Examining Health Care Aide Utilization in Continuing Care Facilities with a Particular Focus on Medication Assistance

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1 Examining Health Care Aide Utilization in Continuing Care Facilities with a Particular Focus on Medication Assistance FINAL REPORT AUGUST 22, 2016 COMPLETED BY: WORKFORCE RESEARCH & EVALUATION, AHS Siegrid Deutschlander, Senior Research & Evaluation Consultant Mubashir Aslam Arain, Senior Research & Evaluation Consultant Mahnoush Rostami, Research & Evaluation Consultant Esther Suter, Director Funded by: Alberta Health

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3 Project Team Members CO-PIS Esther Suter Director, Workforce Research & Evaluation, AHS Siegrid Deutschlander Sr Research & Evaluation Consultant, Workforce Research & Evaluation, AHS CO-INVESTIGATORS Thorsten Duebel former Administrator, Kipnes Centre for Veterans, CapitalCare Mubashir Aslam Arain Sr Research & Evaluation Consultant, Workforce Research & Evaluation, AHS Mahnoush Rostami Research & Evaluation Consultant, Workforce Research & Evaluation, AHS Amanda Wilhelm former Research & Evaluation Consultant, Workforce Research & Evaluation, AHS ADVISORY COMMITTEE MEMBERS Henry Dakurah Nora Yaghi Kathryn Brandt Lenora Carriere Barbara Fredrich Carol Henckel Reena Kelndorfer Geraldine Clark Aruna Mitra Karin van Goudoever former Workforce Analyst, Workforce Design, Alberta Health Manager, Quality Improvement, Continuing Care Branch, Alberta Health Director, Practice Development, Seniors Health, AHS Senior Consultant, HCA Competency Development Program, Health Professions Strategy and Practice, AHS Director Chronic Care, Royal Park, Carewest Director of Care, AgeCare Glenmore, AgeCare Acute Care & LTC Manager, Covenant Killam, Covenant Health Site Administrator, Covenant Killam, Covenant Health Senior Director, Clinical Operations, Bethany Care Society Site Manager, Bethany Harvest Hills, Bethany Care Society ACKNOWLEDGEMENTS We thank management and staff for sharing their valuable time to speak with us about medication delivery at their site between June 2014 and March We are truly grateful for the insights and perspectives they shared with us. Staff and families face many challenges in continuing care. Caring for seniors is complex, and all sites have demonstrated that quality resident centered care can be achieved through collaboration and commitment. We also thank our advisory committee members for their insightful and invaluable contributions to this study. HCA Utilization in Continuing Care, August 2016

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5 Table of Contents Executive Summary... 1 Key Messages... 1 Project Description (March 2014 June 2016)... 3 Objectives... 3 Workforce Research in Continuing Care... 4 HCAs in the Alberta Context... 4 Optimizing Workforce Utilization in Long-term Care... 4 The HCA Role in Medication Assistance... 5 Research Activities... 6 Survey of Continuing Care Sites... 7 HCA Staffing... 8 Other Healthcare Professionals... 8 In-depth Analysis of Five Long-term Care Sites... 9 Staff Interviews... 9 Medication Error Reports... 9 Resident Assessment Instrument (RAI) Data Research Questions Question 1: What is the utilization of HCAs at continuing care facilities with particular focus on the role of HCAs in medication assistance? HCA Medication Assistance - Differences Between SL and LTC The Medication Delivery Process at the Five LTC Study Sites Staff Views: Strength and Concerns about the Medication Process Staff Views: Medication Assistance as Part of the HCA Role Research Question 2: What is the impact of HCA medication assistance on staff utilization and resident safety in continuing care facilities? Results from the Medication Error Reports Staff Views: Circumstances Leading to Medication Errors Staff Views: Resident Safety and Workforce Utilization Resident Safety Workforce Utilization HCA Utilization in Continuing Care, August 2016 i

6 Discussion of Findings References Appendices A-B Appendix A Tables 4, 6, 7, 8, 9, 10, Appendix B Staff Questionnaire and Interview Guide HCA Utilization in Continuing Care, August 2016 ii

7 Executive Summary This study provides a comprehensive understanding of Health Care Aide (HCA) utilization in continuing care. Using survey data from 130 continuing care sites, we highlight the current roles of HCAs at supportive living (SL=52) and long term care (LTC=64) sites with a particular focus on oral medication assistance. Our in depth analysis of five LTC sites gives a detailed description of medication administration and examines the impact of HCA medication assistance on resident safety at two of these sites where HCAs give oral medications. We show that HCA oral medication assistance in LTC is extremely rare and occurs at only three LTC sites in our sample. Our data indicate that HCAs do not pose a greater threat to resident safety than other providers handing out oral medications, even for complex residents. All sites have internal processes in place to address medication errors. While we suggest the following key messages, these results need further validation given our small sample of LTC sites. KEY MESSAGES HCA Education The majority of HCAs in Alberta continuing care are trained at educational institutions with the government approved curriculum graduating with a HCA certification (81% HCAs). The certification comprises a range of competencies including oral and non oral medication assistance. This high number of certified HCAs is encouraging and shows a highly trained workforce. HCA Utilization The utilization of HCAs appears to be greater at SL than at LTC sites based on the range of HCA responsibilities in general and oral medication assistance in particular. Given that there is different HCA utilization between type of setting, not all HCA skills are translated into practice. From a workforce utilization perspective, this implies unused resources for the healthcare system, loss of provider skills and knowledge, and less benefits to the residents. Medication Errors Based on error reports from two LTC sites, medication errors do occur but the overall incidence rate is fairly low ( errors per 10,000 medications for different providers). HCAs show a lower error rate than regulated nursing staff, and most of these are dose omissions. HCAs can be involved in oral medication assistance in LTC if appropriate training, technology, and supports are in place. Distractions in the medication process are seen as a major cause for medication errors. Opportunities to enhance the medication process overall through technology can reduce errors, for example by adding monitors for scanning multi medication packages or electronic charting. Resident Safety While HCAs do not only have a relatively low error rate, they are also less likely to cause moderate harm to the residents (the sites did not report any severe harm). These error related findings have emerged in the context of high resident complexity and total care needs of most residents. HCA Utilization in Continuing Care, August

