How Do We Achieve Person-Centered Care Across Health Care Settings? Expanding Ideological Perspectives Into Practice to Advance Person-Centered Care.

Person or patient-centered care (PCC) is touted as the gold standard in geriatric medical care across care settings. However, despite more than 3 decades of research and practice initiatives, it remains a challenge to consistently implement PCC that fully places the individual at the center of care planning and the delivery process. The lack of universal implementation of PCC, we argue, may be in large part due to the use of multiple terms and ideologies leading to an inability to coordinate efforts across medical settings. This article reviews recent ideological PCC movements ("What Matters to You," the Age Friendly Health Systems 4 Ms/5 Ms, "Whole Health," Patient Priorities Care, and Medicare/Medicaid person-centered care initiatives), provides a discussion of how these ideologies are implemented in a nursing home setting through preference-based care and provides implications for coordinated integration of PCC across all care settings now and into the future. We argue for the need to draw on known information and validated methodologies for assessing and implementing PCC to collectively move beyond an ideological representation of the concept into an integrated model of PCC for all older adults receiving care.

Preference Importance Ratings among African American and White Nursing Home Residents.

OBJECTIVES: The Preferences for Everyday Living Inventory (PELI-NH) assesses psychosocial preferences of nursing home (NH) residents. This study explored the association of race with importance ratings of self-dominion preferences (i.e., preferences for control). METHODS: PELI-NH interviews were conducted with 250 NH residents. Tests of mean differences compared African American (n = 57) and White (n = 193) residents on demographic (age, gender, education, length of stay) and clinical attributes (self-rated health, depressive symptoms, anxiety, functional limitations, hearing, vision, cognition). Stepwise multiple regression accounted first for associations of demographic and clinical attributes then for the unique association of race with total importance of self-dominion preferences to determine whether African American and White residents differ. For between group demographic/clinical differences, interaction effects were tested. RESULTS: African Americans were younger and more functionally impaired. After accounting for the effects of gender (female), age (younger), anxiety (greater), and functional impairment (less) with higher reports of importance of self-dominion preferences, race was significant. There were no significant moderating effects. CONCLUSIONS: African American residents reported greater importance of self-dominion preferences than Whites. CLINICAL IMPLICATIONS: Cultural sensitivity is critical; it may be more important to provide opportunities for autonomous decision-making for African American than for White residents.

Emotion-focused communication training online: Development and evaluation of acceptability.

Emotion-focused communication can improve the delivery of care for long-term care recipients, especially individuals' living with dementia. The purpose of this manuscript is to describe the process of translating the Emotion-Focused Communication Training (EFCT) for long-term care staff from an in-person workshop to an online program and evaluate its acceptability and impact on knowledge of emotion-focused communication and perceived self-efficacy for utilizing emotion-focused communication. The online course was developed following the ADDIE (Analysis, Design, Development, Implementation, Evaluation) Model. The program teaches participants to better identify and manage their own emotions and others' emotions in care. Pre- and post-training t-test comparisons on data collected from 247 caregivers across disciplines in long-term care (direct care workers, life-enrichment/activities staff, health care providers, case managers, health educators, students, administrators, ombudsmen, dietary, housekeeping, or maintenance staff, human resources employees, family care partners, and others) indicated a significant increase in level of knowledge of emotion-focused communication and confidence in applying the learned knowledge and skills in care (increased self-efficacy). Participants also reported high levels of program acceptability. Overall, findings indicate the benefits of translating an in-person training opportunity for caregivers into an interactive online experience; implications for caregivers and care recipients are discussed.

Applying Agile Methodology to Reengineer the Delivery of Person-Centered Care in a Nursing Home: A Case Study.

