On Monday November 30, 2015 I presented a workshop to share my observations and suggestions for improvement on the Alzheimer's Special Care Unit at the Lieberman Center for Health and Rehabilitation.
All of the department heads, managers, and key players were invited for a luncheon from 11:30 - 1:00 which was catered by Max's deli. I figured it was the least I could do to appreciate these people for spending time with me.
I prepared a folder for each participant which contained a number of informative handouts on Dementia/Alzheimers: Biomedical and Experiential Models of Dementia, 12 top tips in working with people with dementia, Speaking Dementia (which offers tips on working as well,) and Dementia Language Guidelines (which offers correct language use when talking to or about people with dementia.)
The following is a transcript of the complete presentation:
BACKGROUND
My purpose for today’s get together is to share my observations and possible ideas to help the Lieberman Center for Health and Rehabilitation’s Alzheimer’s Special Care Unit be the best it can be and possibly become a model for others to follow.
I am a very observant person. I consider that to be a blessing AND a course. Besides being observant, I believe that I am able to see the many sides to any situation.
When I was a young man working for the State of Illinois Department of Mental Health, I worked on a behavior modification unit where young adults in trouble with the law were sent by the courts for rehabilitation. One of the responsibilities for which I was trained was to be an “Independent Observer.” Write down what you see, make no judgements, assign no value.
As an elementary school teacher of over 30 years, I became intensely aware of classroom environment, social milieu, planning and strategy. I worked with children diagnosed with Autism, pre-schoolers and teenagers with developmental disabilities, directed a day camp, taught regular fourth and fifth grades, and taught Junior High Spanish. As an administrator for the Glenview Schools Gifted Education program for seventeen years, I worked as a consultant to teachers, an advisor to other administrators, an advocate for parents, and an educator of children.
DISCLAIMERS
While I believe that my background has enabled me to prepare for this meeting, I must make a few disclaimers.
In no way do I believe that I have “all the answers.” In no way do I pretend to be as knowledgeable in the area of resident care as each of you are in your individual fields. I know that I can not begin to understand all of the complexities and ramifications of running a facility like Lieberman.
My observations and suggestions for improvement are based on 18 months of engagement with staff, CNAs, residents, other families, and with my life partner Gregory. They do not necessarily reflect what goes on with other care floors in the building or what may currently be in place since Gregory died two months ago.
I am grateful for Manny Kagatan, Gregory’s private-pay care-worker, who provided for Gregory many of the suggested improvements mentioned here.
I apologize in advance if I offend anyone, am incorrect in my observations, or am naive in my understanding of the immense task with which you all are entrusted. I hope that you do not feel the need to explain, defend, or apologize, but rather if any of my observations or suggestions can create the beginning of new conversations about the Alzheimer’s Special Care Unit EXPERIENCE, then my purpose is served!
I am honored to be able to share my ideas with you!
IDEAL SITUATION BELIEFS - Unit
In the idea, the fifth floor Alzheimer’s Special Care Unit is a place where the atmosphere is pleasant, friendly, and warm most all of the time. It is a place where residents can enjoy safe surroundings, have their medical needs met, feel part of a community, and have their social/emotions needs met as well. It is a place where residents, as much as possible, do not feel alone, or isolated, or bored.
If the fifth floor is to truly be a Alzheimer’s SPECIAL Care Facility, it needs to be special, different from how the other floors are run, organized, staffed, maintained, etc. It needs to look and feel and behave differently.
Higher Standards:
The care given on the unit must attempt to raise above state rules and regulations, insurance restrictions, bottom line budget decisions, lack of time for proper planning and implementation, and other limitations.
Home vs Hospital Model:
The Alzheimer’s Special Care Unit should attempt to follow more of a “home” model of care than a “hospital” model of care, when ever possible, in which residents do not feel isolated, alone, bored, angry … but rather feel a sense of home, of camaraderie, of community and maybe even joy!
Experiential vs Biomedical Model:
The unit should attempt to follow more of an “experiential” model than a “biomedical” model of care, whenever possible, in which residents needs are met in individualized, meaningful, diverse, loving ways with Lieberman’s continued minimal use of drugs and medications to control, damper, or suppress behaviors.
Summary:
I see the need to re-think programming for the unit in six areas: 1) staff scheduling, training, and communication; 2) meeting resident social and emotional needs; 3) meeting resident dining needs; 4) activity planning, presentation, and delivery; 5) unit space design, utilization, and furnishing; and 6) volunteer use.
IDEAL SITUATION BELIEFS - Staff
Nursing Staff:
The nurse director and floor nurses provide excellent health care in the anticipation and meeting of resident needs, even when residents cannot communicate for themselves. Regular assignments of nurses, minimal use of floating nurses, would benefit residents. In addition to delivering medications, more attention during dining time to feeding, conversation, supporting, and offering choices should be the rule.