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9 Project Description (March2014 June 2016) In this mixed methods study, we examined workforce utilization with a particular focus on healthcare aide (HCA) roles in continuing care in Alberta. Workforce utilization has emerged as a critical issue given staff shortages and fiscal constraints. While we examined the role of HCAs overall, we had a particular interest in understanding whether and how HCAs are involved in medication delivery. In Alberta, the involvement of HCAs in medication delivery is referred to as medication assistance to indicate that HCAs do not make decisions about medication management (Brandt 2013). HCAs follow a clearly circumscribed process when handing out medications and are always supervised by regulated nursing providers. While medication assistance may refer to handing out any type of medications to residents, we are specifically interested in HCAs assisting with oral medications. Medication assistance by HCAs is a controversial topic involving patient safety concerns with medication errors and their potential harm to patients. Beside the human cost, medication errors amount to billions of dollars for the healthcare system annually. The WRE project team conducted this study between March 2014 and June Prior to starting data collection, we obtained ethics approval from the Conjoint Health Research Ethics Board (CHREB), University of Calgary. OBJECTIVES 1. To gather data on HCA education and utilization across continuing care sites. 2. To understand the medication management process at five longterm care sites with a focus on the roles of HCAs in medication assistance. 3. To identify the strengths and challenges of the medication management process in addressing medication errors and mitigating future errors. Workforce utilization refers to the organization and deployment of regulated and unregulated healthcare providers to optimize their collective ability to work to full scope of practice (Alberta Health Services 2012). Health care aide is the generic term utilized in this document to describe unregulated nursing providers assisting clients with personal support and basic health services in the health system in Alberta (based on Brandt 2014). Oral medication assistance is a service provided to clients to ensure medication is taken as intended by the prescriber when the client is assessed as being unable to independently take his or her own medication safely (Brandt 2013). 4. To compare HCA utilization between SL and LTC sites. 5. To examine how HCAs assisting with medications affect resident safety and workforce utilization. HCA Utilization in Continuing Care, August

10 Workforce Research in Continuing Care HCAS IN THE ALBERTA CONTEXT HCAs are unregulated direct care providers working across the continuum of care (Hewko et al. 2015) also known as personal care attendants, resident care workers, nursing aides and others. HCAs are a valued and major component of the workforce in all three subsectors of continuing care (e.g., home living, supportive living and facility based living) in Alberta. As a member of the team, they provide physical and emotional support for clients with medical conditions or major functional limitations under the supervision of regulated nursing staff or other health professionals. The range of care depends on the patient population, care setting, knowledge and skills of individual HCAs, legislation and policy (in Brandt 2014). HCAs may be recent newcomers to Canada with varying levels of skills and qualifications from their countries of origin. Some have been trained internationally as healthcare workers, in particular RNs, but did not complete the training requirements for these roles in Canada. In Alberta, HCAs are classified in one of three competency statuses including certified, substantially equivalent and deemed competent (see sidebar). Their status depends on whether they completed the government approved curriculum comprising the competencies as outlined in the HCA Competency profile (Alberta Health & Wellness 2001; under revision). Alberta appears to be the only province in Canada where HCAs have a competency profile guiding their practice in patient care. An environmental scan on Canadian educational standards for HCAs reported that the vast majority of private institutions and all public colleges in Alberta follow the Government of Alberta Health Care Aide Provincial Prototype Curriculum (HCA PPC) from 2005 with all 37 modules (2012). The certification includes various core competencies with medication assistance as one of them. OPTIMIZING WORKFORCE UTILIZATION IN LONG-TERM CARE Four recent studies have highlighted workforce utilization issues including HCAs in continuing care in Alberta (Alberta Continuing Care Association 2012, Strain et al. 2011, Cummings et al. 2013, Suter et al. 2013). ACCA has predicted significant shortages of LPNs, RNs and HCAs for 2015 in this subsector while it is a high priority area of special need. HCAs have low job satisfaction as their skills and training are not fully utilized. It recommended aligning educational practicums with continuing care workforce priorities and needs (ACCA 2012). In a comprehensive study on 59 supportive living (SL) and 54 long term care (LTC) sites, Strain et al. outlined the need for changes to staff roles as frequently Competency refers to the specific knowledge, behavior, attitudes and skills required by workers to effectively and successfully fulfill the requirements of a specific job description. Certified HCA: certificate obtained from a Government of Alberta licensed postsecondary institution using the provincial HCA curriculum. Substantially Equivalent: an educational background deemed equivalent to the approved provincial HCA curriculum. Deemed competent: assessed as competent using the provincial Competency Assessment Profile (CAP) tool. (All definitions based on Fact Sheet, HCA Competency Development Committee, AHS, no date). related to challenges of multi skilling and working to full scope of practice (2011:145). The changing role of the RN toward increased care management and leadership responsibilities and the complex care needs of the residents require a fresh look at the roles of other providers. In 2013, the WRE research team completed a study on workforce utilization in continuing care in Alberta (Suter et al. 2013). The authors pointed to differences in staff utilization, in particular of HCAs, as one of the top two issues: HCA Utilization in Continuing Care, August

