Implementation of the Community Homes for Opportunity Program Among Community Mental Health Staff in Southwestern Ontario.

Supportive housing programs such as the Community Homes for Opportunity (CHO) that provide combined formal (off-site healthcare providers) and informal (on-site supports are effective in reducing erratic housing and homelessness. This study explored the views of the Community Mental Health Agency staff on their experiences with the CHO and related changes for further improvement of the program. We applied focused ethnographic techniques to recruit 47 agency staff from 28 group homes in Southwestern Ontario, Canada. Focus group discussions were conducted at two-time points (baseline-spring 2018 and post-implementation - winter 2019). Data analysis guided by Leininger's ethnographic qualitative analysis techniques produced three main themes and 11 subthemes themes. The main themes include facilitators of CHO, challenges to the CHO implementation, and strategies for improving the CHO program. Overall, supportive housing models have been found to constitute an effective pathway to reducing precarious housing and ending chronic homelessness for those in need while enhancing their social integration.

Influence of the organizational environment on challenging behaviour in people with intellectual disabilities: Professionals' views.

BACKGROUND: We examined the influence of the organizational environment on challenging behaviour in people with intellectual disabilities to increase understanding of the quality of support services for people with intellectual disabilities. METHOD: Twenty-one professionals and managers from four specialized Dutch disability service organizations were interviewed. Data were analysed with a grounded theory approach, using Bronfenbrenner's ecological theory as a sensitizing frame. RESULTS: The organizational environment (i.e., vision, values, sufficient resources) is related via the support service (i.e., providing stability, constant awareness) to residents' challenging behaviour and is also linked directly to challenging behaviour (e.g., living environment, values). Organizations are restricted by national regulations, negative media attention and changing societal values, which negatively influence quality of support. CONCLUSIONS: The creation of a supportive organizational environment for staff, who in turn can provide quality support services to residents with demanding care needs, was found to prevent challenging behaviour in people with intellectual disabilities.

Training for Direct Support Staff at Group Homes for People with Chronic Mental Illness.

For people with chronic mental illness, their support system (including direct support staff at group homes) play a key role in ameliorating exacerbations leading to crisis care. However, little information exists on curriculum or training programs focused on reducing exacerbations while promoting compassionate care. We developed, implemented and evaluated such a program that featured role-playing and animated videos supplemented with limited didactics. During development phase, direct support staff reviewed videos and rated them as depicting realistic situations with high acceptability. During implementation, the 6-week course (at least one staff from six different group homes not involved in the development phase) using a 3-month pre-post design found reductions in total number of incident reports and pre-specified outcomes of recipient right complaints, emergency calls, and psychiatric hospitalizations. The program demonstrated acceptability, improved care and better outcomes on some but not all outcomes. Improved training of direct support staff is possible and has positive outcomes.

How frontline staff manage paperwork in group homes for people with intellectual disability: Implications for practice.

BACKGROUND: Paperwork is a key tool that transforms organizational intentions into actions in group homes, although prescriptive procedures may limit how frontline staff use it in practice. The aim of this study was to explore how frontline staff use paperwork in group homes for people with intellectual disability and identify practice implications. METHOD: Constructivist grounded theory methodology guided the research. Data collection included semi-structured interviews and participant observations. Coding, comparison and sorting methods were adopted to analyse how staff used paperwork. RESULTS: Staff followed organizational paperwork rules when they aligned with their resident-focused approach to work. When they perceived rules to misalign with this approach, they managed paperwork by adjusting the time and place of completion, managing content, creating alternative tools and refusing completion. CONCLUSIONS: Staff purposefully managed paperwork rather than simply following procedures. Disability service organizations could develop flexible paperwork procedures and include frontline perspectives in paperwork development.

Caring and Uncaring Encounters between Assistant Nurses and Immigrants with Dementia Symptoms in Two Group Homes in Sweden-an Observational Study.

BACKGROUND: The total number of people with dementia symptoms is expected to double every 20 years and there will also be an increase in the number of older immigrants in several countries. There are considerable deficiencies in the present knowledge of how to conduct well-functioning health care for immigrants with dementia symptoms. The aim of this study was to explore caring and uncaring encounters between assistant nurses and immigrants in two group homes for persons with dementia symptoms in Sweden: a Finnish-speaking as well as a Swedish-speaking context. In addition, this study aims to describe how caring and uncaring encounters are manifested in these two contexts according to Halldórsdóttir's theory of "Caring and Uncaring encounters". METHOD: Descriptive field notes from 30 separate observations were analyzed using qualitative deductive content analysis. RESULTS: The main category "caring encounters" focused on reaching out to initiate connection through communication, removing masks of anonymity by acknowledging the unique person, acknowledgment of connection by being personal. Reaching a level of truthfulness by being present and showing respect, raising the level of solidarity by equality and true negotiation of care, based on the residents' needs. The main category, uncaring encounters, focused on disinterest in and insensitivity towards the other, coldness in the connection and lack of humanity in care situations. The observations showed that caring encounters occurred more in the Finnish-speaking context and uncaring encounters more often in the Swedish context. CONCLUSION: Encounters could be caring, uncaring, and carried out using a person-centered approach. Communication and relationships could be facilitated using the same language but also through learning to interpret residents' needs and desires.

