Green House Blog

Innovations and Trends in Elder Care

Lisa McCracken, Ziegler

In the first of our four-part “Making the Business Case for Culture Change” series, Lisa McCracken, Director of Senior Living Research & Development at Ziegler shares an overview of key trends and innovations in elder care. Ziegler is one of the nation’s leading underwriters in financing for not-for-profit senior living providers and works with merger and acquisition activity in the private sector. As the Director of Senior Living Research & Development, Lisa conducts market research and trend analysis and contributes to educational articles and white papers on key industry topics.

Rising demographic changes are driving evolution and innovation in senior living organizations. Specifically, there are two key stakeholder groups providers need to target when thinking about their market audience, the baby boomers and millennials. As roughly 10,000 baby boomers turn 65 each day, the aging services spectrum enters a large period of scale. We now see a trend in non-traditional healthcare players entering the industry as they discover their unique role in solutions around aging, from technology to transportation. Senior living providers will need to adapt and evolve to meet the new preferences and characteristics of the baby boomer generation to connect with the new older adult. Specifically, Lisa discusses language changes, wellness initiatives, resident engagement and support services, and community life. As a major part of the workforce of the future, millennials have new values regarding recruitment, retention, and employee engagement. Lisa encourages providers to be “thinking smart” about attracting millennials into our field, particularly when competing with other industries. Four out of the six top projected in-demand occupations fall in our field, creating a growing number of professional opportunities for this rising workforce (Personal Care Aide, Registered Nurse, Home Health Aide, and Certified Nursing Assistant). Lisa shares labor challenges many organizations face and presents best practices to overcome workforce barriers to attract and retain great talent.

How is senior living changing and growing? There are significant differences between not-for-profit and for-profit growth and development. In the not-for-profit sector, organizations are focused on expanding and renovating current communities rather than building new locations to adapt to the changing demographic. Not-for-profit providers are also focused on repositioning their skilled nursing neighborhoods away from the institutional model and reinvesting in real home environments, such as The Green House model to support organizational culture change and provide elder-centered care. In the for-profit sector, Ziegler is seeing a growing number of new communities, particularly in the Assisted Living and Memory Care space across the country. However, in both sectors, there is a growing number of sponsorship transitions and mergers and acquisitions because of several factors, including the increased complexity of healthcare reform and organizational leadership turnover.

In our dynamic environment, Lisa provides an overview of the pressures many providers are facing, particularly in the post-acute rehab space. Decreased length of stay, higher acuity levels, narrowing hospital networks, and an increasing number of treatment plans that skip skilled care entirely place high pressures on skilled nursing providers as occupancy trends decline. Lastly, as we look toward the future, we see new technology entrepreneurs continue to emerge providing innovative solutions that are paving the future of resident care, organizational staffing, caregiver communication, and family engagement.

To listen to the full webinar, please register to receive the recording: https://attendee.gotowebinar.com/register/8988540930301490433

A Person-Centered Approach to Rehab & Recovery

 

Reposted from The Pioneer Network Newsletter

 

 

Lisa Milliken serves as the Director of Education for Select Rehab, where she researches evidence based practices and develops continuing education courses on current hot topics for therapeutic intervention in the post-acute setting. Her goal is to assist this field in the prevention of unnecessary re-hospitalizations and to help therapists deliver the highest level of rehab practices for the most optimal clinical outcomes. 

 

 

“If my therapist asks me to do something that makes sense to help me achieve I want to do, then I would be motivated to do it. It would make sense to me. But how is this bicycle thing going to help me work in my garden or wash my clothes? That doesn’t make sense, so why should I have to do them?”

