 Good afternoon everybody and welcome to the CLSA webinar series today. My name is Ena Wolb and I'm the Managing Director of the CLSA and we're very pleased to have Dr. Bernstein with us and to have so many participants in our webinar right now. On the first slide that's up right now you can see that some of the instructions for users just as a reminder that the only people that can speak is of course the presenter and the moderators here. If you have any questions you can leave those in the chat box in the left corner of your screen and at the end of the session I will summarize those questions to Dr. Bernstein and moderator's session. So with that I'm very pleased to introduce Dr. Bernstein. Dr. Bernstein has completed his MA and PhD in political sciences at Harvard University and he has been the Director of the Newfoundland and Labrador Center for Applied Health Research since the Center's establishment in 1999. He's also the Director of Safety Net at Memorial University Centers for Research on Occupational Health and Safety and at the Newfoundland and Labrador Center for Applied Health Research he leads the contextualized health research since this program which is an integrated knowledge translation program that addresses pressing health services, policy and technology questions for the provincial health system. And today Dr. Bernstein is going to demonstrate in his presentation to us how research can help shape policy and practice on aging lessons learned from Newfoundland and Labrador. So Dr. Bernstein the floor is yours just to remind us to hit the talk button before you get started. Thank you for that kind introduction. I will try to move the slides forward. Here we go. Today I'm talking to you about a program that the center that I direct has been undertaking for the past seven or eight years and in which we have ended up doing a considerable amount of knowledge synthesis work on aging issues. The program is called CRISP, the contextualized health research synthesis program in which the key words are synthesis and contextualized. Synthesis stands for the fact that what we do is not a digital research but it's synthesis, analysis, summary of existing research, particularly systematic reviews, and the really important word is contextualized. And as I'll explain to you in a moment what makes this program unusual is that we don't simply tell our decision makers answers to the generalized question what works but we give them answers to a more interesting question from their perspective which is what is likely to work here for us. So not what works but what will work here. So there is a very quick outline of what I'll be talking about. And I'll now go through this trying to take about 35 or 40 minutes to leave enough time for your questions and possibly my answers. So first a word about my center of the Center for Applied Health Research was established in 1998-99. You can see it's three main objectives and you can see our three principal activities although normally support does not have two O's. So that's the center. The CRISP program was a program that we introduced in order to respond to a challenge that we felt as a research center and as our associated research group and that we also learned was felt in a different way by the leaders of the healthcare system with whom we were partnered and by whom we were principally funded. The challenge for us as researchers was how can we get them to pay attention? How can we get the decision makers in the system and sometimes we meant clinicians but mainly we meant policy makers. How can we get them to use evidence more? And the challenge for the healthcare system was how can we get the best evidence as an input into our decision making. And we came up with a program which we think actually does the trick and which I'll explain to you in a moment for the last couple of years has been very heavily dominated by questions about aging issues, aging related issues. So as I said a moment ago in the intro, most evidence support, decision support, knowledge translation programs tell decision makers and clinicians the answer to the question what works. What we discovered working with our decision makers here is they were less interested in that than they were interested in a narrower question, a more specific question. Of the things that the evidence says works, what exactly will work here for us? We're different. This is a very different place. There's no point in reading the evidence in general. We need to know if it will work here. So we developed a program called CRISP to tell them the answer to that second question. So is that the right slide or did I skip one? No, that's the right slide. So as I told you before what we do is evidence synthesis. Our system leaders and we work with six of them. We work with the two deputy ministers that is the deputy minister of health and community services for one and the deputy minister of the ministry for seniors and wellness. We work with those two deputy ministers and the CEOs of the four regional health authorities in the province. They come up with issues where they would like to know what the evidence says about what they should and shouldn't do and how they should do it. And we find the evidence and contextualize it. That is, we tailor it, we shape it to the specific features of the context that is faced by our decision makers. And you can see a list in the box at the bottom of the categories, the types of contextual factors that we try