models and generalized estimating equations were used to identify caregiver and care recipient items in the RAI-Home Care (RAI-HC) as predictors of long term care home admission. The evaluation of a respite service examined changes in the caregiver distress index and items from the caregiver survey using paired t tests. Changes in the caregiver items of interRAI assessments of care recipient from the respite program and a similar cohort were compared using logistic regression models. Rates of long term care home admission and length of time before admission were compared using survival models. Results: Three domains were identified in the caregiver survey: 1) psychosocial resources and well-being; 2) physical; and 3) mental health. This study also showed a significant association between care recipient depression and caregiver feelings of loneliness and poor self-esteem. The caregiver distress index developed as part of this research identifies low, moderate and high risk levels for adverse outcomes. Compared with the low risk group, caregivers in the high risk group were more likely to visit the doctor or nurse practitioner, self-report poor health, and report that the care recipient would be better off elsewhere. The RAI-HC predictors of long term care home admission were: care recipient MAPLe score, age, caregiver distress, caregiving dyad relationship, and living arrangements. There was an interaction between caregiver and care recipient coresidence and caregiving dyad relationship. A care recipient cared by a coresiding child caregiver was less likely to be admitted to a long term care home than a care recipient cared by a coresiding nonchild caregiver. In the respite program evaluation, an overall improvement in the frequency of mood items and positive symptoms were observed for all caregivers participating in the program. Caregivers in the moderate risk group experienced an increase in pain frequency and inability to go where they wanted in the spur of the moment. While the odds for improving caregiver distress was not affected by caregiver participation in the respite program, the odds of improvement in the caregiver ability to continue was notably higher for caregivers in the respite program. The length of time before institutionalization was greater for care recipients with MAPLe 5 in the respite program than for care recipients with MAPLe 5 receiving home care services from a local agency. Conclusions: This dissertation highlights the complexity involved in caregiving experiences and the need for valid and reliable assessments for understanding caregiver issues and their needs. The caregiver distress index can be used to identify caregivers at risk of adverse outcomes that would benefit from respite and further assessments. Analysis including interRAI assessments for the care recipient and caregivers identified the positive impact of a respite program on caregiver quality of life and also for delaying institutionalization emphasizing the value of these assessments for the development, evaluation and allocation of resources for caregiver interventions.
Examining Worsening Positive Symptoms During the COVID-19 Pandemic in Older Adult Home Care Clients in Ontario
(University of Waterloo, 2023-09-26) France, Charlene; Hirdes, John
Background: In response to the COVID-19 pandemic, lockdown restrictions were implemented to minimize the spread of infection. Older adults over the age of 60 account for majority of COVID-19-related deaths, hospitalizations, and intensive care admissions (Government of Canada, 2023). Thus, since the beginning of the pandemic, older adults were a vulnerable cohort with a high-risk of mortality. Older adults with a mental disorder may be even more vulnerable to worsening physical health and mortality, as well as may experience greater psychological distress or a relapse in symptoms of their diagnosis due to social isolation and loneliness experienced during the pandemic. Research highlighting the pandemic effects on the general population of older adult psychological health have had mixed results. It is not well understood how the pandemic has affected positive symptoms of older adults with mental disorders. Objectives: The goal of part I of this paper was to identify and synthesize existing literature focusing on older adults with mental disorders, their experience throughout the COVID-19 pandemic, and the outcomes that have been researched in this realm. The goal of part II of this paper was to explore the changes of positive symptoms prior to and during the COVID-19 pandemic on older adults experiencing mental disorders in Ontario, and to examine risk factors that make them prone to experiencing worsening positive symptoms. Methods: Part I consisted of a rapid review and critical appraisal of the current research on older adults with mental disorders and COVID-19. Five electronic databases (PubMed, MEDLINE, Scopus, CINAHL, and PsycINFO) were searched. Part II entailed secondary data analysis using Ontario interRAI HC collected between September 1, 2018, to August 31, 2022. The sample was divided into four subsamples, “Pre-COVID,” “COVID Year 1,” “COVID Year 2,” and “COVID Year 3,” to conduct bivariate analyses. Bivariate analyses guided the development of three binary logistic regression models that were selected with modified stepwise selection. The final multivariate model determined predictors of worsening positive symptoms at time two for the total sample. Two additional models explored stratified logistic regression models of anti-psychotic use. Results: 40 studies were included in part I of this study. The results revealed that majority of existing research has been conducted from older adults with depression, in the first year of the pandemic, where the outcome was mood symptoms effected by social isolation in a variety of study settings. In part II of this study, risk of worsening positive symptoms was found to be associated with several variables. Variations in risk factor was present in main effects from the final model through LHIN region, higher MAPLe & CHESS scores, financial trade-offs, exercise, medication adherence, and difficulty sleeping, indicating that these factors had considerable associations with worsening positive symptoms prior to, and during the pandemic. Delirium and anti-psychotic use remained consistent prior to and during the pandemic in the COVID interactions. Older adults aged 64-75 with a diagnosis of schizophrenia had a AOR of 9.99 (reference = 18-64 and no mental illness). Variations of these risk factors were also found in the stratified logistic regression models of anti-psychotic use. Conclusion: Existing literature points to the pandemic leading to adverse health outcomes for older adults with mental disorders. Age-related risk factors and mental disorders were found to be of notable concern for worsening of positive symptoms, however, these factors may not have been exacerbated due to the COVID-19 pandemic. Future research is still needed to unpack this further.
The Feasibility, Reliability, and Validity of Using the Self-report Version of interRAI Check-Up Among Community Dwelling Older Adults
(University of Waterloo, 2019-10-23) Iheme, Linda Ogechi; Hirdes, John
As the result of population aging around the world, the prevalence of chronic conditions is increasing. Early detection through constant monitoring is an effective strategy of minimizing the impact of chronic conditions on morbidity and mortality. However, clinician administered assessments are often not routinely completed nor done for the entire population because they require resources that may not be available. A self-report tool that can be administered by older adults and their caregivers could help achieve broader surveillance at minimal cost and contribute to enhancement of chronic disease management globally. In the meantime, as the population of cultural minorities in Canada is increasing, it will be important to examine the feasibility and acceptability of using self-report interRAI Check-Up (CU) assessment tool among older adults from different backgrounds. The study compared the experiences of older adults who electronically completed the assessment tool entirely by themselves with approaches involving the help of a lay interviewer or their informal caregiver. Also, this study evaluated the reliability and validity of data collected with self-report CU. This study concluded that CU was optimally accepted by older adults in this study. Also, the internal consistency and validity of data collected with CU is comparable to data collected by trained health professionals in Ontario using the RAI-HC among home care population.
