“Quality First” is a quality initiative of both major national LTC organizations, AHCA and AAHSA.  A commendable goal.  Or so we think.  But I heard someone speak at a conference (not AHCA, AAHSA or any of their affiliates) who challenged this concept.  And I have to admit I agree with him.

His concept is that a quality initiative in LTC should be “Employees First.”  This supports what we often say, “if we take care of our employees, they will take care of the residents.”  We hear this in every seminar that Seasons Seminars provides on quality care issues.

So why do we spend so little time devoted to employee training, assuring their satisfaction, and most of all, communicating with them effectively?  I hear what you are saying.  “We only have so much money in the budget for training.”  “We have an employee recognition program, what more do you want?”  “We communicate.  We have a 24 hour report.” 

Think about this…the cost of replacing a nurse assistant is estimated to be $2500-$3,000.  A lot of training can be done with that amount of money.  And well-trained employees are known to not leave their jobs.

Employee recognition programs are good, but the three top items that employee satisfaction surveys indicate are most important to them are: that management cares, that management listens, and help with job stress and burnout (MyInnerview, 2006).  When is the last time you had an inservice on stress management?  In case you’re wondering, pay was last.

I know that effective communication is difficult in a 24 hour a day business.  So I have this theory.  Instead of a 24 hour report, we need a minimum of a 72 hour communication cycle.  This helps to assure that those employees who come back from two days off will have what happened on those days communicated to them.  This is similar to why local news cover severe weather for hours on end.  Yes, you may have heard it, but not those that are just turning on their TV.  It also emphasizes how important the information is that they are communicating.  Consistent quality care is dependent on all staff having the information they need.

One other thing to think about.  Compare the amount of time, and quality of time, you spend to assure that your beds are filled, and that your residents/families are satisfied.  Is it the same for your employees?  You treat residents as valuable assets.  Do you do the same for employees, or are they treated as disposable commodities?

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I talked with a friend today who has asked for help.  His wife’s family is in the process of making a decision about moving his in-laws to a nursing home.  The conversation took an interesting twist considering he is a full-blooded Republican (I don’t hold that against him).

The family is not going to admit them until they assure that they have found all the loopholes to transfer funds legally so that the in-laws will be eligible for the government to pay.  I called him on that non-Republican view. 

Here’s his rationale.  As long the government is giving money to illegal immigrants and other welfare recipients he feels that his in-laws should benefit from the welfare system as well.

I tried to explain to him that his in-laws had saved for their retirement, and while their retirement was not what they expected, that’s why they had saved.  I continued to explain that nursing home care was a service the same as any other service that people have to pay for.  His response to that was that he wants the nursing home to get paid, just not from his in-laws funds, but the governemnt’s funds.

I ended the conversation then because I knew that he was not got going to change his mind no matter what I said.  I’ll take it up again later.

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“After lunch we put them down.”  Is this a quote from someone who works in an animal shelter that has too many cats or dogs he can’t find owners for?  No.  It is actually a statement that is heard in nursing homes throughout the nation.  We all know that it means that after lunch residents are assisted to bed for a nap.  But what a different picture these words paint. 

Language has subtle, if not direct, impact on perception.  Think about this.  “We have a locked unit.”  I don’t know about you, but when I hear this I think about jails or old psychiatric wards for the physically dangerous; those places that house persons who are being punished or are at high risk of hurting someone.  Yet, on a regular basis I hear dementia care units referred to as “locked.”  Are they secure?   Yes.  Is the  security for the benefit of those on the outside?  Or is the security for the benefit of those on the inside?  Both sides can be argued, but the better option is the latter.  Actually, I prefer the phrase “special care environment.”  It sends the message that those who live there receive the specialized care that those with dementia need.

Another common quote I hear, including in the media by long term care experts, that makes me cringe is, “Why would someone work as a nurse aide when they can make the same amount of money flipping burgers?”  I understand that the purpose of that comparison is to stress the point that the pay scale should be higher, but it also sends the message that dollar for dollar flipping burgers is a better job.  If that is true then how do we explain the choice that well over 1 million persons have made to work as nurse aides?  Is the message that they made the wrong choice?  If you were to ask, I know that your nurse aides overwhelmingly will tell you, “no”, that they made the right choice. 

Let me share one more of my language pet peeves.  Often stories about residents, when wanting to maintain confidentiality, start with “I have this little lady/man…..”  For those who don’t know me, I will never be little, no matter how old I get.  And I know that not all of the residents in nursing homes are little.  Even if they are little, unless it is relevant to the story, why do we call them little?  Is it cute, or is it condescending?

I could go on.  Listen carefully to the language used in your facility, including behind closed doors.  Is it subconsciously sending the wrong message about how you want your residents, your staff, your facility, long term care to be perceived?

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I was talking with a stay at home mom today who attended seminars last week.  I commented that she seemed to be enjoying herself.  Her response was, that unlike her normal days of interacting with her elementary school age boys, she was actually able to listen to and think about what other adults had to say.   A sharing of ideas, an opportunity to look at things from different points of view, a chance to share the knowledge that she had.

