Evaluating a National Person-Centered Training Program to Strengthen the Dementia Care Workforce

This project will compare two training models of an evidence-based online dementia care training program for direct care staff in assisted living to a waitlist control: 1) essentiALZ training and 2) essentiALZ training + Project ECHO. It will examine the extent to which each model is implemented and achieves its intended outcomes to improve staff knowledge and attitudes, change care practices, and improve the wellbeing of staff, residents, and residents' family members. Results will inform next steps in dementia care training for the assisted living (AL) and broader long-term care workforce.

To examine these outcomes, data will be collected from AL staff and families over the course of 6 months. Staff will complete questionnaires and participate in interviews (as applicable) at baseline, post-training, 3-months, and 6-months. Families will participate in interviews at baseline, 3-months, and 6-months.

More than 75% of persons living with Alzheimer's disease and related dementias who reach 80 years of age require residential long-term care, which is increasingly provided in assisted living (AL). Across the country, almost 29,000 AL communities with more than 996,000 beds have become the primary residential care provider for persons with dementia: 90% of AL residents have cognitive impairment and 42% have recorded moderate or severe dementia, with actual rates being higher. AL provides supportive but not nursing services; consequently, virtually all care is provided by direct care workers (nursing assistants and personal care aides).

Unfortunately, direct care workers are undervalued and under-trained, leading to poor care, workplace injury, dissatisfaction, and high turnover. AL is state-regulated, and only 17 states stipulate minimum training hours (some being as low as one hour), meaning that two-thirds of states are silent on training. Fewer than 40% of staff have education beyond high school, and so it is not surprising that a minority report sufficient knowledge to care for persons with dementia. In striving to fill this gap, training for direct care workers must be accessible and have efficacy in benefitting the staff, organization, and persons with dementia.

Online training is an especially promising option due to its low cost, wide availability, and potential for self pacing, automated skills tests, and certification. The Alzheimer's Association is the national leader in dementia care training, and in 2021 developed essentiALZ (pronounced "essentials"), an online program teaching evidence-based, person-centered care, which can be accessed from a computer, tablet, or mobile device. Already more than 1,500 staff have essentiALZ certification, but as is true of the majority of training programs, evidence as to its ability to improve care and outcomes is lacking. It is possible that essentiALZ is effective in changing care and outcomes, but it may also be that additional supports are necessary to do so. A timely model of support is Project ECHO, which has flooded the field of long-term care as a proven way to provide expert guidance and peer support via a remote, online approach. Adding ECHO to online dementia training might provide a necessary boost to achieve care change and improved outcomes.

The project responds to the National Institute on Aging Notice of Special Interest that calls for strengthening the workforce through enhancing and supporting skills training. It will conduct a hybrid implementation/effectiveness randomized trial in 126 AL communities, comparing essentiALZ alone, essentiALZ + ECHO enhancement, and a waitlist control. Outcomes grounded in the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) model and the Kirkpatrick training effectiveness model will be examined over six months, comparing the arms in terms of (1) implementation and (2) effectiveness, and (3) examining the extent to which implementation and effectiveness differ based on characteristics of the AL community, staff, residents, and family members. Results will inform next steps in dementia care training for the AL and broader long-term care workforce.

Eligibility Criteria:
Inclusion Criteria:

AL Staff:

* Staff (part-time, full-time, and including contract staff) who provide direct care to residents at the participating assisted living community (e.g., certified nursing assistants, personal care aides, registered nurses, licensed practical nurses, activity directors, social workers, and others) as determined by the administrator/health care supervisor
* Are 18 years of age or older
* Are able to read and speak English fluently

Family:

* Resident not expected to die or be transferred in the next six months at baseline
* At follow-up, resident lived in AL community at least one month during the three months prior to interview date
* Are a family member/legally authorized representative (LAR), or designated contact of a resident with Alzheimer's disease and related dementia (ADRD) of a participating AL community
* Are 18 years of age or older
* Are English speaking
* Visit the resident at least monthly

Exclusion Criteria:

AL Staff \& Family:

- Are under 18 years of age