From Less Invisible to More Transparent: Need for and Outcomes of Formal Personal Support Services in Long-Stay and Short-Stay Home and Community Care
(University of Waterloo, 2019-08-28) Sinn, Chi-Ling Joanna; Hirdes, John
Background: Home and community care is a critical part of an effective health care system. For many clients and families, home and community care services provide the necessary supports so they can manage various short- and long-term needs effectively and safely in their homes. In Ontario, personal support and homemaking (PS/HM) services account for three-quarters of all publicly funded home care services. PS/HM services assist clients with basic self-care and other tasks known as Activities of Daily Living and Instrumental Activities of Daily Living. Yet the processes for determining eligibility, priority, and allocation of publicly funded PS/HM services are neither consistent between Local Health Integration Networks (LHINs) nor accessible to clients and families. Client outcomes attributable to PS/HM service provision are also poorly understood. The overarching goal of this thesis is to develop and refine decision support tools to guide the allocation of publicly funded PS/HM services, and to characterise the relationship between the quantity of publicly funded PS/HM services and outcomes. Study 1: Across Canada, Ontario is the sole province that has implemented the interRAI Home Care (HC), interRAI Community Health Assessment (CHA), and interRAI Contact Assessment (CA). The HC and CHA are standardised comprehensive assessments developed to assess the needs, values, and preferences of adults receiving services in home and community-based settings. The CA although much briefer follows the same interRAI standard, allowing direct comparisons across the three populations. To date, there is little published evidence on Ontario’s CA- and CHA-assessed populations. This chapter comprised of four sub-chapters based on a single retrospective cohort of unique clients (age ≥18 years) newly admitted to Ontario’s publicly funded home care program between April 1, 2016 and March 31, 2017 and assessed with the CA or HC (n=268,667) and unique clients assessed with the CHA between April 1, 2015 and March 31, 2016 (n=15,307). Sub-study A identified unique characteristics and service use patterns among Ontario’s public home and community care clients assessed with the CA, HC, and CHA. Sub-study B modelled the relationship between the Assessment Urgency Algorithm (AUA) and time to HC assessment using cumulative incidence competing risk and Kaplan-Meier methods. Higher AUA levels are strongly associated with greater likelihood of receiving an HC assessment and shorter time to HC assessment, although 26.6% of clients in the highest AUA level were not subsequently assessed. The AUA calculated from the CA at intake is also moderately positively correlated with the Method for Assigning Priority Levels (MAPLe) algorithm that is used to guide decisions related to eligibility and priority for services and long-term care placement following the HC assessment. Sub-study C investigated the agreement between the receipt of publicly funded PS/HM services after the CA and HC. Three multivariable logistic models were fit to identify predictors of clients receiving significantly more or less service after the HC. As expected, measures of need are most strongly associated with service plan adjustments although enabling characteristics, especially the LHIN in which a client lives, are also highly influential. Sub-study D compared the self-reported and billed services data over the same seven-day lookback period and found that formal PS/HM services accounted for a small fraction of the total help that most home and community care clients received. Study 2: In 2018, Ontario’s LHINs formally adopted the Personal Support (PS) Algorithm as a standard approach to identify need for PS/HM services. The PS Algorithm classifies clients based on functional and cognitive impairment and other need characteristics known to be associated with need for PS/HM services. Recent publications have suggested additional characteristics (“modifiers”) that may be relevant. The study sample consisted of 126,001 unique HC assessments completed between April 1, 2016 and March 31, 2017 that is a representative sample of Ontario’s public long-stay home care client population. To test the relevance of additional modifiers to the PS Algorithm, the median publicly funded PS/HM hours and total (i.e., formal and informal) home support hours per month were compared across PS Algorithm groups and selected modifiers. The PS Algorithm explains 25.5% and 33.4% of the variance in publicly funded and total PS/HM hours, respectively. Clients living alone receive more publicly funded PS/HM hours, but clients living with their primary informal caregiver receive much more total home support hours. Publicly funded and total PS/HM hours increase with the severity of cognitive impairment and caregiver distress, but generally do not respond to health instability except for very high health instability. Finally, comparison of the distribution of publicly funded PS/HM hours between FY 13/14 and FY 16/17 suggests that allocations have begun to cluster as LHINs move away from local allocation practices toward a common provincial standard. Study 3: While the PS Algorithm is helpful for guiding the allocation of PS/HM services for HC-assessed home care clients, there is no equivalent tool to guide the allocation of PS/HM services for short-stay clients and within short-term service plans for long-stay clients. The goal of this study is to create a conceptually similar algorithm based on the CA that differentiates need for PS/HM services. The derivation sample consisted of 228,354 unique CA assessments completed between April 1, 2016 and March 31, 2017. Among CA-assessed clients, 15.4% received any publicly funded PS/HM services after the CA. Given the zero-inflated nature of the dependent variable, bivariate logistic models predicting the odds of receiving any publicly funded PS/HM services were fit for the full derivation sample, and bivariate linear models predicting the amount of services were fit for clients receiving any publicly funded PS/HM services. Automatic and interactive decision trees were developed based on need characteristics identified in exploratory analyses. An out-of-time validation sample was used to assess each model’s explained variance of the amount of publicly funded PS/HM services received after the CA and weighted kappa of the PS Group at the time of HC assessment. Consistent with the derivation of the PS Algorithm, measures of functional impairment, cognitive impairment, and caregiver distress are strongly associated with the amount of PS/HM hours received after the CA. Similar performance statistics were observed across the candidate trees; thus, the model replicating the PS Algorithm was selected as the final algorithm (“PS Algorithm for the CA”). In the validation sample, the PS (CA) Algorithm explains 20.4% of the variance in publicly funded PS/HM hours and is moderately associated with the PS Group at the time of HC assessment (weighted kappa statistic=0.36). In comparison, the AUA only explains 11.6% of the variance in publicly funded PS/HM hours. Study 4: Derivation of the PS Algorithm and PS (CA) Algorithm was based on the premise that the average historical allocation of PS/HM services is an indicator of need. While the relative differences in allocation can be reliably used to differentiate levels of need, there is concern that the status quo may not represent the “right” amount of services and therefore the average historical allocation should not serve as a benchmark for future allocation practices. To address this concern, a multi-state analytic approach was used to test the hypothesis that some level of service below a threshold would increase the risk of poor outcomes or some level of service above a threshold would decrease risk of poor outcomes. Data for this study was provided by the Hamilton Niagara Haldimand Brant LHIN. Clients referred on or after January 1, 2010 and subsequently admitted for home care services were eligible for the study. For each eligible client, all HC assessments completed on or after January 1, 2013 were retrieved. Each HC assessment up to December 2017 was assigned to one of three initial states based on the presence of caregiver distress. A period of up to 456 days (15 months) was allowed to observe a follow-up HC assessment or home care episode discharge. The sample consisted of 57,208 observation pairs representing 30,625 unique clients. The independent variable of interest was the quintile of publicly funded PS/HM services, where the reference group was the 3rd quintile that represents the median allocation within a given PS Group. Adjusting for baseline client characteristics, providing less than the median PS/HM services significantly increases the odds of new caregiver distress, moving to long-term care, and death. Among distressed caregivers, providing less than the median PS/HM services significantly decreases the adjusted odds of resolving caregiver distress. Among clients with non-distressed caregivers, providing more than the median PS/HM services significantly decreases the adjusted odds of moving to cluster residence. Conclusions: This thesis sought to provide actionable evidence on the predictors and outcomes of publicly funded PS/HM service allocation in Ontario. It is the first comprehensive study of the CA since its province-wide adoption in 2010. The CA is part of an efficient assessment process that identifies clients who should be at the highest priority to receive the more comprehensive HC assessment. As well, information from the CA can be used in a structured way to guide the allocation of PS/HM services for short-stay clients as well as within short-term service plans for long-stay clients. Together, the PS (CA) Algorithm and PS Algorithm provide a unified evidence-informed approach for allocating publicly funded PS/HM services throughout the home care episode. To date, Ontario’s LHINs have adopted the PS Algorithm without the corresponding Framework of Hours for specifying hours of service. The final part of this thesis demonstrates that the Framework of Hours identifies minimum thresholds below which publicly funded PS/HM allocation may lead to poorer client and caregiver outcomes. The findings provide compelling evidence for policy-makers to set standard service guidelines and monitor PS/HM-sensitive outcomes. Doing so will ensure that clients and families know what supports to expect from the public home and community care system, that public resources are distributed fairly, that investments in home care can be demonstrated, and that the valuable contributions of personal support workers can be properly recognised.
