Category: Resident care
Posted by Dr. El - November 12, 2018 - Business Strategies, Dementia, McKnight's Long-Term Care News, Motivating staff, Personal Reflections, Resident care
Here’s my latest article on McKnight’s Long-Term Care News:
I headed to the 2018 LeadingAge convention last week looking for a fix of long-term care enthusiasm and that’s exactly what I got.
I met up with old colleagues, put faces to voices I’d spoken to for years and wandered through the expo hall catching snippets of conversations that might be exciting only to long-term care professionals.
PDPM
Armed with a large cup of black coffee, I attended an early morning seminar on the Patient-Directed Payment Model (PDPM), mostly so I’d know what everyone was freaking out about at work. “Are there any payment adjustments for residents with behavioral health problems?” I inquired of the speakers. “No,” came the reply.
Facilities will continue to have to manage residents with anxiety, substance abuse and other difficult and time-consuming behaviors without financial remuneration through PDPM. For those looking for immediate answers, consulting psychologists can be a good resource for staff training and local associations may be able to offer educational sessions on specific topics across facilities.
Team building
I participated in a session offered by Christopher Ridenhour, GFN entitled, “The Other Voice: Race, Class, Culture and the Other ‘Isms’ in Aging Services.”
“And you wonder why we have a staffing crisis,” he said, pointing out, for example, that attendees walking briskly through the conference hall without acknowledging one another were likely to be doing the same thing with their staff members back at home.
Ridenhour emphasized that all workers, regardless of their race, age or any other characteristic, want to be recognized and appreciated.
The session included practice exercises that highlighted commonalities between participants. I left with a new friend with whom I “LinkedIn” the next day. We were born in different countries, work in different LTC roles and have almost a decade between us, but given the directive to “tell each other your life story in thirty seconds,” we found the kind of common ground that any employer would want for their team members.
Montessori for staff
The theme of connection was echoed in a session offered by psychologist Cameron Camp, Ph.D., and his colleagues at the Center for Applied Research in Dementia on teaching Montessori techniques to staff members.
Posted by Dr. El - October 24, 2018 - Business Strategies, Customer service, McKnight's Long-Term Care News, Resident care, Transitions in care
Here’s my latest article on McKnight’s Long-Term Care News:
Long-term care success is about steady, reliable relationships. That’s my takeaway after attending two recent conferences that echo my experiences in the field.
The first event delivered the results thus far of an ongoing program that won a coveted grant from the Center for Medicare & Medicaid Services’ Center for Innovation. The OPTIMISTIC project is an effort of Indiana University and local partners, including the University of Indianapolis Center for Aging and Community. OPTIMISTIC is an acronym for Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care.
The model entails placing registered nurses in nursing facilities, as well as giving staff access to nurse practitioners. The nurses function as educational trainers and as resources for the team.
The consistent relationships with these nursing experts produced astounding results, including a 32.6% reduced relative risk of potentially avoidable hospitalizations and a net savings to Medicare of $3.4 million.
The second conference in which I participated was a National Readmission Collaborative event.
Keynote speaker Eric A. Coleman, M.D., discussed research on phone calls following up with patients after discharge from the hospital. While such contacts have been touted as an effective means of identifying and remedying precursors to hospital readmission, patients are often barraged with contacts from various service providers. These well-intentioned efforts thus become annoyances without real value to the patient and their family.
Having one consistent, informed care manager across the healthcare continuum proves more useful and effective, he reports.
As a psychologist, I’m not at all surprised.
For the entire article, visit:
Posted by Dr. El - October 10, 2018 - Communication, Customer service, McKnight's Long-Term Care News, Personal Reflections, Resident care
Here’s my latest article on McKnight’s Long-Term Care News:
Observing the customary cacophony at the nursing station, I’d estimate that so-called “alarm fatigue” contributes to more than a few tragedies in long-term care.
Here’s one example that resulted in a lawsuit filing after a resident died when nursing staff ignored the alarm signaling that her ventilator had become disconnected.
