Redesigning dementia care An evaluation of small-scale, homelike care environments dr. 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

Department of Health Care and Nursing Science 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

Department of Health Care and Nursing Science Dementia Symptoms: –Global cognitive and functional decline –Behavioral and psychological symptoms 1 out of 5 people will develop dementia –Approximately people have dementia in the Netherlands at this moment About 1/3 requires institutional nursing care

Department of Health Care and Nursing Science Traditional nursing homes Originally based on ‘medical model of care’: –Hospital-like, large wards, long corridors –Routines of the organization mainly determine daily life

Department of Health Care and Nursing Science 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

Department of Health Care and Nursing Science 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 Int Psychogeriatr, 21: )

Department of Health Care and Nursing Science 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

Department of Health Care and Nursing Science 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?

Department of Health Care and Nursing Science 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

Department of Health Care and Nursing Science Effect study: design 28 units in small-scale facilities21 regular wards Screening and selection of residents Baseline measurement Follow-up at 6 months Follow-up at 12 months Baseline measurement Follow-up at 6 months Follow-up at 12 months Verbeek et al BMC Geriatr, 9:3

Department of Health Care and Nursing Science 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

Department of Health Care and Nursing Science Residents Characteristics and primary outcomes: quality of life and behavior

Department of Health Care and Nursing Science Residents’ characteristics Matching successful

Department of Health Care and Nursing Science 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

Department of Health Care and Nursing Science Behavior No effect on total neuropsychiatric symptoms Residents in small-scale facilities display more physically non-aggressive behavior after 12 months

Department of Health Care and Nursing Science Family caregivers Primary outcomes: Cargiver burden, involvement and satisfaction with care

Department of Health Care and Nursing Science 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

Department of Health Care and Nursing Science 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

Department of Health Care and Nursing Science Nursing staff Primary outcomes: job satisfaction and motivation

Department of Health Care and Nursing Science 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 Job satisfactionJob motivation

Department of Health Care and Nursing Science Conclusion Unable to demonstrate convincing effects for primary outcome measures (Verbeek et al JAMDA, 11: ) Despite positive experiences, small-scale homelike facilities are not necessarily better care environments –Other options should be carefully considered

Department of Health Care and Nursing Science 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

Department of Health Care and Nursing Science Societal impact: debate NRC Handelsblad, Dec 2010

Department of Health Care and Nursing Science 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

Department of Health Care and Nursing Science Thank you

Department of Health Care and Nursing Science Assessment criteria in daily practice Observation questionnaire (range 18-90) Regular Wards (n=21) Small-scale living (n=28 houses) Mean = 42.3 Range Mean = 67.6 Range 60-77