These are often the thoughts of residents in a community’s rehab department who are there to regain a prior function. I’m reminded of a story shared by a colleague about one man (Tom) who was in short-term rehab following his stroke. His goal was to regain function of his left arm and leg to go home and resume work on his farm. Initially Tom did not like doing the same old exercises, which were assigned to him by the physical therapist to improve his leg strength. And he surely didn’t enjoy the tabletop pegboard and exercise putty his occupational therapist gave him to work on. His comment to all of this was, “This is ridiculous, why I am doing this?” So they stopped and asked “What would you like to be able to do again?” To this he responded, “Well, I want to go home and get on my tractor and get back to work!” So the therapist called Tom’s son and they arranged for the tractor to be brought to Tom’s senior rehab community and parked it in the parking lot. Every therapy task from that point included goals to get on and operate the tractor. This meaningful therapy had a purpose and Tom’s progress then increased dramatically.

Each elder’s rehab goal is different. We should not assume that everyone wants to walk 100 feet and improve standing balance to 15 minutes. There may be no meaning or purpose to such goals. But if we ask them, they will often tell us exactly what they want. It may be that they want to sweep their own floors, go get their mail or walk to the living room to visit with other elders by themselves. Or maybe it’s to independently work in the kitchen because they’re a chef and frequently volunteer at a local shelter to help with meals.

A successful meaningful therapy task includes the following components:
• Person-centered and individualized
o Based on preferences
o Meaningful versus rote
o Graded to abilities
• Volume and content are appropriate to skill level
• Therapy and nursing team members’ attitudes are supportive of the elder’s goals

According to a study by Port and others in 2011, we can effectively solicit an elder’s preferences through a series of steps, including the systematic narrative history of activities enjoyed prior to admission and a direct interview of the elder about activity preferences and available choices. We can then identify health-related or contextual obstacles and develop novel interventions to re-engage each elder in their preferred task. Historically, traditional therapy would focus on impairment-based treatment approaches. And components of such approaches may still be necessary and beneficial at specific points of treatment, such as to collect baseline data for range of motion, strength and activity tolerance.

But functional-based treatment approaches should also be included in the elder’s skilled plan of care. Each elder needs to be challenged and tested in functional skills that will be required of him/her in the following skilled rehab, whether that be within a community setting such as a nursing home or assisted living, , or in their own home. This approach prepares the client for the specific activities and skill sets which they will need to attain their optimal level of functioning in any setting, and where possible, to successfully transition and remain in their home without the potential risks.

The recently updated Rules of Participation for Long-Term Care now cites the resident’s preferences as a requirement in many of the codes of federal regulations. For instance, the Resident’s rights section includes this statement:

“A facility must provide a person-appropriate program of activities that should match the skills, abilities, needs and preferences of each resident with the demands of the activity and the characteristics of the physical, social and cultural environments.”

Furthermore, payer sources such as Medicare and various managed care and insurance companies stress the importance of quality outcomes in a timely manner. So it should be of no surprise that our detailed graphs and charts of outcome data per client shows better and faster improvements as a result of the functional based therapy where we focused on the residents’ personal goals.

Such regulatory and outcome requirements further support our priority to first seek the resident’s input regarding their preference and then help them to achieve their unique goals. Whether we’re working to get Tom back on his tractor, helping Louise to return to her kitchen, or supporting the best quality of life possible as defined by each resident in a community, we can cater each therapy session to their unique goals and the result is a win-win for us all.

Behavioral and Psychological Symptoms of Sonya

 

Reposted from, Being Heard: The Voice of A Revisionary Gerontologist

Sonya Barsness is a proud gerontologist with over 20 years of experience. Gerontology is the multidimensional, non-medical, study of aging. This is important because each one of us is multi-dimensional. Aging is multi-dimensional.  Her mission is to help person-centered values come to life in order to better support people in growing older and growing with dementia.

 

 

 

Hi. My name is Sonya and I have behavioral and psychological symptoms of Sonya (BPSS). Yes, it is true. You see, sometimes when I am doing something I don’t want to do, I get agitated. And then there are the times when I am tired or not interested and I have apathy. The other day I was combative when my husband tried to feed me a strawberry and I pushed his hand away (I really do not like being fed by others, although I really like strawberries.). I irritably yelled at my computer for several minutes this morning when I read the headlines. I am anxious any time I have to drive in this heavily congested area. Unfortunately, I also am paranoid. I KNOW that my husband took the car keys and hid them from me.

