Continuing Care Retirement Community Research Articles

Research Status and Trends in Retirement Communities: A bibliometric Analysis

In the context of global aging, the study of retirement communities has attracted the attention of scholars. However, there needs to be more systematic bibliometric studies. This study aims to sort out the current research status of the retirement community and explore research trends. This study adopts a bibliometric approach, using the Web of Science Core Collection (WoSCC) as a database, VOSviewer to analyze research collaboration networks, and CiteSpace to analyze keyword co-occurrences. The study’s conclusion showed that the significant scholars are Ayalon, Resnick, Bennett, Royall, Courtin, and Knapp. The major journals are the Journal of the American Geriatrics Society, Gerontologist, and Journal of Applied Gerontology.The main research areas are Geriatrics Gerontology, Public Environmental Occupational Health, and Nursing. The primary research countries are the United States, Canada, and China, with the United States leading the way. The study found that the author’s research collaboration network was more active, with Bolling as the bridge author. Institutional collaboration networks were also active, with the University of Washington’s research collaboration network being the most prominent. The research collaboration networks between countries (regions) needed to be more expensive. There are three possible research trends in retirement community research: (1). naturally occurring retirement community (NORC); (2). aging in place; (3). continuing care retirement community (CCRC); (4). physical activity.

Wellness Promotion In A Continuing Care Retirement Community During The Covid-19 Pandemic

Wellness Promotion In A Continuing Care Retirement Community During The Covid-19 Pandemic

고령자 돌봄 주거복합단지(CCRC, Continuing Care Retirement Community) 조성을 위한 법적 과제

Providing an appropriate residential environment for the elderly, who spend most of their time in their residence, is one of the most important tasks facing the aging society. In particular, the elderly’s physical function may deteriorate quickly, which makes it necessary to provide a residential environment that can cover everything from being able to live independently to being in need of medical care. In Korea, various housing policies for the elderly have been promoted based on the Elderly Welfare Act; however, pre-sale elderly welfare housing no longer exists due to disruptive operation, and silver town has become a place where only the wealthy can enter. In addition, nursing homes are considered as unwelcome facilities for the elderly which isolate them from society. Accordingly, some local governments in Korea have recently been actively promoting the introduction of the Continuing Care Retirement Community(CCRC), which has developed in the US at the level of “aging in place.” In this study, domestic implications were examined by referring to US, where CCRC first began, and Japan, which has recently actively promoted CCRC in order to revitalize the region. Although CCRC in US was established naturally in the market, Korean state authorities have actively intervened through the legal system to stabilize the elderly’s residence by considering that one contracting party is an elderly. In US, most of the CCRCs are operated by the private sector, as it is characterized by the establishment of a legal system not only to protect consumers but also to stabilize its management. In Japan, it is notable that the CCRC’s initiative itself is being carried out to overcome low birth rates and aging societies and to revitalize local areas to overcome problems caused by the concentration of population in the metropolitan area. Therefore, Japan’s legal system focuses not on management stability, but on the contents of the service and the eligibility of housing of the elderly. However, there is a fundamental difference from Korea’s elderly-related law system for low-income families, for it has legal system that oversees the residential environment of the elderly separably from the Elderly Welfare Act.

Digital communication use before and during COVID among residential older adults

Many older adults living in residential care facilities do not use digital communication technologies. The study was a retrospective pre-post study testing the impact of a digital communication program instituted at two Continuing Care Retirement Communities. We distributed a survey between March 2021 and April 2021 to examine study objectives. Data analyses were performed using JMP Pro 16.1 and SAS 9.4. One hundred twenty-six people started the survey, with 120 completing the survey and included in the analysis. The mean age was 84 years, 67.5% were female, 95.8% were White, 64.2% were widowed, and 35.3% reported at least a bachelor's degree level of education. There were minimal increases in digital communication behavior and communication frequency. Older adults most notably reported privacy concerns and have mixed responses about the utility of digital communication for social engagement. We apply the results to the Stage of Change model and provide recommendations to promote behavior change.

