Can a Nursing Home Psychotropic Reduction Project be Successfully Implemented in Assisted Living?

Abstract

The objective of this study was to compare implementation of a psychotropic medication reduction project across two types of residential long-term care settings: nursing homes (NH) and assisted living (AL) facilities. Fifteen NHs and 14 AL facilities from within a single corporate chain participated in the psychotropic medication reduction project. Using a comparative case study approach, we conducted in-person and telephone interviews with 62 staff members from participating NH and AL facilities to investigate the experience of project implementation. Project implementation within the more institutional NH model produced dramatic changes in residents’ lives and medication use. Conversely, changes made in the AL environment appeared to have less impact on resident medication use and resident-centric narratives, and AL staff identified numerous barriers to implementation. Identifying methods to monitor processes and outcomes of care without increasing the regulatory burden of AL facilities may increase transferability of quality improvement efforts across settings.

Keywords

dementia implementation nursing home assisted living

Until recent decades, nursing homes (NHs) have been the single environment available for residential long-term care (LTC) in the United States. NHs have historically been linked to an institutional-type medical-model of care that lacks privacy, individuality, and personal autonomy for residents (Koren, 2010). Notable improvements have occurred within the NH industry within recent decades, including increased regulatory oversight, expanded education and training requirements for staff, improved physical facilities, and a culture-change movement that seeks to promote resident autonomy and quality of life (Koren, 2010). Despite these advances, NHs continue to be portrayed negatively in the media (Miller et al., 2012) and carry a negative perception among LTC consumers in the United States (Khatutsky et al., 2017). As older adults with higher functional abilities and financial means sought additional options for residential care, the assisted living (AL) industry emerged (Stevenson & Grabowski, 2010).

The definition of AL varies considerably between regions and facilities (Han et al., 2017). State regulation of AL is also highly variable, allowing for wide regulatory fluctuations between states in areas such as staff/leadership credentials, admission criteria, services offered, and regulatory oversight (Stevenson & Grabowski, 2010). For example, 37 states require AL facilities to have a registered or licensed nurse on staff or available, whereas 13 states do not (Rome et al., 2019). There is growing overlap in services offered and the populations served in AL and NH facilities (Grabowski et al., 2012; Han et al., 2017), with AL viewed as both a transition point into LTC and a substitution for NH services in some markets (Grabowski et al., 2012; Han et al., 2017). However, AL facilities generally market themselves as providing a less institutional, less medically focused, and more home-like LTC living environment than what is available within NHs. Evidence to support this claim, however, is mixed and additional research is needed that compares AL with NH settings on specific aspects of care (Zimmerman et al., 2003, 2013).

Because NHs have served as the primary mode of LTC in the United States for many decades, considerable evidence has been generated surrounding the effectiveness of care processes and quality improvement (QI) within the NH setting. What remains less clear is the transferability of this knowledge to the AL setting. Although similarities exist between NH and AL environments, the differences are many, and research is needed to determine what NH QI processes can be successfully transferred to AL settings.

As part of federally and state-funded evaluations of two separate Minnesota state policy initiatives aimed at promoting quality improvement in NHs (Cooke et al., 2009) and home- and community-based settings, including AL facilities (Abrahamson et al., 2016; Noureldin et al., 2019), we utilized a comparative case study approach (Bartlett & Vavrus, 2016; Vogt et al., 2011) to examine the implementation of a comprehensive dementia care QI project aimed at reducing unnecessary psychotropic medications and improving resident quality of life across NHs and AL facilities within a large senior housing corporation in Minnesota. The QI project received financial support from the Minnesota Department of Human Services, first for implementation of the project in the corporation’s NHs and later for expansion to the corporation’s AL facilities. The QI project was one of the many QI initiatives funded by the state, with other organizations focusing QI efforts on other quality issues, including falls, avoidable rehospitalization, pain, and staff turnover.

