Background: Providing Veterans “personalized, proactive, patient-driven health care” is central to VHA’s Blueprint for Excellence’s mission. Enabling Community Living Center (CLC) residents to use their time meaningfully constitutes a key facet of this care. Yet busy frontline staff concentrating on medical care frequently overlook this fundamental human need, resulting in poorer resident clinical and social outcomes. Montessori-based Activity Programming (MAP) is a community nursing home- developed structured, evidence-based intervention that fills this critical gap. It enables resident engagement in structured, meaningful activities using clearly outlined principles and strategies focusing on resident strengths. MAP is effective for a variety of resident outcomes: social behavior, basic cognitive abilities, engagement, caloric intake, antipsychotic and sedative use, and behavioral disturbances. This proposal will address three issues before MAP can be used successfully with Veterans in CLCs: (1) adapting it for CLCs’ heterogeneous population; (2) developing a delivery strategy for the complex and difficult- to-change CLC system that is not dependent on MAP’s current lengthy, in-person training; and (3) testing the adapted program and strategy to finalize it for regional or national roll out Objectives: This 3-year pre-implementation study will address these gaps across three aims. Aim 1 (Phase 1): Adapt MAP for the CLC population (MAP-VA) and define the delivery method in collaboration with staff at 2 CLCs. Aim 2 (Phase 2): Compare onsite and remote implementation strategies for the implementation guide at 6 sites. Aim 3 (Phase 3): Finalize a revised, practical, and effective MAP-VA delivery guide to enable sustainable dissemination and implementation. Methods: The study will take place in 3 phases using mixed-methods and a purposive sample of CLCs. In Phase 1 (12 months) we will visit 2 sites to gather data to adapt the materials and develop the delivery guide. In Phase 2 (18.5 months) we will have 6 sites implement the guide, each over a 6-month period. We will compare: (a) an onsite strategy at 3 sites, involving in-person, on-the-ground training prior to and during the implementation period, and (b) a remote strategy at 3 sites, where training and follow up will be done via conference calls and LiveMeeting. In Phase 3 (5.5 months) we will revise and finalize the guide and implementation plan, making it ready for regional / national roll-out. Anticipated Impacts: Over 40,000 Veterans receive care in VHA CLCs nationwide each year. Efforts to improve care quality have resulted in the “culture change” movement over the last decade, which has been fully embraced by the VA. Essential to the success of this shift in treatment climate is careful consideration of the intimate link between staff-related factors and resident outcomes in long-term care settings. Evidence-based staff training on activity delivery is urgently needed to provide more appropriate care for Veterans, over half of which are diagnosed with mental health disorders and / or dementia. Recreation therapists alone cannot provide the density of activity required. Meaningful time use has been shown to benefit physical health, longevity, well-being, and quality of life. Interdisciplinary frontline staff with the most patient contact, including nursing assistants, need evidence-based practical tools and strategies for engaging Veterans in meaningful activities that promote quality of life and reduce behavior disturbances. MAP-VA may fill this gap. Interim deliverables and final products will be shared with operations partners who are collaborating on this project as Advisory Panel members. The knowledge gained from this study will be of immediate applicability to CLCs nationwide and will be helpful for guiding further improvements in patient-centered care in VHA.

Over 40,000 Veterans receive care in VA Community Living Centers (CLCs) nationwide each year. Providing residential patient-centered care to this heterogeneous group affected by high rates of serious mental illness, dementia and related disorders, and life-limiting physical disabilities is an urgent priority. Social and cognitive engagement, sustained independence, and optimal involvement in activities are essential to well-being, longevity, and other critical outcomes. Busy staff need additional training to learn strategies for infusing meaningful activity into the daily lives of this vulnerable population. Montessori-based Activity Programming (MAP) is an obvious yet innovative approach that could foster environments that more fully support veterans in the CLCs. The proposed research will adapt MAP for VA, develop a CLC-specific delivery guide, and compare two implementation strategies providing knowledge necessary for scalability within the VHA system.