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Popular TopicsAltarum Institute Alzheimers assisted living cancer CCAL chemo Commonwealth Fund dement dementia FICO FrontLine Health Affairs health care reform Jackie Pinkowitz Karen Love Larry Minnix Martin Bayne medication compliance medication errors oliver Sachs Oliver Sacks Penny Cook person-centered person-centered care Rhonda Rotterman Richard Leider SNF the power of purpose therapeutic touch University of Buffalo School of Nursing
Jackie Pinkowitz, M.Ed., and Chair of the CCAL, discussed her experience with person-centered care with A Place for Mom, and writes about how utilizing a person-centered approach is changing the senior care industry.
Like many of you, I have been a loving family caregiver for four elder parents, each of whom had individual needs, which changed over time. I spent much time and energy seeking quality options across the spectrum of senior living: from independent living apartments, to assisted living communities, to special Alzheimer’s communities, and finally to long-term skilled nursing facilities.
As Chair of CCAL, I hope that you will adopt a person-centered perspective as you seek senior living options for yourself or your loved ones.
Such a perspective requires an understanding that person-centered care is a holistic approach that focuses on enhancing all the dimensions of one’s health and well-being, which includes:
•Social and emotional wellness
Person-centered living encompasses care, services and meaningful engagement that are planned according to residents’ personal preferences, values and goals. This approach honors each senior’s dignity, choice, self-determination and individuality, which enhances quality of life and quality of care for seniors.
What Person-Centered Care Means for Seniors
From the seniors’ perspective, this type of care includes the following principles and practices:
•“Nothing about me, without me.”
•I have the right to determine how best to meet my needs.
•My care should optimize my physical and psychosocial well-being.
•My care must be nurturing, empowering and respectful.
•It must include me, my family and care team in decision-making.
What Matters Most: Positive Emotional Connections and Experiences
When seniors offer their perspective on quality of care and services, they most often describe how the care or service was experienced by them. Although seniors would probably say, “It’s all about providing positive emotional connections and taking a new view of me,” I believe they are really saying something else. They are saying, “See me for the person I truly am. See me for all the things I believe in, care about, and love to do. Don’t diminish my personhood just because I need some assistance with activities of daily living.”
It’s all about relationships and valuing the uniqueness of each resident.
How Person-Centered Care Affects Memory Care
When applied in memory care settings, all of the above-mentioned values, relationships, experiences and practices are enhancing the lives of individuals with dementia and other cognitive issues.
How person-centered memory care enhances dementia patients’ lives, and how to create a person-centered memory care setting can be found on CCAL’s website.
Person-Center Care Slow to Evolve in the U.S.
In 2001, the Institute of Medicine’s (IOM) report titled “Crossing the Quality Chasm” called for a redesign of our nation’s healthcare system, and described healthcare in America as impersonal and fragmented. The IOM report stated that a critical element needed in the redesign was a shift to a person-centered approach moving away from the traditional clinician/disease centered one.
In the decade following the IOM report, however, little national progress had been made to shift to making person-centeredness the standard of healthcare and long-term services and supports (LTSS). The Affordable Care Act (ACA) of 2010 helps to reinforce the need for change by requiring that services funded by the Centers for Medicare and Medicaid Services be provided in a person-centered manner.
A growing body of empirical evidence indicates that person-centered practices are more pleasant to experience, help to optimize health and well-being outcomes, and result in higher satisfaction.
According to Jason A. Wolf, PhD, and Executive Director of the Beryl Institute, “The healthcare experience… is based on every interaction a patient and/or their family have on the care journey and is ultimately measured by the very perceptions those individuals have of their experience.”
Excerpted from: Dementia Care: The Quality Chasm, K. Love and J. Pinkowitz (eds). Falls Church, VA. National Dementia Initiative, CCAL
Seeking Person-Centered Living Communities
As you visit different communities, I encourage you to spend time at the community and see how comfortable you and your loved ones feel being there. Ask yourselves if you feel the following principles are being practiced:
•Every person is provided a choice, autonomy and independence, and is treated with dignity, respect and privacy.
•Services are provided in a respectful way that also includes their family and larger caregiving and support network.
•People have the right to determine their needs, decide how best to have those needs met, and to be provided a means to give feedback about the quality and nature of the services and supports.
Moving into a new community is a major transition for the prospective resident and your entire family, so I urge you to drop by the community at different times of the day and week. Chat informally with residents and staff. Are they friendly and positive about the community? Look for life enrichment within the community. Does it feel as if they are honoring the residents’ life experiences, choices and routines in the natural rhythms of daily living? These are the person-centered elements that contribute to residents’ and families’ sense of belonging and well-being.
Wishing you much success in seeking person-centered senior living!
It’s rare for me to write a personal article for our newsletter but I want to share a recent experience I had with our health care system. A few weeks ago I started out my morning like many others by going for a run. Before I even took the first bounding step, I twisted my foot (I was looking up at the full moon and was taught once again that I can’t always do two things at once). Luckily I didn’t fall or one of you might have put an alarm on me. Not thinking anything of it, I continued on that run and only hours later did I realize my stupidity as my foot swelled and I became unable to bear weight on it. Normally I try not to access our health care system for myself because of my cynicism and stubbornness but when I couldn’t even walk, it was time. My son drove me to the nearest Urgent Care Center and even as I hobbled in I was dreading it. I thought the wait would be forever, I would just be a number, the doctor wouldn’t really care about me, etc. You know what? It ended up being the two most fun hours of my day. Really! Here’s why.
The first thing they did after asking my name is told me how long I would most likely be there. How respectful of them. Next they asked me if I prefer Penny or Miss Cook. Rarely do I get to make that choice. They even gave me the option of using a wheelchair or not. Not wanting to lose my independence there, I said no. After completing the required paperwork I sat down to wait. But then another pleasant surprise when someone came out to the waiting room and passed around a basket with a variety of snacks. And they left it there so we all had access to food at any time.
