Community-based Residential Settings Research Articles

Building Resilience in the Face of Crisis: Lessons Learned from a Community Behavioral Healthcare Organization.

The novel coronavirus (SARS-CoV-2 or COVID19) has defied the healthcare system at every turn. The impact of this pandemic on ensuring the health and safety of individuals with serious and persistent mental illness—particularly those living in community-based residential settings—has been challenging. As one of the largest community behavioral health organizations in Oregon, the authors present a descriptive study of an organizational response to the COVID-19 pandemic. This paper presents barriers, strategies, and lessons learned, through firsthand experience and interviews with key residential staff. This paper is not formal research, but the integration and assessment of staff perspective, and organizational experience and knowledge. By sharing these insights and experience, this paper contributes to a collective roadmap for the future, to guide responses to public health crises or other unprecedented events that threaten organizations caring for some of the most vulnerable members of the community.

Service Availability in Assisted Living and Other Community-Based Residential Settings at the End of Life.

Background: Community-based residential settings (e.g., assisted living facilities and retirement communities), are increasing, where vulnerable older adults are living as they age and die. Despite prevalent serious illness, functional impairment, and dementia among residents, the mix and types of built-in services available are not known. Objective: To classify older adults in community-based residential settings by the types of services available and examine associations between service availability and hospice use and location of death. Design: Pooled cross-sectional analysis. Setting: Medicare Current Beneficiary Survey data (2002-2018). Subjects: U.S. adults 65 years of age and older, who lived in a community-based residential setting and died between 2002 and 2018 (N = 1006). Measurements: Availability (yes/no) of nursing care, medication assistance, meals, laundry, cleaning, transportation, and recreation. Results: Our sample resided in assisted living facilities (32.0%), retirement communities (29.0%), senior citizen housing (13.7%), continuing care facilities (13.5%), and other (11.8%). Four classes of individuals with distinct combinations of available services were identified: 48.2% lived in a residence with all measured services available; 29.1% had availability of all services, except nursing care and medication assistance; 12.6% had availability of only recreation and transportation services; and 10.1% had minimal/no service availability. Of the 51.8% of older adults residing in settings without clinical services, more than half died at home and fewer than half died with hospice. Conclusions: The majority of older adults who die in community-based residential settings do not have access to built-in clinical services. Palliative care training for staff in these settings may be warranted, given variable rates of hospice use and high rates of home death.

Using Group Concept Mapping to Develop a Conceptual Model of Housing and Community-Based Residential Settings for Adults With Severe Mental Illness.

BackgroundMost existing conceptual models of residential environments and housing programs were developed over a decade ago or lack comprehensiveness. The attributes to be used to describe housing programs with adequate specification remain unclear including the attributes that mediate service user outcomes. In this study, group concept mapping was used to develop a conceptual model of housing and community-based residential settings for adults with severe mental illness based on stakeholder perceptions and values.MethodsParticipants were selected through purposive sampling and included service users, family members, staff working in residential facilities, mental health workers and managers. Participants (n=221) generated 1,382 statements describing attributes of housing and community-based residential settings for adults with severe mental illness (99% saturation). Thematic content analysis was conducted to analyze the statements and create a list of 140 selected statements. Participants then rated (n=416) and sorted into categories (n=73) the selected statements. Descriptive statistics were computed for each statement relative importance. Multidimensional scaling and hierarchical cluster analysis were used to produce the conceptual model (maps). Stakeholders (n=12) were also involved in the interpretation of the maps.ResultsThe findings show overall concordance between stakeholders in relation to statements perceived importance (rating) and the statements inter-relationships (sorting). The stress value of 0.23 indicates that the two-dimensional solution of the multidimensional scaling analysis fits the data set (goodness of fit). The final conceptualization includes 12 clusters: (1) A balanced and healthy housing system; (2) Quality and management practices (facility/local level); (3) Physical external environment; (4) Services tailored to needs and preferences; (5) Services and interventions provided (linkage); (6) Equality, policies and availability of activities; (7) Organizational structure and staff qualities; (8) Services and interventions (learning skills); (9) Services and interventions (daily living support); (10) Personal space and right to privacy; (11) Physical interior environment; (12) Respect, functioning and atmosphere.ConclusionThe results illustrate the multifaceted and multilevel nature of community-based residential settings through a visual representation. They articulate a number of attributes, clusters and dimensions that could be included in a common conceptual model of community-based residential settings and housing for adults with severe mental illness.

