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Purpose: To better understand the experiences and potential unmet need of persons who die in long-term care. Design and Methods: We conducted after-death interviews with staff who had cared for 422 decedents with dementia and 159 who were cognitively intact and received terminal care in U.S. nursing homes (NHs) or residential care-assisted living (RC-AL) settings. We conducted family caregiver interviews for 293 decedents. Results: We noted no differences between decedents with and without dementia in terms of pain, psychosocial status, family involvement, advance care planning, most life-prolonging interventions, and hospice use. Dying residents with dementia tended to die less often in a hospital, have less shortness of breath, receive more physical restraints and sedative medication, and use emergency services less frequently on the last day of life. Persons with dementia dying in RC-AL settings tended to have more skin ulcers and poorer hygiene care than nondemented persons in RC-AL settings. In comparison with persons dying with dementia in NHs, those in RC-AL settings tended to be restrained less often, have emergency services called more often on the day of death, and have family more satisfied with physician communication. Implications: These results suggest that the overall quality of care for persons dying with dementia in long-term-care settings may not differ markedly from that provided to persons who are cognitively intact. Similarly, large discrepancies in the overall quality of palliative care for persons with dementia in RC-AL facilities and NHs were not identified. However, numerous specific areas for care improvement were noted.

Purpose: The purpose of this article is to discuss the benefits and limitations of, and considerations in, developing a typology of assisted living (AL). Design and Methods: We conducted a review and comparison of nine AL typologies drawn from the literature. Results: Typologies addressed matters related to the structure, process, population, and philosophy of AL to varying degrees. A lack of available data and different sampling frames hindered attempts to quantitatively compare the typologies. Implications: Typologies are potentially useful for consumers, practitioners, policy makers, and researchers. It is advisable to identify state-based typologies and then empirically determine types that have national representation. Stakeholders should consider the tradeoff between sensitivity and specificity and allow any resulting typology to anticipate ongoing evolution in the field of AL.

Purpose: Residential care/assisted living describes diverse facilities providing non-nursing home care to a heterogeneous group of primarily elderly residents. This article derives typologies of assisted living based on theoretically and practically grounded evidence. Design and Methods: We obtained data from the Collaborative Studies of Long-Term Care, which examined 193 assisted living facilities in four states: Florida, Maryland, New Jersey, and North Carolina. By using mixture modeling, we derived typologies in five different ways, based on: structure; process; resident case-mix; structure and process; and structure, process, and resident case-mix. Results: Although configurations of typologies varied as a function of criterion variables used, common themes emerged from different cluster solutions. A typology based on resident case-mix yielded a five-cluster solution, whereas a typology based on structure, process, and resident case-mix resulted in six distinct clusters. Medicaid case-mix/psychiatric illness and high resident impairment were two clusters identified by both strategies. Implications: Because of the wide variation in structure, residents, and services within assisted living facilities, typologies such as those described here may be useful in clinical practice, research, and policy. To the extent that public payment defines its own cluster, the potential for inequities in care merits careful attention. (Contains 4 tables.)

Background and Objectives State-regulating agencies use 350 different licenses and certifications to govern assisted living (AL), resulting in significant variation in regulations governing health services, the scope of practice, and capacity. This lack of standardization makes it difficult to compare and contrast AL operations and residents' outcomes across similarly regulated communities. Research Design and Methods We used qualitative and quantitative methods to empirically develop and describe a typology of state AL regulations that captures inter- and intrastate variation. Based on the rules governing health services, we created regulatory specificity scores for 5 thematic dimensions: medication administration, third-party care, skilled nursing, medication review, and licensed nurse staffing. With these scores, we conducted a K -means cluster analysis to identify groups of AL license types. To differentiate the regulatory types, we calculated standardized mean differences across structure, process, outcome, and resident characteristics of the AL communities licensed under each type. Results We identified 6 types of AL differentiated by the regulatory provisions governing health services: Housing, Holistic, Hybrid, Hospitality, Healthcare, and Health Support. The types align with previous work and reflect tangible differences in resident characteristics, health service structures, processes, and outcomes. Discussion and Implications This typology effectively captures differences across regulated dimensions and can inform and support quality of care. Researchers, policy-makers, and consumers may benefit from using this typology and acknowledging these differences in AL licensure when designing research studies, developing policies, and selecting an AL community. [ABSTRACT FROM AUTHOR]

