Characteristics of residents and providers in the assisted living pilot program

Development and evaluation of a sleep education program for older adults with dementia living in adult family homes

OBJECTIVES

To investigate the feasibility of implementing a Sleep Education Program (SEP) for improving sleep in adult family home (AFH) residents with dementia, and the relative efficacy of SEP compared with usual care control in a pilot randomized controlled trial.

PARTICIPANTS

Thirty-seven AFH staff-caregivers and 47 residents with comorbid dementia and sleep disturbances.

INTERVENTION

SEP consisted of four training sessions with staff-caregivers to develop and implement individualized resident behavioral sleep plans.

MEASUREMENTS

Treatment fidelity to the SEP was assessed following the National Institutes of Health (NIH) Behavior Change Consortium model utilizing trainer observations and staff-caregiver reports. Resident sleep was assessed by wrist actigraphy at baseline, 1-month posttreatment, and 6-month follow-up. Caregiver reports of resident daytime sleepiness, depression, and disruptive behaviors were also collected.

RESULTS

Each key area of treatment fidelity (SEP delivery, receipt, enactment) was identified, measured, and yielded significant outcomes. Staff-caregivers learned how to identify sleep scheduling, daily activity, and environmental factors that could contribute to nocturnal disturbances and developed and implemented strategies for modifying these factors. SEP decreased the frequency and disturbance level of target resident nocturnal behaviors and improved actigraphically measured sleep percent and total sleep time over the 6-month follow-up period compared with the control condition.

CONCLUSION

Results suggest behavioral interventions to improve sleep are feasible to implement in adult family homes and merit further investigation as a promising intervention for use with AFH residents with dementia.

The effect of licensure type on the policies, practices, and resident composition of Florida assisted living facilities

PURPOSE

Most assisted living facility (ALF) residents are White widows in their mid- to late 80s who need assistance with activities of daily living (ADLs) because of frailty or cognitive decline. Yet, ALFs also serve younger individuals with physical disabilities, traumatic brain injury, or serious mental illness. We compare Florida ALFs with different licensure profiles by admission-discharge policies and resident population characteristics.

DESIGN AND METHODS

We use state administrative data and facility survey data from the Florida Study of Assisted Living (FSAL) to classify ALFs by licensure type and to determine how licensure influences ALF policies, practices, and resident population profiles.

RESULTS

Standard-licensed traditional ALFs primarily serve elderly White women with physical care needs and typically retain residents when their physical health deteriorates. Some ALFs that hold specialty licenses (extended congregate care and limited nursing services) offer extra physical care services and serve an older, more physically frail population with greater physical and cognitive challenges. ALFs with limited mental health (LMH) licenses serve clientele who are more racially and ethnically diverse, younger, and more likely to be men and single. LMH facilities also have a significant proportion of frail elder residents who live alongside these younger residents, including some who exhibit behavioral problems. LMH facilities also employ discharge policies that make it more difficult for frail elderly residents to age in place.

IMPLICATIONS

These differences by facility type raise important quality of life issues for both the frail elderly individuals and assisted living residents who do not fit the conventional demographic profile.

The spectrum of medical illness and medication use among residents of assisted living facilities in central Maryland

BACKGROUND

Although increasing numbers of older adults are living in assisted living facilities, there is little information on the types and amount of chronic medical illness and the medications required by such residents. To better inform efforts to optimize care in this setting, we sought to quantify chronic medical illnesses and their treatment.

METHODS

Medical diagnoses and treatments were derived from chart reviews and interviews of 198 residents of 22 randomly selected assisted living facilities (AL) in central Maryland. To evaluate the burden of medical illnesses, chronic conditions were categorized and quantified according to general (organ system) diseases, as well as 7 specific long-term care Clinical Practice Guidelines (CPG). Using logistic regression, we calculated the associations between facility-level characteristics and those residents with a) conditions from 3 or more general disease categories and, b) 2 or more CPG conditions. To evaluate medical treatment complexity, we categorized oral and certain non-oral medications, as well medications that typically require additional monitoring.