11 There were notable differences in the HCA roles and responsibilities in the three facilities studied, with HCAs having restricted roles in the LTC facilities as compared to the supportive living facility. Although a standard provincial HCA curriculum has existed since 2005, there is wide disparity of education levels (provincial curriculum vs. equivalent training vs. practice experience) and competency levels among HCAs currently employed in continuing care. Organizations have different internal hiring standards, which may lead to confusion [about] the expectations of HCAs and their roles (Suter et al. 2013). Shining a Light is a study that specifically focused on the complexity and diversity of the HCA workforce in Alberta (Cummings et al. 2013). The authors reported on the increased demand for highly qualified HCAs given that HCAs are viewed as least prepared (lowest skill set, least education) workers caring for the most complex patients (2013: 70). Cummings and colleagues commented on the various levels of HCA curricula and lack of a standardized education approach to HCA training (2013). Appropriate workforce utilization can have many benefits for patients, providers and the system. Researchers have argued that HCA involvement in oral medication assistance in LTC could improve the utilization of HCAs and optimize the use of other health human resources (Hussein & Manthorpe 2005; Pan Canadian Planning Committee 2009; Stone et al. 2004; Stone & Harahan 2010). Involving nonregulated health care providers in the care process can also be a cost effective choice (MetLife 2010). THE HCA ROLE IN MEDICATION ASSISTANCE Medication delivery is seen as a high risk area in all healthcare sectors due to the potentially serious consequences of medication errors for the clients. It tends to be the responsibility of regulated nursing staff (RNs and LPNs) as part of their scope of practice, in particular prescribed oral medications. Medication delivery implies that nurses make decisions and assessments about the clients when giving medications. By comparison, medication assistance by HCAs occurs under close supervision of regulated nurses without any decisionmaking by HCAs. As outlined by several provincially developed documents (Alberta Provincial Continuing Care Medication Assistance Manual 2014; HCA Role in Medication Assistance 2013; HCA Provincial Curriculum, Lab and Practicum Skills Checklist 2012), medication assistance comprises a range of oral and non oral medications: A Medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer (National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP), 2012). Table 1 HCA Medication Assistance HCAs are allowed to assist with Oral medications Topical medications (lotions, creams, ointments) Ophthalmic medications (eye drops and ointments) Nasal medications (sprays, drops), Otic medications (ear drops) Inhaled medications Rectal suppositories é fleet enemas Transdermal patches HCA are not allowed to assist with High risk medications Medications where assessment is needed prior to administering Un packaged medications Medications for unstable residents Injectable medications HCA Utilization in Continuing Care, August

12 While HCAs obtain medication assistance competencies, the employer ultimately decides whether to involve HCAs in any medication delivery. This decision tends to be based on HCA qualification and resident complexity. If HCAs are involved, they assist with routine, regularly scheduled oral medications in multi dose packages to stable residents. Cummings and colleagues mentioned medication delivery as one of many tasks of HCAs but did not specify the setting or the type of medications (2013). Strain and colleagues mentioned all three nursing groups (RNs, LPNs, HCAs) being involved in medication administration (2011). Out of 113 DAL and LTC sites, HCAs were part of medication delivery at 87% of these. While not specifying which setting, some of these sites must have been LTC sites since their sample only included 52% DAL sites. Strain and colleagues did not clarify the type of medications HCAs gave at these but stated that 39% of the [DAL] facility representatives reported that only [HCAs] administered medications (2011: 143). They recommended further research on the role and medication It might be a safety risk to have HCAs assist with meds given the population, esp. with dementia. They aren t necessarily able to say who they are or that they understand the medication. (Manager) training of unregulated staff at DAL and LTC sites. The various authors also use medication delivery more broadly than we do by including non oral medications (e.g., creams, oitments, suppositories) as part of medication delivery. When focusing on oral medications only, the number of sites where HCAs give these becomes much smaller. Some researchers suggested that involving unregulated providers in medication assistance may result in more medication errors, potentially jeopardizing the health of residents (Woods et al. 2010). Other evidence suggested that assistive personnel like HCAs do not make more mistakes related to medications than professional nursing staff (Scott Cawiezell et al. 2007; Young et al. 2008; Zimmerman et al. 2011). Young et al. showed that in 12 assisted living facilities, medication errors by assistive personnel were most commonly related to their timing (i.e., medications given more than one hour before or after the scheduled time; 2008). Medication errors related to time (i.e., given at the wrong time) were more about policies, staffing levels and processes at the facility than about the skills or knowledge of the individuals administering the medications, thus time errors could occur with any staff giving medications (Young et al. 2008; Scott Cazwiezell et al. 2007). A lack of consistency in delegating medication assistance to HCAs and unclear processes around medication management were also seen a risk factor for increased medication errors (Budden 2012; Mitty 2009). This study further examines HCA utilization with a particular focus on the role of HCAs in medication assistance. Research Activities We surveyed 319 continuing care facilities associated with AHS. The survey collected information on site context, staffing, HCA utilization and service delivery. Five long term care sites were part of the in depth study. In these five sites, we collected additional information through staff interviews and we reviewed RAI data and medication error reports where possible. This information helped us better understand the medication process at these sites, HCA involvement in medication assistance and potential safety concerns, and complexity of the residents. Table 2 below summarizes all project activities. HCA Utilization in Continuing Care, August

13 Table 2 Research Activities Survey of 319 continuing care sites affiliated with AHS; 130 completed questionnaires (40% return) In depth study of 5 LTC sites Data collected Site A Site B Site C Site D Site E Medication error Yes Yes No No No reports RAI data Yes Yes Yes Yes Yes Staff interviews Project Management Activities Literature search Research team meetings Advisory Committee meetings Knowledge Translation Activities We searched for HCAs and medication assistance using synonyms for HCAs, continuing care, and medication administration. The members of the research team met regularly to discuss their analysis and findings to plan next steps over the last 2 years. The AC met monthly during the first year of the project. When the research team conducted the data collection, the regular meetings with the AC were discontinued. The project colead provided written updates via to keep the AC informed of the progress. A. Presentations at Conferences Canadian Association of Gerontologists 2014 (Oct 16 18): Exploring HCA Medication Assistance in Alberta; HCA Utilization in Alberta. Canadian Association of Gerontologists 2015 (Oct 23 25): HCA Utilization and their Perceptions of Medication Assistance in LTC in Alberta; Safe Medication Delivery: The Role of HCAs in LTC facilities. B. Presentations Other Online Presentations to stakeholders in Continuing Care: Safe Medication Delivery in Long term Care: The Role of Healthcare Aides in Medication Assistance January 28, 2016 to the Provincial Medication Management Committee February 18, 2016 at Practice Wise (internal AHS informative 1 hr lunch session) March 15, 2016 to the LTC Collaborative Working Group We were also invited by other stakeholders (Covenant Health, Supportive Living Working Group) to present in the Fall C. Publications: Arain MA, Deutschlander S, Rostami M, Suter E Should healthcare aides be involved in medication assistance in long term care? Gerontology & Geriatric Medicine, Vol 2: manuscripts are in progress (1 on the perceptions of staff on HCA medication assistance; 1 on the survey results with a focus on workforce utilization). Survey of Continuing Care Sites With the endorsement of the five zonal Seniors Health Executive Directors, the WRE study team distributed a questionnaire (Appendix B, p. 29) to management of continuing care sites affiliated with AHS. The questionnaire asked for: Site context and staffing (type of services, bed count, public/private ownership, staff numbers and full time equivalents (FTEs)) HCA Utilization in Continuing Care, August

