Highlight:

The staff says 24-hour dining and all the changes it produced have had a huge impact on quality of life for every elder. They now may choose exactly what and when they want to eat. They can sleep in if they wish and are able to maintain the same daily routine as they had at home. Physical health has improved. The number of elders eating a puréed diet was reduced from 30 people to seven because of the selection of food available and because there is time for one-on-one interaction while dining. Pressure ulcers have also decreased due to increased food intake and ability to choose the food they like. Residents are gaining weight, pain and behavioral issues are improving, and elder satisfaction with the entire home has improved. “Our care plan meetings and elder council meetings no longer revolve around food issues,” Godfrey says. “In fact, at our annual state survey in May, there were no elder complaints about food.” The surveyors who stayed for lunch even complimented the food!

There has been such a demand for meals that sales to staff and family have gone from $2,000 per month to $6,400 per month. There has been such a demand for families to eat with their elder, Rolling Fields has hired a hostess to seat and take reservations. Some family members were even coming without their elder to eat. “This was happening so often we had to put up some parameters to limit family members to only eating when accompanied by their elder,” Moody says.

I wonder what will eventually happen to this program, if this insightful administrator ever resigns from this facility, er, home?

“It was like being in jail,” Mr. Brown said on a recent afternoon. “In the nursing home you’ve got to do what they say when they say it, go to bed when they tell you, eat what they want you to eat. The food was terrible.”

But recently state workers helped Mr. Brown find a two-bedroom apartment in public housing here, which he shares with his daughter. “It just makes me more relaxed, more confident in myself,” he said, speaking with some difficulty, but with a broad smile. “More confident in the future.”

A growing number of states are reaching out to people like Mr. Brown, who have been in nursing homes for more than six months, aiming to disprove the notion that once people have settled into a nursing home, they will be there forever. Since 2007, Medicaid has teamed up with 29 states to finance such programs, enabling the low-income elderly and people with disabilities to receive many services in their own homes.

The nursing home industry is fighting these ideas, in order to keep their doors open. By empowering residents to go back into their communities these states are finding out that people come first and it’s not nearly as expensive as some like us to think.

“Medicaid has had an institutional bias in favor of nursing homes,” even for people who do not need them, said Gene Coffey, a staff lawyer at the nonprofit National Senior Citizens Law Center. “Federal law requires states to provide nursing home services. They don’t have to provide home or community-based services.”

I think this bias lives on due to the herd belief: It’s cheaper, easier and more managable to keep lots of people together in one building (institution). They use safety as an excuse, often…but does that really justify taking away a person’s independence? I don’t think so- not for those who can think for themselves and who can get by with a little help.

Advancing Excellence in America’s Nursing Homes is a coalition-based campaign concerned with how we care for the elderly, chronically ill and disabled, as well as those recuperating in a nursing home environment.

There are over 7300 nursing homes participating on a voluntary basis.

Originally the group listed 8 goals member nursing homes should work on. Those goals are located HERE.

Newly revised and updated, three are of interest to CNA’s- this is a PDF file.

GOAL 6 — STAFF SATISFACTION
NEW
Participants in this goal will have to assess staff satisfaction at least annually and upon separation; plus incorporate results into quality improvement efforts. AE has not yet decided on a target objective for this goal but it will probably be twofold: A) Increasing the number of staff surveyed and B) Raising satisfaction scores by a yet undetermined amount.

GOAL 7 — STAFF TURNOVER
REVISED
AE will ask nursing homes to reduce current levels of staff turnover for each of the following categories of employees: RN, LPN, CNA, DON, and NHA. Turnover will be measured separately for each of those categories. Participants will have to regularly measure and report staff turnover and develop plans to reduce the rate of turnover for each of the staff categories.

