Center for Excellence in Assisted Living CEAL@UNC

Advancing the well-being of the people who live and work in assisted living through research, practice, and policy.

Academic Publication

The Role of Workday Characteristics on Perceived Stress and Time Pressure among Nurses in Finnish Long-Term Care – A Cross-Sectional Study

Dec 1, 2024
Background Aging populations and nursing workforce issues are causing challenges for long-term care globally, and therefore, improving the work-related wellbeing and retention of nurses is crucial. As such, gaining a further understanding of the factors that affect work strain in long-term care is important. Previously, the effect of job demands on the wellbeing of nurses […]

The Role of Workday Characteristics on Perceived Stress and Time Pressure among Nurses in Finnish Long-Term Care – A Cross-Sectional Study

by Lea Efird-Green

Background Aging populations and nursing workforce issues are causing challenges for long-term care globally, and therefore, improving the work-related wellbeing and retention of nurses is crucial. As such, gaining a further understanding of the factors that affect work strain in long-term care is important. Previously, the effect of job demands on the wellbeing of nurses […]

Applications of Blockchain Technology in Long-Term Care: Use Cases, Potentials, and Barriers

Dec 1, 2024
Background Digitalization in long-term care (LTC) is being discussed as a means of easing pressures on care service delivery, optimizing care coordination and planning processes, and improving service quality. With its advanced data protection and process automation features, blockchain technology could help solve data security and privacy issues, especially for the implementation of assistive technologies. […]

Applications of Blockchain Technology in Long-Term Care: Use Cases, Potentials, and Barriers

by Lea Efird-Green

Background Digitalization in long-term care (LTC) is being discussed as a means of easing pressures on care service delivery, optimizing care coordination and planning processes, and improving service quality. With its advanced data protection and process automation features, blockchain technology could help solve data security and privacy issues, especially for the implementation of assistive technologies. […]

A New Measure of Professional Caregiver Coping in Long-Term Care: The LTC COPE

Dec 1, 2024
INTRODUCTION: The professional caregiver workforce (nursing assistants and personal care aides) is critical to quality of care and quality of life in nursing home (NH) and assisted living (AL) settings. The work is highly stressful, so improving responses to stress in this workforce could contribute to satisfaction and retention. This research developed a coping measure […]

A New Measure of Professional Caregiver Coping in Long-Term Care: The LTC COPE

by Lea Efird-Green

INTRODUCTION: The professional caregiver workforce (nursing assistants and personal care aides) is critical to quality of care and quality of life in nursing home (NH) and assisted living (AL) settings. The work is highly stressful, so improving responses to stress in this workforce could contribute to satisfaction and retention. This research developed a coping measure […]

Stress-Related Coping and its Relationship to Well-Being in Nursing Assistants and Personal Care Aides in Nursing Homes and Assisted Living

Dec 1, 2024
INTRODUCTION Professional caregivers (nursing assistants and personal care aides) in nursing homes (NH) and assisted living (AL) provide the majority of long‐term residential care for persons with Alzheimer’s disease and related dementias. Their work is stressful, but until recently, no measures were available to assess stress in this workforce. Using the new Long‐Term Care Cope […]

Stress-Related Coping and its Relationship to Well-Being in Nursing Assistants and Personal Care Aides in Nursing Homes and Assisted Living

by Lea Efird-Green

INTRODUCTION Professional caregivers (nursing assistants and personal care aides) in nursing homes (NH) and assisted living (AL) provide the majority of long‐term residential care for persons with Alzheimer’s disease and related dementias. Their work is stressful, but until recently, no measures were available to assess stress in this workforce. Using the new Long‐Term Care Cope […]

Examining Engagement Calendar Deviations in Assisted Living: A Focus on Residents With Dementia

Dec 1, 2024
Early in our longitudinal qualitative study on meaningful engagement and quality of life among assisted living (AL) residents with dementia, researchers observed differences between the activities scheduled on monthly engagement calendars and those taking place. Yet, we were unable to identify any research examining such deviations or their implications. Thus, drawing on data from three […]

Examining Engagement Calendar Deviations in Assisted Living: A Focus on Residents With Dementia

by Lea Efird-Green

Early in our longitudinal qualitative study on meaningful engagement and quality of life among assisted living (AL) residents with dementia, researchers observed differences between the activities scheduled on monthly engagement calendars and those taking place. Yet, we were unable to identify any research examining such deviations or their implications. Thus, drawing on data from three […]

