Browsing by Author "Snow, A. Lynn"
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Item Adaptation of a Nursing Home Culture Change Research Instrument for Frontline Staff Quality Improvement Use(American Psychological Association, 2017) Hartmann, Christine W.; Palmer, Jennifer A.; Mills, Whitney L.; Pimentel, Camilla B.; Allen, Rebecca S.; Wewiorski, Nancy J.; Dillon, Kristen R.; Snow, A. Lynn; Boston University; Baylor College of Medicine; University of Massachusetts Amherst; University of Alabama TuscaloosaEnhanced interpersonal relationships and meaningful resident engagement in daily life are central to nursing home cultural transformation, yet these critical components of person-centered care may be difficult for frontline staff to measure using traditional research instruments. To address the need for easy-to-use instruments to help nursing home staff members evaluate and improve person-centered care, the psychometric method of cognitive-based interviewing was used to adapt a structured observation instrument originally developed for researchers and nursing home surveyors. Twenty-eight staff members from 2 Veterans Health Administration (VHA) nursing homes participated in 1 of 3 rounds of cognitive-based interviews, using the instrument in real-life situations. Modifications to the original instrument were guided by a cognitive processing model of instrument refinement. Following 2 rounds of cognitive interviews, pretesting of the revised instrument, and another round of cognitive interviews, the resulting set of 3 short instruments mirrored the concepts of the original longer instrument but were significantly easier for frontline staff to understand and use. Final results indicated frontline staff found the revised instruments feasible to use and clinically relevant in measuring and improving the lived experience of a changing culture. This article provides a framework for developing or adapting other measurement tools for frontline culture change efforts in nursing homes, in addition to reporting on a practical set of instruments to measure aspects of person-centered care.Item Applying a Theory-Driven Framework to Guide Quality Improvement Efforts in Nursing Homes: The LOCK Model(Oxford University Press, 2018) Mills, Whitney L.; Pimentel, Camilla B.; Palmer, Jennifer A.; Snow, A. Lynn; Wewiorski, Nancy J.; Allen, Rebecca S.; Hartmann, Christine W.; Baylor College of Medicine; University of Massachusetts Worcester; University of Alabama Tuscaloosa; Boston UniversityPurpose of the Study: Implementing quality improvement (QI) programs in nursing homes continues to encounter significant challenges, despite recognized need. QI approaches provide nursing home staff with opportunities to collaborate on developing and testing strategies for improving care delivery. We present a theory-driven and user-friendly adaptable framework and facilitation package to overcome existing challenges and guide QI efforts in nursing homes. Design and development: The framework is grounded in the foundational concepts of strengths-based learning, observation, relationship-based teams, efficiency, and organizational learning. We adapted these concepts to QI in the nursing home setting, creating the "LOCK" framework. The LOCK framework is currently being disseminated across the Veterans Health Administration. Results: The LOCK framework has five tenets: (a) Look for the bright spots, (b) Observe, (c) Collaborate in huddles, (d) Keep it bite-sized, and (e) facilitation. Each tenet is described. We also present a case study documenting how a fictional nursing home can implement the LOCK framework as part of a QI effort to improve engagement between staff and residents. The case study describes sample observations, processes, and outcomes. We also discuss practical applications for nursing home staff, the adaptability of LOCK for different QI projects, the specific role of facilitation, and lessons learned. Implications: The proposed framework complements national efforts to improve quality of care and quality of life for nursing home residents and may be valuable across long-term care settings and QI project types.Item A Break-Even Analysis for Dementia Care Collaboration: Partners in Dementia Care(Springer, 2015) Morgan, Robert O.; Bass, David M.; Judge, Katherine S.; Liu, C. F.; Wilson, Nancy; Snow, A. Lynn; Pirraglia, Paul; Garcia-Maldonado, Maurilio; Raia, Paul; Fouladi, N. N.; Kunik, Mark E.; University of Texas Health Science Center Houston; University of Texas School Public Health; Cleveland State University; US Department of Veterans Affairs; Veterans Health Administration (VHA); Vet Affairs Puget Sound Health Care System; University of Washington; University of Washington Seattle; Baylor College of Medicine; University of Alabama Tuscaloosa; Providence VA Medical Center; Brown University; Alzheimer's AssociationDementia is a costly disease. People with dementia, their families, and their friends are affected on personal, emotional, and financial levels. Prior work has shown that the "Partners in Dementia Care" (PDC) intervention