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Objectives: Most older adults with lesbian, gay, bisexual, queer, questioning, transgender, and related identities (LGBTQ+) are concerned about receiving lower-quality care and/or being mistreated in nursing homes. Older LGBTQ+ veterans may have additional reservations about care in Department of Veterans Affairs (VA) nursing homes (Community Living Centers [CLCs]) because of experience with past discriminatory military policies (eg, bans on participating in military service, Don't Ask Don't Tell). This article describes one of the first VA CLCs to participate in the Human Rights Campaign-developed Long-Term Care Equality Index (LEI)., Design: A single-site formative evaluation was completed to support quality improvement and identify opportunities for growth using the LEI. The LEI is a facility benchmarking tool to support more inclusive environments for LGBTQ+ residents and employees. The LEI offers 4 evaluation criteria: (1) Non-Discrimination and Staff Training; (2) LGBTQ+ Resident Services and Support; (3) Employee Benefits and Policies; and (4) Resident and Community Engagement. Facilities receive ratings based on the number of requirements achieved in each category., Participants and Methods: Older LGBTQ+ veterans, current CLC residents, interdisciplinary CLC providers and leadership, and national Geriatrics and Extended Care program managers collaborated to pilot the LEI and develop tools and materials to support other VA facilities' participation in the LEI., Results: Qualitative interviews with veterans and CLC residents supported inclusion of gender identity and sexual orientation in resident handbooks, discussions about person-centered care, and opportunities for additional staff training and community engagement (eg, observing Pride Month in June). Resources to support VA long-term care facilities' participation in the LEI were developed., Conclusions and Implications: The LEI offers a structured approach to identifying areas for improvement in providing high-quality and equitable care in long-term care settings. Practical suggestions for CLCs and other nursing home settings considering the LEI for the first time are discussed., Competing Interests: Disclosure The authors declare no conflicts of interest., (Published by Elsevier Inc.)

Objective: To characterize the physical function of older veterans with serious mental illness (SMI) across endurance, strength, and mobility domains., Design: Retrospective analysis of clinical performance data., Setting: Gerofit program, a national outpatient supervised exercise program for older veterans, delivered in Veterans Health Administration sites., Participants: Older veterans aged 60 and older (n = 166 with SMI, n = 1,441 without SMI) enrolled across eight national Gerofit sites between 2010 and 2019., Measurements: Performance measures of physical function covering endurance (6-minute walk test), strength (chair stands, arm curls), and mobility (10-m walk, 8-foot-up-and-go), were administered at Gerofit enrollment. Baseline data from these measures were analyzed to characterize the functional profiles of older veterans with SMI. One sample t tests were examined to compare functional performance of older veterans with SMI to age- and sex-based reference scores. Propensity score matching (1:3) and linear mixed effects models were used to evaluate differences in function between veterans with and without SMI., Results: Older veterans with SMI performed worse on all measures of function (chair stands, arm curls, 10-m walk, 6-minute walk test, 8-foot-up-and-go) compared to age- and sex-based reference scores with statistically significant differences present in the male sample. Functional performance of those with SMI was also worse compared to propensity-score matched older veterans without SMI with statistically significant differences on chair stands, 6-minute walk test, and 10-m walk., Conclusion: Older veterans with SMI have compromised strength, mobility, and endurance. Physical function should be a core component of screening and treatment for this population., (Published by Elsevier Inc.)

Older veterans are vastly underrepresented in studies that shape national suicide prevention strategies. This is of great concern because factors that impact younger veterans may not be as robust in later life. Although younger veterans have higher rate of suicide, the highest counts of death by suicide are in older veterans. However, it remains unclear from the extant literature what factors may influence increased or decreased risk of late-life suicide in veterans. The objective of this systematic review was to identify risk and protective factors related to suicide outcomes (i.e., ideation, attempt, death, or suicide-related behavior [SRB]) among older veterans. Furthermore, it offers data regarding future study directions and hypothesis generation for late-life suicide research and for informing potential intervention and prevention efforts in this area. We searched 4 databases from inception up to May 5, 2022. We screened 2,388 abstracts for inclusion and 508 articles required full text review. The final sample included 19 studies published between 2006 and 2022. We found five domains of factors studied (i.e., neuropsychiatric, social determinants of health, aging stereotypes, residential and supportive housing settings, and multifactorial-neuropsychiatric/mental health and physical health) with more risk factors than protective factors reported. Across the three suicide outcomes only neuropsychiatric factors were consistently identified as risk factors. Neuropsychiatric factors also comprised the largest group of risk factors studied. More innovative targets to consider for intervention and more innovative methods to predict suicide in late-life are needed. There is also continued necessity to design suicide prevention interventions for older veterans given lethality trends., (Published by Elsevier Inc.)

