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QUERI Evaluates STAR-VA: A Veteran-Centered Intervention for Management of Dementia

Takeaway: STAR-VA implementation helps lower the risks related to the management of the behavioral symptoms of dementia among Veterans living in VA Community Living Centers by decreasing potentially inappropriate medication use and staff injuries.

The Staff Training in Assisted Living Residences (STAR) intervention was originally developed for training direct care workers in assisted living residences to improve the care of older adults with dementia by successfully managing the challenging behaviors commonly exhibited by these residents. VA adapted this intervention (called STAR-VA) to be a Veteran-centered, interdisciplinary, behavioral approach for managing the behavioral symptoms of dementia (BSD) among Veterans in VA Community Living Centers.

The QUERI Sustaining STAR-VA Partnered Evaluation of Veteran, Implementation and Facility Factors Contributing to Positive Sustained Outcomes was created to:

• Develop and validate a quality indicator for monitoring BSD;
• Evaluate the effect of STAR-VA over time by comparing site and Veteran outcomes associated with BSD at trained and untrained CLCs;
• Examine variations in STAR-VA sustained implementation, as well as barriers and facilitators; and
• Identify best practices in sustainable implementation and evaluation strategies.

A distress behavior indicator (DBI) was developed from mandatory routine CLC resident assessments to aid in this evaluation. This indicator was found to be internally consistent, significantly correlated with validated STAR-VA clinical outcome measures as predicted, and sensitive to change.

Evaluation Findings

The longitudinal effect of STAR-VA implementation was compared for site and Veteran outcomes at trained and untrained CLCs. Findings show:

• Behavior Symptoms of Dementia (BSD). STAR-VA implementation did not have a significant effect on the DBI in STAR-VA CLC resident cases compared with eligible resident comparisons at untrained CLCs. It also did not have a significant effect on CLC-level DBI or national disruptive behavior reporting rates. The lack of effect on the DBI may be related to missing data, under-reporting, or misalignment of routine quarterly assessments and STAR-VA implementation. It also may be that STAR-VA implementation does not impact the frequency or severity of BSD and rather helps CLC teams better manage BSD to lower associated risks.
• Psychotropic Medications. Antipsychotic and benzodiazepine dose equivalents used were reduced for residents and CLCs in the STAR-VA program relative to eligible comparisons. The most significant effect was a 50% reduction in as-needed doses given specifically for agitation or anxiety for STAR-VA training cases, relative to eligible comparison residents, even after adjusting for overall comorbidity, healthcare use, previous drug use, and facility-level characteristics.
• Staff Injuries. Significant decreases were found in staff injury rates due to assault in CLCs the year of and following completion of STAR-VA training and consultation compared with non-completing CLCs, accounting for important site characteristics.

Facilitators and Barriers

Important facilitators included the engagement of STAR-VA champions, leaders, and the entire clinical team, routines that foster open communication, and information sharing tools. The most frequent barriers were staffing issues, unsupportive work culture, poor collaboration between disciplines, lack of written policies/procedures, and the need to integrate with performance evaluations.

Summary and Recommendations

STAR-VA implementation helps lower the risks related to the management of the behavioral symptoms of dementia among Veterans living in VA Community Living Centers by decreasing potentially inappropriate medication use and staff injuries. Thus, this evaluation supports continued STAR-VA implementation. Recommendations include ensuring accurate, complete, and frequent BSD assessment and feedback, the presence of local champions, effective team interactions, routine use of communication tools, and a supportive work culture. Findings will guide the development of an outcome-driven, tailored sustainability implementation and evaluation strategy.

For more information about STAR-VA QUERI, contact Principal Investigator, Kim Curyto, PhD, at kimberly.curyto@va.gov.