I was reading this month’s online edition of Provider Magazine and found an article about Culture Change and the regulatory process…how one interferes with the other so many times. The articles posted at Provider are all pdf files, annoyingly, but worth reading.

This is a small section I’m quoting from, about a culture change concept called Planetree.

PLANETREE CONTINUING CARE COMPONENTS PDF

■ Recognizing the Primary Importance of Human Interactions: Human beings caring for other human beings, creating caring relationships among all members of the Planetree community, including residents, families, employees, and volunteers.

■ Enhancing Each Individual’s Life Journey: A Planetree continuing care community supports personal growth, self-expression, and the fulfillment of individual dreams.

■ Supporting Independence, Dignity, and Choice: A Planetree community supports an individual’s autonomy, lifestyle, and interests. Each individual’s routines and preferences determine the pace of care and services.

■ Incorporating Family, Friends, and Social Support Networks in the Life of the Community: A Planetree community supports connections to family and friends and encourages their involvement in the life of the community. Individuals are encouraged to maintain and expand their social support networks.

■ Supporting Spirituality as a Source of Inner Strength: A Planetree community offers opportunities to strengthen the relationship with one’s faith and inner resources. A variety of programs provide meaningful spiritual support.

■ Promoting Paths to Well-Being: A Planetree community provides holistic wellness programs that maintain health and complement Western scientific medical care.

■ Recognizing the Nutritional and Nurturing Aspects of Food: Food choices and personalized service, in combination with sound nutrition practices, are a source of pleasure, comfort, and fellowship.

■ Empowering Individuals Through Information and Education: A Planetree community provides the information necessary to maximize physical, mental, emotional, and financial well-being. A continuous quality improvement process engages the entire Planetree community in working together to solve problems and exceed quality standards.

■ Offering Meaningful Arts, Activities, and Entertainment: Planetree recognizes that people need opportunities for camaraderie, laughter, and creativity. A Planetree community responds to individual interests and allows for spontaneity.

■ Providing an Environment Conducive to Quality Living: Planetree recognizes the influence that the continuing care living environment has on health and wellness. The design incorporates residential décor, natural light, and access to nature.

Source: The Planetree Continuing Care Components were developed by United Methodist Homes, based in Shelton, Conn.,
in collaboration with Planetree.

Snacks. We all love them. But we all get fat from eating them, right?

Not for the elderly:

MONTGOMERY, Ala. (AP) - Jo Spann used to be a steak-and-potatoes, three-squares-a-day type, but as the years have gone by, the 72-year-old now finds herself snacking “all the time.” A full meal now is usually a once-a-day event. Researchers say such snacking is OK - in fact, regular nibbling can be good for older people.

An Auburn University study of the diets of 2,000 people aged 65 and older found that snackers ate more calories at a time in their lives when they are susceptible to weight loss and poor nutrition. Snacking provided significantly more protein, carbohydrates and fat.

So while snacking might fuel obesity for the young, it may ensure that seniors are eating enough calories, said Claire Zizza, an assistant professor of nutrition at Auburn and lead author of the study published in this month’s Journal of the American Dietetic Association.

She said several factors, including health problems, medication and changes in taste could lead to poor appetite and weight loss in seniors. Compared to 25-year-olds, 70-year-old men ate 1,000 to 1,200 fewer calories; the decline for women was between 600 to 800 calories a day, according to the study.

Zizza’s research, based on a federal nutrition survey from 1999-2002, found that snackers ate about 250 more calories than non-snackers.

This should send some waves through nursing homes. Snacks often are the only thing our residents will eat. Let them. Keep the food healthy and allow junk now and again. Now, if we could only keep OUT hands out of this snacking habit!

Congress is investigating long term care insurance.

A Congressional committee yesterday began looking into business practices in the long-term care insurance industry.

The House Committee on Energy and Commerce has asked Conseco and the Penn Treaty American Corporation, two of the nation’s largest sellers of long-term care insurance, to produce documents showing how the companies market long-term care policies and handle policyholder claims.

The requests, which are expected to be a precursor to hearings by the committee, come as the Government Accountability Office prepares to begin a separate investigation. At least five senators, including Hillary Clinton, Democrat of New York, and Barack Obama, Democrat of Illinois, have asked the agency to open an inquiry.

