Research into Practice
Research into Practice: Experiences from the Research Division of the Hebrew Home at Riverdale 2008
The Research Division Background
The Research Division at the Hebrew Home at Riverdale (RD-HHAR) is at the forefront of conducting cutting-edge gerontological research.
Why do we need Research in Long-Term Care?

-Baby Boomers represent 27% of the current US population, and the absolute numbers are growing.

-Baby Boomers are both care recipients and care providers. -The use of evidence-based medicine in determining best care practices on the rise.

-Translational research that bridges the gap between theory and practice is needed.

-Without research in long-term care, there will be no innovations in the way care is developed.

Programs Developed by RD-HHAR that are used Nationally

Evidence-Based Quality of care

1. Improving end of Life Care: involvement of Dr. Jeamme Teresi, as Panelist, in the National Institute of Health State-of-the-Science Conference (2004);

2. Vision Care for Persons with Dementia in Nursing Homes;

3. Recognition of Depression among Residents with Dementing Illness;

4.Promary Care Nursing;

5. National Workgroup on Research and Evaluaion of Special Care (WRESCU);

6. Sexual Expression.

The RD is continuing its mission of fostering research leading to a better quality of life for an increasingly aging population.

Technology

InfoAIDE, a way of measuring staff time, was developed by Dr. Douglas Holmes, Administrator and Director Emeritus of the RD-HHAR. This method was used by the NYSDOH to recalibrate Resource Utilization Groups (RUGs).

Telemedicine, developed in collaboration with Columbia University, uses computers in a home environment to facilitate the monitoring and care of patients with diabetes.

The Research Division

-Initiated a broad-based program of externally supported research in the mid-1980’s.

Internationally known for its members’ contributions across a wide spectrum of aging research.

Has grant support in excess of one million dollars from Foundations, the New York State Department of Health, and from the Federal Government.

I.

Enhancing Staffing and Environments for Residents of Chronic Care Facilities

Coordinating Center to the 11 National Dementia Special Care Projects

Funded by the National Institute on Aging:

-RD-HHAR developed a common core data set used across all sites;

-Conducted a three-day national training conference held here at the HHAR;

-Hosted numerous national meetings of investigators;

-Responsible for the analyses of all common core data from across the projects.

Impacts of Special Care Units (SCUs)

-Became the eleventh project of the “Initiative on Collaborative Studies of Special Care Units for Alzheimer’s Disease” by the NIA.

This nationwide collaboration resulted in the publication of Volume #4 (2000) of Research and Practice in Alzheimer’s Disease entitled Special Care Units.

Became the eleventh project of the “Initiative on Collaborative Studies of Special Care Units for Alzheimer’s Disease” by the NIA. • This nationwide collaboration resulted in the publication of Volume #4 (2000) of Research and Practice in Alzheimer’s Disease entitled Special Care Units.

Funded by National Institute on Aging:

-Using an innovative barcode recording and database system (InfoAide©) designed by Dr. Holmes, this study provided precise information concerning staff inputs;

-It appears that incremental staff inputs made in SCUs have substantially greater impact on residents than they do in traditional units.

National Workgroup on Research and Evaluation of Special Care Units (WRESCU)

-Dr. Holmes, Administrator and Director Emeritus of the RD-HHAR, envisioned the need for a national workgroup for dementia research.

-Created the national Workgroup on Research and Evaluation of Special Care Units.

-The Supplement to the Alzheimer's Journal - Special Dementia Care: Research, Policy, and Practice Issues, 1994, was an example of the collaborated efforts by WRESCU.

National Research on Quality of Care (RESQCARE)

-Dr. Teresi, Administrator and Director of the RD- HHAR, created the National Research on Quality of Care work group.

-Both WRESCU and RESQCARE were supported as "Formal Interest Groups” by the Gerontological Society of America.

II.

Quality of Life: Improving Behavior and Affect

Recognition of Depression Among Residents With Dementing Illness

Funded by the New York State Department of Health:

-The study was a probability sample of several hundred residents from multiple nursing homes;

-This study assessed the degree to which depression among dementia patients was not recognized by nursing staff.

