Assisted Living Residents Research Articles

Hospital Proximity and Emergency Department Use among Assisted Living Residents.

To examine the relationship between AL communities' distance to the nearest hospital and residents' rates of emergency department (ED) use. We hypothesize that when access to an ED is more convenient, as measured by a shorter distance, assisted living (AL)-to-ED transfers are more common, particularly for nonemergent conditions. Retrospective cohort study, where the main exposure of interest was the distance between each AL and the nearest hospital. 2018-2019 Medicare claims were used to identify fee-for-service Medicare beneficiaries aged ≥55 years residing in AL communities. The primary outcome of interest was ED visit rates, classified into those that resulted in an inpatient hospital admission and those that did not (ie, ED treat-and-release visits). ED treat-and-release visits were further classified, based on the NYU ED Algorithm, as (1) nonemergent; (2) emergent, primary care treatable; (3) emergent, not primary care treatable; and (4) injury-related. Linear regression models adjusting for resident characteristics and hospital referral region fixed effects were used to estimate the relationship between distance to the nearest hospital and AL resident ED use rates. Among 540,944 resident-years from 16,514 AL communities, the median distance to the nearest hospital was 2.5 miles. After adjustment, a doubling of distance to the nearest hospital was associated with 43.5 fewer ED treat-and-release visits per 1000 resident years (95% CI-53.1,-33.7) and no significant difference in the rate of ED visits resulting in an inpatient admission. Among ED treat-and-release visits, a doubling of distance was associated with a 3.0% (95% CI-4.1,-1.9) decline in visits classified as nonemergent, and a 1.6% (95% CI-2.4%,-0.8%) decline in visits classified as emergent, not primary care treatable. Distance to the nearest hospital is an important predictor of ED use rates among AL residents, particularly for visits that are potentially avoidable. AL facilities may rely on nearby EDs to provide nonemergent primary care to residents, potentially placing residents at risk of iatrogenic events and generating wasteful Medicare spending.

A National Typology of Health Service Regulation in Assisted Living.

State-regulating agencies use 350 different licenses and certifications to govern assisted living (AL), resulting in significant variation in regulations governing health services, the scope of practice, and capacity. This lack of standardization makes it difficult to compare and contrast AL operations and residents' outcomes across similarly regulated communities. We used qualitative and quantitative methods to empirically develop and describe a typology of state AL regulations that captures inter- and intrastate variation. Based on the rules governing health services, we created regulatory specificity scores for 5 thematic dimensions: medication administration, third-party care, skilled nursing, medication review, and licensed nurse staffing. With these scores, we conducted a K-means cluster analysis to identify groups of AL license types. To differentiate the regulatory types, we calculated standardized mean differences across structure, process, outcome, and resident characteristics of the AL communities licensed under each type. We identified 6 types of AL differentiated by the regulatory provisions governing health services: Housing, Holistic, Hybrid, Hospitality, Healthcare, and Health Support. The types align with previous work and reflect tangible differences in resident characteristics, health service structures, processes, and outcomes. This typology effectively captures differences across regulated dimensions and can inform and support quality of care. Researchers, policy-makers, and consumers may benefit from using this typology and acknowledging these differences in AL licensure when designing research studies, developing policies, and selecting an AL community.

Comparing quality of care outcomes between assisted living and nursing homes before and during the COVID-19 pandemic.

