CHOICE+ Quality Improvement for Long Term Care Homes (CHOICE+)

A Time Series Design to Evaluate the Implementation and Effectiveness of the Virtual CHOICE+ Mealtime Experience Training Program for Long Term Care Homes

CHOICE+ is an eLearning program that empowers staff to improve the mealtime experience of long-term care (LTC) residents. This program is based on principles that align with relationship-centered care and promote resident quality of life and food intake. In a prior study, the investigators have showed that this program can improve the mealtime experience; eLearning has been created to promote spreading of this training. The investigators have created an implementation model that supports uptake of this eLearning. Designated home staff Champions will complete the eLearning, be provided four virtual training sessions to reinforce key concepts and be mentored in monthly virtual community of practice sessions around making improvements. Champions will work with a small team of staff, residents, and family to identify and make improvements (e.g., less rushed mealtime). This study will evaluate this model of implementation in 13-18 LTC homes. Homes in the region of research centres are invited to apply, and where required, will be randomly selected. Investigators will also determine if the mealtime experience, resident health (body weight and food intake), resident/family food and care satisfaction, and staff job satisfaction improve. This implementation study is designed to sustain improvements that the Champions and their team make and build capacity to improve the quality of care in their home. The research team will track implementation activities and influences on implementation through champion diaries, monthly meetings, and end of study interviews. Researchers will measure the mealtime experience with a standardized observational tool and aggregate food waste (to assess food intake). Resident body weight to determine nutritional status will be collected monthly. Questionnaires will be used with staff, residents, and family members for other outcomes. Outcomes will be measured six months before, during, and six months after the one year of implementation. Findings and learnings about implementation will support the scaling of CHOICE+ to other LTC homes.

Study Overview

• Status: Enrolling by invitation
• Conditions: Malnutrition Elderly; Malnutrition Risk in Elder; Long Term Care Homes
• Intervention / Treatment: Other: CHOICE+ virtual training program

Detailed Description

All long-term care (LTC) residents participate in mealtimes daily, offering an ideal opportunity to enhance quality of life through relationship-centred mealtime practices. Unfortunately, task-focused mealtime practices are the norm in LTC with efficiency being prioritized over the social and emotional needs of residents. Compared with relationship-centred mealtimes, residents in a task-focused dining environment have reduced food intake and poorer nutritional status. Building on 20 years of research, the CHOICE+ staff training program supports relationship-centred care using the principles of Connecting, Honouring Dignity, Offering Support, Identity, Creating Opportunities and Enjoyment. CHOICE+ principles and eight steps of implementation have undergone developmental and efficacy evaluation using an external facilitator model. To promote scale and spread, an implementation model consisting of an asynchronous eLearning module, synchronous virtual training sessions, and a virtual monthly community of practice has been created. Staff Champions are trained on behaviour change and implementation techniques to make locally initiated changes that are aligned with the CHOICE+ principles, tailored to their dining room. Staff Champions work with their Dining Team to make these changes. This study's goals are to evaluate this implementation model in 13- 18 diverse homes across Canada and demonstrate that this training improves mealtime experience, resident health, and quality of life for residents, family and staff. A type 2 hybrid implementation study (co-primary purposes of evaluating implementation processes and effectiveness) based on a multi-site three-phase interrupted time series design will be used. Specific research aims are to: a) evaluate this CHOICE+ implementation model according to the Consolidated Framework for Implementation Research (CFIR), b) identify what program adaptations are required for future scaling, and c) determine if the mealtime experience, resident health outcomes, resident/family food and care satisfaction, and staff work life are impacted by CHOICE+. Champion training is evaluated via questionnaires and on-line polling. Implementation processes will be assessed with monthly recorded virtual community of practice sessions, weekly staff Champion diaries, and end-of study interviews with staff, residents and family. Framework Analysis using CFIR as an analytical framework for deductive coding will be completed to evaluate the implementation model. Standardized meal observations, aggregate food waste (to assess food intake), and monthly body weight of residents will be collected six months prior to implementation, during one year of implementation, and six months post-implementation (5 meals observed at each of 13 observation periods in each home). Standardized questionnaires pre- and post-implementation will assess resident/family food and care satisfaction and staff work-life perceptions, and findings will be mapped to the home implementation process. The research team includes clinician researchers with experience in intervention development, implementation, and evaluation in LTC. The findings and knowledge generated will support the scaling and spread of the CHOICE+ program.