Maybe you are saying, “Sonya, what are you talking about? BPSS? Why can’t you just say you are angry or anxious? Why the labels? You are so weird.”

Maybe you are also wondering to yourself whether you have some form of BPSS. “I get angry too”, you might be saying to yourself. In fact, you are getting more angry and anxious as you read this. “Sonya, where are you going with this?” you are thinking nervously.

Have you noticed that we take actions of a person with dementia and ab-normalize and medicalize them? I have.

There is a term, called Behavioral and Psychological Symptoms of Dementia (BPSD) that is used to describe the following “symptoms” that occur in people with dementia: agitation, aberrant motor behavior, anxiety, elation, irritability, depression, apathy, disinhibition, delusions, hallucinations, and sleep or appetite changes.

A 2012 study¹ said that 90% of people with dementia have BPSD. Hmm. What percentage of the general population has BPSD? 100%?

I experience these symptoms and as far as I know, I do not have dementia. So, if I have them, and you have them, what are they symptoms of? Maybe of being human? So, because I do not have dementia, they must be Behavioral and Psychological Symptoms of Sonya. And if we are going to describe them that way for people with dementia, it is only fair that I describe them this way for myself.

Note: For the purposes of this article, I will refer to these “symptoms” instead as actions or expressions.

In everyday life we use these terms to describe our actions. They are, for the most part, considered “normal”. Yet, we seem to have a double standard when we are talking about people with dementia.

A person without dementia might be angry because he does not want to wake up. But a person with dementia is agitated when he does not want to wake up.

A person without dementia flirts with the waiter and it is just flirting. A person with dementia flirts with the waiter and she is disinhibited.

I am in no way minimizing the seriousness of these expressions/actions. These expressions are very distressful for both people with dementia and those who care for them. They are very real. But I want to suggest that they are not abnormal. They are human responses.

Being with many people living with dementia, and those who care for them, has taught me that living with dementia is very, very hard. People with dementia are doing the best they can. They are trying their best to make sense of everything and everyone around them. Because they are human, of course they are going to experience the same human emotions as any of us. If not more, because of the challenges of living with dementia. Their actions are expressions. Normal, human expressions to what are often experienced by them as abnormal situations. I have sat with many of these humans, and heard their experiences. They made me change the way I thought about their “behaviors”.

For these reasons, and more, we need to reconsider this term of BPSD. Perhaps more importantly, we need to think about the meaning behind it.

I understand why we use this term. We needed a way of describing some things we were seeing, so we created a term. But there is a danger in this term that is bigger than these words, I am afraid. Because a term is often, if not always, a reflection of a paradigm.

When we define these actions and expressions as symptoms, we do several things:

 

  • When we describe these expressions as symptoms, we medicalize them. We also then frame them as “abnormal”.
  • We are suggesting that the only explanation for them is the underlying medical condition of dementia. Then we are less inclined to try to understand the reasons behind these actions. They are “just what people with dementia do”. When we don’t understand the reasons, or what people are communicating to us through their actions, we are not able to meet their needs.
  • When we medicalize expressions that might be normal for the person and his or her situation, although abnormal to us, we also contribute to a paradigm that sees people with dementia as different than us. Because WE certainly don’t ever have those expressions, but people with dementia do because of their dementia. A very concerning possible consequence of seeing people as different than us, “othering” them, is de-humanizing them.
  • When we frame expressions in medical terms, as a medical problem, the next step is to try to address them with medical solutions. This might mean using antipsychotics unnecessarily.
  • To take this a step further, when we frame these expressions in medical terms, even if we are looking for non-medical ways of addressing them, we still see them as medical problems to be addressed by these “non-pharmacological” solutions. The challenge with this is that we are still limiting ourselves to seeing these expressions through a medical lens, rather than trying to understand what they might mean for that person, and trying to address the underlying reasons behind the expressions, whether they be unmet needs, or emotional distress. Even a non-pharmacological solution can be a band-aid and not address the reason behind a person’s action and what it means.

