Category: McKnight’s Long-Term Care News

4 ways to find out why your aides are leaving

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

4 ways to find out why your aides are leaving

Once, when I worked for a managed care company, I rode down a packed elevator with the CEO, who commented drily on the crowd, saying, “It must be 5:01.”

What I thought, but did not say, was that there were reasons his staff members weren’t staying more than a minute past the hour. It was a reflection of a disengaged workforce without connections to the job or each other that might extend to a post-work conversation. (It should come as no surprise that I left my position shortly after this elevator ride.)

To stem the tide of departures, it’s important to find out why certified nursing aides are flying out the door either for the evening or for good. Here are some methods for getting the inside scoop:

1. Ask them — It might sound obvious, but it isn’t often done. The National Nursing Assistant Survey (NNAS), conducted in 2004, is an eye-opening view into the lives and challenges of working as an aide on a national level. Adapting the NNAS questions for use in a particular facility — or using an assessment company to measure employee satisfaction — can help determine, among other things, whether the initial training programs you offer meet the needs of your staff or if transportation problems are interfering with their ability to report to work. Such information could lead to relatively easy fixes that reduce turnover.

2. Join them — I spoke with Sarah Poat Stewart, LNHA, CNA, an administrator who trained as an aide and recently worked the 3-11 shift. Stewart, who is based at Signature HealthCARE’s Oakview Nursing & Rehabilitation Center in Kentucky, finds her participation as an aide reduces the barriers between management and employees and leads to more respect on both sides. In a video about Signature’s goal to have all staff trained as CNAs, managers who worked on the floor had a better understanding of the jobs done by aides and the tools they need to do so.

3. Read the minds of those who stay — If you can’t roll up your sleeves and help a resident into a Hoyer lift yourself, reading CNA Edge is the next best thing.

For the entire article, visit:

4 ways to find out why your aides are leaving

To reduce staff turnover, lead with LTC strengths

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

To reduce staff turnover, lead with LTC strengths

When I spoke about the challenges of staff turnover at the Louisiana Nursing Home Association convention last week, I asked the group, “If you were able to bring in the same salary you were currently making, would you want to have the job of an aide?”

The response was a ratio that would likely hold at any LTC convention – in an audience of close to two hundred people, only one person said yes.

“You do realize what we’re doing here,” I commented. “Over the next hour or so we’re going to talk about how to get people to take and remain with jobs we wouldn’t want to have ourselves.”

As attendees pointed out, being an aide is physically and emotionally demanding work for low pay, little autonomy and not enough respect. These downsides – once partially offset by longstanding, gratifying relationships with medically stable, cognitively intact residents – have given way to more challenges as facilities take in increasing numbers of shorter-term, higher acuity residents.

To woo workers to the field – and keep them from the lure of relatively stress-free retail positions at the same pay – it might be time to re-envision our role as employers.

They come for the “special sauce” – and they’ll stay for the buffet

The main appeal of jobs in long-term care (our “special sauce,” if you will) is the opportunity to help others. No fast food joint can compete with that. We need to offer more, however, if we want our workers to stick with us.

In addition to traditional benefits, we can enhance our appeal by providing a “buffet” of nontraditional benefits that build on our missions and on employees’ desires to help others.

One of the unique features of LTC is our access to wisdom from elders, which can offer perspective on life and how to live it. If we envision ourselves not just as caregivers for the aged and ailing but also as organizations that can impart life wisdom to those with whom we come into contact, we can strengthen our allure as employers.

For the entire article, visit:

To reduce staff turnover, lead with LTC strengths

What’s all this about PBJ? Guest Post by “Miss Emily Litella”

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

What’s all this about PBJ?

(Guest post by Miss Emily Litella)

So what’s all this about peanut butter and jelly? Emily Mongan wrote the other day that, “Providers could face Five-Star sanctions for late PBJ data.”

Why are they keeping track of our peanut butter and jelly sandwiches? I appreciate their concern that we residents might have our lunches served late, but what about the tuna fish sandwiches? And the chicken? Doesn’t it matter if those are served late as well?

