VA Community Living Center Research Articles

EVALUATING THE BEHAVIORAL RECOVERY OUTREACH (BRO) TEAM MODEL: TEAM MEMBERS’ PERSPECTIVES

Abstract The VA’s Behavioral Recovery Outreach (BRO) Team model seeks to address the unmet needs of aging Veterans with complex behavioral, psychological, neurocognitive, and medical concerns. Consisting of a core team of a social worker, nurse, and psychologist, BRO teams collaborate with the broader VA Community Living Center or inpatient team on behavioral assessment and treatment planning to help stabilize the Veterans’ behaviors and ready them for discharge to the community. Then, upon discharge the BRO Team provides ongoing behaviorally focused transitional support services to help ensure the Veterans’ sustained stability in the community and prevent unnecessary rehospitalizations. While dissemination efforts have demonstrated positive clinical outcomes for the Veterans served, little was known about the factors that support or hinder successful implementation of this complex program. This paper presents results from qualitative interviews with ten members from seven BRO Teams (out of ten active teams at the time) undertaken in late 2021 as part of a larger BRO program evaluation. The BRO Team model, including the goals and core components of BRO, are defined. Determinants of successful BRO implementation and team operations, including staffing, inter-departmental relationships, model clarity, and support, are described. BRO Team members’ views of the impact on and response of BRO recipients (BRO-enrolled Veterans, family members, and VA and community care partners), such as helping family members understand dementia, assistance with navigating the VA system, and support with behavioral health care planning and modification leading up to and following transitions to community care, are also detailed.

Fall-related Injuries and Opioid Administration Among Veterans With Dementia in US Department of Veterans Affairs Community Living Centers.

Opioid use is associated with fall-related injuries (FRI) among older adults, especially those with dementia. We examined FRI following changes in national opioid safety initiatives over 3 regulatory periods [preinitiatives baseline (period 1): October 2012 to June 2013; post-Veteran Affairs (VA) opioid safety initiative (period 2): January 2014 to November 2015; post-VA and CDC opioid prescribing guidelines (period 3): March 2017 to September 2018] among Department of VA Community Living Center (CLC) long-stay residents with dementia. VA provided and purchased care records, Medicare claims, CLC Minimum Data Set (MDS) assessments. VA bar-code medication administration data, VA outpatient prescription refill data, and Medicare Part D data were used to capture medication from inpatient, outpatient, and Medicare sources. A total of 12,229 long-stay CLC residents with dementia between October 2012 and September 2018. We applied Veteran-regulatory period level (1) generalized linear model to examine the unadjusted and adjusted trends of FRI, and (2) difference-in-difference model with propensity score weighting to examine the relationship between opioid safety initiatives and FRI in 3 regulatory periods. We applied propensity score weighting to enable the cohorts in periods 2 and 3 had similar indications for opioid administration as in period 1. FRI prevalence per month among CLC residents with Alzheimer disease and related dementias decreased from 3.1% in period 1 to 1.6% and 1.2% in periods 2 and 3, and the adjusted probability of FRI was 17% and 40% lower in periods 2 and 3 compared with period 1. The any, incident, and continued opioid administration were significantly associated with higher FRI, whereas the differences in FRI probabilities between opioid and nonopioid users had no significant changes over the 3 regulatory periods. FRI was reduced among CLC residents with Alzheimer disease and related dementias receiving care in VA CLCs over the 3 regulatory periods, but the FRI reduction was not significantly associated with opioid safety initiatives. Other interventions that potentially targeted falls are likely to have helped reduce these fall events. Future studies could examine whether opioid use reduction ultimately benefitted nursing home residents by focusing on other possible outcomes or whether such reduction only resulted in more untreated pain.

Guiding Post-Hospital Recovery by 'What Matters:' Implementation of Patient Priorities Identification in a VA Community Living Center.

