Seeing the ‘invisible patient’ in LTC

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

Seeing the ‘invisible patient’ in LTC

Jane Gross’ recent post Seeing the ‘Invisible Patient’ in the “New Old Age” blog of the New York Times discusses how professionals often ignore the needs of caregivers of the elderly because they are focused on their identified patient. As the author states, “Not once in the years I cared for my mother did any of her physicians ask me how I was doing.”

While the article centers on the burdens of caregivers in the community, it got me thinking about whether we’re meeting the needs of families whose loved ones are in long-term care.

What are the burdens of family members in LTC?

Some families have been down a long road of illness with their loved one and are physically and emotionally depleted. Others have had the shock of a sudden shift in the condition of their relative and have been swiftly thrust into the world of LTC. Virtually all of the families are coming into a system that’s new for them and they could use our help in successfully navigating this change.

Benefits to the facility

Addressing the needs of family members can:

• Increase the likelihood of families making positive contributions to the lives of the residents, which is good for the residents and reduces the workload of the staff. If families are purchasing clothes, for example, that’s one less task for staff members.

• Improve satisfaction with our services and increase the chances that they’ll recommend our facility to others.

• Provide a benefit that appeals to the adult children decision-makers and makes our organization more competitive.

Below are some ways to creatively and inexpensively attend to the needs of families:

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Seeing the ‘invisible patient’ in LTC

10 reasons I’m thankful to work in LTC

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

10 reasons I’m thankful to work in LTC

Every year as Thanksgiving approaches, I take a special moment for gratitude and to reflect on the many blessings of my life. I owe a lot of them to working in long-term care, and my LTC career is a blessing in itself.

1. I get the chance to learn from experience — other people’s experience. Talking to elders gives me insight about what leads to happiness and what doesn’t. I’d like to think this has spared me a few mistakes along the road.
2. LTC has improved my perspective. On days when I feel the weight of too many tasks to accomplish, I remember how lucky I am to be physically capable of taking care of my responsibilities. This allows me to focus on constructing a life I’ll be able to look back on with satisfaction when I’m 85 years old.

3. I’m told regularly how much I’m appreciated. Residents express their gratitude for my assistance in various ways. It could be a beaming smile at my approach, finding out from a family member that I’m talked about all the time, or a warm comment like, “I don’t know what I’d do without you.” It’s a good reason to get to work every day.

4. Little things make people so happy. Cleaning off a pair of smudged eyeglasses or changing a clock battery can turn me into a hero. It’s really easy and feels really good.

For the entire article, visit:

10 reasons I’m thankful to work in LTC

Working on how to communicate in facilities (McKnight’s LTC News)

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

Working on how to communicate in facilities

Poor communication and coordination between staff members contribute to medication errors and adverse events. These problems are more likely to occur during a transition of care from one setting to another.

AMDA, The Society for Post-Acute and Long-Term Care Medicine, working with the National Transitions of Care Coalition (NTOCC), recently released its free Transitions in Care in the Long-Term Care Continuum guideline. The goal of the document is to identify areas where problems in transitions occur and to offer methods to avoid these common errors.

Reading through the guideline got me thinking about the in-house communication glitches I’ve noticed in my role as a psychologist. While we clearly need to address communication and coordination between settings, we also can look within our own facilities to see if there are areas where communication could be improved.

Below are examples of problems I’ve observed in some high-quality facilities. (Imagine how much better the care would be if these problems were addressed!) While I mentioned my concerns to the relevant staff members, interdepartmental communication issues can sometimes fall into that gray area between job descriptions and don’t always receive the attention they deserve.

• Each floor of one facility had a notebook where staff members could leave messages for the social worker. Except that the social workers never looked at those notebooks. New staff members would leave notes in there until they learned it was pointless. But nobody took the notebooks away.

• There are communication books for the attending physicians at most nursing stations, but the doctors vary in their diligence about looking at the information. Sometimes I’d check the log to see the status of something I’d previously reported and see that nothing had been checked off in the book for a month or even several months. While very urgent information should be reported directly to the charge nurse, many staff members don’t have the training to know what’s urgent.

• Along those lines, I once mentioned to a charge nurse that I wrote a note in the communication book and she said, “Oh, Dr. Smith never looks in there. If you have something important to tell him, you let me know and I’ll write it on a sticky note and tell him when he comes in.” She pointed to the ledge of the desk filled with scrawled memos. Things I pondered: What if the sticky note loses its “stick,” falls to the floor, and is swept up by the porter? Who else is leaving notes in the logbook without realizing they’re never seen? What if the nurse is off from work on the day the physician comes in? The nurse retired shortly thereafter. I wonder what they’re doing now.

