Academic Publication

Do-Not-Hospitalize Orders in Assisted Living Facilities: Direct Care Workers’ Perspectives

Apr 1, 2024

WHAT THIS MEANS FOR YOU: Eight participants were surveyed and interviewed to inform an intervention that would prevent direct care workers from sending residents with do-not-hospitalize orders to the hospital. Results revealed care workers were unfamiliar with do-not-hospitalize orders and had binary thinking (e.g., residents had to be sent to hospice or the hospital) on end-of-life issues. Supportive leaders in the assisted living communities that could assist direct care workers during these complex situations were found to be helpful.

Do-Not-Hospitalize Orders in Assisted Living Facilities: Direct Care Workers’ Perspectives

April 1, 2024 by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Eight participants were surveyed and interviewed to inform an intervention that would prevent direct care workers from sending residents with do-not-hospitalize orders to the hospital. Results revealed care workers were unfamiliar with do-not-hospitalize orders and had binary thinking (e.g., residents had to be sent to hospice or the hospital) on end-of-life issues. Supportive leaders in the assisted living communities that could assist direct care workers during these complex situations were found to be helpful.

Do End-of-Life Outcomes Differ by Assisted Living Memory-Care Designation?

Apr 1, 2024

WHAT THIS MEANS FOR YOU: An analysis of 15,152 Medicare beneficiaries with ADRD examined end-of-life outcomes (mortality, hospice use, and number of days receiving hospice in the last month of life) for residents who moved to a large (25+ bed) AL between 2016 and 2018. Residents living in memory care units had a statistically significantly higher rate of mortality, higher hospice use, and more days spent receiving hospice in the last month of life than residents in general AL units.

Do End-of-Life Outcomes Differ by Assisted Living Memory-Care Designation?

April 1, 2024 by Lea Efird-Green

WHAT THIS MEANS FOR YOU: An analysis of 15,152 Medicare beneficiaries with ADRD examined end-of-life outcomes (mortality, hospice use, and number of days receiving hospice in the last month of life) for residents who moved to a large (25+ bed) AL between 2016 and 2018. Residents living in memory care units had a statistically significantly higher rate of mortality, higher hospice use, and more days spent receiving hospice in the last month of life than residents in general AL units.

Evacuation and Health Care Outcomes Among Assisted Living Residents After Hurricane Irma

Apr 1, 2024

WHAT THIS MEANS FOR YOU: Using 2017 Medicare data, researchers compared health outcomes from over 25,000 Florida AL residents who resided in an AL on the day of Hurricane Irma’s landfall and either sheltered in place (86% of residents) or evacuated (14% of residents). Evacuation was statistically significantly associated with a 16% higher risk of emergency department visits and with a 51% higher risk of nursing home admissions within 30 days of the hurricane, while hospitalization and mortality rates were similar between the two groups.

Evacuation and Health Care Outcomes Among Assisted Living Residents After Hurricane Irma

April 1, 2024 by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Using 2017 Medicare data, researchers compared health outcomes from over 25,000 Florida AL residents who resided in an AL on the day of Hurricane Irma’s landfall and either sheltered in place (86% of residents) or evacuated (14% of residents). Evacuation was statistically significantly associated with a 16% higher risk of emergency department visits and with a 51% higher risk of nursing home admissions within 30 days of the hurricane, while hospitalization and mortality rates were similar between the two groups.

Perceptions of the Use of Terms of Endearment among Older Adults in an Assisted Living Facility

Apr 1, 2024

WHAT THIS MEANS FOR YOU: Elderspeak, which includes terms of endearment used by healthcare workers for older adults, was examined via interviews with 15 New York AL residents. Participants’ opinions varied; some liked the terms, some were neutral, and some thought they were disrespectful; thus, it is recommended that healthcare workers adjust their communication based on residents’ personal preferences.

