1. Introduction
Long-term care (LTC) homes in Canada serve high-risk and vulnerable older populations, with the majority living with complex and multiple chronic comorbidities. The assumption that LTC home residents are stable with low needs is no longer applicable [
1,
2]. Cognitive impairments and dementia rates are rising amidst overcrowding and understaffing challenges at LTC homes, including lack of appropriate staffing levels and training to meet the increasingly acute and complex needs of residents [
3,
4,
5]. These issues were exacerbated by the COVID-19 global pandemic, which had a devastating and deadly impact on residents, family caregivers (FCGs), and staff [
1,
5,
6,
7,
8]. In addition, cultural and ethnic diversity is on the rise among residents in Canadian LTC homes, especially in urban areas. Ethnocultural diversity can have an impact on the quality and safety of care delivery, such as communications with staff [
9].
Despite increases in LTC residents’ physical, cognitive, and emotional-social needs over recent decades, LTC staffing decisions are often based on arbitrary standards and economic reasons rather than residents’ needs [
8,
10]. The same staffing models and provider hours per resident per day (HRPD) have remained static for decades, implying a presumption that resident needs do not vary across individuals, units, care homes, and over time. In fact, for the last 20 years, HRPD standards in Canada have been based on US data from 15,000 care homes in 10 States [
11]. Depending on the resident case mix, which is a US measure of acuity, the 2001 recommendations were for a range of 2.4 – 2.8 HRPD for care aides (CAs), 1.15 – 1.30 HPRD for licensed or registered practical nurses (LPNs or RPNs depending on jurisdiction), and 0.55 – 0.75 HPRD for registered nurses (RNs), totaling 4.1 – 4.85 hours of direct care provider daily per resident. Since then, US recommendations have largely prevailed without further examination of residents’ needs in Canadian LTC homes. In many instances, LTC homes from some provinces in Canada do not meet the 2001 recommended standards. For example, average HPRD in Ontario was 3.73 in 2018, and 3.28 HPRD in British Columbia in 2020 [
12,
13].
Non-profit advisory groups in Canada regularly report on HPRD staffing averages and resident outcomes using quality indicators, such as falls with and without injuries (Office of the Senior’s Advocate British Columbia., 2020; Ontario Long-Term Care Staffing Study Advisory Group, 2020). Lower HPRD standards in Canadian LTC homes no doubt compromise basic resident-centered care needs and outcomes [
10,
14]. Research evidence is beginning to link richer skill mix of regulated nurse (RNs and LPNs/RPNs) HPRD with improved resident outcomes, including decreased falls, urinary tract infections, pressure ulcer occurrence and weight loss; and improved pain management [
15,
16,
17,
18].
In Canada, there is limited literature on current resident care needs and effective staffing levels and skill mix to ensure safe, quality care delivery. From a resident-centered care perspective, it is necessary to know residents’ acuity and dependency needs to staff according to these needs. Some recent evidence suggests that one resident assessment tool, the Synergy tool, can provide real-time information about individual residents’ priority care needs, to determine an appropriate staffing complement. The conceptual Synergy Model and its accompanying patient needs assessment tool (Synergy tool) were developed in the 1990s in the US to assist nurses with objectively assessing and quantifying their patients’ acuity and dependency needs. Acuity refers to patient needs that are overseen by regulated nurses, and dependency needs include activities of daily living (e.g., bathing, feeding, ambulating) that are delivered by unregulated CAs or non-nurse professionals (e.g., nutritionists, physio-occupational therapists). Psychometric evaluation of the Synergy tool for acute care and specialty settings was carried out in the US where the tool was widely adopted over the last 20 years [
19]. Subsequently, the conceptual model and tool spread internationally, including in Canadian jurisdictions [
20,
21,
22].
