Implementation Lessons Learned: Distress Behaviors in Dementia Intervention in Veterans Health Administration.

BACKGROUND AND OBJECTIVES: Evidence-based practices to manage distress behaviors in dementia (DBD) are not consistently implemented despite demonstrated effectiveness. The Veterans Health Administration (VA) trained teams to implement Staff Training in Assisted Living Residences (STAR)-VA, an intervention to manage DBD in VA nursing home settings, or Community Living Centers (CLCs). This paper summarizes multiyear formative evaluation results including challenges, adaptations, and lessons learned to support sustained integration into usual care across CLCs nationwide. RESEARCH DESIGN AND METHODS: STAR was selected as an evidence-based practice for DBD, adapted for and piloted in VA (STAR-VA), and implemented through a train-the-trainer program from 2013 to 2018. Training and consultation were provided to 92 CLC teams. Evaluation before and after training and consultation included descriptive statistics of measures of clinical impact and survey feedback from site teams regarding self-confidence, engagement, resource quality, and content analysis of implementation facilitators and challenges. RESULTS: STAR-VA training and consultation increased staff confidence and resulted in significant decreases in DBD, depression, anxiety, and agitation for Veterans engaged in the intervention. Implementation outcomes demonstrated feasibility and identified facilitators and barriers. Key findings were interpreted using implementation frameworks and informed subsequent modifications to sustain implementation. DISCUSSION AND IMPLICATIONS: STAR-VA successfully prepared teams to manage DBD and resulted in improved outcomes. Lessons learned include importance of behavioral health-nursing partnerships, continuous engagement, iterative feedback and adaptations, and sustainment planning. Evaluation of sustainment factors has informed selection of implementation strategies to address sustainment barriers. Lessons learned have implications for integrating team-based practices into system-level practice.

Supporting Sustained STAR-VA Implementation: Evaluation of a Sustainment Coaching Program.

OBJECTIVES: The Veterans Health Administration (VA) STAR-VA program is a person-centered, interdisciplinary intervention for managing distress behaviors in dementia in VA nursing homes, called Community Living Centers (CLCs). Teams often struggle to sustain STAR-VA after site-lead partner turnover. The STAR-VA Sustainment Coaching Program was developed to support a new local STAR-VA behavioral coordinator and/or nurse champion (ie, site-leads) and engage the team to implement sustainment strategies. The aims of this evaluation were to document sustainment needs, barriers and facilitators, and effective strategies used during a sustainment intervention. DESIGN: We describe qualitative and quantitative findings of a program evaluation of the STAR-VA Sustainment Coaching pilot program. SETTING AND PARTICIPANTS: Eight CLC teams participated in the pilot program, 5 training a new nurse champion, 2 a new behavioral coordinator, and 1 both new site-leads. METHODS: CLC teams completed a needs assessment, developed sustainment goals and plans, tracked sustainment interventions implemented, and reported case outcomes. Outcome assessment and tracking reports were summarized and themes identified using a qualitative inductive approach. RESULTS: Common sustainment needs were to train a new nurse champion, promote staff understanding of dementia and distress behaviors, and promote a culture of person-centered dementia care. Most sites selected sustainment goals of implementing training procedures and behavioral rounds. Sustainment barriers included limited staff time, staff turnover, lack of supportive routines and tools, and limited awareness of STAR-VA. Facilitators included leadership support, staff interest, and training resources. Most sites reported successful implementation of STAR-VA behavior rounds, whereas strategies to achieve training-related goals had variable success. CONCLUSIONS AND IMPLICATIONS: The STAR-VA Sustainment Coaching Program helped CLC teams identify and implement strategies to support sustained STAR-VA implementation. The results of this project are informing ongoing efforts to integrate STAR-VA components into usual care processes for CLC residents with dementia.

Impact of STAR-VA on Staff Injury and Disruptive Behavior Reports in VA Nursing Homes.