-Depression was under-recognized.

-Previously it was estimated that approximately 4%- 5% of nursing home residents were depressed. In this study it was determined that upwards of 16% of demented residents were depressed.

Depression Recognition Program for Nursing Home Staff

Funded by National Institute for Nursing Research (NINR): in partnership with Dr. Robert Abrams at Weill Cornell Medical College.

-Three training modules were developed:

1. Distinguishing dementia and depression;

2. Treatment of confusion and behavior disorders;

3. Recognition of depression.

-Evaluation of the intervention showed significant improvement in staff knowledge.

III.

Health Related Training Programs: Reduction of Adverse Events

Behavioral Consequences of Vision Care for Persons with Dementia

Funded by NYSDOH (in collaboration with the Jewish Guild for the Blind):

-The prevalence of low vision in nursing homes is estimated at 36% to 48%;

-Excess disability and behavior disorder can result from undiagnosed and uncorrected vision impairment;

-Prevention of excess disability associated with correctable low vision is key.

Two training modules were used:

1.A 22-minute educational video, The World Through Their Eyes, developed by the Lighthouse, Inc.

2.An experimental segment demonstrating how a person actually experiences vision impairment.

-The training program resulted in significantly less functional decline and increased positive affect in the intervention group where staff was provided training.

Informatics for Diabetes Education and Telemedicine (IDEATEL) Demonstration Project

In collaboration with Dr. Stepehen Shea- Vice Dean Columbia University Faculty of Medicine

-A decade long demonstration project funded by the Centers for Medicare and Medicaid services.

-Goals of Evaluating the cost-effectiveness of telemedicine in the management of older patients with diabetes.

-Participants have diabetes and are Medicare Eligible residents of federally designated, medically underserved areas.

-Over 2,100 participants were randomized throughout New York State.

-Intervention participants recieved telemedicine units.

The RD-HHAR serves as the Coordinating Center

Technology issues: only 23.5% had ever used a computer.


Major Findings:

-Telemedicine resulted in significant, meaningful reduction in hemoglobin A1c, blood pressure, and lipids.

Different Approaches to Information Dissemination

Funded by the Agency for Health Care Research and Quality in partnership with the NYSDOH.


Aims:

1.Disseminate evidence-based best practices in nursing homes and adult care facilities.

2.Select three evidence-based practices that have associated training modules.

3.Evaluate two methods for disseminating research findings.

Sample

Forty-five nursing homes and twenty-one adult care facilities, throughout New York State.


DESIGN:

a)The Control Group: fifteen nursing homes and seven adult care facilities, with staff receiving only standard training.

b) Experimental Group One: the intervention was additional staff training in best practices.

c)Experimental Group Two: both provider staff and state inspectors were trained, and best practices were integrated into the survey process.

Best Practices Training Modules: Selection Process

The review process started with 79 potential modules.

-The review protocol first identified those potential trainings that were evidence-based.

-Of the 79 identified, less than 15% addressed best practices that were evidence-based.

-Project staff and Advisory Group members were very surprised that there were so few off-the-shelf affordable training packages available.

The Advisory Group strongly recommended the following training modules:

1.Bathing Without A Battle (Phillip Sloane, A.L. Barrick and D. Calleson, 2003).

2.Vision Awareness (Elaine Yatzkan, J. Teresi, 2000).

3.Staff Training for Dementia Care in Assisted Living Residences (STAR) (Linda Teri, 2003).

Findings

Initiation of the training program was associated with reduced falls and enhanced quality of life in nursing homes.

An Evaluation of the Vigil Nurse Call and Passive Monitoring System

Funded by the New York State Department of Health:

-The Vigil project assesses the extent to which modern technology can augment direct staff intervention.

-This technology provides an innovative system, centered on resident movement.

-The Vigil monitoring system notifies the appropriate staff that a certain resident has violated expectancies to which the C.N.A. is trained to respond immediately.

Supported by Vigil data, the system software identifies expected patterns of behavior.

Nursing home staff utilizes this feedback data to refine and enhance individualized care plans for preventative and proactive interventions.

