Family Involvement among Oregon Adult Foster Home Residents, 2018-2023

OBJECTIVES

To track the changes that occurred in family involvement among Oregon Adult Foster Home (AFH) residents following the COVID-19 pandemic and to examine the associations between home and resident characteristics and family involvement.

DESIGN

Retrospective analysis of repeated cross-sectional data.

SETTING AND PARTICIPANTS

A total of 2027 responses from AFH providers that replied to a mailed questionnaire from a sample of eligible licensed Oregon AFH selected to participate annually between 2018 and 2023 (6 waves).

METHODS

AFH providers filled out a questionnaire containing questions about family involvement (residents who received 6 types of support from family members or friends, such as help with personal care or social visit) and resident characteristics (activities of daily living needs, payer mix, age, gender, dementia status). Additional contextual data (size, rural/urban) were obtained from state agencies. Associations among family involvement and home and resident characteristics were examined using multivariable linear regression models.

RESULTS

Bivariate analyses showed statistically significant declines in social visits and outings and help getting to medical appointments during the first 2 years (2021 and 2022) of the COVID-19 pandemic, but little change in help with personal care or taking medications or phone calls. By 2023, social visits had recovered to pre-pandemic levels but remained significantly lower for help getting to medical appointments and going on outings. Multiple regression models that included controls showed that rural AFH and those with higher Medicaid use reported significantly lower family involvement in social visits, outings, and help getting to medical appointments.

CONCLUSIONS AND IMPLICATIONS

The continued decline in assistance for medical appointments and outings portends potential challenges in resident socioemotional well-being and accessing health care services in this setting. Understanding the long-term impacts of the pandemic on quality of life and quality of care for residents living in community-based care settings may require a multifaceted approach to measuring family involvement.

Evaluating Elements of the Care Partner Experience in Individuals Who Care for People with Alzheimer's Disease Across the Severity Spectrum

INTRODUCTION

Non-professional care partners play an important and often evolving role in the care of persons living with Alzheimer's disease (PLWAD). We investigated two elements of the care partner experience, namely time and strain incurred by care partners providing care to PLWAD across the severity spectrum.

METHODS

Data gathered from the Alzheimer's Disease Patient and Caregiver Engagement (AD PACE) What Matters Most (WMM) study series were analyzed to determine how much time care partners spent providing care to PLWAD based on where the care recipients lived. Additionally, quantitative assessments of weekly hours providing care and the strain experienced by care partners were conducted using the UsAgainstAlzheimer's A-LIST Insights Series survey, which included the Modified Caregiver Strain Index (MCSI). Finally, a targeted literature review was conducted to contextualize findings and characterize the existing literature landscape.

RESULTS

Care partners in the AD PACE WMM studies (n = 139) spent significantly more hours providing care for recipients who lived with someone (mean ± standard deviation [SD], 57.3 ± 44.3 h/week) than for recipients who lived alone (26.0 ± 12.0 h/week) (P = 0.0096) or lived in assisted living/nursing home (23.6 ± 14.4 h/week) (P = 0.0002). In the A-LIST Insights Series survey, care partners provided an overall mean (± SD) 58.1 ± 53.0 h of direct care each week, with caregiving hours increasing with increasing severity of AD/AD-related dementias (AD/ADRD). Additionally, care partners for recipients with mild (n = 14), moderate (n = 111), and severe AD/ADRD (n = 91) had overall mean MCSI scores of 9.0 ± 3.8 (range 2-14), 13.3 ± 4.8 (range 4-23), and 17.5 ± 5.3 (range 4-26), respectively, with higher scores suggesting greater care partner strain.

CONCLUSIONS

Persons living with AD require increasing levels of care along the spectrum of disease, and even individuals with early disease need care from partners. Early interventions that slow progression of AD and programs that improve family function may have beneficial impact on the experiences of care partners for recipients with mild, moderate, or severe AD.

Factors influencing emotional support of older adults living in the community: a scoping review protocol

BACKGROUND

Emotional support is key to improve older adults' subjective health, and psychological, social and emotional well-being. However, many older adults living in the community lack emotional support, increasing the risk for loneliness, depression, anxiety, potentially avoidable healthcare use and costs, and premature death. Multiple intersecting factors may influence emotional support of older adults in the community, but these are poorly understood. Studies have focused on specific populations (e.g., older adults with depression, cancer). Although relevant, these studies may not capture modifiable factors for the wider and more diverse population of older adults living in the community. Our scoping review will address these important gaps. We will identify and synthesize the evidence on factors that influence emotional support of older adults in the community.

METHODS

We will use the Johanna Briggs Institute updated methodological guidance for the conduct of scoping reviews to guide our review process. We will search MEDLINE, EMBASE, APA Psycinfo, CINAHL, Dissertations and Theses Global, and Scopus from inception. We will include studies published in English, examining factors influencing emotional support of older adults residing in community, without restrictions on the study design or year of publication. We will also include gray literature (dissertations and reports). Two independent reviewers will conduct title, abstract, and full-text screening, as well as risk of bias assessment, using validated quality appraisal tools based on study designs. Discrepancies will be resolved by consensus. The primary reviewer will extract the data from all studies, and the second reviewer will check the extractions of all the studies. We will use descriptive statistics and narrative synthesis for analysis. Family/friend caregivers and older adults involved as an advisory group will help with explaining the findings in terms of whether associations observed reflect their experiences and reality. We will analyze the discussion and generate themes, and summarize in a narrative form.

