This information was provided in an earlier post, but what I alluded to is SO important, I believe, that I want to share it again -- with a special focus on our many convent retirement settings which, because they are not licensed, do not have the same easy access to information from CMS.
I want to share some information with Sisters and lay person who serve our Sistsers about a marvelous resource, the "Hand in Hand Toolkit". My copy of this resource arrived a couple of weeks ago. After reviewing it, I highly recommend it for use in your retirement setting. Added to this good news is that the resource is FREE to all, available upon request!
The Center for Medicare and Medicaid Services (CMS) has created this training tool that emphasizes person-centered care in the care of persons with dementia. There are six modules, each one hour in length, four of which relate to dementia and caring for residents living with dementia. The two remaining modules deal with the recognition and prevention of abuse.
The Patient Protection and Affordable Care Act (commonly called Obamacare or the federal healthcare law) mandates that licensed nursing homes provide CNAs regular training annually on caring for residents with dementia and on preventing abuse. Licensed or unlicensed, the information contained in this resource is vital information for caregivers and for those who act as family members to our Sisters in the retirement setting.
The two-inch thick manual provides step-by-step guidance (like a teacher’s manual!) for effective presentation of each of the six modules. Suggested teaching materials are also included and can be duplicated for each participant trainee.
There is a very helpful glossary and a rich resource section in the Toolkit.
Karen Schoeneman, a major player in the development of resident-centered regulations at CMS and Dr. Al Power, author of the outstanding book, DEMENTIA BEYOND DRUGS, each give a short audio-visual introduction, and overview on the first of the DVDs included.
This is how you request this FREE, EXCELLENT resource: go to this link:
http://www.cms-handinhandtoolkit.info/Downloads.aspx
(Enter the name of your convent or the name of your retirement center for “facility”.)
I encourage you to forward this letter to any appropriate parties, to request a copy of this valuable resource, and encourage your team in the retirement center to engage in the use of this excellent training. Our elder members as well as our devoted staff will be the beneficiaries.
Wednesday, March 13, 2013
Wednesday, February 20, 2013
I got a letter the other day from the government that I want to share with you.
Now I know that perhaps the cynical among you will think that I’m sending this with a smirk. Actually I’m not. Actually I’m sharing it with the same sense of enthusiasm that I experienced when I read it. The letter came with a resource offered by CMS entitled “Hand in Hand” which is available FREE OF CHARGE to anyone who requests a copy. Information about how to request this excellent resource is included in the letter.
The letter that follows will be of great interest to anyone who works in a retirement setting, licensed or unlicensed, or for anyone who knows someone living in a retirement center, licensed or unlicensed. This is because in reading the letter one sees that the government agency that sets the minimum standards of care in nursing homes, in this letter, makes clear that it is the individual elder who comes first, not the task, not the paperwork, not staff convenience or efficiency. CMS refers to this aspect of standards of care as person – centered care. Note the entire paragraph in which person – centered care is described and defined.
CMS also makes clear that if person – centered care is adopted as a philosophy in a nursing home, organizational changes will be called for. We can’t keep doing the same things the same way and just say we have person – centered care. We can’t keep using the same words and say that we have person – centered care. One word that comes to mind is “compliant.”
The letter is from the Department of Health and Human Services, within the Center for Medicare and Medicaid services (CMS) and I quote it here in its entirety.
Dear Nursing Home Administrator:
Section 6121 of the Affordable Care Act requires the Centers for Medicare and Medicaid Services (CMS) to ensure that nurse aides receive regular training on caring for residents with dementia and on preventing abuse. CMS created Hand in Hand, the training you are receiving today, to address the annual requirement for nurse aide training on these important topics.
Our mission is to provide nursing homes with one option for a high – quality program that emphasizes person – centered care in the care of persons with dementia and the prevention of abuse. The Hand in Hand training materials consist of an orientation guide in six one – hour video – based modules, each of which has a DVD and an accompanying instructor guide.
Person – centered care is an approach to care that focuses on residents as individuals while also emphasizing the role of the caregivers working most closely with them. It involves a continual process of listening, trying new approaches, seeing how they work, and changing routines and organizational approaches in an effort to individualize and de – institutionalize the care environment. Person – centered care is at the heart of the Hand in Hand training.
Consistent staffing, empowering nurse aides, making person – centered care a team commitment, and building relationships, you and your staff will be able to better understand and respond to residents’ needs. These practices may also play a role in preventing abuse by helping caregivers put themselves in the shoes of residents, understand residents’ actions, look at their own actions, and know themselves and their limits.
Implementation
Though Hand in Hand is targeted to nurse aides, it has real value for all nursing home caregivers, administrative staff, and others. For this training to be most effective, it is important to choose a team approach to training. Hand in Hand asks nursing home administrators to educate, empower, and create an environment of person – centered care with an emphasis on a team approach and building relationships.
Person – centered care is about seeing the person first, not as a task to be accomplished or a condition to be managed. It is the fulfillment of the Nursing Home Reform Law (1987) to consider each resident’s individual preferences, needs, strengths, and lifestyle in order to provide the optimum quality of care and quality of life for each person.
While annual training for nurse aides on dementia care and abuse prevention is required in current nursing home regulations, we do not require nursing homes to choose Hand in Hand specifically as a training tool. Many other excellent tools and resources are also available.
Thank you for your commitment to utilizing available materials such as Hand in Hand for the required annual training for nurse aides. We anticipate that these enhanced training programs will enable you to continuously improve dementia care and abuse prevention, as well as resident and caregiver satisfaction in your community.
For information to download the training modules or inquire about replacement copies of the Hand in Hand Toolkit please visit http://www.cms-handinhandtoolkit.info/Index.aspx
Sincerely,
Patrick Conway, M.D., MSc
CMS chief medical officer
Director, CCSQ
http://www.cms-handinhandtoolkit.info/Order.aspx
The letter that follows will be of great interest to anyone who works in a retirement setting, licensed or unlicensed, or for anyone who knows someone living in a retirement center, licensed or unlicensed. This is because in reading the letter one sees that the government agency that sets the minimum standards of care in nursing homes, in this letter, makes clear that it is the individual elder who comes first, not the task, not the paperwork, not staff convenience or efficiency. CMS refers to this aspect of standards of care as person – centered care. Note the entire paragraph in which person – centered care is described and defined.
CMS also makes clear that if person – centered care is adopted as a philosophy in a nursing home, organizational changes will be called for. We can’t keep doing the same things the same way and just say we have person – centered care. We can’t keep using the same words and say that we have person – centered care. One word that comes to mind is “compliant.”
The letter is from the Department of Health and Human Services, within the Center for Medicare and Medicaid services (CMS) and I quote it here in its entirety.
Dear Nursing Home Administrator:
Section 6121 of the Affordable Care Act requires the Centers for Medicare and Medicaid Services (CMS) to ensure that nurse aides receive regular training on caring for residents with dementia and on preventing abuse. CMS created Hand in Hand, the training you are receiving today, to address the annual requirement for nurse aide training on these important topics.
Our mission is to provide nursing homes with one option for a high – quality program that emphasizes person – centered care in the care of persons with dementia and the prevention of abuse. The Hand in Hand training materials consist of an orientation guide in six one – hour video – based modules, each of which has a DVD and an accompanying instructor guide.