While assisted living (AL) and nursing home (NHs) residents in share vulnerabilities, AL provides fewer staffing resources and services. Research has largely neglected AL, especially during the COVID-19 pandemic. Our study compared trends of practice-sensitive, risk-adjusted quality indicators between AL and NHs, and changes in these trends after the start of the pandemic. This repeated cross-sectional study used population-based resident data in Alberta, Canada. Using Resident Assessment Instrument data (01/2017-12/2021), we created quarterly cohorts, using each resident's latest assessment in each quarter. We applied validated inclusion/exclusion criteria and risk-adjustments to create nine quality indicators and their 95% confidence intervals (CIs): potentially inappropriate antipsychotic use, pain, depressive symptoms, total dependency in late-loss activities of daily living, physical restraint use, pressure ulcers, delirium, weight loss, urinary tract infections. Run charts compared quality indicators between AL and NHs over time and segmented regressions assessed whether these trends changed after the start of the pandemic. Quarterly samples included 2015-2710 AL residents and 12,881-13,807 NH residents. Antipsychotic use (21%-26%), pain (20%-24%), and depressive symptoms (17%-25%) were most common in AL. In NHs, they were physical dependency (33%-36%), depressive symptoms (26%-32%), and antipsychotic use (17%-22%). Antipsychotic use and pain were consistently higher in AL. Depressive symptoms, physical dependency, physical restraint use, delirium, weight loss were consistently lower in AL. The most notable segmented regression findings were an increase in antipsychotic use during the pandemic in both settings (AL: change in slope = 0.6% [95% CI: 0.1%-1.0%], p = 0.0140; NHs: change in slope = 0.4% [95% CI: 0.3%-0.5%], p < 0.0001), and an increase in physical dependency in AL only (change in slope = 0.5% [95% CI: 0.1%-0.8%], p = 0.0222). QIs differed significantly between AL and NHs before and during the pandemic. Any changes implemented to address deficiencies in either setting need to account for these differences and require monitoring to assess their impact.

Assisted Living: New Initiatives, Brighter Future

Assisted Living: New Initiatives, Brighter Future

Implementation Lessons Learned: Distress Behaviors in Dementia Intervention in Veterans Health Administration.

Evidence-based practices to manage distress behaviors in dementia (DBD) are not consistently implemented despite demonstrated effectiveness. The Veterans Health Administration (VA) trained teams to implement Staff Training in Assisted Living Residences (STAR)-VA, an intervention to manage DBD in VA nursing home settings, or Community Living Centers (CLCs). This paper summarizes multiyear formative evaluation results including challenges, adaptations, and lessons learned to support sustained integration into usual care across CLCs nationwide. STAR was selected as an evidence-based practice for DBD, adapted for and piloted in VA (STAR-VA), and implemented through a train-the-trainer program from 2013 to 2018. Training and consultation were provided to 92 CLC teams. Evaluation before and after training and consultation included descriptive statistics of measures of clinical impact and survey feedback from site teams regarding self-confidence, engagement, resource quality, and content analysis of implementation facilitators and challenges. STAR-VA training and consultation increased staff confidence and resulted in significant decreases in DBD, depression, anxiety, and agitation for Veterans engaged in the intervention. Implementation outcomes demonstrated feasibility and identified facilitators and barriers. Key findings were interpreted using implementation frameworks and informed subsequent modifications to sustain implementation. STAR-VA successfully prepared teams to manage DBD and resulted in improved outcomes. Lessons learned include importance of behavioral health-nursing partnerships, continuous engagement, iterative feedback and adaptations, and sustainment planning. Evaluation of sustainment factors has informed selection of implementation strategies to address sustainment barriers. Lessons learned have implications for integrating team-based practices into system-level practice.

Caregiver Involvement and Concerns with Care of Residents of Assisted Living before and during the COVID-19 Pandemic

Introduction: Family/friend caregivers play an essential role in promoting the physical and mental health of older adults in need of care – especially during the COVID-19 pandemic and especially in assisted living (AL) homes, where resident care needs are similarly complex as in long-term care homes but fewer staffing resources and services are available. However, little research is available on caregiver involvement and concerns with care of AL residents prior to and during waves 1 and 2 of the COVID-19 pandemic. This study addressed this important knowledge gap. Methods: This prospective cohort study used baseline and follow-up online surveys with primary caregivers to AL residents in Western Canada who were 65 years or older and had lived in the AL home for at least 3 months before Mar 1, 2020. Surveys assessed the following outcomes in the 3 months prior to and during waves 1 and 2 of the pandemic: sociodemographics, 5 ways of visiting or communicating with residents, involvement in 16 care tasks, concerns with 9 resident physical/mental health conditions, perceived lack of resident access to 7 care services, and whether caregivers felt well informed and involved with resident care. Results: Based on 386 caregiver responses, in-person visits dropped significantly in wave 1 of the pandemic and so did caregiver involvement in nearly all care tasks. While these rates increased in wave 2, most did not return to pre-pandemic levels. Correspondingly, caregiver concerns (already high before the pandemic) substantially increased in wave 1 and stayed high in wave 2. These were particularly elevated among caregivers who did not feel well informed/involved with resident care. Conclusions: Restricted in-person visiting disrupted resident care and was associated with worse perceptions of resident health and well-being. Continued caregiver involvement in resident care and communication with caregivers even during lockdowns is key to mitigating these issues.

