BACKGROUND/RATIONALE:
Numerous studies have shown that many long term care (LTC) residents receive inadequate staff assistance with eating, which places them at risk for under-nutrition, dehydration and weight loss. Moreover, improvements in feeding assistance care have been shown to improve residents' daily food and fluid consumption and weight loss outcomes. However, these improvements have only been achieved through the use of research staff as opposed to indigenous LTC staff due to staffing resource limitations that exist in most LTC facilities. The purpose of this program evaluation project is to train indigenous LTC staff how to improve nutritional care within the constraints of existing staffing resources.

OBJECTIVE(S):
The PI of this proposal has developed standardized assessment, monitoring and staffing needs projection tools that can be used by long-term care (LTC) providers to improve feeding assistance care delivery and unintentional weight loss outcomes. The primary objective of this project is to train indigenous LTC staff how to (1) identify residents in need of feeding assistance, (2) effectively monitor daily care delivery; and, (3) utilize existing, non-nursing staff for some mealtime tasks to improve care.

METHODS:
A multiple baseline design was used to evaluate the effectiveness of the program in one federal and one state VA long-term care (LTC) facility. Research staff collected baseline measures related to organizational characteristics, including staffing, nutritional care processes and resident outcomes including oral food and fluid intake and weight status. All LTC units in each of the two sites were divided into two groups for program implementation purposes (for a total of 4 groups across the 2 sites) based on the proximity of a unit to other units, resident and staff characteristics. The program was implemented with staff and residents on the units in the first site/group; while, the second site/group remained in usual care and continued to be monitored monthly for all care process and resident outcome measures. Research staff trained LTC staff in the implementation of program protocols during a 12-week intervention period. Research staff then monitored LTC staff implementation of the program monthly following intervention to determine the sustainability of the program in the absence of research staff. All staff training and monitoring was repeated for the LTC units in groups three and four. The intent of this program evaluation study was to determine the effectiveness and cost of translating efficacious research protocols into care practice to improve the nutritional status of LTC veterans.

FINDINGS/RESULTS:
A total of five manuscripts have been published related to this study. Across the two participating VA sites, a total of 222 of 270 eligible residents participated in this study. Of these, 200 completed the baseline phase, 147 completed the intervention phase, and 130 completed the follow-up phase of data collection. Overall, LTC staff participation in training activities was high at both sites and across all units. Initial training sessions were attended by 134 total staff (43% licensed nurses, 37% nurse aides, 7% dietary, 7% Activities, and 6% upper-level Administrative personnel). A total of 57 supervisory-level staff members (mean = 8.14 total staff per unit) were trained in the quality improvement monitoring tool for feeding assistance care delivery (51% licensed nurses, 21% nurse aides, 5% dietary, 9% Activities and 14% upper-level Administrative personnel). For the subsequent weekly staff training and feedback sessions, a total of 163 staff (mean = 23.29 staff per unit) were in attendance across all six sessions, with an average attendance per session ranging from 4 to 8 staff per week. Staff attendees were comprised mostly of licensed nurses (46%) and nurse aides (42%) with intermittent attendance by dietary (3%) and other miscellaneous staff (e.g., activities, administrative).
As a result of training and monitoring activities, LTC significantly improved the quality of daily feeding assistance care delivery according to multiple measures based on direct observations by research staff. Specifically, significant improvements occurred from baseline to intervention for the accuracy of oral intake documentation in residents' medical records, staff offers of alternatives to the served meal when residents ate poorly, increase in the total amount of time staff spent providing assistance to residents in need of staff help to eat, and an increase in the amount of socialization that occurred during mealtime to promote both intake and residents' quality of life. Follow-up data demonstrated maintenance of these care quality improvements beyond the intervention phase. These results are published in the journal of Translational Behavioral Medicine, 2013. These findings also were shared during a nationwide VA web-cast in 2013.



IMPACT:
The positive intervention results from this study demonstrate that daily feeding assistance care delivery can be improved within VA long term care with existing staffing resources with standardized assessment and quality monitoring tools, and these improvements can be maintained without research staff involvement. Recent culture change initiatives within the VA system related to resident-centered care, in particular around dining, should further support improvements in this care area. In addition, regulations that allow both VA and community facilities to train non-nursing staff, including volunteers, to assist with feeding allow facilities to augment their existing staffing in a feasible, cost-effective way.

In addition to improving nutritional care practices within the participating VA sites, this project had a broader impact in several ways. First, Dr. Simmons served on the Office of Geriatrics and Extended Care (GEC) National VA Cultural Transformation Steering Committee for VA Community Living Centers and the Nursing Assistant Sub-Committee (2011-2012) during this study. As part of this committee, she developed two TMS learning modules for CLC nurse aides: one focused on dining care practices (and informed by this study) and one focused on the provision of choice to residents in the context of daily care (e.g., bedtimes, dressing, incontinence care, activities, dining location), which was informed by a separate NIH-funded challenge grant. These two TMS learning modules were to be released to all VA CLCs nationwide in 2013-2014.

