Seeing Care Through a Different Lens

Established in 2007, Translating Research in Elder Care (TREC) is a partnership of researchers, knowledge users, policy makers, and citizens who study how to create quality-of-care improvements for long-term care residents and staff.

Since its inception, TREC has created a measurement system to gather data pertaining to topics such as work environments, best practices and resident outcomes within 94 randomly chosen Canadian long-term care homes of various sizes and models — public, not-for-profit and private — throughout British Columbia, Alberta and Manitoba.

In 2016, a TREC pilot called Safer Care for Older Persons (in long-term care) Environments (SCOPE) was launched in seven Winnipeg-based long-term care homes that were already participating in TREC’s measurement system.

"We can’t just focus on ‘more’ [care], we also have to focus on ‘different’ approaches to care. Both are needed to improve health-care delivery.”

– Dr. Malcolm Bray Doupe

According to Dr. Malcolm Bray Doupe, provincial lead for Manitoba’s TREC program, the idea behind SCOPE was to approach care differently.

“We can’t just have one lens to look at this,” Doupe says. “We can’t just focus on ‘more’ [care], we also have to focus on ‘different’ approaches to care. Both are needed to improve health-care delivery.”

SCOPE challenged traditional research by designating care aides as the study leads instead of researchers. Within the seven pilot care homes, teams of five to seven front-line staff, led by care aides, chose one of three themes — pain, mobility or behaviour — under which they would design and implement a simple intervention within one unit of their care home that could improve residents’ quality of life.

Dr. Malcolm Bray Doupe

Over the course of a year, TREC supported these teams with training, researcher check-ins, educational resources, funding and red-tape navigation. In return, care aides provided TREC with feedback on the efficacy of their interventions, the challenges they faced and any general observations they had. 

Doupe says one mobility-focused team put signs on residents’ doors that read: “When’s the last time I was walked?” The signs prompted front-line staff to write times down so that residents were taken for walks more frequently. 

“The more we can do to approach things differently without a huge influx of dollars, the better off we are,” Doupe says.

“We all have a natural human tendency to revert to our old behaviours, and old ways of doing things.”

– Dr. Whitney Berta

After Manitoba’s SCOPE trial wrapped up in 2017, the pilot expanded into 14 randomly chosen care homes in Alberta and 17 in BC — all of which were already part of TREC’s measurement system. The pilot ran until May 2019 in these two provinces, and the care initiatives that came out of the project were promising. But were they long-lasting?

That was the question that intrigued TREC member Dr. Whitney Berta, who works as a professor, organization scientist and health services researcher with the Institute of Health Policy, Management and Evaluation at the University of Toronto. 

Berta wondered if the foundational elements of SCOPE’s various quality improvements were still present years after the intervention was introduced.  

“We all have a natural human tendency to revert to our old behaviours, and old ways of doing things,” Berta says — especially when supports like researchers, reminders and funding cease. She also questioned what the minimum level of assistance required would be in order to sustain practice change. 

To find out, Berta assembled a team and, in Fall 2018, launched a new initiative with TREC: the Sustainment, Sustainability, and Spread Study (SSaSSy). Working with the same seven Manitoba care homes that participated in SCOPE during its first pilot, Berta’s team set out to assess the extent to which SCOPE quality improvement processes had been maintained, while also interviewing care aide staff to find out what influenced, enabled, and detracted from the sustainment after SCOPE concluded.

Cited detractions included frequent new policies and staff turnover, while enablers included supportive directors and policy-makers who helped implement SCOPE team initiatives. 

A second aim of SSaSSy was to test the impact that “boosters” might have on extending quality improvement practices longer than seen in the past.

Boosters are post-SCOPE supports (i.e., education, motivation, reminders) that SSaSSy’s research team would provide via in-person meetings (when possible due to COVID-19 protocols), emails, training sessions (called “learning congresses”) and virtual meetings.

Participating care homes were randomly selected to receive different levels of boosters: low or high. A low-dose team would receive one check-in call with a SSaSSy quality advisor at the midway point of the trial, while a high-dose team got three calls, one roughly every three months. 

