Data Collection for THRIVE Projects is Now Complete

By / Posted on October 31st, 2014

The Green House Project has partnered with the Robert Wood Johnson Foundation’s THRIVE (The Research Initiative Valuing Eldercare) collaborative to learn more about the Green House model as well as other models of care. Supported by the Robert Wood Johnson Foundation, the THRIVE team is conducting a series of interrelated research projects that together will comprise the largest research effort undertaken to date in Green House homes. Each quarter, a member of the THRIVE team will contribute a blog post to the Green House Project website.

Data collection for the THRIVE projects is now complete, and the research team is analyzing the results.  The THRIVE team will share research findings in upcoming articles in a special issue of the journal Health Services Research, and through conference and webinar presentations and blog posts.  In 2014, conference presentations will include those at annual meetings of LeadingAge (October), and the Gerontological Society of America, and the Green House (both in November).  This blog post is part of our series devoted to explaining research terms so that non-researchers can better understand these articles, presentations, and posts.  This post focuses on quantitative research – research based in numbers – and explains the important topic of “significance.”

Quantitative research findings are often discussed in terms of their statistical significance.  What does it mean to say a finding is significant?

Let’s consider an example.   A researcher thinks that there may be more female than male elders living in Green House homes.  This hunch is called a hypothesis.  The researcher visits all the Green House homes in the state, tallies the numbers of females (85) and males (15) and performs a statistical test to compare males and females.  The statistical test will result in a p-value (probability value) expressing whether the difference is large enough to indicate that it isn’t just by chance.

 

To better understand what it means to have a “large enough” difference, think of it this way:  if the number of females was 52, and the number of males was 48, the difference between these numbers is pretty small, and it’s not likely statistically significant.  The question is, is the difference between 85 and 15 large enough to suggest that there are statistically more females than males living in Green House homes?  A difference of 85 to 15 is probably large enough to not be by chance (i.e., it is statistically significant), whereas a difference of 52 to 48 is so small that it quite likely occurred by chance.

It’s also important to realize that findings that are statistically significant may not be clinically significant.  Clinical significance means that the information is important for clinical care.  In terms of care, does it matter that there are more females than males residing in Green House homes?  It does matter, for example, if women tend to be more depressed than men, or to have more family members.  However, if there are no clinical implications related to the difference, than they are statistically, but not clinically, significant.

The bottom line is that it’s important to carefully consider the meaning of all findings, and use your knowledge and judgment to interpret when differences matter and when they don’t.

Stay tuned for the next THRIVE blog post.  In the meantime, if you have questions about this post, or suggestions for future ones, please let us know.

Questions about THRIVE can be directed to Lauren Cohen (lauren_cohen@unc.edu or 919-843-8874).


THRIVE: Understanding the Language of Research

By / Posted on June 30th, 2014

The Green House Project has partnered with the Robert Wood Johnson Foundation’s THRIVE (The Research Initiative Valuing Eldercare) collaborative to learn more about the Green House model as well as other models of care. Supported by the Robert Wood Johnson Foundation, the THRIVE team is conducting a series of interrelated research projects that together will comprise the largest research effort undertaken to date in Green House homes. Each quarter, a member of the THRIVE team will contribute a blog post to the Green House Project website.

As the THRIVE research projects head toward completion later this year, our research team has developed plans to share our research findings.  In addition to publishing articles in a special issue of the journal, Health Services Research, we also will share findings through conference and webinar presentations and blog posts.

Because some commonly used research terms may sound like jibberish to non-researchers (after all, who really knows what a p-value is?), we will devote our next few blog posts to explaining a few terms that will help non-researchers better understand the THRIVE articles, presentations, and posts.  We’ll start by reviewing Quantitative and Qualitative research designs.

When people think of research, they’re usually thinking of a Quantitative research design, which essentially measures and compares things.  Quantitative research asks questions like “How many residents in one nursing home have falls compared to residents in another?” or “Does providing one type of care work better than providing a different type of care?”  A quantitative research design allows a researcher to establish “how much”, whether one thing is related to another (such as whether falls are less frequent when certain care is provided), and also – depending on the details of the design – to establish cause and effect.  The data collected are usually in numerical form, and findings are expressed in terms including percents, means, and p-values (to answer the earlier question, a p-value denotes whether or not a number is or isn’t significantly ‘different’ from another…..we’ll come back to this in a future blog post).