To determine the feasibility of conducting a trial of a novel nighttime lighting system designed to support postural stability in assisted living (AL) residents, and to estimate intervention effectiveness by comparing the incidence of nighttime falls during the novel lighting condition to that in a control condition featuring a standard nightlight. Randomized crossover trial. The intervention consisted of 3 custom-designed linear arrays of amber light-emitting diodes (LEDs) arranged in strips: 1 strip aligned horizontally across the top of the bathroom/entry doorframe containing 68 LEDs and 2 strips of 140 LEDs each aligned vertically down the sides of the doorframe. The control condition was 1 standard nightlight in the bedroom and 1 in the bathroom. Residents were randomized to treatment sequences, receiving each condition for 1-2 quarters. Five AL communities serving exclusively residents with dementia or having separate units for residents with dementia, with at least 30 beds and at least 5 residents in private rooms. Residents were eligible if they had dementia, were ambulatory, did not share a bedroom, were not on hospice or expected to die within the year, and were not expected to transfer to another setting within the year. Outcomes included recruitment, retention, incident falls, and satisfaction. Thirty-eight residents of the 5 communities participated (56% recruitment rate), and 24 family members completed surveys about their satisfaction with the lighting system. Cameras captured falls data for 92% of 8591 resident nights. The incidence density for falls was 34% lower in the intervention condition than the control condition (incidence density ratio 0.66, 95% CI 0.35, 1.22), which did not reach statistical significance (P =.18). This low-cost intervention was feasible with high satisfaction. Building on these results, the intervention is being evaluated in a larger clinical trial. A novel lighting system to reduce falls could ultimately benefit millions of older adults across all settings. [ABSTRACT FROM AUTHOR]

Objectives To create data-driven typologies of licensed nurse staffing and health services in residential care and assisted living ( RC/ AL). Design Cluster analysis was used to describe the patterns of licensed nurse staffing and 47 services and the extent to which these clusters were related. Setting RC/ AL communities in the United States. Participants A convenience sample of administrators and healthcare supervisors from 89 RC/AL communities in 22 states. Measurement RC/ AL characteristics, licensed nurse staffing (total number of hours that registered nurses ( RNs) and licensed practical nurses ( LPNs) worked), number of hours that contract nurses worked, and availability of 47 services. Results Analysis revealed four licensed nurse staffing clusters defined according to total number of hours and the type of nurse providing the hours ( RN, LPN, or a mix of both). They ranged from no or minimal RN and LPN hours to high nursing hours with a mix of RNs and LPNs. The 47 services clustered into five clusters: basic services; technically complex services; assessments, wound care, and therapies; testing and specialty services; and gastrostomy and intravenous medications. The availability of services was related to the presence of nurses ( RNs and LPNs) except for the gastrostomy and intravenous medication services, which were not readily available. Conclusion The amount and skill mix of licensed nurse staffing varies in RC/ AL and is related to the types of services available. These findings may have implications for resident care and outcomes. Future work in this area, including extension to include nonnurse direct care workers, is needed. [ABSTRACT FROM AUTHOR]

Nursing homes and residential care/assisted living settings provide care to 2.4 million individuals. Few studies compare the experience of, and relationships between, family and staff in these settings, despite ongoing family involvement and evidence that relationships are problematic. Data from 488 families and 397 staff members in 24 settings examined family involvement and family and staff burden, depressive symptoms, and perceptions; and staff absenteeism and turnover. There were few differences across setting types. Although conflict rarely occurred, there was room for improvement in family–staff relations; this area, and preparing family for their caregiving roles, are appropriate targets for social work intervention. [ABSTRACT FROM PUBLISHER]