Person – centered care is an approach to care that focuses on residents as individuals while also emphasizing the role of the caregivers working most closely with them. It involves a continual process of listening, trying new approaches, seeing how they work, and changing routines and organizational approaches in an effort to individualize and de – institutionalize the care environment. Person – centered care is at the heart of the Hand in Hand training.
Consistent staffing, empowering nurse aides, making person – centered care a team commitment, and building relationships, you and your staff will be able to better understand and respond to residents’ needs. These practices may also play a role in preventing abuse by helping caregivers put themselves in the shoes of residents, understand residents’ actions, look at their own actions, and know themselves and their limits.
Implementation
Though Hand in Hand is targeted to nurse aides, it has real value for all nursing home caregivers, administrative staff, and others. For this training to be most effective, it is important to choose a team approach to training. Hand in Hand asks nursing home administrators to educate, empower, and create an environment of person – centered care with an emphasis on a team approach and building relationships.
Person – centered care is about seeing the person first, not as a task to be accomplished or a condition to be managed. It is the fulfillment of the Nursing Home Reform Law (1987) to consider each resident’s individual preferences, needs, strengths, and lifestyle in order to provide the optimum quality of care and quality of life for each person.
While annual training for nurse aides on dementia care and abuse prevention is required in current nursing home regulations, we do not require nursing homes to choose Hand in Hand specifically as a training tool. Many other excellent tools and resources are also available.
Thank you for your commitment to utilizing available materials such as Hand in Hand for the required annual training for nurse aides. We anticipate that these enhanced training programs will enable you to continuously improve dementia care and abuse prevention, as well as resident and caregiver satisfaction in your community.
For information to download the training modules or inquire about replacement copies of the Hand in Hand Toolkit please visit http://www.cms-handinhandtoolkit.info/Index.aspx
Sincerely,
Patrick Conway, M.D., MSc
CMS chief medical officer
Director, CCSQ
http://www.cms-handinhandtoolkit.info/Order.aspx
Thursday, January 31, 2013
Selling well-being in a pill
The title here is not original. I wish it were! The phrase comes from Al Power, M.D., author of DEMENTIA BEYOND DRUGS. This morning the St. Louis Post-Dispatch carried an article about research being done at St. Louis University (SLU) to study the effects of Ritalin on persons living with Alzheimer’s. I read the article amidst several mental alarms going off.
Source of one alarm: persons living with Alzheimer’s, according to their family members, often display apathy, social withdrawal, loss of enthusiasm and indifference. Alarm: what might be some underlying causes of an apparent emotional change? Other medications? Bcoming depersonalized via an institutional task-oriented nursing home environment? Boredom? Lonliness?The sense of losing one's self in the institution?
Never fear, help is on the way! No need to reflect or investigate external stressors. A pharmaceutical company paid this SLU MD/professor $ 183,540 to see if their product might be just the right intervention, “well-being in a pill.” Oh, another thing, this same company, according to the article paid the professor $28,000 in 2010 to speak to other physicians about its products. Hmmmm.
In his book, Powers points out that all of the research done on the use of antipsychotics for persons living with dementia were funded by --- guess who --- yep, pharmaceutical companies.
Second alarm. This logic is presented by the SLU physician-researcher in this morning’s article: if a person is depressed, s/he is less focused on the environment and therefore at greater risk for falls. So if individuals have “greater energy” they will be more focused on their environment and less likely to fall. Pass the pills!
I wrote to Dr. Power about this article and asked his opinion. He wrote back saying that there has been some benefit in the use of Ritalin for depression, “but it's not well-studied, and it begs the question of whether we just continue to try and sell well-being in a pill.”
Dr. Power has a blog which can be found at www.changinganging.org. In a recent post, Power states succinctly the misplaced role of drugs for persons living with dementia in typical nursing homes. He says this: “The bigger issue is the inability to realize that much distress comes from our institutionalized, dehumanized approach to care for people with dementia. The real problem lies not so much with one particular class of drugs, but rather the idea that ANY pill is the solution to unmet needs or environmental stressors." (Emphasis mine.)
If you have not read DEMENTIA BEYOND DRUGS, you're missing a whole new world of understanding of dementia and a world of hope beyond its too-often-prescribed drugs.
Source of one alarm: persons living with Alzheimer’s, according to their family members, often display apathy, social withdrawal, loss of enthusiasm and indifference. Alarm: what might be some underlying causes of an apparent emotional change? Other medications? Bcoming depersonalized via an institutional task-oriented nursing home environment? Boredom? Lonliness?The sense of losing one's self in the institution?
Never fear, help is on the way! No need to reflect or investigate external stressors. A pharmaceutical company paid this SLU MD/professor $ 183,540 to see if their product might be just the right intervention, “well-being in a pill.” Oh, another thing, this same company, according to the article paid the professor $28,000 in 2010 to speak to other physicians about its products. Hmmmm.
In his book, Powers points out that all of the research done on the use of antipsychotics for persons living with dementia were funded by --- guess who --- yep, pharmaceutical companies.
Second alarm. This logic is presented by the SLU physician-researcher in this morning’s article: if a person is depressed, s/he is less focused on the environment and therefore at greater risk for falls. So if individuals have “greater energy” they will be more focused on their environment and less likely to fall. Pass the pills!
I wrote to Dr. Power about this article and asked his opinion. He wrote back saying that there has been some benefit in the use of Ritalin for depression, “but it's not well-studied, and it begs the question of whether we just continue to try and sell well-being in a pill.”
Dr. Power has a blog which can be found at www.changinganging.org. In a recent post, Power states succinctly the misplaced role of drugs for persons living with dementia in typical nursing homes. He says this: “The bigger issue is the inability to realize that much distress comes from our institutionalized, dehumanized approach to care for people with dementia. The real problem lies not so much with one particular class of drugs, but rather the idea that ANY pill is the solution to unmet needs or environmental stressors." (Emphasis mine.)
If you have not read DEMENTIA BEYOND DRUGS, you're missing a whole new world of understanding of dementia and a world of hope beyond its too-often-prescribed drugs.
Tuesday, January 15, 2013
“If You Change Your Words You Can Change the World” or “Never Say ‘Pet Therapy’”
Imagine you are returning home from a day’s work, from a trip, or from the grocery story. You have a pet at home – a dog we’ll call Lucy. You know what to expect when Lucy sees you: Lucy’s tail begins to wag energetically. She may bound up to you and wants to lick your face. You automatically reach down to pet her, to receive her unconditional love, her pure doggie affection. You automatically smile and even chuckle a little over this creature in your life, this creature who affords such delight by her very being, such company and comfort.
Now step back mentally from this image. Would you use the word “pet therapy” to describe the effect on you of Lucy’s warm greeting and presence? Would you describe Lucy to others as your therapy dog?
What do we mean when we use the word ‘therapy’? A quick Internet search surfaced these definitions.
--“Therapy” the treatment of disease or disorders, as by some remedial, rehabilitating, or curative process: speech therapy.
-- Therapy is the action taken to begin a healing process.
-- Therapy is a session where (sic) a health professional aims to provide remedial or compensatory strategies and treatment to improve a participant’s function or well-being. It may first involve assessment of needs, then planning of goals, treatment and finally, review of progress / success of treatment.
What all the definitions have in common, and what we also instinctively conclude when we hear or use the word ‘therapy’, is that it is an approach to addressing a deficit, a treatment to cure an illness, to bring health in place of a lack of it. It is a medical term.
