We conducted a randomized trial in three nursing homes in the Pittsburgh area. Within each nursing home, residents were randomized to receive a QOL Care Plan or usual care. A total of 64 residents were randomized (39 to the intervention and 25 to the control). Forty six were available at the 90 follow-up and 37 at the 180 day follow-up. After180 days, the study ended and all control group members were provided with a QOL Care Plan.
The table directly below summarizes the care plans in the treatment group by domain at baseline.
Care plans were developed by University of Pittsburgh staff. Each care plan was presented to an appropriate facility representative for approval (e.g., social work, activities, dietary, nursing, etc.). The care plan task then became part of the standing orders for that resident.
We calculated the average change in QOL in the domain targeted by the care plan from baseline to 90 days. (Changes in non-targeted domains are not charted.) The number of residents with a care plan in each domain at 90 days is summarized on this page below. For comparison, we also put on the chart the average change in the control group.
In each targeted domain in the chart, the change in QOL for the treatment group exceeds the improvement or decline in the control group. In the Functional Competence (FC) domain, both groups decline, however the change in the treatment group is smaller indicating lower loss of QOL. In previous studies, we have found that as ADL limitations increase, Functional Competence tends to decrease.
When we calculate the overall average of the difference in QOL across all domains, the change in QOL for the treatment group exceeds the control group (p = .0524). The treatment group actually improves overall at 90 days while the control group experiences a small, non-significant decline.
The chart below shows the difference between the changes in the treatment group and changes in the control group from baseline to 90 days and from baseline to 180 days. In other words we calculated the “difference in differences.” For comparison, we used the entire control group for each domain. For the treatment group, we used the actual number of residents who had care plans in each specific domain. The colored bar is the difference between changes in the treatment group and changes in the control group from baseline to 90 days and the white/gray bar is the difference between changes in the treatment group and the changes in the control from baseline to 180 days.
For all domains from baseline to 90 days, the treatment always does better than the control: changes in treatment from baseline to 90 days are always greater than the changes in control from baseline to 90 days, resulting in positive scores. For baseline to 180 days, the differences between the changes in the treatment group and changes in the control group are mostly positive. However, for Individuality, Relationships and Enjoyment the differences are negative.
We did not change the care plans from 90 to 180 days. We see that there is decay or decline in QOL from 90 to 180 days. This was done purposively to see how often the Care Plan should stay in place. There are a lot of tradeoffs such as time, boredom, and effectiveness as to how frequently it should be changed.
Finally, we see that the average effect across all domains is greater for the change in the treatment group from baseline to 90 days than the change in the control group. This average effect is in the same direction, but somewhat attenuated from baseline to 180 days.
The Quality of Life Structured Resident Interview and Care Plan is a system for creating individualized, person-centered care plans in the nursing home. This interview-based approach to care planning generates the information staff need to tailor a resident's care plan to their preferences, as well as quantitative measurement of individual and facility-level outcomes.
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Howard Degenholtz, PhD
Department of Health Policy and Management
Center for Bioethics and Health Law
University of Pittsburgh
130 DeSoto St., A616
Pittsburgh, PA 15213