Understanding Capacity and Optimizing Meaningful Engagement among Persons Living with Dementia.

Meaningful engagement is a key dimension of quality of life among persons living with dementia, yet little is known about how to best to promote it. Guided by grounded theory methods, we present analysis of data collected over a 1-year period in four diverse assisted living (AL) communities as part of the study, "Meaningful Engagement and Quality of Life among Assisted Living Residents with Dementia." Our aims are to: (a) learn how meaningful engagement is negotiated among AL residents with dementia and their care partners; and (b) identify how to create these positive encounters. Researchers followed 33 residents and 100 care partners (formal and informal) and used participant observation, resident record review, and semi-structured interviews. Data analysis identified "engagement capacity" as central to the negotiation of meaningful engagement. We conclude that understanding and optimizing the engagement capacities of residents, care partners, care convoys, and settings, are essential to creating and enhancing meaningful engagement among persons living with dementia.

Using Medicare Enrollment Data to Identify Beneficiaries in Assisted Living.

Develop an approach for identifying Medicare beneficiaries residing in US assisted living (AL) communities in calendar year2018. We used the following data sources: national directory of licensed ALs, file of US addresses and their associated 9-digit ZIP codes (ZIP+4), Medicare Enrollment Database (EDB), Master Beneficiary Summary File (MBSF), and the Minimum Data Set (MDS). A total of 412,723 Medicare beneficiaries who lived in ZIP+4 codes associated with an AL were identified as residents. Approximately 28% of the 16,682 ALs in which these beneficiaries resided were smaller communities (<25 beds). For each AL, we identified ZIP+4 codes associated with its address. Using this ZIP+4 file, we searched through the Medicare EDB to identify beneficiaries who lived in each ZIP+4 code. The MBSF and MDS were used to exclude beneficiaries who died before 2018 and those whose AL and nursing home stays overlapped. We identified 3 cohorts of Medicare beneficiaries: (1) residents of a specific AL (one AL address per ZIP+4), (2) most likely AL residents, and (3) not likely AL residents. Comparisons across these cohorts were used to examine construct validity of our approach. Additional comparisons were made to AL residents based on the National Survey of Long-Term Care Providers (NSLTCP) and to fee-for-service (FFS) Medicare community-dwelling and long-stay nursing home residents. The cohorts of beneficiaries identified as AL residents exhibited good construct validity. AL residents also showed similarity in demographic characteristics to the 2018 sample from the NSLTCP, and as expected were different from FFS community and nursing home beneficiaries. We developed a methodology for identifying Medicare beneficiaries who reside in ALs. As this residential setting continues to grow, future studies will need effective approaches for identifying AL residents in order to evaluate the quality of care they receive.

Are online reviews of assisted living communities associated with patient-centered outcomes?

Existing literature on online reviews of healthcare providers generally portrays online reviews as a useful way to disseminate information on quality. However, it remains unknown whether online reviews for assisted living (AL) communities reflect AL care quality. This study examined the association between AL online review ratings and residents' home time, a patient-centered outcome. Medicare beneficiaries who entered AL communities in 2018 were identified. The main outcome is resident home time in the year following AL admission, calculated as the percentage of time spent at home (i.e., not in institutional care setting) per day being alive. Additional outcomes are the percentage of time spent in emergency room, inpatient hospital, nursing home, and inpatient hospice. AL online Google reviews for 2013-2017 were linked to 2018-2019 Medicare data. AL average rating score (ranging 1-5) and rating status (no-rating, low-rating, and high-rating) were generated using Google reviews. Linear regression models and propensity score weighting were used to examine the association between online reviews and outcomes. The study sample included 59,831 residents in 12,143 ALs. Residents were predominately older (average 81.2 years), non-Hispanic White (90.4%), and female (62.9%), with 17% being dually eligible for Medicare and Medicaid. From 2013 to 2017, ALs received an average rating of 4.1 on Google, with a standard deviation of 1.1. Each one-unit increase in the AL's average online rating was associated with an increase in residents' risk-adjusted home time by 0.33 percentage points (p <0.001). Compared with residents in ALs without ratings, residents in high-rated ALs (average rating ≥4.4) had a 0.64 pp (p <0.001) increase in home time. Higher online rating scores were positively associated with residents' home time, while the absence of ratings was associated with reduced home time. Our results suggest that online reviews may be a quality signal with respect to home time.

