Person-centered care practices in nursing homes: Staff perceptions and the organizational environment.

Person-centered care (PCC) is considered the standard to assure quality of care and quality of life in long-term care, benefiting both residents and staff. This study examines the associations between nursing home staff perceptions of person-centered care practices, the organizational system, and work-related attitudes in a sample of 340 nurses and direct care workers across 32 nursing homes in Oregon. Random-intercepts regression models were used to estimate within- and between-nursing home variation in staff perceptions of PCC practices as measured by the Staff Assessment of Person-Directed Care (SA-PDC), and identify characteristics associated with these perceptions. Staff in nursing homes that accept Medicaid reported lower SA-PDC scores, and higher scores were reported in nonprofit nursing homes. Staff perceptions varied extensively within nursing homes, suggesting a lack of staff cohesion regarding core aspects of PCC. Cultivating a supportive work environment is key to promoting person-centered care practices, increasing job satisfaction, elevating affective commitment, and reducing turnover intention.

"This 'Family Setting' Is Not that Anymore": Rewards and Challenges of Adult Foster Home Owners.

Small residential care settings for older adults and people with disabilities are found throughout the United States. Those with fewer than 25 residents account for half of residential care settings. Adult foster homes (AFH) are under-studied although they provide personal and health-related services to residents, including people with Alzheimer's disease. This qualitative study collected data from 726 AFH owners over four years. Results provide a contemporary perspective on owners' experience of the rewards and challenges of operating a small home. These results are relevant since many residents prefer small settings, and because federal regulatory changes affect AFH policies and practices.

Trends in Serious Mental Illness in US Assisted Living Compared to Nursing Homes and the Community: 2007-2017.

OBJECTIVE: Little is known about the prevalence of serious mental illness (SMI) in assisted living (AL) communities in the United States. Trends in the prevalence of SMI in AL communities were examined over time and in relationship to characteristics such as dual eligibility and health conditions. Within- and between-state variability of SMI in AL was also examined. DESIGN: Samples of Medicare beneficiaries who lived in the 48 contiguous states were created: individuals who resided in the community, in a nursing home (NH), and in an AL community on December 31st of each year (2007-2017). We conducted univariate analysis to display the trends in SMI over time in AL compared with NHs and the community. To demonstrate intrastate variability, we examined the prevalence of SMI for each state. We described within-nation and within-state variability using a Lorenz curve and GINI coefficients, respectively. RESULTS: The prevalence of SMI in AL increased by 54%, rising from 7.4% in 2007 to 11.4% in 2017. Residents with SMI were more likely to be dually eligible for Medicare and Medicaid than residents without SMI. The prevalence of SMI in AL ranged from to 3.2% in Wyoming to 33.1% in New York. Approximately 10% of AL communities had over half of the sample's AL residents with SMI. CONCLUSION: Given the increased proportion of residents with SMI in AL, research is needed into the mental health and social care needs of this population. Analysis is needed to uncover reasons for variations among states.

The Resident VIEW in Community-Based Care Residential Settings.

The Resident VIEW is a measure of person-centered care (PCC) from residents' perspectives and was previously studied in nursing homes. The current study presents descriptive data for the Resident VIEW in community-based care settings including assisted living, residential care (AL/RC), and adult foster homes (AFH). Using a two-stage sampling design, we recruited 31 AL/RC and 119 AFH in Oregon and completed face-to-face structured interviews with 227 and 195 residents, respectively. Residents provided ratings for both the importance of and their experience with 66 items that tapped into PCC practices in eight domains. Results are provided for each item, many of which are significantly associated with greater quality of life, better resident satisfaction, and fewer depressive symptoms, especially in the domains of personalized care and being treated like a person. Incongruence between importance and experience ratings indicate many residents experience unmet needs across multiple domains. The Resident VIEW performed well in different types of settings, providing an important tool for researchers and providers who wish to learn about the PCC experience from residents' points of view.

Supporting the Behavioral Health of Older Adults: Evaluating a Multi-Site, Multi-Actor, Multi-Agency Initiative.

Policymakers often overlook people living with physical disabilities and older adults' behavioral health (BH) needs. Older adults experience alarmingly high rates of mental illness and substance use disorders, which often intersect with neurocognitive challenges. Emerging evidence suggests the SARS-COV-2 pandemic has exacerbated these disparities. BH needs amongst older adults and people living with physical disabilities have major implications for policy and service delivery. While a multitude of local interventions to support BH exist, few state-level programs focus on this population. In 2015, Oregon established the Behavioral Health Initiative for Older Adults and People with Physical Disabilities (referred to as the Initiative) with this specific purpose. A multi-year evaluation of this Initiative suggests several important improvements have occurred. Yet, barriers remain that hinder optimal service provision and enable siloed aging and BH services between agencies. The findings indicate ways the Initiative can leverage initial successes to further support this population.

"What Keeps Me Awake at Night": Assisted Living Administrator Responses to COVID-19.

