Exploring the Age-Friendly Health Systems Framework in Memory Care Centres: A protocol for a mixed-methods study

Study design

This study will involve a mixed-methods approach. Focus groups and one-to-one interviews will be performed with participants from each stakeholder group (including Memory Care Centre residents and their families, HSCPs and management staff ). The focus groups will be moderated by the research team (CH, RG, IO’S) using a prepared semi-structured interview guide. The qualitative study will adhere to the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines.¹⁰ This study will be guided the 4Ms Framework of AFHS.^4,5

The profile of Memory Care residents, process, clinical and patient-reported outcomes related to the 4Ms framework will be captured over an 8-month period. Description of elements of age-friendly healthcare received and initiatives for implementation carried out by staff of will 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.¹¹ Participant data collection and follow-up will occur 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 from eligible participants, in accordance with the Data Protection Act 2018 (Section 36(2).¹²

Setting

The study setting will be across two Mowlam Memory Care residential centres; Cloverlodge, Kildare and Adare, Limerick. 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. Both Adare and Kildare care for a mix of long-term care and residents living with dementia. 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, OT) 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 two Mowlam Memory Care residential centres; those important to residents; staff members at each Mowlam Memory Care residential 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 two Mowlam Memory Care residential 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 introduced the 4Ms in each of the three care centres. This includes revision of documentation, care planning and process changes and dedicated staff education. Alterations were introduced to the electronic health record to include mandatory assessments that capture the 4Ms as well as changes to the Care Plan structure and process. The daily safety pause now includes the 4Ms to reinforce its use 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 stakeholders including families and residents, producing posters on the 4Ms that provide 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 at four months post baseline data collection. An interview guide will be prepared in advance to guide open-ended questioning on key areas of interest 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 Mowlam Memory Care residential centres in Ireland.

Secondary outcomes include mobility, falls, medications, dementia, pain, mortality, hygiene and comfort, QoL, safety incidents, AFHS initiatives used, staff joy at work and level of training completed by staff.

Sample size

It is expected that that approximately ten participants from each stakeholder group (Memory Care residential centre residents/families and staff ) will participate in either one-to-one interviews or focus groups, depending on participant preference.

This prospective cohort study will not be hypothesis driven; therefore, formal power calculations will not apply. All 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 for an AFHS designed by Karami et al. (2023) will be employed to profile the dimensions of the AFHS within the Mowlam Memory Care centres ( Table 1).¹³ This framework defines an AFHS as being made up of eight core dimensions including governance, resources, service delivery, intermediate objectives, goals, stakeholders, information and an Age Friendly environment. Karami and colleague’s framework highlights specific features of each dimension required for an AFHS to realise its goals.¹³ This study will systematically map activities within Mowlam’s Memory Care residential centres to this framework and will include both a qualitative and quantitative component.

Qualitative data analysis will involve verbatim transcription of focus groups and interviews conducted by members of the research team. The transcripts will be stored in a password-protected online database. Reflexive thematic analysis will be performed following Braun and Clarke’s six-step approach; familiarisation; coding; generating initial themes; reviewing and developing themes; refining, defining and naming themes; and writing up.^14,15 NVIVO (Version 15) software will be utilised for qualitative analysis.

Anonymised data will be securely stored in a password-protected online database, while hard copies of consent forms and follow-up questionnaires will be kept in a locked cabinet in an office with restricted access. Descriptive statistics will be employed to profile the baseline characteristics of the cohort. Categorical data (e.g. biological sex) will be analysed using frequencies and percentages, whereas 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 assess differences across timepoints. Multivariate logistic and linear regression analysis will be used to identify predictors of adverse outcomes. Anonymised data generated will be made available in an open-access repository.

Study status

Not yet recruiting.