Medical Care Provider Involvement in Ontario Assisted Living Homes: A Descriptive Cross-Sectional Survey Analysis

Dec 1, 2024
Objectives: Assisted living is growing in Ontario. Medical services are not regulated in Ontario, resulting in variability of physician involvement. We described medical service provider involvement and practice characteristics in assisted living homes. Design: Descriptive cross-sectional study. Setting and Participants: A total of 88 assisted living homes in Ontario, Canada, which responded to a survey […]

Medical Care Provider Involvement in Ontario Assisted Living Homes: A Descriptive Cross-Sectional Survey Analysis

by Lea Efird-Green

Objectives: Assisted living is growing in Ontario. Medical services are not regulated in Ontario, resulting in variability of physician involvement. We described medical service provider involvement and practice characteristics in assisted living homes. Design: Descriptive cross-sectional study. Setting and Participants: A total of 88 assisted living homes in Ontario, Canada, which responded to a survey […]

Transitions to Nursing Homes Among Residents of Assisted Living and Community-Dwelling Home Care Recipients

Dec 1, 2024
Objectives To examine transitions to a nursing home among residents of assisted living relative to community-dwelling home care recipients. Design Population-based retrospective cohort study emulating a target trial. Setting and Participants Linked, individual-level health system data were obtained from older adults (≥65 years of age) who made an incident application for a bed in a nursing […]

Transitions to Nursing Homes Among Residents of Assisted Living and Community-Dwelling Home Care Recipients

by Lea Efird-Green

Objectives To examine transitions to a nursing home among residents of assisted living relative to community-dwelling home care recipients. Design Population-based retrospective cohort study emulating a target trial. Setting and Participants Linked, individual-level health system data were obtained from older adults (≥65 years of age) who made an incident application for a bed in a nursing […]

The Efficacy of a Mobile-Based Multidomain Program on Cognitive Functioning of Residents in Assisted Living Facilities

Dec 1, 2024
Objectives The purpose of this study is to test the efficacy of a mobile-based multidomain application, Silvia Program, on cognitive functioning of residents in assisted living facilities (ALFs). Study design Pilot randomized controlled trial using a two-group pretest-posttest design. Methods Twenty participants living in ALFs were randomized to a Silvia group or usual care group. Silvia group received mobile-based […]

The Efficacy of a Mobile-Based Multidomain Program on Cognitive Functioning of Residents in Assisted Living Facilities

by Lea Efird-Green

Objectives The purpose of this study is to test the efficacy of a mobile-based multidomain application, Silvia Program, on cognitive functioning of residents in assisted living facilities (ALFs). Study design Pilot randomized controlled trial using a two-group pretest-posttest design. Methods Twenty participants living in ALFs were randomized to a Silvia group or usual care group. Silvia group received mobile-based […]

“What Does ‘Age-Friendly’ Mean to You?”: The Role of Microaggressions in a Retirement and Assisted Living Community

Dec 1, 2024
Background and Objectives: In conversations about expanding age-friendly ecosystems, the concept of “age-friendliness” has not been explored in relation to residential settings. Research Design and Methods: This multiple-case study compared four residents’ perspectives on the age-friendliness of a retirement and assisted living community, combining individual semi-structured interviews with observational data and organizational document analyses in […]

“What Does ‘Age-Friendly’ Mean to You?”: The Role of Microaggressions in a Retirement and Assisted Living Community

by Lea Efird-Green

Background and Objectives: In conversations about expanding age-friendly ecosystems, the concept of “age-friendliness” has not been explored in relation to residential settings. Research Design and Methods: This multiple-case study compared four residents’ perspectives on the age-friendliness of a retirement and assisted living community, combining individual semi-structured interviews with observational data and organizational document analyses in […]

Risk of Hospitalization Among Assisted Living Residents Dually Enrolled in Medicare and Medicaid

Dec 1, 2024
Objectives To examine how risk of hospitalization among assisted living (AL) residents differs by dual enrollment in Medicare and Medicaid and by the percent of dually enrolled individuals in an AL community. Design Retrospective cohort study. Setting and Participants We used Medicare data from 2008 to 2018 and a national directory of licensed AL communities […]