Patient priorities care (PPC) is an effective age-friendly health systems (AFHS) approach to aligning care with goals derived from 'what matters'. The purpose of this quality improvement program was to evaluate the fidelity and feasibility of the health priorities identification (HPI) process in VA Community Living Centers (CLC). PPC experts worked with local CLC staff to guide the integration of HPI into the CLC and utilized a Plan-Do-Study-Act (PDSA) model for this quality improvement project. PPC experts reviewed health priorities identification (HPI) encounters and interdisciplinary team (IDT) meetings for fidelity to the HPI process of PPC. Qualitative interviews with local CLC staff determined the appropriateness of the health priorities identification process in the CLC. Over 8 months, nine facilitators completed twenty HPI encounters. Development of a Patient Health Priorities note template, staff education and PPC facilitator training improved fidelity and documentation of HPI encounters in the electronic health record. Facilitator interviews suggested that PPC is appropriate in this setting, not burdensome to staff and fostered a person-centered approach to AFHS. The HPI process is an acceptable and feasible approach to ask the 'what matters' component of AFHS in a CLC setting.

Transmission of multidrug-resistant organisms by VA CLC residents: A multisite prospective study

Background: Veterans Health Administration (VHA) community living centers (CLCs) provide postacute and long-term care. CLC veterans visit myriad locations outside their rooms (eg, rehabilitation, dialysis). Pathogen transmission during out-of-room visits is unknown. Methods: We recruited newly admitted veterans at 3 CLCs. After obtaining informed consent, we cultured nares, groin, hands, and 7 surfaces in the patient rooms. We accompanied veterans to up to 5 out-of-room visits and cultured patients’ hands and surfaces they touched. We tested for multidrug-resistant organisms (MDROs) including methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), and quinolone, carbapenem, and/or ceftazidime-resistant gram-negative bacteria (R-GNB). We defined transmission as a positive culture following an initial negative culture during the same visit. Results: We enrolled 137 veterans (median follow-up, 29 days; mean, 5.9 visits); 97% were postacute patients. We conducted 539 patient-room sampling visits (mean, 3.9 per veteran; 5,490 swabs) and accompanied 97 veterans to 266 out-of-room sampling visits (mean, 2.7 per veteran; 2,360 swabs). Of 137 patients, 47 (35%) were colonized with an MDRO at enrollment and 74 (58%) of 128 patients were colonized on any follow-up patient-room visits. Of 133 patients, 55 (41%) acquired a new MDRO, most often VRE (31 of 97, 32%). In patient rooms, toilet seats [114 (21%) of 538], curtains [101 (19%) of 530] and bedrails [98 (18%) of 539] were most frequently contaminated. Among 266 out-of-room visits, 17% had surfaces contaminated with MDROs, most commonly involving dialysis [4 (31%) of 13], radiology [2 (25%) of 8], and rehabilitation therapy [29 (18%) of 159] (Fig. 1).Transmission of MDROs during out-of-room visits was common and occurred in 18% of visits with 8% (9 MRSA and 12 VRE) acquiring a new MDRO on their hands and 12% (9 MRSA and 23 VRE) of MDRO transmission occurring from hands to a surface that the patient touched (Fig. 1). In 18 (58%) of 31 cases, the organism transmitted to a surface was on patient hands at the start of the visit. Transmission was most common during visits to dialysis (3 to patients and 2 to surfaces), radiology (1 to a patient and 2 to surfaces), and rehabilitation therapy (13 to patients and 21 to surfaces) (Fig. 2). Conclusions: New MDRO acquisition during VHA CLC stay was common, and nearly one-fifth of out-of-room visits resulted in MDRO transmission. Our analyses suggest that veterans’ hands may shed MDROs (MRSA and VRE) to surfaces. Interventions to reduce MDRO transmission during visits for rehabilitation, dialysis, and other therapies are needed.Disclosures: None