PROFILE OF DECEDENTS FROM A NATIONAL COHORT OF ASSISTED LIVING RESIDENTS

Abstract An increasing number of older adults reside in assisted living (AL) toward the end of life, and it remains unclear if this trend represents an additional place of care and end-of-life transition before eventual nursing home admission. Our objective was to examine the characteristics and healthcare utilization of AL residents who died during a two-year follow-up. We conducted a prospective cohort study of Medicare beneficiaries residing in large AL communities (25+ beds) in January 2017, and followed them until the end of 2018 using a variety of administrative healthcare claims data. The national population of Medicare beneficiaries in AL included 273,722 fee-for-service (FFS) beneficiaries, and 143,258 Medicare Advantage beneficiaries. From 2017 to the end of 2018, 23.7% of residents died. Of the 66,605 FFS Medicare beneficiaries who died during follow-up, 77.0% were 85 years old or older, 72.2% were diagnosed with Alzheimer’s disease and related dementia (ADRD) and 80.8% were diagnosed with heart failure or chronic obstructive pulmonary disease. Most FFS decedents (97.3%) resided in AL during their last 12 months of life, with 23.0% leaving AL before the last month of life. Half of FFS decedents died in AL, while another 24.1% died in a nursing home. AL communities represent an increasingly common place of end-of-life care for dying Medicare beneficiaries. These findings point to the need for state and federal policies to protect a growing population of frail and vulnerable AL residents.

LONELINESS AND PSYCHOLOGICAL DISTRESS AMONG AFRICAN AMERICAN ASSISTED LIVING RESIDENTS APPROACHING END OF LIFE

Abstract Social isolation and loneliness are common at end of life and important contributors to psychological distress, particularly among older adults. Despite evidence that isolation and loneliness are generally prevalent in assisted living (AL), little research has examined these states within the context of end of life (EOL). This study uses secondary data from an EOL study in assisted living to qualitatively characterize the experience of isolation and loneliness in African American AL residents with varying levels of psychological distress. We performed a thematic analysis using ethnographic and interview data collected from 25 residents (64% female) in a large (90+ bed) all-African American AL community in metropolitan Atlanta. We assessed psychological distress using the PHQ-4 and used this measure in qualitative analysis to explore varying patterns of social isolation and loneliness across residents. Findings showed high variability in psychological distress based on PHQ-4 scores (range 0–12, mean = 3.5, SD = 3.75). Across themes of social isolation and loneliness, we compared experiences of residents with low and high psychological distress. The maintenance of agency in the face of isolation and loneliness was the predominant pattern among the low-distress group, while passive withdrawal was consistently identified among the high-distress group. We classified these themes in terms of individual interpersonal relationships characterized by self-isolation and negotiation of family connections, as well as AL community-level relationships characterized by the liminality of the lived AL experience. Results have important implications for multilevel interventions designed to reduce social isolation, loneliness, and psychological distress among this population.

COVID-19 Pandemic Experiences across the Shelter-Care Continuum in Older Adults

The COVID-19 pandemic’s impact on older adults (55+) living at the mid-point of the shelter-care continuum, in seniors housing (SH) and assisted living (AL), remains largely unexplored. This study compares survey responses of SH and AL residents with those of age peers living in private conventional community-based dwellings (CD) in British Columbia, Canada. Despite more SH/AL residents reporting feelings of isolation and changes to social support access, the pandemic appears to have had a greater negative impact on the routines of CD older adults. AL residents were more likely to engage in advance care planning discussions before and since the COVID-19 outbreak. These data are important for improving response to current and future disasters across the shelter-care continuum, particularly in ways to reduce the psychosocial effects of isolation or routine disruption, and strategies to increase advance care planning engagement.

Return to community living and mortality after moving to a long-term care facility: A nationally representative cohort study.