The objective of this study was to compare the implementation of a psychotropic medication reduction project across NH and AL settings. The project provides a unique context to compare QI implementation processes across settings because it evolved within a single corporation and received financial and technical support under similar state policy initiatives. Our guiding research question was the following: To what extent is a project that successfully reduced psychotropic medication use in the NH setting transferrable to the AL context?

Psychotropic Medication Reduction

The overuse of psychotropic medications (antidepressants, antipsychotics, antianxiolytics, stimulants, and other mood-enhancing medications) is a documented quality problem within residential LTC settings and a regulatory priority of the Centers for Medicare and Medicaid Services (CMS) (Stefanacci, 2017), the largest payer of LTC services in the United States (Reaves & Musumeci, 2015). Although use of psychotropic medications has decreased among NH residents in recent years, use of psychotropic medications remains prevalent among the LTC population, with approximately 15% of NH residents nationally receiving an antipsychotic medication (CMS, 2019). Evidence surrounding psychotropic medication use in AL is less clear, with studies suggesting that between 30% and 50%, or more, of AL residents are taking one or more psychotropic medications (Lakey et al., 2006; Smith et al., 2008). Research indicates that psychotropic medications among older adults are often unnecessary or inappropriately prescribed, and that reducing use of these medications can improve quality of life and reduce the adverse effects and health risks associated with these medications (Lapane et al., 2016; Lindsey, 2009).

Residents with dementia are at particular risk for psychotropic medication overuse to manage the behavioral and psychological symptoms or “expressions” (Caspi, 2013) of dementia. These symptoms include agitation, restlessness, pacing, wandering, excessive worry, depression, psychosis, aggression and sleep disturbances, among others (Gruber-Baldini et al., 2004; Kronhaus et al., 2016). Behavioral and psychological symptoms of dementia can be distressing for other facility residents, families, and staff, and treatment with medications can be effective in reducing distressing behaviors or emotions and improving resident quality of life. However, the symptoms of dementia change over the course of the illness, and a medication that was appropriate in the past may not be appropriate currently (Kales et al., 2015; Tampi et al., 2016). Risks include over-sedation, masking of clinical or cognitive changes that require treatment, falls, decreased communicative ability, exacerbation of cognitive decline, incontinence, and decreased social interaction, all of which decrease resident quality of life and the quality of the care provided (Chiu et al., 2015; Lindsey, 2009). “Off-label” use of medications, or prescribing a medication to treat a condition for which it is not approved, is common and poses additional risks beyond the already dangerous side-effects of this class of medications (Crystal et al., 2009).

Reducing Psychotropic Medications for Residents With Dementia: The Project

The psychotropic medication reduction project was first developed and implemented within a single NH belonging to a nonprofit corporate chain in Minnesota. After seeing success, the corporation expanded the project to its other NH facilities through funding from the Minnesota Department of Human Services. The funded 2-year project (2010–2012) included 15 NH sites. Each site had a project leader or “champion,” who directed the project components which included selection of residents to participate based upon use of psychotropic medicines that may be negatively impacting resident quality of life without a clear supporting diagnosis; comprehensive medical review and health assessment with the resident’s medical provider to guide the plan of action; a personal discovery team to develop a biography of the resident, including, interests, vocational and spiritual history, prior daily routines, and other personal preferences to best plan intervening activities; interdisciplinary care strategy development; and implementation of sensory activities to decrease the need for psychotropic medications. Examples of activities included cooking, storytelling, aromatherapy, exercise interventions, among others. Activities were generally carried out by nursing assistants or activity aides. Resident responses to activities, including their behaviors and mood, were logged for close evaluation, and intervention modalities were adjusted by the interdisciplinary team accordingly.

The NH project achieved substantial success within the 2-year period, with all 15 participating facilities reporting a reduction in psychotropic medication use. The average facility reduced its use by about 55% (range 1%–98%). Other positive outcomes included numerous dramatic resident transformation narratives, including residents who had been essentially noncommunicative becoming socially engaged, improved resident independence in daily activities, improved resident mobility, and decreased incidence of disturbing behaviors.

