What Does Research Mean for Providers?
September 17, 2018 | by Gene Mitchell
Participating in research projects offers great benefits, but providers should make sure they’re prepared for what the work entails.
Participating in research projects offers great benefits, but providers should make sure they’re prepared for what the work entails.
“There’s that trifecta of process, culture and discernment that needs to go into it. You need a culture of inquiry, trust with stakeholders, and you have to think there’s a benefit. The service culture must be solid and have [its] operational ducks in a row before going forward.”
So says Tabassum Majid, Ph.D., executive director of the Integrace Institute, Sykesville, MD, when describing how a provider organization should prepare to participate in a research project.
LeadingAge members participate in research projects for many reasons. They may pilot new programs of their own design or from third parties. They may participate in grant-funded studies. They may simply allow university researchers to gather data by surveying willing residents.
But how does participating in research affect providers? Does it lead to permanent change? Does it impose a burden on staff?
Parker, a full-continuum provider based in Piscataway, NJ, has been involved in many research projects, but has taken the unusual step of funding outside research into one of its innovations—a new “small house” model of care in a nursing home.
Parker at Monroe opened in 2014. Its 6 small homes house 16 people each, and are internally connected to a community center offering enriching programs, rehabilitation services, dining and more. Two of the 6 homes are for residents with early- to mid-stage dementias, 3 serve residents with moderate to severe dementias, and one serves residents with complex physical issues who do not require memory care.
“We took a brand-new site and developed a number of teams with [varied] expertise to help create the ideal small home model for people living in this unique setting,” says Roberto Muñiz, president and CEO of Parker. The organization calls it a small home model, and Muñiz says it’s different from the Green House™ model.
The conceptual foundation of the new community goes back to Parker’s first small home model, launched in 2001 at the Parker at River Road campus.
“While planning the new community, we decided to expand the original small home model, which consisted of 12 residents, and convert it to 16, to determine effectiveness and efficiency,” Muñiz says. “The additional 4 residents per home would not affect the care and services model provided, while at the same time, it would be more cost-effective caring for 16 people vs. 12. We were able to prove that the change made sense. We still have the staff ratios we required: 1 nurse, 2 CNAs minimum (in addition to recreation, dining and other support staff), which provide the highest quality of care for 16 residents.”
“We have neighborhood guides that are nursing clinicians that manage each home,” says Muñiz. “We have created the small home atmosphere without it feeling like an institution. Employees are responsible for multitasking; cooking breakfast, leading recreation activities and providing therapy. It’s an all-hands approach.”
Parker approached the LeadingAge LTSS Center @UMass Boston about evaluating the model, and funded an 18-month study, complete with 2 control homes—an older skilled nursing community and a newly acquired property, the latter “a very typical institutional setting,” in Muñiz’ words. You can read about the results here and here on the LeadingAge website. An article on the project appeared in Innovation in Aging, 2017, Vol. 1, No. 2, from The Gerontological Society of America.
The organization’s philosophy regarding research is an outgrowth of its mission, “Discover ways to make aging manageable, relatable and enriching for all of society.”
“Research helps us discover new and better ways to help people successfully manage aging needs and allows them to stay active and connected, Muñiz says.
“We focus on finding ways to improve quality and improve the lives of those we serve, and we’ve gotten pretty good at that,” he says. “The additional mission is to provide thought leadership and share knowledge. All of our research is in the public domain and none of these things are proprietary. We want to share our findings with all in the field.”
Other projects Parker has been involved with include:
Parker is also working with Meals on Wheels America, and is involved in studies of voice digital assistants such as the Amazon Echo and used with the ParkerLife Skill Application. The latter is a voice application developed to support assistant living residents with daily activities, appointments, exercise calendars, dining options and more.
Moorings Park is a 2-site life plan community based in Naples, FL. It serves more than 700 people in independent living, assisted living and skilled nursing, and also has a home health agency, a physician clinic, and an outpatient therapy center.
