Philip D. Sloane’s research while affiliated with University of North Carolina at Chapel Hill and other places

Accreditation is a widely used health care review process to determine if an organization meets a defined standard of quality. The opportunity for accreditation recently moved into the field of assisted living (AL); today, seven states have statutes and regulations allowing third party accreditation to satisfy full or partial compliance with state licensure or certification. Data indicate that compliance with accreditation standards may result in improved care, but it has not been evaluated in AL. In 2021, the state of North Carolina funded an AL accreditation pilot program to evaluate whether accreditation improves or maintains quality. Communities were randomly allocated to a control or accreditation arm and are being followed for two years to evaluate care and outcomes in five areas (workforce, resident outcomes, care coordination and transitions, medication management, person-centered care). Of the 146 communities originally enrolled that provided data, most are for-profit (96%) and part of a chain (73%); 44% pf residents have dementia, 25% have mental illness, and 53% receive state financial assistance. Preliminary results in the first two quarters (Q) found an overall increase in advance care planning discussions (53% in Q1 and 63% in Q2), and a decrease in medication administrations with one or more errors (1.2% in Q1 and 0.6% in Q2). This session will present results comparing communities in the control arm, accreditation arm, and those that successfully achieved accreditation, with findings having wide-ranging implications for the future of AL accreditation and regulation in North Carolina, and implications across the country.

The concept of person-centeredness (PC) has become commonplace in health and supportive care, and perhaps for this very reason, there is no agreed upon understanding as to what constitutes “person-centeredness.” To clarify the concept, a systematic review of current definitions of PC in the literature was conducted; it revealed that most papers referencing person-centered or patient-centered interventions do not define the term, and that definitions that when they do, they vary widely. Given the benefit of having a common understanding of PC, think-tank meetings were held with 65 experts in the fields of health and aging policy, research, and practice. The experts were provided numerous prompts (e.g., in the context of being person-centered, how do issues of dependency and competency enter in?); responses indicated that they conceptualize and implement the concept of PC differently at the macro, meso, and micro levels. At the macro level, there is a focus on core values, the influence of privilege and oppression, and how PC is implemented – or not – in systems and cultures. On the meso level, there is a focus on organizational responsibility, the applicability of PC to various communities, and the importance of relationships. On the micro level, PC is focused on care, including individualization and personalization, the importance of care partners/family, and the limitations of PC in individual settings. This presentation will address the three levels of PC, including each level’s focus, implementation, and challenges, with the goal of establishing a multilevel conceptualization of PC.

Systems perspectives generally identify three levels of action: the interpersonal (micro) level, the institutional (meso) level, and the broader societal (macro) level. Person-centeredness is generally viewed at the interpersonal level, but especially in the context of health and supportive care, broader systems can shape and impact the quality and outcomes of these one-on-one interactions. To better understand how and why person-centeredness varies across health care settings (e.g., hospitals, nursing homes), we conducted interviews and convened think tank meetings with 31 diverse stakeholders including direct care workers, administrative staff, consumer advocates, and academic researchers focusing on care of older persons. Prompts asked examples of person-centeredness (or lack thereof) in numerous settings. The following themes were identified that help explain the wide range in person-centeredness across health care settings: 1) variation in system goals related to person-centeredness; 2) variation in systems’ perceived need to limit person-centered; 3) relationships between resource availability and person-centeredness; 4) cultural values and societal inequity as root causes of much variation in person-centeredness; and 5) influence on person-centeredness of the degree to which hospitality is a core value within a given system. Understanding and responding to these themes within a given setting may more effectively help meet resident needs and preferences; it also has implications for policymaking, such as creation of training guidelines for care staff and benchmarks for program leaders.

In 2021, the North Carolina Legislature approved and funded the Adult Care Home [Assisted Living] Accreditation Pilot Program. Across the state, the program’s goal is to evaluate the effectiveness of accreditation through quality outcome measures to determine whether accreditation achieves compliance with licensure requirements and improves or maintains quality of care compared to a control group. Assisted living communities were selected using stratified random sampling that accounted for geographic region and state-assigned quality rating. A total of 146 communities originally agreed to participate. Of the 73 communities randomly assigned to the accreditation arm, to date 39 (53%) either withdrew or chose to not go through the process of accreditation; 4 (5%) withdrew after beginning the accreditation process; 24 (33%) achieved accredited status; and 6 (8%) are delayed in completing the process or not likely to do so. The key reason for withdrawal from the accreditation process is the time and effort required in the context of staffing shortages, which has implications for long-range implementation even if accreditation is found to be beneficial. This session will present the aims and methods of the evaluation; the accreditation process itself (including benefits, potential administrative burden, and types of deficiencies found during surveys); the feasibility of becoming accredited for diverse participating communities; and potential strategies to bolster capacity for accreditation. (Additional contributors to this and the outcome presentation include Teresa Hoosier [ACHC], Jeff Horton [NCSLA], Frances Messer [NCALA], Barbara Sylvester [ACHC], and London Grantham, Aja Johnson, Danielle Owens, Toni Parker, and Katrice Perry [UNC].)