Influential factors toward the quality of dining services at continuing care retirement communities: Manager's perspective

A growing number of older adults are moving into continuing care retirement communities (CCRC) to meet their aging needs, and dining services attract critical consideration when older adults decide on CCRC. However, scarce research investigates the dining aspects of CCRC operations, and little is known about the foodservice managers' perspective on dining services. Therefore, this study explores the factors that influence the quality of dining services by interviewing foodservice managers at CCRC in the U.S. (n = 15). Nine major subcategories under generic foodservice-related, aging-related, and organization-related aspects of dining services emerged and guided the subsequent thematic analysis. Moreover, the foodservice managers' shared vision of instilling more hospitality to older adults into the future CCRC dining services was identified and discussed. This study contributes to the CCRC literature by adding foodservice manager's perspectives and providing pragmatic strategies for CCRC operators and managers to strengthen the quality of dining services for existing and prospective residents.

Social sustainability of continuing care retirement communities in China

PurposeChina’s population is ageing. Continuing care retirement communities (CCRCs) are an emerging living arrangement of older Chinese. Incorporating social sustainability features into CCRCs helps to create age-friendly residential environments for residents. However, it is still unclear what kinds of social sustainability features are incorporated into the residential environments of CCRCs in China. Therefore, this study aims to address this research gap.Design/methodology/approachQualitative content analysis is adopted to analyse the retrieved business information of representative CCRC developers in China.FindingsThis study revealed 36 social sustainability features in CCRCs, with the top-ranked ones being health care and management, social connection and engagement, high-quality and diverse services and daily life support and assistance. Additionally, a preliminary social sustainability framework of CCRCs was proposed, and this framework includes the five components of care and health, environment and management, service and facility, age-friendly life philosophy and social support and inclusion.Originality/valueIn theory, this research’s findings clarify the meaning of social sustainability within the context of CCRCs, which supports future relevant explorations in the CCRC research community. In practice, these findings enhance stakeholders’ understanding of the social sustainability in CCRCs, which promotes the development of age-friendly living environments for older people in an ageing society.

Medical Aid in Dying: Gaining Attention in America

Medical Aid in Dying: Gaining Attention in America

Engaging Sexual and Gender Minority Older Adults to Elicit Concerns and Recommendations for Communicating Care Preferences in Long-Term Care: Focus Group Findings

ABSTRACT Objectives 1) Describe sexual and gender minority (SGM) older adults’ current practices and concerns for communicating end-of-life (EOL) and daily care preferences in long-term care (LTC); 2) Elicit ideas about adapting a video-based intervention to facilitate communication. Methods After consulting a community advisory board, we conducted two focus groups with SGM older adults ≥55 years of age recruited from a community-based service organization (n = 4) and a continuing care retirement community (n = 9). We audio-recorded, transcribed, and coded data using directed content analysis methods and summarized results descriptively. Results Most participants were cisgender (n = 12), female (n = 11), lesbian (n = 10), White and non-Hispanic (n = 13); mean age was 70.62. Participants’ concerns included discrimination, autonomy, chosen family, and community; they linked daily care preferences with personhood and quality of life. They advocated for building intentional community-based support networks to help peers discuss preferences and produce videos before LTC transition and ensure compliance after. Conclusions For SGM older adults, asserting and protecting their full personhood, through daily care preferences, is essential to quality of life in LTC. Clinical Implications Video-recorded statements of daily preferences, facilitated and supported by a peer network, could promote culturally competent, person- and community-centered care for SGM older adults in LTC settings.

우리나라 연속보호체계형 은퇴주거단지(CCRC)의 운영 요인에 관한 연구

Korea is rapidly entering a super-aged society, creating housing issues for the elderly. Determining the necessity to understand the continuing care retirement community (CCRC), a model that enables the realization of the value of “aging in place” (AIP), was the starting point of this study. This study aims to identify the types of facilities that most closely resemble the “Korean style of CCRC” and to analyze the factors affecting its operation because there is currently no complete CCRC type in Korea. The subjects of this study were 31 senior welfare housing and 3 paid elderly care facilities among the residential welfare facilities for the elderly registered with the Ministry of Health and Welfare as of 2020. The “Korean style of CCRC” was defined as facilities with four or more of the independent living, assisted living, nursing home, daycare center, and community center . Subsequently, logistic regression analysis was conducted. The results indicated that the probability of operating as a “Korean-style CCRC” increases when the following factors are greater: land area, total number of households, efficiency rate, number of community facilities, number of workers, and monthly living expenses. Meanwhile, the number of years elapsed and the move-in price per 3.3㎡ were analyzed to have no effect. This study is expected to identify the current status of residential welfare facilities for the elderly and suggest implications for potential consumers who wish to move into CCRCs in order to facilitate their facility selection.

