A Changing Landscape in Long-Term Care:

A Changing Landscape in Long-Term Care: Looking Forward to New Place-types and Evolving Person-Center Care Practices Migette L. Kaup, PhD Kansas State University

Nursing Homes are a broken technology. Long-term care administrator, Think Tank, 2010

Culture Change Person-Centered Care

KEY PRINCIPLES OF CULTURE CHANGE 1. resident-directed care and activities; 2. close relationships between residents, family members, and staff and community; 3. empowerment of staff; management that enables collaborative and decentralized decision making; 4. a systematic process for continuous quality improvement; 5. and living environments that are designed to be homelike rather than institutional. (Colorado Foundation for Medical Care, 2006).

What does the Research Show Us? 2007 Commonwealth Fund Survey Findings 2009/2010 Survey Findings (Miller, et al., 2013) 44% 25% 31% 15% 52% 33% Culture Change Implementers Culture Change Strivers Traditional Nursing Homes Culture Change Implementors Culture Change Strivers Traditional Nursing Homes Implementers include partial and complete CC practices Strivers included homes with no implementation but a leadership interest/ commitment Traditional NH with no CC implementation

Although there has been much growth in culture change practice implementation, it must be emphasized that the vast majority of nursing homes (72%) have only partially implemented these practices. (Miller, et al., 2013)

WHY IS THIS SO HARD?

OPERATIONAL ORGANIZATIONAL ENVIRONMENTAL

The Design of the Place-type Matters..a lot

TODAY. brief history of the place-type known as a nursing home application of the 3 critical dimensions of person-centered practices research on person-centered care environment

ALMSHOUSE -1940 1950 1960 1970 1980 1990 2000 2010+ TIME LINE OF LONG-TERM CARE PLACE-TYPES for OLDER ADULTS IN AMERICA (Image: Boston s Pauper s Institute, circa 1989)

INSTITUTIONALLY DESIGNED & OPERATED NURSING HOMES ALMHOUSE -1940 1950 1960 1970 1980 1990 2000 2010+ TIME LINE OF LONG-TERM CARE PLACE-TYPES for OLDER ADULTS IN AMERICA

the hidden program of longterm care (Silverstein & Jacobson, 1985) Medicaid & Medicare Regulations Healthcare Industry Nursing Home Core Patterns Policy initiatives based on medical criteria shaped the assumptions about the behaviors of the people who would live and work in these places. The Facility Medical Care Structured Activities Institutional Living

Typical architectural arrangements follow a hospital model with the assumption of limited activity of residents and a command and control center for nursing staff. (Kaup, 2008) Meadowlark Hills ( 1990) Graphic developed by Migette L. Kaup

Ohio Barrister (n.d.) Website provided by The Law Offices of Attorney David H. Davies. Image retrieved from: http://www.ohiobarrister.com/nursing_homes2.jpg

Nursing homes environments that are designed around an institutional framework exaggerate these dependences resulting in unintentional outcomes; well-cared for but powerless elders. Image retrieved from: http://catalog.flatworldknowledge.com/bookhub/reader/1806?e=barkan-ch12_s06

SPECIALIZED DEMENTIA CARE UNITS INSTITUTIONALLY DESIGNED & OPERATED NURSING HOMES ALMHOUSE -1940 1950 1960 1970 1980 1990 2000 2010+ TIME LINE OF LONG-TERM CARE PLACE-TYPES for OLDER ADULTS IN AMERICA

DESIGNING FOR DEMENTIA Philadelphia Geriatric Center Corinne Dolan Center Woodside Place Woodside Place, Oakmont, PA. Images retrieved from: http://www.google.com/imgres?imgurl=http://archpaper.com/uploads/image/woodsideexterior.jpg&imgrefurl=http://archpaper.com/news/articles.asp?id%3d3563&h=328&w=430&sz=47&tbnid=zti5vqcn CnZ_fM:&tbnh=94&tbnw=123&zoom=1&usg= xzx1ivh_ukqfyrbg9oemht1wk_8=&docid=2csnm7l5w-slbm&sa=x&ei=bsxyubbce8odrggh8ygoaw&ved=0cdeq9qewaa&dur=397#imgdii=_ Gathering Area at Woodside Place. Oakmont, PA as shown in Designing for Alzheimer's Disease by E.C. Brawley (1997)

HOUSEHOLDS SPECIALIZED DEMENTIA CARE UNITS INSTITUTIONALLY DESIGNED & OPERATED NURSING HOMES ALMHOUSE -1940 1950 1960 1970 1980 1990 2000 2010+ TIME LINE OF LONG-TERM CARE PLACE-TYPES for OLDER ADULTS IN AMERICA

