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Objective To assess effect of a complex, multidisciplinary intervention aimed at reducing avoidable acute hospitalization of residents of residential aged care (RAC) facilities. Design Cluster randomized controlled trial. Setting RAC facilities with higher than expected hospitalizations in Auckland, New Zealand, were recruited and randomized to intervention or control. Participants A total of 1998 residents of 18 intervention facilities and 18 control facilities. Intervention A facility-based complex intervention of 9 months' duration. The intervention comprised gerontology nurse specialist (GNS)-led staff education, facility bench-marking, GNS resident review, and multidisciplinary (geriatrician, primary-care physician, pharmacist, GNS, and facility nurse) discussion of residents selected using standard criteria. Main outcome measures Primary end point was avoidable hospitalizations. Secondary end points were all acute admissions, mortality, and acute bed-days. Follow-up was for a total of 14 months. Results The intervention did not affect main study end points: number of acute avoidable hospital admissions (RR 1.07; 95% CI 0.85–1.36; P = .59) or mortality (RR 1.11; 95% CI 0.76–1.61; P = .62). Conclusions This multidisciplinary intervention, packaging selected case review, and staff education had no overall impact on acute hospital admissions or mortality. This may have considerable implications for resourcing in the acute and RAC sectors in the face of population aging.

Background: Local health services expressed interest in supporting a nurse practitioner (NP) program specifically designed for rural practice environments. Aim: To develop and deliver a generalist NP program that prepares candidates for practice in rural contexts. Methods: The Master of Clinical Nursing (Nurse Practitioner) program was designed with an understanding of the burden of disease impacting on rural Australians, application of the national health priorities, the Australian Government's refocus on preventative health care and rural health workforce shortages. Results: This program offers nurses who work in rural and remote settings an opportunity to advance their careers. Increasing the numbers of rural NPs will improve rural populations access to healthcare and potentially improve health outcomes. Conclusion: This program will equip those seeking endorsement as a NP to effectively work in rural contexts.

To explore an innovative primary healthcare gerontology nurse specialist role from the perspectives of older people and health professionals.Primary care is struggling to meet the needs and demands of complex older people. New models which incorporate holistic assessment and care coordination are necessary.A qualitative descriptive general inductive design was used.Older people at risk of health and functional decline were identified and received a comprehensive gerontology assessment and care coordination. Older adults (75 years+) enrolled within one of three primary healthcare practices in Auckland, New Zealand were eligible. Healthcare professionals directly involved with the primary healthcare gerontology nurse specialist model were invited for study participation. Face-to-face interviews were held with five older people and six health professionals were interviewed by telephone. A semistructured interview guide was used for all interviews. A general inductive approach was undertaken for analysis to systematically identify codes and themes.Data analysis revealed two central themes from the older people perspective: "holistic expertise" and "communication." Two main themes were identified from the health professional perspective: "competency" and "service delivery." Results showed the gerontology nurse specialist role was highly regarded by both older people and the health professionals. The in-home comprehensive geriatric assessment was identified as greatly beneficial.The competence and care coordination of the gerontology nurse specialist reduced fragmentation and were deemed immensely valuable. Care coordination should be recognised as a key component to meeting the complex needs of at-risk older people in the community.The expert knowledge of the gerontology nurse specialist and in-home comprehensive geriatric assessment were crucial aspects of the new model. Equally important was the assimilation of primary and secondary care infrastructure to upskill and deliver mentorship to the gerontology nurse specialist.

Purpose: To address a gap in the literature by exploring bereaved families' perceptions of the transition to palliative care for their relative in long-term care. Methods: In-depth interviews were conducted with a convenience sample of twenty-six family members who were most involved in the care of residents who had died within the last 12 months. Interviews explored care, perceptions of staff palliative care knowledge, communication with staff, care planning and decision-making. The range of responses fit the Donabedian (1966) health care model of structure/process/outcome. In the case of long-term care, structure includes staff training; process is the manner of care and outcome would be a ‘good’ (or bad) death. Results: There was little evidence that a well-managed transition to a palliative approach to care was being initiated. Key themes included: 1) unrecognised need for transition; 2) information gaps and 3) feeling ‘out of the loop’. Ten subthemes were also identified. Implications: Engaging family and relevant internal and external health providers in care planning not only promotes care in line with resident wishes but also assists family bereavement. Results indicate the need for the development of a new collaborative, multidisciplinary model to enhance the delivery of palliative care in long-term care.

OBJECTIVE This article estimates length of completed stay and resident transitions for RAC residents over 12 months in Auckland. METHODS Data from a census-type survey of nursing home residents (n = 6816) were linked with national mortality data. Transitions described include entry to residential aged care (RAC), movement between RAC facilities and deaths. RESULTS When reweighted for missing data and adjusted for length bias, an estimated 9676 residents (95% CI 8368-10 985) used care over a 12-month period. Half of new residents entered RAC via an acute hospital. Median survival was 2.0 years; 17% died within 3 months, and 23% survived over 5 years. CONCLUSION Cross-sectional survey data, when appropriately adjusted for length-biased sampling, enable estimates of period prevalence and transition probabilities that are useful for simulation studies. Given population ageing and the costs of ongoing care, these results can inform policy and planning for long-term care needs of older people.