The quality of life impacts associated with the presence of such technology with the quality of care provided to residents with dementing illness are central findings of the study.

Weinberg Center Evaluation (Daniel Reingold, MSW, JD)

-The HHAR Harry and Jeanette Weinberg Center for Elder Abuse Prevention provides a safe haven for older adults who have been physically, emotionally, and/or financially abused;

-An outcome evaluation will be conducted: clients will be assessed at admission and three months after discharge on domains such as abuse and mistreatment, ADL/IADL function, general health status, comorbidity, cognition, nutrition, and social support.

Staff Training in Resident-to-Resident Elder Mistreatment (R-REM)

Funded but the New York State Department of Health in Collaboration with Terry Fulmer, RN, PhD, FAAN, Dean of NYU School of Nursing, Marck Cachs, MD, and Karl Pillemer, PhD Weill Cornell Medical College, and Joy Solomon, JD, Weinberg Center on Elder Abuse

-This project examines violence and aggression committed by nursing home residents that are directed toward other residentd


The aims of the Projects are:

-To develop a training program for staff that enhances identification and intervention with respect to episodes of R-REM;

-To enhance staff knowledge related to recognition and treatment of R-REM;

-To evaluate the impact of the impact of the training intervention on falls, accidents, injuries and on quality of live

Nurses Improving the Care of Healthsystem Elders (NICHE)

In collaboration with Elizabeth Capezuti, PhD, RN, FAAN, Hartford Foundation Institute for Geriatric Nursing, New York University College of Nursing

-Started in 1992, NICHE has evolved into a national geriatric nursing program comprising 143 active sites in 34 states as well as parts of Canada and The Netherlands.

-The goal of NICHE is to achieve systematic nursing change that will benefit hospitalized older patients by providing materials and services necessary to support geriatric care planning and implementation.

The Geriatric Institutional Assessment Profile (GIAP) is the current assessment tool used to assess institutional readiness to implement the NICHE system.This tool will be expanded to include information on six common clinical syndromes.

Health Information Technology (HIT) Evaluation

In collaboration with Karl Pillemer, PhD, Weill Cornell Medical College

-The overall purpose of this demonstration project is the implementation and evaluation of a mobile electronic medical records (EMR) system (SigmaCareTM) to help nursing homes in New York State improve care delivery, decrease medical records, and lower health care costs.

Health Disparities Research and Mentoring Minority Investigators

Resource Centers for Minority Aging Research

(RCMARs) – In 1997, the National Institute on Aging/ National Institutes of Health established the RCMAR initiative as part of the effort to reduce health disparities between minority and non-minority older adults. The RCMAR mission is to decrease these disparities by:


Increasing the number of researchers who focus on the health of minority elders;

-Enhancing diversity in the professional workforce by mentoring minority academic researchers for careers in minority aging health research;

-Improving recruitment and retention methods used to enlist minority elders in health disparities research;

-Creating culturally sensitive measures that assess the health status of minority elders for greater precision, and increase the effectiveness of interventions designed to improve their health and well-being.

The RD-HHAR/Columbia RCMAR

Funded by the National Institute on Aging and the National Institute on Nursing Research (Drs. Teresi and Ramirez)

-Collaborating Organization(s): Columbia University, University of California at San Francisco, University of California at Los Angeles, University of Colorado, University of Michigan, Medical University of South Carolina, and Harvard University.

-The overall goals of the Columbia Center for the Active Life of Minority Elderly (CALME) are to foster expansion of minority aging research, with the objective of reducing health disparities.

Examples of recently funded projects include:

Funding Cycle II:

-The relationship between lung function, body fat composition and insulin resistance in the elderly;

-Age and race-related disparities in the use of adjuvant chemotherapy for early stage breast cancer;

-Characterization of Alzheimer’s disease susceptibility locus on chromosome 18q21 among Caribbean Hispanic families;

-A genetic dissection of age-related macular degeneration;

-A comparison of androgen receptor polymorphism in African American and in Caucasian women with breast cancer;

-Reducing health risks and social isolation among elderly blacks in naturally occurring retirement communities;

-Coping and health among older Latinos with arthritis;

-Vitamin E intake as primary prevention in stroke: The Northern Manhattan stroke study;

-Feasibility of an advance directive counseling program for Spanish patients with mild to moderate dementia;

-Race/ethnic variations in periodontitis in older populations;

-Neighborhood environments, cardiovascular health, and functional status among the elderly.