Understanding the implementation of maternity waiting homes in low- and middle-income countries: a qualitative thematic synthesis.

BACKGROUND: Maternity waiting homes (MWHs) are accommodations located near a health facility where women can stay towards the end of pregnancy and/or after birth to enable timely access to essential childbirth care or care for complications. Although MWHs have been implemented for over four decades, different operational models exist. This secondary thematic +analysis explores factors related to their implementation. METHODS: A qualitative thematic analysis was conducted using 29 studies across 17 countries. The papers were identified through an existing Cochrane review and a mapping of the maternal health literature. The Supporting the Use of Research Evidence framework (SURE) guided the thematic analysis to explore the perceptions of various stakeholders and barriers and facilitators for implementation. The influence of contextual factors, the design of the MWHs, and the conditions under which they operated were examined. RESULTS: Key problems of MWH implementation included challenges in MWH maintenance and utilization by pregnant women. Poor utilization was due to lack of knowledge and acceptance of the MWH among women and communities, long distances to reach the MWH, and culturally inappropriate care. Poor MWH structures were identified by almost all studies as a major barrier, and included poor toilets and kitchens, and a lack of space for family and companions. Facilitators included reduced or removal of costs associated with using a MWH, community involvement in the design and upkeep of the MWHs, activities to raise awareness and acceptance among family and community members, and integrating culturally-appropriate practices into the provision of maternal and newborn care at the MWHs and the health facilities to which they are linked. CONCLUSION: MWHs should not be designed as an isolated intervention but using a health systems perspective, taking account of women and community perspectives, the quality of the MWH structure and the care provided at the health facility. Careful tailoring of the MWH to women's accommodation, social and dietary needs; low direct and indirect costs; and a functioning health system are key considerations when implementing MWH. Improved and harmonized documentation of implementation experiences would provide a better understanding of the factors that impact on successful implementation.

Immigrants with dementia in Swedish residential care: an exploratory study of the experiences of their family members and Nursing staff.

BACKGROUND: Worldwide, there is a growing population of older people who develop dementia in a country other than that of their origin. When their dementia has reached an advanced stage, residential care is most often needed. People with dementia in Sweden are often cared for in group homes. For immigrants, this may mean a linguistically challenging care environment for both healthcare staff and the patients' family members. The aim of this study was to explore and describe the experiences of family members and professional caregivers regarding the care provided to immigrants with dementia in group homes in Sweden. METHODS: An exploratory, descriptive study with a qualitative approach was chosen. In-depth semi-structured interviews were conducted with nine professional caregivers and five family members of people with dementia with Finnish, Estonian, Hungarian and Ingrian backgrounds; all were chosen purposefully. All people with dementia had lost their Swedish language skills as their second language. The data was analysed using qualitative content analysis. RESULTS: Three main categories and seven subcategories were identified. The first main category: A new living situation comprised the subcategories: adjusting to new living arrangements and expectations regarding activities and traditional food at the group home, the second main category: Challenges in communication with the subcategories: limited communication between the immigrant with dementia and the Swedish-speaking nursing staff and the consequences of linguistic misunderstandings and nuanced communication in a common language and the third main category: The role of the family member at the group home with the subcategories: a link to the healthy life story of the family member with dementia and an expert and interpreter for the nursing staff. CONCLUSIONS: The family member played a crucial role in the lives of immigrants with dementia living in a group home by facilitating communication between the nursing staff and the PWD and also by making it possible for PWD to access the cultural activities they wanted and which professional caregivers were either not able to recognise as needed or could not deliver.

Meanings associated with the core component of clubhouse life: the work-ordered day.