Speaking of late, what about the times when the call bell is rung and the aides don’t show up for 45 minutes and then say they were working short? Is the “call bell delay due to working short” on the five-star rating system too?

And regarding shorts, I lost mine in the laundry the other day and they haven’t been able to trace them. I spent a lot of money on those shorts and believe me, clothes in my size aren’t easy to come by. Usually they come in teeny-tiny-itty-bitty little sizes. I had to have my daughter-in-law go to Kmart and Walmart before we finally found them on Amazon.

I have good news about the Amazon, by the way. A friend of mine is working to plant trees in the Amazon, doing her part to give back to the world.

Now that I mention backs, I should tell you that mine is hurting. I went down to rehab to ask them to give me a hot pack, or a cold pack, I forget which it is that they’re recommending these days, but anyway, a nice young man whose name I can’t pronounce or recall, gave me one of them and it felt so much better. But now it’s aching again.

For the entire article, visit:

What’s all this about PBJ?

Wisdom from elders

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

Wisdom from elders

I’ve learned a lot from listening to residents over the years, but it’s rare that I request specific advice. This month, I decided to change that.

In private conversations, I told residents that I was writing an article on advice from elders about how to live life and I asked them if they had any wisdom they wanted to share with young people.

Their responses were immediate and enthusiastic, as if they’d been waiting for someone to ask. They were so pleased with the question that I decided to ask my own elder relatives for their opinions as well. One family member, inspired by the inquiry, called to contribute further advice after her initial offering.

Many of the comments focused on wellbeing and taking risks in life:

• “If there’s something you want to do, go for it. Even if it doesn’t work out, at least you tried.”

• “Do what you can while you can do it. Take a chance!”

• “Do things you enjoy and keep as busy as your health will allow.”

• “Don’t overdo it.”

Others centered on maintaining independence:

• “Do the best you can and save a dime, because now when they jump me for money, I got a little something to pull out.”

• “Try to have something of your own, not your mother’s, not your father’s.”

Several people offered relationship advice:

• “Pay attention to your spouse but be an individual too.”

For the entire article, visit:

Wisdom from elders

‘Healthwear’ and other culture changes

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

‘Healthwear’ and other culture changes

My mother has a knack for taking something awkward and, as she puts it, “turning it into a feature.”

For example, the previous owners of our family home placed the living room couch in front of a protruding radiator so that the sofa was oddly and obviously a foot away from the wall. By contrast, my mother had shelves installed above the radiator so that it became a pleasant focal point for books, photos and the stereo system.

I follow this line of thought with regard to the need for assistive devices such as canes, walkers, and eyeglasses. It’s possible to convert something unappealing yet necessary into an item that bestows confidence, evinces a sense of humor or becomes more useful.

Turning assistive devices into a feature creates a psychological shift for the wearer. It gives residents an element of control over mostly uncontrollable circumstances and allows them to retain their personal style in a situation that tends to strip them of their uniqueness despite our best efforts.

An organization providing the opportunity to purchase or design desirable devices can generate a change in their culture. Seeing residents sporting colorful walkers or personalized wheelchairs rather than standard equipment sends a message of individualized care and a zest for life despite disability.

In the spirit of giving your residents an emotional boost and taking the sting out of the need for assistive devices, your organization might try some of the following ideas (found through my handy search engine):

• Residents can purchase sophisticated walking canes featuring fancy handles or colorful shafts with a wide selection of items under $50. I know many residents who would find that an excellent use of their Personal Needs Allowance (PNA).

• Another company features a colorful range of walking canes for about $40 each. Choices include floral motifs, Irish themes, US military and biker inspired designs.

• With PNA funds being as limited as they are, a decorating event is a great addition to the recreation calendar. Help residents embellish canes or create personalized walker or wheelchair bags to carry their belongings using colorful duct tape, Velcro and other supplies, or sew a handy cup holder.