I was sure this couldn’t last when I was shown to a typical, sterile examination room but when the nurse came in and asked if she could take my blood pressure and pulse before she even got out the cuff, I knew these people were my kind of folk. It only got better from there. The doctor spent time with me and didn’t even laugh when I told him what I’d done. The x-ray technician asked what I did for a living and when I told him, we bonded over the fact that his first job in high school was in a nursing home. He told me how it totally changed what he thought of nursing homes because people were living vibrantly in small households with lots of choices. Hmm…that’s a little ironic. Come to find out he’s from my old stomping ground in Rochester, New York and worked at the iconic, Fairport Baptist Home, one of the pioneer homes of culture change.
As I got fitted just right for my crutches, I thanked everyone who I met that day. I told them what a pleasure it was to be treated as a person by people who obviously liked to do what they do and work where they work.
My son could only laugh as I gingerly navigated the sidewalk on crutches with a huge smile upon my face. We are changing this institutional world of health care, one small step at a time. If you have your own story about person-centered care, please share it with.
by: Karen Love, Founder & Treasurer CCAL; Principal, Fit Interactive & Pathways to Care
Touch is one of the most basic elements of human development. Since ancient times and throughout the world, people have used touch as a healing technique. The word ‘touch’ is even used in our everyday language to convey a feeling. We say things like “that was so touching” to mean we are emotionally moved by something.
Therapeutic Touch is a term used to describe intentional and compassionate touch. It has the power to ease physical and emotional discomfort and increase feelings of calmness, relation, and a sense of well-being.
Therapeutic Touch uses different hand techniques depending on what part of the body is receiving it. Both hands are lightly and gently placed on various parts of the clothed body for five seconds or more so that the person can feel the warmth from the hands. Therapeutic Touch techniques are simple to learn and easy to use. The more practice one gets, the better their skills become.
Besides the physical benefits to ease stiffness, joint pain, and other physical discomforts, Therapeutic Touch can convey caring, affection, trust and an emotional closeness and connection that is especially important for people who have become socially isolated.
Reiki is a specialized type of healing touch. It is a natural method of hands-on healing that channels Universal life energy by the Reiki practitioner to the receiver’s body so their body can use the energy for healing and restoration of well-being. According to the American Hospital Association, 15% of American hospitals today offer Reiki as part of their services.
I participated in a research study funded under the Alzheimer’s Disease Supportive Services Program by the U.S. Administration on Aging that studied the use of Therapeutic Touch and Reiki by over 200 home care aides in the District of Columbia during 2011 to 2013. One of the findings from the study was the benefits experienced by the practitioners themselves. Applying Therapeutic Touch or Reiki instilled a sense of calming and well-being in them as well. (Click here for a pocket guide about Therapeutic Touch and Reiki.)
I sat in a doctor’s office while the urologist calmly and rationally drew me a picture on exam-table paper of where the cancer was and what we would do about it. I sat calmly listening to him, but I definitely was not rational. I could not think straight.
What he didn’t know was that in those few minutes of our conversation, I had been transformed — from a busy, healthy person to a cancer patient who was about to step into the unknown and perhaps closer to the end of the line. He has no idea what is really going on inside of me, I thought, so how can he take care of me?
When our visit ended he said, “Well, by our age, we all get something. This is yours. Me, I have a bad back.”
But cancer is different. So is every serious illness. Walking back from that visit, I decided I would try to use my experience to show doctors and others what it was like to have cancer and to be a patient. I started by trying to describe how cancer shakes one’s sense of self, and that became the first entry in this journal.
CANCER MADE ME LOSE MY COOL
One thing cancer taught me is that robust health can be deceiving.
I have always thought of myself as fairly cool. I am an active, walking-everywhere, traveling-to-interesting-places, non- (well, almost) TV-watching lady. Then I heard I had cancer — probably treatable, and even better, curable. And now I am none of those other things. I cannot exercise except for some stretches and short walks; my trips are cancelled; all my conversations seem to be about my health or lack of it. Oh, and I watch “Storage Wars” on cable TV, over and over.
I have so much time on my hands that I am boring myself. Even my dogs are finding me less interesting, missing their long walks. I miss laughing.
I used to talk to gym friends about politics, art and going to the ballet. Now I talk to my doctor about going to the bathroom. When he asks, “How are you feeling?” how do I tell him, “Uncool,” and have him realize this is serious?
They are so young, the doctors doing a residency in this specialty. “Where did you go to medical school?” I ask, and I learn they went to Harvard, or Georgetown, or George Washington University, or other satisfactory places. “Well, that’s good,” I say, while thinking, “Who was president when you were born?” Oh, dear.
My friend said I should ask how the bars were around their schools. If they say, “I was too busy studying to find out,” it is good news. I ask this once to a young resident, he replied, and then I tell him why I asked. “You got me,” he said. The bars in LA, he had answered, were just fine.
“No one wants to have an urologist,” I observe to one of the residents. “Most of us want to have a family doctor, lots of us want an obstetrician, a few want a plastic surgeon, but no one wants a urologist, you should know this.”
“But if we need one, we are very glad you are there,” I quickly tell him. “We are glad to hear that this is a special specialty, for the best and brightest.”
I went to confession. I had not gone since before Vatican II, so the timing seemed right. The priest, Father O., new to our parish and wonderful, said God forgives us our sins, but the sacrament of reconciliation celebrates grace and forgiveness. Father O. said he goes twice a year, sins or no.