Social functioning is defined as how a person operates in their unique social environment (ie, engagement in activities, connectedness with others, and contributions to social roles). Healthy social functioning is important for nursing home residents as they are at increased risk for loneliness and isolation. Social functioning has long been an underacknowledged aspect of nursing home residents' health, but now, with the COVID-19 pandemic, residents' risk for decreased social functioning is increased. Several reliable and well-validated tools are available to supplement routine care planning and delivery and track and improve changes in social functioning over time. The overarching aim of this article is to provide resources and recommendations for interdisciplinary team assessment related to social functioning for nursing home residents. We describe 2 domains of social functioning measures, care-planning measures and outcome measures, and provide recommendations for how to integrate said measures into practice. Healthy social functioning is needed to maintain nursing home residents' well-being and quality of life. Measures and recommendations outlined in this article can be used by nursing home staff to understand residents' social preferences and address social functioning during COVID-19 and beyond., (Published by Elsevier Inc.)

Objective: This study aimed to further knowledge of older Veterans' experiences with transitioning to the community from Veterans Affairs nursing homes (Community Living Centers or CLCs) with emphasis on social functioning., Design: A qualitative study design was used in addition to administration of standardized depression and mental status screens., Setting and Participants: Veterans (n = 18) and caregivers (n = 14) were purposively sampled and recruited from 2 rural CLCs in Upstate New York., Methods: Semistructured interviews were completed with Veterans in the CLC prior to discharge (to explore experiences during the CLC stay and expectations regarding discharge and returning home) and in the home 2-4 weeks postdischarge (to explore daily routines and perceptions of overall health, mental health, and social functioning). Caregivers participated in 1 interview, completed postdischarge. The 9-item Patient Health Questionnaire and the Brief Interview for Mental Status were administered postdischarge., Results: Thematic analysis of verbatim transcriptions revealed 3 inter-related themes: (1) Veterans may experience improved social connectedness in CLCs by nature of the unique care environment (predominantly male, shared military experience); (2) Experiences of social engagement and connectedness varied after discharge and could be discordant with Veterans' expectations for recovery prior to discharge; and (3) Veterans may or may not describe themselves as "lonely" after discharge, when physically isolated. Veterans lacked moderate to severe cognitive impairment (Brief Interview for Mental Status: range = 14-15); however, they reported a wide range in depressive symptom severity postdischarge (9-item Patient Health Questionnaire: mean = 4.9, SD = 6.1, median/mode = 3, range = 0-23)., Conclusions and Implications: This study identified a potential for increased social isolation and disengagement after discharge from Veterans Affairs nursing homes. Nursing homes should integrate social functioning assessment for their residents, while extending care planning and transitional care to address patient-centered social functioning goals., (Published by Elsevier Inc.)

Objectives: Capacity for safe and independent living (SAIL) refers to an individual's ability to solve problems associated with everyday life and perform activities necessary for living independently. Little guidance exists on the assessment of capacity for SAIL among nursing home residents. As a result, capacity for SAIL is not fully considered in the development of discharge plans to ensure safety and independence in the community. We reasoned that this problem could be addressed with the Making and Executing Decisions for Safe and Independent Living (MEDSAIL) tool, developed to screen for capacity for SAIL among community-dwelling older adults. In this report, we describe findings on the validity of the MEDSAIL when used with nursing home residents., Design: Prospective cross-sectional pilot study., Setting and Participants: Twenty-four residents of a Veterans Health Affairs Community Living Center (CLC; nursing home); exclusion criteria were cognitive impairment too severe to complete the protocol, diagnosis of serious mental illness or developmental disability, inability to hear, or inability to communicate verbally., Methods: Participants completed 2 assessments: the MEDSAIL interview administered by a research assistant and the criterion standard capacity interview administered by a geriatric psychiatrist. We examined internal consistency, divergent validity, and criterion-based validity., Results: Five of 7 MEDSAIL scenarios approximated acceptable levels of internal consistency (α >0.70). MEDSAIL scores were highly positively correlated with criterion standard capacity determination (0.88, P = .001), and the Wilcoxon rank-sum test statistic for the 2 assessments was also statistically significant (P = .001)., Conclusions and Implications: MEDSAIL has promise as a user-friendly brief screening tool for use by nursing home staff to understand resident capacity for SAIL. This information can be used in the development of discharge plans to keep the resident safe and independent in the community. In addition, tailoring the MEDSAIL scenarios specifically to the nursing home setting may further enhance the tool's validity and utility in this new application., (Published by Elsevier Inc.)

