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LTC-CGA KT Project Report, March 2012
Project Title:
Implementation and evaluation of a Comprehensive Geriatric Assessment designed for use in
Long Term Care Settings (LTC-CGA)
Executive Summary:
Most older people who live in long-term care facilities require medical care because they are
frail, have dementia, or are nearing the end of their lives. Traditionally, people kept their
previous family physicians when they moved into long-term care facilities (LTCF). This
provided some benefits in terms of continuity of care, but was also problematic in that a given
physician might have just a few patients spread between many LTCF. This meant that the
physicians often had limited time to spend with their patients and it was hard for health care
teams to work together to provide the best care for residents. For example, nurses in LTCF were
sometimes unsure of whom to call and were unable to reach the resident’s physician in case of
acute illness or medical emergency, which frequently led to the resident being transferred to
hospital emergency departments (ED). Unfortunately, this sometimes happened even to older
people who had specifically asked to live out their days receiving comfort-oriented care in the
LTCF and not be taken to hospital.
A new model of primary care has recently been introduced into LTCF in the Capital District
Health Authority (CDHA). Under the new system, all residents of a floor or wing of a LTCF will
be cared for by the same dedicated family doctor, and there is a clear schedule of on-call
coverage after hours. There also is a new system of standardized comprehensive assessment of
the health status of each resident, the long-term care comprehensive geriatric assessment (LTCCGA), which is meant to be kept up-to-date and sent to the hospital along with the resident
should s/he have to go to the ED. It is expected that this new model will improve the quality of
care provided to older residents of LTCF in CDHA, but this has not been proven.
The LTC-CGA was developed based on existing evidence-based Comprehensive Geriatric
Assessment tools, in consultation with experts who tailored it to the LTC setting. The present
project, which evaluates the implementation and use of the LTC-CGA as a Knowledge
Translation tool, is part of a larger research study that has begun evaluating the new model of
primary care in LTCF using a mix of scientific methods including both quantitative and
qualitative approaches to study the quality of health care provided in LTCF.
As is often the case when research studies are designed to investigate “real-world” questions
such as these, the real world can present unforeseen challenges. In this instance, the LTC-CGA
was supposed to be implemented in April 2010, where in fact its initiation was delayed until June
2011. Given that we could not expect its uptake to be instantaneous (and since many of our
research questions hinged on its use becoming routine), our data collection was necessarily
delayed. As such, while our initial timeline would have allowed full reporting on the final results
of the study, we are now able to report on the aspects of the study that are completed and those
that are underway.
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LTC-CGA KT Project Report, March 2012
As an additional yet welcome challenge, February 2011 saw the implementation of Extended
Care Paramedic (ECP) units serving Long Term Care Facilities. These specially trained ECP
teams are available for calls to LTCFs with the aim of providing increased acuity of care and
assessments on-site. This includes competencies such as suturing wounds, end of life care,
consultation with LTC physicians to develop specialized care plans, and referrals to hospital for
quicker access to diagnostic imaging. Effectively, this introduced another category of 911 calls,
adding to the complexity of our analyses.
Given that data collection and analysis are still underway, we do not yet have final findings to
report. However, dissemination plans are in place. For the academic audience, we have two
upcoming presentations at local and national research conferences. Additionally, we have
developed a plan to share our findings with other researchers and policy makers, so that positive
aspects of this unique system of primary care in LTCF may be helpful in the future to further the
goal of making care better for older people who live in LTCF. The underlying goal of this study
is to evaluate the LTC-CGA as a tool which has broad potential for use in Long Term Care
settings both locally and in other jurisdictions. It is our hope that our study of this evidencebased tool will aid in further refining its implementation and day to day use in order to help make
care better for older adults in LTCF, many of whom have dementia.
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LTC-CGA KT Project Report, March 2012
Introduction and Purpose:
In Nova Scotia, 64% of LTCF residents have dementia (Smetanin & Kobak, 2009).
Comprehensive assessment of health and functional status is key to planning and providing good
care for frail older adults who live in LTCF, including those with dementia. The Comprehensive
Geriatric Assessment (CGA) is a validated method for assessing frail older adults in ambulatory
and acute care environments (Jones, Song, Mitnitski, & Rockwood, 2005; Jones, Song, &
Rockwood, 2004; Rockwood, Rockwood, Andrew, & Mitnitski, 2008). The CGA is a one-page
form that documents an older patient’s health status, including cognition (e.g., dementia,
delirium), mood, mobility, function, appetite, weight, bowel and bladder function, medical
condition, and medications.
