Dissemination and Implementation of Function Focused Care for Assisted Living

Abstract

Assisted living (AL) settings are residential settings that provide housing and supportive services for older and disabled adults. Although individuals in AL are less functionally impaired than those in nursing home settings, they engage in limited amounts of physical activity and experience more rapid functional decline than their peers in nursing homes. Function Focused Care for Assisted Living (FFC-AL) was developed to prevent decline, improve function, and increase physical activity among residents living in these settings. The purpose of this study was to disseminate and implement the previously established, effective FFC-AL approach to 100 AL settings. Evidence of our ability to successfully disseminate and implement FFC-AL across these settings was established using the Reach, Efficacy/Effectiveness, Adoption, Implementation, and Maintenance model. Settings were eligible to participate if they had more than eight beds and identified a nurse (i.e., registered nurse, licensed practical nurse, or direct care worker) champion to facilitate the implementation process. Setting recruitment was done via mailed invitations to 300 eligible ALs and e-mails to relevant AL organizations. Evidence of reach was based on our ability to recruit 99 ALs with adoption of the intervention in 78 (78%). There was a significant improvement in policies supporting function-focused care and in establishing environments that supported function-focused care, and there was evidence of enduring changes in settings indicative of maintenance. We were able to implement all aspects of the intervention although challenges were identified. Future work should focus on using more face-to-face interactions with champions along with identified stakeholders, evaluating characteristics of champions to establish those who are most successful, and recruiting residents to obtain resident-specific outcomes.

Keywords

dissemination function implementation older adults physical activity

Although the description of assisted living (AL) varies by state (National Center for Assisted Living, 2012), this term generally refers to residences that provide housing and supportive services, 24-hour supervision, and at least two meals a day to meet the individual needs of residents. Care is provided by direct care workers (DCWs), often, but not always, under the supervision of licensed nurses. Approximately 31,100 AL settings with 971,900 licensed beds serve 733,400 residents (National Center for Assisted Living, 2012). A little over a third of residents (37%) in AL need help with three or more activities of daily living (ADLs), 42% have some cognitive impairment, and 39% need skilled nursing services (National Center for Assisted Living, 2012).

Although residents in AL are less functionally impaired than residents in nursing facilities (NFs; e.g., nursing homes), they are similar in that they engage in very limited amounts of physical activity (Chung, 2013; De Lange, Van Der Veen, & Van der Werf, 2008; Galik, Resnick, Lerner, Hammersla, & Gruber-Baldini, 2015; Król-Zielińska, Kusy, Zieliński, & Osiński, 2011; McConnell, Pieper, Sloane, & Branch, 2002; Resnick, Galik, Gruber-Baldini, & Zimmerman, 2010). Moreover, AL residents have been noted to experience more rapid functional decline than their peers in NFs (Fonda, Clipp, & Maddox, 2002; Frytak, Kane, Finch, Kane, & Maude-Griffin, 2001; Resnick & Galik, 2015). This finding may be explained by the fact that AL environments often impose barriers to engaging residents in physical activity in an attempt to assure safety (Benjamin, Edwards, & Caswell, 2009; Chung, 2013; De Lange et al., 2008; Król-Zielińska et al., 2011; McConnell et al., 2002; Resnick et al., 2010). For example, ambulation may be discouraged because nursing staff (mainly DCWs) and families fear residents will fall if they do not remain seated. In addition, the AL industry is primarily based on a fee-per-service model in which residents pay for services provided. Residents and families expect that monthly payments assure DCWs will provide the service (i.e., complete the task) rather than provide the verbal encouragement, cueing, or minimal assistance needed to assure that residents walk, dress, or bathe at their highest level. Consequently, DCWs tend to meet the expectations of residents and families and complete the task for the resident. Once no longer allowed or encouraged to perform or participate in an activity (e.g., upper extremity bathing), residents lose the ability and motivation to do so (Resnick, 1998, 1999).

