Understanding the intersection of individual needs and choices with organizational practices: the case of medication management in assisted living.
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Practical depression screening in residential care/assisted living: five methods compared with gold standard diagnoses.
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OBJECTIVE: To test the accuracy of five practical depression screening strategies in older adults residing in residential care/assisted living (RC/AL). DESIGN: Cross-sectional screening study. SETTING: Four RC/AL communities in North Carolina. PARTICIPANTS: A total of 112 residents aged > or =65 and 27 staff members involved in their care. MEASUREMENTS: Direct care staff was trained in and completed the Cornell Scale for Depression in Dementia, modified for use by long-term care staff (CSDD-M-LTCS). They additionally responded to a one-item question "Do you believe the resident is often sad or depressed?" and the Minimum Data Set Depression Rating Scale (DRS). Residents responded directly to the Geriatric Depression Scale (15-item version; GDS-15) and the Patient Health Questionnaire, 2-item version (PHQ-2). A geriatric psychiatrist performed gold standard diagnostic interviews using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Sensitivities and specificities were calculated for all instruments at predetermined cutpoints. RESULTS: Gold standard diagnoses yielded 14% prevalence of major or minor depression. The CSDD-M-LTCS and one-item screen completed by caregivers failed to significantly discriminate depressed cases. The DRS yielded high specificity (0.85) but low sensitivity (0.47). For the two resident reported measures, the PHQ-2 had a sensitivity of 0.80 and specificity of 0.71, and the GDS-15, 0.60 and 0.75, respectively. CONCLUSION: Measures completed by caregivers failed to adequately detect depression. Of the measures completed directly by residents, the PHQ-2 seems to have the best mix of brevity, sensitivity, and ease of administration. (+info)
Administrators' perceptions of medication management in assisted living facilities: results from focus groups.
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OBJECTIVE: Assisted living (AL) residents are vulnerable to adverse events as a result of using numerous medications and frequently need assistance in administering medications. Very little is known, however, about the ways in which medications are managed within this level of care. DESIGN: AL administrators from the metropolitan Baltimore, Maryland area were invited to participate in focus groups to explore issues involved in medication management. SETTING AND PARTICIPANTS: Four administrators from smaller (15 beds or fewer) and six larger (more than 15 beds) certified AL facilities serving primarily older residents participated. Administrators must have served in their position at least six months. RESULTS: Administrators described interactions with residents, physicians, and pharmacists as well as the issues of state regulations and their enforcement. We uncovered themes concerning the challenges faced in negotiating competing needs of residents, providers, and regulatory bodies. CONCLUSIONS: Administrators often feel torn between competing requirements of their position, and they experience some degree of conflict in allowing residents to retain autonomy in the face of demands of family, providers, and regulators. Small-facility administrators especially report being in a position to allow them to monitor residents' medication reactions and needs. Large-facility administrators sometimes find their actions hampered by decisions made at higher (ownership) levels. Administrators want AL facilities to remain at an intermediate level of care, with less stringent regulations than for those for nursing facilities, but would also like more consistency in enforcement of regulations. Qualitative assessment of medication-related issues in AL can help to guide policy in this area. (+info)