Workforce development to provide person-centered care

Evaluation of an Online Learning Concept for Nursing Students in Caring for Patients with Dementia: Results of a Questionnaire Survey

BACKGROUND

Nurses have key roles in caring for patients with dementia. To prepare them for demand-oriented nursing care, there is a need for education. An online course with a focus on healthcare needs assessment was designed.

METHODS

A quantitative study with a qualitative component using questionnaire-based interviews was implemented. The recruitment of students used the following inclusion criteria: (a) second-year students, and (b) absent from less than three lectures. Overall, n = 48 met the inclusion criteria. Twenty-eight students participated. Quantitative data were analyzed using descriptive statistics. Qualitative data were evaluated using Kuckartz's content analysis with the software MAXQDA.

RESULTS

Nursing students judged the overall course structure as very good (M 1.36, SD 0.48). The learning aims were clearly defined (M 1.61, SD 0.68) and the learning content was adequately demonstrated (M 1.68, SD 0.67). The exercise on geriatric assessment promoted the internal learning process (M 1.67, SD 1.00). The online simulation training made the lectures' contents easier to understand (M 1.86, SD 0.89). Correlations were determined, among others, between the course structure and the clear definitions of the learning aims (r^Sp 0.566, p = 0.002).

CONCLUSIONS

The study describes the feasibility of the online course. To identify the impact on patients' health and caregivers' lives, further studies are needed.

From dementia mindsets to emotions and behaviors: Predicting person-centered care in care professionals

BACKGROUND AND OBJECTIVE

High-quality care standards for dementia care are increasingly based on person-centered care principles. To better understand facilitating factors of person-centered care this research focuses on individual characteristics of care professionals. Applying mindset theory to dementia care, we examined dementia mindsets (viewing dementia symptoms as either malleable or fixed) in care professionals. We tested whether there is a positive relationship between a malleable dementia mindset and person-centered care as well as a negative relationship between a fixed dementia mindset and person-centered care. Moreover, we examined whether care professionals' emotional responses in care situations help explain associations between dementia mindsets and person-centered care.

RESEARCH DESIGN AND METHOD

In two cross-sectional studies, care professionals of long-term care facilities (total N = 370) completed a measure of dementia mindsets and reported their emotional and behavioral responses to five care scenarios. Regression and mediation analyses were performed.

FINDINGS

The tested hypotheses were partially supported. A fixed dementia mindset predicted reported person-centered care negatively, while a malleable dementia mindset did not. Mediation analyses suggest that reduced negative emotions may underlie the association between a malleable mindset and reported person-centered care, while reduced positive emotions in care situations may underlie the association of a fixed mindset and reported person-centered care. Study 2 partially replicated these findings. A fixed mindset and positive emotional responses were the most robust predictors of reported person-centered care.

DISCUSSION AND IMPLICATIONS

This study extends knowledge on facilitators (positive emotional responses to care situations) and barriers (fixed dementia mindset) to person-centered care in care professionals working with persons with dementia. We discuss how dementia mindsets and emotional responses to care situations may be a fruitful target for trainings for care professionals.

Older Persons' Views on Important Values in Swedish Home Care Service: A Semi-Structured Interview Study

Introduction

Knowledge of older person's experiences of important values in home care service can facilitate the development and delivery of high-quality services supporting their well-being, dignity and participation in the care provided. To date, few studies have explored older person's values and experiences of home care services.

Purpose

This study aimed to explore values that older person holds regarding home care services and their experiences of how these values manifest in home care service delivery.

Participants and Methods

The study has a qualitative exploratory design. Semi-structured interviews were conducted with 16 older persons aged 74-90 who received home care service. Data were analysed using qualitative content analysis.

Results

Two themes (each with sub-themes) of values relating to the experience of home care service from the perspective of the 16 older persons were identified: to be supported as an autonomous person and to be supported as a relational being. The participants experience that these two values were only partly manifested in the home care services they received. They also noted that their well-being was negatively affected when staff failed to implement these values. The fundamental values identified in study related to the older person feeling safe, being autonomous, maintaining control and independence, and having relationships. The values constitute help to guide practice from the perspective of older persons who receive home care services.