Nursing home (NH) providers would benefit from adopting evidence-based measures for gathering and utilizing resident preference information in their daily care activities. However, providers face barriers when implementing assessment tools used to promote person-centered care (PCC). Although Agile methodology is not commonly used in NH settings, this case study shows how it can be used to achieve the goal of delivering preference-based, PCC, within a large NH. We present a road map for breaking down care processes, prioritizing, and implementing iterative plan, do, study, act cycles using Agile methodology to enhance group collaboration on quality improvement cycles, to achieve our goal of providing preference-based PCC. We first determined if care plans reflected each resident's important preferences, developed a method for tracking whether residents attended activities that matched their preferences, and determined if residents were satisfied that their preferences were being met. These efforts had positive effects throughout the NH particularly when COVID-19 limited visitors and significantly modified staff workflow. Specifically, Agile processes helped staff to know how to honor preferences during quarantines which necessitated a shift to individualized (and not group) approaches for meeting preferences for social contact, comfort, and belonging. The ready availability of preference-based reporting was critical to quickly informing new staff on how to meet residents' most important preferences. Based on lessons learned, we describe a developmental approach that other providers can consider for adoption. Implications of this work are discussed in terms of the need for provider training in Agile methodologies to support iterative improvements, the need for policies that reimburse providers for their efforts, and additional research around workflow processes.

Community Goal Setting and Attainment: Organizational Characteristics and Indicators of Staff Adoption.

In residential care communities (CCs), implementation strategies can improve the use of person-centered approaches for residents' behavioral symptoms of distress. We examined staff perceptions of how well their organizational goals for achieving person-centered care (PCC) were met following implementation of the strategy, Evidence Integration Triangle for Behavioral and Psychological Symptoms of Distress. We also identified organizational characteristics and indicators of staff adoption associated with perceived goal attainment. Goal attainment was evaluated by staff using goal attainment scaling (GAS) at the completion of the implementation trial in 26 CCs. Correlations, t tests, and linear regression were used to determine which factors were associated with goal attainment. Total time spent with the research facilitator, stable staff group membership, and presence of a survey deficiency during the study period explained 63% of the variance in goal attainment. Staff can set achievable organizational goals to improve PCC for residents' behavioral symptoms of distress. [Journal of Gerontological Nursing, 48(5), 5-12.].

The Stability of Nursing Home Residents' Ratings of Importance of Recreation Preferences Over One Year.

Long-term stability of nursing home (NH) residents' everyday preference remains unknown. We examined 1-year stability in reports of importance of 34-recreational activity preferences (8-MDS 3.0 Section F items; 26-Preferences for Everyday Living Inventory-NH items) by NH residents (N = 161). We examined mean differences on demographic and clinical characteristics of residents for preferences showing change. Importance ratings of preferences were highly stable over 1-year, with 91% of items retaining the same valence of importance for the majority of the sample (<20% change). Three preferences showed greater change. More functionally able residents were more likely to change their importance on "being with groups of people," and older residents were more likely to change their preferences for being "involved in religious practices" and "around animals such as pets". Overall, annual assessments of recreational activity preferences capture an accurate representation of preferences with reassessment only needed in a few circumstances.

Change in Loneliness Experienced by Older Men and Women Living Alone and With Others at the Onset of the COVID-19 Pandemic.

Building on theory suggesting that loneliness is distinct from living arrangements, social isolation, and perceived social support, we examined change in loneliness for older people at the onset of the COVID-19 pandemic. Analyzing 14-years of data with multilevel mixed-effects models, we found higher levels of loneliness among people living alone, people more socially isolated, and people with less perceived support. Gender affected changes in loneliness, controlling for social isolation, perceived support, living arrangements, age, education, income, health, and marital status. Women, whether living alone or with others, experienced increases in loneliness; women living alone reported the greatest increase in loneliness. Men living alone reported high levels of loneliness prior to the pandemic, but only a slight increase over time. These analyses, which demonstrate that loneliness changed at the onset of the pandemic as a function of gender and living arrangement identify older people most likely to benefit from intervention.

The Prospective Association of Personality Traits and Successful Aging.

