Testing of the Function Focused Environment Assessment and the Function Focused Policy Assessment in Assisted Living

Testing Function Focused Care for Acute Care using the Evidence Integration Triangle: Protocol description

This manuscript provides the protocol for a National Institute of Aging-funded cluster randomized clinical trial that focuses on helping nurses in acute care to engage patients with dementia in physical activity while hospitalized using an approach referred to as function-focused care. Physical activity is defined as bodily movement produced by skeletal muscles resulting in the expenditure of energy and includes functional tasks such as bathing and dressing, leisure activity, ambulation, and moderate and vigorous intensity physical activity such as dancing, bike riding, or walking upstairs. The development of Function Focused Care for Acute Care (FFC-AC) was based on the Social Ecological Model and Social Cognitive Theory and includes four steps: (1) Environment and Policy Assessments; (2) Education; (3) Establishing Patient Goals; and (4) Mentoring and Motivating of Staff (all levels of nursing staff), Patients, and Families. Function-focused care activities include motivating older patients to participate in bed mobility; personal care activities such as bathing, dressing, ambulating as they are able; and other types of physical activities. The integration of the intervention among the nurses on the units is guided by the Evidence Integration Triangle (EIT), which includes the participation of a stakeholder team and practical outcome measures. The intervention is therefore referred to as FFC-AC-EIT. In addition to describing the protocol developed to test the effectiveness and feasibility of FFC-AC-EIT, a description of ways to overcome some of the barriers and challenges that can be encountered with this study is provided.

Impact of Function-Focused Care on Psychotropic Medications and Opioid Use Among Assisted Living Residents

Objective To test the impact of the Function Focused Care Intervention on use of psychotropic medications and opioids over a 12-month period in assisted living residents. Setting The study included 794 residents from 85 general assisted living communities in the United States. The general assisted living communities that had at least 25 beds and 10 residents per community were enrolled. Results There was no significant difference in the treatment groups regarding medication use except for a decrease in opioid use at 4 months (P = 0.03). In the full sample there was a significant increase in use of benzodiazepines from baseline to 12 months (P = 0.04) and an increase in the use of antipsychotics between 4 and 12 months (P = 0.04). Conclusion Function-focused care does not increase the need for psychotropic medications or opioids and may help decrease the need for opioids. Further, we recommend the involvement of a pharmacy consultant to provide oversight and medication reviews for all residents in assisted living to consider deprescribing, if possible, for potentially unnecessary use of psychotropic medications or opioids.

Implementation of the Evidence Integration Triangle for behavioral and psychological symptoms of dementia (EIT-4-BPSD) in care communities

BACKGROUND

Federal regulations stipulate that behavioral interventions be used for behavioral and psychological symptoms of distress in dementia (BPSD). Care community staff have difficulty implementing these approaches.

PURPOSE

This study tested an implementation strategy, the Evidence Integration Triangle for BPSD (EIT-4-BPSD), for assisting staff in the use of evidence-based behavioral approaches for BPSD.

METHODS

About 55 care communities were randomized to EIT-4-BPSD or usual care; 553 residents were enrolled. The implementation strategy was delivered by research facilitators, staff, stakeholders, and champions over 12 months. It involved four components: Environment and policy assessments; Staff education; Establishment of person-centered care plans; and Mentoring and motivating staff. The implementation strategy was evaluated using the Reach, Effectiveness, Adoption, Implementation, Maintenance model.

FINDINGS

There was no evidence for resident or care community effectiveness. There was evidence of adoption and implementation.

DISCUSSION

EIT-4-BPSD was helpful as an implementation strategy and staff altered how care was provided.