To address the persistent functional decline and increased time spent in sedentary activity seen among AL residents, we suggest implementing a previously tested, effective, evidence-based function-focused care approach. Function-focused care is a philosophy of care that teaches nurses to evaluate older adults’ underlying capability with regard to function and physical activity and to assure that older individuals optimize and maintain their functional abilities and increase time spent in physical activity (Resnick, Galik, Boltz, & Pretzer-Aboff, 2011). Examples of function-focused care interactions include modeling behavior, providing verbal cues to perform a given behavior, and walking a resident to the dining room rather than pushing him or her in the wheelchair. Prior research has consistently supported the clinical benefits of function-focused care for residents (Galik et al., 2008; Galik, Resnick, Hammersla, & Brightwater, 2014; Gruber-Baldini, Resnick, Galik, Zimmerman, 2011; Resnick, Galik, & Boltz, 2013; Wells, Dawson, & Sidani, 2000). Benefits included maintenance or improvement in function and physical activity, and residents were less likely to be transferred to hospitals. Moreover, there was no evidence that function-focused care increased falls or other adverse events.

Challenges to Dissemination and Implementation of Effective Care Approaches in ALs

Dissemination focuses on the targeted distribution of information and implementation is the process through which an innovation is communicated, over time, through certain channels of a social system (Glasgow, Vinson, & Chambers, 2012; Rogers, 2003). Challenges to dissemination and implementation of evidence-based interventions into AL settings and other NFs vary by setting and include beliefs about the utility and feasibility of the new approach, insufficient training of staff, insufficient recognition and support from administration, inadequate staffing levels, competing workload concerns, staff turnover, costs associated with the intervention, and lack of fit between the intervention and culture or philosophy of care within the community (Beck et al., 2005; Lekan-Rutledge, Palmer, & Belyea, 1998; Resnick et al., 2008; Schnelle et al., 2002). At the resident level, challenges to engaging in functional and physical activity include acute medical events such as cerebrovascular accidents, advanced age, sociodemographic characteristics, comorbidities that affect function, cognitive impairment and associated behavioral symptoms, depressed mood, poor perceived health status, lack of motivation, cultural expectations, pain, fear of falling, high body mass index, and polypharmacotherapy (Ouslander et al., 2005; Resnick et al., 2008).

Theoretical Models to Optimize Behavior Change and Dissemination and Implementation

Social cognitive theory (SCT; Bandura, 1997) is one of the major theoretical frameworks used to change behavior in nurses and older adults (Jeffries et al., 2011; Rejeski, Mihalko, Ambrosius, Bearon, & McClelland, 2011; Schnoll et al., 2011; Sherriff, Burston, & Wallis, 2011; van Stralen, de Vries, Mudde, Bolman, & Lechner, 2011). SCT is a behavior change theory suggesting that the stronger the individual’s self-efficacy and outcome expectations, the more likely it is that he or she will initiate and persist with a given activity. SCT approaches can be used to overcome resident-level challenges, particularly with regard to motivation.

Setting-level challenges are best addressed through the additional consideration of the social ecological model (SEM; Resnick, Galik, Gruber-Baldini, & Zimmerman, 2013). The SEM includes intrapersonal (e.g., physical capability), interpersonal (e.g., staff and resident interactions), environmental (e.g., clear pathways for walking), and policy factors (e.g., falls policies that encourage physical activity) that influence behavior. In this study, all aspects of the SEM were considered to optimally address resident and setting specific barriers and thereby change behaviors among nurses and residents (Fleury & Lee, 2006; Resnick et al., 2013; Sallis, Bauman, & Pratt, 1998). SCT was used to guide the interpersonal interactions that motivated residents to change behavior. Using this theoretical approach, the purpose of this study was to disseminate and implement our evidence-based Function Focused Care for Assisted Living (FFC-AL) approach to care into 100 AL settings. We hypothesized that (1) 100 settings would identify nurse champions and participate in the implementation process and (2) participating settings would demonstrate improvements in their environments and policies to facilitate function and physical activity among residents, and there would be fewer falls and transfers to higher levels of care (acute care or NFs).