14 HCA training and responsibilities (HCA competency status, type of responsibilities, medication involvement, concerns about medication delivery) Service delivery and resident care (collaborative activities, workforce utilization) Table 3 below shows the survey responses from LTC and SL sites across the five zones with a response rate of 40% (130 out of 319). Nearly half of the respondents were at LTC sites (49%), 41% at SL sites and 10% at sites offering both types of services. We analyzed survey responses in SPSS version 19. Table 3 Survey Response by Zone Types of Sites North Edmonton Central Calgary South Unknown* Total LTC (%) 7 (10.9) 18 (28.1) 10 (15.6) 18 (28.1) 9 (14.1) 2 (3.1) 64 SL (%) 6 (11.3) 17 (32.1) 11 (20.8) 6 (11.3) 10 (18.9) 3 (5.7) 53 LTC and SL (%) 1 (7.7) 2 (15.4) 3 (23.1) 4 (30.8) 3 (23.1) 0 13 All sites (%) 14 (10.8) 37 (28.5) 24 (18.5) 28 (21.5) 22 (16.9) 5 (3.8) 130 *Fax transmission provided incomplete sender information HCA STAFFING Our survey results showed that HCAs were a significant part of the workforce in continuing care (Appendix A, Table 4, p. 24). On average, 60 HCAs worked at continuing care sites including full time, part time and casual positions. The HCAs workforce comprised mainly certified HCAs (81%) as compared to substantially equivalent or deemed competent HCAs (9.5% each) (Figure 1 below). We did not find a statistically significant difference in certified HCAs between SL and LTC sites (about 79% at each type of setting; we excluded combined SL and LTC sites from this comparison). Figure Competency Status of HCAs 4846 Numbers Fully Certified Substancially Equivalent Deemed Competent OTHER HEALTHCARE PROFESSIONALS The other nursing staff comprised on average 6 LPNs and 5 RNs per site but sites tended to have a large range in staff (Appendix A, Table 4, p. 24). This likely corresponds to the large range in bed count across sites and the required onsite presence for RNs at LTC sites 24/7. There was a greater site presence of management staff including care managers and administrators rather than nurse practitioners, clinical educators or care coordinators. Among the allied health staff, we found higher average FTEs for recreational therapy aide/assistants (1.5 FTE) and recreational therapists (0.7 FTE), for occupational therapy/assistants (0.9 FTE) and occupational therapist (0.5 FTE) than other allied health staff. It is also HCA Utilization in Continuing Care, August

15 noteworthy that volunteers can give significant resident support to continuing care sites with their numbers adding up to 242 (average 6 volunteers). The managers at the sites told us that staffing arrangements respond to the care and safety needs of their residents while also considering current funding constraints. LTC sites required at least one RN on duty at all times. The RNs were in charge of patient assessments, determining resident status, care planning, interventions and care evaluation. Sites tended to increase staffing at specific times when the workload is particularly heavy. For example, more staff was needed in the mornings for getting the residents ready for breakfast, bathing and taking their medications. Therefore, management maximized staff under the current funding model to optimize patient care. In-depth Analysis of Five Long-term Care Sites We conducted an in depth analysis of five LTC sites. This included three sites where HCAs assisted with oral medications. Table 5 below shows the five sites with sites A, B and C engaging their HCAs in oral medication assistance. Table 5 Study Site Information Site Ownership/Location Location Bed Count Site A Publicly owned and operated, Edmonton Zone Urban 120 beds (60 secure beds) Site B Publicly owned and operated, Central Zone Rural 44 secure beds (1 palliative care bed) Site C Private for profit, Calgary Zone Urban 215 beds Site D Publicly owned and operated, Calgary Zone Urban 50 beds Site E Private not for profit, Calgary Zone Urban 60 secure beds STAFF INTERVIEWS At these five sites, we collected qualitative information on HCA utilization in staff interviews (face toface/telephone, up to 1 hour long) (Appendix B, Interview Guide, p. 40). We interviewed 28 HCAs and 48 other staff about various aspects of the medication process and medication assistance as part of the HCA role. The interviews were held with all three types of nursing providers (RNs, LPNs, HCAs), pharmacists, practice leads, safety coordinators and managers (site administrators and care managers). We analyzed the open ended responses in NVivo10. MEDICATION ERROR REPORTS We approached the five LTC study sites for their medication error reports to examine the nature of errors, especially as related to the staff professions. We received reports from three sites for errors reported over 16 months (October 2012 to January 2014). One site did not report on the staff professions and thus we omitted this report from our analysis. Site managers compiled the reports based on self reported medication incidents by nursing staff. They provided information about the errors including date, time, profession making the error, type of error, and the severity of harm. Severity of harm was classified as no apparent harm, minimal harm, moderate harm, severe harm and death (for definitions Appendix A, Table 12, p. 27). We statistically analyzed the reports to calculate the incidence rate of errors and severity of harm related to HCAs and other health professions. HCA Utilization in Continuing Care, August