Research with the Synergy tool has demonstrated its capacity to facilitate safe staffing and workload management decisions in real-time by using health professionals’ assessments of patients’ acuity and dependency needs. The ultimate purpose of the Synergy tool is to enhance the quality and safety of care delivery by creating a better ‘fit’ between staffing assignments and patient needs [
20,
21,
23,
24]. Research evidence suggests that Synergy tool use leads to optimization of existing health human resources [
20,
21,
23], positive care delivery experiences and outcomes for patients and providers, and reduced costs in healthcare delivery [
22,
23]. The majority of research with the Synergy tool has been in acute care, emergency services and specialty and ambulatory care programs [
20,
21,
22,
23,
25,
26,
27,
28,
29]. To our knowledge, research with the Synergy tool has not been conducted in the LTC sector. In addition, there has never been any research containing an economic evaluation of Synergy tool implementation, despite the importance of cost analysis for guiding operational and policy-level decisions [
30,
31,
32]. The purpose of this study was to implement and evaluate the impact of the Synergy tool on residents’ care delivery in two ethnically diverse LTC homes in large urban areas within British Columbia, Canada, including evaluation from an economic perspective.
Long-term care (LTC) homes in Canada serve high-risk and vulnerable older populations, with the majority living with complex and multiple chronic comorbidities. The assumption that LTC home residents are stable with low needs is no longer applicable [
1,
2]. Cognitive impairments and dementia rates are rising amidst overcrowding and understaffing challenges at LTC homes, including lack of appropriate staffing levels and training to meet the increasingly acute and complex needs of residents [
3,
4,
5]. These issues were exacerbated by the COVID-19 global pandemic, which had a devastating and deadly impact on residents, family caregivers (FCGs), and staff [
1,
5,
6,
7,
8]. In addition, cultural and ethnic diversity is on the rise among residents in Canadian LTC homes, especially in urban areas. Ethnocultural diversity can have an impact on the quality and safety of care delivery, such as communications with staff [
9].
Despite increases in LTC residents’ physical, cognitive, and emotional-social needs over recent decades, LTC staffing decisions are often based on arbitrary standards and economic reasons rather than residents’ needs [
8,
10]. The same staffing models and provider hours per resident per day (HRPD) have remained static for decades, implying a presumption that resident needs do not vary across individuals, units, care homes, and over time. In fact, for the last 20 years, HRPD standards in Canada have been based on US data from 15,000 care homes in 10 States [
11]. Depending on the resident case mix, which is a US measure of acuity, the 2001 recommendations were for a range of 2.4 – 2.8 HRPD for care aides (CAs), 1.15 – 1.30 HPRD for licensed or registered practical nurses (LPNs or RPNs depending on jurisdiction), and 0.55 – 0.75 HPRD for registered nurses (RNs), totaling 4.1 – 4.85 hours of direct care provider daily per resident. Since then, US recommendations have largely prevailed without further examination of residents’ needs in Canadian LTC homes. In many instances, LTC homes from some provinces in Canada do not meet the 2001 recommended standards. For example, average HPRD in Ontario was 3.73 in 2018, and 3.28 HPRD in British Columbia in 2020 [
12,
13].
Non-profit advisory groups in Canada regularly report on HPRD staffing averages and resident outcomes using quality indicators, such as falls with and without injuries (Office of the Senior’s Advocate British Columbia., 2020; Ontario Long-Term Care Staffing Study Advisory Group, 2020). Lower HPRD standards in Canadian LTC homes no doubt compromise basic resident-centered care needs and outcomes [
10,
14]. Research evidence is beginning to link richer skill mix of regulated nurse (RNs and LPNs/RPNs) HPRD with improved resident outcomes, including decreased falls, urinary tract infections, pressure ulcer occurrence and weight loss; and improved pain management [
15,
16,
17,
18].
In Canada, there is limited literature on current resident care needs and effective staffing levels and skill mix to ensure safe, quality care delivery. From a resident-centered care perspective, it is necessary to know residents’ acuity and dependency needs to staff according to these needs. Some recent evidence suggests that one resident assessment tool, the Synergy tool, can provide real-time information about individual residents’ priority care needs, to determine an appropriate staffing complement. The conceptual Synergy Model and its accompanying patient needs assessment tool (Synergy tool) were developed in the 1990s in the US to assist nurses with objectively assessing and quantifying their patients’ acuity and dependency needs. Acuity refers to patient needs that are overseen by regulated nurses, and dependency needs include activities of daily living (e.g., bathing, feeding, ambulating) that are delivered by unregulated CAs or non-nurse professionals (e.g., nutritionists, physio-occupational therapists). Psychometric evaluation of the Synergy tool for acute care and specialty settings was carried out in the US where the tool was widely adopted over the last 20 years [
19]. Subsequently, the conceptual model and tool spread internationally, including in Canadian jurisdictions [
20,
21,
22].