Residents of long-term care facilities have highly complex care needs and quality of care is of international concern. Maintaining resident wellness through proactive assessment and early intervention is key to decreasing the need for acute hospitalization. The Residential Aged Care Integration Program (RACIP) is a quality improvement intervention to support residential aged care staff and includes on-site support, education, clinical coaching, and care coordination provided by gerontology nurse specialists (GNSs) employed by a large district health board. The effect of the outreach program was evaluated through a randomized comparison of hospitalization 1 year before and after program implementation. The sample included 29 intervention facilities (1,425 residents) and 25 comparison facilities (1,128 residents) receiving usual care. Acute hospitalization rate unexpectedly increased for both groups after program implementation, although the rate of increase was significantly less for the intervention facilities. The hospitalization rate after the intervention increased 59% for the comparison group and 16% for the intervention group (rate ratio (RR) = 0.73, 95% confidence interval (CI) = 0.61-0.86, P < .001). Subgroup analysis showed a significantly lower rate change for those admitted for medical reasons for the intervention group (13% increase) than the comparison group (69% increase) (RR = 0.67, 95% CI = 0.56-0.82, P < .001). Conversely, there was no significant difference in the RR for surgical admissions between the intervention and comparison groups (RR = 1.0, 95% CI = 0.68-1.46, P = .99). The integration of GNS expertise through the RACIP intervention may be one approach to support staff to provide optimal care and potentially improve resident health.

IntroductionPalliative care delivery has become integral to the role of healthcare staff in residential aged care (RAC) internationally. Challenges within this work environment (e.g. workload, staffing levels, resources) may impact on healthcare staffs’ willingness to undertake formal palliative care education. The study described herein explored factors (socioenvironmental and psychological) that influence staff willingness to engage in palliative care education.MethodsThe predictors of palliative care education uptake for healthcare staff (n = 431) from 52 New Zealand RAC facilities in one large urban District Health Board were assessed. Logistic regression was used to explore willingness to engage in education.ResultsHigher scores for burnout predicted a decreased likelihood of engaging in palliative care education (odds ratio (OR) 0.41, P = 0.01). The identified predictor of willingness to engage in education was previous palliative care experience (OR 1.59, P = 0.027).DiscussionThese results ...

Context Central to appropriate palliative care management in hospital settings is ensuring an adequately trained workforce. In order to achieve optimum palliative care delivery, it is first necessary to create a baseline understanding of the level of palliative care education and support needs among all clinical staff (not just palliative care specialists) within the acute hospital setting. Objectives The objectives of the study were to explore clinical staff: perceptions concerning the quality of palliative care delivery and support service accessibility, previous experience and education in palliative care delivery, perceptions of their own need for formal palliative care education, confidence in palliative care delivery and the impact of formal palliative care training on perceived confidence. Methods A purposive sample of clinical staff members (598) in a 710-bed hospital were surveyed regarding their experiences of palliative care delivery and their education needs. Results On average, the clinical staff rated the quality of care provided to people who die in the hospital as ‘good’ (x=4.17, SD=0.91). Respondents also reported that 19.3% of their time was spent caring for end-of-life patients. However, only 19% of the 598 respondents reported having received formal palliative care training. In contrast, 73.7% answered that they would like formal training. Perceived confidence in palliative care delivery was significantly greater for those clinical staff with formal palliative care training. Conclusions Formal training in palliative care increases clinical staff perceptions of confidence, which evidence suggests impacts on the quality of palliative care provided to patients. The results of the study should be used to shape the design and delivery of palliative care education programmes within the acute hospital setting to successfully meet the needs of all clinical staff.

Background: Recent studies have concluded that there is significant potential to reduce the extent of ‘inappropriate’ hospitalisations among patients with palliative care needs. However, the nature of, and reasons for, inappropriate hospitalisations within a palliative care context is under-explored. Aim: To explore the opinions of ‘generalist’ palliative care providers regarding the nature of, and reasons for, inappropriate admissions among hospital inpatients with palliative care needs. Design: Qualitative study with data collected via individual interviews and focus groups. Setting/participants: Participants (n = 41) comprised ‘generalist’ palliative care providers working in acute hospital and community settings. Setting: One District Health Board in an urban area of New Zealand. Results: The majority of participants discussed ‘appropriateness’ in relation to their own understanding of a good death, which typically involved care being delivered in a ‘homely’ environment, from known people. Differing attitudes among cultural groups were also evident. The following reasons for inappropriate admissions were identified: family carers being unable to cope, the ‘rescue culture’ of modern medicine, the financing and availability of community services and practice within aged residential care. Conclusions: On the basis of our findings, we recommend a shift to the term ‘potentially avoidable’ admission rather than ‘inappropriate admission’. We also identify an urgent need for debate regarding the role of the acute hospital within a palliative care context. Interventions to reduce hospital admissions within this population must target societal understandings of death and dying within the context of medicalisation, as well as take into account cultural and ethnic diversity in attitudes, if they are to be successful.