Qualitative research designs essentially answer “how” and “why”.  Qualitative research asks questions such as “Why are so many falls occurring?” or “What conditions are necessary for a nursing home to provide a certain type of care?”  A qualitative research design permits a researcher to better understand events and the circumstances under which they occur and vary.  The information gathered in these types of studies are usually textual, and include the researchers notes and observations, as well as in-depth interviews and quotes from people who have knowledge of the event being studied.  This information is analyzed by looking for common themes across all of the information collected and reporting these findings – often contextualized using exemplative quotes.

The THRIVE team is using both quantitative and qualitative methods in their research, which is considered mixed-methods.  This is the best of both worlds, and is allowing us to answer questions such as:

Quantitative:    What was the annual turnover rate for shahbazim over the past two years?
Was this turnover rate statistically different (higher or lower) than that found
among CNAs in other nursing homes?

Qualitative:      What was the role of the Director of Nursing in the Green House homes?
How might variations in this role relate to shahbazim turnover?

Stay tuned for the next THRIVE blog post.  In the meantime, if you have questions about this post, or suggestions for future ones, please let us know.

Questions about THRIVE can be directed to Lauren Cohen (lauren_cohen@unc.edu or 919-843-8874).


Early Research Findings from THRIVE

By / Posted on March 26th, 2014

The Green House Project has partnered with the Robert Wood Johnson Foundation’s THRIVE (The Research Initiative Valuing Eldercare) collaborative to learn more about the Green House model as well as other models of care. Supported by the Robert Wood Johnson Foundation, the THRIVE team is conducting a series of interrelated research projects that together will comprise the largest research effort undertaken to date in Green House homes. Each quarter, a member of the THRIVE team will contribute a blog post to the Green House Project website.

Early findings from the THRIVE research collaborative were published in The February 2014 Gerontologist supplement, Transforming Nursing Home Culture: Evidence for Practice and Policy, a themed issue providing evidence to inform practice and policy related to culture change.  The full articles can be accessed at http://gerontologist.oxfordjournals.org/content/54/Suppl_1.toc and are summarized here.

A paper entitled “A “Recipe” for Culture Change? Findings from the THRIVE Survey of culture change Adopters” provided information from a survey that assessed which components of culture change – and in what combinations – have been adopted by nursing homes.  The survey was completed by 164 nursing homes that had already adopted culture change.  Results showed that adopted components of culture change varied across the type of nursing home model (i.e., small house, household, traditional unit).  As one example, respondents from small houses reported a significantly higher rate of direct care workers preparing meals (79%), but these were some of the least adopted practices for other adopters (22% of households and 13% of traditional units).  Results also showed that some traditional environments have been able to implement certain culture change components without large capital investments.  For instance, respondents reported similar rates of practices related to educational support and quality improvement regardless the nursing home model.  Taken together, these findings suggest that although practices do vary by model, some components of culture change are attainable for homes that have fewer resources to invest in large-scale renovations or reorganization.

A paper entitled “Who are the Innovators? Nursing Homes Implementing Culture Change” focused on the organizational factors associated with culture change implementation.  Using a sophisticated analytic process, information from 16,835 nursing homes was used to determine which resident, facility, and state characteristics related to a nursing home later being identified by experts as having implemented culture change.   These characteristics included being nonprofit, larger in size, and with fewer Medicaid and Medicare residents. Implementers also had better baseline quality with fewer health-related survey deficiencies and greater licensed practical nurse and nurse aide staffing. These findings suggest that nursing homes are in a better position to implement culture change if they start out with more resources and fewer challenges.   In a related article entitled “Culture Change and Nursing Home Quality of Care”, analyses examined how culture change implementation related to later nursing home quality.  This study found that nursing homes identified as culture change adopters later had fewer health-related survey deficiencies, but there was no improvement in the MDS-based metrics of quality.  These finding may suggest that culture change improves nursing home processes of care, and/or that surveyors recognized the homes’ culture change efforts in their ratings.  The lack of impact on MDS outcomes may suggest that either the early focus of such efforts has not been on clinical outcomes, or that because nursing homes adopting culture change already had better outcomes, there was less room for improvement.