Health, Health Service Use and Informal Caregiver Distress among Older Korean Home Care Clients in Canada and Korea
(University of Waterloo, 2016-04-29) Chang, Byung Wook; Hirdes, John
Background: Immigration results in many different changes to life: diet, culture, lifestyle, and language (Hynie et al., 2011; Kim, 2006; Lee Kim, 2001). Immigration later in life is a stressful process for older adults as they are uprooted from their native society and need to readjust to a culturally different society (Hynie et al., 2011; Kim, 2006; Mui, 1996; Mui, 2001; Yoo, 2014). Challenges such as discrimination, language barriers, lack of social resources, and feelings of detachment from the new society may arise especially for elderly Asian immigrants when adapting to host environments (Bernstein et al., 2011; Hossen, 2012; Kiefer et al., 1985; Kim, 2006; Kim, 2010; Lai & Chau, 2007; Mui, 2001; Noh, 2008; Noh & Kaspar, 2003; Noh et al., 2007; Yoo, 2014). Elderly Asian immigrants often lack the information and resources to adjust to major differences between Asian and Western cultural norms and social expectations (Mui, 1996; Mui, 2001). Difficulties coping with the new society and the inappropriate use of resources can increase social isolation, depression, and other health concerns (Kang et al., 2013), which can in turn affect the lives and health of other family members as they become more dependent on these informal caregivers (Chung, 2013; Han et al., 2008; Kim & Knight, 2008; Kwak & Lai, 2012; Lee & Farran, 2004; Yoo, 2014; Wong et al., 2005). However, these struggles are often overlooked as a major issue or concern of immigration policies. Therefore, more studies are required on these Asian immigrants with limited official language proficiency. Koreans have been one of the fastest growing groups of immigrants in Canada, with a growth rate of 42% from year 2001 to 2006 (Statistics Canada, 2006; Statistics Canada, 2007). Of this group, it is estimated that approximately 6% of Korean immigrants are aged 65 and older (Kwak & Hiebert, 2010; Statistics Canada, 2006). In order to examine the possible health disparities faced by minority groups, such as Korean Canadians, an investigation into the quality of care and health service use is vital. However, only a limited amount of research on Korean immigrants has been done in Canada, and fewer than a dozen studies focused on older Korean Canadians. Purpose: This dissertation examined the health disparities in older Korean Canadian home care clients by investigating their health and health service use, informal caregiver distress, and quality of care. More specifically, it compared (1) health and health service use of Korean Canadians, native Koreans, Chinese Canadians, and other Canadians; (2) the risk and protective factors related to the onset of and improvement in caregiver distress; and (3) quality of care using the Home Care Quality Indicators (HCQIs) in Korean Canadians, Chinese Canadians, and other Canadians. Methods: This research was based on secondary data analysis of health information from two different datasets, one from Ontario and the other from Korea. The Ontario health information was based on the Resident Assessment Instrument-Home Care (RAI-HC), an assessment tool used to identify a person’s functioning and quality of life that addresses needs, strengths, and preferences in a broad range of domains (Canadian Home Care Association, 2013; Morris et al., 1997; Morris et al., 2009). This health information is managed by the Canadian Institute for Health Information (CIHI) and was made available through the partnership between CIHI and the University of Waterloo. The health information from Korea was obtained using the interRAI Home Care (interRAI HC) assessment tool. The interRAI HC is the updated version of RAI-HC but data from both can be compared with only modest adjustments (Gray et al., 2009; Hirdes et al., 2008a). The research sample was drawn from the population of all long-stay home care clients admitted during the study period between January 2002 and March 2015 in Ontario and between February 2011 and October 2012 in the Republic of Korea. Long-stay home care clients were defined as clients who require more than 60 uninterrupted days of service through a home care agency. The sample only consisted of long-stay home care clients aged 65 and older. Using a variable for primary language, Korean and Chinese home care clients in Ontario were identified. As a result, primary languages other than Korean and Chinese were grouped as ‘others’, referring to other Canadians. For the analyses and results, Korean home care clients in Ontario were referred to as ‘Korean Canadians’, Korean home care clients in Korea were referred to as ‘native Koreans’, Chinese home care clients in Ontario were referred to as ‘Chinese Canadians’, and other Canadian home care clients in Ontario were referred to as ‘other Canadians’. Chapter 5 examined the descriptive profile of the health of older Korean Canadians compared to native Koreans, Chinese Canadians, and other Canadians, by obtaining the descriptive statistics with percentages and frequencies. Chapter 6 investigated the risk and protective factors for caregiver distress accounting for Korean Canadians, Chinese Canadians and other Canadians using bivariate and multivariate logistic regression models, and generalized estimating equations (GEE). Lastly, Chapter 7 used the second-generation HCQIs to explore quality of care by ethnicity in Ontario. Results and Discussions: This dissertation is the first cross-cultural study to examine the health disparities and caregiver distress of Korean older adults in Ontario and in Korea using the RAI-HC/interRAI HC. It is also the first study to use the second-generation HCQIs to explore quality of care by ethnicity. Health disparities were evident from the overall findings in Chapter 5 where both Korean Canadians and native Koreans generally exhibited higher impairments compared with Chinese Canadians and other Canadians. In addition, high caregiver distress was present in the three Asian groups compared to other Canadians. Upon further examination of caregiver distress, results in Chapter 6 demonstrated that being a Korean or Chinese Canadian was associated with lower odds of an improvement in caregiver distress and higher odds of an onset of caregiver distress over time. However, language barriers based on need for an interpreter appeared to be the main explanation for this effect rather than the ethnicity alone. Lastly, Chapter 7 examined quality of care using the second-generation HCQIs and identified different areas where service providers for different groups have opportunities to improve quality. For Korean Canadians, such initiatives should focus on cognitive and psychosocial factors, whereas Chinese Canadians need interventions to target pain, and other Canadians need to improve on the use of hospital, emergency department or emergent care. Most importantly, all groups exhibited an increase in continued caregiver distress over time, though the two Asian groups’ rates seemed to increase more steeply. Overall, the older Korean Canadian home care clients demonstrated substantial health needs and family caregivers had a dire need for additional supports from formal services. However, this clients tended to have a lower use of home care services (i.e., personal support/ homemaking services, and the use of hospital, emergency department or emergent care), and higher levels of caregiver distress indicated that their informal caregivers were struggling. Thus, more practical interventions or resources need to be devoted to this population.
Identification of Re-assessment Intervals to Support a Measurement Based Care (MBC) approach with the interRAI Community Mental Health (CMH) Assessment
(University of Waterloo, 2022-11-09) Monakhova, Sveltana; Hirdes, John; Reaume-Zimmer, Paula; Perlmann, Chris
Background: Mental health is a fundamental aspect of people’s health and is a leading cause of disability worldwide. Ineffectively treated mental health problems could result in a shorter life expectancy as a result of death by suicide or serious health problems. These could be improved with a proper treatment plan based on results from systematic assessments. Measuring quality of care is challenging worldwide and varies among organization due to the absence of standardize instruments and lack of ability to regularly collect data within the health care settings. The potential use of the interRAI Community Mental Health (CMH) assessment, as a measurement based care (MBC) instrument, generates data that help to adjust the care planning and resource allocation based on the identified changes in the client’s strengths, preferences, and need. However, further research is needed to identify the optimal re-assessment interval from the initial interRAI CMH assessment. Objective: This thesis investigated the relationship of time between initial assessment and re-assessment with rates of change in clients’ needs. Methods: This retrospective study used secondary data from interRAI CMH assessments completed on clients in Ontario, Canada between 2007 and 2020, which are stored on the interRAI Canada server at the University of Waterloo. A variety of statistical techniques were used to identify the shortest period of re-assessment time to see the meaningful rate of changes. Results: This study showed that DSI and PSS-Short scales are valid and reliable over time. The highest rate of change of 75.9% for the DSI was among clients who have been re-assessed within 3-6 months. On average, the rate of change for the DSI was 73.6. The most noticeable rate of change for the PSS-short scale was for clients who have been re-assessed after 6 months: 28.2% between 6-9 months, 25.9% between 9-12 months, and 27.6% after 12 months or more. On average, the rate of change for the PSS-short was 22.7%. The most noticeable rate of change of 14.8% for the traumatic life events CAP was for clients who have been re-assessed after 12 months or more. On average, the rate of change for the traumatic life events CAP was 10.9%. The best rate of improvement (46.7%) after the initial assessment were between 6-9 months and 9-12 months. The period of time when clients worsen their initial score to 20.0% was after 12 months from the initial assessment. Conclusion: Through a thorough analysis of the dataset, this study confirmed that existing re-assessment period of 6 month is appropriate. Understanding the benefits of MBC, specifically the interRAI instruments, in CMH settings makes decision makers to apply standardized measurement instruments to the service delivery to improve quality of care, healthcare outcome, to achieve clients’ goals at the end of the treatment, and to help clinicians to monitor clients’ treatment progress and address their changes appropriately by observing the symptoms on a regular basis.
