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 If home is where the heart is, then many long-term care facilities are working to get their rhythm in sync. The last few years have brought on a culture change where nursing homes not only look more "homey," but "feel" like home as well.
"This is substantially more than just environmental changes. It is a shift in the care paradigm," explained Jim Kinsey, LPN, senior consultant and director of development at the Institute for Caregiver Education, a Pennsylvania-based continuing education and professional development company. "In a medical model, care is delivered on task and on schedule - not the resident's schedule, but the healthcare provider's schedule. In a social or community model of care, the assistance to the resident is provided based on their priority and preference, not ours."
As more demands are being placed on LTC facilities, administrators are embracing the individual care approach to compete in the market.
Transformation
One facility following this approach is Garden Spot Village, New Holland, PA, which turned its long-term care facilities into two-story "households" that have private rooms complete with shower, family room, living room, spa, dining room and kitchen. Gone are the long hallways, the flashing room lights and the med carts, which were replaced with private bathroom cabinets where medications are kept locked and given when convenient for the resident.
Individual-focused care is at the heart of the transformation, said Tabitha Lofland, LPN.
"Everyone has more choices and freedom," she said. "Residents choose when they want to get up or go to bed, when and what they want to eat, and what they want to do during the day."
Such changes are helping shift the mindset of what long-term care is, added Valerie Rodriquez, LPN.
"I think most people don't look forward to getting old and the possibility of needing to go to a long-term care facility," she explained. "However, if they see that they can still enjoy some of the comforts of home, the transition can be easier. As an LPN who has experienced both styles of long-term care delivery, I feel I'm able to give more compassionate care and get to know my residents as people in a true ?resident-centered- care' household model."
Staff members at Osborn Pavilion, Rye, NY, work to create a similar experience for their residents by trying to empathize with their needs.
"It is completely the opposite of the old, cold, impersonal nursing home idea," explained Alice Terlizzi, LPN. "We saw that there were some residents who didn't want to be up early or didn't get hungry at certain times of day, and we tried to put ourselves in their shoes. How would you feel if someone came in at 5 a.m. and took your clothes off or woke you up to take medications?"
Instead, Osborn Pavilion staff gradually moved away from the medical model, letting residents design their own care protocols. If people want to sleep in or take a shower later in the day, the staff tries to accommodate those wishes. There's also a new dining program where residents have better meal selections, said Susan Brancato, RN, nurse manager.
"We're finding residents are eating better because they have a choice in what they eat and in how much they want," she said. "In the past, we had people saying they were so overwhelmed by the portions that they didn't want to eat at all."
Making Progress
Changing the culture of a long-term care environment is a gradual process that usually involves extensive staff training, Kinsey said.
"Education is essential because the team members need to?begin their own de-institutionalization process, so they will be successful in de-institutionalizing residents," he explained. "Providers can no longer make the assumption that professional caregivers come hardwired for communication skills, conflict resolution and other skills that promote success in this type of environment. For the LPN, the development of leadership and supervisory skills is important because, as the model evolves, they are an essential part?of the?community leadership team."
This is especially true at Osborn Pavilion, which changed its model of care to empower CNAs by informing them of their residents' wants and needs. The nursing assistants then communicate that information to the LPN or charge nurse.
"About a year-and-a-half ago, we sent all of our staff to a program called LEAP, which stands for learn, empower, achieve and produce. It focused on resident-centered care and empowers the nurse's aide to be the primary person who knows the resident better than anyone else, because they are with them 24/7," explained Brancato. "They take what they know to the lead nurse, typically an LPN, and she becomes a leader to the care team and validates the CNA's concerns and investigates if necessary. If there's an issue that needs to be brought to the doctor or me, they do that."
Now, there is a flow sheet in the resident's care plan that outlines the person's lifestyle preferences and the routine they are comfortable with.
"Our system is so efficient now," Terlizzi said. "If you have a rapport with the CNAs, they feel comfortable coming to you, and we all brainstorm back and forth on what to do to help the resident."
Power of Communication
Garden Spot Village - campus wide - went through 18 months of extensive educational training to develop a more social household model fostered by culture change.
"The training sessions emphasized the importance of delivering care in a manner that takes the residents' desires into consideration instead of giving care that was convenient for me," Rodriguez said. "Role-playing and ?learning circles' helped me to better understand this new resident-centered care."
Learning circles were exercises for the staff to discover the power of communication by flattening the hierarchy and giving every team member as well as every resident a voice in decisions.
This is quite a change from the typical medical model, so it may initially be a challenge for nurses to consider what is best for the resident, rather than what is most convenient for them, said Connie Fasnacht, RN, director of nursing at Garden Spot Village.
"Following rules and regulations is always easier than being creative in keeping with a resident's choice and still being within those rules and regulations," she said.
But nursing teams typically rise to the occasion and find they enjoy envisioning what "home" means to each person, Fasnacht added. This often illuminates an obvious gap between that idea of home and institutionalized care. Garden Spot Village residents now make choices such as what house artwork to have, what to do to celebrate holidays and even what the rules for pets and child visits should be.
"This new nursing style has made me more aware of the residents' personal preference," Rodriguez said. "For example, meds are given based on the time a resident gets up in the morning rather than a set time schedule. My delivery of care totally revolves around the individual resident's needs on a daily basis. We must continue to evolve as we learn about the lifestyles of our residents and strive to meet their needs."
What keeps many facilities from trying this style of care is fear of the unknown, said Kinsey. "Facilities also hold back because they fear giving up the old models of leadership and supervision, moving from an autocratic style to a more inclusive-empowered model," he said.
The Payoff
The atmosphere of the LTC facility can be brightened by this kind of care, which enhances the lives of the residents and the staff, Brancato said.
"We've gotten a lot of positive feedback from the residents' about it," she explained. "We do have some people with advanced dementia, so we don't get as much of a response, but we are able to see more cooperation and ease with them."
Family members who visit are often relieved to see the residents' routine kept similar to homelife.
"I believe if you can meet your resident's needs, whatever they might be, inadvertently you can avoid some other problems down the road." said Terlizzi. "This is holistic care at its finest."
Sarah Lebo is a freelance writer based in Royersford, PA.
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