Category: Business Strategies

NYTimes: Too Old for Sex? Not at This Nursing Home

Food for thought in this New York Times article:

Too Old for Sex? Not at This Nursing Home

By WINNIE HU

JULY 12, 2016

When Audrey Davison met someone special at her nursing home, she wanted to love her man.

Her nurses and aides at the Hebrew Home at Riverdale did not try to stop her. On the contrary, she was allowed to stay over in her boyfriend’s room with the door shut under the Bronx home’s stated “sexual expression policy.” One aide even made the couple a “Do Not Disturb” sign to hang outside.

“I enjoyed it and he was a very good lover,” Ms. Davison, 85, said. “That was part of how close we were: physically touching and kissing.”

Ms. Davison is among a number of older Americans who are having intimate relationships well into their 70s and 80s, helped in some cases by Viagra and more tolerant societal attitudes toward sex outside marriage. These aging lovers have challenged traditional notions of growing old and, in some cases, raised logistical and legal issues for their families, caretakers and the institutions they call home.

Nursing homes in New York and across the country have increasingly broached the issue as part of a broader shift from institutional to individualized care, according to nursing home operators and their industry groups. Many have already loosened daily regimens to give residents more choice over, say, what time to bathe or what to eat for dinner. The next step for some is to allow residents the option of having sex, and to provide support for those who do.

For the entire article, visit:

Too Old for Sex? Not at This Nursing Home

Super-utilizers: LTC has them too

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

Super-utilizers: LTC has them too

I was flying home after visiting some family elders last week (a story itself perhaps for another time) when I happened upon a Kaiser Health News article about “super-utilizers” of emergency room services.

Research on Medi-Cal, California’s state health insurance for those with limited income, found that 1% of the patient population accounted for about one-fourth of the healthcare spending.

The reason: Super-utilizers were more often homeless and had substance abuse and mental health problems.

This echoes my experience working as a case manager for a managed care organization years ago. For the particular account I was working on, the mental health managers had access to both the medical and mental health data.

My main observation was that those with the highest medical costs were also those who had been in and out of rehab for substance abuse. The problem was that because our company was a “mental health carve-out,” with HIPAA-protected information, we couldn’t share that information with the medical team.

“Ask them if they’ve been drinking!” I wanted to shout, when I saw they were getting readmitted to the medical hospital for the third time in two months.

It’s a question we might consider asking in long-term care too (along with checking on psychiatric medications). The “super-utilizer” problem affects us in ways that may be less obvious but just as costly.

The super-utilizer in long-term care

Our super-utilizer of services is a resident who exhibits behaviors due to a mental health or substance problem that results in a series of staff meetings and discussions that takes time away from other residents.

It could be someone who needs repeated psychiatric hospitalizations because of psychiatric medication changes during the transition from home to medical hospital to skilled nursing, or an individual ready to be discharged after rehab but difficult to place due to comorbid physical and mental health needs. (A problem also faced in psychiatric hospitals, by the way, when a now-stable patient has comorbid physical health needs.)

Families can be super-utilizers of services. Consider the time-consuming challenges when a substance-abusing relative is found to be taking money from a resident or a discharge home is deemed unsafe because of a mentally unstable family member. I guarantee that’s not a one-meeting decision.

Reducing expense of super-utilizers

For the entire article, visit:

Super-utilizers: LTC has them too

Creating a dialysis-friendly facility

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

Creating a dialysis-friendly facility

Studies show there will be an increasing number of people on dialysis in the coming years. It’s likely many of them will be in long-term care.

There is much that can be done to improve the quality of life for these individuals and to showcase your facility as dialysis-friendly. Unfortunately, many providers are not doing all they can to help these people, or boost their own business operations, for that matter.

New diagnoses of end-stage renal disease (ESRD) in residents should prompt a team discussion with them and their families about wishes for end-of-life care (see Dialysis: Gauging its need, and how to reduce its stress). Some may prefer to avoid dialysis, but many of the newly diagnosed will choose to begin dialysis treatments. In addition, most facilities already have residents committed to the ongoing process of dialysis.

To understand how to best improve care, let’s consider what life is currently like for many hemodialysis patients in long-term care.

