Montessori Approaches in Person-Centered Care (MAP-VA): An Effectiveness-Implementation Trial in Community Living Centers

以人为本的护理中的蒙特梭利方法 (MAP-VA)：社区生活中心的有效性实施试验

• 批准号: 10219831
• 负责人: Michelle M. Hilgeman
• 金额: --
• 依托单位: TUSCALOOSA VETERANS AFFAIRS MEDICAL CTR
• 依托单位国家: 美国
• 财政年份: 2021
• 资助国家: 美国
• 起止时间: 2021-02-01 至 2025-01-31
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10219831
• 关键词: Address; Adoption; Aggressive behavior; Aging; Agitation; Anti-Anxiety Agents; Antipsychotic Agents; Behavior; Behavioral; Behavioral Symptoms; Body Weight decreased; Caring; Clinical; Cluster randomized trial; Collaborations; Communities; Complex; Continuity of Patient Care; Data; Data Collection; Data Set; Data Sources; Dementia; Diagnosis; Distress; Eating; Educational Intervention; Educational process of instructing; Effectiveness; Emotional; Employee; Environment; Evaluation; Female; Fostering; Frontline worker; Geriatrics; Home; Hybrids; Individual; Intervention; Interview; Lead; Long-Term Care; Mental Health; Methodology; Modeling; Modernization; Moods; Movement; Neighborhoods; Nursing Homes; Nursing Services; Organizational Culture; Outcome; Pain; Patient Self-Report; Pharmaceutical Preparations; Pharmacy facility; Positioning Attribute; Primary Health Care; Problem Solving; Process; Provider; Proxy; Quality Indicator; Quality of Care; Quality of life; Questionnaires; Randomized; Randomized Controlled Trials; Reach Effectiveness Adoption Implementation and Maintenance; Recreation; Rehabilitation therapy; Reporting; Research Personnel; Role; Safety; Sampling; Schizophrenia; Standardization; Stress; Suicide prevention; Surveys; System; Techniques; Testing; Time; Time trend; Training; Trust; Urinary tract infection; Veterans; Work; affective disturbance; base; burnout; care providers; cognitive ability; community living; depressive symptoms; design; effectiveness evaluation; effectiveness implementation design; effectiveness implementation study; effectiveness implementation trial; effectiveness outcome; effectiveness-implementation randomized trial; empowered; empowerment; fall risk; falls; functional decline; implementation barriers; implementation evaluation; implementation facilitation; improved; innovation; intervention delivery; mortality; mortality risk; neuropsychiatric symptom; person centered; physical conditioning; preference; professional atmosphere; programs; sedative; severe mental illness; skills; social engagement; success; system-level barriers; theories; tool; treatment effect

Background: VA Community Living Center (CLC) staff struggle to address behavioral and neuropsychiatric symptoms of Veterans with dementia and serious mental illness (SMI) such as schizophrenia. These behaviors of distress (agitation, aggression, and mood disturbance) are not just associated with staff stress and burnout; they also hasten residents’ functional decline, decrease quality of life, and increase mortality. Staff training in non-pharmacological interventions can be effective. Yet systems barriers, task-based traditional biomedical care models, and time constraints often result in staff employing “quicker,” less effective strategies. Montessori Approaches to Person-Centered Care for VA (MAP-VA)— a staff training, intervention, and delivery toolkit— developed in collaboration with VA operational partners, Veterans, and frontline CLC staff is positioned to respond to this challenge. Our pilot data show probable impacts on CLC quality indicators at the individual and unit level (e.g., psychotropic medications, depressive symptoms, weight loss, falls, pain). Significance / Impact: Intense media scrutiny focused on care quality in VA CLCs has created an urgent problem for VA over the past year. To restore perceived trust, safety, and quality— as described in VHA’s Modernization Plan— frontline staff need to be empowered to lead quality improvement efforts like the ones taught through MAP-VA. Innovation: MAP-VA is distinct from existing interventions in its: 1) application to Veterans with a range of diagnoses and cognitive abilities; 2) emphasis on pairing practical skill-building for staff with overcoming system-level barriers that inhibit person-centered care; and 3) engagement of all staff rather than a reliance on provider-level champions. Yet, MAP-VA is a complex intervention that requires participation of multiple stakeholder groups, making implementation facilitation necessary. To date, no studies have evaluated MAP implementation success in operational settings (community or VA) and sustainability is rarely examined. Specific Aims: A hybrid (Type 3) implementation-effectiveness study is necessary to evaluate MAP-VA for Veterans and staff in CLCs. Study Aims include: 1) evaluate implementation facilitation and identify barriers to MAP-VA adoption and fidelity; 2) determine effectiveness of MAP-VA implementation on resident behavioral, emotional, and physical health outcomes; 3) determine effectiveness of MAP-VA implementation on person- centered care practices and organizational culture; and 4) examine the extent to which MAP-VA is sustained after external facilitation support has ended. Methodology: A stepped-wedge cluster randomized controlled trial will be used to evaluate within- and between-cluster implementation success and treatment effects over 18 months. Eight CLCs (24 CLC neighborhoods) will be randomized to a sequential crossover to the intervention with six months of facilitation. Analyses will account for time trends and correlations within cluster. Normalization process theory and the RE- AIM evaluation framework will guide the implementation evaluation and integration of qualitative and quantitative data. Data sources include primary data collection (e.g., resident interviews, staff interviews, surveys, researcher observation) and existing VA administrative data (e.g., Minimum Data Set 3.0, pharmacy, disruptive behavior reporting system, annual employee survey). Implementation / Next Steps: Our partners in the VA Offices of Geriatrics and Extended Care, Nursing Services, Mental Health and Suicide Prevention, and Recreation Therapy are enthusiastic about using MAP- VA to improve Veteran-centered care, care quality, and staff engagement within and beyond the CLCs. Outcomes from this work will be applicable to supporting staff and improving quality for complex aging Veterans across the continuum of care (e.g., Home Based Primary Care).