Objective To evaluate the effect of ambient bright light therapy (BLT) on agitation among institutionalized persons with dementia. Methods High intensity, low glare ambient lighting was installed in activity and dining areas of a state psychiatric hospital unit in North Carolina and a dementia-specific residential care facility in Oregon. The study employed a cluster-unit crossover design involving four ambient lighting conditions: AM bright light, PM bright light, All Day bright light, and Standard light. Sixty-six older persons with dementia participated. Outcome measures included direct observation by research personnel and completion by staff caregivers of the 14-item, short form of the Cohen-Mansfield Agitation Inventory (CMAI). Results Analyses of observational data revealed that for participants with mild/moderate dementia, agitation was higher under AM light (p = 0.003), PM light (p < 0.001), and All Day light (p = 0.001) than Standard light. There was also a trend toward severely demented participants being more agitated during AM light than Standard light (p = 0.053). Analysis of CMAI data identified differing responses by site: the North Carolina site significantly increased agitation under AM light (p = 0.002) and PM light (p = 0.013) compared with All Day light while in Oregon, agitation was higher for All Day light compared to AM light (p = 0.030). In no comparison was agitation significantly lower under any therapeutic condition, in comparison to Standard lighting. Conclusions Ambient bright light is not effective in reducing agitation in dementia and may exacerbate this behavioral symptom. Copyright © 2010 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Purpose: Researchers know little about the physical performance ability of residential care/assisted living (RC/AL) residents and its relationship to adverse outcomes such as fracture, nursing home placement, functional decline, and death. The purposes of this article are to (a) describe the functional characteristics of RC/AL residents, (b) examine the relationships between resident- and facility-level characteristics and physical performance, and (c) determine the predictive value of physical performance for adverse outcomes. Design and Methods: Data came from 1,791 residents in 189 RC/AL facilities participating in the Collaborative Studies of Long-Term Care. At baseline, residents were tested on four performance measures (grip strength, chair rise, balance, and walking speed), and other resident- and facility-level information was collected. Adverse out- comes were measured over 1 year. Results: Average grip strength was 14 ± 7 kg, 61% of residents walked <0.6 m/s (M = 0.41 m/s), 26% could perform five chair rises, and only 19% could perform a tandem stand for a least 1 s. Multivariable analyses showed that more cognitive and functional impairment, depressive symptoms and comorbid conditions, and for-profit ownership were associated with poorer physical performance. Controlling for individual characteristics, we found that better performance on the four physical performance measures was associated with a reduced risk of nursing home placement, fracture, and decline in function over 1 year. Implications: Simple performance measures identify modifiable functional deficits and suggest targeted interventions to prolong independent mobility and aging in place in RC/AL facilities. [ABSTRACT FROM AUTHOR]