Many nursing homes and assisted living communities have pets who live in ‘the community, and/or pets that are brought in on occasion. That’s a good thing! What is not so good in the vast majority of these circumstances is that the pets are labeled “therapy dogs” or “therapy cats”.
In these circumstances the ‘therapy dogs’ “help combat loneliness, helplessness and boredom among seniors at nursing care centers by offering sensory stimuli and a way to give and receive affection.” (Source is at link below. Accessed January 15, 2013.)
Is this how you or I view the impact our pets have on us? You get it, don’t you. In such labeling, we are medicalizing a human experience. We are medicalizing the normal human activities of interacting with another creature, a pet. We are also revealing the fact that our view of our residents is not holistic but medical.
In the movement of transformational culture change in which the nursing home moves from INSTITUTION to HOME, pets are seen, experienced and described for the wonderful creatures they are, for the gift they give to all of us. You know, just like you and I experience our pets at HOME.
We make changes in our practices and in our concepts by changing our words. Let’s use words that express what we really intend. The delight, the company, the gift of domesticated animal creatures living in or visiting our home is “pet”. Period.
Read about therapy dogs at
http://wcfcourier.com/lifestyles/resident-therapy-dog-brightens-seniors-days/article_ef0657bf-2ef1-5839-913c-7995251a3f7a.html
Now step back mentally from this image. Would you use the word “pet therapy” to describe the effect on you of Lucy’s warm greeting and presence? Would you describe Lucy to others as your therapy dog?
What do we mean when we use the word ‘therapy’? A quick Internet search surfaced these definitions.
--“Therapy” the treatment of disease or disorders, as by some remedial, rehabilitating, or curative process: speech therapy.
-- Therapy is the action taken to begin a healing process.
-- Therapy is a session where (sic) a health professional aims to provide remedial or compensatory strategies and treatment to improve a participant’s function or well-being. It may first involve assessment of needs, then planning of goals, treatment and finally, review of progress / success of treatment.
What all the definitions have in common, and what we also instinctively conclude when we hear or use the word ‘therapy’, is that it is an approach to addressing a deficit, a treatment to cure an illness, to bring health in place of a lack of it. It is a medical term.
Many nursing homes and assisted living communities have pets who live in ‘the community, and/or pets that are brought in on occasion. That’s a good thing! What is not so good in the vast majority of these circumstances is that the pets are labeled “therapy dogs” or “therapy cats”.
In these circumstances the ‘therapy dogs’ “help combat loneliness, helplessness and boredom among seniors at nursing care centers by offering sensory stimuli and a way to give and receive affection.” (Source is at link below. Accessed January 15, 2013.)
Is this how you or I view the impact our pets have on us? You get it, don’t you. In such labeling, we are medicalizing a human experience. We are medicalizing the normal human activities of interacting with another creature, a pet. We are also revealing the fact that our view of our residents is not holistic but medical.
In the movement of transformational culture change in which the nursing home moves from INSTITUTION to HOME, pets are seen, experienced and described for the wonderful creatures they are, for the gift they give to all of us. You know, just like you and I experience our pets at HOME.
We make changes in our practices and in our concepts by changing our words. Let’s use words that express what we really intend. The delight, the company, the gift of domesticated animal creatures living in or visiting our home is “pet”. Period.
Read about therapy dogs at
http://wcfcourier.com/lifestyles/resident-therapy-dog-brightens-seniors-days/article_ef0657bf-2ef1-5839-913c-7995251a3f7a.html
Monday, December 24, 2012
A Christmas Message
LeadingAge offers a daily news clipping service as one of its membership benefits. So each day I get an e-mail with links to a half dozen or so current news articles that relate to aging and aging services. This morning one of the articles is from an article originally in The Boston Globe, but quoted from the San Francisco Chronicle. The article is about lack of enforcement for inappropriate use of antipsychotics on nursing home residents in Massachusetts, particularly those living with dementia. It's not a happy Christmas Eve message, but one that too often is found in newspaper and journal articles -- reflecting a tragic reality for too many elders in our country.
I quote just one sentence here, but include the link to the article also:
“A few reports detailed cases when residents were so overmedicated
they were unable to open their mouths to eat or do much but sleep.”
Federal and State regulations forbid use of antipsychotics for the “treatment” of “behaviors” for good reason. Such use does not address the issues at hand, does damage to the resident physically and psychologically and is a cruel imposition of “treatment” – fierce and deadly chemical restraints – on helpless individuals. It is abuse clear and simple and must be stopped.
Not a pleasant message to post on Christmas Eve. However I am reminded of Howard Thurman’s message, “The Work of Christmas.” I offer it here. We must do what we can to “heal those broken in spirit” and to “radiate the Light of Christ . . . in all that we do
When the song of the angels is stilled,
when the star in the sky is gone,
when the kings and princes are home,
when the shepherds are back with the flocks,
then the work of Christmas begins:
to find the lost,
to heal those broken in spirit,
to feed the hungry,
to release the oppressed,
to rebuild the nations,
to bring peace among all peoples,
to make a little music with the heart…
And to radiate the Light of Christ,
every day, in every way, in all that we do and in all that we say.
Then the work of Christmas begins.
Newspaper article quoted can be accessed at:
http://www.sfgate.com/news/article/Report-Mass-rarely-nixes-nursing-home-sedatives-4141901.php
Tuesday, December 4, 2012
“Would you give your mother . . . ”
Later today the Missouri Quality Improvement Organization is providing a webinar for those involved in long-term care. The topic is antipsychotic medication use in the elderly. The phrase that I have used as the title of this post heads one of the slides for this presentation and goes on to list the serious negative side effects of all categories of antipsychotics. It’s scary, really to read all the side effects in one place at one sitting.
A few thoughts come to mind about this. When antipsychotics are used to “treat” “behavioral issues” as a result of dementia, the drugs don’t work! The drugs don’t address the “cause” of the “behavior.” So in addition to not working, the resident living with dementia suffers a myriad of negative side effects, not the least of which includes strokes and as much as a 1.7 fold increased mortality.
My second thought: no, I would not give that to my mother. Who would, really, if one is informed about these issues. This surfaces the importance of being fully informed. Within birth families, when a parent begins to show signs of increased frailty or cognitive disabilities, the adult children are often bewildered. It’s all a new experience; they have little or no knowledge of the aging process or of the avenues of appropriate services that can and should be provided. Often times, there is an admission that when the second parent needed more services, the adult children were more knowledgeable and comfortable in providing them or seeing that they were provided. The adult children have through their previous experiences become informed about appropriate issues: aging process, medications or other treatments, and how to make a decision of informed consent in keeping with the wishes of the parent.
And thirdly, for those of us who live in communities of Religious Institutes, we shouldn’t feel so flustered. Seeing our mentors, our congregational giants, and our friends move along this path, it is not so new to us. With our experience, with our growing knowledge of the intricacies of aging, normal or with more chronic disorders, we should be able – in a very informed way – to companion our Sisters wisely, gently, compassionately and competently.
A few thoughts come to mind about this. When antipsychotics are used to “treat” “behavioral issues” as a result of dementia, the drugs don’t work! The drugs don’t address the “cause” of the “behavior.” So in addition to not working, the resident living with dementia suffers a myriad of negative side effects, not the least of which includes strokes and as much as a 1.7 fold increased mortality.