to consider. We have a table of these factors and for each topic, we fill in a number of subheadings under each of those categories and perhaps others as well. In order to be able to deal with the evidence, to answer the question, what would work here? In a nutshell, the CRISP program is, we think, a very good example of what CIHR has been calling integrated KTE, integrated knowledge translation and exchange. That is, the system leaders, the knowledge users play a crucial, generalized, comprehensive role in the process. They identify their priorities. We work with them to formulate those priorities as researchable questions that make sense to them. The teams that we put together for each project include both knowledge producers, people like me, and knowledge users, people like the CEOs of the deputy minister or their employees. And then, as I was saying, the decision makers, the crucial knowledge users are engaged in the process from the beginning all the way to the end. So it's integrated KTE, but we also think it's effective and we think it's effective because it's integrated. We have multiple report formats, both short and long. We place a heavy emphasis on the implications of what we have found for our decision makers. We tend to call them considerations. We used to call them recommendations, but that sounded a little pretentious. So we move back a little bit and we talk about considerations or implications. And what we get as a result is an unusually high level of buy-in from the key decision makers to the process. After all, they fund it and they are continuing to fund it, although the budget is about to come down and nobody knows what's going to happen, as well as uptake for our findings. So that's CRISP in a nutshell. What's interesting about CRISP and the reason that I'm talking to you today and not to some knowledge translation symposium is that over the past few years, about half of the topics that we have worked on have been aging related. The mandate of our six senior system leaders is to come up with questions on which they need answers, covering their entire mandates. But increasingly, they have been saying, tell us about this aging-related topic or that aging-related topic. So CRISP and aging are linked in a rather intimate way over the past few years. Why is that the case well in some senses? It's perfectly obvious. Newfoundland is Canada's oldest province or maybe second oldest, depending on who's counting and what's being counted. And as you can see, by 2036, a very high percentage of our population will be over 65. And according to current predictions, that will certainly be the highest in Canada. This is in particular an issue in rural Newfoundland where the population percentages are considerably higher. You can see the percentages region by region. The only region where the percentage is comparatively low is Labrador, where the population is largely Aboriginal and therefore, at least for the moment, largely young. So aging figures very highly on our agenda for the CRISP program because it figures very highly on the agenda of our decision-makers and the provincial health system. What I'm going to do in the next however minutes remain, about 20 or 25, is to give you a quick overview of five studies that we've done over the past few years on aging-related issues so you can see how this process goes. And what I'm suggesting is that this process might actually be useful for those of you who are either decision-makers or knowledge providers, knowledge synthesizers, but you can tailor it to aging instead of asking your decision-makers and your systems what topics in healthcare and health system issues do you care about? Do you need to make a decision in the next six months to 12 months about? You can say, tell us about the aging issues you'll want to deal with. And by looking at this and then talking to us offline afterwards if you're interested, you can mimic this process and tailor it to the needs of your jurisdiction and your context and your decision-makers. So the first project that I'm going to tell you about is on what we call age-friendly acute care. The research question we came up with and we try to keep these as short and clear as possible. Sometimes they get a bit out of hand if the question is really complex. This one was pretty straightforward. They wanted to know for a decision about 12 months into the future what programs and or services are associated with improved outcomes for older adults admitted to acute care hospitals. So age-friendly acute care. That was the question. So first we tell them what works. This is a synthesis of the evidence. You will notice that already the question has been contextualized in that it's the question about aging and about acute care that our decision-makers know they want the answer to. There are many others. This is one of the questions they have formulated. So it's a tailored or contextualized question. Then we go and do a careful systematic review of all the evidence out there with a very heavy emphasis on existing systematic reviews. So we short-circuit the process. We take a shortcut by focusing on reviews that somebody else has already done. So you'll see what we found in our synthesis of the evidence. We found six main findings for which there was relatively strong evidence. Self-contained units for seniors within a hospital, staffed with workers who have expertise in gerontology work better than non-specialized units. First point. Second point is