addresses unmet needs and improves psychosocial outcomes and satisfaction with care. We examined whether PDC reduced direct Veterans Health Administration (VHA) health care costs compared with usual care. This study was a cost analysis of the PDC intervention in a 30-month trial involving five VHA medical centers. Study subjects were veterans (N = 434) 50 years of age and older with dementia and their caregivers at two intervention (N = 269) and three comparison sites (N = 165). PDC is a telephone-based care coordination and support service for veterans with dementia and their caregivers, delivered through partnerships between VHA medical centers and local Alzheimer's Association chapters. We tested for differences in total VHA health care costs, including hospital, emergency department, nursing home, outpatient, and pharmacy costs, as well as program costs for intervention participants. Covariates included caregiver reports of veterans' cognitive impairment, behavior problems, and personal care dependencies. We used linear mixed model regression to model change in log total cost post-baseline over a 1-year follow-up period. Intervention participants showed higher VHA costs than usual-care participants both before and after the intervention but did not differ significantly regarding change in log costs from pre- to post-baseline periods. Pre-baseline log cost (p a parts per thousand currency signaEuro parts per thousand 0.001), baseline cognitive impairment (p a parts per thousand currency signaEuro parts per thousand 0.05), number of personal care dependencies (p a parts per thousand currency signaEuro parts per thousand 0.01), and VA service priority (p a parts per thousand currency signaEuro parts per thousand 0.01) all predicted change in log total cost. These analyses show that PDC meets veterans' needs without significantly increasing VHA health care costs. PDC addresses the priority area of care coordination in the National Plan to Address Alzheimer's Disease, offering a low-cost, structured, protocol-driven, evidence-based method for effectively delivering care coordination.Item Characteristics of Generalized Anxiety Disorder in Patients With Dementia(Sage, 2011) Calleo, Jessica S.; Kunik, Mark E.; Reid, Dana; Kraus-Schuman, Cynthia; Paukert, Amber; Regev, Tziona; Wilson, Nancy; Petersen, Nancy J.; Snow, A. Lynn; Stanley, Melinda; Baylor College of Medicine; University of Alabama TuscaloosaBackground: Overlap of cognitive and anxiety symptoms (i.e., difficulty concentrating, fatigue, restlessness) contributes to inconsistent, complicated assessment of generalized anxiety disorder (GAD) in persons with dementia. Methods: Anxious dementia patients completed a psychiatric interview, the Penn State Worry Questionnaire-Abbreviated, and the Rating for Anxiety in Dementia scale. Analyses to describe the 43 patients with and without GAD included the Wilcoxon Mann-Whitney two-sample test, Fisher's exact test. Predictors of GAD diagnosis were identified using logistic regression. Results: Those with GAD were more likely to be male, have less severe dementia and endorsed more worry, and anxiety compared to patients without GAD. Gender, muscle tension and fatigue differentiated those with GAD from those without GAD. Conclusions: Although this study is limited by a small sample, it describes clinical characteristics of GAD in dementia, highlighting the importance of muscle tension and fatigue in recognizing GAD in persons with dementia.Item A conceptual model for culture change evaluation in nursing homes(Elsevier, 2013) Hartmann, Christine W.; Snow, A. Lynn; Allen, Rebecca S.; Parmelee, Patricia A.; Palmer, Jennifer A.; Berlowitz, Dan; Boston University; University of Alabama TuscaloosaThis article describes the development and particulars of a new, comprehensive model of nursing home culture change, the Nursing Home Integrated Model for Producing and Assessing Cultural Transformation (Nursing Home IMPACT). This model is structured into four categories, "meta constructs," "care practices," "workplace practices," and "environment of care," with multiple domains under each. It includes detailed, triangulated assessment methods capturing various stakeholder perspectives for each of the model's domains. It is hoped that this model will serve two functions: first, to help practitioners guide improvements in resident care by identifying particular areas in which culture change is having positive effects, as well as areas that could benefit from modification; and second, to emphasize the importance in culture change of the innumerable perspectives of residents, family members, staff, management, and leadership. Published by Mosby, Inc.Item Concordance of self- and proxy-rated worry and anxiety symptoms in older adults with dementia(Pergamon, 2013) Bradford, Andrea; Brenes, Gretchen A.; Robinson, Roberta A.; Wilson, Nancy; Snow, A. Lynn; Kunik, Mark E.; Calleo, Jessica; Petersen, Nancy J.; Stanley, Melinda A.; Amspoker, Amber B.; UTMD Anderson Cancer Center; Wake Forest University; Wake Forest Baptist Medical Center; Baylor College of