0358 Prevalence of Insomnia Symptoms and Insomnia Disorder within VA Subacute Rehabilitation

Abstract Introduction Approximately 40% of Veterans report insomnia symptoms and 12% of Veterans have a formal insomnia disorder diagnosis. While these numbers reflect outpatient prevalence rates, there is little data on the prevalence of insomnia symptoms and insomnia disorder among the 32,000 Veterans receiving care within VA Community Living Centers (CLC) (rehabilitation and long-term care facilities) each year. The present analysis provides an initial step in understanding the prevalence of insomnia disorder vs. insomnia symptoms within a local VA CLC subacute rehabilitation unit. This analysis is part of a clinical innovation project that evaluated Veterans’ sleep during admission for the purposes of informing clinical interventions. Methods 67 Veterans were admitted to a VA subacute rehabilitation unit following hospital discharge between March and August 2022. Veterans were asked to complete a brief evaluation within 7 days of admission, including the Insomnia Severity Index (ISI), Sleep Need Questionnaire (SNQ), and Epworth Sleepiness Scale (ESS). Sleep disorder diagnoses were obtained through chart reviews. Descriptive statistics were used to evaluate the prevalence of sleep disorders, insomnia severity, sleep need, and daytime sleepiness. Results 48 of 67 (71.6%) Veterans (Mage=72.8±12.0;97.9%male;79.2%white) completed evaluations within 7 days of admission. 52.1% of Veterans reported at least subthreshold insomnia (ISI≥8) with 22.9% reporting moderately severe clinical insomnia (ISI≥15). 50% reported not meeting their sleep need (SNQ≥13) and 33.3% reported at least mild levels of daytime sleepiness (ESS≥11). Chart reviews indicated only 25% of Veterans had a formal sleep disorder diagnosis in their chart and only 4.2% Veterans had a formal diagnosis of insomnia disorder. Conclusion The results of this preliminary analysis highlighted the discrepancy between national outpatient statistics and local inpatient statistics on the prevalence of insomnia symptoms and disorder. While the Veterans admitted to the CLC may be experiencing additional factors influencing their sleep (e.g., environmental disruptors), this does not wholly explain the discrepancy between the local and national ­samples. Future evaluations should include multiple VA sites to obtain a more representative sample of Veterans. Clinically, these findings suggest that insomnia disorder should be considered a standalone diagnosis and added to Veterans’ charts when clinically elevated symptomology is endorsed. Support (if any)

Quality Improvement Efforts in VA Community Living Centers Following Public Reporting of Performance

ABSTRACT For two decades, the U.S. government has publicly reported performance measures for most nursing homes, spurring some improvements in quality. Public reporting is new, however, to Department of Veterans Affairs nursing homes (Community Living Centers [CLCs]). As part of a large, public integrated healthcare system, CLCs operate with unique financial and market incentives. Thus, their responses to public reporting may differ from private sector nursing homes. In three CLCs with varied public ratings, we used an exploratory, qualitative case study approach involving semi-structured interviews to compare how CLC leaders (n = 12) perceived public reporting and its influence on quality improvement. Across CLCs, respondents said public reporting was helpful for transparency and to provide an “outside perspective” on CLC performance. Respondents described employing similar strategies to improve their public ratings: using data, engaging staff, and clearly defining staff roles vis-à-vis quality improvement, although more effort was required to implement change in lower performing CLCs. Our findings augment those from prior studies and offer new insights into the potential for public reporting to spur quality improvement in public nursing homes and those that are part of integrated healthcare systems.

Interprofessional care of patients with advanced dementia during critical transitions

