Evaluating non-pharmacological approaches to nursing home dementia care: A protocol.

Background: The COVID-19 pandemic has underscored the daily challenges nursing home (NH) staff face caring for the residents living with Alzheimer's Disease and Related Dementias (ADRD). Non-pharmacological approaches are prioritized over off-label medication to manage the behavioral and psychological symptoms of ADRD. Yet, it is not clear how to best equip NH staff and families with the knowledge and strategies needed to provide non-pharmacological approaches to these residents. Methods: This clustered randomized trial will compare team- and problem-based approaches to non-pharmacological ADRD care. The team-based approach includes core training for all NH staff using a common language and strategies to support continuity and sustainability. The problem-based approach capitalizes on the expertise of the professional healthcare providers to target issues that arise. A convergent mixed methods design will be used to examine (a) comparative effectiveness of the two approaches on long-term NH resident outcomes and (b) whether either approach is protective against the negative consequences of COVID-19. The primary outcome is the percentage of ADRD residents with off-label antipsychotic medication use, which will be evaluated with an intent-to-treat approach. Staff and family caregiver perspectives will be explored using a multiple case study approach. Conclusion: This trial will be the first-ever evaluation of team- and problem-based approaches to ADRD care across multiple NHs and geographic regions. Results can provide health system leaders and policymakers with evidence on how to optimize ADRD training for staff in an effort to enhance ADRD care delivery.

Optimizing Post-Acute Care Patient Safety: A Scoping Review of Multifactorial Fall Prevention Interventions for Older Adults.

Accidental falls are preventable adverse events for older post-acute care (PAC) patients. Yet, due to the functional and medical care needs of this population, there is little guidance to inform multidisciplinary prevention efforts. This scoping review aims to characterize the evidence for multifactorial PAC fall prevention interventions. Of the 33 included studies, common PAC intervention domains included implementing facility-based strategies (e.g., staff education), evaluating patient-specific fall risk factors (e.g., function), and developing an individualized risk profile and treatment plan that targets the patient's constellation of fall risk factors. However, there was variability across studies in how and to what extent the domains were addressed. While further research is warranted, health system efforts to prevent accidental falls in PAC should consider a patient-centered multifactorial approach that fosters a culture of safety, addresses individuals' fall risk, and champions a multidisciplinary team.

Social Networks in an Assisted Living Community: Correlates of Acquaintance and Companionship Ties Among Residents.

OBJECTIVES: Social relationships are important for older adults' well-being, including those who live in assisted living (AL) communities. This study explores coresident networks within an AL community and identifies factors associated with residents' social ties. METHODS: Acquaintance and companionship networks within the community are described using cross-sectional survey data (N = 38). We use inferential network statistical methods to estimate parameters for factors associated with residents' acquaintance and companionship ties. RESULTS: Residents reported an average of 10 acquaintances and almost 4 companionships with other residents in the sample. The likelihood a resident had an acquaintance was associated with higher levels of cognitive functioning (p < .05), higher levels of physical limitations (p < .01), living in the AL community for a longer time (p < .01), and less frequent contact with outside family and friends (p < .05). Acquaintances were more likely between residents who moved in around the same time as each other (p < .01), lived on the same floor (p < .001), or had similar levels of physical limitations (p < .05). Companionships were more likely to be reported by male residents (p < .05) and residents with higher levels of cognitive functioning (p < .05) or depressive symptoms (p < .05). Longtime residents were more popular as companions (p < .01). Companionships were more likely between residents who lived on the same floor (p < .001) or were similar in age (p < .01). DISCUSSION: This research contributes to the literature of older adults' nonkin social relationships by providing detailed descriptions of the acquaintance and companionship networks within an AL community, quantifying correlates of residents' social ties, and distinguishing between acquaintances and companions.

Network Modeling of Assisted Living Facility Residents' Attendance at Programmed Group Activities: Proximity and Social Contextual Correlates of Attendance.