Purpose: Residential care/assisted living facilities have become an alternative to nursing homes for many individuals, yet little information exists about staffing in these settings and the effect of staffing. This study analyzed the intensity and skill mix of nursing staff using data from a four-state study, and their relationship to outcomes. Design and Methods: We obtained longitudinal data for 1,894 residents of 170 residential care/assisted living facilities participating in the Collaborative Studies of Long-Term Care. Descriptive statistics assessed the levels of direct care staff (registered nurse, licensed practical nurse, personal care aide). Regression analyses evaluated the relationship between two staffing measures (intensity measured as care hours per resident and skill mix measured as the percentage of total care hours by licensed nurses), facility characteristics, and four health outcomes (mortality, nursing home transfer, hospitalization, and incident morbidity). Results: Care hours per resident decreased with facility size (economies of scale) only for very small facilities and increased with dementia prevalence (case-mix effect). Licensed staff accounted for a greater proportion of total hours in nonprofit settings. Health outcomes did not vary by total care hours per resident, but hospitalization rates were significantly lower in facilities with higher proportions of skilled staff hours; this effect was stronger as dementia case mix increased. Implications: Current staffing levels for the outcomes analyzed meet most residents' needs. Reduced hospitalization in relation to greater use of licensed staff suggests that increased use of these workers might result in reductions in acute care expenditures. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To estimate the sensitivity, specificity, and reliability of the Minimum Data Set Cognition Scale (MDS-COGS) in screening for undetected dementia when completed by direct care staff in residential care/assisted living (RC/AL) facilities and secondarily to determine the prevalence of dementia in the sample. DESIGN: A cross-sectional study in which staff were trained to complete the MDS-COGS. Research interviewers and a neuropsychologist obtained information on each participant. Two neurologists reviewed the data and examined the participant, rendering a probable diagnosis of dementia/non-dementia diagnosis. MDS-COGS results were compared with the neurologists' determination. SETTING: Fourteen RC/AL facilities in North Carolina. PARTICIPANTS: Data were collected from 50 staff on 166 residents without a diagnosis of dementia. MEASUREMENTS: In addition to the MDS-COGS, measures included a comprehensive neuropsychological battery. Depression and other neuropsychiatric symptoms were also assessed. RESULTS: Neurologists determined that 38% of participants had probable dementia. An MDS-COGS cutpoint of 2 was highly specific (0.97) but not very sensitive (0.49) for dementia. Test–retest and interrater agreement for a negative screen were high (88% and 93%, respectively). CONCLUSION: The MDS-COGS is a simple, brief screen that RC/AL staff can complete. It will identify with high specificity a subset of residents with undetected dementia, allowing rapid identification of those likely to need dementia care. Caution needs to be exercised in light of its low sensitivity, because some with milder dementia will not be detected. Further work is needed to determine whether staff can and will use the MDS-COGS as a trigger for more-thorough assessment and to guide care and improve outcomes. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To describe two versions of a new measure, The Quality of Dying in Long-Term Care, for postdeath administration to surrogate respondents (staff and family caregivers) of all decedents (QOD-LTC) and of cognitively intact decedents (QOD-LTC-C) who die in nursing homes (NHs) and residential care or assisted living (RC/AL) facilities. DESIGN: Using two levels of exploratory factor analysis, 15 candidate items for the QOD-LTC and 36 candidate items for the QOD-LTC-C were tested using multiple criteria to determine factor structure and interpretability of the quality of dying in long-term care (LTC). SETTING: One hundred seventeen RC/AL facilities and 31 NHs in FL, MD, NC, and NJ. PARTICIPANTS: Family (n=439) and staff (n=332) caregivers of 633 decedents from a stratified random sample from RC/AL facilities and NHs in four states. MEASUREMENTS: Trained interviewers asked respondents to rate statements describing potentially important aspects of the quality of dying using a 5-point Likert scale. The scale items were analyzed using exploratory factor analysis with communalities set to unity using a Promax rotation. RESULTS: The 11-item QOD-LTC (α=0.66), appropriate for surrogate respondents for all decedents, consists of three domains (personhood, closure, preparatory tasks). The 23-item instrument for surrogate respondents of cognitively intact decedents, the QOD-LTC-C (α=0.85), consists of five domains (sense of purpose, closure, control, social connection, preparatory tasks). CONCLUSION: The QOD-LTC and QOD-LTC-C are psychometrically acceptable measures of the quality of the dying experience, developed for and tested in LTC settings. Use of these measures can increase understanding of the dying experience in LTC. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To assess family perceptions of communication between physicians and family caregivers of individuals who spent their last month of life in long-term care (LTC) and to identify associations between characteristics of the family caregiver, LTC resident, facility, and physician care with these perceptions. DESIGN: Retrospective study of family caregivers of persons who died in LTC. SETTING: Thirty-one nursing homes (NHs) and 94 residential care/assisted living (RC/AL) facilities. PARTICIPANTS: One family caregiver for each of 440 LTC residents who died (response rate 66.0%) was interviewed 6 weeks to 6 months after the death. MEASUREMENTS: Demographic and facility characteristics and seven items rating the perception of family caregivers regarding physician–family caregiver communication at the end of life, aggregated into a summary scale, Family Perception of Physician-Family caregiver Communication (FPPFC) (Cronbach alpha=0.96). RESULTS: Almost half of respondents disagreed that they were kept informed (39.9%), received information about what to expect (49.8%), or understood the doctor (43.1%); the mean FPPFC score (1.73 on a scale from 0 to 3) was slightly above neutral. Linear mixed models showed that family caregivers reporting better FPPFC scores were more likely to have met the physician face to face and to have understood that death was imminent. Daughters and daughters-in-law tended to report poorer communication than other relatives, as did family caregivers of persons who died in NHs than of those who died in RC/AL facilities. CONCLUSION: Efforts to improve physician communication with families of LTC residents may be promoted using face-to-face meetings between the physician and family caregivers, explanation of the patient's prognosis, and timely conveyance of information about health status changes, especially when a patient is actively dying. [ABSTRACT FROM AUTHOR]