THE HOUSEHOLD AS AN EXPRESSION OF CULTURE CHANGE PRIORITIES (Abushousheh, Proffitt & Kaup, 2010, p. 19) A household is a small grouping of residents and their dedicated staff fostering self directed, relationship based life. A household has pleasing homey spaces with a functional kitchen, intimately-sized with clear boundaries and a variety of spaces typical of home, It includes clinical best practices, the tasks and routines to encourage life choices and promote functionality, mobility, wellness and growth. Household life is facilitated by an empowered self-led team of residents and staff supported by the resources of the organization. The organization has been redesigned to position households and their leadership with the autonomy and accountability to respond to the individual resident needs; the households together as a team with the administrator and Director of Nursing Services become the vehicle for all operational decisions and administration, replacing the traditional department structure. The Household Model has been described as A household is a small grouping of residents and their dedicated staff fostering self directed, relationship based life. The household has pleasing homey spaces with a functional kitchen at its hub. It is intimately-sized with clear boundaries and a variety of spaces typical of home. It includes clinical best practices, the tasks and routines to promote functionality. The organization is redesigned to promote autonomy replacing the traditional departmental structure. Image from Greenhouse facilities. Source of images: ncbcapitalimpact.org

household environments Private Room Back Patio Private Room all settings included: resident rooms (privacy options) kitchen / dining that was contiguous living /social spaces bathing room laundry spaces Shared Room Private Room Private Room Living Dining Staff Storage Kitchen Med. Rm. Laundry Shared Room Private Room Private Room soiled utility room a room designated for staff (medication storage) Bathing Strg. Private Room Private Room Private Room Private Room RR Jantr. Util. Strg. Entry Cedar House Floor plan, The Cedars, McPherson, KS

This sets up different patterns of behavior between residents and staff, and, the daily activities are based on the opportunities that the features of these environments provide. Image courtesy of: Perham Living, Perham, MN.

organizational structure Small Number of Residents HH Staff Team CNAs CMAs Nurses Homemakers Other care workers In order to make this work, effectively, however, we have to think carefully about how the care team does their work households will only feel residential if staff have role assignment that contribute to this experience. we can all do our part in the kitchen. (CNA) a different role assignment creates opportunities for a different set of relationships between staff on the household.

organizational structure Households are also team-based made up of the right mix of professional caregivers and other support staff who work with the residents to set up the priorities for how the house will be run. the homemaker is another set of eyes on the household, we like that she s able to help out with the little things when we need a hand. (Nurse)

temporal patterns organizational structure all HHs teams included: Certified Nurse Aides (CNA) Certified Medication Aides (CMA) Nurses a member who floated on a shift not all HHs teams included: Homemakers A designated HH leader Universal workers Site 1 Site 2 Site 3 Team Member AM Shift PM Shift Night Shift (1) RN Coordinator 8:00-10:00-5:00 8:00 (1) Homemaker 7:00 3:00 (1) Nurse** 6:00 2:00 2:00 10:00 10:00 6:00** (1) CNA 6:00 2:00 2:00 10:00 (1) Homemaker 7:00 3:00 (1) CMA** 6:00 2:00 3:00 11:00 (1) CNA 6:00 2:00 3:00 11:00** 11:00 7:00 Coordntr/ Leader (CNA) 8:00 5:00 (1) Homemaker 7:00 3:00 4:00 8:00 (1) CMA 6:00 2:00 2:00 10:00 (1) CMA or CNA 7:00 11:00 3:00 11:00 (1) Nurse 7:00 3:00 3:00 11:00** 11:00 7:00 (1) DON 8:00-5:00 (1) Care Coordinator 8:00-5:00 (1) Nurse 6:00 2:30 2:00 10:30 10:00 6:00** (2) CNA /CMA 6:00 2:30 2:00 10:30 (1) CNA/ CMA 10:00 6:00

operational issues these residential settings must still deliver highly regulated routines. Regulatory Statutes Routine Federal S.O.M State K.D.O.A 28-39-158 Dietary Services Meals Laundry Medication Distribution Charting 483.35 Dietary Services 483.65 Infection Control 483.60 Pharmacy Services 483.30 Nursing Services 28-39-162a Physical Environment 28-39-161 Infection Control 28-39-162a Physical Environment 28-39-156 Pharmacy Services 28-39-162a Physical Environment 28-39-154 Nursing Services 28-39-162a Physical Environment Categories Individual Stipulations 12 77 1 7 1 12 1 11 8 29 1 9 2 14 1 4 S.O.M. = State Operations Manual K.D.O.A. = Kansas Department on Aging

{ meals: the interior details } Definitions of functional kitchens are varied. Staff assignments based on meal routines are impacted by environmental features. Household is equipped with steam wells. Main dish is transported from the central kitchen fully cooked and placed in steam wells. Only breakfast is made in the HH.