背景：VA社区生活中心（CLC）员工努力解决行为和神经精神病学 痴呆症和严重精神疾病（SMI）的退伍军人的症状，例如精神分裂症。这些行为 困扰（躁动，积极和情绪障碍）不仅与员工的压力和倦怠有关； 他们还有十名居民的功能下降，降低生活质量并增加死亡率。员工培训 非药理学干预措施可能是有效的。但是系统障碍，基于任务的传统生物医学 护理模型和时间限制通常会导致员工采用“更快”，效率较低的策略。 蒙特梭利以人为本的VA（MAP-VA）的护理方法 - 员工培训，干预和 交付工具包 - 与VA运营合作伙伴，退伍军人和前线CLC员工合作开发 定位应对这一挑战。我们的飞行员数据显示出对CLC质量指标的有问题影响 个人和单位水平（例如，精神药物，抑郁症状，体重减轻，跌倒，疼痛）。 意义 /影响力：强烈的媒体审查着重于VA CLC的护理质量 过去一年中VA的问题。恢复感知的信任，安全和质量 - 如VHA的所述 现代化计划 - 前线工作人员需要授权领导质量改进的工作 通过map-va教授。 创新：MAP-VA与其现有干预措施不同：1）向具有一定范围的退伍军人申请 诊断和认知能力； 2）强调为员工配对实用技能，并克服 抑制以人为中心的护理的系统级障碍； 3）所有员工的互动，而不是放心 提供者级冠军。但是，MAP-VA是一项复杂的干预措施，需要多个参与 利益相关者群体，使实施设施必要。迄今为止，尚无研究评估地图 很少检查在运营环境（社区或VA）和可持续性方面的实施成功。 具体目的：混合（3型）实施效应研究对于评估MAP-VA是必要的 CLC的退伍军人和员工。研究目的包括：1）评估实施设施并确定 MAP-VA采用和忠诚； 2）确定MAP-VA实施对居民行为的有效性， 情绪和身体健康成果； 3）确定MAP-VA实施对人的有效性 - 集中的护理实践和组织文化； 4）检查MAP-VA持续的程度 外部设施支持结束后。 方法论：阶梯式斜线群集随机对照试验将用于评估和 群集实施成功和治疗效果18个月。八个CLC（24 CLC） 社区）将随机分配到六个月设施的干预措施中。 分析将考虑群集内的时间趋势和相关性。归一化过程理论和重新 AIM评估框架将指导定性的实施评估和集成 定量数据。数据源包括主要数据收集（例如，居民访谈，员工访谈， 调查，研究人员观察）和现有的VA管理数据（例如，最低数据集3.0，药房， 破坏性行为报告系统，年度员工调查）。 实施 /下一步：我们在老年医学和扩展护理的VA办事处的合作伙伴，护理 服务，心理健康和预防自杀以及娱乐疗法对使用地图的热情 - VA以改善CLC内外的以老兵为中心的护理，护理质量和员工参与。 这项工作的成果将适用于支持员工并提高复杂衰老的质量 在整个护理的连续体中的退伍军人（例如，基于家庭的初级保健）。