By Claire Lucas / Posted on October 17th, 2017
Many traditional nursing homes are scrambling to meet the new person-centered regulatory standards; however, it is business as usual for Green House homes. What set’s Green House homes apart is the comprehensive transformation of the homes… physical design, organizational structure and philosophy of care are all changed to reflect elder-directed care. The three Core Values: Real Home, Empowered Staff & Meaningful life provide a guidepost for establishing operational practices.
CMS is placing a larger focus on use of non-pharmalogical interventions and staff having appropriate competencies and skills. Appropriate treatment and services for Elders living with dementia is also emphasized in the new regulations.
A key element of The Green House model is the use of specially trained versatile workers, whose responsibilities include food preparation and service, activities, light housekeeping, and laundry. The versatile workers are called Shahbaz, and are Certified Nursing Assistants who receive an additional 128 hours of education which encompasses all elements of their work including infection control procedures, culinary skills, dementia, communication skills and activities. Not only are staffed provided the training they need, but consistent staffing allows for Shahbazim to get to know their Elders, establish strong bonds of friendship. Being well-known supports allows for non-pharmalogical interventions to be effective.
Residents Rights has become the largest section in the new CMS regulations.
Shahbazim understand that one of their fundamental roles is to nurture, sustain and protect the Elders in their care. Elders are in control, driving decisions in the home from menu choices to daily activities. Staff learn about how to provide Meaningful Life to elders in their care, including honoring their natural rhythms. Elders can sleep in and go to bed when they wish.
New regulations set new standards for care planning.
Elders can decide who attends and now must participate in setting goals. A nurse aide and a member of food services staff are required to attend care plan meetings. Again, this has always been part of the Green House model. Shahbazim lead the care plan meetings. Because they are consistently assigned to work in one home, they know their Elders well. Staff are coached on how to respect Elder’s wishes, while informing them of risks and benefits of proposed care. Ultimately, the Elder decides.
Grievances must be acted on quickly by staff and recommendations from Elders must now be considered. In a Green House home staff are talking to Elders daily, hearing their concerns and following up on their issues in “real time.”
Shahbazim are empowered and therefore can often make immediate changes to address Elder’s concerns, eliminating the need to go through a long chain of command to have issues heard and changes made.
CMS has put more emphasis on creating a “homelike” environment.
Green House takes it to another level providing “real home.” Every elder has a private bathroom and their own bathroom/shower. Elders can personalize their bedrooms, bringing in many items from home.
Meaningful Engagement is now a greater focus of new regulations.
Elders must be provided with a choice of activities that encourage both independence and interaction with the community. Activities in a Green House home include a combination of planned and spontaneous events, with a majority of activity occurring naturally and recorded as appropriate. Although the full-time activities director will act in a facilitative role, providing assessment and evaluation of activity preferences and individual engagement, assistance with activity programming, coaching and teaching; versatile workers within each home will have primary responsibility for leading meaningful and engaging activities on a daily basis. While anticipated activities can be scheduled, the spontaneity fostered in a Green House home means not all activities can be planned. Some programs will occur naturally, such as folding laundry, a family visit, or assisting with the day’s meal.
The Green House team is proud of the work of our adopters and the strides we have made to lead the field, creating better lives and better jobs.
By Rachel Scher McLean / Posted on April 7th, 2017
As thought leaders Green House adopters lead the way by supporting, and deeply knowing each individual living in their homes. With the introduction of new CMS regulations comes the opportunity for Green House homes to demonstrate how the model is designed to ensure each elder is able to live on his/her own terms. “Language and being focused on the elder vs. the disease, makes a difference. At The Green House Cottages of Carmel, we developed our policies and procedures prior to these new regulations, and it felt great to see that what we knew in our hearts to be right, was reflected in government mandates.” said Melody DeCollo, Guide of The Green House homes of Carmel, in Indiana.
The Green House Project invited, Carmen Bowman, a nationally recognized expert in all things regulatory and culture change to facilitate two webinars exclusively for The Green House Peer Network about the new CMS regulations. In these webinars, Carmen highlighted where, specifically, the new regulations support The Green House Core Values, and how Green House adopters can leverage them to even more fully realize the benefits of the model. Says Carmen, “There is power in the institution to shut people down, and there is power in the home to bring people back to life.”