if you can't do specialized units, non-specialized units can also work, but they require specialized professional staff or at least enhanced training staff. As in a number of things, interprofessional approach works better than single professional pillar-based approach. We found the evidence is very strong in favor of geriatric assessments performed at intake using one of the standard assessment tools. We also found that enhanced, careful discharge planning really helped. And finally, although some of this is perfectly obvious, the evidence makes it clear that when caregivers and families and health professionals are communicating properly and proper communications is not a great specialty of the health care profession, but when communication is done properly, outcomes are better. So age-trembly acute care in general has the following features according to the generalized evidence. We then took a look at the special contextual factors that we thought our decision makers should pay attention to. First of all, we said, well, you know, this is not a rich province. Our health care system is under a lot of financial pressure, so you should take a careful look at the costs and benefits of specialized units before you set them up. We suggested that every acute care unit should have a special place, a special space for intake assessment and triage of seniors, not of everybody, but of seniors. We also suggested that they hire more specially-trained workers. We added, and this is really, I think, special to Newfoundland and Labrador, we have very few allied health professionals in the public system, in the community. Very few OTs, PTs. We need many more of those. We thought that our system should establish a set of formal standards for hospital care so that they could do the kinds of things that the evidence suggested would work in general. There's the communications and the multidisciplinary message. And the final point involved having the people do the work who actually know what they're doing. So that's what we found, and that's what we recommended or suggested as considerations for our decision makers a couple of years ago. That was the first age-related study that I'm reporting to you on. The second was basically how do you keep seniors out of institutions in the first place? How do you design community-based service models to take care of seniors? And you can see the exact wording of the question there, and I'm trusting that the font is large enough for you to read it on your screens and save me the time and efforts of reading it. But while you're reading it, I'm going to get a drink of water. I would note only that dementia is included in one of our complex chronic health conditions on which we looked at the research. So what works? What did the evidence say works in general? Well, kind of an overlap with the previous study. Geriatric assessment is a very important part of integrated care, or even if you're not doing integrated care, you should do geriatric assessments anyway, and we don't for the most part, or if we do it's fairly haphazard and we're suggesting it should be systematically applied. We also suggested that for appropriate clients, and I frankly can't remember what is appropriate and what isn't appropriate, case management would be extremely useful. Somebody with professional skills to follow the patient through the system from intake through discharge or through their entire community-based treatment program. We also suggested that the evidence is clear that exercise programs tailored to fall prevention, organized in the community, have evidence that they work. There is also evidence, this is the fourth point we found in summarizing the general evidence, that integrated care works, whether it's partial or fully integrated. Fully integrated is better. Think of the California model where everybody's in the same building, people are talking to one another all the time across the entire spectrum. That would be fully integrated care. We found the evidence that even partially integrated care works better than siloed care. The evidence also suggests that patients can benefit if their caregivers get help from community-based support groups. The evidence also suggests that you can keep seniors out of institutions more effectively if you have home visits designed for preventive purposes. So have home visits by physicians or advanced practice nurses or PTs before people need to be institutionalized. The evidence also suggests clearly that systematizing and facilitating access to community-based health and social services, in some senses this is a no-brainer, keep people out of institutions, as does involving people's primary care providers in the various services that the evidence discusses. So that's what works in general. Let's see what we found needs to be done for a place like Newfoundland and Labrador. What are the implications for our decision-makers? And here we used wishy-washy language. We said they may wish to consider the following, by which we recommend the following, but we can't say it. What we found is that in small-world communities, there is already unintentionally integrated care going on because we're talking about small communities where all the health professionals and the social care providers know one another, work or live in close proximity. So there's actually what we would call organic or almost accidental forms of care integration. So it's unusual for us to say this in one of our recommendations, but