The support from Lieberman’s Director of Nursing, Assistant Directors of Nursing, and Restorative Nurses offer excellent support to the overall operation of the Fifth Floor.
Social Work Staff:
The social worker provides excellent support to family members and to residents, although I believe that the ratio of 1:48 is a little too high for our specialized population. Social work and grieving support is needed for staff as well.
The Lieberman Social Worker Director provides excellent support to the overall operation of the Fifth Floor.
Milieu Manager Role:
I have imagined the new role of Milieu Manger. This person would work closely with the Nurse Director and the Social Worker, would have extensive training and background in Dementia/Alzheimer’s care, and would be responsible for overall oversight of the daily functioning of the unit in non-health and non-social work areas.
She would help create and oversee a friendly, engaging therapeutic environment for residents based on best practices research. She would oversee lunch and dinner time, and would provide supervision for CNAs and floor nurses during her modified PM shift from 12 until 8 pm, at which time most residents are moving towards bedtime.
She would also be responsible for making sure CNA supplies were stocked in the main storage area and in each wing. She would be available for support, in a hands on way, anytime it was needed.
Staff Training:
More attention would be given to all staff training in the area of Dementia and Alzheimer’s. The training would be intensive and exceed usual expectations. A plan would be instituted to quickly and efficiently bring new employees up to date.
IDEAL SITUATION BELIEFS - CNAs
A plan would be in place which includes special, extensive, detailed Dementia/Alzheimer’s training and would include instructions for proper handling of residents who cannot move themselves, make sure resident clothing is neatly arranged and comfortable, ensuring proper posture and seating in wheel chairs with placement of pillows if appropriate.
The plan would include detailed procedures for sanitary care and cleaning of residents after soiling, appropriate verbal interaction with residents, appropriate disruptive behavior support, detailed eating support for residents, and more.
Currently, fifth floor CNAs, who work very hard, spend most of their time moving residents from place to place, meeting resident physical needs, delivering food, assisting those who need feeding support at mealtimes, and supporting floating or new CNAs who are unfamiliar with residents and the needs of the floor.
CNAs have very little time to socialize or interact with residents, to engage residents in activities, or to support activities presented by the activity therapist. When the unit is fully staffed by regular fifth floor CNAs, it runs more smoothly. When the unit is supported by floating CNAs, the job is not as well done and the environment suffers.
More informative two-way communication, from managers, should be available to all CNAs, including a daily report by the nurse manager at shift change as well as better communication with new staff or “floaters.”
The number of CNAs on the floor should be increased to 8 for the day shift and 8 for the PM shift. This would allow four teams with two CNAs per team to be assigned to each of the four wings. Currently, many if not most of the residents on the fifth floor need more than one CNA to assist with toileting, cleaning up after soiling, and bathing. Instead of spending time finding another CNA who is free to help, the teams would work together more efficiently.
Residents would be assigned to a team based on which wing they lived in. If “personality differences” arose, there would be two CNAs on the wing with whom a resident could interact.
This increase in staffing would allow for better wing supervision, more efficient and meaningful mealtimes, opportunities for more appropriate activities (discussed later,) more conversational and interactive time with residents, and overall better care of the residents physical, social and emotional needs not to mention safety. Also, regular CNAs would be better able to support the fewer, hopefully, floating CNAs which were needed on the unit.
With two CNAs at a time supervising wing time, residents needs would be better met and safety no longer an issue.
IDEAL SITUATION BELIEFS - Mealtime
All food departments at Lieberman contribute to the well being of the fifth floor residents; including Dietitians, Nutritionists, Kitchen Managers, Chefs, kitchen workers, and food servers on the floor.
There is usually plenty of delicious food with seconds available to residents. Regular, mechanical, and pureed selections are always tasty. Food for those on regular diets is cut into bite size pieces. Alternatives at times are available when residents do not like a particular selection.
All fifth floor staff would be trained to assist and would participate in meal time duties including CNAs, activity therapists, social worker, nurses, Nurse Manager, and Mileiu Manager.
All breaks and meals for staff would be scheduled during non-meal times to allow for a better experience for residents. A better eye would be kept for when residents need seconds on food, alternate selections, or beverages refilled.
With everyone helping deliver food and helping residents who need help with eating, long waits during mealtimes become unnecessary. Also, residents would experience more meaningful interactions while eating, as well as not feeling rushed.
IDEAL SITUATION BELIEFS - Social/Emotional
Besides health care, more attention needs to be given to the social and emotional well being of residents. They should be regarded in ways that engage and support who they are as people, not only who they are as patients.
Depending on the minute, hour, day, week, and month; the unit’s functioning can vary from smooth to chaotic! When residents are upset, angry, screaming, arguing, trying to get out of their wheel chairs, etc, not only is the social/emotional environment difficult but also safety issues arise. A contingency plan needs to be in place to help handle “more difficult” days on the unit.