Measuring and Responding to Mental Health Needs of Emerging Adults Receiving Care in Canadian Psychiatric Settings: Evidence for the Importance of Assessing Anxiety Symptoms
(University of Waterloo, 2021-08-05) Little, Jerrica; Hirdes, John
Background: Emerging adulthood (EA) is a developmental period between the ages of 18-29 that is characterized by numerous life transitions, as well as high rates of psychological distress and onset of several psychological disorders. Despite a high need for mental health services, EA are more likely to disengage from psychological treatment than other age groups, prompting a national policy review on mental health care systems and EA. Lack of comprehensive research on mental health needs and service use patterns among EA, as well as gaps in coordinated care across health systems, were two major issues identified in the report. To address these gaps, this thesis focuses on investigating clinical characteristics among EA receiving care in inpatient psychiatry, emergency departments (EDs), and community mental health agencies across Canada, with a particular focus on issues related to anxiety. Study one: While several research studies have explored mental health trends among EA in general and post-secondary settings, relatively little is known about individuals accessing formal mental health services. To determine clinical needs and service use patterns among EA in these settings, interRAI mental health assessment data for 18- to 35-year-olds were obtained from three sources: 1) Resident Assessment Instrument – Mental Health (RAI-MH) data from all inpatient psychiatric hospitals and units across Ontario between 2005-2019 (n=85,762); 2) Community Mental Health (CMH) data from participating agencies across Ontario between 2005-2006 and 2017-2019, as well as Newfoundland between 2012-2014 (n=2,548) and; 3) Emergency Screener for Psychiatry (ESP) data from participating departments across Ontario between 2013-2014 and 2018-2019 (n=1,368). While clinical needs did not vary greatly across age groups within EA, a notable exception was observed for substance use, with more non-primary substance use disorders and recent cannabis use among those aged 18-25. Across care settings, clinical characteristics often reflected aspects of system design, such as greater risk of harm to self and others in inpatient psychiatry and more severe symptoms of depression and social withdrawal in community mental health. Unlike the other two settings, the ED observed a greater proportion of primary to non-primary anxiety disorders, signaling potential gaps in continuity of care for anxiety. The depth of information provided in this study can be used to support research targeted at improving coordination of mental health care for EA across Canada. Study two: To adequately measure anxiety for clinical practice and research, a symptoms scale is needed in addition to diagnosis, but one has not yet been developed for the interRAI assessment instruments. This study fills this gap by creating an initial interRAI anxiety scale using data available through the RAI-MH. Admission and discharge assessments were obtained for adults aged 18+ from 2005-2019, representing all psychiatric inpatient hospitals and units across Ontario (n=237,862). Six items representing psychological symptoms of anxiety were tested, as well as five somatic health items. Factor analysis revealed that a unidimensional factor comprised of only the six psychological indicators was the best fit for the data (CFI=0.94, RMSEA=0.08), and so an additive, continuous scale was created. However, latent class analysis (LCA) and item response theory (IRT) revealed that the compulsive behaviour item did not perform well in the scale, and so an alternative version with five items was created, as well as a class-based structure representing frequency of symptom occurrence. Finally, decision tree algorithms were also developed, incorporating complex interactions between psychological and somatic symptoms. After testing each version through logistic regression analyses with anxiety disorders, the five-item continuous scale was selected as the best candidate (c=0.70). Criterion validity measures of the anxiety scale were explored, as well as responsiveness to treatment, providing support for the creation of an anxiety scale using interRAI items. Although new items may be needed to complete the scale, such as social anxiety and generalized anxiety symptoms, the initial version can be used in research and clinical practice to address issues related to anxiety. Study three: Although anxiety disorders are prominent in the general population and are a major driver of emergency department visits among youth and EA, they have traditionally been rare in psychiatric hospitals. As rates of anxiety increase in health care settings, it is important to understand the current treatment patterns for individuals admitted to hospital with anxiety. Using RAI-MH admission data from 2005-2019 for EA aged 18-30 (n=65,528), as well as short-stay data (n=98,607), several treatment and social resource variables were examined using anxiety disorders and symptoms. Symptoms of anxiety shared a more consistent pattern with symptoms of depression than vice versa, indicating that anxiety is often treated as comorbid to depression in psychiatric hospitals. This is consistent with primary anxiety disorders demonstrating greater odds of short-stay hospitalizations (OR=1.78), with increasing severity of anxious symptoms decreasing the odds (OR=0.77-0.26). Opposite effects of anxiety disorders and symptoms were also observed for social resource variables, such as lower odds of staff reporting frustration when anxiety disorders were present (OR=0.66-0.56), but greater odds as symptoms of anxiety increased (OR=1.23-2.65). The results of this chapter indicate that anxiety is a major concern for EA seeking psychiatric help, and to properly address this need, both diagnoses and symptoms are required to gain a holistic understanding of care patterns and outcomes. Conclusions: Cross-sectoral mental health research that identifies gaps in continuity of care among EA is urgently needed to address high rates of disengagement from treatment in this population. To fulfill this need, this thesis provided information on clinical characteristics and service use of EA accessing inpatient psychiatry, ED, and community mental health settings. To better promote care for EA experiencing anxiety, an initial anxiety scale was created for the interRAI health assessment instruments, containing five psychological indicators of anxiety. The anxiety scale was then used to examine treatment patterns among EA receiving services in psychiatric hospitals and units, revealing that anxiety disorders and anxious symptom severity have opposite effects on care outcomes and social resources. Altogether, identifying the needs and service use patterns of EA is essential for building an evidence-based mental health system that promotes effective and coordinated care.
Predicting Resource Use of Community Mental Health Services at the Transition from Inpatient Psychiatry
(University of Waterloo, 2020-08-17) Tran, Nam; Hirdes, John
Mental health is a major health problem for many Canadians. Methods to predict expected mental health care resource use are an essential component in balancing the needs of the population and equitable allocation of limited health care resources. This research examined the relationship between the resource use of community mental health services and the characteristics of their clients using a case-mix classification approach. A scoping review showed that most of the research on this topic focused on inpatient psychiatry settings. The number of identified studies (n=17) and case-mix systems (n=32) reflected the modest level of research activity in this area. Secondary analyses were done with a sample of adults discharged from a local psychiatric hospital unit in Ontario (n=4,688 discharges) that was tracked to examine the use of community mental health services after discharge. Only about half of the discharges subsequently used publicly funded community mental health services. Further, only n=1,207 discharges had services initiated within 30 days and were not censored by readmission. Clinical characteristics measured at discharge from inpatient psychiatry were associated with observed use and high use (as binary variables) of community mental health services post-discharge. Usage of services specially designed for persons at risk of self-harm and harm to others (as binary variables) were also associated with higher risk of self-harm and harm to others measured at discharge. A community episode of 90 days from first contact with the community mental health agency post-discharge appeared to be the most practical for implementation. Two high performing case-mix classification systems were examined for their possible predictive utility for post-discharge community mental health service use. The System for Classification of In-Patient Psychiatry (SCIPP) achieved 6% explained variance of community resource use for an episode. When prior contact with the community mental health agency within 30 days prior to the inpatient episode was included, the model with SCIPP explained up to 14.1% of variance in resource use. The Australian Mental Health Classification (AMHCC) was found to be not immediately applicable outside of the Australian context, and most of its explained variance was likely attributed to the “phases of care” that are subjectively determined by clinicians at the beginning of an episode. The remaining components of the AMHCC explained only 1.2% of variance in resource use. Using machine learning, new classification models using discharge clinical characteristics achieved up to 12% of explained variance in cross-validation. The two simplest decision tree models showed similar performance in cross-validation as more complex models. Although machine learning identified relevant relationships between clinical characteristics and observed resource use, some relationships required human expertise to adjust to align with the goals of the health care system. This was exemplified by a manual decision tree model that achieved 11.1% explained variance on the development data set. These results pointed to the need for additional research to: expand the sample size; include a broader range of community mental health service users; use more contemporaneous clinical assessment data measured at community service initiation; and broaden the participation of community mental health agencies. Although clinical characteristics measured at discharge yielded only modest predictive utility, designing a system that could leverage both inpatient information and community agency assessment information could improve both predictive utility and care integration across the care continuum. Further development of case-mix classification for community mental health will require a broad collaboration across the health care system.