There were many areas to highlight, but here are a few of the hot topics:
Language – Words Matter! Where are the opportunities for Green House adopters to utilize language that is more person-centered and less institutional?
- Community (or home) vs Facility
- Individual vs Resident/Patient
- Real Home vs Homelike
- Meaningful Engagement vs Activities
- Approaches vs Interventions
Proactive Approach- How can we learn to be ‘preventionists’ and align with an elder’s natural rhythms, patterns and preferences to meet their needs before an issue escalates?
Daily Community Meetings – How does The Green House model support teams to approach issues in real time to emulate the concept of daily community meetings? Where are the opportunities to involve/engage elders in decision making
Care Planning – What are Green House adopters doing to ensure Shahbazim (direct care staff), elder, and family voices are heard in care plan meetings? How can we intentionally gain the rich information that yields deep, knowing relationships?
Highest practicable level of well-being – By intentionally focusing on the physical, social and mental wellness of the person, it expands and elevates the experience. What do individuals need to thrive?
Creating Real Home and Personal Belongings – “We really want to know who you are, so please bring in things that are special to you to decorate our home”. WHO is doing WHAT to ensure elder’s personal belongings are brought into the home/their room?
Meaningful Engagements – Take a moment and consider, is it real life, or fake life? Break apart the word to understand… What is meaningful? What is engaging? People want to make a difference, how can we support people to live lives of purpose?
Food and Nutrition – What are Green House homes doing that showcase the power of deep knowing that supports individual preferences? What can we do to expand ‘choice’ and offer it around the clock.
These new regulations were created in response to person-directed care, that means that our work to change the culture of aging is making a difference! We need to keep telling our stories, and letting the world know that aging and long term care can be different. We want to hear from you! If these new regulations are supporting you to shine—email us at firstname.lastname@example.org.
Maggie Calkins, Long Time Friend of The Green House Project, Named Executive Director of Mayer-Rothchild Foundation
By Admin / Posted on July 18th, 2016
The Green House Project would like to congratulate long time friend and collaborator, Maggie Calkins, on her recent appointment as Executive Director of the Mayer-Rothchild Foundation. Calkins has contributed greatly to the field of culture change in long term care, and brings more than 25 years of experience as a researcher, consultant, and educator to the foundation.
Originally established under the will of Hulda B. Rothschild as The Hulda B. & Maurice L. Rothschild Foundation, it was led by Dr. Rob Mayer for 35 years. The name was changed to honor Rob after his death last year, “We will continue to follow Rob’s inspiring approach and work to build networks of communities and organizations to collaborate in both creating incentives and identifying pragmatic solutions to the challenging issues that face our elders today, so that the elders of tomorrow will be able to live deep and meaningful lives” Calkins says.
For the past five years, the foundation has focused on codes, guidelines, regulations, and funding research that needed to be done in order to create better lives for elders and those working closest to them. The Green House Project’s pursuit of real home was furthered by their advocacy with CMS to update fire safety codes and allow for a more residential environment. We are grateful to the work of this foundation, and Maggie’s leadership to further person-centered practices.
By Mary Hopfner-Thomas / Posted on September 15th, 2015
If you thought you would not have enough time to offer your input on the long-term care regulation reform rule you have just been given another 30 days!
The Centers for Medicare & Medicaid Services have extended the comment period until October 14, 2015.
If you are a Green House adopter or an advocate for culture change it’s important we share our vision and core values to change long term care in our country. The last time regulations were written was 1991!
Culture change advocate, Carmen Bowman who was a Colorado state surveyor for nine years and policy analyst with CMS Central Office, strongly urges everyone to make sure their voice is heard on the proposed changes. Carmen, who now is a consultant, trainer, author and owner of Edu-Catering said “As representatives of the culture change movement, what a grand opportunity we all have to encourage CMS to make some changes–to especially look at language.” She went on to say there are many other culture change practices that advocates may want to urge CMS to include in these new regulations.
Let’s make sure our thoughts and concerns are part of the process!
Click here to read more about the announcement
By Meaghan McMahon / Posted on December 9th, 2014
The President and CEO of The American Health Care Association (AHCA), Mark Parkinson, recently released a statement to AHCA members regarding President Obama’s Executive Action on October 6th to improve the Five-Star Rating Program.