Recent long-term care facility (LTCF) policy has focused on transitioning nursing home (NH) residents back to community settings, yet we lack recent descriptions of this phenomenon and how it compares in assisted living (AL). Using the National Health and Aging Trends Study, we studied adults over age 65 who had moved from community living into an LTCF between 2011 and 2018. Persons or their proxies reported residence in annual interviews. NH was defined by facility staff. ALs were multi-unit buildings helping with activities of daily living. We excluded temporary short-stay NH patients and independent AL residents. Our primary outcome was cumulative incidence of return to community living, with death as co-primary outcome and modeled as a competing risk, stratified by NH versus AL entry. We identified covariates (age, gender, race/ethnicity, dementia, activity limitations, and prior living arrangement) associated with return to community living through bivariate and multivariable logistic regression. Among 739 participants, weighted mean age was 84 years (SD 7.5), 66% were women, 13% were non-White, 57% had dementia, and 41% entered NH. At 1, 2, and 4 years, the cumulative incidence of return to community living was 2.9% (95% CIs: 1.9%-4.3%), 6.4% (4.7%-8.4%), and 7.4% (5.5%-9.8%); the cumulative incidence of death was 28% (95% CIs: 24%-31%), 44% (40%-48%) and 66% (61%-70%). Outcomes were similar in persons entering NH versus AL. Older persons (aOR 0.88, 95% CI 0.83-0.94), those with dementia (aOR 0.33, 95% CI 0.12-0.88), and those previously living alone (aOR 0.39, 95% CI 0.17-0.89) were less likely to return. Few returned to community living after entering either NH or AL. Mortality was similar. Results highlight limits in transitioning persons out of LTCFs and the need to observe AL use to ensure policies do not merely displace persons between institutional care sectors.

Successful Aging in Assisted Living: The Importance of Near Visual Acuity

Successful aging among independent community-dwelling older adults and those in residential settings is paramount to aging in place. The purpose of the current study was to explore how sensory, cognitive, and functional impairments affect successful aging in assisted living (AL) settings. Vision compromise was noted for near visual acuity (NVA) (14.3%) and distance visual acuity (11.9%). More than one third (34.1%) of participants screened positive for compromised cognition, functional impairment was present in 48.9%, and successful aging was present in 55.7%. NVA and functional status were related to successful aging ( r = 0.328, p = 0.004; r = 0.341, p = 0.002, respectively), and explained 9.3% of the variance in successful aging (F[2, 75] = 3.83, p = 0.026). Having a lower NVA score (β = −0.277, p = 0.021) uniquely affected the successful aging score. Interventions supporting AL residents' sensory and cognitive health should be a priority to improve successful aging. [ Journal of Gerontological Nursing, 48 (9), 8–14.]

Prevalence and correlates of anxiety and depression in caregivers to assisted living residents during COVID-19: a cross-sectional study

BackgroundFamily and friend caregivers play significant roles in advocating for and ensuring quality health and social care of residents in Assisted Living (AL) homes. However, little is known about how the COVID-19 pandemic and related visitor restrictions affected their health and mental well-being. We examined the prevalence and correlates of anxiety and depressive symptoms among caregivers of AL residents during the initial wave of COVID-19 in two Canadian provinces.MethodsA cross-sectional web-based survey was conducted among family/friend caregivers of AL residents in Alberta and British Columbia (Oct 28, 2020—Mar 31, 2021) to collect data on their sociodemographic, health and caregiving characteristics, as well as concerns about residents’ health and social care before and during the first wave of the pandemic. A clinically significant anxiety disorder and depressive symptoms were assessed with the GAD-7 and CES-D10 instruments, respectively. Separate multivariable (modified) Poisson regression models identified caregiver correlates of each mental health condition.ResultsAmong the 673 caregivers completing the survey (81% for Alberta residents), most were women (77%), white (90%) and aged ≥ 55 years (81%). Clinically significant anxiety and depression were present in 28.6% and 38.8% of caregivers respectively. Both personal stressors (comorbidity level, income reduction, low social support) and caregiving stressors exacerbated by the pandemic were independently associated with caregiver anxiety and depression. The latter included increased concern about the care recipients’ depression (adjusted risk ratio [adjRR] = 1.84, 95% confidence interval [CI] 1.19–2.85 for caregiver anxiety and adjRR = 1.75, 95% CI 1.26–2.44 for caregiver depressive symptoms) and reported intention to withdraw the resident from AL because of COVID-19 (adjRR = 1.24, 95%CI 0.95–1.63 for caregiver anxiety and adjRR = 1.37, 95%CI 1.13–1.67 for caregiver depressive symptoms).ConclusionsCaregivers of residents in AL homes reported significant personal and caregiving-related stressors during the initial wave of COVID-19 that were independently associated with an increased likelihood of experiencing clinically significant anxiety and depressive symptoms. Healthcare providers and AL staff should be aware of the prevalence and varied correlates of caregivers’ mental health during public health crises so that appropriate screening and support may identified and implemented.