Assisted living facilities have become increasingly popular for older adults needing assistance. They are intended to enable privacy and provide support, but the extent to which they do so, and the degree to which these relate to residents' needs, are unknown. This observational study of 1,830 residents in 182 facilities indicates that, during the mid-afternoon, the majority of residents are awake (79%), and one-half (49%) are awake and in public spaces. Residents who are cognitively and functionally impaired are more likely to be in public spaces, but less likely to be engaged. Residents who are awake and alone in private spaces are less likely to be impaired, but more likely to have medical conditions. Thus, residents needing more oversight seem to be positioned to obtain that oversight. [ABSTRACT FROM AUTHOR]

Purpose: Residential care/assisted living describes diverse facilities providing non-nursing home care to a heterogeneous group of primarily elderly residents. This article derives typologies of assisted living based on theoretically and practically grounded evidence. Design and Methods: We obtained data from the Collaborative Studies of Long-Term Care, which examined 193 assisted living facilities in four states: Florida, Maryland, New Jersey, and North Carolina. By using mixture modeling, we derived typologies in five different ways, based on: structure; process; resident case-mix; structure and process; and structure, process, and resident case-mix. Results: Although configurations of typologies varied as a function of criterion variables used, common themes emerged from different cluster solutions. A typology based on resident case-mix yielded a five-cluster solution, whereas a typology based on structure, process, and resident case-mix resulted in six distinct clusters. Medicaid case-mix/psychiatric illness and high resident impairment were two clusters identified by both strategies. Implications: Because of the wide variation in structure, residents, and services within assisted living facilities, typologies such as those described here may be useful in clinical practice, research, and policy. To the extent that public payment defines its own cluster, the potential for inequities in care merits careful attention. [ABSTRACT FROM AUTHOR]

Purpose: There are few empirical studies relating components of long-term care to quality of life for residents with dementia. This study relates elements of dementia care in residential care/assisted living (RC/AL) facilities and nursing homes to resident quality of life and considers the guidance this information provides for practice and policy. Design and Methods: We used a variety of report and observational measures of the structure and process of care and 11 standardized measures of quality of life to evaluate the care for and quality of life of 421 residents with dementia in 35 RC/AL facilities and 10 nursing homes in four states. Data were collected cross sectionally on-site, and we conducted a 6-month follow-up by telephone. Results: Change in quality of life was better in facilities that used a specialized worker approach, trained more staff in more domains central to dementia care, and encouraged activity participation. Residents perceived their quality of life as better when staff was more involved in care planning and when staff attitudes were more favorable. Better resident–staff communication was related to higher quality of life as observed and reported by care providers. Also, more stable resident–staff assignment was related to care providers' lower quality-of-life ratings. Implications: Improvement in resident quality of life may be achieved by improved training and deployment of staff. [ABSTRACT FROM AUTHOR]

Purpose: This study compares health and functional outcomes and health care utilization of persons with dementia residing in residential care/assisted living (RC/AL) facilities and nursing homes. Design and Methods: The study uses data from a longitudinal cohort study of 1,252 residents with dementia in 106 RC/AL facilities and 40 nursing homes in four states. Results: Rates of mortality; new or worsening morbidity; and change in activities of daily living, cognition, behavioral problems, depressive symptoms, social function, and withdrawal did not differ between the two settings. However, because of death or transfer, only about one half of the persons with mild dementia and one third of those with moderate to severe dementia remained in RC/AL facilities 1 year after enrollment. In addition, hospitalization rates were greater among individuals with mild dementia in RC/AL facilities, largely because of a medically unstable subgroup with high nursing-home-transfer rates. Implications: Many persons with dementia can be served equally well in either setting; however, those with major medical care needs may benefit from nursing home residence. [ABSTRACT FROM AUTHOR]