BACKGROUND AND OBJECTIVES: Assisted living (AL) constitutes an important sector of residential long-term care, yet there has been limited research about the impact of the coronavirus disease 2019 (COVID-19) pandemic in this setting. This qualitative study sought to understand the impact of the early stages of the pandemic (February-August 2020) from AL administrators' perspectives. RESEARCH DESIGN AND METHODS: Semistructured phone interviews were conducted with 40 AL administrators in Oregon. A stratified sampling method emphasizing rurality, profit status, Medicaid acceptance, and memory care designation was used to maximize variation in perspectives. We asked 8 questions aimed at understanding the impact of the COVID-19 pandemic on their roles and AL residents and their families, as well as AL operations, such as staffing and resource procurement. Audio-recorded interviews were transcribed and analyzed using an iterative thematic analysis. RESULTS: We identified 3 themes that characterize AL administrators' response to COVID-19: emotion and burnout management, information management, and crisis management. Based on their experiences, administrators made suggestions for managing future crises. DISCUSSION AND IMPLICATIONS: Our findings demonstrate the slow-burning but devastating impact of the COVID-19 pandemic in AL communities similar to recent findings in nursing homes. Coupled with the limited resources, perceived external pressures, and the ongoing pandemic, many administrators were managing but not thriving in these domains. AL as a care setting, and the role of administrators, requires more scholarly and policy attention, especially regarding emergency preparedness and response.

Coronavirus Disease 2019 Regulatory Response in United States-Assisted Living Communities: Lessons Learned.

Coronavirus disease 2019 (COVID-19) has disproportionately affected residents, their families, staff, and operators of congregate care settings. Assisted living (AL) is a type of long-term care setting for older adults who need supportive care but not ongoing nursing care and emphasizes a social model of care provision. Because AL is a type of long-term care, it has at times been referenced along with nursing homes in discussions related to COVID-19 but not recognized for its different care practices that pose unique challenges related to COVID-19; in that manner, it has largely been left out of the COVID-19 discourse, although ~812,000 older adults live in AL. To identify COVID-19 issues specific to AL, stakeholders with expertise in AL operations, policy, practice, and research (n = 42) were recruited to participate in remote interviews between July and September 2020. Using a thematic analysis, we derived the following overarching themes: (1) Policymakers are disconnected from and lack an understanding of the AL context; (2) AL administrators were left to coordinate, communicate, and implement constantly changing guidelines with little support; (3) AL organizations faced limited knowledge of and disparate access to funding and resources; (4) state-level regulatory requirements conflicted with COVID-19 guidelines resulting in uncertainty about which rules to follow; and (5) AL operators struggled to balance public health priorities with promoting their residents' quality of life and well-being. To develop evidence-informed policy and avoid unintended consequences, AL operators, direct care workers, residents, and clinicians practicing in these settings should have opportunities to provide feedback throughout the policy development process, both state and national.

Connecting policy to licensed assisted living communities, introducing health services regulatory analysis.

OBJECTIVE: To document dementia-relevant state assisted living regulations and their changes over time as they pertain to licensed care settings. DATA SOURCES: For all states, current directories of licensed assisted living communities and state regulations for each year, 2007-2018, were obtained from state agency websites and Nexis Uni, respectively. STUDY DESIGN: We identified multiple types of regulatory classifications for each state and documented the presence or absence of specific dementia care provisions in the regulations for each type by study year. Maps and summary statistics were used to compare results to previous research and document change longitudinally. DATA COLLECTION/EXTRACTION METHODS: We used a policy analysis approach to connect communities listed in directories to applicable regulatory text. Then, we employed policy surveillance and question-based coding to record the presence or absence of specific policies for each classification and study year. PRINCIPAL FINDINGS: Our team empirically documented provisions requiring dementia-specific training for administrators and direct care staff, and cognitive impairment screening for each study year. We found that 23 states added one or more of these requirements for one or more license types, but the states that had these provisions for all types of licensed assisted living declined from four to two. CONCLUSIONS: We identified significant, previously undocumented, within-state policy variation for assisted living licensed settings between 2007 and 2018. Using the regulatory classification instead of the state as the unit of analysis revealed that many policy adoptions were limited to dementia-designated settings. This suggests that people living with dementia in general assisted living are not afforded the same protections. We call our approach health services regulatory analysis and argue that it has the potential to identify gaps in existing policies, an important endeavor for health services research in assisted living and other care settings.

The Resident VIEW in Nursing Homes.

This article presents the Resident VIEW (Voicing Importance, Experience, and Well-Being), a measure designed to learn directly from long-term care residents the extent to which they experience support that matters most to them. The Resident VIEW contains 63 items across eight domains developed through cognitive interviews with residents in different types of residential settings (e.g., nursing homes, assisted living, and adult foster care). Residents rate items on both importance and their experience. In total, 258 nursing home residents living in 32 Oregon nursing homes were selected through a two-stage random sampling design and participated in the study. Results demonstrate that what matters most to residents varies, emphasizing the value of asking residents directly about their preferences. The relationship between importance and experience differed by item. Residents who experienced support rated very important within some domains, reported better quality of life and reported lower levels of depressive symptoms than those who did not experience these things. The interaction between importance and experience, however, did not reach statistical significance, suggesting that positive experiences may provide benefit even in some areas that are not perceived as important by residents. Results underscore the value of incorporating the resident perspective into measure development in long-term care.