Enhancing allied health for older people in residential care: EAHOP RC

Model of Care The trial will use the Institute for Healthcare Improvement 4Ms framework of an age-friendly health system as the model of care to organise allied health interventions. The 4Ms are: • What Matters: Know and align care with each older adult’s goals and care preferences. • Mentation: Prevent, identify, treat and manage dementia, depression and delirium across care settings. • Medication: If medication is necessary, it should not interfere with What Matters to the older person. • Mobility: Ensure that older people move safely every day. Case conferencing Following consent into the study each participant and their family member/carer will have the option of undertaking a case conference where the General Practitioner, the clinical liaison manager and all allied health professionals will discuss the need for one or more allied health interventions. The participant will be screened prior to the case conference to inform the decision making. The participant will then be referred to the relevant allied health professional to commence the intervention. The nature and timing of the interventions across disciplines will vary according to the needs of individual participants. Each participant is expected to be discussed for 20 minutes during the case conference with up to 5 participants being discussed each case conference. Clinical Liaison Manager A clinical liaison manager will be embedded within the aged care home with the overall goal of ensuring the case conferences and interventions are implemented as intended and providing a communication link between the aged care team the embedded allied health team and the research team. The Clinical Liaison Manager will be responsible for participant recruitment and consent processes as well as outcome measures data collection in consultation with the allied health professionals and allied health assistants, and the implementation of the Action Falls program within the residential aged care site. Allied Health Professionals and General Practitioner There are six allied health professionals: dietitian, pharmacist, physiotherapist, occupational therapist, optometrist and speech pathologist who will provide discipline specific interventions as identified in the case conference with a general practitioner assisting with coordination of care. Allied Health Assistants Allied health assistants will work directly with four of the allied health professionals (dietitian, occupational therapist, physiotherapist and speech pathologist) to implement the prescribed allied health interventions. Intervention This is a stepped design where six groups of 10 participants will start the intervention every three weeks from the start of the previous group. Participants will be allocated to groups based upon when they enrol in the study. Every participant will complete the primary outcome measures. The secondary outcome measure relating to pain will be completed by every participant. The other secondary outcome measures will be completed by participants as relevant to their allied health needs. The exceptions to this will be all participants will complete the Subjective Global Assessment (Dietetics) and the Holden Communication Scale (Speech pathology) but only participants assessed as mild to moderately malnourished (B), or severely malnourished (C) or with communication challenges will be referred to the dietetics or speech pathology interventions respectively. The intervention period for all participants is 36 weeks. Occupational Therapy: Participants will identify tasks and activities of everyday living with specific reference to self-care, leisure activities and productivity that are meaningful to them that they would like to be engaged with and/or become more satisfied with. The occupational therapist will develop individualised occupational therapy interventions to improve performance and satisfaction with identified occupational performance challenges. The duration and frequency of occupational therapy will vary depending on the participant's goals however an estimate is three times per week for 1 hour. Physiotherapy: Participants will engage in the SUNBEAM program ( Hewitt et al., 2018) involving 2 hours per week of individually tailored strength and balance exercises prescribed by the physiotherapist for 25 weeks (total 50 hours) and then a maintenance program for the duration of the trial. Strength training includes resistance training with varying levels of resistance bands. Balance training involves activities that vary the base of support. In some instances, participants may not be suitable for the SUNBEAM program. In these cases, they will be offered a virtual cycling experience (D'Cunha et al., 2021) once a week for the duration of the trial. Dietetics and Nutrition: Participants diagnosed as mild to moderately malnourished (B), or severely malnourished (C) (using the Subjective Global Assessment) will be provided: a high protein, high energy diet by fortifying menu items such as porridge, soups, mashed potato, and desserts; and/ or oral nutrition supplements. In addition, the dietitian will provide modified menus to Food Service Staff and training to Food Service staff on how to fortify menu items as per modified menus. The duration and frequency of dietetic intervention will vary depending on the participant's goals however an estimate is three times per week for 1 hour. Speech Pathology: Participants will receive interventions focused on communication partner training over the period of the trial. The speech pathology intervention will include communication repair strategies, an education component, role play, practice and recording of communication interactions to identify and address communication challenges. If the following: swallowing related difficulties, coughing during or after swallowing, excessive drooling, having a weak or soft voice, aspirating, difficulty chewing, trouble moving food to the back of the mouth or food sticking in throat are observed in a participant a registered nurse within the residential aged care home will be notified. We will provide the registered nurse with a letter to the GP, requesting a referral to the speech pathology provider associated with the organisation. The duration and frequency of speech pathology will vary depending on the participant's goals however an estimate is three times per week for 1 hour. Optometry: Participants will receive an assessment by an optometrist evaluating visual function (including refraction and visual acuity, macula and lenticular opacities and intra-ocular pressure) to address visual impairments that may contribute to falls risk. Actions arising from assessment of visual function may include new spectacle prescriptions or referral of participants for management of ocular disease. Participants will see an optometrist 2-3 times in total for 45 minutes each session. Pharmacy: Participants will receive an onsite medication review by a pharmacist who will provide recommendations regarding medication changes to the participant’s GP. After the initial medication review participants will receive an initial 2-week follow-up visit to ensure that medication decisions are implemented in the medication treatment and charts. Each participant will then have a follow-up visit from the pharmacist every 3 months (online or in person). Action Falls program: In addition to the allied health interventions for individual participants (described above), the trial will also involve an organisational intervention through implementation of the Action Falls program (Logan et al., 2021). An Action Falls checklist will be completed with each participant (and or carer/family member, as appropriate). The Clinical Liaison Manager will oversee the completion of the checklist, which can be done by any member of the trial team or residential aged care staff once training is complete. Completing the checklist will take 30 minutes per resident.