My second thought: no, I would not give that to my mother. Who would, really, if one is informed about these issues. This surfaces the importance of being fully informed. Within birth families, when a parent begins to show signs of increased frailty or cognitive disabilities, the adult children are often bewildered. It’s all a new experience; they have little or no knowledge of the aging process or of the avenues of appropriate services that can and should be provided. Often times, there is an admission that when the second parent needed more services, the adult children were more knowledgeable and comfortable in providing them or seeing that they were provided. The adult children have through their previous experiences become informed about appropriate issues: aging process, medications or other treatments, and how to make a decision of informed consent in keeping with the wishes of the parent.
And thirdly, for those of us who live in communities of Religious Institutes, we shouldn’t feel so flustered. Seeing our mentors, our congregational giants, and our friends move along this path, it is not so new to us. With our experience, with our growing knowledge of the intricacies of aging, normal or with more chronic disorders, we should be able – in a very informed way – to companion our Sisters wisely, gently, compassionately and competently.
Thursday, November 15, 2012
"An Encore Presentation" -- Lee Chung Hi
This entry was posted originally on August 10, 2008. I have put it here 'at the top' of my blog again because the story, told by Steve Shields, is so profound; because the story is so well-written; because the description of "traditional" nursing home care is so heart-breaking when viewed from the humanistic, holistic view of culture change; because the story has such a wonderful, inspiring ending for all of us in service to elders.
--- "In screaming, Lee Chung Hi had used her only tool for hanging on to herself…" ---
This blog entry is longer than most of mine. The sacredness, poignancy and deep symbolism of the story that I excerpt here, however, merits its telling. It's a story of a woman with courage, reaching out in the only way left to her, and of an exceptional leader who trusted his gut instincts about his nursing home which kept telling him: 'It can be better. We must make it better.'
The author of the events recounted in the story that follows is Steve Shields, CEO of Meadowlark Hills, a nursing home, in Manhattan, Kansas that Steve guided from "traditional" nursing home to "home", an ongoing journey. I know Steve. He is an effective, professional executive, a leader with qualities stretching across the four types of leadership: intellectual, reformist, revolutionary and charismatic. (For more information about these types of leadership, see Sister Joan Chittister's address at the 2007 LCWR Assembly when she was presented with the Outstanding Leadership award.) Steve's actions flow from a profound faith and contemplative spirit.
I direct you to the book, quoted here, (co-written with LaVrene Norton another faith-based driven advocate for our frail elders). In Pursuit Of The Sunbeam: A Practical Guide To Transformation From Institution To Household. Published by Action Pact Press, 2006.
FROM CHAPTER ONE: 'The Way It Is."
"She screamed for years but nobody ever really heard it until she stopped. It was a shrill, penetrating, constant and unsettling shriek; a noise not readily identified as human. Words were not part of it. She could not form them. Instead, it was the cry of a trapped and desperate animal hoping someone could hear and understand. The howl haunted the nursing home corridors like a shackled ghost intent on settling its business, belying that the source of the sound was less than five feet tall, not even 90 pounds and unable to walk.
Her Asian skin was healthy and beautiful. The Meadowlark Hill staff moistened it with lotion, turned her at night and positioned her at specified intervals. Lee Chung Hi lived year after year, perched in a reclining Geri-chair. It kept her safe and in place. Her graying black hair was brushed and shining. Vital signs were monitored with regularity and her care-plan was carefully executed. She was bathed on schedule at three 'clock on Tuesday and Friday afternoons. By all valued and applied measures in long-term care, she was well cared for. In the nursing notes, and in the minds of all who cared for her, the never-ending screams were the result of dementia . . . an illness of the mind, which surely must have caused her initial placement. But then nobody remembered for sure.
The other residents were routinely lined up outside the dining room to wait for lunch. Lee Chung Hi ate alone in her chair, parked in the corridor farthest from where people gathered. Nobody – residents, staff or visitor – wanted to be near her. Caregivers attended to her dutifully, yet her noise repelled them. She ate alone, sat alone and slept alone.
She became her noise in the eyes of everyone. But nobody could hear her screaming for what it truly was. It never occurred to us that we might be the cause of it – we, who carry out the biddings of a system lethal to the human spirit.
Years passed before we finally understood it. And not until we transformed Meadowlark Hills into a vibrant household community and witnessed Lee Chun Hi's parallel transformation did we realize how profoundly appropriate her screaming had been in response to the dehumanizing conditions in which she lived."
FROM CHAPTER SIX: "The Essential Elements of the Household Model"
"I rang the doorbell and Susan, a household employee, answered the door and welcomed me in. I saw a warmly furnished living room and an adjacent kitchen and dining room; all appointed like any other home in America. The residents, an average of sixteen per household, had moved in less than two weeks before.
The signs of home were already visible amid what previously had been public corridors, cramped bedrooms and large public gathering rooms. The institutional odor was gone. My stomach growled in response to the smells of breakfast floating from the household kitchen. The previous set of monotonous unit style chairs, tables and other office-like trappings had gone to the auction block to make way for more cozy furnishings.
People were visiting with one another and, in stark contrast to the dismal scene of slumping, slumbering elders once parked at the now-dismantled nurses' station, a more inspiring dance of life unfolded. My heart warmed with hope.
But all the blossoming signs of home faded into the background when my eyes found Lee Chung Hi, the lady who screams. She had abandoned her Geri-chair and was sitting comfortably at the dining table, just as my wife had sat at our kitchen table when I left home for work that morning.
It was the first time I had seen Lee Chung Hi when she wasn't screaming.
She was smiling. Her eyes locked with mine, conveying a warmth of well-being that sent me into a suspended sense of time and place. All I could see was her warm smile and radiating eyes of peace, and I felt myself walking toward her as if in slow motion.
I stopped near her table. With her hands at her side, she bowed her head slowly forward and then back up, all the while continuing her smile. This gesture of greeting and respect, practiced in her culture yet universally understood, enveloped my whole being. I found myself returning the gesture in full communion. I was able to return eye contact and nod in mutual affirmation before emotion overtook me.
Her years of screaming, contrasted with the moment we had just shared, represented to me everything we must leave behind and everything we must achieve. The glaring reality was that she hadn't screamed for years because she was sick, but because we were.
In screaming, Lee Chung Hi had used her only tool for hanging on to herself rather than giving in to vacant slumping. She was a fighter -- a screaming indictment of the traditional nursing home system and proof in the pudding that we can overcome; that we have a moral imperative to do so."
Friday, November 9, 2012
Does Honoring all Creation Include Having Pets Live in our Homes?
Texas LeadingAge has a short article in this Friday’s e-newsletter entitled “Senior Care Center Sees the Power of Pets.” A not-for-profit nursing home in the greater Dallas area is featured. Mary Poole, Director, attests to the physiological and psychological benefits that pets bring to the residents who live in her center. The video is 2 ½ minutes long and is worth watching.
Viewer advisory: there are scenes of residents lined up in chairs totally unengaged, and there are some “slumpers.” Not the reality we want to see in today’s nursing homes. However the scenes with the pets are replete with LIFE!
For those of us who profess a strong adherence to Creation Spirituality, does that conviction extend to four legged furry creatures that bring such life by their very presence?
Granted, any pet living in a more-than-one household must be a good community member. Not every cat or dog is suitable for a nursing home. Personality, temperament and adaptability are important factors. But beyond that, what is the sticking point in so many retirement centers that prohibit the ongoing, in-house presence of pets as part of everyday-life?
Comments anyone? Any great in-house pet stories to share? See "Post a Comment" below.