DISCUSSION

This scoping review may identify factors that could be modified or mitigated to improve emotional support provision for older adults residing in community. The knowledge will inform the development of tailored interventions directed to older adults and their caregivers.

SYSTEMATIC REVIEW REGISTRATION

https://doi.org/10.17605/OSF.IO/4TAEB (associated project link: osf.io/6y48t).

Staying in the loop: Quality of family-paid caregiver communication and influences on resident mental health in long-term care

BACKGROUND

Considerable research has examined communication dynamics among family members and staff in nursing homes (NHs) and has demonstrated that better communication is associated with more optimal mental health outcomes in both family caregivers and paid caregivers. However, the literature on how communication dynamics influence mental health in long-term care residents is limited and it has yet to be determined how communication impacts residents across care contexts, such as assisted living facilities (ALFs). The purpose of this study is to examine family caregivers' perceptions of communication with paid caregivers and its influence on long-term care resident outcomes and to compare how results differ across care settings (NHs vs. ALFs).

METHODS

Data were drawn from a subsample of the National Health and Aging Trends Study (NHATS) and the National Study on Caregiving (NSOC). The sample consisted of 142 NHATS participants residing in long-term care (n = 93 ALF residents; n = 49 NH residents) with an eligible family caregiver who participated in the NSOC. Family caregivers' perceived quality of communication was assessed via questions regarding the frequency, availability, and helpfulness of communication with paid caregivers. Resident mental health was assessed via measures of positive and negative affect, depressive symptoms, and anxiety.

RESULTS

Across the total sample, greater availability of communication between paid and family caregivers was associated with lower depressive symptoms and negative affect in residents. When examining how these relationships varied across care settings, communication was a stronger predictor of fewer depressive symptoms among residents in ALF settings.

CONCLUSIONS

Study findings provide insights into how interpersonal dynamics between family and paid caregivers influence resident mental health and underscore the importance of enhanced communication among all members of the primary care team, that is, paid caregivers, residents, and their family members.

Disruptions in Relational Continuity: The Impact of Pandemic Public Health Measures on Families in Long-Term Care

Although the value of family caregivers' involvement with relatives in long-term care (LTC) is well recognized, tensions remain regarding their role. Such tensions were exacerbated during the COVID-19 pandemic as strict public health measures restricted family access to LTC homes. Using interpretive description, we examined the impact of visitation restrictions on family caregivers' experiences caring for a relative in LTC between March 2020 and June 2021. In-depth interviews were conducted with 14 family caregivers (five spouses and nine adult daughters) and two key themes were identified. The first theme, "seeking to maintain relational continuity," illustrates how caregivers sought to sustain connections with residents prior to and during the pandemic. The second theme, "disrupted relational continuity," highlights the impact of severed relational connections on caregivers' sense of self and ongoing feelings of loss and anger. Findings call for a trauma-informed approach that recognizes the pervasiveness of trauma for family caregivers and the avoidance of re-traumatization.

A Qualitative Analysis of Mechanisms of Benefit in the Residential Care Transition Module: A Telehealth Intervention for Caregivers of Relatives With Dementia Living in Residential Long-Term Care

This study sought to determine the perceived benefits of the Residential Care Transition Module (RCTM), a novel multi-component, psychoeducational/psychosocial, telehealth intervention for caregivers of cognitively impaired relatives living in residential long-term care (RLTC). Few support programs exist for these caregivers. Determining the intervention's mechanisms of benefit will provide actionable clinical and research information regarding which key features aspects RLTC and public health agencies should offer their families. We conducted semi-structured interviews with 30 purposively selected participants randomly assigned to receive the RCTM. Additionally, an open-ended survey question solicited feedback at 4 (n = 90), 8 (n = 79), and 12 months (n = 77). Available qualitative data were analyzed for thematic content. Participants endorsed 9 mechanisms of benefit. Six mechanisms were related to RCTM content: education dementia progression and dementia behavior management, personalized resource provision, strategies for communication and engagement with the care recipient (CR) and others, management of multiple roles, and relaxation exercises. Three mechanisms were related to coaching: emotional support, knowledgeability, and being a neutral third party. Common benefits attributed to RCTM included improvement in mood, caregiving confidence, and communication and interactions with CR and others. Using qualitative data and analyses, we discovered the most valued aspects of the RCTM intervention. These mechanisms of benefit have not been described in the literature. Notably, we were unable to detect mechanisms of benefit in a separate analysis utilizing quantitative data. Findings emphasize the importance of including qualitative measures in intervention research and selecting quantitative measures that reflect the intervention's real effects, if any.

Long-Distance Caregivers: What are Their Experiences with Formal Care Providers?

