Assisted Living Facilities Staff Research Articles

Replication of Implementing a Sit-to-Stand Exercise Program in an Assisted Living Facility.

The current quality improvement project aimed at replicating the implementation of a sit-to-stand exercise program in a small 20-bed assisted living facility (ALF) in rural North Carolina. The primary outcome was for residents to maintain or improve function in performance of activities of daily living (ADLs). Even with the challenges of the coronavirus disease 2019 pandemic, ALF staff and residents found a way to continue the exercise program with a high level of participation and thus prevent avoidable decline in residents' independence with ADLs. [Journal of Gerontological Nursing, 48(3), 30-36.].

Characterization of COVID-19 in Assisted Living Facilities - 39 States, October 2020.

The coronavirus disease 2019 (COVID-19) pandemic has highlighted the vulnerability of residents and staff members in long-term care facilities (LTCFs) (1). Although skilled nursing facilities (SNFs) certified by the Centers for Medicare & Medicaid Services (CMS) have federal COVID-19 reporting requirements, national surveillance data are less readily available for other types of LTCFs, such as assisted living facilities (ALFs) and those providing similar residential care. However, many state and territorial health departments publicly report COVID-19 surveillance data across various types of LTCFs. These data were systematically retrieved from health department websites to characterize COVID-19 cases and deaths in ALF residents and staff members. Limited ALF COVID-19 data were available for 39 states, although reporting varied. By October 15, 2020, among 28,623 ALFs, 6,440 (22%) had at least one COVID-19 case among residents or staff members. Among the states with available data, the proportion of COVID-19 cases that were fatal was 21.2% for ALF residents, 0.3% for ALF staff members, and 2.5% overall for the general population of these states. To prevent the introduction and spread of SARS-CoV-2, the virus that causes COVID-19, in their facilities, ALFs should 1) identify a point of contact at the local health department; 2) educate residents, families, and staff members about COVID-19; 3) have a plan for visitor and staff member restrictions; 4) encourage social (physical) distancing and the use of masks, as appropriate; 5) implement recommended infection prevention and control practices and provide access to supplies; 6) rapidly identify and properly respond to suspected or confirmed COVID-19 cases in residents and staff members; and 7) conduct surveillance of COVID-19 cases and deaths, facility staffing, and supply information (2).

Does Service Provider Matter During a Pandemic? COVID-19 Cases and Deaths Among Nonprofit vs. For-Profit Assisted Living Facilities in Florida

When COVID-19 hit the U.S. in early 2020, individuals aged 65+ were identified as a higher risk population. In Florida, Governor DeSantis issued Emergency Order 20-006 to prohibit visitation to facilities housing groups of high-risk people, including assisted living facilities (ALFs). Regardless, 672 ALFs of the 3,119 in Florida had reported at least one positive case of COVID-19 by a resident or staff member as of June 30, 2020. Prior research has highlighted the differences in service delivery between nonprofits and for-profits. This manuscript fills the void of minimal research on nonprofit service delivery during a pandemic. We find that nonprofit ALFs have experienced fewer positive cases of COVID-19 among their residents, but there is no difference between nonprofit and for-profit ALFs in terms of resident deaths. We also find evidence that ALF staff are infecting residents, and the provision of nursing services matters for protecting ALF residents from COVID-19.

REDUCING PSYCHIATRIC HOSPITALIZATIONS FOR ASSISTED LIVING RESIDENTS USING AN INTEGRATED BEHAVIORAL HEALTH / PRIMARY CARE MODEL