A week in the life …

Most people undergoing hemodialysis leave their LTC facility three days a week in order to receive treatments that last for about 3 ½ to 4 hours. In the case of James, for example, he is awakened at 6:30 a.m. to get ready for a 9 a.m. pickup for a 10 a.m. dialysis appointment. He spends the day dozing on and off in front of the television while hooked up to the dialysis machine. By 2 p.m., he’s disconnected from the machine and has a 2:30 p.m. pickup time that sometimes doesn’t happen until 3 p.m. He’s back at the facility by 4 p.m.

Not surprisingly, James and other residents are frequently fatigued on the days in between treatments, making it less likely they’re able to participate in rehab or in the life of the LTC community.

A typical dialysis patient has interacted for hours with an entirely different staff that generally has little contact with the facility care team. They’ve been on an ambulette dealing with various personalities in close quarters (and possibly in traffic or bad weather) and it’s likely that lunch was a renal diet sandwich eaten while being dialyzed.

Considered from a “patient experience” perspective, the bar is set pretty low and there’s a lot we can do to raise it.

For the entire article, visit:

Creating a dialysis-friendly facility

Clone this woman. Steal this idea.

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

Clone this woman. Steal this idea.

A few months ago, I was consulting at the Margaret Tietz Nursing and Rehabilitation Center in Jamaica, NY, when a remarkable woman named Trudy Schwarz walked down the hall. Her noteworthy qualities were obvious in several ways.

A diminutive woman, she nevertheless was pushing a sizable rolling metal cart filled with all manner of neatly arranged goods. This was despite being as old or older than many of the residents at the facility.

She exuded a calm, pleasant demeanor enhanced by her smile and her peach-colored lab coat as she purveyed merchandise from what I’ve previously termed an “independence cart,” an essential yet rare enterprise in long-term care.

“Trudy’s here!” exclaimed the resident I’d been speaking with, excusing herself for a moment to exchange a few dollars for a bottle of lotion. “She buys me the things I can’t get here. She’s a real lifesaver.”

It was a sentiment I heard echoed by many other residents over the next few months.

Overcoming systems failure

An “independence cart” is a small store on wheels that brings goods to residents. While many residents have personal needs allowances and therefore a small amount of money for purchases, it’s virtually impossible for many frail elderly to spend it due to a systems failure within long-term care communities.

Residents generally have no access to a store unless it’s one that visits their facility or they’re physically able to go off-campus with a family member or as part of a staffed excursion. Social workers are usually too inundated with other tasks to assist with online purchases and most residents don’t have access to a credit card, debit card or PayPal account necessary for web-based transactions anyway. Residents without family members to make purchases on their behalf are left to ask for help from staff members who sometimes assist them out of kindness — but against facility policy.

The psychological impact

For the entire article, visit:

Clone this woman. Steal this idea.

Upcoming Quality Initiatives

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

Upcoming Quality Initiatives

Last week I was speaking about the needs of younger residents at the North Carolina Health Care Facilities Association convention and had the opportunity to hear a presentation by David Gifford, MD, MPH, Senior Vice President of Quality and Regulatory Affairs of the American Health Care Association (AHCA). He was discussing what providers could expect from upcoming AHCA quality initiatives. I was listening with a clinician’s ears and, aside from feeling grateful that I’m a clinician and not an administrator, several points stood out for me.

• Turnover is going to be added to the 5-Star Rating System. Better-rated facilities will be expected to have a turnover rate of 40% or less. He didn’t specify how to accomplish this, but my article, “Keys to reducing turnover in LTC,” offers many suggestions to address the problem. As I noted in the column, a 2007 Donoghue and Castle study found that “increasing the number of aides per resident from 33 per 100 to 41 per 100 reduced CNA turnover from 65% to 41% and also lowered LPN and RN turnover.” Taking that action alone could bring your facility to the sought-after turnover rate.

• Analyze problems with the right attitude. When doing a root-cause analysis of challenges such as falls, infections, pressure ulcers, etc., Gifford recommends operating from the assumption that “everything is preventable” rather than a defeatist whaddayagonnado stance. (OK, I’m paraphrasing that last part.) In his experience, this attitude makes a big difference in finding areas of potential change.

He also points out that difficulties frequently stem from a systems problem or lack of skill rather than a knowledge deficit on the part of staff. Rather than providing knowledge-focused in-service trainings in an attempt to rectify situations, ask staff members what “frustrates” them about a particular problem and whether they have suggestions about how to remedy it.

