The majority of the clients living in long-term care facilities, like residential or (skilled) nursing homes, are mainly female and over the age of 80 (Caffrey et al. 2012; Schüssler and Lohrmann 2015; Lohrmann et al. 2015). Over half of the clients had two or more chronic conditions (Caffrey et al. 2012), whereby dementia is one of the most common chronic conditions treated in residential and nursing homes (Caffrey et al. 2012; Fulton 2010). At least four in ten clients needed assistance with three or more activities of daily living (ADL’s) (Caffrey et al. 2012).

Long-term care facilities can be either smaller residential care facilities or larger facilities such as a skilled nursing facility or nursing home. The size can be ranging from only four beds (Caffrey et al. 2012; Schüssler et al. 2014) to 400 beds (Schüssler et al. 2014) and more. Taking into consideration the size of a facility may impact the type and kind of training and educational programs which are able to be considered.

In the United States, skilled nursing facilities (size range from 50 to over 200 bed) are licensed by each state and certified by the federal government for receipt of Medicare or Medicaid dollars (Centers for Medicare and Medicaid Services (CMS) 2015). In 2014 there were around 16,000 skilled nursing homes receiving Medicare/Medicaid dollars, with a slight shift to more for profit agencies and fewer facilities. Three percent of the over-65 population and 9.5% of the over-85 population were listed as permanent residents of skilled nursing facilities, many of these having dementia. In 2015, the CMS developed focused surveys to evaluate, specifically, the provision of dementia care in nursing homes (CMS 2015). These surveys are developed to have metrics to meet in order to provide dementia-specific care. Meeting the survey metrics will help define what is needed to provide optimal care to those residents with dementia as well as provide information to include in the education and training programs. Understanding which type of facility, under which licensure and reimbursement a facility is operating, will help evaluate the type of educational and training programs which can and should be offered to the health-care staff. In addition to understanding the type and licensure under which a facility is operating, evaluating the facility for resources that are available to provide educational and training programs is an ongoing process.

Evaluating facilities for resources available to provide staff development is the responsibility of the administration. An analysis of a facility size, type of licensure, as well as their strengths and weaknesses in providing care for the dementia client is essential in developing education and training programs. Evaluating the facility for time, space for meetings, staff available to free up other staff to attend educational events, and finances available to provide such training becomes a challenge for the leaders of the organization. The size of the organization may determine the size and variety of staffs who are available to both provide the education and attend the training sessions. In smaller residential care facilities, one person may function in the role which in another facility would be covered by several positions. In a smaller facility, the administrator and the human resource staff may be the same individual. Larger organizations have additional concerns with training more staff at varying shifts and through different job descriptions. The organization should evaluate if there is the ability to have a specialist for dementia care available, or if an outside consultant or contract staff resources are available (Warchol 2012; Stein-Parbury et al. 2012).

Education and training of health-care staff can be made available within or outside the long-term care facility, depending on the size and type of organization, and they can be offered face to face or online. A pilot study by Hobday et al. (2010) demonstrated that online education is a cost-efficient and time-saving method for training staff in long-term care facilities. In Sect. 8.11, you can find some resources for online education available for health-care staff working in long-term care.

Whether an education and training program is offered as a face-to-face course or through website technology, organizations would need to review the effectiveness of the educational offerings and ensuring that the educational objectives are being implemented. Having staff available to ensure that the education and training content are applied in the care facility would need to be integrated into the caregiving processes. Evaluating a facility for money, staff, and space to provide education and training programs also entails reviewing and evaluating the facility model of care being implemented to optimize care of the dementia client.

Several models of care have been developed for clients with dementia. Some models are based upon functional tasks, focusing on supporting activities of daily living, hygiene, and medication management. Kales et al. (2014) utilize a multidisciplinary panel to develop the DICE approach to manage neuropsychiatric behaviors by all caregivers. Newer models of care are focusing more on the individual client and engaging their preferences. Cline (2014) describes in his model that aging is an individual process; however, he makes no reference on how a health-care system, such as a long-term care facility and staff, should interact with an individual. Understanding the individuals’ unique aging process, the clients’ prior experiences and biography will help collaborating with the client and their family members. In addition to knowing a patient’s individual history and biography, other models offer more specific details on how to implement such knowledge of a dementia client.