A version of the CGA, the “LTC-CGA”, has been modified and validated for use in LTCF
(Rockwood, Abeysundera, & Mitnitski, 2007). Modifications from the original CGA include
documentation of behavioural disturbances common in dementia, foot and dental care
requirements, skin integrity, if a legal next of kin has been appointed, and goals of care (e.g.,
whether resuscitation is to be attempted or hospital transfer for acute illness). The LTC-CGA is
currently implemented in LTCF within CDHA and is expected to improve quality of care and
health outcomes.
This project was undertaken as part of a larger umbrella study titled: Improved outcomes with a
new model of dedicated primary care physician and team approach for long-term care facilities?
A mixed-methods study. This larger study has multiple funders and is still ongoing. Since its
inception, the umbrella project has grown to reflect a new aspect of the “Care by Design” model
of care, extended care paramedics through Emergency Health Services (EHS), which began in
February 2011. Due to this additional aspect and a delay in the implementation of some of the
components of the “Care by Design” model of care we are evaluating (i.e., the LTC-CGA
assessment forms weren’t approved for billing by the Department of Health and Wellness until
the Spring of 2011) we were delayed approximately a year in getting started (see below). The
umbrella project is now in the data collection stage.
Timeline of Care by Design components
September 2009:
Physician per floor component began
February 2011:
Extended Care Paramedics began
June 2011:
LTC-CGA implemented
Objectives:
The traditional model of primary care in CDHA’s LTCF had patients being cared for by many
different local physicians. This contributed to confusion among nursing staff about whom to call
in emergencies, and difficulties coordinating health care teams (Clarke & Prya, 2006). As part of
a new model of primary care in LTCF, all patients on a single floor will be under the care of a
dedicated physician, with a clearly coordinated system of on-call coverage.
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LTC-CGA KT Project Report, March 2012
The goal of the umbrella research project is to investigate how implementation of this new model
of primary care in LTCF affects health and health care outcomes using both quantitative and
qualitative approaches (see Appendix B). The LTC-CGA was implemented as part of this new
care model. The LTC-CGA is expected to be completed within a reasonable timeframe upon
resident admission to the LTCF and at regular intervals (every 6 months, or after a major event
or clinical change) thereafter. A completed LTC-CGA should accompany residents transferred
outside of the LTCF (i.e., to the ED or another facility). The LTC-CGA has the potential to be a
powerful tool for assessment and communication in LTCF, however its uptake (i.e., is it
completed fully, is it accompanying transfers?) and acceptability (i.e., is it easy to use? Useful?
Meeting needs?) to end users are not known.
The objectives of this study are to evaluate the implementation of the LTC-CGA including:
- the process of educating primary care physicians and nurses about the importance of the
tool and how to use it
- uptake and completion rates of the LTC-CGA
- acceptability to users
- use of the new physician billing code for LTC-CGA completion
- measuring the efficacy of the LTC-CGA (i.e. does it use improve care for older adults
who live in LTCF?). Specific elements to be studied include usefulness in defining goals
of care and impact on clinical care (e.g., whether it accompanies patients transferred to
ED visits, hospital admissions, and inter-facility transfers).
Planning and Delivery:
A mixed methods approach is being undertaken, including focus groups; in-depth semistructured interviews; chart reviews of acute care, EDs, LTCF and LTC-CGA data and
quantitative measures. A mixed methods approach is valuable in this study as it allows for the
data gathered during the qualitative phase of the study to inform the findings of the chart review
and vice versa (the chart review findings may instigate questions that can be answered when
analyzing the qualitative data).
For the quantitative component of the project, retrospective chart reviews are being conducted
for the period between September 1, 2008 and February 28, 2009, and prospective chart reviews
are being conducted for September 1, 2011 through February 28, 2012, reflecting the new model
of primary care in LTCF. With all of the required data elements now in place, including EHS
data identifying individual 911 calls and ambulance transfers, the chart abstraction database has
been created and the chart abstractors have been hired and trained. The chart abstractions will be
starting the first week in April 2012.
In the qualitative phase of the study we are currently exploring the lived experience under the
new model from the perspectives of stakeholders including family doctors, nurses,
administration and staff as well as residents and family members through focus groups. In the
near future we will begin exploring that experience through in-depth semi-structured interviews.
Depending on the results of the quantitative chart review, we may be able to elucidate the
advantages and remaining challenges of the new model through the experiences of the
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LTC-CGA KT Project Report, March 2012
stakeholders. Moreover, results can be compared to the perceptions of the stakeholders that are
shared in focus groups and interviews.
