Factors Associated With Deficient Housing Among Community-Living Older Adults in the United States

Housing quality is a recognized social determinant of health. Qualitative evidence suggests the ability of older adults to maintain their homes is affected by the domains of financial resources, social environment, and functional abilities, but this conceptualization has not been tested quantitatively. This cross-sectional study examined associations between financial resources (indicated by socioeconomic characteristics: education, racial-status, annual income, financial hardship, Medicaid eligibility), social environment (living arrangement, social integration), and functional abilities (lower extremity performance, self-care disability, independent-living disability, homebound-status, dementia, depression) with deficient housing among 6,489 community-living adults ≥ 65 years participating in the nationally representative 2015 National Health and Aging Trends Study. Sampling weights accounted for study design and non-response. An estimated 9.2% (3.2 million) older Americans lived in housing with ≥1 deficiency (any peeling paint, evidence of pests, flooring in disrepair, broken windows, crumbling foundation, missing siding, or roof problems). In bivariate logistic regressions, factors from all three domains were associated with deficient housing. In a multivariable model that included all variables above and adjusted for age and sex, indicators of financial resources and social environment remained associated with deficient housing (including financial hardship, adjusted odds ratio (aOR)=1.48, 95% confidence interval (CI): 1.10,1.98; and living with non-spousal others versus alone, aOR=1.48; 95% CI:1.09, 2.03), whereas indicators of functional abilities did not. To ensure quality housing for all community-dwelling older adults, efforts that increase financial resources and further examine the role of social environment in deficient housing are needed.

Establishing a Dementia-Inclusive Community: The Evaluation of Dementia Friends in Cleveland Heights

Cleveland Heights, in northeast Ohio, is currently working towards becoming a member of the Dementia Friendly America National Network. Utilizing the Dementia Friends curriculum to raise community members’ awareness of issues related to dementia is a key component of this initiative. Our initial efforts toward this goal targeted two sectors, namely community member and libraries. Participants completed on-line surveys at the beginning and end of each session. The surveys include the Brief Tool for Dementia-Friendly Education and Training Sessions developed by the Administration for Community Living. Of the 22 participants, nine had not previously attended a Dementia Friends session and completed both pre- and post-session surveys. Results indicated participants felt more confident interacting with people living with dementia at post-session compared to pre-session (t = -2.83, p=.022). Changes at the individual level may create more inclusive communities for people living with dementia and those who care for and about them.

Residential Environment, Depressive Symptoms, and Anxiety Symptoms Among Community-Living Older Adults

Past literature has suggested significant relationships between neighborhood environment and mental health of older adults. However, the effect of residential environments is underexplored. The present study aims to study: (Q1) how residential built environments are associated with depressive and anxiety symptoms among community-living older adults, and (Q2) whether the associations of their physical and cognitive health status with mental health vary by residential environments. We analyzed data from Round 9 of National Health and Aging Trends Study. Residential environments were indicated by home despair, cluttered home, and existence of entrance ramp. Covariates included age, gender, race, living arrangement, ADL limitations, physical capacity, and cognitive status. The logistic regression results show that higher levels of clutter at home and the lack of entrance ramp were significantly associated with more depressive symptoms and that levels of clutter were positively associated with anxiety symptoms. Residential environments significantly moderated the association between physical health and mental health. With similar physical capacity, older adults with higher levels of home despair and clutter had more depressive and anxiety symptoms. Older adults who had more cluttered home reported significantly higher levels of anxiety than those who had similar ADL limitations, but lived in a less cluttered housing environment. However, we didn’t find any moderating effect of residential environments on cognitive impairment and mental health. Our findings promote the necessity for practitioners and policymakers to consider the effect of residential environments on mental health among both physically healthy and impaired older adults in the United States.

Distress Behavior Conversations: Supporting Whole Person Whole Team Responses in VA Community Living Centers

Resident distress behavior, a prevalent challenge in long-term care, contributes to resident morbidity, staff burden, and turnover. We describe an education model developed in the Veterans Administration (VA) Community Living Centers (CLC) through a CONCERT (VA CLCs’ Ongoing Center for Enhancing Resources & Training) quality improvement series. The Distress Behavior Conversation (DBC) uses a team meeting structure and process. Informed by unmet need and relational coordination theories, it guides the whole team, inclusive of interdisciplinary team members and front-line staff with resident contact, through a collaborative problem-solving action-planning discussion. DBC uses facilitated round-robins to identify potential resident behavior causes and individualized solutions. DBC supports the team in maintaining whole person and whole team mindsets, thus challenging the narrower medical model of discipline-specific clinical mindsets and staff level hierarchies. Over two years we have co-created and refined DBC through trainings and team debriefings with over 80 CLCs. Care teams reported “aha” moments during DBCs their thinking shifted (“we are now looking at the REAL why”; “we went from asking, how did he fall? to, why did he fall?; “tended to try to treat falls in a standardized way, [but] when you focus on a specific person you get to focus on HIS needs”; “personal information about the Veteran is the 5th vital sign!”). Teams additionally reported reduced strain and improved collaborative thinking (“I feel better about what I’m doing...more motivated to keep going!; “Now I see it is a team approach – don’t have to do it by myself.”).

