Over 40,000 Veterans receive care in VHA community living centers (CLCs) nationwide each year. Over half of these Veterans are diagnosed with mental health disorders and / or dementia. Behavioral disturbances are reported in 68.7% of individuals with dementia and 67.8% of those with dementia and serious mental illness. Frontline staff need evidence-based practical tools and strategies for engaging Veterans in meaningful activities that promote quality of life and reduce behavior disturbances. Montessori-based Activity Programming (MAP) may fulfill this need. MAP is a community nursing home-developed, evidence-based intervention that enables resident engagement in structured, meaningful activities using clearly outlined principles and strategies focusing on resident strengths. A series of studies on the application of MAP for dementia have shown decreased behavioral disturbances (e.g., yelling and aggressive behaviors), as well as demonstrated improvements in basic cognitive abilities such as attention and object permanence, social behavior, increases in active engagement, reduced agitation, and reduced antipsychotic and sedative use.
This study has three primary objectives, which will occur in three phases, to adapt MAP for successful use with Veterans in VA CLCs.
Objective/Phase 1: Adapt MAP materials and training for CLCs' unique Veteran population;
Objective/Phase 2: Develop a delivery strategy for the complex and difficult-to-change CLC system that is not dependent on MAP's current lengthy, in-person training;
Objective/Phase 3: Test the adapted program and training strategy to finalize it for regional or national roll out.
The study will take place in 3 phases using mixed-methods and a purposive sample of CLCs. In Phase 1 (12 months) we will visit 2 sites to gather data to adapt the existing MAP training materials and develop the delivery guide. In Phase 2 (18.5 months) we will have 6 sites implement the guide, each over a 6-month period. We will compare: 1) an onsite strategy at 3 sites, involving in-person, on-the-ground training prior to and during the implementation period, and 2) a remote strategy at 3 sites, where training and follow up will be done via conference calls and LiveMeeting. In Phase 3 (5.5 months) we will revise and finalize the guide and implementation plan, making it ready for regional / national roll-out.
Phase 1 focused on expert advisory panel recommendations, and completion of initial interviews at Sites 1 (n=28) and Site 2 (n=35). Advisory panel findings and interview data from Site 1 guided training and implementation efforts which began 9/2017. These efforts resulted in tailored CLC staff training (n=51) and implementation in 4 CLC neighborhoods. Interdisciplinary staff including Nursing, Recreation Therapy, and Dietary Services are in leadership roles. Preliminary findings from Site 1 have led to development of MAP adaptations appropriate for the VA CLC environment and population, as planned.
Advisory Panel findings and interview data from Site 2 are being used to further refine training, intervention components, and the implementation bundle. Findings from Site 2 (in progress) will further inform MAP adaptations for Phase 2.
Providing residential patient-centered care to Veterans residing in VA CLCs is an urgent priority. This heterogeneous group is often affected by high rates of serious mental illness, dementia and related disorders, and life-limiting physical disabilities. Social and cognitive engagement, sustained independence, and optimal involvement in meaningful, purposeful activities are essential to well-being, and other critical outcomes. MAP has been shown to be effective for a variety of resident outcomes: increased socialization, retention of intact cognitive abilities, activity engagement, caloric intake, reduced antipsychotic and sedative use, and reduced behavioral disturbances. The knowledge gained from this study will be of immediate applicability to CLCs nationwide and will be helpful for guiding further improvements in patient-centered care in VHA.
Preliminary outcomes from Site 1 suggest positive impact of the project on quality of care and Veteran behavioral and functional outcomes, including decreased agitation and need for psychopharmacological intervention, improved orientation to place, and increased participation in community activities. It is anticipated that Site 2 outcomes will demonstrate additional positive impact, also reaching Veteran family members. This project's findings have implications for VA CLC policy as it pertains to methods of care delivery, to further improve quality of care and Veteran outcomes.
External Links for this Project
Grant Number: I01HX002223-01
- Madrigal C, Mills WL, Keleher VC, Pimentel CB, Hartmann CW, Snow AL, Camp C, Hilgeman MM. A Spotlight on Adaptation: Preimplementation of Montessori-Based Activity Programming in Long-Term Care Using the Framework for Reporting Adaptations and Modifications-Enhanced (FRAME). The Gerontologist. 2023 Mar 21; 63(3):589-603. [view]