Place of death, specifically the percentage who die in hospital or residential aged care, is largely unreported. This paper presents a cross-national comparison of location of death information from published reports and available data. Reports of deaths occurring in hospitals, residential aged care facilities, and other locations for periods since 2001 were compiled. Over 16 million deaths are reported in 45 populations. Half reported 54 % or more of all deaths occurred in hospitals, ranging from Japan (78 %) to China (20 %). Of 21 populations reporting deaths of older people, a median of 18 % died in residential aged care, with percentages doubling with each 10-year increase in age, and 40 % higher among women. This place of death study includes more populations than any other known. In many populations, residential aged care was an important site of death for older people, indicating the need to optimise models of end-of-life care in this setting. For many countries, more standardised reporting of place of death would inform policies and planning of services to support end-of-life care.

To describe changes in aged care residents' dependency over a 20-year period.All residents in 1988, 1993, 1998, and 2008 were assessed using the same 23-item functional ability survey.Residential aged care facilities in Auckland, New Zealand.In 1988 there were 7516 participants (99% response rate), 6972 in 1993 (85% response rate), 5056 in 1998 (65% response rate), and 6828 in 2008 (89% response rate). Data were weighted to accommodate variation in response.A composite dependency score with 5 ordinal levels was derived from a census-type survey reporting mobility, activities of daily living ability, continence, and cognitive function.The proportion of "apparently independent" residents decreased from 18% in 1988 to 9% in 1993, 5% in 1998, and 4% in 2008, whereas those "highly dependent" increased from 16% in 1988, to 18% in 1993, 19% in 1998, to 21% in 2008. All functional indicators demonstrated increased dependency over the 20-year period (P.0001). However, between 1998 and 2008 there were significant increases in dependency for continence, mobility, self-care, and orientation, but no significant changes in memory and behavior.The increased dependency over 20 years directly affects care requirements for this population.

Background in Auckland, New Zealand in 1988, 7.7% of those aged over 65 years lived in licenced residential aged care. Age-specific rates approximately doubled for each 5-year age group after the age of 65 years. Even with changes in policies and market forces since 1988, population increases are forecast to drive large growth in demand. This study shows previously unrecognised 20-year trends in rates of care in a geographically defined population. Methods four cross-sectional surveys of all facilities (rest homes and hospitals) licenced for long-term care of older people were conducted in Auckland, New Zealand in 1988, 1993, 1998 and 2008. Facility staff completed survey forms for each resident. Numbers of licenced and occupied beds and trends in age-specific and age-standardised rates in residential aged care are reported. Results over the 20-year period, Auckland's population aged over 65 years increased by 43% (from 91,000 to 130,000) but actual numbers in care reduced slightly. Among those aged over 65 years, the proportion living in care facilities reduced from 1 in 13 to 1 in 18. Age-standardised rates in rest-home level care reduced from 65 to 33 per thousand, and in hospital level care, from 29 to 23 per thousand. Had rates remained stable, over 13,200 people, 74% more than observed, would have been in care in 2008. Conclusion growth predicted in the residential aged care sector is not yet evident. The introduction of standardised needs assessments before entry, increased availability of home-based services, and growth in retirement villages may have led to reduced utilisation.

Objective: The objective was to test the ability of the Brief Risk Identification for Geriatric Health Tool (BRIGHT) to identify older emergency department (ED) patients with functional and physical impairment. Methods: This was a cross-sectional study in which 139 persons ≥75 years, who presented to an urban New Zealand ED over a 12-week period, completed the 11-item BRIGHT case-finding tool. Then, within 10 days of their index ED visit, 114 persons completed a comprehensive geriatric assessment. A “yes” response to at least 3 of the 11 BRIGHT items was considered “positive.” Primary outcome measures were instrumental activities of daily living (IADL), cognitive performance scale (CPS), and activities of daily living (ADL). Results: The BRIGHT-identified IADL deficit (64% prevalence) with a sensitivity of 0.76, specificity of 0.79, and receiver operating characteristic (ROC) of 0.83 (95% confidence interval [CI] = 0.74 to 0.91, p