Excess Mortality Among Assisted Living Residents With Dementia During the COVID-19 Pandemic.

ObjectiveTo evaluate whether assisted living (AL) residents with Alzheimer’s disease and related dementias (ADRD) experienced a greater rate of excess all-cause mortality during the first several months of the COVID-19 pandemic compared to residents without ADRD, and to compare excess all-cause mortality rates in memory care vs general AL among residents with ADRD.DesignRetrospective cohort study.Setting and ParticipantsTwo cohorts of AL residents enrolled in Medicare Fee-For-Service who resided in 9-digit zip codes corresponding to US AL communities of ≥25 beds during calendar year 2019 or 2020.MethodBy linking Medicare claims and Vital Statistics data, we examined the weekly excess all-cause mortality rate, comparing the rate from March 12, 2020, to December 31, 2020, to the rate from January 1, 2019, to March 11, 2020. We adjusted for demographics, chronic conditions, AL community size, and county fixed effects.ResultsOf the 286,350 residents in 2019 and the 273,601 in 2020 identified in these cohorts, approximately 31% had a diagnosis of ADRD. Among all AL residents, the excess weekly mortality rate in 2020 was 49.1 per 100,000 overall during the pandemic. Compared to residents without ADRD, residents with ADRD experienced 33.4 more excess deaths per 100,000 during the pandemic. Among residents with ADRD, those who resided in memory care communities did not experience a statistically significant different mortality rate than residents who lived in general AL.Conclusions and ImplicationsAL residents with ADRD were more vulnerable to mortality during COVID-19 than residents without ADRD, a finding similar to those reported in other settings such as nursing homes. Additionally, the study provides important new information that residents with ADRD in memory care communities may not have been at differential risk of COVID-19 mortality when compared to residents with ADRD in general AL, despite prior research suggesting they have more advanced dementia.

Feasibility of Routine Quality of Life Measurement for People Living With Dementia in Long-Term Care.

Maximizing quality of life (QoL) is the ultimate goal of long-term dementia care. However, routine QoL measurement is rare in nursing home (NH) and assisted living (AL) facilities. Routine QoL measurement might lead to improvements in resident QoL. Our objective was to assess the feasibility of using DEMQOL-CH, completed by long-term care staff in video calls with researchers, to assess health-related quality of life (HrQoL) of NH and AL residents with dementia or other cognitive impairment. Cross-sectional study. We included a convenience sample of 5 NHs and 5 AL facilities in the Canadian province of Alberta. Forty-two care staff who had worked in the facility for ≥3months completed DEMQOL-CH assessments of 183 residents who had lived in the facility for 3months or more and were aged ≥65years. Sixteen residents were assessed independently by 2 care staff to assess inter-rater reliability. We assessed HrQoL in people with dementia or other cognitive impairment using DEMQOL-CH, and assessed time to complete, inter-rater reliability, internal consistency reliability, and care staff ratings of feasibility of completing the DEMQOL-CH. Average time to complete DEMQOL-CH was <5minutes. Staff characteristics were not associated with time to complete or DEMQOL-CH scores. Inter-rater reliability [0.735, 95% confidence interval (CI): 0.712-0.780] and internal consistency reliability (0.834, 95% CI: 0.779-0.864) were high. The DEMQOL-CH score varied across residents (mean= 84.8, standard deviation= 11.20, 95% CI: 83.2-86.4). Care aides and managers rated use of the DEMQOL-CH as highly feasible, acceptable, and valuable. This study provides a proof of concept that DEMQOL-CH can be used to assess HrQoL in NH and AL residents and provides initial indications of feasibility and resources required. DEMQOL-CH may be used to support actions to improve the QoL of residents.