• Use pilot studies. When making needed modifications, start with a very small sample rather than immediately making a facility-wide adjustment of systems. Follow the model of “one staff member, one resident, one day.” This trial run provides the opportunity to see how the new system works and creates staff buy-in before committing the entire facility to the changes. Staff buy-in is enhanced if the selected staff member is someone respected by peers.

For the entire article, visit:

Upcoming Quality Initiatives

‘Just a picture of her butt’ — an analysis

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

 ‘Just a picture of her butt’ — an analysis

In “A potential lawsuit in every worker’s pockets?”, McKnight’s Editorial Director John O’Connor describes two of many recent incidents of long-term care workers using their cell phones to record residents in embarrassing situations and post the photo or video to social media.

Despite leading to termination of employment and lawsuits, some of the employees involved appear to have no idea that this behavior is a serious ethical breach. Staff writer Emily Mongan offers the following quote in her article on this topic: “They just blew everything out of proportion,” [the offending employee] said. “It was just a picture of her butt.”

Wondering how an employee could possibly think posting a photo of a resident’s behind to social media would be a reasonable action to take, I contacted psychologist and social media expert Keely Kolmes, PsyD , to find out.

Changing expectations of privacy

Dr. Kolmes notes that it’s become commonplace for people to record moments from their lives and post them to social media, generally without consent from others who might be captured in the photos or videos that are shared.

For example, while I get my daughter’s permission before I post anything about her to my private Facebook page, I occasionally find her featured in photos with friends on their pages without prior approval. Posting friendly pictures is considered acceptable in one’s personal life (and a parent who asks permission from their child is, I suspect, unusual).

One might argue that there’s a distinction between personal and professional situations, yet similar situations frequently occur in professional settings as well, such as discovering you’ve been featured in a photo on the website of an organization after attending their conference or on your facility website after the holiday party.

Most people are pleased to be highlighted in such photos, but if an organization expects employees to follow their social media policy, these situations are a prime opportunity to show workers that the policy is being followed at the corporate level as well. At facility events, for instance, notify staff members that photos will be taken and may be posted.

Resident/staff boundaries: Whose life/home is it?

For the entire article, visit:

‘Just a picture of her butt’ — an analysis

Dr. El’s subversive guide to culture change

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

Dr. El’s subversive guide to culture change

We often think of culture change as a formal process initiated by company leaders that involves setting organizational goals and moving employees in big and small ways toward those goals.

But culture change also can be a grassroots effort that shifts the dynamics between residents, staff and community, one unit at a time.

Altering expectations

As a psychologist, I’ve been trained to observe the interactions of groups of people. The current dynamics of many long-term care settings involve residents who are in the passive role of “recipients of care” while the staff members are in the active role of “providers of care.” The residents are frequently isolated from each other and from the community outside the facility. They feel bored and useless, leading to depression.

Leaders in the culture change movement, the Eden Alternative calls loneliness, helplessness and boredom the “three plagues” of long-term care. Its aim is to eliminate these plagues through transforming the culture of the facility. Another culture change resource, the Pioneer Network, refers to the need for elders to have, among other things, “purposeful living.”

These organizations and others offer tried-and-true paths to alter the dynamics of your facility, but not every setting is ready for them yet. If you’re working in a culture-change-resistant organization and find yourself yearning for a way to make a difference — today — consider the possibilities here.

Grassroots culture change ideas

• Purposeful pursuits such as knitting and crocheting

As part of a therapeutic recreation program, these crafts can dramatically shift the dynamics noted above, especially when the needlework has a point. (Sorry, I couldn’t resist!) Residents who are working together to make lap blankets for new residents or hats for premature infants change from being passive recipients of care to active providers of care for others within the facility and in the larger community. Industrious and engaged residents show workers that elders can contribute to the world despite their age and physical or mental limitations. (For more on this, see the Recreation audios on my website. For more on therapeutic knitting, visit stitchlinks.com.)

• An active welcoming committee

Entering long-term care is very stressful for newcomers and an effective welcoming committee is an excellent way for long-time residents to recognize their own value and share their expertise.

For the entire article, visit:

Dr. El’s subversive guide to culture change

Growing Good

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

Growing Good

Woohoo! My first column of 2016.