Trends In Residential Setting And Hospice Use At The End Of Life For Medicare Decedents.

As more people live and die in the community despite complex health needs and functional impairment, the need for hospice increases. We found high and increasing penetration of hospice in community-based residential settings, compared with hospice use in private residences and nursing homes.

Experiences of Tobacco Use among Chinese Individuals with Schizophrenia in Community-Based Residential Settings: A Qualitative Study.

Although there is a high prevalence of smoking among individuals with schizophrenia, no previous attempt has been made to explore experiences of tobacco use and cessation within a Chinese sample of this population. A qualitative descriptive study was conducted to explore through the use of individual and semi-structured interviews the experiences of tobacco use and quitting in a sample Chinese population with schizophrenia. Twenty-three eligible participants with schizophrenia who currently smoke were recruited from three community residential mental health service settings. Four main themes representing the experiences of the participants were uncovered in this study: (1) smoking and illness; (2) environment and culture; (3) reasons for smoking; and (4) beliefs about cessation methods. The findings indicated that the participants considered the disease to be far more harmful than smoking, and perceived many benefits to smoking. Although some thought of quitting at times, most gave up the idea or failed to quit due to internal factors such as disease-related suffering, the use of an avoidance coping strategy, and a lack of cessation support. The most notable finding concerns the use of avoidance coping by the participants, who relied on smoking as a way to avoid the suffering brought about by the disease.

Predicting Youth Improvement in Community-Based Residential Settings with Practices Derived from the Evidence-Base.

The current investigation conducted descriptive analyses on key variables in community-based residential (CBR) settings and investigated the extent to which disruptive youth between the ages of 13 and 17years improved based on therapists' reported alignment with using practices derived from the evidence-base (PDEBs). Results from both the descriptive analyses and multilevel modeling suggested that therapists are using practices that both do and do not align with the evidence-base for disruptive youth. In addition, both PDEBs and practices with minimal evidence-support predicted or marginally predicted final average progress rating for these youth. Findings are discussed as they relate to the importance of continued exploration of treatment outcomes for CBR youth.

Using Human-Centered Design Leadership to Improve Care of Older Adults With Disabilities

As the population of individuals with disabilities is rapidly aging, organizations face new challenges in person-centered care, especially in residential facilities where their caregivers are not family members but individuals with diverse cultural backgrounds and limited understanding of American culture. There are many organizations which offer a range of services to individuals with disabilities, including community-based residential settings where caregivers work with adults to increase independence in daily living skill development, behavior management, personal care, medication administration, and other services and activities. Complications arise when caregivers lack the knowledge, training, cultural understanding, and communication skills necessary to provide quality care. Much more skill acquisition is needed than the minimal State-required 40-hour orientation and training. This article outlines the leadership needs for specific studies that use human-centered designs to develop new trainings and work processes that are tailor-made to suit needs of caregivers and individuals for whom they care. Additionally, it discusses the need for studies that could lead to practice and policy changes needed based upon results of research to determine the levels of knowledge diverse caregivers, serving adults with disabilities, have regarding activities of daily living and the aging process.

Should we provide oral health training for staff caring for people with intellectual disabilities in community based residential care? A cost-effectiveness analysis