RESULTS

Almost one-half (46%) of AL residents had chronic conditions in 3 or more different general disease categories and one-fourth (25.2%) had 2 or more specific Clinical Practice Guideline (CPG) conditions. Residents with chronic conditions in 3 or more different general disease groups were more likely to live in larger facilities; otherwise, no other facility-level characteristics that we assessed were associated with residents having conditions from 3 or more general disease categories or 2 or more CPG conditions. One-half of all residents were taking medications that typically require additional monitoring and 25% of residents were receiving treatments of respiratory inhalers, eye drops and/or injections.

CONCLUSIONS

Many AL residents have multiple medical illnesses of different types and complexity. Given the increasing role of AL providers in the management of such conditions, appropriate adjustments in care provision will be needed for facilities to meet the needs of these residents.

Pathways to Assisted Living: The Influence of Race and Class

This article examines how race and class influence decisions to move to assisted living facilities. Qualitative methods were used to study moving decisions of residents in 10 assisted living facilities varying in size and location, as well as race and socioeconomic status of residents. Data were derived from in-depth interviews with 60 residents, 43 family members and friends, and 12 administrators. Grounded theory analysis identified three types of residents based on their decision-making control: proactive, compliant, and passive/resistant. Only proactive residents (less than a quarter of residents) had primary control. Findings show that control of decision making for elders who are moving to assisted living is influenced by class, though not directly by race. The impact of class primarily related to assisted-living placement options and strategies available to forestall moves. Factors influencing the decision-making process were similar for Black and White elders of comparable socioeconomic status.

Assisted living pilot program: utilization and cost findings

Objective. The Department of Veterans Affairs funded assisted living, adult family home, and adult residential care for the first time in the Assisted Living Pilot Program (ALPP). This article compares the use and cost for individuals that entered ALPP and a comparison group. Method. This was a nonrandomized study. The comparison group consisted of VA patients who were eligible but did not enter an ALPP facility. The ALPP (n = 393) and comparison (n = 259) groups were followed for 12 months to assess ALPP facility, case management, and health care costs. Results. ALPP facility and ALPP case management costs were respectively $5,560 and $2,830 per individual. Total health care costs, including ALPP costs, were $11,533 higher for the ALPP group compared to the comparison group after adjusting for baseline differences. Discussion. Although ALPP successfully helped individuals transition to longer term care in these facilities, it was more costly than the comparison group.

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.

Assisted living pilot program: background, methods, and facility characteristics

Objectives. The Department of Veterans Affairs (VA) funded assisted living (AL), adult family home (AFH), and residential care for the first time in the Assisted Living Pilot Program (ALPP). This article describes the background and methods of the ALPP evaluation and the characteristics and experiences of the facilities. Method. Facility data were collected from the contracting/inspection process and a survey of ALPP facilities and those contacted but not participating in ALPP. Results. Data on 131 participating facilities are presented: 41 AFHs, 47 assisted living facilities (ALFs), and 43 residential care facilities (RCFs). The average facility had 33 beds (about one quarter Medicaid beds), for-profit ownership, and private rooms for ALPP residents, and about half had private baths. About two thirds of ALPP AFH providers spoke a primary language other than English. Discussion. Findings indicate that a wide range of community facilities were willing to provide care to residents with heterogeneous needs on VA funding.

Managing sleep disturbances in adult family homes: recruitment and implementation of a behavioral treatment program

This article describes a sleep education program (SEP) designed to teach owner/operators and direct-care staff working in adult family homes (AFHs) how to improve the sleep and nighttime behavior of older residents with dementia. There have been no sleep intervention studies conducted in AFHs, and strategies that are known to improve sleep in community-dwelling older adults or nursing home residents may not be feasible or effective in AFHs because of their unique care environment. The SEP was developed on the basis of experiences treating sleep disturbances in community-dwelling older adults with dementia (the Nighttime Insomnia Treatment and Education in Alzheimer's Disease study). In this article, we address both the clinical and empirical challenges faced by researchers recruiting and intervening in AFHs, raise issues pertinent to assessment of residents and staff, and discuss implications for evaluating the impact of behavioral treatments for sleep-wake disturbances in AFH residents.