by IDEAS, Inc.; 1999; Kirtland, OH: IDEAS, Inc.
There is increasing recognition of the important role of the physical environment in care settings for people with dementia, starting in the late 1970s with the work of M. Powell Lawton at the Philadelphia Geriatric Center. Other organizations also have contributed significantly to this area of research, such as the eight studies conducted at the Corinne Dolan Alzheimer Center at Heather Hill in Ohio, which examined such issues as orientation to the bedroom and bathroom, agitation related to access or denied access to outdoor spaces, visual partitions to increase concentration on activities, and more. There also are an increasing number of books, journal articles, and conference presentations related to the design of environments for this population.
While there is a need for more research, it also is clear that, despite consensus that the environment makes a difference, few faculties seem to implement the appropriate physical environmental modifications.
What are the barriers to implementation? One cited frequendy is cost. Consultants can provide the necessary information individualized for each facility, but often at a cost beyond the budget of the facility or out of scale with the scope of the project. However, many interventions are very low cost and can be created within the facility. Another barrier may be the faculty's perceived lack of access to information, although information is available readily through many sources. Most likely, the chief barrier to appropriate environmental modifications is lack of knowledge of what specific interventions should be implemented within a given facility. Books, journal articles, and conferences only provide generalized information but do not tell the facility how to address their specific problems and issues, which arise from an interaction of residents, program, staffing, and physical environment. For example, in some facilities, the resident who spends much of her day walking around the unit is viewed as being disruptive to other residents and to activities and, thus, staff want to minimize this behavior. In other faculties, this same resident would be considered as getting an appropriate amount of exercise, which is healthy and to be encouraged. Therefore, the resident and her behavior would not be viewed as a problem.
To address this situation, IDEAS, Inc. applied for and received funding from National Institute on Aging to develop the REMODEL, a costeffective alternative to traditional consultation services. The REMODEL is facility-specific, based on a comprehensive questionnaire completed by staff who are knowledgeable about the dementia-care setting and photographs taken with a disposable camera provided as part of the consultation package. REMODEL provides information back to the facility that is both specific to that facility and focuses on a problemsolving process, so solutions can go beyond current problems because their population undoubtedly will change over time.
A REMODEL consult provides the facility with three distinct levels of information. First, they receive a facility-specific report, which details specific recommendations based on their residents, staff, program, environment, and budget. Facility reports for individual modules range from 15 to 30 pages, depending on the state of the unit. Second, the facility receives a comprehensive Resource Manual, which describes in greater detail background information about why each topic is an issue for individuals with dementia, what staff can do about it, what the environment can do, and where to go to find products. Finally, the facility receives a staff training video directed toward educating line staff about the importance of the environment and ways in which they can positively impact their caregiving environment.
DEVELOPMENT PROCESS OF THE REMODEL
A thorough literature review was conducted to develop an exhaustive list of therapeutic goals for people with dementia. This was subjected to a concept mapping process to empirically derive a set of therapeutic goals on which the REMODEL was based. The concept mapping was completed by a panel of national experts, which resulted in 12 therapeutic goals providing the foundation for developing the assessment instrument. There was some tension between trying to make the assessment comprehensive and keeping it manageable. This resulted in dividing the instrument into three conceptually distinct models: Minimizing Disruptive Behaviors; Maximizing Cognitive and Functional Independence; and Enhancing Self and Sense of Home. A questionnaire was developed for each, incorporating both items from well-established instruments and newly defined terms. ,
The assessment covers resident status, unit philosophy, staffing issues, frequency, and importance oí 17 different core areas, staff response, and physical environment correlates. The core areas are: wandering, attempting to leave, rummaging, hoarding, combativeness, socially inappropriate behaviors, orientation, mobility, continence, eating, dressing, bathing, personalization, roles and activities, privacy, autonomy and control, and residential design.
Psychometric properties of the instrument were tested. High interrater reliability (.94 to .97), and concurrent validity with the Professional Environment Assessment Protocol (PEAP) were established (.86).
Preliminary reports from facilities that have used REMODEL are very positive. One facility has set up an "environmental committee' that meets monthly to discuss relevant topics and how to address them. Another nurse participant reported that she "carries this [the Manual] around with her like it's her Bible. If anyone has a question, she just looks up the answer." Recognizing that the process of implementing facility change can take substantial amounts of time, facilities are given 1 year after receiving their individualized report to assess their satisfaction. Thus, much of this data still is being collected.
The REMODEL is a unique product that helps long-term care facilities address the current issues they face in caring for a cognitively impaired population. In addition, REMODEL is structured to provide information which can be used long into the future as the needs, abilities, and characteristics of the unit, its residents, and staff change over time.
For more information, contact Eileen Lipstreuer, IDEAS, Inc., 8055 Chardon Road, Kirtland, OH 44094, or call (440) 256-1880 or (888) 41 -IDEAS, or e-mail IDEASel@aol.com. The REMODEL is available at $950 per module, or all three modules at the discounted price of $2,500.