The University of Sydney Page 1

The Feasibility of the

European Quality

Indicators for

Psychosocial Dementia

Care in Long-term Care

Facilities in Asia-pacific

Countries

Yun-Hee Jeon1, Wai Tong Chien2, Ju-Young Ha3, Rahimah binti Ibrahim4, Belinda Kirley1, Lay Ling Tan5, Papan Thaipisuttikul6, Emmelyne Vasse7, Myrra Vernooij-Dassen8, Huali Wang9, Jongchul Youn10, Henry Brodaty11

1 Sydney Nursing School, University of Sydney, Sydney, Australia

2 School of Nursing, The Hong Kong Polytechnic University, Hong Kong

3 College of Nursing, Pusan National University, Pusan, Republic of Korea

4 Institute of Gerontology, Universiti Putra Malaysia, Selangor, Malaysia

5 Dept. of Psychological Medicine, Changi General Hospital, Singapore

6 Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand

7 Radboud Alzheimer Center, Nijmegen, Netherlands

8 Radboud University Medical Center, Nijmegen, Netherlands

9 Institute of Mental Health, Peking University, Beijing, China,

10 Neuropsychiatry, Seoul National University, Yongin, Republic of Korea,

11 Centre for Healthy Brain Ageing, UNSW, Sydney, Australia

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Impetus for the

study

– ~47 million people with dementia worldwide (ADI, 2016). Over half of the global population with dementia lives in the Asia-Pacific region (ADI and Alzheimer’s Australia, 2014)

– Psychosocial care research in the Asia Pacific region, in particular in Asian countries, is somewhat limited

– Establishment of PROMOTE (Psychosocial Research Consortium to Advance Mental Health of Older People in the Asia-Pacific region) in 2013

– Limited evidence around the implementation of Person centred dementia care in long-term care settings in the region

– No known evaluation of quality psychosocial care for residents with dementia in long-term care settings in the region

– The European Quality Indicators for psychosocial dementia care (Vasse et al. 2012) – face and content validity established

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Questions to be asked in measuring ‘Quality of

care’

– What is ‘Quality’?

e.g., effective, appropriate, efficient, responsive, accessible, safe, continuous, capable and sustainable

– What is the purpose of measuring quality?

– Who determines it?

– How is it measured?

e.g., questionnaire, self assessment, observation, document audit

– How specific or generic should it be?

e.g., disease/condition or even further, profession, setting

– What aspects of Structure-Process-Outcome quality are measured?

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(Donabedian, 1988, p.1744-45)

Donabedian A. The quality of care: How can it be assessed? Journal of the American Medical Association.

1988;260(12):1743-8.

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“indicators are explicitly defined and measurable items, which act as building blocks in the assessment of care. They are a statement about the structure, process (interpersonal or clinical), or outcomes

of care and are used to generate subsequent review criteria and standards, which help to operationalise quality indicators.”

Campbell SM et al. Research methods used in developing and applying quality

indicators in primary care. Quality and Safety in Health Care 2002; 11(4): 358-64.

What do we mean by quality indicators?

Commonly used indicators of quality …

Falls Pressure injuries Physical restraints Polypharmacy Weight loss

Cognitive

impairment

Medical cond.↑ BMI↓

Mobility↓

Hip Weakness

Balance↓

QoL↓

Insomnia

Psychotropics↑

Phy. restraints↑ Gait aid

Polypharmacy↑

Staffing↓ (ratio, mix, hours)

RN Turnover↑ For-Profit Large Facilities Medicaid beneficiari𝐞𝐬 ↑

Dependence↑, Mobility↓ Pressure inj. Hx. Weight Loss Eating prob.