GOAL 8 — CONSISTENT ASSIGNMENT
REVISED
AE will increase its efforts to encourage and help nursing homes to adopt “consistent assignment” of front line staff – that is 85% of long stay residents in a nursing home have a maximum of seven (7) CNA caregivers each month AND 85% of short stay residents have a maximum of seven (7) CNA caregivers over two (2) weeks. Participants will be asked to set targets to increase the number of residents being served by a consistent assignment model by a yet undetermined amount.

In another post we will examine, more closely, what some of the AE member nursing homes are doing to promote the goals.

The changes, which go into effect on June 17, 2009, are intended to support efforts underway to transform nursing homes into “homey” environments through both environmental changes and resident-centered caregiving. Whereas in the past, these changes were sometimes stymied by fear that regulators would cite organizations for deficiencies, CMS is now making it clear that the OBRA regulations should be interpreted to support personal choice in the full range of daily activities, including waking, bathing, dining, and sleeping. The new guidance also calls for visitors to have 24-hour access to residents, regardless of familial relationship.

The new interpretive guidelines call on nursing homes to begin or to continue de-institutionalizing their physical environments. Suggestions include: reducing noise such as overhead paging and alarm bells, eliminating nursing stations, taking down institutional signage, and refraining from serving meals on institutional trays.

Get ready for the complaining. Eliminating nursing stations!?! But how can they expect us to do our work…But we can’t…and so on.

Pony up folks. Culture change is much needed process and we’ll all be better off with it. Allowing the residents to control their environment and choices is really a human right. Safety, and all those other excuses we tend to use, are just that: EXCUSES. We don’t want to give up our “power”. It’s not about us. It is about our customers- the residents.

Some Culture Change Sites of Interest:
Pioneer Network

Check out the PN’s vast selection of resource links HERE.

Ohio could save millions in Medicaid spending by making greater use of home- and community-based care for those needing long-term care, but it won’t be an easy transition.

As Ohio’s elderly population increases, the number of potential caregivers — those ages 25 to 64 — is shrinking, making it difficult for friends and family to provide care, according to a new study.

An updated economic study of long-term care costs in Ohio found the state ranks 44th in the nation in the percentage of Medicaid spending on home- and community-based care.

In 2008, a third of Ohio’s long-term care budget went toward such care, while two-thirds went toward costlier nursing-home care.

If Ohio were able to meet the 2004 national average of 39 percent for home care — the latest national figures available — the state could save at least $140 million a year, said Howard Fleeter, an economic analyst who conducted the study for the Ohio Council for Home Care.

State officials have been aware of the potential savings and in recent years have been pushing to expand home-care services for Medicaid patients like the state’s popular PASSPORT program and a new assisted-living program.

I think President Obama and his team should further evaluate this. I realize there will always be some people who truly need nursing home care. Let that be. But for the majority of residents I see, they could live at home or in a smaller group home setting for a lot less money. The care would be much better. The “residents” would become “people” again and THAT is a very important factor. We seen to forget that.

Aides working in nursing homes could become home health aides- and that would improve a lot of the numbers mentioned in the article. Address the (CNA) pay and benefit structures with the money saved from less use of expensive nursing homes- I think we have a solution right before our eyes. As it stands now, we get what we pay for. That can change if people really think outside the box.

If home health care agencies can’t find enough reliable, compassionate caregivers to tend to the growing number of elderly and disabled, why not pay clients to hire their own relatives or friends to provide their in-home care?

More than a dozen states, including Ohio, are exploring that choice as a way to head off a looming shortage of home health aides and to help control skyrocketing Medicaid costs for nursing home care.

Home care typically costs less than a third of what states pay for nursing homes. But at current wage scales of $10 to $12 an hour, the turnover rate among home health agency staff is high — 90 percent of aides leave their jobs within the first two years, according to the Institute of Medicine.

Would friends and family do a better job while also saving states hard-pressed Medicaid dollars?

Initial reports from states that allow elderly clients to hire and fire their own in-home workers, including family and friends, suggest it may be one solution.

Sounds good to me.