Medicine; University of Alabama TuscaloosaWe compared the psychometric performance of two validated self-report anxiety symptom measures when rated by people with dementia versus collaterals (as proxies). Forty-one participants with mild-to-moderate dementia and their respective collaterals Completed the Geriatric Anxiety Inventory, the Penn State Worry Questionnaire-Abbreviated, and a structured diagnostic interview. We used descriptive and nonparametric statistics to compare scores according to respondent characteristics. Receiver operating characteristic (ROC) curves were calculated to establish the predictive validity of each instrument by rater type against a clinical diagnosis of an anxiety disorder. Participant and collateral ratings performed comparably for both instruments. However, collaterals tended to give more severe symptom ratings, and the best-performing cut-off scores were higher for collaterals. Our findings suggest that people with mild-to-moderate dementia can give reliable self-reports of anxiety symptoms, with validity comparable to reports obtained from collaterals. Scores obtained from multiple informants should be interpreted in context. (C) 2012 Elsevier Ltd. All rights reserved.Item The context of dementia: visualizing the features of daily life for rural-dwelling, informal, veteran dementia dyads(University of Alabama Libraries, 2021) Loup, Julia; Snow, A. Lynn; Hilgeman, Michelle M.; University of Alabama TuscaloosaRural-dwelling, informal, veteran dementia caregiving dyads (a veteran diagnosed with dementia (PWD) and their caregiver) make up a population with unique needs compared to their non-caregiving or urban caregiver counterparts. However, according to commonly used measures of and approaches to studying rurality (e.g., Rural-Urban Commuting Area Codes, RUCA), individual differences are underrepresented in the design, implementation, and delivery of dementia-focused care for rural older PWDs and their caregivers. The present study qualitatively categorized daily life needs in the context of informal, rural-dwelling, dementia caregiving, and developed visualizations to present the findings across several stakeholder groups. In turn, the objective of this study was to gain more contextualized awareness this population’s daily-life needs by means of this novel qualitative-visual analysis approach. Rapid, thematic, and content analyses were performed on 30 semi-structured interviews with dementia dyads associated with the Tuscaloosa VA Medical Center. A categorical understanding of the sample’s daily life needs (including activities and resources) emerged and was translated visually using two data visualization modalities: Network Analysis and Life-Space Mapping. Results suggest this two-stage method of qualitative and visual analysis successfully delivers insight into the daily life needs of rural-dwelling, veteran, dementia dyads for care providers and policy makers. Taking a visual approach to qualitative needs assessment and rural care may assist in the development of tailored dementia caregiving interventions from integrated medical systems, such as the Veterans Health Administration.Item A controlled trial of Partners in Dementia Care: veteran outcomes after six and twelve months(BMC, 2014) Bass, David M.; Judge, Katherine S.; Snow, A. Lynn; Wilson, Nancy L.; Morgan, Robert O.; Maslow, Katie; Randazzo, Ronda; Moye, Jennifer A.; Odenheimer, Germaine L.; Archambault, Elizabeth; Elbein, Richard; Pirraglia, Paul; Teasdale, Thomas A.; McCarthy, Catherine A.; Looman, Wendy J.; Kunik, Mark E.; Cleveland State University; University of Alabama Tuscaloosa; US Department of Veterans Affairs; Veterans Health Administration (VHA); Baylor College of Medicine; University of Texas Health Science Center Houston; University of Texas School Public Health; National Academies of Sciences, Engineering & Medicine; Alzheimer's Association; Harvard University; VA Boston Healthcare System; University of Oklahoma Health Sciences Center; Providence VA Medical Center; Brown UniversityIntroduction: "Partners in Dementia Care" (PDC) tested the effectiveness of a care-coordination program integrating healthcare and community services and supporting veterans with dementia and their caregivers. Delivered via partnerships between Veterans Affairs medical centers and Alzheimer's Association chapters, PDC targeted both patients and caregivers, distinguishing it from many non-pharmacological interventions. Hypotheses posited PDC would improve five veteran self-reported outcomes: 1) unmet need, 2) embarrassment about memory problems, 3) isolation, 4) relationship strain and 5) depression. Greater impact was expected for more impaired veterans. A unique feature was self-reported research data collected from veterans with dementia. Methods and Findings: Five matched communities were study sites. Two randomly selected sites received PDC for 12 months; comparison sites received usual care. Three structured telephone interviews were completed every 6 months with veterans who could participate. Results: Of 508 consenting veterans, 