The larger study will enable us to explore how well implemented and useful is the LTC-CGA as
a Knowledge Translation tool using the following means:
Process goal:
 Education and training: Qualitative – To be explored in semi-structured interviews (e.g.,
was training experienced as sufficient and well-implemented?)
 Uptake: Quantitative – Chart review (e.g., were all sections of the LTC-CGA
completed? Proportion of resident charts with completed LTC-CGA)
 Acceptability to users (i.e., physicians and nurses in LTCF): Qualitative – To be
explored in semi-structured interviews
 Billing: Quantitative – Proportion of LTCF residents for whom the new billing code has
been claimed (data to be accessed through an agreement with the Department of Health)
Outcome goal:
 Qualitative: Usefulness of the instrument in clarifying results of assessment and care
goals, to be explored in semi-structured interviews with physicians and nurses
 Quantitative: Rates of completed LTC-CGA in documentation accompanying residents
who are transferred to acute care and between LTCF
Team collaboration has been a key component in the umbrella project with team members
bringing a variety of experiences and knowledge to the project (See Appendix C). Members of
the team have provided support in securing space for focus groups as well as assisting in
connecting with administrators of the LTCF and physicians working within the Care by Design
model of care. The larger project has also provided the opportunity to collaborate with EHS. This
collaboration has lead to the Principal Investigator of the umbrella study partnering with two
members of our research team in putting together a request for funding for a study to explore the
period of time in the Care by Design implementation where there was a physician per floor at the
LTCF but the Extended Care Paramedic (ECP) program was not in operation.
The project has ethical approval from the Capital District Health Authority Research Ethics
Board.
Participants:
For the quantitative component of the umbrella project, retrospective chart reviews will be
conducted for the period between September 1, 2008 and February 28, 2009 and prospective
chart reviews will be conducted for September 1, 2011 to February 28, 2012 reflecting the new
model of primary care in LTCF. Records of all hospital transfers during the study period will be
reviewed as part of the larger study evaluating the new model of care; for this KT study, we will
ascertain whether a completed LTC-CGA was transferred with the patient. The study will
examine data from a total of 1482 beds in ten LTCFs within CDHA at each of the two time
periods. Data on the use of the new fee code for CGA will be obtained from the Department of
Health, through the manager of the Master Agreement, who has agreed to provide us with this
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LTC-CGA KT Project Report, March 2012
data. We are using data received from EHS to identify charts from which to abstract the data. For
the “pre” time period, we will be collecting data from 330 charts of residents who had 911 calls
and 100 charts of control residents who did not have 911 calls. For the “post” period, we will be
collecting data from the charts of 400 residents who had 911 calls along with the charts of 100
residents who did not have 911 calls, for a total of 930 charts.
For the qualitative component, focus groups and individual semi-structured interviews with
stakeholders (physicians, nurses, ECPs, and administrators) using LTC-CGA will be conducted
with stratification by institution to ensure representation across the ten LTCF. As of the time of
writing there have been focus groups held for physicians, nurses, ECPs, and administrators. A
total of 31 people have participated in these focus groups. Of the 31 participants nine were
physicians, three were RNs, four were LPNs, seven were ECPs, and six were administrators. See
Appendix A for focus group and interview topics.
Findings:
Preliminary focus group findings are showing mainly positive feedback regarding the LTC-CGA
form as a summary of the resident. The nursing focus group participants indicated they find it
beneficial to have it available to copy and send to emergency if required. The ECPs liked the
consistency using one chart provided for them and how it simplified their work. The physicians
discussed the benefit of having the LTC-CGA when filling in for another physician. It enabled
them to recognize if a behaviour (i.e. aggression) was typical for that resident or what particular
drugs were being used for.
There were some concerns raised regarding the LTC-CGA. The ECPs and physicians both raised
the concern that it is not always in the same place in the file and, occasionally, there is no
completed LTC-CGA for a given resident. The physicians also raised concerns around
funding/remuneration when updating the LTC-CGA. They indicated they had a billing code for
initial completion of the LTC-CGA and for the bi-annual updates but were not able to bill if they
updated the LTC-CGA due to a critical incident. The nursing staff indicated they were not
trained on the LTC-CGA.
With regard to the quantitative research questions, although chart abstraction is just now getting
underway due to the delays in the LTC-CGA implementation timeline as detailed above, we do
have some preliminary EHS data findings.
