Category: Business Strategies

A look at Germany’s intriguing long-term care system

I was in Berlin, Germany, last week and did some research into their long-term care system during my visit. I was curious about how it might be different or similar to ours, given the country’s national healthcare program.

Briefly, the German system has public and private healthcare insurance options and 100% of the population has coverage. That’s compared to the 28 million Americans without insurance and the 48% of Americans between ages 19 and 64 who are underinsured¹. Private insurers in Germany are not profit-making enterprises and people cannot be turned away for pre-existing conditions. There are caps on charges for services so that healthcare is still affordable even when medical needs increase. They have better health outcomes than the U.S., and at significantly lower costs.²

The system has financial incentives for exercise and regular medical checkups, rather than cost-prohibitive copayments that can lead to delays in medical attention.

Long-term care insurance

About 79 million of Germany’s 82 million people have long-term care insurance, composed of 88% public and 12% private insurance.³ Payments can be used for care at home, given to professional, family or friend caregivers, or applied to one of the 12,000 care facilities in the country. If the insurance payment, along with pensions and other income, isn’t enough to cover facility costs, then families contribute or the elder applies for social assistance.

Exploring LTC in Berlin

I had dinner with Ilse Biberti, an actor and director who authored a best-selling German-language book on the six years she spent caring for her aging parents. I chatted about parents with middle-aged Germans over birthday cake at a party. And I got an informative tour of the aforementioned nursing home by Amélie Herberhold, one of its social workers.

I was staying in a friend’s sixth-floor walkup apartment. This wasn’t an anomaly; there were walkup apartments all over the city. “What do the old folks do?” I queried everyone I met. The answer: “They put a chair on each landing and they take their time.” This sounded very much like apartments in New York City, with elders somehow managing to walk up too many stairs until it’s no longer possible.

Journalist Johannes Buck shared an idea he had come across for those unable to reside alone. Multiple families bring their older relatives to live together in one home and then share the care for all of them as a collaborative effort. The concept of cooperative family responsibilities could be a welcome step on a continuum of care for some organizations or communities in the U.S.

For the entire article, visit:

A look at Germany’s intriguing long-term care system

The Minister for Loneliness in LTC

The Minister for Loneliness in LTC

According to researcher Julianne Holt-Lunstad of Brigham Young University, loneliness has a greater impact on health than smoking 15 cigarettes daily, or obesity, which is associated with 300,000 to 600,000 deaths a year in the United States alone.

In England, the “loneliness epidemic” has reached such proportions that they’ve appointed a Minister for Loneliness to address the problem.

This idea led me to consider the benefits of designating such a position in long-term care. Yes, we have recreation departments that encourage resident socialization, but a Minister for Loneliness could do so much more. The Minister also could target staff loneliness and the isolation of those in the community.

Minimizing staff loneliness has the potential to reduce turnover, alleviate staff stress and improve the culture of the organization. Seeking to decrease the isolation of those in the neighborhood would enhance the reputation of the facility as a community player and create a way for locals to connect with the home before they need it, so that it becomes a natural choice for later care.

Below are some ideas of ways in which the Minister for Loneliness could affect change (but there doesn’t need to be a formal role to try these suggestions).

For residents and their families, the minister could: 

• Establish a communal table for residents interested in engaging with peers for a particular meal.
• Ensure that residents who needed hearing aids and other assistive devices had fully functioning equipment available.
• Train staff to facilitate like-minded friendships between residents, seating them together at meals and during activities.

For the entire article, visit:  The Minister for Loneliness in LTC

The last-minute guide to trauma-informed care

The last-minute guide to trauma-informed care

With trauma-related F-tags beginning in less than two weeks, many providers have spent months training their staff and feel quite prepared to manage this sensitive aspect of resident mental health care.

For those who might not be completely ready for the Nov. 28 start date, I offer below some basics on trauma-informed care practices. While none of us know exactly how the survey process will play out, these fundamentals can make it less likely to run afoul of regulations.

The Concept

The general idea of trauma-informed care is that residents who have had exposure to trauma can experience increased sensitivity to interactions in the long-term care setting that “trigger” old feelings and reactions.  For instance, Bob, a resident who was physically assaulted several years ago, feels very unsafe and distressed when other residents become agitated.

The Symptoms

An individual who has experienced trauma may have symptoms of Post-Traumatic Stress Disorder (PTSD), such as an exaggerated startle response or repeated intrusive thoughts of the event. Using our example above, Bob shouts loudly in alarm when other residents are noisy or frightening, showing an exaggerated startle response.

The Goal

The new F-tags are an effort to increase awareness that the nursing home environment can trigger past experiences of trauma or exacerbate current traumas and to encourage facilities to make every effort to avoid re-traumatization.

The Interview

The first step in complying with the regulations is to determine whether or not a resident has a current or past experience with trauma. The challenge of the interview is to avoid the possibility that the manner in which the questions are asked becomes traumatizing in and of itself.

To minimize this possibility, hold the interview in as private and discreet a manner possible and “normalize” the process, explaining to interviewees that all residents are being asked about their past experiences.