This conversation led to me talking about how if I could make money being a professional student that’s what I would do.  I actually have a job that is as close to that as you can get.  I get to sit in on over 50 continuing education classes a year.  I also attend another 20+ seminars or other educational formats.

Do I always learn something?  Sometimes alot, sometimes not so much.  But even in those that I don’t learn as much as I would have liked to, it often reassures me that the knowledge I have is accurate or still current.  Many times I learn as much from the other people attending as I do from the presenter. 

The seminars I like the most are those that surprise me.  Those that make me say “I didn’t know that!”  Especially if I didn’t think I would learn anything new.  It reminds me that many times we don’t always realize what we don’t know.  And the sad thing about that is that we then miss out on opportunities that could help us do our jobs better. 

In this ever changing, in fact quickly changing profession, we need all the new ideas, tools and strategies we can get to help us hire and retain the best staff who can implement new ideas, tools and strategies that result in better care and quality of life for the residents that live in our facilities.

So I challenge all of you.  The next time an opportunity of any kind comes along that you think “oh, that’s nothing new,” take a chance.  You might be surprised.

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The Special Focus Facility (SFF) list of under-performing, or poor performing nursing homes has hit the media again.  Last November, CMS released some of the homes.  This week they released another list.  Texas has five homes on the list with another one that “graduated”, having shown “sustained significant improvement for about 12 months.

I’m glad that CMS is addressing those facilities that “yo-yo” in and out of compliance, and the information they provide indicates that they will expand the program.

But…only five homes  out of 1100+ in Texas?  That seems awfully low.  Many of us probably know at least that many homes that cycle in and out of compliance.  I would like to see more homes added to this list.  Why?  Because they are the ones that give the nursing home profession a bad name, making quality providers defend themselves.

Would having more homes listed be embarrassing?  Maybe so.  Maybe embarrassment is what will spur our legislators to take notice.   But then they have ignored that Texas is listed as #49 in the nation in Medicaid reimbursement for nursing homes.  They have ignored a report from Texas Health and Human Services that proves that reimbursement rates are about 25% less than what it costs to provide the care provided.  I even recently heard a Texas legislator brag that Texas is #50 nationwide in per capita spending.  I appreciate keeping our taxes low, but not by underfunding services.

Federal and state rules all ready allow, in fact mandate, the state oversight agency (DADS) to take action to protect nursing facility residents from poor care.  I believe that allowing facilities to cycle in and out of compliance does not meet that mandate.  But the GAO reported that CMS allows facilities to cycle in out.  This following quote is from the March 2007 GAO Report “Nursing Homes: Efforts to Strengthen Federal Enforcement Have Not Deterred Some Homes from Repeatedly Harming Residents”

“Terminations of homes is infrequent, in part because of concerns such as local access to other nursing facilities and the effect on residents if they are moved, and in part because CMS allows some problem homes to continue operating until the homes eventually close voluntarily.”

I find this hypocritical.  I am not suggesting that the regulatory agencies become overzealous, as we have known them to do, but I would at least would expect that they do not tolerate what could be considered chronic neglect and abuse to occur.

I’ve been reading about the 100 Best Companies to Work For as recently named by Fortune magazine.  Only one LTC company made the list, Erickson Retirement Communities at #93. 

To be considered for this recognition a company has to have 1000+ employees.  So, my first thought was that the number of employees kept most LTC companies off the list.  But then I looked at the size of the 50 largest nursing home companies  and realized that all those companies have at least 1000 employees.  The same with most of the 40 largest assisted living companies.

So now I wonder, again, why there was only one LTC company on the list.  The Great Place to Work Institute, who does the research for this recognition, defines a great place to work as a place where employees “trust the people they work for, have pride in what they do, and enjoy the people they work with.” The model they offer has five dimensions: credibility, respect, fairness, pride and camaraderie.  I know that many LTC company meet this definition.  

So how can my company be considered for this annual list of the Best, you’re asking?  It’s simple.  A company nominates itself at the Great Place to Work website.  The deadline for nominations is March 31 for consideration for the January 2009 list.

Not that large?  Here’s the good news!  Companies with 50 to 999 employees have their own list.  The deadline for nominations is August 15 for the June 2009 list.  By the way, there were no LTC providers on this list for 2007.  Maybe when the 2008 list is published in June???

Every time the subject of hospice comes up in a seminar there are different views, ranging from “We don’t need it in our facility” to “Yes, it’s the best thing for our residents.” 

I believe that hospice is beneficial and improves the care that those at the end of life receive,  but I can understand those who don’t.  Unfortunately, not all hospice providers are quality providers.  And in some areas, there may not be enough options to be able to choose a good one.  As a result, the negative perception forms.

What I have seen when a quality hospice is partnering, yes, I said partnering, to provide care to a dying person, all involved benefit.  The person who is dying receives support and care from those who are the experts in end of life care, including pain management.  The family also receives the emotional support they need, again from those specifically trained in end of life issues.  The staff may also receive the emotional support from the hospice staff.   

