According to the model of person-environment fit (P-E fit), older adults are at risk for poor outcomes when the demands and resources available in the environment are no longer in balance with the individual's everyday competence (the ability to solve problems associated with everyday life). It has been estimated that 29% of Community Living Center (CLC;VA nursing homes) residents may not require nursing home levels of care and could safely reside in the community with appropriate rehabilitative services. In VA, a major focus is to minimize time in CLCs by providing rehabilitation and transitioning Veterans to the community. CLC staff and Veterans face barriers to facilitating these transitions (e.g., caregiving needs, housing, etc.). N standardized process exists to assure that treatment planning includes processes to maximize P-E fit. The objective of this study is to develop a toolkit the CLC interdisciplinary team can use to 1) assess the Veteran's everyday competence;2) develop personally meaningful rehabilitation goals based on everyday competence;and 3) conduct structured treatment planning to support resident goals around transitions back into the community. Acknowledging that even the most effective intervention is worthless if no one actually uses it, we propose a three-phase research process: Understand ? Develop ? Trial. Phase 1 (Understand) focuses on gaining an understanding of the current environment, discharge planning processes, and outcomes in CLCs.
In Aim 1 a, we will use administrative data to examine outcomes and predictors of successful/unsuccessful transitions among CLC residents.
Aim 1 b employs qualitative interviews, to understand the current barriers and facilitators to transitioning CLC residents, identify everyday scenarios residents face, and collect staff suggestions for appropriate goal-setting domains.
For Aim 1 c, we will use field observation to understand the workflow, relationships, and interactions between members of the interdisciplinary team during transition planning. Phase 2 (Develop) will use information gathered in Phase 1 to develop the Everyday Competence Assessment and Planning for Community Transitions (ECAP-CT) toolkit components, including rehabilitation goal-setting domains and creation of a structured manual to guide the CLC interdisciplinary team through the assessment, goal-setting, and treatment planning steps. Phase 3 (Trial) will be a quasi-experimental effectiveness trial of the ECAP-CT toolkit in the Houston (n=30 residents) and Tuscaloosa (n=30 residents) VA CLCs. The toolkit will be implemented sequentially in the two sites allowing for adaptation. Our primary outcome is transition outcome (successful/not successful), which will be compared to concurrent administrative data gathered from two matched comparison sites (n=60). We will conduct an exploratory cost-effectiveness analysis of the toolkit compared to usual care within the context of this trial. The PI's overall career aim is to become an independent rehabilitation researcher with expertise in developing and testing interventions targeting the needs of CLC residents, maximizing autonomy, independence, and function. Long-term, her career goals include developing strategies for assessment of everyday competence among CLC residents, setting resident-directed goals, and developing care plans to transition Veterans back into the community. The CDA-2 mentoring team includes established VA researchers with expertise in vulnerable older adults, assessing everyday competence, intervention development and evaluation, and long- term care transitions. With the guidance of the mentoring team, areas that would benefit from additional training have been identified The training aims outlined in this CDA-2 award will provide additional experience in these areas: 1) evaluation of patient-centered interventions, including cost-effectiveness and psychometrics methodology;2) intervention development;3) experience and knowledge of VA rehabilitation services;and 4) submission of a RR&D Merit Review Award. These objectives will be achieved through mentoring and attending seminars, formal courses, and conferences.

Public Health Relevance

Older adults prefer to live as in the community as long as possible. Creating a standardized treatment planning process that includes assessments of everyday competence and goal-setting techniques to help Veterans move from VA nursing homes back to the community can improve functional health, well-being, and quality of life for older Veterans. Research has shown that 29% of nursing home residents might be able to live safely in the community instead. Currently, VA provides nursing home care to more than 13,000 Veterans across the country, which costs about $3.3 billion a year. It is expensive for VA to provide nursing home care to these inappropriate residents and they are using limited resources that could be given to another Veteran with more urgent needs. The Everyday Competence Assessment and Planning for Community Transitions (ECAP-CT) toolkit will help these Veterans to move back into the community with the services and supports they need based on their individual level of everyday competence.

National Institute of Health (NIH)
Veterans Affairs (VA)
Veterans Administration (IK2)
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Michael E Debakey VA Medical Center
United States
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Mills, Whitney L; Pimentel, Camilla B; Palmer, Jennifer A et al. (2018) Applying a Theory-Driven Framework to Guide Quality Improvement Efforts in Nursing Homes: The LOCK Model. Gerontologist 58:598-605
Harrison, Jill; Tyler, Denise A; Shield, Renée R et al. (2017) An Unintended Consequence of Culture Change in VA Community Living Centers. J Am Med Dir Assoc 18:320-325