We used data (N = 928) from ORANJ BOWL, a six-wave panel of adults (aged 50-74 at baseline) to address the association between personality and successful aging at two points in time, 8 years apart. Regressions examined the associations between Wave 2 neuroticism, extraversion, openness, agreeableness, and conscientiousness and Wave 3 subjective success, functional ability, pain, and chronic conditions. Models tested personality traits independently and then simultaneously, with interactions. Confirmatory analyses used Waves 5/6 data. All traits but openness were individually associated with successful aging at both time points. When testing traits simultaneously, only neuroticism and extraversion were consistently associated with subjective success, with an interaction at Waves 2/3. Neuroticism (Waves 2/3) and conscientiousness (Waves 5/6) were associated with functional ability. Neuroticism was associated with pain (Waves 2/3). Personality was not associated with chronic conditions. These analyses set up future work examining relationships between change in personality and change in successful aging.

Adverse childhood experiences, adult trauma, and depressive symptom trajectories.

OBJECTIVES: Associations among adverse childhood experiences prior to age 18 (ACEs), subjective reports of trauma during Hurricane Sandy, and trajectories of depressive symptoms reported by community-dwelling older people were examined. METHODS: We analyzed 6 waves of data from 5,688 people aged 50-74 recruited in 2006 and followed for 12-years using multilevel mixed effects models. RESULTS: We found that: (1) people who experienced ACEs had trajectories of depressive symptoms in late life that were higher than people not having these experiences, (2) people experiencing two or more ACEs were more likely to report fear and distress when Hurricane Sandy hit than people experiencing either one or no adverse childhood experiences, and (3) while both ACE exposure and peri-traumatic stress were associated with trajectories having higher levels of depressive symptoms, the risk associated with ACEs (especially multiple ACEs) was greater. CONCLUSION: Findings support life course stress theories including the cumulative inequality theory and stress proliferation theory, suggesting that inequalities are manifested over the life course and that people experiencing adversity during childhood are at increased risk of experiencing adversity in late life. By studying the relationship between adverse childhood experiences and response to Hurricane Sandy our findings demonstrate that adverse childhood experiences can alter the way traumatic events in adulthood are experienced. This finding in turn, has important implications for clinical practice, as it identifies a group of people likely to be at risk for adult trauma.

Subjective Successful Aging: Measurement Invariance Across 12 Years.

BACKGROUND AND OBJECTIVES: Debates about how to define successful aging have dominated gerontology for over 60 years. Regardless of how successful aging is conceptualized, in order to accurately understand how the construct changes over time and how it differs between people of varying ages, successful aging must be measured with instruments that are valid, reliable, and have measurement invariance. These analyses focus on subjective successful aging and examine the extent to which a reliable, valid, 3-item scale has measurement invariance across 12 years for individuals aged 50-86. RESEARCH DESIGN AND METHODS: We analyzed 5 waves of data collected from a panel of 5,688 community-dwelling people aged 50-74 when recruited in 2006. We tested measurement invariance using the standard 4 nested steps,, introducing increasing parameter constraints at each step. Analyses were conducted using Mplus 7. RESULTS: Analyses revealed that the 3-item scale measuring subjective successful aging has adequate measurement invariance across time. We demonstrated that the scale has configural, metric, and scalar invariance by most standard metrics. Only residual invariance was not supported. However, because residuals are not part of the latent factor, invariance of the item residuals is inconsequential to interpretation of latent mean differences. DISCUSSION AND IMPLICATIONS: Findings provide the foundation needed for researchers to examine change in subjective successful aging over time, differences in subjective successful aging between people of varying ages, and predictors of subjective successful aging, confident that the scale has adequate measurement invariance.

Effects of peri-traumatic stress experienced during Hurricane Sandy on functional limitation trajectories for older men and women.