Introduction There is a high burden of psychiatric illness in Assisted Living Facilities (ALFs), and a tremendous unmet need for psychiatric care within their “social model”. Existing models of psychiatric care for ALF residents include: 1) outpatient behavioral health clinic visits, often precluded by comorbid medical, cognitive, and functional limitations, 2) on-site psychiatric care that is neither team-based nor formally integrated with primary care, and 3) ER visits for acute psychiatric needs. Hospitalizations, in particular psychiatric hospitalizations, can be distressing for caregivers, disruptive to resident routines, and can be associated with functional decline, deconditioning, delirium, and hospital-acquired infections. It is no surprise, therefore, that many ALF residents and their families wish for “aging in place,” to the extent possible. Methods In July 2018, a collaborative care practice was established for homebound and ALF-residing elders (Perfect Health, Boston Metro North), consisting of a geriatrician, a geropsychiatrist, two geriatric NPs, a geriatric social worker (SW), an RN, and medical assistants. At any given time, 30-40 patients were members of a Medicare Advantage plan (average age 78.7). By late 2018, the team examined specific factors that may have related to potentially avoidable psychiatric hospitalizations. Distillation of these factors led to the development of a Behavioral Health (BH) referral system framed around 1) systematic screenings (e.g. for depression, dementia, substance use disorders), with thresholds for BH referral, or 2) requests for psychiatric consultation by a patient, caregiver, or the geriatrician. BH consultations began with an in-depth assessment by LICSW, followed by diagnosis and treatment planning with the following outcomes: 1) brief psychosocial interventions with patient, caregiver, and/or ALF staff, 2) telephone consultation by the social worker with the geropsychiatrist, and/or 3) referral for geropsychiatrist visit at the ALF. This face-to-face consultation would result in recommendations to the PCP, and specific instructions for follow-up by the RN and/or SW. Select patients would be seen in follow-up by the geropsychiatrist. Weekly interdisciplinary team rounds were held, to triage patients perceived to be at high risk for hospitalization, and to prevent crises. In addition to biweekly rounds with the BH team, ALFs were provided with 24/7 psychiatric support via the practice. Results Prior to full implementation of the interdisciplinary BH model in early 2019, 3 Medicare Advantage (MA) patients were psychiatrically hospitalized for a total of 4 hospitalizations from July through December 2018, for a total of 77 hospitalized days, exceeding MA-wide psychiatric hospitalization rates. Once the above model was implemented, this number decreased to 0 MA psychiatric hospitalizations in 2019. During 2019, hospitalized days were markedly reduced over MA-wide psychiatric hospitalization rates. Factors identified as contributing to early psychiatric hospitalizations included: 1) inadequate or inaccurate psychiatric diagnosis, risk assessment, and treatment planning, 2) lack of timely access to psychiatric care, 3) deficits in coordination among facilities, pharmacies, and family, 4) inadequate “respite” options for ALF staff and residents from high-needs patients and families, 5) cyclical patterns of behavioral difficulty in otherwise stable patients, with apparent lack in contingency planning, and 6) overestimation by families and ALF staff of potential benefits-versus-risks of psychiatric hospitalization. Referral and intervention models are continually being revised as the team retrospectively assesses factors leading to psychiatric hospitalizations and ER transfers. This has led to a working “Behavioral Health Risk Score” which is currently utilized to enhance staff awareness of static and dynamic factors suggestive of patients at high risk, leading to more timely referrals. As an additional benefit, case-based learning about core geriatric psychiatry topics during interdisciplinary rounds has allowed PCPs and other staff members to rely less on the BH team for routine psychiatric issues, holding promise for future scalability. Conclusions Patients, their families and caregivers, and ALFs are strongly motivated to keep residents embedded in their communities. In implementing an integrated behavioral and primary care approach to assessment and treatment, the Perfect Health Boston Metro North practice has seen a substantial decrease in resident hospitalizations. Future research directions include refinement and implementation of the BH Risk Score towards directing BH referrals. Future implementation directions include marketing these encouraging findings to stakeholders such as patients, families, and ALF leadership. The novelty and value of ALFs offering on-site BH is likely appealing to the consumer, and might attract ALF leadership based on maintenance of higher resident occupancy and satisfaction, with fewer losses due to transitions (e.g. extended hospitalizations, rehabilitation, and long-term care stays). This research was funded by: None.