OBJECTIVES

Extensive literature has documented the experiences of informal caregivers and their interactions with formal care providers, yet this research is almost entirely limited to caregivers who live near their care-recipients. This study aims to describe long-distance caregivers' (LDC) experiences (e.g., satisfaction and challenges) with formal care providers. Subgroup differences were examined based on the care-recipient's (CR) dementia status and residential setting (community versus residential care).

METHODS

Data were collected from 296 LDCs (Mage = 56.64, SD = 12.40) categorized into four subgroups based on CR dementia status and residential setting. Participants rated their overall satisfaction, satisfaction with communication and information, and described challenges faced in their interactions with formal care providers.

RESULTS

Challenges related to formal care providers were significantly greater and satisfaction significantly lower among LDCs of CRs in residential care, irrespective of dementia status, when compared to LDCs of CRs in the community.

CONCLUSIONS

This study provides insights into the experiences of a growing segment of the caregiver population managing care from a distance, specifically in their interactions with formal care providers.

CLINICAL IMPLICATIONS

The results of this study point to the possible necessity for the development of novel interventions to improve and enhance communication and collaboration between FCPs and informal caregivers.

Family involvement in nursing homes: an interpretative synthesis of literature

Background

Family involvement in nursing homes is generally recognized as highly valuable for residents, staff and family members. However, family involvement continues to be challenging in practice.

Aim

To contribute to the dialogue about family involvement and develop strategies to improve family involvement in the nursing home.

Methods

This interpretative synthesis consists of a thematic analysis and care ethical interpretation of issues regarding family involvement from the perspective of families in nursing homes reported in literature.

Findings

This study reveals the complexities of family involvement in the nursing home by drawing attention to the moral dimension of the issues experienced by families, as seen through the theoretical lens of Baier’s care ethical concept of trust as a theoretical lens. The synthesis of literature resulted in a thematic categorization of issues reported by families, namely, family–staff relationship, psychosocial factors and organizational circumstances. The care ethical interpretation of the synthesis of literature showed that the concept of trust resonates with all reported issues. Trust evolves over time. Early issues are mostly related to getting to know each other. Secondly, families want to experience that staff are competent and of good will. Difficult feelings families may have, such as guilt or loneliness, and dealing with the deterioration of the loved one puts families in a vulnerable position. This power imbalance between family and staff impedes a trusting relationship. Issues related to organizational circumstances, such as understaffing, also undermine families' trust in staff and the nursing home.

Discussion and conclusion

Baier’s theoretical concept of trust provides a deeper insight into the moral dimension of family involvement from the perspective of families in the nursing home. To improve family involvement in practice, we propose to aim future interventions at reinforcing trust in the relationship between family and staff as well as in the organizational context in which these care relationships occur.

Governance of Assisted Living in Singapore: Lessons for Aging Countries

A global trend toward aging populations means that the challenge of providing adequate long-term care to older people looms large in many countries. In Singapore, a public discourse revolving around the expansion of assisted living to create age-friendly environments in long-term care has emerged. This study examines Singapore's experience in developing regulations for assisted living by documenting the different levels of regulation in place and by identifying the regulatory gaps remaining to govern assisted living. Anchoring in a conceptual framework on the governance of assisted living, different regulatory components of assisted living at the micro-, meso-, and macro-levels are analyzed. Using a case study method, primary and secondary data examining the experiences of governing and implementing assisted living in Singapore were collected. Analysis was conducted using a thematic analysis approach. Micro- and some macro-level regulations, which include admission assessment, staffing, and infrastructural requirements for assisted living, are maturing and evolving, while meso-level regulations, such as operational management, the monitoring framework, and stipulations for training requirements for staff, remain a work-in-progress in Singapore. The regulations for assisted living are currently primarily guided by soft laws, such as practice guidelines; the government has committed toward enacting permanent regulations for all long-term care facilities with the phased implementation of the Health Care Services Act from 2021 to 2023. We conclude that assisted living, despite the early stage of its development in Singapore, is a viable care model that should be expanded to meet the rising demand for care on the part of a majority of older people, who fall in the middle of the care continuum (that is, they can neither live independently nor need complete institutionalization). We also propose five policy recommendations for all aging countries to strengthen the governance of assisted living in long-term care. These include establishing (i) clear provisions on care quality assessment and the redress of grievance, (ii) minimum standards of care, (iii) differential regulations for assisted living, (iv) routine care assessment, and, (v) applying technology in assisted living facilities to address a shortage of care workers.

Reimagining Family Involvement in Residential Long-Term Care

Although descriptions of family involvement in residential long-term care (RLTC) are available in the scientific literature, how family involvement is optimized in nursing homes or assisted living settings remains underexplored. During the facility lockdowns and visitor restrictions of the COVID-19 pandemic, residents experienced social deprivation that may have resulted in significant and adverse health outcomes. As with so many other critical issues in RLTC, the COVID-19 pandemic has magnified the need to determine how families can remain most effectively involved in the lives of residents. This article seeks to better understand the state of the science of family involvement in RTLC and how the COVID-19 pandemic has expedited the need to revisit, and reimagine, family involvement in RLTC.