For the entire article, visit:

‘Healthwear’ and other culture changes

Racism and LTC

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

Racism and LTC

A friend of mine called me this week, upset about the racial tension making headlines in the news. We discussed what we could do as individuals to improve the situation.

“I called a friend of mine of a different race,” she said. “I told him we need to stay in touch right now, even if we’re busy.”

“My column this week is about the issue,” I responded. We talked about how differences are bridged in a healthcare environment.

In long-term care, we provide services to, and work with, individuals from backgrounds different than our own. Residents share rooms and break bread with types of people they may never have encountered more than superficially in their previous 80 years of life. Barriers recede when we come to know each other as people, yet it’s not always a smooth road.

Studies of racism in LTC

I’ve observed firsthand various culturally charged interactions — both positive and negative — and I wondered what types of racial challenges are common in long-term care.

I turned to the research to see what’s been studied formally and found that racism is observed in the following ways:

• Residents refusing care based on the racial or ethnic group of the caregiver, as noted in the New England Journal of Medicine article, “Dealing with Racist Patients.”

• Unpleasant work environments due to hearing racial remarks by family members or other workers, in “Racism Reported by Direct Care Workers in Long-Term Care Settings.”

• Nursing homes in areas with high poverty being more likely to close: “Why Medicaid’s Racism Drove Historically-Black Nursing Home Bankrupt.”

• The changing demographics of nursing homes due to people from minority groups having increased entrance to that level of care, but reduced access to privately paid home and community-based care such as assisted living: MedicareAdvocacy.org, “The Changing Demographics of Nursing Home Care: Greater Minority Access…Good News, Bad News.”

Increasing inclusion

While some of these problems are beyond the scope of any one LTC organization, there are ways in which the first two points can be addressed within our communities:

For the entire article, visit:

Racism and LTC

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

From abysmal to mediocre: Encouraging hand hygiene

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

From abysmal to mediocre: Encouraging hand hygiene

As a consultant in long-term care, I learned how to properly wash my hands by reading the hand hygiene poster hung above the sink at one of my first nursing homes.

I’ve gotten more diligent over the years (read: paranoid), making an effort to sanitize my hands as I move from room to room, but I wonder about those whose roles in long-term care don’t specifically emphasize infection control procedures.

While infection control is an integral part of training for most staff members, there are many other people in facilities — visitors, volunteers, vendors and residents, among others — who might not fully recognize the importance of hand washing to prevent the spread of infection.

In fact, a recent study suggests that even those who should know better don’t wash their hands as often as they should. Researchers found that doctors in a California hospital had a hand hygiene compliance rate of about 22% when they didn’t realize they were being observed and a rate of 57% when they recognized that the infection control staff was watching them.

The research paper is titled, “Hawthorne Effect in Hand Hygiene Compliance Rates,” referring to the change in behavior due to being observed. To me, however, the takeaway is that hand hygiene compliance rates range from being abysmal to mediocre. Clearly, this is an area that needs more attention.

A study presented at this month’s Association for Professionals in Infection Control and Epidemiology conference suggests a novel method of increasing hand-washing compliance.

Because prior research had found success in appealing to emotional motivators such as disgust in changing hand-washing behavior, investigators exposed subjects to unappealing photos of bacterial contamination. This visual exposure helped participants imagine the contamination on their own hands and increased their likelihood of hand washing by 11% to 46%.

We could call it the “Eww, Gross! Method.”

Other techniques suggested by infection control and other researchers to increase hand hygiene compliance are below:

• Publishing (in-house) rates of hand-washing observance for each unit to create a healthy sense of competition. The best team could be rewarded, perhaps with pizza or a special lotion to soothe frequently cleansed hands.

For the entire article, visit:

From abysmal to mediocre: Encouraging hand hygiene

Full code: Discussing advance directives

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

Full code: Discussing advance directives

Assistance in creating a “good death” is a fundamental task of any organization working with elders and may be addressed by a number of team members singly or in combination. Since these discussions are often easier said than done, I thought it might be helpful to share some of my experiences since I, as a geropsychologist, regularly discuss dying with residents and their families.