Research with the Synergy tool has demonstrated its capacity to facilitate safe staffing and workload management decisions in real-time by using health professionals’ assessments of patients’ acuity and dependency needs. The ultimate purpose of the Synergy tool is to enhance the quality and safety of care delivery by creating a better ‘fit’ between staffing assignments and patient needs [
20,
21,
23,
24]. Research evidence suggests that Synergy tool use leads to optimization of existing health human resources [
20,
21,
23], positive care delivery experiences and outcomes for patients and providers, and reduced costs in healthcare delivery [
22,
23]. The majority of research with the Synergy tool has been in acute care, emergency services and specialty and ambulatory care programs [
20,
21,
22,
23,
25,
26,
27,
28,
29]. To our knowledge, research with the Synergy tool has not been conducted in the LTC sector. In addition, there has never been any research containing an economic evaluation of Synergy tool implementation, despite the importance of cost analysis for guiding operational and policy-level decisions [
30,
31,
32]. The purpose of this study was to implement and evaluate the impact of the Synergy tool on residents’ care delivery in two ethnically diverse LTC homes in large urban areas within British Columbia, Canada, including evaluation from an economic perspective.
4. Discussion
Our study demonstrated how the Synergy tool can be used in real-time and over time to capture and operationalize the acuity and dependency needs of individual residents, and to provide an overall average of acuity and dependency needs for specific units or resident populations over time. These findings reflect what healthcare providers and the literature have been saying about our resident populations. Advanced aging with accompanying physical, cognitive and social-emotional conditions means that every resident will have different healthcare needs to consider when delivering resident-centered care. In addition, seniors, especially the baby boomer generation, have strong preferences for alternative living accommodations, and they expect more control over the quality and types of services they receive [
47]. Resident-centered care models that acknowledge and respond to individual variability in resident needs are also associated with decreased behavioural symptoms and antipsychotic medication use in residents with dementia [
48]. As stated by family caregivers in the focus groups and interview, attention to residents’ specific needs was of great value to them. We were unable to include residents in our focus groups due to the high dementia rates in our two LTC homes, but one US study found that cognitively intact residents appreciated many aspects of resident-centered care delivery, particularly waking and bedtime choices, having consistent staff, and having a voice to discuss concerns and to make changes via resident councils. Residents also noted how their ‘homes’ had a long way to go to de-institutionalize their living environments [
49].
The Synergy tool is a resident-centered assessment tool that can be easily used by healthcare professionals to collaboratively plan and personalize care with residents and their family caregivers. As evidenced by our Synergy score data, there can be considerable individual variability in LTC residents’ acuity and dependency needs, and on some units, those needs can change daily. In our data, one unit (Unit 1B) had acuity needs similar to medical-surgical acute care units in other research we have conducted [
20]. Our findings have dispelled the assumptions that LTC homes have stable residents with non-changing basic care needs. The Synergy scores can inform creative ways of utilizing the funded HPRD based on resident needs, such as through assigning the more experienced, regulated nurse to high acuity residents. Likewise, Synergy scores can be used by researchers to evaluate the validity of the funded HPRD for quality and safe resident care delivery.