As dementia progresses, individuals and their caregivers experience a prolonged course of disability, frequently characterized by an increase in neuropsychiatric symptoms, acute medical events, and need for higher levels of care. In addition to the challenges caused by disease progression, transitions between levels of care contribute to distress for a number of reasons, including greater difficulty on the patient's part in comprehending what is happening and why, unfamiliar settings and people, and unnecessary or overly aggressive medical interventions. Successful long-term placement can be challenging, particularly for those with behavioral symptoms. Many of these patients end up requiring hospitalization, often leading to a "revolving door" cycle of failed placement attempts and rehospitalizations.Various models of care have been developed to address these issues. The Behavioral Recovery Outreach (BRO) Team, an interprofessional team providing inpatient care and assistance with community placement for patients with advanced dementia, represents one such model. This model of care originated at the Des Moines VA in 2012 and has expanded to other VA systems across the country with variations in implementation but an overall core philosophy of holistic dementia care. Non-pharmacologic interventions are first-line therapy for commonly encountered symptoms of emotional distress, agitation, and aggression. Some of these include tailoring the environment to a Veteran's preferences, creating space for safe movement or music, or individualizing bedside cares to reduce distress. BRO Teams have been shown to reduce distressing behaviors associated with dementia and increase success of long-term placement for these patients.The BRO Team at the Minneapolis VA was created in 2016. The team provides subacute behavioral management in the VA's Community Living Center (CLC), after Veterans have been hospitalized on acute med-surg units for behavioral symptoms related to dementia. The team then supports Veterans through their transitions to long-term care settings.This presentation will provide an introduction to BRO Teams and describe the efficacy of the BRO Team and unit at the Minneapolis VA. Additionally, we will discuss how the BRO Team model of care fits into dementia services in the larger health care system. We will review data on various paths that patients with dementia take through the many specialized services and levels of care. In doing so, we will reflect on issues related to disparities in health care, and key points in a patient's and family's journey that may be particularly beneficial in terms of reducing stress, planning effectively for the future, and maintaining a positive quality of life. Our discussion will conclude with a literature review on the implementation of interprofessional teams for managing dementia-related behavioral challenges across different models of care.

Association of Mortality and Aspirin use for COVID-19 Residents at VA Community Living Center Nursing Homes

Association of Mortality and Aspirin use for COVID-19 Residents at VA Community Living Center Nursing Homes

Successful Discharge of Short Stay Veterans from VA Community Living Centers

ABSTRACT The Veterans Health Administration (VHA) long-term care rebalancing initiative encouraged VA Community Living Centers (CLCs) to shift from long-stay custodial-focused care to short-stay skilled and rehabilitative care. Using all VA CLC admissions during 2007–2010 categorized as needing short-stay rehabilitation or skilled nursing care, we assessed the patient and facility rates of successful discharge to the community (SDC) of these short-stay Veterans. We found large variation in inter- as well as intra- facility SDC rates across the rehabilitation and skilled nursing short-stay cohorts. We discuss how our results can help guide VHA policy directed at delivering high-quality short-stay CLC care for Veterans.

Whole Team, Whole Person High-Involvement Quality Improvement Training for VA Community Living Center Leaders

Long-term care is a challenging environment for quality improvement due to the high resident acuity, wide variation in resident needs, and wide variation in types and backgrounds of the large staff across three daily shifts. We report results from a learning collaborative undertaken to improve care quality and staff quality improvement skills in the VA CLCs through development of high functioning relationally coordinated teams operating in accord with person-centered care principles. The collaborative included 27 CLCs. Over 9 months leadership teams completed action assignments supported by 5 workshops and regular group coaching calls. Evaluation included fidelity monitoring (attendance, mid- and final progress reports), satisfaction questionnaires, and review of the VA quality measures (CLC Compare). Pre-post participant evaluations revealed a significant increase in positive responses to the question “to what extent do you think applying these new skills/knowledge will improve quality in your CLC?” and positive responses trending toward significance in ratings of abilities to apply new skills. Open-ended survey comments were positive and indicated change in understanding and practice: “utilizing the daily huddle to facilitate real time communication afforded the team a proactive approach to providing care and reducing acute exacerbations. We are able to avert, evaluate as a real time team and make it happen in the now not as a look back.”; “definitely unified front-line staff and CLC leadership.” Some changes were achieved in CLC Compare quality scores (e.g., falls with major injury rate had a 9.6 reduction (average rate = 3.39 pre, 3.07 post)).

Rolling Out Behavioral Recovery Outreach (BRO) Teams: Perspectives From an Inaugural Partner Site

The Sioux Falls VA Community Living Center (CLC) is a partner site for the Behavioral Recovery Outreach (BRO) Team dissemination. This CLC is home to over 55 Veterans requiring a variety of specialty needs such as dementia care, short-term rehabilitation, respite, hospice, and/or psychosocial needs. Many of the Veterans followed by the BRO Team on the CLC experienced frequent rehospitalizations and difficult placement in the community due to behavioral concerns. Local leadership encouraged participation in the BRO Team dissemination due to the growing need in this VA system to open access to dementia and mental health care, successfully discharge Veterans to appropriate community settings, and reduce unnecessary rehospitalizations. This presentation will discuss BRO Team development, including several factors facilitating successful BRO Team implementation (e.g., leadership support, community outreach approaches, staff partner buy-in), and identify barriers impacting successful implementation with a case example to illustrate strategies to overcome such barriers.

