BACKGROUND: Emerging technologies such as artificial intelligence (AI) require an early-stage assessment of potential societal and ethical implications to increase their acceptability, desirability, and sustainability. This paper explores and compares 2 of these assessment approaches: the responsible innovation (RI) framework originating from technology studies and the co-design approach originating from design studies. While the RI framework has been introduced to guide early-stage technology assessment through anticipation, inclusion, reflexivity, and responsiveness, co-design is a commonly accepted approach in the development of technologies to support the care for older adults with frailty. However, there is limited understanding about how co-design contributes to the anticipation of implications.
OBJECTIVE: This paper empirically explores how the co-design process of an AI-based decision support system (DSS) for dementia caregivers is complemented by explicit anticipation of implications.
METHODS: This case study investigated an international collaborative project that focused on the co-design, development, testing, and commercialization of a DSS that is intended to provide actionable information to formal caregivers of people with dementia. In parallel to the co-design process, an RI exploration took place, which involved examining project members\' viewpoints on both positive and negative implications of using the DSS, along with strategies to address these implications. Results from the co-design process and RI exploration were analyzed and compared. In addition, retrospective interviews were held with project members to reflect on the co-design process and RI exploration.
RESULTS: Our results indicate that, when involved in exploring requirements for the DSS, co-design participants naturally raised various implications and conditions for responsible design and deployment: protecting privacy, preventing cognitive overload, providing transparency, empowering caregivers to be in control, safeguarding accuracy, and training users. However, when comparing the co-design results with insights from the RI exploration, we found limitations to the co-design results, for instance, regarding the specification, interrelatedness, and context dependency of implications and strategies to address implications.
CONCLUSIONS: This case study shows that a co-design process that focuses on opportunities for innovation rather than balancing attention for both positive and negative implications may result in knowledge gaps related to social and ethical implications and how they can be addressed. In the pursuit of responsible outcomes, co-design facilitators could broaden their scope and reconsider the specific implementation of the process-oriented RI principles of anticipation and inclusion.

Long-term care (LTC) is one of the most pressing public policy challenges today. Implementing policies to meet the population\'s demands becomes relevant in many countries, particularly in a context of rapid population aging. Both the technical complexities and the financial burden of implementing LTC policies discourage policy makers\' actions in this area. In this environment, targeted policies arise as a solution to reduce the cost of implementing LTC policies. This article presents several arguments in favor of implementing universal-vs targeted-LTC initiatives. Arguments are divided into general arguments against targeting public policies, using categories proposed by Amartya Sen, and LTC-specific arguments, based on the concept of LTC as social security. Information shows that despite the financial arguments in favor of targeted policies, in the case of LTC, its costs may overcome the benefits. These results provide important lessons for policy makers, particularly regarding the design of (universal) LTC policies, warning that the allegedly simple solution of targeting benefits needs to be revisited, and replaced for policies that could balance universalism and resource constraints. This message is particularly important today for countries that face the challenge of increasing LTC needs and tighter resource constraints.

UNASSIGNED: As health-care demand is growing, our health-care system will require the optimization of the care trajectories. Patients with an alternate level of care (ALC) status could be a target for flow optimization. We aimed to characterize ALC patients and risk factors for ALC status, and to propose an integrated model to analyze the trajectory of ALC patients and discuss solutions to reduce their burden.
UNASSIGNED: A case-control design was used to compare 60 ALC and 60 non-ALC patients admitted to the geriatric unit of the Centre hospitalier de l\'Université de Montréal in 2021, collecting medical and sociodemographic data. Based on our model, univariate statistical analyses were computed to compare groups and identify risk factors for ALC status.
UNASSIGNED: ALC patients were less independent (22% performed five to six activities of daily living vs. 43%, p = .03). Both groups were comparable in terms of mobility and neurocognitive disorders. ALC patients were more likely to receive a new diagnosis of a neurocognitive disorder or new behavioural or psychological symptoms (37% vs. 15%, p = .008). Up to 25% of ALC patients were admitted despite presenting no active medical condition (vs. 3% of non-ALC patients, p = .002).
UNASSIGNED: The optimization of the care trajectory of ALC patients is mainly based on pre-hospital and post-hospital factors. A proportion of ALC admissions might be avoidable with additional investment in home care resources and relocation procedures. Fluidity of ALC trajectory may benefit from improved orientation at discharge procedures. Full optimization of ALC trajectories requires a systemic understanding of the health-care system.