It’s a more-than-timely topic. As I once wrote in my column, “Creating better deaths in long-term care,” end of life care has been the subject of increased media attention in recent years. The importance of a conversation or series of conversations about the resident’s wishes has been emphasized by organizations like The Conversation Project and writers such as Atul Gawande, M.D. in his bestselling book, “Being Mortal.”

Here’s some added perspective. Not too long ago, I was checking the medical orders in a long-term resident’s chart when I noticed that she was “full code.” Bernice was 92 years old with a history of chronic illnesses and a recent decline in functioning.

While many residents have advance directives that prohibit care in the event that breathing or the heart stops (such as a Do Not Resuscitate order), full code allows for all interventions needed to restore breathing or heart functioning, including chest compressions, a defibrillator and a breathing tube.

I thought of the distraught expressions on the faces of the nurses who had rushed to provide full code care to Jim, a frail elderly man who’d been a staff favorite during the course of his stay. The full code was at the insistence of his son, who couldn’t bear the thought of his dad’s passing. Jim’s ribs were cracked, the effort was unsuccessful and the nurses were devastated – at having to perform the procedure, not because Jim had died. It was obvious to everybody in the nursing home that Jim had been dying for months despite his son’s desire to forestall the inevitable.

Mindful of Jim’s painful demise, I raised the issue of advance directives with Bernice, asking her if she knew what “full code” meant and if she’d given any thought to how much medical treatment she wanted at the end of her life.

“What will be, will be,” she told me. “I don’t want to talk about it.” Her tone made it clear that persistence would be futile.

“There’s a lot more to it than that,” I replied, “but we don’t have to talk about it today.” I made a mental note to pursue the topic when she seemed less inclined to throw me out of her room.

For the entire article, visit:

Full code: Discussing advance directives

Depression – AND its treatments – are fall risks

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

Depression – AND its treatments – are fall risks

Feeling “down” takes on a wicked double-meaning for some seniors. Even conscientious providers could be unaware of it, let alone know what to do about it.

As McKnight’s Staff Writer Emily Mongan points out in “Depression treatments may increase risk of falls in SNF residents, study shows,” a psychosocial treatment for depression increased the likelihood of resident falls. I spoke with Suzanne Meeks, Ph.D., first author of the study, to discuss the problem and the results of her research.

Meeks and her colleagues studied the impact of the Behavioral Activities Intervention (BE-ACTIV) on depressed nursing home residents. They determined that the risk of falls in the treatment group was six times that of the control group, a statistically significant number.

Meeks told me all treatments for depression, including medication and behavioral interventions, increase the chance of falls. When an individual is no longer depressed, he or she has more energy to stand and walk, thus creating more opportunities to fall. If depression has immobilized them for some time, deconditioning may exacerbate the problem.

Meeks points out that more than 81% of her research subjects in both treatment and control groups were receiving antidepressants, suggesting that the behavioral intervention activated the residents more than the medication.

It’s important to treat people for depression despite the increased risk for falls because, as Meeks states, “depression is a fall risk.” Other researchers have found that the risk of falls increases when an individual has more of the following risk factors: depressive symptoms, antidepressant use, high physiological fall risk, and poorer executive function. Any two of these risk factors increase the likelihood of a fall by 55%. Participants with three or four risk factors were 155% more likely to fall — 155%!

The BE-ACTIV intervention

The BE-ACTIV model was quite successful in reducing depression, Meeks and her colleagues found, as described in an earlier article about their work. Study subjects in the 10-week treatment group were encouraged and assisted to participate in pleasant activities such as regularly scheduled group programs, in-room crafts and self-care such as haircuts. Compared to the “treatment as usual” control group, BE-ACTIV was “superior … in moving residents to full remission from depression.”

For the entire article, visit:

Depression – AND its treatments – are fall risks