Forbes has an article up about this very subject:

Frail seniors, as well as adults with disabilities, often need help with routine medical care such as taking pills, receiving injections, getting oxygen, or managing catheters. Traditionally, this assistance has been provided only by nurses. But, especially for people living at home or even in assisted living facilities, having a nurse provide this routine care is prohibitively expensive and can lead to long delays in getting assistance. As a result, states are increasingly permitting home health aides or certified nursing assistants to take on these responsibilities.

Personally I don’t see where I would have the time to collect meds and pass them. If a system could be set up that made this process very simple and involve very little time, I think it could work.

You would expect the DON to be involved in every aspect of recruiting a CNA, and Judson is indeed involved. But, at the hour of decision, she silently steps aside and the residents take over.

A team of four to six residents, their homework done and ready to meet the applicant, stroll into the conference room. It is a meeting of the ages. On one side is arrayed the accumulated wisdom of the seniors who look benignly across the table at the eager young aspirant, Angelica Riviera, 19, idealistic but nervous. The dialogue across generations goes on for 45 minutes, with storytelling, jokes, and much laughter, as each side wonders how the other side will affect its future.

Isn’t this great? Imagine being a resident, and having some power in who is hired to work with you, to take of you, help you?

The DON is instrumental in this process:

“Seeing residents hire their caregivers is rewarding enough,” says Judson. “It has also elevated my understanding of what matters most to the residents. It has made me a better leader and a better person. It is an empowering and uniting experience for us all. Sitting on the sidelines, I listen to residents tell a budding caregiver what living in a facility is all about; at each session I learn something new.”

Read the whole article HERE.

In order to care for their residents, staff members in a dementia wing need to learn and periodically be reminded of the difference between normal aging and dementia-related changes.

Very true, and this book offers lots of educational articles on this subject. In plain language.

One of the things I like most about this book is the chapters on utilizing ALL nursing facility staff to engage residents in activities.

The activity department must be considered a staff group that supplements the activity-focused care provided by other departments.
All team members can be trained in reminiscing techniques using events that happened long ago, sensory stimulation such as massaging the hands or scalp, discussions of smells in their environment, reading a story, or normalization tasks like sorting silverware, folding towels, addressing envelopes, winding yarn, and organizing drawers.

Person centered care is the other hallmark of this book:

The person-centered care approach gives personal attention to the people who live in seniors housing and empowers staff members to be resident advocates. A caregiver’s knowledge of each resident’s pre-dementia story is essential to be able to gain the attention of that resident quickly when his or her behavior needs to be redirected.

Finally, an Alzheimer’s Disease Bill of Rights:

According to “The Best Friends Approach to Alzheimer’s Care,” every person diagnosed with Alzheimer’s disease or a related disorder deserves the following rights:
■ To be informed of one’s diagnosis;
■ To have appropriate, ongoing medical care;
■ To be productive in work and play for as long as possible;
■ To be treated like an adult, not like a child;
■ To have expressed feelings taken seriously;
■ To be free from psychotropic medications, if possible;
■ To live in a safe, structured, and predictable environment;
■ To enjoy meaningful activities that fill each day;
■ To be outdoors on a regular basis;
■ To have physical contact, including hugging, caressing, and hand-holding;
■ To be with individuals who know one’s life story, including cultural and religious traditions; and
■ To be cared for by individuals who are well trained in dementia care.
Source: “The Best Friends Approach To Alzheimer’s Care,” Virginia Bell and David Troxel, Health Profession Press, 1997, www.bestfriendsapproach.com

I highly recommend the book even if it was published several years ago. Get the book HERE.

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.