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LTC-CGA KT Project Report, March 2012
Number of EHS calls in the pre and post time periods:
Total number of 911 calls:
September 2008 – February 2009 = 451
September 2011 – February 2012 = 652
Total number of residents who had 911 calls:
September 2008 – February 2009 = 428
September 2011 – February 2012 = 580
Table 1. Number of EHS calls per facility, in both pre and post time periods.
Facility
A
B
C
D
E
F
G
H
I
J
K
Pre (Sept 2008-Feb 2009)
37
(not yet opened)
34
14
18
21
117
24
36
30
(not yet opened)
Post (Sept 2011-Feb 2012)
36
14
18
17
31
50
128
15
36
45
13
Number of regular ambulance calls versus Extended Care Paramedic calls
(all September 2011 – February 2012):
Regular ambulance call – 317
ECP call – 257
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LTC-CGA KT Project Report, March 2012
Next Steps and dissemination plan:
Data collection will continue along with collaboration with EHS. Planning has begun for
dissemination of the study’s findings, once further analysis has been done and more results are
available. We will be doing a poster presentation at the Canadian Association for Health Services
and Policy Research (CAHSPR) conference in May 2012. We will also be participating in
Northwood’s 2012 Research Symposium on May 24, 2012 with a presentation.
A preliminary report of anonymized and aggregate findings will be presented back to
stakeholders for discussion and mutual feedback in a series of workshops. These workshops with
participants will assist with report preparation for policy-making stakeholders including CDHA,
the Department of Health, the Department of Family Medicine, the School of Nursing, and
clarify policy goals. Further dissemination of findings about this potentially care-reforming tool
will include presentations at regional, national and international conferences and peer reviewed
journal publications.
Why this is an important Knowledge Translation opportunity
Benefits of Comprehensive Geriatric Assessment include identification of issues that affect an
older person’s health, provision of a framework within which to plan interventions to address
these problems, and establishing a platform for discussing and setting goals of care appropriate
to the older person’s level of frailty and comorbidity.
Until now, comprehensive geriatric assessment has not been a consistent feature of primary care
provided in Nova Scotian LTCF. The introduction of changes to the model of primary care
delivery affords an opportunity to study the LTC-CGA as a Knowledge Translation tool;
knowledge about how to conduct a CGA which is based on years of clinical and research
experience can now be applied to a setting in which it has the potential to greatly improve care.
This study is an opportunity to understand the process of LTC-CGA implementation, including
education for the users, rates of uptake and acceptability, and also to test its efficacy.
The underlying goal of this study is to evaluate the LTC-CGA as a tool which has broad
potential for use in Long Term Care settings both locally and in other jurisdictions. It is our hope
that our study of this evidence- based tool will aid in further refining its implementation and day
to day use in order to help make care better for older adults who are frail and have dementia.
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References:
Clarke, B., & Prya, K. (2006). From care by Default to care by design: Improving primary care
of the elderly in Capital Health. Report of Capital Health’s primary care of the elderly
project.
Jones, D., Song, X., Mitnitski, A., & Rockwood, K. (2005). Evaluation of a frailty index based
on a comprehensive geriatric assessment in a population based study of elderly
Canadians. Aging Clin Exp Res. Dec;17(6):465-71.
Jones, D.M., Song, X., & Rockwood, K. (2004). Operationalizing a frailty index from a
standardized comprehensive geriatric assessment. J Am Geriatr Soc. Nov;52(11):192933.
Rockwood, K., Abeysundera, M.J., & Mitnitski, A. (2007). How should we grade frailty in
nursing home patients? J Am Med Dir Assoc. Nov;8(9):595-603. Epub 2007 Oct 22.
Rockwood, K., Rockwood, M.R., Andrew, M.K., & Mitnitski, A. (2008). Reliability of the
hierarchical assessment of balance and mobility in frail older adults. J Am Geriatr Soc.
Jul;56(7):1213-7. Epub 2008 May 22.
Smetanin, P., & Kobak. P. (2009). Rising Tide: The impact of dementia in Nova Scotia, 2008 to
2038. RiskAnalytica.
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LTC-CGA KT Project Report, March 2012
APPENDIX A
Focus group and interview topics
The focus group questions included:
 Can you tell us about your experience with the new model of care (Care by Design)?
a) How has the model of care changed primary care provision at the facility? (For
the better? For the worse?)
b) What have been the challenges?
Probe: How could the model be improved?
Probe: Are there any services that are lacking that you would like to see included?