Influencing Factors Associated with Implementation of INTERACT (Interventions to Reduce Acute Care Transfers) in VA Community Living Centers (CLCs) Using the Consolidated Framework

ABSTRACT Our objective was to identify the influencing factors associated with the implementation of the INTERACT (Interventions to Reduce Acute Care Transfers) Quality Improvement program within a national healthcare system. INTERACT focuses on early identification and management of changes in residents’ condition leading to a reduction in potentially preventable hospital transfers. The Consolidated Framework was used to evaluate implementation data from eight VA Community Living Centers. Qualitative implementation data suggest two influencing Consolidated Framework domains had a strong influence: 1) key attributes of the intervention (e.g., adaptability or complexity) and 2) internal organizational factors (e.g., culture or compatibility). Using the Consolidated Framework can assist future adaptations to this and other complex quality improvement initiatives.

1048-P: Factors Contributing to Early Mortality in Persons with Type 2 Diabetes with Lower Extremity Amputation

Introduction: Type 2 diabetes continues to be one of the most common and costly conditions in the United States. Complications and co-morbidities that develop, such as amputations, add to the financial toll and can reduce the life expectancy of these individuals. The aim of this study was to identify risk factors that lead to early mortality (12 months or less) following subacute inpatient, interdisciplinary rehabilitation at a VA Community Living Center (CLC). Methods: A retrospective medical chart review was conducted on forty-seven Veterans who had a lower extremity amputation and died between 2015-2018. Demographic variables collected included age, months between discharge and death, and social support at home. Conditions on status of hypertension, type 2 diabetes, coronary artery disease, congestive heart failure, smoking status, end-stage renal disease and chronic renal disease were gathered at date of death. Results: The mean age at CLC admission was 68 years and the average time of death was 14.2 months after discharge. It was shown that 50.5% of the patients returned home to social support. Mean HbA1c was 7.1% prior to amputation. A multiple logistic regression was performed associating status of persons with type 2 diabetes (P=.043, 95% CI = .09 - 5.25) and concurrent chronic renal disease (P=.02, 95% CI = .33 - 4.79) leading to death at less than 12 months. There was no significant relationship between hypertension, smoking, age, end-stage renal disease, congestive heart failure with mortality after discharge from the CLC. No association was found between pre-operative HbA1c status and survivorship. Conclusion: There was a relationship between those who died within 12 months and diagnosis with both type 2 diabetes and chronic renal disease after an inpatient stay at a VA Community Living Center. These results suggest diabetes along with concurrent chronic renal disease management needs to be maintained after an inpatient stay to prevent premature death. Disclosure J. Chan: None. K. Yan: None.

Nursing surveillance and immediate jeopardy in Veteran Health Administration community living centers unannounced survey program 2018 to 2019

BackgroundThe VA Community Living Center (CLC) Unannounced Survey Program aims to assess standards of care set by the government to protect residents. PurposeTo describe patterns of practice failures in nursing surveillance causing or having potential to cause immediate jeopardy, as defined by the Centers for Medicare and Medicaid Services. MethodsUsing CLC survey data consisting of 200 statements of deficiency (SODs) for 2018 to 2019, we collected a SOD sample (n = 20) of immediate jeopardy events. They were described using descriptive statistics and discourse content analysis. FindingsWe identified clinical events, their duration, work shift, and nursing skill mix for each SOD. Most to least common themes about failures in nursing surveillance were acquisition/transfer of information; decision-making; and early recognition of problems. DiscussionOur analysis of nursing surveillance failures in CLC immediate jeopardy SODs provides insight into opportunities for registered nurses and the nursing skill mix to reduce avoidable harms.

