key: cord-0912704-z7eenu80
authors: Lingum, Navena R.; Sokoloff, Lisa Guttman; Meyer, Raquel M.; Gingrich, Shaen; Sodums, Devin J.; Santiago, Anna Theresa; Feldman, Sid; Guy, Stacey; Moser, Andrea; Shaikh, Salma; Grief, Cindy J.; Conn, David K.
title: Building long-term care staff capacity during COVID-19 through just-in-time learning: Evaluation of a modified ECHO model
date: 2020-11-02
journal: J Am Med Dir Assoc
DOI: 10.1016/j.jamda.2020.10.039
sha: 68f3030c58d805b6b3c262d24470decfe7e18093
doc_id: 912704
cord_uid: z7eenu80

Objectives The onset of the COVID-19 pandemic significantly challenged the capacity of long-term care (LTC) homes in Canada resulting in new, pressing priorities for leaders and healthcare providers (HCPs) in the care and safety of LTC residents. This study aimed to determine whether Project ECHO® (Extension for Community Healthcare Outcomes) Care of the Elderly Long-Term Care (COE-LTC): COVID-19, a virtual education program, was effective at delivering just-in-time learning and best practices to support LTC teams and residents during the pandemic. Design Mixed methods evaluation. Setting and Participants Interprofessional HCPs working in LTC homes or deployed to work in LTC homes primarily in Ontario, Canada, who participated in 12 weekly, 60-minute sessions. Methods Quantitative and qualitative surveys assessing reach, satisfaction, self-efficacy, practice change, impact on resident care and knowledge sharing. Results Of the 252 registrants for ECHO COE-LTC: COVID-19, 160 (63.4%) attended at least one weekly session. Nurses and nurse practitioners represented the largest proportion of HCPs (43.8%). Overall, both confidence and comfort level working with residents who were at risk, confirmed or suspected of having COVID-19 increased after participating in the ECHO sessions (effect sizes≥0.7, Wilcoxon signed rank p<.001). Participants also reported impact on intent to change behavior, resident care and knowledge sharing. Conclusions and Implications The results demonstrate that ECHO COE-LTC: COVID 19 effectively delivered time sensitive information and best practices to support LTC teams and residents. It may be a critical platform during this pandemic and in future crises to deliver just-in-time learning during periods of constantly changing information.

The COVID-19 pandemic has disproportionately affected older adults, particularly those in areas that require support. 8, 9 38 Project Extension for Community Healthcare Outcomes (ECHO) is a virtual, capacity-building 39 education program with the capability to provide rapid real-time dissemination of best 40 practices. 10 caring for frail, medically complex older adults in both the community and LTC.

The onset of the COVID-19 pandemic necessitated many changes including the uptake and 55 utilization of virtual platforms to provide opportunities for enhanced knowledge exchange, 56 education and to promote collegial networks. To support HCPs in LTC build capacity, strengthen 57 their LTC teams, and support residents during this pandemic, we mobilized our existing practices for LTC HCPs to support their teams and residents.

Study Design was implemented whereby participants could flexibly attend one or more sessions, but did not 91 need to commit to 75% attendance. A total of 12 weekly, one-hour sessions were offered. The 92 typical case submission by partner/spoke homes was modified in order to accommodate the 93 increased demands on HCPs for pandemic efforts. Instead, cases in our sessions were related to 94 participants' personal experiences and narratives, which were elicited and shared spontaneously The curriculum was developed based on a needs assessment survey of HCPs in Ontario LTC 104 homes, alumni of ECHO COE-LTC programs and through discussions with Hub team members 105 (N=75; see Appendix 1 for curriculum). As we extended our program from four weeks to 12 106 weeks, we continued to plan the curriculum in four-week blocks to take into consideration the 107 changing pandemic education needs of HCPs and care needs of residents and to allow for just-in-108 time learning and knowledge exchange across the LTC sector. Self-Efficacy 128 Self-efficacy was assessed at pre-and-post-ECHO as well as weekly after each session. At pre-129 and-post-ECHO, participants were asked to rate their comfort level working with residents who satisfaction rating was 4.4 on a 5-point Likert scale indicating that participants were satisfied 181 with the sessions (see Table 2 for full item reporting for the Weekly Satisfaction Survey).