Risk of Hospitalization Among Assisted Living Residents Dually Enrolled in Medicare and Medicaid

by Lea Efird-Green

Objectives To examine how risk of hospitalization among assisted living (AL) residents differs by dual enrollment in Medicare and Medicaid and by the percent of dually enrolled individuals in an AL community. Design Retrospective cohort study. Setting and Participants We used Medicare data from 2008 to 2018 and a national directory of licensed AL communities […]

Factors Associated with Transfer from Assisted Living Facilities to a Nursing Home: National Health Aging Trends Study 2011-2019

Nov 1, 2024
Background Residents of assisted living facilities (ALF) transfer to a nursing home when they require a higher level of care, but limited research has examined risk factors for transfer to a nursing home. The aims of this study were to identify (1) baseline factors associated with transfer to a nursing home and (2) time-varying factors […]

Factors Associated with Transfer from Assisted Living Facilities to a Nursing Home: National Health Aging Trends Study 2011-2019

by Lea Efird-Green

Background Residents of assisted living facilities (ALF) transfer to a nursing home when they require a higher level of care, but limited research has examined risk factors for transfer to a nursing home. The aims of this study were to identify (1) baseline factors associated with transfer to a nursing home and (2) time-varying factors […]

Clinical and Sociodemographic Characteristics of New Residents of Assisted Living: A Nested Case-Control Study

Nov 1, 2024
Objective To examine transitions to an assisted living facility among community-dwelling older adults who received publicly funded home care services. Design Nested case-control study. Setting and Participants Linked, population-level health system administrative data were obtained from adults aged 65 years and older who received home care services in Ontario, Canada, from April 1, 2018, to December […]

Clinical and Sociodemographic Characteristics of New Residents of Assisted Living: A Nested Case-Control Study

by Lea Efird-Green

Objective To examine transitions to an assisted living facility among community-dwelling older adults who received publicly funded home care services. Design Nested case-control study. Setting and Participants Linked, population-level health system administrative data were obtained from adults aged 65 years and older who received home care services in Ontario, Canada, from April 1, 2018, to December […]

Effects of a Meaning in Life Enhancement Program on Depression among Older Adult Residents of Assisted Living Facilities

Nov 1, 2024
Older adults residing in assisted living facilities often experience higher rates of depression. This study aimed to examine the effects of a program to enhance meaning in life on depression among older adult residents. The samples included 60 older adults living in two assisted living facilities. The experimental group participated in the meaning in life […]

Effects of a Meaning in Life Enhancement Program on Depression among Older Adult Residents of Assisted Living Facilities

by Lea Efird-Green

Older adults residing in assisted living facilities often experience higher rates of depression. This study aimed to examine the effects of a program to enhance meaning in life on depression among older adult residents. The samples included 60 older adults living in two assisted living facilities. The experimental group participated in the meaning in life […]

The Relationship between Perceived Engagement in Meaningful Activity and Behavioral and Psychological Symptoms of Dementia among Assisted Living Residents

Nov 1, 2024
The purpose of this study is to assess the relationship between engagement in meaningful activities and behavioral and psychological symptoms of dementia (BPSD), including agitation, apathy, irritability, and depression among 71 assisted living (AL) residents with moderate to severe dementia. This secondary analysis used baseline data from a randomized controlled trial, Meaningful Activity for Managing […]

The Relationship between Perceived Engagement in Meaningful Activity and Behavioral and Psychological Symptoms of Dementia among Assisted Living Residents

by Lea Efird-Green

The purpose of this study is to assess the relationship between engagement in meaningful activities and behavioral and psychological symptoms of dementia (BPSD), including agitation, apathy, irritability, and depression among 71 assisted living (AL) residents with moderate to severe dementia. This secondary analysis used baseline data from a randomized controlled trial, Meaningful Activity for Managing […]

Effect of a Digital Two-Dimensional Animation Program on Attitude Toward Walking Aids, Performance, and Fall Avoidance Behaviors among Older Adults in Assisted Living Facilities

Nov 1, 2024
The study investigated the impact of a two-dimensional animation program on attitudes towards walking aids, performance, and fall avoidance behaviors among older adults in assisted living facilities. A quasi-experimental pretest-posttest control group study was conducted on 128 older adults aged 60 years and above. The intervention group showed more favorable attitudes towards walking aids, improved […]