IDENTIFICATION AND EVALUATION OF BEHAVIORAL SYMPTOMS IN DEMENTIA USING PASSIVE RADIO SENSING AND MACHINE LEARNING

Introduction Behavioral symptoms of Alzheimer's disease (e.g. delusions, wandering, aggression, sleep disturbance) lead to increased emergency room visits, caregiver burden, and transfers to memory care facilities. Sensor technologies may hold the potential to facilitate early detection and pre-emptive intervention for these symptoms by enabling continuous passive monitoring in a way that in-person monitoring may not be able to. We present preliminary data for such an approach using a device called the Emerald, developed at MIT, which emits low-powered radio signals and can identify and track parameters related to human behavior (sleep, motion, spatial motion, and respiratory rate) based on how these waves reflect off the human body. Artificial Intelligence (AI) algorithms elicit behavioral markers from sensor data. The device does not require any contact or direct interaction by the person being monitored, thus representing true passive sensing. Methods The Emerald device was installed in the rooms of two dementia patients (N=2) with behavioral symptoms residing in an assisted living facility (ALF). Motion data was gathered continuously for a period of three months and was mapped on to spatial location and time frame. Data processing and analysis occurred simultaneously during the collection period. Additionally, study staff administered weekly standardized assessments to both the participant (MMSE) and ALF staff (NPI-NH, CMAI, PAS) to augment data collected from the Emerald. Device data was compiled and made available to the study clinician for clinical analysis and identification of emergent behavioral complications. Results In both participants, device data were used to identify specific behavioral patterns. The device detected variations in behavior by time of day, escalations in pacing, and moments of restlessness throughout the night for both participants. For one participant, clinical interpretation of device data led to the proposition that the participant was experiencing Periodic Limb Movement Disorder, which was unbeknownst to the participant or clinician prior to study participation. The device was able to identify periodic spasms, which occurred when the person was asleep, and localize these to the patient's legs. The second participant showed increase pacing, wandering, and motor agitation before being hospitalized for heightened anxiety and aggression. Device data indicates the period prior to hospitalization featured increased movement episodes relative to this participant's baseline. Conclusions We propose that behavioral phenotyping using an AI-backed passive sensing approach is feasible and safe, and that this approach can help digitally phenotype behavior symptoms in dementia. While the device merits validation against the current standard of behavior measurement in dementia, its advantages include low cost and ongoing engagement, and continuous monitoring while giving patients the option of stopping monitoring at their discretion. Further studies evaluating sensitivity and reliability are warranted to validate the clinical utility of this device. This research was funded by This project is supported by an Innovations grant from the Massachusetts Institute of Technology.

Consultant Pharmacist⁻Provider Collaboration in U.S. Assisted Living Facilities: A Pilot Study.

The purpose of this pilot study was to explore the impact of pharmacist-provided recommendations to general practitioners (GPs) of patients living in assisted living facilities (ALFs). A secondary objective of this study was to explore prescriber and ALF staff perceptions. This was a mixed-method, quasi experimental 1-group pre/post-test study with an explanatory qualitative arm using in-depth semi-structured interviews at five regional ALFs and one independent community pharmacy in East Tennessee. Residents older than 65 years of age, with confirmed diagnosis of Type II diabetes in the pharmacy’s medical record, taking anti-diabetic medication for at least 14 days and resident of affiliated ALF for at least past 30 days were enrolled. Phase 1 demonstrated a 35.1% (13/37 recommendations) acceptance rate of pharmacist recommendations. Phase 2 demonstrated a similar 31.3% acceptance rate of pharmacist recommendations (5/16 recommendations). The mean pre–post difference in average 30-day FBG was greater in the accepted group than the rejected recommendation group (−9.1 vs. −2.3 mg/dL). Pharmacist–GP collaboration in the ALF population was feasible and may improve the quality of patient care of these residents.