Perceptions of the Use of Terms of Endearment among Older Adults in an Assisted Living Facility

April 1, 2024 by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Elderspeak, which includes terms of endearment used by healthcare workers for older adults, was examined via interviews with 15 New York AL residents. Participants’ opinions varied; some liked the terms, some were neutral, and some thought they were disrespectful; thus, it is recommended that healthcare workers adjust their communication based on residents’ personal preferences.

Objectively Measured Physical Activity and Sedentary Behaviors Among Older Adults in Assisted Living Facilities: A Scoping Review

Apr 1, 2024

WHAT THIS MEANS FOR YOU: This scoping review included 20 articles from 15 studies that used devices to track physical activity behavior in AL residents. On average, residents spent between 96 and 201 minutes each day doing light physical activity, but only 1 to 9.74 minutes on moderate to vigorous activity. In addition, residents were sedentary for 8.5 to 11 hours while awake. Personal, social, and environmental factors influenced completion of physical activity in the included studies; however, none of the included interventions successfully increased activity or reduced sedentary behavior.

Objectively Measured Physical Activity and Sedentary Behaviors Among Older Adults in Assisted Living Facilities: A Scoping Review

April 1, 2024 by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This scoping review included 20 articles from 15 studies that used devices to track physical activity behavior in AL residents. On average, residents spent between 96 and 201 minutes each day doing light physical activity, but only 1 to 9.74 minutes on moderate to vigorous activity. In addition, residents were sedentary for 8.5 to 11 hours while awake. Personal, social, and environmental factors influenced completion of physical activity in the included studies; however, none of the included interventions successfully increased activity or reduced sedentary behavior.

Examining Pain, Function, Behavioral Symptoms and Associations with Engagement in Meaningful Activity for Residents with Dementia in Assisted Living

Apr 1, 2024

WHAT THIS MEANS FOR YOU: In a study of 71 residents with dementia from 5 AL facilities, pain was linked to lower engagement in meaningful activities (i.e., activities that provide meaning and value to the person based on their individual interests and preferences), even when controlling for age, gender, health conditions, and cognitive capacity.

Examining Pain, Function, Behavioral Symptoms and Associations with Engagement in Meaningful Activity for Residents with Dementia in Assisted Living

April 1, 2024 by Lea Efird-Green

WHAT THIS MEANS FOR YOU: In a study of 71 residents with dementia from 5 AL facilities, pain was linked to lower engagement in meaningful activities (i.e., activities that provide meaning and value to the person based on their individual interests and preferences), even when controlling for age, gender, health conditions, and cognitive capacity.

Experiences of COVID-19 Restrictions on Physical Activity in Assisted Living

Apr 1, 2024

WHAT THIS MEANS FOR YOU: Interviews with 7 participants from one South Carolina AL community revealed overall reduced levels of physical activity during the COVID-19 pandemic. Key barriers to physical activity included health issues, resource limitations (e.g., gyms being closed), and negative physical activity experiences (e.g., being required to wear a mask during exercise).

Experiences of COVID-19 Restrictions on Physical Activity in Assisted Living

April 1, 2024 by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Interviews with 7 participants from one South Carolina AL community revealed overall reduced levels of physical activity during the COVID-19 pandemic. Key barriers to physical activity included health issues, resource limitations (e.g., gyms being closed), and negative physical activity experiences (e.g., being required to wear a mask during exercise).

A Step Toward Better Care: Understanding What Caregivers and Residents in Assisted Living Facilities Value in Health Monitoring Systems

Apr 1, 2024

WHAT THIS MEANS FOR YOU: Expert interviews, cognitive walkthroughs, and semi-structured interviews were conducted with 7 caregivers and 5 residents from an AL community to understand the role that health monitoring technology plays in their work and lives. Monitoring technology was viewed as a way to reduce caregivers' workload and improve team communication. Residents were open to using the technology, but protecting their privacy and autonomy was a concern for its implementation.