Method

Design and Sample

This study used a single-group pre–posttest design rather than a randomized controlled trial, as the focus was on learning about the process of dissemination and implementation of FFC-AL to the 100 settings and not on the effectiveness of function-focused care (Proctor, Khinduka, Aarons, Brown, & Carpenter, 2015). A large convenience sample of AL settings was included in this study as a way in which to evaluate our ability to reach as many different settings as possible. Settings were eligible to participate if they were (1) in Maryland and within the greater Washington-Baltimore area (i.e., within 150 miles of Baltimore) and (2) willing to identify a nurse to participate with us as the champion in the implementation process. Settings were excluded if they had fewer than eight beds. Invitations to participate in the study were sent to approximately 300 AL settings that were eligible via traditional mailings. A total of 99 eligible facilities expressed interest in the study and wanted to participate. The size of the facilities ranged from 11 to 265 beds, with an average size of 49 (SD = 47) beds. The majority of the settings were single settings (n = 78, 79%), 13 (13%) were chains (more than one setting with the same owner), and the remaining 8 (8%) were continuing care retirement settings in which multiple levels of care were available. All of the champions were either the AL managers and/or the delegating nurses within the settings. The study was reviewed and approved by a university institutional review board.

Intervention

Our FFC-AL has been described previously (Resnick, Galik, Gruber-Baldini, & Zimmerman, 2011). The intervention involves teaching the function-focused care champions in each of the participating settings to implement the following four components of function-focused care: (1) Environment and Policy Assessments; (2) Education of staff, residents, and families, including use of our Function Focused Care website, which has six short video coaching sessions (Function Focused Care, 2015); (3) Developing Function-Focused Service Plans for Residents; and (4) Mentoring and Motivating (Table 1). Components are implemented sequentially, although activities within each component continue indefinitely as the philosophy of function-focused care is integrated and becomes routine care in that setting.

Table 1.

Description of the Implementation Process of Function-Focused Care.

Component	Description of activities
1. Environmental and Policy Assessments	Champions were taught to complete the Environment and Policy/Procedures for Function and Physical Activity Evaluation forms and encouraged to assess their physical environments and policies and culture within their settings.
	During the face-to-face meeting in the facility, the assessments were completed with the Research Nurse Facilitator and discussions about ways to alter the environment using the NASCO gift certificate.
	Drafts and examples of policies/procedures to optimize function and physical activity of residents were provided as needed.
2. Education	Face-to-face education of champions was provided for those who could attend the session, or an opportunity was provided to review the session via a recorded webinar or participate in face-to-face education during the first setting visit.
	The website was reviewed with champions, and they were specifically shown resources for education of the staff, residents, and families; tidbits and ideas for implementing function-focused care activities; and the video coaching sessions.
3. Establishing Function-Focused Care Goals for Residents	Champions were taught how to evaluate the residents’ physical capability using the Physical Capability Assessment tool (Resnick, Boltz, Galik, & Wells, 2013) and apply findings to the service plan during the face-to-face education session.
	Champions were encouraged to do these assessments as relevant for their residents (i.e., for residents who required help with functional activities).
	Activity goals (going to exercise class; walking to the dining room; taking out the garbage) were encouraged for those residents that were independent with activities of daily living.
4. Mentoring and Motivating	The champions were provided with techniques for how to motivate residents and engage other staff via the weekly tidbits and online website resources. Examples of motivation interventions included photo contests across sites to see who had the most innovative way in which to engage residents in physical activity during a holiday such as Halloween or Christmas.

The champions were invited to participate in a half-day face-to-face training or were exposed to training information during the first face-to-face visit with the Research Nurse Facilitator in the setting. In addition, during the first face-to-face visit to the setting, the Research Nurse Facilitator worked with the champion to plan setting specific implementation of all four components of the intervention. Each setting was provided with a gift certificate to purchase resources to encourage physical activities among the residents from an online health supply company (NASCO; http://www.enasco.com/c/healtheducation/Fitness/). The site champions also received weekly e-mail tips with ideas for activities and motivational techniques to engage residents in functional tasks and physical activities (Function Focused Care, 2015). Last, the Research Nurse Facilitator visited the sites at the end of the 12-month period to review experiences and gather follow-up data.

Measures

Dissemination and implementation of FFC-AL were evaluated using the Reach, Efficacy/Effectiveness, Adoption, Imple-mentation, and Maintenance (RE-AIM) model (Glasgow, Toobert, Hampson, & Strycker, 2002). Table 2 delineates the RE-AIM dimensions and how each was measured.

