Original Study| Volume 22, ISSUE 8, P1706-1713.e1, August 2021

Testing the Implementation of Function-focused Care in Assisted Living Settings

Published:October 29, 2020DOI:



      The purpose of this study was to evaluate the Function-Focused Care for Assisted Living Using the Evidence Integration Triangle (FFC-AL-EIT) intervention.


      FFC-AL-EIT was a randomized controlled pragmatic trial including 85 sites and 794 residents.


      FFC-AL-EIT was implemented by a Research Nurse Facilitator working with a facility champion and stakeholder team for 12 months to increase function and physical activity among residents. FFC-AL-EIT included (Step I) Environment and Policy Assessments; (Step II) Education; (Step III) Establishing Resident Function-Focused Care Service Plans; and (Step IV) Mentoring and Motivating.

      Setting and Participants

      The age of participants was 89.48 years [standard deviation (SD) = 7.43], and the majority were female (n = 561; 71%) and white (n = 771; 97%).


      Resident measures, obtained at baseline, 4, and 12 months, included function, physical activity, and performance of function-focused care. Setting outcomes, obtained at baseline and 12 months, included environment and policy assessments and service plans.


      Reach was based on 85 of 90 sites that volunteered (94%) participating. Effectiveness was based on less decline in function (P < .001), more function-focused care (P = .012) and better environment (P = .032) and policy (P = .003) support for function-focused care in treatment sites. Adoption was supported with 10.00 (SD = 2.00) monthly meetings held, 77% of settings engaged in study activities as or more than expected, and direct care workers providing function-focused care (63% to 68% at 4 months and 90% at 12 months). The intervention was implemented as intended, and education was received based on a mean knowledge test score of 88% correct. Evidence of maintenance from 12 to 18 months was noted in treatment site environments (P = .35) and policies continuing to support function-focused care (P = .28)].