The capability model of dementia care (CMDC) attempts to provide not only theory of individualized aging but also practical strategies for achieving optimal outcomes (Moyle et al. 2013). Developed by M. Nussbaum, a philosopher and lawyer, the essential ten capabilities are values which are centered on individual human dignity. Moyle et al. (2013) further applied these capability values to enhance the strengths and capabilities of the client with dementia. This focus on the individual is in contrast to the utilitarian care of dementia patient focused on meals and medication administration.

Warchol (2012) describes dementia capable care as facilitating engagement with the client, focusing on abilities the client can achieve, and being able to integrate the client’s biography and life story in order to activate the client’s long-term memory. Taking a proactive approach to implementing these components has been shown to reduce aggressive behaviors, falls, and weight loss. Konno et al. (2014) also describe implementation of individualized, person-centered care as reducing a client’s resistance to care.

A comprehensive model of education for provision of care with the dementia client would include knowing the clients’ biography, knowing how to engage the client, focusing on their abilities, and meeting them at their cognitive stages in order to engage them in enjoyable activities. Stinson (2000) offers simple tips for engaging and communicating with the Alzheimer’s patient in areas of communication, hygiene, nutrition, elimination, pain control, and comfort. In each of the previous areas, a calm demeanor, gestures and demonstrations, simple language, and limited choices are helpful to engage a client’s cooperation. Another person-centered care model is the DementiAbility Method, which focuses on Montessori-based principles to create roles, routines, and activities for the client within a safe and supportive environment (Bourgeois et al. 2015). For this care model, a homelike environment is important, where clients are encouraged to create routines similar to a home environment such as washing dishes, setting tables, or making their bed. The aim is to help people to be as independent as possible and make meaningful contributions to their community. The model includes a strong knowing of the client, creating activities and memory supports to optimize functioning as well as evaluating the clients’ preferences and outcomes.

A different model developed by Sheard (2013) uses emotional intelligence to maintain an active engaging environment with dementia clients. His homes are called “Butterfly Care Homes” and allow staff to blend with clients in a way to engage with them in the moment. Staffs eat with clients and are more integrated with the clients. His model focuses on understanding the clients’ meanings behind their behaviors and uses positive team relationships in order to deliver personalized care. He emphasizes the lived experience of patients living with dementia and encourages staff to meet clients where they are currently at with their experience and help them develop an emotional connection in order to have a meaningful experience.

All of such models of dementia care emphasize understanding the client with dementia, knowing their prior history, preferences, and values as well as what stage they are currently at. In order to develop education and training materials, an evaluation of staff’s current knowledge and performance should be performed.

Staff in a given facility should be assessed as to their knowledge, skills, and attitudes regarding care of the dementia client. Some staff may be hired without any formal training, such as in environmental services. Other challenges include rapid turnover of staff, entailing frequent needs for orientation of new staff with unknown education or training. Evaluating staff upon their hire as to their knowledge, basic training, and experience with dementia-specific clients can help begin the development of an education and training program. All personnel having contact with dementia clients should have a uniform and consistent understanding of their part in providing a therapeutic environment and ensuring positive patient outcomes. Direct patient caregivers may have varying levels of experiences, education, and skills dealing with dementia clients in particular. Evaluating personnel in regard to the existing policies, procedures, and job standards will help develop orientation and ongoing training programs for staff to care for the dementia client.

Job descriptions, policies, and procedures all help develop structure in emphasizing valuing the client with dementia, seeing the client as an individual, and providing person-centered care as well as providing the guidance for the development of the education and training programs. Evaluating such policies, procedures, and job descriptions for evidence of dementia-specific competencies for all staff will ensure that education and training programs meet the needs of the clients. Having clear competencies in place will allow for evaluation of employees to assist in the care of the client with dementia.