In March, The New York Times reported that some long-term care insurance companies had developed procedures that made it difficult, if not impossible, for policyholders to get paid. That article — which focused on Conseco and Penn Treaty — was cited by the House committee and in the senators’ letters as the instigation for their investigatory requests.

What has prompted this:

According to court documents, Conseco, Penn Treaty and other insurers developed policies that rejected policyholders’ claims because they had failed to submit unimportant paperwork, filled out the wrong forms after receiving them from the insurance companies or because facilities had been deemed inappropriate even though they were licensed by state regulators. In California alone, nearly one in every four long-term care claims was denied in 2005, according to the state.

Those details, when reported by The Times in March, prompted an outcry of complaints among insurers who said that most long-term care policyholders were satisfied with how their claims had been handled.

“There is a tiny percentage of disgruntled policyholders filing complaints,” said Frank A. Keating, president of the American Council of Life Insurers, an industry trade group. “To the extent that this probe will shine a light on companies that are making mistakes, that will be a positive thing.”

I hope Congress can weed through real problems for many vs. a few because this regulation could just drive up the costs for insurance- many elderly people have purchased LTC policies that are designed to cover the first couple years of assisted living or nursing home stays. I have a policy that I bought a few years ago and I add a small amount to it each month; my hope is to pay for my own care and have a choice as to where I might be admitted. When the government is paying your bill, you don’t have that choice and you go wherever the empty bed is. Usually this is within a reasonable distance of your hometown or nearby where your children live. But not always. And no thanks. I want to go where I deem fit.

From North Carolina:

An estimated 550 older and disabled North Carolinians will be able to live at home instead of in nursing homes or psychiatric hospitals, thanks to a $16.9 million federal grant, state officials said.

The money, part of a $1.75 billion, five-year federal project called Money Follows the Person, will pay for caregivers to provide personal services, hygiene, cooking and other activities in an older person’s home.

It’s a start on meeting the desire of a large majority of older people to live at home as they age; the federal money could help those moved from institutions with everything from housing deposits to hot meals in their new homes. Another goal is to save money, keeping people out of high-dollar, high-maintenance settings such as nursing homes.

Consumer costs for a nursing home easily run $50,000 a year. Medicaid is likely to save more than two-thirds of the $1.75 billion it’s spending on the project by keeping patients out of nursing homes, the Congressional Budget Office estimates. But Medicaid rules have typically made it easier to get care in a nursing home or other institution than at home.

“We know that a lot of people would not wind up in care facilities if they had the option of someone helping them at home,” said Alice Watkins, executive director of the Alzheimer’s Association, Eastern North Carolina branch.

In addition to personal care, the grant money will pay for help with transportation, counseling and even home modifications, said Dr. William Lawrence Jr., deputy director of the state Division of Medical Assistance. It could also pay for respite care, paying for someone to fill in occasionally for a family member who normally handles the care.

“We are going to target elderly and disabled people in nursing homes who have been there for at least six months,” Lawrence said. “It will be those who are now stabilized and clearly in a situation where they could benefit from moving back to a least restrictive environment.”

There’s much more to this article…read it all. More and more states are trying to figure out ways to keep people OUT of nursing homes, and that is a GOOD thing.

An almost haunting article from today’s New York Times. This is about elderly people who resign themselves to live their last years in a nursing home; many are not aware of the newer models of care.

At some point in life, you can’t live on your own anymore. We don’t like thinking about it, but after retirement age, about half of us eventually move into a nursing home, usually around age 80. It remains your most likely final address outside of a hospital.

To the extent that there is much public discussion about this phase of life, it’s about getting more control over our deaths (with living wills and the like). But we don’t much talk about getting more control over our lives in such places. It’s as if we’ve given up on the idea. And that’s a problem.

How do we get the word out that not all nursing homes are the hell holes? That, some nursing homes are actually HOMES where the resident actually makes the rules; where the resident actually makes her own schedule and is able to pick and chose just about every “option” we all take for granted in our own homes….

