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Culture Change in Long Term Care:

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Culture Change in Long Term Care:

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    1. Culture Change in Long Term Care: Why Licensed Practical Nurses Should Care Dr. Linda Rhodes, Director Hirtzel Institute on Health Education & Aging lrhodes@mercyhurst.edu

    2. What needed to change? High staff turn-over rates High deficiency rates Poor public confidence Higher acuity rates High staff injury rates Institutionalization factor No one’s happy

    3. A Vicious Cycle A you recall from the first LS, Eaton identified the following vicious cycles that occurs in facilities. This can happen fast.A you recall from the first LS, Eaton identified the following vicious cycles that occurs in facilities. This can happen fast.

    4. Vicious Cycle Fall Out Impact Vacant Shifts C.N.A.’s report what gets neglected: Range of motion Hydration Feeding Bathing Impact High Turn Over Interrupts continuity: Incontinence Facility acquired pressures sores Urinary Tract infections Falls and fractures Tacit knowledge disconnect (Lifting safely, social context of care)

    5. LHB infectious disease in nursing homes Loneliness Lack of meaning I don’t matter Depression Helplessness Catheters 90% giving care Compliance Easier for staff to do it Boredom “Killing Time”

    6. Catalysts for change Sensational press coverage Investigative Hearings 1987 OBRA Nursing Home Reform Act OSCAR Data and online surveys Advocacy organizations: The National Citizens' Coalition for Nursing Home Reform (NCCNHR) The Pioneer Network Movement

    7. Pioneer Network Values: 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.

    8. Pioneer Network Values Risk taking is a normal part of life. Put person before task. All people are entitled to self-determination wherever they live. Community is the antidote to institutionalization. Do unto others as you would have them do unto you.

    9. Pioneer Network Values Promote the growth and development of all. Shape the environment: physical, organizational, and psycho-social / spiritual. Practice self-examination, search for new creativity and opportunities for doing better. Culture change and transformation are not destinations but a journey, always a work in progress.

    10. The Pioneer Vision Thing Our vision is a culture of aging that is life-affirming, satisfying, humane and meaningful. The Pioneer Network supports models where elders live in open, diverse, caring communities. Everybody changes: Governmental policy and regulation Individual's and society's attitudes toward aging and elders Elders' attitudes towards themselves and their aging Caregiver’s attitudes and behavior Our aim is nothing less than transforming the culture of aging in America.

    11. LHB Antibiotic Attachment Bonding to someone -- Family Comfort Feeling safe and secure Inclusion Make me feel part of group/community Purpose Allow me to be involved in life in a significant way Identity Know myself and you know me

    12. Culture Change Three R’s: Core Concepts Renovating into Home Reframing the Organization Renewing the Spirit It’s about feeling at home

    13. Having the FREEDOM to: Walk around in your underwear? Get up in the middle of the night & watch old movies or get a midnight snack? Sleep as late as you want? Let the dog sleep with you? Listen to your favorite music? Watch Oprah? Take a bubble bath? Open the fridge and grab a cold one? Source: Patrice Acosta, Beverly Enterprises So, what makes you feel at home?

    14. Renovating to Home Create excitement Organize process Creates households Requires input Causes disruption Requires funds Alternatives exist Neighborhood. Neighborhood.

    15. Reframing the Organization Moves leadership closer to elders Flattest organizational structure Eliminates departmental barriers Requires self-directed teams Embraces versatile workers Builds relationships Presents risks Family

    16. Renewing the spirit Involves Everyone Requires Training Requires Communication Unites Residents, Staff and family Members Involves Learning Circles Renewal of residents and staff

    17. Person Directed Care “I” Plans

    18. Person Directed Care Planning It is directed by the person it is about. Written in language everyone understands. (Family & Elder) Focus on person’s strengths. Recognize issues of the moment. Starts with elders – their needs & perspective It’s about me! (“I”) Includes a social history A team approach

    19. “I” Plans Person Centered Care Plans Old Way Diagnosis: CVA Cognitive deficit AMB: STM loss Treatment: R/O Therapy 3 x wk Facility calendar posted in room New Way Problem: I have a problem with my memory due to a stroke. When I wake up in the morning and after naps I have trouble remembering where I am. Goal: I would like to use my calendar to get to activities I enjoy. The Activity Aide will put a calendar on my bulletin board each week. When I get ready in the morning, show me my clock and calendar to help me pick out activities I like. If I appear confused, help me get back on track by showing me my calendar of what I planned on doing.

    20. I Plan: Nutrition Example Since my stroke, my appetite just hasn’t been the same. I have been losing weight since July. It helps to have my special adaptive silverware at the table. I eat better when I sit with Marlene so please have our special table set so we can eat together at every meal. I’ve loved snacks since my hiking days. I enjoy Almond Joy’s, chocolate milkshakes and a burger from McDonalds which my daughter brings in. Offer me a snack between meals and before bed. Also invite me to join the cooking group. Food always tastes better when you make it yourself I always say. Goal: I want to keep my current weight and maybe even gain five pounds.

    21. I Plan Mobility Example Old Way Mobility Treatment: Ambulation 2X/day New Way Mobility “I like to walk. My favorite times for walking are after lunch and dinner. On nice days I like walking outside for about 15 minutes.” Goal: “I want to remain active as long as possible.”

    22. Culture Change How you can tell the difference

    23. How you can tell the difference: Neighborhoods, communities & households rather than wings or floors. No mega-nursing station. Residents instead of patients. Residents wake up and go to bed when they want. Nurses know the life stories of each resident. Residents decorate their rooms with their belongings from home.

    24. How you can tell the difference: Dogs and cats roam hallways; hugged and stroked. Birds, fish and plants adorn halls. Residents dine in small communal areas. Small is better. Resident in charge of daily routine. Person directed care planning. No bureaucracy – team directed. Relationships with family, staff and resident top priority.

    25. How you can tell the difference: Staff are cross-trained: No rotations Everyone is accountable to everyone else Learning Circles Life Stories Medical model takes back seat to social model Less staff turn-over rates, higher morale Less medicated residents

    26. How you can tell the difference: Medical vs. Social Medical Model Standardized Rx plans based on diagnosis Schedules & routines designed by staff for efficiency Residents comply Decision making centralized Hospital-like environment Structured activities Sense of isolation & loneliness Social Model Caregiving relationship based on desires of resident Resident & staff design schedules reflecting personal needs Decision making is as close to resident as possible Comforts of home environment Spontaneous activities Sense of community & belonging

    27. What you can do even without culture change Think of care plans in the context of “I” plans. Practice team building leadership Include CNAs in care plans, ask advice, RESPECT them, foster autonomy Include residents in care planning Build your communication & conflict resolution skills

    28. What you can do even without culture change Create a blame free environment Be flexible Advocate for consistent assignments of CNAs with residents (Family) Lead by example: pitch in on short-staff days Feedback: How do they know you value them? Identify Caring Outcomes – not just clinical Ask to lead study group for culture change

    29. Study for Action National Citizens Coalition for Nursing Home Reform www.nccnhr.org American Associations of Homes & Services for the Aging www.aahsa.org The Pioneer Network www.pioneernetwork.net Culture Change Now www.culturechange.now.com American Health Quality Association www.ahqa.org

    30. Study for Action Greenhouse Project (www.greenhouseproject.com) Wellspring Project (www.wellspringis.org) Eden Alternative (www.edenalt.com) Better Jobs, Better Care (www.bjbc.org) Institute of Medicine (www.iom.edu) Hirtzel Institute (www.hirtzelinstitute.org)

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