The success and positive reception of the NH QI project led the corporation to further expand the project to its AL facilities in 2015 for a 1-year project period, also with funding from the state. Project components and implementation methods were modeled after the NH project. A key difference between settings, and a motivation to expand the project to AL, was the very high prevalence of psychotropic medication use in many of the corporation’s AL facilities, often reaching 60%, far higher than psychotropic medication use within the participating NHs. Although the AL project was modeled after the successful NH project, upon completion of the 1-year project there was no measurable decrease in the use of psychotropic medications across AL facilities, with rates of use remaining near 60%. Despite similarities in corporate leadership, state policy context, and geographical location, the project was highly successful in the NH setting, yet challenged to succeed in the AL setting. This disparity in success highlights the need to examine the similarities and differences in the implementation experiences of the project between NH and AL settings.

Method

We conducted semi-structured in-person and telephone interviews with 62 organizational leaders and staff members who were centrally involved in implementing the antipsychotic medication reduction project within the participating 15 NH and 14 AL facilities. Participating facilities were from within a single nonprofit corporation, and were geographically dispersed between urban and rural settings in Minnesota. In total, the participating AL facilities served approximately 1,000 residents between the 14 facilities; the participating NHs had an average size of 70 beds with five facilities having fewer than 50 beds and three facilities having more the 100 beds. Both the NH and AL facilities were Medicaid certified, and payer sources varied between facilities. Respondents included corporate and facility project leaders (typically registered nurses), facility administrators, directors of nursing, other nurses, social workers, activity directors, and unlicensed caregiving staff, including nursing assistants (NH), resident assistants (AL), and activity aides. Interview guides were constructed using a complexity science framework, which describes NHs as complex adaptive systems within which persons communicate and adapt to changing internal and external conditions through self-organization in frequently non-linear patterns. Communication patterns, cognitive diversity, and inter-connectedness of persons are of particular salience to a complexity science framework (Anderson et al., 2003). Interview questions addressed implementation topics such as challenges, facilitators, perceived successes, information flow, interpersonal relationships and patterns of influence, and advice to others seeking to implement QI in LTC settings. Interviews were conducted during the time of project implementation within each setting. Because the NH and AL projects were implemented sequentially, interviews with NH personnel were completed in 2012, and interviews with AL staff were completed in 2015.

For the NH project, we selected three facilities for day-long site visits, which involved individual, in-person interviews with five to 11 staff members representing different roles at each site. For the remaining 11 facilities, we conducted telephone interviews with the facility project champion for a total of 34 interviews with NH personnel. Within participating ALs, we selected two facilities for day-long site visits involving interviews with multiple staff members and conducted telephone interviews with the project champion at the remaining 12 participating facilities, for a total of 25 interviews. We also interviewed three corporate-level project leaders. Participant roles are highlighted in Table 1.

Table 1.

Participant Characteristics.

Role	Corporate	Nursing home	Assisted living	Total
Project director/manager^a	3	14	15	31
Assistant/aide		6	3	8
Director of nursing/other nurse		5	1	6
Activity director		3	2	6
Facility administrator		2	2	4
Social worker		3	0	2
Other		1	2	3
Total	3	34	25	62

Typically a registered nurse, although several AL administrators also served as site project managers.