Here is the link to the video: Senior Care Center Sees the Power of Pets
Viewer advisory: there are scenes of residents lined up in chairs totally unengaged, and there are some “slumpers.” Not the reality we want to see in today’s nursing homes. However the scenes with the pets are replete with LIFE!
For those of us who profess a strong adherence to Creation Spirituality, does that conviction extend to four legged furry creatures that bring such life by their very presence?
Granted, any pet living in a more-than-one household must be a good community member. Not every cat or dog is suitable for a nursing home. Personality, temperament and adaptability are important factors. But beyond that, what is the sticking point in so many retirement centers that prohibit the ongoing, in-house presence of pets as part of everyday-life?
Comments anyone? Any great in-house pet stories to share? See "Post a Comment" below.
Here is the link to the video: Senior Care Center Sees the Power of Pets
Wednesday, October 31, 2012
When an Older Adult is Hospitalized
One journal that I always look forward to receiving in the mail is Caring for the Ages from the American Medical Directors Association. The current issue, October 2012, is chuck full of great articles. I write about only one of them here.
When an elder is hospitalized, there is a high risk for the onset of delirium. Delirium was once perceived as a short-term, transient cognitive disorder. Now there is increasing evidence that delirium carries longer-term effects on cognitive function.
Studies which show such results highlight the importance of “proactive interventions” to prevent delirium and to lessen its impact if and when delirium is diagnosed. One highly recognized program that addresses this very issue is the Hospital Elder Life Program (HELP).
The website for that program is this: http://www.hospitalelderlifeprogram.org/public/public-main.php
I encourage readers to access that website for the valuable resource that it is.
On the left side of the HELP homepage, you will find numerous helpful links. For anyone who is responsible as a family member for an elder, click on the “Older Adults/Caregivers” link near the top of that long list of links on the left. There is a wealth of information there for the elder and for the caregiver.
As a corollary to this topic of delirium, I’m reminded of some writings of Jerald Winakur, MD, a geriatrician in San Antonio, Texas. Dr. Winakur-- speaking both as a geriatrician and a son who cared for his elderly father – says again and again that an elder should never be left alone the first night s/he is in the hospital.
Good reading for good advocates! Carry on your noble work!
Wednesday, October 10, 2012
Information about Psychoactive Drugs
Yesterday I posted an article about antipsychotic drug use on our elders in nursing homes. Today I post this table for your use. It is a list of all the drugs that CMS looks for in reporting on usage of antipsychotic drugs in nursing homes.
You can Google the name of any drug here and learn much more about that drug's intended (on label, FDA-approved) use and its side effects.
DRUG | On Label Use | Trade Name(s) |
Clozapine | Schizophrenia | Clozaril, Gen-Clozapine |
Haloperidol Deconate | acute psychosis, schizophrenia, and Tourette's syndrome | Haldol |
Droperidol | Used as an antiemetic and antipsychotic. Droperidol is also often used for neuroleptanalgesic anesthesia (a state of quiescence) and sedation in intensive-care treatment | Inapsine, Droleptan, Dridol, Xomolix, Innovar |
Loxapine | Loxapine is used to treat the symptoms of schizophrenia | Loxitane |
Thioridazine | Thioridazine is used to treat the symptoms of schizophrenia | Mellaril |
Molindone | Molindone is used to treat the symptoms of schizophrenia | Moban |
Theothixene | Thiothixene is used to treat the symptoms of schizophrenia | Navane |
Olanzapine | is used to treat the symptoms of schizophrenia | Zyprexa |
Pimozide | Pimozide is an atypical antipsychotic drug used to treat serious motor and verbal tics associated with Tourette's syndrome | Orap |
Fluphenazine Deconate | An antipsychotic medication used to treat Schizophrenia. It is a highly potent behavior modifier with a markedly extended duration of effect. | (This is an injection medication.) |
Fluphenazine | Fluphenazine is an antipsychotic medication used to treat schizophrenia and psychotic symptoms such as hallucinations, delusions, and hostility. | Prolixin, Permitil |
Quetiapine | Quetiapine tablets and extended-release (long-acting) tablets are used to treat the symptoms of schizophrenia | Seroquel |
Risperidone | Risperidone is used to treat the symptoms of schizophrenia | Risperdal |
Mesoridazine | Mesoridazine is a neuroleptic drug used in the treatment of schizophrenia. | Serentil |
Promazine | An older medication used to treat schizophrenia. | Sparine |
Trifluoperazine | Trifluoperazine is used to treat the symptoms of schizophrenia | Stelazine |
Chlorprothixene | Chlorprothixene's principal indications are the treatment of psychotic disorders (e.g. schizophrenia) and of acute mania occurring as part of bipolar disorders. | Cloxan, Taractan, Truxal |
Chlorpromazine | Chlorpromazine is used to treat the symptoms of schizophrenia | Thorazine |
Acetophenazine | Acetophenazine is an antipsychotic drug of moderate-potency. It is used in the treatment of disorganized and psychotic thinking. It is also used to help treat hallucinations or delusions. | Tindal |
Perphenazine | Perphenazine is used to treat the symptoms of schizophrenia | Trilafon |
Lorazepam | Lorazepam is in a group of drugs called benzodiazepines and is used to treat anxiety disorders. Includes | Ativan |
Oxazepam | Oxazepam is used to relieve anxiety, including anxiety caused by alcohol withdrawal | Serax |
Prazepam | Prazepam is indicated for the short term treatment of anxiety. | Centrax |
Diazepam | Diazepam is used to relieve anxiety, muscle spasms, and seizures and to control agitation caused by alcohol withdrawal. | Valium, Valrelease |
Clonazepam | Clonazepam is used alone or in combination with other medications to control certain types of seizures. It is also used to relieve panic attacks (sudden, unexpected attacks of extreme fear and worry about these attacks). | Klonopin or Klonapin |
Hydroxyzine | Hydroxyzine is used to relieve the itching caused by allergies and to control the nausea and vomiting caused by various conditions, including motion sickness. | Vistaril, Atarax |
Halazepam | Halazepam is indicated for the treatment of anxiety. | Alapryl, Pacinone |
Chlordiazepoxide | Chlordiazepoxide is used to relieve anxiety and to control agitation caused by alcohol withdrawal. | Angirex, Elenium, Klopoxid, Librax, Libritabs, Librium, Mesural, Multum, Novapam, Risolid, Silibrin, Sonimen and Tropium. |
Aripiprazole | Aripiprazole is used to treat the symptoms of schizophrenia | Abilify |
Alprazolam | Alprazolam is used to treat anxiety disorders and panic disorder | Niravam, Xanax |
Amoxapine | Amoxapine is used to treat depression. | Asendin |
Nortriptyline | Nortriptyline is used to treat depression | Aventyl, Pamelor |
Wellbutrin | Wellbutrin is used to treat depression. Bupropion is also used to treat seasonal affective disorder | Buproprion |
Trazodone | Trazodone is used to treat depression | Desyrel, Oleptro |
Venlafaxine | Venlafaxine is used to treat depression. | Effexor |
Amtriptyline | Amitriptyline is used to treat symptoms of depression | Elavil, Endep, Vanatrip |
Lithium | Lithium is used to treat and prevent episodes of mania (frenzied, abnormally excited mood) in people with bipolar disorder (manic-depressive disorder; a disease that causes episodes of depression, episodes of mania, and other abnormal moods). | Eskolith, Lithobid |
Maprotiline | Maprotiline is used to treat depression, bipolar disorder (manic depressive disorder; a disease that causes episodes of depression, episodes of mania, and other abnormal moods), and anxiety. | Ludiomil |
Isocarboxazid | Isocarboxazid is used to treat depression in people who have not been helped by other antidepressants | Marplan |
Phenelzine | Phenelzine is used to treat depression in people who have not been helped by other medications | Nardil |
Serzone | Nefazodone is used to treat depression. | Nefazodone |
Desipramine | Desipramine is used to treat depression. | Norpramin, Pertofrane) |
Tranylcypromine | Tranylcypromine is used to treat depression in people who have not been helped by other medications. | Parnate |
Paroxetine | Paroxetine tablets are used to treat depression, panic disorder and social anxiety disorder | Paxil, Pexeva |
Fluoxetine | Fluoxetine is used to treat depression, obsessive-compulsive disorder, some eating disorders, and panic attacks | Prozac, Sarafem, Fontex |
Sertraline | Sertraline is used to treat depression, obsessive-compulsive disorder, panic attacks, posttraumatic stress disorder, and social anxiety disorder | Zoloft |
Doxepin | Doxepin is used to treat depression and anxiety. | Sinequan, Adapin, Silenor |
Imipramine | Imipramine tablets and capsules are used to treat depression | Tofranil |
Protriptyline | Protriptyline is used to treat depression. | Vivactil |
Flurazepam | Flurazepam is used to treat insomnia | Dalmane |
Quazepam | Quazepam is used to treat insomnia | Doral, Dormalin |
Estazolam | Estazolam is used for the short-term treatment of insomnia | ProSom |
Temazepam | Temazepam is used on a short-term basis to treat insomnia | Restoril |
Triazolam | Triazolam is used on a short-term basis to treat insomnia | Halcion |
Zolpidem | Zolpidem is used to treat insomnia | Ambien, Edular, Intermezzo, Zolpimist |
Tuesday, October 9, 2012
Are you an advocate for someone living in a nursing home?