The Impact of Cognitive impairment on Clinical Symptoms, Physical Activity and Care Interactions among Residents in Assisted Living Settings

The purpose of this study was to describe differences in pain, behavioral symptoms, quality of staff-resident interactions, participation in function focused care and physical activity among residents with and without cognitive impairment in assisted living. This was a secondary data analysis using baseline data from an ongoing trial testing Function Focused Care for Assisted Living using the Evidence Integration Triangle (FFC-AL-EIT). A total of 550 residents were recruited from 59 communities. The average age of participants was 89.30 (SD = 7.63), the majority were white (98%), female (69%), had evidence of cognitive impairment (75%), and 5.16 (SD = 1.86) comorbidities. Those with cognitive impairment had more pain, were more sedentary and less likely to engage in function focused care activities. Addressing pain and implementing interventions for those with cognitive impairment to participate in function focused care may help optimize function and physical activity in assisted living residents.

Testing the Implementation of Function-focused Care in Assisted Living Settings

OBJECTIVES

The purpose of this study was to evaluate the Function-Focused Care for Assisted Living Using the Evidence Integration Triangle (FFC-AL-EIT) intervention.

DESIGN

FFC-AL-EIT was a randomized controlled pragmatic trial including 85 sites and 794 residents.

INTERVENTION

FFC-AL-EIT was implemented by a Research Nurse Facilitator working with a facility champion and stakeholder team for 12 months to increase function and physical activity among residents. FFC-AL-EIT included (Step I) Environment and Policy Assessments; (Step II) Education; (Step III) Establishing Resident Function-Focused Care Service Plans; and (Step IV) Mentoring and Motivating.

SETTING AND PARTICIPANTS

The age of participants was 89.48 years [standard deviation (SD) = 7.43], and the majority were female (n = 561; 71%) and white (n = 771; 97%).

METHODS

Resident measures, obtained at baseline, 4, and 12 months, included function, physical activity, and performance of function-focused care. Setting outcomes, obtained at baseline and 12 months, included environment and policy assessments and service plans.

RESULTS

Reach was based on 85 of 90 sites that volunteered (94%) participating. Effectiveness was based on less decline in function (P < .001), more function-focused care (P = .012) and better environment (P = .032) and policy (P = .003) support for function-focused care in treatment sites. Adoption was supported with 10.00 (SD = 2.00) monthly meetings held, 77% of settings engaged in study activities as or more than expected, and direct care workers providing function-focused care (63% to 68% at 4 months and 90% at 12 months). The intervention was implemented as intended, and education was received based on a mean knowledge test score of 88% correct. Evidence of maintenance from 12 to 18 months was noted in treatment site environments (P = .35) and policies continuing to support function-focused care (P = .28)].

CONCLUSIONS AND IMPLICATIONS

The Evidence Integration Triangle is an effective implementation approach for assisted living. Future work should continue to consider innovative approaches for measuring RE-AIM outcomes.

The Impact of a Randomized Controlled Trial Testing the Implementation of Function-Focused Care in Assisted Living on Resident Falls, Hospitalizations, and Nursing Home Transfers

The purpose of this study was to test the impact of function-focused care on adverse outcomes in assisted living. This was a randomized trial including 85 settings. The age of the 794 recruited participants was 89.48 (SD = 7.43) years, the majority was female (n = 561, 71%) and White (n = 771, 97%). The percentage of residents in the treatment group experiencing a fall decreased at 12 months from 26% to 20% and the control group increased from 24% to 25%, p = .02. A greater percentage of residents in the treatment group transferred to nursing facilities at 4 months (4-1% in control vs. 4-5% in treatment, p = .02) and 12 months (4-2% in control and 4-7% in treatment, p = .01). There was no treatment effect on emergency room or hospital transfers. The findings support the safety of function-focused care related to falls and need for hospital transfers.

Testing the Impact of FFC-AL-EIT on Psychosocial and Behavioral Outcomes in Assisted Living

BACKGROUND

This study tested the impact of Function Focused Care for Assisted Living Using the Evidence Integration Triangle (FFC-AL-EIT) on: (1) care interactions between residents and direct care staff; and (2) behavior and psychological symptoms associated with dementia among residents.

DESIGN

This was a randomized controlled trial.

SETTING

A total of 59 assisted living facilities in Maryland, Pennsylvania, and Massachusetts participated.

PARTICIPANTS

The sample included 550 mostly White (98%), female (69%) residents with a mean age of 89.30 (standard deviation = 7.63) years.