For the entire article, visit:

Working on how to communicate in facilities

The White House Conference on Aging: Why it should matter to you (McKnight’s LTC News)

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

The White House Conference on Aging: Why it should matter to you

If you, like me, completely missed the 2005 White House Conference on Aging (or if you weren’t in the field at the time), you may be wondering what the WHCOA is, what it does, and how one can get involved. Below, I share the answers to my own questions under the theory that I can’t possibly be the only one who doesn’t know enough about the conference.

What it is

The White House Conference on Aging is a once-a-decade national conversation about the needs of our aging population. The goal, according to the WHCOA website, is “to identify and advance actions to improve the quality of life of older Americans.” The first WHCOA was held in 1961, with subsequent conferences in 1971, 1981, 1995, and 2005. As indicated on the conference’s website, the 2015 conference takes place during a year that marks the 50th anniversary of Medicare, Medicaid and the Older Americans Act, as well as the 80th anniversary of Social Security.

The 2015 WHCOA agenda

Next year’s conference will focus on four main areas:

• Retirement security

• Long-term services and supports that allow elders to remain in the community

• Healthy aging

• Preventing financial exploitation, abuse and neglect of elders (elder justice)

What it does

For a positive view of the conference, Anne Montgomery’s article for the National Academy of Social Insurance points out concrete actions taken as a result of previous conferences.

According to Montgomery, the 1961 conference led to the development of 50 State Units on Aging as part of the Older Americans Act; the 1971 WHCOA resulted in the creation of the Supplemental Social Insurance program and establishing the National Institute on Aging within the National Institutes of Health; the 1995 WHCOA lead to the National Family Caregiver Support Program; and the 2005 WHCOA “provided momentum for reauthorizing the Older Americans Act in 2006, which strengthened the role of Aging Disability Resource Centers.”

Delegates to past conferences commented on her article, stating that the WHCOAs have been crucial in identifying problems and their solutions.

No stranger to controversy

For the entire article, visit:

The White House Conference on Aging: Why it should matter to you

Dear Diary, Last week I attended my first AHCA convention … (McKnight’s LTC News)

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

Dear Diary, Last week I attended my first AHCA convention …

There’s nothing like the first time you get to meet people, attend education sessions and see the exhibit hall at the American Health Care Association, as I found out last week.

10/5/14, 2 p.m. — I just arrived in D.C. on the Bolt Bus. $40 round-trip from New York City. You can’t beat it with a stick. Now I have to get over to my hotel room and get ready to meet McKnight’s Editor Jim Berklan.

9:30 p.m. — Just came back from dinner with McKnight’s staff members Jim Berklan, John O’Connor, and Tim Mullaney. Really nice guys, really into long-term care. It made me proud to be part of McKnight’s.

10/6/14, 3 a.m. – I can’t sleep.

3:30 a.m. — I just downloaded the AHCA app. Very handy how I can see what programs are available and send them to my calendar.

6 a.m. — Time to get up and get ready for the convention!

8 a.m. — I’m sitting in the session led by Denise Boudreau-Scott, MHA, LNHA, on “Creating the Ultimate Customer Service Experience.” I can download her slides from the app!

9 a.m. — The talk confirmed my perceptions around customer service. I ran into an administrator I used to work with who said how hard it was to create the “ultimate customer service experience.” He should have asked me. I had plenty of suggestions for him. Instead I said, “Mmmm,” the classic noncommittal psychologist response. I’ll bet a lot of shrinks working in long-term care have great ideas for their facilities.

11:30 a.m. — Just heard General Colin Powell speak! He was witty, self-deprecating, on topic, and pointed in his criticism of current Washington politics. I’m very impressed.

1:30 p.m. — I’m in the expo hall now and OMG!!! I’m so excited. I finally got the chance to ride in a patient care lift after years of wanting to try one. (Thanks, ArjoHuntleigh staff.) Now I see what my residents have been talking about. A newer lift has a better angle than an earlier model and almost swaddles the rider, creating a sense of security lacking in the traditional device. Plus, it allows a person to be weighed in the lift instead of having to be transferred to the scale. Of course it costs more. But it seems worth it in terms of customer experience and staff time and effort saved in the weighing process.