16 RESIDENT ASSESSMENT INSTRUMENT (RAI) DATA We also examined resident composition and health conditions of the residents at the five sites using their RAI data. From the RAI data, we pulled demographic data (age, gender) and various outcomes scales and Quality Indicators from October 2014 to July RAI indicators are validated measures originally designed for care planning that can also be used for research purposes. We used the RAI data to create a profile of the residents based on their most recent RAI assessment. The profile included number of medications, number of days residents receive injections, pain scores, ADL scores, CPS scores, PURS stages, ISE scores, short term/long term memory loss, indicators on depression, peptic ulcers, incontinence, falls, antipsychotic medication, and chemical restraints. We analyzed the RAI data to show whether there were differences between the health status of the residents at the LTC sites with HCA oral medication assistance and the two other LTC sites. On most RAI indicators, the residents were similar in characteristics (Appendix A, Table 6, p. 25). On the following indicators, the residents were more complex at sites where HCAs assisted with oral medications (significance p<0.01): Older seniors (average 87 years) Lower social engagement (ISE) Higher end stage disease scale (CHESS) Higher percentage of seniors with depression Staff at the sites told us that, with a few exceptions, their residents were dependent on individualized total care. Caring for dependent residents, many of them immobile, is physically demanding and timeconsuming since transfers often require two staff members. Three quarters or more of the residents had short term or long term memory loss (Appendix A, Table 6, p. 25). Besides a greater need for assistance with ADLs, residents with cognitive decline and functional impairments are unable to communicate and their behaviours must be managed. According to staff, the majority of the residents at our study sites also needed extra care and attention (e.g., urethral catheterization, wound care, feeding tubes, and addressing seizures). Our tentative conclusion based on this small number of sites is that the residents at LTC sites with HCA medication assistance were equally, if not more complex on some of the characteristics than residents at other LTC sites. Thus, the complexity of residents may not be a barrier to involving HCAs in medications. Research Questions QUESTION 1: WHAT IS THE UTILIZATION OF HCAS AT CONTINUING CARE FACILITIES WITH PARTICULAR FOCUS ON THE ROLE OF HCAS IN MEDICATION ASSISTANCE? Based on the survey, we found statistically significant differences in the way HCAs are utilized in LTC versus SL sites, as well as in public versus private sites. Based on the data from 52 SL sites and 64 LTC sites, we found that HCA do significantly more of the following tasks at SL compared to LTC sites (p<0.01) (Appendix A, Table 7, p. 26): HCA Utilization in Continuing Care, August

17 Meal preparation (39% versus 6%) Housekeeping (60% versus 13%) Laundry services (73% versus 20%) Charting in resident charts (90% versus 63%) Assisting with therapy activities (67% versus 41%) Equally common at both types of sites are support with ADLs, tick charting, assisting with recreational activities and taking vital signs. Significantly more respondents viewed HCAs as fully utilized in SL than LTC (91% versus 55%, respectively). We also found some statistically significant differences across the LTC sites when dividing these into private (combining for profit and not for profit) and publicly owned and operated sites (Appendix A, Table 8, p. 26). Specifically, HCAs do more of the following tasks at public than at private LTC sites (p<0.01): Housekeeping (23% versus 0%) Laundry services (31% versus 7%) Charting in resident charts (91% versus 28%) Doing vital signs (77% versus 38%) Assisting with recreation activities (80% versus 35%) Equally common at both types of sites are support with ADLs, tick charting, assisting with therapy activities, and preparing meals, and medication assistance. More than 50% of respondents viewed HCAs as fully utilized at private and public LTC sites. The HCAs at our five study sites were typically assigned 7 10 residents on their shift and support residents in all ADLs. Staff tended to work in teams with at least two HCAs in each team to facilitate lifting and transferring patients and answering call bells in the morning. HCAs work in pairs to bath residents and some sites have permanent bath teams. Assisting with respiratory equipment (e.g., filling oxygen tanks) and simple wound care are also part of their duties. HCAs were expected to assist nurses with changing dressings or catheters. Furthermore, they answered resident calls for assistance, communicate with them and ensure their safety and comfort. HCAs also take regular measurements including weight, blood pressure, temperature, oxygen levels, respiration rate and pulse and they collect samples for testing. At two sites, they also do housekeeping. Since HCAs are closely involved with resident care, they offer valuable observations about resident health conditions and behaviors. Two study sites have adopted Point of Care (POC) charting for more immediate and standardized reporting at computer stations throughout the units. This electronic system allows HCAs to choose between multiple responses for each activity. This information also feeds into the RAI assessments carried out by the nurses. While tick charting with checklists is more common across sites, more extensive charting would allow HCAs to document their observations and insights. At LTC sites, mandatory training in narrative charting was offered at 64% private LTC sites to HCAs as compared to 36% HCAs at public sites (statistically significant p<0.01). This result is surprising given that significantly more public LTC sites involve their HCAs in charting in resident charts (=narrative charting). HCA Utilization in Continuing Care, August