INTERVENTION

The four-step FFC-AL-EIT intervention was implemented by a function focused care nurse facilitator working with a facility champion over 12 months. The steps included: (1) environment and policy assessments; (2) education; (3) establishing resident function focused care service plans; and (4) mentoring and motivating.

MEASURES

Resident descriptive data (e.g., age, sex, education, and comorbidities), depression, agitation, resistiveness to care, and the quality of care interactions were obtained at baseline and 4 and 12 months. Treatment fidelity data included environment and policy assessments, performance of function focused care by staff, and service plan assessments.

RESULTS

There was a significant positive treatment effect related to depression, agitation, resistiveness to care, and quality of care interactions with either less decline or some improvement in these behaviors and symptoms in the treatment versus control group.

CONCLUSION

The study provides some statistical support, which may not necessarily be clinically significant evidence, for psychosocial outcomes of residents and care interactions between staff and residents in assisted living settings.

A Cluster Randomized Controlled Trial Testing the Impact of Function and Behavior Focused Care for Nursing Home Residents With Dementia

OBJECTIVE

The purpose of this study was to test the effectiveness of the Function and Behavior Focused Care for the Cognitively Impaired (FBFC-CI) intervention on function, physical activity, and behavioral symptoms among nursing home residents with dementia, and to explore the adoption of the intervention at the facility level.

DESIGN

This study was a clustered, randomized controlled trial with a repeated measures design that was implemented in 12 nursing homes randomized to either treatment (FBFC-CI) or educational control [Function and Behavior Focused Care Education (FBFC-ED)].

SETTING AND PARTICIPANTS

Twelve nursing homes (6 treatment and 6 control) and 336 residents (173 treatment and 163 control) with moderate to severe cognitive impairment.

MEASURES

Outcomes included functional ability (Barthel Index), physical activity (actigraphy and survey), behavioral symptoms (Resistiveness to Care Scale, Cohen-Mansfield Agitation Inventory, Cornell Scale for Depression in Dementia), and psychotropic medication use.

RESULTS

The participants were 82.6 (SD = 10.1) years of age, mostly female, and were moderate to severely cognitively impaired (Mini-Mental State Exam of 7.8, SD = 5.1). There was a significantly greater increase in time spent in total activity (P = .004), moderate activity (P = .012), light activity (P = .002), and a decrease in resistiveness to care (P = .004) in the treatment versus control group at 4 months. There was no change in mood, agitation, and the use of psychotropic medications. There was some evidence of adoption of the intervention at treatment sites.

CONCLUSIONS AND IMPLICATIONS

This study provides some support for the use of the FBFC-CI Intervention to increase time spent in physical activity and decrease resistive behaviors during care commonly noted among nursing home residents with moderate to severe cognitive impairment.

Developing and Testing A Model of the Assisted Living Environment

The assisted living (AL) environment plays an important role in supporting residents' satisfaction and helping them to age in place. The AL environment is multidimensional and has many interrelated components including staffing (e.g. direct care workers, nursing, activity staff), services provided (e.g. medical, mental health, pharmacy), amenities offered at the setting (e.g. beauty salon, library, exercise facilities), and the physical environment. Evidence suggests that aspects of the AL environment can enhance or detract from the physical function, well-being, social engagement, and behavioral outcomes among residents. The purpose of this study was to develop and test a multidimensional AL environment measurement model that includes indicators of staffing, services, amenities, and the physical environment. Baseline data was used from a study testing the Dissemination and Implementation of Function Focused Care in AL. A total of 54 AL facilities across three states were included in the sample. Settings ranged in size from 31 to 164 beds with an average size of 82.2 (SD=26.2) beds and the majority were for profit facilities (n=41, 74.5%). Structural equation modeling was used to test the proposed model. Results showed that the model fit the data (χ2/df=1.861, p<.05; CFI=.858, RMSEA=.126). Having a comprehensive AL environment measurement model will advance future research that explores the impact of the environment on resident outcomes. Findings from this study will inform interventions and programs designed to modify AL environments to optimize residents' satisfaction with AL.