Conclusion

The identified values are primarily interpersonal-level values. However, such values are also of importance for home care service organisations when promoting delivery of person-centred care. Taking such a position implies adopting a relation-oriented rather than a task-oriented approach in providing home care services for older persons.

[Transfer of Physicians' Tasks to Nurses in the Care of People with Dementia]

THE AIM OF THE STUDY

A transfer of medical activities to nurses and thus the redistribution of tasks has been discussed for almost 15 years. A legal base for model projects has been enacted. However, clearly defined tasks for substitution are still lacking. The aim of this study was to solicit opinions of general practitioners, nurses, people with dementia (PwD) and their relatives about the possibility of a large number of specific General practitioner (GP) tasks being performed by nurses in outpatient dementia care.

METHODS

A mixed-methods study with a sequential in-depth design was conducted. The analysis presented here refers to the quantitative survey of the four participant groups. 865 participants were asked about the acceptance of substitution of assessments, primary and follow-up prescriptions, health monitoring measures and other activities currently performed by physicians.

RESULTS

Across all groups of subjects, the highest level of approval for substitution was achieved for the assessment of mobility restrictions, everyday competencies, nutritional abnormalities, prescription of transportation, nursing aids, home nursing services and drawing of blood samples. Among PwD and relatives, the level of acceptance for substitution was very high. 88% of the PwD and relatives indicated that many activities can be substituted while the general practitioner remained their first point of contact. More GPs (63.2%) than nurses (56.7%) would accept the substitution.

CONCLUSION

The results indicate that a large number of GPs, nurses, patients and their relatives welcome substitution. However, PwD and relatives have a significantly more positive attitude towards substitution.

Advanced nursing practice and interprofessional dementia care (InDePendent): study protocol for a multi-center, cluster-randomized, controlled, interventional trial

BACKGROUND

A redistribution of tasks between specialized nurses and primary care physicians, i.e., models of advanced nursing practice, has the potential to improve the treatment and care of the growing number of people with dementia (PwD). Especially in rural areas with limited access to primary care physicians and specialists, these models might improve PwD's quality of life and well-being. However, such care models are not available in Germany in regular healthcare. This study examines the acceptance, safety, efficacy, and health economic efficiency of an advanced nursing practice model for PwD in the primary care setting in Germany.

METHODS

InDePendent is a two-arm, multi-center, cluster-randomized controlled intervention study. Inclusion criteria are age ≥70 years, cognitively impaired (DemTect ≤8) or formally diagnosed with dementia, and living in the own home. Patients will be recruited by general practitioners or specialists. Randomization is carried out at the physicians' level in a ratio of 1:2 (intervention vs. waiting-control group). After study inclusion, all participants will receive a baseline assessment and a follow-up assessment after 6 months. Patients of the intervention group will receive advanced dementia care management for 6 months, carried out by specialized nurses, who will conduct certain tasks, usually carried out by primary care physicians. This includes a standardized assessment of the patients' unmet needs, the generation and implementation of an individualized care plan to address the patients' needs in close coordination with the GP. PwD in the waiting-control group will receive routine care for 6 months and subsequently become part of the intervention group. The primary outcome is the number of unmet needs after 6 months measured by the Camberwell Assessment of Need for the Elderly (CANE). The primary analysis after 6 months is carried out using multilevel models and will be based on the intention-to-treat principle. Secondary outcomes are quality of life, caregiver burden, acceptance, and cost-effectiveness. In total, n=465 participants are needed to assess significant differences in the number of unmet needs between the intervention and control groups.

DISCUSSION

The study will provide evidence about the acceptance, efficacy, and cost-effectiveness of an innovative interprofessional concept based on advanced nursing care. Results will contribute to the implementation of such models in the German healthcare system. The goal is to improve the current treatment and care situation for PwD and their caregivers and to expand nursing roles.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04741932 . Registered on 2 February 2021.

