Specialized dementia programs in residential care settings

Internet Resources and Searching for a Residential Care Setting: What Information Is Available for Consumers?

By making information about long-term-care facilities readily available, consumers in need of services are able to compare facilities and select one that is best for the elder. However, it is unclear how much information is available for residential care settings. In this investigation, an Internet search was performed to determine what information is available in each state. It was found that most states had a number of descriptive indicators. The way in which the information was displayed varied substantially among states, and very little quality-of-care information was available. Although the authors found a variety of useful information, they offer some suggestions to standardize the way in which the information could be presented, thus allowing a direct comparison between residential care settings to be made more easily.

The Impact of Social Resources on Depressive Symptoms in Racially and Ethnically Diverse Older Adults

The objectives of this study were (1) to develop an empirical typology of physical health risks in racially and ethnically diverse older adults and (2) to examine whether the impact of social resources on depressive symptoms differs across the identified health risk groups (low, moderate, and high risks). The data source was the Survey of Older Floridians, a statewide survey of older adults aged 65 and older ( n = 1,432). Latent profile analysis with multiple indicators of physical health (chronic conditions, functional disability, and self-rated health) was used to identify three health risk groups (low, moderate, and high risks). The direct and interactive effects of the health risk group membership and social resources (social support and religious service attendance) on depressive symptoms were found. Of particular interest was that the positive impact of social support was most pronounced in the moderate health risk group.

Definition and classification of assisted living

PURPOSE

The purpose of this article is to discuss the benefits and limitations of, and considerations in, developing a typology of assisted living (AL).

DESIGN AND METHODS

We conducted a review and comparison of nine AL typologies drawn from the literature.

RESULTS

Typologies addressed matters related to the structure, process, population, and philosophy of AL to varying degrees. A lack of available data and different sampling frames hindered attempts to quantitatively compare the typologies.

IMPLICATIONS

Typologies are potentially useful for consumers, practitioners, policy makers, and researchers. It is advisable to identify state-based typologies and then empirically determine types that have national representation. Stakeholders should consider the tradeoff between sensitivity and specificity and allow any resulting typology to anticipate ongoing evolution in the field of AL.

Assisted Living Pilot Program

Objectives: Assisted living programs demonstrate variation in structure and services. The Department of Veterans Affairs funded this care for the first time in the Assisted Living Pilot Program (ALPP). This article presents resident health outcomes and the relationship between facility characteristics and outcomes. Method: This article presents results on 393 ALPP residents followed for 12 months after admission to 95 facilities. Results: A total of 19.8% residents died, and the average activities of daily living impairment did not change significantly. Half of the residents remained in an ALPP facility, with the average resident spending 315 days in the community during the 12-month follow-up period. This article found a limited number of characteristics of structure and staffing to be significantly associated with outcomes. Discussion: If differences among facility characteristics are not clearly related to differences in outcomes, then choices among type of setting can be based on the match of needs to available services, location, or preferences.

An ethnographic study of stigma and ageism in residential care or assisted living

PURPOSE

This study explored aspects of stigmatization for older adults who live in residential care or assisted living (RC-AL) communities and what these settings have done to address stigma.

DESIGN AND METHODS

We used ethnography and other qualitative data-gathering and analytic techniques to gather data from 309 participants (residents, family and staff) from six RC-AL settings in Maryland. We entered the transcript data into Atlas.ti 5.0. We analyzed the data by using grounded theory techniques for emergent themes.

RESULTS

Four themes emerged that relate to stigma in RC-AL: (a) ageism in long-term care; (b) stigma as related to disease and illness; (c) sociocultural aspects of stigma; and (d) RC-AL as a stigmatizing setting. Some strategies used in RC-AL settings to combat stigma include family member advocacy on behalf of stigmatized residents, assertion of resident autonomy, and administrator awareness of potential stigmatization.

IMPLICATIONS

Findings suggest that changes could be made to the structure as well as the process of care delivery to minimize the occurrence of stigma in RC-AL settings. Structural changes include an examination of how best, given the resident case mix, to accommodate care for persons with dementia (e.g., separate units or integrated care); processes of care include staff recognition of resident preferences and strengths, rather than their limitations.

Characteristics of residents and providers in the assisted living pilot program

PURPOSE

The number of residents in assisted living has rapidly increased, although these facilities still primarily serve people who can pay out of pocket. The U.S. Department of Veterans Affairs was authorized to provide this level of care for the first time in the Assisted Living Pilot Program (ALPP). We describe the residents and providers, comparing them across three facility types and other populations, to assess the characteristics and feasibility of this new approach.

