An article in the Washington Post brings to light the effect of culture change for our elderly citizens.
Twenty years after Congress vowed to improve the way we care for the old and the infirm, nursing homes still inspire dread. But some mavericks are working to deinstitutionalize them and make them more like home.
“We want to change the culture of aging,” said Bonnie Kantor, executive director of the nonprofit Pioneer Network, a Rochester, N.Y.-based umbrella group leading the effort, “and we’re beginning with nursing homes.” Rather than warehouse those who are frail or disabled, the advocates of change argue, providers of long-term care need to create genuine communities where people receive needed services while continuing to lead meaningful lives.
OBRA ‘87 did create standards and offered protections. But it also led to more institutional settings, and the nursing home industry has blamed the federal regulations for much of this.
So how do we change?
What distinguishes a humane nursing home? Pioneering homes go by a variety of names and descriptions — Eden Alternative, Green House, Planetree, resident-directed, person-centered — but share common features: autonomy and choice for residents, homey personal spaces, valued staff and a strong community of residents, staff, families and volunteers.
The phrase HUMANE NURSING HOME is strange to hear, and it hurts when we think that the vast majority of these places are the exact opposite. Many nursing homes have done some window dressing- but the actual culture has not changed. One little bit.
In 1987 Congress passed the Nursing Home Reform Law, promising fundamental rights to residents. But the law’s promise has gone unmet, advocates say. “Rights, respect, being treated as a unique individual, staff who are trained, quality of care and quality of life — these key principles of the Nursing Home Reform Law are now 20 years old,” said Alice Hedt, executive director of the National Citizens’ Coalition for Nursing Home Reform. “We’re eager for culture change to take hold so that each resident can enjoy truly individualized, person-directed care.”
Many who are “against” culture change claim we don’t NEED to change anything. They’re wrong.
Here are some key elements to a truly humane nursing home:
· Nursing home residents want to make their own decisions. In her 20 years of research on quality of life for nursing home residents, Rosalie Kane, a professor at the University of Minnesota’s School of Public Health, has found that residents want more control than most have over their daily lives and that this freedom is key to their “well-being, mental health and even physical health.” Among the things residents want to decide, Kane’s surveys show: how and when they use the phone or leave a facility for visits, who their roommate is, what food they eat, and what time they wake up and go to bed. By getting rid of strict institutional schedules and reorganizing staff time, pioneering homes aim to deliver on these desires.
Recognize any of these as being practiced in your nursing home? I doubt many can offer these elements.
· Life can have meaning, no matter where we live. Nursing home residents want to be more than just recipients of care, studies show. Pioneering homes find that many residents enjoy making a contribution, whether it’s helping prepare meals, caring for a dog, volunteering to teach English to a staff member or comforting another resident who feels low. The more spontaneous and personalized the activities, the more residents remain engaged.
I have to say that the very oversight regs prevent, or are used as an excuse to prevent, these initiatives from coming to life. It’s always about resident safety, right? Do you ever see a resident in the kitchen, cooking a meal? Didn’t think so.
Most nursing homes emphasize custodial care to the exclusion of normal life, said John Henry, administrator at Ruxton Health of Denton, Md. “If I asked you what did you do last week, you wouldn’t say, ‘I ate, I went to the bathroom, I got dressed.’ It’s the life beyond that that is fun,” he said.
No wonder so many residents are depressed. We all would be too.
· Aides can be caring and competent, given a supportive culture. Industry-wide, the high turnover of nursing home aides — 70 to 100 percent a year — makes it nearly impossible to deliver quality care. Researchers who interviewed aides for a study, published in 2003 in the Journal of Gerontological Nursing, found that aides believed supervisors “treated them individually as if they were all unskilled, dishonest, lazy, and stupid.” Often working without adequate assistance, aides surveyed in numerous studies say they can’t give residents what they most want — consistent care and friendship.
Transformational homes reduce staff turnover and encourage aides to build relationships with residents.
Ruxton’s director of nursing, Lisa Havelow, expects her staff members to talk to residents, show them affection and make their wishes their top priority. That suits geriatric nursing assistant Sheretta Jenkins just fine. “My old jobs, I used to hate to wake up and go to work,” she said. “I don’t feel that way here. You can be happy. You can joke with residents. You can sit down and read to them.”