That’s why I was so interested in a Stat news article “Anatomy of a Beep,” which focused on collaboration between Medtronic, a medical device company, and Yoko K. Sen, an ambient electronic musician. The feature describes how medical devices came to have the sounds that they do — “alarms that are easily confused and difficult to learn and don’t really tell us what’s wrong” — and efforts to create a more helpful and appealing healthcare soundscape.
While the Medtronic project is geared toward a hospital emergency department with its plethora of health monitors, long-term care operators hoping to avoid alarm-fatigue-related medical catastrophes might take note of their efforts.
Among the many sounds typically competing for the attention of nursing home staff members are ringing telephones, television sets, conversations among staff members, overhead pages, elders calling for help, chair alarms, escalating arguments between residents, completed tube-feed nutrition cycle indicators, noisy nebulizers and oxygen concentrators, exit door and elevator warnings, and call bell signals. Specialized units such as ventilator programs will blare additional alerts.
While some employees are fortunate enough to be able to move to a quieter unit to complete their duties, most must contend with a din they have limited power to change. Researchers have found that noisy healthcare environments can significantly increase workers’ level of distress.
Residents, unless they can independently ambulate, have virtually no ability to escape the hubbub, which can border on an abusive level of noise pollution and can negatively affect their perceptions of their stays. In addition, studies have shown that noise can disrupt sleep and increase the likelihood of delirium.
Consider taking a moment to listen to the soundscape of your facility. Stand by the nursing station, close your eyes and imagine that the sounds are the backdrop for your eight-hour workdays, or your life, 24/7.
Below are some adjustments that can enhance the aural environment:
For the entire article, visit:
Posted by Dr. El - September 5, 2018 - Business Strategies, Depression/Mental illness/Substance Abuse, Engaging with families, McKnight's Long-Term Care News, Resident care, Stress/Crisis management
Here’s my latest article on McKnight’s Long-Term Care News:
In most of my long-term care career, I’ve witnessed short-term rehabilitation (STR) residents housed together, but occasionally facilities have scattered them throughout the building. I don’t know the reasoning behind dispersing residents, but from my perspective, dedicated rehab units work better.
My thinking is based on the fact that people entering rehab are almost invariably in the middle of a life crisis (see The stress of nursing home admission) – as are their family members – and that staff members are often stretched to the limits of their capacity to manage their responsibilities.
Keeping rehab residents together is better because:
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STR residents lodged together find a group of peers in the same situation as themselves, which can be enormously reassuring in anxiety-provoking times.
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Co-housing makes it more likely that STR residents will develop stress-reducing friendships and find a team of peers to support their progress in rehab. The ability to form friendships with peers is one of the major strengths and selling points of long-term care.
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Being around LTC residents can be alarming for STR residents, who usually have fears that they’ll “never get out.” Observing others being discharged upon completing rehab can ease their apprehension.
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STR residents, who are frequently younger and more cognitively intact, can feel isolated on LTC floors that have fewer people with whom to engage socially, and none in their particular situation. This increases their depression and anxiety.
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Family members can benefit greatly from talking with other families in similar situations. They’re much more likely to meet other families “in the trenches” on an STR unit. Yes, there are families on the long-term floors, but they’re in marathon mode while STR families are sprinting through a crisis that has reordered their lives.
For the entire article, visit:
Posted by Dr. El - August 28, 2018 - Business Strategies, Communication, Customer service, Engaging with families, Inspiration, McKnight's Long-Term Care News, Motivating staff, Resident care
Here’s my latest article on McKnight’s Long-Term Care News:
The Nursing Home Compare star rating system assesses quality of care based on health inspections, staffing and quality of resident care measures. It examines important factors such as emergency preparedness, resident/staff ratios, re-hospitalization rates, falls and antipsychotic use.
After writing about turnover in my last column, I wondered what might happen if high marks were also awarded to facilities for strong staff retention, which has been positively correlated with better care (in this research, for example). From there, I began to imagine an entire rating system based on my view of long-term care.
