Association of Nursing Home Organizational Culture and Staff Perspectives with Variability in Advanced Dementia Care: The ADVANCE Study

Ruth Palan Lopez
Meghan Hendricksen
Ellen P. McCarthy
Kathleen M. Mazor
Ashley Roach
Anita Hendrix Rogers
Fayron Epps
Kimberly S. Johnson
Harriet Akunor
Susan L. Mitchell
Peer-Reviewed Article
January 2022
Cover of a JAMA Internal Medicine issue.


Identifies opportunities for nursing homes to support more equitable and low-intensity care for nursing facility residents with advanced dementia.


Many people with dementia die in nursing homes, and high-intensity interventions for these individuals, such as tube-feeding and hospitalization, have limited clinical benefit and can often be traumatic for patients. There are racial and regional disparities in the rates of nursing home residents with dementia who receive these high-intensity interventions. This qualitative study includes staff perspectives and researcher observations on 14 nursing home facilities to assess what organizational factors are associated with high-intensity dementia care. It also identifies opportunities to advance more equitable care.


Nursing home facilities that provided the lowest-intensity care for people with dementia had standardized advance care planning processes, more pleasant physical environments, a higher level of staff engagement in shared-decision making, and agreement across staff that tube-feeding was a poor outcome. Researchers identified pervasive staff biases related to the proxies for Black residents, such as assumptions that Black nursing home residents and their caregivers were reluctant to engage in advance care planning and favored more aggressive care.


Modifiable nursing home factors, such as a more standardized approach to advance care planning, staff training on evidence-based care and shared decision-making, and more funding for low-resource facilities can help support more equitable dementia care and reduce the impact of staff bias on nursing home residents with advanced dementia.

Posted to The Playbook on