Table 2.

Description of RE-AIM and Relevant Indicators and Evidence.

Dimension	Indicators of achievement	Sources of evidence
Reach refers to the proportion of representativeness of the population targeted by the innovation.	Recruitment of settings, numbers of residents potentially reached	Site recruitment rates, total number of residents potentially affected by function-focused care
Effectiveness refers to the extent to which the intervention improved outcomes of participants.	Evidence of change in the environment, policy and service plans to optimize function and physical activity, decreased falls and hospitalizations of residents	Measurement of the environment, policy and service plans, measurement of resident falls and hospital transfers in the month prior to and in the last month of the 12-month study period.
Adoption refers to the proportion of organizations or settings that adopt the innovation.	Setting willingness to provide a nurse champion to work with the Research Nurse Facilitator on implementation activities	Setting identification of a nurse champion and participation in implementation of function-focused care activities (e.g., completing policy and environment assessments)
Implementation refers to evidence that the intervention was implemented as intended.	Implementation consistency was based on delivery and receipt; in addition, we evaluated needed adjustments in the intervention activities per setting.	Delivery based on evidence that all champions received the initial face-to-face training, that the champions were provided with the resources to teach and raise awareness of function-focused care among their staff, residents, and families; that the environment and policy assessments were completed and appropriate changes discussed; and that champions received the weekly tidbits
		Receipt based on evidence that the setting used the NASCO gift certificate
Maintenance refers to long-term adherence to the intervention and transition of the intervention into routine care.	Evidence of adherence to function-focused care activities at the end of the 12-month study period	Evidence of enduring changes in the environment and policies within settings to facilitate function-focused care

Reach

Evidence of Reach was based on the number of facilities that volunteered to participate in the study. We also described the number of residents potentially reached via intervention activities in these settings.

Effectiveness: Facility Outcomes

Effectiveness of FFC-AL was based on evidence of expected outcomes at the level of settings versus individual residents. These outcomes included evidence of changes in environments and policies and an overall decrease in the number of falls and hospital and/or NF transfers among all residents in each setting. The Environment Assessment includes 18 items, 14 items that have a positive impact on function and physical activity and 4 that are negative. The Policy Assessment includes 15 items all reflecting different policies and their potential impact on function and physical activity. Both measures have prior evidence of reliability and validity (Galik et al., 2014; Resnick et al., 2013; Resnick & Galik, 2015). In addition, descriptive data related to number of all resident falls, hospital visits (in-patient hospitalizations and emergency room visits), and NF transfers were obtained. Falls included all of the falls that occurred regardless of the number of residents actually falling. Data were collected for the periods 2 months prior to implementation of FFC-AL and the past 2 months of the study from the AL managers or champions in each of the settings.

Adoption, Implementation, and Maintenance of Function-Focused Care

Adoption was based on participation of settings and champions with participation defined as attending the group or individual setting training and completing the four components of the FFC-AL. In addition, we considered if there were differences in adoption based on setting size or type (e.g., single setting, chain, or continuing care retirement community). Evidence of implementation was based on exposing settings to all four components of FFC-AL. Last, maintenance of function-focused care in each setting was based on evidence (quantitative and qualitative) of institutionalized changes in service plan formats to address function-focused care, marketing materials that highlighted function-focused care, enduring environment and policy changes, and evidence of increased opportunities for physical activity in the activities offered to residents at 12 months postimplementation of the FFC-AL.

Data Analysis

Descriptive data were used to describe participation of sites and other relevant facility-based aggregate outcomes (e.g., falls, hospitalizations). Chi-square and single-group analysis of variance was used to consider differences between setting type (e.g., single setting, chain) and size with regard to adoption. Single-group repeated-measure analysis was used to compare baseline and follow-up outcomes for falls, hospitalizations, emergency room visits, and environment and policy assessments. A p ≤.05 significance level was used for all analyses. Last, feedback from participating champions was used to provide evidence of maintenance of function-focused care in these settings.