But does this save money?
Yes.

In a 2006 report, Arkansas found it reduced nursing home admissions 18 percent over a three-year period through a program called Cash and Counseling. The program gives elderly clients the option to employ their own caregivers, direct their own mix of services and pay aides through a budget they control. Case managers advise clients and monitor care.

While the program raised the state’s costs for in-home care, higher costs were offset by savings in reduced nursing home admissions and other long-term care costs, Arkansas found.

And:

For the past decade, Ohio has been struggling to shift more of its frail elderly and disabled away from nursing homes and into lower cost alternatives such as assisted living and home care. In 1995, 90 percent of Ohio’s long-term care recipients were living in nursing homes. By 2005, that percentage had dropped to 65 percent. The Ohio Department of Aging estimates the shift has saved Ohio taxpayers $1 billion.

That’s A LOT of money!

Consider:

States like Oregon and Washington that have long advocated a variety of care choices for the elderly spend more than 60 percent of their Medicaid dollars on nursing home alternatives, including adult foster homes and group facilities as well as home care.

In the national discussion about health care reform, perhaps programs like these should be brought to the table. A lot of people are fussing about the potential severe shortage of aides, nurses and money to cover nursing home care, for the baby boomers. It seems to me we can save a real lot of money by thinking outside the box.

An article explores how the use of meds can cut short the life of a person with Alzheimers.

LONDON (AP) – Anti-psychotic drugs commonly used to treat Alzheimer’s disease may double a patient’s chance of dying within a few years, suggests a new study that adds to concerns already known about such medications.

“For the vast majority of Alzheimer’s patients, taking these drugs is probably not a worthwhile risk,” said Clive Ballard, the paper’s lead author, of the Wolfson Centre for Age-Related Diseases at King’s College London.

“Would I want to take a drug that slightly reduced my aggression but doubled my risk of dying? I’m not sure I would,” Ballard said.

I’m sure if they asked a CNA who has to deal with an agitated and acting out person with Alzheimers, the answer would be YES. Aggression takes many forms…some harmless and others not so. CNA’s get the brunt of these aggressions: We get hit, kicked, bitten, pulled, punched and so on. The violence a person with Alzheimers can produce and aim towards us is quite amazing.

Alzheimer’s disease is the most common cause of dementia and causes symptoms including aggression, delusions and hallucinations. Previous studies have shown anti-psychotic drugs, which can help control the aggression and hallucinations for a few months raise the risk of death in older patients with dementia. There are other side effects, including respiratory problems and stroke.

The violence isn’t always aimed at the aides. Other residents and families are often targets. Most of us do realize the person with AD cannot control their behaviors. We know they would not do these things in their “right” mind. The reality is clear though: An aggressive resident is a threat to all, in the nursing home setting.

Ballard and colleagues followed 165 patients aged 67 to 100 years with moderate to severe Alzheimer’s disease from 2001 to 2004 in Britain. Half continued taking their anti-psychotic drugs, which included Risperdal, Thorazine and Stelazine. The other half got placebos.

Of the 83 receiving drugs, 39 were dead after a year. Of the 82 taking fake pills, 27 were dead after a year. Most deaths in both groups were due to pneumonia.

After two years, 46 percent of Alzheimer’s patients taking the anti-psychotics were alive, versus 71 percent of those not on the drugs. After three years, only 30 percent of patients on the drugs were alive, versus 59 percent of those not taking drugs.

I wonder if they kept track of behaviors of the people who were given the placebos? THAT would be interesting data to see. It’s pretty clear that these drugs somehow hasten the death of Alzheimer victims. In the end, they all die- a sad fact. Alzheimer’s is an awful and brutal disease and one I do not wish upon anyone.

Experts aren’t sure how the anti-psychotics increase patients’ risk of dying. But they think the drugs could be damaging to the brain and their sedative effects make patients less able to exercise and more susceptible to deadly infections.