I think of nursing homes holistically, as microcosms that thrive when each group of participants is thriving. The three groups in each long-term care world are the residents, staff and families. If these contingents are happy, it’s more likely that there will be filled beds, fewer lawsuits and reduced turnover expenses, consequently making CEOs happy.
The supplemental rating system would be based on quality of life rather than on quality of care and it would examine the quality of life of all the participants.
The ratings would review:
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Staff turnover — To improve retention, facilities would invest in their staff members not just by reviewing their salaries (because nobody goes into direct care for the money), but also by investing in training, onboarding, teamwork, educational reimbursement and other initiatives (such as offering onsite childcare) that make the organization a good place to work over the long haul.
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Resident independence and uniqueness — This facet focuses on how well residents are encouraged and assisted to maintain their interests and connections, reducing depression and creating a more lively, joyful environment. Greater opportunity for resident autonomy would result in decreased “behaviors,” reduced use of medications, improved staff retention, fewer empty beds and positive public relations when skillfully publicized. To accomplish this, therapeutic recreation would be elevated to its proper position as a crucial department charged with designing programs that enhance life for all within the home. A director of volunteers would be hired and supported, psychology services would be well-utilized and the social work department would be staffed in a way that allows social workers to exercise the skills they were trained for rather than being limited to charting admissions and facilitating discharges.
For the entire article, visit:
Posted by Dr. El - July 31, 2018 - Business Strategies, McKnight's Long-Term Care News, Motivating staff, Resident care
Here’s my latest article on McKnight’s Long-Term Care News:
I once rode down a crowded afternoon elevator with the CEO of a managed care company. “It must be 5:01,” he commented wryly. I heard a measure of scorn for his employees’ lack of dedication to the job. What I saw was a group of people fleeing from utterly uninspiring and unappreciated work.
Similarly, in long-term care facilities with high staff turnover, some may see an absence of commitment on the part of workers, while others recognize that there’s something wrong with the job and the way employees are being treated. If workers are fleeing for the private sector, it’s not because they have an intense desire to work at Burger King.
Managers are no doubt familiar with many ramifications of turnover, such as the time and expense of finding and training new hires, the overtime costs for filling in shifts and the need to engage expensive agency workers. It’s also recognized that staff become demoralized in a high-turnover environment and that the quality of care can suffer — two points worth considering in more depth.
When key employees depart — such as nursing supervisors, department heads and nurses — direct care staff may be hesitant to bring problems to new workers just settling in to their jobs. Without the ease that develops between team members over time, important information may not be relayed, glitches in the system aren’t identified and resolved, and problems can fester and multiply.
When staff retention is low, workers become burned out on meeting new team members. They don’t want to put in energy toward welcoming newbies because they know the likelihood is that the individual isn’t going to stick around. This exacerbates the problem because a new worker who doesn’t feel welcomed is less likely to remain with the job.
The impact on residents is profound. Residents are in a vulnerable position, reliant on others for their most personal needs. It’s difficult for them to adjust to being assisted with toileting and bathing by a familiar person, but an unpredictable rotation of strangers who are new to the work adds another level of stress to their lives. For residents with dementia, expect an increase in distress — and the kinds of behaviors that make new hires less likely to remain on the job.
Turnover begets more turnover.
Posted by Dr. El - July 19, 2018 - Depression/Mental illness/Substance Abuse, For Fun, For Recreation Staff, McKnight's Long-Term Care News, Resident care, Stress/Crisis management, Tips for gifts, visits
Here’s my latest article on McKnight’s Long-Term Care News:
“Scream as loud as you can,” I encouraged my companions before we plunged down the waterslide in our rubber raft at the water park on Independence Day. “There aren’t enough opportunities for yelling in everyday life. Let’s make the most of it while it’s socially acceptable.” The shouts of our foursome pierced the air as we flew down the steep slopes and then dissolved into laughter as we splashed to a halt at the bottom of the ride. “That was great!” we all agreed.
Our residents tend to be stressed out. At a minimum, they’ve suffered debilitating and often sudden physical losses, they’re living 24/7 in a communal environment and they have to rely for assistance on helpers they’re sharing with other people. Add to this unfamiliar food, financial stressors, physical separation from their homes and family and worries about the future.