BACKGROUND AND METHODS: Although the short-term effects of disasters on the physical health of mid-life and older people have been documented, little is understood about the long-term effects that disasters have on the physical health of these people. Based on the environmental docility hypothesis and research regarding gender effects on functional limitations and disaster, our analyses examined the effects of peri-traumatic stress experienced during Hurricane Sandy using longitudinal data from 5688 people aged 50 and older collected over six waves (2006-2019). RESULTS: We found that functional limitations follow three trajectories, with people in each group having a significant linear increase over time and all but the highest functioning people also having a significant quadratic effect, indicating that the linear increase peaked post-Hurricane and then slowed in later waves. CONCLUSION: Consistent with the environmental docility hypothesis, peri-traumatic stress had its greatest impact on people with more functional limitations before the hurricane. Men experiencing peri-traumatic stress during Hurricane Sandy were more likely to experience an increase in functional limitations than women. These findings, which identify people most likely to experience long-term health effects following a disaster, can be used to inform health policies before, during, and after disaster strikes.

Impact of Upper and Lower Body Functional Ability on Affect in Older Couples.

Objective: We explore how upper and lower body functional ability of older adults and their partners relate to affect in later life. Methods: Data regarding own and partner's upper and lower body functional abilities were reported by 1767 married/partnered persons aged 57-83. Using multilevel modeling to account for nesting within couples, we examined the impact of a respondent's own functional abilities, their perception of their partner's abilities, and the interaction of respondent's and perceived partner's abilities on respondent's positive and negative affect. Results: Higher upper and lower body ability of both respondents and partners were associated with higher positive and lower negative affect. Moderating effects demonstrated a protective role of respondents' ability on affect when their partners experienced lower ability. Discussion: There is a potential compensatory relationship between older couples adapting to functional changes; it is important to support the functional abilities of both partners in couples to maximize psychological well-being.

Understanding Attrition and Bolstering Retention in a Longitudinal Panel of Older Adults: ORANJ BOWL.

BACKGROUND AND OBJECTIVES: Attrition from longitudinal studies can affect the generalizability of findings especially when studying developmental constructs such as successful aging. RESEARCH DESIGN AND METHODS: Using data from a 12-year (6-wave) panel of 5,688 older people (aged 50-74 at baseline), we compared people retained in the panel with people lost to follow-up on demographic characteristics and measures of successful aging. After instituting expanded retention strategies at Wave 6 (i.e., a team-based approach, social media, and paid web search engines), we compared different groups of people lost to follow-up (i.e., deceased and withdrawn due to lack of interest) and different types of completers (i.e., full completers vs. lost and reengaged completers). RESULTS: At baseline, Wave 6 completers were significantly younger, less likely to be African American, more likely to be married, reported higher levels of income and education, were more likely to be working full-time, had less pain and fewer chronic illnesses, and reported higher levels of subjective successful aging and functional ability than those lost to follow-up. Analyses demonstrated differences across groups based on the reason for loss (i.e., deceased, impaired, and not interested). Participants who missed an interview but returned to the panel were significantly different from those who participated in all waves of data collection. Expanded retention efforts improved generalizability, as people returning to the panel reported lower levels of education, lower levels of income, and were more likely to be African American. DISCUSSION AND IMPLICATIONS: Biased attrition within longitudinal research affects the interpretation of study findings, especially when studying developmental outcomes. However, expanded retention strategies can reduce bias and loss and should be used to enhance retention efforts in longitudinal work.

Challenges Experienced by Older People During the Initial Months of the COVID-19 Pandemic.