Second, Dr. Simmons continued to work closely with the York CLC team after study completion to implement an 8-hour state-approved training curricula to train community volunteers to assist with feeding on select CLC units. The importance of this non-nursing personnel training effort was underscored by the results of this study demonstrating the amount of staff time required to implement feeding assistance care to all residents in need on the CLC units and the fact that some units had many more residents in need of this care than others but without additional staff support. To date, three groups of community volunteers have been trained to assist with feeding on the York CLC units.

Finally, also following the completion of this study, the York CLC units significantly expanded the availability of snack options between meals and made these items more easily accessible on each CLC unit, as opposed to being stored in the kitchen and requiring a formal request from the resident or staff, as was the case during the study period. The broader culture change initiatives supported by the VA nationwide are consistent with the dining care practices that were the focus of this training effort and should further support VA CLCs to improve their care practices in this and other daily care areas to be more resident-centered.

Data from this and other funded studies to Dr. Simmons were presented in a number of national and international conferences during the study period (listed below in chronological order):

-Simmons SF. "Improving nursing home care quality: Application of continuous quality improvement principles to staff training and management", Tennessee Health Care Association (August, 2009).
-Simmons, SF. A staff training and management intervention to improve nutritional care in VA nursing homes. GRECC symposium, "Transitions in Care" (November, 2010). Gerontological Society of America's 63rd Annual Scientific Meeting, New Orleans, LA.
-Simmons, SF. An overview of providing nutrition in long-term care: Culture change leads the way. National Registered Dietitian Executive Council Meeting (July, 2010).
-Simmons, SF. Centers for Medicare and Medicaid Services (CMS) and the American Health Care Association (AHCA) Quality Symposium, "Food and Dining in the Nursing Home" (February, 2010).
-Simmons SF. A Model for Quality improvement in Long-term Care. University of Alabama, Center for Mental Health & Aging (September, 2011).
-Simmons SF. Nutritional Issues in Long Term Care. National VA web-cast for Community Living Centers as part of the National Cultural Transformation Committee (August, 2011).
-Simmons SF. A Model for Quality Improvement in Long Term Care. Geriatrics and Long Term Care Conference, "Powerful Practical Partnerships" hosted by the University of Hawaii, Department of Geriatric Medicine. Invited Speaker (September, 2013).
-Simmons SF. Nutritional Issues in Long Term Care: Research Findings and Practice Implications, Grand Rounds, University of Hawaii, Department of Geriatric Medicine (September, 2013).
-Simmons, SF. Nutritional Care Quality in Long Term Care: Overview of Research Findings. Nestle Research Institute, Lausanne, Switzerland (July, 2013).
-Simmons, SF. An Intervention to Improve Nutritional Care in VA Community Living Centers. GRECC Audio Conference (May, 2013).

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Durkin DW, Umayam SP, Sims N, Cleeton P, Simmons SF. Whom do veteran nursing home residents prefer to talk to about satisfaction with care?: implications for nursing staff. Journal of gerontological nursing. 2012 Dec 1; 38(12):38-45. [view]

Center Products

1. Simmons SF. An Intervention to Improve Nutritional Care in VA Community Living Centers. 2013 May 1. [view]

VA Cyberseminars

1. Simmons SF. Nutritional Issues in Long Term Care. [Cyberseminar]. 2011 Aug 26. [view]

Conference Presentations

1. Simmons SF. A Model for Quality Improvement in Long Term Care. Paper presented at: University of Hawai'i at Manoa John A. Burns School of Medicine Long-Term Care Conference; 2013 Sep 24; Honolulu, HI. [view]
2. Simmons SF. A staff training and management intervention to improve nutritional care in VA nursing homes. Presented at: Gerontological Society of America Annual Scientific Meeting; 2010 Nov 19; New Orleans, LA. [view]
3. Simmons SF. Nutritional Care Quality in Long Term Care: Overview of Research Findings. Paper presented at: Nestlé Research Institute Conference; 2013 Jul 1; Lausanne, Switzerland. [view]
4. Simmons SF. Nutritional Issues in Long Term Care: Research Findings and Practice Implications. Paper presented at: University of Hawaii Department of Geriatric Medicine Grand Rounds; 2013 Sep 1; Honolulu, HI. [view]

DRA: Aging, Older Veterans' Health and Care, Health Systems
DRE: Prevention
Keywords: none
MeSH Terms: none