Category: McKnight’s Long-Term Care News

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

Dr. El tries on the Genworth aging suit

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

Dr. El tries on the Genworth aging suit

I’d read about the Genworth R70i Aging Experience and when I discovered the exhibit was making a brief appearance near me at the Liberty Science Center in New Jersey, I headed over with my 9-year old assistant to see what it was all about.

The Aging Experience involves a high-tech suit designed to help younger people gain insight into the physical effects associated with aging. When I told residents I was going to age myself via the suit, reactions ranged from an incredulous, “Why in the world would you want to do that?!” to “Great! We can compare notes,” to, “Can they make a suit to make you feel twenty-five?”

My assistant and I arrived 15 minutes before the 11 a.m. demonstration so that I’d be dressed and ready. The Applied Minds staff, who partnered with Genworth on this project, took us into the back of a tech-filled room where they Velcroed various parts of the suit onto me, adding an extra 40 pounds strategically placed to mimic age-related weight gain.

This resulted in the constant thought throughout the half-hour presentation that it would be really nice to sit down.

The helmet included goggles and headphones, so that they could give me various disorders including glaucoma, macular degeneration, cataracts, age-related hearing loss, tinnitus and aphasia. I was finally able to see what one of my patients referred to when she said, “I have macular,” as if she was intimate enough with the condition to be on a first name basis.

After undergoing vision and hearing loss, I was faced with rheumatoid arthritis and hip problems that made walking on the treadmill a chore. Even without the additional physical challenges, trudging on the virtual beach was so difficult that I estimated a two-minute hike would be enough before it lost its pleasure – and I love walking on the beach.

The audience was able to observe my heart rate and perceptions on the screens behind me and then to try on goggles and headsets and experience the ailments themselves.

For the entire article, visit:

Dr. El tries on the Genworth aging suit

Help for hoarders, and those who care for them

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

Help for hoarders, and those who care for them

It can be challenging for long-term care providers when residents amass large quantities of possessions. Facilities generally worry about hoarding when the amount of belongings prohibits the resident or staff members from safely moving about their room or apartment.

Other concerns include fire safety and the possibility of attracting vermin in spaces that are unable to be properly cleaned, as well as apprehension that a cluttered room will attract negative attention from state surveyors.

On the other hand, cleaning out a room against the will of a resident could be perceived as a violation of their right to “security of possessions.”

Facilities often feel stuck between the proverbial rock and a hard place.

Firsthand observations

Over the years, I’ve observed many different scenarios that arise when facility try to manage residents’ hoarding. Here’s a small sample:

• “The State is going to be here any minute,” the Director of Social Work told me, her voice rising a couple of octaves with panic, “We need you to tell Mrs. White that she’s got to get rid of all that junk.”

• Hoarder Number One, complaining bitterly about Hoarder Number Two: “Why are they telling me I need to throw away my things when she has even more stuff than I do? Her room is a mess! At least mine is organized. They just don’t bother her because she’s friends with the administrator.” (All accurate perceptions.)

• Comment from the maintenance guys to the hoarding resident after showing up at the door with cardboard boxes and a dolly: “We’re going to pack up your room for a few weeks until after the State visits, then we’ll bring it back.”

• Sitting with Ms. Rosario following an unannounced purge of her room while she was at dialysis: “How could they do this to me? I trusted them! That stuff was really important to me,” she said, referring to, among other things, an assortment of straws and every food tray slip she’d gotten since her arrival at the facility over a year ago.

What is hoarding?

For the entire article, visit:

Help for hoarders, and those who care for them

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.

McKnight’s Online Expo, FREE, March 29th and 30th 2016

Once again, McKnight’s will host its annual online expo, which is a chance to attend a conference without leaving your desk. 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:

PAYMENT: MDS 3.0 Update: Get ready for more changes March 29, 10 am EST / 7 am PST

WOUND CARE: Deep-tissue injuries — Recognition, Strategies and Risk March 29, 11:30 am EST / 8:30 am PST

TECHNOLOGY: Trends and best practices March 29, 1 pm EST / 10 am PST

QUALITY: Engaging staff in reducing readmissions to improve quality March 30, 11:30 am EST / 8:30 am PST

CAPITAL: The state of capital availability March 30, 1 pm EST / 10 am PST

To register, go to: www.mcknights.com/Expo2016

Using light to improve sleep, reduce agitation

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

Using light to improve sleep, reduce agitation

Poor sleep, reversed sleep/wake cycles, depression and falls are common problems in older adults. In addition, elders with dementia frequently experience late afternoon agitation, or “sundowning.” Because our residents live in a communal environment, a single individual’s agitation or late-night roaming can create a unit-wide problem for staff and other residents.