18 HCA MEDICATION ASSISTANCE - DIFFERENCES BETWEEN SL AND LTC One major focus of the questionnaire was on medication assistance by HCAs. We asked specific questions about types of medications given, training in medication assistance, concerns about patient safety, and other. We examined medication assistance by type of site including LTC versus SL, and public versus private LTC. The results for public versus private LTC sites only differed significantly in assistance with eye/ear/nasal drops occurring in more public LTC sites (Appendix A, Table 9, p. 26). Otherwise, medication assistance did not differ between public and private LTC sites. By contrast, the survey results showed statistically distinct differences in medication assistance at SL versus LTC sites (Appendix A, Table 10, p. 27). Specifically, HCAs give more of the following medications at SL sites than at LTC sites (p<0.01): Inhaled (79% versus 6%) Oral (83% versus 6%) Eye/ear/nose (81% versus 19%) Vaginal (36% versus 2%) Patches (77% versus 8%) HCAs applying topical creams were equally common at both types of sites while rectal suppositories were more often given by HCAs at LTC sites than at SL sites (90% versus 72%). The two sets of bar graphs below (Figures 2 and 3) illustrate the differences in all medication assistance versus oral medications only between SL and LTC sites. Figure 2 on the left shows the results to the general question: Do HCAs give medications at your site? These results tell us that HCAs at SL sites more commonly assist with medications than HCAs at LTC sites. The medications at SL sites include all types of medications as listed above. Figure 2 HCA Medication Assistance Figure 3 HCA Oral Medication Assistance The left set of graphs also shows that HCA medication assistance in SL is a common practice, with only a few SL sites noting that HCAs were not involved. In LTC, almost half of the sites reported that HCAs were involved in some form of medication assistance. This result was somewhat surprising and may be HCA Utilization in Continuing Care, August

19 reflective of the broad definition of medication that respondents used likely including non oral medications. Figure 3 on the right focuses on HCAs assisting with oral medications and a pronounced difference between SL and LTC is visible. The data show that at only 3 LTC sites HCAs give oral medications whereas this practice is much more widespread in SL sites. These three sites are included in our in depth study. The results are not surprising and they confirm what we assumed that HCAs assisting with oral medication in LTC is rare. Hence, mandatory medication training is much more common at SL sites (Appendix A, Table 10, p. 27). This study shows that HCAs assist with oral medications at 3 long-term care sites in Alberta. At all five sites, HCAs give suppositories and fleet enemas and they provide routine skin care with topical creams and ointments to residents under supervision of regulated providers. HCAs often delegate the suppositories fleet/enema (glycerin suppository) to the night shift for residents who do not respond to the oral laxatives. They apply the topical skin creams / lotions to the affected areas before dressing residents in the morning shift; they apply oral hygiene rinses (chlorhexidine mouthwash) generally under the guidance and supervision of nurses. HCAs at two sites also assist with ophthalmic, nasal, otic and inhaled medications and they remove transdermal patches like pain or smoking cessation patches under nurse supervision. At one site, HCAs assist with eye drops. THE MEDICATION DELIVERY PROCESS AT THE FIVE LTC STUDY SITES Nursing staff across the five LTC sites described a similar medication process with some minor variations and the HCA role being essentially the same. The RNs, best practice leads, and physicians and clinical pharmacists collaborated closely to develop and improve the medication management for each resident to reduce medication interactions and side effects. Physicians prescribed medication orders (on site and off site) that the RNs subsequently processed and kept as paper records in the resident chart. They then entered all medications into each resident Medication Administration Record (MAR) guiding the nursing providers in their medication administration. After receiving the electronic medication request from the RN, the off site pharmacist entered the orders into their information system to verify them and flag any medication interactions or clinical alerts. These pharmacies tended to deliver to continuing care sites only without medication services to the public. At all five sites, the routine oral medications were dispensed in multi dose pouches by delivery time for the weekly supply of medications to the sites (unless urgent changes to medications were required). Each sealed PacMed pouch was clearly labeled with resident name and delivery time as well as number, shape, and color of the content. For each resident, the pharmacy delivered a weekly roll of sealed pouches. As a further control, a pharmacist did manual checks of the pouches before they left the pharmacy. All nursing staff had to follow the 7 Rights as a check to ensure safe medication delivery: right medication, right dose, right client, right route, right time and frequency, right documentation, and right reason. The RNs checked and placed the pouches of oral medications in locked drawers or locked boxes the night before in preparation for the nursing staff to dispense the next day. Each box had a photo of the resident to prevent mix ups. After cutting open the pouch (the top is disposed securely in a separate disposal bin for shredding), nursing staff might prepare medications (e.g., crushing them and mixing them with fluids or sauces) in medication cups on top of the cart. After giving all medications and watching the resident swallow them (some residents try to dispose of them in imaginative ways), staff signed the MAR to indicate that the medication pass for that resident was complete. Nursing staff then moved to the next resident. Some residents may refuse taking the medications. In these cases, the HCA Utilization in Continuing Care, August

20 nursing staff must approach residents three times before documenting refused medication in the MAR. At three sites, the HCAs closely followed the same process as the other nursing staff with the prepackaged oral medications. One site involved HCAs in medication delivery starting in 2008, followed by another site in 2010 and the third one in HCAs did not know what the individual pills were for but they did know that medication errors were serious. HCAs checked the packages for the right number, colour, shape, name and time as well as the resident information. Pre packaged medication given by HCAs comprised nutritional supplements (vitamins, calcium) as well as other key medications (antihypertensive, antipsychotics, antidepressants, and medicine for diabetes and pain). If given to the wrong resident, any of these medications can have serious consequences. HCAs did not give any unpackaged medications. Also, they did not assist with medications to unstable and acutely sick residents or those requiring assessments prior to getting their medications. Staff noted some variations across the five sites: While staff at four sites gave medications 3 to 5 times daily, staff from one site changed medication times from 4 to 2 times daily to reduce the workload for staff. This required switching to long acting (sustained release) medications in consultation with pharmacists and physicians. Two sites did not have proper medication carts, they used utility carts instead and installed a locked box for the medications on top of the cart. Two sites reduced the number of medications to spend less time on medication delivery (especially important for residents with dementia). At four sites, staff handed out medications during meal times in the dining area. One site wanted to provide a more satisfying and exclusive dining experience without interruptions. Thus, medications were given in resident rooms outside of the meals. Two sites planned to support their staff with emar technology (e.g., monitors to scan the barcode on the packages). This monitoring system increases safety by reducing medication errors and omissions. One site used to involve LPNs and HCAs in medication delivery without any RN involvement. Due to reductions in HCA staffing and perceived high medication error rates, only regulated nursing providers were subsequently involved with medication delivery. STAFF VIEWS: STRENGTH AND CONCERNS ABOUT THE MEDICATION PROCESS Staff shared their perceptions on the safety of the current medication process at their site. Most staff saw a number of strengths in the medication process, especially where HCAs assisted with medications. The HCAs expressed that they were well trained to assist with oral medications (e.g., exams and observations on medication passes, regular meeting with the best practice leads, recertification training) and that they could always approach the nurses for questions and support. While all HCAs were trained for oral medication assistance at the three sites, not all HCAs give medications on a regular basis. At one site, only two HCAs handed out oral medications and both were internationally trained RNs. While that did not apply to all three sites, there appeared to be a preference to assign medication assistance to specific HCAs based on their qualifications and experience. All five sites had adopted measures to increase medication safety including training, automated medication dispensing (multi packs), regular meetings with best practice leads and safety checks. The 1 2 hours flexibility to give the medications appeared to be sufficient. HCAs at one site emphasized that consistency and routine were important for medication assistance. Furthermore, that they needed to know the residents, their medications, and HCA Utilization in Continuing Care, August