In Canadian LTC homes, residents are assessed using the Resident Assessment Instrument-Minimum Data Set 2.0 (RAI-MDS 2.0) questionnaire, which is done on admission and quarterly. The questionnaire contains over 300 items, making it difficult to use for real-time assessments. Several problems have been identified by the developers of the RAI-MDS, such as its medical/acuity orientation and its inability to assess characteristics that are quickly changeable over time [
50]. Absent from the questionnaire are questions about quality of life, resident autonomy, satisfaction and level of dependency [
51]. Some Canadian provinces, such as BC, have created resident/family experience surveys, but these surveys are administered and reported through the Seniors’ Advocate annually [
52]. In a qualitative, descriptive study of RAI-MDS, researchers’ interviews with RAI-MDS coordinators who collect data in their LTC homes described the data as “decontextualized” and a “click box of predetermined items” (
Armstrong et al., 2017, p. 359). The collected data, by trained coordinators, is sent to the national Canadian of Institute of Health Information (CIHI), cleaned, synthesized and sent to provincial seniors advocate offices. Due to the nature of data collection and reporting, it is highly unlikely that data can be used to efficaciously inform decisions of providers, residents, and their family caregivers [
51]. In contrast to current resident assessment tools in place, such as the RAI-MDS, the Synergy tool characteristics and assessment indicators can be quickly adapted and validated by expert healthcare professionals in the LTC home and implemented in real time and as frequently as deemed appropriate by the expert providers.
In our study we used a quality indicator from LTC homes’ administrative data, falls rate, to determine if the use of the Synergy tool had any impact on resident outcomes. Falls rates are a quality indicator reported to CIHI as part of the RAI-MDS, and for licensing and accreditation purposes, LTC homes need to track falls [
50]. Falls are common in residents for a number of reasons, including physical and cognitive impairments that affect perception, balance and coordination; and medications that increase the risk of falls. Other factors include urinary incontinence (e.g., trying to get to the bathroom quickly), and disinhibited, risk-taking behaviours associated with certain mental health conditions [
53]. In a 2015 Dutch study that recorded reasons for falls in one nursing home, there was considerable variability related to factors influencing falls in residents. Over a 19-month observational period, 85% of the residents had falls, and about 30% of these falls had serious consequences, such as broken hips. The researchers concluded that preventively, it is important to identify those individuals at highest risk for falls and to provide more effective, individualized fall prevention [
53]. Our preliminary declining falls rates during the study’s implementation period suggests that Synergy tool has the potential to detect and intervene with high falls-risk residents.
We were unable to locate any recent LTC cost analyses in published literature. Acute care cost analyses typically focus on quality indicator outcomes and compare how different interventions result in cost savings from decreased adverse outcomes. One cost analysis study conducted in a US Acute Care for Elderly (ACE) unit, for example, demonstrated how specialized care for bedbound, frail elderly in an ACE unit resulted in significant hospital cost savings from decreased length of hospital stay and unplanned hospital readmissions, and increased functional capacity at the time of discharge [
54]. Cost analyses, therefore, should be an integral component of intervention evaluation, especially given finite healthcare resources. Based on published acute care economic evaluations, we used documented fall rates, a quality indicator, to determine the cost effectiveness of Synergy tool implementation. Our economic evaluation yielded promising results, although it was a six-month period of time and it is unknown if Synergy tool impact would extend to other resident outcomes, such as pressure ulcers [
54].
Based on our qualitative data, we know that family caregivers observed and sometimes participated in conversations about individual residents’ care needs. Synergy scoring helped to raise awareness of residents with specific needs or safety risks, such as potential for falls, and to explore and confirm subtle changes in resident status with family caregivers. Our qualitative findings are congruent with research conducted in emergency services with the Synergy tool, where staff stated that use of the Synergy tool made them more aware of holistic needs of each patient, especially overlooked needs, such as psychosocial needs [
25,
26]. These studies also found that nurses were more apt to proactively contact other healthcare team members to address other care needs concerns, such as social care needs for vulnerable individuals with housing and food insecurity issues.