There are other benefits as well.  Hospice rules often make it easier to obtain medications and supplies that will improve comfort and dignity for the dying person.  The added support of the hospice professional staff add another layer of support for the resident and family.  They do not replace the facility staff, but add to, so that in this time of grief and fear and anxiousness, the resident and family receive the additional personal interactions that they might need.

Having a good hospice agency as a resident care partner also assures that the other residents continue to receive the care they deserve.  Without hospice present, a resident who is dying, and/or the family may require additional time of your staff that is then taken away from other residents. 

One other thing…hospice agencies have continued contact with the family for 13 months after the resident dies to assist with the grief.  Offering hospice is one more feather in your hat when someone asks the family for a recommendation for long term care for their loved one.

Contracting with a hospice agency to assist with end of life care is like contracting with a rehab company to assist with improving the physical functioning of a resident.  It is a partnership, expanding the interdisciplinary care team.

As with contracting with a rehab company or any other contract provider, if you don’t like the service you get from a hospice agency with whom you are contracted, take action to correct it.  The facility is still responsible for the care and services that the hospice staff provide.  You are now the customer along with the resident on hospice services. Expect quality, and do not accept anything less.

I heard a story from an activity director last week that touched my heart.  A resident who knew that she was dying was asked by the staff, who are members of Second Wind Dreams, if there was anything she wanted to do before she died.  “Party one more time” was her response.

With the help of the Gaylord Texan Resort Hotel in Grapevine, her dream came true.  The Gaylord provided a suite for the resident and family, meals and drinks at the hotel’s restaurants, and most anything else that would make her dream come true, including “purchasing” gifts at the hotel’s many retail shops.  The bill for this was all paid for by the Gaylord Texan.  It was truly a dream come true.

The resident died two weeks later, still smiling, according to the activity director.

Second Wind Dreams is an organization whose goal is to fulfill the dreams of elders, to help enrich their lives with hope, joy and compassion.  From their website:

“You will have a great time making dreams come true in your eldercare community. How the program traditionally works is: the eldercare community (nursing home, assisted living, retirement, CCRC) joins Second Wind Dreams. The eldercare community (ECC) identifies a ‘dreamweaver’ and SWD sends you a training manual that teaches you how to: identify the dream; get the residents, staff, and families excited; involve the local community so that everyone can see how wonderful these folks are who live in nursing homes; how to get positive media coverage so that we can change the perception of aging. The Dreams Impact Study has proven that having the dreams program active in your ECC lowers resident depression, lowers staff turnover and increases staff morale.”

I have had involvement with Second Wind Dreams for about 5 years.  I have seen dreams large and small come true.  I encourage you to take a look at www.secondwind.org.  What a way to “change the preception of aging, one dream at a time!” (Paraphrased from the SecondWind Dreams website)

I belong to an email list for those caring for loved ones with Alzheimer’s and other dementias.  More and more there are emails posted about the care that their loved one is receiving in an assisted living or nursing facility.  Or should I say the lack of care they are receiving.

This worries me for several reasons.  First, I cringe whenever I read the stories of overmedicating, no activities, poor staffing, etc.  I hope that these facilities are the exception, but I am beginning to wonder if that is true.  I do believe, however, the lack of quality care is due to a lack of knowledge, not a lack of concern and compassion.

It worries me that the members of this group overall believe that the stories posted are true.  And you know the old adage…if someone is unhappy with care they will tell 11 other people.  These stories are being told to 655 members, who then may share the stories with 11 others.  Probably more since many of them are well connected with other caregivers.

These same caregivers who are sharing their stories also often say that they don’t want to complain.  They don’t want to make trouble.  They’ll wait to see if things change. 

Do you know if your family members are satisfied?  Are they telling 11 others, or more, about the care you provide?

With 60-70% of residents in LTC facilities having some form of dementia, we (those of us who work in LTC) really need to examine our protocols for dementia care.  The state of Texas only requires 1 hour annually of dementia care training for nursing homes.  Assisted livings do not require any unless they advertise as specifically as an Alzheimer’s or dementia care facility.

Would we  consider only providing 1 hour of annual training to our staff if 60-70% of our residents were on vents  or had HIV ?  As those populations need specialized care, so do those with Alzheimer’s and related dementias.  The research supports it.  We owe it to not only our residents, but to our staff, to provide more than the minimally required training.  It is the right thing to do.  It is the ethical thing to do. It is the right thing from a business perspective. 

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I have been a great supporter of the American Medical Directors Association for a long time now, and today I learned of a new reason to do so.  The AMDA offers tools for helping facilities manage physicians, including improving communication with and participation by the physicians that care for your residents.  I wish I could say that there are never such problems, but we all know that is not the truth.

The other resources available from this organization (clinical guidelines, journal articles, Q&As regarding compliance issues, medical director agreements and more) are invaluable.  They are written and developed specifically for physicians who are medical directors in nursing facilities. 

I suggest that all facilities should buy a membership for their medical directors and their facilities.  The cost is minimal.  It’s  another way of supporting your medical director, as well as keeping him/her updated on LTC issues.

So, check out http://www.amda.com.

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