A comparative case study approach was used to examine similarities and differences in project implementation between the NH and AL settings (Bartlett & Vavrus, 2016; Vogt et al., 2011). First, all interviews were transcribed for analysis. The structure of the interview questions lent itself to an initial categorization of themes, including challenges, facilitators, communication, roles, and advice. Subthemes were developed through three to four investigators simultaneously examining interview text using the Consolidated Framework for Implementation Research (CFIR), a structured approach to categorize intervention characteristics (Damschroder et al., 2009). Investigators first developed a set of emergent codes independently. These codes were grouped into initial themes, then compared and discussed to reach a consensus taxonomy for coding. The interviews were then re-coded using the agreed upon coding taxonomy. Throughout the coding process, the team of investigators met periodically to discuss possible revisions to the coding taxonomy. We also maintained a codebook with definitions for each code to assist with inter-rater consistency. The codebook was updated based upon periodic discussions to assure interpretations of codes remained consistent between team members, and interviews were subsequently re-coded when necessary. After all the interviews were coded, interview findings were compared for NH and AL projects. We used NVivo 11 qualitative software (QSR International) for data management and analysis. Prior to data collection, the study was approved by the Institutional Review Board (IRB) at the University of Minnesota (no. 1008S87933). Protocol included verbal consent for interviews documented by a research associate.

Findings

Table 1 provides information about the 62 study participants, including 31 project leaders (most of whom were registered nurses, although several AL project leaders were facility administrators), nursing assistants/activity aides, other nurses, activities directors, administrators, and other personnel. Themes related to similarities and differences in project implementation across NH and AL settings are discussed and briefly summarized in Table 2.

Table 2.

Implementation Challenges.

Implementation challenges: similarities between NH and AL settings• Initial resistance from staff members and medical providers• Lack of knowledge regarding environmental dementia care techniques• Project timeframe and sustainabilityImplementation challenges: differences between settings• Fewer licensed nursing and direct care staff in AL• Less staff control over medication use and regulatory guidelines in AL• Less QI experience in AL compared with NHsImplementation facilitators: similarities between settings• State funding support• Supportive corporate leadership• Staff support for project goalsImplementation facilitators: differences between settings• AL could benefit from “lessons learned” from prior NH implementation• NHs tended to have access to more psychologist and/or psychiatrist expertise• NHs had built-in mechanisms for collecting data and reporting outcomes (e.g., minimum data set)

Note. NH = nursing homes; AL = assisted living; QI = quality improvement.

Implementation Challenges: Similarities Between Settings

Project leaders in both AL and NHs reported initial resistance from staff members to project participation. Staff buy-in was most challenging at project start in both settings. As one AL project leader noted, “In the beginning, when staff realized we were going to take away medication, it was probably the hardest thing in the world.” Project leaders highlighted lack of knowledge or awareness of the psychotropic medication overuse problem as a key challenge to obtaining buy-in. Similarly, leaders in both settings described experiencing resistance from medical providers/prescribers. An NH project leader commented, “We have to keep on encouraging, especially the older doctors because they’re the ones used to giving all these medications. That can be a barrier at times if we’re not proactive for the resident.” In addition to reluctance to adapt new practices to address behavioral symptoms, respondents from both settings described staff turnover, insufficient available staff, and staff who felt they were already too busy to take on project duties as project challenges.

A related similarity was the perceived lack of knowledge of the variety and effectiveness of environmental dementia care techniques among both NH and AL staff members. Although staff members in both settings were provided with education related to the project, respondents noted a need to change thinking regarding dementia care, and to think more broadly about resident quality of life. An AL project leader noted,

. . . Reducing all of your psychotic medications is a big win, but still if no one is spending any quality time with you or nobody is making you happy, well did we really do our job? No. So how do we work to get to know everybody on a deep enough level to make their quality of life better?

Similarly, an NH project leader said,

It’s just the knee-jerk reaction when someone is having agitation, anxiety. You know the first step or the first thing you think of is, well, let’s give them a pill to calm them down . . . so the biggest challenge is just changing everybody’s way of thinking on that.

Because the project was supported by state funding, an additional challenge found in both settings concerned the sustainability of the project once external funding was removed, which can be more widely translated to a need for additional resources to maintain project components. The NH setting addressed this challenge through extensive marketing of project successes to increase their market share. Marketing project successes was more difficult in the AL setting, partially because measurable outcomes were not observed within the 1-year funding period. One AL project leader commented, “It is too short a timeframe to implement something this big.” Similarly, another AL project leader said,

I think the biggest challenge . . . obviously resident care comes first, then okay, we have got to keep the lights on. We can’t operate 15 beds down forever and then keep the [project] going. So I think to juggle that has been difficult, by far the biggest challenge.