INTRODUCTION global population projections forecast large growth in demand for long-term care (LTC) and acute hospital services for older people. Few studies report changes in hospitalisation rates before and after entry into LTC. This study compares hospitalisation rates 1 year before and after LTC entry. METHODS the Older Persons' Ability Level (OPAL) study was a 2008 census-type survey of LTC facilities in Auckland, New Zealand. OPAL resident hospital admissions and deaths were obtained from routinely collected national databases. RESULTS all 2,244 residents (66% = female) who entered LTC within 12 months prior to OPAL were included. There were 3,363 hospitalisations, 2,424 in 12 months before and 939 in 12 months after entry, and 364 deaths. In the 6 to 12 months before LTC entry, the hospitalisation rate/100 person-years was 67.3 (95% confidence interval [CI] 62.5-72.1). Weekly rates then rose steeply to over 450/100 person-years in the 6 months immediately before LTC entry. In the 6 months after LTC entry, the rate fell to 49.1 (CI 44.9-53.3; RR 0.73 (CI 0.65-0.82, P < 0.0001)) and decreased further 6 to 12 months after entry to 41.1 (CI 37.1-45.1; rate ratio [RR] 0.61 (CI 0.54-0.69, P < 0.0001)). CONCLUSIONS increased hospitalisations a few months before LTC entry suggest functional and medical instability precipitates LTC entry. New residents utilise hospital beds less frequently than when at home before that unstable period. Further research is needed to determine effective interventions to avoid some hospitalisations and possibly also LTC entry.

Objectives Previous research has indicated that staff in aged residential care (ARC) may be unprepared for their role in palliative care provision. The need for palliative care knowledge among ARC staff has been characterised as ‘pervasive’. Determining the palliative care education, communication and support needs of ARC clinical care staff is, therefore, of critical importance to the delivery of quality healthcare in this setting. Methods A survey of clinical staff (n=431) in 52 ARC facilities in 1 urban district health board was conducted, using a paper-based questionnaire. Instruments included the 3-item Experiences with End of Life scale, developed measures of communication and support (13 items), support accessibility (12 items), and palliative care education (19 items). Results Only 199 (46.2%) of staff participants reported undertaking palliative care education. Nurses were more likely to have engaged in palliative care education in comparison with healthcare assistants (HCAs) (χ 2 (1, N=387)=18.10, p=0.00). Participants (n=347) who wanted further education preferred an interactive, hands-on applied education (13.9%) in comparison to short topic-specific sessions/seminars (6.5%) or lecture-based courses (7.7%). Conclusions The study reveals an ongoing need for staff palliative care education. Results suggest the development of an integrated model of care which draws on both hospice and ARC staff expertise.

Organisational culture has been shown to impact on resident outcomes in residential aged care (RAC). This is particularly important given the growing number of residents with high palliative care needs. The study described herein (conducted from January 2013 to March 2014) examined survey results from a convenience sample of 46 managers, alongside interviews with a purposively selected sample of 23 bereaved family members in order to explore the perceptions of organisational culture within New Zealand RAC facilities in one large urban District Health Board. Results of the Organisational Culture Assessment Instrument (OCAI) completed by managers indicated a preference for a ‘Clan’ and the structured ‘Hierarchy’ culture. Bereaved family interviews emphasised both positive and negative aspects of communication, leadership and teamwork, and relationship with residents. Study results from both managers’ OCAI survey scores and next of kin interviews indicate that while the RAC facilities are culturally oriented towards providing quality care for residents, they may face barriers to adopting organisational processes supportive of this goal.

In New Zealand, no reliable information describes use of long-term residential aged care. Instead, when estimating use, records of government subsidy payments are upscaled to adjust for private payers. This paper assesses consequential bias in reporting use of long-term care and considers the implications.Data from OPAL, a census-type survey of residents of aged-care facilities in Auckland in 2008, linked to routinely-collected hospitalisation, mortality and subsidy data from national databases. Demographic, functional and service use characteristics of unsubsidised residents were compared to subsidised.Records of 5961 OPAL residents aged 65+ years were matched with subsidy data; 25% were unsubsidised. In low-level care (51% of all), unsubsidised residents had similar care needs to subsidised residents, but were 1.7 years older on average (p0.001) with shorter length of stay. In high-level care (41% of all), unsubsidised residents had significantly lower care needs on six different measures and were less likely to die during the follow-up period. Upscaling yields undercounts at all care levels.National reports derived from current upscaling methods undercount residents. Stratification by region and age group would improve estimates. Age and care needs are misrepresented. Population policies that depend upon upscaled counts should, where possible, ascertain the biases introduced.