As a result of the President’s Executive Action, the Five-Star Program, created by CMS six years ago, will change in two key ways. First, payroll data will be collected in order to improve accuracy of staffing information. Second, the administration has developed three new quality measures that will be added to the nine existing measures: rehospitalizations, discharge back to community and antipsychotic use.
According to Parkinson, “As CMS changes the staffing and quality measures, it will need to create new scoring and therefore, new cut points. This inevitably will impact the staffing scores and quality measure scores for a significant number of providers.” In light of this, AHCA has issued a collective call to action in order to educate providers, legislators and CMS about the potential problems that may result from the Executive Action.
To learn more about the history of the program and AHCA’s call to action, read the full statement here.
By David Farrell / Posted on September 3rd, 2014
It was disheartening to read the NY Times story this week about the CMS 5 Star rating system. Such reporting leaves both the providers and the consumers asking, “If a 5 Star nursing home isn’t a 5 Star nursing home … then does that mean that a 1 Star nursing home isn’t a 1 Star nursing home?” “Hip, hip hooray,” say the 1 Star homes. “I told you that those 5 Star homes weren’t better than us. They just game the system.” Wow!
The article asserts that nursing home leaders game the 5 Star system in two ways – 1) By falsely documenting better clinical outcomes via the Quality Measures; and 2) By staffing up during the survey and then reducing staff after the inspectors are gone. I would like to address both.
Regarding the accusation of gaming the Quality Measures (QMs) – consider that the QMs are calculated from each of the residents’ Minimum Data Set (MDS) assessments. The MDS is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. MDS assessments are required on admission and then periodically throughout their stay. The participants in the assessment process are licensed healthcare professionals including RNs, therapists, dieticians and social workers. MDS assessments are legally signed by these professionals and submitted electronically to CMS. So … are these professionals falsifying the coding of the MDS in order to game the QMs? No way!
Regarding the accusation of staffing up – it may be happening. Let’s start collecting payroll data in order to ensure accurate reporting and that nursing homes are consistently, appropriately staffed.
Another solution is for providers to adopt innovative, evidence-based models like The GREEN HOUSE® model. One of the essential elements of the model is higher direct care staffing than traditional nursing homes. Traditional SNFs average about 2.50 C.N.A. hours per resident, per day (HPPD) compared to Green House homes that average 4.00 HPPD. Green House homes are able to provide this consistent, high level of staffing by utilizing a versatile caregiver service approach. And organizations that follow The Green House staffing and organizational model can deliver high quality care at a cost that is no more than a traditional institutional nursing home.
The elders depicted in the article were in need of short-term rehabilitation with a plan to get back home. Green House homes focused on short-term rehabilitation are achieving great results. Elders rehabilitating in Green House homes experience fewer rehospitalizations and typically get back home 10 days sooner than the elders in traditional, post acute SNFs. The Green House model, with its’ unique approach to care and staffing, plays a key role in these outcomes.
The vast majority of Green House model adopters are 4 and 5 Star nursing homes and they deserve the high ratings. But, if the goal of the Five Star rating system is to guide consumers to the best performing homes, perhaps CMS should add a specific mark of excellence designed to identify providers that have adopted innovative, evidence-based models like The Green House model.
CMS currently cautions consumers to be wary of certain nursing homes that have had consistently low performance via a Special Focus Facility designation next to their name on the CMS site. I’m sure consumers appreciate the chance to steer clear of the lowest performers. Let’s find a better way to direct them to the best.
By Rachel Scher McLean / Posted on August 26th, 2014
Providing pain and symptom management along with religious, spiritual and emotional support can create the conditions for a good death. In order to do this, a deep knowing of the individual is paramount. But too often in skilled nursing settings, this is not the case.
In fact, a recent survey by Centers for Medicare and Medicaid (CMS) has found that traditional nursing homes were lowest ranked for end of life care experience when compared with home care and hospital settings. The survey is a pilot right now but it will be officially launched by CMS in 2015 in an effort to provide better information to elders and their family members about hospice programs in their area.