Implementation Challenges: Differences Between Settings

Respondents in the AL setting highlighted clear differences between the care context of AL and NHs that they believed negatively impacted their ability to carry out the project. First, fewer licensed nursing and direct care staff per resident in the corporation’s AL facilities compared with its NHs made translating the project between settings difficult. A corporate leader noted,

One of the biggest challenges (in AL) is the staffing. The levels of staff are so different (from NH) and the interdisciplinary and interprofessional supports and teams that you have in AL are much less robust than they are in a skilled nursing setting.

Although respondents in both settings noted awareness of the psychotropic medication problem and knowledge of non-pharmaceutical approaches to be a challenge, respondents in the AL setting emphasized that gradual dose reduction (GDR) requirements, medication use, and concerns about overmedication are well-documented in the NH setting, with little data existing to fully understand the extent of the problem within AL settings. Project leaders discovered that AL facilities used different tracking systems, and there was inconsistency in how sites were defining what was considered a psychotropic medication and reporting psychotropic medication use. Valuable time at the beginning of the short project period was spent aligning data collection efforts between sites. After a tracking system was implemented to monitor psychotropic drug use as part of the project, AL staff reported being “shocked” by the level of psychotropic drug use in their facilities. Similarly, AL facility personnel described having less control over resident medications due to regulatory differences between the settings, including monitoring of medication administration, and GDR efforts. A corporate project leader commented,

The medication use in AL is actually significantly higher than it ever was in the skilled sector. Because, in the skilled sector, they . . . have regulations that at least guide them and prevent them from extreme overuse of medications, but that is not the case in AL. It is so under-regulated [in AL], that when a client comes in with a certain amount of medications, chances are that they stay with them until something tragic happens.

Quality improvement has been a mandatory part of NH industry operations for years, and AL leaders noted a gap between the QI mindset of AL staff when compared with NH staff. One AL facility project leader commented,

. . . To be honest with you, I kind of forget this is a QI project. The last 10 years I have worked in AL and QI is nowhere on the radar, good, bad or otherwise, it’s just not. I think that we need to do a better job reminding people why we are doing the project and that it is part of QI . . .

Relative to the NH setting, the AL sector lacks validated tools to assess resident outcomes such as quality of life, functional independence, and other psychosocial measures. Furthermore, the federally mandated minimum data set (MDS) used in NHs provided numerous indicators that demonstrated improved resident outcomes, such as behavior and activities of daily living (ADL) decline, which assisted the NH in tracking and celebrating their successes. Conversely, participating NHs faced higher resident acuity and more government oversight, which was a challenge as facilities implemented creative, and perhaps “out of the box” methods, to deal with problem behaviors. For example, an NH respondent noted that a behavioral altercation between residents had occurred during a dose reduction, resulting in an immediate jeopardy action from the State, and commented that such oversight could influence providers’ ability to take risks in the NH setting.

Implementation Facilitators: Similarities Between Settings

A common facilitator between AL and NH settings was the injection of additional funds from the state, which supported additional staff time, corporate-wide and facility-level project coordinators, and other resources. Although the external funding contributed to the challenge of sustainability in both settings, additional resources also facilitated project initiation in both settings. It must be noted, however, that the NH project length was twice that (2 years) of the AL project length (1 year), and that the original pilot test for the project took place in the NH, providing some additional design advantage to the NH project.

The project also shared supportive corporate leadership in both settings. This may have been a particular advantage for the AL setting, given the successful outcomes and positive attention received by prior implementation of the project in the NH setting. Corporate marketing efforts and a strong business case supported the continuation of the project in the corporation’s NHs, as well as the project’s translation to AL. At the same time, implementation of the project in the corporation’s ALs was informed by the experiences of the project’s initial NH implementation. An AL marketing manager responded,

I think it (the project) has made me be very proud of being here and what we offer. I know that my competition, not many have a similar program, so it is an asset for me from a marketing standpoint.

