Sustaining STAR-VA: Partnered Evaluation of Veteran, Implementation and Facility Factors Contributing to Positive Sustained Outcomes to Inform Ongoing Program Implementation

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STAR-VA, a Veteran-centered, interdisciplinary, behavioral approach for managing behavioral symptoms of dementia (BSD) among Veterans Health Administration Community Living Center (CLC) residents, has been implemented in 66 trained CLC sites between 2013 and 2016. Collaborative evaluation is necessary to demonstrate the longitudinal impact of STAR-VA on CLC Veteran and site level outcomes, and determine factors associated with sustained implementation and positive outcomes, in order to support program sustainability and expansion. This project intends to identify a quality indicator for monitoring behavior change among CLC residents with dementia, determine Veteran, intervention, and facility/site factors that predict sustained positive behavioral and systemic outcomes, and identify facilitators and barriers to sustained STAR- VA implementation. Project outcomes will inform development and recommendations for an implementation and evaluation strategy for an outcome-driven, tailored intervention to support CLC teams in sustaining STAR-VA. Specific aims are to: 1. Develop and validate a quality indicator for monitoring the prevalence of BSD, using Minimum Data Set 3.0 behavior measures, validated by STAR-VA outcome measures; 2. Evaluate the longitudinal impact of STAR-VA by comparing site and resident outcomes at trained and untrained CLCs in years 2013-2016 on BSD, psychotropic use, and, for sites, staff injuries, and identify high and low performing CLC sites. 3. Explain variations in the sustained implementation of STAR-VA using qualitative methods with a purposeful sample of trained CLC sites, examine what Knowledge Reservoir (KR) domains are present in CLC sites and the impact of these KRs and additional factors on sustainment. Objective #1: Create a BSD quality indicator from mandatory Resident Assessment Instrument Minimum Data Set (MDS) 3.0 behavior variables, validated by STAR-VA outcome measures of behavior, depression and anxiety collected for 280 Veterans enrolled in STAR-VA between 2013 and 2016. STAR-VA participating Veterans have a dementia diagnosis and display repeated behaviors that are distressing to the resident or others, not directly related to delirium, other acute illness, psychotic symptoms, or recent brain injury. Objective #2: Evaluate the impact of STAR-VA by comparing trained and untrained CLC sites and residents in years 2013-2016 on selected outcomes, and identify resident, implementation, and facility factors associated with BSD. Resident level outcomes will include rates of BSD and psychotropic use in CLC residents using MDS 3.0 behavior quality indicator and Psychotropic Drug Safety Initiative (PDSI) data. CLC site level outcomes will be based on: a) Overall rates of BSD in the CLC (using MDS 3.0 behavior quality indicator and Workplace Behavioral Risk Assessment disruptive behavior reporting system), b) Antipsychotic and antianxiety medication use from PDSI program data, and c) Nursing staff injuries, using Occupational Health Automated Safety Incident Surveillance and Tracking Systems (ASSISTS) data. Objective #3: Explain variations in the sustained implementation of STAR-VA using prospective qualitative methods in a purposeful sample of trained CLC sites. Mixed methods, including interviews of high and low performing and high and low adherence sites, will be used to determine what KR domains including People, Routines, Artifacts, Relationships, Information space, Culture, and Structure and additional factors are present in trained CLC sites and the impact of these KRs and additional factors on STAR-VA program sustainment. Quantitative and qualitative factors related to sustained implementation and positive outcomes will be integrated and guide the development and recommended implementation and evaluation strategy for an outcome-driven, tailored sustainability intervention designed to improve poor-performer and maintain high-performer outcomes..