Quality Improvement in Senior Living: The Need for Objective Data

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Quality Improvement in Senior Living: The Need for Objective Data Sandra F. Simmons, Vanderbilt University Medical Center Chris Coelho, Abe’s Garden Beverly Sanborn, Belmont Village

Disclosures • Consultant for Abe’s Garden and Belmont Village - Staff training, management and quality improvement protocols (Abe’s Garden, Chris Coelho) - Program evaluation (Belmont Village, Beverly Sanborn)

Objectives • To describe the usefulness of objective data to: 1) Assess the quality of daily care provision 2) Evaluate and improve programs 3) Inform on-going quality improvement efforts Panelists: Chris Coelho and Beverly Sanborn

What does ‘Objective Data’ mean? • Standardized, performance-based assessments: Cognition: Brief Interview for Mental Status (BIMS) , Montreal Cognitive Assessment (MoCA), Mini Mental Status Exam (MMSE) Physical Function: 6-Meter Walk, Get-Up-and-Go, Handgrip Strength • Standardized Resident Interviews: Depression: Geriatric Depression Scale (GDS), Patient Health Questionnaire (PHQ9) • Standardized Observations: of staff (routines, care delivery, care quality) and residents (sleep/wake patterns, behavioral disturbance, refusals)

What is NOT ‘Objective Data’? • Staff self-report (estimation of residents’ care needs) e.g., Staff checklist of activities the resident needs help with each day • Staff documentation (of care delivery) Usually not required for most aspects of daily care and/or minimal information • Informal ‘walk-through’ observations by supervisors

Each of these approaches may have value but NOT in isolation

What is NOT ‘Objective Data’? WHY NOT? • Staff Report: Variability between staff in amount and quality of care provision - One aide encourages independence and one doesn’t • Documentation: Bias toward documenting more care than what is provided - Document care consistent with care plan and/or intent • Informal Observations: Variability between supervisors – subjectivity yields biased view - How often does it happen? How many residents are affected? What other factors may be contributing to the problem?

Why do we need data in Assisted Living? • Assisted-Living as an alternative care setting for those with dementia: - 72% of ALFs offer dementia care services - 22% of ALFs have distinct dementia care units/neighborhoods

- 42% of residents have a dementia diagnosis - 74% of residents require staff assistance with 1 or more ADLs

Why do we need data in Assisted Living? • ALF residents have become comparable to nursing home residents in risk for: - Functional decline - Falls - Polypharmacy - Hospitalization and ER visits Thus, concerns about care quality and resident safety are similar • Significant variability both within and between states in ALF care services and resident populations

Why do we need data in Assisted Living? • Many ALFs offer care services “a la carte” such that any routine assessments are used primarily for determination of care needs and billing of services • However, objective data also can be used to: - Educate families about what to expect, when a care transition is necessary - Evaluate potential benefits of programs - Evaluate suitability of programs for those with varying stages of dementia - Assess care quality among care providers - Identify aspects of care and/or programs for quality improvement efforts - Identify management strategies to support care delivery

Usefulness of Objective Data: Examples from Two ALF Dementia Care Settings • Beverly Sanborn, Belmont Village, Circle of Friends Program: - Evaluate potential benefits of programs - Identify aspects of program implementation in need of improvement • Chris Coelho, Abe’s Garden: - Assess care quality among care providers - Identify aspects of care for quality improvement efforts - Identify management strategies to support care delivery

Abe’s Garden Alzheimer’s and Memory Care Center of Excellence

Graduated from Vanderbilt University Medical School

Established one of Nashville’s first racially integrated practices in an underserved community

Battled Alzheimer’s for 11 years

Mother and sister also died from Alzheimer’s disease

Lived in five different care facilities

Woodbine Clinic, Southeast Nashville, 1966

Through observation and data analysis, identify systems requiring improvement

Provide immediate feedback to staff following observation

Create weekly and monthly management summaries of observations and care documentation

Continuous Quality Improvement Process Identify System to Improve

Increased Observations

Immediate Feedback and Discussion


Continuous Maintenance Observations

Data Summary and Analysis

Nutrition Program: Environment and Service Home-like kitchen and dining area in each neighborhood Pleasant lighting

Enjoyable music Aroma of food preparation

Attractive presentation Menu options Serving time options

Objective Standardized Observations Weekly observations across meals and households Systematic approach to scheduling observations Consistent data points tracked over time Ability to document multiple data points to identify root causes

Summarizing Data First 3 Months of Observations:

20-33% of residents were not receiving adequate assistance to promote meal consumption

18-27% of residents were not offered snacks between meals

Using Data For Staff Management, Training and Quality Improvement Weekly training huddles Brief (10 minute sessions) Held in each household Improvements: Individualized assistance for specific residents Residents in need of assistance seated together Assigned staff to sit with residents throughout the meal Assigned staff to snack pass twice/day High calorie snacks prepared for those with weight loss Standard alternatives made readily available