here we're saying, listen, folks, in Newfoundland and Labrador, there may be less to do than there may be in Toronto. Our second suggestion was a... well, the second suggestion is a list of things that need to be done, improved communication. We have to help family physicians, schedule meetings with other providers, particularly specialists. That has proved extremely difficult according to the people we interviewed for our contextualization exercise, and something has to be done about it, although we're not sure what. We think it must be some sort of electronic messaging system and appointment system. We found that the way health professionals are remunerated in our province, rather like the way they're remunerated in most other Canadian jurisdictions, really does not give them much incentive to collaborate, and we are suggesting that our folks do something about that. The Ontario model may be one model. I'm not sure we can afford it, but it's an idea. We suggested strongly that, aside from all the other good reasons for there to be a single, unified, interactive electronic health record for all patients in Newfoundland and Labrador, this treatment of seniors, preventive treatment, community-based treatment for seniors would benefit enormously from the development of this, and it's been very slow here. We also suggested, and this parallels the recommendation of the previous study, that we need a lot more community-based allied health professionals. You can count the number of community-based OTs and PTs on one or two hands in the entire province, and that's really not enough. So those are architecturalized recommendations on community-based services. The next study we did, and I'm on slide number 20, was about falls prevention, but not in the community this time. It's for older adults who are in institutional health care systems. What interventions are most effective and in our case are likely the most effective for us in Newfoundland and Labrador health care settings to prevent falls or in particular to prevent fall-related fractures. The emphasis was on fractures. So what does the evidence say in general? It says, a daily combined dose of vitamin D and calcium can really help. Notice that it's combined. One or the other separately doesn't work nearly as well according to the evidence in the systematic reviews that we studied. The evidence also suggested that there are forms of balance training for seniors that can really help in reducing falls. It also suggested that the amount of physiotherapy that is regularly given to patients in rehab wards in Newfoundland, in hospitals in general, are not sufficient. More physiotherapy would make a big difference. The evidence on hip protectors, which you would think would be pretty clear in a no-brainer, is not. The evidence is uncertain in large part because the people in the studies that have been done tend to not wear them. They hate them. Generally, there isn't sufficient evidence for various things called multifactorial fall prevention programs. That's what the evidence in general says about what works. What does it say about what is likely to work? What ought to be done in one specific provincial context? Well, one recommendation was that even within Newfoundland and Labrador, all interventions don't work equally well in all settings and with all populations. So you have to pick and choose among the interventions that have evidence to say that they work to tailor the interventions to the settings and the populations with which you are dealing. And obviously, small town and rural would be different from larger town and urban. Training is absolutely important so the healthcare workers are all doing the same thing at the same time and the evidence we gathered in the research, the paper-based research, and in particular the key informant interviews that we did suggested that it's not happening now in Newfoundland. Again, the same thing about hiring and training. More allied health professionals. We probably have enough doctors and nurses, but we need allied health professionals and we need to train them for this kind of care delivery. One thing we discovered is that our system employees designing new facilities for long-term care were not really applying lessons that could have been learned from mistakes they made in designing earlier long-term care facilities. So, for example, they just built a very large, I think it's 700-bed facility. I could be wrong. Suzanne Brake will correct me if I have the number wrong up on a hill above St. John's. And they let the architect design the bathrooms without noticing that if people are in wheelchairs they can't get the arms of the wheelchair up against the sink unless they're under the sink, unless the sink is higher than an average sink. So they built all these rooms with sinks that are too low and have had to be replaced. There is also the recommendation that we need established, agreed upon, and well-publicized care processes for a whole range of things including safe patient handling. It was also suggested that the current feedback mechanism doesn't tend to cover patients who have fallen or their caregivers and that it would be really useful to do that. The evidence talked about communication, going back to what works part. Part of it was client feedback. The finding about vitamin D was not self-evident and is clearly not universally known among our clinicians, so some education would be necessary. And then there are all sorts