Are you an advocate for someone living in a nursing home? Are you a medical power of attorney for someone living in a nursing home? If so, please read this. You cannot advocate well for someone until you are well informed about standards of care. Of course this is true whether the nursing home is licensed or unlicensed, as is the case with many Sisters who receive skilled nursing care at "home."
Did you know that across our country almost one of every four nursing home residents is on an antipsychotic medication? In the majority of cases, these drugs are prescribed for elder residents who are living with dementia. These antipsychotic drugs given to persons living with dementia are being prescribed "off label." This means that the drug, approved for a particular use (psychosis, depression, etc) is being used for another purpose: to eliminate "problem behaviors."
All too often in retirement settings, persons living with dementia are seen as "having behavior problems, difficult, non-compliant, hostile, aggressive" and on and on all because staff is not trained to understand that all behavior is meaningful, and that the "problem" is not with the resident, but with the staff not yet able to understand the message or need the resident is attempting to convey. Such understanding takes time and a genuine knowledge of the resident. Thus the call for consistent assignment of those providing care.
The quick answer to "problems" in too many nursing homes is use of antipsychotic medications which, among other things, can so sedate a resident that the "problem" seems to be taken care of. Of course there are so many negative outcomes from such abusive use of powerful drugs. There are negative outcomes to every system in the body in addition to the side effects of these powerful drugs. I encourage you to Google the name of any drug below, for example, and learn its side effects.
Several years ago the Federal Drug Administration (FDA) issued a Black Box Warning in the case of several antipsychotic drugs when they are used off label for older adults with dementia. Those drugs include the following: Tinclude Compazine (prochlorperazine), Haldol (haloperidol), Loxitane (loxapine), Mellaril (thioridazine), Moban (molindrone), Navane (thithixene), Orap (pimozide), Prolixin (fluphenazine), Stelazine (trifluoperazine), Thorazine (chlorpromazine), and Trilafon (perphenazine).
Newer drugs that continue to carry the black-box warning include Abilify, Clozaril, FazaClo, Geodon, Invega, Risperdal, Seroquel, Zyprexa, and Symbyax. Source of information (accessed Oct. 9, 2012): http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/Downloads/AntipsychoticMedicationQM.pdf
The Center for Medicare and Medicaid Services (CMS) reports that information covering March through December of 2011 reveal that the national average among nursing home residents who received at least one antipsychotic was 23.9%. CMS has begun an initiative to reduce this usage rate by December 31, 2012.
To emphasize the importance of correcting the abuse of overprescribing antipsychotics for nursing residents living with dementia, CMS has added this topic as one of its Quality Measures (QM). These Quality Measures are found on the CMS Nursing Home Compare website for consumers to do precisely that --- compare nursing homes based on certain quality measures. This measure will be show for nursing home inspection reports made beginning in July, 2012.
(Go to http://www.medicare.gov/NursingHomeCompare/)
As an advocate, ask questions if a doctor or nurse suggests that an antipsychotic drug is advised. What questions should you ask:
- For what medical issue is this drug being prescribed?If the 'medical issue' is really what they call a 'behavior' such as agitation, restlessness, anxiety, etc. be very, very wary. This is the very abuse CMS is addressing in their new initiative to reduce the use of antipsychotics.
3. What are the benefits of this medicine?
4. What are the risks of taking this medicine? (What are the side effects?)
5. How long will the treatment last? (How long will the person be on this medicine?)
Only when you have all this information are you qualified to weight all the facts and then to give informed consent for the treatment to proceed, or informed refusal for that treatment too proceed. The resident, and you, on behalf of that resident if s/he cannot speak for him/herself, has the right to choose or to refuse treatment.
Monday, October 8, 2012
More than just cosmetic: the link between lack of dentures and dementia
When I first started working in the field of long-term care, I was hired as an ombudsman in Charleston, WV, not because of any special expertise in the field of long-term care, but because of my mother. I experienced such frustrations and helplessness in the institutional, task-oriented environment of the first nursing home she was in. Luckily, I found a much better nursing home, a not-for-profit home sponsored by the Episcopal Church. My brother and sisters were happy with the change too. My mother lived there for a year before her death, three years before I became an ombudsman. I hadn't needed to bring issues to the attention of the administrator of the director of nurses at Bishop Davies, but I did wonder where one went when there were problems, and solutions were not to be found within the nursing home itself. As a previous community organizer, I thought there must be something that could be done with and for families when they were companioning one of their own in a nursing home. And so I landed in Charleston, West Virginia!
My first task was to become familiar with the federal and state regulations so that I could advocate for nursing home residents, or for their family members should they ask me to look into a particular concern. One of the regulations that always remained sort of in the forefront of them all was the responsibility of the nursing home to replace – at their expense -- a resident's dentures should they become lost. I learned that staff should be trained to shake out dinner napkins before throwing them into the laundry receptacle, as well as to check a resident's dinner tray before discarding everything, unexamined, as trash.
Not having one's dentures does change one's appearance, and it is a matter of the acknowledgement of the resident's dignity – also covered in the regs – to see that the resident is wearing his or her dentures (unless he or she chooses not to). I've always wondered how someone really eats well without dentures. This morning my wondering was grounded in a report that shows a strong link between a lack of dentures (or lack of chewing) and a higher risk for dementia. Several studies demonstrate "an association between not having teeth and loss of cognitive function and a higher risk of dementia."
The report of this research goes onto say that one reason for this correlation between lack of chewing and risk for dementia may be that when chewing is difficult because of lack of teeth or dentures, there is less blood flow to the brain.