Results

Reach

A total of 300 AL settings were invited to participate in the study. Of these, 99 sites (33%) volunteered to participate. The size of the settings (49 residents, SD = 47) was consistent with the average size of settings in Maryland but somewhat smaller than the national average, which is approximately 75 residents (Stevenson & Grabowski, 2010). Working with these 99 AL settings, we were able to potentially influence care of approximately 3,676 older adults.

Efficacy/Effectiveness

As shown in Table 3, at baseline, the average positive environment score was 9.17 (SD = 1.71) and at follow-up the score was 10.97 (SD = 1.62) with a significant improvement overall across sites (F = 22.34, p ≤ .001). The negative environment subscale score was 0.12 (SD = 0.33) and the follow-up was 0.03 (SD = 0.17) with a nonsignificant change (F = 3.19, p = .08). Overall, we helped sites increase positive aspects of their environments such that they were more likely to encourage physical activity. There was little evidence overall of negative aspects of the environment.

Table 3.

Descriptive Outcomes at Baseline and Follow-Up.

Variable	Baseline (SD)	Follow-up (SD)	F (p)*
Falls	12.00 (16.21)	9.33 (16.40)	4.1 (.05)*
Hospitalizations	2.60 (2.61)	2.27 (4.76)	0.11 (.74)
Emergency room visits	1.69 (1.25)	1.92 (2.43)	0.09 (.76)
Policy	4.15 (3.70)	10.79 (1.67)	78.22 (.001)*
Environment: positive subscale	9.17 (1.71)	10.97 (1.62)	22.34 (.001)*
Environment: negative subscale	0.12 (0.33)	0.03 (0.17)	3.19 (.08)

p ≤ .05.

At baseline, the mean policy score was 4.15 (SD = 3.70), and at follow-up, the policy score increased to 10.79 (SD = 1.67), showing a statistically significant improvement in policies (78.22, p ≤ .001) that optimized function and physical activity. With regard to falls, at baseline, the sites reported a mean number of 12.00 falls (SD = 16.21) in the 2 months prior to the start of the study, and during the last 2 months of the study, there were 9.33 (SD = 16.40) falls (F = 4.1, p = .05). At baseline, there was a mean of 2.60 (SD = 2.61) hospitalizations and a mean of 1.69 (SD = 1.25) emergency room visits. At follow-up, there were 2.27 (SD = 4.76) hospitalizations (F = .11, p = .74) and 1.92 (SD = 2.43) emergency room visits (F = .09, p = .76). There were no transfers to NFs. These findings suggest that there was a significant decrease in falls over the course of the study period, but there were no significant changes in hospitalizations, emergency room visits, or transfers to NFs during the study period.

Adoption

Adoption was based on participating in the training and working with us to implement the four components of FFC-AL. Of the 99 settings that volunteered to participate in the study, 38 individuals attended the initial face-to-face training, representing 28 settings (28%). Fifty settings participated in the initial training during the first face-to-face visit in the settings. The remaining 21 settings (21%) were not willing or able to attend the full-group face-to-face training session or arrange for the follow-up meeting with the Research Nurse Facilitator. These 21 settings were willing, however, to receive the weekly e-mail tidbits. Their reasons for not participating with any face-to-face interactions or engage in study-related activities (i.e., implementation of the four steps involved with FFC-AL) were time constraints, given other initiatives within the settings. There were no differences in setting size among those that adopted FFC-AL (mean number of beds was 59.00, SD = 38.86) versus those that did not adopt (mean number of beds was 46.94, SD = 49.84, p = .34). Likewise, there was no difference between those who adopted versus those that did not adopt in terms of setting type (χ² = 2.18, p = .54).

Implementation

All aspects of the intervention were implemented as intended in 78 of the sites. Specifically, the sites were visited by a Research Nurse Facilitator, environment and policy assessments were completed and reviewed, and plans for training of staff, families, and residents initiated. The sites varied in terms of how they performed the education. Family and resident awareness and education were generally done via newsletters, flyers, and announcements on facility-based social media sites. Eighty percent of the settings used their gift certificates and obtained resources to increase function and physical activity among residents. The majority of the settings focused implementation activities at the level of the setting and encouraged setting-based programs and activities, such as having all residents walk or self-propel to meals, or engaging the residents in daily home maintenance, such as taking out the garbage and setting and clearing the table for meals.

