For older adults receiving long-term services and supports (LTSS), health-related quality of life (HRQoL) has emerged as a critical construct to examine because of its focus on components of well-being, which are affected by progressive changes in health status, health care, and social support. HRQoL is a health-focused quality of life (QOL) concept that encompasses aspects of QOL that affect health such as function, physical, and emotional health. Examining existing theoretical constructs and indicators of HRQoL among LTSS recipients led us to posit a revised conceptual framework for studying HRQoL among LTSS recipients. We adapted the Wilson and Cleary HRQoL model by expanding function to specifically include cognition, adding behavior and LTSS environmental characteristics in order to create a more robust HRQoL conceptual framework for older adults receiving LTSS. This refined conceptual model allows for the measurement of a mix of structural, process, and outcome measures. Continued development of a multidimensional conceptual framework with specific HRQoL measures that account for the unique characteristics of older adults receiving LTSS will contribute significantly to LTSS research, policy, and planning efforts.

Results contribute to an emergent body of research that utilizes patient preferences to achieve the goals of person-centered care. The complexity of these responses substantiates the use of qualitative inquiry to thoroughly assess and integrate NH resident preferences into the delivery of person-centered care.

This study demonstrates the value of individualized activities for nursing home residents with dementia. In a stringent test, residents were happier and less angry during a customized intervention compared with a standardized intervention. Even brief individualized CNA-led activities bring pleasure to nursing home residents and constitute an effective strategy to enhance positive affect and engagement in persons with dementia.

Findings indicate that nursing home residents' preferences may change in importance or fulfillment in relation to personal or environmental circumstances. In order to develop formal care that matches older adults' preferences, regular assessment of both elders' preferences and the contextual factors affecting preferences is needed. However, given the changing nature of preference importance, there is also a need to determine how to best balance older adults' changing preferences within care delivery environments.

Knowledge of individuals’ everyday preferences is a cornerstone of person-centered care (PCC). Initial evidence demonstrates the positive impact of honoring preferences in care for older adults receiving long-term services and supports (LTSS). Yet, the mechanisms through which preference-based care affects individual well-being remain poorly understood. This article proposes a theoretical model of PCC entitled the Preference-Based Model of Care that integrates the Theory of Human Motivation, Self-determination Theory, the Competence-Press Model of person and environment fit, the Living Systems Framework, and the Broaden-and-Build theory of positive emotions to deepen our understanding of the processes through which preference-based care affects well-being among older adults receiving LTSS. The Preference-Based Model of Care illustrates how goal-directed behaviors facilitate need fulfillment through the expression of individual preferences and how these behaviors mediate the relationship between person–environment fit and affect balance within a particular social, cultural, and political context. The Preference-Based Model of Care can advance research on PCC in LTSS and can inform LTSS clinical practice guidelines for older adults, regardless of functional or cognitive capacity.

The no-cost PCC toolkit provides a new means to measure the quality of PCC delivery. As of February 2014, over 700 nursing homes have selected the Advancing Excellence in America's Nursing Homes PCC goal as a focus for quality improvement. The toolkit enables providers to incorporate quality improvement by moving beyond anecdote, and advancing more systematically toward honoring resident preferences.

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Objectives To explore differences in having an advance directive among older adults newly transitioned to long-term services and support settings (LTSS; i.e., nursing homes, NH; assisted living facilities, ALF; home and community-based services, H&CBS). Design Cross sectional survey. Setting LTSS in New York and Pennsylvania. Participants Four-hundred and seventy older adults who recently started receiving LTSS. Included in this analyses, N=442 (ALF: n=153; NH: n=145; H&CBS: n=144). Measurements Interviews consisted of questions about advance directives (Living will and Health Care Power of Attorney-HCPOA), significant health changes in the six month prior to the start of long-term care support services, Mini-Mental State Examination, and basic demographics. Results Sixty-one percent (270/442) of older adults receiving LTSS reported having either a living will and/or a HCPOA. ALF residents reported having an advance directive more frequently than NH residents and older adults receiving LTSS in their own home (living will: Χ2[2]= 120.9; P < .001; HCPOA: Χ2[2]= 69.1; P < .001). In multivariate logistic regression models, receiving LTSS at an ALF (OR = 5.01; P < .001), being white (OR = 2.87; P < .001), having greater than 12 years of education (OR = 2.50; P < .001) and experiencing a significant health change in last 6-months (OR = 1.97; P = .007) were predictive of having a living will. Receiving LTSS at an ALF (OR = 4.16; P < .001), having greater than 12 years of education (OR = 1.74, P = 0.022), and having had a significant change in health in the last six months (OR = 1.61; P = .037) were predictive in having a HCPOA in this population of LTSS recipients. Conclusions These data provide insight into advance directives and older adults new to LTSS. Future research is needed to better understand the barriers to completing advance directives before and during enrollment in LTSS as well to assess advance directive completion changes over time for this population of older adults.