My penance was an “Our Father,” and he asked if I remembered the Act of Contrition. I did, but it evolved into the Memorarae, “despise not my petition but in thy mercy hear and answer me,” which I have been saying at every stop light.
A lot of nuns are praying for me. According to Jennie, one of my two daughters, her college roommate has all of New Jersey praying for me. My primary care physician is praying for the cells to reverse themselves, and she is a very good prayer. A nun from Syracuse is up for sainthood and needs a miracle to make it all the way, so I have been praying to her. I think I have my bases covered.
In religious circles there is a joke about a man about to drown in a flood. A car comes by, offering to take him to dry land, but he says, “God will provide.” The waters rise to the second floor of his house and a boat comes by, offering to take him to safety. “No,” he says. Then, when the water gets so high he is on his roof, a helicopter tries to save him, but he insists that God will provide. When he drowns and gets to heaven, he asks God why he did not save him, and God says, “I sent a car, a boat and a helicopter.”
I, too, had three chances. When I first saw blood, and going to the bathroom hurt, my doctor said to go to the ER and let’s see if it is an infection, the most common cause. The physician assistant at the hospital gave me a prescription for an antibiotic and said, “See a urologist.” But I got better with the antibiotic, so I followed up with my doctor because a urologist was bound to do something awful to me, and it was probably just an infection.
I looked up “blood in the urine” on the Internet and read, “This must be attended to.”
At a solidarity meeting, Betty said, “I saw a drop a blood, just a drop, found out it was kidney cancer, had surgery and now I am fine.”
I kept treating myself with lots of fluids and asking my physician, often when I was traveling, for a prescription for urinary tract infections. When I mentioned the blood during a physical, I made light of it, slipping it between “I have been eating more vegetables,” and “I think my eyes are getting worse with age.”
I told my GYN that when I got a urinary tract infection, I saw blood, and sometimes after spin class. “At your age, that happens,” she said. “Don’t stop spinning, it is great exercise.”
When I told my boss, a nurse, she asked, “How long have you been treating this as an infection?” When I said two years, she said, “Oh dear.”
I am a nurse too, or at least used to be. I should have warned myself.
HOW I FOUND OUT
I thought I was having lots of urinary tract infections, until we did a culture and no germs were there.
I saw a urologist who said my symptoms were most likely from stress, so I should take a vacation and drink less coffee, but to get a sonogram and “give us a sample to be on the safe side.”
The sonogram showed something was there.
“These tumors are very common,” said the radiologist who looked at the sonogram. “Take it out, get checked every few months for a few years, and you are good to go.”
But there were cancer cells in the sample.
“Get a CAT scan, and schedule surgery to get it out,” said the urologist. “All tumors have some cancer cells, so it could be minimal, but let’s find out.”
I waited two weeks to hear cancer was in the lining of the bladder but not the muscle.
“It could be hiding. I am haunted by the faces of patients who had hiding cells, so let’s dig deeper and biopsy again,” said the urologist.
“OK,” said I, who used to be afraid of anything a urologist might do.
Let’s do it and wait some more.
So how did I get this cancer? I don’t smoke, at least not since everyone did. I don’t drink diet drinks or eat processed foods. I exercise and have a positive outlook on life. I think it is those X-ray machines in airports. I told this theory to my recovery room nurse, who said I shouldn’t blame it on airports. He asked: “Were you ever exposed to well water? It might have had arsenic.”
Now the research is telling us that smoking — ever — seems to be responsible for a lot of bladder cancer. So, maybe, because of bad decisions in my 20s, this was my fault after all.
Between procedures, I went on a short business trip and loved every minute: driving to the airport, getting a newspaper, standing in line to board, finding a nice restaurant. At my meeting, no one looked at me with sad eyes or had any idea of what was going on in my bladder. “How was your trip?” asked daughter Elizabeth. “Wonderful,” I replied, “I felt so normal.”
“Well, you are normal,” she said.
“I sometimes don’t feel normal when I think of what is going on,” I said.
She looked at me and said, “Then don’t think about it!”
So I stopped thinking about it most of the time, and she is right. It helps me feel normal.
I make my doctors cookies. I want them to know that I am not just the 2:15 appointment, but someone. I want them to know I appreciate their gifts but that I have gifts, too, even if it is just mixing butter with sugar and flour and putting it in the oven. I want them to look forward to seeing me and what I bring, to give me full attention. It always worked for subcontractors when we had our house remodeled. I am hoping it works on doctors, too.
WHAT PATIENTS WANT TO KNOW
The cancer center websites tell me a lot: the warning signs, probable causes, cell structure, treatments, percentages. But the National Institutes of Health (NIH), the Cleveland Clinic, Johns Hopkins, Sloan-Kettering, Dana-Farber — they don’t tell me what I really want to know: What will happen next? Will it hurt? Will it work? What then?
My friend Lawrice said I should ask, What am I supposed to be learning from this?
So, OK, what have I learned: I have more friends than I thought and they are better friends than I thought. You cannot do enough sit-ups to protect yourself from cancer. Feeling well does not mean being well.
I wonder if this is what she meant?
“I am really a lifestyle urologist,” says my doctor (something I wish he had told me before operating on me twice), “so I am sending you to two specialists.”
One is an oncologist who specializes in blood and urinary cancer. I am a bit concerned about this because those cancers don’t seem to have much in common, but she did a fellowship at NIH so that is all right.
The other referral is to a urologist who specializes in cancer. I am concerned that is a euphemism for cancer surgeon (which it was), and surgery is not my personal treatment preference. But he was kind and competent. Just what I needed.
A classmate’s husband is a cancer guru and promised to look over my treatment plan. A friend came through with the name of a personal trainer who has recovered from cancer and helps others to do the same. The Cancer Hope Network gave me Zooey and Anne, lovely ladies who have been there, done that, with bladder cancer. I am assembling quite a team.