ATTITUDES TOWARD AGING AND WELLNESS ENGAGEMENT IN LIFE PLAN COMMUNITIES

Abstract Life Plan Communities, also known as Continuing Care Retirement Communities, typically offer a wide range of wellness programs and services, including fitness classes, educational lectures, volunteer opportunities, and social events. Despite the convenience of onsite wellness resources, some residents choose not to participate in wellness offerings available at the community. One factor that may influence engagement in wellness behaviors is older adults’ attitudes toward aging, which has been associated with differences in health and well-being over time. The purpose of this research was to examine the relationship between attitudes toward aging and wellness engagement among residents of Life Plan Communities. A total of 447 residents (ages 59 to 97; M = 81.82, SD = 6.55; 65% female) of 10 communities completed surveys that measured their attitudes toward aging, self-reported wellness, interest in improving wellness, participation in wellness programs, and barriers to wellness participation. Multiple regression analyses revealed that more positive attitudes toward aging were associated with better wellness, higher interest, more frequent participation, and fewer barriers, controlling for age, gender health, education, and marital status. Follow-up analyses revealed that these effects could be accounted for by specific types of aging attitudes (i.e., psychological growth, psychosocial loss, and physical change). For example, greater psychological growth was associated with greater wellness, interest in improving wellness, and wellness participation, whereas greater psychosocial losses was associated with greater perceived barriers and lower wellness. These findings have implications for the development, implementation, and promotion of wellness programs for older adults.

RESILIENCE AMONG RESIDENTS, THEIR FAMILY, AND STAFF OF A CONTINUING CARE RETIREMENT COMMUNITY

Abstract There is emerging literature about older adults’ experience of loneliness during the COVID-19 pandemic in long term care (LTC) facilities due to isolation protocols. Additionally, staff challenges while providing care for older adults in LTC has also been highlighted. While the literature emphasizes negative pandemic experiences, a gap exists with understanding resilience during the pandemic in LTC settings. The aim of this qualitative descriptive study was to explore the experience of resilience in a Continuing Care Retirement Community (CCRC) among residents, their family members, and staff. We conducted 19 in-person interviews and 1 via Zoom in fall 2021 with 5 residents (65 and older), 5 family members, and 10 staff (e.g., administrators, nurses, nursing assistants). A conventional content analysis was employed. While we did hear how the pandemic had a negative impact on everyone, the main themes of resilience identified were: 1) overcoming the pandemic together (sense of community); 2) experience and adaptation (over time being able to adapt to the disruption in their life); 3) staying safe (engaging in precautions and self-care strategies); and 4) positivity (mindset of getting through anything and relying on spirituality). Study findings can inform CCRC administrators on how to support residents, their family, and staff during future pandemics and other challenging times that may disrupt normal routines.

ARE WE GOING TO FEEL COMFORTABLE THERE?: EMERGENT FINDINGS FROM THE DIVERSITY IN LIFE PLAN COMMUNITIES STUDY

Abstract Life Plan Communities (LPCs), formerly known as Continuing Care Retirement Communities, offer an array of amenities as well as a continuum of care where residents may live independently or access assisted living or skilled care if needed. Racial/ethnic minority older adults are under-represented among LPC residents. One likely contributor to this lack of diversity is that racial/ethnic minorities make up a relatively small proportion of higher income groups. However, there may be additional reasons for their relative absence in most LPCs. The purpose of the ‘Diversity in Life Plan Communities’ study is to (1) identify barriers that impact the decision to move into an LPC for racial/ethnic minorities, and (2) identify strategies to increase resident diversity in LPCs. In this presentation we share preliminary findings from in-depth, semi-structured, qualitative interviews with community-dwelling Black, Latinx, and South Asian adults (n=10) living in Chicagoland and case study interviews with current LPC ‘resident champions’ (n=3) who are actively involved in efforts to increase resident diversity at their respective LPCs. Thematic analysis of the data showed that lack of awareness about LPCs, concerns about racism, desire to age-in-place among loved ones, and perceived non-availability of culturally-congruent activities were key barriers to moving into an LPC. These findings suggest that in order to increase resident diversity within their communities, LPC operators, staff, and current residents may consider targeted outreach efforts in racial/ethnic communities, take steps to create a welcoming environment and engage in more culturally congruent activities, and involve adult children/grandchildren in the decision-making process.