“Our quality advisors are experts from the field of quality improvement,” Berta explains, adding that they also work closely with SSaSSy researchers.

The check-in calls were for progress checks, troubleshooting and discussing next steps. Sponsors (a.k.a. care home directors or decision-makers) were also given opportunities to speak with quality advisors about team dynamics and care aide leadership.

All other supports for low- and high-dose teams were the same — these included a binder of educational material; a SCOPE refresher workshop to reintroduce the idea of teams leading their own quality care improvement projects; the quality advisor’s contact information so that teams could reach out whenever needed; a monetary stipend to support workshops and time relief; and a celebratory meeting at the end of the SSaSSy intervention to share stories and learnings with other participating SSaSSy teams.

The initial trial was designed to last one year, but due to recruitment issues, that timeline was reduced to seven months. Once Manitoba’s trial ended, the TREC team launched a larger SSaSSy pilot (Phase 2) in Alberta and BC in June 2020. All the homes that participated in SCOPE — 14 in Alberta and 17 in BC — were recruited, but due to COVID-19 impacting the long-term care sector so severely, some homes were unable to participate at that time. 

Currently, SSaSSy Phase 2 has four long-term care homes that started the intervention in November 2020, four in March 2021, and five in June 2021, and all meetings are being done online (virtually) for the time-being. (The option is still open for the other 17 Alberta and BC homes to join in sometime in the future.) 

Just like in Manitoba, participating homes were randomly selected to receive low and high doses of boosters. The other 17 homes are still factored into the study but are referenced as receiving “no boosters” while researchers go about simply gathering standard, consensual data through TREC’s measurement system. 

"They really enjoyed hearing the stories; being able to know that not every care home is perfect; other care homes have their own challenges … and hearing about different ways they’ve chosen to deal with problems is really inspiring to other teams."

– Lauren MacEachern

SSaSSy's deeper roots

Berta’s SSaSSy team first began work on the idea in 2017 — when they first applied for a grant to do their research.  They received the grant that fall, which enabled them to bring on Lauren MacEachern as a TREC doctoral trainee (now candidate) and SSaSSy’s research coordinator.

MacEachern first joined TREC in 2016 as a trainee while working toward a master’s degree in Family Studies and Gerontology with Mount Saint Vincent University. At TREC’s annual general meeting in June 2018, she presented her thesis on the motivation for sharing advice in the Canadian long-term sector. And that’s when her path crossed Berta’s.

Lauren MacEachern

“I think what piqued [Berta’s curiosity] in my work was my interest in how decision-makers and facility leaders think and the way they make decisions,” MacEachern says. “And that’s pretty similar to what brought me to U of T for my PhD, which was organization and management studies.”

MacEachern started her doctorate studies in Health Services Research at the University of Toronto in Fall 2018, aligning with when she joined the SSaSSy team.

“I’ve always been interested in how we learn things, but similarly how we unlearn things, so I’m trying to apply that knowledge to administrative work within the long-term care sector,” MacEachern says about the dissertation proposal she defended on June 9, 2021. 

“These are the types of practices that I hope to identify since we don’t know what they are yet, but I’m pretty certain they exist … and then after we have learned what they are, we can learn how to reduce or remove them,” she says.

This practice has commonly been applied in the medical field, but not long-term care. MacEachern will work on her own research along with SSaSSy over the next two years and apply cross-learnings where she can.

Manitoba’s SSaSSy pilot paper is still being written, but one key observation includes how sponsor support is key, MacEachern says. “A good team dynamic between sponsor and health-care aides is critical.”

Sharing with other SSaSSy teams was also important to care aides. “They really enjoyed hearing the stories; being able to know that not every care home is perfect; other care homes have their own challenges … and hearing about different ways they’ve chosen to deal with problems is really inspiring to other teams,” MacEachern says.

If SSaSSy finds the right recipe of supports — quantity, intensity, frequency, duration — to empower care aides and reduce their stressors, the hope is that those living with dementia will have an improved quality of life in care homes.

“Long-term care has historically been understudied in the health-care sector,” Berta says, noting that COVID-19 highlighted long-standing issues like resource shortages, giving her hope that long-term care will get the attention it deserves from this point on.