Is there any one of us who wouldn’t be angry about something in that situation? Yet we as organizations strive to have units filled with residents without “behaviors.”
I’m not suggesting nightly “primal scream” sessions, but we could add into the rotation some activities where residents get to be “bad,” or at least aren’t expected to be so darn good all the time.
For example, I used to counsel a 100-year old woman, Claire, whose active life had slowed to a crawl due to age, arthritis and other maladies. She often let out her frustrations by making sarcastic comments to her aides and other residents, which led to conflicts.
To help her blow off steam, as we talked, we slowly set up dominoes in a circuitous row on a table. When the domino chain was completed, I’d give her the signal and she’d gently push the first domino over with one arthritic finger and watch with glee as the whole chain loudly self-destructed. On some days, Claire was particularly “bad” and didn’t wait for the signal. This activity allowed her to be “good” bad and her sarcasm diminished.
For the entire article, visit:
Posted by Dr. El - May 14, 2018 - Customer service, McKnight's Long-Term Care News, Resident care
Here’s my latest article on McKnight’s Long-Term Care News:
You know the scenario: A resident wants to eat donuts, but it will send her blood sugar skyrocketing. The staff members aren’t sure whether to let her indulge as part of person-centered care or to insist on a sugar-free alternative so that they’re not out of compliance with her care plan.
A recent study by Parker et. al examined the staff-perceived conflicts between providing services that are consonant with resident-centered care and those that are in compliance with regulations and the rights of other residents, referred to in their research as “care quality.” They made recommendations based on their findings to ease these conflicts.
The research
They interviewed nursing home staff at 12 different Veterans Administration facilities, including senior leaders, middle managers and direct care staff, asking them questions about care such as, “Is resident-centered care implementation competing with other facility goals?”
All of the nursing homes found some level of conflict between resident-centered care and quality.
The three main areas of divergence were in 1) resident preferences versus medical care, such as issues around dietary compliance, 2) resident preferences and the rights or safety of others, such as someone disrobing in common areas, and 3) “limits on staff ability to respond, related to either time or regulations.”
The first type of conflict was the most common by far, with issues not only around dietary compliance, but also around situations such as when the resident wants to go outside to smoke but weather extremes make it physically unsafe, or residents who are in danger of falling but want to assume the risk and walk unaided.
The second area of friction was related to social or emotional health, such as roommate conflicts. Others related to concerns about physical health, such as when a resident with an infection wants to engage in activities that could put the health of others at risk.
A complicating factor in these instances was the need to explain these situations to family members who might feel that the limits being put on a loved one are not consonant with resident-centered care.
In the third category of conflict, staff members found it difficult to accommodate resident preferences when they were short-staffed, especially at mealtimes when there were multiple demands on their time.
The recommendations
The authors of the study made several recommendations to help minimize these conflicts in the approach to care.
• Determine how each resident feels about the balance of quality of life versus long-term survival. Assess and document the risks involved in their choices and the efforts of team members to mitigate the risks. Helpful tools and examples can be found in this Ideas Institute document, “A Process for Care Planning for Resident Choice.” McKnight’s blogger The Real Nurse Jackie wrote more about the document here.
For the entire article, visit:
Posted by Dr. El - April 27, 2018 - Business Strategies, Customer service, Depression/Mental illness/Substance Abuse, McKnight's Long-Term Care News, Resident care, Role of psychologists, Stress/Crisis management, Transitions in care
Here’s my latest article on McKnight’s Long-Term Care News:
In Editorial Director John O’Connor’s April 16th column, he reported on a study from the Kaiser Family Foundation indicating that increasing numbers of new residents have dementia, are more physically ill and are more likely to be on psychoactive medications.
The study showed that there has been a shift away from long-term services and toward short-term rehab treatment. O’Connor noted the pressure that this puts upon facilities to provide high-quality care in the midst of the churn of residents.