Catheter use↑

Staffing↓ Specialists↓ Staff Turnover↑ Staff Knowledge

Medicaid beneficiaries↑ For-Profit Small Facilities Chain Membership

Dependence↑ Mobility↓ Dementia Cognitive impairment Male Younger Age Mental illness Longer LOS

Falls & Risks↑ BPSD

Fall Risk↑ Mobility↓ Multiple Physician prescribing

Staffing (RN↓) Medicaid beneficiaries↑

Dependence↑, Mobility↓

Polypharmacy↑ Assistance↓

Purple: Structure indicators

Blue: Resident characteristics

Red: Process indicators

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• Diagnosis and assessment: Dx being discussed with Person; Assessment of depression & anxiety; records of life history, social family circumstances and needs & preferences

• Care plan and treatment: Tailored psychosocial interventions; personalised care plan shared; content of care plan (ADL, social, structured activities); regular contacts between staff, person, family

• Behavioral problems: Tailored care plan based on assessment of behaviours; psychosocial interventions prioritised

• Caregivers: Respite care offered; psychosocial interventions; assessment for mood and coping; staff training

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The University of Sydney Page 9

PROMOTE QI Pilot Study: Aims

– Overarching question: “Can the European QIs be applied to the residential aged care facilities in Asia-Pacific countries to measure the quality of psychosocial dementia care?”

– Primary objective: To examine the implementation processes required to complete the assessment using the QI indicators

– Secondary objective: To provide snapshots of psychosocial dementia care in residential aged care in the participating Asia-Pacific countries and to explore the potential for international comparison of the quality of psychosocial dementia care in the region

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PROMOTE QI Pilot Study: Methods

Participating sites: ‘Typical’ residential aged care facilities in Australia, Hong Kong Special Administrative Region (SAR) China (Hong Kong SAR, hereafter), Mainland China (China, hereafter), Malaysia, Singapore, South Korea, and Thailand. Ethics approval Data collection: Clinical records of residents with dementia & field notes EQI protocol, Auditors, Training & inter-rater reliability. Data analysis: Descriptive analysis (rates of endorsed resident records for each QI), Qualitative content analysis for field notes

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PROMOTE QI Pilot Study: Results

Data extracted from medical records of 275 residents from 16 facilities.

Indicators Countries

Hong

Kong

(N=2)

HK 1 HK2

Aust

ralia

(N=2)

AU1 AU2

South

Korea

(N=4)

SK 1 SK 2 SK 3 SK 4

Mala

ysia

(N=2)

ML 1 ML 2China

(N=3)CN 1 CN 2 CN 3

Thail

and

(N=2)

TH 1 TH2

Singa

pore

(N=1)

Diagnosis, assessment, care plan, and

treatment(n=34) (n=18) (n=16) (n=17) (n=10) (n=7) (n=34) (n=10)(n=10) (n=10) (n=4) (n=20) (n=10) (n=10)(n=144)(n=50) (n=59) (n=35) (n=16) (n=6) (n=10) (n=10)

1. Diagnosis discussed with resident (%) 74 72 75 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

2. Depression/anxiety assessed <12 months

(%)82 83 81 65 100 14 0 0 0 0 0 100 100 100 35 100 0 0 0 0 0 80

3. Personal information in file (%) 26 28 25 94 90 100 50 70 100 0 0 100 100 100 0 0 0 0 6 0 10 100

4. Tailored psychosocial interventions (%) 59 56 69 88 80 100 74 90 100 60 0 100 100 100 10 0 24 0 100 100 100 70

5. Personalised care plan (%) 41 33 50 0 0 0 29 0 0 100 0 100 100 100 34 98 0 0 38 100 0 40

6. Care plan includes activities (%) 50 44 56 71 60 86 62 90 100 20 0 100 100 100 65 92 17 94 38 100 0 60

7. Assigned professional who has regular

contact (%)65 61 69 94 100 86 100 100 100 100 100 100 100 100 76 100 100 0 88 100 80 0

Behavioural Problems (n=28) (n=13) (n=15) (n=16) (n=9) (n=7) (n=24) (n=6) (n=7) (n=8) (n=3) (n=5) (n=1) (n=4) (n=89) (n=50) (n=39) (n=0) (n=14) (n=6) (n=8) (n=8)

