Allison R. Heid

New Toolkit to Measure Quality of Person-Centered Care: Development and Pilot Evaluation With Nursing Home Communities

BACKGROUND Increasingly, nursing home (NH) providers are adopting a person-centered care (PCC) philosophy; yet, they currently lack methods to measure their progress toward this goal. Few PCC tools meet criteria for ease of use and feasibility in NHs. The purpose of this article is to report on the development of the concept and measurement of preference congruence among NH residents (phase 1), its refinement into a set of quality indicators by Advancing Excellence in Americas Nursing Homes (phase 2), and its pilot evaluation in a sample of 12 early adopting NHs prior to national rollout (phase 3). The recommended toolkit for providers to use to measure PCC consists of (1) interview materials for 16 personal care and activity preferences from Minimum Data Set 3.0, plus follow-up questions that ask residents how satisfied they are with fulfillment of important preferences; and (2) an easy to use Excel spreadsheet that calculates graphic displays of quality measures of preference congruence and care conference attendance for an individual, household or NH. Twelve NHs interviewed residents (N = 146) using the toolkit; 10 also completed a follow-up survey and 9 took part in an interview evaluating their experience. RESULTS NH staff gave strong positive ratings to the toolkit. All would recommend it to other NHs. Staff reported that the toolkit helped them identify opportunities to improve PCC (100%), and found that the Excel tool was comprehensive (100%), easy to use (90%), and provided high quality information (100%). Providers anticipated using the toolkit to strengthen staff training as well as to enhance care planning, programming and quality improvement. CONCLUSIONS The no-cost PCC toolkit provides a new means to measure the quality of PCC delivery. As of February 2014, over 700 nursing homes have selected the Advancing Excellence in Americas Nursing Homes PCC goal as a focus for quality improvement. The toolkit enables providers to incorporate quality improvement by moving beyond anecdote, and advancing more systematically toward honoring resident preferences.

Multiple Chronic Condition Combinations and Depression in Community-Dwelling Older Adults

BACKGROUND The U.S. Department of Health and Human Services recently called for a paradigm shift from the study of individual chronic conditions to multiple chronic conditions (MCCs). We identify the most common combinations of chronic diseases experienced by a sample of community-dwelling older people and assess whether depression is differentially associated with combinations of illnesses. METHODS Self-reports of diagnosed chronic conditions and depressive symptoms were provided by 5,688 people participating in the ORANJ BOWL(SM) research panel. Each respondent was categorized as belonging to one of 32 groups. ANOVA examined the association between depressive symptoms and combinations of illnesses. RESULTS People with more health conditions experienced higher levels of depression than people with fewer health conditions. People with some illness combinations had higher levels of depressive symptoms than people with other illness combinations. CONCLUSIONS Findings confirm extensive variability in the combinations of illnesses experienced by older adults and demonstrate the complex associations of specific illness combinations with depressive symptoms. Results highlight the need to expand our conceptualization of research and treatment around MCCs and call for a person-centered approach that addresses the unique needs of individuals with MCCs.

Religiosity and quality of life: a dyadic perspective of individuals with dementia and their caregivers

Objectives: Dyadic coping theory purports the benefit of joint coping strategies within a couple, or dyad, when one dyad member is faced with illness or stress. We examine the effect of religiosity on well-being for individuals with dementia (IWDs). In particular, we look at the effect of both dyad members’ religiosity on perceptions of IWDs’ quality of life (QoL). Neither of these issues has been extensively explored. Method: One hundred eleven individuals with mild-to-moderate dementia and their family caregivers were interviewed to evaluate IWDs’ everyday-care values and preferences, including religious preferences. Using an actor–partner multi-level model to account for the interdependent relationship of dyads, we examined how IWD and caregiver ratings of religiosity (attendance, prayer, and subjective ratings of religiosity) influence perceptions of IWDs’ QoL. Results: After accounting for care-related stress, ones own religiosity is not significantly related to IWDs’ or caregivers’ perceptions of IWD QoL. However, when modeling both actor and partner effects of religiosity on perceptions of IWDs’ QoL, caregivers’ religiosity is positively related to IWDs’ self-reports of QoL, and IWDs’ religiosity is negatively associated with caregivers’ perceptions of IWDs’ QoL. Conclusion: These findings suggest that religiosity of both the caregiver and the IWD affect perception of the IWDs QoL. It is important that caregivers understand IWDs’ values concerning religion as it may serve as a coping mechanism for dealing with dementia.