As proposed, we provided weekly e-mails to all participants during the course of the 12-month intervention period. Many of the champions shared this information with their activity staff and nurses and sent our information to colleagues at other facilities. Approximately half of the sites responded to e-mails and participated in contests held during the course of the study as part of Component 4.

Maintenance

There were no changes made to service plan formats or marketing materials pre- and postimplementation of the intervention to suggest maintenance of function-focused care. At the time the study was initiated the state regulatory agency released a new service plan format, the use of which was not required but was strongly encouraged. Thus the sites generally all used the recommended format for service plans. Qualitative feedback from champions at the end of the study period provided some support for maintenance of function-focused care within settings (Table 4). Specifically, settings reported using the weekly tidbit ideas, such as requiring residents to walk/self-propel wheelchairs to collect their prizes during the routinely provided BINGO games, and incorporating fun physical activities throughout the day, such as getting to meals and activities by dancing in a conga line.

Table 4.

Qualitative Feedback on Maintenance of Function-Focused Care From Settings.

I would like to submit a tidbit of a way we encourage physical activity in our setting. We want the residents to be comfortable, feel “at home,” and make use of the whole house just like they would if they were living in their own home. We accomplish this by having book readings in the family room, bible study in one of the sunrooms, flower and vegetable planting in our raised flowerbed on the back terrace, cooking in the activity room, etc. We also encourage family members to use different areas when they visit. This promotes function-focused care because our residents have to travel/walk throughout the home.

One of our activity directors leads a conga line when she is coming back from an activity that she has conducted in one of our sun rooms. The residents love it and they are exercising at the same time! This same activity director also plays on the residents’ competitive natures with a beach ball activity that she incorporates into an exercise program. She positions herself in the doorway and tells the residents that they can’t leave the room until they get the ball past her 10 times. The residents really enjoy the challenge and have had a good workout by the time they accomplish the task.

To motivate our residents to engage in physical activity we have a program in which we pay the residents to help out by doing chores around the house. We have Country Acres Dollars, similar to monopoly money. The residents can shop with the Country Acres Dollars in our Country Acre’s Store filled with items such as toiletries, air fresheners, stickers, or little games for their grandchildren who visit such as cards, clothes, hair accessories, etc.

Thank you again for all you’re doing in this project. Our residents are now busy with Garden club; outdoor plants in the patio are growing fine and they are committed to watering them and seeing them grow. It’s very therapeutic and good physical activity!

We now have a set Garden club, disco club, and large amount of residents now in the bingo group. For bingo, they have to walk to get their prizes as you recommended!

Discussion

Using a RE-AIM Model we demonstrated our ability to disseminate and implement function-focused care into 78 (78%) of the settings recruited into this study. The outcomes included were descriptive in nature and based on settings and not residents. Further settings were not randomized, and there was no comparison group. At the level of the settings, there were significant changes in policies, the environment, and decreased falls prior to and 12 months postimplementation of FFC-AL. There were, however, several challenges to our dissemination and implementation approach and our ability to integrate function-focused care across a large group of AL settings. These challenges provide guidance for future research.

Although we were able to reach 99 settings initially, only 28 (28%) attended the face-to-face group training, and an additional 50 met with the Research Nurse Facilitator to go through the face-to-face training during the first meeting at the setting. Other studies testing dissemination and implementation approaches have noted better reach when doing training via a webinar, teleconferencing, electronic media, and regular conference calls (Buffum, Buccheri, Trygstad, & Dowling, 2014; Rahman, Schnelle, & Osterweil, 2014; VandenBerg, 2014). Given our experiences and feedback from the settings, we would not recommend group training even via a webinar format. Rather, the initial training should be face-to-face in each setting so that settings can identify their individual challenges. Furthermore, we would encourage use of approaches such as brainstorming (Wilson, 2013) to help stakeholders within settings identify the most important “drivers” facilitate function-focused care within their setting.