At post-ECHO, a total of 78 participants responded to the Feedback Survey with varying 183 numbers of respondents depending on the survey item (minimum=59). Participants responded 184 "Agree" that ECHO COE-LTC: COVID-19 met their expectations. All respondents indicated 185 that they would recommend ECHO COE-LTC: COVID-19 to others. Post-ECHO (mean=4.3, ES=0.7 or medium, p<.001). 190 As a whole, participants' levels of confidence increased (mean=16.5%) from before to after 191 participating in the ECHO sessions (p<.001, ES=1.1 or large, Table 3 ). Individual sessions also 192 showed large increases in confidence levels, which were all statistically significant and had large 193 effect sizes.

Intent to Change Behavior, Resident Care and Knowledge Sharing 195 In terms of impact on behavior, 62.7% reported that they are now using or plan to use a new tool 196 or knowledge learned through ECHO. Regarding impact on resident care, the mean rating was Overall, the majority of participants providing responses reported a positive experience with 213 ECHO COE-LTC: COVID-19. Participants stated that the program was "a great learning 214 opportunity," with "knowledgeable presenters," and "encouraging and engaging moderators," 215 which "has been an invaluable source of support during the pandemic." As one participant noted: 216 "The sessions highlighted the professional and personal realities we bring to the work we 217 do; the people we serve; and, those we feel a great sense of responsibility for, especially, 218 in light of COVID-19 this includes our residents; LTC staff colleagues; our loved ones; 219 and ourselves. Being able to speak with staff who are returning to the LTC, not just 220 around their plans for the care they hope to provide to residents with responsive 221 behaviors, but also, how they are 'feeling' about going back in, was critically important. I 222 know there may be challenges ahead, but [I] have a few more tools in the 'kit bag' to draw with COVID-19 cases in LTC." Some also spoke to their comfort making suggestions for 250 changes, with one participant commenting that, "I feel more secure in suggesting changes within 251 [the] LTC I work." These sentiments were confirmed by supporting quotes presented below: At the same time, several participants expressed neutral sentiments, stating that they "were doing 313 those things already", "all relevant tools are in place that were discussed" or that "most of 314 discussed items had already been addressed by our home." homes that were better prepared. Lastly, only a subset of participants provided responses to 384 certain open-ended questions, as this was not a mandatory requirement for all questions. This 385 limitation was mitigated by data triangulation between qualitative and quantitative data, which 386 complemented and strengthened each other.

In summary, ECHO COE-LTC: COVID-19 is an innovative and effective way to deliver time 389 sensitive information and best practices for healthcare providers in LTC to support their teams 390 and residents. With the unprecedented rate of changing information and system practices, just-in-391 time learning using a structured format of brief didactic presentations paired with multiple 392 situational exemplars and facilitated group discussions is useful for building capacity in LTC 393 healthcare providers during this evolving pandemic and in future crises.

The author(s) declare no potential conflicts of interest.

J o u r n a l P r e -p r o o f 

The coronavirus and the risks to the elderly in long-21. Berry, LE. Creating community: Strengthening education and practice partnerships 441 through communities of practice

General practice training and virtual communities 444 of practice-a review of the literature

A virtual community of practice for general 446 practice training: a preimplementation survey

Communities of practice: acknowledging 448 vulnerability to improve resilience in healthcare teams

ECHO Care of the Elderly: 451 Innovative Learning to Build Capacity in Long-Term Care

Delirium: Prevention, assessment and management

Abbreviation: LTC, long-term care

Preparing your long-term care home for COVID-19" as it was added at Week 3 to account for the rolling enrolment process. 459 *Unadjusted Wilcoxon signed rank test 460 † Standardized response mean