The truth hurts, and the truths spoken in this first paragraph of this quote really bite hard. We are viewed as lazy, uneducated and unmotivated. When our leaders expect this of us, they get it. We need to be inspired not de-motivated. We need to be praised and encouraged. And we need to be told we’re human, and that’s ok to become friends with our favorite residents. But we also need the tools to do this: Better ratios that allow more time; pay that rewards a hard days work and benefits that compete with other facilities that want our skills as well.
· Enriching the environment enriches life. Forget hospital hallways and double rooms with flimsy privacy curtains. Some cutting-edge homes have living rooms, country kitchens, private bedrooms and baths — available to all residents, including those on Medicaid. Families can host potlucks, birthday parties or make a pot of coffee. Many homes have cats and dogs, or gardens with raised beds for people in wheelchairs. Others have on-site day-care centers, with children a normal part of life.
Even those saddled with an old building, such as Ruxton of Denton, can make it homier. Geneva Gibbs is proud of her room, decorated in purple, her favorite color. She also enjoys rocking on the home’s front porch. A new spa with plush towels, soft music and a faux fire in the small fireplace turned residents’ bathing experience from grim to luxurious, staff members say.
SO home like…and why not? WHY can’t a resident paint their room a color of their choosing? WHY can’t we build porches and have some rocking chairs? Cookouts, family and staff and resident potluck meals, fund raisers for the troops, quilting clubs, garden clubs and the like ALL cost little to implement and offer so much more true quality to the lives of all who are involved with a nursing home.
And what about culture change for those with dementia?
· Person-centered care improves life for people with dementia. A study in a British medical journal found that dementia patients in homes with specially trained staff, a more hospitable environment and family caregivers were less dependent on antipsychotic drugs than were those in more typical nursing homes. Another study found that agitation, aggression and discomfort decreased in dementia patients who received more individualized care. By tapping into people’s lifelong interests and offering them new opportunities, such as art and dance, homes such as Providence Mount St. Vincent report that difficult behaviors subside.
I believe many nursing homes made strides in improving the programming for people with dementia. But I also see a lack in good training for aides and NURSES who care for them…along with activities that could be better.
· The best doesn’t have to cost more. For her recent doctoral dissertation, Amy Elliot at Ohio State University’s John Glenn School of Public Affairs found that transformed homes had better operating margins than traditional ones. “Overall, pioneering homes really outperformed the control homes,” she said. “It shows it’s the right business model.”
Reduced staff turnover is part of the reason. Nationally, the cost of turnover among direct-care staff is $4 billion a year, according to a study by Better Jobs, Better Care, a research and demonstration program funded by the Robert Wood Johnson Foundation and the Atlantic Philanthropies. In 2003, when St. John’s Home in Rochester, N.Y., became an Eden Alternative home, its turnover was 30 percent; three years later it had fallen to 13 percent. “It’s had so many good results,” said Al Power, assistant medical director. “Our surveys have been without a major deficiency, and our elder and family satisfaction has gone up every year.”
This always comes up. COSTS. As we see, it’s not a major factor when they consider the savings from staff turnover ALONE. Replacing aides costs a lot of money- in terms of hiring them, training them and investing time and resources into them. In outr line of work the turnover rate is astronomical.
And finally the reason culture change takes on life is the leadership:
· Leaders must lead. The culture change at pioneering homes depends on the commitment of the administrator, director of nursing and board, say those who have undertaken it. “From the beginning, I tell [employees] I’m a different kind of director of nursing,” Havelow said. “I expect interaction [between the staff] and the residents.” Administrator Henry models the relationships he wants people to have. “I’ve never seen another administrator like John,” said Deborah Jackson, a cook and veteran of 29 years in long-term care. “If you need a hand cleaning up, he pitches in. He compliments us on the food daily.”
“When we eat dinner, I’ve known him to eat at our table,” Geneva Gibbs said. “He’s the big boss — I thought he wouldn’t eat with us!”
Yes. And good leaders will eat many meals a week with the residents. So will the staff- DON, Cooks, housekeepers, aides…everyone. Better yet, they will eat meals prepared by the residents. Even better they will help with cleaning up the tables and washing the dishes after.
It’s all about doing what we all do at home. The little things that make life worth living- are what we need to see happen in nursing homes. We’ve come a long way but have a long road ahead of us still.