IMPLEMENTATION BARRIERS AND FACILITATORS OF COGNITIVE STIMULATION THERAPY ACROSS CARE SETTINGS

Abstract Cognitive Stimulation Therapy (CST) is an evidence-based treatment for people living with dementia that is not in widespread use in the United States. To better understand barriers and facilitators to implementation of CST, we conducted virtual focus groups of newly trained facilitators of Cognitive Stimulation Therapy (CST). Of 12 facilitators trained, representing two settings of care (The Program for All-inclusive Care of the Elderly and a Continuing Care Retirement Community), 4 facilitators, representing Social Work n = 2, Speech Therapy n = 1, and Recreation Therapy n = 1, participated. We analyzed interview transcriptions using framework analysis guided by constructs from the Consolidated Framework for Implementation Research (CFIR). Themes that emerged across constructs were 1) balancing competing personal, stakeholder, and organizational needs; 2) lack of mastery experiences and the need for opportunities for more practice, reflection, and feedback from trainers; 3) building a community of facilitators to provide peer support; 4) logistical concerns; and 5) identifying appropriate participants who would most benefit from CST. The barriers to implementation imposed by the ongoing COVID-19 pandemic were also a cross-cutting theme. Many of these barriers are readily managed, and professionals who implement CST in their sites should be aware of and take into consideration these barriers and facilitators.

NORTH CAROLINA NURSING HOME AND PUBLIC HEALTH RESILIENCE DURING 2021 OF THE COVID-19 PANDEMIC

Abstract Since the onset of the COVID-19 pandemic many healthcare organizations have operated in a climate of uncertainty. Building resilience is one method used to survive and thrive during periods of uncertainty. Measuring an organization’s resilience (ability to prepare for, respond and adapt during time of change) allows the organization to identify its vulnerabilities and set priorities to avert negative outcomes during an untoward event. Through collaboration with four long-term care professional associations, the Benchmark Resilience Tool (BRT-13) resilience survey was disseminated to North Carolina long-term care leaders in April 2021. The BRT-13 survey was also sent to North Carolina public health officials via email during the same timeframe. The BRT-13 contains 13 resilience (RES) items divided into two factors of adaptive capacity (AC) and planning (PL) on a five-point Likert scale of strongly disagree (1) to strongly agree (5). Organizational factors surveyed included type of facility, rural-urban classification area designation, ownership type, level of debt, level of profitability, and employee satisfaction. A total of 142 completed surveys were received, 101 (71%) from long-term care leaders and 41 (28.9%) from Public Health officials. Overall average resilience scores ranged from 3.96 for public health respondents to 4.46 for continuing care retirement communities (CCRC) respondents. Analysis of Variance (ANOVA) was employed to compare the three factors (AC, PL, and RES) to the organizational factors. Resilience was significantly associated with one factor, employee satisfaction. Our findings indicate that organizations can build resilience through processes that contribute to staff satisfaction.

COVID-19 PANDEMIC AND RESILIENCE IN STAFF OF A CONTINUING CARE RETIREMENT COMMUNITY

Abstract Residents and staff of continuing care retirement communities (CCRC) experienced many challenges during the COVID-19 pandemic including loss, social isolation, and staff turnover. This study examined factors that contribute to resilience in staff during the late stage of the pandemic using the Connor-Davidson Resilience Scale. Resilience scores ranged from 0 (low) to 100 (high). A total of 96 staff (76% female) were enrolled, and average age was 48.41 years (SD = 16.16). Average resilience in staff was 75.16 (SD = 11.81). Those under 35 years of age reported lower resilience scores (M = 67.38) compared to those 35-49 years of age (M = 76.65), 50-64 (M = 75.83), and 65 years and older (M = 82.71), p <.05. Staff who were married scored higher than those who were not (M = 76.63 vs 69.05), p < .05. Findings can inform professional development programs aimed at increasing coping skills in staff.