BACKGROUND AND OBJECTIVES: Social engagement, including participation in group activities, supports older adults' mental and physical health. However, many residents of assisted living facilities do not participate in their facility's programmed group activities. Explaining residents' attendance at group activities is complex; attendance is associated with a confluence of individual-level and contextual factors. The aim of this study was to assess the effects of multilevel factors on attendance, including residents' proximity to activity location and the potential for one resident's attendance to depend on other residents' attendance. RESEARCH DESIGN AND METHODS: We used bipartite exponential random graph models to examine the attendance of 35 residents at 563 programmed group activities. We simultaneously modeled the effects of the geospatial distance from a resident's apartment to the activity and the tendency for residents to attend activities with similar groups of other residents (i.e., shared attendance) on the likelihood of attendance, while controlling for individual-level factors (demographic and health indicators) and activity popularity. RESULTS: Greater distance was associated with a reduced likelihood of attendance (p < .001) and residents tended to attend activities with similar subsets of other residents (p < .001). DISCUSSION AND IMPLICATIONS: Findings suggest that greater distance to group activities may be a barrier to attendance. Implications include facility design, placement of activities and apartments, and mobility-related strategies to increase activity participation. It is also important to recognize that participation in activities is dependent on social context. We recommend that proximity to activities and social contextual factors be considered in future examinations of attendance at group activities.

Understanding Communication Between Rehabilitation Practitioners and Nurses: Implications for Post-Acute Care Quality.

Objective: This study examined post-acute care (PAC) rehabilitation practitioner's perspectives on communication. Method: This is a secondary data analysis of a larger qualitative study, which included PAC rehabilitation provider (n = 99) focus groups that were held in a purposive sample of 13 skilled nursing facilities (SNFs). Results: Participants emphasized the importance of bidirectional communication between rehabilitation and nursing. Three themes were identified: (a) communication between rehabilitation practitioners and registered nurses or licensed practical nurses, (b) communication between rehabilitation practitioners and certified nursing assistants, and (c) communication between rehabilitation practitioners and nursing leaders. Two subthemes within each of the three themes were further characterized to understand how information was exchanged: (a) static communication and (b) action-oriented communication. Conclusion: Our findings highlight opportunities for better communication in PAC between rehabilitation practitioners and nursing and thus lay a foundation for future efforts to improve care coordination through enhancing interdisciplinary communication.

Stakeholder engagement in research: a scoping review of current evaluation methods.

Aim: Evaluating stakeholder engagement can capture what meaningful engagement in research entails, how it develops, and how it is experienced by all collaborators. We conducted a scoping review of recent approaches for evaluating engagement in research and present a descriptive overview of our findings. Methods: We searched peer-reviewed journal articles published worldwide in English between January 2013 and June 2018. Results: Our final sample consisted of 17 articles. Various approaches for evaluating stakeholder engagement were identified including qualitative approaches, surveys and engagement logs. Discussion & conclusion: We identified evaluation approaches that varied in quality, detail and methods. Valid, systematic and inclusive approaches that are developed with research partners and are inclusive of diverse perspectives are an important area for future research.

Occupational Therapy Practitioners' Perspectives on Occupation-Based Interventions for Clients With Hip Fracture.

OBJECTIVE: Occupational engagement is the foundation of occupational therapy. We identified perspectives of 18 occupational therapy practitioners on integrating occupation-based interventions during postacute care (PAC) rehabilitation for persons with hip fracture to identify occupational therapy's distinct contribution. METHOD: We conducted six focus groups derived from a purposive national sample of occupational therapy practitioners (N = 18). A secondary analysis was conducted to analyze the transcripts for major subthemes around occupation-based interventions. RESULTS: Three major themes arose from practitioners' perspectives regarding the role of occupation in rehabilitation: (1) conducting an occupational profile, (2) integrating occupation-based intervention in the facility, and (3) identifying goals for occupational engagement after discharge. Challenges and strategies for integrating occupation-based interventions were also identified. CONCLUSION: Identifying practitioners' perspectives on integrating occupation into rehabilitation may inform strategies to facilitate occupation-based interventions in PAC and define occupational therapy's role in this setting.

Clinicians' Perspectives of Patient Engagement in Post-Acute Care: A Social Ecological Approach.