This week, I visited a woman who just moved into a nursing home. She is 89 years old with congestive heart failure, disabling arthritis, and after a series of falls, little choice but to leave her condominium. Usually, it’s the children who push for a change, but in this case, she was the one who did. “I fell twice in one week, and I told my daughter I don’t belong at home anymore,” she said.

My own thoughts about this are that when our parents can no longer stay in their own homes safely, one of the grown children should make some concessions for their folks…after all, they raised us, wiped our butts and fed us, nurtured us…don’t we owe them this back? I think we do. We live in a material world; we have two income families struggling to make ends meet - for what? A big pretty house and fancy cars and expensive toys and gadgets for our kids? Where does family value fit in with this?

She moved in a month ago. She picked the facility herself. It has excellent ratings, friendly staff, and her daughter lives nearby. She’s glad to be in a safe place — if there’s anything a decent nursing home is built for, it is safety. But she is struggling.

The trouble is — and it’s a possibility we’ve mostly ignored for the very old — she expects more from life than safety. “I know I can’t do what I used to,” she said, “but this feels like a hospital, not a home.” And that is in fact the near-universal reality.

Ahh yes…SAFETY. The old stand by reasoning for nursing staff in every medical facility. Safety comes first, even at the price of another person’s humanity. And dignity. And personhood. And privacy. Self determination. All this is lost upon an admission to a nursing home, let’s face that.

Nursing home priorities are matters like avoiding bedsores and maintaining weight — important goals, but they are means, not ends. She left an airy apartment she furnished herself for a small beige hospital-like room with a stranger for a roommate. Her belongings were stripped down to what she could fit into the one cupboard and shelf they gave her. Basic matters, like when she goes to bed, wakes up, dresses, and eats were put under the rigid schedule of institutional life. Her main activities have become bingo, movies, and other forms of group entertainment. Is it any wonder most people dread nursing homes?

I believe the nursing home industry has long forgotten what it’s like to allow for some humanity…and the things we do that are just part of the job, are robbing people of this. All the baths and showers and turning and positioning and feeding and everything else, are tasks we provide…caring…nursing…but do we forget the human being we’re so busy nursing?

The things she misses most, she told me, are her friendships, her privacy, and the purpose in her days. She’s not alone. Surveys of nursing home residents reveal chronic boredom, loneliness, and lack of meaning — results not fundamentally different from prisoners, actually.

The difference between a nursing home and a prison are simple: One houses criminals and the other houses an entire portion of our population that society has forgotten about. A little harsh perhaps, but true. If we really cared, we wouldn’t send our folks to a nursing home. We would FIND another way.

It’s not all doom and gloom though:

There has been, however, a small band of renegades who disagree. They’ve created alternatives with names like the Green House Project, the Pioneer Network, and the Eden Alternative — all aiming to replace institutions for the disabled elderly with genuine homes. Bill Thomas, for example, is a geriatrician who calls himself a “nursing home abolitionist” and built the first Green Houses in Tupelo, Miss. These are houses for no more than 10 residents, equipped with a kitchen and living room at its center, not a nurse’s station, and personal furnishings. The bedrooms are private. Residents help one another with cooking and other work as they are able. Staff members provide not just nursing care but also mentoring for engaging in daily life, even for Alzheimer’s patients. And the homes meet all federal safety guidelines and work within state-reimbursement levels.

Why aren’t we all renegades? Are we incapable of thinking outside the box?

They have been a great success. Dr. Thomas is now building Green Houses in every state in the country with funds from the Robert Wood Johnson Foundation. Such experiments, however, represent only a tiny fraction of the 18,000 nursing homes nationwide.

“The No. 1 problem I see,” Dr. Thomas told me, “is that people believe what we have in old age is as good as we can expect.” As a result, families don’t press nursing homes with hard questions like, “How do you plan to change in the next year?” But we should, if we want to hope for something more than safety in our old age.

Do you know where a Greenhouse style nursing facility is located in your state?

The last paragraph speaks loud to those who dare to listen:

“This is my last hurrah,” the woman I met said. “This room is where I’ll die. But it won’t be anytime soon.” And indeed, physically she’s done well. All she needs now is a life worth living for.