By David Farrell / Posted on June 11th, 2013
Changing performance metrics can catalyze a dramatic improvement. I recall the story of Walgreens in the book “Good to Great” by Jim Collins. Collins and his research team describe Walgreens as nothing more than a sleepy retail pharmacy chain that limped along for years before a dramatic rise to great results that lasted for over 15 years. The researchers examined what triggered the change and discovered that Walgreens had deviated from the industry norm of measuring their performance. All retail pharmacies, including Walgreens before their rise to greatness, had used one key performance metric to measure their performance – revenue per square foot per store. When Walgreens began measuring their own performance with a new measure – revenue per customer visit – their dramatic acceleration began. Gradually, all other retail pharmacies followed suit and began to use this new performance metric and it changed the retail pharmacy industry forever. The change in this one performance metric led to new systems, improved staffing and re-designed stores. In fact, when Walgreens reset their measure they set a new goal. The goal was $40 per customer visit. My wife consistently exceeds that goal.
In the Skilled Nursing profession, for over 45 years, we have all measured our performance by, generally, a single measure – our annual department of health inspection results. Recently, my Dad shared with me a newspaper article that described 5-Star nursing home closing its’ doors in Massachusetts and the article kind of shook me up. After all, the whole intent of the 5-Star rating system is to drive consumers to the best performing SNFs. So…why do 5-Star homes close and 1-Star homes remain full? Perhaps the 1-star home is actually a better performer than the 5-star home. The answer lies outside of our one key performance measure.
The metrics of SNFs are shifting – and this bodes well for the profession as a whole. Two performance measures are taking hold that will surely help to separate the star performers from the rest of the pack. The two we are speaking of have been hammered away at the nursing home professionals nationwide – reduce or eliminate the off-label use of antipsychotics and reduce the avoidable re-hospitalizations. Just like Walgreens, the improvements in these two measures will require improving the systems of care, enhanced staff composition and competence, and changing the physical environment of SNFs.
Reducing or eliminating the off-label use of anti-psychotics triggers providers to get serious about delivering person-centered care. Organizations will need to reduce their C.N.A. to resident ratios and de-institutionalize their physical environments (and we are not talking about simply new wallpaper). Enhancing the competence of the entire staff through a significant increase in education hours that are focused on caring for those living with dementia will be foundational to their success.
Reducing re-hospitalization rates leads SNF leader’s to raise the bar on increasing clinical competence and adding talented and compassionate RNs to their staff. Also, this new measure forces leaders’ to re-examine their turnover rates and absenteeism because staff instability does not allow for consistent assignment and diminishes communication. Clearly, the health of the relationships among the staff of each SNF is reflected in their re-hospitalization rate. Therefore, better systems of communication and new job descriptions are needed to strengthen staff relationships. Today, many providers can see that their current physical environment – an average of 85 elders living together in tight quarters, shared rooms, shared bathrooms, shared shower rooms – is perfectly designed to spread infections among the elders and staff. Private rooms with private baths and showers for each elder will become the new norm. A smaller and better designed environment is critical to both clinical outcomes and a dignified quality of life.
Of course, a SNF’s performance on their annual department of health inspections is important and always will be. It has to remain a key measure with the other 5-Star metrics. Examined next to a SNF’s performance on these two measures will provide consumers, operators, surveyors and policy makers a way to more clearly identify where elders should flock to for their care.
Notes from The Green House Director: Achieving the Triple Aim of Long Term Care: Quality, Health, Affordability
By David Farrell / Posted on March 22nd, 2013
Recently, I was honored to speak at the Michigan LANE (Local Area Network for Excellence) conference in East Lansing that was attended by close to 300 dedicated leaders of skilled nursing facilities. It was there that I was reminded of the Centers for Medicare and Medicaid Services (CMS) Triple Aim –
1.) Improve the persons’ experience of care – both quality and satisfaction
2.) Improve the health of people and the community’s health
3.) Reduce the cost and wasteful spending
I feel confident that The Green House Model addresses all three of these goals. And we have a significant amount of independent research to support this feeling. Thanks to the support of The Robert Wood Johnson Foundation, The Weinberg Foundation and AARP, model is spreading and Green Houses nationwide have the outcomes that hit these marks and outpace traditional SNF’s.
After the LANE event, I stayed in Michigan and I saw an excellent example of how visionary leaders in Michigan collaborated in order to hit the CMS Triple Aim while helping to revitalize downtown Detroit. I had the opportunity to tour the new Rivertown Neighborhood, an affordable senior community that will provide over 770 seniors access to desperately needed housing and supportive services. The grand opening is April 12th.