21 their MARs as otherwise the medication pass will take longer and may lead to medication mistakes. Other staff and managers had a few concerns about HCA medication assistance. Some staff were not convinced that the medication training prepared HCAs sufficiently to think critically about any issues with the residents when giving the medications. HCAs generally did not know what a specific medication was for, and some HCAs saw an advantage to understanding them better (also to better answer questions from the residents). Some staff suspected that HCAs were not always willing to bring forward issues or questions arising for them. They suspect that medication errors were under reported due to fear of reporting or poor communication. Even if they did, the nurses were not always available to answer questions and supervise the HCAs given their own workload. According to staff, some nurses also lacked the supervision and leadership skills to support the HCAs. STAFF VIEWS: MEDICATION ASSISTANCE AS PART OF THE HCA ROLE We also wanted to find out whether medication assistance would add value to the work of the HCAs at the five sites. Most of them were certified and also received additional medication training at their site if part of their role. Almost all of them said that after overcoming their initial discomfort and anxiety, medication assistance had become part of their daily routine and they were comfortable doing I feel it adds to my job in a good way, I am actually trained to do something else than dress someone. (HCA) it. Most of the HCAs found medication assistance rewarding in that it allowed them to more fully use their knowledge and skills. Almost all HCAs who assisted with medications at Sites A, B, and C expressed that they worked to their full potential utilizing all their learned skills. My job is all about heart and soul, it is not about meds; it is about the care and compassion I give. I think LPNs can do the medication, that s their job. Why not let me have that extra time to give to the resident without having the stress in my brain about whether I m giving the right meds. (HCA) Other HCAs at these three sites did not see it as adding to their role in providing care to the residents but rather taking away from being on the floor focusing on resident care. Even after many years, these HCAs did not like the responsibility of giving medications and still think of medication delivery as belonging to the nurses job. The HCAs not assisting with medications at the two other sites told us that they would have a hard time handing out medications. It appeared to them as an overwhelming responsibility since they have not received post secondary or on site medication training. Some of them were previously asked by nurses to help with oral medications for residents who were uncooperative. In these cases, a nurse would unsuccessfully approach residents with medications and had to ask the HCA to hand over the medications while they stood by. While some HCAs were satisfied with this level of involvement in medication assistance, others would like to take it on more fully. Some residents are a challenge and they choose the person they like [for medications]. (HCA) While the HCAs welcomed assisting with medications, they had concerns about the heavy workload, especially in times of short staffing or when working with more inexperienced staff who also need their attention. HCAs on the day shift start with a heavy workload in the morning. Medication assistance is time consuming, in particular when giving them to residents in their rooms or when the residents are un cooperative. They worried about potential errors and causing harm to the residents. Some HCAs suggested hiring more HCAs to be on the floor at all times and sharing ADL care with the LPNs if they were to take on more tasks. HCA Utilization in Continuing Care, August

22 RESEARCH QUESTION 2: WHAT IS THE IMPACT OF HCA MEDICATION ASSISTANCE ON STAFF UTILIZATION AND RESIDENT SAFETY IN CONTINUING CARE FACILITIES? We answered this research question by analysing site specific medication error reports and staff perceptions on patient safety and workforce utilization from our survey and interviews. Our survey results showed that about 27% of respondents at LTC and 15% of respondents at SL reported concerns about patient safety in the medication process (not statistically significant) (Appendix A, Table 10, p. 27). Staff and managers at the sites expressed concern about medication errors and told us that these can occur at any stage in the medication delivery process with potentially serious consequences for the residents. Other staff were concerned about under reporting medication errors (e.g., fear of reprisals, not done before). All sites have procedures in place to address medication errors that involve any of the strategies below: Completing the Quality Assurance Unusual Occurrence Report Close monitoring of residents for any adverse effects Notifying the site physician, family members and residents Filing Severe Incident Reports for serious effects of medication errors with Alberta Health and Continuing Care We analyzed the error reports from two sites where HCAs assist with oral medications and where medication training is mandatory for HCAs. Site staff compiled their own medication error reports internally and each site had its own reporting template. These reports were voluntarily filed when individual staff bring forward any problems with medication delivery. The reports tracked medication errors by date and time, type of profession, type of error and/or the severity of harm to the resident (7 levels: death, severe harm, moderate harm, minimal harm, no apparent harm, close call and hazard). We examined the types of errors and severity of harm made by HCAs and other healthcare professionals related to oral medication delivery (including pharmacists). RESULTS FROM THE MEDICATION ERROR REPORTS Over 16 months (October 2012 to January 2014), the two sites had a combined total of 220 errors for oral medication delivery. While the number of errors was different at each site, the sites also had different bed counts (44 LTC beds versus 120 LTC beds). We took the different number of resident beds into account when we calculated error rates. HCAs assisted with about 50% of medications at one site and about 70% of medications at the second site. Table 11 below shows the various types of errors by healthcare providers. Table 11 Type of Error by Healthcare Provider at 2 Sites (n=220*) Type of Error Type of Healthcare Provider HCAs (%) Other Providers (%) Documentation Error 0 (0.0) 3 (100.0) Dose Omission 96 (71.6) 38 (28.4) Extra Dose to Resident 1 (16.7) 5 (83.3) Extra Dose in Package 0 (0.0) 1 (100.0) Incorrect Drug 3 (25.0) 9 (75) Incorrect Time 11 (91.7) 1 (8.3) Frequency Scheme Error 2 (66.7) 1 (33.3) Incorrect Narcotic Count 0 (0.0) 1 (100.0) Not Performed Where Indicated 2 (22.2) 7 (77.8) HCA Utilization in Continuing Care, August

