Microsoft word - minutes workvisit gapna_may 2006_2.doc

Minutes of the 2-day international GAPNA-visit, 16-17 May 2006, Atlanta, Georgia, USA
(Pat Parmelee, Karel Bruhl, Anneke Francke and Renate Verkaik)
1. Group discussion with Nell Hodgson Woodruff School of Nursing faculty
(Tuesday 16 May. 1.00 pm)

Meeting with:
- Kenneth Hepburn, PhD (Professor; Associate Dean for Research; PhD program School of
Interests/background: community residents with dementia (now); Belmond Village small scale
dementia facility; 15 years surveying nursing homes/creditation units
- Gerri S. Lamb, PhD, RN, FAAN (Independence Foundation and Wesley Woods Chair; Adult
and Elder Health Nursing Department)
Interests/background: long term care (now); Casemanager home care, Minimum Data Set;
Subicute units: a systems person!
- Jennifer …………(doctoral student): community health nurse; symptoms of depression in
stroke survivors.
-Rebecca …………. (………………): depression and heart failure
-Charlene ………….(…………….): end of life decision making
Important topics/suggestions:
-Laura Gittlin (Philidelphia) does research into the effectiveness of REACH, a comparable day-
to-day care program that also focuses on activities, but from an occupational therapy perspective.
We should have a look at that study.
-The educational level of the CNA’s in de US is much lower (about 6 weeks training) than that
of the CNA’s in the Netherlands (about 2 years training). The CNA’s don’t make care plans, but
LPN’s do. The LPN’s (Licensed Practical Nurses) are comparable with Dutch CNA’s in
educational level. When adapting the guideline we should focus on the differences regarding
responsibilities/activities of the US care teams.
-Systems approach: it is important to consider the total environment surrounding the patient
when measuring changes in depression in the multi centre study, this in order to explain why the
Pleasant-Activities-Method does (or does not) reduce depression. In the Dutch multi centre study
we do this (among others) by performing case studies that are not yet described in the research
protocol and by interviewing the Pleasant-Activities-workgroup in the participating wards. When
the protocol for the case studies is finished, we’ll translate it and send it to Pat.
2. Meet with Karen Bacheller from Georgia Department of Human Resources
(Tuesday 16 May. 3.00 pm)

Meeting with:
-Karen Bacheller, Section Manager Community Care Services Program, Georgia Department of
Human Reseources, Division of Aging Services.
-Allan B. Goldman, MPH, Adjunct Assistant Professor Department of Health Policy and
Management, The Rollins School of Public Health of Emory University.
The internet pages of DHR (www.dhr. summarizes the following background of the
Community Care Services Program:
The Community Care Services Program
For 23 years the CCSP has provided Medicaid for eligible consumers with a range of community-based services that support the consumer's choice to remain at home or in the community. Consumers must meet the same medical, functional and financial criteria as for placement in a nursing facility under Medicaid. The CCSP assists older functionally disabled consumers, consumers, their families and caregivers to achieve safe, self-reliant lives. The CCSP supports consumer choice and responsibility. Appropriate, quality services are delivered in a cost effective manner through the coordination of a range of community resources and Medicaid services. The Division of Aging Services (DAS) operates the CCSP and contracts with the 12 Area Agencies on Aging (AAAs) to provide local program management and coordination. The Department of Community Health Division of Medicaid is the administrative and fiscal authority for the CCSP waiver program The care coordinator screens and assesses the consumer's medical, functional and social problems/needs to determine the appropriateness for Community Care and, with input from the client, caregiver, and physician develops a specific plan of care for each consumer admitted to the CCSP. The care coordinator brokers/monitors provider services for consumers by planning, arranging, coordinating, and evaluating the service delivery to assure that appropriate, quality services are provided in a timely and cost effective
manner and assures that consumer costs are contained.
We discussed the recent activities of the Community Care Services Program regarding the
screening of older adults for depression. They use the Geriatric Depression Scale for that.
According to Pat, the care coordinators who do the screening, experience quite some problems
using the GDS.
The Community Care Services Program does not yet offer therapy programs to those that suffer
from depression. Renate and Anneke advise them to take a look at the work done by Linda Teri
on BeaviorTherapy-PleasantEvents, BehaviorTherapy-ProblemSolving and the recent work in
the STAR-program for community residents.