Despite the clubhouse model's 60-year existence internationally, the central nature of its core program, the "work-ordered day" (WOH) (Beard et al. in Psychosocial Rehabilitation Journal 5:47-53, 1982), is not well understood; hence, the primary focus of the present study was to explore members' experiences of the nature and meaning of the WOH. The study drew on qualitative interview data collected in 2009-2013 through open-ended questions and probes with 102 members and 24 staff from 5 Clubhouse International-certified clubhouses (2 US and 3 Finnish). Participant observation supplemented the interviews and all data were analyzed using a grounded theory approach (Charmaz in Rethinking methods in psychology, 1995; Glaser and Strauss in The discovery of grounded theory: strategies for qualitative research, 1967). Two major themes clustered around: (a) WOH in service of autonomy (things to do, sense of accomplishment, respite, development of occupational skills) and (b) WOH in service of relationships (receiving support; collaboration; and making contributions to the clubhouse community). Clubhouse members appeared to experience the WOH as meaningful because it helps them, as its best, reconstruct a life, develop their occupational self and skill sets, and experientially learn and live what parallels a good life in the general community. It appears that these experiences, interconnecting with the fundamental human needs for autonomy and relationship, point to wellbeing and recovery as part of personal growth. These findings can guide clubhouse daily practice in assessing members' psychosocial strengths and needs pertaining to recovery. Future research should elaborate on influences of sources of meaning, including work designs and the contributions of everyday socio-cultural interactive and reciprocal processes to these meanings.

Stories of rediscovering agency: home-based occupational therapy for people with severe psychiatric disability.

As part of a larger study, we offered Everyday Life Rehabilitation (ELR) as a model for integrated occupational therapy in sheltered or supported housing facilities, to enable meaningful daily occupations for people with psychiatric disabilities. Our aim with this study was to understand how participants made sense of their occupational transformations in the context of their everyday life and life history. We carried out qualitative interviews and field observations with 16 participants with psychosis-related disorders. We used narrative analysis and disclosed stories of "rediscovering agency," referring to occupational and identity transformations. A parallel outcome study has shown positive results for participants, and by using narrative inquiry we contribute with a deeper understanding of the meaning making of their transformations and mechanisms of the intervention; i.e., hope, extended value of reaching goals, reentering the majority world, transparency of process, and attunement to the individual. The findings support the use of the ELR intervention.

Implementation of active support in Victoria, Australia: an exploratory study.

BACKGROUND: Active support is an effective intervention to support engagement of residents with intellectual disability in group homes. This survey explored resident characteristics of the people supported by organisations implementing active support, the provision of active support, its procedures and systems, and resident engagement in meaningful activity and relationships. METHOD: Information was collected through questionnaires and direct observation of 33 group homes from 6 organisations in Victoria, Australia, with a 5-10-year history of implementing active support. RESULTS: Residents with lower support needs were engaged with little staff contact or assistance. Use of active support systems and structures was mixed. Only one organisation consistently provided good active support. CONCLUSIONS: Administrative systems and structures are not sufficient to change staff interaction and thus resident experience. Shared supported accommodation services may represent an inefficient use of resources for more able residents, as staff resources are not maximised to support for resident engagement.

Evaluating a bilingual voluntary community-based healthcare organization.

The current study compared traditional recovery homes for individuals with substance use disorders with homes that had been modified to feature culturally congruent communication styles. Findings indicated significant increases in employment income, with the size of the change significantly greater in the culturally modified houses. Significant decreases in alcohol use over time were also found, with larger decreases over time in the traditional recovery homes. Use of prescribed medications and days using drugs significantly decreased over time, but not differentially for those in the two types of recovery homes. The implications of these findings are discussed.

Diagnostic grouping among adults with intellectual disabilities and autistic spectrum disorders in staffed housing.

BACKGROUND: There is little evidence to guide the commissioning of residential provision for adults with autistic spectrum disorder (ASD) in the UK. We aim to explore the degree and impact of diagnostic congregation among adults with intellectual disabilities (ID) and ASD living in staffed housing. METHODS: One hundred and fifty-seven adults with intellectual disabilities from a sample of 424 in staffed housing were assessed as having the triad of impairments characteristic of ASD. They lived in 88 houses: 26 were non-congregate (40% or fewer residents had the triad) and 50 congregate (60% or more had the triad); 12 with intermediate groupings were eliminated. Non-congregate and congregate groups were compared on age, gender, adaptive and challenging behaviour, house size, staff per resident and various measures of quality of care and quality of outcome. Comparisons were repeated for Adaptive Behavior Scale (ABS)-matched, congregate and non-congregate subsamples. RESULTS: Non-congregate settings were larger, had lower staff per resident and more individualised social milieus. Groups were similar in age and gender but the non-congregate group had non-significantly higher ABS scores. The non-congregate group did more social, community and household activities. After matching for ABS, these outcome differences ceased to be significant. Non-congregate settings were significantly larger and had significantly more organised working methods. CONCLUSIONS: The findings are consistent with other research that finds few advantages to diagnostic grouping.