For the entire article, visit:

Dear Diary, Last week I attended my first AHCA convention …

Creative activities for residents with dementia (McKnight’s LTC News)

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

Creative activities for residents with dementia

Greetings from Montana! I was in Billings last week conducting a training session for the Montana Department of Health. An enthusiastic group of over 100 LTC staff members from various departments joined the discussion and I came away with some excellent suggestions on how to engage residents with dementia.

The subject of how to best provide care for people with dementia without using antipsychotic medications was a particularly hot one at the conference. As well it should have been.

The topic is particularly timely given that CMS has increased its antipsychotic reduction goal from 15% (below 2011 levels) this year to 25% next year and 30% below for 2016. As G. Allen Power, MD, pointed out in his recent McKnight’s article, antipsychotic medication reduction should be preceded by educating staff members about alternatives to medication.

One important alternative is offering activities that enrich the lives of people with dementia so that they’re engaged in positive pursuits that build on remaining strengths.

Many participants in the Montana training were from the recreation/activities/life enrichment departments and they shared some great ideas they’ve successfully used to engage residents with dementia. These include:

• Off-campus trips to a variety of locations, including many of the scenic outdoor attractions in Montana. “A lot of work, but worth it!”
• A “whack-a-mole” game where residents use water pistols to shoot down plastic cups decorated as moles. A game such as this allows residents to release anger in a healthy, socially acceptable manner. (It was suggested that since I’m from New York City, we use a “whack-a-rat” version, but I think New Yorkers might enjoy “whack-a-pigeon.” Pigeons, or “flying rats,” as some people refer to them, are much more ubiquitous and annoying but get less media attention.)

For the entire article, visit:

Creative activities for residents with dementia

Preventing difficult family situations (McKnight’s LTC News)

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

Preventing difficult family situations

I listened with great interest last week to McKnight’s Fall Expo talk on Pain relief: Dealing with difficult family and resident situations. Attorney Matthew J. Murer provided excellent information on how to work with families to prevent conflicts over treatment and other care issues.

Here, from a psychological perspective, are some additional ideas to prevent or reduce disagreements over care, thereby decreasing the likelihood that the situation will result in legal action.

1. Create systems that easily allow family members to be part of the treatment team.

We collect initial data from families upon admission, but there’s often more family members can and want to add to care.

Staff members may have difficulty adequately involving families because it’s not a fluid part of their workflow. Family members tend to visit in the evenings and weekends when the administrative and day shift workers are no longer in the facility, for example, and care plan meetings are held during working hours when many family members aren’t available.

Inviting relatives to meetings via secure video chat, establishing weekend or evening hours for key personnel such as social workers, and implementing a comprehensive communication system that transmits family information between shifts and departments can help.

In addition, staff members should be trained so that they’re genuinely receptive to information provided by loved ones rather than creating the impression that the family is a nuisance. (I’ve seen this!)

2. Educate families about the illnesses of their loved ones.

Many residents are given diagnoses just prior to or upon admission, but receive little information about their conditions. Similarly, family members often struggle to come to terms with new diagnoses and have many time-consuming questions to ask of staff.

They also may look for health information from less-than-reputable resources. Set up a magazine rack in the lobby with information and resources about common illnesses such as diabetes or stroke and/or add a page to your website with helpful links for families. This meets a genuine need, generates more knowledgeable conversations between families and staff, and helps to create more realistic expectations on the part of families regarding treatment and prognosis.

For the entire article, visit:

Preventing difficult family situations

Reducing antipsych meds: 5 ways psychologists can help (McKnight’s LTC News)

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

Reducing antipsych meds: 5 ways psychologists can help

With the mandate to reduce the use of antipsychotics, many facilities are looking for alternative methods to address the behaviors often associated with dementia. There are several good resources available for training staff (such as the Center for Medicare & Medicaid Services’ Hand in Hand toolkit and the Pioneer Network’s programs).

Within each facility is another good resource — your consulting psychologist. Here’s how psychologists can help:

1. Psychology is all about nonpharmocological alternatives. The most frequent question for any psychologist during their career is, “What’s the difference between a psychologist and a psychiatrist?”

The answer: “Psychiatrists go to med school and prescribe medications to help people feel better. Psychologists go to graduate school to study interpersonal interactions and talk with people to help them feel better.”

The cornerstone of what psychologists do is to look at behavior and find ways to treat people without medication. While psychologists might not be able to use the exact same techniques for those with memory loss, they can offer behavioral insights that aid the team.

2. Psychologists are trained to understand group dynamics. They can support ways in which your treatment teams are working well to help those with dementia and offer alternatives in areas where conflicts arise. For example, if psychologists have observed that mealtimes are stressful for staff and residents, they can offer suggestions that reduce triggers for behaviors on the part of persons with memory loss.