DESIGN AND METHODS

We assessed ALPP residents and providers across seven Veterans Affairs Medical Centers. We obtained information from medical records, assessment tools, and a provider survey.

RESULTS

We report here on 743 residents placed from 2002 to 2004. The Department of Veterans Affairs contracted with 58 adult family homes, 56 assisted living facilities, and 46 residential care facilities. The average ALPP resident was a 70-year-old unmarried White man referred from an inpatient hospital and living in a private residence prior to placement. Adult family homes enrolled residents requiring greater levels of assistance with activities of daily living than other facility types. Assisted living facilities were less likely than adult family homes to admit residents with functional disabilities and less likely than either adult family homes or adult residential care facilities to admit residents with certain care needs.

IMPLICATIONS

ALPP placed residents with a wide range of characteristics in community facilities that varied widely in size and services. This information can help determine the role of this type of care in and outside of the Department of Veterans Affairs.

An empirical typology of residential care/assisted living based on a four-state study

PURPOSE

Residential care/assisted living describes diverse facilities providing non-nursing home care to a heterogeneous group of primarily elderly residents. This article derives typologies of assisted living based on theoretically and practically grounded evidence.

DESIGN AND METHODS

We obtained data from the Collaborative Studies of Long-Term Care, which examined 193 assisted living facilities in four states: Florida, Maryland, New Jersey, and North Carolina. By using mixture modeling, we derived typologies in five different ways, based on: structure; process; resident case-mix; structure and process; and structure, process, and resident case-mix.

RESULTS

Although configurations of typologies varied as a function of criterion variables used, common themes emerged from different cluster solutions. A typology based on resident case-mix yielded a five-cluster solution, whereas a typology based on structure, process, and resident case-mix resulted in six distinct clusters. Medicaid case-mix/psychiatric illness and high resident impairment were two clusters identified by both strategies.

IMPLICATIONS

Because of the wide variation in structure, residents, and services within assisted living facilities, typologies such as those described here may be useful in clinical practice, research, and policy. To the extent that public payment defines its own cluster, the potential for inequities in care merits careful attention.

Measuring Physical and Social Environments in Nursing Homes for People with Middle- to Late-Stage Dementia

OBJECTIVES

To evaluate measures of dementia care environments by comparing a special care facility (SCF) with traditional institutional facilities (TIFs).

DESIGN

A cross-sectional comparative study of nursing home environments conducted as part of a longitudinal study on quality of life for residents with dementia.

SETTING

Twenty-four traditional nursing homes and one special care facility.

PARTICIPANTS

One SCF with six distinct environments, 24 TIFs with 45 distinct environments, and 88 family members.

MEASUREMENTS

Therapeutic Environment Screening Scale-2+ (TESS-2+); Special Care Unit Environmental Quality Scale (SCUEQS), a subset of the TESS-2+ items; Composite Above Average Quality Score (CAAQS), a composite score of all items on the TESS-2+; and Models of Care Instrument (MOCI).

RESULTS

The SCUEQS did not detect a significant difference between the SCF and the TIFs (30.0 vs 27.2, P = .28). The CAAQS detected a significant difference between the SCF and the TIFs, whereby the SCF environments were rated as having above-average quality in 71.4% of the domains, compared with 57.3% for the TIF environments (95% confidence interval (CI) for difference = 2.6-25.6%, P = .02). Using the MOCI, SCF families were 1.8 times as likely to rate the SCF as a home or resort versus a hospital as TIF families rating TIFs (95% CI for odds ratio = 1.5-2.1, P < .001).

CONCLUSION

The TESS-2+ CAAQS differentiated between physical environments better than the more established SCUQES. The MOCI distinguished between environments using a more holistic approach to measurement. The availability of environmental measures that are able to discriminate between specialized and traditional long-term care settings will facilitate future outcome-based research.

STAR: a dementia-specific training program for staff in assisted living residences

PURPOSE

This article describes, and provides data on, an innovative, comprehensive, dementia-specific training program designed to teach direct care staff in assisted living residences to improve care and reduce problems in residents with dementia.

DESIGN AND METHODS

STAR-which stands for Staff Training in Assisted living Residences-provides two 4-hr workshops augmented by four individualized on-site consultations and three leadership sessions. Developed by means of an iterative process of implementation and revision, it was then evaluated in a small randomized controlled trial. A total of 114 staff and 120 residents in 15 residences participated.