3. Meet with Dr. Joe Ouslander
(Wednesday 17 May. 8.00 am)

Meeting with:
-Joseph G.Ouslander, M.D., Professor of Medicine and Nursing Director, Division of Geriatric
Medicine and Gerontology Chief Medical Officer, Wesley Woods Center of Emory University
Director, Emory Center for Health in Aging. Clinical Director, Atlanta VA Rehabilitation
Research & Development Center.
Important topics/suggestions:
- We talked about suitable locations for the pilot-project. According to Joe Budd Terras Nursing
home provides typical American nursing home care (CAN’s and LPN’s) and seems to have a
quiet comparable group of patients compared to the current Dutch RCT of Renate. It also is
conveniently located. But at this moment they have some problems and there are staff changes.
Within a few months whoever Joe thinks these should be resolved.
Other possible nursing homes are: 1) AG roads (also quite typical), with contact person Russel
Williams. Russel is always eager to improve the quality of care. 2) Foutain View (specifically for
dementia care).
Alternative might be Assisted living facilities with many psychogeriatric patients (but at the
same time probably not so comparable as a group to the Dutch RCT group): -Sunrise (Mariott)
- Joe told and showed us that the goals of our research project do fit in with goals of the 8-scope
of Work of the gmcf (Medicare Quality Improvement Organisation for Georgea), which has
specific targets for 2008 to improve depression-care and staff turnover.
- Joe suggests the following order of activities in our research: 1) adapt the guideline to the more
multidisciplinaire USA nursing home context 2) interview nurses (LPN’s/CNA’s) 3) expert
panel 4) testing the measures.
Pat suggests that the interviews with the nurses could probably be integrated within the focus
group discussions with CNA ’s she’s planning to have by the end of the summer.
-Pat proposes Holly Brown (School of Nursing) as a very appropriate person to do the training of
the CNA’s/LPN’s and possible other disciplines in using the guideline. She’s a nurse, has
training experience and ‘speaks the language’ of the various disciplines. Joe agrees with this.
- Joe offers to help us with entering into the nursing homes.
4. Group discussion with Veterans Affairs staff
(Wednesday 17 May. 10.00 am)

Meeting with:
-Betty Rose: psychologist and background in dementia research.
- …(Pat, could you please add the names of the nice people we talked to, especially the name of
the woman with blond hair who also joined the research presentations and our lunch?)
Important topics/suggestions:
- Betty suggests to look at some interesting materials developed by others in relation to Pleasant
Events with people with dementia: 1) the book: ‘Creating Successful Dementia Care Settings’
by Margaret P. Calkins, Ph.D 2) the work by Lynn Snow (University of Houston).
-To stimulate CNA’s/LPN’s to use the guideline it should be part of their job evaluation and/or
they should be rewarded for following the guideline.
-The suggestion is made to control for ‘seasonal-effects’ on depression in the multi centre
studies (e.g. winter depression).
-The importance of ‘person/emotion-oriented care’ is mentioned. One practical way to establish
this is a ‘chair with wheels’ that the CNA’s should sit on when interacting with the residents with
dementia that sit/lay in bed.
-The amount of text/attention in the training should be more on the importance of
communication with the residents and with the other staff than is now the case in the Dutch

5.Research presentation
(Wednesday 17 May. noon)

Meeting with:
-Joe Ouslander
-(Pat, could you please add the other names?)
Important topics/suggestions:
-Differences between Dutch nurse assistants and US CNA’s is again pointed at.
-Joe Ouslander: we should also think about engaging other disciplines in training of the
guideline, especially those disciplines that already undertake activities with residents, like
recreational therapists, but also occupational therapists, food assistants and others.
-One of the VA nurses mentions that it will not be easy to implement the guideline, it will need a
cultural change, but she finds it worth the challenge.
-Joe Ouslander: for a multi centre study in the US like we perform in the Netherlands, it will be a
challenge to find in one nursing home two comparable wards of which the nurses don’t work at
both wards (to have an independent control group). This should be carefully looked at when
developing the US multi centre proposal.
6.Meet with Dr. Bill McDonald and others at Fuqua Center
(Wednesday 17 May. 2.00 pm)

Meeting with:
- William M. McDonald, MD
Fuqua Center Director

Dr. William M. McDonald graduated from Duke Medical School in 1984 and was the Chief
Resident in Psychiatry at Duke and a member of the clinical faculty before moving to Emory in
1993. Throughout his career, Dr. McDonald has concentrated extensive research efforts on
understanding the neuroanatomy and clinical features of mood disorders such as mania and
depression, particularly when these disorders occur late in life. Dr. McDonald’s primary
contribution to clinical services was the development of the Geriatric Mood Disorders Program
at Wesley Woods. Dr. McDonald is a Diplomate of the American Board of Psychiatry and Neurology, with added qualifications in Geriatric Psychiatry. He is a reviewer for the American Psychiatric Association's guidelines on electroconvulsive therapy. He has been named by Woodward-White as one of the Best Doctors in America and received the 2001 Dean's Award for Medical School Teaching. Dr. McDonald currently holds the J.B. Fuqua Chair in Late-Life Depression at Emory University's School of Medicine.
- Eve H. Byrd, MSN, MPH, RN, FNP
Associate Director