Although staff buy-in was an initial challenge across settings, both AL and NH respondents described staff expressing support for the evolution toward more person-centered care and the individualized nature of the project intervention as the standard for the future. An NH nursing assistant said, “[Project] is a program that I feel benefits the residents’ spiritual, physical, emotional, mental needs. It helps with more one-on-one time with the residents which, you know, in NHs is greatly needed.” Similarly, an AL staff member commented,

I mean the culture has really changed or at least we are well on our way toward changing how we think about people with dementia, how we care for them. I want somebody to know me well enough to know that I’d rather have a dog come visit than paint a picture.

Implementation Facilitators: Differences Between Settings

Although both settings experienced corporate support, the AL staff had observed the success of the NH project and could benefit from “lessons learned” from the project’s 2-year implementation period in the corporation’s NHs. An AL corporate leader noted that is the case of some facilities,

The campus has multiple services and they already had implemented the project on their skilled side, so it wasn’t a huge jump for AL to do it and also it was their culture already because it was already in skilled. So it had spread on its own throughout their building.

Given this AL advantage, the structural differences between AL and NH are worth noting further. For example, many NHs had an available psychologist or psychiatrist as a consultant, which respondents noted was a significant benefit to the project, while most ALs did not have specialized psychiatric prescribers available to them. Also, documentation to track outcomes was already built into the work structure of NH due to regulatory and reimbursement requirements, as well as the more medically focused operating norms. This was noted as a challenge on the AL side, where detailed tracking and monitoring were sometimes a new way of thinking and lack of monitoring structure may have contributed to a lack of documented project success despite anecdotal success being noted by AL respondents. Established processes of documenting, monitoring, and controlling medication use was a facilitator in the NH setting, while such processes needed to be established in the corporation’s AL facilities.

Discussion

Psychotropic medications have been targeted as a class of medications that can be reduced among residential LTC residents through multidimensional intervention. However, residential LTC facilities face numerous challenges in reducing psychotropic medications, including but not limited to behavior and communication difficulties in advanced dementia, lack of staff training/awareness of needed environmental modifications, and use of medications to manage the cascade of side-effects that occur with polypharmacy and multi-morbidity in the LTC population. The objective of this comparative case study was to explore the experiences and insights of NH and AL personnel who had implemented a QI project focused on reducing the unnecessary use of antipsychotic medications among their residents. The project was implemented in two settings within the same organization, and yet yielded very different documented outcomes. Despite a seemingly translatable intervention, similar corporate structure and support, and similar state funding mechanisms, the NH context provided measurable outcomes and dramatic success stories, while the AL context resulted in far less dramatic outcomes. The intervention techniques were essentially the same in both settings, including staff training, placing priority on communication with family and medical providers, and a primary emphasis on individualized interactions between staff members and residents. The similar intervention within different contexts provided a unique opportunity to explore the implementation differences and similarities between settings that may have impacted the transferability of the intervention.

The high level of government regulation in the NH industry provides potential for constraints on care innovation. Regulatory oversight has been accused of encouraging rigidity and promoting institutional models of care. However, regulation and mandated care infrastructure was actually the primary facilitator for the NH in regard to this person-centered QI project. Unlike the AL setting, project implementation in the NH benefited from a structured data collection instrument (MDS) that is required for reimbursement and public reporting of quality indicators, and designed in a manner that allowed facilities to accurately track and monitor outcomes. Because of well-established GDR requirements, NH staff were aware of the prevalence of psychotropic use in their facilities, the need for monitoring and reducing psychotropic use, as well as the need for mandated monthly medication review, symptom monitoring, and documentation of medication administration, whereas the AL facilities struggled to initiate these processes.