Finally, a paper entitled “Developing the Green House Nursing Care Team: Variations on Development and Implementation” explored the roles of the nurse and the Shahbazim in the Green House model, focusing on how variations in the nursing team related to clinical care practices. Data were collected through observations and interviews with nurses, Shahbazim, Guides, and Directors of Nursing, and found that implementation of the nursing role within the Green House model varied both within and across sites.  Four nursing model types were identified: Traditional (nurse manages both care and non-care activities); Parallel (nurse manages care, Shahbaz manage non-care activities); Integrated (nurse and Shahbaz collaboratively manage care and non-care activities); and Visitor (Shahbaz manage care and non-care activities, with input from nurse as requested).  Care processes, Shahbaz skill development, and worker stress varied across each model, and although the Integrated model presents considerable challenges in terms of clarifying boundaries, it seemed to offer the greatest benefits in the areas addressed in this study.  

The THRIVE team will be expanding upon these and other findings in 2014, and will be sharing those with you and others via conference presentations, webinars, blog posts, and more journal articles.  As always, we invite your feedback about the best ways to keep you informed of the latest findings.

Questions about THRIVE can be directed to Lauren Cohen (lauren_cohen@unc.edu or 919-843-8874).

 


THRIVE (The Research Initiative Valuing Eldercare) Update on Green House Homes

By / Posted on January 27th, 2014

The Green House Project has partnered with the Robert Wood Johnson Foundation’s THRIVE (The Research Initiative Valuing Eldercare) collaborative to learn more about the Green House model as well as other models of care. Supported by the Robert Wood Johnson Foundation, the THRIVE team is conducting a series of interrelated research projects that together will comprise the largest research effort undertaken to date in Green House homes. Each quarter, a member of the THRIVE team will contribute a blog post to the Green House Project website.
The THRIVE research team is committed to the timely dissemination of findings relevant to The Green House Project homes and stakeholders.  Members of the THRIVE team recently presented preliminary research findings at the 2013 Green House meeting and in a January 2014 webinar.  Highlights from these presentations include:

David Grabowski (Harvard Medical School) debunked several common myths about The Green House model.  Using administrative data, David’s presentation showed that although higher resource nursing homes are more likely to adopt the Green House model than are lower resource nursing homes, these lower resource homes can be successful adopters with adequate vision and internal and external support.  His data also looked at culture change more generally, and found that culture change homes perform better on survey inspections — in fact, they lowered their health-related survey deficiencies by almost 15%!  David’s findings appear in the February issue of The Gerontologist journal:

Culture Change and Nursing Home Quality of Care

Who Are the Innovators?  Nursing Homes Implementing Culture Change

Lauren Cohen (University of North Carolina at Chapel Hill) presented data comparing the characteristics of Green House, higher culture change, and lower culture change nursing homes.  Interviews with guides and administrators found that a greater proportion of Green House homes offer resident choice in bedtime and get-up time, but not in bath time.  Lauren noted that previous research has shown that the desire for choice is not universal, and that predictability may be most important.  Her data also showed that Green House homes were less likely than culture change nursing homes to offer prescheduled daily activities, but were more likely to empower caregivers to lead activities.  So, it remains essential that empowered caregivers offer activities and encourage participation.

Kim Nolet (University of Wisconsin – Madison) reviewed the variations in how the Green House model is being implemented across homes, and discussed the implications of this variation.  Kim described variations in several Green House elements, including the role of the Shahbazim and the use of the den.  Her presentation suggested that model variations occur due to the challenges presented by critical events, organizational changes, daily routines, and subtle evolution in how things are done in Green Houses.  These challenges lead to problem-solving that sometimes results in reinforcement of the model and its core values, and other times in practices that are inconsistent with the core values of the model.

The THRIVE team will be expanding upon these and other findings in 2014.  We have planned conference presentations, webinars, blog posts, and journal articles to communicate our findings to you and others, and invite your feedback about the best ways to keep you informed of the latest findings.

Questions about THRIVE can be directed to Lauren Cohen (lauren_cohen@unc.edu or 919-843-8874).