Montessori Approaches in Person-Centered Care (MAP-VA): An Effectiveness-Implementation Trial in Community Living Centers

背景：VA社区生活中心（CLC）的工作人员努力解决行为和神经精神问题 患有痴呆症和精神分裂症等严重精神疾病（SMI）的退伍军人的症状。这些行为 痛苦（激动，攻击和情绪障碍）不仅与员工压力和倦怠有关; 也加速了居民的机能衰退，降低了生活质量，增加了死亡率。员工培训 非药物干预可能有效。然而，系统障碍，基于任务的传统生物医学 护理模式和时间限制往往导致工作人员采用“更快”、效率较低的战略。 蒙台梭利方法以人为本的VA护理（MAP-VA）-员工培训，干预， 交付工具包-与VA业务合作伙伴，退伍军人和前线CLC工作人员合作开发， 有能力应对这一挑战。我们的试点数据显示，CLC质量指标可能受到影响， 个人和单位级别（例如，精神药物、抑郁症状、体重减轻、福尔斯、疼痛）。 意义/影响：媒体对VA CLC护理质量的密切关注， 去年的问题。恢复信任、安全和质量-如VHA的 现代化计划-需要授权前线员工领导质量改进工作，如 通过MAP-VA教学。 创新：MAP-VA与现有干预措施的不同之处在于：1）适用于退伍军人， 诊断和认知能力; 2）强调将工作人员的实际技能培养与克服 阻碍以人为本的护理的系统级障碍; 3）所有工作人员的参与，而不是依赖 供应商级别的冠军。然而，MAP-VA是一种复杂的干预措施，需要多个参与者的参与。 利益攸关方群体，因此有必要为执行工作提供便利。迄今为止，没有研究评估MAP 在业务环境（社区或退伍军人事务部）中的执行成功率和可持续性很少得到审查。 具体目标：有必要进行混合（类型3）实施有效性研究，以评估MAP-VA， CLC的退伍军人和工作人员。研究目的包括：1）评估实施便利性，并确定障碍， MAP-VA采用和保真度; 2）确定MAP-VA实施对居民行为的有效性， 情绪和身体健康结果; 3）确定MAP-VA实施对人的有效性- 中心护理实践和组织文化;以及4）检查MAP-VA持续的程度 在外部便利化支持结束后。 方法学：一项阶梯楔形分组随机对照试验将用于评估内和 集群间实施成功率和18个月的治疗效果。八个CLC（24个CLC 社区）将被随机分配到一个连续的交叉干预与六个月的促进。 分析将说明集群内的时间趋势和相关性。规范化过程理论与RE- AIM评价框架将指导实施评价和定性与定量相结合， 定量数据数据源包括原始数据收集（例如，居民访谈，员工访谈， 调查，研究人员观察）和现有的VA管理数据（例如，最低数据集3.0，药房， 破坏性行为报告系统、年度员工调查）。 实施/下一步：我们在老年病和延续护理，护理VA办公室的合作伙伴 服务，心理健康和自杀预防，以及娱乐治疗都热衷于使用MAP- VA改善以退伍军人为中心的护理，护理质量和CLC内外的工作人员参与。 这项工作的成果将适用于支持工作人员和提高复杂老化的质量 整个护理过程中的退伍军人（例如，家庭基本护理（Home Based Primary Care）

Background: VA Community Living Center (CLC) staff struggle to address behavioral and neuropsychiatric symptoms of Veterans with dementia and serious mental illness (SMI) such as schizophrenia. These behaviors of distress (agitation, aggression, and mood disturbance) are not just associated with staff stress and burnout; they also hasten residents’ functional decline, decrease quality of life, and increase mortality. Staff training in non-pharmacological interventions can be effective. Yet systems barriers, task-based traditional biomedical care models, and time constraints often result in staff employing “quicker,” less effective strategies. Montessori Approaches to Person-Centered Care for VA (MAP-VA)— a staff training, intervention, and delivery toolkit— developed in collaboration with VA operational partners, Veterans, and frontline CLC staff is positioned to respond to this challenge. Our pilot data show probable impacts on CLC quality indicators at the individual and unit level (e.g., psychotropic medications, depressive symptoms, weight loss, falls, pain). Significance / Impact: Intense media scrutiny focused on care quality in VA CLCs has created an urgent problem for VA over the past year. To restore perceived trust, safety, and quality— as described in VHA’s Modernization Plan— frontline staff need to be empowered to lead quality improvement efforts like the ones taught through MAP-VA. Innovation: MAP-VA is distinct from existing interventions in its: 1) application to Veterans with a range of diagnoses and cognitive abilities; 2) emphasis on pairing practical skill-building for staff with overcoming system-level barriers that inhibit person-centered care; and 3) engagement of all staff rather than a reliance on provider-level champions. Yet, MAP-VA is a complex intervention that requires participation of multiple stakeholder groups, making implementation facilitation necessary. To date, no studies have evaluated MAP implementation success in operational settings (community or VA) and sustainability is rarely examined. Specific Aims: A hybrid (Type 3) implementation-effectiveness study is necessary to evaluate MAP-VA for Veterans and staff in CLCs. Study Aims include: 1) evaluate implementation facilitation and identify barriers to MAP-VA adoption and fidelity; 2) determine effectiveness of MAP-VA implementation on resident behavioral, emotional, and physical health outcomes; 3) determine effectiveness of MAP-VA implementation on person- centered care practices and organizational culture; and 4) examine the extent to which MAP-VA is sustained after external facilitation support has ended. Methodology: A stepped-wedge cluster randomized controlled trial will be used to evaluate within- and between-cluster implementation success and treatment effects over 18 months. Eight CLCs (24 CLC neighborhoods) will be randomized to a sequential crossover to the intervention with six months of facilitation. Analyses will account for time trends and correlations within cluster. Normalization process theory and the RE- AIM evaluation framework will guide the implementation evaluation and integration of qualitative and quantitative data. Data sources include primary data collection (e.g., resident interviews, staff interviews, surveys, researcher observation) and existing VA administrative data (e.g., Minimum Data Set 3.0, pharmacy, disruptive behavior reporting system, annual employee survey). Implementation / Next Steps: Our partners in the VA Offices of Geriatrics and Extended Care, Nursing Services, Mental Health and Suicide Prevention, and Recreation Therapy are enthusiastic about using MAP- VA to improve Veteran-centered care, care quality, and staff engagement within and beyond the CLCs. Outcomes from this work will be applicable to supporting staff and improving quality for complex aging Veterans across the continuum of care (e.g., Home Based Primary Care).