3. As part of their studies, psychologists collect and synthesize data. Combined with their group/team experience, this makes psychologists ideal sleuths to gather information from various team members about particular residents and identify the cause(s) of agitation.

The fact that they don’t necessarily leave at change of shift allows them the opportunity to discuss the cross-shift behaviors of the residents.

For the entire article, visit:

Reducing antipsych meds: 5 ways psychologists can help

Taking vacations when residents can’t do the same (McKnight’s LTC News)

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

Taking vacations when residents can’t do the same

Like many, I’m taking some vacation time during the month of August. It got me thinking about the ways workers interact with residents when they take time off from their jobs. It’s more important than you might first think.

Notifying residents

I know some staff members whose residents are so attached to them and become so anxious at the thought of them being away, the staff members don’t tell them they’re going. This seems to me like passing the buck to the covering coworkers who have to deal with the anxiety of the residents plus their feelings of betrayal that they weren’t informed in advance.

Other staff members don’t seem to think that residents will be missing them, so they don’t prepare them for their absence. As their psychologist, I know that residents acutely miss their regular staff members and really appreciate knowing in advance that they’ll be gone. When you’re not there – especially if you’re a CNA – it’s a generally bad time for your residents unless there’s been some consideration of the personalities of the residents and covering staff members.

Psychotherapist model

In my training as a psychologist, we spent a lot of time talking about leave-taking, vacation coverage, and termination of therapy. The gist of it is preparing patients for the vacation in advance, talking about who will be there in the therapist’s absence, and ways patients can cope on their own.

I think that’s a good model to follow in most cases in LTC. It’s respectful to let the residents know you’ll be away and to tell them who’s covering or who might be good to ask for help while you’re gone.

Anxious residents

I once treated a very attached, emotionally fragile resident whom I knew would be panicky about my two-week absence, which we discussed at length prior to my departure. Before I left, I gave her a sheet of paper on which I’d written down the dates I’d be away, the names of staff members she could talk to if she needed help, and healthy activities she could engage in such as journaling or talking to a friend. At the top of the paper I wrote in big letters, “I will return on September 14^th.” When she saw that, she laughed with relief.

For the entire article, visit:

Taking vacations when residents can’t do the same

The psychology of falls in long-term care (McKnight’s LTC News)

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

The Psychology of Falls in LTC

According to the American Geriatrics Society, one in three adults over the age of 65 falls each year. Falls represent the leading cause of fatal and nonfatal injuries among older adults. You might be surprised to hear some of the contributing factors of falls and the psychology behind them. I also have advice on ways residents and staff can reduce the likelihood of falls.

Factors associated with falling
Falls are caused by many different influences, often in combination. Some common elements (1) include:

• Medication — the major contributors are psychotropics (especially benzodiazepines, antidepressants, and antipsychotics), medications that reduce blood pressure and anticonvulsants
• Polypharmacy — one study found a 14% increase in fall risk with the addition of each medication beyond a four-medication regime, regardless of the group of drugs studied
• Orthostatic hypotension — researchers noted a 69% increased risk of having an injurious fall during the first 45 days following antihypertensive treatment
• Alcohol abuse
• Diabetes mellitus
• Confusion and cognitive impairment
• Gait and balance disorders
• Muscle weakness
• Poor vision
• Urinary incontinence
• Inappropriate footwear
• Environmental factors including home hazards

Impact of falls for residents
Falls can have a huge effect on the quality of life of our elders, who may have diminished mobility following an injurious fall. One-third of those who have fallen develop a fear of falling again and often reduce their activities in order to decrease the likelihood of similar mishaps. For those who have fallen in a facility, staff may limit the resident’s activities. Restricted activities, whether self-imposed or enforced by others, can contribute to depression. As noted above however, prescribing anti-depressants can increase the risk of future falls.

Concealed falls
Due to fear that their independence will be limited, some elders may hide the fact they’ve fallen. Residents have confessed past falls to me in their psychotherapy sessions, saying they were afraid they’d be forced into a wheelchair if anyone knew, or that they wouldn’t be allowed to go home after rehab. Psychotherapy might focus on the toll of untreated injuries due to silence following a harmful fall, whether or not returning home is realistic, or on ways to safely manage the activity that led to the fall.

(1) http://www.patient.co.uk/doctor/prevention-of-falls-in-the-elderly-pro

For the entire article, visit:

The Psychology of Falls in LTC