Supporting Evidence-Informed Policy

TREC’s research is valuable in setting policy—applying data from the TREC Measurement System to analyze and modify a facility’s work environment, its staffing and services, staff’s use of best healthcare practices, and staff health and well-being. Examples include TREC projects on how and why care aides are rushed in their daily tasks, on burnout among staff, and on length of stay by residents. In addition, TREC’s System Projects are smaller “proof of concept” studies. Stakeholders and TREC researchers jointly identify a problem to analyze, and results often influence policy. The early years of TREC saw three preliminary system projects: 

  • the role of life stories in helping care aides learn about residents
  • coaching for managers in long-term care
  • supportive supervision for registered nurses in long-term care

System projects continue to evolve and are now conducted in partnership with decision makers.

Can we Monitor Quality at the System Level?

The Trajectories Project

The Trajectories project studied modifiable symptoms and potentially inappropriate care practices experienced by residents in Canadian nursing homes near the end of life. The project was conceived after conversations with people working in the nursing home system, partnering TREC researchers with care providers and decision makers. It used TMS data to determine which symptoms and practices place the most burden on residents, and to develop and evaluate ways to measure and monitor burden. In all sites, the burden of modifiable symptoms worsens as the end of life approaches. However, nursing homes with better work environments have lower rates of burdensome resident symptoms. This is significant because work environment is modifiable.

When a provincial health minister asked if TREC could use TMS data to detect shifts in nursing home quality at the system level, the Canary project was born (named for the birds that miners carried into tunnels to warn of dangerous gases—an early detection system).

The Canary Project

Canary is a “proof of concept” project, using TREC data to build an indicator that measures the overall health of the system. The goal was a single composite indicator that could be monitored every three months to signal quality at the system level. It is based on 12 carefully chosen quality indicators from standardized resident assessment data that is collected by all Canadian nursing homes.

The Canary team has completed stage 1 of this work, showing that watching this score over time can show how changes affect the system. For instance, in 2010 Alberta began using funding for long-term care that is based on patient and health needs. The Canary score changed, with some indicators getting better and some worsening. One key take-home message is that quality indicators need to be monitored when changes are implemented as often when one improves in response to a change, another will worsen (because there are finite resources in the system).

Early application of the Canary score to seasonal flu data has been promising, showing a predictable pattern of lagged quality worsening after each flu outbreak.The Canary team will assess the score’s validity with data from the Canadian Institute for Health Information. TREC’s goal is to hand the scoring technique over to decision makers in health ministries and regions, allowing them to generate their own reports and readily monitor quality of care at a system level.

“We wanted to look at the system level and not individual nursing homes. We decided we weren’t just going to look for the canary dying but whether it was singing a better song than it had been for a while—an indicator that would tell us whether the system is getting better, worse or staying the same.”

Developing Energy for Evidence-Based Decision Making

Marian Anderson has been involved with TREC since 2007, when she was director of care for the Shepherd’s Care Foundation. She remembers the early days as a real driver for the nursing home’s use of data and evidence-based change. For Anderson, TREC’s impact extends far beyond the day-to-day operations of the two Shepherd’s Care facilities in Edmonton. “Personally, I never believed I would have the opportunity to be involved with research the way I was with TREC,” she explains. “Through that involvement I have developed a real passion for evidence-based care which made me start questioning how people make decisions. And I know I have passed that passion on to managers and practice leads at Shepherd’s Care because I hear them say those very words. I really feel like the benefit was amazing for me. I became more confident in my leadership and I wouldn’t be where I am today if not for involvement with TREC.”

Sharing Data to Inform Policy

TREC is committed to supporting people working within the long-term care sector and to informing policy, with significant feedback from its research. After every wave of data collection, nursing homes in the TMS database receive feedback reports individualized for their sites and for different levels of staff. This gives them access to a rich source of information that links work environment, staff and resident data. TREC has now begun feeding results back to decision makers midway through studies to encourage input and information sharing. TREC’s commitment to feedback is pivotal in its partnerships with decision makers and knowledge users at all levels. Making a difference in long-term care requires getting research findings to the front line and to people who can use the information.

“We continue to have a need and desire to extend research to the front lines in long-term care. TREC is the only research being done with care aides in the driver’s seat and leading research at the front lines. It’s also a robust means to provide jurisdictional comparisons in long-term care outcomes across Canada—the ability for us to see how we compare against other regional health authorities.”

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