There are many difficulties that can arise from this shift in pace and population, but I’ll focus here on the mental health aspects and their effects on nursing facilities.
One problem that occurs when the length of stay decreases is that the team has a shorter period in which to get to know their residents. They are less likely to notice subtle changes in behavior and mood and they have less time to make the type of personal connection that reassures residents.
Adding to this, the fact that many facilities are operating short of staff in an environment of high employee turnover creates a “perfect storm” of emotional neglect.
Residents enter long-term care facilities in distress. When I adapted the classic Holmes-Rahe Stress Inventory to the circumstances of nursing home admission, I found that residents are experiencing a level of stress considered to be a “life crisis” that puts them at a high risk for further health breakdown. Their families also tend to be in crisis.
Residents and their family members are likely to expect that when they enter long-term care, staff members will provide compassionate medical treatment. Instead, what they frequently find are stressed out nurses and overworked aides who have just enough time to dispense medications or to make up a bed, but none to sit and talk with an understandably anxious resident and their family members about what they can expect regarding their stay and their future.
Social workers — most of whom got into the field in order to provide such counsel — are now buried under a flood of admissions and discharges. They cannot offer emotional sustenance when they need to complete the paperwork on three new admissions and order a walker for the lady whose family wants to take her home tomorrow because her insurance coverage ran out.
It is impossible for direct care staff to provide the same level of service that they did prior to this change in acuity and length of stay. In turn, distress over providing suboptimal care contributes to staff turnover, exacerbating the problem.
For the entire article, visit:
Posted by Dr. El - April 13, 2018 - Business Strategies, Communication, Customer service, End of life, Engaging with families, McKnight's Long-Term Care News, Resident care, Stress/Crisis management, Transitions in care
Here’s my latest article on McKnight’s Long-Term Care News:
In one of the more disturbing encounters I’ve had in long-term care — in a 5-Star deficiency-free nursing home — I offered my condolences to an aide on the loss of a resident she’d cared for over a period of two years.
The aide, a heavyset woman, smiled as she told me that she’d known the resident was dying and had urged the nurse to send her to the hospital quickly. The reason? She didn’t want to wrap the body of the equally heavyset resident after she died.
The resident died among strangers in an ambulance on the way to the hospital.
While I’d like to think the incident was an anomaly, I suspect many if not most nursing homes lack a mission statement for end-of-life care and that most teams can be better prepared for the last months and days of their residents.
Without leadership and training, disorganization and staff priorities can derail the care philosophy of the facility.
Providing decent end-of-life care is more than determining if a resident is DNR or full code. It includes recognizing that someone may be nearing the end of life, referring him or her to hospice while they’re most able to benefit from it, communicating regularly with the resident and their family about their needs, and treating the dying person, their remains and their belongings with respect.
Impact on families
Incidents such as the one above reflect poorly on the organization, even if family members don’t realize that it could have been averted with proper staff training. We often hear how important it is to make a good first impression, but as community institutions relying on reputation and referrals, it’s also essential to make a good last impression.
I’ve heard family members comment that they hadn’t always been pleased with the care at the home but they felt that their mother’s death had been handled with great respect. They left with a feeling of overall satisfaction.
Other families had been reasonably satisfied all along, but departed from the facility in shocked dismay at the end of their parent’s life at the poor communication, insufficient pain management and casual disregard for the belongings of the deceased.
Resident impact
Residents are closely observing how their neighbors’ deaths are handled because they know that this is how they will be treated when their time comes. Based on my experience, the things they find most disturbing are inadequate pain management, unacknowledged deaths and seeing the belongings of their friends removed in clear plastic garbage bags rather than in labeled boxes. They find it most comforting when they see that patients are referred to hospice, surrounded by loved ones, sleeping calmly through the night and when there’s a discussion of the loss among the residents, staff and chaplaincy.
Staff impact
The ways in which facilities handle deaths can have a big impact on staff members as well. As I suggest in “Absenteeism and turnover? Death anxiety could be the cause,” lack of attention to the experience of staff members in handling loss can contribute to employee turnover.
For the entire article, visit:
