1. Health Services Research Focusing on Chronic Care and Ageing 1 Hilde Verbeek, PhD Department of Health Services Research ADI Conference, March 8th 2012 QUALITY OF LIFE IN SMALL-SCALE, HOMELIKE CARE ENVIRONMENTS: A QUASI-EXPERIMENTAL STUDY INTO EFFECTS ON RESIDENTS.

2. Health Services Research Focusing on Chronic Care and Ageing 2 The Netherlands Dutch government stimulates small-scale, homelike care settings 80 million euro program (2009-2011) Development of new small-scale living facilities ICT and assistive technology in facilities In 2010 ± 25% small-scale living facilities in institutional dementia care –Aim within 5 year: 33% Little knowledge on effects

3. Health Services Research Focusing on Chronic Care and Ageing 3 Small-scale homelike facilities General characteristics of 28 units included: –Small resident group (6-7) –Familiar, homelike environment –Joint daily household –Integrated tasks nursing staff –Resemblance archetypal home Worldwide several similar concepts (Verbeek et al. 2009. Int Psychogeriatr. 21:252-264)

4. Health Services Research Focusing on Chronic Care and Ageing 4 Control group: Regular wards Criteria regular wards: (n=21 wards) –Min. 20 residents per group –Staff have differentiated tasks –Organization daily life mainly determined by routines of the nursing home Matching of residents at baseline on cognition and ADL profile –Previous research: differences between residents in small- scale living and regular wards (Verbeek et al., 2010;Te Boekhorst et al. 2009)

5. Health Services Research Focusing on Chronic Care and Ageing 5 Baseline FU 6 months FU 12 months 124 residents135 residents 111 residents 93 residents 111 residents 97 residents Small-scale Regular wards

6. Health Services Research Focusing on Chronic Care and Ageing 6 Residents’ baseline characteristics

7. Health Services Research Focusing on Chronic Care and Ageing 7 Primary outcome measures Quality of Life (as measured with Qualidem) Neuropsychiatric symptoms (NPI-NH) Agitation (CMAI) Mixed-model multi-level analyses (Verbeek et al. 2010. J Am Med Dir Assoc 11:662-670)

8. Health Services Research Focusing on Chronic Care and Ageing 8 Quality of life No effects on total QoL –No differences in trend and no difference in mean total score between groups Small-scale living facilities: adjusted mean score 18.3 Regular wards: adjusted mean score 18.5

9. Health Services Research Focusing on Chronic Care and Ageing 9 Quality of Life - Subscales Assessed by nursing staff: –Two scales significantly differed: –Residents in small-scale living had… Higher QoL “having something to do” (p<.001) Lower QoL regarding “negative affect” (p=.01) Assessed by family caregivers: –Residents in small-scale living had… higher QoL regarding “having something to do” (p=.018), “ feeling at home” (p=.023) and “social relations” (p=.020)

10. Health Services Research Focusing on Chronic Care and Ageing 10 Neuropsychiatric symptoms No overall effect –No differences in trend and no difference in mean total score between groups Small-scale living facilities: adjusted mean score NPI-NH 15.8 Regular wards: adjusted mean score 14.5

11. Health Services Research Focusing on Chronic Care and Ageing 11 Agitation Difference in trend –Small-scale living: agitation stable over time –Regular wards: agitation decreased over time –Significant difference after 12 months: Residents in small-scale living facilities displayed more agitated behavior (p=.035)

12. Health Services Research Focusing on Chronic Care and Ageing 12 Secondary outcomes Use of physical restraints (yes/no) Psychotropic drug use (yes/no) Generalized Estimating Equations (GEE) Social engagement (ISE from RAI-MDS) Mixed-model multi-level analyses

13. Health Services Research Focusing on Chronic Care and Ageing 13 Promising results Fewer physical restraints (p=.003) and psychotropic drug use (p=.023) in small-scale living facilities –Differences were present at baseline and remained stable over time –E.g use of belts: 1% vs 10% More social engagement for residents in small-scale living, although this disappeared over time (only at baseline after 6 months)

14. Health Services Research Focusing on Chronic Care and Ageing 14 Neuropsychiatric symptoms & agitation Residents in small-scale living displayed:… –More aberrant motor behavior at all measurements (p=.020; NPI-NH) –More physically non-aggressive behavior (e.g. wandering) after 12 months (p=.001; CMAI) …than residents in regular wards

15. Health Services Research Focusing on Chronic Care and Ageing 15 Conclusion No effects on primary outcomes –Influence Dutch health care policy? Some promising effects on secondary outcomes (physical restraints, psychotropic drugs) Inconclusive effects behavior Automatic transition towards small-scale homelike care environments is not recommended –Focus should be on care program

16. Health Services Research Focusing on Chronic Care and Ageing 16 Implications Changing role of nursing staff: adequate training and education of staff is essential –Knowledge and skills –Attitude towards care Small-scale homelike facilities have encouraged development of new care concepts –Which elements are effective, how and for whom? –Which and how can active ingredients be transferred to other dementia care settings as well?

17. Health Services Research Focusing on Chronic Care and Ageing 17 Thank you Email: h.verbeek@maastrichtuniversity.nl Funding: Maastricht University Province of Limburg 5 Health care organizations (MeanderGroep, Orbis, Sevagram, Vivre & De Zorggroep) Research group: dr. Hilde Verbeek dr. Erik van Rossum dr. Sandra MG Zwakhalen prof. Gertrudis IJM Kempen prof. Jan PH Hamers