Evaluating an enhanced care program (for You For Life Tapestry) for Australian residential aged care.

Evaluation of the Tapestry program at Royal Freemasons The 'For You For Life Tapestry' program (short name Tapestry) is an enhanced model of care that predicts, tracks and coordinates a resident’s journey in aged care. This then facilitates and integrates the ongoing assessment and management of all the medical, physical, functional and emotional requirements of each resident from the moment they enter residential care, as well as throughout all stages of their subsequent care journey. This new model enables better administrative overview, promotes teamwork, and fosters closer collaboration with family. The program uses both existing and newly developed tools to enhance the approach to residential care. A key feature is a tool specifically designed for the program called a 'Transition Map', an information-rich yet simple tool to track and coordinate a resident’s journey in aged care. Other components of the Tapestry program include the Cumulative Illness Rating Scale Geriatrics (CIRS-G, an existing scale), and resident goal care plans (developed specifically for the Tapestry program), as well as systems and policies to support the integration of the Tapestry program with existing care. Prior to the trial commencement, focus groups will be run separately for each care facility to discuss the Tapestry Project and Transition Map. At each site a focus group for relatives and care staff will be run. Care staff focus groups will be further broken down into the different types of staff, i.e. Personal Care Workers, Registered Nurses/Case Managers, Enrolled Nurses, etc. Focus groups will only be run prior to data collection. At the beginning of the 12-month trial period, research assistants will approach all cognitively appropriate residents at each aged care facility. If a resident agrees to participate, they will complete an informed consent form, a Quality of Life scale, a Katz Activities of Daily Living Scale and a Standard Mini Mental State Examination. 24 randomly selected residents will also be ask to complete the Personhood “This is Me” Questionnaire. For residents who are unable to provide their own consent, next of kin will be asked to provide consent on behalf of the individual. These 4 measures will be repeated every 3 months for 12-months and will completed by the same research assistants, each assessment will take approximately 20-40 minutes. For non-English speaking residents, an interpreter will be arranged. Transition Maps will be completed by relatives and care staff about the resident. The Transition Map assesses a person’s overall health and determines what stage of health they are in and what care staff and family can expect to happen at this point. For example, if an individual in the care facility is palliative, the Transition Map would help to begin a conversation between staff and family members regarding treatment plans and care goals for the resident. The research assistants will not be involved in the Transition Map conversations. Transition Map discussions can be expected to range from 20minutes to 1 hour depending in the family and resident’s needs. Each facilities care staff will asked to complete a Staff Experience Questionnaire individually without the presence of research assistants. Staff will also be asked to complete a Personhood “This Is Me” Questionnaire in the presence of a research assistant. This will take approximately 20 minutes and will be conducted at the baseline, 6- months and 12-month’s time points. The Cumulative Illness Rating Scale will be completed about each resident by care staff. This will occur at the baseline, 3-months, 6-months, 9-months and 12-month time points. The Tapestry program will be incorporated into existing Royal Freemasons care services at seven residential aged care facilities, and this trial is an evaluation of that program. Therefore the implementation of the Tapestry program will be conducted by Royal Freemasons aged care staff, whilst the National Ageing Research Institute will conduct the evaluation of the Tapestry program. This trial will evaluate the impact of the program in improving resident related outcomes (such as resident quality of life), and family-staff communication.