Increase the interviewee’s sense of control by offering them the option not to answer any items if they feel uncomfortable.

For the entire article, visit:  The last-minute guide to trauma-informed care

If toileting were a billable service …

If toileting were a billable service …

The other day over lunch a colleague said to me, “Imagine how things would change if toileting were a billable service.” I laughed, briefly considered that fanciful notion and continued eating my meal.

As I gave the idea further reflection, however, it might not be as laughable as it first appears.

Consider the following:

Funding

Remuneration for toileting would mean that aides would hold income-generating positions. We’d expect that nursing departments would become fully staffed in order to take advantage of this new funding stream and that compensation for aides would increase.

Respect

We might also anticipate that CNAs would become more highly valued for their services by others in the facility.

Philosophical shift

Direct payment for the tasks of aides would strengthen incentives for employers to support ways for employees to manage their jobs around their lives, which often entail demanding family caregiving responsibilities.

Retention programs/employee benefits

The funds could be used to develop retention efforts such as flexible schedules, onsite daycare, financial contributions to staff education and other employee benefits.

Training

Increased remuneration for personal care would lead to more resources for training and for creating programs that promote the development of CNAs, such as peer mentorships.

For the entire article, visit:

If toileting were a billable service …

McKnight’s FREE Online Expo 6/20/19

I’ll be speaking about Behavioral Health in Senior Living at McKnight’s free Online Expo at 11am ET on Thursday, 6/20. To register for the virtual Expo, see the info below.

McKnight’s Online Expo, FREE, Thursday June 20^th
Earn 3 Free CEUs at 3 Free webinars

Finally, a virtual trade show just for senior living professionals! During this one-day event on June 20, you’ll hear from dynamic speakers with great ideas about the senior living issues that matter. This is the show you’ve been waiting for and you don’t even need to leave your desk to attend!

Register for the conference in advance, and then log in to hear the talks, visit the vendors, and chat with the reps and attendees.

This year’s topics are:

• Behavioral Health in Senior Living: Improving Practices, Reducing Risk
• Mobile Tech: Friend or Foe in the Senior Living Workplace?
• The Talent War: 3 Strategies for Winning in Today’s Competitive Market

To register, go to: www.mcknightsseniorliving.com/June20Expo

The added value of social workers and psychosocial services

The top recommendation in the April 9 McKnight’s article “Researchers share 6 tips to improve nursing home care for blacks and Latinos” was to include a social worker on staff in the facility. “Great,” a reader commented, but “ask CMS … if they will pay for it.”

Perhaps, though better yet, social workers will pay for themselves.

A study published in March discussed the role and value of social work staff, with the surprising finding that deficiency scores are reduced twice as much when there’s an increase in social service staffing as compared to an increase in nursing staff. Lower deficiency scores can translate into better CMS star ratings and increased admissions, as well as reduced liability risk, creating a financial savings worth the price of a social worker salary.

The research brief goes on to report that while there’s been an increase in staffing in many other departments over time, the number of social workers remains low. The authors also note that there are no mandated qualifications for social work staff but that when social workers have higher qualifications such as a master’s degree, resident outcomes improve.

Interestingly, the other department that had almost as much effect on improving deficiency scores was the activities department, another psychosocially focused part of the team. (They didn’t study consulting psychologists, but I’d like to think we would have helped as well!)

For the entire article, visit:

The added value of social workers and psychosocial services

McKnight’s Online Expo, FREE, March 27th and 28th 2019

How to quit like a shrink

Here’s my latest article on McKnight’s Long-Term Care News:

How to quit like a shrink

Employees leave their positions for many reasons — organizational restructuring, family needs, a better offer — and they exit their jobs in a variety of different ways. Some sneak out quietly so that their coworkers find out only after they’re already gone. Others have a swift, drama-filled exit, walking off after an argument, never to return.

While we as individuals may have no say over how our companies discharge workers, if we’re voluntarily leaving an organization, we’re likely to have a significant amount of control over how we depart. For professionals hoping to maintain connections with colleagues, leave-taking is an opportunity to create a positive last impression. While we’re making the effort to finish up our work and create a smooth handoff of responsibilities, we also can showcase our expertise in handling exits.

As I noted in a column about how to fire staff members, “The Good-bye Guide: Why and how to terminate tenderly in LTC,” endings of all kinds are especially important in this field. Beloved residents may die unexpectedly or be transferred to the hospital and vanish from our lives. With the departure of each resident, their families disappear as well, compounding the loss.

This steady but generally unacknowledged drumbeat of sadness has a strong impact on workers. (I believe it’s why many employees don’t complete their first year. For more on that topic, see “Absenteeism and turnover in LTC? Death anxiety could be the cause”.) In an environment where there are many sudden and sometimes disturbing endings, well-planned departures can be opportunities to heal some of this pain.

They also can help to solidify connections and offer an opening to obtain contact information for colleagues with whom you’d like to stay in touch after you’ve gone.