Effect of a Digital Two-Dimensional Animation Program on Attitude Toward Walking Aids, Performance, and Fall Avoidance Behaviors among Older Adults in Assisted Living Facilities

by Lea Efird-Green

The study investigated the impact of a two-dimensional animation program on attitudes towards walking aids, performance, and fall avoidance behaviors among older adults in assisted living facilities. A quasi-experimental pretest-posttest control group study was conducted on 128 older adults aged 60 years and above. The intervention group showed more favorable attitudes towards walking aids, improved […]

Progress of Rehabilitation in Assisted Living for Mentally Ill According to STAX-SA Taxonomy

Nov 1, 2024
Objective: The transition from institutional psychiatric care to community-based mental health services has resulted in the rapid development of assisted living services (AL) for mentally ill. Focus of the current study is to add internationally comparable evidence-based knowledge on the rehabilitation of AL residents by examining progression and mortality in relation to the level of […]

Progress of Rehabilitation in Assisted Living for Mentally Ill According to STAX-SA Taxonomy

by Lea Efird-Green

Objective: The transition from institutional psychiatric care to community-based mental health services has resulted in the rapid development of assisted living services (AL) for mentally ill. Focus of the current study is to add internationally comparable evidence-based knowledge on the rehabilitation of AL residents by examining progression and mortality in relation to the level of […]

Association Between Organizational Context and Resident Pain in Assisted Living: A Repeated Cross-Sectional Study

Nov 1, 2024
Objectives: Resident pain has been a common quality challenge in congregate care for older adults, and organizational context may explain variations in resident pain beyond resident-level factors. Most studies have focused on nursing homes (NHs), largely neglecting assisted living (AL). AL residents are at similar risk for pain as NH resident, but with AL providing fewer […]

Association Between Organizational Context and Resident Pain in Assisted Living: A Repeated Cross-Sectional Study

by Lea Efird-Green

Objectives: Resident pain has been a common quality challenge in congregate care for older adults, and organizational context may explain variations in resident pain beyond resident-level factors. Most studies have focused on nursing homes (NHs), largely neglecting assisted living (AL). AL residents are at similar risk for pain as NH resident, but with AL providing fewer […]

Residency in Long-Term Care Facilities: An Important Risk Factor for Respiratory Syncytial Virus Hospitalization

Nov 1, 2024
Older age and comorbid conditions increase risk for severe for respiratory syncytial virus (RSV). Skilled nursing facilities (SNFs) and assisted living (AL) facilities represent an intersection of risk factors. In a 3-year prospective study in Rochester, New York, we compared the population-based incidence of RSV-associated hospitalization for communitydwelling (CD), SNF, and AL adults aged ≥65 […]

Residency in Long-Term Care Facilities: An Important Risk Factor for Respiratory Syncytial Virus Hospitalization

by Lea Efird-Green

Older age and comorbid conditions increase risk for severe for respiratory syncytial virus (RSV). Skilled nursing facilities (SNFs) and assisted living (AL) facilities represent an intersection of risk factors. In a 3-year prospective study in Rochester, New York, we compared the population-based incidence of RSV-associated hospitalization for communitydwelling (CD), SNF, and AL adults aged ≥65 […]

Staffing Patterns in Nursing Homes, Assisted Living Communities, and Memory Care Units: Variation Across Shifts

Nov 1, 2024
Objectives To assess the staffing patterns of direct care nursing staff by shift in nursing homes (NHs), assisted living communities (ALCs), and their corresponding memory care units (MCUs). Design Observational study of the 2021 Ohio Biennial Survey of Long-Term Care Facilities and the Payroll-Based Journal data for December 2021. Setting and Participants NHs (n = 678) and […]

Staffing Patterns in Nursing Homes, Assisted Living Communities, and Memory Care Units: Variation Across Shifts

by Lea Efird-Green

Objectives To assess the staffing patterns of direct care nursing staff by shift in nursing homes (NHs), assisted living communities (ALCs), and their corresponding memory care units (MCUs). Design Observational study of the 2021 Ohio Biennial Survey of Long-Term Care Facilities and the Payroll-Based Journal data for December 2021. Setting and Participants NHs (n = 678) and […]