Do Family Proxies Get It Right? Concordance in Reports of Nursing Home Residents’ Everyday Preferences:

Limited work has examined how well family proxies understand nursing home residents’ preferences. With 85 dyads of a nursing home resident and relative, we utilize descriptive statistics and multi-level modeling to examine the concordance in reports of importance ratings of 72 everyday preferences for residents. Results reveal significant mean differences at the p < .001 level between proxies and residents on 12 of 72 preferences; yet, perfect agreement in responses is poor and only increases when dichotomizing responses into an important versus not important outcome. Multi-level modeling further indicates that dyads are discrepant on reports of the importance of growth activities for residents, with residents reporting higher levels of importance than proxies. This discrepancy is associated with residents’ hearing impairment and proxies’ perception of resident openness. The findings highlight not only how proxies may be able to inform care for residents in nursing homes but also where further discussions are warranted.

Health Care Preferences Among Nursing Home Residents: Perceived Barriers and Situational Dependencies to Person-Centered Care

Although much research has examined end-of-life care preferences of nursing home (NH) residents, little work has examined resident preferences for everyday health care. The current study conducted interviews with 255 residents recruited from 35 NHs. Content analysis identified barriers (i.e., hindrances to the fulfillment of resident preferences) and situational dependencies (i.e., what would make residents change their mind about the importance of these preferences) associated with preferences for using mental health services, choosing a medical care provider, and choosing individuals involved in care discussions. Barriers and situational dependencies were embedded within the individual, facility environment, and social environment. Approximately one half of residents identified barriers to their preferences of choosing others involved in care and choosing a medical care provider. In contrast, the importance of mental health services was situationally dependent on needs of residents. Results highlight opportunities for improvement in practice and facility policies that promote person-centered care. [Journal of Gerontological Nursing, 42(2), 11-16.].

Vulnerable, but why? Post-traumatic stress symptoms in older adults exposed to Hurricane Sandy

OBJECTIVE Drawing on pre-disaster, peri-disaster, and post-disaster data, this study examined factors associated with the development of post-traumatic stress disorder (PTSD) symptoms in older adults exposed to Hurricane Sandy. METHODS We used a sample of older participants matched by gender, exposure, and geographic region (N=88, mean age=59.83 years) in which one group reported clinically significant levels of PTSD symptoms and the other did not. We conducted t-tests, chi-square tests, and exact logistic regressions to examine differences in pre-disaster characteristics and peri-disaster experiences. RESULTS Older adults who experienced PTSD symptoms reported lower levels of income, positive affect, subjective health, and social support and were less likely to be working 4 to 6 years before Hurricane Sandy than were people not experiencing PTSD symptoms. Those developing PTSD symptoms reported more depressive symptoms, negative affect, functional disability, chronic health conditions, and pain before Sandy and greater distress and feelings of danger during Hurricane Sandy. Exact logistic regression revealed independent effects of preexisting chronic health conditions and feelings of distress during Hurricane Sandy in predicting PTSD group status. CONCLUSIONS Our findings indicated that because vulnerable adults can be identified before disaster strikes, the opportunity to mitigate disaster-related PTSD exists through identification and resource programs that target population subgroups. (Disaster Med Public Health Preparedness. 2016;10:362-370).

Older adults’ influence in family care: how do daughters and aging parents navigate differences in care goals?