We are already seeing ramifications of this paradigm in how we view and treat people with dementia. One of these areas is in the use of antipsychotic medications, which are used to address BPSD in people with dementia. A recent report by Human Rights Watch reiterated the overuse of antipsychotics for people with dementia. The article pointed out various possible reasons for overuse. Unfortunately, they are not untrue. Not having enough staff and training to meet the needs of people with dementia is unfortunately real in too many cases. In some cases, these medications are used for convenience. However, in my experience, I think it is more often due to people not knowing how else to respond.

Yet, I think it is something much bigger. It is a reflection of this paradigm of dementia – the story of dementia that we have told ourselves for too long. This is the story that tells us that the way people with dementia act are symptoms or “behaviors”. The story tells us that not only are behaviors bad, they are not normal. Because they are abnormal medical problems, we need to address them with medication.

However, what we are neglecting in this story is this – the way people act, i.e. behaviors, are not abnormal for them. In many cases they are perfectly normal responses to how a person is experiencing the world around him or her. They are an expression of what a person is experiencing, what she or he is telling us, and what needs we might not be meeting for a person.

Yes, it is true that there are changes in the brain that happen as a result of various types of dementia that influence the way a person acts. Parts of the brain that regulate emotions are affected, making it more difficult to control various emotions. There are indeed various part of the brain that cause a person with dementia to see and experience the world differently. So yes, dementia changes the way we might act.

I am also not dismissing the intent behind terminology such as BPSD – to attempt to understand and help people with dementia.

It is for all these reasons that we have to think differently. There is too much at stake, and we want and need to do better for people with dementia.

This term of BPSD can perpetuate a paradigm of dementia that does not honor the human experience of dementia. Who people are as individuals. What they need. What is important to them.

It is time for a new paradigm. One that sees people with dementia as no different than us. That strives to see things from the perspectives of people with dementia so we can find better ways to support them. A paradigm that truly sees people with dementia as whole, not broken. And one part of building a new paradigm is to critically and respectfully question how we are describing and thinking about the way people with dementia act.

Note: I am well aware that I am not alone in this desire to change the paradigm of dementia. I am being heard here, with my own voice, but know that there are many who are in this together. They are people living with dementia, their care partners, and people whose professional lives are dedicated to making life better for people with dementia. I learn from them every day. Rather than speak for all of you, I hope you will chime in, as much more needs to be said.

¹Cerejeira, J., Lagarto, L., & Mukaetova-Ladinska, E. B. (2012). Behavioral and Psychological Symptoms of Dementia. Frontiers in Neurology, 3, 73. http://doi.org/10.3389/fneur.2012.00073

Advances in Person-Centered Dementia Care

In 2001, the Institute on Medicine released a seminal report titled “Crossing the Quality Chasm” that called for a redesign of the nation’s healthcare system and described healthcare in America as impersonal and fragmented (IOM, 2001). The report noted that a critical element needed in redesigning the healthcare system was a shift to person-centered practices. These practices are rooted in humanistic psychology and the work of Carl Rogers and Abraham Maslow among others. Unfortunately, little progress has been made in the past dozen years to transform systems and practices to support person-centered outcomes. Recently, a group of concerned national dementia care experts decided to focus on advancing person-centered values and practices for dementia care.