Which was started during a bout of insomnia in the last week of 2015.

What did I do when sleep failed me? What electronics-addicted individuals often do in the middle of the night. I grabbed my computer, caught up on email, and headed over to Facebook to find out what my Friends had been up to.

There I discovered a post about a company founded by two brothers called Life is Good, which emerged from the standing request the founders’ mother had for them as children in a chaotic home environment: Tell me something good about your day.

This helped the brothers become “glass half full” kind of guys, the type of people who donate 10% of their profits to help children overcome adverse childhood experiences.

And what does a T-shirt company have to do with long-term care? Well…

What if we started off this brand new year asking ourselves and our coworkers, employees and residents to tell us something good?

What if we put time and thought into focusing on the positive — into growing the good — and reminding ourselves why we’re all here working with elders?

I predict we’ll have more productive staff, better functioning teams, and happier residents.

It’s not just me doing the predicting. The Positive Psychology Center, led by director Martin Seligman, Ph.D., describes positive psychology as “the scientific study of the strengths that enable individuals and communities to thrive.”

For the entire article, visit:

Growing Good

7 employee wellness ideas for the holidays (and beyond)

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

7 employee wellness ideas for the holidays (and beyond)

After a staff training on reducing burnout in long-term care last week, a look through the evaluation forms was illuminating. A significant number of attendees — mostly nursing aides, nurses, and environmental workers — wrote that the most valuable point they got from the training was how important it was to take time for themselves, even if it was for just a few minutes.

Apparently the 10-minute meditation we practiced using an app on my smartphone made a big impression on them. What struck me was how novel that experience was for them.

With frequent callouts and turnover rates troublingly high (50% for nurses and 51.5% for aides, according to a 2012 AHCA report), working short-staffed seems to be the rule rather than the exception. It means workers are being stretched ever thinner and being pulled in many directions by the needs of their residents.

With the holidays upon us, staff members have extra duties at home — gifts to purchase, parties to plan and attend, and special foods to cook.

By this time in December, your workers are probably maxed out.

This is a great opportunity to show that you’re thinking of them and that you recognize how stressful the holidays can be. It’s also a good way to prevent the staff burnout that leads to callouts, resignations and injuries.

For the entire article, visit:

7 employee wellness ideas for the holidays (and beyond)

The secret to LTC success? A focus on well-being

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

The secret to LTC success? A focus on well-being

Despite the diversity of the events I attended during my brief visit to the LeadingAge convention in Boston last week, a theme clearly emerged. The thread that ran through the varied offerings was well-being.

Retaining staff

In researcher and consultant Joanne L. Smikle, PhD’s talk on staff retention, rather than focusing on why employees are leaving, she looked instead at why they stay.

Based on her studies of long-term care organizations, she found that “if the leadership of the organization lacks passion, you will have trouble with retention and commitment.”

In healthy organizations, staff members “from the top of the house to the bottom of the house” stay because they can say, “I felt I mattered.” Experiences that contribute to that feeling: Recognizing staff in formal and informal ways, an open dialogue with staff rather than top-down communication, and a focus on the human elements enabling employees to make connections with each other, the residents and the families.

Dementia care

G. Allen Power, MD, FACP titled his presentation, “Enhancing well-being for people living with dementia,” so it wasn’t surprising that this was a central point in his talk.

He asserted that antipsychotics don’t work and don’t treat the true causes of the behaviors associated with dementia. Instead, he recommends focusing on the seven primary domains of well-being, which are part of the Eden Alternative model of care: identity, growth, autonomy, security, connectedness, meaning and joy.

In one instance, a resident who became agitated when he was prevented from leaving the building was allowed outside. The man looked at the cows in a nearby field and returned to spend the rest of the day calmly. The team, who subsequently learned that the resident had been a farmer whose daily routine included an early morning check on his animals, had given him not only autonomy, but had also affirmed his identity and added meaning and joy to his life. His agitation disappeared.

Keynote address

Atul Gawande, MD delivered a Monday morning keynote address. Author of the book “Being Mortal,” Dr. Gawande discussed ways in which to improve end of life treatment. He advocated for care that takes into account the desires of the patient and noted that there is more to living than extending the amount of time we live.

For the entire article, visit:

The secret to LTC success? A focus on well-being

Leonard Florence ALS unit entrance