There are entire volumes devoted to the psychological process of termination, but I’ve created a quick guide below based on my experiences with leave-taking in LTC:

1. Give people time to emotionally and practically process your departure. Typically, this is two to four weeks, depending on the level of your interactions with them.

For the entire article, visit:

How to quit like a shrink

Severely mentally ill residents: A ‘perfect storm’ creates a SNF wave

Here’s my latest article on McKnight’s Long-Term Care News:

Severely mentally ill residents: A ‘perfect storm’ creates a SNF wave

Long-term care facilities are admitting more residents with longstanding psychiatric illnesses. Such individuals enter the nursing home for physical rehabilitation but are difficult to discharge back to the community due to their mental health needs, weak or nonexistent support networks and unstable prior housing situations.

This column focuses on why the severely mentally ill (SMI) population is increasing, and the impacts of this change and on strategies to manage care.

A mounting possibility

I predict we’ll be seeing greater numbers of SMI residents due to the combination of factors outlined below.

The movement toward deinstitutionalization in the 1970s and 1980s closed many psychiatric facilities without increasing community assistance. Because of the lack of community resources, parents of children with severe mental illness frequently became their lifelong supports.

Many SMI people are now over 50 years old; their caregiver parents are in their seventies and eighties. Older parents are less able to provide financial, practical and emotional aid for their adult children due to their own aging and health problems.

In addition, as adults with SMI get older themselves, they’re increasingly likely to experience medical problems requiring hospitalization and rehab, which brings them to our doors.

To estimate the numbers of older SMI individuals, I looked at statistics on mental illness and aging. According to the National Institute of Mental Health (NIMH), 2.7% of US adults aged 50 and older were diagnosed with SMI in 2016. In 2014,  AARPnotes that there were 108.7 million people aged 50 and over in the US. Combining these statistics gives us a rough estimate of almost 3 million SMI adults over age 50 in the US, with the number increasing as the baby boomers age.

I looked at the statistics on LTCfocus.orgto ascertain whether this trend toward increasing numbers of people with SMI in LTC is beginning. The data show the numbers of residents diagnosed with schizophrenia and bipolar disorder between the years of 2000 and 2016. In my state, New York, 6.45% of residents had those diagnoses in 2000; in 2016 it was 11.8%. In Pennsylvania, the numbers increased during that time period from 4.45% to 9.3%. California: 8.87% to 15%. Texas: 4.91% to 13.4%.

The pattern is clear.

As a complicating factor, the US healthcare system has distinguished between treatment for physical health and mental health. There are very few institutional or community resources that are able to care for people with both physical and mental health impairments. There is virtually nowhere to discharge residents without family support who need assistance for comorbid medical disorders and severe mental illness.

Thus we have a perfect storm of treatment failures for our aging severely mental ill population and one that’s likely become more critical as the number of aging SMI individuals increases due to demographic shifts.

Severely mentally ill residents: A ‘perfect storm’ creates a SNF wave

Healthcare changes that burn me out — and burn me up

Here’s my latest article on McKnight’s Long-Term Care News:

Healthcare changes that burn me out — and burn me up

I was recently required to take an online training module on burnout for physicians and allied professionals. It was the first time in 20-plus years that I’d received a formal message about self-care from any long-term care institution (aside from yearly staff appreciation barbecues and survey completion parties).

While I was impressed and grateful for the focus on caregiver well-being, a couple of points bothered me.

The questionnaire asked readers to select the phrase they most associated with provider burnout. There were options such as “workplace dissatisfaction” and “challenging patients.” I chose “changes in the healthcare system,” which triggered a pathway specific to that option.

I was guided through a series of vignettes discussing issues old-timers might have trouble with, such as adapting to the electronic medical record. Following the vignettes, helpful strategies were offered to manage stress.

Then came the part I found disturbing: The details of the “changes in the healthcare system” choice included “the emphasis on the healthcare experience of consumers” and “the shift from volume to value.” Let me explain why that irks me.

The experience of healthcare

Regarding consumer experience, most of my direct care team members and I have been very focused over the years on accommodating the needs of residents. It’s become more difficult, however, to maintain care quality and orderly surroundings in a healthcare environment where financial pressures have led to staff reductions and increased turnover amidst higher acuity residents.

Trying to deliver a decent customer experience without the necessary tools is part of the change in the healthcare system that induces my feelings of burnout — not the “new” attention to perceptions of consumers.

I’d be gratified to see a genuine, top-down focus on the healthcare experience of residents and their families — complete with Resident Experience Officers in every long-term care facility (sign me up!). Such an emphasis would realign resources with a mission of care that can stabilize staffing and sustain facilities over time.

Volume to value

“The shift from volume to value” stresses me in a different way.

Part of my role as a psychologist in the “volume” approach has been to aid residents in negotiating their illnesses and treatments.

If necessary, I could help them stop a lucrative but unwanted onslaught of painful medical interventions by fostering communication with their physicians and families.

For the entire article, visit:

Healthcare changes that burn me out — and burn me up