As a student nurse, a real nurse, as a visitor, I have passed many doors labeled “Oncology” and each time, yes, each time, I have said, “Not me, thank God, this is not for me.” Today it was for me, and I was happy to get the appointment so quickly. The office had dim lights, soft music and there was a waterfall. The oncologist was warm and welcoming and sympathetic. But still it all meant CANCER.
So it is not an infection, not stress, not a benign tumor and not an easy kind of cancer. It is the bad kind of bladder cancer (who knew there was a good kind?). Three doctors explained it to me, and I think I finally get it, although I acted like I did the first time. I say, “Take it out, get rid of it, I hate this troublesome bladder.”
But then I think, maybe if I pray hard enough, a miracle will happen and it will go away by itself. But no, that won’t happen. I need to be optimistic that surgery will go well, and I will soon be better.
So there you have it, all the stages: denial, anger, bargaining and finally acceptance. Guess the books are right.
Trish was in my nursing school class and now does mind/body work. On the phone, she asks, “What is troubling you right now?” I say, “I think of surgery as an assault on my body, a violent act about to happen.”
For 30 minutes, she guided me to realize surgery will be healing, not damaging. “You must talk to your body,” she said. “Tell your circulatory system to get ready, your immune system to stay strong. Tell your urinary system you are sorry it is hurting. Tell them all you will need them to get well, that you love them and that you will all get through this. This works,” she says. And I believe her.
Finish this, finish that. Cancel this meeting, reschedule another. Find a substitute, find a gift to thank substitute. Tell her, her and him. Buy lightweight books and lightweight robes. Change dental appointment. Make list for wonderful sister, Suzy, who will be coming from Wisconsin. Google “gas pains after abdominal surgery,” and buy what is recommended. Get pre-op prep and post-op pain meds. Buy and send birthday presents, order Christmas presents. Pack a bag, repack. Go to church to get blessed. Rest. Reassure everyone. Thank people for praying.
Bladder cancer has become a full-time job.
Here are my goals for surgery:
Don’t get an infection
Stand and walk that night
Walk a lot
Get my digestive system working quickly so I can get home
Leave cancer behind
Here are my observations:
I always thought that ICU nurses cared for machines, not people, but turns out they are the best, most compassionate nurses in the world. I had the same thoughts about operating room nurses, and the best nurse I met was an OR supervisor. She took charge of making sure I did not have pain after surgery. Some things you have to experience to believe.
All the quality policies in the world cannot make a quality hospital. Nurses had policies for doing a nursing assessment on each 12-hour shift, but only one nurse did so. All staff must wash hands entering a room, but only 1 in 3 did. When I asked a nurse to wash her hands, she gave me some look!
Travel and temporary nurses should be banned. They did not know the equipment or the policies. Nurses and aides who worked there the longest were the nicest, most caring, most competent. Longevity matters.
A teaching hospital is full of teaching. My first morning walking, I opened my door to the sight of about a dozen green-clad med students in short white jackets, spilling over the chairs in the chart room like puppies. I thought I was in an episode of “Gray’s Anatomy.”
The residents are so earnest, even when I tried to coax personal information and gossip. One of them, the most solemn, said very matter-of-factly when I had a discouraging moment, “Hey, this is the biggest surgery we do, and you are doing great.” It was the best hug I could have had.
Doctors don’t talk to nurses. These groups are on parallel paths, caring for the same patient. I would say to a resident, “… as I told the nurse, this is happening,” and it would always be news. They work in teams, but doctors and nurses are not on the same team. Makes me wonder what team I am on.
Infections happen, despite all efforts. Five days after discharge, I was in the emergency room for 10 hours, then readmitted to get IV antibiotics.
It takes a village to recover from surgery. Every day in the hospital, I was visited by the residents on my service and a team of pain specialists. My daughter Elizabeth came daily, usually in the evening to play a few hands of gin to help me fall asleep. My wonderful sister Suzy came to take me home, and she never stopped cooking and doing. Her custard was amazing.
Daughter Jennie left her Florida school where she teaches — and her dissertation — to spend a week, ordering clothes and supplies and taking me on walks outside. Home-care nurse won’t quit until I get the hang of self care. Husband stepped up to all the chores. I told friends we did not need meals, but several brought soup, and each bowl was wonderful. I am not used to needing people, but needing I did, and the help was not only welcome and humbling, but healing.
WORDS TO LIVE BY
So many lovely and funny and touching cards and notes have come. But my favorite words came from a catalog: “Life is not about how fast you can run or how high you climb, but how well you BOUNCE.”
I am back in surgical admitting for the fourth time; I am getting a port for easier chemotherapy. I see some familiar faces, including the lovely lady who, my first day, had just graduated from probation to full time and who had taken down my information each time. (Actually she collected the exact same information each time — what are electronic records for?)
Everyone is nice, as always; everyone knows what they are doing; everyone went to good schools (I always ask, and I quiz the radiologist on bars in my hospital’s neighborhood). As I am wheeled into the room, my nurse and I spot a dozen blue-suited young men and women.
“FBI?” I ask the nurse. “No, looks like Secret Service,” he replies. Turns out they are med students interviewing for residencies in radiology. “Good luck,” I say to them.
I had been promised music during the procedure and that it wouldn’t hurt a bit. The music is Bing Crosby Christmas carols, and I tell the radiologist a surgeon would not stand for this. But they were right about it not hurting.