A Step Toward Better Care: Understanding What Caregivers and Residents in Assisted Living Facilities Value in Health Monitoring Systems

April 1, 2024 by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Expert interviews, cognitive walkthroughs, and semi-structured interviews were conducted with 7 caregivers and 5 residents from an AL community to understand the role that health monitoring technology plays in their work and lives. Monitoring technology was viewed as a way to reduce caregivers’ workload and improve team communication. Residents were open to using the technology, but protecting their privacy and autonomy was a concern for its implementation.

Quality of Life in Assisted Living Facilities for Seniors: A Descriptive Exploratory Study

Mar 1, 2024

WHAT THIS MEANS FOR YOU: Seventeen residents in two AL communities were interviewed about their perceived quality of life. Their perspectives reflected an emphasis on the physical environment, social environment, and home-like atmosphere. The two major indicators of quality of life in the AL community were the resident’s ability to adapt to change and the community’s ability to meet residents’ diverse needs.

Quality of Life in Assisted Living Facilities for Seniors: A Descriptive Exploratory Study

March 1, 2024 by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Seventeen residents in two AL communities were interviewed about their perceived quality of life. Their perspectives reflected an emphasis on the physical environment, social environment, and home-like atmosphere. The two major indicators of quality of life in the AL community were the resident’s ability to adapt to change and the community’s ability to meet residents’ diverse needs.

Hospice Providers Serving Assisted Living Residents: Association of Higher Volume with Lower Quality

Mar 1, 2024

WHAT THIS MEANS FOR YOU: Using Medicare Compare and claims data for over 2800 hospice providers, this analysis found that hospices with higher AL patient volume (i.e., a higher share of their annual patient days were from AL residents) had lower quality ratings from family caregivers in key areas such as pain management, breathing help, emotional support, communication, and family training, even when controlling for profit status and daily patient census. This result indicates that hospice providers who more frequently serve AL resident patients are on average of lower quality, and more research to understand this relationship is recommended.

Hospice Providers Serving Assisted Living Residents: Association of Higher Volume with Lower Quality

March 1, 2024 by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Using Medicare Compare and claims data for over 2800 hospice providers, this analysis found that hospices with higher AL patient volume (i.e., a higher share of their annual patient days were from AL residents) had lower quality ratings from family caregivers in key areas such as pain management, breathing help, emotional support, communication, and family training, even when controlling for profit status and daily patient census. This result indicates that hospice providers who more frequently serve AL resident patients are on average of lower quality, and more research to understand this relationship is recommended.

Using Assisted Living Communities to Enhance Nursing Student Attitudes Toward Older Adults

Feb 1, 2024

WHAT THIS MEANS FOR YOU: A total of 70 nursing students at one Western US university participated in a clinical project in which they interviewed an AL resident and provided an educational session to residents at an AL community. Students, AL communities, and instructors all reported positive experiences in this clinical experience, and students reported more positive attitudes towards older adults.

Using Assisted Living Communities to Enhance Nursing Student Attitudes Toward Older Adults

February 1, 2024 by Lea Efird-Green

WHAT THIS MEANS FOR YOU: A total of 70 nursing students at one Western US university participated in a clinical project in which they interviewed an AL resident and provided an educational session to residents at an AL community. Students, AL communities, and instructors all reported positive experiences in this clinical experience, and students reported more positive attitudes towards older adults.

Worse Quality at For-Profit Assisted Living Facilities in Non-Urban Minnesota

Feb 1, 2024

WHAT THIS MEANS FOR YOU: This study examined the results of licensure surveys for 292 AL communities in non-urban Minnesota between 2021 and 2023. All AL communities received at least one citation, with an average of 15 citations. Citations were most commonly related to meals (e.g., not providing nutritious meals) and fire protection (e.g., safety and evacuation plans). The average number of citations and resulting fines were higher in for-profit communities than in non-profit/government communities.