Barriers and Facilitators to Physical Activity Among Older Adults in Residential Aged Care Facilities: A Mixed Methods Systematic Review Using the Social Ecological Model

Nov 1, 2024
Objective To ascertain the barriers and facilitators to physical activity (PA) for older adults in Residential Aged Care Facilities (RACFs), from the perspective of residents, staff, and family. Methods A mixed-methods systematic review, underpinned by the Social Ecological Model (SEM). Five databases were searched from inception to May 2024. Data synthesis followed a convergent integrated […]

Barriers and Facilitators to Physical Activity Among Older Adults in Residential Aged Care Facilities: A Mixed Methods Systematic Review Using the Social Ecological Model

by Lea Efird-Green

Objective To ascertain the barriers and facilitators to physical activity (PA) for older adults in Residential Aged Care Facilities (RACFs), from the perspective of residents, staff, and family. Methods A mixed-methods systematic review, underpinned by the Social Ecological Model (SEM). Five databases were searched from inception to May 2024. Data synthesis followed a convergent integrated […]

Perceived Physical Activity Levels and Objective Measures: A Mixed-Methods Study of Residents Aged 65 and Above in Assisted Living Homes in Australia

Nov 1, 2024
Background and Purpose: Communities face a mounting social, economic and health burden as the global population of older adults continues to grow. Regular physical activity is consistently reported as an effective means of maintaining health and independence in older adults, yet engagement in activity remains low. This study assesses the activity levels of adults aged over […]

Perceived Physical Activity Levels and Objective Measures: A Mixed-Methods Study of Residents Aged 65 and Above in Assisted Living Homes in Australia

by Lea Efird-Green

Background and Purpose: Communities face a mounting social, economic and health burden as the global population of older adults continues to grow. Regular physical activity is consistently reported as an effective means of maintaining health and independence in older adults, yet engagement in activity remains low. This study assesses the activity levels of adults aged over […]

Feasibility of a Novel Lighting System to Reduce Nighttime Falls in Assisted Living Residents With Dementia

Oct 1, 2024
Objectives 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. Design Randomized crossover […]

Feasibility of a Novel Lighting System to Reduce Nighttime Falls in Assisted Living Residents With Dementia

by Lea Efird-Green

Objectives 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. Design Randomized crossover […]

An Initial Exploration into Job Satisfaction Among Long-Term Care Administrators and State Tested Nursing Assistants in Ohio

Oct 1, 2024
This pilot study examines Ohio’s licensed nursing home administrators and state tested nursing assistant’s perspectives about job satisfaction, future career and employment plans, potential beneficial changes to their organizations, and their thoughts on reducing turnover rates in their field. Ohio Board of Executives of Long-Term Services and Supports provided their contact list of all 1,969 […]

An Initial Exploration into Job Satisfaction Among Long-Term Care Administrators and State Tested Nursing Assistants in Ohio

by Lea Efird-Green

This pilot study examines Ohio’s licensed nursing home administrators and state tested nursing assistant’s perspectives about job satisfaction, future career and employment plans, potential beneficial changes to their organizations, and their thoughts on reducing turnover rates in their field. Ohio Board of Executives of Long-Term Services and Supports provided their contact list of all 1,969 […]

Postimplementation Evaluation in Assisted Living Facilities of an eHealth Medical Device Developed to Predict and Avoid Unplanned Hospitalizations: Pragmatic Trial

Oct 1, 2024
Background: The proportion of very old adults in the population is increasing, representing a significant challenge. Due to their vulnerability, there is a higher frequency of unplanned hospitalizations in this population, leading to adverse events. Digital tools based on artificial intelligence (AI) can help to identify early signs of vulnerability and unfavorable health events and […]

Postimplementation Evaluation in Assisted Living Facilities of an eHealth Medical Device Developed to Predict and Avoid Unplanned Hospitalizations: Pragmatic Trial

by Lea Efird-Green

Background: The proportion of very old adults in the population is increasing, representing a significant challenge. Due to their vulnerability, there is a higher frequency of unplanned hospitalizations in this population, leading to adverse events. Digital tools based on artificial intelligence (AI) can help to identify early signs of vulnerability and unfavorable health events and […]