Oral health training is often introduced into community-based residential settings to improve the oral health of people with intellectual disabilities (ID). There is a lack of appropriate evaluation of such programs, leading to difficulty in deciding how best to allocate scarce resources to achieve maximum effect. This article reports an economic analysis of one such oral health program, undertaken as part of a cluster randomized controlled trial. Firstly, we report a cost-effectiveness analysis of training care-staff compared to no training, using incremental cost-effectiveness ratios (ICERs). Effectiveness was measured as change in knowledge, reported behaviors, attitude and self-efficacy, using validated scales (K&BAS). Secondly, we costed training as it was scaled up to include all staff within the service provider in question. Data were collected in Dublin, Ireland in 2009. It cost between €7000 and €10,000 more to achieve modest improvement in K&BAS scores among a subsample of 162 care-staff, in comparison to doing nothing. Considering scaled up first round training, it cost between €58,000 and €64,000 to train the whole population of staff, from a combined dental and disability service perspective. Less than €15,000–€20,000 of this was additional to the cost of doing nothing (incremental cost). From a dental perspective, a further, second training cycle including all staff would cost between €561 and €3484 (capital costs) and €5815 (operating costs) on a two yearly basis. This study indicates that the program was a cost-effective means of improving self-reported measures and possibly oral health, relative to doing nothing. This was mainly due to low cost, rather than the large effect. In this instance, the use of cost effectiveness analysis has produced evidence, which may be more useful to decision makers than that arising from traditional methods of evaluation. There is a need for CEAs of effective interventions to allow comparison between programs. Suggestions to reduce cost are presented.

The Influence of Living Situations on Family Therapy Involvement Among Youth Adjudicated of a Sexual Crime.

Clinical and research professionals working with youth who have sexually offended have increasingly advocated for community-based care. However, other scholars have noted the appropriateness of residential placements for many youth. Research is inconclusive concerning the degree to which youth with sexually harmful behaviors receive family services, particularly family therapy in either community-based care settings or residential settings, and has yet to thoroughly identify how placement influences family therapy involvement. This study reviews the files of youth who have been adjudicated of a sexual crime (N = 85) to quantitatively identify how living situations influence family therapy involvement. Using bivariate estimations, findings reveal that youth living out of the home and those who change placements were more involved in family therapy than those treated in their own communities or homes. Implications and future research directions are considered.

Home Environmental Health Risks of People With Developmental Disabilities Living in Community-Based Residential Settings: Implications for Community-Health Nurses

Chronic, long-term exposure to indoor air pollutants is increasingly being recognized as a threat to health. Vulnerable populations, such as those with cognitive disabilities, the elderly, and children, are frequently at increased risk from these hazards. This study assessed home environmental health hazards, home characteristics, and household practices that create risk in a sample of community-based group homes. A survey and a home environmental assessment of each home were used to assess the presence of neurotoxicants, such as lead, mercury, and pesticides, in the home and use of protective measures such as carbon monoxide detectors and radon testing.

Relationship between diagnostic criteria, depressive equivalents and diagnosis of depression among older adults with intellectual disability

Depression is more common among persons with an intellectual disability (ID) than the general population, and may be expected to increase with age just as in the general population. However, little is known about depression among older adults with ID. The literature has questioned the use of standard diagnostic criteria for depression among both older adults and persons with ID, and behavioural depressive equivalents have been suggested. This study uses the interRAI ID assessment instrument to investigate the relationship between standard diagnostic criteria for depression, depressive equivalents and a diagnosis of depression among older and younger adults with ID in community and institutional settings in Ontario, Canada. Items in the interRAI ID assessment instrument that were representative of The Diagnostic and Statistical Manual of Mental Disorders 4th Edition (DSM-IV) criteria and depressive equivalents were examined among persons with ID in institutional (census-level data) and in community-based (sample) residential settings. Bivariate logistic regression was used to examine the relationship between depressive symptoms and a diagnosis of depression. Descriptive statistics were used to examine the prevalence of depressive symptoms among those who did not have a diagnosis of depression. The results indicate that DSM-IV diagnostic criteria and depressive equivalents were significantly related to a diagnosis of depression among older and younger adults with ID, and that both types of symptoms were exhibited by a non-trivial proportion of individuals without a diagnosis of depression. The depression rating scale embedded in the interRAI ID is helpful in identifying older adults at risk of depression. Contrary to other studies, few significant differences were found in depressive symptoms by age.

Eight-year follow-up of the impact of environmental characteristics on well-being of adults with developmental disabilities.