Informal Caregivers Provide Considerable Front-Line Support In Residential Care Facilities And Nursing Homes

Informal care, or care provided by family and friends, is the most common form of care received by community-dwelling older adults with functional limitations. However, less is known about informal care provision within residential care settings including residential care facilities (for example, assisted living) and nursing homes. Using data from the Health and Retirement Study (2016) and the National Health and Aging Trends Study (2015), we found that informal care was common among older adults with functional limitations, whether they lived in the community, a residential care facility, or a nursing home. The hours of informal care provided were also nontrivial across all settings. This evidence suggests that informal caregiving and some of the associated burdens do not end when a person transitions from the community to residential care or a nursing home setting. It also points to the large role that families play in the care and well-being of these residents, which is especially important considering the recent visitor bans during the COVID-19 epidemic. Family members are an invisible workforce in nursing homes and residential care facilities, providing considerable front-line work for their loved ones. Providers and policy makers could improve the lives of both the residents and their caregivers by acknowledging, incorporating, and supporting this workforce.

Transitioning to Long-Term Care: Family Caregiver Experiences of Dementia, Communities, and Counseling

Objectives: Previous analyses of interventions targeting relationships between family caregivers of people with Alzheimer's disease and related dementias and residential long-term care (RLTC) staff showed modest associations with caregiver outcomes. This analysis aimed to better understand interpersonal and contextual factors that influence caregiver-staff relationships and identify targets for future interventions to improve these relationships. Methods: Using a parallel convergent mixed methods approach to analyze data from an ongoing counseling intervention trial, descriptive statistics characterized the sample of 85 caregivers and thematic analyses explored their experiences over 4 months. Results: The findings illustrated that communication, perceptions of care, and relationships with staff are valued by family caregivers following the transition of a relative with dementia to RLTC. Discussion: The findings deepen understanding of potential intervention targets and mechanisms. These results can inform future psychosocial and psychoeducational approaches that assist, validate, and empower family caregivers during the transition to RLTC.

Getting Along in Assisted Living: Quality of Relationships Between Family Members and Staff

BACKGROUND AND OBJECTIVES

Assisted living facilities (ALFs) have quickly expanded as an alternative to nursing homes. Research on nursing homes has revealed problems in relationships between family members and staff. However, little is known about these relationships within ALFs. The purpose of the current study was to examine the prevalence of conflict and positive and negative interactions from the perspective of both family members and staff and to examine the effects of positive and negative aspects of the relationship on salient staff and family outcomes in ALFs.

RESEARCH DESIGN AND METHODS

Data were collected from 252 family members and 472 staff members across 20 ALFs who participated in the Partners in Care in Assisted Living study. Participants completed measures including interpersonal conflict, depressive symptoms, perception of treatment, and stress related to caregiving.

RESULTS

Conflict among family and staff members was found to be relatively low. For staff, interpersonal conflict and treatment by family members significantly predicted burnout and depressive symptoms. For families, only female gender significantly predicted burden. Subgroup analyses, however, indicated that the effect of interpersonal conflict was significantly associated with perceived caregiver burden among family members whose relative had dementia.

DISCUSSION AND IMPLICATIONS

Despite the relatively harmonious relationships among family-staff in ALFs, sources of conflict and negative interactions were identified, revealing the importance of collaborative relationships and the influence these relationships have on both family and staff outcomes. These findings can inform intervention efforts to improve family-staff interactions within ALFs.

The Predictors of and Motivations for Increased Family Involvement in Nursing Homes

BACKGROUND AND OBJECTIVES

Quantitative and qualitative data from a statewide survey of family members of nursing home residents were analyzed to determine the predictors of, and motivations for, family involvement.

RESEARCH DESIGN AND METHODS

We examined 3 types of involvement: visiting, providing personal care, and family-staff communication. Our mixed methods approach used (a) multilevel regression models to examine predictors of family involvement, including family member perceptions and resident, family member, and facility characteristics, and (b) a thematic analysis of qualitative data regarding the experiences of family members and their motivations for involvement.

RESULTS

Families were more involved when a short-term stay (<3 months) was expected, and when residents were in poorer physical condition. Spouses and female family members were more involved than others, yet the effect of gender varied by relationship type. At the facility level, families of residents in rural facilities reported less family involvement. Aside from these commonalities, predictors of each type of involvement varied. Themes from the qualitative data identify unique motivations for each type of involvement-to enhance residents' identity, care, or quality of life.

DISCUSSION

Families visit more and provide more hands-on assistance when they are not confident in the care being provided or the well-being and stability of their resident loved one. Receiving adequate information, perceiving staff as friendly, and residents as looking well cared for promote greater family-staff communication.

IMPLICATIONS

Findings can inform strategies to increase meaningful family involvement in nursing homes.

Maneuvering Together, Apart, and at Odds: Residents' Care Convoys in Assisted Living

Objectives

Frail and disabled individuals such as assisted living residents are embedded in "care convoys" comprised of paid and unpaid caregivers. We sought to learn how care convoys are configured and function in assisted living and understand how and why they vary and with what resident and caregiver outcomes.

Method

We analyzed data from a qualitative study involving formal in-depth interviews, participant observation and informal interviewing, and record review. We prospectively studied 28 residents and 114 care convoy members drawn from four diverse assisted living communities over 2 years.