Worse Quality at For-Profit Assisted Living Facilities in Non-Urban Minnesota

February 1, 2024 by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study examined the results of licensure surveys for 292 AL communities in non-urban Minnesota between 2021 and 2023. All AL communities received at least one citation, with an average of 15 citations. Citations were most commonly related to meals (e.g., not providing nutritious meals) and fire protection (e.g., safety and evacuation plans). The average number of citations and resulting fines were higher in for-profit communities than in non-profit/government communities.

Accelerometer-Measured Physical Activity and Posture among Older Adults in Assisted-Living Residences

Jan 1, 2024

WHAT THIS MEANS FOR YOU: A total of 35 Japanese AL residents had their physical activity tracked and were then divided into 3 groups based on how much help they needed for daily tasks, based on a previously validated index: fully independent, requiring minimal assistance, and requiring care. Fully independent residents walked an average of 3,587 steps per day, those requiring minimal assistance walked 1,681, while those needing care walked 429 steps. Amount of time spent upright and amount of time spent standing were lower for participants who required assistance and care. Lying down for long periods was associated with preexisting diagnoses of depression.

Accelerometer-Measured Physical Activity and Posture among Older Adults in Assisted-Living Residences

January 1, 2024 by Lea Efird-Green

WHAT THIS MEANS FOR YOU: A total of 35 Japanese AL residents had their physical activity tracked and were then divided into 3 groups based on how much help they needed for daily tasks, based on a previously validated index: fully independent, requiring minimal assistance, and requiring care. Fully independent residents walked an average of 3,587 steps per day, those requiring minimal assistance walked 1,681, while those needing care walked 429 steps. Amount of time spent upright and amount of time spent standing were lower for participants who required assistance and care. Lying down for long periods was associated with preexisting diagnoses of depression.

A Collaborative Approach to Improving Care Outcomes for Residents in Assisted Living

Jan 1, 2024

WHAT THIS MEANS FOR YOU: A longitudinal study of 50 residents and 119 care partners in 8 AL communities in Georgia over 2 years examined the concept of a “care convoy” (a dynamic network of formal and informal care partners) for AL residents. This model was supported by formal and informal interviewing, participant observation, and record review. The model is recommended for use by physicians and other healthcare providers to assist them in supporting the needs and goals of the residents and their care convoys, which is theorized to achieve better care outcomes.

A Collaborative Approach to Improving Care Outcomes for Residents in Assisted Living

January 1, 2024 by Lea Efird-Green

WHAT THIS MEANS FOR YOU: A longitudinal study of 50 residents and 119 care partners in 8 AL communities in Georgia over 2 years examined the concept of a “care convoy” (a dynamic network of formal and informal care partners) for AL residents. This model was supported by formal and informal interviewing, participant observation, and record review. The model is recommended for use by physicians and other healthcare providers to assist them in supporting the needs and goals of the residents and their care convoys, which is theorized to achieve better care outcomes.

Resident and Caregiver Dyads Talk About Death and Dying in Assisted Living: A Typology of Communication Behaviors

Jan 1, 2024

WHAT THIS MEANS FOR YOU: Interviews and fieldnotes from 15 resident-family caregiver dyads in 3 Atlanta AL communities found that conversations about death and dying were conducted in four patterns: open discussions (both partners were talking with each other about death), blocked conversations (one partner wanted to talk about death, but the other did not), avoidance due to assumptions (each partner perceived that the other did not want to talk about death), and inability to engage in conversations due to cognitive decline or strained relationships. While 60% of residents wanted to talk about end-of-life, caregivers often avoided it.

Resident and Caregiver Dyads Talk About Death and Dying in Assisted Living: A Typology of Communication Behaviors

January 1, 2024 by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Interviews and fieldnotes from 15 resident-family caregiver dyads in 3 Atlanta AL communities found that conversations about death and dying were conducted in four patterns: open discussions (both partners were talking with each other about death), blocked conversations (one partner wanted to talk about death, but the other did not), avoidance due to assumptions (each partner perceived that the other did not want to talk about death), and inability to engage in conversations due to cognitive decline or strained relationships. While 60% of residents wanted to talk about end-of-life, caregivers often avoided it.