PREPARING FOR CHEMO
Monday is my first day. Daughter Elizabeth is coming with me, and we will be bringing catalogs and an iPad for shopping, because it is “Cyber Monday.” We have done other things to get ready; for example we packed snacks and books and hard candies from sister Suzy, who heard that chemotherapy can leave a bad taste. Elizabeth’s friend, Richard, who is an oncology nurse, gave me Chemotherapy for Dummies, which I have read carefully. I am wearing Betty’s Cancer Survivor bracelet because she is cured and does not need it, and Jennie’s Fighting Bladder Cancer bracelet which has the official bladder cancer colors: marigold, blue and purple. I have asked my sodality to pray that the chemotherapy will be healing, not hurting.
Yesterday we stopped by church to get a blessing for this next stage of the process. Father O. proved to be a powerful advocate with the Almighty before my surgery, so I am sticking with him, and I thanked him with blueberry cookies.
I have been listening to and will bring an imagery/visioning/meditation tape. I decided against the ones with warring themes — little soldiers or motorcycle gangs battling cancer cells — in favor of a tape about a glowing light and being surrounded by loving people from my past and present.
I changed my toothbrush, as you should for any big occasion. I also had my hair done. Looking my best for a new audience seemed the right thing to do.
Yes, I am ready.
ROUND ONE, DAY ONE
Waiting seems to be the permanent speed in oncology. Everyone is gentle, and no one is in a hurry. Good thing I left my type A personality behind months ago. We wait for blood work, then to see the resident, then to see my oncologist,
Blood work shows red cells up, so I can cut back on the iron pills. I am able to advise the resident what to do for her twin boys who are teething. Dr. A-C is informative and caring, and I am glad Elizabeth can meet her. Elizabeth says, “I feel well-informed now.” The doctor writes me a prescription for an antinausea drug that she says I will not need.
Once in the infusion room, sunny and surprisingly cheerful, my chemo nurse explains everything and gives me hand-out information about the drugs and side effects.
“Psst,” says Shirley, my neighbor to the right, “I have found it best not to read those things. They only put ideas in your head.” So I put it all away and start a great mystery novel.
Elizabeth stays for five hours, and we eat our way through the treatment: graham crackers, nuts, turkey sandwiches, soup. We have so much fun talking that we forget to cyber-shop. When it’s time for Elizabeth to get ready for her job, Debbie from my office comes to sit with me, and she swears it is not bringing up past bad memories of her own chemotherapy (which she did without taking a day off). My neighbor to the left shops feverishly on his computer. “Yes!” he yells, “I just got a $185, complete Nerf war game for $56!”
The drugs start. First I get saline for hydration, then two antinausea medicines and a steroid to boost everything, then Drug No. 1 and then No. 2. For each of these big-boy drugs, I listen to my imagery tape and have a vision of being surrounded by friends and family in Cape Cod with a warm light coming from a fountain that flows into every organ, every cell.
I did not know how I would feel: weak, sick? I had told myself, I will feel exactly the same. But what I feel is good. It’s working — all of it, the therapy, imaging, the prayers, the support (I got over a dozen “You go, girl” e-messages during the day), and the belief that all will be well.
There is nothing humorous about chemotherapy’s side effects, but there are some heartwarming signs: Elizabeth brings home a thermometer and saltines. Wonderful sister Suzy researches integrative care solutions and suggests “sea bands” used for sea sickness. Jennie orders them — and everything else Amazon has for nausea. Husband shops for oyster crackers and ginger ale. Lawrice brings chicken soup and good company.
Wonderful brother Peter sends the most unexpected thing: ice cream. I think mint chocolate chip may be chemotherapy’s equivalent of penicillin for strep. Jill, who has had chemo twice, promises to walk me through this, and she promises it will not feel like this every day.
My insurer had a nurse manager call; she mostly talked about herself but distracted me for 15 minutes. And the dogs won’t leave my side, but that might have to do with the oyster crackers I generously hand around to all of us.
My college roommate, Margaret, takes me for my second chemotherapy. She is a labor and delivery nurse; I knew she would be helpful. She gets a phone call right when we reach the treatment room. “Is it OK to use a cell phone here?” she asks the infusion nurse. “Of course,” is the answer. “There are no rules.”
In other words, what happens in oncology, stays in oncology. It’s true. Where in other parts of the department doctors rule, here, (fabulous) nurses rule. An example: Meg, my nurse, hears that I have been feeling like crawling in a hole, and she asks to see what I have been prescribed. She rearranges the order and times of the medicines and says, “I think this will work for you.”
There is a friendliness here you never see on the Metro or at the grocery store. “Your purse is great,” I tell the wife of a chemo neighbor. “$75 Vera Christmas item, my sister got it at an estate sale for $1!” she replies, and we spend 20 happy minutes talking about bargains and how to find them. “Love your dress,” calls a lady who is leaving for the day. “Vermont Country Store,” I shout across the room. “They mostly sell candy and nightgowns, but they have three dresses, and I got all three!”
Around the room, lots of pens and papers come out, since everyone here is looking for advice, any advice.
by: DEBRA WOOD, R.N.
With millions of Americans experiencing dementia and the number growing with an aging population, researchers continue to seek effective prevention and treatment methods, while many long-term care providers are placing more emphasis on how best to care for people with dementia.
“We’re hearing more from families regarding their concerns about the quality of care and services available for their loved ones with dementia, not surprising given the millions of people affected by it and how costly care is,” says Jackie Pinkowitz, M.Ed, chair of CCAL-Advancing Person-Centered, a national advocacy organization, that created the person-centered National Dementia Initiative. Pinkowitz is also an instructor at Rutgers University School of Social Work, Gerontology Program.
The 2013 Alzheimer’s Disease Facts and Figures from the Alzheimer’s Association estimated 5.2 million Americans have Alzheimer’s disease, a number projected to increase to 7.1 million by 2025 and 13.8 million by 2050.
“The best practice is person-centered care,” reports Ruth Drew, director of family and information services at the Alzheimer’s Association in Chicago. “Care is focused on the individual.”