of balanced training techniques out there. More research is necessary, we say, to pick a good one. So that's that study, falls prevention. Here is a topic that I'm sure has come up in a number of your jurisdictions. Residents in long-term care with dementia often become agitated and aggressive. And the question that our system people wanted us to answer aside from physical restraints or psychotropic drugs, what else can you do to prevent, manage, reduce agitation and aggression in dementia patients in long-term care institutions? So as of about 2014, we started dividing the evidence up according to the strength of the studies that we found and the quality of the evidence. So we divided the interventions that we wanted to recommend into three categories. For some, we said that the evidence was promising. That's our strongest category, which means that a decision-maker can be reasonably confident that if he or she introduces one of these measures, one of these interventions, it will work. The next level of evidence strength has to do, we call suggestive. And where we say the evidence isn't strong enough to say, really, you can do this, you should do this, what we can say is you should try this. You might want to think about trying this. That's the second category. And you can see that there are seven kinds of interventions where there is this kind of moderate quality, moderate amount of evidence. The third category is one in which there is currently insufficient evidence. And there's a fourth category which doesn't appear here, which is evidence that it's a bad idea to do this. We rarely find that, but occasionally you do. So from now on, we will be presenting our evidence in these three groups. So what you see is that the three types of intervention that have really strong, solid evidence for them are music therapy, intensive training of staff, and reducing the inappropriate use of antipsychotics, not all use of antipsychotics, but those that are deemed for a good reason to be inappropriate. So that's what the evidence suggests works in general. Now let's see what we told our decision makers to pay attention to in terms of what is likely to work for them or what will help them. We're suggesting that there was actually a number of research projects ongoing in the province that we found out about when we did our interviews with key informants on reducing the use of antipsychotic medications, and we suggested that they should keep on doing and funding those studies and paying attention to the results. None of that is obvious, particularly the paying attention to the results. And that's true all across the country. We also suggested that they talk to one another more. In our interviews with key informant interviews from the four regional health authorities, we discovered that some regional health authorities were doing interesting stuff that corresponded to the evidence, fit with the evidence, but the other regional health authorities had no idea they were doing it. Or they might have an idea they were doing it, but they didn't know how it was working out. So we're suggesting at some level what's obvious that the four regional health authorities should talk to one another more often. And that the various long-term care facilities should talk to one another more often. We also found particularly in our interviews that there were serious health human resource challenges, HR challenges, in particular personnel shortages and long-term care, many of which were related to chronic absenteeism. And although it's obvious, we're suggesting that the system has to do something about that, even if what's involved is fumbling resources from elsewhere and management resources into fixing the health human resource challenges and gaps. We also heard from many of our key informants that supervisory and management skills at the unit level, that is in long-term care facility units, could be considerably better, particularly in terms of managing team-based care. And then a couple of other messages, particularly the bottom one, fix the infrastructure and following on the bathroom sink message, pay attention to what didn't work the last time you built long-term care facilities. So those are the recommendations from that study. The next study, and I think this is the last, let me just check. No, let me keep on going a second. It is the last. So the sixth, the last one, has to do with supporting the independence of persons with dementia. How do you delay their admission as long as possible, safely to long-term care facilities? So this is a community-based care research study but focused entirely on dementia patients, rather similar to the previous one, but more targeted. What works? What does the literature say? The literature says that caregiver supports of a psychoeducational sort, training programs, group therapy sessions, group guidance sessions, work. That's strong evidence. There is partial or qualified evidence that is in that second group for three kinds of interventions. Case management for dementia patients, exercise interventions which have some evidence suggest not only can they reduce falls among people with dementia, but they can reduce the decline of functional abilities and mobility problems. So exercise works. Evidence is not bad but not as strong as one might like. And the evidence also suggests mixed quality but fairly strong that interventions that focus on ADL and particularly interventions that involve face-to-face contact with