Practitioner Burnout and Productivity Levels in Skilled Nursing and Assisted Living Facilities, Part 1: A Descriptive Quantitative Account

Jan 1, 2024

WHAT THIS MEANS FOR YOU: When 366 AL and NH therapy practitioners (occupational therapists, physical therapists, speech-language pathologists, and occupational/physical therapy assistants) across the US were surveyed, results showed that 21% of practitioners were burned out, with high levels of emotional exhaustion and depersonalization (unfeeling and impersonal response towards service recipients), and reduced personal accomplishment (feelings of competence in one’s work) on the Maslach Burnout Inventory. There were statistically significant relationships between high productivity demands and burnout, as well as between high productivity demands and engaging ethically questionable service behaviors.

Practitioner Burnout and Productivity Levels in Skilled Nursing and Assisted Living Facilities, Part 1: A Descriptive Quantitative Account

January 1, 2024 by Lea Efird-Green

WHAT THIS MEANS FOR YOU: When 366 AL and NH therapy practitioners (occupational therapists, physical therapists, speech-language pathologists, and occupational/physical therapy assistants) across the US were surveyed, results showed that 21% of practitioners were burned out, with high levels of emotional exhaustion and depersonalization (unfeeling and impersonal response towards service recipients), and reduced personal accomplishment (feelings of competence in one’s work) on the Maslach Burnout Inventory. There were statistically significant relationships between high productivity demands and burnout, as well as between high productivity demands and engaging ethically questionable service behaviors.

Home Time and State Regulations Among Medicare Beneficiaries in Assisted Living Communities

Dec 1, 2023

WHAT THIS MEANS FOR YOU: A study of “home time" (days alive and not in healthcare institutions such as hospitals or skilled nursing facilities) of over 59,000 Medicare beneficiaries who transitioned into assisted living in 2018 found that residents spent 94% of their first year at home in the community. Characteristics associated with lower home time included dual Medicare-Medicaid eligibility, having more chronic conditions, and specific conditions (e.g., dementia). Additionally, in states with more specific regulations for direct care worker staffing and training, and lower specificity for staff licensing requirements, residents tended to spend more time at home. Thus, both individual characteristics and state regulations may impact home time for new assisted living residents.

Home Time and State Regulations Among Medicare Beneficiaries in Assisted Living Communities

December 1, 2023 by Lea Efird-Green

WHAT THIS MEANS FOR YOU: A study of “home time” (days alive and not in healthcare institutions such as hospitals or skilled nursing facilities) of over 59,000 Medicare beneficiaries who transitioned into assisted living in 2018 found that residents spent 94% of their first year at home in the community. Characteristics associated with lower home time included dual Medicare-Medicaid eligibility, having more chronic conditions, and specific conditions (e.g., dementia). Additionally, in states with more specific regulations for direct care worker staffing and training, and lower specificity for staff licensing requirements, residents tended to spend more time at home. Thus, both individual characteristics and state regulations may impact home time for new assisted living residents.

Characteristics and End-of-Life Care Pathways of Decedents From a National Cohort of Assisted Living Residents

Dec 1, 2023

WHAT THIS MEANS FOR YOU: Medicare data from 2017 to 2020 for nearly 270,000 individuals from larger AL communities (25+ beds) found that about 35% of residents died during the study period, most often those 85 or older or with dementia. Most residents stayed in assisted living until their last year of life, but almost 20% left before their last month of life. Among those who lived in the community 30 days before death, nearly half died at the community without any healthcare transition, while over 13% had 3 or more healthcare transfers before death. Due to the prevalence of residents dying while in residence in assisted living, end-of-life practices and policies should be evaluated.