The impact of environmental features of residences on adaptive behavior, community integration, and health of adults with mental retardation over an 8-year period was examined. Environmental features included residence type, size, choice-making opportunities, physical attractiveness, and family involvement. We assessed 186 residents who initially lived in nursing homes. At the 8-year follow-up, 133 had moved to community-based residential settings. Findings indicated that residents who moved to community settings had higher levels of adaptive behavior and community integration than residents who remained in nursing homes. A more attractive physical environment and greater opportunity for choice-making were associated with higher levels of adaptive behavior at follow-up. Greater opportunity to make choices and family involvement were associated with higher levels of community integration.

Environmental opportunities and supports for exercising self-determination in community-based residential settings

Information was collected on the environmental opportunities for exercising self-determination among 281 adults with mental retardation receiving community-based residential supports. The results indicated that: (1) the majority of participants had little or no opportunity to exercise self-determination over major life decisions (e.g., with whom and where to live, the recruitment and retention of care staff); (2) even in more mundane areas, such as where and when to eat, the majority of participants were not supported to exercise effective control; (3) variation in environmental opportunities to exercise self-determination was strongly related to a range of factors including participant ability, previous residential history, and structural and procedural aspects of the residential supports currently provided.

Balancing freedom with risks: The experience of nursing task delegation in community-based residential care settings

Background: In 1995, Washington State implemented law reforming the state's long-term care system, favoring provision of service in less restrictive, lower-cost settings. Purpose: The purpose was to systematically evaluate one facet of the new law regarding the implementation of a policy authorizing delegation of designated nursing tasks by registered nurses in community-based residential care settings. Method: This was a descriptive study driven by the inductive process of grounded theory. Qualitative data sources included interviews, public forums, document review, and open-ended survey questions to facility operators, nurses, nursing assistants, and inspectors. Discussion: The study identified an overarching social process, balancing freedom with risks involving tension at the intersections, which is evident from 3 main perspectives: consumer, professional, and the health care system. Conclusions: The study has implications for regulatory consistency, nursing practice and education, collaboration between overlapping providers of skilled nursing services in residential settings, and subsequent health policy.Nurs Outlook 2001;49:193-201.

Environmental characteristics of nursing homes and community-based settings, and the well-being of adults with intellectual disability.

The present study examined whether characteristics of the environment of nursing homes and community-based residential settings are associated with the adaptive behaviour, health and community integration of adults with intellectual disability living in those settings. The specific characteristics of the environment were type of facility, size, level of residential involvement in policy-making, and the degree of variety and stimulation of the physical environment. The study assessed 249 residents with intellectual disability over a 3-year period who lived in nursing homes at baseline. At follow-up, 50 of the residents had moved to community-based facilities while 199 of the residents remained in nursing homes. The results indicated that type, size and characteristics of the environment were related to the level of adaptive behaviour and community integration at follow-up. Residents living in community-based settings had better health and greater levels of community integration than residents living in nursing homes. Residents living in smaller facilities had greater adaptive behaviour at follow-up than residents living in larger facilities. More variety and stimulation in the residential physical environment was associated with greater adaptive behaviour among residents at follow-up. Residential facilities that permitted greater resident involvement in policy-making, and had greater variety and stimulation in their physical environment were associated with greater levels of community integration among their residents at follow-up.

The Role of Social Competence in the Community Adjustment of Persons with Developmental Disabilities

This paper reviews literature and professional practices which affect the community adjustment and adaptation of developmentally disabled persons. The role of social competence in determining satisfactory adjustments to community-based vocational and residential settings by adult persons with developmental disabilities is explored. The paper is divided into five sections. Section one briefly reviews the community adjustment status of persons with developmental disabilities. Section two discusses the construct of social competence in terms of definitional issues and social validation approaches within community-based vocational and residential settings. Section three describes three types of adjustment (behavioral, social, personal) that are considered important to successful community adaptation. Section four reviews the consequences that accrue to developmentally disabled persons from adjustment failure in vocational and residential settings. Finally, section five advocates for adoption of a social ecological approach in the study of community adjustment for developmentally disabled persons and presents a series of recommendations governing future efforts in this area.