health professionals have some evidence that they work. In some sense, that's again an o-brainer, but a lot of scientific evidence involves confirming what looks like an o-brainer because sometimes no braiders are myths. So that's what the evidence says in general. What does it mean? What do we think it means for our local decision makers? So we say they may wish to consider again the weasel words to avoid saying we recommend. We recommend that they prioritize early identification. If you catch people early as they are moving into dementia, you will do better. You will be able to keep them out longer if you catch them early rather than starting to deal with them when they're already in crisis where you don't have that many choices about whether to institutionalize them or not. We also suggested that our system is lacking in system navigation support and that it would be very useful to provide support both when people have not yet applied for services, when they first apply for services, and to follow them up if they're ever discharged in the community again. The third point was that we need to improve the qualifications of home support workers so that they are really capable of treating people with dementia in the community rather than having to have them sent into institutions. We also suggested dementia-care, dementia-friendly day programs as well as programs for caregivers. And then we suggested exploring a wide range of residential options but non-institutional and affordable for people outside long-term care with dementia. There are institutions here that cost a large amount of money. The suggestion is we should take a look at the kinds of low-cost, basically subsidized residential options that have been developed in one of our health regions, its western health region on the western side of the island for what they call residential bungalows for seniors with dementia. Not institutionalized, seems to work very well, but nobody else has copied it so we're suggesting a little bit of copycatting. And then the final one which seems to come up in all of our recommendations do something about community-based allied health professionals. So that's the sixth one. That's what we recommended. Now, very quickly, to talk not only about those six or five, sorry, aging-related studies, does CRISP in general work? Because we've done about 26 or 27 studies thus far. Does it work? Well, the answer is yes, but that's obviously what you would expect me to say, but I have good reasons for saying that. The process of topic selection, in which basically we get the six decision-makers to pick the topics and then to prioritize them, started out not working very well. So from some of our bigger systems we got laundry lists of issues, not researchable questions but long lists of things that were bothering them, and from some of the smaller ones we got dead silence. After we'd run this program for about a year, a year and a half, including providing some training materials about what is a researchable topic, what isn't, our system contacts learned much better how to formulate questions, and we learned much better how to talk to them. So there was mutual learning on each side, which is I think a clear, important component of what KT and integrated KT should be about. So we now find that the topic selection process works very nicely. All of our system partners are able to select topics and help us refine them so they're researchable and then agree on a priority list. And as I told you before, for the last couple of years, aging-related issues have been right up there. We are finding that contextualization can be done and actually produces helpful recommendations. The most useful contextualization is through the interview process in which we identify and then use snowball processes to identify more people to interview, and they tell us all sorts of stuff you can't find out from documents. For each of our studies, we hire on contract a leading national or international expert to guide our work and to lead the research, and that has proved fairly easy to recruit. They like doing these projects. Our teams, including the decision makers and their associated employees because each of the six top decision makers has what we call a set of crisp champions, more junior employees working with them to help pick the topics and help select the people to interview and to be on the team. We have been able to produce the results fairly quickly. It takes us roughly a year. We've been hoping for six months, so we've introduced a short version that takes a month. We call it a rapid evidence review, and we're also working to shorten the timeline for the full ones. And finally, and I think most importantly, our recommendations have very often been adopted by the decision makers. So, Chris does work, can work, works better than just summarizing the general research for our decision makers. They actually pay attention, and they actually change stuff. So that's it, and I'm delighted to answer questions. Thank you so very much, Dr. Bornstein. This was an excellent presentation, giving us an overview of how your program works and what your achievement has been today related to all kinds of questions regarding ageing. We already have a couple of questions, so I'm going to read them out to you. The first one came from Florian, who asked, like in pharmaceutical companies, are there also lobbying groups involved from those that provide the real, scientific evidence that might