A Quality Improvement System to Manage Feeding Assistance Care in Assisted-Living

PurposeTo describe a feasible quality improvement system to manage feeding assistance care processes in an assisted living facility (ALF) that provides dementia care and the use of these data to maintain the quality of daily care provision and prevent unintentional weight loss. Design and methodsSupervisory ALF staff used a standardized observational protocol to assess feeding assistance care quality during and between meals for 12 consecutive months for 53 residents receiving dementia care. Direct care staff received feedback about the quality of assistance and consistency of between-meal snack delivery for residents with low meal intake and/or weight loss. ResultsOn average, 78.4% of the ALF residents consumed more than one-half of each served meal and/or received staff assistance during meals to promote consumption over the 12 months. An average of 79.7% of the residents were offered snacks between meals twice per day. The prevalence of unintentional weight loss averaged 1.3% across 12 months. ImplicationsA quality improvement system resulted in sustained levels of mealtime feeding assistance and between-meal snack delivery and a low prevalence of weight loss among ALF residents receiving dementia care. Given that many ALF residents receiving dementia care are likely to be at risk for low oral intake and unintentional weight loss, ALFs should implement a quality improvement system similar to that described in this project, despite the absence of regulations to do so.

Assessing Staff Satisfaction with Indoor Environmental Quality in Assisted Living Facilities

This study contributed to knowledge of indoor environmental quality (IEQ) in assisted living facilities (ALFs) by examining staff satisfaction with the work environment, perceived productivity, and attitudes toward environmental sustainability in the workplace. An ALF Staff IEQ Survey was administered to staff ( N = 94) at 12 ALFs, which were newly constructed or renovated within the last 10 years. Staff who participated in the survey were divided into three age groups (young, middle–aged, and older) and two categories of responsibilities (medical and nonmedical). The questionnaire was designed to incorporate the Occupant IEQ Survey (Center for the Built Environment, 2013) and the Leadership in Energy and Environmental Design (LEED) rating criteria. It comprised six IEQ categories: space layout, thermal comfort, air quality, lighting and views, acoustic quality, and facility cleanliness and maintenance. Spearman's rank–order correlation coefficient, Kruskal–Wallis, and Mann–Whitney U tests were used for data analysis. Results identified 23 IEQ factors in all IEQ categories that significantly contributed to staff productivity. Six IEQ factors in four IEQ categories (space layout, thermal comfort, lighting, and facility cleanliness) were significantly related to staff environmental attitudes. In addition, 12 IEQ factors within five IEQ categories (except lighting quality) were found to have notable differences by age discrepancy, whereas five IEQ factors of air quality and facility cleanliness were significantly different for medical and nonmedical staff. The findings of this study provide designers with prioritized demands and preferences for decision making in terms of improving the work environment for the health and well–being of ALF staff. By incorporating the paradigms of evidence–based design (EBD), human–centered design (HCD), and sustainable design (SD), this study proposes a new triadic framework to transition from the current resident–centered model in elder care to a multistakeholder–focused model.

Lessons Learned From a Program Evaluation of a Statewide Continuing Education Program for Staff Members Working in Assisted Living and Adult Day Care Centers in Virginia.

The number of older adults residing in assisted living facilities (ALF) and utilizing adult day care services is expanding with the increasing population of older adults. Currently, there are no standardized requirements for continuing education for assisted living and adult day care service staff at a national level. Given that 62% of states within the United States require continuing education for ALF staff and/or administrators, a more formalized system is needed that provides evidence-based gerontological training to enhance the quality of care and services provided to older adults. This article describes the challenges and lessons learned from conducting a program evaluation of a Statewide Training and Continuing Education Program for Assisted Living Facility and Adult Day Care Service staff in Virginia. Survey evaluation data from a 6-year period was examined and a formative program evaluation was conducted. The findings from the survey evaluation and formative evaluation are discussed as are the lessons learned.

Depression Training in an Assisted Living Facility: A Pilot Study.

Depression in older adults residing in assisted living facilities (ALFs) is often not recognized. ALF staff who work with residents on a daily basis are the most likely individuals to recognize residents' depressive symptoms. The purpose of the current pilot study was to determine feasibility of a 4-week training program for 15 direct care staff to recognize any depression symptoms of 32 residents. Although training significantly improved knowledge, it did not improve staff recognition of residents with positive depressive symptoms. Staff reported the training provided them a better understanding about depression and rated the training as very helpful to be able to recognize depression symptoms. Staff requested more information on ways to respond to someone who is depressed. Additional training should emphasize staff-resident communication skills for staff. Challenges included resident attrition and dwindling staff participation. Strategies to address these challenges are presented. [Journal of Psychosocial Nursing and Mental Health Services, 54(5), 25-31.].