IDEAL SITUATION BELIEFS - Environment
Housekeeping does an excellent job of keeping the unit clean. Environment is a very important factor and includes cleanliness, visual attractiveness, comfortable furniture, lack of odors, calmness, and comfortable spaces for small group and large groups. The laundry department keeps clothes washed and returned promptly.
New furniture is on the list when renovations are done on the other floors. This is most needed. New bins for trash and waste should obtained which can be sealed to keep odors in. The current ones, even though newer, do not serve this purpose. Rather than replace these, perhaps the current bins could be changed more often.
Periodically building custodians would touch up painted walls and doors so most of the time the unit would look clean and in order. Rooms would be cleaner, especially in the corners. Beds, dressers, and other room furniture would periodically be wiped down and disinfected.
IDEAL SITUATION BELIEFS - Activities
The Activity Therapist works hard to provide residents with meaningful activities. The Lieberman Life Enrichment Manager supports her work and provides an overall building approach to activities as do the other building activity people and art therapist, who work periodically on five.
It would be good if there were two, full time Activity Therapists on the fifth floor. Small and large group wing supervision and activities, with engagement supported by CNAs, would take place more often and in more than one area. The activities would run throughout the day and early PM shifts and would include weekends as well.
At times, residents would be divided according to abilities, interests, and needs. If a resident’s ability changes or could go either way; activity levels would be re-evaluated.
Activities would include folding laundry, art, music appreciation, singing, cooking, exercise, dance, clay modeling, sensory units, reading aloud, exploring photographs of famous people or places, aroma therapy, parachute games, fish tank discussions, current event discussions, using headphones and a iPod to play music tailored to the resident’s likes, or just having a back massaged and being touched. Other activities could be created. Off campus field trips are scheduled for those who are able to attend them.
Watching appropriate television programing, a musical or old time video on DVD, nature scenes backed by classical music, etc are done on TVs that are large enough for everyone to see, with sound that is turned loud enough for everyone to hear, and in a room or two rooms if the group is divided that are large enough for everyone to have a “good seat.“ TV programs that portray violence or crime and news programs would never be shown.
Physical and Occupational Therapists provide overall support to fifth floor residents in their space on the second floor. They would also be seen on five working with residents and periodically looking for ways to support staff with their expertise. Group activities at times would be facilitated by the therapists.
A “day room” somehow needs to be provided. One which is large enough so that most residents can attend functions and be comfortable while participating in activities. It should be well furnished, equipped, and provisioned to provide for art, music, discussion, exercise, cooking, movies, TV, and other activities.
If a space like this cannot be created, then perhaps dining room use might be re-thought. Smaller tables on wheels can be set up ahead of time by kitchen staff and moved into a corner of the dining room to make space for activities. Then at meal time, the tables would be rolled back where they belong, and with wheels lowered, would sit securely and safely in place.
With activities in the dining room just before or just after meals, less time would be spent moving residents from place to place. A larger than life TV screen, mounted on the wall, would allow for theater like experiences with most of the residents being able to be in the room and to have a good seat.
IDEAL SITUATION BELIEFS - Volunteers
The Volunteer Manager would continue to do her good job of vetting and training individual volunteers who would work independently with residents. She would supervise groups of less or untrained volunteers during activities. Supervised children would spend time with residents in a “Grandparent Program” and school groups would put on performances.
Volunteers would also assist with transportation within the unit and with bringing residents to the first floor for building activities, ice cream and hot chocolate in the Nosh, or just outside during good weather, for some fresh air.
Volunteers would include adults, organizations, children, school groups, family members, and pets. Language specific volunteers would support and engage residents who do not speak English.
IDEAL BELIEFS SITUATION SUMMARY - Excellent
- Health care and nursing on 5
- Staff are well meaning, caring people
- Staff works very, very hard to meet resident needs
- Meals are hot, delicious, ample, and meet resident abilities to eat
- Environment is clean, sanitary, and safe
IDEAL BELIEFS SITUATION SUMMARY - Need Attention
- Staffing of regular CNAs vs “Floaters”
- Staff communications and training needs attention
- Meeting social, emotional, and behavioral issues
- Mealtime experience needs
- Space use, availability, and furnishing
- Activities
IDEAL SITUATION BELIEFS - In Conclusion
My hopes and purpose today has been that this fantasy story will give you a different picture or a new way of looking at what the Special Memory Care Unit at Lieberman could be.
Like releasing balloons, wherever they may land, perhaps the observations which helped create this story, will help begin the process of discussing what a total milieu on the fifth floor should and could look like.
Sometimes status quo is the rule when time and energy, adherence to state mandates, insurance regulations, and budgetary constraints do not allow for studying, planning, and making effective, needed change. I ask you to continue your fine, loving work with those in your charge and to look at making that work even better.