be used in any of the recommendations such organizations put forward? No. We are very reluctant to trust pharmaceutical companies to produce real evidence. Even when they fund systematic reviews, often they can't be reproduced. We read journal-based peer-reviewed evidence. We then interviewed clinicians, practitioners, decision makers. But I should point out that we don't tend to do the kinds of pharmaceutical product studies that catapult it. So talking to drug companies is, we think, less relevant, even if it weren't sometimes this effective and dangerous. I would point out that we are in the process of adding a new layer of participation, adding patients and caregivers so that over the course of the course of the year, we are going to do a number of experiments in creating a patient-slash-cared-giver advisory panel incorporating members of that panel on appropriate studies as part of the team, and we'll see how that works. The next question is from Khaled. He asks, to go from what works to what will work for you, do we need separate studies or do you just use the interviews, for example, as she mentions, to contextualize the study or what other methods do you use in your contextualization of the scientific findings? Okay. So we use both documentary evidence, data from the provincial healthcare system and the provincial economic data to do the demographic analysis. And then we do a whole range of face-to-face interviews or telephone interviews with key informants, either individually or in groups. We find that that works, although occasionally we think that maybe there's a more systematic way to do this contextualization, and we are moving towards thinking about whether there is a more systematic way to do it. A separate study I would say no. We do gather data specifically for the contextualization, and sometimes that can take two or three months. So in a way we are doing an additional study rather than a different study. Does that answer your question? I believe so. The other second part of this question was, and I think this question came from a CLSA team member, and I'm sure you're somewhat known about what the CLSA is, Dr. Bornstein. The question is, do you think that from a study such as the CLSA, we are able to derive evidence for the separate provinces? It depends on the numbers. I'm not sure you have big enough numbers for a small province like Newfoundland, but you would know better than I do. All I know is that I'm one of your numbers. I'm a participant in the Newfoundland sample, but it depends how large those participant groups are. If they're large enough, or certainly for larger provinces, the data would be extremely useful, and therefore participation by somebody from the CLSA on some of our teams, or at least an interaction so we can use your data would be extremely useful. Okay, great. I'm so excited to hear that you are a participant in our study. There's another question from Renu Minas. You may have already answered it, but how long does it take to complete a study and to come up with recommendations? I think you said something about 45 days would be like a speedy one. Do you have an average number for us? We do two different studies. We do a full one and an abbreviated one. The abbreviated one is more like an evidence scan. It takes 30 business days from the moment where the system leaders and we have agreed on the question. So I would say 45 days is pretty much standard. We introduced that because of the big ones with the full systematic reviews and the full contextualization, we're taking sometimes 14 months, sometimes more. We've now reduced it, so unless we come upon an extremely complicated question, and we're just finishing up one on diabetes that's taken us 16 months, we're trying to keep it to within a year. Okay, thank you very much. Another question from the Alberta's Tomorrow Project, and you may have already answered it, but I'll read it out to you. The question here was, what are strategies used to be able to understand the current situation and therefore be able to contextualize recommendations to the decision makers? So are the DMs interviewed or are other individuals identified, for example, the key informants that you mentioned? There will be a DM or a CEO on each of the projects. They're actually members of the team, so there's already one DM or CEO, we call them the system leaders, actually part of the project. We will then interview other DMs where the question is one that's relevant to them or where they think they have a special amount of knowledge or a special challenge. And then we go down the ladder to people they or their champions recommend with specific expertise or concerns on that specific question. And we interview both clinicians and decision makers both at the provincial level and regionally, we try to cover both rural and urban and in particular where the question is relevance to rural, we make sure that we have a lot of rural interviewees. We also work with the local health data organization called NLCHI, the Center for Health Information, to locate the appropriate data either from national surveys or from their income input, excuse me, from their data, and that's how we do our contextualization. There was a second question as well that the participant is curious about how many considerations for the different projects are actually taken up and acted upon because from the slides that we've seen for each of the projects there are multiple recommendations. Does your