Person-centered care offers a humanistic and holistic approach to caring for someone. It incorporates not only physical considerations but also the person’s psycho-social and spiritual well-being. “It’s a multidimensional framework, and it requires owners and a governance board wanting to make these changes,” says Pinkowitz.
The Dementia Initiative brought together an expert panel to determine best person-centered practices and offer guidance. The initiative produced a consensus white paper, Dementia Care: The Quality Chasm. “We want stakeholders across research, policy and practice to use this paper as a call to action to collectively address and advance person-centered solutions,” Pinkowitz adds. The document presents a history of the philosophy for person-centered care as well as operational and personalized practices for delivering care in this way. It also offers recommendations to address barriers and challenges to care.
Many LeadingAge members have embraced person-centered care and have developed innovative programs to advance dementia care within their organizations.
by: Richard Leider, founder of Inventure – The Purpose Company – Richard is one of the foremost executive coaches in the world. Richard Leider holds a Master’s Degree in Counseling and is a Nationally Certified Master Career Counselor, a Senior Fellow at the University of Minnesota’s Center for Spirituality and Healing, a Carlson Executive Fellow at the University of Minnesota School of Management and a guest lecturer in the Harvard Business School and Duke Corporate Education. Richard is quoted regularly in the Wall Street Journal, The New York Times and USA Today, and on PBS public television, NPR public radio, and other media sources.
by Martin Bayne: Martin has been an assisted living resident for more than 10 years, and credits many of his ideas to his experiences as a Zen Buddhist monk and an MIT scholar. His website is TheVoice0fAgingBoomers.com; his literary journal—showcasing authors ages 60 and older—can be found at TheFeatheredFlounder.com.
Imagine you are 70, your spouse has just died and your children have decided it’s no longer safe or prudent for you to live alone. It’s your worst nightmare—complete with memories of the insecurities and trepidation felt in the first days of school, but this time it’s an assisted living facility, and, like you, the other “kids” are in their 70s, 80s and 90s. For many assisted living residents, the first days and weeks are the most traumatic. Many arrive in a surreal haze; some just days after burying their spouse; others following years of steady losses to a chronic illness like Parkinson’s. And then there are the legions of poor souls with cognitive disorders, who neither understand why they’re sleeping in a different bed nor know who just served them breakfast. And every resident is susceptible to the ambient despair that comes with the recognition of their community’s unprecedented levels of dementia, disability, depression and death.
Rethinking Assisted Living At age 52, I entered an assisted living facility because I had young-onset Parkinson’s disease. But my knowledge and experience of long-term care go beyond living in an assisted living facility. As the publisher from 1993 to 2001 of the website, MrLTC.com, I have had the opportunity to interview Hillary Clinton, Jimmy Carter, Clint Eastwood and a number of other prominent Americans about long-term care.
For many assisted living residents, the first days and weeks of residency are the most traumatic.
After nearly a decade as an assisted living resident, I decided it was time to create the next generation of assisted living communities. I developed a program called Therapeutic Assisted Living, which I believe will change the way Americans think about institutional aging. My vision of Therapeutic Assisted Living is made up of two immutable truths, eight principles and five interventions.
A New Vision: the two immutable truths are that aging and death are natural attributes of being human, and love and compassion are the most powerful forces in the universe. The eight principles of Therapeutic Assisted Living, which originated in my practice as a Zen Buddhist monk, are that with stillness, we lay the foundation; with courage, we move forward—despite our fear; with forgiveness, we discover true freedom; with insight, we accept the change of life’s seasons; with gratitude, we honor our ancestors; with tenderness, we turn the stream of com-passion within; with faith, we learn surrender; with mindfulness, we do just this thing, now.
The five interventions make up a set of instructions, or an operational guide, for a Therapeutic Assisted Living community. First, there should be a Welcoming Committee—each new resident should be greeted by a group of existing residents. The interchange is simple, yet the rewards are often profound for new residents. There should be a Peer Support Group, a weekly, residents-only meeting. This provides a safe, supportive environment for honest exchange between community members on myriad issues. This group is the heart of the community, and its objective—purposeful living—the soul. A Crisis Team, made up of residents, should be available to other residents around the clock. This team is composed of three or four residents who agree to be available at all times for any resident who asks for their help. A Crisis Team member is not a therapist, psychologist or professional healer, but simply some-one willing to listen, comfort and demonstrate compassion to a resident in trauma. To anyone who has ever suffered a panic attack at 3:00am, and just needed a kind and reassuring voice to walk them through the rough spots—not an often-ambivalent ambulance crew or 10 hours in an emergency room—this concept needs no explanation.
Community Volunteering is a key component as volunteering says to the world, “I am worthwhile; a fellow human being with something to offer, regardless of my age.”
A Peer Support Group is the heart of the community, and its objective—purposeful living—the soul.
And finally, there should be Legacy When a resident dies, the community should come together to honor and pay respect to one of their own as the fallen resident embarks on the Great Adventure. Therapeutic Assisted Living says “dying is completely safe,” and if all goes well, the residents can expect to be greeted by another Welcoming Committee, albeit one with a bit more spirit.
By Rhonda Rotterman, Program Director for the UB Inst. for Person-Centered Care, University of Buffalo School of Nursing; and the former executive director for the Western New York Alliance for Person-Centered Care, a grassroots collaborative of communal living environments funded by the Oishei Foundation.