Objective More than 90% of people spend time in hospital in the last year of life and, in many developed countries, hospitals are the setting in which most people will die. Previous research indicates that a proportion of these hospital admissions could have been avoided. The objective of this study was to establish the extent and cost of potentially avoidable hospital admissions among patients with palliative care needs. Methods A prospective survey of hospital inpatients was undertaken to identify patients who met clinical criteria indicating palliative care need. Case notes were reviewed by two expert palliative care clinicians to determine if the hospital admission was potentially avoidable. An analysis of the cost of potentially avoidable admissions compared to all other admissions for those patients identified as being in the last year of life was carried out using the statistical analysis software R V.2.15.1. Logistic regression was performed using the logit (log of OR) link. The binary outcome of the logistic regression model was a potentially avoidable admission. Results Of the 99 patients who met the criteria for palliative care need, 22 were deemed to have experienced a potentially avoidable admission. Those living in a residential aged care facility were more at risk of experiencing such admissions. The mean total cost of hospital care for those with palliative care needs was lower for those whose admission was deemed potentially avoidable. Conclusions A significant proportion of patients with palliative care needs experience a potentially avoidable admission. Although these admissions are relatively short compared to those whose admissions are unavoidable, any hospital admission impacts on the experiences of patients and families and may contribute to unnecessary hospital expenditure.

To describe short-term mortality among residential aged care (RAC) residents in Auckland, New Zealand.Prospective follow-up, 6828 residents (median age 86 years, 69.8% women) from census-type survey (10/9/2008); 152 facilities. Mortality data from central sources.Eight hundred and sixty-one (12.6%) died by 6 months. Survival related to RAC length of stay before the survey: those resident1 month (subgroup, n = 380) having 80.0% survival, 1-6 months 83.2% and6 months 87.4% (P0.0001). In those admitted to private hospital from acute hospital (n = 104 of the subgroup of 380), 6-month mortality was 36.5% (P0.0001 vs other 'short stayers'). Significant mortality predictors were: private hospital admission from acute hospital (hazard ratio (HR) = 2.02), unscheduled GP visit during the prior 2 weeks (HR = 1.90), personal care disability (HR = 1.90) and acute hospital admission number during the previous 2 years (≥3; HR = 5.40).RAC mortality (especially post admission) is high. Training and resource in the sector should reflect this.

frail older people living in residential long-term care (LTC) have limited life expectancy. Identifying those with poor prognosis may improve management and facilitate transition to a palliative approach to care.to develop methods for predicting mortality in LTC.a population-based cohort study.LTC facilities, Auckland, New Zealand.five hundred randomly selected older people in a census-type survey of those living in LTC in 2008.mortality data were obtained from New Zealand Ministry of Health. Two methods for assessing mortality risk were developed using demographic, functional and health service information: (i) two geriatricians blinded to identifying data and to mortality, independently reviewed survey, medications and pre-survey hospitalisations data, and grouped residents according to perceived risk of death within 12 months; (ii) multivariate logistic regression model used the same survey and medication items as the geriatricians.for the geriatricians' assessment, each quintile of perceived risk was associated with a significant increase in mortality (P0.001). Area under the curve (AUC) for both physicians was 0.64. The logistic regression model included age, gender, assistance with feeding and requiring night attention, all variables which are easily available from LTC records. AUC for the model was 0.70, but when validated against the entire OPAL cohort, it was 0.65. When either or both geriatrician and the model together predicted high risk of death, 1-year mortality was50%.two methods with the potential to identify older people with limited prognosis are described. Use of these methods allowed identification of over half of those who died within 12 months.

Nurse practitioners (NPs) have been registered in New Zealand (NZ) since 2002. This article describes a sample of their practices and outcomes across a variety of healthcare specialties. The PEPPA model was used as a guide for the organization of data, the discussion of findings, and recommendations for the future.Two e-mailed surveys of registered NPs (including qualitative and quantitative data) were conducted by the professional organization, NPNZ in 2011 and 2012.After 10 years, NPs in NZ demonstrated efficient practice and have produced measurable improved healthcare outcomes.NP practices are continuing to develop and are contributing to increased access to health care and improved health outcomes in NZ.

Background Improving palliative care management in acute hospital settings has been identified as a priority internationally. The aim of this study was to establish the proportion of inpatients within one acute hospital in New Zealand who meet prognostic criteria for palliative care need and explore key aspects of their management. Methods A prospective survey of adult hospital inpatients (n = 501) was undertaken. Case notes were examined for evidence that the patient might be in their last year of life according to Gold Standards Framework (GSF) prognostic indicator criteria. For patients who met GSF criteria, clinical and socio-demographic information were recorded. Results Ninety-nine inpatients met GSF criteria, representing 19.8% of the total census population. The patients’ average age was 70 years; 47% had a primary diagnosis of cancer. Two thirds had died within 6 months of their admission. Seventy-eight of the 99 cases demonstrated evidence that a palliative approach to care had been adopted; however documentation of discussion about goals of care was very limited and only one patient had evidence of an advance care plan. Conclusion One fifth of hospital inpatients met criteria for palliative care need, the majority of whom were aged >70 years. Whilst over three quarters were concluded to be receiving care in line with a palliative care approach, very little documented evidence of discussion with patients and families regarding end of life issues was evident. Future research needs to explore how best to support ‘generalist’ palliative care providers in initiating, and appropriately recording, such discussions.