Objective: This study seeks to address how older adults influence their daily care when their preferences conflict with those of their adult daughter caregivers. Method: Using a sample of 10 dyads (N = 20) of an older adult and adult daughter, we utilize content analysis strategies to analyze in-depth, semi-structured interview data with QSR NVIVO to investigate how older adults influence their care, how daughters respond to such efforts of influence, and how dyads navigate differences in care goals. Results: When there is agreement in goals, dyads report tasks going well and both individuals’ requests are honored. When there are differences in care goals, daughters most frequently reason with their older parents, while parents walk away or ‘let go’ of their requests. Daughters report making decisions for their parents for health or safety-related needs. However, all dyads discuss differences in care goals, whereby parents are perceived as insisting, resisting, or persisting in care. Conclusion: Findings illustrate complex patterns of responses by families when navigating differences in daily care goals that carry important implications for research and the development of dyadic-based family interventions.

“We Can’t Provide Season Tickets to the Opera”: Staff Perceptions of Providing Preference-Based, Person-Centered Care

ABSTRACT Knowledge of a nursing home resident’s everyday living preferences provides the foundation for ongoing individualized care planning. Objective: The purpose of this study is to identify nursing home (NH) staff perceptions of facilitators and barriers to learning about and meeting residents’ preferences and reasons why staff feel residents change their minds about preferences. Methods: Focus group sessions and interviews were conducted with 36 NH staff members working in a facility that has been actively assessing resident preferences for five years. Results: Thematic codes classifying facilitators, barriers, and dependencies were identified. Staff shared ways they are able to help meet residents’ preferences as well as barriers to fulfilling resident preferences through their own behaviors, facility characteristics, the social environment, and resident characteristics. In addition, staff believe that residents change their minds about important preferences ‘depending on’ several factors including; global environmental characteristics, social environment, resident characteristics, and general staff perceptions. Conclusions: This work identifies key facilitators and barriers to consider when implementing quality improvement efforts designed to improve the person-centered nature of care in nursing homes and is intended to further inform the culture change movement, which aims to transform NHs by empowering staff and delivering person-centered care.

Modeling Successful Aging Over Time in the Context of a Disaster.

Objective Positing that successful aging (SA) has independent, yet related components that are both objective and subjective, we examine how the indicators of SA change over time and how exposure to a disaster affects the developmental course of SA. Method Data were gathered from 5,688 people aged 50-74 years living in New Jersey who participated in baseline telephone interviews between 2006 and 2008 and then were reassessed up to four times over the following 9 years. Multilevel mixed effects models were used to examine change in objective and subjective SA over time and to evaluate the impact of Hurricane Sandy on SA. Results Over the 9-year period, controlling for age, gender, education, and income, average levels of both subjective SA and objective SA declined. People exposed to Hurricane Sandy experienced sharper declines in subjective SA and indicators of objective SA (pain and functional ability) than people not exposed. Discussion Findings have important implications for expanding our conceptualization of SA, clarifying the measures used to understand SA, and the importance of accounting for the effects of disasters on SA.

Spatial Associations of Multiple Chronic Conditions Among Older Adults

Multimorbidity, the presence of two or more chronic conditions in an individual, presents a major challenge for meeting the health care needs of older adults. This study advances understanding of multiple chronic conditions by using local colocation quotients to reveal spatial associations for five chronic conditions (arthritis, diabetes, heart disease, hypertension, and pulmonary disease) in a statewide panel of older adults in New Jersey. Among adults with three or more conditions, large concentrations of Arthritis-Heart Disease-Pulmonary Disease, Arthritis-Hypertension-Pulmonary Disease, and Diabetes-Heart Disease-Hypertension were observed, each triad located in different regions of the state. Individuals with other triads of conditions, in contrast, were distributed among all older adults in the sample as expected with no areas of local concentration. The study provides gerontologists with a new and effective method for uncovering geographical patterns in combinations of chronic conditions among the populations they serve, thereby enabling more effective interventions.