Patient-Centered Care for Patients with Depression or Anxiety Disorder: An Integrative Review

People have specific and unique individual and contextual characteristics, so healthcare should increasingly opt for person-centered care models. Thus, this review aimed to identify and synthesize the indicators for the care process of the person with depression and/or anxiety disorders, based on patient-centered care, going through the stages of diagnostic assessment and care planning, including intervention. An integrative literature review with research in seven scientific databases and a narrative analysis were carried out. Twenty articles were included, with indicators for diagnostic evaluation and care/intervention planning being extracted. Care planning focused on people with depression and/or anxiety disorder must be individualized, dynamic, flexible, andparticipatory. It must respond to the specific needs of the person, contemplating the identification of problems, the establishment of individual objectives, shared decision making, information and education, systematic feedback, and case management, and it should meet the patient's preferences and satisfaction with care and involve the family and therapeutic management in care. The existence of comorbidities reinforces the importance of flexible and individualized care planning in order to respond to the specific health conditions of each person.

Promoting Quality of Life in Advanced Dementia Care: Reading Buddies Program as Service-learning

The Reading Buddies Program was developed as a service-learning component of an Occupational Therapy Practice with Older Adults course as a collaboration between Tufts University and the VA Bedford Health Care System. The purpose of this service-learning program was to challenge graduate students' implicit biases and improve communication skills when working with older adults with significant cognitive impairments. Through this collaboration, occupational therapy students provided individualized, activity-based care to Veterans with advanced dementia. In this qualitative study, a total of 55 guided reflection papers submitted by students were analyzed using NVivo. Four major themes emerged: "I was a fish out of water," "I finally took a risk," "And then I thought, maybe I should give myself a little credit," and, "I am still experimenting with how I feel," illustrating student outcomes and perceived benefits of participation in the Reading Buddies Program. Each theme reflected the development of clinical reasoning which was the targeted impact. Outcomes confirm service-learning as an effective tool and suggest further use for academic programs, emphasizing the potential of creative partnerships to meet educational goals while providing valuable programming to vulnerable populations.

2021 Alzheimer's disease facts and figures

This article describes the public health impact of Alzheimer's disease (AD), including incidence and prevalence, mortality and morbidity, use and costs of care, and the overall impact on caregivers and society. The Special Report discusses the challenges of providing equitable health care for people with dementia in the United States. An estimated 6.2 million Americans age 65 and older are living with Alzheimer's dementia today. This number could grow to 13.8 million by 2060 barring the development of medical breakthroughs to prevent, slow or cure AD. Official death certificates recorded 121,499 deaths from AD in 2019, the latest year for which data are available, making Alzheimer's the sixth-leading cause of death in the United States and the fifth-leading cause of death among Americans age 65 and older. Between 2000 and 2019, deaths from stroke, heart disease and HIV decreased, whereas reported deaths from AD increased more than 145%. This trajectory of deaths from AD was likely exacerbated in 2020 by the COVID-19 pandemic. More than 11 million family members and other unpaid caregivers provided an estimated 15.3 billion hours of care to people with Alzheimer's or other dementias in 2020. These figures reflect a decline in the number of caregivers compared with a decade earlier, as well as an increase in the amount of care provided by each remaining caregiver. Unpaid dementia caregiving was valued at $256.7 billion in 2020. Its costs, however, extend to family caregivers' increased risk for emotional distress and negative mental and physical health outcomes - costs that have been aggravated by COVID-19. Average per-person Medicare payments for services to beneficiaries age 65 and older with AD or other dementias are more than three times as great as payments for beneficiaries without these conditions, and Medicaid payments are more than 23 times as great. Total payments in 2021 for health care, long-term care and hospice services for people age 65 and older with dementia are estimated to be $355 billion. Despite years of efforts to make health care more equitable in the United States, racial and ethnic disparities remain - both in terms of health disparities, which involve differences in the burden of illness, and health care disparities, which involve differences in the ability to use health care services. Blacks, Hispanics, Asian Americans and Native Americans continue to have a higher burden of illness and lower access to health care compared with Whites. Such disparities, which have become more apparent during COVID-19, extend to dementia care. Surveys commissioned by the Alzheimer's Association recently shed new light on the role of discrimination in dementia care, the varying levels of trust between racial and ethnic groups in medical research, and the differences between groups in their levels of concern about and awareness of Alzheimer's disease. These findings emphasize the need to increase racial and ethnic diversity in both the dementia care workforce and in Alzheimer's clinical trials.

