Exploring the Implementation of Age-Friendly Health Systems in Long-Term Care: A protocol for a mixed-methods study.

Study design

This programme of work will employ a mixed-methods approach and will include both qualitative and quantitative study components.

Focus groups and one-to-one interviews will be performed with participants from each stakeholder group (including LTRC residents and those important to them, healthcare professionals and management staff ) to explore their early experiences of the implementation of the AFHS and any impact it may have had in the period under study. The focus groups will be moderated by multiple researchers (CH, RG, IO’S) using a prepared semi-structured interview guide. The qualitative interviews/focus groups will use a participatory design to data collection and will adhere to the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines.¹² This study will be guided by the 4Ms Framework of AFHS.^6,7

The profile of LTRC residents, process, clinical and patient-reported outcomes related to the 4Ms framework will be captured over an 8-month period. Description of elements of care received or initiatives for implementation carried out by staff of will also be recorded through the conduct of a prospective cohort study. The STROBE standardised reporting guidelines will be followed in the conduct and reporting of this study.¹³ Participant data collection and follow-up will take place between February 2026 and October 2026 (inclusive). This study has been submitted for registration on clinicaltrials.gov registry.

Ethics

Ethical approval for this study was received from the Education and Health Sciences (EHS) Research Ethics Committee at the University of Limerick (2025_11_11_EHS). Written informed consent will be obtained, in accordance with the Data Protection Act 2018 (Section 36(2).¹⁴

Setting

The study setting will be across three Mowlam LTRC centres; Killarney, Kerry; Ballincollig, Cork; and Swords, Dublin. All care homes share a similar population with residents having high levels of dependency and complexity. Most residents are from the local community and are admitted when they are unable to independent care of themselves as a result of medical illness. Residents have a variety of dependency needs that typically require full time nursing care in order to fulfil daily activities. All homes are predominantly staffed with a combination of Registered Nurses and Healthcare Assistants overseen by Clinical Nurse Managers, Assistant Directors of Nursing and a Director of Nursing. This is supported by a Regional Healthcare Manager and a Quality and Compliance Co-ordinator. A dedicated Health and Social Care Professional (physiotherapist) is allocated to the care centre based on bed capacity with others available as required (dietetics, occupational therapy) and each centre has a visiting General Practitioner. Finally, care centres are linked to specialist community services as part of an integrated care agenda. This includes Integrated Care Programme, Older Persons (ICPOP), Palliative care or Psychiatry of Later Life.

Population of interest

Mowlam staff at various levels and fulfilling various functions. Older adults aged ≥65 years who are resident in one of the three Mowlam LTRC centres; those important to residents; staff members at each LTRC centre; and Mowlam management staff who consent to participate will be eligible to participate in the interviews/focus groups.

Older adults aged ≥65 years who reside in one of the three Mowlam LTRC centres and provide consent to participate will be deemed eligible for recruitment in the prospective cohort study.

Exclusions to recruitment will apply where older adults or staff decline to consent or LTRC residents with limited capacity or change of condition.

Exposure

Mowlam has been introducing the 4Ms in each of the three care centres. This includes revising documentation, introducing care planning and process changes and education of staff. Changes were made to the electronic health record to introduce mandatory assessments that capture the 4Ms as well as changes to the Care Plan structure and process. The daily safety pause now incorporates the 4Ms to reinforce the use of the 4Ms in practice and links the daily care to individual care plans. Each care centre has introduced AFHS champions and hold regular meetings to monitor implementation. Each centre introducing the 4Ms have collaborated with families and residents, producing posters on the 4Ms that are providing information as well as individualised 4 M templates in each resident’s room that captures What Matters to Them. A suite of educational modules has been introduced that are available through the Mowlam Academy for all staff. Finally, regular three monthly audits capture the application of 4Ms for each resident as a matter of Mowlam’s audit cycle.