333 (65.6%) completed baseline interviews. Among those who completed baseline interviews, 263 (79.0%) completed 6-month follow-ups and 194 (58.3%) completed 12-month follow-ups. Regression analyses showed PDC veterans had significantly less adverse outcomes than those receiving usual care, particularly for more impaired veterans after 6 months, including reduced relationship strain (B = -0.09; p = 0.05), depression (B = -0.10; p = 0.03), and unmet need (B = -0.28; p = 0.02; and B = -0.52; p = 0.08). PDC veterans also had less embarrassment about memory problems (B = -0.24; p = 0.08). At 12 months, more impaired veterans had further reductions in unmet need (B = -0.96; p < 0.01) and embarrassment (B = -0.05; p = 0.02). Limitations included use of matched comparison sites rather than within-site randomization and lack of consideration for variation within the PDC group in amounts and types of assistance provided. Conclusions: Partnerships between community and health organizations have the potential to meet the dementia-related needs and improve the psychosocial functioning of persons with dementia.Item Decision-Making Across the Lifespan: an Examination of the Influence of Ease of Comprehension on the Utilization of Heuristic Versus Systematic Thinking(University of Alabama Libraries, 2023) Evans, Teairra Z; Black, Sheila; Glenn, AndreaThis study examined age differences in decision-making in a healthcare context. Specifically, I examined whether older adults may be more likely to rely on the recommendation of a credible source, especially when information is difficult to understand, and forgo systematic processing in a decision about their health. Ninety younger (ages 18-25) and 90 older (ages 55-85) participants were exposed to an advertisement in which a physician (presented as a credible source) promotes the use of a supplement. The advertisements presented varied in ease of comprehension, as this has been found to affect the likelihood of using either heuristic or systematic processing in decision-making, and the description of the quality of the supplement was also manipulated. After viewing the advertisement, participants indicated the likelihood that they would purchase the supplement. Consistent with existing literature, the quality of the supplement was shown to impact decision-making in both younger and older adults. Contrary to predictions, younger adults were more likely to purchase the supplement as compared to older adults. Results indicate that older adults were not heavily influenced by the recommendation of the physician and based their decisions on the quality of the supplement. The expertise of older adults possibly provided a framework to attend to the supplements quality and inhibit extraneous source information such as the credibility of the physician.Item Developing a Pain Intensity Measure for Persons with Dementia: Initial Construction and Testing(Oxford University Press, 2019) Ersek, Mary; Herr, Keela; Hilgeman, Michelle M.; Neradilek, Moni Blazej; Polissar, Nayak; Cook, Karon F.; Nash, Princess; Snow, A. Lynn; McDarby, Meghan; Nelson, Francis X.; University of Pennsylvania; University of Iowa; University of Alabama Tuscaloosa; University of Alabama Birmingham; Northwestern University; Feinberg School of Medicine; Washington University (WUSTL)Objective. The goal of this study was to identify a limited set of pain indicators that were most predicive of physical pain. We began with 140 items culled from existing pain observation tools and used a modified Delphi approach followed by statistical analyses to reduce the item pool. Methods. Through the Delphi Method, we created a candidate item set of behavioral indicators. Next, trained staff observed nursing home residents and rated the items on scales of behavior intensity and frequency. We evaluated associations among the items and expert clinicians' assessment of pain intensity. Setting. Four government-owned nursing homes and 12 community nursing homes in Alabama and Southeastern Pennsylvania. Participants. Ninety-five residents (mean age = 84.9 years) with moderate to severe cognitive impairment. Results. Using the least absolute shrinkage and selection operator model, we identified seven items that best predicted clinicians' evaluations of pain intensity. These items were rigid/stiff body or body parts, bracing, complaining, expressive eyes, grimacing, frowning, and sighing. We also found that a model based on ratings of frequency of behaviors did not have better predictive ability than a model based on ratings of intensity of behaviors. Conclusions. We used two complementary approaches-expert opinion and statistical analysis-to reduce a large pool of behavioral indicators to a parsimonious set of items to predict pain intensity in persons with dementia. Future studies are needed to examine the psychometric properties of this scale, which is called the Pain Intensity Measure for Persons with Dementia.Item Developing the Supporting Choice Observational Tool (SCOT) A Formative Assessment Tool to Assist Nursing Home Staff in Realizing Resident Choice(Slack, 