Presbyterian Villages of Michigan (PVM), in collaboration with Henry Ford Health System and United Methodist Retirement Communities, have creatively adapted an old dilapidated pharmacy plant and expanded The Center for Senior Independence (CSI) program (nationally recognized as PACE). Two Green Houses serving 20 – 24 elders will be an integral part of the Rivertown Neighborhood.
At the end of the tour, Roger Myers, the President and CEO of PVM, and his incredible team of partners, brought us into bottom floor of a cold, open space of a four-story brick building attached to the beautifully renovated building. None of the floors were in the building so that you could look up to the ceiling that was 4 stories up. This is where a huge vat of cough syrup used to brew and this is where the two Green Houses will sit on two floors above a café.
The Rivertown Neighborhood demonstrates how we can tackle complex social factors that effect elders’ heath and their well-being. Over 200 employees (and Shahbazim) at Rivertown will address the social determinants of health, and the healthcare, of hundreds of the community’s seniors every day. In so doing, they will give peace-of-mind to thousands of the elders’ family and friends. Its’ an exciting project and am thrilled the Green House Project is a part of it.
By Carmen Bowman / Posted on October 15th, 2012
Drs. Judah Ronch, Dean of the Erickson School of Aging, and Dr. William Thomas, founder of the Eden Alternative and Green House Project, have coined a new term and developed a new concept called surplus safety. Instead of risk meaning the possibility that only something bad might happen, they teach that the real definition of risk is the possibility of an unanticipated outcome. They further explain that there are two kinds of risk, upside and downside. Downside risk is an outcome that is worse than expected and upside risk is an outcome that is better than expected. They point out that our obsession with downside risk unfortunately leads to the taking away of any chance of upside risk for those living in long term care environments and that we prevent outcomes better than expected (upside risk) because we our obsessed with minimizing the risk of a worse outcome. Dr. Thomas as a physician and Dr. Ronch as a psychologist point out that no other part of the human life cycle allows this removal of upside risk. For instance, we do not restrain toddlers as they try to learn to walk because they might fall. Not too many people talk about our development and growth at an older age but thankfully they do. Each advocate that our human development includes a balance of both upside risk and down side risk.
The current landscape of safety where the current conception of risk includes only downside risk – in which harm may come to elders if they attempt certain activities such as getting out of bed – has resulted in very restrictive policies and practices, such as bed and chair alarms. Many safety measures, such as alarms, are designed with only downside risk management in mind i.e. preventing falls. However, the upside risk of preserving one’s ability to continue walking and to keep their balance and strength are not evaluated. Nor is the other downside risk of losing these abilities talked about. Nor is the quality of life considered according to the person of being immobilized by an alarm or agitated or isolated. Therefore, there is a strong need to look at upside risk management in addition to the traditional focus of managing downside risk.
Thus the first-ever Surplus Safety Symposium was held on September 12 – 13, 2012 in Baltimore, MD. Many thanks to the Hulda B. and Maurice L. Rothschild Foundation for funding and to the Erickson School for hosting this event.
Approximately 50 stakeholders from a diverse group of constituencies discussed the current state of the safety landscape. Experts addressed the areas of: Policy as Written and Interpreted; Risk Assessment Methodologies; Case Law; Management and Workforce Conditions; and Resident Perspective presenting key issues and identifying levers of change. Workgroups then recommended ways to implement a strategy to change how risk is perceived, understood, managed and regulated.
The goals for the two-day symposium were to:
1. Identify strategies to promote a full evaluation of risk vs. potential outcomes in long term care.
2. Reframe the current concept of safety to better balance both upside and downside risk potential.
3. Identify codes and standards which should be addressed in order to better balance upside and downside risk.
4. Identify stakeholder groups to enlist in seeking necessary code and standard changes.
Some ideas collected (not consensus) were the following:
• Consider using probability instead of potential for harm in the CMS scope and severity grid; gather the research to back the use of probability of harm instead of potential which can be anything.
• Consider adding to every regulation “if the resident desires” or “according to the resident;” for example, Tag F363 Menus be followed if the resident desires.
• Discontinue making policies for the 1%, make the policies for the 99%. Broad global policies limit life for the 99%, individualize polices by stating that individual care plans will be adapted for each person in relationship to risk, safety, etc.