This article describes the characteristics associated with activity involvement in 400 residents with dementia in 45 assisted living facilities and nursing homes. Activity involvement was related to family involvement in care and staff encouragement, after adjusting for resident age, gender, race, cognitive and functional status, and comorbidity. [ABSTRACT FROM AUTHOR]

This article describes the prevalence, assessment, and treatment of, as well as characteristics associated with, mobility limitation in 343 residents with dementia in 45 assisted living facilities and nursing homes. Overall, 89% of residents had some degree of mobility limitation. Mobility limitation was associated with fewer behavioral symptoms, low fluid intake, professional assessment, and professional and informal treatment. [ABSTRACT FROM AUTHOR]

This article describes the prevalence, assessment, and treatment of pain, as well as characteristics associated with pain, in 331 residents with dementia in 45 assisted living facilities and nursing homes. Overall, 21% of residents had pain, and pain was more commonly reported in for-profit facilities, and for those receiving professional assessment and treatment. [ABSTRACT FROM AUTHOR]

This article describes care for behavioral symptoms related to dementia (BSRD) and identifies their potential correlates among 347 residents with dementia living in 45 assisted living facilities and nursing homes from four states. The prevalence of BSRD was associated with staff training and resident cognition, mood, mobility, and psychotropic use. Attention to staff training and depression management might improve BSRD. [ABSTRACT FROM AUTHOR]

Purpose:The goals of this study are to describe the current state of residential care/assisted living (RC/AL) care and residents in comparison with nursing home (NH) care and residents, identify different types of RC/AL care and residents, and consider how variation in RC/AL case-mix reflects differences in care provision and/or consumer preference.Design and Methods:Data were derived from the Collaborative Studies of Long-Term Care, a four-state study of 193 RC/AL facilities and 40 NHs. Multivariate analyses examined differences in ten process of care measures between RC/AL facilities with less than 16 beds; traditional RC/AL with 16 or more beds; new-model RC/AL; and NHs. Generalized estimating equation models determined differences in resident case-mix across RC/AL facilities using data for 2,078 residents.Results:NHs report provision of significantly more health services and have significantly more lenient admission policies than RC/AL facilities, but provide less privacy. They do not differ from larger RC/AL facilities in policy clarity or resident control. Differences within RC/AL types are evident, with smaller and for-profit facilities scoring lower than other facilities across multiple process measures, including those related to individual freedom and institutional order. Resident impairment is substantial in both NHs and RC/AL settings, but differs by RC/AL facility characteristics.Implications:Differences in process of care and resident characteristics by facility type highlight the importance of considering: (1) the adequacy of existing process measures for evaluating smaller facilities; (2) resident case-mix when comparing facility types and outcomes; and (3) the complexity of understanding the implication of the process of care, given the importance of person–environment fit. Work is continuing to clarify the role of RC/AL vis-à-vis NHs in our nation's system of residential long-term care. [ABSTRACT FROM AUTHOR]

Objectives. In this study, we examined racial separation in long-term care. Methods. We used a survey of a stratified sample of 181 residential care/assisted living (RC/AL) facilities and 39 nursing homes in 4 states. Results. Most African Americans resided in nursing homes and smaller RC/AL facilities and tended to be concentrated in a few predominantly African American facilities, whereas the vast majority of Whites resided in predominantly White facilities. Facilities housing African Americans tended to be located in rural, nonpoor, African American communities, to admit individuals with mental retardation and difficulty in ambulating, and to have lower ratings of cleanliness/maintenance and lighting. Conclusions. These racial disparities may result from economic factors, exclusionary practices, or resident choice. Whether separation relates to inequities in care is undetermined. (Am J Public Health. 2002;92:1272-1277) [ABSTRACT FROM AUTHOR]