The above quote is the perfect phrase to depict person-centered care and one that holds true despite physical or mental frailty. When we begin to deteriorate, there is one facet that remains intact – our emotions. Our feelings, even if we can’t accurately express them, are always there.(Click for video)
Caregivers often feel helpless about what to do when their loved one is suffering from a cognitive impairment, where the individual is no longer able to navigate their world “normally” or able to communicate the way we do. Usually we perform trial and error responses such as food/hydration, use of the bathroom, rest or activity. When those don’t work and we are out of ideas we often ignore, placate, fabricate tales to deflect whatever they happen to be obsessing about at the time. The problem with that is that we still haven’t solved the root cause of the problem or unmet need they are trying to convey to us.
Think about what makes you who you are: your passions, interests, customary routines, careers and your relationships. If you were to become ill, you still would remain the same person with the same desires and needs. Physically we all need the same things: food/water, shelter, safety and the means to provide these things. Aside from these basic human needs, what sets us apart from one another are our unique skills, interests, personalities, etc. THAT is what makes us who we are and THAT remains throughout our life. Our brains become programmed based on the skills we develop; our interests become habits, our habits become our personalities and our personalities become our uniqueness.
If we are to understand those with dementia, we need to truly know the individual, their uniqueness, what makes them who they are and to be able to tune into their feelings. There is where a higher communication lies. Use your intuition, your gut, and your feelings when the things we view as behaviors are manifesting. If the individual’s brain can no longer communicate in a way we can understand, then we must find a new way to understand.
Everyone, every moment needs to have a sense of purpose. All of us need to live in and through that sense of purpose; otherwise, we are simply passing the time until we die. Relationships contain an element of spirit, mind and body and relationships are the fundamental building blocks of humanizing care.
How often do you take the time to understand the person with dementia, as well as be understood?
by: Anthony Cirillo, FACHE; ABC; Healthcare & Aging Expert; Director CCAL
After watching, for some reason I was not as shocked at what I saw and maybe that is because I have heard about tragic incidents here in the Charlotte area that certainly equal those reported. The most notable was a nursing facility where a resident was locked in a closet for days. No one could find her. When they did she died shortly after at the hospital.
I would hate to think I am numb to the repercussion. But I do think that what one woman said on the special was most telling – if it had been a child care center that caused a death they would have shut it down and sent people to jail.
There is simply no outrage and there needs to be. If we had a culture that truly was concerned about our elders there would be outrage. And culture is at the heart of this. It is a societal culture around aging. And it is also the culture of organizations that set the tone for the care delivered.
The quantity of incidents reported on the special at the largest AL provider might suggest that there is a culture that places more emphasis on money than people. But that is a blanket statement and they are never very accurate. Yet, the tone of the culture is the leading edge for the care that follows. I have reported on companies that I know get it. And it is all about culture.
I do think Emeritus was quick to blame staff error and residents with dementia for why things don’t always go well. When things like this happen, it is the leadership, period, that needs to own up. That is where the tone of the culture is set.
Next topic, transparency. It is all the buzz in the hospital sector and by hook, crook or regulation, SNFs have been dragged into this as well. Here is the thing. Whether regulated or not, you need to own transparency. I am sure you have lost count of the number of sites that rate facilities and progressive companies like Silver Living are upping the ante. Companies that sign on with them embrace a level of transparency until now unseen in the arena.
People will find things out! And if you have the wrong type of culture, employees will leak things out.
Next, I believe that the litigious culture we have in healthcare is causing many of the problems. But having seen this special, it is clear it has to stay in place. There is no other recourse at the moment in assisted living.
So let me end with two things.
All of my hospital, SNF and AL clients hear me harp non-stop on this point. The experience of care is the marketing. Your front line staff is the marketing department. You must make that connection in the organization to see how this all works together.
And speaking now as one human being to another. I am a baby boomer and I want to and am preparing to age in place. From the house retrofit to the technology I need, my wife and I are planning now. Talk privately to any ED whether in a SNF or AL and they will tell you they want to do the same – age in place. No one wants what you offer and in time no one will. The implication is that you need to take a serious look at your business model.
And on an individual level, it means preparing for aging sooner in life – physically, financially , emotionally. I call it educated aging. It is about aging with a quality of life not a crisis at the end of life. This entails a huge amount of self-responsibility in a culture where we have become totally dependent on the healthcare system and the expectation that we can go to pot because there will be a pill, implant, or procedure to fix everything. Come on. Suck it up cupcake.
For now, let’s take a breath. I do not think it can be business as usual in AL after this special. The damage is done. So move on from here. Create the best experiences you can and then tell your story.
P.S. Major kudos for Larry Minnix’s eloquent commentary to this special. There is someone not afraid to say it like it is. I am sure he’ll hear about it too, positively and negatively.
by: Larry Minnix, President & CEO LeadingAge
If you did not see the Frontline exposé about an assisted-living company, it is a must-see for boards of directors, senior management, and staff of our organizations. If you are like me, you will feel powerful, mixed emotions about the Frontline PBS episode. You will feel horrified about the human tragedy that is portrayed.
You will be angry because you know that many people watching — and beyond — will assume that all assisted living is similar to the Frontline depiction. You will feel defensive of good providers who do not deserve to be painted with the same brush that the company in question is painted. You will, initially, be angry with the media for doing a hatchet job that doesn’t portray balance. You also may have the impulse to blame policymakers and regulators for making the services program too complicated or too lax. You may even blame various associations for allowing bad actors to function in the service-delivery world. After all, nursing homes have been under this kind of microscope for years.
Who Is Responsible?
But, who is really responsible for such stories, and what do WE plan to do about it? Here is my take:
The corporate executives interviewed by Frontline blamed residents with Alzheimer’s disease for unpredictable behavior. They blamed staff for being human and making mistakes. They even blamed families for understanding the negotiated risk of putting a loved one in an assisted living facility instead of placement in the “dreaded nursing home.” They blamed everyone but themselves, except for issuing the now common “we’re not a perfect company” message too often used in similar situations of corporate scandal.