23 Wrong Dose Strength 4 (57.1) 3 (42.9) Wrong Duration 0 (0.0) 4 (100.0) Wrong Resident 16 (80.0) 4 (20) Wrong Storage 0 (0.0) 1 (100.0) Wrong Technique 1 (100.0) 0 (0.0) Other 1 (25.0) 3 (75.0) Total number of Errors 137 (63%) 81 (37%) *Two errors were not linked to professional background and omitted from the analysis When examining type of error, the three most frequent errors included dose omissions (61.5%; n=134) followed by medicines given to the wrong resident (9.2%; n=20), and given at the incorrect time and the incorrect drug (each 5.5%, n=12). Only 4% or less of the incidents include: not performed where indicated (4.1%; n=9), wrong dosage (3.2%; n=7), extra dose to resident 2.8% (n=6), frequency scheme error 1.4% (n=3), wrong duration 1.8% (n=4), documentation errors (1.4%; n=3), extra dose in package 0.5% (n=1), incorrect narcotic count 0.5% (n=1), wrong storage 0.5% (n=1), wrong technique 0.5% (n=1) and others 1.8% (n=4). When analyzing these errors by profession, HCAs were involved in 137 errors (63%) and the other providers in 81 (37%). Out of the latter, pharmacists were involved in only four errors (2%) (e.g., extra dose in package, frequency scheme error, wrong dose strength, and not performed where indicated). Table 11 shows that HCAs accounted for two thirds of the dose omissions. HCAs also approached the wrong resident (12%) and gave the medication at the wrong time (8%) more often than other providers even though these errors were rare. By comparison, other nursing providers gave the incorrect drug relatively more often (11%). We then calculated the incidence rate of medication errors for each type of provider based on all medications administered at each site as provided by the pharmacist. The average monthly incidence rate of medication errors is 2.6 per 10,000 medicines administered by all staff. HCAs were slightly below this average with 2.4 per 10,000 while regulated nursing providers were above this average with a rate of 3.1 per 10,000 medications. We examined the severity of harm to the residents resulting from these errors (Appendix A, Table 12, p. 27 for definitions). Neither of the reports documented death or severe harm (high severity), thus moderate harm was the highest level reported for any error. Most errors were of minimal severity at 53% (n=117), followed by no apparent harm with 43% (n=95) and moderate severity with 4% (n=8) of the time. When comparing moderate harm with all other less severe harm levels combined (minimal/no apparent harm/close call and hazard), HCAs were significantly less likely to be involved in errors of moderate severity than all other health care providers (2% vs 7%; Chi Square=5.1; p value=0.04). Thus, the data from two sites show that HCAs not only made less medication errors per number of medications administered, they were also less likely to cause moderate levels of harm to the residents. We also analyzed the time of the medication errors (Figure 4). Staff have a window of two hours for giving the scheduled medications before these are considered omissions. For some conditions (e.g., Parkinson s disease), the delivery time is more tightly prescribed than for others. The two spikes reflect the morning and evening medication rounds at which most of the medications were handed out. Only a few errors occurred in between these major medication delivery times. At all five study sites, the morning medication delivery was still the most time consuming and intense, typically taking at least two HCA Utilization in Continuing Care, August

24 hours. Most staff talked about mornings as the most likely time for errors while this graph shows evenings as the time for more errors. Figure 4 Medication Errors by Delivery Time STAFF VIEWS: CIRCUMSTANCES LEADING TO MEDICATION ERRORS While all five sites had safety measures in place, staff pointed to a number of factors affecting safe medication delivery. In combination with staff shortages and high workloads, staff listed distractions, multitasking, rushing and unfamiliarity with residents as contributors to medication errors. These errors comprise omissions and other mistakes. Almost every staff member viewed distractions as the most frequent cause for errors. Interruptions by peers, family members and residents or call bells happened constantly during medication passes. In case of emergency People were coming up and talking to the person as she was delivering the meds. She got really flustered and picked up the wrong med and went to the wrong person. (Manager) situations (e.g., a resident falling and needing the help of several staff, acute care referrals), nursing staff interrupt the medication delivery, lock the cart and help out. Staff told us that RNs or LPNs may not be as distracted as HCAs since the nurses do not necessarily have resident assignments. Staff routinely multitask during morning care when medications are given. At meal times, they have to focus on feeding residents and responding to residents meal requests while handing out medications. Other omissions easily happen when staff do not wake residents either early in the morning or at night, or when the resident is out of their room at medication time. In other cases, residents with dementia often refuse medication increasing the likelihood of omissions. Staff also frequently rush to get patient care done in the morning and easily forget to give the non packaged medications (e.g., eye and ear drops, patches, and insulin). When staff give medications to the wrong resident, confusing residents with the same name may be one reason. Some staff may be unfamiliar with the residents and their medication requirements. For example, while some casual staff give medications who have worked on a site for a long time, they may still not be as familiar with the residents as the permanent staff. Some staff also mentioned the small writing on the medication packaging that makes it difficult to read the information. In other cases, discontinued medications are not removed from the medication rolls, while others are not added to the roll on time. In a few cases, a language barrier may exist for staff decreasing their understanding of the HCA Utilization in Continuing Care, August