OBJECTIVES: Workplace disruptive behavior incidents can be costly for organizations, employees, and customers. Persons with dementia living in long-term care settings have a high risk of exhibiting distressed behaviors. We examined whether a resident-centered, behavioral intervention for residents with dementia led to a reduction in reported workplace disruptive behaviors and staff injury rate due to assault. Impactful interventions are important for quality of care. DESIGN: We examined whether a team-based behavioral program in community living centers (CLCs), where a nurse champion and behavioral coordinator were trained to work with the clinical team to understand and manage distressed behaviors commonly associated with dementia, was associated with reductions in behavior incidents. SETTING AND PARTICIPANTS: The setting was Veterans Health Administration CLCs. The sample consisted of 120 aggregated CLCs operating between 2012 and 2017 with 62 completing training. CLCs were distributed across the United States. METHODS: Outcomes included CLC-level rates of staff injury and number of workplace disruptive behavior incidents. Outcomes were regressed on measures of intervention completion, time since intervention, and several CLC characteristics. RESULTS: The intervention was significantly associated with lower incidence of assault with staff injury rates overall, particularly following the first year of training, but not with other reported workplace disruptive behavior incident rates. CONCLUSIONS AND IMPLICATIONS: A team-based behavioral intervention was associated with reduction of employee assaults, a critical repercussion of distressed behavior in dementia. Given rapid growth in patients with dementia in nursing homes, effective treatment practices, such as interdisciplinary behavioral management approaches may be impactful and valuable to implement.

Impact of an interdisciplinary intervention for distress behaviors in dementia on psychotropic drug use in Veterans Health Administration Community Living Centers: STAR-VA impact on psychotropic drug utilization.

STAR-VA is an interdisciplinary behavioral approach for managing distress behaviors in residents with dementia, implemented at Veterans Health Administration nursing homes. This study evaluated the impact of STAR-VA implementation on psychotropic drug use. The study design is a retrospective, quasi-experimental cohort analysis of residents enrolled as STAR-VA training cases compared with eligible residents at untrained sites to evaluate treatment effects on psychotropic medication use. We matched 229 STAR-VA cases with 1,163 comparisons. STAR-VA cases experienced an average reduction of 0.92 "as-needed" doses per month (95% confidence interval [CI] -1.82, -0.02) compared with controls. No significant effect on non-STAR-VA cases in trained facilities was detected. STAR-VA programs are an important option for reducing potentially inappropriate psychotropic use.

Addressing Behavioral Symptoms of Dementia Through STAR-VA Implementation: Do Outcomes Vary by Behavior Type?

OBJECTIVES: The STAR-VA program in Veterans Health Administration Community Living Centers (CLCs, nursing home settings) trains teams to implement a psychosocial intervention with residents with behavioral symptoms of dementia (BSD). METHODS: Across 71 CLCs, 302 residents selected as training cases had target behaviors categorized into one of 5 types: physically aggressive (PA), physically nonaggressive, verbally aggressive, verbally nonaggressive, and behavior deficit (BD). RESULTS: Across all groups, there were significant declines in team-rated behavior frequency (36%) and severity (44%), agitation (10%), distress behaviors (42%), depression (17%), and anxiety (20%). The magnitude of changes varied across behavior category. For example, those with a PA target behavior experienced a greater percentage decline in agitation and distress behavior scores, and those with a BD target behavior experienced a greater percentage decline in depressive and anxiety symptoms. CONCLUSIONS: STAR-VA, a multicomponent intervention, is generally effective across various types of behavioral symptoms associated with dementia.

Managing Challenging Behaviors of Dementia in Veterans: Identifying and Changing Activators and Consequences Using STAR-VA.