Results

Care convoys involved family and friends who operated individually or shared responsibility, assisted living staff, and multiple external care workers. Residents and convoy members engaged in processes of "maneuvering together, apart, and at odds" as they negotiated the care landscape routinely and during health crises. Based on consensus levels, and the quality of collaboration and communication, we identified three main convoy types: cohesive, fragmented, and discordant.

Discussion

Care convoys clearly shape care experiences and outcomes. Identifying strategies for establishing effective communication and collaboration practices and promoting convoy member consensus, particularly over time, is essential to the creation and maintenance of successful and supportive care partnerships.

"Being in-Between": Spouses That Cohabit With and Provide Care for Their Partners in Nursing Homes

It is increasingly possible for couples with differing care needs to move to nursing homes together. To our knowledge, this is the first study about spousal caregiving in this context. This study explores spouse and staff experiences when relatively healthy spouses cohabit with and provide care to their partners in Swedish nursing homes. The overarching theme, "being in-between," reflects the spouse's overlapping role transition and the staff's unfamiliarity with the spouse's role. The spouses are both "insiders" and "outsiders" and are torn between maintaining and letting go of caregiving. Meanwhile, the staff express concern about the spouse's need for respite yet being constantly present, and struggle to balance the staff's and the spouse's control of the caregiving situation. This article provides insight into the challenges experienced by spouses who accompany their partners to residential care and how to best support them in this unfamiliar role.

Family involvement in timely detection of changes in health of nursing homes residents: A qualitative exploratory study

Aims and objectives

To explore family perspectives on their involvement in the timely detection of changes in their relatives' health in UK nursing homes.

Background

Increasingly, policy attention is being paid to the need to reduce hospitalisations for conditions that, if detected and treated in time, could be managed in the community. We know that family continue to be involved in the care of their family members once they have moved into a nursing home. Little is known, however, about family involvement in the timely detection of changes in health in nursing home residents.

Design

Qualitative exploratory study with thematic analysis.

Methods

A purposive sampling strategy was applied. Fourteen semi‐structured one‐to‐one interviews with family members of people living in 13 different UK nursing homes. Data were collected from November 2015–March 2016.

Results

Families were involved in the timely detection of changes in health in three key ways: noticing signs of changes in health, informing care staff about what they noticed and educating care staff about their family members' changes in health. Families suggested they could be supported to detect timely changes in health by developing effective working practices with care staff.

Conclusion

Families can provide a special contribution to the process of timely detection in nursing homes. Their involvement needs to be negotiated, better supported, as well as given more legitimacy and structure within the nursing home.

Relevance to clinical practice

Families could provide much needed support to nursing home nurses, care assistants and managers in timely detection of changes in health. This may be achieved through communication about their preferred involvement on a case‐by‐case basis as well as providing appropriate support or services.

Live-in Care Workers in Sheltered Housing for Older Adults in Israel: The New Sheltered Housing Law

Supportive housing schemes were historically aimed to provide group accommodation for older adults. With the aging of residents, facilities were required to enable them to receive care services in order to allow them to age in place. Thus, different countries and different facilities developed different models of housing with care, reflecting cultural and policy diversities. Despite all of the different models, there are many commonalities among the supportive housing schemes across countries. These include provision of dwelling units and care services provided by either the facility or by external agencies. The aims of this article are threefold: to describe the historical development of the ever-evolving supportive care housing phenomena; to point at variations in models of housing and care within the international context; and to present a new Israeli model that enables residents to privately hire live-in care workers to meet their care needs. This is a unique model in the international context that has not been reported before. The article describes the main ideas of the new model and discusses the challenges that it raises and pinpoints the unresolved issues associated with the presence of live-in care workers employed by residents of sheltered housing that should be addressed.

The Disproportionate Impact Of Dementia On Family And Unpaid Caregiving To Older Adults

The number of US adults ages sixty-five and older who are living with dementia is substantial and expected to grow, raising concerns about the demands that will be placed on family members and other unpaid caregivers. We used data from the 2011 National Health and Aging Trends Study and its companion study, the National Study of Caregiving, to investigate the role of dementia in caregiving. We found that among family and unpaid caregivers to older noninstitutionalized adults, one-third of caregivers, and 41 percent of the hours of help they provide, help people with dementia, who account for about 10 percent of older noninstitutionalized adults. Among older adults who receive help, the vast majority in both community and residential care settings other than nursing homes rely on family or unpaid caregivers (more than 90 percent and more than 80 percent, respectively), regardless of their dementia status. Caregiving is most intense, however, to older adults with dementia in community settings and from caregivers who are spouses or daughters or who live with the care recipient.