Predictors of Alternate Level of Care within Mental Health Inpatient Units across Ontario
(University of Waterloo, 2016-01-04) Little, Jerrica; Hirdes, John
Purpose: The main purpose of this study was to identify clinical predictors of alternate level of care (ALC) status within inpatient mental health units across Ontario. In addition, the distribution of ALC days among designated patients, the proportion of patient episodes designated ALC over time, and the demographic and clinical characteristics of mental health inpatients are also described. Methods: This project was conducted via a secondary data analysis of data obtained from the Resident Assessment Instrument – Mental Health (RAI-MH). RAI-MH data was provided by the Ontario Mental Health Reporting System (OMHRS) for the years 2005 to 2014, including information on ALC days. Furthermore, an additional ALC variable was obtained from the Wait Time Information System (WTIS) for the years 2011 to 2013. All analyses were performed using admission episodes only. For the descriptive statistics, rates of ALC designations and odds ratios (OR) were examined across several characteristics, providing a basis for variable selection in the multivariate modeling stage. To determine the clinical predictors of ALC status, a multivariate logistic regression was performed in OMHRS using a 30+ ALC day cut-point. Once the model was ascertained in OMHRS, it was tested again in WTIS and adjusted accordingly, providing a final model for 30+ ALC days. Results: The proportion of ALC episodes designated as ALC over time was low (~3% for 1+ ALC days and ~1% for 30+ ALC days), but the distribution of ALC days across patients was comparatively large (Median = ~20 days). The final logistic regression model for 30+ ALC days identified several predictors of ALC status, including IADL, ADL and cognitive impairment, social isolation, aggression, older age, male sex, speaking a primary foreign language, greater lifetime admissions to a psychiatric hospital, symptoms of depression, positive psychosis and social withdrawal, disorders of childhood/adolescence, intellectual disabilities, and substance use. Conclusions: There are a multitude of risk factors implicated in ALC designations among mental health inpatients in Ontario, indicating that their needs are varied and complex. Policy makers and mental health care practitioners may utilize early predictors of ALC status to introduce treatment interventions and policies that reduce the risk of ALC designations in mental health settings.
Predictors of Loneliness and Transitions in Loneliness in Ontario Home Care Clients: Before and During the COVID-19 Pandemic
(University of Waterloo, 2022-11-11) Ochwat, Sandra Kinga; Hirdes, John
Background Older adults over the age of 65 receiving home care services are particularly vulnerable to experiencing loneliness and social isolation. Loneliness and social isolation have been associated with adverse health outcomes, including depression, cardiovascular disease, and mortality, as well as increased service utilization. Research has widely explored cross-sectional predictors of loneliness, though factors that predict the onset of loneliness, particularly in the home care population remain largely understudied. With the COVID-19 pandemic exacerbating rates of social isolation, loneliness, and exposure to predictors, further research is necessary to understand how the pandemic influenced the risk of loneliness and the onset of loneliness in the Ontario older adult home care population. Objectives The goal of this research was to identify predictors of loneliness and the onset of loneliness that were significant prior to and during the first wave of the COVID-19 pandemic in Ontario. The way in which the COVID-19 pandemic modified the relationship between loneliness and predictors was also explored. Methods Secondary data analysis was conducted using Ontario interRAI Home Care data collected between September 1, 2018, to August 31, 2020. The sample was divided into two subsamples, the “comparison” and “COVID” sample to conduct respective bivariate and multivariate analyses. Bivariate analyses guided the development of six binary logistic regression models that were selected with modified stepwise selection. The final multivariate models determined cross-sectional predictors of loneliness at T1 and longitudinal predictors of the onset of loneliness at T2 in both sub-samples. Two additional models explored the main effect and interaction effects of the COVID-19 pandemic on the onset of loneliness across the entire study sample. A social isolation scale was developed to supplement the analysis. Results Risk of loneliness and onset of loneliness with found to be associated with several demographic, physical, clinical, psychological, social, and environmental variables. Variations in risk factor significance was present across models, though sex, LHIN region, sleep disturbance, ADL impairment, depressive symptoms and social isolation were consistent across all models indicating that these factors had a considerable association with loneliness prior to and during the pandemic. When significant, depressive symptoms, anhedonia, geographic variations, and social isolation demonstrated the strongest association with loneliness. The first wave of the COVID-19 pandemic led to a slight increase in loneliness rates and significant interactions demonstrated that the pandemic exacerbated the influence of several risk factors on loneliness. Conclusion The prevention and reduction of loneliness must be targeted through an integrated approach by practitioners, home care organizations, researchers, and program and policy makers to combat risk factors of all dimensions beyond those that are clinical. Future research should aim to fill the gaps presented in this research and work to develop evidence-based indicators and practice protocols to aid in systematic risk identification and intervention of loneliness.