28-39-158(k). Food Preparation: The facility shall ensure that the food preparation area is not used as a dining area. 28-39-158(j). Authorized Persons: The facility shall ensure that only persons authorized by the facility are in the dietary service area or areas. Operational incompatibility with regulatory oversight (Kaup, 2012) But sometimes there are miss-fits between the regulations and the goals of PCC It is critical that regulatory implication are carefully considered and regulators are included in the discussions so that staff can continue to operate within compliance of the SOM and other state regulations and codes. It can be done, but it does require that every regulated routine is thought through and the supporting features of the space carefully planned. we can all do our part in the kitchen. (Certified Nurses Aide)

, the way it (the building) looks impacts the way people behave. My mood is different working here than there (in the main building). CHANGING THE WORK EXPERIENCE FOR NURSING STAFF (Kaup, 2012) Our (med) system over here (in the HH) wouldn t work over there (in the main building) because of those long hallways. Here we administer meds one at a time, some in their rooms before meals.

outcomes qualitative/ mixed method HHs can influence staff perceptions of resident outcomes which seems to influence their feelings about the nature of their work. One staff member who worked outside of the HH observed Sick people seem to bounce back faster over there (in the HH). Something about the atmosphere seems to make a difference. Another HH staff member noted One of our residents was over there (in the main building), she just walked the hallways crying out for people. She does good over here (in the household), very content.

yeah, that s great.but what about all of those existing nursing homes that we have?

Meadowlark Hills ( 1990) Graphic developed by Migette L. Kaup

Nurses Desk Nurses Station is in a separate office.

Embedded households in a traditionally institutional building Nurses Desk

all of this costs money.what is the return on the investment in time and resources?

Research from Person-Centered Care Programs The Center on Aging at K-State partnered with researchers at the national office of LeadingAge to review and analyze the data that was generated from Kansas PCC program (PEAK 2.0) MDS, publically reported organization-level data My InnerView.

0.080 0.070 0.060 0.050 0.040 0.030 0.071 ** * 0.061 0.060 0.050 **** 0.038 **** Major depressive symptoms declined by 42% from non-participating homes (Stage 0) to homes with full PCC implementation (Stage 4: Levels 3-5). 0.020 0.010 0.000 Stage 0 Stage 1 Stage 2 Stage 3 Stage 4 Depressive Symptoms Stage: F(4,1837)=3.70, p=.0052 https://proyectayemprende.wikispaces.com/2015+idea+de+negocio+del+proyecto+5 We believe that the level of engagement that PCC creates as well as residents being honored as a person and having more control over their own lives are significant factors in this reduction. Stage 0 = Homes not in PEAK Stage 1 = Homes in Foundation Year Stage 2 = Homes at Level 1 Stage 3 = Homes at Level 2 Stage 4 = Homes at Levels 3-5

Low-risk residents with pressure ulcers declined by 38% from non-participating homes (Stage 0) to homes with full PCC implementation (Stage 4: Levels 3-5). 0.070 0.060 0.050 0.040 0.030 0.063 **** *** 0.051 0.053 **** 0.047 **** 0.039 0.020 0.010 http://blog.dnevnik.hr/jja/2008/10/index This is an important health outcome for residents, and a strong indicator of better quality care. 0.000 Stag Stag e 1 Stage 2 Stage: F(4,1574)=7.24, p<.0001 Stage 3 Pressure Ulcers Stage 4 Stage 0 = Homes not in PEAK Stage 1 = Homes in Foundation Year Stage 2 = Homes at Level 1 Stage 3 = Homes at Level 2 Stage 4 = Homes at Levels 3-5

Comprehensive adoption appears to be a tipping point for many QoL items. 90 Stage 0 Stage 1 Stage 2 Stage 3 Stage 4 % Good/ Excellent 85 80 79 79 Homes at full PCC Adoption 80 82 86 * 75 Engage in Meaningful Activities Stage: F(4,102)=2.07, p<.15 http://iwalkthroughlife.blogspot.com/ Stage 0 = Homes not in PEAK Stage 1 = Homes in Foundation Year Stage 2 = Homes at Level 1 Stage 3 = Homes at Level 2 Stage 4 = Homes at Levels 3-5 51

94 92 90 Residents overall satisfaction with their (Kansas) nursing homes did not increase significantly until Stage 4 (relative to Stage 0). 89 93*** Homes at full PCC Adoption % Good/ Excellent 88 86 84 85 87 86 82 80 Stage 0 Stage 1 Stage 2 Stage 3 Stage 4 Overall Satisfaction Stage: F(4,102)=2.85, p=0.0278 Stage 0 = Homes not in PEAK Stage 1 = Homes in Foundation Year Stage 2 = Homes at Level 1 Stage 3 = Homes at Level 2 Stage 4 = Homes at Levels 3-5

PEAK 2.0 PCC Domains Resident Choice Food Sleep Bathing Daily Routines Staff Empowerment Relationships Decision- Making Resident Care Decision- Making Staff Work Career Development Home Environment Resident Bedrooms Resident Use Space Meaningful Life Supporting the Human Spirit Community Involvement

Design Matters

Thank you Migette L. Kaup, PhD kaup@ksu.edu http://www.he.k-state.edu/aging/