Competencies of front-line managers in supported accommodation: issues for practice and future research.

BACKGROUND: Front-line managers of supported accommodation for people with intellectual disability are assumed to have a key role in the realisation of outcomes for service users. Yet, their job has been little researched. A job analysis from Minnesota that identified 142 competencies required of effective front-line managers was used to examine what was expected of the equivalent position in Victoria, Australia. METHODS: These competencies formed the basis of semistructured interviews with an extreme sample of 16 high-performing house supervisors and 5 more senior managers. RESULTS: Ninety-two percent of the original competences were retained, with changes in language and terminology to reflect the local context. Emergent findings highlighted the importance of house supervisors' "orientations." CONCLUSIONS: The findings support the proposition that the front-line manager's job is underpinned by core competencies and that the role merits further study. Issues of wider significance for human service organisations and researchers are discussed.

Targeted support and telecare in staffed housing for people with intellectual disabilities: impact on staffing levels and objective lifestyle indicators.

BACKGROUND: Increased provision of out-of-family residential support is required because of demographic changes within the intellectual disabilities population. Residential support now has to be provided in a climate requiring both financial constraint and high quality service outcomes. The aim was to evaluate the quality of life consequences of living with less intensive staff support, resulting from the introduction of more targeted staff allocation coupled with telecare. METHODS: The study comprised 91 participants who lived in 33 settings. The targeted support/telecare intervention was implemented at staggered intervals in 25 of these settings (63 participants). Data on a range of participant and setting descriptors, quality of care, and a range of objective lifestyle indicators were collected at four points in time over 2 years. Impact of the intervention was evaluated using within-group comparisons over time. RESULTS: Comparison between pre- and post-intervention showed that staffing levels were significantly reduced by 23%, whereas they were constant in the absence of intervention. One health indicator improved in the absence of intervention and another improved following intervention. There were no significant changes in any other lifestyle indicators (safety, money, social and community activity, independence or choice). CONCLUSIONS: A combination of targeted support and telecare had no adverse short-term affect on participants' quality of life, but reduced staff input so it seems that they have a role to play in the strategic development of out-of-family placements for adults with intellectual disabilities. Further research is needed to explore in more detail how efficiency is achieved in practice.

Physically violent behaviour in dementia care: Characteristics of residents and management of violent situations.

OBJECTIVE: Physically violent behaviour (PVB) is common among residents with dementia and often complicates nursing care. This study aims to explore types of caring situations, resident characteristics related to PVB and professional caregivers' management of PVB. METHODS: The study included 40 group homes for 309 residents with dementia. Data was gathered by means of structured interviews, the Multi-Dimensional Dementia Assessment Scale and the Geriatric Rating Scale. RESULTS: Ninety-eight of the residents (31.7%) were assessed as showing PVB during the preceding week. Three factors were independently associated with PVB: male gender, antipsychotic treatment and decline in orientation. Violent residents were more likely to have impaired speech, difficulties understanding verbal communication and prescribed analgesics and antipsychotics than were non-violent residents. PVB occurred mainly in intimate helping situations and was managed by symptom-oriented approaches, such as distraction, medication and isolation. The working team also held frequent discussions about the residents with PVB. CONCLUSION: This study shows that PVB is frequently displayed among residents in group homes for persons with dementia and the caregivers mainly manage PVB in a symptom-oriented way. To enhance the quality of care for patients with dementia, there is a need for interventions that aim to understand and manage the residents' physical violent behaviour.

Contrasting social climates of small peer-run versus a larger staff-run substance abuse recovery setting.

This study compared the social climate of peer-run homes for recovering substance abusers called Oxford House (OH) to that of a staffed residential therapeutic community (TC). Residents of OHs (N = 70) and the TC (N = 62) completed the Community Oriented Programs Environment Scales. OHs structurally differ on two primary dimensions from TCs in that they tend to be smaller and are self-run rather than professionally run. Findings indicated significantly higher Involvement, Support, Practical Orientation, Spontaneity, Autonomy, Order and Organization, and Program Clarity scores among the OH compared to TC residents. Additional analyses found the OH condition was higher Support, Personal Problem Orientation, and Order and Organization scores among women compared to men residents. These results suggested that these smaller OH self-run environments created a more involving and supportive social milieu than a larger staff-run TC. These findings are interpreted within Moos' (2007) four theoretical ingredients (i.e., social control, social learning, behavioral economics, and stress and coping), which help account for effective substance abuse treatment environments.