Background Internationally, increases in the numbers of older people will be reflected in larger numbers of more socioculturally diverse groups of older people requiring care provided by residential care facilities. Covert and overt instances of homophobia are evident within residential care services provided to older lesbian, gay and bisexual people. Aims To explore the perceptions of care staff working in residential care homes towards older lesbian, gay and bisexual people. Design Critical gerontology formed the methodological foundations for focus group discussions with care staff from seven residential care facilities. Hypothetical vignettes were used to stimulate discussion amongst participants. Results Thematic analysis of the seven focus group interviews illuminated three themes: ‘Knowing me knowing you’, ‘Out of sight out of mind’ and ‘It's a generational thing’. Subtle as well as not so subtle forms of homophobia were evident in each of the themes. Care staff felt they were largely unprepared to provide care to older lesbian, gay and bisexual people. Conclusion This small-scale New Zealand study identifies that the residential care sector is not always supportive, or prepared, to provide a care service to those people identifying as lesbian, gay and bisexual. Implications for practice Findings from this study recommend the implementation of principle-based guidelines, opportunities to participate in ongoing education and partnering with non-heterosexual community organisations in order to provide culturally appropriate care to older lesbian, gay and bisexual people.

To describe an international comparison of dependency of long-term care residents.All Auckland aged care residents were surveyed in 1998 and 2008 using the 'Long-Term Care in Auckland' instrument. A large provider of residential aged care, Bupa-UK, performed a similar but separate functional survey in 2003, again in 2006 (including UK Residential Nursing Home Association facilities), and in 2009 which included Bupa facilities in Spain, New Zealand and Australia. The survey questionnaires were reconciled and functional impairment rates compared.Of almost 90,000 residents, prevalence of dependent mobility ranged from 27 to 47%; chronic confusion, 46 to 75%; and double incontinence, 29 to 49%. Continence trends over time were mixed, chronic confusion increased, and challenging behaviour decreased.Overall functional dependency for residents is high and comparable internationally. Available trends over time indicate increasing resident dependency signifying care required for this population is considerable and possibly increasing.

Background For residents of long term care, hospitalisations can cause distress and disruption, and often result in further medical complications. Multi-disciplinary team interventions have been shown to improve the health of Residential Aged Care (RAC) residents, decreasing the need for acute hospitalisation, yet there are few randomised controlled trials of these complex interventions. This paper describes a randomised controlled trial of a structured multi-disciplinary team and gerontology nurse specialist (GNS) intervention aiming to reduce residents’ avoidable hospitalisations. Methods/Design This Aged Residential Care Healthcare Utilisation Study (ARCHUS) is a cluster- randomised controlled trial (n = 1700 residents) of a complex multi-disciplinary team intervention in long-term care facilities. Eligible facilities certified for residential care were selected from those identified as at moderate or higher risk of resident potentially avoidable hospitalisations by statistical modelling. The facilities were all located in the Auckland region, New Zealand and were stratified by District Health Board (DHB). Intervention The intervention provided a structured GNS intervention including a baseline facility needs assessment, quality indicator benchmarking, a staff education programme and care coordination. Alongside this, three multi-disciplinary team (MDT) meetings were held involving a geriatrician, facility GP, pharmacist, GNS and senior nursing staff. Outcomes Hospitalisations are recorded from routinely-collected acute admissions during the 9-month intervention period followed by a 5-month follow-up period. ICD diagnosis codes are used in a pre-specified definition of potentially reducible admissions. Discussion This randomised-controlled trial will evaluate a complex intervention to increase early identification and intervention to improve the health of residents of long term care. The results of this trial are expected in early 2013. Trial registration Australian New Zealand Clinical Trials Registry: ACTRN 12611000187943

New Zealand is one of 20 countries implementing the Liverpool Care Pathway for the Dying Patient (LCP) to improve quality care of the dying. The LCP is an integrated care pathway that guides healthcare professionals to deliver evidence-based, best practice care to dying patients and their families in the last days and hours of life, irrespective of diagnosis or care setting. Currently the LCP Central Team coordinates LCP implementation and dissemination for all international collaborating countries except New Zealand, from its base in Liverpool in the UK. With the support of the LCP Central Team, New Zealand is the first country to establish a National Office to assume the responsibility for promoting the sustainable implementation of the LCP within its own borders and context of end-of-life care.To evaluate the role and value of a New Zealand National LCP Office (NZ LCP Office) from the perspective of key stakeholders.A mixed methods approach was applied, which intentionally combined two different survey methods in sequence. In Phase 1, key stakeholders (n = 28) were interviewed to explore their perspectives for the role and value of the NZ LCP Office. Findings from Phase 1 informed an online questionnaire distributed to a larger group of key stakeholders (n = 36, 62% response rate) in Phase 2.When considering the role of the NZ LCP Office, key stakeholders identified two core services as highly important, namely the promotion of the sustainable implementation of LCP and the provision of a national LCP information network. Other key initiatives identified by key stakeholders as important included the NZ LCP Office continuing to work in consultation and collaboration with the LCP Central Team and to be a voice for end-of-life care issues in New Zealand. The value or benefit of the NZ LCP Office was endorsed, in that service performance was rated as good or very good by at least 90% of the respondents, plus 40% of participants perceived the NZ LCP Office had contributed to positive changes in LCP document compliance, program integrity and improvement in care of the dying to a moderate extent.Having a National LCP Office in New Zealand to coordinate sustainable LCP implementation and maintain the integrity of the LCP program within the context of the country's own healthcare system was seen as crucial by key stakeholders.