RESULTS

STAR was exceptionally well received. Training details are provided with a discussion of unique challenges inherent in implementation. Following training, STAR residents evidenced significantly reduced levels of affective and behavioral distress compared with control residents. Furthermore, STAR residents improved whereas control residents worsened (p < .05). Staff with STAR staff training reported less adverse impact and reaction to residents' problems (p < .05) and more job satisfaction (p < .10) compared with control staff.

IMPLICATIONS

STAR is an effective training program for direct care staff working with dementia residents in assisted living. The importance of continued development and investigation of STAR efficacy and effectiveness is underscored by the growing numbers of residents with dementia who are receiving care in these settings.

Health and Functional Outcomes and Health Care Utilization of Persons With Dementia in Residential Care and Assisted Living Facilities: Comparison With Nursing Homes

PURPOSE

This study compares health and functional outcomes and health care utilization of persons with dementia residing in residential care/assisted living (RC/AL) facilities and nursing homes.

DESIGN AND METHODS

The study uses data from a longitudinal cohort study of 1,252 residents with dementia in 106 RC/AL facilities and 40 nursing homes in four states.

RESULTS

Rates of mortality; new or worsening morbidity; and change in activities of daily living, cognition, behavioral problems, depressive symptoms, social function, and withdrawal did not differ between the two settings. However, because of death or transfer, only about one half of the persons with mild dementia and one third of those with moderate to severe dementia remained in RC/AL facilities 1 year after enrollment. In addition, hospitalization rates were greater among individuals with mild dementia in RC/AL facilities, largely because of a medically unstable subgroup with high nursing-home-transfer rates.

IMPLICATIONS

Many persons with dementia can be served equally well in either setting; however, those with major medical care needs may benefit from nursing home residence.

Community residential care: comparison of cognitively impaired and noncognitively impaired residents

Community residential care (CRC) is growing, with cognitive impairment the most common reason for CRC placement. We enrolled cognitively impaired and noncognitively impaired residents, informal caregivers, and providers in 219 CRC facilities for this study. Residents with cognitive impairment were older (p < .001), needed more activities of daily living (ADL) assistance (p < .001), and had a higher frequency of behavior problems (p < .001) than noncognitively impaired residents. Cognitively impaired and noncognitively impaired residents did not significantly differ in the facility-related factors they perceived as important or in the amount of control they felt they had over the decision to move. Including residents with cognitive impairment in future research and separately analyzing residents by cognitive status will give a more accurate picture of the needs of CRC residents.

Special care for persons with Alzheimer's disease and related dementias in Virginia adult care residences

Designing supportive care for persons with Alzheimer's disease and related dementias in residential care is one of the most challenging issues facing researchers, policymakers, and facility administrators. To gain a better knowledge of the types of special care offered by adult care residences (ACRs) and assisted living facilities, the results of a survey of all licensed ACRs in the state of Virginia are presented. Examined are the facilities with special care units (SCUs) and special programs (SPs), the organizational characteristics of facilities that offer special care, the characteristics of existing SCUs and SPs, and the opinions of owners/operators on the elements needed for establishing these units and programs. The discussion focuses on improvements needed within special care and the implications of the views of owners/operators about special care.

International field test results of the Observable Indicators of Nursing Home Care Quality instrument

Researchers at the University of Missouri-Columbia developed the Observable Indicators of Nursing Home Care Quality instrument to measure the dimensions of nursing home care quality during a brief on-site visit to a nursing home. The instrument has been translated for use in Iceland and used in Canada. Results of the validity and reliability studies using the instrument in 12 nursing homes in Reykjavik, in a large Veterans Home in Ontario with 14 units tested separately, and in 20 nursing homes in Missouri, are promising. High-content validity was observed in all countries, together with excellent inter-rater reliability and coefficient alpha. Test-retest reliabilities in Iceland and Missouri were good. Results of the international field test of the Observable Indicators of Nursing Home Care Quality instrument points to the usefulness of such an instrument in measuring nursing home care quality following a quick on-site observation in a nursing facility. The instrument should be used as a facility-wide assessment of quality, rather than for individual units within a facility. We strongly recommend its use by practising nurses in nursing homes to assess quality of care and guide efforts to improve care. We recommend its use by researchers and consumers and further testing of the use of the instrument with regulators.