Baseline data collection

Anonymous data will be extracted from Mowlam’s central database. Baseline data collection will include participant’s age, sex, ethnicity, marital status, length of residential status, socioeconomic status and education level. In addition to demographic data collection, health information including mobility status (DEMMI, TUG, FRASE), falls incidence in the previous six months, medications, history of dementia diagnosis (MMSE), pain (Numeric Rating Scale (0–10), Wong Baker Scale and FLACC), hygiene and comfort (oral health, wound care, falls, pain, continence, swallow), emotional well-being (HAD, Geriatric Depression Scale), advanced care planning (end of life).

Follow-up data collection

Qualitative interviews and focus groups will be conducted four months post baseline data collection. One-to-one interviews will be expected to last approximately 30 minutes and focus groups will be expected to last between 50–60 minutes. An interview guide will be prepared in advance, which will allow for open-ended questioning on key topics around the AFHS 4Ms framework. All interviews will be audio recorded, anonymised to ensure confidentiality and transcribed verbatim and checked by the research team for accuracy.

All data will be retrieved from Mowlam’s database by an independent member of the research team (CH) at four and eight months. The number of primary and secondary healthcare use including emergency department (ED) presentations, hospitalisations, General Practitioner visits will be ascertained from Mowlam’s database. Withdrawals and participants lost to follow-up will be recorded.

Health information including mobility status mobility status (DEMMI, TUG, FRASE), falls incidence in the previous four months, medications, history of dementia diagnosis (MMSE), pain (Numeric Rating Scale (0–10), Wong Baker Scale and FLACC), mortality, hygiene and comfort (oral health, wound care, falls, pain, continence, swallow), emotional well-being (HAD, Geriatric Depression Scale), safety incidents, resource use, advanced care planning (end of life).

Outcome variables

The primary outcome of this study is stakeholder experiences of the implementation process of an AFHS for older adults in Mowlams’ LTRC centres in Ireland.

Secondary outcomes include mobility, falls, medications, dementia, pain, mortality, hygiene and comfort, QoL, safety incidents, AFHS initiatives used (e.g. use of care plans, story boards etc.), joy at work and level of training completed by staff.

Sample size

It is anticipated that approximately ten participants each per stakeholder group (LTRC residents, those important to them and staff ) will participate in either one-to-one interviews or focus groups, allowing for participant preference.

The prospective cohort study will not be hypothesis driven; therefore, formal power calculations will not be applicable. All prospective older adults that meet inclusion criteria will be invited to participate during the study recruitment period (January 2026– April 2026 inclusive).

Data analysis

Overarching framework

The conceptual framework proposed by Karami et al. (2023) will be employed to characterise the dimensions of the AFHS within the LTRCs ( Table 1).¹⁵ This framework outlines eight core dimensions of an AFHS including governance, resources, service delivery, intermediate objectives, goals, stakeholders, information and an age-friendly environment.¹⁵ It outlines the specific characteristics of each dimension that are needed for the provision of evidence-based services so that the AFHS can achieve its goals. In terms of mapping activities to this framework, our study will employ a mixed-methods approach and will include both a qualitative and quantitative component. Specifically, this study will systematically characterise the dimensions of age-friendly healthcare within Mowlam LTRCs according to the conceptual framework by Karami et al. (2023).

Qualitative data analysis will be undertaken after verbatim transcription of the focus groups and interviews, by members of the research team. Transcripts will be stored on a password protected online database. Reflexive thematic analysis will be conducted in line Braun and Clarke’s six-step approach; familiarisation; coding; generating initial themes; reviewing and developing themes; refining, defining and naming themes; and writing up.^16,17 NVIVO (Version 15) software will be used to conduct qualitative analysis.

Anonymised data will be stored on a secure password protected online database. Hard copies of consent forms and follow-up questionnaires will be stored in a locked cabinet in an office with restricted access. Descriptive statistics will be used to profile the baseline characteristics of the cohort. Categorical data (e.g. biological sex) will be analysed using frequencies and percentages. Continuous data (e.g. age) will be analysed using means and standard deviations (SD) or median and interquartile ranges (IQR) where data demonstrates evidence of skewness. One-way within-subjects ANOVAs will be conducted to examine differences across timepoints. Multivariate logistic and linear regression analysis will be used to explore predictors of adverse outcomes. Anonymised data generated will be made available in an open access repository.

Study status

Not yet recruiting.