Implementing an Interdisciplinary Committee to Reduce Psychotropic Drug and Increase Behavioral Intervention Use

In Fiscal Year (FY) 2018, the Butler VA Health Care System’s Psychotropic Medication and Behavior Management Committee was identified as a Veterans Integrated Service Network 4 Best Practice. The goal of this committee is to reduce unnecessary psychotropic medication use and polypharmacy and to increase behavioral intervention implementation among Community Living Center (CLC) Veterans. This committee meets quarterly to review Psychotropic Drug Safety Initiative data, behaviors and behavior care plans, and all psychotropic medications prescribed to Veterans. Psychiatric diagnoses, changes to psychotropic medications, and appropriate behavioral interventions are discussed. Committee members take responsibility for action items in accordance with their discipline; documentation of recommendations are made in quarterly behavioral health assessments in CPRS; and follow-up on action items is completed at twice weekly interdisciplinary treatment team meetings, weekly behavior rounds, and/or as needed. From the first quarter (Q1) of FY16 to Q1 FY20, the Butler VA CLC has seen decreased prescriptions of 2 or more anticholinergics (6.6% to 0.80%), antihistamines (12.5% to 5.9%), benzodiazepines (24.7% to 11.0%), and benzodiazepines or sedative hypnotics (23.2% to 9.0%). While prescription of antipsychotic use has increased (Q1 FY20 = 23.8%), the committee will follow Long Term Care Institute guidelines for gradual dose reductions, behavioral interventions, and as needed psychotropic medication PRN use. This committee provides an interdisciplinary forum to discuss and implement beneficial changes to pharmacological and non-pharmacological interventions among all CLC Veterans. The committee is a valuable process for monitoring and reinforcing best practices that may be easily replicated across VA CLCs nationwide.

Goals‐of‐care Conversation Prevalence and Life‐Sustaining Treatment Preferences Among VA Nursing Home Residents with and without Dementia

Research ObjectiveThe Veterans Health Administration uses structured goals‐of‐care conversations (GoCCs) to document veterans’ preferences for life‐sustaining treatments (LST). Responses include information on decision making capacity, goals, and preferences for LST following cardiopulmonary and noncardiopulmonary events. Durable medical orders are generated to inform care decisions and are accessible to clinicians across the VA health care system. We conducted a descriptive analysis of GoCC documentation among veterans residing in VA Community Living Centers (CLC), with a focus on those diagnosed with dementia. This population of veterans is at high risk of life‐threatening events and is suited to have GoCCs.Study DesignData were pulled from the VA’s Corporate Data Warehouse (CDW). Inpatient data were used to identify veterans who resided in a CLC for one or more days between January 2018 and June 2019. Veterans were considered to have dementia if they had one or more dementia diagnoses during an inpatient stay or two or more face‐to‐face diagnoses at outpatient visits in the last two years. Completed GoCCs that were documented between one year prior to admission, or January 2018 if admitted earlier, and discharge, or June 2019 if discharged later, were analyzed. The prevalence of GoCC documentation, responses to the LST questions, and dementia status were cross‐tabulated.Population StudiedVeterans in CLCs between January 2018 and June 2019 (N = 55 271).Principal FindingsAmong all CLC veterans, 29 460 (53%) had a documented GoCC. Dementia was indicated for 14 231 veterans (26%). Completed GoCC documentation was more prevalent for those with dementia than those without (59% vs 51%). Proxies provided consent for 74% of responses for veterans with dementia and 21% for veterans without dementia. Of the 29 460 CLC veterans with completed GoCC documentation, 43% were deceased within 6 months.Among veterans with completed GoCCs, veterans with dementia were more likely to document a preference of being comfortable (71% vs 57%) and less likely to document a preference of improving/maintaining function or prolonging life (40% and 14% vs 48% and 22%). The documentation of a preference to “attempt CPR for cardiopulmonary events” was less prevalent for veterans with dementia (20% vs 36%) as was a preference for the full scope of treatment for noncardiopulmonary events (27% vs 41%).ConclusionsThe high mortality rate following documented GoCCs for this population highlights the urgency with which documented care preferences are needed in order to provide goal concordant care; it also suggests that providers may be targeting high‐risk CLC veterans. The differences in LST goals documented for veterans diagnosed with dementia highlight how clinical conditions may shape goals and preferences and should be taken into consideration by providers. Since proxies responded for many more veterans with dementia than those without, it is unclear whether differences in preferences reflect those of the veterans or their proxies.Implications for Policy or PracticeThe documentation of LST preferences can capture meaningful patient preferences across different populations and can augment end‐of‐life care planning.Primary Funding SourceDepartment of Veterans Affairs.