BACKGROUND: Following the legalization of cannabis in Canada in 2018, people aged 65 + years reported a significant increase in cannabis consumption. Despite limited research with older adults regarding the therapeutic benefits of cannabis, there is increasing interest and use among this population, particularly for those who have chronic illnesses or are at end of life. Long-term Care (LTC) facilities are required to reflect on their care and policies related to the use of cannabis, and how to address residents\' cannabis use within what they consider to be their home.
METHODS: Using an exploratory case study design, this study aimed to understand how one LTC facility in western Canada addressed the major policy shift related to medical and non-medical cannabis. The case study, conducted November 2021 to August 2022, included an environmental scan of existing policies and procedures related to cannabis use at the LTC facility, a quantitative survey of Healthcare Providers\' (HCP) knowledge, attitudes, and practices related to cannabis, and qualitative interviews with HCPs and administrators. Quantitative survey data were analyzed using descriptive statistics and content analysis was used to analyze the qualitative data.
RESULTS: A total of 71 HCPs completed the survey and 12 HCPs, including those who functioned as administrators, participated in the interview. The largest knowledge gaps were related to dosing and creating effective treatment plans for residents using cannabis. About half of HCPs reported providing care in the past month to a resident who was taking medical cannabis (54.9%) and a quarter (25.4%) to a resident that was taking non-medical cannabis. The majority of respondents (81.7%) reported that lack of knowledge, education or information about medical cannabis were barriers to medical cannabis use in LTC. From the qualitative data, we identified four key findings regarding HCPs\' attitudes, cannabis access and use, barriers to cannabis use, and non-medical cannabis use.
CONCLUSIONS: With the legalization of medical and non-medical cannabis in jurisdictions around the world, LTC facilities will be obligated to develop policies, procedures and healthcare services that are able to accommodate residents\' use of cannabis in a respectful and evidence-informed manner.

BACKGROUND: A key role of nurses working in long-term care homes (LTCHs) is to promote the involvement of care partners in end-of-life (EOL) care. However, studies on the involvement of care partners in EOL care in LTCHs have focused on care planning and decision-making. While care partners can participate in other ways, it\'s unclear how they are currently involved in EOL care by staff.
OBJECTIVE: We aimed to explore the involvement of care partners in the EOL care of an older adult living in a LTCH.
METHODS: A qualitative case study was conducted. Data was collected from a sample of four nurses and three care partners, using sociodemographic questionnaires, individual semi-structured interviews, documents pertaining to the LTCH\'s philosophy for EOL care, and a field diary.
RESULTS: The results of a thematic analysis showed the broad scope of care partners\' possible involvement, including contributing to care, obtaining information, and being present. As there was some variation in care partners\' desire to be involved, nurses seemed to rely on them to convey their wishes. To promote this involvement, some strategies aimed at health professionals and managers were suggested.
CONCLUSIONS: These results can guide improvement in clinical practices and raise awareness on the EOL care experiences of care partners.

BACKGROUND: Persons with severe Multiple Sclerosis (PwsMS) face complex needs and daily limitations that make it challenging to receive optimal care. The implementation and coordination of health care, social services, and support in financial affairs can be particularly time consuming and burdensome for both PwsMS and caregivers. Care and case management (CCM) helps ensure optimal individual care as well as care at a higher-level. The goal of the current qualitative study was to determine the experiences of PwsMS, caregivers and health care specialists (HCSs) with the CCM.
METHODS: In the current qualitative sub study, as part of a larger trial, in-depth semi-structured interviews with PwsMS, caregivers and HCSs who had been in contact with the CCM were conducted between 02/2022 and 01/2023. Data was transcribed, pseudonymized, tested for saturation and analyzed using structuring content analysis according to Kuckartz. Sociodemographic and interview characteristics were analyzed descriptively.
RESULTS: Thirteen PwsMS, 12 caregivers and 10 HCSs completed interviews. Main categories of CCM functions were derived deductively: (1) gatekeeper function, (2) broker function, (3) advocacy function, (4) outlook on CCM in standard care. Subcategories were then derived inductively from the interview material. 852 segments were coded. Participants appreciated the CCM as a continuous and objective contact person, a person of trust (92 codes), a competent source of information and advice (on MS) (68 codes) and comprehensive cross-insurance support (128 codes), relieving and supporting PwsMS, their caregivers and HCSs (67 codes).
CONCLUSIONS: Through the cross-sectoral continuous support in health-related, social, financial and everyday bureaucratic matters, the CCM provides comprehensive and overriding support and relief for PwsMS, caregivers and HCSs. This intervention bears the potential to be fine-tuned and applied to similar complex patient groups.
BACKGROUND: The study was approved by the Ethics Committee of the University of Cologne (#20-1436), registered at the German Register for Clinical Studies (DRKS00022771) and in accordance with the Declaration of Helsinki.