Almost 1.7 million people in the U.S. receive residential long-term care, more than half who reside in assisted living -- broadly defined as congregate settings that provide at least two meals a day, around-the-clock supervision, and help with personal care. Whereas nursing homes are federally regulated, assisted living is state regulated, which recognizes it as a community-based setting and allows for innovative practices and policies to promote better care and outcomes. Over the years, numerous state-based initiatives have been enacted across the country; this session will discuss new initiatives in two states, addressing their implementation, findings, and broad implications. Minnesota’s legislation recently created an online report card based on resident and family surveys; the presentation by Dr. Shippee will overview three years of data from more than 12,000 residents, noting the areas scored most favorably (e.g., environment) and least favorably (e.g., engagement). Dr. Moone will discuss the Minnesota assisted living regulatory framework and how the absence of broad representation in licensure development resulted in inconsistency in and preparation for survey inspections, as well as inadequate reimbursement. North Carolina recently undertook a statewide randomized trial of accreditation for assisted living; Ms. Efird-Green will discuss challenges implementing accreditation in more than half of the communities, and Dr. Zimmerman will present two years of outcome data comparing control and accreditation arms in relation to workforce and resident outcomes, care coordination and transitions, medication management, and person-centered care. Results will be put in context to inform quality initiatives across the country.

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 (LTC COPE) scale, this study evaluates the relationship of coping with staff demographic characteristics and outcomes; the findings can be used to develop and evaluate interventions to improve staff well‐being. METHODS We used a cross‐sectional online questionnaire completed by professional caregivers working in a purposive selection of 10 NHs and three AL communities in California, New York, and North Carolina. The sample included 391 professional caregivers and had a representative distribution by age; it was 87% female; 42% non‐Hispanic/Latinx (NHL) Black, 25% NHL White, 20% Hispanic/Latinx, and 7% NHL Asian. Worker job satisfaction, mental health, and health‐related quality of life were examined in relation to caregiver demographics and the following approaches to coping as measured by the LTC COPE: avoidance, adaptive psychological strategies, active engagement, maladaptive psychological strategies, minimizing emotional impact, and substance use. Statistical comparisons used non‐parametric Spearman correlation coefficients. RESULTS Little difference in coping strategies was noted by sex and education; older caregivers used adaptive psychological strategies more than younger caregivers; and traditionally minoritized adults (NHL Black, NHL Asian, and Hispanic/Latinx), compared to NHL White adults, more often used adaptive and less often used maladaptive psychological coping strategies. The use of maladaptive and avoidance strategies was strongly associated with depressive symptoms, anxiety, and burnout. DISCUSSION Professional caregivers report using a wide variety of coping strategies, with multiple strategies being the norm, and both adaptive/engaged and maladaptive/disengaged approaches are common. Certain coping approaches are strongly linked to depression, anxiety, and burnout; attention to training and support of adaptive and positive coping may augment other efforts to improve job satisfaction and performance. The LTC COPE scale has the potential to guide and evaluate practices to improve workers’ well‐being. Highlights Professional caregivers in nursing homes and assisted living generally use multiple strategies to cope with work‐related stress. Certain coping approaches are strongly linked to depression, anxiety, and burnout. The Long‐Term Care Cope scale has potential to guide and evaluate practices to improve worker well‐being.

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 appropriate for the diverse professional caregiver workforce. METHODS A multistage process identified and refined existing and new items. Ten racially and ethnically diverse professional caregivers advised on item selection and refinement. Subsequently, using an online QR code‐accessed questionnaire, data were collected from 391 professional caregivers from 10 NHs and 3 AL communities in three states, yielding a sample that was 87% female, widely distributed in age and experience, and racially/ethnically diverse (42% Black, non‐Hispanic/Latinx; 25% White, non‐Hispanic/Latinx; 20% Hispanic/Latinx; 7% Asian, non‐Hispanic/Latinx; and 21% born outside the United States). Analyses examined psychometric properties and principal components analysis identified factors within which items and scales aggregated. RESULTS The final instrument, named the Long‐Term Care Cope (LTC Cope), includes 26 items aggregated into six factors, which explained 60% of the variance: avoidance (five items, loadings 0.58–0.76); adaptive psychological strategies (six items, loadings 0.33–0.89); active engagement (five items, 0.47–0.89); maladaptive psychological strategies (three items, loadings 0.90–0.93); actions to minimize emotional impact (four items, loadings 0.28–0.74); and substance use (three items, loadings 0.61–0.88). Respondents often reported using multiple items within multiple factors when responding to stressful situations at work. DISCUSSION The coping strategies of professional caregivers are highly individual, with caregivers tending to utilize multiple strategies. The LTC Cope instrument and its component subscales are promising for future research to improve understanding of stress‐related coping in this diverse workforce and inform and evaluate interventions. Highlights A new measure was developed to help us better understand how professional caregivers (nursing assistants and personal care aides) deal with work‐related stress. Professional caregivers in nursing homes and assisted living tend to use multiple approaches to deal with job stress. Ways professional caregivers cope with stress vary widely—some address problems directly, some try to deal with the emotional toll of the work, and others involve avoiding the problems or their emotional consequences.

Background and Objectives A better understanding of factors associated with assisted living admission and discharge practices can help identify communities that are more likely to allow residents to age in place. This study examined how state regulations and assisted living organizational characteristics relate to community admission and discharge practices for bathing, getting out of bed, and feeding. Research Design and Methods Using data from a representative sample of 250 assisted living communities in 7 states and a database of assisted living state regulations, we employed multilevel logistic regression models to examine regulatory and organizational correlates of assisted living community admission and discharge practices for three activities of daily living (ADLs [bathing, getting out of bed, and feeding]). Results States’ regulations were not associated with assisted living community admission and discharge practices. However, assisted living communities above the median in the number of personal care staff members per resident were 17% (95% CI: 6.5%, 27.1%) were more likely to admit residents who needed assistance with feeding and 25.5% (95% CI: -37.7, -13.2) less likely to discharge these residents. For-profit communities were more likely to admit residents with bathing and feeding limitations. Discussion and Implications Organizational characteristics (e.g., for-profit affiliation, staffing levels) may in part drive admission and discharge practices, especially related to different care needs. The ability to house residents with advanced care needs may be influenced more by the organizational resources available to care for these residents than by states’ admission and discharge regulations.