Strategies for Implementing Group Mental Health Interventions in a VA Community Living Center

ABSTRACT Objectives: Group mental health interventions are difficult to implement into rehabilitation facilities, but no one has studied the specific barriers. This mixed-methods project systematically examined the implementation of a mental health (MH) group intervention in a VA community living center (CLC) for residents on subacute rehabilitation units, using the Promoting Action on Research Implementation in Health Services (PARIHS) implementation framework. Methods: We implemented a group MH intervention, tracking team referrals, attendance rates, and reasons for declining to participate. We conducted qualitative interviews with attendees. Results: Individual barriers to attendance included acute illness (n = 67, 20%), attitudes toward MH (n = 50; 15%), and perceived busyness (n = 19; 6%). Facility barriers included competing appointments (n = 69; 21%). Interviews demonstrated challenges to implementation, including stigma toward mental health (Theme: Challenges and Supports to Implementation). Attendees found the group relatable, and noted that both positive and negative group dynamics contributed to their experience (Themes: Content Relevance and Group Dynamics). Conclusions: The results provide insight into implementing a group MH treatment into the CLC setting, with implications for the MH care of older adults residing in CLCs. Clinical Implications: 1) Group leaders should consider matching attendees for ability levels (physical or cognitive). 2) At the facility level, leaders may take steps to address stigma toward MH by adopting approaches (e.g., music) or framing MH issues (e.g., use of language) in a way that is approachable. 3) Modifiable barriers at the individual and facility level could be addressed to encourage ease of implementation.

GRADUAL DOSE REDUCTION (GDR) CONCERNS IN GERIATRIC PATIENT WITH MENTAL HEALTH DISORDERS, LIVING IN LONG TERM CARE FACILITIES

Introduction Omnibus Budget Reconciliation Act (OBRA) of 1987 limited the use of psychotropic medications in residents of long-term care facilities. Update of OBRA guidelines have even farther increased some dosing restrictions, however documentation of necessity and periodic trials of medication withdrawal (GDR) are still emphasized. Almost 20% of American age 55 and older are suffering from some type of mental health disorders which include but not limited to mood disorders (Unipolar/Bipolar), psychosis, anxiety as well as symptomatic management of agitated patients due to other medical condition. Mental health disorders are implicated as a factor for suicide. Men aged 85?years or older have a suicide rate of 45.23 per 100,000, compared to an overall rate of 11.01 per 100,000 for all ages. While other treatment modalities (psychotherapy etc.) are implemented most of the time one or more psychotropic medication are used for management of these patient's population. In 2006 Center for Medicare and Medicaid Services (CMS) published guidelines about antipsychotic drug therapy only for specific condition, prescribed at the lowest possible dose, used for the shortest period, and continually undergo gradual dose reduction (GDR). There is significant literatures on guidelines and recommendation of GDR in geriatric patients. However, there is limited research and publications on prohibiting or avoiding GDR in some circumstances. We are presenting a case of a patient suffering from mental health disorder comorbid with other medical condition whose GDR might have been the cause of her symptom relapse and the need for acute inpatient management. Methods Ms. GM is 70?years old female with psychiatric diagnosis of schizoaffective disorder bipolar type has been admitted to VA Community Living Center (CLC), after she is medically diagnosed with stage III endometrial cancer and CVA for palliative chemotherapy. She was managed initially with Risperidone 5mg in the morning and 3mg at night, Haloperidol 2mg in the morning and 1mg at night, Gabapentin 200mg twice daily, under the GDR protocol her medication was decreased to Risperidone 2mg twice daily and stop the Haldol all together. Her response were monitored and documented on Computerized Patient Record System (CPRS). While she was initially stable with GDR, gradually she developed hypomanic sxs of paranoid ideation, irritability with hypersexuality as well as expansive thought, disorganized behavior. Ms. GM was not responding to initial behavioral intervention which rendered to an acute inpatient admission for management of her symptom. Once stabilized in the acute inpatient setting, Ms. GM was re-admitted to CLC for continuation of her palliative care of her endometrial cancer, CVA and schizoaffective disorder. Her current psychotropic medication is Risperidone 2mg in the morning and 3mg at night, Gabapentin 300mg QHS, she is responding to the current psychiatric intervention with minimal residual depressive symptoms still remaining. In the last visit her affect improved and she is no longer on one-one observation of irregular behavior. Results Consideration for the exceptions can be as part of GDR for some patient with mental health problem. With proper documentation of patient's response to GDR, utilizing clinical expertise and medication side effects will help prevent relapse of symptoms. Conclusions The goal of recommending psychotropic medication in patients 50 and older is to address mental health disorder and provide quality of life to patients suffering from mental health disorders with or without other medical comorbidities. With respect to their side effects and to avoid polypharmacy, CMS recommended guideline of GDR is an optimal consideration to most of psychiatric patients. However, applying these guidelines are challenging and complex, which requires knowledge of existing clinical evidence, standard of practice on using psychotropic medication with appropriate professional rational on attempting to reduce its dosage. This research was funded by: Zero funding

