Redesigning dementia care
An evaluation of small-scale, homelike care
environments
dr. Hilde Verbeek
Research program ‘Innovation in care for the elderly’
Acknowledgements
Financing:
• CAPHRI, Maastricht University
• Province of Limburg
• MeanderGroep, Orbis, Sevagram, Vivre
and De Zorggroep
Research team:
• Supervisors:
• Co-supervisors:
Prof. dr. JPH Hamers
Prof. dr. GIJM Kempen
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 235.000 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. 2009. Int Psychogeriatr, 21: 252-264)
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 facilities
21 regular wards
Screening and selection of residents
Baseline measurement
Baseline measurement
Follow-up at 6 months
Follow-up at 6 months
Follow-up
at Geriatr,
12 months
Verbeek et al.
2009. BMC
9:3
Follow-up at 12 months
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
Residents
Age (years)
Women, %
Living condition prior to admission*
At home
Other institution / unknown
Length of Stay, months†
Dementia type
Alzheimer’s Disease
Vascular Dementia
Other
Not Otherwise Specified / unknown
Stage of dementia
Cognition
Activities of Daily Life
Comorbid diseases
Department of Health Care and Nursing Science
Small-scale
n = 124
82.4 (7.9)
99 (80)
Regular Ward
n = 135
83.1 (6.5)
95 (70)
37 (30)
87 (70)
15.7 (11.3)
80 (59)
55 (41)
24.4 (22.0)
33 (27)
19 (15)
20 (16)
52 (42)
5.3 (1.1)
11.1 (7)
3.1 (1.7)
4.3 (2.3)
44 (32)
24 (18)
27 (20)
40 (30)
5.1 (1.0)
10.5 (6.6)
3.3 (1.4)
3.8 (1.9)
Matching
successful
Quality of life
25
20
15
10
5
0
m
on
th
th
s
12
FU
FU
6
m
on
lin
Ba
se
s
Small scale
Regular ward
e
Mean score
• 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
25
20
15
10
5
0
th
s
12
m
6
FU
FU
45
40
35
30
25
on
th
12
FU
FU
6
m
m
on
in
e
th
s
s
Small scale
Regular ward
se
l
Ba
Department of Health Care and Nursing Science
m
on
lin
Ba
se
Total score
• Residents in small-scale
facilities display more
physically non-aggressive
behavior after 12 months
on
th
s
Small scale
Regular ward
e
• No effect on total
neuropsychiatric symptoms
Total score
Behavior
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
8
6
4
2
0
on
th
th
s
m
on
12
FU
FU
6
m
el
Ba
s
s
Small scale
Regular ward
in
e
Total score
– 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 motivation
on
th
m
12
FU
6
m
el
on
in
e
th
s
s
Small scale
Regular ward
FU
m
12
FU
Department of Health Care and Nursing Science
10
8
6
4
2
0
Ba
s
th
s
on
FU
6
m
el
Ba
s
on
th
s
Small scale
Regular ward
Total score
20
15
10
5
0
in
e
Total score
Job satisfaction
Conclusion
• Unable to demonstrate convincing effects for
primary outcome measures
(Verbeek et al. 2010. JAMDA, 11: 662-670)
• 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
h.verbeek@maastrichtuniversity.nl
Department of Health Care and Nursing Science
Assessment criteria in daily practice
• Observation questionnaire
(range 18-90)
Mean = 42.3
Range 36-55
Regular Wards
(n=21)
Department of Health Care and Nursing Science
Mean = 67.6
Range 60-77
Small-scale living
(n=28 houses)