Barbara Resnick

Implementation fidelity in community-based interventions

Implementation fidelity is the degree to which an intervention is delivered as intended and is critical to successful translation of evidence-based interventions into practice. Diminished fidelity may be why interventions that work well in highly controlled trials may fail to yield the same outcomes when applied in real life contexts. The purpose of this paper is to define implementation fidelity and describe its importance for the larger science of implementation, discuss data collection methods and current efforts in measuring implementation fidelity in community-based prevention interventions, and present future research directions for measuring implementation fidelity that will advance implementation science.

Testing the Effect of Function-Focused Care in Assisted Living

To develop and test the Function‐Focused Care in Assisted Living (FFC‐AL) intervention so as to alter the decline that older adults in AL experience.

Meaningful improvement in gait speed in hip fracture recovery.

OBJECTIVES: To estimate meaningful improvements in gait speed observed during recovery from hip fracture and to evaluate the sensitivity and specificity of gait speed changes in detecting change in self‐reported mobility.

Testing a family-centered intervention to promote functional and cognitive recovery in hospitalized older adults.

A comparative trial using a repeated‐measures design was designed to evaluate the feasibility and outcomes of the Family‐Centered Function‐Focused‐Care (Fam‐FFC) intervention, which is intended to promote functional recovery in hospitalized older adults. A family‐centered resource nurse and a facility champion implemented a three‐component intervention (environmental assessment and modification, staff education, individual and family education and partnership in care planning with follow‐up after hospitalization for an acute illness). Control units were exposed to function‐focused‐care education only. Ninety‐seven dyads of medical patients aged 65 and older and family caregivers (FCGs) were recruited from three medical units of a community teaching hospital. Fifty‐three percent of patients were female, 89% were white, 51% were married, and 40% were widowed, and they had a mean age of 80.8 ± 7.5. Seventy‐eight percent of FCGs were married, 34% were daughters, 31% were female spouses or partners, and 38% were aged 46 to 65. Patient outcomes included functional outcomes (activities of daily living (ADLs), walking performance, gait, balance) and delirium severity and duration. FCG outcomes included preparedness for caregiving, anxiety, depression, role strain, and mutuality. The intervention group demonstrated less severity and shorter duration of delirium and better ADL and walking performance but not better gait and balance performance than the control group. FCGs who participated in Fam‐FFC showed a significant increase in preparedness for caregiving and a decrease in anxiety and depression from admission to 2 months after discharge but no significant differences in strain or quality of the relationship with the care recipient from FCGs in the control group. Fam‐FFC is feasible and has the potential to improve outcomes for hospitalized older adults and their caregivers.

Feasibility and Impact of a Function Focused Care Intervention for Parkinson's Disease in the Community.

Background:Parkinsons disease (PD) results in a progressive loss of function such that family caregivers provide a large percentage of the personal care to PD patients living in the home setting. Objectives:The aim of this study was to test the feasibility and impact of function-focused care for PD (FFC-PD) developed to optimize function and physical activity among people with PD who live in the community. Methods:This pilot study was a single-group, 2 pretest, 3 posttest repeated-measures design to investigate the impact of the FFC-PD intervention over a 12-month period. Measurements included the Self-Efficacy and Outcome Expectations for Exercise and Functional Activities, Yale Physical Activity Scale, Unified Parkinsons Disease Rating Scale, Barthel Index, Schwab & England, Timed Chair Rise, Parkinsons Disease Questionnaire-39, and Geriatric Depression Scale. Results:The impact of FFC-PD on a person with PD showed a statistically significant increase in outcome expectations for exercise, F(3, 60) = 3.09, p = .034; hours a week exercising, F(1, 24) = 4.95, p = .004; mean weekly energy expenditure, F(2,43) = 4.32, p = .017; hours spent in overall activities, F(3, 60) = 6.06, p = .001; decreased disability based on the Unified Parkinsons Disease Rating Scale, F(2, 40) = 9.48, p < .001; improved Parkinsons Disease Questionnaire-39 score, F(3, 60) = 3.81, p = .014; and a trend toward significance on Barthel Index, F(1.6, 31) = 3.47, p = .055. Discussion:Function-focused care for PD has a significant effect on increasing and on strengthening outcome expectations related to exercise, time spent in exercise, and physical activity and in improving functional performance in people with PD. Further research is needed to explore the use of objective measurements of functional performance and activity and to test FFC-PD in a randomized controlled trial.

