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Zimmerman S, Sloane PD, Wretman CJ, Cao K, Silbersack J, Carder P, Thomas KS, Allen J, Butrum K, Chicotel T, Giorgio P, Hernandez M, Kales H, Katz P, Klinger JH, Kunze M, Laxton C, McNealley V, Meeks S, O'Neil K, Pace D, Resnick B, Schwartz L, Seitz D, Smetanka L, Van Haitsma K. Recommendations for Medical and Mental Health Care in Assisted Living Based on an Expert Delphi Consensus Panel: A Consensus Statement. JAMA Netw Open 2022; 5:e2233872. [PMID: 36173637 DOI: 10.1001/jamanetworkopen.2022.33872] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
IMPORTANCE Assisted living (AL) is the largest provider of residential long-term care in the US, and the morbidity of AL residents has been rising. However, AL is not a health care setting, and concern has been growing about residents' medical and mental health needs. No guidance exists to inform this care. OBJECTIVE To identify consensus recommendations for medical and mental health care in AL and determine whether they are pragmatic. EVIDENCE REVIEW A Delphi consensus statement study was conducted in 2021; as a separate effort, the extent to which the recommendations are reflected in practice was examined in data obtained from 2016 to 2021 (prepandemic). In the separate effort, data were from a 7-state study (Arkansas, Louisiana, New Jersey, New York, Oklahoma, Pennsylvania, Texas). The 19 Delphi panelists constituted nationally recognized experts in medical, nursing, and mental health needs of and care for older adults; dementia care; and AL and long-term care management, advocacy, regulation, and education. One invitee was unavailable and nominated an alternate. The primary outcome was identification of recommended practices based on consensus ratings of importance. Panelists rated 183 items regarding importance to care quality and feasibility. FINDINGS Consensus identified 43 recommendations in the areas of staff and staff training, nursing and related services, resident assessment and care planning, policies and practices, and medical and mental health clinicians and care. To determine the pragmatism of the recommendations, their prevalence was examined in the 7-state study and found that most were in practice. The items reflected the tenets of AL, the role of AL in providing dementia care, the need for pragmatism due to the diversity of AL, and workforce needs. CONCLUSIONS AND RELEVANCE In this consensus statement, 43 recommendations important to medical and mental health care in AL were delineated that are highly pragmatic as a guide for practice and policy.
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Affiliation(s)
- Sheryl Zimmerman
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill
- School of Social Work, University of North Carolina at Chapel Hill, Chapel Hill
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill
| | - Philip D Sloane
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill
- Department of Family Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill
| | | | - Kevin Cao
- School of Medicine, University of Illinois Chicago, Chicago
| | - Johanna Silbersack
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill
| | | | | | - Josh Allen
- Allen Flores Consulting Group, Searcy, Arkansas
| | | | - Tony Chicotel
- California Advocates for Nursing Home Reform, Berkeley
| | | | | | - Helen Kales
- Department of Psychiatry, University of Michigan, Ann Arbor
| | - Paul Katz
- Department of Geriatrics, College of Medicine, Florida State University, Tallahassee
| | | | - Margo Kunze
- American Assisted Living Nurses Association, Belmar, New Jersey
| | | | | | - Suzanne Meeks
- Department of Psychological & Brain Sciences, University of Louisville, Louisville, Kentucky
| | | | | | | | - Lindsay Schwartz
- Workforce & Quality Innovations, LLC, Bear Creek, North Carolina
| | - Dallas Seitz
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Lori Smetanka
- National Consumer Voice for Quality Long-Term Care, Washington, DC
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Levy C, Zimmerman S, Mor V, Gifford D, Greenberg SA, Klinger JH, Lieblich C, Linnebur S, McAllister A, Nazir A, Pace D, Stone R, Resnick B, Sloane PD, Ouslander J, Gaugler JE. Pragmatic Trials in Long-Term Care: Implementation and Dissemination Challenges and Opportunities. J Am Geriatr Soc 2022; 70:709-717. [PMID: 35195281 PMCID: PMC8944211 DOI: 10.1111/jgs.17698] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 02/01/2022] [Indexed: 11/28/2022]
Abstract
Randomized controlled trials are considered the most rigorous research design in efficacy and effectiveness research; however, such trials present numerous challenges that limit their applicability in real-world settings. As a consequence, pragmatic trials are increasingly viewed as a research design that overcomes some of these barriers with the potential to produce findings that are more reproducible. Although pragmatic methodology in long-term care is receiving increasing attention as an approach to improve successful dissemination and implementation, pragmatic trials present complexities of their own. To address these complexities and related issues, experts with experience conducting pragmatic trials, developing nursing home policy, participating in advocacy efforts, and providing clinical care in long-term care settings participated in a virtual consensus conference funded by the National Institute on Aging in Spring 2021. Participants identified 4 cross-cutting principles key to dissemination and implementation of pragmatic trial interventions: (1) stakeholder engagement, (2) diversity and inclusion, (3) organizational strain and readiness, and (4) learn from adaptations. Participants emphasized that implementation processes must be grounded in the perspectives of the people who will ultimately be responsible for implementing the intervention once it is proven to be effective. In addition, messaging must speak to long-term care staff and all others who have a stake in its outcomes. Although our understanding of dissemination and implementation strategies remains underdeveloped, this article is designed to guide long-term care researchers and community providers who are increasingly aware of the need for pragmatism in disseminating and implementing evidence-based care interventions.