group, for example, help in prioritizing which recommendation they should, for example, implement or is that decision left up to the policy and decision makers themselves? Sometimes they talk to us and say, you know, which of these are you really serious about? Sometimes they don't talk to us at all. Some of our studies, although these five are not, have one recommendation. So, for example, we did a study a couple of years ago on whether it was safe to reuse medical equipment that had been designed and produced for single use only. And we discovered that, in fact, many of our healthcare units were doing that. They were cleaning and reusing health equipment, medical devices, that had been designed for single use only. We recommended not doing that for a long list of types of equipment and interventions, and they simply changed the policy. They established a province-wide policy that said thou shall not do that. Similarly, we came up with a recommendation from an earlier study on dialysis in rural and remote communities, which came up with a decision-making tree, a matrix that could be used by decision makers to respond to requests for yet another rural dialysis unit, and they adopted it and used it. We came up with some of our studies with multiple uses. Actually, all the recommendations have been adopted. So, for example, we did a study on whether this province, this small province, needed a PET scanner. And we said, one, you don't. But two, if you're going to buy one anyway, which it turns out they would, here's what you need to do. Here's what you need to know. And it turns out there were six key points, none of which they had considered and all of which they then considered in the planning stages. For the aging recommendations, I would have to take a harder look at the specific recommendations. I don't think we've done all that well yet, but these are fairly recent. It takes a while for people to cotton on, pay attention, start using your language and terminology in their discussions, and then actually make decisions. So, of course, in the next year, we'll be doing a canvas of organizations saying, we did the following studies. Did you do anything about it? One, do you know about it? Two, have you read it? Three, was it discussed? And four, has anything changed? So, for the moment, I can't really answer that question very effectively for these five studies. Okay, thank you. We're very close to two o'clock, so I'm going to ask you one more question. And my apologies for the large number of questions that are still sitting in the chat function. The last slide here does provide you with the complete information if you want to connect directly with Dr. Bornstein or his group. The last question is a little bit different. Can you describe some of the specific things that you're trying to do to reduce the time it takes you to complete these studies and recommendations? So, for example, to reduce the time, so it's more maybe just a business model question to ask, is it just human resources that you need more funding for, or are there other strategies that you, as an organization, apply to improve efficiency to deliver the services that you deliver? Very good question. Let me just say, because you and I were talking at the same time, I'd be happy to answer by email any questions that anybody sends me. Send me your question by email. My email is S-B-O-R-N-S-T-E at munn.ca. Or you can send them to the email address on the screen. I will get them. I promise to answer them within a couple of days. What have we done to shorten the time? Very good question. One, we've hired more staff. Two, as the staff gets more used to the methodology, things go faster. Three, we've developed an electronic system by tailoring the Excel program. That processes our studies, the list of the studies, and the quality assessments that we give them, and produces a table automatically without anybody touching anything of whether we have strong evidence, medium strength evidence, or weak evidence. The other thing that we've done is reduce somewhat the role of the external scientific leader. We used to have them write the first draft of the report, and we discovered that that wasn't a good idea. It often led to major delays and some not very good writing. So now we write them in-house, and the expert reviews and produces a second draft from our first draft. So there's a number of things that we've done, but crucial is to keep on adding to the size of the staff. Okay, thank you so much, Dr. Bornton, for a very interesting presentation, and it was very valuable for us to hear how your organization works and how you help policy shaping in Newfoundland and Labrador on aging, and hopefully some of your attendants can take something away from that in their own careers, in their own roles in this field. Finally, I just want to draw your attention to our next CLSA webinar, which is going to be held on April 19th. We actually have two graduate students that actually have applied to use the CLSA data to study and to do an analysis on labor transitions and about retirees who return to work. So this should be a very interesting session to actually see what you can do with the CLSA data. So again, thank you all for participating today, and thank you so much, Dr. Bornstein. This presentation will be on our CLSA website in the form of a video, and we will promote this out on our social media as soon as it's available. Thank you very much, everyone. Thank you, everybody.