Objective: the size of the burden of unmet needs of older people living in the community is unknown. We aim to validate a brief postal questionnaire, the Brief Risk Identification of Geriatric Health Tool (BRIGHT) questionnaire, to find cases of older people with disabilities (case-finding) living in the community. Methods: community-dwelling patients over the age of 75 years were invited from two general practitioners in Auckland, New Zealand. Participants completed the 11-item BRIGHT questionnaire twice and were assessed at home using the Minimum Dataset for Home Care (MDS-HC) comprehensive geriatric assessment tool by a trained gerontology nurse. Retest reliability of the BRIGHT was assessed with a correlation coefficient, and receiver operator characteristic (ROC) curves were used to assess the utility of the tool against standard outputs from the MDS-HC reflecting level of disability; the instrumental activities of daily living clinical assessment protocol (IADL CAP), and the MAPle score for dependency. Results: 101 participants completed both the BRIGHT questionnaires and the comprehensive MDS-HC assessment. Test-retest reliability was modest with a correlation of 0.77. A sensitivity of 0.86 and specificity of 0.86 were observed for a score of 3 or more on the questionnaire in relationship to the IADL CAP. A sensitivity of 0.65 and specificity of 0.84 were observed when BRIGHT questionnaire score of 3+ was related to the MAPLe score from the MDS-HC assessment. Conclusions:theBRIGHTquestionnairehasacceptableutilityinidentifyingcommunity-dwellingolderpeoplewithdisability, and excellent utility in ruling them out of needing further assessment. This tool may be useful as part of an intervention process to detect unmet needs and to improve systematic surveillance of primary care populations.

The objective was to test the ability of the Brief Risk Identification for Geriatric Health Tool (BRIGHT) to identify older emergency department (ED) patients with functional and physical impairment.This was a cross-sectional study in which 139 personsor = 75 years, who presented to an urban New Zealand ED over a 12-week period, completed the 11-item BRIGHT case-finding tool. Then, within 10 days of their index ED visit, 114 persons completed a comprehensive geriatric assessment. A "yes" response to at least 3 of the 11 BRIGHT items was considered "positive." Primary outcome measures were instrumental activities of daily living (IADL), cognitive performance scale (CPS), and activities of daily living (ADL).The BRIGHT-identified IADL deficit (64% prevalence) with a sensitivity of 0.76, specificity of 0.79, and receiver operating characteristic (ROC) of 0.83 (95% confidence interval [CI] = 0.74 to 0.91, p0.01); cognitive deficit (35% prevalence) sensitivity of 0.78, specificity of 0.54, and ROC of 0.66 (95% CI = 0.55 to 0.76, p = 0.006); and ADL deficit (29% prevalence) sensitivity of 0.83, specificity of 0.53, and ROC of 0.64 (95% CI = 0.53 to 0.75, p = 0.020). Positive likelihood ratios (LR+) for the three outcomes of interest were 3.6, 1.7, and 1.8, respectively. Negative likelihood ratios (LR-) were 0.3, 0.4, and 0.3.The 11-item BRIGHT successfully identifies older adults in the ED with decreased function and may be useful in differentiating elder patients in need of comprehensive assessment.

We tested the hypothesis that exogenous substance P (SP) could enhance rat aortic permeability to plasma albumin. Fluorescein-labeled bovine serum albumin was used as the tracer. In vivo normalized albumin mass transfer rates (x10(-8) cm/sec) were 9.16 +/- 1.73, 14.20 +/- 2.76 (P less than 0.05) and 20.31 +/- 3.31 (P less than 0.001) for groups infused i.v. with 0.01 N acetic acid vehicle, 7.4 pmol and 0.74 pmol SP/kg/min for 5 min, respectively. No significant differences from the control group were found in rats receiving 150 pmol, 74 pmol nor 74 fmol SP/kg/min for 5 min. The results indicate that aortic permeability dynamics for plasma albumin can be enhanced by pmol levels of the tachykinin SP.