Source for this information: Medical News Today. http://www.medicalnewstoday.com/releases/251176.php
Wednesday, August 22, 2012
When Are Antipsychotic Medications Necessary?
The issue addressed in this article from the journal, Caring for theAges, carries important information in two areas of interest to anyone serving elders in a retirement setting: 1) the appropriate place of antipsychotic medications for elders who have no diagnosis of a mental disorder and 2) the role of the family member, the medical power or attorney or the "decision maker" if the resident is not capable of making her own decisions. I will refer to these individuals by one common term, "advocate."
The issue of excessive, inappropriate prescribing of antipsychotic drugs -- in violation of state and federal regulations -- for persons living with dementia in nursing homes has been mainstream news for more than two years now. Luxenberg states clearly and simply what the State and Federal guidelines are in this regard.
The author goes on to state the standard of care when he names all those engaged with the resident in assuring appropriate planning and implementation of treatment for elders iu a nursing home. He says: the "prescriber", the facility (sic) and the family work together and communicate with one another in setting care goals. Gone are the days when "the doctor ordered" suffices to stifle all questions. Gone are the days when family members are viewed as intruders rather than the strongest allies in achieving the best outcomes for the resident physically, mentally and psychosocially.
Acknowledging the role of these advocates, Luxenberg poses four questions that the resident, or the person acting on her behalf should ask the physician when medications are prescribed. Note: this article applies to antipsychotic medications, but the same questions should be asked and answered to the satisfaction of the resident or advocate for any medication or plan of treatment. If these conditions are not satisfied, "informed consent" for treatment has not been provided. No one of us, resident of a nursing home or not, should ever submit to treatment (medication, diet, surgery, therapy, psychological counseling) without giving our informed consent. Answers to the four questions posed will provide sufficient information to provide informed consent.
For advocates ( including medical power of attorney) of nursing home residents who cannot speak for themselves, the responsibility the advocates bear in this role is to seek adequate information about any proposed plan of care so that he or she, the advocate, can give informed consent for the suggested course, or can deny that treatment according to the wishes of the resident as put forward in his or her advance directives.
Here is the article in its entirety
When Are Antipsychotic Medications Necessary?
In this first of a two-part series on dementia-related behaviors, Dr. Jay Luxenberg, chief medical officer at On Lok Lifeways in San Francisco, talks about antipsychotic medications (Caring for the Ages. August, 2012. Vol. 13, No. 8. Page 18)Antipsychotic medications are Food and Drug Administration (FDA) approved and used mostly for psychotic illnesses such as schizophrenia and bipo¬lar disorder. While none of these drugs has been formally approved by the FDA to treat dementia-related behaviors, they sometimes can be helpful for this purpose. By talking with your physician, you can learn more about when these drugs can help and when other treatments are better choices.
Antipsychotic medications are Food and Drug Administration (FDA) approved and used mostly for psychotic illnesses such as schizophrenia and bipolar disorder. While none of these drugs has been formally approved by the FDA to treat dementia-related behaviors, they sometimes can be helpful for this purpose. By talking with your physician, you can learn more about when these drugs can help and when other treatments are better choices.
Federal nursing home regulations state that antipsychotics should be used for dementia patients only when the behaviors pose a risk to self or others or symptoms are bad enough to cause great and prolonged distress for the person or seriously hurt his or her ability to function. The regulations also say that these drugs can’t be used for behaviors that don’t put the person or others in danger or at risk of physical injury. These include wandering, crying out or yelling, poor self-care, memory problems, mild anxiety, insomnia, and nervousness.
In general, antipsychotics should only be used after trying other means of managing the problem behavior, only in the lowest dose needed, and only for the shortest possible time. The physician will work with the resident and his or her family, as well as facility caregivers and staff, to figure out what is causing the problem behavior and what nondrug treatments might help. When it is decided that an antipsychotic may be needed, risks, benefits, and treatment options should be discussed with the resident and his or her family to be sure they understand them (except in some emergency situations).
The prescriber and facility staff also will work with the resident and family to set care goals. For example, if the drugs are used to help a man who is delusional and is terrified of people he sees under his bed, the care goal might be to get his delusions under control so that he can relax, sleep well, and have a better quality of life. Facility staff will work with the physician to track the person’s progress and to watch for possible adverse drug reactions or other drug-related problems.
4 Questions to Ask Your Physician:
• What are the pros and cons of this medication in this situation?
• What if I don’t want antipsychotic drugs to be used? What are some drug and nondrug options?
• How long will this medication be used?
• How do we decide treatment/care goals?
4 What You Can Do:
• Make sure the physician and facility staff know as much as possible about your or your family member’s personality, background, likes and dislikes, favorite things, fears and phobias, hobbies, habits, and so on.
• Let the physician know if you or your family member has a history of mental illness.
For More Information:
• Antipsychotics in the Elderly: www.amda. com/consumers/antipsychotics.cfm
Tuesday, August 14, 2012
What's Wrong with this Picture?
One of my e-subscriptions is to a quarterly newsletter published by the Missouri Department of Health and Human Services. In their current issue, there is an article with the title, “Missouri Nursing Homes Have Happy Clients, MU Researchers Say”. I have been unable to successfully access the URL listed for the entire article, so I can’t critique the research as such. But so many red flags waved brazenly as I read the article. But my first response when I read the title of the article was WHAT?!!
The whole system of traditional long-term care is sick, dysfunctional and “lethal to both resident and staff” (quote is from Steve Shields, culture change leader). Those deficits are reflected in the newsletter article.
1. Who of us wants to be seen or to be considered a “client” if we are living in a nursing home? Do any of us consider those with whom we live “clients”?
2. The survey may well have been valid and reliable for what it tested, but consider these facts:
a. Residents and family members are usually extremely uninformed about the minimum standards of care in a nursing home. So if the resident sits at the table for 45 minutes before a meal is served, does she or the family even know to complain? If the resident is awakened each morning and prepared for bed each evening at the convenience of the staff, rather than at the time she chooses, does she know her rights are being violated? I could go on and on.
b. For the most part, family members can sense the good will among caregivers. Perhaps that is why they and the resident think life can’t be any better in a nursing home. That’s where hopelessness seeps in.
c. I can’t think of a single family member who would say, “I intentionally put my mom in a third-rate nursing home.” Rather, we so often hear, “Mom’s nursing home is the best one in town.”
d. Jude Rabig, Ph.D. did a fascinating study that I regret has not received more recognition. Rabig interviewed residents of a “good”, traditional nursing home about their perception of their quality of life. The residents rated the nursing home highly. This nursing home undertook new construction, providing the same number of beds but with the architectural environment of households. (Household model, public space and private space – person-directed – transformative culture change – global workers – etc.). Six months after these same residents had moved into the household nursing home, Rabig interviewed them again about their quality of life. It is not surprising that they rated their quality of life as very high. It is quite revealing, however, that from their new home (not homelike, folks, HOME!) they looked back on their life in the “good” traditional nursing home as a very negative experience. “Incarceration” was one term used to describe life in a “good” nursing home before culture change.
So for 90% of Missourians to say that things are good, may well reflect that there is no concept that life can be better in a nursing home. (Oh, how I’d love to talk to the 10% dissident population! Perhaps they are the dreamers who won’t accept the overhead call system, the restraint alarms going off constantly, the deadened “activity” schedule, the uncertainty of never knowing who your caregiver will be today.)