It is one of more than 80 life plan communities participating in the Age Well Study by Mather LifeWays Institute on Aging and Northwestern University. It has also hosted pilots of a wellness score calculator, and a home monitoring program collecting blood pressure and weight data over the internet, to be fed into electronic medical records.
Moorings Park has also hosted several studies done by student interns from Florida Gulf Coast University (FGCU).
“We have probably 3 to 4 interns every year from them,” says CEO Dan Lavender, “and they have done a couple of studies with residents. There was one on pre-testing and post-testing of cognitive function, and one on the impact of strength training over time.”
Lavender, like Muniz, says the organization’s mission is what drives its decisions to participate in research.
“Our mission is to help people successfully age,” Lavender says. “They are also interested in wellness and health. Whenever we can find something our residents are excited about and interested in, and if it can help better position the organization’s efforts in helping people successfully age, that’s when we’re interested.”
Participating in studies leads to concrete changes, which lead to concrete improvements at Moorings Park. Administering the Seniors Fit Test to as many as 300 residents every year has given the organization insight into how to improve.
“We benchmark our population, which is averaging about 83, to the 65-plus population, so we’re at an age disadvantage,” says Lavender. “A couple of times we’ve uncovered an area where our population was a little further off of the benchmarks than we’d like. One year the posture [scores] came out pretty weak, so we designed posture-improving classes for our program the next year. Another year, balance wasn’t as strong as we liked, so we instituted balance classes, or individual exercises on balance. In both cases, when we measured again the next year, we saw improvements against the benchmarks.”
The Integrace Institute and Mather LifeWays Institute on Aging are both research arms of LeadingAge-member provider organizations. As such, both concentrate their efforts on improving the practice of providing aging services.
“There is a vision and philosophy of research that is advancing person-centered practices,” says Majid, of the Integrace Institute. “We have focused on dementia-specific research, but now are focused on neurocognitive topics: prevention, caregiver research, person-centered models, culture change and more.” Studying the ways technology can improve the lives of older adults is an important part of the Institute’s work. Click here for more information on the Institute’s 2018 studies.
Much of the Institute’s work is done in partnership with universities, technology companies and other provider organizations. While some research is done within the Integrace group of communities, most projects go outside the Integrace walls. Last year, Majid says, there were 10 external projects and this year there are at least 12.
One requirement for every project is that results are reported back to those studied, and to the aging services field. “Results have to be understandable by pros across the industry,” Majid says. The Institute holds periodic research forums around Maryland to report on its studies.
“When a project is completed there’s a report, and we expect them to share it with stakeholders,” says Majid. “A negative study is just as powerful as a positive one. Honestly, there are lots of organizations that claim they have evidence behind their practices, but they don’t. This [research] offers an objective set of eyes. Outcomes for an organization might be a new policy, a change in approach, or a collection tool they’re able to use.”
The Mather Institute divides its research into 2 main categories—wellness and workforce—says Director of Research Catherine O’Brien, Ph.D.
“We are very open to different topics within those 2 broad categories, and we’re always looking … across organizations, both in senior living and across the broader industry, and listening to what people are saying informally or through conferences, and then thinking about opportunities to contribute,” O’Brien says.
The Mather Institute also studies social engagement, either among Mather residents or people in the broader community. It has done studies on technology advances and a number of projects with village organizations.
“What carries through all projects is a positive, strength-oriented approach,” O’Brien says. We’re not really focused on disease or deficits, but on helping people thrive.”
The Institute also has annual awards programs to honor innovative research and promising practices.
As with Integrace, research partnerships are common for Mather.
“We’re also looking for projects that are innovative and address the research gap,” O’Brien notes, “and not just doing research for research’s sake. We look at projects that have an impact for people in our field, and then look at our internal staff expertise. [In] our collaborative research partners program, we work with various researchers from universities across the country. We look at what our staff can bring to the table and what those university researchers bring to the table, so we have a stronger team overall.”