In nursing homes (NHs), psychoactive medication use has received notable attention, but less is known about prescribing in assisted living (AL). This study examined how antipsychotic and antianxiety medication prescribing in AL compares with NHs. Observational, cross-sectional AL data linked to publicly reported NH measures. Random sample of 250 AL communities and the full sample of 3371 NHs in 7 states. We calculated the percentage of residents receiving antipsychotics and antianxiety medications. For each AL community, we calculated the distance to NHs in the state. Linear models estimated the relationship between AL prescribing and that of the closest and farthest 5 NHs, adjusting for AL characteristics and state fixed effects. The prescribing rate of potentially inappropriate antipsychotics (i.e., excluding for persons with recorded schizophrenia and Tourette syndrome) and of antianxiety medications (excluding for those on hospice) in AL was 15% and 21%, respectively. Unadjusted mean antipsychotic prescribing rates were nominally higher in AL than NHs (14.8% vs 14.6%; P =.056), whereas mean antianxiety prescribing was nominally lower in AL (21.2% vs 22.6%; P =.032). In adjusted analyses, AL rates of antipsychotic use were not associated with NH rates. However, being affiliated with an NH was associated with a lower rate of antipsychotic use [b = −0.03; 95% confidence interval (CI) −0.50 to −0.001; P =.043], whereas antianxiety rates were associated with neighboring NHs' prescribing rates (b = 0.43; 95% CI 0.16–0.70; P =.002). This study suggests reducing antipsychotic medication use in NHs may influence AL practices in a way not accounted for by local NH patterns. And, because antianxiety medications have not been the focus of national campaigns, they may be more subject to local prescribing behaviors. It seems advantageous to consider prescribing in AL when efforts are implemented to change NH prescribing, as there seems to be related influence whether by affiliation or region. [ABSTRACT FROM AUTHOR]

Context The two primary residential options for older adults who require supportive care are nursing homes and residential care/assisted living. More than one-quarter of all deaths in the U.S. occur in these settings. Although the information available on end of life in long-term care has been growing, the comparative suitability of various measures to guide this work is unknown. Objectives To determine the optimal measures to assess end-of-life care and outcomes in nursing homes and residential care/assisted living. Methods A total of 264 family members of decedents from 118 settings were interviewed and provided data on 11 instruments that have been used in, but not necessarily developed for, long-term care populations; Overall, 20 scales and subscales/indices were evaluated. Measures were compared on their psychometric properties and the extent to which they discriminated among important resident, family, and setting characteristics. Results Prioritizing measures that distinguish the assessment of care from the assessment of dying, and secondarily that exhibit an acceptable factor structure, this study recommends two measures of care—the Family Perceptions of Physician—Family Caregiver Communication and the End of Life in Dementia (EOLD)-Satisfaction With Care—and two measures of outcomes—the EOLD-Symptom Management and the EOLD-Comfort Assessment in Dying. An additional measure to assess outcomes is the Mini-Suffering State Examination (MSSE). The care measures and the MSSE are especially valuable as they discriminate between decedents who were and were not transferred immediately before death, an important outcome, and whether the family expected the death, a useful target for intervention. Conclusion Despite these recommendations, measurement selection should be informed not only on the basis of psychometric properties but also by specific clinical and research needs. The data in this manuscript will help researchers, clinicians, and administrators understand the implications of choosing various measures for their work. [ABSTRACT FROM AUTHOR]

Objectives Develop self-administered questionnaires of person-centeredness for completion by residents and staff in assisted living (AL), in response to concerns that AL is not person-centered; also, demonstrated person-centeredness is necessary for Medicaid support as a home- and community-based services provider. Design Community-based participatory research partnership among a research team, a consortium of 11 stakeholder organizations, and others. Methods included literature review, item generation and reduction, cognitive testing, field testing, exploratory factor analysis, and convergent and discriminant validity testing. Setting Cognitive testing conducted in 2 AL residences and field testing conducted in 19 diverse, stratified AL residences in 6 states. Participants Eight residents and staff participated in cognitive testing, and 228 residents and 123 staff participated in field testing. Measurements Feasibility and psychometric testing of draft questionnaires that included 75 items (resident version) and 102 items (staff version), with parallel items on both versions as appropriate. Results The final resident questionnaire included 49 items and 4 factors: well-being and belonging, individualized care and services, social connectedness, and atmosphere. The staff questionnaire included 62 items and 5 factors: workforce practices, social connectedness, individualized care and services, atmosphere, and caregiver-resident relationships. Staff scored person-centeredness higher than did residents, reflecting their different perspectives. Conclusion The Person-Centered Practices in Assisted Living (PC-PAL) questionnaires measure person-centeredness from the perspectives of residents and staff, meaning that they reflect the concepts and items considered to be important to these key stakeholders. Use of these instruments to describe, assess, quantify, ensure, and ultimately improve person-centeredness in AL is feasible and appropriate for all AL settings, and supported by numerous national organizations. [ABSTRACT FROM AUTHOR]