NURSING HOME ADMINISTRATOR EXPERIENCES DURING COVID-19: AN EXPLORATORY STUDY

Abstract Nursing homes have been the epicenter for the COVID-19 pandemic; 149,107 residents and over 2,200 staff have died of COVID-19. In addition to the loss of lives, 99% of nursing homes report staffing shortages. Various exploratory studies have emerged gathering the experiences of frontline nursing home staff during COVID-19, however less is known about the experiences of Nursing Home Administrators (NHA) responsible for overseeing personnel and operating a facility in line with shifting state and federal mandates. Thus, this study explores the experiences of NHA during the pandemic. A cross-sectional online survey was conducted. In addition to demographic and facility-level questions, open-ended questions explored prior training on infection prevention, day-to-day operational challenges, needs, and considerations of leaving their role as administrator. The total sample (N=60) included 47 NHA of record and 13 assistant administrators/other; 53% worked in corporate NHs and 23% were part of continuing care retirement communities. Respondents report prior infection prevention training, but indicate it was not adequate preparation for COVID-19. Moreover, administrators describe challenges in recruiting and retaining staff, and in supporting staff mental health needs (e.g., burnout, PTSD). The majority of NHAs endorse a desire to step away from their role, but indicate a commitment to residents keeps them from resigning. Findings indicate that NHAs, like other members of the NH team, have experienced the effects of COVID-19, and point to specific training and support needs to equip NHAs for work in the context of this pandemic and future emergencies.

CARING FOR OLDER ADULTS ACROSS THE CARE CONTINUUM: EXPERIENCES OF OLDER ADULTS AND FORMAL CAREGIVERS

Abstract As individuals age, they are at risk of experiencing health challenges that can contribute to poorer health outcomes and increase health care costs. During acute care crises and through the continuum of dealing with chronic diseases, older adults rely on formal caregivers to provide care and support. Formal caregivers’ delivery of care can be challenged during difficult patient cases (e.g., providing wound care to a person exhibiting behavioral and psychological symptoms of dementia) and during high stress times, such as working through a pandemic. However, during difficult times, resilience among formal caregivers can have a positive affect on care delivery. This symposium identifies some of the health challenges experienced by aging adults, challenging experiences of nurses, levels of resilience among formal caregivers, and discusses the implications for nursing care and future research. Ms. Coates examines trends in adverse drug admissions among older adults in the United States using the 2018 Healthcare Cost and Utilization Project’s National Inpatient Sample. Dr. Hwang explores the relationship between nutrition, inflammation, and physical and mental health in aging adults with chronic leg wounds. Dr. Sefcik discusses nurses’ experiences caring for community-dwelling persons living with dementia and chronic wounds. Mr. Hathaway examines factors that contribute to resilience in staff of a continuing care retirement community during the late stage of the COVID-19 pandemic. Dr. DiMaria-Ghalili, discussant, will synthesize these findings and offer insights on designing interventions to address health challenges and recommendations for supporting formal caregivers.

TEXAS NURSING HOMES INCREASED DIRECT-CARE STAFFING LEVELS DURING WINTER STORM URI

Abstract Prior work suggests that nursing homes (NHs) increase their registered nurse (RN), licensed practical nurse (LPN), and certified nursing assistant (CNA) staffing levels in anticipation of a major hurricane. However, less is known about NHs’ ability to increase staffing levels during a winter storm. We examined RN, LPN, and CNA staffing levels in 1,170 Texas NHs during Winter Storm Uri from February 13-20, 2021. This storm was characterized by cold temperatures and snow/ice accretion that affected the Texas power grid. Linear mixed effects models were adjusted for profit status, continuing-care retirement community status, resident census, overall star rating, a weighted deficiency score, number of citations for infection control, number of substantiated complaints, and county fixed-effects. After adjustment, Texas NHs decreased RN (β=-0.005;b=-0.002;p=.004) but increased LPN (β=0.022;b=0.009;p<.001) and CNA (β=0.044;b=0.026;p<.001) staffing levels. NHs face unprecedented challenges during winter storms, including maintaining adequate staffing levels to meet the needs of their residents.