Objectives: Quality improvement (QI) may be a promising approach for staff to improve the quality of care in nursing homes. However, little is known about the challenges and facilitators to implementing QI interventions in nursing homes. This study examines staff perspectives on the implementation process., Design: We conducted semistructured interviews with staff involved in implementing an evidence-based QI intervention ("LOCK") to improve interactions between residents and staff through targeted staff behavior change. The LOCK intervention consists of 4 practices: (1) Learn from the bright spots, (2) Observe, (3) Collaborate in huddles, and (4) Keep it bite sized., Setting and Participants: We interviewed staff members in 6 Veterans Health Administration nursing homes [ie, Community Living Centers (CLCs)] via opportunistic and snowball sampling., Measures: The semistructured interviews were grounded in the Capability, Opportunity, Motivation, Behavior (COM-B) model of behavior change and covered staff experience, challenges, facilitators, and lessons learned during the implementation process. The interviews were analyzed using thematic content analysis., Results: Overall, staff accepted the intervention and appreciated the focus on the positives. Challenges fell largely within the categories of capability and opportunity and included difficulty finding time to complete intervention activities, inability to interpret data reports, need for ongoing training, and misunderstanding of study goals. Facilitators were largely within the motivation category, including incentives for participation, reinforcement of desired behavior, feasibility of intervention activities, and use of data to quantify improvements., Conclusions/implications: As QI programs become more common in nursing homes, it is critical that interventions are tailored for this unique setting. We identified barriers and facilitators of our intervention's implementation and learned that no challenge was insurmountable or derailed the implementation of LOCK. This ability of frontline staff to overcome implementation challenges may be attributed to LOCK's inherently motivational features. Future nursing home QI interventions should consider including built-in motivational components., (Published by Elsevier Inc.)

Objectives: Individuals with serious mental illness (SMI; schizophrenia spectrum disorders and affective psychoses) are increasingly aging into older adulthood and are overrepresented in residential long-term care settings. The present study aimed to examine the preparedness of staff in these settings to care for individuals with SMI., Design: A multidisciplinary US Department of Veterans Affairs (VA) workgroup of professionals with expertise in geriatric mental health collected voluntary feedback via online questionnaire as part of a quality improvement project., Setting and Participants: Respondents were mental health providers (N=51) embedded in VA nursing homes called Community Living Centers (CLCs)., Measures: The questionnaire contained multiple-choice, Likert-type scale, and open-ended questions regarding the opportunities and challenges associated with caring for Veterans with SMI in CLCs., Results: Respondents identified a lack of training of front-line staff as a key challenge in providing high-quality care to residents with SMI. Specifically, respondents indicated a need to increase staff knowledge about SMI symptoms and diagnoses, to improve staff communication and interactions with residents with SMI, and to decrease mental illness stigma among staff., Conclusions/implications: The present study revealed significant areas of training need for front-line staff in nursing homes. Many perceived staff training needs overlap with the knowledge and skill set required to provide high-quality dementia care. Integrating training regarding the care of residents with SMI into dementia care training efforts may be a fruitful future direction. Strategies for this and a suggested curriculum are provided., (Published by Elsevier Inc.)