Barthel Index of Activities of Daily Living: Item Response Theory Analysis of Ratings for Long-Term Care Residents

BackgroundThe Barthel Index (BI) is a frequently used measure of independence in the activities of daily living (ADLs). Item functioning of various versions of the BI have been examined using Rasch analysis. Item response theory (IRT) models for ordered polytomous responses may provide more insight into item functioning across levels of independence in ADLs. ObjectivesTo compare the fit and appropriateness of the one-parameter logistic model (1PL), the partial credit model (PCM), and the extension of the generalized partial credit model implemented in ConQuest (GPCM-CQ) for the 15-item BI. MethodsThis article is a secondary analysis of baseline BI data obtained from four randomized controlled trials for 788 residents from multiple long-term care facilities. Parameters of three different IRT-based models (1PL Rasch model, PCM, and GPCM-CQ) were estimated. Fit of items and response vectors was assessed. Overall fit was compared across the three models. ResultsItem difficulties were similar for all three models. Most of the 15 items were located at a moderate level of functional independence. In all three models, “don brace” was the easiest ADL but had poor discrimination; “climbing stairs” was the most difficult ADL. Multiple items showed misfit in both 1PL and PCM. Item parameters and person proficiency estimates were highly correlated for the PCM and GPCM-CQ models. The difference in deviance between the PCM and GPCM-CQ was significant. In the GPCM-CQ, most items showed good discrimination, but several had negative or very low discrimination parameters. DiscussionGPCM-CQ results suggested that further revision of the BI may be warranted. Because some items showed poor discrimination, caution should be used when measuring ADL independence with the BI item set.

A Prospective Study of Outcomes of Nursing Home Residents with Chronic Kidney Disease with and without Anemia

To determine whether anemia is a risk factor for functional decline in nursing home (NH) residents with chronic kidney disease.

When Will We Ever Learn the Benefits of Teams

As is well described in the article by Reuben and colleagues, “Effect of Nurse Practitioner Comanagement on the Care of Geriatric Conditions,” there is a critical care need for better management of chronic illness and geriatric syndromes. Moreover, it is virtually impossible to address all of the care needs for patients during a single encounter. The purpose of the study was to test whether a “comanagement” model that combined services provided by nurse practitioners and physicians was effective in implementing the Assessing Care of the Vulnerable Elders (ACOVE-2) model in nonacademic primary care settings. The ACOVE-2 model focuses on addressing geriatric conditions in primary care settings through case finding and using a standardized multicomponent practicechange effort to best address these challenging care conditions in older adults. In the model tested, all of the clinical staff were involved in screening patients to identify specific geriatric syndromes, and systems were put in place to facilitate access to resources and optimal ways for clinicians to address those syndromes (e.g., education materials and community resources). Physicians practicing in the clinics included in the study could also refer patients to a nurse practitioner within the practice to provide focused management of the geriatric syndromes addressed in the study (falls, urinary incontinence, dementia, and depression). This study demonstrated that a team approach is the best way to address the complex needs of older adults in the community. Prior studies have likewise demonstrated the benefits of teams in geriatric care, particularly when managing chronic illnesses such as congestive heart failure and diabetes mellitus. In addition to this reminder to consider the use of a team approach to optimize care and quality outcomes, the findings from this study raised several other issues worthy of note: the persistent inability to understand, appreciate, and recognize what each provider and discipline brings to the care management of any individual patient; the lack of recognition of the importance of beliefs versus knowledge in terms of changing provider behavior; lack of understanding of how healthcare providers make referral decisions; and the need to move beyond looking at process outcomes (provider interventions) and consider patient outcomes (fewer falls, better management of urinary incontinence).