Predictors of Palliative Home Care Costs in Ontario, Canada
(University of Waterloo, 2021-07-21) Cheng, Clare; Hirdes, John
Background: The demand for palliative care in Canada is expected to grow in coming years due to a confluence of factors that include population aging, a more gradual dying process, emphasis on the early provision of palliative care, as well as the expansion of the scope of palliative care beyond cancer. In particular, there is emphasis on the provision of palliative care in home settings as individuals prefer to remain at home for as long as possible, and for health systems, the potential reduction in end of life care costs. The proportion of Canadian decedents who received palliative home care services prior to death is low, however, and may reflect an inadequate supply of palliative home care services resulting from the dearth of information required to support health system planning activities. Specifically, the need to understand the characteristics, service utilization patterns and costs of palliative home care clients has been emphasized in reports on palliative care in Canada. Objectives: This dissertation sought to address information gaps on palliative home care in Ontario, Canada by: 1) characterizing palliative home care clients and examining their service utilization patterns; 2) estimating formal service-related palliative home care costs, informal care costs, and combined formal and informal care costs; 3) identifying predictors of formal, informal and combined care costs, with particular emphasis on the Palliative Performance Scale (PPS). Methods: A sample of palliative home care clients was drawn from home care clients in Ontario assessed using the interRAI Palliative Care (PC) between 2011 and 2017 (n=68,731). For each client, their first interRAI PC assessment was selected and linked to home care referral information and service billing/payment records of up to 181 days post-assessment contained in Health Shared Services Ontario’s Client Health Related Information System. Descriptive statistics were used to characterize these clients and describe their patterns of palliative home care service utilization. A subsample of clients on service for five or more weeks post-assessment and with a PPS score was then drawn from the original sample (n=39,072). Mean weekly costs of formal palliative home care services over the first five weeks of service post-assessment were estimated for this sample, as were informal care costs and combined formal and informal care costs. Predictors of these costs were then identified using linear and logistic regression models. Candidate variables considered as predictors of cost were organized based on Andersen and Newman’s framework on health service utilization, and informed by existing literature and by one-on-one interviews with individuals familiar with the management or provision of palliative care in Ontario. These variables were obtained from clients’ assessment records that included PPS scores and interRAI PC scales and items. Results: A large majority of palliative home care clients had a cancer diagnosis (85.0%) and over half had an expected prognosis of less than six months (60.7%), with half dying during the follow-up period. Almost all (93.4%) clients had at least some loss of function based on the Instrumental Activities of Daily Living-Activities of Daily Living (IADL-ADL) Functional Hierarchy Scale, and moderate to high health instability based on the Changes in health, End-stage Disease Signs and Symptoms (CHESS) Scale. Services were initiated within days of assessment and utilization of services was particularly great in the first week post-assessment. Essentially all clients received case management and nursing services, while the most frequently used services were for nursing and personal support. For clients who were discharged during the follow-up period, increasing service use could be observed with closer proximity to discharge. The estimated mean weekly formal palliative home care cost over the first five weeks of service was $352.91 (2020 Canadian dollar [CAD]). Linear regression using generalized linear models found the PPS to be significant in predicting formal care costs and explained 29.4% of variation in costs. By comparison, interRAI scales and items corresponding to components of the PPS explained 31.2% of cost variation. Expanded models containing interRAI PC scales and items both related and unrelated to components of the PPS had an explained variance of 37.7%, and addition of the PPS to this model led to a small increase in the explanation of cost variation (39.7%). Logistic regression models used to assess the probability of being a ‘high’ cost palliative home care cost client performed well (c-statistic between 0.81 and 0.94) and identified similar characteristics to those identified as predictors of cost in linear regression. Across models, characteristics that were consistently significant in predicting formal care costs included clients’ region of residence (Local Health Integration Network [LHIN]), having a live-in caregiver, being designated as an end of life home care client, having an informal caregiver who reported being unable to continue in care activities, having family and friends who felt overwhelmed by the client’s illness, poorer functioning (PPS and IADL-ADL Functional Hierarchy Scale), greater health instability (CHESS), altered mode of nutritional intake, the presence of dyspnea, presence of fatigue, greater pain, need for and use of intravenous (IV) medications, and bladder and bowel incontinence. Estimates of weekly informal care costs were between $565.24 and $693.55, and ranged between $918.15 and $1,046.45 for combined mean weekly formal and informal care costs for the first five weeks of service post-assessment (all 2020 CAD). As a share of the total combined care costs, between 61.6% and 66.3% of care costs were for informal care. The generalized linear model of informal care costs and interRAI PC scales and items explained 41.4% of variation in costs. Addition of the PPS to this model increased variance explanation to 42.1%. A large number of characteristics were identified as significant predictors of informal care costs, although clients’ marital status, LHIN of residence, poorer function (IADL-ADL Functional Hierarchy Scale), greater fatigue, presence of expressions of unrealistic fears, and greater bowel incontinence had particularly large effect sizes. The association between formal care costs and informal care costs was also examined and the two types of costs were found to be complementary. In regard to the combined mean weekly formal and informal care costs, variance explanation using interRAI PC scales and items was 51.7%, and increased to 53.3% with the addition of the PPS. A large number of characteristics were also found to be predictive of combined care costs. Characteristics with particularly large effect sizes included LHIN of residence, function, need for altered mode of nutritional intake, dyspnea, fatigue, and daily use of intravenous medications. Conclusions: This dissertation provides a detailed description of palliative home care clients in Ontario, and their home care service utilization patterns and associated costs. The PPS appears to be a reasonable predictor of formal, informal and combined palliative home care costs. A number of other client characteristics were also identified as being predictive of these costs with substantial overlap in the characteristics identified for each type of cost. The majority of these characteristics can be categorized as illness (need) factors within Andersen and Newman’s framework on health service utilization indicating that cost variations are influenced primarily by clients’ clinical and/or functional needs. Caregiver characteristics, including indicators of distress, were also predictive of formal, informal and combined costs indicating the importance of caregiver capacity to provide care in the care of palliative home care clients. One application of findings from this dissertation may be to inform on future development of a case-mix system for palliative home care as variance explanation of palliative home care costs observed in this dissertation were high, suggesting that the classification of palliative home care clients into groups with relatively similar clinical characteristics and levels of resource utilization is possible.
Rehabilitation, Recovery, and Adverse Events Following Discharge from Ontario Complex Continuing Care Hospitals
(University of Waterloo, 2019-01-23) Turcotte, Luke; Hirdes, John
Purpose: The purpose of this dissertation was to characterize rehabilitative care in Ontario Complex Continuing Care hospitals and to examine the association of patient, structure, and process factors on functional outcomes and health state transitions. Methods: First, a retrospective cross-sectional study of patients admitted to Ontario Complex Continuing Care hospitals between March 31st, 2011 and March 31st, 2016 (n = 100,778) was conducted to characterize rehabilitative care service utilization in this health service setting. The MDS 2.0 comprehensive health assessment that is completed at admission to this post-acute care service setting was used as the primary source of patient health status and service utilization data. A series of zero-inflated negative binomial regression models were fit to study the association of patient, facility and system-level factors on physical, occupational, and speech-language pathology therapy receipt and intensity. Second, a retrospective study of patients admitted to Ontario Complex Continuing Care hospitals between January 1st, 2010 and March 31st, 2015 (n = 30,924) who were subsequently re-assessed with an interRAI assessment in either a Complex Continuing Care hospital, residential long-term care facility, or home care service setting was completed. This study aimed to describe patterns of functional gain following rehabilitation in Complex Continuing Care. The MDS 2.0 assessment that is completed at admission to Complex Continuing Care was used as the baseline measure of physical function, and was compared to measures collected with the next available MDS 2.0 or RAI-HC assessment completed in hospital, long-term care, or community care. A series of multivariate linear regression models were fit to study the association of patient, process, facility, and system-level factors on functional gain following rehabilitative care. Third, a retrospective study of patients admitted to Ontario Complex Care hospitals between January 1st, 2010 and March 31st, 2015 (n = 76,132) that were either discharged from hospital or re-assessed with an interRAI assessment was performed to study factors associated with health transitions immediately following rehabilitative care in Complex Continuing Care hospital. The MDS 2.0 assessment that is completed at admission to Complex Continuing Care was used the primary source of patent health information and was used to stratify the sample into three baseline functional states. A multistate transition model was fit to study the association of patient, process, facility and system-level factors on health transitions at follow-up. Possible transition states included functional improvement and decline, discharge to community care, discharge to residential long-term care, discharge to acute care, and death. Finally, a Markov chain multistate transition model was fit for a sample of Ontario Complex Continuing Care patients that were discharged to community care between January 1st, 2010 and January 1st, 2014 and assessed with a RAI-HC assessment within 105 days of discharge (transitions = 12,824). This analysis aimed to describe the effect of hospital-based rehabilitation therapy intensity on health state transitions after community discharge. Patients were classified into two initial states using functional measures from the RAI-HC assessment. Possible transition states of interest included functional improvement and decline, hospital admission, residential long-term care facility admission, death, and discontinuation of home care services. Results: Overall, 79% of Ontario Complex Continuing Care patients received physical therapy, 69% received occupational therapy, and 16% received speech-language pathology therapy. The mean therapy intensity was 103 (SD = 92) minutes per week for physical therapy, 75 (SD = 87) minutes per week for occupational therapy, and 11 (SD = 37) minutes per week for speech-language pathology therapy. Patient-level factors including age, diagnosis group, baseline functional and cognitive status, medical instability, and rehabilitation potential were predictive of both receipt and intensity of therapy across each provider type. However, these associations were stronger for the receipt-component of the model, suggesting that after determining eligibility for rehabilitation, providers allocate therapy time based on other factors. After adjusting for patient characteristics, facility size, facility rurality, and region were significant factors across the models. This indicates that there are likely inter-facility and inter-region differences for rehabilitation service utilization. On average, Complex Continuing Care patients improved by 3.24 points (Cohen's d=0.36) on the ADL-Long Form Scale between admission and follow-up. Statistically significant functional gain was observed for most activities of daily living; however, patients that were discharged to community care achieved greater gains than patients that were in hospital or residential long-term care at follow-up. Across baseline functional levels, the multivariate regression models explained between 19% and 23% of the variance in functional gain. Patient-level factors associated with functional outcomes included age, diagnosis group, cognitive status, and rehabilitation potential. Receipt of physical therapy was associated with functional gain; however, small amounts of additional physical therapy time were generally not associated with additional functional gain. Additionally, physical therapy time beyond 135 minutes per week did not result in additional gains in function. Receipt of occupational therapy resulted in gains in function for the least functionally impaired patients. However, more intensive occupational therapy was not associated with greater functional gains. Within 105 days admission to a Complex Continuing Care hospital, 43% of patients were discharged to a community care setting, 11% were discharged to a long-term care facility, 8% were discharged to an acute care hospital, and 22% died. Among the 17% of patients that remained in Complex Continuing Care, 8% transitioned to a more impaired functional state and 16% transitioned to less impaired functional state. After adjusting for patient, facility, and system-level factors, patients that received more intensive physical therapy were generally more likely to be discharged to community care and hospital, and were less likely to die. Among patients that were not discharged, those that received more intensive physical therapy were generally more likely to transition to a less impaired functional state. Greater occupational therapy intensity was generally associated with greater odds of community discharge and lower odds of discharge to a residential long-term care facility. Among patients that were discharged from Complex Continuing Care to home care, 13% of state transitions resulted in re-hospitalization, 5% resulted in residential long-term care admission, and 6% resulted in death. Among non-absorbing state transitions, 7% resulted in functional improvement and 6% resulted in functional decline. After adjusting for both patient and system-level factors, physical and occupational therapy intensity in Complex Continuing Care was not associated with greater odds of experiencing most health state transitions after discharge. Conclusions: This dissertation represents the first comprehensive study of rehabilitation service patterns and outcomes for patients admitted to Ontario Complex Continuing Care hospitals. Through the use of national administrative health databases with near census-level coverage, this dissertation succeeds in answering research questions that span multiple health service settings along the continuum of care. The models that were developed in this dissertation lend support for the quality of rehabilitative care in Ontario Complex Continuing care hospitals; however, they suggest that there are opportunities to better allocate rehabilitation therapy for certain patient populations. Additionally, the results of this dissertation indicate that greater therapy intensity in Complex Continuing Care is associated with positive health state transitions; however, it is not protective over the long-term for patients that return to the community.