Client safety in assisted living: perspectives from clients, personal support workers and administrative staff in Toronto, Canada

As the population ages, the demand for long-term care settings is expected to increase. Assisted living is a suitable and favourable residence for older individuals to receive care services specific to their needs while maintaining their independence and privacy. With the growing transition of older individuals into assisted living, facilities need to ensure that safe care is continually maintained. The purpose of this study was to determine the gaps and strengths in care related to safety in assisted living facilities (ALFs). A qualitative descriptive research design was used to provide a comprehensive understanding of client safety from the perspectives of clients, administrative staff and personal support workers. Interviews were conducted with 22 key informants from three ALFs in Toronto, Ontario throughout July 2012. All interviews were semi-structured, audio-recorded and transcribed verbatim. Initial deductive analysis used directed coding based on a prior literature review, followed by inductive analysis to determine themes. Three themes emerged relating to the safety of clients in ALFs: meaning of safety, a multi-faceted approach to providing safe care and perceived areas of improvement. Sub-themes also emerged including physical safety, multiple factors, working as a team, respecting clients' independence, communication and increased education and available resources. The study findings can contribute to the improvement and development of new processes to maintain and continually ensure safe care in ALFs.

Family visits in shared-housing arrangements for residents with dementia--a cross-sectional study on the impact on residents' quality of life

BACKGROUND

Shared-housing arrangements (SHA) are a German type of small-scale living arrangements for people with dementia (PwD). The involvement of family members is one core domain of SHA. But it has not been investigated yet, what are factors associated with family visits and if family involvement within SHA contributes to better residents' quality of life (QoL).

METHOD

A cross-sectional study including all SHA in Berlin/Germany was performed. Main parameters of interest were residents' QoL (QUALIDEM) and frequencies of family visits within the SHA. Besides descriptive analyses we used logistic regression and ANCOVA to analyze the data.

RESULTS

58 SHA with 396 residents (78.4 years, 69.4% female) participated in the study. Older (OR: 1.034; 95% CI: 1.005; 1.064) and female residents (OR: 2.006; 95% CI: 1.018; 3.950) got more often visited by family members. An active participation of family members in SHA contributes on average to a better QoL in terms of social relationship and social isolation (all ANCOVA p < 0.005). A decreased QoL was found for people without family visits compared to those without family members.

CONCLUSIONS

The involvement of family members in SHA is common but on a similar level compared to other care arrangements. Staff should convince available family members to visit PwD, in order to improve residents QoL. However, the response rate in the present study was about 13%, which may limit the results.

Dementia in relation to family caregiver involvement and burden in long-term care

To better understand the process and outcomes of family involvement for long-term care residents with varying stages of dementia, we analyzed family and staff data for 467 residents of 24 residential care/assisted living and nursing-home settings. Adjusted analyses found that although the amount of family visitation did not significantly vary by resident cognitive status (15 versus 20 visits/month to persons with and without dementia, respectively), the nature of the visit did. Families of cognitively intact residents spent more time in activities related to social and community engagement, such as taking residents on trips and calling and writing letters (p<.001), while families of more impaired residents spent more time on care-related activities, including tasks related to nutrition (p<.027), mobility (p=.001), and discussing care with staff (p=.007), the latter of which was associated with greater burden (p<.001). Staff identified similar patterns but perceived less family involvement.

Coming together and pulling apart: Exploring the influence of functional status on co-resident relationships in assisted living

Social relationships can have considerable influence on physical and mental well-being in later life, particularly for those in long-term care settings such as assisted living (AL). Research set in AL suggests that other residents are among the most available social contacts and that co-resident relationships can affect life satisfaction, quality of life, and well-being. Functional status is a major factor influencing relationships, yet AL research has not studied in-depth or systematically considered the role it plays in residents' relationships. This study examines the influences of physical and mental function on co-resident relationships in AL and identifies the factors shaping the influence of functional status. We present an analysis of qualitative data collected over a one-year period in two distinct AL settings. Data collection included: participant observation, informal interviews, and formal in-depth interviews with staff, residents, administrators and visitors, as well as surveys with residents. Grounded theory methods guided our data collection and analysis. Our analysis identified the core category, "coming together and pulling apart", which signifies that functional status is multi-directional, fluid, and operates in different ways in various situations and across time. Key facility- (e.g., admission and retention practices, staff intervention) and resident-level (e.g., personal and situational characteristics) factors shape the influence of functional status on co-resident relationships. Based on our findings, we suggest strategies for promoting positive relationships among residents in AL, including the need to educate staff, families, and residents.

Social relations and resident health in assisted living: an application of the convoy model

PURPOSE

This article, based on analysis of data from a mixed methods study, builds on a growing body of assisted living (AL) research focusing on the link between residents' social relationships and health. A key aim of this analysis, which uses the social convoy model as a conceptual and methodological framework, was to examine the relative importance of coresident relationships and other network ties to residents' subjective well-being.

DESIGN AND METHODS

We analyzed data from structured face-to-face interviews and social network mapping conducted with 192 AL residents in 9 AL facilities in Georgia.

RESULTS

Having a higher proportion of family ties in one's network was the single most important predictor of well-being, whereas possessing some ties to coresidents and nonfamily members outside AL also had a positive effect. Findings showed that relationships among coresidents generally were important although not emotionally close. Having more close ties was associated with lower well-being, suggesting that not all close ties are beneficial. The majority (84%) of residents' closet ties were with family members.

IMPLICATIONS

Findings illuminate the crucial role families play in residents' overall health and well-being and demonstrate the importance of helping residents develop and maintain a range of network ties, including "weak" ties with coresidents and nonfamily outside AL.