One of the most challenging clinical issues for long-term care staff is the management of dementia-related behavioral symptoms. STAR-VA is an interdisciplinary intervention for managing challenging behaviors of Veterans with dementia in Community Living Centers (CLCs) within the U.S. Department of Veterans Affairs. The goals of the current article are to delineate categories of challenging behaviors found in CLCs, the context in which behaviors occurred, and the interventions used by CLC clinical teams when implementing STAR-VA. In 2013, 17 CLC teams completed STAR-VA training, enrolling 71 Veteran participants. Four independent raters identified common assessment and intervention themes for six behavior categories, coding activators, consequences, goal behaviors, and care plans for each category. Successful care plans included staff changes in communication approaches, incorporation of pleasant events into care, and individualized environmental modifications. Findings illustrate the range of interventions that CLC teams may apply as a result of systematic behavioral assessment informing an understanding of activators and consequences of dementia-related behaviors. [Journal of Gerontological Nursing, 43(2), 33-43.].

Cognitive Interviewing: Revising the Preferences for Everyday Living Inventory for Use In the Nursing Home.

A valid tool is needed to assess preferences that are relevant and important to nursing home (NH) residents. Originally developed for older adults receiving home care services, the authors adapted the Preferences for Everyday Living Inventory (PELI) for use with NH residents. Content validity was initially established using a panel of experts in long-term care. PELI items were cognitively interviewed with 31 Veteran and 39 non-Veteran participants (N = 70). Responses from cognitive interviewing guided substantial revisions of the PELI (>25% of items) to include language that NH residents use and understand, reducing potential measurement error and ensuring the preferences assessed are relevant to NH residents. Future work will further adapt the PELI for use with more diverse groups and health care settings, and assess its psychometric properties. Using the PELI will help move clinical teams closer to the goal of providing person-centered care informed by individual preferences.

New toolkit to measure quality of person-centered care: development and pilot evaluation with nursing home communities.

BACKGROUND: Increasingly, nursing home (NH) providers are adopting a person-centered care (PCC) philosophy; yet, they currently lack methods to measure their progress toward this goal. Few PCC tools meet criteria for ease of use and feasibility in NHs. The purpose of this article is to report on the development of the concept and measurement of preference congruence among NH residents (phase 1), its refinement into a set of quality indicators by Advancing Excellence in America's Nursing Homes (phase 2), and its pilot evaluation in a sample of 12 early adopting NHs prior to national rollout (phase 3). The recommended toolkit for providers to use to measure PCC consists of (1) interview materials for 16 personal care and activity preferences from Minimum Data Set 3.0, plus follow-up questions that ask residents how satisfied they are with fulfillment of important preferences; and (2) an easy to use Excel spreadsheet that calculates graphic displays of quality measures of preference congruence and care conference attendance for an individual, household or NH. Twelve NHs interviewed residents (N = 146) using the toolkit; 10 also completed a follow-up survey and 9 took part in an interview evaluating their experience. RESULTS: NH staff gave strong positive ratings to the toolkit. All would recommend it to other NHs. Staff reported that the toolkit helped them identify opportunities to improve PCC (100%), and found that the Excel tool was comprehensive (100%), easy to use (90%), and provided high quality information (100%). Providers anticipated using the toolkit to strengthen staff training as well as to enhance care planning, programming and quality improvement. CONCLUSIONS: The no-cost PCC toolkit provides a new means to measure the quality of PCC delivery. As of February 2014, over 700 nursing homes have selected the Advancing Excellence in America's Nursing Homes PCC goal as a focus for quality improvement. The toolkit enables providers to incorporate quality improvement by moving beyond anecdote, and advancing more systematically toward honoring resident preferences.

Direct observation of behavior: a review of current measures for use with older adults with dementia.

This review article reports on methods of direct observation of behaviors for use in long-term care settings, particularly with older adults who have dementia. This article provides information on the theoretical roots, administration methods, and psychometric properties of measures of direct observation of individual behavior. It is hoped that this review will help gerontological nurses make informed choices about the direct observation measures that suit their specific needs, highlight the role of direct observation in quality improvement for dementia care, and facilitate a balance between identifying a gold standard and allowing flexibility to assess project-specific behaviors.