2017) Palmer, Jennifer A.; Parker, Victoria A.; Burgess, James F.; Berlowitz, Dan; Snow, A. Lynn; Mitchell, Susan L.; Hartmann, Christine W.; Harvard University; Hebrew SeniorLife; Boston University; Harvard Medical School; University of Alabama TuscaloosaQuality of care in nursing homes has begun to address the importance of resident choice in daily life, yet there are no published tools to teach nursing home staff how to offer such choice. In the current study, a formative assessment tool was developed that can provide staff with detailed and concrete feedback on how to realize resident choice. The tool was created and refined through 22 hours of ethnographic observation in two Veterans Health Administration Community Living Centers (CLCs), 22 hours of developmental testing in two CLCs, review by a modified Delphi panel, and use of an algorithm to assess its logical structure. The resulting Supporting Choice Observational Tool (SCOT) documents how choice is or is not offered and is or is not enabled within a singular staff-resident interaction. SCOT findings could be used in clinical teaching, quality improvement, or research efforts intent on enhancing nursing home resident quality of life.Item Development of a New Tool for Systematic Observation of Nursing Home Resident and Staff Engagement and Relationship(Oxford University Press, 2018) Snow, A. Lynn; Jacobs, M. Lindsey; Palmer, Jennifer A.; Parmelee, Patricia A.; Allen, Rebecca S.; Wewiorski, Nancy J.; Hilgeman, Michelle M.; Vinson, Latrice D.; Berlowitz, Dan R.; Halli-Tierney, Anne D.; Hartmann, Christine W.; University of Alabama Tuscaloosa; Boston UniversityPurpose of Study: To develop a structured observational tool, the Resident-centered Assessment of Interactions with Staff and Engagement tool (RAISE), to measure 2 critical, multi-faceted, organizational-level aspects of person-centered care (PCC) in nursing homes: (a) resident engagement and (b) the quality and frequency of staff-resident interactions. Design and Methods: In this multi-method psychometric development study, we conducted (a) 120 hr of ethnographic observations in one nursing home and (b) a targeted literature review to enable construct development. Two constructs for which no current structured observation measures existed emerged from this phase: nursing home resident-staff engagement and interaction. We developed the preliminary RAISE to measure these constructs and used the tool in 8 nursing homes at an average of 16 times. We conducted 8 iterative psychometric testing and refinement cycles with multi-disciplinary research team members. Each cycle consisted of observations using the draft tool, results review, and tool modification. Results: The final RAISE included a set of coding rules and procedures enabling simultaneously efficient, non-reactive, and representative quantitative measurement of the interaction and engagement components of nursing home life for staff and residents. It comprised 8 observational variables, each represented by extensive numeric codes. Raters achieved adequate to high reliability with all variables. There is preliminary evidence of face and construct validity via expert panel review. Implications: The RAISE represents a valuable step forward in the measurement of PCC, providing objective, reliable data based on systematic observation.Item Dignity During a Pandemic: Dignity Therapy Delivered Through Telehealth is not Feasible in the Deep South(University of Alabama Libraries, 2024) Reel, Candice Danelle; Allen, Rebecca S.As time is limited, creation of a legacy document, particularly when aided by a care partner, is an effective method of facilitating a sense of dignity. However, access to care has been a problem for many individuals enrolled in community dwelling hospice care. Providing Dignity Therapy, (DT) a short-term individualized psychotherapy intervention for those at end of life, via telehealth could be one possible response to address this lack of access. Enrollment in hospice is often late in the disease process, indicating a need for short term interventions and a consideration of hospice participant attrition rates. The current study examined feasibility and efficacy of a telehealth delivery of the DT protocol to community dwelling hospice patients and their care partners and investigated challenges associated with hospice research recruitment through semi-structured interviews with hospice staff. Results of feasibility showed three potential participants were recruited but none consented to participate. The results from the feasibility study precluded our ability to assess efficacy as planned. Seven members of the hospice staff completed qualitative interviews designed to understand the lack of feasibility of this study. Results identified four main themes that point to the value of the DT intervention, an overwhelming disapproval of telehealth delivery of interventions, a close consideration of research methods, and the need for future research to further the advancement and clinical use of this effective intervention, particularly in rural and