Attitudes towards advanced nursing roles in primary dementia care - Results of an observational study in Germany

AIMS

To demonstrate the attitudes of general practitioners (GPs), nurses, persons with dementia, and caregiver towards suitable tasks and qualification needs for and the acceptance and impact of advanced nursing roles in German dementia primary care.

DESIGN

Observational study using a questionnaire survey with 225 GPs, 232 nurses, 211 persons with dementia, and 197 caregivers, conducted between December 2017-August 2018.

METHODS

A questionnaire was generated that includes specific assessment, prescription, and monitoring tasks of advanced nursing roles in dementia primary care as well as qualification requirements for and the acceptance and the impact of advanced nursing roles. Data were analysed using descriptive statistics. Group differences were assessed using the Fisher's exact test.

RESULTS

Advanced nursing roles were highly appreciated across all groups. Assessment and monitoring tasks were rated as highly suitable, and prescription authorities as moderately suitable. Nurses felt less confident in assessment and monitoring, but more confident in prescribing as practitioners expected. Patients and caregivers would appreciate a takeover of tasks by nurses; nurses and practitioners preferred a delegation. A dementia-specific qualification was rated as best suitable for advanced nursing roles, followed by 'no specific qualification' if medical tasks that only can be carried out by practitioners were delegated and an academic degree if tasks were substituted. Advanced nursing roles were rated as beneficial, strengthening the confidence in nursing care and improving the cooperation between professionals and the treatment. Practitioners assumed that advanced nursing roles would improve job satisfaction of nurses, which was not confirmed by nurses.

CONCLUSION

There is an extended consensus towards the enlargement of advanced nursing roles, represented by high endorsement, acceptance, and willingness to reorganize tasks.

IMPACT

Results debunk the common notion that German practitioners would be reluctant towards advanced nursing roles and a takeover of current practitioner tasks, supporting the implementation of advanced nursing roles in Germany.

Patient and caregiver outcomes at the integrated memory care clinic

The purpose of this longitudinal cohort study was to explore the outcomes of persons living with dementia (PLWD) and their caregivers during their first 9 months at the Integrated Memory Care Clinic (IMCC). IMCC advanced practice registered nurses provide dementia care and primary care simultaneously and continuously to PLWD until institutionalization. Changes were examined in caregivers' psychological well-being (perceived stress, depressive symptoms, caregiver burden, and anxiety) and health status and in PLWDs' quality of life and neuropsychiatric symptoms. Data were collected at baseline, then 3 and 6 months post-baseline. Forty-two caregivers completed all 3 assessments. Most variables remained unchanged. Statistically significant improvements in 5 sub-scales of the Neuropsychiatric Inventory were observed: caregivers' distress regarding their PLWDs' delusions and anxiety, and PLWDs' severity of delusions, depression, and total symptom severity. Further testing of the IMCC is required, including in quasi-experimental studies, to determine its efficacy.

2020 Alzheimer's disease facts and figures

This article describes the public health impact of Alzheimer's disease (AD), including incidence and prevalence, mortality and morbidity, use and costs of care, and the overall impact on caregivers and society. The Special Report discusses the future challenges of meeting care demands for the growing number of people living with Alzheimer's dementia in the United States with a particular emphasis on primary care. By mid-century, the number of Americans age 65 and older with Alzheimer's dementia may grow to 13.8 million. This represents a steep increase from the estimated 5.8 million Americans age 65 and older who have Alzheimer's dementia today. Official death certificates recorded 122,019 deaths from AD in 2018, the latest year for which data are available, making Alzheimer's the sixth leading cause of death in the United States and the fifth leading cause of death among Americans age 65 and older. Between 2000 and 2018, deaths resulting from stroke, HIV and heart disease decreased, whereas reported deaths from Alzheimer's increased 146.2%. In 2019, more than 16 million family members and other unpaid caregivers provided an estimated 18.6 billion hours of care to people with Alzheimer's or other dementias. This care is valued at nearly $244 billion, but its costs extend to family caregivers' increased risk for emotional distress and negative mental and physical health outcomes. Average per-person Medicare payments for services to beneficiaries age 65 and older with AD or other dementias are more than three times as great as payments for beneficiaries without these conditions, and Medicaid payments are more than 23 times as great. Total payments in 2020 for health care, long-term care and hospice services for people age 65 and older with dementia are estimated to be $305 billion. As the population of Americans living with Alzheimer's dementia increases, the burden of caring for that population also increases. These challenges are exacerbated by a shortage of dementia care specialists, which places an increasing burden on primary care physicians (PCPs) to provide care for people living with dementia. Many PCPs feel underprepared and inadequately trained to handle dementia care responsibilities effectively. This report includes recommendations for maximizing quality care in the face of the shortage of specialists and training challenges in primary care.