BACKGROUND AND OBJECTIVES: The coronavirus disease 2019 (COVID-19) pandemic has created unique stressors for older people to manage. Informed by the Stress Process Model and the Transactional Model of Stress and Coping, we examined the extent to which older people are adhering to physical distancing mandates and the pandemic-related experiences that older people find most challenging. RESEARCH DESIGN AND METHODS: From May 4 to May 17, 2020, a web-based questionnaire focused on the COVID-19 pandemic was completed by 1,272 people (aged 64 and older) who were part of an ongoing research panel in New Jersey recruited in 2006. Frequencies for endorsement of physical distancing behaviors were tabulated, and open-ended responses to the biggest challenge of the pandemic were systematically coded and classified using content analysis. RESULTS: More than 70% of participants reported adhering to physical distancing behaviors. Experiences appraised as most difficult by participants fell into 8 domains: Social Relationships, Activity Restrictions, Psychological, Health, Financial, Global Environment, Death, and Home Care. The most frequently appraised challenges were constraints on social interactions (42.4%) and restrictions on activity (30.9%). DISCUSSION AND IMPLICATIONS: In the initial weeks of the pandemic, the majority of older adults reported adhering to COVID-19 physical distancing mandates and identified a range of challenging experiences. Results highlight the factors having the greatest impact on older adults, informing quantitative modeling for testing the impact of the pandemic on health and well-being outcomes, and identifying how intervention efforts may be targeted to maximize the quality of life of older adults.

Person-Centered Care Plans for Nursing Home Residents With Behavioral and Psychological Symptoms of Dementia.

Little literature exists examining the development and implementation of person-centered care (PCC) plans focused on behavioral and psychological symptoms of dementia (BPSD). The current study aimed to describe BPSD documented in nursing home (NH) residents' care plans, the types of approaches staff document in addressing those symptoms, and whether resident and/or facility characteristics are associated with documentation of PCC approaches. The sample included 553 residents from 55 NHs in two East Coast states. Resistiveness to care (44.9%), agitation (42.2%), and aggression (42%) were most frequently documented in care plans. PCC approaches were documented in care plans in 21.3% to 62.7% of cases depending on BPSD type. Resident (e.g., younger age, lower functional ability, lower cognitive ability, longer length of stay, male gender) and facility (e.g., less certified nursing assistant staffing hours, greater percentage of residents taking antipsychotic medications, non-profit status) characteristics were associated with increased odds of PCC approaches being documented. Optimal PCC planning is discussed, and a sample PCC plan is provided. [Journal of Gerontological Nursing, 46(11), 17-27.].

Timing of onset and self-management of multiple chronic conditions: A qualitative examination taking a lifespan perspective.

OBJECTIVES: Over two-thirds of older individuals live with multiple chronic conditions, yet chronic diseases are often studied in silos. Taking a lifespan approach to understanding the development of multiple chronic conditions in the older population helps to further elucidate opportunities for targeted interventions that address the complexities of multiple chronic conditions. METHODS: Semi-structured interviews were conducted with 38 older adults (age 64+) diagnosed with at least two chronic health conditions. Content analysis was used to build understanding of how older adults discuss the timing of diagnoses and subsequent self-management of multiple chronic conditions. RESULTS: Findings highlight the complex process by which illnesses unfold in the context of individuals' lives and the subsequent engagement and/or disengagement in self-management behaviors. Two primary themes were evident regarding timing of illnesses: illnesses were experienced within the context of social life events and/or health events, and illnesses were not predominantly seen as connected to one another by patients. Self-management behaviors were described in response to onset of each illness. DISCUSSION: Findings provide insight into how older adults understand their experience of multiple chronic conditions and change in self-management behaviors over time. In order for practitioners to ignite behavioral changes, a person's history and life experiences must be considered.

A Preference-Based Model of Care: An Integrative Theoretical Model of the Role of Preferences in Person-Centered Care.

Knowledge of individuals' everyday preferences is a cornerstone of person-centered care (PCC). Initial evidence demonstrates the positive impact of honoring preferences in care for older adults receiving long-term services and supports (LTSS). Yet, the mechanisms through which preference-based care affects individual well-being remain poorly understood. This article proposes a theoretical model of PCC entitled the Preference-Based Model of Care that integrates the Theory of Human Motivation, Self-determination Theory, the Competence-Press Model of person and environment fit, the Living Systems Framework, and the Broaden-and-Build theory of positive emotions to deepen our understanding of the processes through which preference-based care affects well-being among older adults receiving LTSS. The Preference-Based Model of Care illustrates how goal-directed behaviors facilitate need fulfillment through the expression of individual preferences and how these behaviors mediate the relationship between person-environment fit and affect balance within a particular social, cultural, and political context. The Preference-Based Model of Care can advance research on PCC in LTSS and can inform LTSS clinical practice guidelines for older adults, regardless of functional or cognitive capacity.