underserved areas.Item Enhancing sleep quality for nursing home residents with dementia: a pragmatic randomized controlled trial of an evidence-based frontline huddling program(BMC, 2021) Snow, A. Lynn; Loup, Julia; Morgan, Robert O.; Richards, Kathy; Parmelee, Patricia A.; Baier, Rosa R.; McCreedy, Ellen; Frank, Barbara; Brady, Cathie; Fry, Liam; McCullough, Megan; Hartmann, Christine W.; University of Alabama Tuscaloosa; University of Texas Health Science Center Houston; University of Texas School Public Health; University of Texas Austin; Brown University; University of Massachusetts LowellBackground: Disturbed sleep places older adults at higher risk for frailty, morbidity, and even mortality. Yet, nursing home routines frequently disturb residents' sleep through use of noise, light, or efforts to reduce incontinence. Nursing home residents with Alzheimer's disease and or related dementias-almost two-thirds of long-stay nursing home residents-are likely to be particularly affected by sleep disturbance. Addressing these issues, this study protocol implements an evidence-based intervention to improve sleep: a nursing home frontline staff huddling program known as LOCK. The LOCK program is derived from evidence supporting strengths-based learning, systematic observation, relationship-based teamwork, and efficiency. Methods: This study protocol outlines a NIH Stage III, real-world hybrid efficacy-effectiveness pragmatic trial of the LOCK sleep intervention. Over two phases, in a total of 27 non-VA nursing homes from 3 corporations, the study will (1) refine the LOCK program to focus on sleep for residents with dementia, (2) test the impact of the LOCK sleep intervention for nursing home residents with dementia, and (3) evaluate the intervention's sustainability. Phase 1 (1 year; n = 3 nursing homes; 1 per corporation) will refine the intervention and train-the-trainer protocol and pilot-tests all study methods. Phase 2 (4 years; n = 24 nursing homes; 8 per corporation) will use the refined intervention to conduct a wedge-design randomized, controlled, clinical trial. Phase 2 results will measure the LOCK sleep intervention's impact on sleep (primary outcome) and on psychotropic medication use, pain and analgesic medication use, and activities of daily living decline (secondary outcomes). Findings will point to inter-facility variation in the program's implementation and sustainability. Discussion: This is the first study to our knowledge that applies a dementia sleep intervention to systematically address known barriers to nursing home quality improvement efforts. This innovative study has future potential to address clinical issues beyond sleep (safety, infection control) and expand to other settings (assisted living, inpatient mental health). The study's strong team, careful consideration of design challenges, and resulting rigorous, pragmatic approach will ensure success of this promising intervention for nursing home residents with dementia.Item Ethnic Differences in Nonverbal Pain Behaviors Observed in Older Adults with Dementia(Elsevier, 2015) Ford, Brianne; Snow, A. Lynn; Herr, Keela; Tripp-Reimer, Toni; University of Iowa; University of Alabama TuscaloosaResearch supports using nonverbal pain behaviors to identify pain in persons with dementia. It is unknown whether variations exist among ethnic groups in the expression of nonverbal pain behaviors in this special population. The purpose of this descriptive study was to examine ethnic differences in the presentation and intensity of nonverbal pain behaviors among African American, Caucasian, and Hispanic older adults with dementia when screened for pain by certified nursing assistants. Six certified nursing assistants were trained to review and score 28 video recordings of subjects with dementia for nonverbal pain behaviors using the Non-Communicative Patient's Pain Assessment Instrument. Chi-square was used to examine differences among ethnic groups with regard to the display of nonverbal pain behaviors, and ANOVA was used to evaluate differences in the intensity of overall pain across ethnic groups. Of the 168 assessments, pain words (28%), pain noises (29.8%), and pain faces (28%) were observed most often as indicators of pain. Rubbing, bracing, and restlessness were rarely noted. Chi-square analysis revealed ethnic differences in the expression of pain words (chi(2) = 19.167, p < .001). No significant differences were noted across ethnic groups with regards to overall pain intensity. These findings are the first to examine ethnic differences in nonverbal pain behaviors for older adults with dementia. However, future work should examine assessment tendencies of providers in a larger, more diverse sample. (C) 2015 by the American Society for Pain Management NursingItem Evaluating the Cornell scale for depression in dementia as a proxy measure in nursing home residents with and without dementia(Routledge, 2012) Towsley, Gail; Neradilek, Moni Blazej; Snow, A. Lynn; Ersek, Mary; University of Pennsylvania; University of Utah; University of Alabama Tuscaloosa; Pennsylvania