But, the thing that made my blood boil the most is that what happened to these residents should not happen to anyone! And no one should be treated the way that these employees were treated! The core failing of a company with multiple problems, violations of state regulations, and lawsuits is a corporate culture based on fundamentally poor values. Laced throughout all of the interviews by former employees and family members was a hidden value of greed over compassion and competence, covered by layers of sweet icing of the trappings of nice facilities.
The Achilles’ heel of assisted living is that those who are in it for the money know how to sell sizzle but offer very little steak. Long-term care leaders have, for years, fretted over this potential. Many of us have complained that assisted living is admitting and keeping residents that they can’t care for. These facilities play on the public psychology that families will gravitate to the nice wall sconces, winding staircases, secure gardens, and public-relations trained admissions staff who know that, as one investor-owned chain marketing person told a friend of mine, “if you get them to cry, you know they will buy.”
Assisted Living Has the Right Ideas
Assisted living is an important program in the buffet of options that should be made available to seniors and their families. It has all the right ideas:
•Familiar and homelike setting.
•A culture of hospitality.
•A program and environment that appeals to the interests and strengths of residents who have impairments.
•A supportive approach to families.
•Flexibility to design services around the needs and interests of residents.
Assisted living has also enjoyed a relatively regulation-free hand to prove that this sector can self-govern using market-based principles without heavy-handed government intervention. LeadingAge, and our colleague associations in collaboration with consumer groups, have worked over a decade to help define standards that could follow in overseeing assisted living at the local level.
Many states have recognized the need for additional standards and training for dementia care, including Illinois, Minnesota, Montana, New York, Oregon and Washington. National groups, such as the Center for Excellence in Assisted Living (CEAL), have been working on best practices in dementia care in assisted living.
Assisted living represents the chance to show that professional and sector self responsibility can be effective — a state of public trust that nursing homes, even with big improvements in quality, do not yet enjoy.
Let us hope that the Frontline exposé has not irreparably derailed that privilege. Unfortunately, regulation is often driven by bad actors who take advantage of the circumstances in which they find themselves. In this case, we cannot let that happen!
So here’s what we need to do…and stand for!
Assisted Living Providers: Make Sure Your House is in Order
First, we need to make sure our house is in order. Take the Frontline video and ask yourself these questions:
•What are our admissions and discharge policies and procedures?
•What are our staffing levels?
•What kind of training and development program do we have for direct-care people?
•What are our quality standards and how do we know we’re achieving them?
•To whom are we accountable for what we deliver, and how does the public know our values and results?
If you find yourself feeling or discussing the tension between filling beds and delivering good quality, you need to have a serious conversation with your board of directors and senior management staff. You should do this because Frontline has exposed that when greed trumps compassion, bad things happen and residents and many others get hurt.
Evaluate Your Culture
Second, evaluate your culture. Indicators of healthy cultures begin with staffing.
Yes, all of our research points to the fact that staffing is the best proxy for quality in nursing homes and assisted living. In fact, the most trusted and supported staff in your organization should be the direct-care people on the night shift between Saturday evening and Sunday morning. Here are some questions to ask:
•When was the last time you checked in with those people to see how things are going?
•When was the last time you made rounds on evenings and nights or weekends?
•Do you have staff satisfaction surveys as well as resident and family satisfaction surveys? Do you act on the results?
•Do you disclose those results to your board and to the public?
•Do you have a culture of ongoing learning opportunities in the arena of contemporary clinical care as well as the often difficult dementia care arena?
Third, do you have a continuous quality improvement program in place beyond the cosmetics of it? Any crafty manager can produce numbers. Not everyone knows how to produce quality and how to measure it.
In less-supervised settings like assisted living, continuous quality improvement is even more critical because of fewer leadership and supervisory people available everyday, 24/7. Does your continuous quality improvement culture include non-punitive, anonymous mechanisms to report incidents or negative dynamics?
Fourth, are you active with policymakers, regulators, and consumer groups to make sure that the proper, transparent public oversight is in place. It is not sufficient to defend what we do, however good we may be.
We must go on offense about constantly improving standards that can be publicly disclosed. Are you advocating for policies in your state that assure disclosure about owners and access to them — even stockholders.
In the not-for-profit sector, ownership accountability is local and transparent. With publicly traded or privately owned organizations, the public often does not know who’s behind the curtain.
Are you advocating for mechanisms that oust ineffective leaders and management — and even governing boards and owners?
We have been working with the Centers for Medicare and Medicaid Services (CMS) on how to deal with chronically bad performing nursing homes. The long-standing tradition has been to punish them, fine the owners, or close them down.
In recent years, we have suggested that punishing residents, families, and employees by closing down a bad actor is punishing the wrong people. Instead, we believe that managers and owners should be relieved of their responsibilities and replaced with competent and compassionate governance and leadership.
You see, the Frontline exposé was not generated by the fault of the disease, the residents and families who cope with it, the employees who try to deliver care in a high-pressure situation, or nosy media or hungry lawyers. No, the Frontline exposé results from a failure of leadership. And, it is our responsibility to advocate for corporate structures that are driven first by quality, which should result in business success whether you are a not-for-profit or a for-profit provider.
In the next few days, the Frontline story will develop broader public-relations legs — or not. It could result in the next OBRA 87 — or the flames could die down quickly. In either case, we cannot treat the Frontline exposé as a temporary public-relations crisis, because we all know that assisted living is an accident waiting to happen if we do not take responsibility aggressively for quality and what should happen to people who don’t produce it.
No one should be subjected to what we saw on Frontline. Quality should be an automatic public expectation. Let’s do something about it. Organizations like the one in the Frontline episode make my blood boil — and they should make your blood boil as well!
But, if we don’t address the underlying issues involved, we will have no one to blame but ourselves