Background.– Elderly people admitted to hospital have complex medical and social problems. They may experience prolonged length of stay and discharge delays. Safe, timely discharge depends on effective multidisciplinary team (MDT) planning and communication. Innovation A daily board-round meeting was undertaken on a 24-bedded elderly medicine ward. This involved all members of the MDT. Each patient was discussed with reference to medical and therapy goals and discharge planning. Actions agreed at the board-roundwere recorded. EachMDTmember completed a questionnaire to evaluate outcomes and overall satisfaction with the board-round process. Evaluation.– Over a four week period 71 actions were made at the board-round. Actions included: – 11 medical actions; – 12 therapy actions; – 42 social work referrals to 34 Section 2 to 8 Section 5; – 10 decisions to refer to Intermediate Care; – dates and times of ‘Best Interests’ meetings were agreed and coordinated for 7 patients, 17 MDT members completed the questionnaire and all stated that the board-round had a positive impact on the discharge process. In particular, responders thought that it improved timely referral to social services and enhanced communication between members of the MDT. Conclusions.–Adaily board-round facilitates discharge planning for older people, improves communication and is well received by all members of the MDT. This is likely to improve patient flow and reduce length of stay. In our Trust, a daily board round is to be introduced to all medical wards.

The evidence base to support the development of ACP processes for people with intellectual disabilities and their families is limited. There is a paucity of studies that have explored the most appropriate means of engaging this population in ACP discussions. Evidence from previous research would suggest that people with intellectual disabilities are at risk of both ‘under-treatment’ at the end of life, for example, through sub-optimum pain management, and ‘over-treatment’, for example overly-interventionist care. As a result the extent to which people with intellectual disabilities and their families want to engage in ACP, and the mechanisms by which this can be achieved, remains unclear, particularly within the New Zealand (NZ) context. IDEA services has over 800 community homes supporting around 5800 people with intellectual disabilities across NZ, of whom 24% are aged over 50 years resulting in an increase in the incidence and prevalence of conditions such as dementia. In this presentation, we report the preliminary findings from a qualitative interview study conducted with individuals including care staff from IDEA services, general practitioners and family care givers regarding their views about ACP focusing on the barriers to, and facilitators of ACP. We report on the views of participants in relation to: understandings of ACP, the importance of interpersonal relations and the role of advocacy. This study suggests the need to rethink the traditional autonomy focused framework of ACP and the need for broader initiatives that incorporate the views of significant others to achieve an individuals9 end of life care wishes.

Background: This paper considers approaches to the question “Which long-term care facilities have residents with high use of acute hospitalisations?” It compares four methods of identifying long-term care facilities with high use of acute hospitalisations by demonstrating four selection methods, identifies key factors to be resolved when deciding which methods to employ, and discusses their appropriateness for different research questions. Methods: OPAL was a census-type survey of aged care facilities and residents in Auckland, New Zealand, in 2008. It collected information about facility management and resident demographics, needs and care. Survey records (149 aged care facilities, 6271 residents) were linked to hospital and mortality records routinely assembled by health authorities. The main ranking endpoint was acute hospitalisations for diagnoses that were classified as potentially avoidable. Facilities were ranked using 1) simple event counts per person, 2) event rates per year of resident follow-up, 3) statistical model of rates using four predictors, and 4) change in ranks between methods 2) and 3). A generalized mixed model was used for Method 3 to handle the clustered nature of the data. Results: 3048 potentially avoidable hospitalisations were observed during 22 months’ follow-up. The same “top ten” facilities were selected by Methods 1 and 2. The statistical model (Method 3), predicting rates from resident and facility characteristics, ranked facilities differently than these two simple methods. The change-in-ranks method identified a very different set of “top ten” facilities. All methods showed a continuum of use, with no clear distinction between facilities with higher use. Conclusion: Choice of selection method should depend upon the purpose of selection. To monitor performance during a period of change, a recent simple rate, count per resident, or even count per bed, may suffice. To find high–use facilities regardless of resident needs, recent history of admissions is highly predictive. To target a few high-use facilities that have high rates after considering facility and resident characteristics, model residuals or a large increase in rank may be preferable.

Central to efforts to assure the quality of patient care in hospitals is having accurate data about quality and patient problems. The purpose was to describe the reporting rates of medication administration errors (MAE), patient falls, and occupational injuries. A questionnaire was distributed to staff nurses (N = 1105 respondents) in a national sample of 25 hospitals. This addressed voluntary reporting, work environment factors, and reasons for not reporting occurrences. More than 80% indicated that all MAEs should be reported, but only 36% indicated that near misses should be reported. Perceived levels of actual reporting were: 47% of MAEs, 77% of patient falls, 48% of needlesticks, 22% of other exposures to body fluids, and 17% of back injuries. Administrative response to reports, personal fears, and unit quality management were related to reporting. Patient and staff safety occurrences are underreported. Strong quality management processes and positive responses to reports of occurrences may increase reporting and enhance safety.