Probe: Are there ways the model could be changed to better meet your needs or
the needs of residents or family members?
Probe: Are there any new challenges that came along with the introduction of this
model? How can these challenges be overcome?
c) Can you tell us about your experiences with patients transferring from the care of
their family physician to your care?
d) What is your vision for primary care in your facility?
 Can you tell us about the team that is involved in the care provided at your facility?
a) Who are the team members?
b) What are the roles of the team members?
c) Who would you ideally like to see as part of the team?
d) Can you tell us about your experiences with the Extended Care Paramedics?
e) Have you noticed changes with the team?
Probe: Any differences in team creation and construction? Any differences in
training as a team?
 What is your experience of end of life care at your facility?
a) How do you know if someone is at end of life? What does it look like? What do
you do?
b) How is care coordinated?
c) How are families involved in end of life planning?
d) What is your experience of the sharing of knowledge about and following of
comfort care requests?
 How does communication with the care teams work in your facilities?
a) Tell us about the level of accessibility you have to other team members.
Probe: When you have needed to speak to a doctor, nurse, etc. how accessible was
the individual? Any suggestions for improvement?
b) Describe how being on site (for physicians) having a physician on site (for others)
has affected the way the team communicates and the care you provide.
c) Describe how the CGA-LTC has affected team communication.
i. Has it been fully implemented?
ii. Does it help with care planning?
iii. Does it help with communication with team and family members?
 Any further thoughts on the benefits/challenges with Care by Design?
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Along with the questions asked during the focus group, participants were also given a sheet prior
to the focus group beginning that included supplementary questions. The following questions
were asked to physicians:
 How long have you worked with the Care by Design program?
 Did you work providing primary care before working within the Care by Design
program? If yes, for how long?
 In which long-term care facility or facilities do you work?
 Would you recommend working in Care by Design to a colleague? If yes, why?
 What do you like best about the Care by Design program?
 What do you like least about the Care by Design program?
 Did you do any training for the LTC-CGA? If yes, was it adequate?
 Do you use the LTC-CGA?
The following questions were asked to administrative and nursing staff:
 What is your role in the long-term care facilities?
 In which long-term care facility or facilities do you work?
 How long have you work in long-term care?
 How long have you worked with the Care by Design program?
 Would you recommend working in Care by Design to a colleague? If yes, why?
 What do you like best about the Care by Design program?
 What do you like least about the Care by Design program?
 Do you use the LTC-CGA? If so, did you do any training for the LTC-CGA and was it
adequate?
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APPENDIX B
Relationship between studies. This KT project is nested within a larger study, titled “Improved
outcomes with a new model of dedicated primary care physician and team approach for longterm care facilities? A mixed-methods study.”
The umbrella study includes collection of data on additional quantitative indicators, as well as
focus groups and interviews with patients, family members and administration and staff of the
LTCF. The objectives are the study include:
Quantitative: What changes in health/ health care outcomes are observed pre/post
implementation of the new model of a dedicated primary care physician and team approach to a
long-term care facility?
Has there been a reduction in ambulance transfers to hospital? Reduction of dying in hospital?
Reduction in polypharmacy? Etc…
Qualitative: How is the dedicated primary care physician and team approach experienced from
the perspective of family doctors, nurses, admin/staff, and patients/families? What experiences
are most improved with this new model? What challenges remain under the new model? How
has this new model had an effect on end of life care?
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APPENDIX C
Team composition/Personnel
 Melissa Andrew, Division of Geriatric Medicine, Department of Medicine, Dalhousie
University, Principal Investigator
 Emily Gard Marshall, Department of Family Medicine, Dalhousie University, CoInvestigator
 Barry Clarke, District Medical Director Long-term Care, Department of Family Medicine,
Dalhousie University, Co-investigator
 Greg Archibald, Department of Family Medicine, Dalhousie University, Co-investigator
 Fred Burge, Department of Family Medicine, Dalhousie University, Co-investigator
 Andrew Travers, Provincial Medical Director for Emergency Health Services, Coinvestigator
 Jan Jensen, Emergency Health Services, Co-investigator
 Michelle Boudreau, Research Associate working for Emily Marshall;
 Catherine MacPherson, Project Manager working for Barry Clarke
 Cherie Gilbert, School of Nursing, Collaborator
 Nancy Edgecombe, School of Nursing, Collaborator
 Anthony Taylor, Administrator, Oakwood Terrace, collaborator
 Gary MacLeod, Resident family member, Glades, collaborator
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