Objective: This paper describes and examines the implementation of a quality improvement (QI) program to reduce potentially inappropriate antibiotic prescribing in residential care/assisted living (RC/AL) and nursing homes (NHs) in the context of organizational performance. Methods: A QI program that included evidencebased medical provider training related to prescribing, use of a standardized form to communicate signs and symptoms of infection, resident and family education, and ongoing monitoring and feedback and monthly QI meetings, was implemented in four RC/AL settings and six NHs in North Carolina. Program fidelity was assessed during monthly team meetings and by medical record review, and facilitators and barriers to implementation were identified by interviews with medical providers and staff. Results were considered in light of both setting types operating as complex adaptive systems. Results: It was challenging to train the numerous medical providers in RC/AL settings, but markedly easier to train the NH providers, who championed the QI program. On the other hand, evidence of change in staff practices was more evident in RC/AL, but staff in both settings were receptive to learning the signs and symptoms of infection that need to be communicated to better inform antibiotic prescribing. Conclusion: Change in antibiotic prescribing in RC/AL and NHs can be achieved through better informed and increased communication between long-term care staff and medical providers. By implementing the same QI program in both RC/AL and NH settings, the centrality of the role of the health care supervisor in RC/AL, and the need for medical provider endorsement in NHs, became clear. Consequently, efforts to change prescribing must be tailored according to the setting. [ABSTRACT FROM AUTHOR]

The article reports on the result of Dementia Care Training Program in nursing homes (NHs) and in residential care or assisted living (RC/AL) settings wherein there are approximately 2.5 million dementia patients. It notes that the training program used linear mixed model to know the training outcomes. Results include an improved knowledge in some of the training areas with less support from their own supervisors and increase in work stress.

Objective: Compare diagnostic characteristics of brief cognitive screening tests in residential care/assisted living (RC/AL) residents. Design: Cross-sectional study involving a comprehensive clinical examination to ascertain a consensus diagnosis of probable dementia, no significant cognitive impairment, or mild cognitive impairment (MCI), including both amnestic and non-amnestic subtypes. Setting: Fourteen RC/AL facilities in North Carolina. Participants: Participants were 146 RC/AL residents, aged 65 years or older, who did not have diagnosed cognitive impairment. Measurements: Diagnostic characteristics of the Mini-Cog, the Mini-Mental State Exam (MMSE), and a new 50-point test based on expanding selected MMSE items (MMX). Results: Overall, 55/146 (38%) participants were diagnosed with probable dementia, and 76 (52%) met criteria for MCI (most non-amnestic). Both the Mini-Cog and the MMSE showed high sensitivity and negative predictive value for dementia, but had relatively low sensitivity and negative predictive value for MCI. The Mini-Cog had low specificity and was less accurate as a dementia screen than either the MMSE or MMX. Reliability and validity data for the MMX were satisfactory, and it performed better as a screening test for MCI than either the MMSE or Mini-Cog. Conclusion: Although the MMSE and Mini-Cog are both sensitive to dementia, modest specificity and positive predictive value may limit their utility as screening tools. Preliminary MMX data suggest it improves screening for MCI compared to the Mini-Cog or MMSE, while providing a similar level of screening for dementia. Further work is needed to identify suitable instruments for cognitive screening across the range of MCI and dementia. [Copyright &y& Elsevier]

The article reports on a research project conducted with the Alzheimer's Association about the practice and policy of the Campaign for Quality in Residential Care (CQRC). It talks about the campaign's research process and its data on select domains of quality of life. It also provides an overview of the steps to evaluate the outcomes of the CQRC.