-Perceptions of risk among the aging first-degree relatives of African Americans with type 2 diabetes;

-Moderate intensity exercise adherence and outcomes in an elderly diabetic minority urban population;

-Improving Therapeutic Lifestyle Changes in Minority Elders with Hypertension.


Funding Cycle I:

-Investigate the relationship among endogenous estrogen, ethnicity, body mass, cognitive function and AD;

-Effect of B Vitamins and Vitamin C on the inflammation markers and endothelial function in obese pre-menopausal women;

-The Impact of Oral Health on the Quality of Life of Older Adults in Central Harlem.

Key Research Staff

-Dr. Mildred Ramirez is the PI for the Data Measurement Core.

-Dr. Teresi is Co-Director of the Center, and directs the mentoring seminars. She was one of the editors of the first major publication of the RCMAR Centers, which focused on measures that have been used among culturally diverse groups. First published as an issue of Mental Health and Aging, and later as a book, the volume, entitled, Multicultural Measurement in Older Populations, and edited by Skinner, Teresi, Holmes, Stahl and Stewart, has been widely cited in recent research publications.

-Dr. Teresi is the senior editor of a special issue of Medical Care published in 2006 that includes articles describing qualitative and quantitative methods for examination of measures used in health disparities research: Measurement in a Multi-ethnic Society, is edited by Teresi, Stewart, Morales and Stahl.

Columbia Center for the Health of Urban Minorities (CHUM)

In collaboration with Olveen Carrasquillo, MD, MPH, Columbia University Medical Center

-CHUM was established as a Center of Excellence in Partnerships for Community Outreach, Research on Health Disparities, and Training (Project EXPORT). The focus of the current phase is research excellence in improving minority health

.
The associated research projects propose to examine two important minority health areas: diabetes and cardiovascular disease.

-The Northern

-The mechanisms of Cognitive Impairment Among Minority Persons with Diabetes Project seeks to establish the predictors (including glycemic control and blood pressure) and mechanisms of memory impairment among minorities with diabetes (Goodwin Olugebenga OgedegdbeJose Luchsinger-Pl)

-The Counseling Older Americans to Control the Hypertension (COACH) Trial will test the effect of a group-based behavioral counseling intervention on reducing blood pressure, improving diet, physical activity, and adherence to prescribed antihypertensive medications among older African American and Latino patients with hypertension (Goodwin Olugebenga Ogedegdbe-Pl)

PROMIS

-Patient Reported Outcomes Measurement Information System (Dr. Teresi, consultant);

-Funded as a NIH-wide Roadmap project;

-Collaborating institutions: David Cella, PhD, Center on Outcomes Research, and Education, Northwestern University;

This is a national item banking project, designed to generate computerized, adaptive assessments of health status;

The PROMIS is described in a special issue of Medical Care published in 2007.

Presentations at Scientific Meetings

Dr. Teresi was one of the invited keynote speakers at a conference in Washington in June 2004 that was devoted to measurement, item banking and computerized adaptive testing. This conference, entitled, Advances in Health Outcomes Measurement, was sponsored by the National Institutes of Health, the Department of Health and Human Services, and the National Cancer Institute.

A special issue of Quality of Life Research was published in 2007 summarizing the proceedings from this conference.

- Dr. Teresi was invited to be one of the panelists for the NIH State-of-the-Science conference on improving end- of-life care. She was a sub-panel chair, responsible for two questions: What defines the transition to end of life? What outcome variables are important indicators of the quality of the end-of-life experience for the dying person and for the surviving loved ones? The conference was held in December 2004 in Washington, and was followed by a press conference. The result will be an NIH State- of-the-Science Consensus Statement regarding end-of- life care.