I agree. I’ve seen many a resident start taking these meds – and the meds DO work. They “calm” the resident down to a level of “safety” that works for the environment. The person is able to stay still longer, so we see less wandering and unsafe movements.

However, I’ve also seen how this turns into a mobility problem: Due to “time restraints” aides tend to push the resident around in a wheelchair vs assist them with ambulating…Legs get stiff, contractures settle in, ambulation is no longer possible. So the resident becomes wheelchair and bed bound, and totally dependent upon us for all care.

We see other outcomes every day: They no longer have control of their bladders and bowels. Skin issues become more pronounced. Sitting in one position for hours on end results in red areas, open areas and everyone knows what this means.

Residents gradually require more and more assistance with eating and drinking. Meds change the appetite, the desire to eat and drink. Meds also alter the ability to smell and taste food. Since there aren’t enough of US to do it all in a timely manner, the food goes in cold and gross; drinks are forced down (and let’s not forget how the disease process screws up the ability to swallow correctly); oral care isn’t the top priority and infection is likely present. The resident loses weight, becomes dehydrated and the vicious cycle continues.

Exactly how much of this is caused by the meds isn’t known, yet. But I think we can all say the decline starts when the meds start. Are they worth it?

The decline will happen no matter what. That’s a given. Those months, even years- of Alzheimer’s induced behaviors are a turning point. Most families will seek a nursing home admission when these things happen. They can’t manage it. Nursing homes “manage” it with drugs.

Is there a better way? Would a really good and targeted Activities Program help? I think so. There are a great many people who believe that all “behavior” is a form of communication, even coming from those whose brains are literally deteriorating. I have seen how well planned yet spontaneous activity programs work WONDERS with people with all forms of dementia. It takes everyone to make these programs work though- aides, housekeepers, the DON, the administrator…everyone. I’d like to see some research done on this. The costs savings alone should make sense: Meds are expensive! Activities are cheap in comparison.

Highlights:

Our enhanced bathing program, “SPA-Venture,” is centered on creating a spa-like atmosphere in what were our “institutional” shower rooms. Bathing is a very private experience that can be physically and emotionally cold, sterile, and institutional. We adapted the physical environment to enable the member to maintain as much independence and dignity as possible. A team of QOL aides, supervised by the restorative nurse, provides support for the functioning and maintenance of this program. Each room is equipped with a heated walk-in safety tub, heated towel racks, hair dryers, curling irons, spa robes, and slippers. Aromatherapy is provided to promote relaxation while soft music is playing. As you enter the spas, the first things you notice are the serene murals painted on the walls. You feel as though you are entering into a relaxing, comforting experience where you have no worries. It brings the bathing experience as close to homelike as possible.

And:

Our enhanced dining/hydration program, “Dining by Design,” offers our members a choice of when to eat, where to eat, and what to eat, while improving nutrition/hydration. This change provides a sense of control and improves self-esteem. This program is only partially complete, but you will see later in this article the impact we have already made with the changes that have occurred. Currently, we have developed three dining areas.

(there’s a lot more on this- go read about the different dining programs.)

Finally:

Our personal comfort program, “Comfort Zones,” focuses on decreasing behaviors, decreasing pharmacological intervention, decreasing pain without narcotic use, improving quality of sleep, and promoting socialization. Our vision here is to couple our current medication regimens with a program designed to promote well-being. The Comfort Zones were designed with three things in mind: relaxation, fun, and pampering. The Comfort Zones are further broken down into three areas: (1) Two Quiet Zones promote relaxation and well-being with the use of a waterfall wall, low-level lighting, gentle touch meassage, aroma/auditory therapy, soft plush recliners, and rocker gliders. We have recently planted a butterfly garden in front of the window of one of the Quiet Zone areas and this has attracted many more members to come relax and let their worries flutter away. (2) In the Fun Zone there are board games, checkers, puzzles, card games, a large-screen TV with DVD player, and many movies (of course you can always bring your favorite), and a Wii system for the adventurous type. (3) The Pamper Zone is designed to make everyone feel special. We encourage all to come down for a hot shave, a hand paraffin treatment, a manicure, a pedicure, and a hand or foot bubble spa treatment. You leave feeling great.