Outcomes of Continuous Quality Improvement • Observations reveal extent of improvements and maintenance • Variability remains by: • Meal/Snack Period • Household • Month

• Intermittent observations support continuous quality improvement

Outcomes of Continuous Quality Improvement Observations of Meals/Snacks helps to prevent weight loss Identify residents at risk for loss for earlier intervention Informs changes in Care Practices (Dietary/Kitchen service, Care Partner Assignments, Resident preferences)

Other Areas this System is Applied - Activity Engagement

Other Areas this System is Applied - Activities of Daily Living Quality

CIRCLE OF FRIENDS A DATA-DRIVEN PROGRAM How Evidence-Based Data Is Used to Create and Update A Constantly Evolving Whole Brain Fitness Program Belmont Village Senior Living

PARADIGM SHIFT IN ASSISTED LIVING: Leisure vs. Therapeutic • Therapeutic activities are based on science 3 B’s of the Leisure Life Typical Activities • Bingo • Ball Toss • Bible

3 C’s of the Purposeful Life Typical Activities • Creativity • Challenge • Cognitive Reserve

Snapshot of Circle of Friends o Cognitive scores in mild to moderate dementia range o Research-based Therapeutic Whole Brain Fitness Program o 8-hour, 7 day-a-week group activities of whole brain fitness o Corporate calendar ensures quality, 6 domains, & Just Right Challenge o Groups consist of 12-16 residents o Certified Enrichment Leaders o Bi-annual program evaluation of cognition, participation, medication & behaviors o Tracking & trending of outcomes for QA and program improvements

Physical Mental Social Nutrition

The Six Domains of a Mental Workout GOAL: To enhance short and long term memory; judgment; sequencing skills; problem-solving skills; speed of processing and verbal skills Critical Thinking

Step-by-Step Sequencing

Memory-Body Movement

Learn Something New

Long-Term Memory

Analytic Solutions

Belmont Circle of Friends Company-Wide • 8 YEARS in the making: 3 ITERATIONS • ESTABLISHED in all 24 buildings

• SERVING 499 residents • CONTROLS are a sample of 176 AL residents who are Circle Eligible but did not enroll in the program

Objective Data Objective Data Collection: • Medications: Psychotropics, Anti-anxiety, Anti-Depressants, Dementia • Cognition: MMSE, MOCA, Clock Drawing Test, Animal Naming • Depressive Symptoms: Geriatric Depression Scale-15 item • Activity Participation: Belmont Scale

• Problem Behaviors: Cohen-Mansfield

Translating MMSE into MoCA Scores: standardized on 675 Residents MMSE Average = 21

MoCA Average = 17

29 – 30 NO dementia 26 – 28 MCI Mild Cognitive Impairment

26 to 30 NO dementia 24 to 25 MCI Mild Cognitive Impairment

20 – 25 Mild Dementia

15– 22 Mild Dementia

18 – 19

13 – 14 Moderate Dementia

Moderate Dementia

Age and Mental Status: COF and Controls (MoCA 13+)

Medications and Behaviors: COF and Controls

Quality of Life: Percent of Day Awake and Engaged in Purposeful Activity: COF and Controls Quality of Life Metrics 90%









0% Percent of Day Spent Awake

Percent of Day Spent Engaged in Purposeful Activity Circle of Friends

Control Group

Percent of Residents That Met Standard for Activity Participation: COF and Controls

Participation Standard: Residents in purposeful activities at least 4 hours per day

Percent of Buildings Whose Residents Met Standards for Activity Participation & Cognitive Maintenance

Participation Standard: 75% or more residents in purposeful activities at least 4 hours per day Cognitive Standard: 50% or more residents declined no more than 1 point in 3 out of 4 tests


The Right Staff and the Right Training The Right Staff

The Right Training Dynamic Video


• Aptitude

• Education • Enthusiasm • Imagination

• World View

Mentoring Certification

The Right Program: Most Important is Exercising The Frontal Lobe

You need daily exercise of your frontal lobe, which gives you: •REASONING •JUDGMENT •PROBLEMSOLVING

The Right Program

Mind-Body Exercise

Long-Term Memory

Analytical Solutions

Questions and Contact Information • Sandra Simmons, PhD, Vanderbilt Center for Quality Aging www.VanderbiltCQA.org Sandra.Simmons@Vanderbilt.edu O: 615-343-6729 • Chris Coelho, Abe’s Garden: www.AbesGarden.org ccoelho@abesgarden.org O: 615-997-3033

• Beverly Sanborn, MSW, Belmont Village: www.BelmontVillage.com bsanborn@belmontvillage.com O: 858-829-5380

Questions? Argentum 1650 King Street, Suite 602 Alexandria, VA 22314

(703) 894-1805

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