Characteristics and End-of-Life Care Pathways of Decedents From a National Cohort of Assisted Living Residents

December 1, 2023 by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Medicare data from 2017 to 2020 for nearly 270,000 individuals from larger AL communities (25+ beds) found that about 35% of residents died during the study period, most often those 85 or older or with dementia. Most residents stayed in assisted living until their last year of life, but almost 20% left before their last month of life. Among those who lived in the community 30 days before death, nearly half died at the community without any healthcare transition, while over 13% had 3 or more healthcare transfers before death. Due to the prevalence of residents dying while in residence in assisted living, end-of-life practices and policies should be evaluated.

Measuring Older Adults’ Wellbeing When Transitioning into Assisted Living Facilities: A Confirmatory Factor Analysis of the Mueller Assessment of Transition (MAT)

Dec 1, 2023

WHAT THIS MEANS FOR YOU: A study of the Mueller Assessment of Transition (MAT) tool in108 older adults in the U.S. who were transitioning into assisted living communities found that the MAT effectively measured wellbeing impact across regions and was internally consistent. Results suggests that the MAT could be a valuable tool for assessing the wellbeing of older adults during the transition to assisted living.

Measuring Older Adults’ Wellbeing When Transitioning into Assisted Living Facilities: A Confirmatory Factor Analysis of the Mueller Assessment of Transition (MAT)

December 1, 2023 by Lea Efird-Green

WHAT THIS MEANS FOR YOU: A study of the Mueller Assessment of Transition (MAT) tool in108 older adults in the U.S. who were transitioning into assisted living communities found that the MAT effectively measured wellbeing impact across regions and was internally consistent. Results suggests that the MAT could be a valuable tool for assessing the wellbeing of older adults during the transition to assisted living.

Older Adults’ Experiences of Participation in Daily Activities in Swedish Assisted Living

Nov 1, 2023

WHAT THIS MEANS FOR YOU: Eleven older adults interviewed in two assisted living communities in Sweden reported their feelings regarding participation and decision-making in daily activities, such as routine personal and medical care. In a qualitative analysis, residents actively participating in these activities reported they led to feelings of happiness, connection, involvement and safety. However, the organization and work environment dictated the ability of care and nursing staff to involve residents in daily activities, a challenge of which the residents were also aware.

Older Adults’ Experiences of Participation in Daily Activities in Swedish Assisted Living

November 1, 2023 by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Eleven older adults interviewed in two assisted living communities in Sweden reported their feelings regarding participation and decision-making in daily activities, such as routine personal and medical care. In a qualitative analysis, residents actively participating in these activities reported they led to feelings of happiness, connection, involvement and safety. However, the organization and work environment dictated the ability of care and nursing staff to involve residents in daily activities, a challenge of which the residents were also aware.

Effect of Immersive Virtual Reality Reminiscence versus Traditional Reminiscence Therapy on Cognitive Function and Psychological Well-being among Older Adults in Assisted Living Facilities: A Randomized Controlled Trial

Nov 1, 2023

WHAT THIS MEANS FOR YOU: A study of 60 assisted living residents observed the effects of virtual reality reminiscence and traditional reminiscence therapy on residents’ cognitive function and psychological wellbeing. Compared to a control group, there was a statistically significant increase in cognition and psychological wellbeing in both the reminiscence groups.

Effect of Immersive Virtual Reality Reminiscence versus Traditional Reminiscence Therapy on Cognitive Function and Psychological Well-being among Older Adults in Assisted Living Facilities: A Randomized Controlled Trial

November 1, 2023 by Lea Efird-Green

WHAT THIS MEANS FOR YOU: A study of 60 assisted living residents observed the effects of virtual reality reminiscence and traditional reminiscence therapy on residents’ cognitive function and psychological wellbeing. Compared to a control group, there was a statistically significant increase in cognition and psychological wellbeing in both the reminiscence groups.