Comparison of Team-Based and Problem-Based Approaches to Dementia Care in Nursing Homes and Their Effects on Resident Outcomes During the COVID-19 Pandemic: A Mixed-Methods Study

Abstract

ObjectivesCompare the effectiveness of 2 nonpharmacologic approaches to dementia care in nursing homes on 12- and 18-month resident outcomes, which was after the emergence of COVID-19. Design and InterventionA cluster randomized pragmatic trial, which included an embedded convergent mixed-methods design. Nursing homes were randomized to a team-based (TB) or problem-based (PB) intervention arm. Setting and ParticipantsResidents (n = 2658 at baseline) and staff (n = 327) from 52 nursing homes in the United States. MethodsThe exploratory quantitative analysis used a difference-in-differences model to compare the change in TB arm resident outcomes between baseline, 12 months, and 18 months relative to the PB arm using the Minimum Data Set 3.0. Outcomes included antipsychotic medication use, behavioral symptoms, wandering, and rejection of care. Staff interview data were analyzed in a 3-phase team-based rapid qualitative analysis approach, after which data were integrated. ResultsRejection of care decreased by 5.9 percentage points in the TB arm relative to the PB arm at 12 months (95% CI –11.7 to −0.2). Emergent results indicated that COVID-19 visitation restrictions prevented PB staff from working with families to manage rejection of care as was done before the pandemic, whereas TB staff described using collaboration strategies not hindered by the pandemic. There was no statistically significant difference between arms in antipsychotic medication use, behavioral symptoms, and wandering at either follow-up period. When integrated, qualitative data provided contradictory information on antipsychotic medication use and confirmatory information on behavioral symptoms and wandering. Conclusions and ImplicationsThe exploratory nature and mixed results of the quantitative data analysis limited the ability to determine a clear benefit of one approach over the other. Findings suggest that dementia care delivery faced complex challenges during COVID-19 and required engagement from a broad range of nursing home staff underscoring the importance of equipping all staff with foundational dementia care knowledge.