In addition to evaluating staff, having knowledge of job descriptions, policies, and procedures regarding care of clients with dementia, having a champion knowledgeable about the best practices in dementia care is essential.

One person in a leadership position needs to be the coordinator of specific dementia educational learning needs of the employees. This responsibility needs to have the tools and resources to implement learning needs of the organization. This person must be able to understand the needs of the dementia patients as well as best practices for educating staff using adult learning principles. Several programs recommend the use of a care coordinator. The Alzheimer’s Society in the United Kingdom has issued a recommendation for developing a dementia champion within facilities to provide support and training and ensure that quality of life is improved for clients (Heath and Sturdy 2009).

In the Healthy Aging Brain Center, the care coordinator is not only in charge of implementing the educational training for caring for clients with dementia but also of ensuring that the plan of care is being implemented. Jeon et al. (2013) mentioned in a study utilizing an educational toolkit that care plans were often not updated, and field notes cited staff mentioning that they did not refer to the care plans when delivering care. A staff specialist in dementia care would be able to ensure that care plans are being implemented and observe teachable moments tying the educational plan to the patients’ specific plan of care. Hollister and Chapman 2015 found that in the United States, long-term care facilities receiving government dollars had a wide variety of titles for persons providing such a coordination of care. In some situations the leaders were not nurses but social workers; however, they required a higher level of education or certification specific to providing dementia-specific care.

Another program, the Forget-Me-Not Care Model, uses therapists, either occupational, physical, or speech therapists, as the leaders in providing a cognitive assessment using validated tools in order to develop the care plans for clients with dementia as well as assist with the training of staff in implementing such care. The use of a cognitive assessment and leveling of clients’ comprehension and verbal abilities allows for an interdisciplinary model of care which supports the best of staff interaction with clients (Warchol 2004). Activities and programs can be leveled to the clients’ ability to maximize their participation in program activities. Direct caregivers are integrated into knowing which level the client is at and may use special approaches during their routine caregiving. Utilizing therapists in such leadership positions allows for a more interdisciplinary approach to understanding the client with dementia as well as allowing clients to function at optimal levels.

Long-term care facilities with dementia clients should have an experienced person in charge of the dementia care program, be knowledgeable regarding dementia-specific competencies, and be able to guide the team into best practices and outcomes.

Job descriptions are often the beginning where person-centered care and valuing of the clients’ biography are found. Position requirements should define the level of education, licensure, and prerequisites that employees have upon hire. A licensed person has passed a level of examination in the area they are practicing in that demonstrates the necessary knowledge and the ability to work in a defined job role. By itself a license does not assure competence in caring for dementia clients specifically. Certain states are now mandating training for long-term care facilities to ensure initial education and training as well as ongoing trainings to demonstrate competence in caring for dementia clients and their families (CMR 2014). Massachusetts requirements include knowledge about dementia, person-centered care, approaches to caregiving, caregiver strain, working with dementia patients and their families, dietary needs of dementia patients, as well as abuse and neglect of dementia patients. Florida law has also mandated 1 h of dementia training and 3 additional hours of training for direct care staff providing care in long-term care facilities (Florida Administrative Code 58A-4.001). Topics include management of behaviors, activities of daily living assistance, social environment, other activities, environmental issues, family issues, and ethical issues. While each state is mandating required additional training and education regarding dementia care, Williams et al. (2005) describe a process for the development of competencies for nursing staff to accomplish such mandated training. These competencies were directly developed to meet the Florida administrative code, but also leveled for the most common caregivers in all long-term care facilities, that of a licensed practical nurse (LPN) (see Table 8.1). There is the ability to simplify such competencies for certified nursing assistants (CNAs) as well as develop more detailed ones for registered nurses. Competencies are described in terms of knowledge, skills, and attitudes required to care for the dementia patient. In addition, the competencies are addressed as outcomes in relation to a class, as well as being leveled from simple to more complex competencies. Competencies focus on understanding the disease of dementia as well as the ability to facilitate communication and perform in a variety of ways to decrease stress and confrontation for the client with dementia.