Medicine; US Department of Veterans Affairs; Veterans Health Administration (VHA); Philadelphia Veterans Affairs Medical CenterObjectives: We evaluated the use of the Cornell Scale for Depression in Dementia (CSDD) as a proxy measure. Study questions were: How do residents' self-reports on the CSDD compare with the nurse proxy CSDD ratings of the resident? How do characteristics of depression as rated by the resident CSDD and the nurse CSDD compare? To what extent are demographic and clinical variables associated with resident CSDD, nurse CSDD, and the discrepancy between resident and nurse CSDD scores? Methods: Residents and nurse proxy pairs (n = 395 pairs) from 28 nursing homes (NHs) participated. We calculated discrepancy scores for total and subscale CSDD scores, examined correlations between resident and nurse CSDD scores, and described rates of clinical depression using each of the scores. We conducted multivariate analyses to examine factors associated with resident and nurse CSDD and discrepancy scores. Results: On average, participants had mild cognitive impairment, were White, and female. Associations between resident and nurse CSDD were low (r = 0.16). The mean discrepancy score was -2.03 (SD = 5.28, p < 0.001), indicating that nurses evaluated residents as less depressed than residents evaluated themselves. Discrepancy scores were not associated with residents' cognitive status, but were associated with a measure of self-report reliability. Regression analyses indicated that depression diagnosis accounted for a small but significant association with resident CSDD, but was not significantly associated with nurse CSDD. Conclusion: These findings underscore the importance of obtaining resident input when assessing depression in NH residents with dementia, and educating NH nurses in the most effective ways to assess depression.Item Examining Homeless Experienced Veterans' Perceived Unsafety within Integrated VA Primary Care Settings: a Structural Equation Modeling Approach(University of Alabama Libraries, 2024) Loup, Julia; Snow, A. Lynn; Hilgeman, Michelle M.Background: Core challenges to primary care delivery for homeless-experienced patients include stigma, prolonged physiological and emotional stress, and a generalized sense of unsafety. The Generalized Unsafety Theory of Stress (GUTS) draws on prolonged stress and stigma literature and posits these factors contribute to generalized ‘perceived unsafety' for marginalized populations. To date, no research has quantitatively tested if these factors operate as one measurable construct or as separate dimensions of primary care quality. Elucidating the construct of perceived unsafety may allow for improved interventions and policy approaches for primary care. This study offers the first effort to apply GUTS and the construct of perceived unsafety in homeless-focused primary care using a large national survey of homeless-experienced veterans (HEV).Methods: This quantitative study uses national survey data of 5,766 HEV collected in 2018 across 26 VA clinical sites. GUTS theoretically guided selection from a validated 33-item Primary Care Quality-Homeless (PCQ-H) experience survey. Confirmatory factor analysis (CFA) and structural equation modeling (SEM) formed the perceived unsafety latent construct.Results: The sample of 5,766 HEV were empaneled VA primary care users. Mean age was 57 (SD 14.86), with 89.5% male, 8.8% female (1.8% other), 43.2% White, and 42% Black. Significant medical and mental health comorbidities were common in this sample.The Perceived Unsafety construct resulted in following acceptable model fit parameters χ 2 (75) = 1796.939, p ≤ 0.000, RMSEA ≤ 0.063 (90% CI 0.061 - 0.066), SRMR ≤ 0.053, CFI ≤ 0.926, TLI ≤ 0.910. Social support, physical health, mental health, and substance use diagnoses emerged as significant predictors of perceived (un)safety. A significant moderation of clinic type was found between mental and physical health and perceived unsafety. No moderation of perceived unsafety was found for age and onset of homelessness. Conclusions: GUTS and the construct of perceived unsafety was theoretically and statistically found to be an acceptable measurable construct of primary care perception for HEV. Further analyses found that perceived unsafety was significantly related to the many social, mental, and physical health concerns often identified in the HEV population. These findings offer safety as novel lens into HEVs perception of integrated primary care.Item Huddles and their effectiveness at the frontlines of clinical care: a scoping review(Springer, 2021) Pimentel, Camilla B.; Snow, A. Lynn; Carnes, Sarah L.; Shah, Nishant R.; Loup, Julia R.; Vallejo-Luces, Tatiana M.; Madrigal, Caroline; Hartmann, Christine W.; Geriatric Research Education & Clinical Center; University of Massachusetts Worcester; University of Alabama Tuscaloosa; Brown University; University of Florida; US Department of Veterans Affairs; Veterans Health Administration (VHA); Providence VA Medical Center; University of Massachusetts LowellBACKGROUND: Brief, stand-up