Several significant events occurred in 2011 that catalyzed the gathering of this group of diverse dementia care experts representing the practice, policy, and research sectors to form consensus on a definition and conceptual framework for person-centered dementia care. This initiative is known as the Dementia Initiative. In early 2011, President Obama signed the National Alzheimer’s Project Act (NAPA) into law. Part of the law mandated the formation of an advisory council to make recommendations to the Secretary of the Department of Health and Human Services on actions to expand and coordinate programs to improve the health outcomes of people who have dementia. NAPA was viewed by many dementia care experts as an opportunity to spotlight and advance the implementation of person-centered dementia care practices. Sadly, NAPA’s primary focus has been on the ‘cure’ aspects of Alzheimer’s disease. The little focus given to dementia ‘care’ has been silent on person-centeredness.

In late 2011, the U.S. Senate Subcommittee on Aging held a hearing focused on the overutilization of antipsychotic medications for nursing home residents with dementia and the need for alternative care strategies other than automatically giving antipsychotic medications for what are perceived as behavioral challenges exhibited by people who have dementia. These behaviors are often expressions of unmet needs such as pain, hunger, thirst, boredom, loneliness, or an underlying medical condition that a person who has dementia is challenged to verbally communicate to a care partner or to address him or herself. Person-centered practices, considered the gold standard by the IOM and the World Health Organization (WHO, 2012), are oriented to the person and thus understanding and addressing the cause of the behavior being expressed.

A person-centered model of care reorients the medical-disease model of care that can be experienced as impersonal and fragmented to one oriented to holistic well-being that encompasses all four human dimensions – bio-psycho-social-spiritual. Person-centered care recognizes this multi-dimensionality dynamic and reorients practices to be delivered in a manner that is positively experienced which, in turn, helps promote holistic well-being.

A recently published article in Health Affairs describes person-centered care from one individual’s experience. While the example describes the experience of someone with a mental illness and not dementia, if a person who has dementia could publish an article in a national publication, they would likely echo this person’s sentiment. Ashley Clayton, a Yale University researcher, suffered for many years in her teens with mental illness. In the article, she describes the care she experienced when hospitalized and how receiving care in a person-centered manner helped her immeasurably. “The nurses got to know me and could support me in ways that were personally meaningful…These might sound like little things – a soda, an art project, a few minutes spent talking…Nothing they did cost extra money or required intensive training, but the fact that they saw me as a person – and treated me like one – helped restore my dignity and sense of personhood” (Clayton, 2013).

The diverse Dementia Initiative experts gathered for a one-day meeting in Washington, DC in June 2012 to form consensus about the definition and conceptual framework of person-centered dementia care. Discussions and email exchanges continued over the course of the next six months. In January 2013 a white paper titled “Dementia Care: The Quality Chasm” that provides the consensus definition and framework for person-centered dementia care was published. The white paper can be accessed online at http://www.ccal.org/national-dementia-initiative/white-paper.

There is no better time for our nation to “cross the quality chasm” for dementia care as NAPA and other national dementia initiatives provide timely pathways to spotlight and transform systems and practices of care to person-centered ones. Successfully evolving to person-centered dementia care practices will require the efforts of all stakeholders including individuals living with early stage dementia, family members and other care partners, healthcare practitioners, long-term care service and support providers, consumer advocates, policy-makers, researchers, funders, regulators, academicians, and scholars among others. The Dementia Initiative white paper provides the blueprint to transform dementia care values, systems and practices in this country to person-centered ones. With 5.4 million Americans living with dementia today and the number projected to increase three-fold by 2050, there is not a moment to lose.

Karen Love is a former speech therapist and long-term care administrator with more than 25 years of experience operationalizing and advancing person-centered practices in all long-term service and support settings. Ms. Love has been co-investigator of numerous research projects to study the effects of and advance knowledge and evidence about person-centered values and practices. Karenlove4@verizon.net

References
Clayton, A. (2013). How ‘person-centered’ care helped guide me toward recovery from mental illness. Health Affairs, 32(2): 622-626.

Institute on Medicine. (2001). Crossing the quality chasm. Washington, DC: Institute on Medicine.

World Health Organization & Alzheimer’s Disease International. (2012). Dementia: A public health priority. United Kingdom: World Health Organization.