Quality Improvement Efforts in VA Community Living Centers Increased Following Public Reporting of Performance

In 2018, the US Department of Veterans Affairs (VA) began publicly reporting performance ratings for its 134 Community Living Centers (CLCs; nursing homes) based on health inspections, staffing, and clinical quality measures. CLCs operate within a large, integrated healthcare system with unique financial and market incentives. Although public reporting has led to quality improvements in non-VA nursing homes, we do not know whether CLCs respond to public reporting differently than private sector nursing homes. To address this knowledge gap, we used a comparative case study approach involving 3 purposively selected CLCs with varied (low, medium, high) performance ratings. We conducted semi-structured interviews with personnel (n=12) responsible for quality measurement and improvement. Interviews focused on opinions of public reporting, actions taken to improve performance ratings, and motivations for change. Participants indicated public reporting improved transparency and provided an “outside perspective” on their performance. Strategies to improve performance ratings involved 1) data/information, 2) individual roles, and 3) teamwork/communication. All 3 CLCs made changes in these areas, yet respondents in the higher performing CLCs described implementing more strategies immediately after learning their ratings. Respondents in all 3 CLCs described being motivated to deliver good care and achieve public ratings that reflected the care they provided. This meant addressing internal weaknesses that contributed to lower scores for 2 CLCs. Our findings suggest public reporting may improve internal data collection, reporting, and quality improvement efforts in CLCs. They highlight the potential positive impact of public reporting in prompting quality improvement in nursing homes.

Butterfly Garden Connects Community Living Center Residents, Family, and Staff During the COVID-19 Pandemic

The COVID-19 Pandemic has led to significant morbidity and mortality in older residents of long-term care facilities. In addition, the stringent restrictions on visitation of family and loved ones has further socially isolated residents leading to an increase in depression, loneliness, and spiritual distress. The Community Living Center (CLC) staff at West Palm Beach VA Medical Center wanted to address this dilemma and created a unique “Butterfly Garden” (BG) visitation space. This space is a therapeutic garden adjacent to the CLC that can be accessed by families without having to enter the facility. Participants in the BG reported feelings of peace, undisturbed reflection, and tranquility as they observed and experienced nature’s life cycle. This show of nature’s beauty promotes visual, tactile, and olfactory sensory stimulation while attracting hummingbirds, bees, butterflies, and peace to this calm garden space. The BG visitations offers residents, family, and staff opportunities to experience the health benefits of nature during their visits under strict CDC social contact guidelines. From September through December 2020 and from January through March 2021 there were 67 and 184 visits respectively as families became more involved. The feedback from residents, families, and staff indicated that the spirits of all participants were raised by the BG visits despite the difficult challenges of social distancing and limited CLC visitations. This BG concept could serve as a model for other long-term care facilities to allow socially distant family visits to loved ones in a safe nature-based environment of care with or without a pandemic.

A Model to Transform Communities Toward Becoming Dementia Inclusive

As the US population ages, the prevalence of people living with dementia will also increase. It is estimated that by 2050, 13.8 million American’s 65 and older will be diagnosed with dementia, and currently only 40% of those living with dementia receive an official diagnosis. 70% of people living with dementia live in the community. In order to optimize quality of life and extend each person’s ability to remain living in their homes for as long as possible, it is important for communities to educate consumers and providers alike about Alzheimer’s Disease and related dementias, focusing on behaviors and interventions. This education must cross multiple sectors to effectively increase awareness, decrease stigma, and enable participation in community living for people living with dementia and their caregivers. Dementia Friends USA offers a framework for implementation of dementia friendly inclusive community initiatives that spans professions and incorporates patient and caregiver perspectives. The four symposia will 1) lead us through the evidence that supports the Dementia Friends USA approach, 2) demonstrate how this approach can be operationalized in a truly integrated fashion at the community level using HRSA’s Geriatric Workforce Enhancement Program (GWEP), 3) provide step-by-step instructions for implementing Dementia Friends Community sessions, focusing on one sector at a time (in this case the Developmental Disability population), and 4) discuss the individual and community level outcomes of Dementia Friends implementation.