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Affiliation(s)
- Cari Levy
- Department of Veterans Affairs, Rocky Mountain Regional VA Medical Center, Aurora, CO, USA,University of Colorado, Aurora, CO, USA,Address correspondence to Cari Levy, MD, PhD, Division of Health Care Policy and Research, University of Colorado at Denver HSC, 13611 E Colfax Ave, Aurora, CO 80045, USA. (C. Levy)
| | - Sheryl Zimmerman
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Vincent Mor
- Center of Innovation in Long-term Services and Supports, Providence VA Medical Center, Providence, RI, USA,Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA
| | - David Gifford
- Center for Health Policy Evaluation, American Health Care Association, Washington, DC, USA,Center for Quality and Innovation, School of Public Health, Brown University, Providence, RI, USA
| | | | | | | | | | | | - Arif Nazir
- Signature HealthCARE, Louisville, KY, USA
| | | | | | - Barbara Resnick
- University of Maryland School of Nursing, Baltimore, MD, USA
| | - Philip D. Sloane
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Joseph Ouslander
- Department of Integrated Medical Sciences, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, USA
| | - Joseph E. Gaugler
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, MN, USA
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Levy C, Zimmerman S, Mor V, Gifford D, Greenberg SA, Klinger JH, Lieblich C, Linnebur S, McAllister A, Nazir A, Pace D, Stone R, Resnick B, Sloane PD, Ouslander J, Gaugler JE. Pragmatic trials in long-term care: Challenges, opportunities, recommendations. Geriatr Nurs 2022; 44:282-287. [DOI: 10.1016/j.gerinurse.2022.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Zimmerman S, Carder P, Schwartz L, Silbersack J, Temkin-Greener H, Thomas KS, Ward K, Jenkens R, Jensen L, Johnson AC, Johnson J, Johnston T, Kaes L, Katz P, Klinger JH, Lieblich C, Mace B, O'Neil K, Pace DD, Scales K, Stone RI, Thomas S, Williams PJ, Williams KB. The Imperative to Reimagine Assisted Living. J Am Med Dir Assoc 2021; 23:225-234. [PMID: 34979136 DOI: 10.1016/j.jamda.2021.12.004] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 11/29/2021] [Accepted: 12/03/2021] [Indexed: 10/19/2022]
Abstract
Assisted living (AL) has existed in the United States for decades, evolving in response to older adults' need for supportive care and distaste for nursing homes and older models of congregate care. AL is state-regulated, provides at least 2 meals a day, around-the-clock supervision, and help with personal care, but is not licensed as a nursing home. The key constructs of AL as originally conceived were to provide person-centered care and promote quality of life through supportive and responsive services to meet scheduled and unscheduled needs for assistance, an operating philosophy emphasizing resident choice, and a residential environment with homelike features. As AL has expanded to constitute half of all long-term care beds, the increasing involvement of the real estate, hospitality, and health care sectors has raised concerns about the variability of AL, the quality of AL, and standards for AL. Although the intent to promote person-centered care and quality of life has remained, those key constructs have become mired under tensions related to models of AL, regulation, financing, resident acuity, and the workforce. These tensions have resulted in a model of care that is not as intended, and which must be reimagined if it is to be an affordable care option truly providing quality, person-centered care in a suitable environment. Toward that end, 25 stakeholders representing diverse perspectives conferred during 2 half-day retreats to identify the key tensions in AL and discuss potential solutions. This article presents the background regarding those tensions, as well as potential solutions that have been borne out, paving the path to a better future of assisted living.
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Affiliation(s)
- Sheryl Zimmerman
- Cecil G. Sheps Center for Health Services Research and Schools of Social Work and Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Paula Carder
- Institute on Aging, College of Urban and Public Affairs and School of Public Health, Oregon Health and Science University-Portland State University, Portland, OR, USA
| | - Lindsay Schwartz
- Center for Health Policy Evaluation in Long-Term Care, American Health Care Association/National Center for Assisted Living, Washington, DC, USA
| | - Johanna Silbersack
- Cecil G. Sheps Center for Health Services Research and Schools of Social Work and Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Helena Temkin-Greener
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Kali S Thomas
- US Department of Veterans Affairs Medical Center, and Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Kimberly Ward
- Cecil G. Sheps Center for Health Services Research and Schools of Social Work and Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Liz Jensen
- Direct Supply Innovation & Technology Center, Milwaukee, WI, USA
| | - Alfred C Johnson
- National Association for Regulatory Administration, Madison, WI, USA
| | | | | | - Loretta Kaes
- American Assisted Living Nurses Association, Napa Valley, CA, USA
| | - Paul Katz
- Department of Geriatrics, College of Medicine, Florida State University, FL, USA
| | | | | | - Beth Mace
- National Investment Center for Seniors Housing and Care, Annapolis, MD, USA
| | | | - Douglas D Pace
- Mission Partnerships, Alzheimer's Association, Washington, DC, USA
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Fazio S, Zimmerman S, Doyle PJ, Shubeck E, Carpenter M, Coram P, Klinger JH, Jackson L, Pace D, Kallmyer B, Pike J. What Is Really Needed to Provide Effective, Person-Centered Care for Behavioral Expressions of Dementia? Guidance from The Alzheimer's Association Dementia Care Provider Roundtable. J Am Med Dir Assoc 2020; 21:1582-1586.e1. [DOI: 10.1016/j.jamda.2020.05.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 05/07/2020] [Accepted: 05/10/2020] [Indexed: 12/27/2022]
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Klinger JH. The changing landscape of assisted living. Geriatr Nurs 2018. [DOI: 10.1016/j.gerinurse.2018.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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