PARTNERED EVALUATION OF LONGITUDINAL IMPACT OF STAR-VA: IMPLICATIONS FOR PROGRAM SUSTAINABILITY

Between 2013 and 2018, 86 Community Living Center (CLC) teams received STAR-VA training and consultation and implemented the intervention. Program evaluation has consistently demonstrated that STAR-VA Veteran training cases experience significantly decreased frequency and severity of target behaviors, symptoms of depression, anxiety, and agitation. VA Central Office leaders responsible for ongoing STAR-VA implementation and evaluation sought to understand the program’s systemic impact on important outcomes, if outcomes are maintained, and factors influencing variation in sustained adherence to STAR-VA. This presentation will describe the rationale for and methods used to develop a valid quality improvement metric to assess behavioral symptoms of dementia, to compare Veteran- and site-level outcomes at trained and untrained CLCs, and to identify factors associated with sustained STAR-VA implementation. This partnered evaluation, combining quantitative and qualitative methodologies, is critical for informing operational strategies for promoting STAR-VA and supporting its sustained implementation in VA CLCs.

QUALITY IMPROVEMENT IN DEMENTIA CARE: EFFECTIVENESS OF IMPLEMENTING STAR-VA IN A VA COMMUNITY LIVING CENTER

Staff Training in Assisted Living Residences adapted for Veterans Affairs (STAR-VA) is an evidence-based, interdisciplinary behavioral intervention to manage challenging Behavioral Symptoms of Dementia (BSD) at VA Community Living Centers (CLCs). Components of STAR-VA included creating realistic expectations for individuals with dementia, effective communication, using a behavioral problem-solving approach, and increasing resident-centered pleasant events. STAR-VA was implemented at VA Western New York CLC to help staff manage Veteran BSD. The purpose of the study was to examine the effectiveness of STAR-VA implementation in 17 CLC Veterans with Dementia who demonstrated BSD distressing to themselves, other Veterans and/or staff and documented in 2017-2018. STAR-VA was facilitated by the behavioral coordinator and nurse champion in partnership with the CLC behavior team during weekly rounds and as needed modeling and debriefing. The team included the medical provider, recreation therapist, social worker, and all levels of nursing. On average, the intervention involved four assessments over 75 days. Outcome measures at baseline and post-intervention included assessments of target behavior frequency and severity, direct care tracking of behaviors, and the Minimum Data Set distress behavior indicator. Compared to baseline scores, clinically meaningful reduction was documented using team assessment and direct care ratings of BSD frequency and severity, and overall inappropriate utilization of antipsychotic medication. CLC clinical staff tailored implementation of STAR-VA to be feasible and effective. Ongoing evaluation of STAR-VA implementation using routine measures promotes measurement based care, providing feedback to the team to improve care quality.