A life worth living. If we must subject our elderly to a nursing home, let’s try to find one that has embraced culture change. Stay away from the old medical model and seek the newer way. As staff, we can educate and push and assist our current places of employment to MAKE change.

This is the middle to end portion of an article about culture change. Read the whole article for context, but here are some more thoughts about making culture change.

With the new atmosphere has come more control over daily activities like flexible times to eat, waking and going to bed, choices in food and beverages and control over when they will get their bath. There are also choices for activities made by the neighborhood residents themselves.

Staff has adopted the new philosophy eagerly, but not without a little resistance in the beginning, Baker said.

“Some thought it would be a lot more time-consuming. We had to do some education to show how it could work,” Baker said. “But it really hasn’t been time-consuming at all. And the staff has noticed the residents are much happier; and that makes the staff happier, too.”

Janice Latvala was brought on staff as a team leader to help with the culture change at Live Oak. One of the new initiatives has been “learning circles.”

“Residents from a neighborhood get together and talk about what type of activities they want,” Latvala said. “We’re talking right now about starting a happy hour for one neighborhood. Of course, we’re checking on the appropriate amount of alcohol for each resident.”

Other activities have included 50s week, a fishing tournament and a Las Vegas week with a talent show being planned for July.

Visitors have noticed the change, too. Bennette Daniel, a member of the Red River Hatters of Shreveport-Bossier, was at Live Oak as part of the tea ceremony Tuesday.

“It was quite different when my mother was in a nursing home. Most residents were bedridden,” Daniel said. “Now many people prefer to live at retirement center because they feel safer and it allows them to still carry on their lives.”

Bigger expansions into the culture change are in Live Oak’s future. It will partner with Willis-Knighton Health System to remodel its health-care center and apartments.

Other area nursing homes also have begun the expansion of the culture change with new building designs.

The Glen Retirement System, which also offers a continuum of care like Live Oak, has built two cottages in a neighborhood environment. Each 11,100-square-foot cottage can house 15 residents in 370-square-foot rooms. The first cottage was filled in November; the second will be ready for residents in early June.

“It’s assisted living for those (who) have dementia or Alzheimer’s disease and will eventually need long-term skilled care. This is a transition for them,” said Susan Skinner, director of development and strategic planning. “It’s more of a social model with the rooms built in a ring around the main living room area and kitchen. There are no hallways. And they can have meals anytime they want. We want them to think of their apartment as their room.”

The staff has noticed marked improvement in the residents.

“We had several come from a home setting where they had 24-hour care, and they have improved so much from just the socialization with other residents,” said Sandra McGrew, director of assisted living at The Glen. “Some came from an apartment setting and their ambulation and mental status has improved. Several also came from a health-care environment and have put weight on and improved. The smaller setting allows us to be more flexible.”

Residents in the cottages can help cook or clean if that’s what they like to do.

“We want to give them things they would do at home,” McGrew said. “We just had our first family picnic. And the staff brought the meat and bread, but the residents all made covered dishes.”

Other culture changes in nursing homes in the area have been movie theaters, private dining rooms that can be booked for families and the removal of the central nursing station, said Kueker.

“The central nursing changes is one of the last vestiges of the hospital model,” said Kueker, who gets excited when she sees the changes going on in long-term care. “It’s recognizing the resident has to be in the forefront of all care. It’s not enough to treat the physical body, you have to treat the whole body.”

Now THAT is change. In the right direction, too. The nursing station sticks out like a sore thumb in every nursing home and assisted living facility that I have worked at, or visited. I think this signals the most significant change a nursing facility can make, and this speaks louder than any words or mission statement.

Over at the Network 54 CNA Forum a CNA brought forth an issue that must be addressed. This is about giving proper notice when an employee decides to quit their job.

NO MATTER what, a CNA must give a two week notice in order to be considered for re-hire status. Also, it’s the right thing to do. Think about it. If an aide is scheduled to work many shifts but suddenly quits, it leaves ALL those shifts open and often unfilled. Who suffers? The residents, patients, clients fist and foremost. Then the aides left behind to do the extra work. Management has to fill the position and do all the human resource things associated with this: Background checks, abuse registry check, hiring, orientation, mentor-ship if there is any, and on the job training.