      Conclusions and Implications

      The Evidence Integration Triangle is an effective implementation approach for assisted living. Future work should continue to consider innovative approaches for measuring RE-AIM outcomes.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of the American Medical Directors Association
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Resnick B.
        • Galik E.
        • Gruber-Baldini A.
        • Zimmerman S.
        Perceptions and performance of function and physical activity in AL communities.
        J Am Med Dir Assoc. 2010; 11: 406-414
        • Król-Zielińska M.
        • Kusy K.
        • Zieliński J.
        • Osiński W.
        Physical activity and functional fitness in institutionalized vs. independently living elderly: A comparison of 70–80-year-old city-dwellers.
        Arch Gerontol Geriatr. 2011; 53: e10-e16
        • Chung G.
        Understanding nursing home worker conceptualizations about good care.
        Gerontologist. 2013; 53: 246-254
        • Resnick B.
        • Galik E.
        Impact of care settings on residents' functional and psychosocial status, physical activity and adverse events.
        Int J Older People Nurs. 2015; 10: 273-283
        • Resnick B.
        • Boltz M.
        • Galik E.
        • et al.
        The impact of function focused care and physical activity on falls in assisted living residents.
        Can J Nurs Res. 2020; 52: 45-53
        • Benjamin K.
        • Edwards N.
        • Caswell W.
        Factors influencing the physical activity of older adults in long term care: Administrators perspectives.
        J Aging Phys Act. 2009; 17: 181-195
        • Buttery A.
        • Martin F.
        Knowledge, attitudes and intentions about participation in physical activity of older post acute hospital inpatients.
        Physiotherapy. 2009; 95: 192-198
      1. Resnick B. Galik E. Boltz M. Pretzer-Aboff I. Implementing Restorative Care Nursing in All Setting. 2nd ed. Springer, New York, NY2011
        • Bonanni D.R.
        • Devers G.
        • Dezzi K.
        • et al.
        A dedicated approach to restorative nursing.
        J Gerontol Nurs. 2009; 35: 37-44
        • Lee S.
        • Kim M.
        • Jung Y.
        • Chang S.
        The effectiveness of function-focused care interventions in nursing homes: A systematic review.
        J Nurs Res. 2020; 27: 1-13
        • Galik E.M.
        • Resnick B.
        • Gruber-Baldini A.
        • et al.
        Pilot testing of the restorative care intervention for the cognitively impaired.
        J Am Med Dir Assoc. 2008; 9: 516-522
        • Wells K.L.
        • Dawson P.
        • Sidani S.
        Effects of an abilities focused program of morning care residents who have dementia and on caregivers.
        J Am Geriatr Soc. 2000; 48: 442-449
        • Dharmarajan T.
        • Choi H.
        • Hossain N.
        • et al.
        Deprescribing as a clinical improvement focus.
        J Am Med Dir Assoc. 2020; 21: 355-360
        • Resnick B.
        • Galik E.
        • Vigne E.
        Translation of function focused care to assisted living facilities.
        Fam Community Health. 2014; 37: 101-165
        • Green L.
        • Richard L.
        • Potvin L.
        Ecological foundations of health promotion.
        Am J Health Promot. 1996; 10: 270-281
        • Bandura A.
        Self-efficacy: The Exercise of Control.
        W.H. Freeman, New York, NY1997
        • Glasgow R.
        • Green L.
        • Taylor M.
        • Stange K.
        An evidence integration traingle for aligning science with poliy and practice.
        Am J Prev Med. 2012; 42: 646-654
        • Lazenby M.
        The international endorsement of US distress screening and psychosocial guidelines in oncology: A model for dissemination.
        J Natl Compr Cancer Netw. 2014; 12: 221-227
        • Irvine A.
        • Billow M.
        • McMahon E.
        • et al.
        Mental illness training on the internet for nurse aides: A replication study.
        J Psychiatr Ment Health Nurs. 2013; 20: 902-912
        • Zhang S.
        • Gamaldo A.
        • Neupert S.
        • Allaire J.
        Predicting control beliefs in older adults: A micro-longitudinal study.
        J Gerontol B Psychol Sci Soc Sci. 2020; 75: e1-e12
        • Resnick B.
        • Galik E.
        • Gruber-Baldini A.
        • Zimmerman S.
        Testing the impact of function focused care in assisted living.
        J Am Geriatr Soc. 2011; 59: 2233-2240
        • Resnick B.
        • Galik E.
        • Boltz M.
        • et al.
        Psychometric testing of the function focused environment assessment and the function focused policy assessment in assisted living.
        J Housing Elderly. 2019; 33: 153-172
        • Resnick B.
        • Galik E.
        • Boltz M.
        • et al.
        Reliability and validity of the Checklist for Function Focused Care in Service Plans.
        Clin Nurs Res. 2020; 29: 21-30
        • Borson S.
        • Scanlan J.
        • Chen P.
        • Ganguli M.
        The Mini-Cog as a screen for dementia: Validation in a population-based sample.
        J Am Geriatr Soc. 2003; 51: 1451-1454
        • Linn B.
        • Linn M.
        • Gurel L.
        Cumulative illness rating scale.
        J Am Geriatr Soc. 1968; 16: 622-626
        • Mahoney F.
        • Barthel D.
        Functional evaluation: The Barthel Index.
        Mad State Med J. 1965; 14: 61-66
        • Resnick B.
        • Simpson M.