Experiences of Assisted Living Facility Staff in Evacuating and Sheltering Residents During Hurricanes

The study examined Florida assisted living facility staff perspectives of disaster preparedness, response, and recovery after the 2004 and 2005 hurricanes. A descriptive study using qualitative and quantitative approaches. One hundred seventy Florida assisted living facility staff who worked in areas under hurricane threat and provided care to residents during a hurricane. A questionnaire that was mailed or administered to staff attending a regional planning conference with quantitative and qualitative items. Of the 143 facilities that were affected by a hurricane, 77 % reported that they sheltered residents in place, while 23 % indicated that they evacuated for one or more of the hurricanes. Almost one-third of facilities lost telephone service and almost half lost electrical power during one or more of the hurricanes. Key topics noted by both evacuating facilities and those that sheltered in place were 1) decision-making, 2) planning, support, and supplies, 3) communication, and 4) electricity. Unique to assisted living facilities is the role of residents’ family in assuming responsibility for evacuation and shelter during hurricanes. Facility staff at both evacuating and sheltering facilities indicated that the decision to evacuate or to shelter in place was difficult and the electrical power was critical to resident well-being. Assisted living facilities should develop disaster preparedness plans in conjunction with local and state emergency offices. Adequate disaster preparedness has implications for residents’ safety as well as assisted living facility staff during disasters.

Infection Prevention and Control Standards in Assisted Living Facilities: Are Residents' Needs Being Met?

Assisted living facilities (ALFs) provide housing and care to persons unable to live independently, and who often have increasing medical needs. Disease outbreaks illustrate challenges of maintaining adequate resident protections in these facilities. Describe current state laws on assisted living admissions criteria, medical oversight, medication administration, vaccination requirements, and standards for infection control training. We abstracted laws and regulations governing assisted living facilities for the 50 states using a structured abstraction tool. Selected characteristics were compared according to the time period in which the regulation took effect. Selected state health departments were queried regarding outbreaks identified in assisted living facilities. Of the 50 states, 84% specify health-based admissions criteria to assisted living facilities; 60% require licensed health care professionals to oversee medical care; 88% specifically allow subcontracting with outside entities to provide routine medical services onsite; 64% address medication administration by assisted living facility staff; 54% specify requirements for some form of initial infection control training for all staff; 50% require reporting of disease outbreaks to the health department; 18% specify requirements to offer or require vaccines to staff; 30% specify requirements to offer or require vaccines to residents. Twelve states identified approximately 1600 outbreaks from 2010 to 2013, with influenza or norovirus infections predominating. There is wide variation in how assisted living facilities are regulated in the United States. States may wish to consider regulatory changes that ensure safe health care delivery, and minimize risks of infections, outbreaks of disease, and other forms of harm among assisted living residents.

The Effects of Restorative Care Training on Caregiver Job Satisfaction

The job satisfaction of assisted living facility staff was examined as part of an evaluation study of a restorative care training program. Participants completed a job satisfaction survey at registration (before the training) and again at follow-up 3 months after registration (1 month after the conclusion of the training). Researchers examined the effects of training on job satisfaction. Researchers found a high level of job dissatisfaction at registration. At follow-up, responses were more positive on most of the items suggesting a slight but significant change to a more positive attitude toward their jobs. Improving staff job satisfaction in the assisted living environment is an important goal and needs further investigation. Providing staff with inservice training may be one way to help nurse educators achieve that goal.

Reactions of Assisted Living Staff to Behavioral and Psychological Symptoms of Dementia

This study investigates the experiences of unlicensed staff providing care for older adults with behavioral and psychological symptoms of dementia (BPSD). The purpose of this study was to describe the types and frequency of BPSD reported by unlicensed caregivers and to describe reactions and training of the caregivers who provide care to residents with BPSD. Data were derived from 87 staff-resident dyads in twelve assisted living facilities (ALFs). Types and frequency of BPSD and staff reaction to BPSD were collected using standardized measures. Demographic data included amount of staff training related to caring for someone with BPSD. Dementia related behaviors and psychological symptoms were prevalent in the ALF residents, with memory related symptoms being the most frequently reported. Symptoms of depression in the ALF residents were less frequent yet accounted for the highest level of staff reaction. Limited training related to caring for residents with cognitive impairment was reported by staff. Developing ALF staff skills in identifying and managing depression in older adults with dementia may serve a dual purpose of improving quality of life for residents and for ALF staff.