OBJECTIVE: Care coordination for children and youth with special health care needs and medical complexity (CYSHCN-CMC), especially medication management, is difficult for providers, parents/caregivers, and -patients. This report describes the creation of a clinical pharmacotherapy practice in a pediatric long-term care facility (pLTCF), application of standard operating procedures to guide comprehensive medication management (CMM), and establishment of a collaborative practice agreement (CPA) to guide drug therapy.
METHODS: In a prospective case series, 102 patients characterized as CYSHCN-CMC were included in this pLTCF quality improvement project during a 9-month period.
RESULTS: Pharmacists identified, prevented, or resolved 1355 drug therapy problems (DTP) with an average of 13 interventions per patient. The patients averaged 9.5 complex chronic medical conditions with a -median length of stay of 2815 days (7.7 years). The most common medications discontinued due to pharmacist assessment and recommendation included diphenhydramine, albuterol, sodium phosphate enema, ipratropium, and metoclopramide. The average number of medications per patient was reduced from 23 to 20. A pharmacoeconomic analysis of 244 of the interventions revealed a monthly direct cost savings of $44,304 ($434 per patient per month) and monthly cost avoidance of $48,835 ($479 per patient per month). Twenty-eight ED visits/admissions and 61 clinic and urgent care visits were avoided. Hospital -readmissions were reduced by 44%. Pharmacist recommendations had a 98% acceptance rate.
CONCLUSIONS: Use of a CPA to conduct CMM in CYSHCN-CMC decreased medication burden, resolved, and prevented adverse events, reduced health care-related costs, reduced hospital readmissions and was well-accepted and implemented collaboratively with pLTCF providers.

Limited information is available regarding the prevalence of pressure ulcers (PUs) in residential homes in Central Asia. Therefore, the aim of this study was to identify the prevalence rates and risk factors associated with PUs among residents of long-term care medical institutions in the Republic of Kazakhstan. This cross-sectional study was conducted in four long-term care institutions in Kazakhstan. The study sample consisted of 640 patients who were assessed for the presence of PUs and associated risk factors. The evaluation was performed using the International Prevalence Measurement of Care Quality (Landelijke Prevalentiemeting Zorgkwaliteit, LPZ), the Braden scale, and the Care Dependency Score (CDS). The overall prevalence of PUs, classified as categories I-IV, was found to be 37%. When excluding category I PUs, the prevalence decreased to 35.6%. The odds ratios (ORs) for presenting with PUs were as follows: history of stroke (OR 5.22), diseases of the digestive system (OR 10.01), presence of spinal cord lesions/paraplegia (OR 20.50), recent reported confusion within the last 7 days (OR 184.00), and limited extent dependency according to the CDS (OR 4.44; 95%CI 1.31-16.1). It is imperative to establish specialized training programs aimed at equipping medical personnel, relatives, and patients themselves with the necessary skills to provide optimal care for individuals affected by PUs.

Systematic assessments of interprofessional collaboration barriers and enablers in long-term care settings are critical for delivering person-centered healthcare. However, research on factors influencing interprofessional collaboration in long-term care settings is limited. For this study, 65 healthcare professionals across multiple facilities experienced in long-term care in Japan participated in online focus group discussions and individual interviews to discuss cases. The qualitative data were analyzed using qualitative content analysis. Seven themes emerged: coordination, the need for care manager training, hierarchy among healthcare professionals, specialization but not the mind-set of overspecialization, casual conversations, electronic group communication tools, and excessive fear of personal information protection. These findings highlight the need to develop coordinator roles and for interprofessional education on the proper approach to personal information protection laws. Furthermore, daily casual conversations, the use of online platforms, and the prevention of patients being left behind due to overspecialization are required.

Within long-term care homes (LTCHs), conflicts occur between residents\' desires, LTCH constraints, and healthcare providers\' concerns about risks of harm. Due to the high prevalence of dysphagia and malnutrition in these settings, decisions regarding food choices are a common source of such tensions. Existing biomedical ethical models fail to capture the complexity of the interprofessional chronic care environment. This article proposes an alternative ethical lens, the relational ethics model. We describe a case illustrating the application of a decision-making framework with a relational ethics lens for a resident with severe dysphagia and malnutrition. We highlight how the bioethics model excludes important actors from ethical decision making. We encourage registered dietitians working in LTCH to incorporate a relational ethics model into their practice to help identify resident\'s values and bring attention to the interconnectedness of caring relationships and contextual factors. This approach can inform difficult decisions regarding the food and nutrition choices of residents and may facilitate meaningful outcomes for both individuals and the long-term care community.