Ms. Eve H. Byrd graduated from the Nell Hodgson Woodruff School of Nursing at Emory
University where she earned her Bachelors in Nursing in 1984 and her Masters in Psychosocial
Nursing in 1999. She is a certified Family Nurse Practitioner and a licensed Psychiatric Clinical
Nurse Specialist. She earned her Masters in Public Health with a concentration in Health Policy
from Rollins School of Public Health at Emory University. Her experience includes
medical/surgical nursing, public health nursing and home health nursing. She is an adjunct
faculty member at Emory's School of Nursing. Ms. Byrd is a member of the Georgia Geriatrics
Society and an affiliate member of the American Association of Geriatric Psychiatry. She also
currently chairs the Atlanta region Aging and Mental Health Coalition.
Nancie A. Vito
Program Coordinator, Community Education and Research
Ms. Nancie Vito graduated from Appalachian State University with a BS in Psychology and a
BA in Spanish. She has completed graduate coursework at New York University's Ehrenkranz
School of Social Work and is currently taking courses at the Rollins School of Public Health at
Emory University. Ms. Vito joined our team in May 2004, bringing with her several years of
experience in the nonprofit and mental health field. She currently coordinates the educational
training program Decreasing Depression and Suicide in Community-Dwelling Older Adults, in
which care managers throughout Georgia receive comprehensive training on depression. As a
part of our research team, she administers neuropsychological tests to study participants
(Janssen-sponsored Reminyl study and NIH-sponsored TMS study) and administers depression
scales to participants in the TMS study.
Important topics/suggestions:
- Bill McDonald was enthousiastic about the guideline, beacause it aims to empower nurse
assistants and reduce the use of antidepressants in residents with dementia.
- Bill McDonald had questions about the specificity of the Olin criteria for depression in SDAT
as opposed to apathy in SDAT. Renate explained that the difference between apathy and
depression is determined by looking at the reaction of people with dementia to events. If
someone is depressed, he/she will not react, or react negatively. If someone is apathetic due to
the dementia, and is not depressed, this person will react in a positive way.
-Bill McDonald suggests to focus in a grant application on the cost-effectiveness of the
guideline: e.g. less time spent by the nursing staff due to less agitated residents, reduced staff
turnover because of empowerment of the nurses, less expensive antidepressant medications (now
it costs about 800 dollar per month per resident).
- Bill McDonald suggests that we could perform the US multi centre study in Sunrise assisted
living facilities. These are comparable. He also liked the post-intervention trainings offer to the
non-intervention ward to get NH participating.
- Eve Bird proposes to also look at the work of Lea Watson for people with dementia in assisted
living facilities. Pat tells the group that she will also contact Linda Teri about her recent work in
assisted living facilities.
-Bill McDonald suggested to use video material for training because that is how CNA
(americans/many people today in general) get new information across: watching TV. He also
had some specific language suggestions for the guideline which will be essential for
understanding the text right.
7.Summary discussion and planning for the future project
(Wednesday 17 May. 4.00 pm)

-We will perform a pilot study and in the mean time write a proposal fro a multi centre study, in
which we also focus on international comparisons. The pilot study could be performed in 2007,
with preparing activities this year (2006). The multi centre study will probably only start in 2008
or even later.
-Fuqua will probably pay for the pilot study.
-Pat will contact NIMH for grant programs that also focus on international collaboration. Renate
has had contact with the NIMH about this already in 2005. She will send the information about
this contact to Pat.
1. Write minutes of the visit (Renate, comments by Pat, Anneke and Karel)
2. Discuss with Linda Teri the content of the guideline and the possibilities in Assisted Living
Facilities (Pat, during shopping…)
3. Choose between NH or Assisted living? (Pat and Anneke)
3. Adapt guideline (Pat/Fuqua)
4. Funding request for GAPNA (Guideline Applicability Project Nursing
Assistants) towards Fuqua for Pilot (Pat)
5. Small Funding request for GAPNA towards RCOAK (already done) and possible
other funders in NL (but i have am not been very lucky so far, except one
time 5000) (Karel)
6. Possible step: interviews NAs and staff (Karel) or a focus group (Pat/./Karel)
7. Expert panel invitation/request for comment on guideline (Pat)
8. Funding Request NIMH for RCT (Pat)
9. 6 months Pilot in 2007/2008 (Pat, Karel, Anneke/Renate)


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