Staff–Family Relationships in Residential Aged Care Facilities

The aim of the study was to examine staff and family members’ perceptions of each other’s roles and responsibilities in the Australian residential aged care setting. Data was collected by interview and focus group from 27 staff and 14 family members at five residential aged care facilities in the state of Victoria, Australia. Findings highlight “communication” as the core category supporting the formation of constructive staff–family relationships, as described by three main themes; “building trust,” “involvement,” and “keeping the family happy.” Staff attitudes, mutual cooperation, meaningful engagement, and shared expectations lay the foundation for relationships. Findings suggest that further efforts to establish and sustain good relationships with families are required by facilities. Characteristics, roles, and expectations of staff and family that can both promote and hinder the formation of constructive staff–family relationships are discussed.

Convoys of care: theorizing intersections of formal and informal care

Although most care to frail elders is provided informally, much of this care is paired with formal care services. Yet, common approaches to conceptualizing the formal-informal intersection often are static, do not consider self-care, and typically do not account for multi-level influences. In response, we introduce the "convoy of care" model as an alternative way to conceptualize the intersection and to theorize connections between care convoy properties and caregiver and recipient outcomes. The model draws on Kahn and Antonucci's (1980) convoy model of social relations, expanding it to include both formal and informal care providers and also incorporates theoretical and conceptual threads from life course, feminist gerontology, social ecology, and symbolic interactionist perspectives. This article synthesizes theoretical and empirical knowledge and demonstrates the convoy of care model in an increasingly popular long-term care setting, assisted living. We conceptualize care convoys as dynamic, evolving, person- and family-specific, and influenced by a host of multi-level factors. Care convoys have implications for older adults' quality of care and ability to age in place, for job satisfaction and retention among formal caregivers, and for informal caregiver burden. The model moves beyond existing conceptual work to provide a comprehensive, multi-level, multi-factor framework that can be used to inform future research, including research in other care settings, and to spark further theoretical development.

"Maintaining connections but wanting more": the continuity of familial relationships among assisted-living residents

Social support is a key component of well-being for older adults, particularly for those who have moved from independent living to assisted living involving a transformation of roles, relationships, and responsibilities. Twenty-nine assisted-living facility residents were interviewed to understand the perceived continuity of relationships with family and friends. An inductive approach to thematic analysis revealed 1 main theme and 3 subthemes. The main theme that emerged was: maintaining connections but wanting more. Residents appreciated maintaining connections with family and friends, but often expressed feelings of discontentment with the continuity of former relationships. The subthemes included: appreciating family and friends, waiting for more, and losing control. Implications for research and practice are discussed.

Comparing the Support-Efficacy Model among Centenarians Living in Private Homes, Assisted Living Facilities, and Nursing Homes

We investigated the influence of social relations on health outcomes in very late life by examining the support-efficacy convoy model among older adults who resided in three different residential environments (centenarians in private homes, n = 126; centenarians in assisted living facilities, n = 55; centenarians in nursing homes, n = 105). For each group, path analytic models were employed to test our hypotheses; analyses controlled for sex, mental status, education, perceived economic sufficiency, and activities of daily living. The hypothesized relationships among the models' variables were unique to each of the three groups; three different models fit the data depending upon residential environment. The direct and indirect effects of social relations assessments were positive for the mental and physical health of very old adults, suggesting that participants welcomed the support. However, residential status moderated the associations between the assessments of social relations, self-efficacy, and both outcomes, physical and mental health.

The influence of hospice use on nursing home and hospital use in assisted living among dual-eligible enrollees

OBJECTIVE

This study examined the impact of hospice enrollment on the probabilities of hospital and nursing home admissions among a sample of frail dual-eligible assisted living (AL) residents.

DESIGN

The study used a retrospective cohort design. We estimated bivariate probit models with 2 binary outcome variables: any hospital admissions and any nursing home admissions after assisted living enrollment.

SETTING

A total of 328 licensed AL communities accepting Medicaid waivers in Florida.

PARTICIPANTS

We identified all newly admitted dual-eligible AL residents in Florida between January and June of 2003 who had complete state assessment data (n = 658) and followed them for 6 to 12 months.

MEASUREMENTS

Using the Andersen behavioral model, predisposing (age, gender, race), enabling (marital status, available caregiver, hospice use), and need (ADL/IADL, comorbidity conditions, and incontinence) characteristics were included as predictors of 2 binary outcomes (hospital and nursing home admission). Demographics, functional status, and caregiver availability were obtained from the state client assessment database. Data on diagnosis and hospital, nursing home, and hospice use were obtained from Medicare and Medicaid claims. Death dates were obtained from the state vital statistics death certificate data.

RESULTS

The mean age of the study sample was 81.5 years. Three-fourths were female and 63% were White. The average resident had a combined ADL/IADL dependency score of 11.49. Fifty-eight percent of the sample had dementia. During the average 8.9-month follow-up period, 6.8% were enrolled in hospice and 10.2% died. Approximately 33% of the sample had been admitted into a hospital and 20% had been admitted into a nursing home. Bivariate probit models simultaneously predicting the likelihood of hospital and nursing home admissions showed that hospice enrollment was associated with lower likelihood of hospital (OR = 0.24, P < .01) and nursing home admissions (OR = 0.56, P < .05). Significant predictors of hospital admissions included higher Charlson Comorbidity Index score and incontinence. Predictors of nursing home admissions included higher Charlson Comorbidity Index score, the absence of available informal caregiver, and incontinence.