Evidence-based practice in group care: the effects of policy, research, and organizational practices.

This article describes the effect of a province-wide vision of evidence-based and outcome-based services for children and youth and the challenges of implementing evidence-based practice (EBP) and evidence-based treatment (EBT) approaches within group care settings. The paper is based on the results of a survey of group care settings in the province of Ontario, Canada, which was designed to understand the factors affecting the use of EBP and EBT. The critical roles of policy, access to research, and organizational structure as they affect the frontline workforce were explored. The results identified key differences between programs who implemented an evidence-based approach and those who are struggling to do so. Differences in case management practices as well as organizational factors affect the program's ability to use an evidence-based approach.

[Shared-housing arrangements for care-dependent older persons - characteristics, development and drivers]. / Ambulant betreute Wohngemeinschaften für alte, pflegebedürftige Menschen - Merkmale, Entwicklung und Einflussfaktoren.

Shared-Housing Arrangements (SHA) for care-dependent older persons gain increasing importance as a setting for nursing care in Germany, both in terms of numbers and user preference. This article aims to answer the questions in which phases SHA have developed over time, what the initiator's objectives are, and what factors contributed to SHA proliferation. A systematic review of the literature was conducted that finally included 73 articles. As a result it can be demonstrated that SHA started from "individual user initiatives", became "developing novel services" and finally established themselves as "regular services" in the nursing setting. A typology of different models of SHA can be organised along two dimensions: Firstly the temporal dimension of care organisation and secondly the way care services are purchased. Objectives formulated by the initiators of SHA are: Establishment of a family - like environment, inclusion of relatives, community orientation, security of care provision and maintenance of self-determination. Tailor-made financial and legal regulations supported the spread of SHAs. In reflection of the available literature it becomes evident that no satisfactory consensus on those elements exist that are constitutive for SHAs. Furthermore, there is a dearth of research on whether postulated objectives and other health related goals are actually being met in SHAs. Open questions pertain also the level of self-determination achieved in practice and other outcomes attained.

[Shared-housing arrangements for care dependent older persons. Support from family members and volunteers]. / Ambulant betreute Wohngemeinschaften für altere, pflegebedürftige Menschen. Unterstützung von Angehörigen und Ehrenamtlichen.

Due to growing numbers of older care dependant persons shared-housing arrangements (SHA) were developed as a new approach, especially for those elderly People suffering from dementia. The involvement of family members and volunteers is a core component of the SHA concept. Besides the active involvement in meaningful activities, relatives also often act as legal representatives. Empirical data concerning how frequently family members and volunteers are involved as well as the tasks they pursue is lacking. The aim of the study is to describe and evaluate the involvement of family members and volunteers in SHA. Special Care Units (SCU) are observed in comparison. In january 2009, all identified SHA and SCU in the city of Berlin were included in a cross-sectional survey as part of the DeWeGE-study. The DeWeGE-study was the first one on SHA in the city of Berlin. Data was collected using a written, standardised questionnaire. We collected data related to the frequency and tasks of family members and volunteer involvement as well as to the residents characteristics. 963 residents of 105 SHA and 17 SCU were included. More persons suffer from dementia in SCU than in SHA. SHA offer events to inform relatives and volunteers about their possible involvement less often than SCU. Family members are involved in meaningful activities in around 50 percent of all SHA and SCU. The proportion of family members who are present in the unit at least once per week is significantly higher in SCU than in SHA. No statistically significant difference between SHA and SCU is found regarding the involvement of volunteers. In SHA, legal representatives are more often paid professionals than in SCU. The real involvement of family members and volunteers in SHA does not reflect the conceptual propositions of this care arrangement.

Hospital experiences of older people with intellectual disability: responses of group home staff and family members.

BACKGROUND: This study reports on the hospitalisation experiences of older adults with intellectual disability living in group homes. METHODS: Grounded dimensional analysis was used to guide data collection and analysis. Group home residents were tracked prospectively over a 3-year period. Interviews were conducted with family, group home, and aged care staff and managers, and some residents. RESULTS: Findings highlighted the difficulty people with intellectual disability experience in hospital settings. Findings revealed extensive strategies undertaken by family members and group home staff to improve hospital experiences. Ageing of the family members and staffing implications for group homes complicated efforts to improve hospital experiences. CONCLUSIONS: The current absence of systems to accommodate the special needs of people with intellectual disability in hospital settings has significant consequences for group homes, family members, hospital staff, and residents. Most hospital systems appear to be poorly designed to care for this vulnerable population.