Specialized Geriatric Services Use by Older Home Care Clients
(University of Waterloo, 2019-08-28) Hogeveen, Sophie; Hirdes, John
Background: Geriatric medicine specialists are experts in the care of vulnerable, older adults with complex medical and psychosocial needs. In Canada, their scope of practice and expertise is communicated through the 5M Framework, and includes the following domains: mind, mobility, multicomplexity, medications, and what matters most to patients. Specialized geriatric resources are limited in Ontario, with an estimated shortage of the full time equivalent of over 100 geriatricians. Beyond simply a lack of resources, there is poor integration, communication, and collaboration between specialized geriatric services (SGS), and other community-based health services, such as home care services, primary care, and outpatient specialist care. The Regional Geriatric Programs of Ontario (RGPO) and the Ontario Ministry of Health and Long-term Care (MOHLTC) expressed an interest in developing a mechanism to assist in the allocation of limited resources by targeting older adults who would most benefit and improving integration between these care sectors. To date, however, there has been little literature published on the practice patterns of geriatric medicine and the determinants of contact with this specialist discipline by community-dwelling older adults. Geriatric organizations and associations in Canada and the United States have published statements on the role and target population of geriatric medicine but there is a lack of empirical evidence on this topic. Standardized assessments in home care provide a wealth of health information that may be linked to service use data to investigate this topic. As older home care clients represent a complex and high needs subset of the general population of community-dwelling older adults, this is an appropriate population to study and target for SGS. While there is interest in examining the broader use of community-based SGS, it is not captured in administrative services data. However, it is possible to examine contact with geriatric medicine as a component of specialized geriatric care. Objectives: The objectives of this dissertation are: 1) to investigate patterns of health care services use by older, home care clients in Ontario, with a focus on contact with geriatric medicine; 2) to identify determinants of contact with geriatric medicine; and 3) to examine determinants of frequent use of community-based physician services as a proxy for need for specialized geriatric care. Methods: The sample included long-stay, community-dwelling, home care clients, 60 years of age and older, in Ontario (N=196,444). For each unique client, their Resident Assessment Instrument – Home Care (RAI-HC) admission assessment was linked to Ontario Health Insurance Plan (OHIP) billing records (contact with physician services on an outpatient basis), National Ambulatory Care Reporting System records (NACRS; unplanned emergency department visits), and the Discharge Abstract Database (DAD; hospital admissions). Service use was counted in the 90 days pre-assessment, 90 days post-assessment, and six months post-assessment. Descriptive statistics were used to describe the frequency of contact with various services and to compare home care clients with and without geriatric medicine contact. Logistic regression was used to examine the associations between home care client characteristics and contact with geriatric medicine on an outpatient basis (one or more contacts in 90 days post-assessment), and frequent contact with all physician disciplines on an outpatient basis (nine or more contacts in 90 days post-assessment). Results: While almost half of the sample (49.6%) had contact with physicians four or more times in the 90 days post-assessment, only 5.2% of older home care clients had any contact with geriatric medicine during that time period. Nonetheless, almost half of the sample had multiple needs within the domains of the expertise of geriatric medicine according to the 5M Framework. While family medicine plays a gatekeeping role in the Ontario health care system, increased frequency of contact with family medicine did not result in much of an increase in any subsequent contact with geriatric medicine. Home care clients who had contact with geriatric medicine had lower odds of subsequent acute care services use than those without contact. However, the benefit varied when stratified by client characteristics. There appeared to be less benefit for those who were acutely ill, complex and unstable, and more benefit for those who were cognitively and functionally impaired. These findings may indicate the need for a more upstream approach whereby geriatric medicine is involved in a client’s care before acute issues lead to functional decline and risk of caregiver distress and institutionalization. In simple logistic regression analyses, functional and cognitive impairment, mental health conditions, risk of caregiver distress and institutionalization were found to be significantly associated with higher odds of geriatric medicine contact while pain, medical instability and complexity, and risk of unplanned ED visits were associated with lower odds. However, provincial experts in the care of older adults have identified all of the above as important for referral to SGS. In the final multivariable model, adjusted for regional effects, female sex, difficulties accessing the home, impaired locomotion outside of the home, good prospects of recovery, diagnosis of hemiplegia/hemiparesis, and cancer were associated with lower odds of geriatric contact. Age, worsening of decision-making, dementia, hallucinations, Parkinsonism, osteoporosis, and risk of caregiver distress and institutionalization (MAPLe score) were associated with higher odds of geriatric contact. Frequent contact with outpatient physicians in general was expected to be a proxy for need for SGS as these home care clients likely had multiple, unmet needs and would benefit from the holistic, patient-centred approach of geriatric medicine. Interestingly, many of the factors driving frequent attendance were the same factors associated with lower odds of geriatric medicine contact. In the final multivariable model, adjusted for regional effects and age, married status, functional improvement potential, congestive heart failure, irregularly irregular pulse, cancer, treatments changed in last 90 days, nine or more medications, medical complexity and instability (CHESS), and at risk for unplanned ED visits (DIVERT) had higher odds of frequent attendance. Female sex, impaired locomotion outside of the home, cognitive impairment, dementia, stroke, multiple sclerosis, Parkinsonism, hip fracture, unusually poor hygiene, older age, and need for urgent referral (AUA) were associated with lower odds of frequent attendance. Conclusions: This dissertation provides empirically-based insight into the current practice patterns and determinants of community-based geriatric medicine use in Ontario and highlights the need for a decision support mechanism to rationally and equitably identify older home care clients who may benefit from referral to SGS in a timely manner. As a result of this research, a decision support tool is proposed which incorporates insights from historical practice patterns, in addition to provincial expertise in the care of older adults, and the 5M Framework, used nationally to describe the scope and expertise of geriatric medicine. According to the proposed tool, home care clients at risk for caregiver distress and institutionalization (based on current practice patterns), with medical instability and complexity (based on provincial expertise), and needs within multiple domains of the 5M Framework should be identified through regular home care assessment for consideration for referral to SGS. A tool that is compatible with standardized assessments within home care and other care sectors will allow for allocation of resources more rationally and equitably, and enhance communication and integration across care providers, sectors, and agencies. Future research should evaluate the proposed tool and explore implementation considerations.