8. Tailored care plan (%) 68 77 60 19 22 14 13 0 0 38 0 100 100 100 8 14 0 0 0 0 0 100

9. Psychosocial intervention first (%) 75 92 80 0 0 0 0 0 0 0 0 100 100 100 99 100 97 0 0 0 0 0

Informal Caregivers (n=22) (n=11) (n=11) (n=8) (n=1) (n=7) (n=19) (n=9) (n=10) (n=0) (n=0) (n=20) (n=10) (n=10)(n=143)(n=49) (n=59) (n=35) (n=16) (n=6) (n=10) (n=9)

10. Tailored interventions received/offered

(%)32 55 64 0 0 0 0 0 0 na na 0 0 0 0 0 0 0 0 0 0 0

11. Mood and coping assessments <12

months (%)50 45 55 0 0 0 0 0 0 na na 0 0 0 0 0 0 0 0 0 0 11

Facility Staff (n=74) (n=38) (n=36) (n=122)(n=62)(n=60) (n=191) (n=23) (n=8) (n=55) (n=105) (n=96) (n=84) (n=12)(n=118)(n=80) (n=38) (n=0) (n=30) (n=15) (n=15) (n=194)

12. Staff with dementia care training <12

months (%)53 53 53 37 11 63 35 100 100 9 29 100 100 100 100 100 100 0 43 20 67 33

The University of Sydney Page 12

PROMOTE QI Pilot Study: Results from field

notes

Key issues impacting on the implementation of the QIs

– Quality of documentation: “poor” “inadequate” and/or “inconsistent” records – e.g. QIs 2 (depression/anxiety), 3, 4, 9

– Time consuming: on average 35 minutes – e.g. QI 9 (BPSD)

– Family attitudes and culture: “care plan” – shared decision making (QIs 5, 6)

– Scoring of partially satisfied items: sub-items, e.g. QIs 1 (Dx), 3, 4 (needs, personal preferences), 8 (BPSD)

– Lack of relevance and applicability: QIs 1 (Dx), 7 (Coordination), 10 & 11 (informal caregivers)

– Unclear definitions: QIs 6 (activities), 12 (staff training)

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PROMOTE QI Pilot Study: Discussion

– Validity of the European QI is limited in most of the residential aged care settings in the participating Asia-Pacific countries.

– Difficulties in scoring seven of the 12 indicators might have resulted in greatly varying responses across different sites and lower inter-rater reliability.

– Can the written records alone truly reflect the full picture of person centred psychosocial care? The issue of inconsistent record keeping practice concerning psychosocial care in the residential care setting needs to be addressed first.

– Family attitudes and cultural differences? or the lack of understanding of what it is that is required to involve the resident with dementia and their families in care planning and decision making?

– Our research has shown the European QI tool needs further refinement and test to ensure its reliability and validity for use in the Asia-Pacific region.

Donabedian A. The quality of care: How can it be assessed? JAMA. 1988;260(12):1743-8.

Measuring and Improving Quality

Structure

attributes of care

settings

Process

what is done in giving & receiving

care

Person Centred

Care

Outcome

effects of care on health status

Jeon 2013 & 2016

The University of Sydney Page 15

PROMOTE QI Pilot Study: Conclusion

The implementation of the QIs needs to be considered as part of the practice improvement activity, for example using a method of audit and feedback.

Importantly, the issue of accurate record keeping concerning psychosocial care in residential aged care settings needs be addressed as part of the QI implementation processes.

Our refined set of the European QIs has provided a crucial step necessary for testing more rigorous psychometric properties as well as the quality improvement practice.

If a measurement matters at all, it is because it must have

some conceivable effect on decisions and behaviour. If we

can't identify a decision that could be affected by a proposed

measurement and how it could change those decisions, then

the measurement simply has no value ― Douglas W. Hubbard, How to Measure Anything: Finding the Value of "Intangibles" in

Business

The University of Sydney Page 16 yun-hee.jeon@sydney.edu.au

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