Factors Associated with Frailty Transitions among the Old-Old in Community: A Prospective Cohort Study

Background: The identification of older adults with different frailty transitions, especially the old-old, is beneficial for stratified management. However, the factors associated with frailty transition in the elderly have not been fully elucidated. This study aimed to explore frailty transitions and associated factors among older adults. Methods: The participants were all from a prospective cohort study of older adults aged ≥75 years in a continuing care retirement community in Beijing, China. Frailty states were assessed using FRAIL at baseline and 1-year follow-up. The association between factors, including comprehensive geriatric assessment and laboratory indicators such as serum albumin and highsensitivity C-reactive protein (hsCRP), and frailty transitions were explored by binary logistic regression. The predicted value of the factors associated with frailty transitions was analyzed using the receiver operating characteristic curve (ROC), and the area under the ROC curve (AUC) was calculated. Results: A total of 183 older adults (mean age: 83.9±4.4 years; females, 59%) completed the frailty state assessment at baseline and 1-year followup. After adjusting for age and sex, walking speed(odds ratio [OR], 0.01; 95%confidence interval [CI]: 0.002-0.12),timed up-and-go (TUG) test(OR:1.08, 95% CI: 1.02-1.15), short physical performance battery(OR:0.79, 95% CI :0.68-0.92), serum albumin (OR:0.78, 95% CI:0.64-0.94), and serum hsCRP (OR:1.21, 95% CI:1.00-1.47) were associated with worsening of the frailty state. Cognitive function (OR:6.73, 95% CI:1.15-39.19) was associated with improving the frailty state. ROC analysis showed that low walking speed (AUC:0.81), long TUG test time(AUC:0.77), low Short Physical Performance Battery (SPPB)score (AUC:0.75), low serum albumin (AUC:0.68), and high serum hsCRP(AUC:0.80) could predict the decline in frailty state. Good cognitive function (AUC: 0.69) predicted an improvement in the frailty state. Conclusions: Frailty is dynamic. The frailty state of the old-old with poor physical function, low serum albumin, and high serum hsCRP was more likely to decline, but it was more likely to improve with good cognitive function. Walking speed, TUG test, SPPB, serum albumin, serum hsCRP, and cognitive function may predict frailty transitions among the old-old.

Self-reported resilience of North Carolina long-term care organizations and public health agencies in the midst of the COVID-19 pandemic

The objective of this study was to determine the self-reported resilience of North Carolina long-term care (LTC) and public health organizations while in the midst of a pandemic. Further, we correlate resilience with several organizational attributes for some insight into the types of organizations that are more resilient. Through collaboration with four LTC professional associations in North Carolina, the Benchmark Resilience Tool-13 (BRT-13) survey was disseminated to LTC leaders across North Carolina, and emailed to Public Health leaders during April 2021. The 13 survey items were divided into adaptive capacity and planning factors. Analysis of variance was used to determine whether organizational factors contributed to resiliency. A total of 142 completed surveys were received, 20 from assisted living administrators, 67 nursing home administrators, 14 from continuing care retirement community leaders, and 41 from public health officials. Average resilience, adaptive capacity, and planning were measured and analyzed against type of facility, RUCA area designation, owner type, level of debt, level of profitability, and employee satisfaction. Average resilience scores were 3.96 (SD = 0.774) for public health, 4.19 (SD = 0.725) for nursing homes, 4.22 (SD = 0.509) for assisted living, and 4.46 (SD = 0.407) for continuing care retirement communities. Results show a significant trend of higher employee satisfaction related to higher adaptive capacity, planning, and overall resilience. A key to organizational resilience in the pandemic was how well an organization cared for their employees. We must prepare before a crisis by being attentive to employee satisfaction and not lose track of employee satisfaction during the crisis. Public health agencies and LTC organizations who maintain high employee satisfaction will be more resilient.