There were 21 settings that were not willing to participate in any intervention activities throughout the course of the study except receive e-mails with weekly tidbits. There was no difference in size or type of setting in terms of participation/adoption. Other factors may be more indicative of likelihood of adopting an evidence-based approach rather than size and type of setting. The settings that did not adopt reported that they had other initiatives and thus felt that a focus on function and physical activity among residents was not consistent with their current needs/goals. Settings may have more salient issues such as survey challenges, financial concerns, and maintaining their census or other related problems. The importance of the fit of the intervention to the setting is likely a more important factor and should be considered to facilitate successful implementation of any intervention (Rogers, 2003).

Repeatedly, champions have been identified as critical for successful implementation of evidence-based interventions across multiple settings (Briggs, Towler, Speerin, & March, 2014; Fakih et al., 2014; Hennessy & Dynan, 2014; Montesano, Sivec, Munetz, Pelton, & Turkington, 2014). Our findings supported the value of champions and prior findings suggesting that the best champions may be those in leadership positions as all of our champions were nurse owners, delegating nurses, or nurses in an administrative role. Leaders in settings generally have access to resources and can facilitate necessary policy changes to assure implementation of the innovation (Greenhalgh, Robert, Macfarlane, Bate, & Kyriakidou, 2004; Lloyd-Smith, Curtin, Gilbart, & Romney, 2014).

There is also prior evidence to suggest that champions should have knowledge related to the topic of relevance, knowledge of dissemination and implementation, the ability to motivate stakeholders, the ability to coordinate groups of people, and a clear goal (Banks et al., 2014; O’Toole, Slade, Brewer, & Gase, 2011). Other characteristics of champions include dedication, willingness to go the “extra mile,” and a willingness to take on the responsibility of making change happen (Greenhalgh et al., 2004; Rogers, 2003). Given that it may be difficult to identify individuals with knowledge on a topic and the interpersonal skills to facilitate behavior change, champions may need the support of others (Banks et al., 2014; Lloyd-Smith et al., 2014). The Research Nurse Facilitators in this project attempted to serve in that supportive role via the face-to-face meetings and weekly e-mails by providing education, resources, and ongoing encouragement. Alternatively, the use of a stakeholder team to work with and support the champion may be helpful. For AL settings, we recommend that the stakeholders include an administrative leader such as the AL manager, a DCW, a family member, a resident, and an activity staff if available. Future research should continue to explore ways in which champions are supported in their roles.

This study used a combined face-to-face and Web-based approach for dissemination and implementation of FFC-AL. There is prior evidence supporting the effectiveness of web-based interventions to change health behaviors (Desroches et al., 2013; Hutton et al., 2011; van den Berg, Schoones, & Vliet Vlieland, 2007) as well as for training caregivers (Buffum et al., 2014; Rahman et al., 2014; VandenBerg, 2014). While all of the settings did have Internet access and responded to our e-mails, we heard back from settings that they would have appreciated additional hands-on visits and help with training of the staff and families, and opportunities to discuss challenges and solutions individually. Although the goal in dissemination research is to reach a large numbers of settings, the appropriate number in any study varies based on the type of intervention being implemented. A smaller number of settings that received more frequent interactions may have improved outcomes, particularly when trying to change behaviors among staff and/or residents.

Study Limitations

This study was limited by the inclusion of only 99 AL settings in a single state and the lack of a control group or randomization of the intervention. State-based differences may have a major impact on translation of interventions such as function-focused care since regulations for AL vary (Center for Excellence in Assisted Living, www.theceal.org). Thus our findings may not be generalizable to ALs in other states. We evaluated setting-level rather than resident-level outcomes and do not have identifiable information or descriptive information on residents or detailed information about champions (e.g., demographic information, knowledge of function-focused care, and length of time working in the setting). Falls included all of the falls that occurred within the setting and thus may have been influenced by single residents falling multiple times. Future work needs to consider additional setting and champion-based factors that may influence adoption such as staffing and test the impact of this dissemination and implementation approach on individual resident outcomes (e.g., resident function, physical activity). Despite these limitations, this study provides some support for our approach to dissemination and implementation of FFC-AL. Furthermore, this model of dissemination and implementation and the lessons learned through this process may be useful when implementing other care approaches into AL settings.

Footnotes

Declaration of Conflicting Interests

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

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by the Helen and Leonard Stulman Foundation.

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