meetings known as huddles may improve clinical care, but knowledge about huddle implementation and effectiveness at the frontlines is fragmented and setting specific. This work provides a comprehensive overview of huddles used in diverse health care settings, examines the empirical support for huddle effectiveness, and identifies knowledge gaps and opportunities for future research. METHODS: A scoping review was completed by searching the databases PubMed, EBSCOhost, ProQuest, and OvidSP for studies published in English from inception to May 31, 2019. Eligible studies described huddles that (1) took place in a clinical or medical setting providing health care patient services, (2) included frontline staff members, (3) were used to improve care quality, and (4) were studied empirically. Two reviewers independently screened abstracts and full texts; seven reviewers independently abstracted data from full texts. RESULTS: Of 2,185 identified studies, 158 met inclusion criteria. The majority (67.7%) of studies described huddles used to improve team communication, collaboration, and/or coordination. Huddles positively impacted team process outcomes in 67.7% of studies, including improvements in efficiency, process-based functioning, and communication across clinical roles (64.4%); situational awareness and staff perceptions of safety and safety climate (44.6%); and staff satisfaction and engagement (29.7%). Almost half of studies (44.3%) reported huddles positively impacting clinical care outcomes such as patients receiving timely and/or evidence-based assessments and care (31.4%); decreased medical errors and adverse drug events (24.3%); and decreased rates of other negative outcomes (20.0%). DISCUSSION: Huddles involving frontline staff are an increasingly prevalent practice across diverse health care settings. Huddles are generally interdisciplinary and aimed at improving team communication, collaboration, and/or coordination. Data from the scoping review point to the effectiveness of huddles at improving work and team process outcomes and indicate the positive impact of huddles can extend beyond processes to include improvements in clinical outcomes.Item Implementation Facilitation Activities Used by an External Facilitator in a Quality Improvement Intervention(University of Alabama Libraries, 2025) George, Regina; Snow, A. LynnImplementation facilitation is a dynamic, multi-faceted practice that supports both the execution and sustainability of interventions, but there is limited understanding of how implementation facilitation activities are carried out. This knowledge gap may have implications for facilitator training and the long-term success of facilitated interventions. Previous studies have relied mainly on interviews with facilitators. To address this gap, this study examines transcripts of recorded meetings between an implementation facilitator and nursing home leadership teams during a complex, psychosocial quality improvement intervention. This study analyzed transcripts from 24 meetings across two nursing home sites, using Braun and Clarke's reflexive thematic analytical approach (2021). The study identified three themes regarding facilitation activities used by an implementation facilitator: (1) Building Relationships with the Team Through a Compassionate and Strength-Focused Approach; (2) Fostering Critical Thinking of Resident Care Practices; and (3) Co-designing Goals and Action Plans. The theme of fostering critical thinking also highlighted the active involvement of the leadership team in these discussions. This research deepens our understanding of facilitation practices and offers insights for improving the training of facilitators and the design of implementation efforts, ultimately enhancing the effectiveness and sustainability of interventions in healthcare settings.Item The Peaceful Mind Manual: A Protocol for Treating Anxiety in Persons With Dementia(Sage, 2013) Paukert, Amber L.; Kraus-Schuman, Cynthia; Wilson, Nancy; Snow, A. Lynn; Calleo, Jessica; Kunik, Mark E.; Stanley, Melinda A.; Baylor College of Medicine; University of Alabama TuscaloosaAnxiety disorders are highly prevalent among individuals with dementia and have a significant negative impact on their lives. Peaceful Mind is a form of cognitive-behavioral therapy for anxiety in persons with dementia. The Peaceful Mind manual was developed, piloted, and modified over 2 years. In an open trial and a small randomized, controlled trial, it decreased anxiety and caregiver distress. The treatment meets the unique needs of individuals with dementia by emphasizing behavioral rather than cognitive interventions, slowing the pace, limiting the material to be learned, increasing repetition and practice, using cues to stimulate memory, including a friend or family member in treatment as a coach, and providing sessions in the home. The manual presented here includes modules that teach specific skills, including awareness, breathing, calming self-statements, increasing activity, and sleep management, as well as general suggestions for treatment delivery.