Hospice in Assisted Living: Promoting Good Quality Care at End of Life

The purpose of this study was to describe good quality care at the end of life (EOL) for hospice-enrolled residents in assisted living facilities (ALFs). A qualitative descriptive design was used to obtain detailed descriptions of EOL care provided by ALF medication aides, caregivers, nurses, and hospice nurses in urban and rural settings. A semistructured interview guide facilitated interviews where 38 participants described specific examples of care that "went well." Findings indicated that the quality and nature of resident-staff and assisted living-hospice staff relationships are critical in promoting good care at EOL for ALF residents on hospice. Length of the resident's stay in the facility and how well staff knew the resident were associated with the quality of the resident-staff relationship. Respectful collaboration, clear communication, use of complementary knowledge and skills of staff, and shared expectations about the care were associated with positive staff relationships. Also important was ALF administrator support for residents' dying in place with hospice services. ALFs choosing to support residents dying in their facility will benefit from developing systems of care that promote resident-staff relationships and optimize communication and collaboration among ALF care providers and with hospice staff. Hospice programs should design their services to support ALF staff as well as patients and families. Now needed are development and testing of models of care by hospice and ALF to support the care needs of ALF residents at EOL.

Use of Self-Prescribed Nonprescription Medications and Dietary Supplements Among Assisted Living Facility Residents

Describe the prevalence of self-prescribed use and misuse as well as users' opinions concerning nonprescription medications and dietary supplements in assisted living facilities. Descriptive cross-sectional study. Two assisted living facilities (ALFs) in Oregon and Washington State. Convenience sample of 45 ALF residents. Chart reviews and face-to-face interviews. Prevalence and types of use of self-prescribed over-the-counter (OTC) medications and dietary supplements; misuse of these products, and participants' opinions concerning use of these products. Among 29 women and 16 men with a mean (+/- SD) age of 84.8 +/- 6.9 years and a mean of 9.9 +/- 6.4 years of education, 84.4% were using selfprescribed OTC medications and dietary supplements at the time of this study. A mean of 3.4 products was used per participant. Nutritional supplements were most frequently used (32% of products), followed by gastrointestinal products (17%), pain relievers (16.3%), herbals (14.4%), topical products (12%), and cold/cough products (8.5%). Potential misuse was identified in 23 (51%) of the participants. Problems in the use of products included duplication (70%), potential drug/disease/food interactions (20.8%), and other inappropriate use (9.1%). The majority (76%) of the participants believed the products were helpful in maintaining health, 56% of them wanted more product information, 49% sought product information from family and friends, 40% turned to their physicians and nurses for information, and 11% asked pharmacists for advice. The use of nonprescription medications and dietary supplements among ALF residents was high, and simultaneous use of multiple products with the same active ingredient was the most prevalent problem. The residents turned to family and friends, physicians, nurses, and ALF staff for information on these products more frequently than they did to pharmacists.

Admission and continued-stay criteria for assisted living facilities.

As residents in assisted living facilities (ALFs) try to "age in place" but decline in health, the facilities, families, and residents must find a balance between protecting the health and safety of residents in ALFs and maintaining their desire to live independently. The assisted living industry incorporates resident autonomy into its goals, but with regard to resident health and safety, recent reports have found that ALF staff are struggling to provide adequate care for residents with increasingly complex needs. Moreover, state regulations are not consistent in obligating ALFs to prioritize adequate health care and protection for residents over resident autonomy, or vice versa. A set of admission and continued stay criteria for individuals residing in assisted living that could serve as a guideline for state regulations in addressing the balance between safety and autonomy in ALFs is recommended.