In any line of work, it is considered absolutely vital to give at least two weeks notice of intention to leave a position. If one holds a college degree, usually this is a four week or one month notice.

In the Network 54 thread, the aide uses the excuse she was sick and couldn’t manage to work- which is a reasonable issue but would have been better handled a different way. She should have gone to her doctor and got a note excusing her from work for several days. We cannot expect to just ask for time off with no notice and get it. The DON refused to grant the aides request.
The aide quit her job..and then when she felt better she tried to go back to work at the nursing home. She was told she wasn’t eligible for re-hire, because she walked off her job. Her action had a consequence.

While I sympathize for this aide, I also resent that she felt it was appropriate to simply quit. And leave her co workers the brunt of the work, probably many unfilled shifts of hours open and most importantly, left the residents in jeopardy of poor care. Had she brought in a doctors note we would have seen the same thing, perhaps. But at least we would know she was truly ill (which I don’t doubt) and management would have kept her on staff; she would have returned to work and spared us all the time and effort of training new hires and all that.

Giving proper notice for leaving a job is just the right thing to do. When it isn’t done, there are many who pay the price.

Some Nursing Home Week Celebrations and Ideas in the news:

In MD:

Moran Manor displays antiques
WESTERNPORT - Residents of Moran Manor in Westernport have been talking about “the good old days” a bit more lately, thanks to some visual reminders of those days gone by.

Many of the reminders - which range from old photographs to antique dolls, mink stoles, and lots of hats and hat boxes - are from the local area, making the trip down Memory Lane especially meaningful to the local residents of the facility.

From ID:

Pocatello Care and Rehab held an open house today to give the community a chance to see the kind of service they provide. It also gave the caregivers a chance to meet with the public in style.

Today they allowed people the chance to walk through the facility, and residents to get out for a little while. The residents managed to have a look at some old era cars. They even voted on their favorite ones.

Derrick Glum/administrator: “Today we are helping to celebrate National Nursing Home Week. This week is especially dedicated to the observance of nursing homes across the country and especially in Pocatello. We’d like to tell everybody what a fantastic job our skilled nursing facilites are doing especially here at Pocatello Care and Rehab.”

Tomorrow, Pocatello Care and Rehab will have pajama day and hold a barbeque for staff and residents. That will be followed by a circus party for residents, staff, and staff family.

This nursing home is celebrating MOVEMENT and EXERCISE.
Video included!!

In Iowa, 6th grade students danced with the residents of this nursing home:

The Park Place Long Term Care Unit in Mt. Pleasant was infused with youthful energy Wednesday as members of the sixth-grade class es from the Mt. Pleasant Middle School showed off their dancing abilities for the nursing home residents.
The students showed a lot of spark as they danced, calling off the steps and counts of the dance as they went along with their P.E. teacher, Julie Gilmore. The dancers were paired off in a large group that moved in circles and back and forth, while the elder audience looked on in front of the care center.

Kansas people know how to cook, and celebrate in style: Video included

Eventide Convalescent Center brought residents to Gary Gilbert’s Woodlawn Farms to celebrate National Nursing Home Week. Residents got the chance to have a Cream Can Dinner. They loaded an old fashioned milk can with vegetables and meat and then put it on an open flame to cook.

While the dinner cooked, residents played horseshoes and looked at Gilbert’s antique tractors. Organizers say the week is a great way to bring enjoyment to those living in nursing homes. Gilbert’s daughter says the residents will be talking about the trip for the next week.

Keep these ideas in mind for next year!!

From the CMS web site:

The New Freedom Initiative (NFI) was announced by President Bush on February 1, 2001, followed up by the Executive Order 13217 on June 18, 2001. The initiative is a nationwide effort to remove barriers to community living for people of all ages with disabilities and long-term illnesses. It represents and important step in working to ensure that all Americans have the opportunity to learn and develop skills, engage in productive work, choose where to live and participate in community life.