        Restorative care nursing activities: Pilot testing self efficacy and outcome expectation measures.
        Geriatr Nurs. 2003; 24: 83-87
        • Resnick B.
        • Simpson M.
        • Bercovitz A.
        • et al.
        Testing of the Res-Care pilot intervention: Impact on nursing assistants.
        Geriatr Nurs. 2004; 25: 292-297
        • Resnick B.
        • Rogers V.
        • Galik B.
        • et al.
        Reliability and validity of knowledge and self-efficacy and outcome expectation for restorative care activities measures.
        J Nurs Care Q. 2008; 23: 162-169
        • Green L.
        • Kreuter M.
        • Deeds S.
        • Partridge K.
        Health Education Planning: A Diagnostic Approach.
        1st ed. Mayfield, Mountain View, CA1980
        • Rogers E.
        Diffusion of Innovations.
        5th ed. Free Press, New York, NY2003
        • Greenhalgh T.
        • Robert G.
        • MacFarlane F.
        • et al.
        Diffusion of innovations in service organizations: Systematic review of recommendations.
        Milbank Q. 2004; 82: 581-629
        • Knapp H.
        • Anaya H.
        Implementation science in the real world: A streamlined model.
        J Healthcare Q. 2012; 34: 27-36
        • Damschroder L.
        • Aron D.
        • Keith R.
        • et al.
        Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science.
        Implement Sci. 2009; 4: 50
        • Proctor E.
        • Silmere H.
        • Raghavan R.
        • et al.
        Outcomes for implementaiton research: Conceptual distinctions, measurement challenges, and research agenda.
        Admin Policy Ment Health. 2011; 38: 65-76
        • Phillips L.
        • Petroski G.
        • Conn V.
        • et al.
        Exploring path models of disablement in residential care and assisted living residents.
        J Appl Gerontol. 2018; 37: 1490-1516
        • Holmes S.
        • Galik E.
        • Resnick B.
        Factors that influence physical activity among residents in assisted living.
        J Housing Elderly. 2017; 60: 120-137
        • Christey G.
        • Amey J.
        • Campbell A.
        • Smith A.
        Variation in volumes and characteristics of trauma patients admitted to a level one trauma centre during national level 4 lockdown for COVID-19 in New Zealand.
        N Z Med J. 2020; 133: 81-88
        • Naylor M.
        • Hirschman K.
        • Hanlon A.
        • et al.
        Factors associated with changes in perceived quality of life among elderly recipients of long-term services and supports.
        J Am Med Dir Assoc. 2016; 17: 44-52
        • LaCroix A.
        • Bellettiere J.
        • Rillamas-Sun E.
        • et al.
        Nutrition, obesity, and exercise association of light physical activity measured by accelerometry and incidence of coronary heart disease and cardiovascular disease in older women.
        J Am Med Assoc Netw Open. 2019; 2: 1-14
        • Landry G.
        • Falck R.
        • Beets M.
        • Liu-Ambrose T.
        Measuring physical activity in older adults: Calibrating cut-points for the MotionWatch 8((c)).
        Front Aging Neurosci. 2015; 7: 165
        • Freedson P.S.
        • Melanson E.
        • Sirard J.
        Calibration of the computer science and applications, Inc. accelerometer.
        Med Sci Sports Exerc. 1998; 30: 777-781
        • Troiano R.
        • Berrigan D.
        • Dodd K.
        • et al.
        Physical activity in the United States measured by accelerometer.
        Med Sci Sports Exerc. 2008; 40: 181-188
        • Corcoran M.
        • Chuf K.
        • White D.
        • et al.
        Accelerometer assessment of physical activity and its association with physical function in older adults residing at assisted care facilities.
        J Nutr Health Aging. 2016; 20: 752-756
        • Chakravarthy A.
        • Resnick B.
        Reliability and validity testing of the MotionWatch 8 in older adults.
        J Nurs Meas. 2017; 25: 7-11
        • CamNtech
        MotionWatch 8 Overview.
        (Available at:)
        • Lichtwarck B.
        • Selbaek G.
        • Kirkevold Ø.
        • et al.
        Time to reduce agitation in persons with dementia in nursing homes. A process evaluation of a complex intervention.
        BMC Health Serv Res. 2019; 19: 1-9
        • Santos S.
        • Tagai E.
        • Scheirer M.
        • et al.
        Adoption, reach, and implementation of a cancer education intervention in African American churches.
        Implement Sci. 2017; 12: 1-11
        • Folta S.
        • Seguin R.
        • Chui K.
        • et al.
        National dissemination of StrongWomen-Healthy Hearts: A community-based program to reduce risk of cardiovascular disease among midlife and older women.
        Am J Public Health. 2015; 105: 2578-2585
        • Chou R.
        Resident-centered job satisfaction and turnover intent among direct care workers in assisted living: A mixed-methods study.
        Res Aging. 2012; 34: 337-364
        • Hyde J.
        • Perez R.
        • Doyle P.
        • et al.
        The impact of enhanced programming on aging in place for people with dementia in assisted living.
        Am J Alzheimers Dis Other Dement. 2015; 30: 733-737
        • Caffrey C.
        • Sengupta M.
        • Park-Lee E.
        • et al.
        Residents Living in Residential Care Facilities: United States, 2010 National Center for Health Statistics Data Brief No. 91, pp1-6.
        National Center for Health Statistics, Hyattsville, MD2012