• Study Type: Observational
• Enrollment (Estimated): 800

Contacts and Locations

Study Locations

• Canada
  • Manitoba
    • Winnipeg, Manitoba, Canada, R3T2N2
      • University of Manitoba
  • Nova Scotia
    • Antigonish Nova Scotia, Nova Scotia, Canada, B2G 2W5
      • St Francis Xavier University
  • Ontario
    • Waterloo, Ontario, Canada, N2L 3G1
      • University of Waterloo
  • Saskatchewan
    • Saskatoon, Saskatchewan, Canada, S7N 5A2
      • University of Saskatchewan

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Child; Adult; Older Adult
• Accepts Healthy Volunteers: No

• Sampling Method: Non-Probability Sample

Study Population

long term care home residents and staff

Description

Inclusion Criteria:

• residents will eat in the intervention dining room on a routine basis
• team members will work in the intervention dining room
• champions will be home leaders who can support the implementation effort

Exclusion Criteria:

• residents not in the intervention dining room
• team members who rarely work in the intervention dining room

Study Plan

How is the study designed?

Number of groups / cohorts

1

Cohorts and Interventions

Group / Cohort	Intervention / Treatment
13- 18 long term care homes; Homes will be provided a quality improvement program called CHOICE+. Home staff will be trained on the principles of CHOICE+ and an 8 step process to implement mealtime improvements in their home.	Other: CHOICE+ virtual training program; The CHOICE+ virtual training program consists of three components a) an elearning course for home champions, b) virtual training of key concepts for home champions, and c) a monthly virtual community of practice to support implementation and mentor home champions.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Mealtime Scan+	a standardized validated observational tool that measures the physical, social and relationship-centred practices; score 0-32, higher scores indicate a better mealtime environment	21 months

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Food /fluid intake	food and fluid waste will be measured in kilograms/grams; lower scores indicate less waste and thus better food and fluid intake	21 months
body weight	weight collected on residents who attend the intervention dining room, measured in kilograms; a stable or increasing body weight would indicate a positive outcome	21 months

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Team member Mealtime Experience Questionnaire	measures relationship centred practices; scale 0- 115, a higher score indicates better team functioning at mealtimes	week 0 and week 52
Mealtime Satisfaction Questionnaire	resident or family perceptions of mealtimes; scale 0- 42, a higher score indicates better mealtime satisfaction	week 0 and week 52

Collaborators and Investigators

• Sponsor: University of Waterloo
• Collaborators: University of Manitoba; University of Saskatchewan; St. Francis Xavier University
• Investigators: Principal Investigator: Heather H Keller, PhD, University of Waterloo

Study record dates

Study Major Dates

• Study Start (Estimated): May 15, 2026
• Primary Completion (Estimated): September 30, 2028
• Study Completion (Estimated): September 30, 2028

Study Registration Dates

• First Submitted: March 17, 2026
• First Submitted That Met QC Criteria: March 25, 2026
• First Posted (Actual): April 1, 2026

Study Record Updates

• Last Update Posted (Actual): April 7, 2026
• Last Update Submitted That Met QC Criteria: March 31, 2026
• Last Verified: March 1, 2026

More Information

Terms related to this study

• Keywords: implementation; mealtimes; relationship-centred care; champion training
• Other Study ID Numbers: REB #46942

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO
• IPD Plan Description: The resident level data will only be body weight and is not anticipated to be relevant to other researchers. Similarly the other measures are quite specific to this research and unlikely to be of use to other researchers, as it is an implementation study

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No