This initiative supports states’ efforts to meet the goals of the Olmstead v. L.C. Supreme Court decision issued in July 1999 that requires states to administer services, programs, and activities “in the most integrated setting appropriate to the needs of qualified individuals with disabilities.” The Olmstead decision interpreted Title II of the Americans with Disabilities Act (ADA), which gives civil rights and protections to individuals with disabilities and guarantees equal opportunity for individuals with disabilities in public accommodations, employment, transportation, State and local government services, and telecommunications. The complete Olmstead decision, and Executive Order 13217, can be accessed below under “Related Links Outside CMS.”

GRANT PROGRAMS

The Centers for Medicare and Medicaid Services (CMS) provide some opportunities for funding to assist in implementing systemic changes to better serve individuals with disabilities in the setting of their choosing. More information on these grant programs can be found by using the links below under “Related Links Inside CMS.”

* Money Follows the Person Demonstration Grants: These programs are part of a comprehensive, coordinated strategy to assist States, in collaboration with stakeholders, to make widespread changes to their long-term care support systems. They will assist States in their efforts to reduce their reliance on institutional care while developing community-based long-term care opportunities, enabling the elderly and people with disabilities to fully participate in their communities.

* Alternatives to PRTF Demonstration Grants: These programs will help States provide community alternatives to psychiatric residential treatment facilities for children. They will also assist States in their efforts to adopt strategic approaches for improving quality as they work to maintain and improve each child’s functional level in the community.

* Real Choice Systems Change: These grants support infrastructure changes that will result in effective and enduring improvements in community long-term support systems.

* Direct Service Worker: These demonstration grants support strategies to help recruit, train, and retain direct service workers who provide personal assistance to people with disabilities who need help with activities of daily living.

* Employment Initiatives: Authorized under the Ticket to Work and Work Incentives Improvement Act of 1999 (TWWIIA), CMS provides funds to states through the Medicaid Infrastructure Grants (MIG) and Demonstration to Maintain Independence and Employment (DMIE) Program to create systemic change that supports employment for people with disabilities.

Remember, elderly people DO have disabilities; these initiatives are not meant for just those who were born with or acquired a disability. In the future it will be interesting to follow the money given out here..to see how it’s spent and to see whether actual people benefit from the programs. Go to the CMS site for more information on this.

Another great idea, and it sounds like it was a lot of fun.

CRESCENT CITY — Gladys Cowart was gingerly being helped from the sidecar of Don Williams’ 1973 BMW motorcycle here Saturday afternoon.

She had just ridden around the parking lot of the Lakewood Nursing Home, a ride that had lasted perhaps two minutes at heart-racing speeds of almost 10 mph, and the look on her face told it all.

“I’ve ridden horses and I’ve ridden calves, but this is the first time I’ve ever ridden one of them things,” the 91-year-old center resident said. “I’ll tell you what, though — riding that thing was a lot more fun.”

Ms. Cowart didn’t know it, but she was in for even more fun.

Jesse Stephens, a white-bearded member of Putnam ABATE, took her by the hand, lifted her up onto the driver’s seat of his Honda, and outfitted her with riding gloves and helmet to the delight of all who were looking on.

It was hard to tell who was having the most fun —- the residents at the Lakewood Nursing Center who were receiving the motorcycle rides, or the leather-clad members of the clubs who came to provide them.

Perhaps three dozen residents were outside the center, many in wheelchairs lined up outside the center when approximately 20 bikers roared up for a 90-minute visit tabbed “Grannies Gone Wild.”

The event is the brainchild of Liz Miller and Jeannie Gulledge, a couple of longstanding members of Putnam ABATE who, between them, have five grandchildren. Four years ago, the grannies had the wild idea of going to local nursing homes and allowing the residents to take short rides in the sidecars on some of the motorcycles.

Ava Swain, who will be 97 on Aug. 17 and who was the oldest resident to ride, said it brought back wonderful memories.

“I loved it. I loved it,” she said. “I would love to go another mile. That’s the first time I have been on a motorcycle in 50 years.

“I almost didn’t come out here because I thought I was too old. But I was wrong. This was a whole lot of fun.”

A nursing home up my way did this a couple years ago- local motorcyclists came and took the residents out for short rides. It was fun and very therapeutic for everyone involved. My husband assisted with the event.