Culture Change in LTC Jessica Shyu, M.S., R.D. Corporate Director of Nutrition & Wellness Morrison Senior Living Culture Change? National Movement for the Transformation of Older Adult Services to create a culture of aging that is life-affirming, satisfying, humane, and meaningful Culture Change? Transformation From Medical Model or Institutional Model - Overemphasis on safety, uniformity, and medical issues To Home Model - Focus on person-centered care, supporting elder s life, dignity, rights, and freedom Philosophy Creating a HOME-like environment Empowering People with CHOICE 1
HOME Is Where The Heart Is I long, as does every human being, to be at home wherever I find myself. Maya Angelou Culture Change Goals: Support personal satisfaction in lives Create individualized living spaces Empower staff as advocates of residents Respect lifestyles, preferences, needs Provide opportunity for growth, contribution Connect to community Culture Change Based on person-directed values & practices Pioneer Network www.pioneernetwork.net CMS Regulations Changes Is a PROCESS, not a project or a program Fundamental to this transformation is a focus on the importance of the relationships between residents and direct care staff. 2
Continuum of Person Directedness Provider Directed Management makes decisions with little conscious consideration of the impact on residents and staff. Residents are expected to follow existing routines. Staff Centered Staff consult residents while making the decisions. Residents may have some choices within existing routines and options. Person Centered Resident preferences or past patterns form basis of decision making. Staff begin to organize routines to accommodate resident preferences. Person Directed Residents make decisions every day about their individual routines. Staff organize their hours and assignments to meet resident preferences. Core Person-directed Values Choices Dignity Respect Selfdeterminat ion Purposeful living Mission of Pioneer Network Guided by 13 Values and Principles: Guided by 13 Values and Principles: Know each person Each person can and does make a difference Relationship is the fundamental building block of a transformed culture Respond to spirit, as well as mind and body Risk taking is a normal part of life Put person before task All elders are entitled to self-determination wherever they live 3
Mission of Pioneer Network Guided by 13 Values and Principles: continue Community is the antidote to institutionalization Do onto others as they want done onto them Promote the growth and development of all Shape and use the potential of the environment in all its aspects: physical, organizational, psycho/social/spiritual Practice self-examination, searching for new creativity and opportunities for doing better Recognize that culture change and transformation are not destinations but a journey, always a work in progress Culture Change? Three Basic Questions: What does the resident want? How did the resident do this at home? How should we do it here? ~ Bump s Law ~ Excellence in Individualization in Dining Choice - true choice, not token choice Accessibility - 24/7 & refrigerator rights Individualization - favorites/preferences Liberalized Diets - evidence-based practice Food First - foods before supplements Quality Service - relationship building Responsiveness - meet resident s needs 4
4 Stages of Culture Change Stage 1 The Institutional Model Traditional Long Term Care environment Traditional and medical in orientation Organized around traditional nursing unit No consistent assignment Top-down organizational structure that lends itself to disempowerment in residents and direct care staff Large central dining, scheduled meal times, tray service 4 Stages of Culture Change Stage 2 The Transformational Model Culture Change Emerges Leadership and direct care staff become more aware and knowledgeable of culture change Consistent assignment is implemented Learning circles develop amongst staff and residents Low-cost changes in décor to a more home-like environment Tray service but taking foods off the tray Have variety of ways to increase choice at mealtimes 4 Stages of Culture Change Stage 3 The Neighborhood Model Transition to smaller neighborhoods Traditional nursing unit broken into smaller neighborhoods Multi-disciplines working as one team Dining area decentralized and residents in smaller dining room on their neighborhoods Residents could sleep and eat when they want Neighborhood identity emerges in both name and actions 5
4 Stages of Culture Change Stage 4 The Household Model Home established again! Elders run and plan their lives Self-directed teams in the households Staff is cross-trained for multiple tasks and reports into a self-led household team, not to a department living in houses with self-contained fully functioning kitchens Transformation of Dining Program Institutional Model -----> Tray service without table setting Non-select menu Fixed meal times Seating chart Large dining hall with no decoration Use of clothing protector Labeled nourishment/snacks Tasks before person Home Model Restaurant style service with table setting Tableside menu selection Open dining hours Seating by choice Decentralized small dining rooms with pleasant decoration Use of cloth napkin Snack stations Put person before tasks Cultural Change Why NOW? Demographics Regulations 6
Cultural Change Why NOW? Demographics Generation Youngest Oldest GI 84 106 Silent 66 83 Boomer 48 65 Silents Want.. Autonomy, choice, control, individuality and continuity of a meaningful personal life over safety! Home-like setting Make decision used to making Consistent caregiver that knows me PCC! Give care where they live, not live where care is the focus.. Living is the focus, not just care Cultural Change Why NOW? Regulations CMS = Culture Change Partner Starting from 1987 OBRA started culture change training at 2002 Major regulations change in 2009 Developing person-centered nurse aide training modules CMS no barriers from certification States its vision for LTC is that the system will be person-centered; the system will be organized around the needs of the individual rather than around the settings where care is delivered. State Surveyors??? 7