AIMS: To identify rehabilitation providers' perspectives on barriers and facilitators of patient engagement in hip fracture patients in skilled nursing facilities (SNFs) within the social ecological model. METHODS: We conducted 13 focus groups in SNFs throughout Los Angeles County comprised of rehabilitation staff (n=99). Focus groups were audio-recorded and transcribed. A secondary analysis of themes related to patient engagement were identified and organized within the social ecological model. RESULTS: Clinicians identified barriers and facilitators of patient engagement across all levels of the social ecological model: public policy (e.g., insurance), organizational (e.g., facility culture), interpersonal (e.g., clinicians fostering self-reflection), and intrapersonal (e.g., patients' anxiety). CONCLUSIONS: Examining barriers and facilitators to patient engagement has highlighted areas which need to be sustained and improved. Thus, these findings future efforts to enhance patient engagement in order can to optimize patient healthcare decisions.

Delivering high quality hip fracture rehabilitation: the perspective of occupational and physical therapy practitioners.

AIM: The majority of post-acute hip fracture rehabilitation in the US is delivered in skilled nursing facilities (SNFs). Currently, there are limited guidelines that equip occupational and physical therapy practitioners with a summary of what constitutes evidence-based high quality rehabilitation. Thus, this study aimed to identify rehabilitation practitioners' perspectives on the practices that constitute high quality hip fracture rehabilitation. METHODS: Focus groups were conducted with 99 occupational and physical therapy practitioners working in SNFs in southern California. Purposive sampling of facilities was conducted to capture variation in key characteristics known to impact care delivery for this patient population (e.g., financial resources, staffing, and patient case-mix). Questions aimed to elicit practitioners' perspectives on high quality hip fracture rehabilitation practices. Each session was audio-recorded and transcribed. Data were systematically analyzed using a modified grounded theory approach. RESULTS: Seven themes emerged: objectives of care; first 72 h; positioning, pain, and precautions; use of standardized assessments; episode of care practices; facilitating insight into progress; and interdisciplinary collaboration. CONCLUSIONS: Clinical guidelines are critical tools to facilitate clinical decision-making and achieve desired patient outcomes. The findings of this study highlight the practitioners' perspective on what constitutes high quality hip fracture rehabilitation. This work provides critical information to advance the development of stakeholder-driven rehabilitation clinical guidelines. Future research is needed to verify the findings from other stakeholders (e.g., patients), ensure the alignment of our findings with current evidence, and develop measures for evaluating their delivery and relationship to desired outcomes. Implications for Rehabilitation This study highlights occupational and physiotherapy therapy practitioners' perspectives on the cumulative best practices that reflect high quality care, which should be delivered during hip fracture rehabilitation. While this study was limited to two professions within the broader interdisciplinary team, consistently occupational and physiotherapy therapy practitioners situated their role and practices within the team, emphasizing that high quality care was driven by collaboration among all members of the team as well as the patient and caregivers. Future research needs to evaluate the (a) frequency at which these practices are delivered and the relationship to patient-centered outcomes, and (b) perspectives of rehabilitation practitioners working in other PAC settings, patients, caregivers, as well as the other members of the interdisciplinary PAC team.

Non-Pharmacological Approaches to Reducing Negative Behavioral Symptoms: A Scoping Review.

The management of negative behavioral symptoms among residents with dementia is a challenge that nursing homes face in delivering quality care. This study examines evidence documenting non-pharmacological interventions that reduce negative behavioral symptoms among nursing home residents with dementia and the role occupational therapy practitioners have in this area. A scoping review was completed for intervention studies published from 1987 to 2014, targeting negative behavioral symptoms among nursing home residents above 60 years of age with dementia. Interventions were categorized based on the American Occupational Therapy Association (AOTA) Occupational Therapy Practice Framework. Twenty-two studies met the inclusion criteria. Four types of interventions were identified: occupation-based interventions, context and environment interventions, exercise interventions, and daily routine-based interventions. The non-pharmacological interventions were found to align with the scope of occupational therapy. This suggests that occupational therapy practitioners can contribute to the development and evaluation of non-pharmacological interventions aimed to reduce negative behavioral symptoms.