• Copy the CMS survey process for homecare where whatever provider has done is recognized and considered into survey findings.
• Incentivize like Colorado P4P bonus reimbursement and Ohio Medicaid Reimbursement where homes must implement a subset of person-directed practices in order to receive full reimbursement.
• Include each person’s goals for themselves and their perspective on risk. This should be individualized based on how much risk they want/can tolerate. Kind of like investing in 401K plans, some of us prefer low risk, others moderate or high risk. Risk needs to be determined by the Elder primarily, and not by surveyors, corporate leaders or other professionals who assign this determination based upon what they think is best for all parties involved.
• Concept of safety is one dimensional regarding the body. Need to add mind/spirit, psychosocial.
• Immediate Jeopardy includes potential for harm which is so very easy to cite, easier to cite IJ than a G. This needs to change because it has the greatest sanction associated with it – possibly move potential for harm somewhere lower down on the grid.
• Equitable attention to all relevant regulations; treat all requirements the same. Preventing accidents is just as important as resident has the right to refuse medical treatment or right to choice.
• Eliminate FOSS/federal surveys as they are over burdensome and do not result in better care for residents; redirect those resources to training of how culture change practices embody intent of OBRA ’87 Nursing Home Reform Law and current regulations.
• Explore legal strategies to promote resident choice and consistent enforcement of all regulations.
• Recognition that accidents happen – differentiate between accident and neglect/systems failure.
• Reconsider the current metrics for success and incentives: do we incentivize surplus safety or highest practicable physical, mental and psychosocial well-being?
• Research the benefits to upside risk.
As you can see, many good ideas on how to eliminate surplus safety were collected. According to Rob Mayer of the Hulda B. and Maurice L. Rothschild Foundation, this is just the start. Be on the alert for more to come. In the meanwhile, do whatever you can to promote the balance in every person’s life of both upside and downside risk. Better yet, do all you can to promote that the person continues to be the boss of their life. Promote this daily with persons you serve. Call for meetings with your survey agency that is to serve the persons living in nursing homes and assisted livings in your state. Lean on your state culture change coalition to bring up these issues in already-established stakeholder meetings. Don’t wait for someone else to do something. See what you can make happen. Go get famous. Eden has a great motto: “It’s Time.” Actually, it’s past time. We all want better.
Carmen Bowman, Regulator turned Educator, owner Edu-Catering: Catering Education for Compliance and Culture Change and Facilitator of the 2012 Surplus Safety Symposium
By Dklein / Posted on March 30th, 2012
Recently, CMS announced important life safety regulatory changes that will support the creation of home in long-term care settings. All of these changes have been approved by the National Fire Protection Association (NFPA) and are effective immediately. It is important to note that elder/resident safety and quality of life were held as top priorities throughout the process of revising the regulations. Among the changes are:
• Allowing open kitchens
• Allowing permanent seating groupings in corridors
• Allowing gas fireplaces in common areas
• Increasing the amount of wall space that may be covered by decorations
These changes are the result of three years of collaborative work by a taskforce known as the National Long-Term Care Life Safety Taskforce organized by The Pioneer Network. The taskforce consisted of individuals representing CMS, state survey agencies, provider associations, architects, researchers, culture change and life safety code experts.
The Green House Project was represented on the Taskforce by Robert Jenkens, Director. The stated goal of the group was to remove “unintended barriers to quality of life” found in the NFPA 101 Life Safety Code which is the standard used by CMS to regulate long-term care settings. These barriers came in the form of regulations that prevent the design of homes for elders/residents in certain ways that honor human needs, culture and preferences. Designing homes for the people who will live in them is a philosophy that is fundamental to The Green House model’s foundational principle of “creating home”.
What is “creating home”?
Creating home is a key culture change principle which holds as a top priority that long-term care environments must be viewed first as homes for the people who live in them. This contrasts the traditional medical model philosophy which held that long-term care settings were to be designed for the efficient delivery of care with little regard for the humanity and individuality of those who live and work there.
Better for everyone
These recent improvements to life safety code will better equip long-term care providers to successfully create home for the elders/residents they care for. While the new regulations are less prescriptive and more flexible, they do not compromise safety. Having increased flexibility to create homes that honor individuality, culture and meaningful engagement equips providers with the ability to accomplish more for the hard work they do and improve the quality of live for elders/residents in the process.