Examining the benefits and harms of Alzheimer's disease screening for family members of older adults: study protocol for a randomized controlled trial

BACKGROUND

Multiple national expert panels have identified early detection of Alzheimer's disease and related dementias (ADRD) as a national priority. However, the United States Preventive Services Task Force (USPSTF) does not currently support screening for ADRD in primary care given that the risks and benefits are unknown. The USPSTF stresses the need for research examining the impact of ADRD screening on family caregiver outcomes.

METHODS

The Caregiver Outcomes of Alzheimer's Disease Screening (COADS) is a randomized controlled trial that will examine the potential benefits or harms of ADRD screening on family caregivers. It will also compare the effectiveness of two strategies for diagnostic evaluation and management after ADRD screening. COADS will enroll 1800 dyads who will be randomized into three groups (n = 600/group): the 'Screening Only' group will receive ADRD screening at baseline and disclosure of the screening results, with positive-screen participants receiving a list of local resources for diagnostic follow-up; the 'Screening Plus' group will receive ADRD screening at baseline coupled with disclosure of the screening results, with positive-screen participants referred to a dementia collaborative care program for diagnostic evaluation and potential care; and the control group will receive no screening. The COADS trial will measure the quality of life of the family member (the primary outcome) and family member mood, anxiety, preparedness and self-efficacy (the secondary outcomes) at baseline and at 6, 12, 18 and 24 months. Additionally, the trial will examine the congruence of depressive and anxiety symptoms between older adults and family members at 6, 12, 18 and 24 months and compare the effectiveness of two strategies for diagnostic evaluation and management after ADRD screening between the two groups randomized to screening (Screening Only versus Screening Plus).

DISCUSSION

We hypothesize that caregivers in the screening arms will express higher levels of health-related quality of life, lower depressive and anxiety symptoms, and better preparation for caregiving with higher self-efficacy at 24 months. Results from this study will directly inform the National Plan to Address Alzheimer's Disease, the USPSTF and other organizations regarding ADRD screening and early detection policies.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03300180. Registered on 3 October.

Using The Apriori Algorithm To Classify The Care Needs Of Patients With Different Types Of Dementia

PURPOSE

To elucidate specific combinations of care needs for people living with dementia (PLWD) and their caregivers according to specific subtypes of dementia.

PATIENTS AND METHODS

A cross-sectional study at memory clinics in Changhua Christian Hospital, Taiwan, was conducted. Five hundred and eight people living with dementia and their caregivers joined the dementia collaborative care model. The care team established 15 care needs containing most of quality measures for PLWD and their caregivers. Individualized care plans including different combinations of care needs were addressed through face-to-face assessments. Apriori algorithm was used to find specific combinations of care needs for particular groups of PLWD and their caregivers.

RESULTS

This study identified the basic care needs of PLWD and caregivers including appropriate scheduling of activities, regular outpatient follow-up treatment, introduction and referral of social resources, referral to family support groups and care skills training, and health education for dementia and behavioral and psychological symptoms of dementia. Patients with Alzheimer's dementia required more care to prevent traffic accidents and getting lost, while patients with vascular dementia required more care to prevent falls. The older (≥75 years old) PLWD were associated with more needs of fall prevention and care for the mood of the caregiver, especially in the female patients with mild Alzheimer's dementia (CDR = 1).

CONCLUSION

Bundling the needed care needs might be a more effective means to care for a wide variety of patients with dementia.