Regulation and definition of AL care is inconsistent and lacking compared with NH, although state requirements related to AL are rapidly changing. Between 2018 and 2019, 27 states updated their AL regulations (Bowers, 2019). Compared with other states, Minnesota has been slower in regulating the AL industry. Until recently, Minnesota was the only state in the United States to not require AL facilities to be licensed (Sudo, 2019). Although a recommendation for more regulation of AL is not likely to be well received, many states already regulate dementia care in AL to some degree (Carder, 2016). At the same time, differences in staffing, structure, regulation, and reporting may limit transferability of successful NH quality initiatives. Developing initiatives aimed directly at increasingly popular AL environments for dementia care and seeking methods to monitor processes and outcomes of care without creating a regulatory burden for AL, may positively impact outcomes. For example, public reporting of comparable quality measures in NH has shown potential to impact provider behavior and the quality of resident care, particularly in areas where market competition between facilities is high (Grabowski & Town, 2011; Werner et al., 2010). Although many states provide basic information about AL facilities online, many of these websites lack information consumers need to make decisions about where to receive services and few—if any—report outcome measures (Han et al., 2017; Roberts et al., 2020). Implementation of “5 Star” type reporting and well-defined quality metrics may assist consumers to understand the scope of quality issues such as psychotropic medication overuse and motivate AL providers to measure and improve in reportable areas.

Psychotropic medication use was significantly higher among the AL population, despite the perception that AL facilities are more individualized and less restrictive than NH. Due to the variability in definition, available services, and resident population in AL, it is difficult to identify clear evidence that AL environments are in fact more home-like and less institutional than NHs, which also vary in regard to provision of resident autonomy, privacy, care assistance, and oversight (Zimmerman et al., 2003). Although there is variability in both AL facilities and NHs, the variability among AL facilities is far wider due to lack of consistent regulation of terms and services, making direct comparisons between the two types of residential LTC challenging.

That this study took place within a single state and single corporate structure was a limitation, but also provided a context for comparison. Previous research has found that flexibility to adapt or move staff, as well as information infrastructure, has a positive influence on the adaption of innovative QI in NHs (Lucas et al., 2005). Respondents noted support from corporate leadership was a strength, and future research would benefit from a comparison between individual and corporate environments given the pooled resource advantage likely held by corporate chains to better describe the perceived benefit of a supportive corporate structure. An additional limitation is the 1-year nature of the project in the AL setting, and lack of data on potential evolution of the program over time.

In regard to the question posed by this research, the potential for transferability of successful QI programs between NH and AL settings, the answer is likely no unless program modifications are applied. Many of the implementation barriers and facilitators shared between the NH and AL settings (staff buy-in; knowledge/training, time, supportive leadership) have been previously noted in the implementation literature, as demonstrated by their inclusion in the CFIR and other established frameworks (Damschroder et al., 2009). However, the implementation barriers and facilitators that differed between the settings (licensing credentials of staff, access to medical specialists, clear regulatory guidelines, mandated data systems, and a history of mandated QI) were unique to comparisons of QI implementation between settings within the long-term care context. Policy actions noted above, such as increased regulatory oversight and public reporting, may strengthen the implementation of some improvements within AL, yet bring about challenges openly faced by NH providers. In addition, they may not be well received by consumers and take away some of the elements that attract persons to AL care. Future work in this area would benefit from studies that build upon these findings and adapt NH QI to measure and address context differences between the two settings prior to AL implementation.

Footnotes

Acknowledgements

All listed authors have contributed to this work and are in agreement regarding this final submission.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The project described was funded by the Minnesota Department of Human Services and the Agency for Healthcare Research and Quality (Grant Number: 5R18HS018464; PI: Arling). The PI on the Minnesota Department of Human Services funding was Mueller.

Institutional Board Approval

The study was approved by the Institutional Review Board (IRB) at the University of Minnesota (no. 1008S87933). Protocol included verbal consent for interviews documented by research associate.

ORCID iD

Kathleen Abrahamson

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