Cultural Change Why NOW? Food & Dining Clinical Standards Task Force Consisted of symposium experts, CMS, FDA, CDC, and national standard setting groups Food and dining are an integral part of individualized care and self-directed living GOAL STATEMENT Establish nationally agreed upon new standards of practice supporting individualized care and selfdirected living versus traditional diagnosis-focused treatment. New Dining Practice Standards 12 National Professional Organizations agree to the New Standards Individualized Nutrition Approaches/Diet Liberalization Individualized Diabetic/Calorie Controlled Diet Individualized Low Sodium Diet Individualized Cardiac Diet Individualized Altered Consistency Diet Individualized Tube Feeding Individualized Real Food First Individualized Honoring Choices Shifting Traditional Professional Control to Individualized Support of Self Directed Living New Negative Outcome New Dining Practice Standards Format: Basis in Current Thinking and Research AMDA American Medical Director Association ADA American Dietetic Association CMS Centers for Medicare & Medicaid Services Current Thinking Relevant Research Trends Recommended Course of Practice 8
New Dining Practice Standards Focus Points of Diet Liberalization Liberalized diets should be the norm, restricted diets should be the exception. Diet is to be determined with the person and in accordance with his/her informed choices, goals, and preferences, rather than exclusively by diagnosis. When a person makes risky decisions, the plan of care will be adjusted to honor informed choice and provide supports available to mitigate the risks. All Decisions default to the person! New Dining Practice Standards Focus Points of Honoring Choices: Choice defines quality of life. For Dining, true choice is exemplified in point-of-service choice. Risk and benefits are being discussed with residents at the same time when asking for choices and preferences. Red Flag trayline or set/limited meal times. Red Flag documentation of resident being non-compliant. Resident dining profiles should be limited to adapted equipment, allergies, consistency modification and unique dietary needs. Person Centered Care - Take Away Points Resident centered with choices Homelike atmosphere with freedom Close relationships with consistent care givers Staff empowerment with self-directed care team Collaborative decision-making among management, staff and residents Quality Improvement Process ongoing! 9
Culture Change Results High Staff Retention Higher Occupancy (competitive advantage) Lower Operational Costs Lower Absenteeism Better Outcomes Calmer Residents High Resident Satisfaction How to Get Started? Educate Self & Staff - Articles, Internet, Tours What Are Our Options? - All Communities are Unique Tour Communities That Have Implemented Start the Journey! Four Buckets of Transformation Organizational Leadership Personal PCC Physical 10
Six Phases of Culture Change I. The Study Circle - High involvement to assess needs II. III. IV. The Design Team Determine the changes Skills Assessment & Development ensuring everyone has the necessary skills and attitudes Team Development - Self-directed work teams V. Implementation Crossing the line together VI. Evaluation - Comparing CQI indicators Health Promotion Institutional Care New Practice Action Action Individualized Care Action Old Practice Action Risk Prevention Points to think about. Regulations need to be expert on interpretations Complete involvement with all disciplines not just dining or marketing alone Resident s choices vs. medical We are their voices for residents with declined cognitive ability Nutrition help residents maintaining their highest possible functional/mental capability It is their HOME! residents need to be involved 11
Action Plan Which Stage is your community at? Stage 1 Traditional Long-Term Care Facility Stage 2 Culture Change Emerges Stage 3 Transition to smaller neighborhoods Stage 4 Final Stage Household Model What can you do to help your community moving forward with culture change? Dining in the Health Suites at Clermont Park Resident-Centered Dining Model Christian Living Communities & Morrison Nursing and Dining Partnership Management team collaboration Resident Service Associates received Caregiver training Nursing and Dining team members meet weekly Eden Alternative training for all team members Manager Hosts at each meal 12
Country Kitchen Set-up Completely self sufficient Little to no dish transport Daily stocking of kitchen from main kitchen Cook/prep to order menu items Main menu items prepped in main kitchen & severed to order Snack items always available Table Setting Linen China and glassware Consider rolled silverware-sanitation Table menus Meal tickets- order taking, intake documentation Restaurant Style Service Open dining 2 hours per meal Open seating Resident is seated, menu presented Offer beverage/s Order taken Serve soup, salad or an alternate Clear first course document on meal ticket Present Entrée Clear second course, document Offer dessert refresh coffee Area is cleared and meal tickets are collected and used to chart 13
Training Safety and Sanitation training program Nursing staff trained on use of kitchen equipment and safe serve practices Dining staff carefully selected to own the area and work autonomously Morrison s Caregiver Training utilized Dining Staff trained to calculate intake and document on meal tickets as well as nursing staff A Great Dining Experience for Residents! Increased satisfaction first and foremost Hot food hot, cold food cold, freshly prepared Preferred dining Family satisfaction and peace of mind Decreased transport traffic in common areas Reduction of noise and institutional model, keeping the homelike feel through out community Increased intake Appetite stimulation Aroma of cooking Person centered approach Promoting choice Reduced usage of clothing protectors People judge their experiences by the way they are treated as a person, not by the way they are treated for their disease. ~Fred Lee If Disney Ran Your Hospital 14
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