Factors Related to Higher and Lower Performance and Adherence in STAR-VA Program Sustainment in Department of Veterans Affairs (VA) Community Living Centers (CLCs).

OBJECTIVES: We identify factors associated with sustainment of an intervention (STAR-VA) to address distress behaviors in dementia (DBD), guided by the Organizational Memory Knowledge Reservoir (KR) framework, compared across 2 types of outcomes: (1) site performance improvement on a clinical outcome, the magnitude of change in levels of DBD, and (2) self-rated adherence to STAR-VA core components, a process outcome. DESIGN: We used a cross-sectional sequential explanatory mixed methods design guided by the Organizational Memory Framework. SETTING AND PARTICIPANTS: We selected 20 of 79 sites that completed STAR-VA training and consultation based on rankings on 2 outcomes-change in an indicator of DBD and reported adherence to STAR-VA core components. We recruited key informants most knowledgeable about STAR-VA resulting in a sample of 43% behavioral coordinators, 36% nurse champions, and 21% nurse leaders. METHODS: We collected data with key informants at each Community Living Center (CLC) from December 2018 to June 2019. We analyzed data using within-case and cross-case matrixes created from the coded transcripts for each a priori KR domain. We then assessed if there were any similarities or differences for CLCs in comparable DBD performance and STAR-VA adherence categories. RESULTS: We found 4 KRs that differentiated sustainment factors based on CLC implementation process and clinical outcomes-3 KRs related to DBD performance (people, relationships, and routines) and 2 related to STAR-VA adherence (relationships and culture). CONCLUSIONS AND IMPLICATIONS: This evaluation found several knowledge retention mechanisms that differ in high and low performance/adherence sites. Our findings highlight knowledge retention/sustainment strategies based on site functioning to support sustainment strategies in the CLC. Understanding sustainment factors as they relate to clinical and process outcomes is innovative and can be used to support CLCs struggling with sustainment. More research is needed to inform tailored sustainment efforts based on site functioning in the nursing home setting.

An MDS 3.0 Distressed Behavior in Dementia Indicator (DBDI): A Clinical Tool to Capture Change.

BACKGROUND/OBJECTIVES: Persons with dementia frequently demonstrate distress behaviors in dementia (DBD), associated with poorer outcomes. This study aimed to create a measure of DBD from routinely administered Minimum Data Set (MDS 3.0) behavior section items that demonstrated sensitivity to change, for evaluation of intervention efforts for VA Community Living Center (CLCs) residents exhibiting DBD. SETTING: 72 VA nursing home settings, or Community Living Centers (CLCs). PARTICIPANTS: CLC residents with DBD (n = 302) were enrolled in an interdisciplinary behavioral intervention between 2013 and 2017. DESIGN: A factor analysis of MDS behavior section items from assessments closest to baseline was conducted. Internal consistency, hypothesized associations between MDS factors and clinical measures, and sensitivity to detect change over time was explored. MEASUREMENTS: Residents were assessed at baseline and post-intervention using the MDS behavior section items and a validated clinical measure of DBD. RESULTS: The Distress Behavior in Dementia Indicator (DBDI) was created as a consistent factor with internal consistency, and was related to a validated measure as predicted at baseline and post-intervention. Sensitivity to change was demonstrated by using change score correlations (r = 0.40-0.50), effect size (d = 0.63), and reliable change indices. CONCLUSION: The DBDI is recommended for routine use in CLCs to evaluate impact of intervention effectiveness and provide quality improvement feedback.

Development of the Knowledge of Dementia Competencies Self-Assessment Tool.

Competent dementia care requires caregivers with specialized knowledge and skills. The Knowledge of Dementia Competencies Self-Assessment Tool was developed to help direct care workers (DCWs) assess their knowledge of 7 dementia competencies identified by the Michigan Dementia Coalition. Item selection was guided by literature review and expert panel consultation. It was given to 159 DCWs and readministered to 57 DCWs in a range of long-term care settings and revised based on qualitative feedback and statistical item analyses, resulting in 82 items demonstrating good internal consistency and test-retest reliability. Performance on items assessing competencies rated as most important was significantly related to training in these competencies. The DCWs in day care obtained higher scores than those in home care settings, and their sites reported a greater number of hours of dementia training. Validation in a more diverse group of DCWs and assessing its relationship to other measures of knowledge and skill is needed.