3. Roughly 95 – 97% of the nursing homes in the United States are still run by a schedule that reflects task-first, person-wherever-she-fits-in philosophy. This reality, as horrendous as it is, does not exist because caregivers are selfish or unfeeling. It exists because this is the “system” in which they were trained. It is this lethal system that is responsible for the extremely high turnover in nursing homes, especially among direct-care staff.
One of the researchers is quoted in the article: “Nursing home administrators have worked diligently throughout the past decade to improve the quality of care delivered to residents and to make care settings more homelike.” Undoubtedly, that is true. But two points:
1. As long as the work is to improve a system that is dysfunctional and lethal to all who are touched by it, the energy is misplaced. The system must be turned on its head! Everything must be seen through eyes focused on person-directed values. Every practice and policy must be evaluated in light of the analysis of, ‘how do we do this at home?’
2. The touchstone of life in a nursing home is NOT the care. I wish I could remember the source of this statement that I read during the past week: “How is it that even when the care is superb, nobody wants to go to a nursing home?” Of course clinical standards must be met. But it must be provided through the prism of person-first, not task-first.
The touchstone of life in a nursing home is honoring the individual, being there in service. There’s a world of difference between “caring for” and being “in service”. How do most of us respond if someone says, “I’m going to take care of you.” We don’t want to be taken care of. If we need services, we want those services provided in a dependable, compassionate and competent manner. But “taking care of” reflects a lot of things that are the topic of another post on this blog.
To read the entire article, visit: http://munews.missouri.edu/expert-comment
The whole system of traditional long-term care is sick, dysfunctional and “lethal to both resident and staff” (quote is from Steve Shields, culture change leader). Those deficits are reflected in the newsletter article.
1. Who of us wants to be seen or to be considered a “client” if we are living in a nursing home? Do any of us consider those with whom we live “clients”?
2. The survey may well have been valid and reliable for what it tested, but consider these facts:
a. Residents and family members are usually extremely uninformed about the minimum standards of care in a nursing home. So if the resident sits at the table for 45 minutes before a meal is served, does she or the family even know to complain? If the resident is awakened each morning and prepared for bed each evening at the convenience of the staff, rather than at the time she chooses, does she know her rights are being violated? I could go on and on.
b. For the most part, family members can sense the good will among caregivers. Perhaps that is why they and the resident think life can’t be any better in a nursing home. That’s where hopelessness seeps in.
c. I can’t think of a single family member who would say, “I intentionally put my mom in a third-rate nursing home.” Rather, we so often hear, “Mom’s nursing home is the best one in town.”
d. Jude Rabig, Ph.D. did a fascinating study that I regret has not received more recognition. Rabig interviewed residents of a “good”, traditional nursing home about their perception of their quality of life. The residents rated the nursing home highly. This nursing home undertook new construction, providing the same number of beds but with the architectural environment of households. (Household model, public space and private space – person-directed – transformative culture change – global workers – etc.). Six months after these same residents had moved into the household nursing home, Rabig interviewed them again about their quality of life. It is not surprising that they rated their quality of life as very high. It is quite revealing, however, that from their new home (not homelike, folks, HOME!) they looked back on their life in the “good” traditional nursing home as a very negative experience. “Incarceration” was one term used to describe life in a “good” nursing home before culture change.
So for 90% of Missourians to say that things are good, may well reflect that there is no concept that life can be better in a nursing home. (Oh, how I’d love to talk to the 10% dissident population! Perhaps they are the dreamers who won’t accept the overhead call system, the restraint alarms going off constantly, the deadened “activity” schedule, the uncertainty of never knowing who your caregiver will be today.)
3. Roughly 95 – 97% of the nursing homes in the United States are still run by a schedule that reflects task-first, person-wherever-she-fits-in philosophy. This reality, as horrendous as it is, does not exist because caregivers are selfish or unfeeling. It exists because this is the “system” in which they were trained. It is this lethal system that is responsible for the extremely high turnover in nursing homes, especially among direct-care staff.
One of the researchers is quoted in the article: “Nursing home administrators have worked diligently throughout the past decade to improve the quality of care delivered to residents and to make care settings more homelike.” Undoubtedly, that is true. But two points:
1. As long as the work is to improve a system that is dysfunctional and lethal to all who are touched by it, the energy is misplaced. The system must be turned on its head! Everything must be seen through eyes focused on person-directed values. Every practice and policy must be evaluated in light of the analysis of, ‘how do we do this at home?’
2. The touchstone of life in a nursing home is NOT the care. I wish I could remember the source of this statement that I read during the past week: “How is it that even when the care is superb, nobody wants to go to a nursing home?” Of course clinical standards must be met. But it must be provided through the prism of person-first, not task-first.
The touchstone of life in a nursing home is honoring the individual, being there in service. There’s a world of difference between “caring for” and being “in service”. How do most of us respond if someone says, “I’m going to take care of you.” We don’t want to be taken care of. If we need services, we want those services provided in a dependable, compassionate and competent manner. But “taking care of” reflects a lot of things that are the topic of another post on this blog.
To read the entire article, visit: http://munews.missouri.edu/expert-comment
Wednesday, May 23, 2012
UNTIE THE ELDERLY AND DISENGAGE THAT ALARM
In the mid 1980s, a movement began mandating that caregivers “UNTIE THE ELDERLY”. The movement grew, and with the passage of the 1987 Nursing Home Reform Act, the use of physical restraints decreased. Before this movement, it was not uncommon to see any number of nursing home residents restrained in their wheelchairs during the day and in their beds at night.
I remember seeing my first grade teacher as a nursing home resident tied to her bed and also having her bed rails up. That’s called “double restraints.”
My own mother was restrained in a nursing home. I remember being shocked when I first saw her in that vest covering the entire front of her upper body. The vest ended in narrow strips of cloth that were tied in the back of her wheelchair. My mother’s response to my question of “why” was a resigned, hopeless shake of her head. The nurse told me it was “doctor’s orders” for her own safety. In those days I did not know better so I didn’t question “the doctor” or the nurse. I know better now and as Maya Angelou says: “We did the best we could. When we knew better, we did better.”
Later in rural West Virginia, Ruby, a middle-aged adult child called me in the ombudsman’s office in a sense of panic. Her mother in a local nursing home had called her earlier that morning saying, “Ruby, they’ve got me tied like a dog.”
Some long-known facts about restraints:
Every system in the body is negatively affected through the imposed, prolonged immobility.
The psychological effects of being restrained are obvious to any observer who would put him/herself in the restrained person’s place.
Studies have shown that caregivers relate less frequently to residents who are restrained than to residents not restrained. Restraints, then, mean further isolation
And here’s the kicker: RESTRAINTS DON'TLESSEN INJURIES OR FALLS.
From a recent study: “Despite unambiguous legal regulation and evidence of a lack of effectiveness and safety, physical restraints remain frequently administered in nursing homes, with a recent survey reporting physical restraint rates of more than 20% for U.S. nursing homes, according to background information in the study, which appears in the May 23/30 issue of the Journal of the American Medical Association
One doesn’t see Posey Vests much anymore, though belts and “lap buddies” and things of that nature are too prevalent. The popular restraint used today is the position alarm. They don’t reduce injuries or falls; they don’t keep residents more safe; they have all the negative side effects of any physical restraint -- and then some.
The call today is not to untie our elderly, but to DISENGAGE THAT ALARM!! Tied up, hooked up, the end results are the same.
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