The impact of nursing home residents' characteristics on ratings of importance of autonomy preferences in daily care over time.

Objective: Nursing home (NH) residents' preferences for everyday living are the foundation for delivering individualized care. Yet, work has not examined the impact of demographic and clinical characteristics of NH residents on the stability of their preferences over time.Method: This study examined the rate of change in reports of importance of 27 autonomy-related everyday preferences from the Preferences for Everyday Living Inventory over 3-months and the demographic and clinical characteristics associated with change for nursing home residents (N = 255). Descriptive frequencies and tests of mean difference were utilized to examine differences between individuals reporting change in importance over time compared to those that did not report change.Results: Autonomy preferences in daily care remained stable over 3-months for the majority of residents. For residents that did report change on autonomy preferences, no systematic associations of demographic or clinical characteristics were found to be associated with change. Rather, change was associated with differential characteristics based on the preference.Conclusion: This study indicates that knowing a person's demographic or clinical characteristics in care will not uniformly inform a caretaker's understanding of the individual's reports of importance for autonomy related preferences over time. Future work should explore the role of care environment on change in preference ratings over time.

Type of Disaster Exposure Affects Functional Limitations of Older People 6 Years Later.

BACKGROUND: Natural disasters, including earthquakes, tsunamis, tornadoes, and hurricanes, are traumatic events that simultaneously affect the lives of many people. Although much is known about the effects that natural disasters have on mental health, little is known about how natural disasters affect physical health. These analyses add to the literature by examining the ways in which four types of disaster exposure (geographic, peri-traumatic stress, personal and property loss, and poststorm hardship) experienced by older people during and after Hurricane Sandy affected functional limitations. METHODS: We analyzed five waves of data from the ORANJ BOWL panel ("Ongoing Research on Aging in New Jersey: Bettering Opportunities for Wellness in Life") using multilevel mixed-effects models. RESULTS: We found that although peri-traumatic stress and poststorm hardship each had independent effects on functional limitations, the effects of peri-traumatic stress dominated and were evident 6 years after the hurricane. Geographic exposure and personal/property loss were not associated with functional limitations. CONCLUSIONS: These findings add important information to what is known about older people who experience a natural disaster and suggest opportunities for intervention. Finding that an individual's emotional response during the disaster plays an important role in the development of functional limitations suggests that reduction of exposure to traumatic stress during a storm (ie, evacuation from a storm area) may be important for older people. Likewise, interventions immediately after a disaster that target older people who experience high levels of peri-traumatic distress may be needed in order to alleviate functional limitations before they develop.

Mapping Core Concepts of Person-Centered Care in Long-Term Services and Supports.

Person-centered care (PCC) has a wide range of definitions, most based on expert opinion rather than empirical analysis. The current study used an empirical concept mapping approach to identify core components of PCC used in long-term services and supports (LTSS). The aim is to help providers and researchers develop a unified set of domains that can be used to assess and improve the quality of PCC in real-world settings. Results yielded six domains describing essential elements of PCC in LTSS: Enacting Humanistic Values, Direct Care Worker Values, Engagement Facilitators, Living Environment, Communication, and Supportive Systems; and two underlying dimensions: Intrapersonal Activities and Extrapersonal Services and Social and Physical Environment. Nurses can use the results to enhance clinical knowledge and skills around delivery of PCC. Researchers can use the results to build a comprehensive and unified measure to accelerate adoption of PCC practices shown to benefit older adults, families, and the LTSS workforce. [Journal of Gerontological Nursing, 45(2), 6-13.].