Research suggests there may be a solution that involves no medication or side effects. The answer could be the use of light.

According to Mariana Figueiro, Ph.D., professor and Light and Health program director at the Lighting Research Center at Rensselaer Polytechnic Institute, the results of the research on light are “very robust.” As she states in the January 2016 American Psychological Association Monitor, “I have no question that if you deliver the right light in Alzheimer’s patients, you improve their behavior; you will improve agitation; they will sleep better.”

Reduced ability to process light

Our bodies receive light via three different types of photoreceptors, the Monitor article explains, and it stimulates the brain in various ways to regulate sleep. As we age, the ability to process this light diminishes. In combination with age-related changes in the circadian rhythms that regulate sleep/wake cycles, reduced production of melatonin which aids slumber, and lifestyle adjustments such as decreased physical activity and exposure to outside light, this contributes to the sleep difficulties of older adults.

Some studies indicate that sleep disturbances have been associated with a buildup of beta-amyloid, a hallmark of Alzheimer’s disease. Researchers speculate that sleep helps to flush toxins such as beta-amyloid out of the brain. By improving the sleep quality of our residents, we therefore may be aiding them in many ways.

Light table

Theorizing that residents with dementia spend a great deal of time sitting around a table, Figueiro created a “light table” using an edge-lit LED television for the surface. This allows staff and residents to interact normally while receiving the appropriate amount of bluish white illumination. Her studies show a significant improvement in the quality of sleep of participants and a significant reduction in depression and agitation. Both of the latter held up fours weeks after the light source was removed.

For the entire article, visit:

Using light to improve sleep, reduce agitation

See video above or click here: http://wnyt.com/article/stories/s3920645.shtml

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

‘Honest’ placebos help without side-effects, expense

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

‘Honest’ placebos help without side-effects, expense

Older residents frequently enter long-term care with multiple medications prescribed for their varying health conditions. In fact, it’s the polypharmacy itself that can bring them to our doors due to harmful medication interactions and symptoms such as dizziness that lead to falls, hospitalizations and the need for increased care.

In long-term care, geriatricians often work to reduce the number of medications their patients receive. A 2011 review in the journal Gerontology suggests that the use of a placebo may be a worthwhile tool in this effort.

Typical purpose of placebos

A placebo is often thought of as a harmless substance used as a control in research to determine the effect of actual medications. In order to be proven effective, the experimental medication must be significantly more beneficial to subjects than the placebo because simply receiving a pill is found to have beneficial effects.

In other words, medical conditions can improve just by thinking that the pill one is taking is going to help, even if it has no medical properties. (This is why I like to read the copy on, say, a bottle of hair conditioner — to enhance its psychological effects … I’m only half-kidding.)

Atypical use of placebos

The studies reviewed in the 2011 Gerontology article consider the placebo not as a control condition but as a substance worthy of study in and of itself, investigating factors that influence its level of effectiveness.

They examined the use of placebos as an analgesic, to address anxiety and depression and for Parkinson’s disease and consistently found a significant reduction in symptoms — especially when paired with verbal suggestions that the placebo will be successful.

‘Honest’ placebos

In Jo Marchant’s “A Placebo Treatment for Pain” in the New York Times this month, she writes of a 2014 study that found that a placebo was 60% as effective as a pain pill. What’s more, when the actual pain medication was labeled “placebo,” it reached 60% of its usual effectiveness.

Even more remarkably, these results held up when the placebo was honestly labeled as such. Despite knowing that the pill they were taking was a placebo it was still half as effective as the pain medication.

(I find this mind power incredible, so much so I almost ended each of the sentences in this section with an exclamation point!)

Application to seniors

For the entire article, visit:

‘Honest’ placebos help without side-effects, expense