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PPO 10-110 – HSR&D Study

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PPO 10-110
Assessing Veteran Preferences In The Community Living Center
Kimberly Joy Curyto PhD
VA Western New York Healthcare System, Buffalo, NY
Buffalo, NY
Funding Period: December 2010 - November 2011

BACKGROUND/RATIONALE:
This project builds on the Preferences for Everyday Living Inventory (PELI), a comprehensive measure of preferences for everyday living created using over 500 randomly selected cognitively intact elderly home care recipients.1 Conceptualizations of optimal care in the nursing home emphasize the need to "know the person" to deliver individualized care and research demonstrates a link between integrating preferences into care and resident satisfaction and quality of life. This project adapted the PELI for use with Veterans in the community living center (CLC) to assess psychosocial preferences based on their perspective, the first step to designing appropriate interventions.

OBJECTIVE(S):
This project addressed the gaps in current preference assessments in order to (i) capture older Veterans' preferences in language they understand, and (ii) reflect the preferences most important to them. Specific objectives are outlined in the results section.

METHODS:
37 CLC residents were found to meet inclusion criteria for cognitive interviewing (CI): Veterans of at least 55 years of age, a Modified Mini-Mental Status Exam (3MS) score in the 2nd percentile or higher, a CLC resident for at least one week, not on hospice, and medically stable. Of these, 31 agreed to participate. 46 CLC residents met inclusion criteria and agreed to participate in the test-retest phase, with 4 participants not completing the PELI interviews due to discharge (2), death (1), and refusal (1). This was a one-year pilot study consisting of two phases. Participants were recruited from one Community Living Center (CLC) in Western New York state. 37 CLC residents were found to meet inclusion criteria for cognitive interviewing (CI): Veterans of at least 55 years of age, a Modified Mini-Mental Status Exam (3MS)2 score in the 2nd percentile or higher, a CLC resident for at least one week, not on hospice, and medically stable. Of these, 31 agreed to participate in CI. PELI items were rated on a 5-point importance scale. The interviewer noted affective reactions (e.g., anxiety, sadness, pleasure), behaviors (e.g., engaged, hesitation, contemplative, rapport with interviewer, talkativeness), and comments (e.g., requests for clarification). After each response, interviewers asked scripted probes which consisted of: 1) What were your thoughts as you gave your answer; 2) Can you give me an example of [insert item stem] when you gave your answer; 3) What do the words {insert stem} mean to you. If the participant said a specific item was not important or only somewhat important, they were further prompted: 4) Has this ever been more important to you. Finally, participants were asked: 5) How did you decide that [insert stem] is {insert importance rating response}; 6) Tell me in your own words what this question is asking. Verbatim responses and observations were reviewed independently, group consensus was used to identify problematic items, code reasons for item difficulty, and develop alternative wording to be retested based on CI responses.

For phase two, 46 CLC residents met inclusion criteria and agreed to participate in the test-retest phase, with 4 participants not completing the PELI interviews due to discharge (2), death (1), and refusal (1). Consenting residents who met study criteria completed a baseline interview consisting of the newly redesigned PELI-NH (T1). One week (5-7 days) after completing the baseline (T1) interview, residents were re-interviewed with the PELI-NH (T2). The interviewer again noted affective reactions and comments.

FINDINGS/RESULTS:
(Aim 1) Examine the content and meaning of preference items with CLC Veteran through CI. All PELI items were interviewed initially with a minimum of 5 participants. When CI revealed difficulty with item comprehension, additional CI was conducted. CI analyses indicated the need for 15 additional items. The majority of the items required no modification (73.9%). In contrast, 26.1% required between 1 and 3 interview rounds, with an average of 1.33 wording changes (range: 1-2) per item. A total of 84 items made up the final PELI.

(Aim 2) Adapt the PELI to incorporate CLC Veterans' perspectives on wording and the preferences important to them. 25 wording changes were made due to difficulties with readability (36%), clarity (32%), assumptions (16%), sensitivity and bias (12%), and other reasons (1%). Most important preferences (defined as 75 percent or more Veterans rating the item as "very important") included choosing how to care for your mouth, having staff show you respect, setting up your bed for comfort, relieving your pain when you want, and to be involved in choosing your roommate. All PELI items were endorsed as very important by some participants, and may prove important to assess for person-centered care.

(Aim 3) Test the feasibility of using the PELI with CLC Veterans with mild to moderate cognitive impairment. Participants were rated by the interviewer to have some difficulty with the complex conceptualization required of the CI procedure. In contrast, participants were rated to understand the PELI items, give good effort, express their answers and enjoy the interview process. Ratings also indicated participants stayed focused with little to no problems with energy or physical discomfort. This suggests that participants with some cognitive difficulties still can report on preferences using the PELI.

(Aim 4) Address the reliability of preferences over one week and the impact of cognitive functioning. We examined reliability between participant responses on 84 PELI items between T1 and T2 interviews. Two criterion measures were derived, 1) percentage of perfect agreement across T1 & T2 PELI items (M=0.56, SD=9.91, range=0.32-0.76), and 2) acceptable agreement based on +/-1 deviation across T1 & T2 PELI items (M=0.88, SD=8.48, range=0.70-0.99).

Multiple regression was used to examine predictors of reliability. Predictors of Perfect Agreement included less hearing impairment, 3MS percentile score, level of understanding, participant distractibility, tiredness, effort, decreased need for assistance with dressing and toileting (adjusted R =0.31, F (8, 33)=3.34, p=0.01). Predictors of +/-1 Agreement included less visual impairment, MMSE total score, 3MS total score and attention items (adjusted R =0.23, F (4, 37)=4.13, p=0.01). Those with visual impairment produced lower +/- Agreement scores, and were a different set of participants than those with lower scores on measures of cognitive functioning who also produced lower agreement measures.

IMPACT:
This project successfully used CI to revise the PELI to include language that CLC Veterans use and understand. CLC Veterans were not as consistent as anticipated in reporting psychosocial preferences over one week, and CI points to the need to better understand how perceived barriers and limited access to key factors in fulfilling preferences contribute to change in reported preferences over time. We identified highly endorsed preferences, primarily preferences for meeting basic needs, which serve as a good starting point when changing care practices.

The VHA and specifically the GEC strategic plans state: the "VA will be the national leader in providing . . . care that is patient centered, integrated, and informed by individual preferences in settings that are safe, affordable, and as home-like as possible." This project leads us one step closer to using the PELI to systematically and comprehensively assess CLC Veterans' preferences for everyday living, and to assess preference fulfillment, link to quality care, and guide interventions integrating preferences into care planning and addressing the cause of behavioral disturbances.

PUBLICATIONS:
None at this time.


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

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