Transitions in Mood Among Residents of Canadian Long-Term Care Facilities: The Effects of COVID-19 Individual Risk Factors and Regional Characteristics
(University of Waterloo, 2024-05-31) Mulla, Reem; Hirdes, John
Long-term care home residents are among the most vulnerable populations due to their advanced age. Their health and well-being can be influenced by physical and psychosocial factors, the surrounding physical environment, and practice patterns that make them more susceptible to increased morbidity, disability, and mortality. Mental health disorders are particularly common among residents of long-term care (LTC) homes affecting between 27% and 40% of all LTC residents in Canada. The COVID-19 pandemic had a substantial impact on the physical and mental health and well-being of residents of long-term care (LTC) homes. The increased vulnerability of older adults combined with essential preventive and infection control measures led to a challenging environment in these care facilities. The COVID-19 pandemic highlighted and magnified pre-existing challenges in the LTC system, emphasizing the importance of comprehensive strategies to safeguard the mental health of LTC residents. Study 1 is a scoping review that investigates the effect of isolation and loneliness on the mood of long-term care (LTC) home residents, both before and during the COVID-19 pandemic. It provides an overview of existing literature to understand the effects of family and friends’ visits or loneliness and of COVID-19 restrictions on residents’ mood. The review shows a diversity of findings highlighting the complexity of factors influencing residents' mood during a global health crisis such as that of COVID-19. It suggests a need for a nuanced understanding of the interplay between social interactions, pandemic-induced restrictions, and individual coping mechanisms. It also highlights the need to use a standardized measure for depressive symptoms globally to prevent biases and inconsistencies that might arise from research based on different measures. Study 2 is a longitudinal study evaluating the effect of COVID-19 pandemic on incident mood disturbance among Canadian long-term care home residents. It also examines the effects of COVID-19 in stratified models using resident and facility-level variables. This study shows that a variety of factors contributed to an increase in mental health challenges during the initial waves of the pandemic including, but not limited to, the potential effects of lockdown procedures. Our findings highlight the importance of implementing broad-based multidimensional interventions to ensure the mental well-being of all individuals during outbreaks. Study 3 is a pan-Canadian retrospective longitudinal analysis of residents in long-term care homes. It examines the complex transition between the different mood states and absorbing states out of LTC settings using a one-step multistate Markov transition analysis. Study 2 reports incident mood disturbance among Canadian long-term care home residents; however, it does not address the multidirectional changes or the absorbing states that act as competing risks. This study can inform decisions on programs that can enhance the mood of long-term care residents by examining predictors of worsening or improving mood as well as factors predicting transition to the absorbing states. Study 4 expands on our knowledge from study 3 by treating COVID-19 as a covariate to examine the effects of COVID-19 on transitions between the transient mood states and the absorbing states in comparison to the pre-pandemic period. A one-step multistate Markov transition analysis was used in a pan-Canadian retrospective longitudinal analysis. The findings suggest further knowledge on the effects of COVID-19 on mood and inform decisions on the effective programs that can improve mood during periods of outbreaks. The importance of this thesis lies in its comprehensive examination of the multifaceted complex interplay between social interactions, pandemic-related measures, as well as individual and facility-level variables pre-pandemic and during the COVID-19 pandemic. The included studies provide important insights for developing targeted interventions to support positive mood of LTC residents. In conclusion, this thesis not only advances our understanding of the mental health implications for LTC residents but also informs the development of evidence-based strategies to mitigate the adverse effects of isolation and pandemic-related stressors on this vulnerable population.
Using Long Term Risk Factors from the Ontario Mental Health Reporting System (OMHRS) dataset to predict suicide admission and suicide severity among acute psychiatric inpatients in Ontario, Canada
(University of Waterloo, 2021-05-04) Garner, Ashley; Hirdes, John
The main purpose of this study was to investigate the relationships between multidimensional long term suicide risk factors (LTRF) and short-term suicide related outcomes known as early warning signs (EWS) among a cross-section of psychiatric inpatients in Ontario between 2005 and 2019. This study conducted a secondary data analysis with statistical methodology using the Ontario Mental Health Reporting System (OMHRS) dataset. This study found a diverse range of LTRF from multiple domains related to a person’s health and wellbeing to be predictive of EWS. These findings indicate that suicide is a complex phenomenon with multiple interrelated contributing factors, and therefore the whole person should be treated with a multi-disciplinary approach to ameliorate suicide potential, rather than focusing on individual or a particular group of LTRFs.
Widening the View: A Standardized Approach to Capturing Family Members’ Perspectives on Quality of Life in Long-term Care
(University of Waterloo, 2023-11-20) Norman, Kathleen; Hirdes, John
Background and Rationale: Family members provide important functional and socio-emotional support to residents living in Long-Term Care (LTC). With high rates of cognitive impairment among residents, family member input is increasingly valued in new LTC standards provided by Health Standards Organization (HSO), given their unique perspectives, knowledge, and role in the resident’s circle of care. A standardized instrument to collect this input is lacking in the current literature. Methods: A scoping review was conducted to gather and evaluate the existing literature studying the instruments used to evaluate family perspectives on Quality of Life (QoL) in LTC. This and retrospective analyses of secondary data collected from 3 previous studies using the interRAI Family QoL LTCF instrument (FamQoL V1), informed the development of a new instrument, the interRAI Family QoL LTCF Version 2 (FamQoL V2). An expert panel participated in the Delphi method to gather expert input into the development of a Version 2 interRAI Family QoL-LTCF (FamQoL V2) Instrument, through the Seniors Quality Leap Initiative (SQLI). Primary data were then collected from 38 LTC homes in Canada and the US with a total of 716 unique family members responding. These data were used to examine the psychometric properties of the instrument, develop summary scales, and examine distributions of Family QoL perspectives in North American LTC homes. Results: The previously published instruments varied considerably with item counts ranging from 21 to 104 and 4 to 15 summary domains. While several common item themes were identified (e.g., living environment, resident care, autonomy, security, global recommendations), others were less consistent among the instruments (e.g., administration, admission process, therapies). Family members had lower positive response rates on the items with higher missing or non-response rates (e.g., bath/shower when wish, affection and romance, social activities). They scored higher than residents on items related to staff responsiveness and trust and lower than residents on items related to social life and personal control. Several Delphi rounds were conducted to build consensus, resulting in a 25-item FamQoL V2 instrument with 12 shared QoL-LTCF and 13 unique FamQoL V2 items. The instrument had strong performance. Five summary scales were developed through factor analysis, with Cronbach’s alpha ranging from 0.88 to 0.92. Conclusion: This dissertation provides actionable evidence that supports the Quadruple Aim of Healthcare Improvement, meeting new national LTC standards, and assisting LTC homes in their quality improvement efforts. Through an extensive scoping review, analysis of a large and multi-study secondary dataset, expert Delphi input, multi-country primary data collection and psychometric testing, and family member feedback, a FamQoL V2 instrument was developed and accepted by a large consortium of LTC providers and researchers (SQLI). The instrument is operationally feasible, with a shorter number of items compared to other surveys and interoperability with other interRAI instruments. The scientific work underlying this instrument’s development has been reviewed and approved by interRAI’s Instrument and Systems Development (ISD) Committee and the FamQoL V2 is now included in interRAI’s published manual for QoL measures. An evidence-informed, reliable instrument is now available for jurisdictions to standardize how this important perspective is collected and measured in LTC.