For the study of Parker at Monroe, defining what was to be studied required a lot of time from Parker staff, involving management, clinical and finance staff. A director of professional education was assigned to serve as liaison to the LTSS Center.
Once the scope of research was defined, Parker presented it to its internal research committee for review and approval. Robyn Stone, co-director of the LeadingAge LTSS Center, presented to the Parker board before the research began.
Figuring out how much staff time the organization can afford to devote to a project is, says Muniz, “probably one of the biggest challenges. We receive a lot of calls from partners who want to use Parker for pilot studies, but that takes a lot of time and effort, and as much as we’d like to, that’s not always possible to accommodate. We have to prioritize based on our objectives.”
“When we invite someone to participate, we want them to understand what’s being asked of them,” says O’Brien. “In some instances, it may equal a small time commitment, such as when we conducted a survey last year on transparency and decision making, and sent it to a large list of communities and invited one staff person from each to take the survey. That might have taken 20 minutes, and that was all that was asked of participants.
“In other instances, the commitment may be greater. For example with the brain health program we did, we invited organizations to attend a one-day training, so they traveled here, attended our workshop, learned the program material, then went back, recruited residents, delivered the program and made sure residents were offered surveys to take. That was a pretty high level of commitment.”
At Moorings Park, Lavender says, the staff commitments have been modest: “We have people whose jobs are to think about programming for residents, so adding research to it is really part of that job to begin with. And a lot of these are collaborations. When we have FGCU students coming every year, we’re training them about how we make sure people stay fit and well, and they bring their ideas. They’ll ask, ‘What if we try this and see what results we get in 12 weeks?’”
Another issue is the need to gain approvals from any residents who might be involved in research.
Lavender says, “We don’t participate [in a study] unless we get volunteer residents excited to participate. In the [Age Well] study we had to have everyone sign a form about what our responsibilities are and what theirs are. In some cases, where we’re asking and longitudinally tracking how people feel about their wellness, we’ve actually slowed them down because we want it to be internet-based and easy, and to be HIPAA-compliant sometimes takes some time to do. Sometimes to implement positive change you have to slow down and be careful that you do that.”
Mather has an institutional review board, as do its partnering universities, where HIPAA and privacy issues can be worked out.
“We have to make sure our consent forms pass every requirement, and we take every step to keep data secure. If an organization is offering surveys to residents, they’ll be given the appropriate consent forms to read and sign,” says O’Brien.
“We have internal valuation committees who have to approve any project,” says Majid. “With that comes a set of questions: Is it ethical, is it providing knowledge to us, will it inform our next generation of services?”
At Parker, Muñiz says, “Residents and families really appreciate the fact that we engage them in these types of research. Not surprisingly, the staff does as well.”
Once the research contract was finalized, interns from Rutgers were recruited to be research assistants. That suggests another benefit of a project like this—developing the field’s future workforce.
“We have a major challenge in the United States of people not knowing about the field of aging, or being afraid of it,” says Muñiz. “Working with colleges and universities and engaging students into the research helped us address some of those challenges.”
Those with research experience, both the studiers and the studied, have good advice for providers interested in evaluation of their own communities.
“First, be committed to making a difference in people’s lives, which every LeadingAge member already is,” says Muñiz. “We all are looking for best practices and it’s important that we share knowledge.”
Muñiz also says finding the funds can be a challenge, but a commitment to research is a commitment to spending or gaining the grants you’ll need. He also recommends always looking for other organizations as partners, or to find existing efforts already underway that you can join.
“I would say every organization has to make up its own mind,” says Lavender. “If your mission is like ours, then being involved in studies is just a natural extension of what we do. If residents are excited about figuring out ways to improve their own health, then these are just a win-win. Data-driven successful aging initiatives can position us for the future.”
Keep the resident experience in mind, says O’Brien.
“Learn as much as you can about the study and what’s involved in it. And think about how residents would enjoy it. Some organizations have gone to residents to try to gauge interest in a program before agreeing to participation.”
Gene Mitchell is editor of LeadingAge magazine.