The qualitative findings of our study reinforce the importance of resident-centered approaches that promote information-sharing and care decision-making between staff, residents, and families. Other themes pertained to ongoing LTC quality of care structural barriers: staff shortages and language barriers. The Synergy tool may play a role in addressing these structural barriers. With respect to staff shortages, during the implementation period, the scorers at both LTC homes, who were regulated professionals, communicated frequently with direct care staff (e.g., CAs) and family members to more accurately assess the needs of individual residents. In many ways, the pattern established between scorers, staff, and residents/families was an example of team-based care. Team-based care is considered one of the most efficient and effective modes of care delivery, and research has shown how this care delivery approach can improve patient outcomes and even decrease provider burnout [
55]. Team-based care, however, rarely happens in LTC homes due to the predominant number of unregulated staff in direct care roles. Given the ongoing nursing shortage, it is unlikely that there will be a significant uptake of regulated nurses within LTC homes. Team-based care, therefore, will need to center on CAs working in collaboration with available regulated nurses (RNs, LPN/RPNs), family caregivers and residents. Our qualitative findings provide feasibility for a LTC approach to team-based care that optimizes the knowledge of residents that CAs possess.
Over a decade ago, health researchers in Canada predicted the need to recognize the growing importance of CAs as a valuable health human resource [
56]. In addition to carrying out activities of daily living (e.g., toileting, bathing, feeding, ambulating), CAs are assuming nurse-related tasks delegated to them [
57]. In the Synergy tool training workshop, we did within the LTC homes, we included CAs in the workshop to invite their perspectives of important assessment indicators to include with the Synergy scoring process. Their knowledge of the residents contributed to the overall implementation process, and although scoring was done by expert regulated professionals, the CAs were integral to the development of resident assessment indicators that accompany the Synergy tool. Including CAs in Synergy tool training and scoring discussions, therefore, may be one significant way of building a greater sense of team and enrich the care planning process for each resident.
Given the rising ethnocultural diversity in residents of LTC homes, the Synergy tool can be used to identify residents and family members with special needs pertaining to their unique ethnic and cultural identities. Communications difficulties for non-English speaking residents are common care delivery barriers in LTC [
9]. Some published literature has addressed LTC language barriers from the staff perspective where English is a second language for many CAs [
58]. As globalization continues, all healthcare services will need to reckon with language barriers due to English-second language providers and residents. Our qualitative findings, however, provided examples of how consistent staff and knowledge of residents and their caregivers resulted in more personalized, and culturally sensitive care. CAs worked with family caregivers to know residents’ cultural needs and to provide services adapted to those needs. In other healthcare sites, such as emergency services and acute care, professional interpreter services are commonly utilized, and interpreters can also act as cultural brokers [
59]. In under-resourced LTC homes that lack professional interpreter services, the relationships forged with families by CAs often act as proxies for overcoming language barriers. The Synergy tool can act as a means to capture CA-family knowledge of ways to better meet diverse ethnocultural needs of individual residents.
To our knowledge, this is the first implementation and evaluation study of the Synergy tool in the LTC context. Despite its novelty, the study has key weaknesses. First, due to structural constraints such as LTC staffing shortages and resource inadequacies, Synergy scoring of residents happened only when scorers had available time. To avoid likelihood of bias, ideally, scorers should have scored assigned residents at a set time each shift after resident assessment. Second, we would like to acknowledge that during Synergy tool implementation, other interventions were taking place in the participating units, perhaps contributing to the declining falls rates. In other words, the declining fall rates might not be completely attributable to the Synergy implementation, neither were the associated cost savings. However, considering its low cost, the Synergy implementation could be still cost effective or cost saving. Third, the intervention took place in two care homes within a specific geographic location; as such, findings should be cautiously generalized to LTC contexts other the partner care homes.
Author Contributions
Conceptualization: F.H., M.M.; Methodology: F.H., M.M., W.Z.; Software: F.K., A.M., B.A.; Validation: A.M.; Formal analysis: F.H., M.M., F.K., A.M., B.A., W.Z; Investigation: F.H., M.M., F.K., A.M., B.A., M.K., W.Z., A.S, S.B., A.E.; Resources: F.H.; Data curation: F.H., F.K., A.M., B.A.; Writing—original draft preparation: F.H., M.M., F.K., A.M., M.K., W.Z.; Writing—review and editing: F.H., M.M., F.K., A.M., M.K., B.A., A.S, S.B., A.E., W.Z.; Visualization: A.M.; Supervision: F.H., M.M.; Project administration, F.H., A.M., M.K.; Funding acquisition, F.H. All authors have read and agreed to the published version of the manuscript.