Physical Activity Programming for Older Adults in Assisted Living: Residents' Perspectives.

Decreasing sedentary behavior and increasing light physical activity could promote the maintenance of functional abilities for older adults in assisted living (AL). The purpose of this qualitative study was to gather residents' recommendations about a proposed self-efficacy enhancing intervention to replace sedentary behavior with light physical activity. We interviewed 20 residents (mean age 83.1; 60% women). Topics included their current activities and thoughts about physical activity. We presented the intervention and asked questions to inform its modification. Data were analyzed with content and thematic analysis. Specific recommendations included shorter one-hour sessions and framing the intervention as increasing light physical activity rather than decreasing sedentary behavior. The thematic analysis identified multiple factors that could influence intervention implementation, including motivation to be active, safety concerns, ageist attitudes about physical activity, varying abilities of residents, social influences, and limited opportunities for physical activity. These results will inform physical activity intervention implementation for AL residents.

As-Needed Prescribing and Administration of Psychotropic Medications in Assisted Living: A 7-State Study.

Psychotropic medications administered on an as-needed basis, often designated as pro re nata (or PRN, hereafter as-needed), can alleviate acute symptoms and facilitate deprescribing, although as-needed use is associated with negative outcomes such as polypharmacy and drug interactions. The aim of this study was to examine the extent to which PRN psychotropic medications are prescribed and administered to assisted living (AL) residents, overall and in relation to resident- and community-level characteristics. Cross-sectional study. All AL residents and select staff in 250 AL communities in 7 states. Data regarding prescribing and administration of 5 types of PRN psychotropic medications in the prior 7days (antipsychotics, mood stabilizers and antiepileptics, antidepressants, anxiolytics/hypnotics, and cognitive enhancers) were abstracted and compared across resident and community characteristics. Prescribing of PRN psychotropics in AL is low (10.3%). Of prescribed PRN medications, 2.5% of residents were administered a PRN and 8% had PRN that was not administered in the previous 7days. Anxiolytics were administered PRN more commonly compared with antipsychotics (2.0% vs 0.2%). Of all PRN psychotropic prescriptions (n= 1039), 70.5% had a written indication describing the reason for administration. Among PRN medications administered (n= 242), the proportion with an indication was lower (62.0%). PRN psychotropic medication prescribing was higher among residents with dementia and a psychiatric diagnosis, and in larger AL communities and those with a higher proportion of dementia care beds. The prescribing and administration of PRN psychotropic medications in AL is relatively rare, although more common among residents with dementia. Emerging psychotropic medication policies should be expanded to address mental health care, anxiolytic/hypnotic use for residents living with dementia, PRN prescribing in chart review, and the use of detailed indications for PRN use, especially when medications are administered by unlicensed care staff.

Developing a toolkit to improve resident and family engagement in the safety of assisted living: Engage-A stakeholder-engaged research protocol.

Assisted living (AL) communities are experiencing rising levels of resident acuity, challenging efforts to balance person-centered care-which prioritizes personhood, autonomy, and relationship-based care practices-with efforts to keep residents safe. Safety is a broad-scale problem in AL that encompasses care concerns (e.g., abuse/neglect, medication errors, inadequate staffing, and infection management) as well as resident issues (e.g., falls, elopement, and medical emergencies). Person and family engagement (PFE) is one approach to achieving a balance between person-centered care and safety. In other settings, PFE interventions have improved patient care processes, outcomes, and experiences. In this paper, we describe the protocol for a multiple methods AHRQ-funded study (Engage) to develop a toolkit for increasing resident and family engagement in AL safety. The study aims are to engage AL residents and family caregivers, AL staff, and other AL stakeholders to (1) identify common AL safety problems; (2) prioritize safety problems and identify and evaluate existing PFE interventions with the potential to address safety problems in the AL setting; and (3) develop a testable toolkit to improve PFE in AL safety. We discuss our methods, including qualitative interviews, a scoping review of existing PFE interventions, and stakeholder panel meetings that involved a Delphi priority-setting exercise. In addition to describing the protocol, we detail how we modified the protocol to address the unique challenges of the COVID-19 pandemic. Study findings will result in a toolkit to improve resident and family engagement in the safety of AL that will be tested in future research.