Objective: Although a growing body of evidence suggests that culture change and its corollary, person-centered care improves resident outcomes in the nursing home setting, little is known about the effect of culture change in a postacute setting in which patients receive skilled nursing and rehabilitation services for a relatively short period of time before returning home., Design: Data for this study were collected as part of a larger project to understand the impact of Veterans Health Administration (VHA) policies to shift the mission of VHA Community Living Centers (CLCs) from long-stay custodial care to short-stay skilled nursing and rehabilitative care., Results: Although qualitative data collected during interviews from site visits to eight geographically diverse CLCs suggest an increase in the quality of life and care for veterans, interview data also indicate an unintended consequence. Specifically, staff described how aspects of the homelike environment, relationship-based care delivery, and attention to veterans' preferences that characterize culture change can prolong a veteran's length of stay beyond treatment completion. In addition to providing skilled nursing and rehabilitation, VHA CLCs also serve a latent function of providing a comfortable home and a peer community for veterans to connect and socialize with one another. A congregate living environment for persons with the shared symbolic status of being a veteran is unique to VHA CLCs. Strong bonding among peers and staff as well as staff respect for veterans' service to the country may increase their sense of obligation to keep veterans past their expected discharge date., Conclusion: Our findings suggest that the complexities of culture change and veteran- centered care in a short-term care setting may be underrecognized. We discuss how findings may also be relevant for the non-VHA sector., (Copyright © 2016 AMDA – The Society for Post-Acute and Long-Term Care Medicine. All rights reserved.)

Objectives: Older adults prefer to remain in their own homes for as long as possible. The purpose of this article is to describe the development and preliminary validation of Making and Executing Decisions for Safe and Independent Living (MED-SAIL), a brief screening tool for capacity to live safely and independently in the community., Design: Prospective preliminary validation study., Setting: Outpatient geriatrics clinic located in a community-based hospital., Participants: Forty-nine community-dwelling older adults referred to the clinic for a comprehensive capacity assessment., Measurements: We examined internal consistency, criterion-based validity, concurrent validity, and accuracy of classification for MED-SAIL., Results: The items included in MED-SAIL demonstrated internal consistency (5 items; α = 0.85). MED-SAIL was significantly correlated with the Independent Living Scales (r = 0.573, p ≤0.001) and instrumental activities of daily living (r = 0.440, p ≤0.01). The Mann-Whitney U test revealed significant differences between the no capacity and partial/full capacity classifications on MED-SAIL (U(48) = 60.5, Z = -0.38, p <0.0001). The area under the curve was 0.864 (95% confidence interval: 0.84-0.99)., Conclusions: This study demonstrated the validity of MED-SAIL as a brief screening tool to identify older adults with impaired capacity for remaining safe and independent in their current living environment. MED-SAIL is useful tool for health and social service providers in the community for the purpose of referral for definitive capacity evaluation., (Published by Elsevier Inc.)

Living independently in the community is a primary goal for older adults, particularly for the estimated 10% to 20% of long-stay nursing home residents who have low care requirements. According to the model of person-environment fit, individuals with high levels of everyday competence have the ability to solve problems associated with everyday life. Nursing home residents with high levels of everyday competence and low care needs have poor person-environment fit, placing them at risk for declines in function, maladaptive behavior, and affective disorders. The goal of this article is to present a framework for the integration of everyday competence with standardized goal-setting and care-planning processes to enable the transition of appropriate nursing home residents back to the community. Barriers to community transitions exist across several Key Domains: rehabilitation, personal assistance and services, caregiver support, finances, housing, and transportation. We propose a research agenda to develop and implement a toolkit based on this framework that nursing home staff can use to overcome barriers to transition by (1) assessing residents' everyday competence, (2) developing personally meaningful goals that facilitate transition, and (3) conducting structured care planning to support resident goals around returning to the community. If successful, this toolkit has the potential to reduce costs associated with nursing home care and to improve functional health, psychological well-being, and quality of life for older adults. The proposed framework and toolkit complement national efforts focused on transitioning nursing home residents back into the community., (Published by Elsevier Inc.)

Objective: To extend the psychometric study of the Cognitive Change Checklist (3CL) by examining the reliability, factor structure, and external correlates of 3CL informant and self-report ratings in community-dwelling adults. We also conducted receiver operating characteristic analyses examining rating scores from this normative sample with those of clinical samples., Design: Scale reliability and validity study., Setting: Community sites., Participants: Six hundred seventy-nine older adults., Results: The pattern of scale relationships within and across versions, and the failure to find associations with age and education, were consistent with findings in clinic samples reported previously. Factor analysis replicated the four-factor structure of the informant ratings. All informant version scales significantly discriminated amnestic mild cognitive impairment cases and patients with mild dementia from normals., Conclusion: These findings provide support for the use of the checklist as a clinical tool to facilitate identification of cases of mild cognitive impairment and early dementia.