redesigning dementia care an evaluation of small-scale, homelike care environments dr. hilde verbeek...

Redesigning dementia careAn evaluation of small-scale, homelike care

environmentsdr. Hilde Verbeek

Research program ‘Innovation in care for the elderly’

Department of Health Care and Nursing Science

Acknowledgements

Financing:• CAPHRI, Maastricht University• Province of Limburg• MeanderGroep, Orbis, Sevagram, Vivre

and De Zorggroep

Research team:• Supervisors: Prof. dr. JPH Hamers

Prof. dr. GIJM Kempen

• Co-supervisors: Dr. E van Rossum Dr. SMG Zwakhalen


Today’s objectives

• Institutional care for people with dementia– Traditional nursing homes– Innovative care

• Small-scale, homelike care environments

• PhD research – Evaluation of small-scale, homelike care environments

• Process evaluation: experiences of family and nursing staff• Effectiveness study: design and main results

• Conclusions and implications


Dementia

• Symptoms:– Global cognitive and functional decline– Behavioral and psychological symptoms

• 1 out of 5 people will develop dementia– Approximately 235.000 people have dementia in the

Netherlands at this moment

• About 1/3 requires institutional nursing care


Traditional nursing homes

• Originally based on ‘medical model of care’:– Hospital-like, large wards, long corridors– Routines of the organization mainly determine daily life


Change in care concept

• From traditional medical models of care- Emphasis on disability - Focus on pathology

Towards

• Psychosocial models of care

- Quality of life and wellbeing- Autonomy, enabling own life style


Small-scale homelike facilities

• General characteristics:– Small resident group (6-7)

– Familiar, homelike environment– Joint daily household

– Integrated tasks nursing staff

• Worldwide several similar concepts (Verbeek et al. 2009. Int Psychogeriatr, 21: 252-264)


Motivation project

• The Netherlands: Strong increase of small-scale, homelike facilities– Stimulated by Dutch government (€80 million program)– Its number has doubled over the past five years– Currently ± 25% small-scale, homelike facilities in

institutional dementia care

• Hardly any knowledge on effects of small-scale, homelike facilities


Research questions

• What are experiences with small-scale, homelike facilities?

• What are the effects of these facilities on…– …residents’ quality of life and behavior?

– …family caregivers’ burden, involvement and satisfaction with care?

– …nursing staff’s job satisfaction and motivation?


Experiences

• In-depth interviews with family caregivers and nursing staff (n=24)

• Mainly positive experiences:– Personal attention– Involvement of nursing staff– Autonomy in daily life

• Important barrier:– Nursing staff work alone during a large part of the day


Effect study: design

28 units in small-scale facilities 21 regular wards

Screening and selection of residents

Baseline measurement

Follow-up at 6 months


Baseline measurement


Follow-up at 12 monthsVerbeek et al. 2009. BMC Geriatr, 9:3


Participants

• Residents (n=259)– Dementia diagnosis– Matching based on cognitive and functional status to

increase comparability of groups at baseline

• Family caregivers (n=206)– One main family member providing informal care

• Nursing staff (n=305)– All nursing staff (i.e. aids, certified assistants and registred

nurses) working on a permanent basis


ResidentsCharacteristics and primary outcomes:

quality of life and behavior


Residents’ characteristics Small-scale Regular Ward Residents n = 124 n = 135 Age (years) 82.4 (7.9) 83.1 (6.5) Women, % 99 (80) 95 (70) Living condition prior to admission* At home Other institution / unknown

37 (30) 87 (70)

80 (59) 55 (41)

Length of Stay, months† 15.7 (11.3) 24.4 (22.0) Dementia type Alzheimer’s Disease Vascular Dementia Other Not Otherwise Specified / unknown

33 (27) 19 (15) 20 (16) 52 (42)

44 (32) 24 (18) 27 (20) 40 (30)

Stage of dementia 5.3 (1.1) 5.1 (1.0) Cognition 11.1 (7) 10.5 (6.6) Activities of Daily Life 3.1 (1.7) 3.3 (1.4) Comorbid diseases 4.3 (2.3) 3.8 (1.9)

Matching successful


Quality of life

• No effect on total quality of life

• Differences on only two subscales– Residents in small-scale living facilities had more to do but also

showed more negative affect

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Behavior

• No effect on total neuropsychiatric symptoms

• Residents in small-scale facilities display more physically non-aggressive behavior after 12 months

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Family caregiversPrimary outcomes:

Cargiver burden, involvement and satisfaction with care


Caregiver burden

• Significant group effect on caregiver burden– Family caregivers in small-scale facilities experience less

burden– Differences are present at baseline and remain stable over

time

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Involvement and satisfaction with care

• No effects for family involvement with care– Frequency and length of visits– Number of activities during visit

• Group effect for satisfaction with nursing staff– Family caregivers in small-scale facilities are more

satisfied with nursing staff contact

• No effects on satisfaction with resident contact


Nursing staffPrimary outcomes:

job satisfaction and motivation


Job satisfaction and motivation

• No effects for job satisfaction and job motivation in total group of participants– No differences in mean scores at all measurements

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Job satisfaction Job motivation


Conclusion

• Unable to demonstrate convincing effects for primary outcome measures (Verbeek et al. 2010. JAMDA, 11: 662-670)

• Despite positive experiences, small-scale homelike facilities are not necessarily better care environments – Other options should be carefully considered


Implications for practice

• Automatic transition towards small-scale homelike care environments is not recommended – Focus should be on care program and scalability

• Changing role of nursing staff: adequate training and education of staff is essential– Knowledge and skills– Attitude towards care


Societal impact: debateNRC Handelsblad, Dec 2010


Implications for research

• Small-scale homelike facilities have encouraged development of new care concepts– Which elements are effective, for whom and how are

effects exerted?– Which and how can active ingredients be transferred to

other dementia care settings as well?

• Need for cost-analyses


Thank you

[email protected]


Assessment criteria in daily practice• Observation questionnaire (range 18-90)

Regular Wards(n=21)

Small-scale living(n=28 houses)

Mean = 42.3Range 36-55

Mean = 67.6Range 60-77

redesigning dementia care an evaluation of small-scale, homelike care environments dr. hilde verbeek...

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