CONCLUSIONS

Hospice enrollment was associated with a lower likelihood of hospital and nursing home admissions, and, thus, may have allowed AL residents in need of palliative care to remain in the AL community. AL providers should support and facilitate hospice care among older frail dual-eligible AL residents. More research is needed to examine the impact of hospice care on resident quality of life and total health care expenditures among AL residents.

Improving family-staff relationships in assisted living facilities: the views of family

AIMS

This article is a report of a study of the key influences on family-staff collaboration in low level residential aged care (assisted living) facilities in Australia as seen by the family carers of residents.

BACKGROUND

Collaboration with the willing family is widely acknowledged to be important in the care of the older person. Previous work in nursing homes has shown that staff-family relationships are often ambiguous. Relatively little is known about the issue of staff-family relationships in assisted living facilities.

METHODS

Using qualitative methodology twelve family carers from five assisted living facilities were interviewed and transcripts analysed thematically. Data were collected in 2006/2007.

RESULTS

Four factors important to the establishment and maintenance of collaborative staff-family relationships were identified: comfort, communication, consultation and confidence.

CONCLUSION

Low level care facilities need to create environments that are conducive to the establishment and maintenance of constructive staff-family relationships. A number of practice considerations for care staff to foster relationship-centred care with the family in these types of facilities are presented.

Willingness to Use Mental Health Services Among Older Residents in Assisted Living

Examining the importance of mental health care in assisted living (AL) settings, the present study examines older AL residents’ willingness to use mental health services and its predictors. Data based on face-to-face interviews with 150 older residents from 17 AL settings in Florida are used in the analyses ( Mage = 82.8, SD = 9.4). Multivariate logistic regression is used to estimate the likelihood of willingness to use mental health services in relation to predisposing (demographics and physical health), mental health needs (depressive symptoms), and enabling variables (social network, instrumental support, emotional support, informational support, satisfaction with support, and previous use of mental health services). Willingness to use mental health services is predicted by younger age, unmarried status, lower levels of emotional support, and higher levels of informational support. The relationship of informational support to higher willingness to use mental health services suggests that AL residents could benefit from educational interventions on late life depression.

Formal care providers' perceptions of home- and community-based services: informing dementia care quality

Little attention has been given to the perceptions of formal care providers on the nature and quality of home- and community-based dementia care. The purpose of this descriptive interpretive research was to explore formal care providers' perceptions of their experiences with Canadian home- and community-based dementia care. Participants within three personal interviews and six focus groups (n = 41) included nurses, social workers, therapists, home care aides, and Alzheimer Society personnel (front line/management) in rural and urban areas of Saskatchewan (n = 16), Manitoba (n = 20), and Ontario (n = 8). Two overarching thematic categories, Service Availability and Service Acceptability, emerged from the data analysis. Subthemes of availability were identified as: (a) challenges of service availability, including service wait lists, lack of home care provider training, lack of community-based dementia care infrastructure, and sociocultural and geographic barriers to accessing dementia services; and (b) essential facilitators of availability, including service infrastructure, service bridging, and agency partnerships to form coordinated care systems. Subthemes of acceptability were revealed as: (a) essential components of dementia care, including provision of comprehensive personal care and the use of dementia care professional practice knowledge within a home care setting; and (b) service challenges, including inadequate service time for the physical care and socioemotional support of the client and family caregiver, caregiver and formal provider difficulty with navigation of a fragmented care system, lack of system coordination, and financial costs of services. Essential, integrated dementia care could be established by listening to the "voices of formal care providers," thereby decreasing dementia care costs and increasing the quality of life for those with dementia, and their family caregivers.

"I get along with most of them": direct care workers' relationships with residents' families in assisted living

PURPOSE

The purpose of this article was to explore staff-family relationships in assisted living facilities (ALFs) as they are experienced by care staff and perceived by administrators. We identify factors that influence relationships and explore how interactions with residents' families affect care staff's caregiving experiences.

DESIGN AND METHODS

The data are drawn from a statewide study involving 45 ALFs in Georgia. Using grounded theory methods, we analyze qualitative data from in-depth interviews with 41 care staff and 43 administrators, and survey data from 370 care staff.

RESULTS

Care workers characterized their relationships with most family members as "good" or "pretty good" and aspired to develop relationships that offered personal and professional affirmation. The presence or absence of affirmation was central to understanding how these relationships influenced care staffs' on-the-job experiences. Community, facility, and individual factors influenced the development of relationships and corresponding experiences. Insofar as interactions with family members were rewarding or frustrating, relationships exerted positive or negative influences on workers' caregiving experiences.

IMPLICATIONS

Findings suggest the need to create environments -- through policy and practice -- where both parties are empathetic of one another and view themselves as partners. Doing so would have positive outcomes for care workers, family members, and residents.