Care coordinator assistants: Job satisfaction and the importance of teamwork in delivering person-centered dementia care

As the prevalence of persons with dementia increases, a larger, trained, and skilled healthcare workforce is needed. Attention has been given to models of person-centered care as a standard for dementia care. One promising role to deliver person-centered care is the care coordinator assistant. An inquiry about care coordinator assistant's job satisfaction is reasonable to consider for retention and quality improvement purposes. We evaluated care coordinator assistants' job satisfaction quantitatively and qualitatively. This study was part of a Centers for Medicare & Medicaid Services Health Care Innovation Award to the Indiana University School of Medicine. Sixteen care coordinator assistants, predominately female, African American or Caucasian, college graduates with a mean age of 43.1 years participated. Care coordinator assistants wrote quarterly case reports to share stories, lessons learned, and/or the impact of their job and completed the revised Job Satisfaction Inventory and Job in General scales during the second year of the Centers for Medicare & Medicaid Services award. For the Job Descriptive Index subscales promotion, supervision, and coworkers and Job in General, care coordinator assistants scored similar to normative means. Care coordinator assistants reported significantly higher satisfaction on the work subscale and significantly lower satisfaction on the pay subscale compared to normative data. Care coordinator assistants completed 119 quarterly case reports. Job satisfaction and teamwork were recurring themes in case reports, referenced in 47.1% and 60.5% of case reports, respectively. To address the demands of increasing dementia diagnoses, care coordinator assistants can constitute a compassionate, competent, and satisfied workforce. Training care coordinator assistants to work together in a team to address the needs of persons with dementia and caregivers provides a viable model of workforce development necessary to meet the growing demands of this population.

Dementia care management in primary care : Current collaborative care models and the case for interprofessional education

BACKGROUND

Dementia is one of the most prevalent diseases in the older population. Various dementia care models have been developed to address patient's healthcare needs. They can be described as "collaborative care" or "person-centered care". Referring to the needs of the workforce working with persons with dementia, a key element is the use of interprofessional education (IPE).

OBJECTIVE

The purpose of this article is to describe different international collaborative care models to define a minimum standard of healthcare professions for collaborative dementia care in primary care. This helps to identify requirements for IPE to optimize care of people with dementia and to support informal caregivers in the future.

MATERIAL AND METHODS

In this article six dementia care models from 4 different countries (Germany, USA, UK and Netherlands) are described and compared regarding aims, interventions and healthcare professionals involved.

RESULTS

Care teams are minimally comprised of general practitioners or primary care providers, nurses, and social workers. Additional healthcare disciplines may be involved for specific interventions. Mostly, care team members received specific training but such training did not necessarily incorporate the IPE approach. To ensure successful collaboration of professions, IPE training programs should at least consist of the following core topics: (1) early diagnosis, (2) postdiagnostic support, (3) advanced care planning for patients and caregivers and (4) effective collaborative care.

CONCLUSION

The IPE programs for dementia should be expanded and must be widely implemented in order to assess the impact on collaborative practice. This study will provide the knowledge base for structuring IPE trainings developing educational agendas and adapting existing guidelines to improve collaborative dementia care in the future.

Response to depression treatment in the Aging Brain Care Medical Home model

Objective

To evaluate the effect of the Aging Brain Care (ABC) Medical Home program’s depression module on patients’ depression severity measurement over time.

Design

Retrospective chart review.

Setting

Public hospital system.

Participants

Patients enrolled in the ABC Medical Home program between October 1, 2012 and March 31, 2014.

Methods

The response of 773 enrolled patients who had multiple patient health questionnaire-9 (PHQ-9) scores recorded in the ABC Medical Home program’s depression care protocol was evaluated. Repeatedly measured PHQ-9 change scores were the dependent variables in the mixed effects models, and demographic and comorbid medical conditions were tested as potential independent variables while including random effects for time and intercept.

Results

Among those patients with baseline PHQ-9 scores >10, there was a significant decrease in PHQ-9 scores over time (P<0.001); however, the effect differed by gender (P=0.015). On average, women’s scores (4.5 point drop at 1 month) improved faster than men’s scores (1 point drop at 1 month). Moreover, both men and women had a predicted drop of 7 points (>50% decline from baseline) on the PHQ-9 at 6 months.

Conclusion

These analyses demonstrate evidence for the sustained effectiveness of the ABC Medical Home program at inducing depression remission outcomes while employing clinical staff who required less formal training than earlier clinical trials.