Sounds great! And the CNA’s are a important part of this transition. Called Quality of Life aides, they provide better care, more personalized and appropriate care, than typically expected.

The article offers much more detail as well as outcomes, and the process to go from average to superlative- the aches and pains of it all. A great and inspirational roadmap.

1) Several weeks ago Kim posted about the LTC industry, and the people who work within this industry, have no trust in Barack Obama when it comes to reforming health care. Surprisingly no comments were left on that post.

2) Over at the PHI Blog they have made a big deal that the Democrats have mentioned direct care workers and fair wages and more training.

3) In fact, the Republicans have mentioned long term care and it’s problems in their past two platform drafts.

This isn’t reported by PHI though- who need to be fair and balanced. I lose respect for groups when I suspect they have a strong political agenda vs. a real desire to make things better for ALL. PHI have shown they favor Democrats a lot lately.

The fact that direct care workers are mentioned is all that matters to this advocacy group. The wishes and desires of the people being pushed into nursing homes and other LTC facilities is a moot point I guess. Older people for the very most, would prefer NOT be spend their last years in nursing homes, which are horribly expensive.

Those who are poor have few choices however.

FACT: Less than 5% of ALL people over 70 reside in nursing homes; they almost all depend upon Medicaid for paying. This is about 1.8 million people.

FACT: It costs the US over a billion dollars each year to fund the care of these 1.8 million people.

THINK: About how much it will cost the US when that percentage of older people increases to 10, 15, 20%…

Reform? We need reform. Because we’re never going to be able to keep up with the fiscal requirements of nursing home care. No other nation in the world keeps as many of it’s senior citizens locked up in nursing homes; it’s not a problem for these countries because their cultures and priorities are different from ours. We like to pretend we care for our elderly and disabled citizens yet we show this by making them leave their homes and enter institutions. And we complain that we don’t get paid enough when it is, after all is said and done, WE WHO PAY OURSELVES.

I want to mention a serious and plausible solution, that PHI and other so called advocates conveniently like to forget…that nursing homes are not the only way to go. That other ideas and programs are out there, being talked about, being tried out and have worked. All without the demand of government funds. While the wages of those who provide care will always be up for debate, the expectation that the government must somehow be more involved with this is crazy. Where is the money going to come from? You.

The Republicans are not perfect in this issue. But in their last platform in 2004, long term care and all the problems associated with it were mentioned. And now, in 2008, we see it again. Republicans want to further the agenda of Choices-real options for older people who wish to stay at home and therefore end the need for so many nursing homes- something we have written about dozens of times here. Will PHI report on this? I doubt it.

From McKinght’s LTC News:

The draft of the Republican party’s 2008 platform calls for new non-institutional long-term care options.

“We must develop new ways to support individuals, not just institutions, so that older Americans can have a real choice whether to stay in their homes,” according to the draft released this week. “This is true not only with regard to Medicaid, where we spend $100 billion annually on long term care, but also for those who do not qualify for that assistance.”

Instead of pushing for reform in places where it isn’t going to happen, how about focusing on some solutions? How about thinking outside the box? How about seeking ideas and feedback from those most effected- the soon to be older people who have the most to lose here?

I know it makes people uncomfortable. But we must be realistic and honest.

So much more money can be saved by avoiding nursing home admissions. The cost of a one year stay for one resident could cover the costs of a home care option for 2 or three elderly people.

THAT’S REAL REFORM. Not political pandering and other games. It doesn’t matter whether one is Democrat or Republican. When it comes to health care reform and all things that come under it’s umbrella, each of us should be independent enough to see through the foggy political forest and not get lost in it.